Using Software-Based Simulation for Resident Physician Training in the Management of Temporary Pacemakers : Simulation in Healthcare

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Using Software-Based Simulation for Resident Physician Training in the Management of Temporary Pacemakers

Crowe, Mark E. MD; Hayes, Christopher T. BA; Hassan, Zaki-Udin MBBS

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: April 2013 - Volume 8 - Issue 2 - p 109-113
doi: 10.1097/SIH.0b013e31826ec3e1
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An understanding of epicardial pacing is essential for the postoperative management of patients having cardiac surgery. Even if a patient does not require epicardial pacing at the conclusion of cardiopulmonary bypass, the risk of requiring early postoperative pacing is high. During this postoperative recovery time, some reports demonstrate that temporary pacing may be necessary for almost 50% of patients.1 With regard to the development of postoperative atrial fibrillation, an occurrence rate of 10% to 40% is widely reported.2–5 Because these arrhythmias may cause cardiovascular compromise and extend the length of hospitalization, it is critical that the care provider is aware of the indications for epicardial pacing and has an adequate knowledge of its management.

By placing epicardial leads intraoperatively, temporary pacing is available for bradycardia therapy or overdrive pacing of an atrial tachyarrythmia such as atrial fibrillation or flutter during the postoperative period. Although an extensive list of indications for temporary pacing is shown in Table 1, the most common reason for pacing therapy is the prevention of hemodynamic collapse or severe symptoms due to a bradycardia from sick sinus syndrome, second- or third-degree atrioventricular (AV) block, or a hypersensitive carotid sinus.6 In addition to the interventional therapy that epicardial pacing provides, recent studies have indicated a role in the prevention of atrial fibrillation by prophylactically pacing both the right and left atria.7

Table 1:
Conditions That May Benefit From Temporary Cardiac Pacing

Because critical care intensivist training during surgery and anesthesiology residency programs commonly involves patients who have undergone heart surgery, the patient simulator may be a valuable learning tool for instructing residents on the management of temporary pacemakers. This could be especially true for residents that have little to no critical care experience. The patient simulator has already been demonstrated as being effective for instructing residents in decision making regarding various clinical scenarios, many of which cannot be performed on actual patients due to the risk of compromised patient care.8–14

By developing a software-based epicardial pacing program to be used with the existing patient simulator, residents may be exposed to various clinical scenarios that might be encountered while caring for a postoperative heart patient. Currently, no simulation training involving epicardial pacing is known to exist to the authors. It is hypothesized that this novel experience will assist junior residents with no prior experience to become familiar and competent in the management of epicardial pacemakers.


Software Indication

At our teaching institution, anesthesiology residents spend approximately 3 months in the cardiothoracic intensive care unit (CT-ICU) as critical care intensivists and approximately 3 months in the intraoperative management of patients undergoing heart surgery. During these rotations, it is expected that the residents develop the knowledge base to successfully manage a temporary pacemaker. However, this can be a difficult process because no formal training exists. Currently, the residents become exposed to epicardial pacemakers from a lecture given by the critical care attending physician. To enhance the education process, an epicardial pacing simulation session was created to educate residents regarding temporary pacing before their first cardiothoracic-based rotation. Therefore, this simulation session targeted anesthesia residents in their postgraduate year 1 to 3 with little or no exposure to epicardial pacing.

Software Development

The simulation session used an internally developed computer program using Flash animation to present arrhythmias and various epicardial pacing interventions commonly used in the postoperative period to the participating anesthesiology residents. This Flash animation software program was created using Adobe Photoshop CS5 and Adobe Flash CS5 of Adobe Systems (San Jose, CA). Clinical pacing examples have been scanned into the computer and converted into a digital format using Adobe Photoshop. Additionally, a digital facade was created to identically replicate the look of an external pacemaker generator and then these graphics were imported into Adobe Flash. It was modeled after a Medtronic 5388 pulse generator (Medtronic, Minneapolis, MN), which is the type of pulse generator used at our institution for epicardial pacing (Fig. 1).

The Flash animation software program was modeled after a Medtronic 5388 pulse generator. The display screen allows a user to select a type of pacing (atrial, ventricular, or dual) and adjust the rate. This figure demonstrates the main page with a list of case scenarios on the right-sided column.

Each clinical scenario is built into a scene, and links are provided on the right side of the screen to switch between different scenes. The user is also able to change the pace frequency, pacing at a slow [60 beats per minute (bpm)], medium (90 bpm), or fast (120 bpm) rate. When these different pacing speeds are selected, changes to the frames per second in the animation occur, resulting in a visualized change of the paced rhythm. This may be done with all types of pacing modes (atrial, ventricular, or dual AV). The user may pace at a slow (60 bpm), medium (90 bpm), or fast (120 bpm). ActionScript programming adds motion and interactivity to the Flash animation. The software program is an interactive flash movie file that can be run from any computer that has the Adobe Flash player installed. An actual Medtronic 5388 was also provided for the user during the simulation session as a complement to the simulation software. The patient simulator developed by Medical Educational Technologies Inc. (2000), in “standard man” mode, was used to supplement the computer software simulation by providing an initial epicardial pacing scenario to the participant as a “primer” to the software simulation.

By modeling the Flash animation software after a pulse generator, the user is given the ability to select a type of pacing (atrial, ventricular, or dual) and adjust the rate. Multiple arrhythmias commonly encountered in the intensive care unit after heart surgery such as atrial fibrillation, complete AV heart block, sinus bradycardia, sinus tachycardia, ventricular tachycardia, and asystole are included in the program as clinical scenarios requiring epicardial pacing intervention. A scenario involving failure to adequately capture during pacing is also included. Once these scenarios are selected from a menu, the software animates the clinical data by displaying the rhythm on the screen in a continuous loop until an intervention is chosen. This provides the user with a feel for operating an actual pulse generator. All simulation sessions were conducted at the University of Kentucky’s human patient simulation laboratory, which is endorsed by the American Board of Anesthesiology as a site for Maintenance of Certification in Anesthesiology (MOCA).

Software Implementation

The epicardial pacing simulation session was introduced to a group of 15 anesthesiology residents that had minimal or no epicardial pacing experience. Upon completion of the session, the residents were asked to grade the educational experience and impact on their clinical practice using an anonymous postscenario questionnaire. Institutional review board approval was granted to collect, analyze, and report the results.

Although the simulation session primarily used the software-based program for temporary pacemaker training, an initial brief scenario involving the patient simulator developed by METI was conducted as a primer to the software simulation. Because many of the junior residents had never been exposed to an epicardial pacing pulse generator before, the patient simulator provided a way to introduce an actual pulse generator to the participant before he or she began the software-based simulation. The participant was presented with a postoperative patient who had been ventricularly paced but now was intermittently having periods of third-degree AV heart block due to loss of electrical pacing capture and a low ventricular output current setting on the pulse generator. Any possible intervention (eg, atropine, transcutanous pacing pad placement, arterial blood gas or electrolyte analysis, defibrillation, and cardiology consult for transvenous pacing) was available to the participant depending on his or her correct or incorrect assessment of the situation. However, any intervention not involving epicardial pacing proved unsuccessful (eg, no drug effect, unable to obtain electrical capture for transcutaneous pacing, and time delay for cardiology consult). The real-time scenario terminated when the resident determines that the cause of the patient’s status is an interval lack of capture due to the pulse generator’s output being set at the pacing threshold. Once the ventricular pacing output is increased, the patient is stabilized, and the simulation session proceeds to the computer software-based training.

A laptop computer containing the simulation program was set up on a desk in the simulation lab. The “home” screen of the computer software-based simulation (Fig. 1) was introduced to the participant and basic pacemaker function concepts such as connection, output (rate, amount, and chamber), capture, and sensitivity are reviewed with the resident. The participant is instructed on how to make changes to the pulse generator’s output. The user may pace at a slow (60 bpm), medium (90 bpm), or fast (120 bpm) rate. The software mimics how a user would make these changes (type of pacing, rate of pacing, and chamber output) with an actual Medtronic 5388 pulse generator.

Using a “pause and teach” technique, different clinical scenarios are presented to the user such as the third-degree AV heart block case seen in Figure 2. The program is then “paused” by the instructor so that the resident can assess and interpret the clinical data. Residents are expected to be able to determine the type of rhythm abnormality and then propose a therapy. Once an intervention is determined, the user selects it from the software program (type of pacing and rate) and makes any necessary pacing output parameters adjustments. It should be noted that the current software does not automatically recognize the adjustments entered by the participant. If the participant makes an appropriate intervention, the instructor must generate the resulting paced rhythm. For the third-degree AV block scenario shown in Figure 2, the user chose a dual chamber pacing strategy as seen in Figure 3. Other scenarios such as atrial fibrillation, tachydysrhythmias requiring overdrive suppression, symptomatic bradycardias, and a failure to obtain adequate electrical pacing capture (Fig. 4) were conducted with the user.

Screenshot from a simulated case scenario involving a patient that has developed third-degree atrioventricular heart block with associated hypotension shortly after cardiac surgery in the intensive care unit.
The user has selected a dual chamber pacing strategy for therapy of a patient with third-degree atrioventricular heart block.
Screenshot from a simulated case scenario involving a situation where there is a loss of pacing capture for a patient requiring epicardial pacing. The user is required to make adjustments to the output current of the pulse generator.

Software Evaluation

Upon completion of the session, the fifteen resident participants were asked to grade the educational experience and its impact on their clinical practice using an anonymous postscenario questionnaire. The survey consisted of 6 items such as: “The simulation session increased my understanding of epicardial pacing,” “I have a better understanding of the role that epicardial pacing has for postoperative patients in the CT-ICU,” “The simulation session increased my confidence with regard to the management of a patient with epicardial pacing wires,” and “I would recommend the epicardial pacing scenario to other residents before a CT-ICU or cardiothoracic operating room rotation.” Each item was given a rating from 1 (poor) to 5 (excellent). All participants completed the survey, and the data obtained from these questions has been included in Table 2. As demonstrated by Table 2, all items received an average rating between 4 (very good) and 5 (excellent).

Table 2:
Results of an Anonymous Resident Survey (n = 15) About Their Experience After the Epicardial Pacing Simulation Session


The epicardial pacing simulation training was developed so that junior residents would be exposed to various clinical scenarios that may occur in the CT-ICU during the postoperative period. The residents were able to obtain practical experience that was supplemented with clinical instruction regarding epicardial pacemakers. By reviewing the indications for temporary pacing, the users were instructed on proper decision making regarding diagnosis and therapy. In addition, residents became more confident in their ability to operate a pulse generator.

Previous studies have demonstrated that well-constructed simulation scenarios have an excellent correlation with actual clinical situations and facilitate learning without a compromise in patient care.8–14 Within our program, the anesthesiology residents have indicated that the epicardial pacing simulation session was extremely beneficial for understanding the role of temporary pacing and increasing confidence with regard to epicardial pacemaker management. Through the confidential, postsession survey, all participants provided positive feedback and have strongly agreed that the simulation session improved their confidence with regard to epicardial pacemakers.

This feedback from our initial or “beta” version of the software is encouraging, and future updates could include many enhancements to improve the user interface or to include advanced pacer functions such as the emergency asynchronous mode or rapid atrial pacing. There is also the possibility of giving the software program the capability of running on more portable devices such as a tablet computer or on a phone as an application. With the software available on a handheld device, it will more accurately represent a pacing box and allow the trainee to have access for future enhancement of learning.

Although these results have been positive and suggest a benefit for simulation training with epicardial pacemakers, the current data represent a small sample size. After the initial success involving anesthesiology residents, it would be practical to expand the simulation sessions to include other training physicians who have clinical duties in the CT-ICU such as surgery and cardiology residents. Future studies should also consider the effectiveness of this type of simulation training with other intensive care personnel such as critical care nurses.

Because the results of an anonymous postscenario questionnaire can be subjective, a study where participants take a pre-knowledge and post-knowledge assessment test could be used with future participants to further demonstrate the benefit of simulation as an educational tool for epicardial pacemaker management. If the study size was large enough, a comparison could be made between a group that was instructed in epicardial pacemaker management through a formal lecture versus a group that obtained their epicardial pacemaker management experience through the simulation session.

Our simulation session was limited for training purposes to postoperative situations in the intensive care unit involving anesthesiology residents. An intraoperative software-based simulation could be created to orient users to the initial testing of the pulse generator when the epicardial leads are placed by the surgeon. In addition, other types of temporary pacing such as transvenous pacemakers could be incorporated into a simulation session, but this would likely be limited to involving the human patient simulator.


Our experience with the epicardial pacing simulation suggests it to be effective in the training of junior anesthesiology residents with little or no prior experience involving temporary pacemakers. The users’ confidence in competently managing epicardial pacemakers was improved upon completion of the session. We believe that simulation training continues to become a beneficial training strategy with regard to difficult case scenarios.


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Temporary pacemakers; Software-based simulation; Resident physician education; Flash animation

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