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J Nurs Care Qual Vol. 29, No. 4, pp. 311–317 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Every Second Counts Innovations to Increase Timely Defibrillation Rates Meredith Borak, MSN, RN; Mary Ann Francisco, MSN, APN, GCNS-BC, CCRN; Mary Ann Stokas, MSN, RN, OCN; Mary Maroney, MSN, RN, FNP-BC; Valerie Bednar, MA, BSN, RN, CCRN; Megan E. Miller, MD; Katherine Pakieser-Reed, PhD, RN Early defibrillation is an essential step in the “chain of survival” for patients with in-hospital cardiac arrest. To increase the rate of early defibrillation by nurse first responders in noncritical care areas, our institution employed a quality resuscitation consultant, implemented nursing education programs, and standardized equipment and practices. Automated external defibrillator application by nurse first responders prior to advanced cardiac life support team arrival has improved from 15% in 2011 to 76% in 2013 (P < .001). Key words: advanced cardiac life support, automated external defibrillator, defibrillation, first responders, in-hospital cardiac arrest, resuscitation
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N THE UNITED STATES, in-hospital cardiac arrest occurs in approximately 200 000 patients annually and is associated with poor survival.1-3 The “formula for survival” from cardiac arrest is a framework integrating science, education, and local implementation
Author Affiliations: Rescue Care and Resiliency (Ms Borak), Center for Nursing Professional Practice and Research (Mss Francisco, Stokas, Maroney, and Bednar and Dr Pakieser-Reed), and Department of General Surgery (Dr Miller), The University of Chicago Medicine, Chicago, Illinois. The authors have no conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Meredith Borak, MSN, RN, Rescue Care and Resiliency, The University of Chicago Medicine, 5841 S. Maryland Ave, Room TC447, Chicago, IL 60637 ([email protected]). Accepted for publication: April 2, 2014 Published ahead of print: May 7, 2014 DOI: 10.1097/NCQ.0000000000000066
to organize resuscitation efforts and improve patient outcomes.4 At the local level of implementation, the “chain of survival” focuses on 4 key steps: (1) early recognition and activation of the emergency medical system; (2) early cardiopulmonary resuscitation (CPR); (3) early defibrillation for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT); and (4) postresuscitation care.5 The third step in the “chain of survival” is based on evidence that early defibrillation is the treatment of VF/VT.6 In particular, the time to first shock is critically important to improve survival from VF/VT arrest for victims of in-hospital cardiac arrest.7 Guidelines for in-hospital cardiac arrest due to VF/VT call for defibrillation within 2 minutes.8,9 Defibrillation after more than 2 minutes is associated with a significantly reduced probability of survival to discharge after cardiac arrest due to ventricular arrhythmias, and there is a graded association between longer times to defibrillation and poorer survival.10 In the hospital setting, the “chain of survival” is initiated by first responders prior 311
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to the arrival of an advanced cardiac life support (ACLS)-trained resuscitation team in a tiered response system.11−13 Because of their primary role in patient care, nursing staff members are frequently the first to witness and respond to in-hospital cardiac arrest and should therefore be trained in basic life support (BLS), including automated external defibrillator (AED), skills.11,12,14,15 In-hospital early defibrillation programs have been recommended,12,16,17 but there are few reports focusing specifically on nursing staff use of AEDs.11,13,18,19 Nurse first responders are especially important for patients in unmonitored beds who are at an increased risk of an unwitnessed cardiac arrest. Almost one-third of our patients (29% in 2011; 28% in 2012) who experienced an in-hospital cardiac arrest were in unmonitored beds on medical-surgical (noncritical care) units, requiring activation of the tiered response system. Direct observation of BLStrained nurses responding to cardiac arrests identified a delay in critical actions such as initiating chest compressions and applying the AED prior to ACLS team arrival. Informal debriefing revealed that they were uncomfortable with first-responder tasks due to lack of familiarity with the AED equipment and lack of confidence about their role in early defibrillation. In particular, they expressed hesitancy to administer a shock without a physician present, a sentiment also found in a cohort of nurses who hesitated to defibrillate due to anxiety and fear of patient harm.20 This targeted needs assessment identified clear deficits in knowledge and skills for medical-surgical nurses responding to inhospital cardiac arrests. The purpose of our initiative was to improve nurse first responders’ performance on the life-saving steps required for a victim of cardiac arrest on medical-surgical units prior to the arrival of the ACLS team. Three strategies were implemented: the quality resuscitation consultant role, a curriculum for nurse education, and institution-wide standardization of equipment and practices.
