Impact of High-Fidelity Simulation and Pharmacist-Specific Didactic Lectures in Addition to ACLS Provider Certification on Pharmacy Resident ACLS Performance

Introduction

Pharmacists are important members of the Advanced Cardiovascular Life Support (ACLS) team with diverse responsibilities including medication preparation; providing recommendations for medication therapy, dosing, and administration; and problem solving as part of the ACLS team. ¹ Pharmacist participation in ACLS has been shown to improve compliance to guidelines and to reduce patient mortality and adverse drug events. ^{2 –4} At our institution, postgraduate year 1 (PGY1) pharmacy residents are required to respond to cardiopulmonary arrest situations occurring in their patient care areas. ACLS provider certification through the American Heart Association (AHA) course is required for all PGY1 residents to ensure competency in this role; however, despite this training pharmacy residents often feel unprepared to perform the essential roles of a pharmacist in ACLS situations including medication preparation, providing medication therapy recommendations, clinical problem solving, and communicating recommendations to the multidisciplinary team. A consensus on the optimal training requirements for pharmacists to develop confidence and competency in ACLS has not been established.

Health care professionals have begun to use high-fidelity simulation for training to provide a realistic, hands-on learning experience that promotes safety and quality. ⁵ The positive impact of the addition of simulation-based training on various components of cardiopulmonary arrest care has been demonstrated when used in training medical residents and medical students, including improved adherence to ACLS guidelines and ability to act as the ACLS team leader. ^{6 –9} This pilot study is the first to explore the use of multidisciplinary high-fidelity simulation and additional pharmacist-focused training methods in training PGY1 pharmacy residents to provide ACLS care.

Materials and Methods

To improve pharmacy resident’s confidence and comfort level in performing the responsibilities of a pharmacist on the ACLS team, as well as to ensure a consistent level of response from the pharmacy department when responding to ACLS situations, the ACLS training requirements for PGY1 pharmacy residents at our institution were revised in 2012 to include pharmacy-specific didactic instruction in ACLS pharmacology and rhythm recognition and participation with a pharmacist mentor in 2 multidisciplinary “code blue” high-fidelity simulation experiences in addition to ACLS provider certification through the AHA course.

The didactic components were completed prior to the residents completing the AHA’s ACLS provider certification course. The ACLS pharmacology session provided a focused review of the medications recommended in the ACLS treatment pathways and any other medications available in the code cart (sodium bicarbonate, naloxone, etc). This 1-hour review was provided by an ACLS-certified pharmacist and reviewed the indication, mechanism, pharmacokinetics, preparation, dosing, administration, and adverse effects of each medication. The rhythm recognition review was a 1-hour session led by an emergency medicine physician and an ACLS-certified pharmacist. This session focused on recognition of cardiac arrest rhythms and tachyarrhythmias and bradyarrhythmias commonly requiring urgent intervention.

The multidisciplinary high-fidelity simulation experiences were completed after ACLS provider certification was achieved, with the first course within 1 month of ACLS provider certification and the second course 3 months later. Nursing and respiratory therapy staff also participated in the simulation, with an intensive care unit resource nurse acting as the ACLS team leader in the simulation. The pharmacy residents were unaware of the simulation scenario prior to the simulation event.

Each simulation began with a brief orientation to the simulation laboratory and the mannequin. A short patient scenario was presented to the participants immediately prior to starting the simulation scenario. The nursing participants began the simulation in the room with the mannequin while the pharmacist mentor, pharmacy resident, respiratory therapist, and the code leader left the room and would enter once the code was called.

The simulation scenario involved an adult male patient hospitalized for hyperkalemia requiring urgent dialysis the day prior. During the scenario, the patient developed chest pain and eventually pulseless ventricular tachycardia. As the scenario progressed his rhythm changed to ventricular fibrillation. His laboratory results immediately prior to the cardiac arrest (which were available upon request and not presented to participants prior to the patient’s cardiac arrest) included a potassium level of 7.2 mEq/L as a potentially reversible cause. This scenario was chosen because it would allow the pharmacy residents to ensure the ACLS team was following the appropriate ACLS protocol for the patient’s rhythm and allowed the resident to prepare both epinephrine and amiodarone, which are commonly used in many ACLS events and are each prepared differently at our institution, with epinephrine available as a premade syringe requiring quick assembly and the amiodarone requiring drawing up the correct dose into a syringe. The pharmacy residents should also recognize the need to evaluate for potentially reversible causes (by asking if any laboratory information was available) and subsequently recommend and prepare appropriate treatment for any reversible causes (hyperkalemia in this case). The presence of a reversible cause requiring pharmacologic therapy in this simulation allowed the pharmacy residents an additional opportunity to utilize their problem-solving and communication skills. After treating hyperkalemia, the patient had return of spontaneous circulation.

Debriefing as a multidisciplinary group occurred after the scenario and focused on allowing the participants to discuss both areas of strong performance and areas for improvement. After the group debriefing, the pharmacist mentor was able to provide any specific feedback to the pharmacy resident and answer any questions the resident might have.

To assess the impact of these additional training requirements on pharmacy resident confidence and comfort level in cardiopulmonary arrest situations, electronic surveys were administered to the residents prior to completing ACLS provider certification and the didactic instruction, after ACLS provider certification and didactic instruction were completed, and again after participation in the multidisciplinary high-fidelity simulations. Surveys were voluntary and anonymous. Survey questions assessing resident confidence and comfort level utilized a 5-point Likert-type scale (1—strongly disagree, 2—disagree, 3—neither agree nor disagree, 4—agree, and 5—strongly agree). The survey also asked the residents to provide feedback on the value of the additional education components in preparing them to function as part of the ACLS team. This project was approved as a quality improvement project at our institution.

Results

Eight PGY1 pharmacy residents completed the revised ACLS training requirements. Prior to beginning PGY1 residency and this training program, none of the residents were ACLS certified, 50% had observed a cardiopulmonary arrest situation in the past, and none had actively participated in a cardiopulmonary resuscitation event. At the end of the ACLS training sequence, all 8 (100%) residents had achieved ACLS provider certification through the AHA certification course, and 3 of the 8 residents had actively participated in a cardiopulmonary resuscitation event.

All 8 (100%) PGY1 residents completed each of the surveys (pre-ACLS certification and didactic education, post-ACLS certification, and postsimulation). Resident perceptions of their comfort level as a member of the ACLS team at each of these time points are described in Table 1. Resident responses on the perceived benefits of the additional ACLS training components added to the residency program (the ACLS pharmacology and rhythm recognition sessions and the high-fidelity simulation scenarios) are listed in Table 2.

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Table 1.

Resident Confidence and Comfort Level in Performing Essential Functions of a Pharmacist in ACLS.^a

	Pre-ACLS training		Post-ACLS training		Postsimulation
	Likert score, mean	Likert score 4-5, %	Likert score, mean	Likert score 4-5, %	Likert score, mean	Likert score 4-5, %
I am familiar with the contents of the code cart	2.88	37.5	3.50	62.5	3.63	62.5
I am familiar with the contents of medication tray in the code cart	3.25	37.5	4.13	87.5	4.25	100
I am comfortable preparing the medications in the code tray for administration	1.875	12.5	3	25	4	87.5
I am comfortable providing recommendations for dosing and administration of code medications	2	12.5	3.75	62.5	3.5	50
I am able to recognize common arrhythmias seen in code blue situations	2.25	0	3.875	87.5	3.75	75
I am familiar with appropriate medication therapy in various code blue situations	2.75	12.5	3.75	75	4	75
I am comfortable problem solving in code blue situations	2	0	3.125	25	3	25
I am comfortable asking questions and providing recommendations in a code blue situation	2.375	0	3	25	3.375	50
I am able to confidently and effectively communicate with health care providers in code blue situations	2.25	0	3.375	50	3.375	50
I am familiar with the pharmacist roles and responsibilities in code blue situations	3	25	4	75	4.375	100
I can confidently execute a pharmacists roles and responsibilities in code blue situations	2.125	0	3	25	3.625	50

Abbreviation: ACLS, Advanced Cardiovascular Life Support.

^a 5-point Likert-type scale: 1—strongly disagree, 2—disagree, 3—neither agree nor disagree, 4—agree, and 5—strongly agree.

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Table 2.

Resident Perception of Value of Added ACLS Pharmacist Training Requirements.^a

	Likert score, mean	Likert score 4-5, %
I found the rhythm recognition session better prepared me (beyond ACLS) to perform the roles and responsibilities of a pharmacist in code blue situations	4.25	100
I found the ACLS pharmacology session better prepared me (beyond ACLS) to perform the roles and responsibilities of a pharmacist in code blue situations	4.625	100
After completing the simulation scenarios
I am more familiar with the contents of the code cart	4.25	100
I am more familiar with the contents of medication tray in the code cart	4.25	100
I am more comfortable preparing the medications in the code tray for administration	4.25	100
I am more comfortable providing recommendations for dosing and administration of code medications	3.875	87.5
I am better able to recognize common arrhythmias seen on code blue situations	2.875	12.5
I am more familiar with appropriate medication therapy in various code blue situations	3.5	50
I am more comfortable problem solving in code blue situations	3.25	37.5
I am more comfortable asking questions and providing recommendations in a code blue situation	3.625	62.5
I am better able to confidently and effectively communicate with health care providers in code blue situations	3.875	87.5
I am more familiar with the pharmacist roles and responsibilities in code blue situations	4.5	100
I can more confidently execute a pharmacists roles and responsibilities in code blue situations	4.25	100
I feel participation in the simulation allowed me to better perform the roles and responsibilities of a pharmacist in  code blue situations	4.5	100

Abbreviation: ACLS, Advanced Cardiovascular Life Support.

^a 5-point Likert-type scale: 1—strongly disagree, 2—disagree, 3—neither agree nor disagree, 4—agree, and 5—strongly agree.

Discussion

The new ACLS training requirements, in addition the AHA’s ACLS provider certification course, resulted in increased resident confidence and comfort level in all assessed pharmacist functions. Completing the simulation scenarios augmented resident confidence in all areas except for providing recommendations for dosing and administration of medications and rhythm recognition when compared to completing ACLS provider certification training and the didactic components alone. At least half of the residents felt comfortable with each of the pharmacist functions assessed after completion of the ACLS training requirements, with the exception of problem solving in code blue situations.

All residents felt the addition of the ACLS pharmacology and rhythm recognition didactic lectures better prepared them to function as a pharmacist in the ACLS team than would completion of the ACLS provider certification course alone. One reason for this consensus may be that the AHA’s course reviews only medications within the ACLS algorithm. In the ACLS pharmacology lecture, all of the medications contained in the code cart were reviewed, including appropriate use, dosing, and administration. Examples of such medications discussed include magnesium sulfate, sodium bicarbonate, and naloxone.

At least half of the residents felt participation in the simulation scenarios improved confidence in each assessed pharmacist function, with the exception of problem solving in code blue situations. This outlier may be because the residents were unaware of the importance of this pharmacist contribution to the ACLS team until they were actually involved in the ACLS simulation scenario in which they were required to assess for reversible causes and recommend treatment for hyperkalemia. All residents felt the simulation requirements improved familiarity with contents of the code cart, preparation of ACLS medications, and execution of pharmacist’s responsibilities as part of the ACLS team. The positive impact of the addition of simulation-based training on various components of cardiopulmonary arrest care for medical residents, medical students, and pharmacy students has been demonstrated. ^{6 –10} This pilot study’s results demonstrate a benefit to pharmacy residents as well.

One limitation of this study is that it uses resident perception of confidence and comfort level as a marker of improvement without objective feedback from formal evaluators or mentors. Although pharmacist mentors were assigned to each resident for the simulation experience, the debriefing and feedback exchanged on each resident’s performance were kept confidential to ensure the residents’ perceived simulation as a safe learning environment. Another potential limitation is that overall competence was assessed by attainment of ACLS provider certification through the AHA course, and further specific competency assessments were not completed (other than via private feedback with mentors) after the simulation experiences. Additionally, at the time the final simulation exercise was completed, 50% of the residents had actively participated in an ACLS event outside the simulation laboratory. This experience may have impacted the overall confidence of each resident in ACLS situations. Also the small sample size of 8 participants and short duration of follow-up (4 months to complete all requirements) limit speculation of the overall impact of additional didactic components and simulation-based training for pharmacists with ACLS responsibilities.

Conclusions

Additional ACLS training requirements for pharmacy residents increased overall awareness of pharmacist roles and responsibilities as part of the ACLS team and greatly improved resident confidence and comfort level in performing most essential pharmacist functions. Overall, pharmacy residents felt the addition of the ACLS pharmacology and rhythm recognition didactic sessions and the multidisciplinary simulation experience better prepared them to function as a pharmacist in the ACLS team.