Research Article: Implications of long-term low-fidelity in situ simulation in acute care and association with a reduction in unexpected cardiac arrests: A retrospective research study

Date Published: March 12, 2019

Publisher: Public Library of Science

Author(s): Chih Jung Wang, Su Yueh Lin, Sheng Han Tsai, Yan Shen Shan, Mojtaba Vaismoradi.


In situ simulation is a new tool for building teamwork during crisis. However, only a few studies have discussed the long-term effects of regular in situ simulations. To better understand these effects, this study retrospectively analyzed the effect of regular (twice a month over a four-year period) in situ simulations in the National Cheng Kung University Hospital acute care ward, which provides care for patients with acute illnesses and requires admission during an emergency room visit. The simulations were held in a real clinical environment using a low-fidelity mannequin and the trainees involved in the simulations were the medical staff of the acute care ward. In this study, we review the effects of such long-term simulations with respect to team performance based on the Ottawa global rating scale (GRS) and incidences of urgent intubation and unexpected cardiac arrest. Our results revealed that among the 84 simulations that were conducted during the study period, 42 could be categorized as “high performance” and the remaining 42 as “low performance” based on the team’s Ottawa GRS. Further, the seniority of nurse leaders and exposure of nurses to repeated simulations did not have any effect on performance. However, although regular simulations did not have any effect on the number of urgent intubations, they caused a marked decrease in the number of unexpected cardiac arrests. The current study did not show that repeated, low-fidelity, regular in situ simulations improve team performance in simulations based on Ottawa GRS, but it was associated with a reduction in the unexpected cardiac arrest rate in the acute care ward. Our results support the use of in situ simulations in acute care wards as an educational tool for first-line caregivers.

Partial Text

The treatment of patients suffering from unexpected clinical deterioration in hospitals is an important healthcare issue and positive patient outcomes require effective resuscitation in the early stages of deterioration [1–4]. Studies have found that a reduction in the rate of occurrence of cardiopulmonary arrests outside of intensive care units depends on the ability of first-line caregivers to know when to call for the help of the rapid response team [1, 5, 6]; however, not all staff can accurately identify the clinical cues in critical situations that enable them to determine the necessity calling for help [7].

This retrospective study evaluated the effectiveness of using long-term, regular ISS in an acute care ward. Our institutional review board approved this study (A-ER-105-323). The study was conducted at National Cheng Kung University Hospital, a 1200-bed tertiary medical center in South Taiwan that has approximately 84,000 emergency room (ER) visits annually. In 2011, the hospital opened a new 44-bed acute care ward to provide better care for ER patients requiring admission: all admitted patients are acutely ill, and some of the cases are complicated. Despite implementing various efforts to ensure better care for critical patients in this ward, the hospital does not have a rapid response team, which implies that nursing staff must help resuscitate patients in critical events. Patients are primarily cared for by young residents and interns, who often lack experience in managing critical events and organizing a medical team. Therefore, to enhance their communication and teamwork skills and help medical teams implement these skills in their routine work, we started an ISS program in the acute care ward in July 2012 [16].

We conducted 84 ISS sessions during the study period. The participating staff members included 53 nurses, of whom 16 served as simulation leaders at least once. We divided the ISS sessions into the following two groups based on the Ottawa GRS score: high-performance sessions, which scored more than 50%, and low-performance sessions, which scored less than 50%.

This study evaluated the effects of regular ISS in an acute care ward over a period of four years. Our findings reveal that nurses’ seniority, and experience with ISS had no effect on Ottawa GRS score. This result differs from that of previous studies, according to which repeated exposure to simulations improved performance. [13, 19, 22] There are several reasons for the differences in the findings of our study from those of earlier studies. First, this was not a short-duration education course in which the trainee received training and evaluation in one day [12, 19]. In this study, ISS was a continued education tool in the acute care ward; we held the simulation twice a month. This may attenuate the effect of each simulation. Some previous studies found that repeated exposure to a simulation more than two times did not guarantee continued improvement [19, 20, 23]. They hypothesized that most observed non-technique improvement occurred in the early phase of simulation training. Second, we did not evaluate the effect of observation in this study. One of the advantages of ISS is that medical staff members in the unit who are not participating in the simulation can act as observers. They have the opportunity to learn critical resuscitation procedures while increasing their teamwork skills by observing the simulation and being involving in debriefing, even when they are not immediately involved in the simulation. The observers can learn CRM skills along with the active participants in the simulation [24, 25]. This study may have not actually evaluated the effect of ISS by not evaluating the effect of observation. In addition, unlike in earlier studies, physicians did not receive ongoing training in ISS and nurses participated in more than one ISS session in our study. Since residents and interns switch wards every month, we could not provide them with ongoing simulation training. This may have negatively affected team performance.

To the best of our knowledge, this is the first study to analyze the impact of long-term regular ISS in an acute care ward. We determined the effects of regular ISS on team performance and revealed that ISS reduced the incidence of emergent intubation and unexpected cardiac arrest. Based on our experience, low-fidelity ISS is a feasible tool for continuous education to build teamwork and teach clinical staff crisis resource management skills. Since the current study is a retrospective one, we did not address the issues like critical patient care quality and comfort care. Further prospective research is necessary to determine the effect of long-term ISS in the health care unit.