MATERIALS AND METHODS Institution and ACLS team characteristics The University of Chicago Medicine is a 568-bed acute care hospital with 300 adult medical-surgical beds. Each nursing unit has a biphasic defibrillator with AED mode capability on its centrally located emergency equipment cart. When a cardiac arrest occurs, nurse first responders initiate BLS while the ACLS team is alerted by an overhead page and an electronic group mobile page. The ACLS team is composed of representatives from internal medicine, anesthesia, respiratory therapy, pharmacy, and critical care nursing. The average ACLS team response time is 3 minutes, and upon arrival, the internal medicine physician assumes leadership of the cardiac arrest event. Role of the quality resuscitation consultant In 2011, the position of quality resuscitation consultant was created to ensure that the institution maintains current best practices for emergency resuscitation. Essential job functions include the collection, analysis, and communication of hospital-wide resuscitation data for all cardiac arrests and rapid response team activations. The quality resuscitation consultant ensures maintenance of quality for the hospital’s emergency response systems by providing direct patient care during cardiac arrests and rapid response team events. In addition, the quality resuscitation consultant facilitates quality performance improvement initiatives including the emergency equipment standardization project, interdisciplinary mock (simulated) codes, monthly cardiac arrest and rapid response team debriefings, and the implementation of a critical care outreach team to proactively be on round for high-risk patients admitted to medical-surgical units. The quality resuscitation consultant successfully facilitated the automated documentation of hospital-wide emergency response data and
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Innovations to Increase Timely Defibrillation Rates the creation of automated reports. This information was communicated and used in ongoing nursing education and standardization efforts. METHODS Nursing education sessions Annual competency sessions in January 2012 were developed and implemented collaboratively by the quality resuscitation consultant and clinical nurse educators. First, 356 nurses attended a didactic session on unitspecific statistics for cardiac arrest incidence and resuscitation performance and reviewed the updated American Heart Association’s BLS guidelines. Each nurse practiced skills using the defibrillator and AED mode on a highfidelity simulation mannequin, emphasizing completion of the tasks and delivery of a successful shock within 2 minutes, as recommended by the American Heart Association Get with the Guidelines–Resuscitation program.8 Second, each nurse participated in a timed group simulation event. All nurses engaged in a debriefing session and underwent remediation until the necessary steps were successfully completed within 2 minutes. Responses from the evaluation survey indicated that 94% of participants felt that the learning objectives were met and material learned to a great extent (score 4/4). Qualitative analysis of comments identified that participants enjoyed the interactive module and the opportunity for direct return demonstration with one-on-one feedback. Since April 2012, more than 450 newly hired nurses have successfully completed the same education, with simulation incorporated into monthly nursing orientation. Standardization efforts During June-August 2012 and 2013, multidisciplinary mock codes were implemented to educate internal medicine physicians leading the ACLS team, respiratory therapists, and staff nurses. These sessions provided an opportunity to practice clinical and leadership skills in a setting with other staff members
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present during a cardiac arrest. Video debriefing followed each session, which allowed participants to identify areas for improvement and remediation if necessary. Evaluations reflected high value placed on the interdisciplinary approach, the video debriefing, and the realistic scenarios. Starting in October 2012, nurse first responders were invited to attend monthly debriefing sessions with all ACLS team members. The multidisciplinary nature of these sessions created a more robust debriefing experience that has improved interactions between nurses and ACLS team members. More recently since October 2013, in situ mock codes have been executed in various locations throughout the hospital campus to further enhance real-time learning among multidisciplinary cardiac arrest responders. In February 2013, a total of 52 defibrillators in adult inpatient areas were upgraded to operate in monitor, defibrillator, pacemaker, and AED modes and to include QCPR technology and end-tidal capnography. Approximately 130 emergency equipment carts were updated with population-specific medications and resuscitation equipment. LEAN methodology was used to standardize processes for restocking and replacing used equipment. In addition, 9 AEDs were placed in strategic outpatient locations. More than 900 adult inpatient nurses received standardized education regarding the use of the new defibrillators and emergency equipment carts, and an additional 761 nonclinical personnel were educated on AED use. Revised institutional policies on emergency equipment preparedness and changes to the ACLS teams were communicated to all clinical and nursing staff members in March 2013. Data analysis Institutional review board approval was obtained for the collection of clinical and outcomes data for in-hospital cardiac arrests. Data were gathered regarding defibrillation after cardiac arrest in each medical-surgical unit. An adult cardiac arrest was defined as loss of consciousness with absence of pulse or breathing in a patient older than 18 years, followed
