Educational Approaches: How does a diagnostic cardiac catheterization lab convert to an interventional lab?

To facilitate the transition, the hospital applied in the spring of 2005 for involvement in the Cardiovascular Patient Outcomes Research Trial (C-PORT). C-PORT was organized to gauge the feasibility of performing percutaneous coronary interventions (PCI) for acute myocardial infarctions in smaller community hospitals. The facilities currently do not perform elective PCIs or have on-site cardiovascular surgical support. In most states, angioplasty may only be performed at hospitals with cardiac surgical programs in the event of complications that require more invasive treatment. Patients were assigned randomly to receive an angioplasty or to be treated with thrombolytic therapy. Some of the requirements for participating facilities included an extensive in-service training for the hospital staff, consignment inventory of angioplasty supplies, and performance of PCI procedures by relatively high-volume operators from neighboring communities. Once the facility received approval, it looked to its neighboring high-volume hospitals to provide PCI support. Piedmont Hospital, also in Atlanta, is serving as the referring high-volume facility for the hospital. Piedmont Hospital is a 458-bed acute tertiary care facility offering all major medical, surgical and diagnostic services. Located on 26 acres in the north Atlanta community of Buckhead, Piedmont is a private, not-for-profit organization with 3,700 employees and a medical staff of more than 900 physicians. Under the guidance of Jackie Vandergriff, VP of Cardiovascular Services at Piedmont, and administrative personnel at the suburban hospital, a plan of action was developed to train the hospital’s cardiac cath lab staff as well as support staff from ICU, ER and CPCU to start in November 2005. The program included simulation training, which is not currently mandated by C-PORT, and on-the-job training in Piedmont’s cath lab. Following one week of preliminary simulation training at the SimSuite® Education Center on Piedmont’s campus, the staff spent three weeks in the cath lab under the supervision of experienced staff. Zukari Logan, SimSuite Clinical Educator, piloted a comprehensive training program for the cath lab staff to provide them with the basics of coronary and peripheral interventional procedures. What is SimSuite? The SimSuite Educational System is set up to address the need for ongoing education for both new and experienced staff. Real-life scenarios are presented in both didactic and simulated form. The opportunity to train in a risk-free environment allows for mistakes without consequences to a living patient. Mistakes can actually enhance the training experience, driving home important lessons. The SimSuite Educational System’s courseware is driven by the standardized Process of Care model, which involves the system’s haptics (the science of touch), combined with actual patient scenarios and real images. The system allows practitioners to formulate diagnoses, assess risk, perform procedures on a simulated patient, Simantha®, prepare post-procedure care plans and receive confidential metric results. Description of the Course Each area of training included didactic information, a review, and a group quiz which tested their knowledge on the management and care of cardiac patients. Some of the questions discussed were: o What is the best course of action for a large anterior myocardial infarction with signs of left ventricular dysfunction? o After arterial sheath removal, the patient complains of pain. He is pale and diaphoretic. What is the appropriate course of action? o What angulated view, also termed Grossman view, is recommended for unstable patients? o What classification of medications used for its vasodilatory effects decrease afterload and myocardial oxygen consumption? o A patient presents with cardiovascular risk factors and no history of exertional chest pain, but describes a sudden, severe pain in chest radiating to back, with normal ECG and a diastolic murmur. What entity do you suspect? Participants were able to reinforce their understanding of the courses presented by following each with simulation training. Dry model equipment was provided by SimSuite for hands-on training of wires, balloons, stents and catheters. Prior to training, demographic data was collected on each participant at the time of initiation. Eight staff members and one manager attended the pilot course, with experience levels ranging from less than 2 years to greater than 6 years (see Graph 1). Professional roles included: cardiovascular technologist (1), radiology technologist (4), registered nurse (3) and manager (1). Experience in other areas of healthcare included the cardiovascular interventional lab, radiology interventional lab, emergency medicine, step down unit, and telemetry. Baseline perception was captured regarding each participant’s confidence in their proficiency and knowledge in the areas listed in Table I. A Likert scale was administered to assess confidence [1 = Not at all; 2 = Very little; 3 = Somewhat; 4 = Very much; 5 = To a great degree]. The participants were also asked about their perceptions regarding the effectiveness of simulation in providing healthcare education (Graph 2) prior to beginning the program. The course was extremely interactive, combining didactic lectures with dynamic simulation and dry model work. The participants were able to perform various interventional procedures while working together as a team to manage the patient’s hemodynamics and possible adverse events. At the completion of the course, the participants were asked to rate their confidence in the same areas (Table II). Participants were also asked post-training to rate the effectiveness of the simulation training experience (Graph 3), the value of the SimSuite Clinical Educator (Graph 4), and whether or not the experience enhanced their desire to obtain more simulation training (Graph 5). The surveys show that the participants improved their confidence on the fundamental areas of interventional procedures, particularly in the areas of hemodynamic monitoring (+2.20), care of the patient undergoing a percutaneous coronary intervention (+2.29), and use of interventional equipment (+1.75). The participants all found the clinical educator to be of great value during the training and that their desire to obtain more simulation training had increased. Cath Lab Experience During each participant’s three-week on-the-job training in the cath lab, each was placed with a preceptor from Piedmont’s cath lab. The knowledge and hands-on skills obtained in the SimSuite were then put to use on real-time cases. Participants were positioned to only scrub interventional cases. An assigned preceptor scrubbed in with the participants until an agreed level of independence was obtained. Preceptors then served as back-up scrub to assist as needed. Preceptors completed a skills checklist to ensure that all areas of interventional scrubbing were covered. If the participant needed more time, then he/she returned for additional days. Initial Results and Conclusion The role of simulation training has great impact on increasing confidence in the healthcare setting. One participant commented, This greatly increased my knowledge and I would have liked to have gone through this when I first started in the cath lab. Another participant commented, Great work. I feel much better about everything now. The transition from performing diagnostic-only procedures to interventions can be facilitated by partnerships with other institutions that have the existing knowledge and technical capabilities, particularly simulation. The cath lab team began successful participation in live interventional procedures in January 2006. Future studies should focus on the ability of simulation training to decrease orientation time as well as improve patient outcomes. Authors Zukari Logan and Myrna Schnur can be contacted at ZLogan (at) medsimulation. com and MSchnur (at) medsimulation. com A version of this article was published as an insert to Medical Simulation Corporation's Simantics newsletter, Vol. 1, Issue 3, Fall 2006.

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