In-situ cardiac arrest simulations in a tertiary-care hospital in Pakistan: a feasibility study exploring challenges and future directions.

Background: In-hospital cardiac arrest (IHCA) survival remains poor in low-resource settings, partly due to skill decay, delayed responses, and inconsistent adherence to resuscitation guidelines. In-situ simulation has been proposed as a strategy to improve resuscitation performance and identify system gaps, but evidence from low- and middle-income countries is limited. Objective: To assess the feasibility and implementation outcomes of an unannounced in-situ cardiac arrest simulation program in a tertiary care hospital in Pakistan, and to determine whether key IHCA processes and performance metrics can be reliably measured using a structured documentation tool. Methods: We conducted a prospective, non-randomized feasibility study at a 710-bed academic hospital from December 2023 to March 2025. Unannounced in-situ cardiac arrest simulations were conducted 1-2 times per month across multiple hospital units. Participants included resident physicians, nurses, and rapid response team members with current American Heart Association (AHA) BLS/ACLS certification. Simulations used real clinical equipment and a high-fidelity manikin, followed by structured debriefing when feasible. Outcomes were evaluated using Proctor et al.'s implementation framework, focusing on feasibility, acceptability, penetration, fidelity, and sustainability. Clinical performance metrics were collected as secondary process measures. Results: Fifty-one simulations were conducted; data from 44 were analyzed. Feasibility and penetration were high, with simulations successfully integrated across diverse clinical areas. Acceptability was strong, with participants rating simulations as realistic and educationally valuable (mean scores 4.2-4.6/5). Fidelity was variable, particularly for debriefing, which was fully completed in 50% of applicable simulations. Sustainability challenges included competing clinical demands and lack of protected time. Conclusions: In-situ cardiac arrest simulation is feasible and acceptable in a low-resource hospital setting and enables systematic assessment of resuscitation processes. Sustained impact will require institutional support, protected time for debriefing, and integration into ongoing quality improvement efforts.