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by chest compressions and/or defibrillation. The time of the ACLS activation call was compared with the time stamped on the transcript from the unit defibrillator and the time that the ACLS team arrived at the bedside. Defibrillators were considered used if the pads were placed on the patient and the defibrillator was turned on, ready for a rhythm analysis. Rates of defibrillator use by unit location were calculated monthly, and annual rates from January 2011 to December 2013 were compared. Patient outcomes by unit were collected. Return of spontaneous circulation (ROSC) was successful if the patient regained and maintained a perfusing rhythm during the resuscitation attempt for more than 20 minutes. To determine survival, patients were followed either until discharge or death based on medical record documentation. Rates of ROSC and survival to discharge by unit location were calculated monthly, and annual rates from January 2011 to December 2013 were compared. Statistical analysis was performed using STATA 12.0 (StataCorp, College Station, Texas), and P values .05 or less were considered significant. RESULTS The utilization of the defibrillator by medical-surgical nurses prior to ACLS team arrival has significantly increased. Of the cardiac arrests that occurred in medical-surgical areas in 2011, the defibrillator was properly attached and compressions were in progress upon the ACLS team’s arrival in only 15% of cases (6/40). In 2012, AED utilization during cardiac arrests in medical-surgical units increased to 60% (28/47; P < .01). Data demonstrate that the AED utilization rate for 2013 was 76% (31/41). This represents a 61% improvement in AED utilization by nurse first responders during cardiac arrests in medicalsurgical units from 2011 to 2013 (P < .01) (Figure). While the ROSC rate for 2012 (64%; 30/47) declined slightly from 2011 (70%; 28/40), it increased by 19% in 2013 (83%, 34/41; P < .05 as compared with 2012). Despite a larger
number of cardiac arrests in medical-surgical patients in 2012, survival to discharge rates increased from 15% (6/40) in 2011 to 17% in 2012 (8/47). Data from 2013 demonstrate an additional improvement in survival to discharge rates for these patients to 27% (11/41). Several specific interventions were associated with improvements in AED use prior to ACLS team arrival (see Supplemental Digital Content, Figure, available at: http://links.lww .com/JNCQ/A88). These included interdisciplinary mock codes during June-August 2012 and 2013, which were highly rated by participants. The addition of nurse first responders to ACLS team debriefings following cardiac arrests in October 2012 correlated with an improvement in AED use in the following month. Improved rates of AED use in 2013 followed the standardization of emergency equipment and institution-wide changes to the emergency response policy. DISCUSSION The purpose of our initiative was to improve nurse first responders’ performance on the life-saving steps required for a victim of in-hospital cardiac arrest on medical-surgical (noncritical care) units. The rate of AED use prior to ACLS team arrival improved from 15% in 2011 to 76% in 2013 (P < .01). During the same time period, the ROSC rate improved from 64% to 83% (P < .05), and survival to discharge rates increased from 15% to 27%. The significant increase in early AED use is particularly important as a process measurement for the effectiveness of our nursingfocused interventions. While outcomes such as ROSC and survival to discharge are clinically relevant, they are influenced by patient characteristics, resuscitation team efforts, and events following initial cardiac arrest. We improved nurse first-responder AED use prior to ACLS team arrival by 61%, successfully addressing a critical step in the “chain of survival” for in-hospital cardiac arrest. A unique and essential component of success was the creation of the quality resuscitation consultant role. Following a needs
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100% 90% 80%
76% b
70%
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60%
a
50% 40% 30% 20%
15%
10% 0%
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2012
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Figure. Automated external defibrillator utilization by nurse first responders for patients with cardiac arrest on medical-surgical units prior to advanced cardiac life support team arrival. a P < .01 for 2011-2012; b P < .01 for 2011-2013.
