Editorial Comment for Huser et al.

This prospective observational study investigates the impact of high-fidelity team simulation on time to removal of the robot, first chest compression, first defibrillation, and time to restoration of stable circulation. The article is pertinent, because it demonstrates how interdisciplinary simulation can be used to effect change in practitioners' behavior and to identify system-based opportunities for improvement.

Evidence in educational research is often separated into Kirkpatrick levels, with Kirkpatrick Level 1 being participant satisfaction, Level 2 representing knowledge acquisition, Level 3 being participant behavior change, and Level 4 being improved patient outcome. ¹ This article is an addition to the current Level 3 simulation literature showing that simulation of cardiac arrest can improve practitioners' performance. Kirkpatrick evidence Level 1 and 2 research is commonly found in the simulation literature; higher evidence levels should be aspired to in simulation, if only because it is such an expensive educational modality.

Simulation also has the benefit of uncovering system-based opportunities to improve practitioners' performance. ² After a simulated critical event, the participants have the opportunity to discuss the events of the simulation in the debriefing. In this article, the teams developed a flow poster to improve their team coordination. This sort of system-based opportunity is infrequently uncovered outside simulation and directly influences the practitioners' practice.

Much of the simulation literature focuses on participant satisfaction and knowledge acquisition. As seen in this article, simulation offers the opportunity to practice critical event response, make system-based changes, and impact participant behavior. I applaud these authors' success in achieving Kirkpatrick Level 3 evidence. With the high cost of simulation, however, it is time to move to research outcomes more directly linked to patient outcomes. ³