Management of simulated maternal cardiac arrest by residents: didactic teaching versus electronic learning

Andrea Hards 0 1 2 Sharon Davies 0 1 2 Aliya Salman 0 1 2 Magda Erik-Soussi 0 1 2 MSc 0 1 2 Mrinalini Balki 0 1 2 0 M. Balki, MD (&) Department of Anesthesia and Pain Management , Mount Sinai Hospital, University of Toronto , Room 19-101, 600 University Avenue , Toronto , ON M5G 1X5, Canada 1 A. Hards, MBChB S. Davies, MD A. Salman, MD M. Erik-Soussi, MSc Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto , Toronto, ON, Canada 2 Funding This work was supported by Innovation funds, Ontario Ministry of Health & Long-term Care , Ontario, Canada ; Merit awards, Department of Anesthesia, University of Toronto , Ontario, Canada Purpose Successful resuscitation of a pregnant woman undergoing cardiac arrest and survival of the fetus require prompt, high-quality cardiopulmonary resuscitation. The objective of this observational study was to assess management of maternal cardiac arrest by anesthesia residents using high-fidelity simulation and compare subsequent performance following either didactic teaching or electronic learning (e-learning). Methods Twenty anesthesia residents were randomized to receive either didactic teaching (Didactic group, - Author contributions Andrea Hards contributed to the study conception and design, acquisition of data, analysis, and interpretation of data. She drafted and revised the article and approved the final version. Sharon Davies contributed to study conception and design, reviewed the analysis of the data, and revised and approved the final manuscript. Aliya Salman contributed to acquisition of data and approved the final manuscript. Magda ErikSoussi contributed to acquisition of data, reviewed the data, and revised and approved the final version. Mrinalini Balki contributed to the study conception and design, acquisition of data, analysis and interpretation of data. She also drafted and revised the article and approved the final version. n = 10) or e-learning (Electronic group, n = 10) on maternal cardiac arrest. Baseline management skills were tested using high-fidelity simulation, with repeat simulation testing one month after their teaching intervention. The time from cardiac arrest to start of perimortem Cesarean delivery (PMCD) was measured, and the technical and nontechnical skills scores between the two teaching groups were compared. Results The median [interquartile range] time to PMCD decreased after teaching, from 4.5 min [3.4 to 5.1 min] to 3.5 min [2.5 to 4.0 min] (P = 0.03), although the change within each group was not statistically significant (Didactic group 4.9 to 3.8 min, P = 0.2; Electronic group 3.9 to 2.5 min, P = 0.07; Didactic group vs Electronic group, P = 1.0). Even after teaching, only 65% of participants started PMCD within four minutes. Technical and nontechnical skills scores improved after teaching in both groups, and there were no differences between the groups. Conclusion There are gaps in the knowledge and implementation of resuscitation protocols and the recommended modifications for pregnancy among residents. Teaching can improve performance during management of maternal cardiac arrest. Electronic learning and didactic teaching offer similar benefits. Resume Objectif La reanimation reussie dune femme enceinte victime dun arret cardiaque et la survie du ftus necessitent une reanimation cardiopulmonaire rapide et de grande qualite. Lobjectif de cette etude observationnelle etait devaluer la prise en charge dun arret cardiaque maternel par des residents en anesthesie utilisant une simulation a` haute fidelite et de comparer leurs performances apre`s un enseignement didactique ou un apprentissage electronique (formation en ligne). Methodes Vingt residents en anesthesie ont ete repartis de facon aleatoire dans deux groupes : le premier a suivi un enseignement didactique (Groupe didactique, n = 10) et le second, une formation en ligne (Groupe electronique, n = 10) sur larret cardiaque maternel. Les competences initiales de prise en charge ont ete testees a` laide dune simulation a` haute fidelite et le test de simulation a ete repete un mois apre`s lintervention denseignement. Le delai ecoule entre larret cardiaque et laccouchement par cesarienne perimortem (PMCD) a ete chronometre et les scores de competences techniques entre les deux groupes denseignement ont ete compares. Resultats Le delai median [ecart interquartile] jusquau PMCD a diminue apre`s lenseignement de 4,5 min [3,4 a` 5,1] a` 3,5 min [2,5 a` 4], P = 0,03), bien que la variation a` linterieur de chaque groupe nait pas ete significative (groupe didactique: 4,9 a` 3,8 min, P = 0,2; groupe electronique: 3,9 a` 2,5 min, P = 0,07; groupe didactique contre groupe electronique, P = 1,0). Meme apre`s lenseignement, seulement 65 % des participants ont commence le PMCD dans un delai de quatre minutes. Les scores techniques et non techniques ont ete ameliores apre`s enseignement dans les deux groupes, et aucune difference na ete trouvee entre les groupes. Conclusion Il existe des lacunes chez nos residents quant aux connaissances et a` la mise en uvre des protocoles de reanimation, ainsi que dans les modifications recommandees dans le cadre de la grossesse. Lenseignement peut ameliorer la performance pour la prise en charge de larret cardiaque maternel. La formation en ligne et lenseignement didactique ont, tous deux, des avantages comparables. Maternal cardiac arrest during pregnancy is rare, with one case for every 20,00030,000 pregnancies.1,2 Successful resuscitation of a pregnant woman and survival of the fetus require prompt, high-quality cardiopulmonary resuscitation (CPR) with some modifications in basic and advanced cardiovascular life support techniques as they apply to pregnancy.3,4 The term perimortem Cesarean delivery (PMCD) refers to a Cesarean delivery concurrent with maternal CPR.5 Katz et al. originally recommended that PMCD be performed within four minutes of maternal cardiac arrest and delivery of the infant by five minutes.5 A subsequent review of published cases from 1985 to 2004 identified 38 cases of PMCD.6 Of the 22 cases where information regarding maternal hemodynamics was provided, 12 women had sudden, often profound improvement following delivery of the fetus. For surviving infants, there was a suggestion that those delivered within five minutes had a lower incidence of neurological and respiratory sequelae. Consequently, the authors concluded that PMCD within four minutes of maternal cardiac arrest improves maternal and neonatal outcomes. However, these times are an extremely tall order that is made more challenging as maternal cardiac arrest is rare and frequently unexpected.7 Furthermore, the 20032005 Confidential Enquiry into Maternal and Child Health (CEMACH) described deficiencies in knowledge and poor resuscitation skills among obstetrical caregivers and recommended that all clinical staff undergo regular training in basic and advanced CPR.1 The report also emphasised tha (...truncated)