The Impact of Simulation on Healthcare Team Training

Clinical Simulation in Nursing (2020) 44, 42-49

Funding: No

* Correspondi

1876-1399/$ – se

https://doi.org/1

www.elsevier.com/locate/ecsn

Featured Article

Effect of a Pediatric Mock Code Simulation

Program on Resuscitation Skills and Team Performance 

Tarek R. Hazwani, MDa,b,c,*, Nicole Harder, RN, PhDd, Naila A. Shaheen, MDc, Zahra Al Hassan, RNe, Mohannad Antar, MDb,c, Ali Alshehri, MDa,b,c, Hamza Alali, MDb,c, Yasser M. Kazzaz, MDa,b,c aCollege of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia bDepartment of Pediatrics, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia cKing Abdullah International Medical Research Center, Riyadh, Saudi Arabia dAssistant Professor, Mindermar Professor in Human Simulation, University of Manitoba, Winnipeg, Manitoba, Canada eNursing Service, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia

KEYWORDS simulation; mock code; resuscitation; cardiac arrest; team performance

ne.

ng author: tarekhazwani

e front matter � 2020 Int 0.1016/j.ecns.2020.01.00

Abstract Background: The timely delivery of high-quality cardiopulmonary resuscitation (CPR) is a key measure of quality life support and patient safety. Code simulation training facilitates the acquisition of resus- citation skills and improves team performance, which significantly improves cardiopulmonary arrest survival rates and improves patient safety. The purpose of this study was to explore the impact of simulation-based training on resuscitation skills and to provide evidence that code simulations can help improve team skills and the quality of team leadership. Method: This was a retrospective descriptive study. All records of the code simulation sessions conduct- ed from July 2016 to June 2019 in the pediatric wards of a hospital were included. The data reviewed and analyzed included a crisis resource management score for the team leader and data related to team mem- bers’ performance, such as the CPR initiation time and the overall team performance assessment. Results: A total of 82 sessions were included. Over a series of simulation sessions that were conducted for each pediatric ward with repeated code sessions, the ward nursing staff showed significant improve- ments in initiating CPR, with a faster CPR initiation time. Conclusions: In situ code simulation is a helpful way to enhance team performance and improve the quality of cardiac resuscitation. The CPR initiation time was greatly improved by continuous code simu- lation training for the code team. The Impact of Simulation on Healthcare Team Training

Cite this article: Hazwani, T. R., Harder, N., Shaheen, N. A., Al Hassan, Z., Antar, M., Alshehri, A., Alali, H., & Kazzaz, Y. M. (2020, July). Effect of a pediatric mock code simulation program on resuscitation skills and team perfor- mance. Clinical Simulation in Nursing, 44(C), 42-49. https://doi.org/10.1016/j.ecns.2020.01.004.

� 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

@gmail.com (T. R. Hazwani).

ernational Nursing Association for Clinic

4

al Simulation and Learning. Published by Elsevier Inc. All rights reserved.

 

 

Mock Code Simulation 43

Background

The early initiation of high-quality cardiopulmonary resus- citation (CPR) significantly improves the outcome of cardiopulmonary arrest in the hospital (Ali & Zafari,

Key Points � This study aimed to explore the impact of simulation-based training on resuscita- tion skills.

� The timely delivery of high-quality cardio- pulmonary resuscita- tion (CPR) is a key measure of quality life support and pa- tient safety.

� Code simulation training facilitates the acquisition of resuscitation skills and improves team performance.

2007; Meert et al., 2009; Peberdy et al., 2003; Topjian, Berg, & Nadkarni, 2008). The timely delivery of high-quality CPR is key, and delayed initiation of CPR has a negative impact on patient outcomes, regardless of the quality of the resuscitation (Abella et al., 2005; Hunt et al., 2008; Wik et al., 2005). Although earlier studies and research focused on the technical components of CPR, the importance of nontechnical components such as leadership, team- work, and communication has recently become the focus of research (Andersen, Jensen, Lippert,

& Østergaard, 2010; Hunziker, Tschan, Semmer, Howell, & Marsch, 2010; Hunziker et al., 2011; Tschan et al., 2006). Moreover, the acquisition and inclusion of leader- ship skills in advanced life support training courses can improve team dynamics and team performance during CPR (Cooper, 2001; Marsch et al., 2004, 2005).