assessment, the quality resuscitation consultant recommended and implemented the nursing-focused AED program to address deficiencies in first-responder actions. The use of high-fidelity simulation and debriefing during nursing education sessions, ACLS orientation, and mock codes was another strength, as this approach improves CPR21,22 and performer confidence.23 Updated equipment provided real-time CPR feedback and prompts, which have been shown to improve CPR skill acquisition and retention and augment CPR quality.24-26 Standardization of AED devices and locations improved nurses’ confidence with the equipment and contributed to effective use in cardiac arrests. While nurse first-responder AED programs have been recommended, few successful projects have been described. Importantly, we provide a detailed account of our early defibrillation initiatives and demonstrate a significant improvement in AED use prior to ACLS team arrival. Limitations The educational initiative was limited to medical-surgical nursing staff, and only the
practice and clinical outcomes of medicalsurgical units were studied. Therefore, ROSC and survival to discharge are reported on a geographic basis rather than by patient characteristics or cardiac arrest rhythm. Prior studies have shown that patients with VF/VT as the initial rhythm are more likely to survive in-hospital cardiac arrest.2,3,11,16 If we had limited our analysis only to patients with VF/VT, we may have demonstrated a greater survival benefit. Although the significant increase in AED use prior to ACLS team arrival can be attributed to nurse first responders, mock codes and debriefings involved interdisciplinary team members and may also have contributed to the overall improvements in ROSC and survival. Return on investment In the hospital setting, early defibrillation programs have been variably successful.11,13,18 It has been suggested that focusing on AED training for nurses is both effective and cost-effective since nurses are most likely to be first responders and require only a “refresher” in AED use, as they are already BLS educated.12,27 In our initiative, AED
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training for nurses was part of required education time, thereby avoiding separate AED sessions and improving cost-effectiveness. From January 2011 to December 2013, there was a 12% increase in survival to discharge rates for patients with cardiac arrest in noncritical care areas. While confounding factors make it difficult to attribute improved survival to AED use alone, there are additional benefits of our nurse-focused AED program. In contrast to the hesitancy and confusion identified by nurses prior to AED training, they now express greater confidence in AED skills and demonstrate first-responder actions. This is reflected in the increased AED use prior to ACLS team arrival on medical-surgical units from 15% in 2011 to 76% in 2013 (P < .01). The return on investment in our AED training program has significantly increased nurse participation in the critical steps of the “chain of survival” and improvement in patient outcomes. Future directions In August 2013, the quality resuscitation consultant began “spot checks” on medical-
surgical units to verify equipment availability and nurses’ AED skills. In situ mock codes began in October 2013 to improve nurse firstresponder and ACLS team response in all geographic areas and to reinforce early defibrillation. We expect further improvement in nurse first-responder AED use following these interventions. CONCLUSIONS Multiple institution-wide initiatives significantly improved nurse first-responder AED use prior to ACLS team arrival for cardiac arrests in medical-surgical units. These included the following: r A dedicated, full-time quality resuscitation consultant. r Nursing education sessions with-high fidelity simulation and required demonstration of BLS AED skills. r Institution-wide standardization of defibrillation equipment and practices. This approach may serve as a model for other institutions challenged to improve early defibrillation rates.
REFERENCES 1. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401-2406. 2. Sandroni C, Nolan J, Cavallaro F, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med. 2007;33(2):237-245. 3. Merchant RM, Berg RA, Yang L, et al. Hospital variation in survival after in-hospital cardiac arrest. J Am Heart Assoc. 2014;3:e000400. doi:10.1161/JAHA.113.0004000. 4. Søreide E1, Morrison L, Hillman K, et al. The formula for survival in resuscitation. Resuscitation. 2013;84(11):1487-1493. 5. Handley AJ, Koster R, Monsiers K, Perkins GD, Davies S, Bossaert L. European Resuscitation Council Guidelines for Resuscitation 2005 Section 2: adult basic life support and use of automated external defibrillators. Resuscitation. 2005;67S1:S7-S23. 6. Link MS, Atkins DL, Passmena RS, et al. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care part
6: electrical therapies. Circulation. 2010;122(18) (suppl 3):S607-S719. 7. Chan PS, Spertus JA, Krumholz HM, et al. A validated prediction tool for initial survivors of in-hospital cardiac arrest. Arch Intern Med. 2012;172(12): 947-953. 8. American Heart Association resuscitation fact sheet. http://www.heart.org/idc/groups/heart-public/ @wcm/@private/@hcm/@gwtg/documents/ downloadable/ucm 434082.pdf. Published October 2013. Accessed November 19, 2013. 9. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol. 2006;48(5): e247-e346.
