Northwestern University Department of Medicine

Northwestern University Department of Medicine

Diane B. Wayne MDRevised 6/2008

Advanced Cardiac Life Support Checklists for Simulation-based Education

Background:

The following checklists are used at NorthwesternUniversity as assessment tools for internal medicine residents in Advanced Cardiac Life Support (ACLS). The checklists are part of a mastery learning program in ACLS for second-year internal medicine residents. Each resident has already completed a traditional American Heart Association (AHA) ACLS course, but is also required to complete the simulation-based training program.

The checklists assess resident performance in 6 common ACLS events. These are: ventricular fibrillation, pulseless electrical activity, supraventricular tachycardia, symptomatic bradycardia and ventricular tachycardia. Checklists were developed for each procedure using the AHA ACLS 2005 guidelines1 and rigorous step-by-step procedures.2

The checklists have been used in our program to assess the competencies of medical knowledge and patient care. They could also be used to teach and assess teamwork and communication/leadership.

The checklists were designed to be used with a full-body human patient simulator. These models allow realistic responses to medications and are compatible with defibrillator and pacemaker equipment. Additionally, practice time for chest compressions and airway management skills are important components of the curriculum.

Timeline and Content of Simulation Program

In our program, 40 internal medicine residents participate in 5 sessions in the simulator center in the fall of the PGY2 year. These are divided into testing sessions (2) and teaching sessions (3). The first session is a pretest in which the resident is asked to lead a clinical response to 6 simulated ACLS scenarios. Each scenario contains a brief clinical history and has a defined endpoint. The resident’s performance is assessed by the examiner on the skills checklist for each scenario. Examinees are not allowed to refer to the checklists or other written materials during pre or posttest assessments.

After pretest, residents attend 3 2-hour teaching sessions in groups of 4. The first session is reserved for deliberate practice of pulseless arrhythmias. The second session is reserved for deliberate practice of tachycardias. The third practice session is reserved for deliberate practice of the bradycardia scenario and review. Activities in each session are focused, standardized, and accompanied by specific feedback from the instructor.3

Checklists are available for review during teaching sessions. In addition to specific ACLS procedures and skills, intubation, airway management and chest compressions are important components of the curriculum. During team based ACLS care practice sessions, residents rotate through 4 roles. These are: team leader, chest compressor, airway manager, and nurse. Residents rotate so that each participant has the opportunity to practice the set of skills associated with each role.

After the educational sessions, residents return to the simulator center individually for posttesting. Residents must meet or exceed a minimum passing score (MPS) for each ACLS scenario. If a resident does not meet the MPS for 1 or more scenarios, they are referred back to the simulator center for more deliberate practice.

Sample Schedule:

July-August – pretesting of residents

Sept-October – teaching sessions for residents

November-December – posttesting of residents

Details regarding development and effectiveness of the ACLS curriculum are available in prior published reports.4-8 These include a randomized trial of simulation training4, standard setting and development of the MPS5, use of simulation training for mastery learning of ACLS procedures,6 documentation of skill retention 14 months after training 7 and a dramatic improvement in actual ACLS patient care after simulator-based training.8

Equipment needed:

-Human Patient Simulator

-Cardiac Monitor

-Defibrillator/AED

-Pacemaker

-Prefilled syringes to administer medications named in ACLS algorithms

-Intubation equipment

-Airway management supplies (oxygen tank, nasal cannula, mask)

Participants in the educational program:

Session / Time / Content / Participants
1 / July- August / Pretest / 1 Resident
1 Simulator center staff*
1 Faculty+
1 Examiner‡
2 / September-October / Teaching: pulseless arrhythmias / 4 Residents
1 Simulator center staff*
1 Faculty+
3 / Teaching: tachycardias
4 / Teaching: bradycardia & review
5 / November-December / Posttest / 1 Resident
1 Simulator center staff*
1 Faculty+
1 Examiner‡

*Simulator staff operate the simulator and provide a voice for the simulated patient. Staff are located behind a one-way mirror at our facility and can see the scenario and simulator but are not visible to the learners.

