Creating an Escape Room for Continuous Renal Replacement Therapy Validation

A new method of annual skill validation for continuous renal replacement therapy (CRRT) that adhered to principles of adult learning was needed at a large academic medical center with more than 5000 CRRT days annually and approximately 200 CRRT-validated registered nurses. Previously, CRRT validations were performed using a checklist that was completed at the bedside. Nurses voiced dissatisfaction with this method, citing inconsistencies in validation and dissatisfaction with teaching methods.The registered nurse–certified specialist along with the critical care leadership team decided to conduct the annual CRRT validation using an escape room. Although the use of escape rooms for education and validation is becoming more common, we did not fully understand how to execute this strategy. Therefore, we conducted a literature review to determine the best way to organize and implement an escape room. We also benefited from a presentation on the key concepts of creating escape rooms that was delivered at the American Association of Critical-Care Nurses National Teaching Institute in 2022.1 The key stakeholders in the successful implementation of the escape room were intensive care leaders and CRRT-trained intensive care unit nurses. We based the content of the educational program on issues identified in incident reports and staff reports, and we sought to deliver this content in a fun, engaging, and informative manner.2Traditionally, an escape room consists of a scenario in which a team is required to complete various puzzles using clues to “escape” the room.3,4 We decided to choose 3 main topics related to CRRT and then create corresponding stations that would incorporate key themes or ways to improve CRRT practices. These key themes identified were principles of therapy, alarm identification, and machine setup. All the educational content was grouped under the 3 main topics. The first station was designated the principles and fluids station, the second station the alarms station, and the third as the machine setup station. The setup of the escape room is shown in Figures 1 and 2.Escape rooms are designed to improve teamwork, communication skills, and critical thinking.5-8 Our escape room sessions lasted approximately 30 minutes, allowing staff members to participate during their workday if possible. Of 185 CRRT-trained nurses, 182 (98.4%) attended the training, which took place over 11 days, with 5 to 7 sessions per day. Because registered nurses rarely work alone, the room structure was designed to encourage a team of participants to work together. Staff members were divided into groups of up to 5 participants per session. Together they completed the tasks at each of the 3 stations. After they completed the tasks at 1 station, they had to open a locked box or a money bag with a key to move to the next station.9,10 Items in each locked box provided clues or items necessary for the next station—for example, a black light needed to uncover hidden numbers on the machine. Completion time was measured, and prizes were awarded for the fastest times.The task at the first station involved a case study. The participants had to read a scenario and, as a group, answer questions based on the case study findings. Questions focused on what principle is most effective, what fluids drive that principle, and what molecules are moved. This station involved 3 sets of questions. To “escape” this station, nurses needed to decipher a clue that would unlock laminated cards with letters needed for the next station. The second station centered on alarms and troubleshooting. This station tested the ability to read alarm descriptions, but a simple matching exercise would not suffice. Therefore, a crossword structure was created that allowed the participants to read questions aloud and, as a team, determine the answer. To “escape” this station, the participants had to decipher a clue based on findings from the crossword results to unlock a black light. The last station focused on machine setup errors. The initial case study unfolded in a way that did not give the participants the CRRT machine orders in the usual format. A Kardex information system and orders were provided so as not to trick the participants or confuse them unnecessarily. The CRRT machine was set up with distinct errors, including the wrong formula of dialysate, incorrect setup of citrate to the return line rather than the access line, incorrect entering of rates, and missing medications. To “escape” this station, participants used a black light that highlighted numbers by the errors, arranging them in a particular order to unlock the final lock. The scenarios were tested with various CRRT users and physicians to ensure that the desired outcome would be achieved and directions for the learners were readily understood.Challenges to successful completion of the escape room activity centered on staff scheduling. Facilitators wanted the timing of the activity to be flexible so that staff members could complete it either before, during, or after their shift. At the time of the validation, the institution was dealing with considerable staffing constraints; therefore, the sessions were conducted with only 2 facilitators (1 was in the room during the activity and 1 reset the room as the session was ending). Another challenge, given the high acuity of illness in the facility, was to ensure that a CRRT machine was available during the training sessions. A plan was put in place to relinquish our machine if it was needed, but this plan did not need to be carried out. Staff acceptance of the new learning style was another challenge: many staff members were initially skeptical of the activity, but they were easily won over as they progressed through the stations.After completion of the activity, a rating scale was used to measure staff acceptance of the change in validation method, and 99.4% of participants indicated acceptance. Verbal comments from participants included that they “enjoyed the escape room,” “really learned a lot,” found it “a great way to learn,” and “enjoyed working in teams.” No incident reports have been submitted to nursing management since the validation was completed. Incident reports will continue to be monitored to assess the need for additional training before future validation sessions.Adapting teaching styles and learning environments to meet staff needs can enhance staff knowledge about subjects requiring annual validation. An escape room can be tailored to meet the skill development needs of staff members in many areas. A plan is underway to create an escape room to improve practices in hemodynamic monitoring in 2023.