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Innovations to Increase Timely Defibrillation Rates 10. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17. 11. Gombotz H, Weh B, Mitterndorfer W, Rehak P. In-hospital cardiac resuscitation outside the ICU by nursing staff equipped with automated external defibrillators—the first 500 cases. Resuscitation. 2006;70(3):416-422. 12. Kenward G, Castle N, Hodgetts TJ. Should ward nurses be using automatic external defibrillators as first responders to improve the outcome from cardiac arrest? A systematic review of the primary research. Resuscitation. 2002;52(1):31-37. 13. Kloppe C, Jeromin A, Kloppe A, Ernst M, Mugge A, Hanefeld C. First responder for in-hospital resuscitation: 5-year experience with an automated external defibrillator-based program. J Emerg Med. 2013;44(6):1077-1082. 14. American Heart Association and International Committee on Resuscitation. The automated external defibrillator: key link in the chain of survival. Resuscitation. 2000;46(1-3):73-91. 15. Moule P, Albarran JW. Automated external defibrillation as part BLS: implications for education and practice. Resuscitation. 2002;54(3):223-230. 16. Cohn AC, Wilson WM, Yan B, et al. Analysis of clinical outcomes following in-hospital adult cardiac arrest. Intern Med J. 2004;34(7):398-402. 17. Laws TA, Zeitz K, Fiedler BA. Seeking an explanation for the poor uptake of in-hospital AED programs. Eur J Cardiovasc Nurs. 2004;3(3):195-200. 18. Forcina MS, Farhat AY, O’Neil WW, Haines DE. Cardiac arrest survival after implementation of automated external defibrillator technology in the in-hospital setting. Crit Care Med. 2009;37(4):1229-1236. 19. Heng KW, Fong MK, Wee FC, Anantharaman V. The role of nurses in the resuscitation of
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in-hospital cardiac arrests. Singapore Med J. 2011;52(8):611-615. Makinen M, Niemi-Murola L, Kaila M, Castren M. Nurses’ attitudes towards resuscitation and national resuscitation guidelines—nurses hesitate to start CPRD. Resuscitation. 2009;80(12):1399-1404. Dine CJ, Gersh RE, Leary M, Riegel BJ, Bellini LM, Abella BS. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med. 2008;36(10):2817-2822. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56-61. Rodgers DL, Securro S Jr, Pauley RD. The effect of high-fidelity simulation on educational outcomes in an advanced cardiovascular life support course. Simul Healthc. 2009;4(4):200-206. Abella BS, Edelson DP, Kim S, et al. CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation. 2007;73(1):54-61. Pozner CN, Almozlino A, Elmer J, Poole S, McNamara D, Barash D. Cardiopulmonary resuscitation feedback improves the quality of chest compression provided by hospital health care professionals. Am J Emerg Med. 2011;29(6):618-625. Yeung J, Meeks R, Edelson D, Gao F, Soar J, Perkins GD. The use of CPR feedback/prompt devices during training and CPR performance: a systematic review. Resuscitation. 2009;80(7):743-751. Stewart JA. Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest. Scand J Trauma Resusc Emerg Med. 2010;18:42.
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J Nurs Care Qual Vol. 29, No. 4, pp. 311–317 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Every Second Counts Innovations to Increase Timely Defibrillation Rates Meredith Borak, MSN, RN; Mary Ann Francisco, MSN, APN, GCNS-BC, CCRN; Mary Ann Stokas, MSN, RN, OCN; Mary Maroney, MSN, RN, FNP-BC; Valerie Bednar, MA, BSN, RN, CCRN; Megan E. Miller, MD; Katherine Pakieser-Reed, PhD, RN Early defibrillation is an essential step in the “chain of survival” for patients with in-hospital cardiac arrest. To increase the rate of early defibrillation by nurse first responders in noncritical care areas, our institution employed a quality resuscitation consultant, implemented nursing education programs, and standardized equipment and practices. Automated external defibrillator application by nurse first responders prior to advanced cardiac life support team arrival has improved from 15% in 2011 to 76% in 2013 (P < .001). Key words: advanced cardiac life support, automated external defibrillator, defibrillation, first responders, in-hospital cardiac arrest, resuscitation
I
N THE UNITED STATES, in-hospital cardiac arrest occurs in approximately 200 000 patients annually and is associated with poor survival.1-3 The “formula for survival” from cardiac arrest is a framework integrating science, education, and local implementation
Author Affiliations: Rescue Care and Resiliency (Ms Borak), Center for Nursing Professional Practice and Research (Mss Francisco, Stokas, Maroney, and Bednar and Dr Pakieser-Reed), and Department of General Surgery (Dr Miller), The University of Chicago Medicine, Chicago, Illinois. The authors have no conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Meredith Borak, MSN, RN, Rescue Care and Resiliency, The University of Chicago Medicine, 5841 S. Maryland Ave, Room TC447, Chicago, IL 60637 ([email protected]). Accepted for publication: April 2, 2014 Published ahead of print: May 7, 2014 DOI: 10.1097/NCQ.0000000000000066
to organize resuscitation efforts and improve patient outcomes.4 At the local level of implementation, the “chain of survival” focuses on 4 key steps: (1) early recognition and activation of the emergency medical system; (2) early cardiopulmonary resuscitation (CPR); (3) early defibrillation for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT); and (4) postresuscitation care.5 The third step in the “chain of survival” is based on evidence that early defibrillation is the treatment of VF/VT.6 In particular, the time to first shock is critically important to improve survival from VF/VT arrest for victims of in-hospital cardiac arrest.7 Guidelines for in-hospital cardiac arrest due to VF/VT call for defibrillation within 2 minutes.8,9 Defibrillation after more than 2 minutes is associated with a significantly reduced probability of survival to discharge after cardiac arrest due to ventricular arrhythmias, and there is a graded association between longer times to defibrillation and poorer survival.10 In the hospital setting, the “chain of survival” is initiated by first responders prior 311