+Faculty facilitate testing sessions by carrying out tasks as assigned by the examinee. Faculty provide direction and feedback during teaching sessions.

‡Examiner scores each resident on the checklists.

Abbreviations used in the Checklists:

1)6H/5T is an abbreviation for reversible causes or contributing factors to pulseless arrythmias.1 The six “H’s” are: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypoglycemia and hypothermia. The five “T’s” are: toxins, tamponade (cardiac), tension pneumothorax, thrombosis (coronary or pulmonary) and trauma.

2)Monitored/Non Monitored. At the beginning of the case scenario, the patient is on a cardiac monitor (monitored) or is not on a monitor (non-monitored). Timing of telemetry monitoring is important for the assessment of each clinical scenario.

References

1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005; 112. Available at: Accessed 6/15/2008.

1. Stufflebeam DL. The Checklists Development Checklist. WesternMichigan

UniversityEvaluationCenter, July 2000. Available at Accessed 12/15/2005.

1. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performancein medicine and related domains. Acad. Med. 2004;79:S70-S81.

1. Wayne DB, Butter J, Siddall VJ, Fudala M, Lindquist L, Feinglass J, Wade

LD, McGaghie WC. Simulation-based training of internal medicine residents

in advanced cardiac life support protocols: a randomized trial. Teaching and Learning in Medicine. 2005;17:202-208.

5. Wayne DB, Fudala MJ, Butter J, Siddall VJ, Feinglass J, Wade LD, McGaghie

WC. Comparison of two standard-setting methods for advanced cardiac life

support training. Academic Medicine. 2005;80(10 Suppl):S63-S66.

6. Wayne DB, Butter J, Siddall VJ, Fudala MJ, Wade LD, Feinglass J, McGaghie

WC. Mastery learning of advanced cardiac life support skills by internal medicine using simulation technology and deliberate practice. Journal of General Internal Medicine. 2006;21:251-6.

7. Wayne DB, Siddall VJ, Butter J, Fudala MJ, Wade LD, Feinglass J, McGaghie

WC. A longitudinal study of internal medicine residents’ retention of advanced

cardiac support life skills. Academic Medicine. 2006;81(10 Suppl):S9-S12

8. Wayne DB, Didwania A, Fudala M, Barsuk JH, Feinglass J, McGaghie WC.

Simulation-based education improves quality of care during advanced cardiac

life support events: a case control study. Chest. 2008;133:56-61.

Data Collection Forms Advanced Cardiac Life Support Simulation Program

Study # ______

Date ______Evaluator ______

Ventricular Fibrillation/Pulseless : Persistent / Refractory

Skill Key: A = Done Correctly B = Done Incorrectly C = Not Done

Check responsiveness / A / B / C
Get Help / A / B / C
Open airway, LOOK, LISTEN, FEEL / A / B / C
Give 2 rescue breaths / A / B / C
Check for a pulse <10 sec / A / B / C
CPR compressions 30:2 / A / B / C
Check rhythm on monitor <10 sec / A / B / C
Charge / A / B / C
Clear / A / B / C
Defibrillate 360J / A / B / C
CPR 5 cycles / A / B / C
Change compressor every 2 minutes / A / B / C
Direct placement of airway device ventilation rate 8-10/minute (note: patient should receive oxygen during pre-arrest stage) / A / B / C
Continue compressions at rate>100/minute / A / B / C
Establish IV access / A / B / C
Epinephrine 1 mg IV push repeat every 3-5 minutes OR Vasopressin 40 U IV single dose to replace first or second dose Epinephrine / A / B / C
Search 6H/5T / A / B / C
Check for rhythm <10 sec / A / B / C
Charge / A / B / C
Clear / A / B / C
Defibrillate 360J / A / B / C
CPR 5 cycles do not stop for meds / A / B / C
Consider antiarrhythmics:
Amiodarone 300 IVP +/- 150mg repeat x1
Lidocaine 1.1.5 mg/kg max 3mg or 3 doses / A / B / C
CPR 5 cycles / A / B / C
Rhythm Check <10 sec / A / B / C
Charge / A / B / C
Clear / A / B / C
Defibrillate 360 J within 30-60 seconds / A / B / C

Participant Instructions: Faculty member at bedside states: “Doctor, please come see this patient in the CCU. She had an MI 24 hours ago. She is complaining of increased chest pain.”