Repeated code simulation sessions can significantly reduce the time between the cardiac arrest event and the initiation of CPR. This type of simulation training facili- tates the acquisition of critical CPR skills and improves team performance, which significantly improves cardiopul- monary arrest survival rates and leads to better clinical outcomes (Andreatta, Saxton, Thompson, & Annich, 2011a; Knight et al., 2014; Ross, Trainor, Eppich, & Adler, 2013). Code simulation also gives the team time to practice and enhance their skills in a safe and nonjudg- mental learning environment, which significantly improves team members’ confidence levels. By providing practice opportunities via hands-on simulated experiences, mock codes provide staff members the opportunity to work as a team (Herbers & Heaser, 2016). The Impact of Simulation on Healthcare Team Training

There are nonmodifiable factors that influence patient outcomes, such as age, sex, race, and comorbidities; howev- er, there are modifiable variables, such as CPR initiation time, that can lead to positive outcomes. If CPR is started within the first minute of cardiac arrest, survival improves significantly, with studies suggesting that the active partic- ipation of hospital staff in a standardized code simulation

program improves in-hospital cardiac arrest survival rates (Herlitz, B�ang, Als�en, & Aune, 2002; Josey et al., 2018). To maximize basic life support and pediatric advanced life sup- port (PALS) training sessions, staff must engage in short, repeated training session, which is more effective at improving the timely initiation of CPR (Sullivan et al., 2015). The repeated practice sessions result in effective skill acquisition and retention when immediate feedback is pro- vided; this concept is referred to as deliberate practice (Ericsson, 2004). As a result of receiving repeated practice opportunities, learners are able to maximize the time they spend in deliberate practice and apply the concepts of over- learning and automatization to their clinical skill develop- ment and acquisition (Kolbe et al., 2013; Puttemans, 2005).

Pediatric residents have limited exposure to cardiopul- monary arrests during their residency training, which results in limited confidence in their resuscitation skills (Van Schaik, Von Kohorn, & O’Sullivan, 2008). Simulation-based training offers an effective and practical way to overcome the paucity of exposure to real cardiac events. Mock codes are a good example of this type of training and have been shown to improve the performance of key measures of quality life support (Hunt et al., 2014; Trainor & Krug, 2000), including improving team leader confidence in responding to pediatric resuscitation situa- tions. In a CPR situation, effective leadership reflects pos- itive patient outcomes (Fernandez Castelao et al., 2011; Gilfoyle, Gottesman, & Razack, 2007). Therefore, training team leaders to effectively direct and coordinate resuscita- tion teams is important and requires more attention (Edwards & Siassakos, 2012; Fernandez Castelao, Russo, Riethm€uller, & Boos, 2013; Hunziker et al., 2011; Hunziker, Tschan, Semmer, & Marsch, 2013; Norris & Lockey, 2012; Tschan et al., 2014; Weidman, Bell, Walsh, Small, & Edelson, 2010; Yeung et al., 2012).

As first responders to a resuscitation situation, nurses must have sufficient confidence to act immediately and deliver the care needed during a cardiac arrest situation. Simulation-based training has demonstrated to be effective at promoting the acquisition of the necessary skills required in a sudden cardiac arrest situation (Beaubien & Baker, 2004; Delac, Blazier, Daniel, & N-Wilfong, 2013; Donoghue et al., 2009; Eppich, Adler, & McGaghie, 2006; Ericsson, 2004; Hill, Dickter, & Van Daalen, 2010; Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005; von Arx & Pretzlaff, 2010; Weinberg, Auerbach, & Shah, 2009). Moreover, simulation is an effective method of increasing the self-confidence of nurses when performing cardiac resuscitation skills, and the nurses reported being highly satisfied with the simulation experience (McRae, Chan, Hulett, Lee, & Coleman, 2017). Simulation-based practice with specific, informative feedback allows nurses to refine their performance, correct errors, and gradually develop their expertise, enabling them able to refine and gradually improve their skills (Oermann et al., 2011).

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Mock Code Simulation 44

There is growing research in pediatrics evaluating the effect of simulation-based training on the clinical perfor- mance of PALS skills during resuscitation (Adler et al., 2009; Donoghue et al., 2009; Eppich et al., 2006; Tofil et al., 2013; Weinberg et al., 2009), with regular training and simulation being recognized as an effective way to reduce anxiety and increase the confidence levels of the hospital staff when performing CPR in a real-world situa- tion (Farah, Stiner, Zohar, Zveibil, & Eisenman, 2007; Settgast, Nguyen, Devries, Krebs, & Duane, 2006).

In situ mock codes allow interprofessional teams to learn how to work together and improve the skills that are necessary to provide optimal CPR in a realistic environ- ment in which patient safety is not threatened. Team performance can be accurately evaluated to provide feed- back for improvement (Andreatta, Saxton, Thompson, & Annich, 2011a; Knight et al., 2014; Lighthall, Poon, & Harrison, 2010). Currently, there is evidence showing the importance of teamwork and communication with regard to the performance of cardiac arrest teams, which can result in safe, reliable, and high-quality health care. The Impact of Simulation on Healthcare Team Training

Methods and Procedures

Simulation Program Design and Participants

In our academic teaching hospital, most pediatricians receive training for resuscitation skills during residency rotations in neonatology, pediatric critical care, and pedi- atric emergency medicine. In these environments, pediatri- cians rarely perform resuscitations; therefore, opportunities for them to gain experience performing resuscitations are limited by the relative infrequency of pediatric cardiac arrests in a real-world environment.

The code simulation program at our hospital was established in 2015. This institution is a tertiary pediatric hospital with nine specialized inpatient pediatric wards in which the code simulation sessions have been conducted. This program uses an in situ code simulation, followed by a debriefing session. The session is held 2 to 3 times per month in random pediatric wards, in any unoccupied regular patient room, at an unexpected time. It is announced as a real code, and the response to the simulation is expected to be as it would for a real cardiac arrest event. This is so that we can also uncover systemic issues affecting the response. Multiple scenarios are offered, including different types of arrhythmias with structured debriefing sessions that focus on CPR and resuscitation skills. A low-fidelity manikin with a rhythm generator is used for the simulations, whereas other instruments used are from actual ward settings, such as defibrillators, oxy- gen, medications, suction machines, and arrest carts.

The pediatric residents in our hospital serve as leaders of the pediatric cardiac arrest team, and all of them are

certified in supportPALS. The pediatric cardiac arrest team is composed of pediatric intensive care nurses, respiratory therapists, pharmacists, and pediatric ward charge nurses. In addition, the pediatric residents function as the code team leaders, and the pediatric ward nurses function as the first responders.

Our purpose in choosing an in situ model over a standard simulation laboratory environment was to create an envi- ronment that felt as real as possible to the participants. In this model, we involved all code team members in real time and in a realistic environment. The training was not limited to only the team leader but included all team members, which enhanced the team dynamics. Also critical to the success of our program was the development of effective and purposeful evaluation tools for both the team leader and the team performance in each session. Each session was evaluated by two assessors from the simulation program faculty: a physician and nurse. Each conducted separate evaluations using paper forms, which were then saved in electronic format in the simulation program database.

Study Design

This was a retrospective descriptive study conducted at King Abdullah Specialized Children’s Hospital at King Abdulaziz Medical City in Riyadh, Saudi Arabia. All records of the code simulation sessions conducted from July 2016 to June 2019 were reviewed. The sessions conducted in the pediatric wards were included, whereas the sessions conducted in other hospital areas were excluded, as they have different code teams. Data were usually recoded and archived for each session in the simulation program database; these data included a crisis resource management (CRM) score for the team leader. Other data related to team members’ performance were also documented, including the CPR initiation time and the overall team performance assessment.

Ethics approval for the study was sought from our local institutional review board before data collection, and as this was an observational retrospective study and no identifiers were collected, the institutional review board considered the study exempt from the need for informed consent. The Impact of Simulation on Healthcare Team Training

Outcomes and Measurements

The purpose of this research project was to explore the impact of simulation-based training on resuscitation skills. This research aimed to provide evidence that code simu- lation can help the team leader and the team improve their skills and the quality of team leadership. The primary outcome was to assess the impact of the code simulation on the team’s performance by assessing CPR initiation, time to first epinephrine dose, and nontechnical skills. The sec- ondary outcome was to assess the team leaders’

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Table 2 CPR Initiation Time, Epinephrine Time, Team Performance Score According to Participation Number

Participation Number No. of Sessions Variable Mean Std Dev Minimum Maximum

First time 9 CPR initiation time 54.333 22.633 19.000 103.000 Epinephrine time 540.444 138.345 298.000 743.000 Team Performance Score 20.667 6.225 17.000 37.000

Second time 9 CPR initiation time 43.000 8.588 28.000 59.000 Epinephrine time 507.778 110.825 348.000 658.000 Team Performance Score 23.889 5.278 18.000 36.000

Third time 9 CPR initiation time 36.889 11.208 20.000 55.000 Epinephrine time 416.111 82.429 288.000 551.000 Team Performance Score 27.111 6.660 19.000 39.000

Fourth time 9 CPR initiation time 32.667 6.764 24.000 42.000 Epinephrine time 384.111 67.848 302.000 547.000 Team Performance Score 31.333 8.529 19.000 44.000

Fifth time 9 CPR initiation time 26.444 7.038 18.000 39.000 Epinephrine time 387.111 69.456 264.000 510.000 Team Performance Score 33.778 6.496 25.000 41.000

More than five times 39 CPR initiation time 21.667 7.314 10.000 46.000 Epinephrine time 314.692 63.642 214.000 499.000 Team Performance Score 37.590 5.505 24.000 47.000

Note. CPR ¼ cardiopulmonary resuscitation.

Table 1 CPR Initiation Time, Epinephrine Time, Team Performance Score According to Location

Location No. of Session Variable Mean Std Dev Minimum Maximum

W42 10 CPR initiation time 34.100 11.921 14.000 46.000 Epinephrine time 394.700 44.214 310.000 464.000 Team performance score 25.300 6.165 17.000 35.000

W45 9 CPR initiation time 31.778 13.636 15.000 59.000 Epinephrine time 422.556 168.162 253.000 743.000 Team performance score 34.111 9.740 18.000 44.000

W46 9 CPR initiation time 30.889 9.006 19.000 44.000 Epinephrine time 511.000 85.849 349.000 626.000 Team performance score 28.778 6.399 20.000 40.000

W47 9 CPR initiation time 34.778 27.064 15.000 103.000 Epinephrine time 380.333 71.744 293.000 497.000 Team performance score 30.000 8.276 19.000 38.000

W48 12 CPR initiation time 33.250 13.247 18.000 59.000 Epinephrine time 341.583 97.740 224.000 521.000 Team performance score 31.833 7.433 20.000 42.000

W53 9 CPR initiation time 27.778 16.392 18.000 64.000 Epinephrine time 404.667 161.241 274.000 720.000 Team performance score 37.667 10.173 19.000 47.000

W54 8 CPR initiation time 34.125 8.476 23.000 48.000 Epinephrine time 413.125 106.688 297.000 578.000 Team performance score 32.125 8.725 18.000 41.000

W69 9 CPR initiation time 31.000 18.076 10.000 58.000 Epinephrine time 343.333 60.700 264.000 463.000 Team performance score 30.444 9.435 17.000 47.000

PICU 9 CPR initiation time Epinephrine time Team performance score

18.444 276.111 39.556

5.615 38.844 3.005

12.000 214.000 36.000

28.000 348.000 43.000

Note. PICU ¼ pediatric intensive care unit; CPR ¼ cardiopulmonary resuscitation.

Mock Code Simulation 45

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Mock Code Simulation 46

performance by evaluating their CRM Global Rating Score over two sessions of code simulation within a six-month interval. Many measures were included in the evaluation tools for both the team leader and the team performance in each session. The time it took to initiate CPR, the time to the administration of the first epinephrine dose, and the time to defibrillation were evaluated as metrics by which to gauge team improvement. The evaluation forms were developed based on the current evidence base to assess both team performance and the nontechnical skills of the team leader (Cooper et al., 2010; Nunnink et al., 2014). The nontechnical skills of the team leader were assessed based on the validated Ottawa Global Rating Scale tool and included communication and interaction, problem solving, situational awareness, leadership, resource utilization, and managerial skills. The team performance assessment was based on the Team Emergency Assessment Measure and included teamwork, team communication, timely task completion, and moral and global perspectives (Cooper et al., 2010; Nunnink et al., 2014). The inter-rater reli- ability, content validity, and concurrent validity of both evaluation methods were evaluated in simulated pediatric sessions with pediatric trainees and assessors when this simulation program started at our institution. The Impact of Simulation on Healthcare Team Training

Data Analysis

A linear mixed model was used to analyze the changes in the CPR initiation time, the time to administer the first dose of epinephrine, and the team performance scores across wards. The calculated estimates were adjusted for different diagnostic scenarios. Maximum likelihood estimation with an unstructured variance covariance structure was used to estimate the parameters. The random intercept and time were included in the model with variation in the simulation location. The results are reported as estimates, standard errors, and the corresponding p-values.

A paired t-test was used to analyze the difference between scores of 1 and 2 among the team leaders. The results are reported as the mean difference and the corresponding p-value. An alpha less than 0.05 indicated significance.

Asystole/pulseless electrical activity (PEA) was used as a reference group for diagnostic scenarios because it is the most common scenario in mock code sessions and repre- sents the most common arrhythmia in children. Highly monitored wards (i.e., the pediatric intensive care unit and the high-dependency unit) were considered the reference group, as all nursing staff in these wards are PALS certified.

Results

The study sample was collected from the simulation data for sessions that met the inclusion criteria from July 2016 to

June 2019. A total of 82 sessions met the inclusion criteria, whereas two sessions were excluded because of incomplete data (Table 1 and 2).

CPR Initiation Time

With each attempt at a simulation in each of the nine pediatric wards in which mock code simulations were conducted, there was a significant 6-second decrease in the CPR initiation time (p ¼ .0002) (Table 3). The diagnostic scenario estimates indicate that there was an increase of 2.73 seconds in the CPR initiation time for bradycardia (p ¼ .656) and a decrease of 1.17 seconds in the case of ventricular tachycardia/ventricular fibrillation (VT/VF) (p ¼ .618) compared with that for asystole/PEA. However, the change was not statistically significant.

When compared to the general ward response times, there was a statistically significant increase of 6.8 seconds in the CPR initiation time in general pediatric wards (p ¼ .02) and an increase of 7.73 seconds in hematology/ surgical wards (p ¼ .01) compared with the times in highly monitored wards.

Time to First Epinephrine Dose

With each code simulation in the specialty pediatric wards, there was a significant decrease of 44 seconds in the time to administer the first dose of epinephrine (¼0.0004) (Table 4). The time to administer the first dose of epineph- rine was increased by 43 seconds (p ¼ .201) in the case of bradycardia and by 6 seconds (p ¼ .615) in the case of VT/ VF compared with the case of asystole/PEA. However, the change was not statistically significant.

There was a statistically significant increase of 89 sec- onds in the time to prescribe the first dose of epinephrine in general pediatric wards (p ¼ .009) and an increase of 125 seconds in hematology/surgical wards (p ¼ .0007) compared with the time in highly monitored wards. The Impact of Simulation on Healthcare Team Training

Nontechnical Team Performance Assessment (Global Rating Score)

The results showed significant improvements over a series of code simulation sessions in team performance as represented by the total Global Rating Score for each specialized pediatric ward team. The score increased 3.4 times (¼0.0001) (Table 5). The total performance score was decreased 0.14-fold (p ¼ .899) in the case of VT/VF and 0.87-fold (p ¼ .768) in the case of bradycardia. However, the changes were not statistically significant. The Impact of Simulation on Healthcare Team Training

There was a nonsignificant decrease in the total perfor- mance score of 4.21 seconds for general pediatric wards (p ¼ .225) and of 4.33 seconds for hematology/surgical wards (p ¼ .237) compared with the score of highly moni- tored wards.

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Table 3 Technical Team Performance Assessment: CPR Initi- ation Time

Variables Estimate Standard Error

p- Value*

Number of participation �5.97 0.89 .0002 Diagnostic scenarios†

VT/VF �1.17 2.35 .618 Bradycardia 2.73 6.12 .656

Ward Location‡

General pediatric wards

6.88 2.89 .020

Hematology/surgical 7.73 3.0 .012

Note. CPR ¼ cardiopulmonary resuscitation; HDU ¼ high dependency unit; PEA ¼ pulseless electrical activity; VT ¼ ventricular tachycardia; VF ¼ ventricular fibrillation; PICU ¼ pediatric intensive care unit. * p-value is based on a linear mixed model. † Asystole/PEA was used a reference group for diagnostic scenarios. ‡ High monitored wards (PICU/HDU) were considered as reference

group.

Table 5 Nontechnical Team Performance Assessment: Total Global Rating Score

Variables Estimate Standard Error

p- Value*

Number of participation 3.49 0.42 <.0001 Diagnostic scenarios†

VT/VF �0.14 1.11 .899 Bradycardia �0.87 2.96 .768

Ward location‡

General pediatric wards

�4.21 3.44 .225

Hematology/surgical �4.33 3.63 .237 Note. PEA ¼ pulseless electrical activity; VT ¼ ventricular tachycardia; VF ¼ ventricular fibrillation. * p-value is based on a linear mixed model. † Asystole/PEA was used a reference group for diagnostic scenarios. ‡ High monitored wards (PICU/HDU) were considered as the refer-

ence group.

Mock Code Simulation 47

Team Leaders’ Performance

Team leader performance was evaluated in each session by the total Global Rating Score. Twenty-four participants had two code simulations within a six-month period, and the score results were compared between the first session and the second session (Table 6). The performance scores of the team leaders increased significantly (7.8 times) between baseline and 6 months (p ¼ <.0001). The Impact of Simulation on Healthcare Team Training

Discussion

The existing data about the impact of the code simulation on the team’s performance by assessing the time to CPR

Table 4 Technical Team Performance Assessment: First Epinephrine Dose

Variables Estimate Standard Error

p- Value*

Number of participation �44.11 7.46 .0004 Diagnostic scenarios†

VT/VF 6.38 12.71 .615 Bradycardia 43.79 33.90 .201

Ward location‡

General pediatric wards

89.16 33.35 .009

Hematology/surgical 125.99 35.18 .0007

Note. PEA ¼ pulseless electrical activity; VT ¼ ventricular tachycardia; VF ¼ ventricular fibrillation. * p-value is based on a linear mixed model. † Asystole/PEA was used a reference group for diagnostic scenarios. ‡ High monitored wards (PICU/HDU) were considered as the refer-

ence group.

initiation are limited, but based on the available literature (Delac et al., 2013; Huseman, 2012; Ross et al., 2013), it is believed that the overall CPR initiation time reflects team performance. The results of this study showed improve- ments in the time it took to initiate CPR over a series of code simulation sessions that were conducted with each pe- diatric ward’s team. The initiation of CPR was essentially a metric pertaining to the first responders, who recognized the cardiopulmonary arrest status and initiated CPR. This was the responsibility of the ward nursing staff in our study, and repeating the mock code sessions led to significant im- provements in the initiation of CPR by the ward nursing staff.

Team performance was assessed using the Global Rating Score by conducting a series of sessions in pediatric wards at three-month intervals. The results showed improvements in team performance overall, specifically in the area of communication. This finding was also represented by improvements in the time to administer the first epinephrine dose, which reflects efficient team work (Huseman, 2012). The Impact of Simulation on Healthcare Team Training

Looking to team leader performance and CRM, the CRM of the team leaders improved over the course of repeated sessions within the six-month period. This statis- tically significant result revealed that repeated sessions for

Table 6 Comparison of Team Leaders’ Performance Scores at Baseline vs 6 Months

Score at Baseline

Score at 6 Months Difference p-Value*

40.79 � 6.22 48.58 � 6.55 7.79 � 5.86 <.0001 * p-value is based on the paired t-test.

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Mock Code Simulation 48

team leaders enhanced their team performance skills and led to better teamwork, which may result in more confi- dence and less stress (McRae et al., 2017).

Limitations

This study has limitations. Regarding the study design, we did not obtain pretraining measurements of the staff CPR skills. Randomization could have addressed this, but we cannot rule out that systematic differences in the nurses’ baseline skills impacted their later performance. Another limitation is that the results are limited to the simulation program, and its impact on patient outcomes has not been verified. Moreover, the study did not include an evaluation of knowledge, which might have influenced the results. Additional studies could address this issue by including different levels of trainees and staff, which is feasible within randomized multicenter studies.

Conclusion

This study showed that in situ code simulation is a beneficial way to enhance team performance and improve the quality of cardiac resuscitation. It can also assist with skill retention for team leaders and with team performance, as the skills improve over the course of multiple sessions. Critical skills and the CPR initiation time were greatly improved by repeated mock code simulation training for the code team. These results suggest advantages of this educational strategy for pediatric residents, code teams, and nursing staff. The results also support the continued use of ongoing code simulation trainings to further improve team performance and maintain team leader confidence. This study suggests that repeated code simulation training can be used effectively with physicians and nursing staff to improve patient safety and the quality of care. The Impact of Simulation on Healthcare Team Training

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