CONSTRUCCIÓN Y VALIDACIÓN DE UN ESCENARIO-CHECKLIST SIMULADO PARA LA EVALUACIÓN E IDENTIFICACIÓN DE ARRITMIAS DESFIBRILABLES: UN ESTUDIO METODOLÓGICO

Costa, Yule Caroline Nunes da; Dias, Amanda Aparecida; Tony, Ana Carolina Carraro; Silva, Marcos Paulo Schlinz e; Dutra, Herica Silva; Prado, Roberta Teixeira; Coelho, Angélica da Conceição Oliveira; Carbogim, Fábio da Costa

Yule Caroline Nunes da Costa

Study design

Data collection

Data analysis and interpretation

Discussion of results

Writing and/or critical review of content

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0003-0975-9411

Amanda Aparecida Dias

Data analysis and interpretation

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0002-8536-406X

Ana Carolina Carraro Tony

Discussion of results

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0003-0937-8360

Marcos Paulo Schlinz e Silva

Discussion of results

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0003-1584-4348

Herica Silva Dutra

Writing and/or critical review of content

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0003-2338-3043

Roberta Teixeira Prado

Review and final approval of the final version

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0001-8738-2248

Angélica da Conceição Oliveira Coelho

Writing and/or critical review of content

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0002-7526-900X

Fábio da Costa Carbogim

Study design

Data analysis and interpretation

Discussion of results

Writing and/or critical review of content

Review and final approval of the final version

Universidade Federal de Juiz de Fora, Programa de Pós-Graduação em Enfermagem. Juiz de Fora, Minas Gerais, Brasil.

http://orcid.org/0000-0003-2065-5998

CORRESPONDING AUTHOR
Fábio da Costa Carbogim fabiocarbogim@gmail.com

CONTRIBUTION OF AUTHORITY

Study design: Costa YCN, Carbogim FC. Data collection: Costa YCN. Data analysis and interpretation: Costa YCN, Carbogim FC, Dias AA. Discussion of results: Costa YCN, Carbogim FC, Tony ACC, Silva MPS. Writing and/or critical review of content: Costa YCN, Carbogim FC, Dutra HS, Coelho ACO. Review and final approval of the final version: Carbogim FC, Prado RT.

CONFLICT OF INTEREST

There is no conflict of interest.

EDITORS

Associated Editors: Manuela Beatriz Velho, Ana Izabel Jatobá de Souza Editor-in-chief: Elisiane Lorenzini

Items	Content Validity Coefficient
Items	First round	Second round	Third round
Scenario theme	0.897	0.923	0.974
Learners’ prior knowledge	0.897	0.974	0.974
Learning objectives	0.897	1.00	1.00
Theoretical foundation	0.897	0.974	0.974
Scenario complexity	0.948	0.948	0.948
Expected interventions	0.897	1.00	1.00
Expected results	0.846	0.923	0.974
Fidelity	0.897	0.948	1.00
Case description for instructor	0.820	0.871	0.974
Reason for hospitalization	0.974	1.00	1.00
Doctor’s prescription	1.00	1.00	0.974
Description case for students	0.846	0.948	1.00
Student guidance	0.794	0.871	0.974
Material resources	0.897	0.871	0.948
Physical space	1.00	0.897	1.00
Human resources	0.923	1.00	0.948
Scenario time	0.974	0.923	1.00
Scenario development	0.923	1.00	0.948
Debriefing	0.871	0.948	0.974
Assessment	0.948	0.923	0.948
Students’ perception	0.948	0.948	0.948
Full scenario	0.909	0.945	0.975

First round items	CVC first round
Assesses patient	0.840
Recognizes changes in vital signs	0.931
Checks monitoring cables	0.909
Recognizes shockable heart rhythm	0.909
Communicates the team	0.931
Requests emergency trolley	0.954
Starts compressions	0.931
Communicates the next steps	0.931
Full instrument	0.917
Second round items	CVC second round
Recognizes changes in vital signs	0.931
Assesses patient	0.886
Assesses central pulse	0.977
Recognize heart rate on the monitor	0.954
Identify as shockable rhythm	1.00
Communicates to the multidisciplinary team that patient is in cardiac arrest	0.977
Full instrument	0.954

Round	Cronbach’s alpha	95.0%CI*
First round	0.84	0.74 - 0.97
Second round	0.73	0.69 - 0.77
Third round	0.79	0.61 - 0.89

Previous scenario components
Learners’ prior knowledge	General knowledge on topics from the undergraduate nursing course, such as clinical medicine, anatomy and physiology of the heart, heart disease, electrocardiogram, causes of cardiorespiratory arrest and basic and advanced life support. Participation in the discipline to obtain skills and abilities to carry out the proposed scenario.
Learning objectives	Primary: - Recognize heart rhythms. Secondary: - Perform physical examination directed to the cardiovascular system. - Identify and describe the heart rhythm found. - Identify the rhythm as shockable or non-shockable.
Theoretical foundation	Dialogued lectures will be held, systematized content delivered previously and theoretical-practical training in the laboratory will be made available. References: American Heart Association1414. Ko Y, Issenberg SB, Roh YS. Effects of peer learning on nursing students' learning outcomes in electrocardiogram education. Nurse Educ Today [Internet]. 2022 [cited 2022 Dec 28];108:105182. Available from: https://doi.org/10.1016/j.nedt.2021.105182 https://doi.org/10.1016/j.nedt.2021.1051... and Brazilian Society of Cardiology guidelines1515. Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation [Internet]. 2020 [cited 2022 Dec 28]142(16 Suppl 2):S366-468. Available from: https://doi.org/10.1161/CIR.0000000000000916 https://doi.org/10.1161/CIR.000000000000... .
Scenario preparation
Theme	Identification of shockable arrhythmias in adults in the ICU
Final elaboration date	September 2021.
Name of person responsible for the scenario	Facilitators.
Scenario complexity	Medium complexity clinical simulation scenario.
Expected interventions	Students are expected to: - Recognize heart rhythms. - Perform a physical examination directed at the cardiovascular system and assess clinical signs and symptoms of possible hemodynamic changes. - Identify and describe the heart rhythm found. - Identify the rhythm as shockable or non-shockable.
Expected results	Students are expected to be able to exercise clinical competency in the assessment and recognition of shockable rhythms in the adult patient in the ICU.
Fidelity	Hybrid model, with medium fidelity simulators.
Check list	Chart 2
Description of the proposed case for the instructor	- Patient (mannequin), JAL, 60 years old, coming from the emergency service two days ago, after CPA reversed by electrical defibrillation. With vital signs controlled by a multiparameter monitor, sedated, intubated with mechanical ventilation assisted breathing. Patient’s past history: hypertensive, diabetic, smoker for 40 years. - Assessed two hours ago, he had a closed nasoenteric catheter (NEC) and suspended diet. Central Venous Catheter in the left subclavian vein, with administration of noradrenaline in an infusion pump at 7 ml/h, sedation (Ramsay: 6) with fentanyl in an infusion pump 5 ml/h and with midazolam in an infusion pump 3 ml/h. He presented with miotic and photoreactive isochoric pupils, pale, afebrile, intense sweating and cold skin. Cardiovascular auscultation (CVA): normophonetic heart sounds (NHS), tachycardia. Respiratory auscultation (RA): breath sounds present (VM+), with wheezing in the right base, bilateral lung expansion. Acyanotic and with edema in the extremities (+++/++++). Urine present, yellowish in indwelling bladder catheter, inadequate urinary volume with 50 ml per hour on average. Absent intestinal elimination for two days. - Vital signs: blood pressure (BP): 90/50 mmHg, heart rate (HR): 138 bpm, axillary temperature (Axt): 35.0ºC, non-invasive arterial oxyhemoglobin saturation (SpO2): 92.0%, blood glucose capillary: 140 mg/dl. Mechanical ventilation: controlled ventilation mode, positive end-expiratory pressure (PEEP): 8 cmH2O, respiratory rate (RR): 18 bpm, fraction of inspired oxygen (FIO2): 100.0%; tidal volume (TV): 6 ml/kg. - The monitor starts to sound the alarm. You are the nurse responsible for a patient and you have been called by a nursing technician. Carry out nursing care/assistance. - Nurse notices change in patient’s vital parameters (decrease in SpO2 to 80.0%, increase in HR and change in heart rate on the monitor, RR: 18rpm). - Checks that the vital signs shown (parameters shown on the monitor) are: BP: imperceptible, HR: 200 bpm, SpO2: 80.0%, Axt: 34.5ºC. - Assesses patient’s central pulse (absence of pulse in the carotid artery). - Recognizes that the electrocardiographic tracing on the monitor is compatible with a shockable heart rhythm, defined as ventricular fibrillation (VF). - Requests help from the multidisciplinary team and informs that patient is in CRA, with a shockable rhythm: ventricular fibrillation.