MannequinBeginningState: Monitored, responsive.During first part of algorithm simulator staff may voice the patient stating she has chest pain and mild shortness of breath.

Telemetry findings: Monitor shows sinus rhythm with ST elevation and increasingly frequent PVC’s for 3 minutes. Rhythm then abruptly changes to pulselessVF until endpoint.

Additional information: During frequent PVCs segment it is appropriate to provide morphine, oxygen, nitrates and aspirin and ensure adequate IV access. Wt 80 kg, Defibrillator used is monophasic

Endpoint: Patient will convert to sinus rhythm after defibrillation after antiarrhythmicgiven

Comments:

Asystole

Skill Key: A = Done Correctly B = Done Incorrectly C = Not Done

Check responsiveness / A / B / C
Get help / A / B / C
Call for Defibrillator / A / B / C
Open airway LOOK, LISTEN, FEEL / A / B / C
Provide 2 rescue breaths / A / B / C
Check for a pulse <10 sec / A / B / C
CPR compressions 30:2 / A / B / C
Give oxygen / A / B / C
Attach monitor/defibrillator / A / B / C
Check rhythm on monitor <10 sec / A / B / C
CPR 5 cycles / A / B / C
Change compressor every 2 minutes / A / B / C
Rapid scene survey – is there any evidence to not attempt resuscitation (DNR order, signs of death) / A / B / C
Direct placement of airway device Rate: 8-10/minute / A / B / C
Compressions at rate >100 / A / B / C
Obtain IV access / A / B / C
Epinephrine 1 mg IV push repeat every 3-5 minutes OR Vasopressin 40 U IV single dose to replace first or second dose Epinephrine / A / B / C
Search for and treat reversible causes: 6H-5T / A / B / C
Check rhythm/pulses <10 sec / A / B / C
CPR 5 cycles / A / B / C
Atropine 1 mg IV repeat every 3-5 minutes Max 3 doses / A / B / C
Check rhythm <10 sec / A / B / C
Call Code, stop efforts / A / B / C

Participant Instructions: Faculty member at bedside states: “Doctor, please come and see this patient. She has a history of CHF and ventricular tachycardia and is admitted for ICD placement tomorrow.”

MannequinBeginningState: Unmonitored, unresponsive

Telemetry Findings: After leads placed: asystole

Additional information:Post intubation ABG: 7.0/28/158/ 100% FIO2. K 4.6. Provide these values when requested or item verbalized as cause of current condition. Dose of Sodium Bicarb is 1mEq/kg is appropriate for known preexisting hyperkalemia, tricyclic antidepressant overdose, and other drug overdose. Transcutaneous pacing may be considered if used immediately.

Endpoint: No shockable or sustainable rhythm achieved. Time to end scenario is per resident team leader.

Comments:

Pulseless Electrical Activity

Skill Key: A = Done Correctly B = Done Incorrectly C = Not Done

Check responsiveness / A / B / C
Get help / A / B / C
Call for Defibrillator / A / B / C
Open airway LOOK, LISTEN, FEEL / A / B / C
Provide 2 rescue breaths / A / B / C
Check for a pulse <10 sec / A / B / C
CPR compressions 30:2 / A / B / C
Give oxygen / A / B / C
Attach monitor/defibrillator / A / B / C
Change compressor every 2 minutes / A / B / C
Direct placement of airway device Rate: 8-10/minute / A / B / C
Compressions at rate >100 / A / B / C
Obtain IV access / A / B / C
Epinephrine 1 mg IV push repeat every 3-5 minutes OR Vasopressin 40 U IV single dose to replace first or second dose Epinephrine / A / B / C
Search for and treat reversible causes: 6H-5T / A / B / C
Check rhythm/pulses <10 sec / A / B / C
CPR 5 cycles / A / B / C
Atropine 1 mg IV repeat every 3-5 minutes Max 3 doses / A / B / C

Participant Instructions: Faculty at bedside states: “The patient was getting up to take a walk and collapsed. She had surgery for a hip fracture two days ago. Please evaluate her condition.”

