Intraoperative cardiac arrests (ICAs) are low-frequency, high-mortality and morbidity situations. Due to the rarity of occurrence, staff are often not adequately prepared to respond effectively. Simulation training has proven to be valuable in preparing staff for crisis situations, such as ICAs. This quality improvement project (QIP) facilitated a cardiac arrest simulation involving the operating room (OR) staff at a large academic medical center in New Jersey (NJ) to measure technical and non-technical skills during ICA management.

In-hospital cardiac arrests are a major contributor to patient morbidity and mortality, with a current estimated annual incidence rate of 300,000 [1]. While a relatively small number of these cardiac arrests occur in the OR, about 5.7 per 10,000 cases, the consequences can be devastating [2]. Mortality increased to 35.7% in admissions involving ICA versus 1.3% [2]. Patient outcomes are dependent on the efficient and skillful response of hospital staff.

The intraoperative setting is unique due to the already present interdisciplinary team required to complete cases; therefore, it is vital that OR staff understand role responsibilities and concepts of teamwork, along with skill and knowledge to be proficient in managing adult emergencies.

How can an intraoperative in-situ cardiac arrest simulation improve technical and non-technical skills in OR staff?

Aim: To improve technical and non-technical skills in OR staff during an ICA.

Objective #1: To decrease the time from onset of crisis to the announcement of patient crisis, between the initial and subsequent simulations.

Objective #2: To decrease the time to role assignment between the initial and subsequent simulations.

Objective #3: To decrease the time to first compression between the initial and subsequent simulations.

Objective #4: To decrease the time to first defibrillation shock between the initial and subsequent simulations.

Objective #5: To enhance teamwork performance that will be evaluated using the Team Emergency Assessment Measure (TEAM) scale at initial and subsequent evaluation.

This QIP was designed to improve technical and non-technical skills during the management of an ICA using simulation-based education. The four objective measures of the project focused on decreasing time in seconds to KAIs (announcement of patient crisis, role assignment, first delivery of chest compression, and first delivery of defibrillation shock) from the initial simulation to the subsequent simulation. The fifth and final objective was to enhance teamwork performance.

Statistical significance, at a p-value of 0.025, showed that the simulation succeeded in reducing time to KAIs during cardiac arrest. Three out of four technical objectives were met with a time decrease of 36 s or greater. As the objectives reflect how quickly the team can achieve return of spontaneous circulation (ROSC), the decrease in KAI times demonstrates how the simulation improved patient management during ICA. The only objective not met with a time decrease was “role assignment”. During the day two simulation, one observer did not witness the leader explicitly assign roles. However, during that simulation, roles were naturally adopted by the participants, therefore assignment by the leader was not necessary. Nevertheless, a time for this KAI on day two simulation was not recorded for comparison. Training and experience may influence individuals’ tendency to assume certain roles during crisis situations, which may explain the natural role adoption observed during the second simulation following experience gained from the initial simulation. The participants also seemed to demonstrate situational awareness when they implicitly took on roles to perform the necessary actions. Situational awareness refers to the ability to understand the environment and is frequently discussed as an important individual element of successful teamwork [5]. Natural role adoption may occur during real-life complex scenarios; however, situational awareness, proper communication, and effective leadership are necessary to fill any teamwork gaps to identify and assign roles that may be missed.

The greatest achievement in time reduction occurred in time to “first defibrillation shock is delivered”. Rapid defibrillation is the single most important treatment in the survival of witnessed ventricular fibrillation/tachycardia and can often achieve ROSC before any other intervention is needed [6]. Neuronal death begins to occur at approximately five to 10 minutes (300 - 600 s) following ischemia from cardiac arrest. On day one, Groups A and B reached “first shock to defibrillation” at 401 s, which could potentially result in ROSC with brain anoxic injuries [7]. On day two, the time reduction of 123 s equates to the achievement of ROSC approximately two minutes faster. Consequently, this time improvement would increase neural tissue preservation when compared with day one results.

The final objective of this project was to enhance teamwork performance during cardiac arrest management. Effective teamwork is vital during crisis management and is associated with faster defibrillation [5]. Poor teamwork, on the other hand, can compromise patient safety and lead to poor outcomes. Post simulations, observers collectively rated a decrease in the execution of essential teamwork elements from day one to day two, while noting an overall improvement in teamwork performance. These inconsistencies rendered the TEAM scale ineffective in evaluating team performance for the purposes of our simulations. The same independent observers could not be present for the second day of simulations, compromising observer consistency. Additionally, the rating system allowed for subjective interpretation. These factors affected the results of the scales, leading to score discrepancy.

Perceived competency and comfort levels using the defibrillator are shown to increase following education through simulations [8]. Comments expressed by participants and the nurse educators were positive regarding their experience with the simulations. Upon reflection, participants highlighted the simulations’ ability to provide hands-on training and ease comfort levels. Participants conveyed a general feeling of better preparedness for cardiac arrest management. These comments are consistent with those from participants in aforementioned simulation studies.

There were several limitations and weaknesses in our QIP. Participant recruitment was reliant on staff scheduling, which only garnered around 40 participants. Subsequently, we were unable to ensure the same personnel participated in the second simulation. However, most of the staff were able to at least observe during the first simulation and debriefing. Time limitations restricted the number of simulations that could be executed as they were carried out during the weekly one-hour staff meetings. OR availability prevented more than two simulation rooms from running at the same time. Therefore, these time and space constraints only allowed for four total simulations to be performed. Different observers were used to rate team performance, using the TEAM scale, on day one and day two of the simulations. This prevented continuity in the assessment of the TEAM scale from day one to day two simulation, contributing to inconsistent results.

Our QIP possessed a considerable number of strengths. The first simulation was performed blind by the staff, who were unaware of the ICA scenario, to emulate a real-life crisis that cannot be predicted. The simulation narrative and checklist were obtained through the AORN organization, which provided a credible and well-constructed format for the scenario. The OR was set up to reproduce an actual case, in order to provide an immersive experience for the participants. Participants were able to open actual code carts. Jet-syringe medications were available for participants to assemble during the simulation. Defibrillators with the ability to charge and deliver shocks were present, along with pads. Vital signs were displayed around the room on multiple devices with audible alarms to notify participants of hemodynamic changes.

In conclusion, ICAs are low-frequency, high-mortality and morbidity situations. As previously aforementioned, due to the rarity of occurrence, staff are often not adequately prepared to respond effectively. Simulations were instituted that resulted in an improvement in performance in the KAIs of the AORN technical skills checklist from baseline simulation to subsequent simulation. A time reduction of approximately two minutes to defibrillation from recognition of deadly arrhythmia would result in improved patient outcomes. Therefore, this QI project has shown that simulations have better prepared staff for the management of ICAs.

Any data and materials pertaining to this article can be requested by contacting the corresponding author.

J.J., K.P., and T.P. contributed to the body of this manuscript. Data and analysis were performed by J.J.

The authors would like to thank the staff members at Rutgers University for their support in the development of this article. A special thank you must go to Dr. Barbara Niedz for her invaluable guidance and expertise.