key: cord-0887051-ola9qm8h authors: Boivin-Proulx, Laurie-Anne; Doherty, Amélie; Rousseau-Saine, Nicolas; Doucet, Serge; Ly, Hung Q.; Lavoie, Patrick; Thibodeau-Jarry, Nicolas title: Use of Simulation-Based Medical Education for Advanced Resuscitation of In-Hospital Cardiac Arrest Patients with Suspected or Confirmed COVID-19 date: 2021-03-26 journal: Can J Cardiol DOI: 10.1016/j.cjca.2021.03.012 sha: f93a6601cbf3fadaf50c57a0e08d6f918480315a doc_id: 887051 cord_uid: ola9qm8h Cardiac arrest is common in critically-ill patients with coronavirus disease 2019 (COVID-19) and is associated with poor survival. Simulation is frequently used to evaluate and train code teams with the goal of improving outcomes. All participants engaged in a training on personal protective equipment donning and doffing for suspected or confirmed COVID-19 cases. Thereafter, simulations of in-hospital cardiac-arrest of COVID-19 patients, so-called “protected code blue”, were conducted at a quaternary academic center. The primary endpoint was the mean time-to-defibrillation. A total of 114 individuals participated in 33 “protected code blue” simulations over 8 weeks: 10 were senior residents, 17 were attending physicians, 86 were nurses and 5 were respiratory therapists. Mean time-to defibrillation was 4.38 minutes. Mean time-to-room-entry, time-to-intubation, time-to-first-chest-compression and time-to-epinephrine were 2.77, 5.74, 6.31 and 6.20 minutes respectively. 92.84% of the 16 criteria evaluating the proper management of a COVID-19 cardiac arrest patient were met. Mean time-to-defibrillation was longer than guidelines-expected time during “protected code blue” simulations. While adherence to the modified advanced cardiovascular life support protocol was high, breaches that carry an additional infectious risk and reduce the efficacy of the resuscitation team were observed. Laurie-Anne Boivin-Proulx MD, 1 Of late, simulation has demonstrated its effectiveness to achieve, measure and maintain skills in many clinical procedures, including advanced cardiovascular life support (ACLS). [3] We report on the use of simulation-based medical education for advanced resuscitation of in-hospital cardiac arrest patients with suspected or confirmed COVID-19. We conducted simulations of in-hospital cardiac-arrest for patients with suspected or confirmed COVID-19, so-called "protected code blue", at a quaternary academic center The performance of the providers in each session was assessed in terms of quality and efficacy through a standardized evaluation form (Supplemental Figure S2) . Efficacy during each simulation was assessed through time-to-room-entry, time-to-firstdefibrillation, time-to-intubation, time-to-first-chest-compression and time-to-epinephrine. Quality of performance was assessed through a 16-point checklist regarding the proper management of COVID-19 cardiac arrest patient, by a physician and a nurse trained in healthcare simulation. A total of 114 individuals participated in 33 "protected code blue" simulations over 8 weeks: 10 were senior residents, 17 were attending physicians, 86 were nurses and 5 were respiratory therapists. Table 1 . Mean time-to-room-entry, time-to-first-defibrillation, time-to-intubation, time-to-first-chest-compressions and timeto-epinephrine were 2,77 minutes, 4.38 minutes, 5.74 minutes, 6.31 minutes and 6.20 minutes, respectively. Results for the quality of the providers' performance are presented in Table 2 . 92.84% of the 16 criteria on the evaluation form were met on average. Percentage of the criterion met for two elements on the checklist could not be reported because of missing data. Frequently addressed topic during the debriefing from our simulations included: unclear distribution of roles for both nurses and doctors, material forgotten outside the room (e.g. CPR board, automatic chest compression device), unclear directives by the infectious disease prevention nurse. The average time-to-first-chest-compression, time-to-first-defibrillation and time-toepinephrine were substantially longer than guidelines suggest. Current guidelines recommend a time-to-first-chest-compression of less than or equal to one minute, timeto-first-defibrillation of less than or equal to two minutes for ventricular tachycardia/ventricular fibrillation (VT/VF) ; and administration of epinephrine or vasopressin for pulseless events (pulseless VT/VF or pulseless electrical activity/asystole) within five minutes. [4] Delayed initiation of CPR, defibrillation or epinephrine treatment were associated with lower survival. [5] The impact of prolonged time-to-defibrillation in COVID-19 cardiac arrest patients remains unsettled. It may differ from the general population given that CPR is not administrated before and after defibrillation until the patient is intubated and that initial cardiac rhythms are commonly pulseless electrical activity and asystole rather than ventricular tachycardia and ventricular fibrillation due the high rate of acute respiratory failure or pulmonary embolism in this population. [1] Significant delays in the management of COVID-19 cardiac arrest patients were expected given the modified ACLS protocol, but a significant time gap between time-to-room-entry and time-to-first defibrillation was noted. While defibrillation did not precede chest compressions or intubation in 13.64% of the stimulations, we speculate that the first person to enter the room on those occasions may not have received the training to install the pads, recognize a shockable rhythm and administer a shock. In spite of the fact that providers' performance in terms of how to manage a COVID-19 cardiac arrest patient was good overall, certain steps of the protocol had a success rate of less than 90%. While it remains controversial if chest compressions are considered an aerosol-generating medical procedure or not, using the video laryngoscope for endotracheal intubation and minimizing the number of providers in the room are established key steps in limiting aerosolization of the virus and the infectious risk to healthcare workers and should be reinforced. The importance of early defibrillation before proceeding to intubation or chest compressions in the modified ACLS protocol should also be emphasized, since delayed defibrillation (more than 2 minutes) is associated with lower survival after in-hospital cardiac arrest. [4] Certain limitations must be acknowledged. rehearsal of the modified protocol to ensure defibrillation before proceeding to intubation and chest compressions may help shorten the time-to-first-defibrillation. COVID-19 cardiac arrest protocol for hospitalized patients resulted in time-to-firstdefibrillation, time-to-first-chest-compression and time-to-epinephrine longer than guidelines-expected times. While adherence to the stepwise approach to a COVID-19 suspect patient with cardiac arrest was overall high, breaches in the protocol that may carry an additional infectious risk to the healthcare workers and reduce the efficacy of the resuscitation team were observed. Simulation-based medical education of in-hospital cardiac arrest of COVID-19 patients may help the training and the evaluation of the performance of resuscitation teams, with the hope of improving patient outcomes and reducing the infectious hazard to the providers. In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study Is Cardiopulmonary Resuscitation Futile in Coronavirus Disease 2019 Patients Experiencing In-Hospital Cardiac Arrest?*. Critical Care Medicine A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills Adult Advanced Cardiovascular Life Support. Circulation Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration All Decrease Survival in In-hospital Cardiac Arrest None. None. None.