MannequinBeginningState: Unmonitored, unresponsive.

Telemetry Findings: After leads placed: sinus Rhythm rate 50. Patient is pulseless until endpoint.

Additional information: ABG: 7.10/30/80/100% FIO2 K 4.8 Temp 37.0. Provide these when requested or when item verbalized as cause of current condition.

Endpoint: Pulse returns after epinephrine/vasopressin plus atropine, and reversible causes looked for

Comments:

Narrow Complex Tachycardia: Stable/Unstable

Key: A = Done Correctly B = Done Incorrectly C = Not Done

Skill

Evaluate Airway / A / B / C
Assess Breathing / A / B / C
Assess Circulation / A / B / C
Initial assessment: monitor vital signs and pulse ox / A / B / C
Identify and treat reversible causes: 6H 5T / A / B / C
Assess if patient is stable / A / B / C
Establish IV access / A / B / C
Request/review 12-lead ecg / A / B / C
Is the tachycardia narrow or wide? / A / B / C
Is the rate regular or irregular? / A / B / C
Vagal maneuvers Valsalva or carotid massage / A / B / C
Adenosine 6 mg IVP over 1-3 seconds then 12 mg IVP may repeat 12 mg in 1-2 minutes if needed one time / A / B / C
Normal saline 20 mL flush / A / B / C
Elevate arm / A / B / C
Consider expert consult / A / B / C
First Line: Ca-channel blocker
Diltiazem 15-20 mg IV over 2 min may repeat in 15 min at 20-25 mg. Infusion 5-15 mg/hr
Verapamil 2.5-5.0 mg IV bolus over 2 min 2nd dose if needed 5-10 mg in 15-30 min OR: / A / B / C
Second Line: Β-Blocker
Atenolol 5 mg slow repeat 10 min
Propranolol 0.1 mg/kg divided 3 equal doses
Esmolol 0.5 mg/kg
Metoprolol 5 mg slow IV at 5-min intervals total 15 mg / A / B / C
Prepare for DC Cardioversion / A / B / C
Have available:
Oxygen, suction, intubation tray, IV line / A / B / C
Premedicate if possible Ativan 1 mg / A / B / C
Turn on defibrillator / A / B / C
Attach leads / A / B / C
Engage synchronization mode / A / B / C
Look for markers on R waves indicating synch mode / A / B / C
Set synch mode / A / B / C
Charge / A / B / C
Clear / A / B / C
DC Cardiovert 50 J / A / B / C
Check monitor / A / B / C
Reset synch mode / A / B / C
Charge / A / B / C
Clear / A / B / C
DC Cardiovert 100 J / A / B / C
Check monitor / A / B / C

Participant Instructions:Faculty at bedside states: “The patient is a 45 y/o admitted yesterday with pneumonia. Her pulse is 140, blood pressure is 110/80, pulse ox is 95%. Can you assess her?”

MannequinBeginningState: Unmonitored, responsive. In response to questions, simulator staff may voice patient stating,“I feel ok, maybe a bit lightheaded and my pulse is pretty fast. I am breathing ok and don’t have any chest pain. I don’t have any heart problems and neither does anyone in my family.”

Telemetry Findings:After leads placed: SVT rate 140. This is confirmed by 12 lead ECG provided to resident as requested.

Additional information: After beta blocker or ca channel blocker given, vital signs change to pulse 170, BP 70/40 Patient states “I feel like I’m going to pass out and it is harder to breathe.” This takes the resident from the stable SVT algorithm to the unstable SVT algorithm in which DC Cardioversion is indicated.

