Background

Emergency resternotomy in the intensive care unit for a patient who has undergone cardiac surgery can be daunting for surgeons and critical care staff. Clinicians involved are often unfamiliar with the surgical instruments and techniques needed.

Local Problem

After an emergency intensive care unit resternotomy resulted in suboptimal performance and outcome, protocols for emergency resternotomy were established and improved.

Methods

Education and simulation training were used to improve staff comfort and familiarity with the needed techniques and supplies. The training intervention included simulations to provide hands-on experience, improve staff familiarity with resternotomy trays, and streamline emergency sternotomy protocols. Preintervention and postintervention surveys were used to assess participants’ familiarity with the implemented plans and algorithms.

Results

All 44 participants (100%) completed the preintervention survey, and 41 of 44 participants (93%) returned the postintervention survey. After the intervention, 95% of respondents agreed that they were prepared to be members of the team for an emergency intensive care unit sternotomy, compared with 52% of respondents before the intervention. After the intervention, 95% of respondents strongly agreed or agreed that they could identify patients who might need emergency sternotomy, compared with 50% before the intervention. The results also showed improvement in staff members’ understanding of team roles, activation and use of the emergency sternotomy protocol, and differences between guidelines for resuscitating patients who experience cardiac arrest after cardiac surgery and the post–cardiac arrest Advanced Cardiovascular Life Support protocol.

Conclusion

Results of this quality improvement project suggest that simulation training improves staff comfort with and understanding of emergency resternotomy.

This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives:

  1. Identify intensive care unit staff members’ shortcomings and weaknesses with emergency resternotomy.

  2. Establish protocols for emergency resternotomy in the intensive care unit.

  3. Demonstrate that through simulation, familiarity with complex, low-volume procedures, such as emergency sternotomy, can increase.

To complete evaluation for CE contact hour(s) for activity C2461, visit aacnjournals.org/ccnonline/ce-articles. No CE fee for AACN members. See CE activity page for expiration date.

The American Association of Critical-Care Nurses is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation, ANCC Provider Number 0012. AACN has been approved as a provider of continuing education in nursing by the California Board of Registered Nursing (CA BRN), CA Provider Number CEP1036, for 1 contact hour.

Simulation-based training has become an essential component of medical education for all health care professionals. It is used to familiarize and train medical staff with various clinical scenarios, simple skills, and highly complex techniques.15  Simulation has also been beneficial for training staff members for low-volume, high-risk procedures, such as emergency bedside resternotomy.68 

The novice-to-expert model proposed by Benner9  provides a conceptual structure to guide facilitators through simulation development. This approach has 5 stages of proficiency: novice, advanced beginner, competent, proficient, and expert. Nurses who take care of cardiac surgical patients in the intensive care unit (ICU) are expected to be at the proficient or expert level.7  Nevertheless, it is unlikely that cardiac ICU nurses at the proficient or expert level have significant experience assisting with low-volume, high-risk scenarios such as emergency resternotomy.7  Furthermore, the frequent turnover of nursing staff in ICUs makes it challenging to maintain a constantly high level of staff proficiency for these infrequent but high-risk procedures.7  Therefore, simulation appears to be the best method to achieve staff comfort with bedside ICU resternotomy.

Cardiac surgery has risks and complications, and one of the most daunting is the need for postoperative emergency resternotomy in a setting that is not the operating room. This situation is challenging for surgeons and also for critical care nursing staff members, who are often unfamiliar with the surgical instruments and techniques needed. These events are fortunately rare, but when they do occur, the degree of chaos that can result if the staff is not prepared can adversely affect patient care.

Through the use of education and simulation, we attempted to build staff comfort and familiarity with techniques and supplies needed in this situation. The main goals were to enhance nursing staff members’ early recognition of the need for emergency resternotomy and understanding of the role of registered nurses (RNs) during an ICU sternotomy. The didactic education and simulation training were based on the 2017 Society of Thoracic Surgeons expert consensus for resuscitating patients who experience cardiac arrest after cardiac surgery (see Figure).10  The consensus report includes 5 key points: (1) Successful resuscitation of a cardiac surgical patient who experiences cardiac arrest requires a team of at least 6 clinicians who have rehearsed these scenarios regularly. (2) Ventricular fibrillation should be treated with 3 sequential attempts at defibrillation, even before external cardiac massage is performed. If defibrillation fails, emergency resternotomy is performed. (3) Asystole or extreme bradycardia should be managed with pacing using temporary epicardial pacing wires (if available) before external cardiac massage, followed by external pacing (optional) and finally resternotomy. (4) Pulseless electrical activity without any identifiable reversible cause warrants prompt resternotomy. (5) Full-dose epinephrine administration should be avoided because of the risk of extreme hypertension, which can cause significant hemorrhage or loss of graft.