Vital parameters	- BP: inaudible; HR: 200bpm; SpO2: 80.0%; RF: 18 irpm, Axt: 34.5ºC. VM: ventilation mode: controlled, PEEP: 8 cmH2O, RR: 18 bpm, FIO2: 100.0%; CV: 6 ml/kg.
Script/instructions for students
Reason for hospitalization	Post-CRA reversed in the emergency sector.
Doctor’s prescription	Enteral diet - suspended, noradrenaline - 7 ml/h, fentanyl - 5 ml/h. Medications registered in advanced life support, 2^nd cycle: epinephrine 1 mg intravenous or intraosseous (IV/IO), every 3-5 min 3^rd cycle: amiodarone (300mg) or lidocaine (1-1.5 mg/kg) IV/IO.
Case description for students	- Patient, JAL, 60 years old, from the emergency department, after cardiac arrest reversed by electrical defibrillation. He was admitted to the ICU two days ago, his vital signs are monitored by a multiparametric monitor, he is sedated, intubated with mechanical ventilation assisted breathing. HPP: hypertensive, diabetic, smoker for 40 years. - Assessed two hours ago, the following data evolved in the medical record: (Note: provide the evolution in medical records in the scenario for students)
	NEC with suspended diet. Central Venous Catheter in the left subclavian with administration of noradrenaline in an infusion pump at 7 ml/h, sedated patient (Ramsay: 6) with fentanyl in an infusion pump 5 ml/h, midazolam in an infusion pump 3 ml/h. Presented with miotic and photoreactive isochoric pupils, pale, afebrile, intense sweating and cold skin. CVA: NHS, tachycardia. AR: VM+, with wheezing in the right base, bilateral lung expansion. Acyanotic and with edema in the extremities (+++/++++). Urine present, yellowish in indwelling bladder catheter, inadequate urinary volume with 50 ml of diuresis per hour, on average. Absent intestinal elimination for two days. - Vital signs: BP: 90/50mmHg, HR: 138 bpm, Axt: 35.0ºC, SpO2: 92.0%, blood glucose: 140 mg/dl. VM: ventilation mode: controlled, PEEP: 8 cmH2O, Rate: 18 rpm, FIO2: 100.0%; CV: 6 ml/kg.
	- The monitor starts to sound the alarm. You are the nurse responsible for a patient and you have been called by a nursing technician. Carry out nursing care/assistance.
Instructions for academics (put on the door of the simulation room)	Heart rhythm recognition/nurse assignments Initial assessment Simulation time: Participants: Clinical case: Case description for students: patient (mannequin), JAL, 60 years old, from the emergency department, after cardiac arrest reversed by electrical defibrillation. Was admitted to the ICU two days ago, his vital signs are monitored by a multiparametric monitor, he is sedated, intubated with mechanical ventilation assisted breathing. HPP: hypertensive, diabetic, smoker for 40 years. - Assessed two hours ago, the following data evolved in the medical record: (Note: provide the evolution in medical records in the scenario for students)
	NEC with suspended diet. Central Venous Catheter in the left subclavian with administration of noradrenaline in an infusion pump at 7 ml/h, patient sedated (Ramsay: 6) with fentanyl in an infusion pump 5 ml/h, midazolam in an infusion pump 3 ml/h. Presented with miotic and photoreactive isochoric pupils, pale, afebrile, intense sweating and cold skin. CVA: NHS, tachycardia. RA: VM+, with wheezing in the right base, bilateral lung expansion. Acyanotic and with edema in the extremities (+++/++++). Urine present, yellowish in indwelling bladder catheter, inadequate urinary volume with 50 ml of diuresis on average per hour. Absent intestinal elimination for two days. - Vital signs: BP: 90/50 mmHg, HR: 138 bpm, Axt: 35.0ºC, SpO2: 92.0%, blood glucose: 140 mg/dl. VM: ventilation mode: controlled, PEEP: 8 cmH2O, Rate: 18 rpm, FIO2: 100.0%; CV: 6 ml/kg.
	- The monitor starts to sound the alarm. You are the nurse responsible for a patient and you have been called by a nursing technician. Carry out nursing care/assistance. Scenario objectives: 1- Recognize changes in patient’s vital parameters. 2- Perform physical examination directed to the cardiovascular system. 3- Identify and describe the heart rhythm found. 4- Identify the rhythm as shockable or not.