End point: Rhythm converts to normal sinus rate 90 after 100 J DC Cardioversion

Note: use ½ dose adenosine if given through central line

Comments:

Symptomatic Bradycardia

Skill Key: A = Done Correctly B = Done Incorrectly C = Not Done

Assess Airway / A / B / C
Assess Breathing / A / B / C
Assess Circulation / A / B / C
Ensure monitor/defibrillator is available / A / B / C
Oxygen / A / B / C
Request and review ECG / A / B / C
Identify correct cardiac rhythm / A / B / C
Pulse ox / A / B / C
Monitor vital signs / A / B / C
Obtain IV access / A / B / C
Assess for signs/symptoms of poor perfusion / A / B / C
Consider causes 6 H/5T / A / B / C
Transcutaneous pacing rate 60-90 / A / B / C
Consider Atropine 0 .5mg. Repeat to 3 mg total / A / B / C
Epinephrine 2 to 10 μg/min / A / B / C
Dopamine 2 to 10 μg/kg per minute / A / B / C
Call for transvenous pacemaker / A / B / C
Consult expert / A / B / C

Participant Instructions: Faculty at bedside states: “I was checking her vitals and noted that her pulse was 40, blood pressure 70/40, pulse ox 90%. She was admitted yesterday for unstable angina; her only medication is aspirin. I told her to lie down and called you.”

MannequinBeginningState: Monitored, responsive. In response to questions staff may voice patient stating, “I can breathe ok. I do not have chest pain. I feel very weak and dizzy.”

Telemetry Findings: Third degree AV block, rate 40. This is confirmed by 12 lead ECG provided to resident as requested.

Additional information:Pacemaker should capture if properly placed but then fail after 1-2 minutes. This requires participants to give medications and call expert to exit scenario.

Endpoint: Sinus rhythm rate 60 will restore after dopamine given. Leave time for resident to ask for transvenous pacemaker and expert.

Comments:

Ventricular Tachycardia: Stable/Unstable

Skill Key: A = Done Correctly B = Done Incorrectly C = Not Done

Assess Airway / A / B / C
Assess Breathing / A / B / C
Assess Circulation / A / B / C
Initial assessment: monitor vital signs and pulse ox / A / B / C
Identify and treat reversible causes 6H/5T / A / B / C
Assess if patient is stable / A / B / C
Establish IV access / A / B / C
Request/review 12-lead ECG / A / B / C
Assess whether the tachycardia narrow or wide / A / B / C
Assess if the rate is regular or irregular / A / B / C
Assess if tachycardia is monomorphic or polymorphic?
Prompt: Describe the EKG findings / A / B / C
Amiodarone 150 mg IV over 10 minutes
Procainamide 20 mg/min STOP if QRS>50% wider, hypotension or 17/mg/kg given
NOTE: may proceed directly to cardioversion / A / B / C
Prepare for DC Cardioversion / A / B / C
Have available:
Oxygen, suction, intubation tray, IV line / A / B / C
Premedicate if possible Ativan 1 mg / A / B / C
Turn on defibrillator / A / B / C
Attach leads / A / B / C
Engage synchronization mode / A / B / C
Look for markers on R waves indicating sync mode / A / B / C
Charge / A / B / C
Clear / A / B / C
DC Cardiovert 100 J / A / B / C
Check monitor / A / B / C
Reset synch mode / A / B / C
Charge / A / B / C
Clear / A / B / C
DC Cardiovert 200 J / A / B / C
Check monitor / A / B / C

Participant Instructions: Faculty at bedside states: “This is a 35 yr. woman admitted for light-headedness & palpitations. She had a similar episode 6 months ago followed by a syncopal episode. She has no history of heart failure. She is feeling lightheaded again, please evaluate her.”

MannequinBeginningState: Unmonitored, responsive. In response to questions, simulator staff may voice patient denying chest pain or discomfort, shortness of breath, nausea, sweating.

Telemetry Findings: After leads placed: monomorphic VT.This is confirmed by 12 lead ECG provided to resident as requested.

Additional Information: After procainamide, amiodarone, or lidocaine given, patient complains of lightheadedness and shortness of breath, blood pressure falls to 70/40. The patient is now in the unstable ventricular tachycardia algorithm in which DC Cardioversion is indicated. Labs from 1 hour ago: K 4.7, Mg 2.0.

Endpoint: Rhythm converts to sinus rate 80 after 200 J DC Cardioversion.

Comments: