Simulation for excellence in cardiopulmonary Arrest

Simulation for Excellence in Cardiopulmonary Arrest

Verónica Palumbo, MD, Soraya Palletti, MD

Clinical Simulation Laboratory (LaSiC), Free Chair of Simulated Emergency and Disaster Training, Faculty of Medical Sciences, University of Buenos Aires

DOI: https://dx.doi.org/10.47772/IJRISS.2025.903SEDU0493

Received: 18 August 2025; Accepted: 25 August 2025; Published: 23 September 2025

ABSTRACT

Training in medical emergencies, especially in the management of cardiopulmonary arrest (CPA), is crucial for future health professionals. This study investigated the effectiveness of a clinical simulation workshop that integrates deliberate practice and structured debriefing (PEARLS model) to improve the performance of medical students in managing CPA.

The objective of this study was to evaluate how a clinical simulation (CS) workshop, which integrates deliberate practice in different simulation zones and structured debriefing, improves the internalization of theoretical knowledge and the ability of medical students to apply CPA management protocols. This analysis also seeks to demonstrate the consolidation of the group into an effective response team.

The materials and methods included a quasi-experimental, pre- and post-test design with 10 teams of 10 final-year students, who participated in a 30-hour program with remote theoretical and in-person practical phases using simulators. The practical phase, spread over five weeks, progressed from acquiring individual technical skills (SimZone 1) to high-fidelity team scenarios involving CPA (SimZone 2), followed by a 20-30 minute PEARLS debriefing. A checklist was used to evaluate technical and non-technical aspects, assigning scores to each behavior.

Part-task simulators were used for the development of technical skills and crisis simulators, along with arrhythmia simulators, semi-automatic and manual cardio-defibrillators, the TrueMonitor program to recreate physiological parameters as a multiparameter monitor, and the necessary medical instruments for each procedure.

The results showed that 8 out of 10 groups significantly improved their performance, with an average increase in effectiveness of 85%. These findings support that clinical simulation, enhanced with deliberate practice and the PEARLS model, is a highly effective strategy for consolidating technical and non-technical skills (communication, leadership, teamwork) in emergency management, promoting deep experiential learning and the formation of cohesive response teams, which directly impacts patient quality and safety.

The observed improvement is attributed to the experiential learning facilitated by simulation and the crucial role of structured debriefing. The pedagogical progression through the different simulation zones allowed for the consolidation of both individual skills and effective integration within a team. This approach not only optimized the assimilation of the CPA protocol but also strengthened the non-technical skills essential for an effective emergency response.

Keywords: Clinical Simulation, Deliberate Practice, Medical Education, Structured Debriefing, Cardiopulmonary Arrest Protocol, Team Performance.

INTRODUCTION

Effective training in the management of medical emergencies constitutes a fundamental pillar in the education of future health professionals. Within this critical field, cardiopulmonary arrest (CPA) is one of the most challenging situations, where timely and appropriate intervention is a key determinant in patient survival rates. International guidelines, such as those from the American Heart Association [1], emphasize the relevance of a rapid, protocol-driven response, which includes the early administration of specific drugs for non-defibrillable rhythms or early defibrillation for defibrillable rhythms.

Historically, medical education has relied on traditional teaching models focused on the theoretical transmission of knowledge and the acquisition of “bedside” experience. However, the complexity of modern medicine and the need to ensure patient safety have driven the adoption of more innovative educational methodologies. In this context, clinical simulation has become an essential pedagogical tool, revolutionizing contemporary medical training by shifting the traditional focus to a model centered on the development of skills and competencies [2].

It allows students to apply their knowledge and skills in realistic, controlled scenarios, in a safe environment where errors are transformed into valuable opportunities for reflective learning [3]. This fosters students’ confidence, autonomy, and ability to improve their future performance without risk to patients. The LaSiC simulation workshop, aimed at medical students in their final mandatory clerkships, is a clear example of this integration of theory and practice, where participants acquire the technical and non-technical skills necessary for effective CPA management, with feedback on their performance.

The training program was designed as a five-week immersion cycle, where students faced CPA scenarios, acquiring essential skills and abilities, such as basic and advanced airway management, proper use of the defibrillator, patient management in cardiac arrest, leadership, and teamwork, among others.

This methodology, centered on experiential learning, demonstrates the transformative potential of clinical simulation in current medical education. Two essential didactic components highlighted in this workshop are deliberate practice and structured debriefing, which are fundamental for developing complex skills and consolidating high-performance teams in emergency situations.

Deliberate practice is defined as a highly structured activity whose explicit objective is to improve performance. It involves the repetitive execution of tasks, precise performance measurement, and continuous feedback [4]. By applying this concept in simulation, students can progressively and systematically perfect both technical and non-technical skills.