Material resources	Will be used to compose the scene: hospital bed, bed identification, ICU identification, identification bracelet, gas ruler on the wall, hospital linen, pillow, medication support, infusion pump, mechanical ventilator, orotracheal tube, tube fixator, tray, screen, sink, 70.0% alcohol dispenser, liquid soap dispenser, nursing station (bench/table, sink, cabinet, chair), multiparameter cardiac monitor, vacuum cleaner, emergency car, manual defibrillator/cardioverter, full body simulator mannequin, medications, stethoscope, pulse oximeter, sphygmomanometer, electrodes, cables, bag -mask valve, compression board, bed ladder, central venous access, macrodrops equipment, photosensitive equipment, bottle of saline solution, glucose solution, identification for medications, dnula/three-way. - Materials needed for participants’ performance: procedure glove, stethoscope, cap, mask, disposable apron.
Physical space	Clinical skills laboratory.
Human resources	Target audience: nursing undergraduate students between the sixth and eighth period. Scene participants: a student and a nursing technician. Scenario organization: researcher, teacher. Facilitator: researcher, teacher. Assessment: individual, by checklist.
Estimated scenario time	10 minutes.
Scenario’s final components
Scenario development	- Situation evolution: patient assessment, recognition of the shockable rhythm, indication of subsequent procedures. The end of the scenario will be after the end of the scenario time or when the learning objectives are achieved. - Scenario’s critical factor: after students carry out the initial assessment of patients, they must identify the severity and perform the initial care in order to stabilize patient. - Students are expected to identify the arrhythmia presented, make the decision quickly, considering the urgency of the clinical condition presented.
Debriefing	Review of care through the assessment checklist, noting strengths, weaknesses and improvements. It will occur after the simulated scenario. The estimated duration of the session will be 20 minutes. Conducting the debriefing regarding reflection and analysis. - Debriefing method: Gather-Analyze-Summarize2121. Vieira TW, Sakamoto VTM, Moraes LC, Blatt CR, Caregnato RCA. Validation methods of nursing protocols: An integrative review. Rev Bras Enferm [Internet]. 2020 [cited 2022 Dec 28];73(Suppl 5):e20200050. Available from: https://doi.org/10.1590/0034-7167-2020-0050 https://doi.org/10.1590/0034-7167-2020-0... .
Satisfaction and self-confidence scale assessment and application	Assessment: verification of theoretical knowledge is done through multiple-choice pre-lecture and post-simulated scenario questions2222. Pasquali L. Instrumentação psicológica: Fundamentos e práticas. Porto Alegre, RS(BR): Artmed; 2010.. Practical knowledge is analyzed using the checklist (Chart 2). Students’ perception of the activity is analyzed using the satisfaction and self-confidence scale2626. Almeida RGS, Mazzo A, Martins JCA, Baptista RCN, Girão FB, Mendes IAC. Validation to portuguese of the scale of student satisfaction and self-confidence in learning. Rev Lat Am Enfermagem [Internet]. 2015 [cited 2022 Dec 29];23(6):1007. Available from: https://doi.org/10.1590/0104-1169.0472.2643 https://doi.org/10.1590/0104-1169.0472.2... .

Scenario: Patient assessment and shockable heart rhythm recognition
Students:
Date:	Beginning:	End:
During simulation, students:	Performed correctly	Performed partially	Did not perform
Recognize changes in monitored vital signs (available on the monitor): (BP, HR, RR, Axt, SpO₂, electro tracing).
Assess patients: identifies changes in breathing and circulation.
Assess central pulse.
Recognize the heart rhythm on the monitor (shockable VF or PVT).
Identify as shockable rhythm.
Recognize that the rhythm is CRA and informs the multidisciplinary team.

[1] CORRESPONDING AUTHOR
Fábio da Costa Carbogim fabiocarbogim@gmail.com

Brasil

Brasil

CONSTRUCCIÓN Y VALIDACIÓN DE UN ESCENARIO-CHECKLIST SIMULADO PARA LA EVALUACIÓN E IDENTIFICACIÓN DE ARRITMIAS DESFIBRILABLES: UN ESTUDIO METODOLÓGICO

RESUMEN

Objetivo:

Método:

Resultados:

Conclusión: