Online education and code simulation among intensive care unit (ICU) nurses markedly improved the time to first shock in hospitalized patients with ventricular fibrillation or pulseless ventricular tachycardia at a single facility, according to findings published in Critical Care Nurse.

The initiative was launched at Orlando Health, Florida, in response to a 42% compliance rate with the American Heart Association’s Get With The Guidelines (GWTG) recommendation that patients who are hospitalized and exhibiting ventricular fibrillation or pulseless ventricular tachycardia should receive defibrillation within 2 minutes to improve outcomes. The facility was 99% compliant with the 3 other GWTG metrics.

“When seconds count, it’s important for everyone to instantly know their role as part of the response team, which can change for each code situation,” said study author Andrea Paddock, DNP, APRN, ACCNS-AG, CCRN, who is a clinical nurse specialist in the cardiac progressive care unit, Dr. P. Phillips Hospital, Orlando Health. “This project helped our hospital improve compliance with GWTG metrics and enhance our care for patients experiencing cardiopulmonary arrests. It’s become a foundation for code simulations and mock code education throughout the hospital.”

Continue Reading

About the Defibrillation Intervention

Real-time auditing of cardiopulmonary arrest events found a lack of timely analysis of the heart rhythm once defibrillator pads were placed on the patient’s chest, Dr Paddock explained. The project began with nurses and ICU physicians collaborating to develop a diagram of a patient room that defines primary and secondary roles for specific team members and the number of staff members needed to respond to a cardiopulmonary arrest (see article for figure).

A mock code simulation video was created and embedded in online education to demonstrate the proper role designations and execution displayed in the diagram.

All 40 ICU nurses were assigned to complete the new online education, which included electrocardiogram recognition and code documentation. An ICU learning specialist then worked with individual nurses as needed.

The structured code simulations included a presimulation discussion, 3 rapid-cycle simulations followed by a short debriefing, and a final conclusive debriefing at the end of the 2-hour training session. The same scenario was used for each simulation, but participants were assigned to different roles, including the position of code leader, each time. The simulations were completed by 31 of the 40 nurses.

“A presimulation discussion and slow code walk-through were crucial elements to equipping participants with the knowledge to respond more appropriately during the simulation and translate that knowledge into practice,” Dr Paddock said.

Improved Compliance With GWTG Guidelines Found

Compliance with the GWTG time to first shock metric improved from 41% in 2018 to 83% in 2019 and 100% in the first 6 months of 2020.  

Nearly 90% of the 14 ICU nurses who completed the 30-month postsimulation survey strongly agreed or agreed that they experienced improvements in knowledge, team leadership and communications, and confidence associated with code events. Practicing the role of code leader during simulation exercises was rated as the most important factor in learning.

Study limitations included small sample size and the potential lack of generalizability of the results in other settings.

“This project has provided the opportunity for nurse collaboration and has served as a foundation for code simulations in other departments and the sustained practice of mock code implementation in the hospital,” Dr Paddock concluded.


Paddock A. Using simulation to improve adherence to get with the guidelines time to first shock. Crit Care Nurse. 2021;41(6):62-68. doi: 10.4037/ccn2021596