Debriefing, for its part, is a reflective analysis following an experience that facilitates knowledge integration and performance improvement [5]. Structured debriefing models, such as the PEARLS (Promoting Excellence And Reflective Learning in Simulation) model [6], enhance self-assessment, focused facilitation, and direct feedback—essential elements for meaningful learning and protocol consolidation [7; 8].

From our perspective, the opportunity to observe the evolution of these teams in a controlled environment was fascinating. Seeing how communication and coordination improved as the weeks went on is conclusive proof of the power of these methodologies. It’s not just about acquiring a skill; it’s about learning to trust teammates and the process, transforming a group of individuals into a unified response unit.

Objectives

General Objective:

To determine the effectiveness of a clinical simulation workshop that integrates deliberate practice and structured debriefing (PEARLS model) to improve the performance of medical students in the management of CPA.

Specific Objective:

To reflect on the contribution of deliberate practice and structured debriefing in the development of non-technical skills (effective communication, leadership, teamwork) essential for an effective response in CPA.

MATERIALS AND METHODS

Study Design: A formative intervention study with a quasi-experimental pre- and post-test design was conducted.

Population and Sample: Final-year medical students (Annual Rotating Internship). Participation in the workshop was voluntary, forming a total of 10 work teams of 10 students each.

Formative Intervention: The training program had a total duration of 30 hours, structured in two complementary stages over five consecutive weeks:

Theoretical Phase (Remote Preparation):

Before the practical sessions, participants were given access to digital resources on the faculty’s educational platform. This material consisted of six videos covering basic/advanced CPR, basic and advanced airway management, teamwork during resuscitations, and acid-base status, complemented by two video guides on managing a semi-automatic external defibrillator (AED) and preparing the table for intubation.

Practical Phase (Simulation Training):

The in-person component consisted of 30 hours distributed over 5 weeks:

– Week 1 (4h): Acquisition of technical skills (SimZone 1) using basic simulators, focusing on CPR, airway management, and AED use, with immediate feedback.

– Weeks 2-5 (26h): Advanced simulations (SimZone 2) with 8 progressive cardiac arrest scenarios, where teams of 10 students assumed specific roles (leader, airway, monitor/defibrillator, compressions, IV line and drug administration, recorder, etc.) to solve complex clinical cases in 10-15 minute sessions without interruptions. After each scenario, a 20-30 minute structured debriefing was conducted, following the PEARLS model:

1. Emotional reactions (“How did you feel?”)
2. Objective reconstruction (“What happened?”)
3. Critical evaluation (self-assessment and discussion of clinical decisions)
4. Pedagogical reinforcement (technical corrections and best practices)
5. Future application (“How will you implement this learning?”)

During the simulation sessions, full-body crisis simulators, various models of semi-automatic and manual cardio-defibrillators, cardiac arrhythmia simulators, and the TrueMonitor multiparameter simulator (to reproduce physiological and pathological parameters such as heart rate, saturation, blood pressure, etc.) were used.

Students performed the assessment, physical examination, requested complementary tests, and provided initial management and treatment, based on the deductions generated by the group from the clinical case presented. The decisions made by the students directly influenced the patient’s reaction, conditioning medical decision-making that, if inappropriate, could trigger patient deterioration or the appearance of complications that had to be managed.

To guide a proper debriefing after each case and facilitate improvement in subsequent exercises, specific checklists were used, which were completed by the instructor observing the scenario as it unfolded.

The aspects evaluated in each scenario using the checklist were as follows:

• Check scene safety.
• Comply with biosafety standards.
• Determine the state of consciousness.
• Evaluate the pulse.
• Recognize the arrest.
• Activate the system appropriately and early.
• Request the cardio-defibrillator early.
• Perform 2 minutes of cardiac massage appropriately.
• Perform electrical and mechanical check every 2 minutes.
• Recognize arrest rhythms.
• Administer the shock with the appropriate energy.
• Develop correct basic airway management.
• Perform series of 5 cycles of 30 compressions with 2 ventilations during basic airway management with a resuscitation bag.
• Rotate the compressor every 2 minutes.
• Minimize interruptions to cardiac massage.
• Correctly indicate and place the intravenous line.
• Correctly use drugs according to the advanced CPR protocol.
• Decide the appropriate time for advanced airway management.
• Disconnect the massage from ventilation after intubation.
• Perform monitoring every 2 minutes.
• Perform Differential Diagnoses.
• Presence and performance of the recorder role.
• Appearance of a resuscitation team leader during the exercise.