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to the arrival of an advanced cardiac life support (ACLS)-trained resuscitation team in a tiered response system.11−13 Because of their primary role in patient care, nursing staff members are frequently the first to witness and respond to in-hospital cardiac arrest and should therefore be trained in basic life support (BLS), including automated external defibrillator (AED), skills.11,12,14,15 In-hospital early defibrillation programs have been recommended,12,16,17 but there are few reports focusing specifically on nursing staff use of AEDs.11,13,18,19 Nurse first responders are especially important for patients in unmonitored beds who are at an increased risk of an unwitnessed cardiac arrest. Almost one-third of our patients (29% in 2011; 28% in 2012) who experienced an in-hospital cardiac arrest were in unmonitored beds on medical-surgical (noncritical care) units, requiring activation of the tiered response system. Direct observation of BLStrained nurses responding to cardiac arrests identified a delay in critical actions such as initiating chest compressions and applying the AED prior to ACLS team arrival. Informal debriefing revealed that they were uncomfortable with first-responder tasks due to lack of familiarity with the AED equipment and lack of confidence about their role in early defibrillation. In particular, they expressed hesitancy to administer a shock without a physician present, a sentiment also found in a cohort of nurses who hesitated to defibrillate due to anxiety and fear of patient harm.20 This targeted needs assessment identified clear deficits in knowledge and skills for medical-surgical nurses responding to inhospital cardiac arrests. The purpose of our initiative was to improve nurse first responders’ performance on the life-saving steps required for a victim of cardiac arrest on medical-surgical units prior to the arrival of the ACLS team. Three strategies were implemented: the quality resuscitation consultant role, a curriculum for nurse education, and institution-wide standardization of equipment and practices.
MATERIALS AND METHODS Institution and ACLS team characteristics The University of Chicago Medicine is a 568-bed acute care hospital with 300 adult medical-surgical beds. Each nursing unit has a biphasic defibrillator with AED mode capability on its centrally located emergency equipment cart. When a cardiac arrest occurs, nurse first responders initiate BLS while the ACLS team is alerted by an overhead page and an electronic group mobile page. The ACLS team is composed of representatives from internal medicine, anesthesia, respiratory therapy, pharmacy, and critical care nursing. The average ACLS team response time is 3 minutes, and upon arrival, the internal medicine physician assumes leadership of the cardiac arrest event. Role of the quality resuscitation consultant In 2011, the position of quality resuscitation consultant was created to ensure that the institution maintains current best practices for emergency resuscitation. Essential job functions include the collection, analysis, and communication of hospital-wide resuscitation data for all cardiac arrests and rapid response team activations. The quality resuscitation consultant ensures maintenance of quality for the hospital’s emergency response systems by providing direct patient care during cardiac arrests and rapid response team events. In addition, the quality resuscitation consultant facilitates quality performance improvement initiatives including the emergency equipment standardization project, interdisciplinary mock (simulated) codes, monthly cardiac arrest and rapid response team debriefings, and the implementation of a critical care outreach team to proactively be on round for high-risk patients admitted to medical-surgical units. The quality resuscitation consultant successfully facilitated the automated documentation of hospital-wide emergency response data and
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LWW/JNCQ
JNCQ-D-13-00170
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23:11
Innovations to Increase Timely Defibrillation Rates the creation of automated reports. This information was communicated and used in ongoing nursing education and standardization efforts. METHODS Nursing education sessions Annual competency sessions in January 2012 were developed and implemented collaboratively by the quality resuscitation consultant and clinical nurse educators. First, 356 nurses attended a didactic session on unitspecific statistics for cardiac arrest incidence and resuscitation performance and reviewed the updated American Heart Association’s BLS guidelines. Each nurse practiced skills using the defibrillator and AED mode on a highfidelity simulation mannequin, emphasizing completion of the tasks and delivery of a successful shock within 2 minutes, as recommended by the American Heart Association Get with the Guidelines–Resuscitation program.8 Second, each nurse participated in a timed group simulation event. All nurses engaged in a debriefing session and underwent remediation until the necessary steps were successfully completed within 2 minutes. Responses from the evaluation survey indicated that 94% of participants felt that the learning objectives were met and material learned to a great extent (score 4/4). Qualitative analysis of comments identified that participants enjoyed the interactive module and the opportunity for direct return demonstration with one-on-one feedback. Since April 2012, more than 450 newly hired nurses have successfully completed the same education, with simulation incorporated into monthly nursing orientation. Standardization efforts During June-August 2012 and 2013, multidisciplinary mock codes were implemented to educate internal medicine physicians leading the ACLS team, respiratory therapists, and staff nurses. These sessions provided an opportunity to practice clinical and leadership skills in a setting with other staff members
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present during a cardiac arrest. Video debriefing followed each session, which allowed participants to identify areas for improvement and remediation if necessary. Evaluations reflected high value placed on the interdisciplinary approach, the video debriefing, and the realistic scenarios. Starting in October 2012, nurse first responders were invited to attend monthly debriefing sessions with all ACLS team members. The multidisciplinary nature of these sessions created a more robust debriefing experience that has improved interactions between nurses and ACLS team members. More recently since October 2013, in situ mock codes have been executed in various locations throughout the hospital campus to further enhance real-time learning among multidisciplinary cardiac arrest responders. In February 2013, a total of 52 defibrillators in adult inpatient areas were upgraded to operate in monitor, defibrillator, pacemaker, and AED modes and to include QCPR technology and end-tidal capnography. Approximately 130 emergency equipment carts were updated with population-specific medications and resuscitation equipment. LEAN methodology was used to standardize processes for restocking and replacing used equipment. In addition, 9 AEDs were placed in strategic outpatient locations. More than 900 adult inpatient nurses received standardized education regarding the use of the new defibrillators and emergency equipment carts, and an additional 761 nonclinical personnel were educated on AED use. Revised institutional policies on emergency equipment preparedness and changes to the ACLS teams were communicated to all clinical and nursing staff members in March 2013. Data analysis Institutional review board approval was obtained for the collection of clinical and outcomes data for in-hospital cardiac arrests. Data were gathered regarding defibrillation after cardiac arrest in each medical-surgical unit. An adult cardiac arrest was defined as loss of consciousness with absence of pulse or breathing in a patient older than 18 years, followed
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by chest compressions and/or defibrillation. The time of the ACLS activation call was compared with the time stamped on the transcript from the unit defibrillator and the time that the ACLS team arrived at the bedside. Defibrillators were considered used if the pads were placed on the patient and the defibrillator was turned on, ready for a rhythm analysis. Rates of defibrillator use by unit location were calculated monthly, and annual rates from January 2011 to December 2013 were compared. Patient outcomes by unit were collected. Return of spontaneous circulation (ROSC) was successful if the patient regained and maintained a perfusing rhythm during the resuscitation attempt for more than 20 minutes. To determine survival, patients were followed either until discharge or death based on medical record documentation. Rates of ROSC and survival to discharge by unit location were calculated monthly, and annual rates from January 2011 to December 2013 were compared. Statistical analysis was performed using STATA 12.0 (StataCorp, College Station, Texas), and P values .05 or less were considered significant. RESULTS The utilization of the defibrillator by medical-surgical nurses prior to ACLS team arrival has significantly increased. Of the cardiac arrests that occurred in medical-surgical areas in 2011, the defibrillator was properly attached and compressions were in progress upon the ACLS team’s arrival in only 15% of cases (6/40). In 2012, AED utilization during cardiac arrests in medical-surgical units increased to 60% (28/47; P < .01). Data demonstrate that the AED utilization rate for 2013 was 76% (31/41). This represents a 61% improvement in AED utilization by nurse first responders during cardiac arrests in medicalsurgical units from 2011 to 2013 (P < .01) (Figure). While the ROSC rate for 2012 (64%; 30/47) declined slightly from 2011 (70%; 28/40), it increased by 19% in 2013 (83%, 34/41; P < .05 as compared with 2012). Despite a larger
number of cardiac arrests in medical-surgical patients in 2012, survival to discharge rates increased from 15% (6/40) in 2011 to 17% in 2012 (8/47). Data from 2013 demonstrate an additional improvement in survival to discharge rates for these patients to 27% (11/41). Several specific interventions were associated with improvements in AED use prior to ACLS team arrival (see Supplemental Digital Content, Figure, available at: http://links.lww .com/JNCQ/A88). These included interdisciplinary mock codes during June-August 2012 and 2013, which were highly rated by participants. The addition of nurse first responders to ACLS team debriefings following cardiac arrests in October 2012 correlated with an improvement in AED use in the following month. Improved rates of AED use in 2013 followed the standardization of emergency equipment and institution-wide changes to the emergency response policy. DISCUSSION The purpose of our initiative was to improve nurse first responders’ performance on the life-saving steps required for a victim of in-hospital cardiac arrest on medical-surgical (noncritical care) units. The rate of AED use prior to ACLS team arrival improved from 15% in 2011 to 76% in 2013 (P < .01). During the same time period, the ROSC rate improved from 64% to 83% (P < .05), and survival to discharge rates increased from 15% to 27%. The significant increase in early AED use is particularly important as a process measurement for the effectiveness of our nursingfocused interventions. While outcomes such as ROSC and survival to discharge are clinically relevant, they are influenced by patient characteristics, resuscitation team efforts, and events following initial cardiac arrest. We improved nurse first-responder AED use prior to ACLS team arrival by 61%, successfully addressing a critical step in the “chain of survival” for in-hospital cardiac arrest. A unique and essential component of success was the creation of the quality resuscitation consultant role. Following a needs
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100% 90% 80%
76% b
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50% 40% 30% 20%
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Figure. Automated external defibrillator utilization by nurse first responders for patients with cardiac arrest on medical-surgical units prior to advanced cardiac life support team arrival. a P < .01 for 2011-2012; b P < .01 for 2011-2013.
assessment, the quality resuscitation consultant recommended and implemented the nursing-focused AED program to address deficiencies in first-responder actions. The use of high-fidelity simulation and debriefing during nursing education sessions, ACLS orientation, and mock codes was another strength, as this approach improves CPR21,22 and performer confidence.23 Updated equipment provided real-time CPR feedback and prompts, which have been shown to improve CPR skill acquisition and retention and augment CPR quality.24-26 Standardization of AED devices and locations improved nurses’ confidence with the equipment and contributed to effective use in cardiac arrests. While nurse first-responder AED programs have been recommended, few successful projects have been described. Importantly, we provide a detailed account of our early defibrillation initiatives and demonstrate a significant improvement in AED use prior to ACLS team arrival. Limitations The educational initiative was limited to medical-surgical nursing staff, and only the
practice and clinical outcomes of medicalsurgical units were studied. Therefore, ROSC and survival to discharge are reported on a geographic basis rather than by patient characteristics or cardiac arrest rhythm. Prior studies have shown that patients with VF/VT as the initial rhythm are more likely to survive in-hospital cardiac arrest.2,3,11,16 If we had limited our analysis only to patients with VF/VT, we may have demonstrated a greater survival benefit. Although the significant increase in AED use prior to ACLS team arrival can be attributed to nurse first responders, mock codes and debriefings involved interdisciplinary team members and may also have contributed to the overall improvements in ROSC and survival. Return on investment In the hospital setting, early defibrillation programs have been variably successful.11,13,18 It has been suggested that focusing on AED training for nurses is both effective and cost-effective since nurses are most likely to be first responders and require only a “refresher” in AED use, as they are already BLS educated.12,27 In our initiative, AED
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training for nurses was part of required education time, thereby avoiding separate AED sessions and improving cost-effectiveness. From January 2011 to December 2013, there was a 12% increase in survival to discharge rates for patients with cardiac arrest in noncritical care areas. While confounding factors make it difficult to attribute improved survival to AED use alone, there are additional benefits of our nurse-focused AED program. In contrast to the hesitancy and confusion identified by nurses prior to AED training, they now express greater confidence in AED skills and demonstrate first-responder actions. This is reflected in the increased AED use prior to ACLS team arrival on medical-surgical units from 15% in 2011 to 76% in 2013 (P < .01). The return on investment in our AED training program has significantly increased nurse participation in the critical steps of the “chain of survival” and improvement in patient outcomes. Future directions In August 2013, the quality resuscitation consultant began “spot checks” on medical-
surgical units to verify equipment availability and nurses’ AED skills. In situ mock codes began in October 2013 to improve nurse firstresponder and ACLS team response in all geographic areas and to reinforce early defibrillation. We expect further improvement in nurse first-responder AED use following these interventions. CONCLUSIONS Multiple institution-wide initiatives significantly improved nurse first-responder AED use prior to ACLS team arrival for cardiac arrests in medical-surgical units. These included the following: r A dedicated, full-time quality resuscitation consultant. r Nursing education sessions with-high fidelity simulation and required demonstration of BLS AED skills. r Institution-wide standardization of defibrillation equipment and practices. This approach may serve as a model for other institutions challenged to improve early defibrillation rates.
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