an acls laboratory rotation for undergraduate medical students

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ORIGINAL CONTRIBUTION ACLS, for medical students; undergraduate training, ACLS An ACLS Laboratory Rotation for Undergraduate Medical Students We have modified the formal advanced cardiac life support (ACLS) course to meet the special needs of undergraduate medical students. A laboratory- based rotation totaling 25 hours is devoted entirely to the practice of psychomotor skills. The ACLS didactic information is presented in a self- instructional format that includes audiotape-slides, videotapes, and self- assessment quizzes. The rotation provided a certification rate of 92%. De- spite impressive test performance by third-year students, retention of car- diac code management skills deteriorated rapidly over time. A laboratory- based rotation may prove to be an effective and efficient means of providing ACLS training to undergraduate medical students. [Dyche WJ, Walsh JH, Nelson JA: An ACLS laboratory rotation for undergraduate medical stu- dents. Ann Emerg Med 12:208-211, April 1983.] INTRODUCTION Physician competency in basic cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) has been assumed by lay people and health professionals alike. However, not all medical schools require basic CPR and ACLS training as part of the undergraduate medical curriculum.1 The absence of training in these vital skills is reflected in appropriate testing of postgraduate physicians. Webb and Lambrew 2 evaluated 35 residents for basic CPR skills, and found that none could meet American Heart Associa- tion (AHA) basic rescuer standards. When Lowenstein et al s tested 45 house officers at a university teaching hospital, they concluded that most interns and residents have inadequate training not only in basic CPR, but also in critical aspects of ACLS, particu- larly intubation and arrhythmia management. To remedy these training deficiencies, the 1979 National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care recommended inclusion of both basic CPR and ACLS in the medical school curriculum. 4 Implementation of this recommendation would assure that all physicians would, at a minimum, be competent in basic CPR. In addition, physicians in emergency departments and critical care units should be certified in ACLS. Beginning in 1977, the University of Osteopathic Medicine and Health Sci- ences implemented a training program requiring basic CPR certification for all freshman medical students {180 per class). From each freshman class 16 students were selected and trained as basic CPR instructors who, as second- year students, would then be responsible for certifying the next freshman class. In January 1982, the University began providing ACLS certification for third-year students through a monthly rotation utilizing a permanently equipped laboratory facility. Typically ACLS programs have been presented as a two- to three-day for- mal course, usually extending over a weekend. Such formal courses involved full days and evenings, and were fatiguing and stressful experiences for par- ticipants and faculty alike. The ACLS course, based on a model program developed by Carveth et al, s was structured for such experienced health pro- fessionals as physicians, nurses, and paramedics whose practice involves some or all of the ACLS skills. While eight hours is allocated to lecture presentations, comparatively little time is given to psychomotor skills prac- tice -- five minutes per student per practical station. 6 This allocation of time William J. Dyche, PhD, EMT-I Joseph H. Watsh, PhD, DO Joe A. Nelson, EMT-P Des Moines, Iowa From the University of Osteopathic Medicine and Health Sciences, Des Moines, Iowa. Supported by grants from the Central Iowa EMS Council, SmithKline Focus Program, the Merck Foundation, and International Drug and Device Consultants, Inc. Address for reprints: William J. Dyche, PhD, University of Osteopathic Medicine and Health Sciences, 3200 Grand Avenue, Des Moines, Iowa 50312. 12:4 April 1983 Annals of Emergency Medicine 208/25

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ORIGINAL CONTRIBUTION ACLS, for medical students; undergraduate training, ACLS

An ACLS Laboratory Rotation for Undergraduate Medical Students

We have modified the formal advanced cardiac life support (ACLS) course to meet the special needs of undergraduate medical students. A laboratory- based rotation totaling 25 hours is devoted entirely to the practice of psychomotor skills. The ACLS didactic information is presented in a self- instructional format that includes audiotape-slides, videotapes, and self- assessment quizzes. The rotation provided a certification rate of 92%. De- spite impressive test performance by third-year students, retention of car- diac code management skills deteriorated rapidly over time. A laboratory- based rotation may prove to be an effective and efficient means of providing ACLS training to undergraduate medical students. [Dyche WJ, Walsh JH, Nelson JA: An ACLS laboratory rotation for undergraduate medical stu- dents. Ann Emerg Med 12:208-211, April 1983.]

INTRODUCTION Physician competency in basic cardiopulmonary resuscitation (CPR) and

advanced cardiac life support (ACLS) has been assumed by lay people and health professionals alike. However, not all medical schools require basic CPR and ACLS training as part of the undergraduate medical curriculum.1 The absence of training in these vital skills is reflected in appropriate testing of postgraduate physicians. Webb and Lambrew 2 evaluated 35 residents for basic CPR skills, and found that none could meet American Heart Associa- tion (AHA) basic rescuer standards.

When Lowenstein et al s tested 45 house officers at a university teaching hospital, they concluded that most interns and residents have inadequate training not only in basic CPR, but also in critical aspects of ACLS, particu- larly intubation and arrhythmia management.

To remedy these training deficiencies, the 1979 National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care recommended inclusion of both basic CPR and ACLS in the medical school curriculum. 4 Implementation of this recommendation would assure that all physicians would, at a minimum, be competent in basic CPR. In addition, physicians in emergency departments and critical care units should be certified in ACLS.

Beginning in 1977, the University of Osteopathic Medicine and Health Sci- ences implemented a training program requiring basic CPR certification for all freshman medical students {180 per class). From each freshman class 16 students were selected and trained as basic CPR instructors who, as second- year students, would then be responsible for certifying the next freshman class. In January 1982, the University began providing ACLS certification for third-year students through a monthly rotation utilizing a permanently equipped laboratory facility.

Typically ACLS programs have been presented as a two- to three-day for- mal course, usually extending over a weekend. Such formal courses involved full days and evenings, and were fatiguing and stressful experiences for par- ticipants and faculty alike. The ACLS course, based on a model program developed by Carveth et al, s was structured for such experienced health pro- fessionals as physicians, nurses, and paramedics whose practice involves some or all of the ACLS skills. While eight hours is allocated to lecture presentations, comparatively little time is given to psychomotor skills prac- tice - - five minutes per student per practical station. 6 This allocation of time

William J. Dyche, PhD, EMT-I Joseph H. Watsh, PhD, DO Joe A. Nelson, EMT-P Des Moines, Iowa

From the University of Osteopathic Medicine and Health Sciences, Des Moines, Iowa.

Supported by grants from the Central Iowa EMS Council, SmithKline Focus Program, the Merck Foundation, and International Drug and Device Consultants, Inc.

Address for reprints: William J. Dyche, PhD, University of Osteopathic Medicine and Health Sciences, 3200 Grand Avenue, Des Moines, Iowa 50312.

12:4 April 1983 Annals of Emergency Medicine 208/25

ACLS LABORATORY ROTATION Dyche, Walsh & Nelson

is suitable for individuals who are fa- miliar with ACLS practical skills, but who have been away from the formal classroom for some time. Undergrad- uate medical students, on the other hand, have limited clinical experience and practical skills, although they do possess a substantial store of didactic information.

We describe a method of providing ACLS training for large classes of medical students (180 per year) utiliz- ing a laboratory-based experience. We hypothesized that extending the time allotted to the total training experi- ence, especially the psychomotor skills, would lead to a high certifica- tion rate and, ideally, to long-term re- tention. Third-year medical students participated in the program.

MATERIALS AND METHODS Curriculum

Each student was provided with an ACLS text, 7 a required reading list, and a packet of self-assessment quiz- zes that cover all didactic material identified as "core" for every ACLS c o u r s e . 6 The quizzes, provided in the absence of an updated AHA pre-test, consist of multiple-choice questions similar to, but not identical to, the post-test examination questions. Stu- dents studied the required readings at their own pace, and were expected to master the self-assessment quizzes be- fore taking the post-test. ACLS slides accompanied by audiotapes with ex- planatory and elaborative information were available for each required read- ing chapter. In addition, sets of elec- trocardiogram strip slides were avail- able for review and self-assessment testing.

The laboratory rotation consisted of eight afternoon sessions, extending over four weeks (Table 11. A max- imum of 24 students could be accom- modated per month.

The first session, divided into two subsections of 12 students each, pro- vided the opportunity for simulta- neous basic CPR recertification and ACLS station #1 testing (basic life support). In this session each student was required to pass all psychomotor performances and a cognitive test to meet basic rescuer r equ i rement s according to AHA standards. 8 One- and two-rescuer adult CPR was per- formed on recording manikins to meet the ACLS requirements for testing sta- tion # 1 . 6 Faculty members who are certified instructors in both basic CPR

TABLE 1. Laboratory rotation schedule (25 hours total instruction)

Session

la

lb

2

3

4

5a

5b

6

Activity

BCLS recertification and ACLS station one test

BCLS recertification and ACLS station one test

Orientation - - ACLS

General practice

General practice

Mega code practice

Mega code practice

Test session

Duration (h)

3

3

3

3

3

3

3

4

and ACLS evaluated skills and cogni- tive knowledge.

Session two was an or ienta t ion laboratory. During this session, stu- dents in groups of four rotated through six stations. The modular teaching stations, each equipped according to

6 ACLS requirements, afforded stu- dents the opportunity to practice tech- niques involving airway adjuncts, in- tubation, intravenous techniques, dys- rhythmia recognition, defibrillation/ cardioversion, and therapeutics (algo- rithmsl. At each of the six stations an ACLS-certified instructor described and demonstrated equipment and pro- cedures. Thus students had an oppor- tun i ty to perform each procedure under supervision. At the end of this session, students viewed a videotape of a "mega code, ''9 ie, a simulated cardiac code involving multiple man- agement problems. The mega code concept was introduced early in the rotation to impress upon students that the goal of the program is to integrate didactic information and psychomotor skills into cardiac code leadership ability.

In the following two general prac- tice sessions students rotated through the modular stations and practiced skills. These sessions were staffed by a single faculty instructor and a student assistant who is an ACLS-certified provider. The faculty member pro- vided immediate feedback to the stu- dents on problems of techniques and answered questions on the didactic in- formation and therapeutic procedures. The student assistant was most in- volved with the defibrillator module. This module required the closest su-

pervision due to safety considerations and student anxieties regarding mas- tery of procedural details. Scheduled concurrently with the ACLS labora- tory was an experimental dog labora- tory in which students performed venipuncture and arterial puncture and analyzed blood gases. Students had approximately 20 minutes of prac- tice time per station (two sessionsl. This was a four-fold increase in the time allotted to skills practice com- pared with a two-day formal course.

Mega code practice was subdivided into two sections to provide max- imum opportunity to practice code management. Each session accommo- dated a maximum of 12 students, and was staffed by two faculty instructors and two student assistants. Two mega code stations provided practice oppor- tuuities for six students at each. The student assistant controlled the ECG simulator and confirmed drug orders. The faculty instructor concentrated on providing a realistic clinical scenar- io, interjecting management problems and complications, and evaluating the code team leader. Students practiced in groups of four: one directed the code, one managed the airway, one managed the IV, and one performed chest compressions. Students had approximately 30 minutes each to practice cardiac code management, a six-fold increase in allotted time com- pared to a typical weekend course.

The testing site was equipped with two stations for airway management, algorithms, and the mega code, and one station for the written test. Eight faculty instructors and two ACLS- provider-certified assistants conducted

26/209 Annals of Emergency Medicine 12:4 April 1983

TABLE 2. ACLS comparative test data

% Achieving Passing Score on First Attempt

Month Rotation Weekend Course Test (n = 96) (n = 24) P*

Basic CPR 97 92 NS

Airway management 94 83 NS

Dysrhythmia algorithms 85 71 NS

Mega code 98 63 < .01

Written 86 54 < .01

*Chi-square test, Yates correction factor applied, NS = not significant.

TABLE 3. ACLS retention test data

% Achieving Passing Score*

Mega Code Written Test

Interval Rotation Course Rotation Course

2 months 71 43 79 64

4 months 67 36 75 58

6 months 60 (--)* 70 (--)*

*Ten to 14 subjects tested per rotation or course test interval. **Chi-square test, Yates correction factor applied, NS = not significant. tParticipants unavailable for testing.

p * ~

m

NS

NS

the test session. All test procedures conformed to AHA nat ional stan- dards.

During the experimental period of rotations, an opportunity arose to con- duct a formal course. The course, con- ducted during a weekend, was pro- vided for the benef i t of s tuden ts whose clinical commitments did not permit them to schedule a laboratory rotation. The two-day course, orga- nized according to the suggested out- line in the ACLS instructor's manual, 6 served as a comparison for student performance and retention. At select- ed intervals after completion of the monthly rotations and the weekend course, re ten t ion of p sychomoto r skills and cognitive information was determined by readministering the mega code and the written post-test.

EVALUATION During a four-month period of rota-

tions, a total of 96 medical students were trained in ACLS. The certifica-

tion rate (percentage passing entire course) was 92%. The certification rate for the weekend course (24 stu- dents} was 63%.

Although student performance in basic CPR, ACLS stat ion #1, was similar in both the monthly rotations and the weekend course, there were notable differences in achievement in the other skill stations [Table 2}. A lower percentage of students received passing scores in airway management, the algorithms, and the mega code during the weekend course, as com- pared with students in rotations. In addition, students in the weekend course had more difficulty passing the written post-test on the first attempt, despite having had the benefi t of ACLS lectures.

After the weekend course, instruc- tors observed that the comprehension level of many students, even those passing a skill station on the first at- tempt, was superficial compared to the knowledge of students taking a

rotation. Instructors made specific ref- erence to students' inability to discuss indications and contraindications to the use of such devices as the esoph- ageal obturator airway (EOA ®) and the details of operation of a defibrillator. Many students in the weekend course became easily confused in the algo- rithm station if an instructor deviated from a protocol to propose a change in cardiac rhythm.

In regard to psychomotor skills, stu- dents in the weekend course who failed a station made gross errors of technique rather than failing to meet time limit requirements. Examples of errors included incorrect assembly of the EOA ® and calling on an entirely inappropriate algorithm to manage a code problem.

In the rotations, students had the mos t difficulty (lowest percentage passing on first at tempt) with the algorithm station and with the new written AHA post-test (Table 2). On the whole, ro ta t ion s tudents per- formed well in the mega code. Com- mon problems in the mega code cited by instructors were forgetting some pulse checks, forgetting to repeat drug administrations at appropriate inter- vals (eg, epinephrine and bicarbonate), and inadequate monitoring of airway management.

Retention testing revealed a rapid deterioration in code management skills following both the month ly rotat ions and the weekend course (Table 3). At two months post rota- tion, barely three-quarters of the stu- dents correctly managed a code prob- lem. Although a higher percentage of rotat ion students passed the mega code and the written test when com- pared with weekend course students (71% and 79% vs 43% and 64% ), the differences were not statistically sig- nificant. At six months post rotation, only slightly more than half the stu- dents could pass the mega code. Writ- ten test performance by rotation stu- dents did not change significantly over the post-rotation test period.

DISCUSSION Formal lectures are not the only

way (nor always the best way) to in- troduce or reinforce information. A completely self-instrucrional ACLS laboratory has been implemented by Herrin et al at the University of Mis- sissippi. 1° A potential problem with a total ly self-instructional approach, particularly with psychomotor skills,

12:4 April 1983 Annals of Emergency Medicine 210/27

ACLS LABORATORY ROTATION Dyche, Walsh & Nelson

is the difficulty students have in rec- ognizing errors in technique. A pre- liminary trial of total self-instruction in ACLS led us to c o n c l u d e tha t medical students would benefit from a m o r e s t r u c t u r e d and s u p e r v i s e d laboratory-based experience wi th a primary emphasis on skills practice. The AHA-ACLS didactic material , w i th its a c c o m p a n y i n g slide sets, lends itself to self-instructional study.

The third year of the medical curric- ulum was selected for the ACLS rota- tion because, by this time, our stu- dents have had a comprehensive car- diology course and the fundamentals of a n e s t h e s i o l o g y . F u r t h e r m o r e , achieving ACLS certification by the end of the third year meant that the students would have the benefit of this training during their fourth year clinical rotations and the first year of internship or residency.

We have developed a me thod of training large groups of undergraduate medical s tudents uti l izing a skills- laboratory-based rotation. In lieu of formal ACLS lectures, students inde- pendently learn the didactic content of the ACLS training program using self-instructional materials. The 25 hours of the ACLS rotation were de- voted to skills practice, a substantial increase in practice t ime compared with a two-day formal course. In this s tudy the cer t i f ica t ion rate of the ACLS rotation (92%) was superior to that of the weekend course (63% }.

It is difficult to make comparisons to other ACLS programs reported in the literature because the ACLS stan- dards and the ACLS course itself were revised in 1980 and 1982, respective- ly. 4'6 The psychomotor skills remain essentially the same, however, with the addition of a skills integration sta- tion, the mega code, and the combin- ing of some test stations. Further- more, the core didactic information, al though updated, was not substan- tially changed. With these qualifica- tions in mind, the certification rate of our program compares favorably with t h a t a c h i e v e d in a t o t a l l y sel f - instructional program (96%, Herrin et aP°), and exceeds the rates reported in some formal two-day courses (60% to 70%, Carveth et alS).

Overall, students performed well in the ACLS rotation. We think they per- formed well because the experience me t the essential requirements for

learning psychomotor skills: frequent repetition, immediate corrective feed- back, and adequate time to assimilate and integrate corroborative didactic information. Some students still had difficulty with successful completion, on first attempt, of the algorithm sta- t ion and the wr i t t en post- test . To assist s tudents w i th these compo- nents, we have recently developed an interactive computer program utiliz- ing a desk top microcomputer (Apple II®). The program is based on the algorithms, but also includes situa- tional content intended to drill stu- dents in ACLS didactic information pertinent to the written post-test.

The rapid de t e r io ra t ion of code management skills evidenced by re- t en t ion tes t ing was disappoint ing. These results corroborated those of Lowenstein et al, 3 who reported that in their examination of code manage- ment performance none of the medi- cal/surgical residents previously certi- fied in ACLS performed acceptably in a simulated cardiac code management test. The fact that psychomotor skills, in general, suffer rapid deterioration has also been documented for basic CPR skills 11 and paramedic practical skills. 12 Regarding mega code reten- tion testing, one must be cautious in drawing conclusions about actual code management performance. The mega code test protocol involves many pro- cedural details, all of which are impor- tant; but not all are of equal impor- tance in terms of ultimate resuscita- tive success. Consequently instructors felt some students who did not pass the mega code retention test still per- formed well enough that they might have successfully resuscitated a pa- tient.

The conclusion to be drawn is that undergraduate medical students will surely benefit from having had ACLS training, but they will need frequent simulated cardiac code drills to main- tain the procedural details of code management . A controlled study of the usefulness of the interactive com- puter program, referred to above, in re- view and retention of mega code skills will be the subject of a future publica- tion.

S U M M A R Y i The ACLS laboratory rotation de-

scribed is an efficient and reliable t ra ining m e c h a n i s m for insuring a

high certification rate while maintain- ing the quality control mandated by the nat ional AHA standards. Addi- tionally the rotation requires fewer in- structors than are usually needed for a full weekend course. Furthermore, the rotation provides for scheduling flex- ibi l i ty - - an absolute m u s t in the medical school curriculum. We be- lieve that this report will serve as a useful mode l for others who m a y want to develop a similar program.

The authors thank Dr Mearl Kilmore, Dr David Leopold, Dr Daniel Deavers, Mark Seeman, BSN, and Bill Case, PA-C, for their contributions to development of the ACLS Laboratory Rotation. We also express our appreciation to Dr William Lawson for his critical review of the manuscript and editorial assistance.

R E F E R E N C E S 1. Association of American Medical Col- leges: AAMC CurNculum Directory. Wash- ington, DC, 1981-1982. 2. Webb DD, Lambrew CT: Evaluation of physician skills in cardiopulmonary resus- citation. JACEP 7:387-389, 1978. 3. Lowenstein SR, Libby LS, Mountain RD, et al: Cardiopulmonary resuscitation by medical and surgical house-officers. Lancet 2:679-681, 1981. 4. Standards and guidelines for cardiopul- monary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 244:453-509, 1980. 5. Carveth SW, Bumap TK, Bechtel J, et al: Training in advanced cardiac life support. JAMA 235:2311-2315, 1976. 6. American Heart Association: Instruc- tor's Manual for Advanced Cardiac Life Support. Dallas, Texas, 1982. 7. American Heart Association: Textbook of Advanced Cardiac Life Support. Dallas, Texas, 1981. 8. American Heart Association: A Manual for Instructors of Basic Cardiac Life Sup- port. Dallas, Texas, 1980. 9. Kaye W, Linhares KC, Breault RV, et al: The mega-code.for training the advanced cardiac life support team. Heart Lung 11):860-865, 1981. 10. Heron TJ, Norman PF, Hill C, et al: Modular approach to CPR training. South Med J 73:742-744, 1980. 11. Weaver FJ, Ramirez AG, Dorfman SB, et al: Trainee's retention of cardiopulmo- nary resuscitation. JAMA 241:901-903, 1979. 12. Skelton MB, McSwain NE: A study of cognitive and technical skill deterioration among trained paramedics. JACEP 6:436- 438, 1977.

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