To comparatively evaluate the variables studied, a score was assigned to each of the students’ behaviors to quantify their performance:

• NC – NOT APPLICABLE: 0 points.
• A – ABSENT: -1 point.
• C – CORRECT: 2 points.
• PC – PARTIALLY CORRECT: 1 point.
• I – INCORRECT: -1 point.

Figure 1: Checklist

For statistical analysis, the pre- and post-test scores of each group were compared using paired measures, calculating mean differences and percentage increases. Descriptive statistics were used to represent performance evolution across groups. Although inferential statistical testing was limited by sample size, the consistent trend of improvement across teams supports the robustness of the observed effect.

RESULTS

8 out of 10 groups improved their performance, with an average of 22 points in the work of all groups in the first evaluation and an average of 40.7 in the second evaluation; demonstrating an increase in effectiveness of 18.7 points (an 85% increase).

DISCUSSION

This study provides solid evidence on the relevance and effectiveness of clinical simulation practices, specifically in the format with deliberate practices in Zone 1 and Zone 2 and structured debriefing, to improve the effectiveness of the response team to CPA.

The observed improvement can be directly attributed to the nature of the experiential learning facilitated by simulation [9]. By recreating high-fidelity scenarios, students can apply and test their knowledge in a safe and controlled environment, which allows for the development of essential technical and non-technical skills [10; 11]. From our perspective as an instructor-facilitator, we have been able to observe how this immersion allows students to climb Miller’s pyramid and, beyond “knowing what to do,” achieve “knowing how to do it” [12].

The progression with scenarios of increasing difficulty, developed in zones 1 and 2 of the SimZone classification [13], Zone 1 for basic skills and Zone 2 for team scenarios), allowed for a logical pedagogical evolution. First, individual skills were consolidated, and then they were integrated into the context of a resuscitation team, where synchronization and communication are as vital as technical skills.

The structured debriefing based on the PEARLS model played a fundamental role in this process. As Raemer et al. [14] and Kessels & van der Vleuten [15] point out, debriefing is often the most critical component of simulation for learning, as it encourages reflection on performance, the identification of strengths and areas for improvement, and the conceptualization of the experience. The self-assessment, focused facilitation, and direct feedback inherent in the PEARLS model allowed students to transform practical experience into applicable knowledge and strengthen the internalization of the protocol. Nonetheless, the implementation of PEARLS in complex, team-based scenarios required adaptation by facilitators, particularly in balancing individual feedback with group-level reflection. This posed challenges in time management and in ensuring that all participants could equally engage in the reflective process—an aspect that deserves further exploration in future studies.

The qualitative improvement in aspects such as team dynamics and effective communication, evidenced during the debriefing, underscores the importance of this component in the development of essential non-technical competencies in emergencies [16]. It is during debriefing that participants articulate their thoughts and feelings, revealing decision-making patterns and allowing for a shared reconstruction of events, which leads to deeper learning.

While the results are promising, this study has some limitations. Being a quasi-experimental design without a control group, the entirety of the improvement cannot be exclusively attributed to the intervention. However, the literature suggests a positive correlation between performance in simulation and clinical competence [17; 18].

Another limitation concerns the exclusive reliance on instructor-completed checklists, which may introduce observer bias. The incorporation of video analysis in future interventions could allow for more standardized assessment and facilitate more objective post-scenario reviews [19]

Despite these limitations, the consistent improvements in a group with a diverse baseline are powerful indicators of the intervention’s impact. Initial errors, pauses in decision-making, fragmented communication—all of these progressively transformed into fluidity and cohesion. It is not just the sum of individual skills; it is the synergy that is generated when a group consolidates into a true response team.

Future research could benefit from the inclusion of a control group, long-term evaluation of skill retention and protocol internalization, and the use of observational performance evaluation tools in simulated scenarios for a more direct measurement of practical application.

CONCLUSIONS

The results of this study strongly support that deliberate practices in Zone 1 and Zone 2, complemented by structured debriefing based on the PEARLS model, proved to be a highly effective educational strategy.

By providing a practical and realistic experience in a safe environment, clinical simulation empowers students to not only acquire and consolidate technical and cognitive skills crucial for CPA management but also to develop essential non-technical competencies such as teamwork, effective communication, leadership, and rapid, precise decision-making. The systematic feedback offered during debriefing was fundamental to this process, facilitating reflection, the identification of areas for improvement, and the consolidation of learning.

Based on the above, clinical simulation is positioned as an indispensable educational strategy in the training of health professionals. Its application improves the preparation and competencies of students to face medical emergency situations more safely and effectively, which has a direct potential impact on the quality of care and patient safety. This experience not only forms capable professionals but transforms them into effective members of response teams, an incalculable added value in emergency care.

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