Simulation has been beneficial for training staff members for low-volume, high-risk procedures, such as emergency bedside resternotomy.

After an emergency resternotomy in our ICU that resulted in a suboptimal outcome, we decided to establish and improve our protocols. After analyzing our performance during this event, we identified multiple shortcomings, specifically team members’ inability to recognize clinical signs that prompted an urgent resternotomy and nursing staff members’ unfamiliarity with their roles in this scenario and with the location and contents of the bedside resternotomy tray.

Didactic Education

To improve patient care in these challenging cases, we began with didactic education (phase 1). Using the guidelines established by the Society of Thoracic Surgeons,10  we started with a discussion of patient care and the unique clinical situation of postoperative cardiac surgery patients. We discussed the creation of a team and the roles of each team member, including a team leader, an airway manager, a medicine/drug administrator, an ICU coordinator, a defibrillation nurse, and the surgeon. We added an additional member to assist in the sternotomy. Our education also focused on the logistics of the unit to ensure that staff members were familiar with our emergency carts and packs.

The objective of phase 1 was to create a shared mental model of bedside resternotomy. The didactic education sessions were 1-hour slide presentations on cardiac arrest (ventricular fibrillation, pulseless ventricular tachycardia, pulseless electrical activity, and asystole), periarrest scenarios (refractory or severe sudden hypotension, oliguria, acidosis, and tachycardia), management of these scenarios according to the Society of Thoracic Surgeons guidelines, items included in the resternotomy tray, and a step-by-step overview of how a bedside resternotomy is performed. All “in-theory” items were translated to “in-practice” actionable items, such as posting telephone and pager numbers and streamlining communication.

Procedure Training

In phases 2 and 3, we conducted hands-on simulation sessions at our interprofessional simulation center to better understand the root cause of our problems. The sessions were attended by representatives of all professions that participate in bedside resternotomy at our institution: cardiac surgeons, cardiovascular ICU physicians, nurse practitioners, nurse educators, RNs, and respiratory therapists. All participants were invited to speak freely and constructively. Didactics and simulation training were provided by cardiac surgeons, the director of the cardiovascular ICU, and the director of the simulation center. The 3 phases (didactic education, procedure training, and low-fidelity simulation) occurred consecutively.

The objectives of phase 2 were to improve nurse-surgeon communication and increase the speed of establishing a sterile field and wire removal. Equipment and supplies were reviewed, and naming conventions and surgeons’ individual preferences for procedural details were standardized. We used a low-fidelity, easily transported, whole-body patient simulator (manikin) with a removable chest plate (Nursing Kelly, Laerdal).

Low-Fidelity Simulation

Phase 3 was a simulation of various scenarios in postoperative cardiac surgery patients that may necessitate emergency resternotomy. This phase used a low-fidelity manikin and combined everything that was discussed in the didactic and procedure training phases.

Surveys

We provided preintervention and postintervention surveys to staff members to assess their familiarity and comfort with the implemented plans and algorithms. The surveys consisted of 10 investigator-generated questions with responses on a Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree). We sent the postintervention survey to all participants by email after the simulation session; participants completed the survey online. No incentive or compensation was provided for survey completion.

Ethical Considerations and Statistical Analysis

Our institution is a university-based tertiary referral center with a dedicated cardiovascular ICU. Participants were advanced practice providers and ICU RNs who worked in the cardiovascular ICU. Institutional review board approval was not required by our institution for this project because no human subjects were studied.

Descriptive statistics such as means, percentages, frequencies, and SDs were used to describe data. Likert data are nonparametric by nature but were treated as parametric by computing the means of the preintervention and postintervention scores. We used t tests to analyze differences for significance. P values of less than .05 were considered significant. The data were analyzed with SPSS Statistics 29 (IBM).

Preintervention Survey

Forty-four clinicians (41 RNs [93%] and 3 advanced practice providers [7%]) participated in the study. All 44 participants (100%) completed the preintervention survey. Before the intervention, only 9 participants (20%) strongly agreed that they were prepared to be a team member in an emergency sternotomy in the ICU, whereas 14 (32%) agreed and 9 (20%) disagreed. Most participants (36 [82%]) strongly agreed that patient safety is a top priority when performing a sternotomy; 2 (5%) strongly disagreed. Of the 44 participants, 17 (39%) agreed that they understood their role in the procedure, whereas 14 (32%) were neutral and 8 (18%) disagreed. When asked whether they felt empowered to make suggestions to improve care and the team, 6 of 44 participants (14%) strongly agreed, 19 (43%) agreed, and 15 (34%) were neutral. Only 4 participants (9%) strongly agreed that they could identify errors in the performance of the procedure; 19 (43%) agreed and 4 (9%) disagreed. When participants were asked if they could identify patients who may need emergency sternotomy, 4 (9%) strongly agreed, 18 (41%) agreed, 14 (32%) were neutral, 5 (11%) disagreed, and 3 (7%) strongly disagreed. Most participants (26 [59%]) agreed that they knew who to call and how to activate the emergency sternotomy protocol, whereas 6 (14%) disagreed. When asked if they felt comfortable educating other team members on emergency bedside sternotomy, 4 (9%) strongly agreed, 16 (36%) agreed, 12 (27%) were neutral, 10 (23%) disagreed, and 2 (5%) strongly disagreed.

Nurses also felt more empowered after the intervention to make suggestions to improve care and team performance.

Postintervention Survey

Of the 44 clinicians who completed the preintervention survey, 41 (93%) participated in the postintervention survey. Three RNs did not return postintervention surveys. Postintervention survey responses showed significant improvement in staff comfort levels with emergency resternotomy. When asked whether they felt prepared to be a team member in an emergency sternotomy in the cardiovascular ICU, 15 of 41 respondents (37%) strongly agreed and 24 (59%) agreed after the intervention, compared with 20% (P = .04) and 32% (P < .01), respectively, before the intervention. After the intervention, 18 of 41 respondents (44%) strongly agreed and 51% agreed that they clearly understood their role in the procedure, compared with 5 of 44 respondents (11%; P < .01) and 17 of 44 respondents (39%; P = .05), respectively, before the intervention. After the intervention, 11 of 41 respondents (27%) strongly agreed (vs 4 of 44 respondents [9%] before intervention [P = .3]) and 26 of 41 respondents (63%) agreed (vs 19 of 44 [43%] before intervention [P = .02]) that they could identify errors in the performance of the procedure. When participants were asked after the intervention if they could identify patients who might need emergency sternotomy, 16 (39%) strongly agreed (vs 4 [9%] before intervention [P < .01]) and 23 (56%) agreed (vs 18 [41%] before intervention [P = .03]). After the intervention, most respondents (18 of 41 [44%]) strongly agreed that they understood who to call and how to activate the open chest pathway, compared with 5 of 44 respondents (11%) before the intervention. When asked after the intervention if they felt comfortable educating other team members on emergency bedside sternotomy, 14 of 41 respondents (34%) strongly agreed, 20 (49%) agreed, and 7 (17%) were neutral, compared with 4 of 44 respondents (9%; P = .01), 16 (36%; P = .09), and 12 (27%; P = .1), respectively, before the intervention. Nurses strongly agreed that they felt more empowered after the intervention to make suggestions to improve care and team performance (17 of 41 respondents [42%] after the intervention vs 6 of 44 respondents [14%] before the intervention; P < .01).

Emergency resternotomy in the ICU because of cardiac arrest in a patient after open heart surgery is infrequent.1114  As a result, adequately preparing staff members for their roles in this situation is very challenging. Nevertheless, all ICU clinicians, including RNs, must be efficiently prepared for these scenarios because their early involvement can be lifesaving for the patient.

After a failed resuscitation attempt in our ICU, we attempted to discern if we could improve staff comfort and preparedness by using simulation training. We sought to establish and improve protocols to manage this clinical situation. We used education and simulation to build comfort and familiarity with the techniques and supplies needed. We provided preintervention and postintervention surveys to staff members to assess their familiarity and comfort with the implemented plans and algorithms. We confirmed that familiarity and comfort levels with bedside resternotomy in the ICU significantly improved after the training intervention. Ninety-five percent of respondents strongly agreed or agreed after the intervention (compared with 52% before the intervention) that they were prepared to be a team member in an emergency sternotomy in the ICU. Ninety-five percent of respondents strongly agreed or agreed after the intervention (compared with 50% before the intervention) that they clearly understood their role in such a scenario. Furthermore, 95% of respondents strongly agreed or agreed after the intervention (compared with 50% before the intervention) that they could identify patients who might need emergency sternotomy. These findings clearly demonstrate that video and manikin-based training improve staff members’ confidence and knowledge with high-risk, low-volume procedures and prepare them for these scenarios in a short period of time.

Our results also show that simulation enhances patient care and safety in a high-acuity ICU with patients with complex conditions; most nursing staff members become comfortable with early recognition of critical illness in patients and can also reliably assist cardiac surgeons with resuscitation efforts and procedures. The postintervention survey results also demonstrated that almost all respondents (98%) knew who to call and how to activate the open chest pathway, compared with 71% of respondents to the preintervention survey.

Our study demonstrated several additional benefits of simulation-based training. The hands-on experience provided nursing staff members with the opportunity to acquaint themselves with surgical instruments and equipment used for emergency bedside resternotomy.6  Familiarity with the sternal reentry cart increases the chances of patient survival.15  In our study, all participants in the postintervention survey reported increased proficiency and comfort with such equipment. Our simulation was also very effective in identifying equipment or systems issues that may arise during a real-life scenario, which enhanced quality improvement in our ICU and allowed us to streamline established protocols. The simulation training occurred 6 months after the failed resuscitation event. Fortunately, as of this writing no emergency ICU resternotomy procedures had occurred since then. Nevertheless, after completing this quality improvement project, we implemented analogous didactic and simulation sessions twice a year for our nursing staff.

Our didactic sessions also alleviated a concern with sterility and infection risk after sternotomy in the ICU. Sternal wound infections increase patient morbidity and mortality after cardiac surgery,1618  but several studies have shown that resternotomy in the ICU is not a risk factor for infection.14,19  Several institutions routinely perform resternotomy procedures in the ICU rather than the operating room and have not reported higher incidences of sternal wound infections.20,21  The low infection risk, in conjunction with the time saved for transporting a patient to the operating room, makes ICU resternotomy advantageous for patients whose condition is unstable. Our ICU staff members are now aware that performing a sternotomy in the ICU can potentially save 30 to 40 minutes of operating room transfer time, which is of great importance for a patient who is in extremis.15  We also found significant improvement in participants’ understanding of the differences between the Society of Thoracic Surgeons guidelines10  for resuscitating patients who experience cardiac arrest after cardiac surgery and the Advanced Cardiovascular Life Support protocol for patients who experience cardiac arrest.

Our favorable results indicate that our training model can also be used for cardiac surgical trainees, who otherwise may enter practice without ever having to perform sternotomy in the ICU, although we did not assess this application in our study. This use would allow residents and fellows to practice the technical aspects of the procedure and also enhance the leadership and crisis management skills required to effectively supervise an ICU team during such a scenario.

This study is not without limitations. As with all surveys, recall bias may have been present.22  Participants might have interpreted the survey questions differently.22  The use of data from a single center somewhat limits the external validity. The relatively small number of participants is also a shortcoming.

Cardiac arrest after cardiac surgery can be a chaotic event, even for experienced nurses and physicians. Preparing for this event is difficult given its rarity. Our quality improvement project suggests that simulation training improves staff comfort with and understanding of these events. The effect on patient care remains to be seen, but the initial results following simulation training are promising.

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Footnotes

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Financial Disclosures

None reported.

 

See also

To learn more about cardiovascular critical care, read “Fasting Versus a Heart-Healthy Diet Before Cardiac Catheterization: A Randomized Controlled Trial” by Woods et al in the American Journal of Critical Care, 2024;33(1):29-33. https://doi.org/10.4037/ajcc2024115. Available at www.ajcconline.org.