01 nurse defib

www.medscape.com

Are Nurses Confident Enough?

Abstract and IntroductionAbstractObjectives To determine the capability of nurses to identify ventricular fibrillation (VF) and ventricular tachycardia (VT) rhythms on an ECG and carry out subsequent defibrillation ontheir own as soon as they identify and confirm cardiac arrest.

Methods This was a prospective cohort study to determine the capability of emergency department (ED) nurses to recognise VF or pulseless VT correctly and their willingness toperform defibrillation immediately in an ED of a teaching hospital in Hong Kong. A questionnaire was completed before and after a teaching session focusing on the identification ofrhythms in cardiac arrest and defibrillation skills. Correct answers for both ECG interpretation and defibrillation decisions scored one point for each question. The differences in meanscores between the pre-teaching and post-teaching questionnaires of all nurses were calculated.

Results 51 pre-teaching and 43 post-teaching questionnaires were collected. There were no statistically significant changes in ECG scores after teaching. For defibrillation scores,there was an overall improvement in the defibrillation decision (absolute mean difference 0.42, p=0.014). Performance was also improved by the teaching (absolute mean difference0.465, p=0.046), reflected by the combination of both scores. Two-thirds (67%) of nurses became more confident in managing patients with shockable rhythms.

Conclusion Nurses improve in defibrillation decision-making skills and confidence after appropriate brief, focused in-house training.IntroductionThe survival rate of in-hospital cardiac arrest remains low despite the extensive efforts of different resuscitation councils to improve clinical management of this common condition.The survival-to-discharge rate ranges from 15.3% to 37%.[18] Nurses are usually the first healthcare staff to identify patients with cardiac arrest. Initial rhythm recognition is crucial tothe management of patients with cardiac arrest because time is critical for survival in patients whose cardiac arrest rhythm is ventricular fibrillation (VF) or pulseless ventriculartachycardia (VT).

Early defibrillation is a major key to increase survival,[9] and therefore the use of an automated external device is included in modern standard basic life support (BLS) training.[10] Thisleads to better survival rates for cardiac arrests outside critical care areas.[11] Boyde and Wotton[12] found that the majority of nurses can effectively manage all components ofcardiopulmonary resuscitation (CPR). Ideally, all nurses should also be competent to recognise VF or pulseless VT and perform defibrillation within the first few seconds aftercollapse, and before any doctor arrives. On the other hand, it is equally important that a nurse should not misinterpret the ECG and give an unnecessary defibrillation shock to thepatient.

It has been shown that the training of nurses in advanced cardiac life support (ACLS) is strongly related to improved survival for patients with cardiac arrest.[13] Nurses can recognise

Nurse-initiated Defibrillation

C K Tai, Giles N Cattermole, Paulina S K Mak, Colin A Graham, Timothy H RainerEmerg Med J. 2012;29(1):24-27.

http://www.medscape.com/viewarticle/756447_print

1 of 9 05/03/2015 00:29

shockable rhythms early and carry out defibrillation immediately. In addition, up-to-date training and greater self-confidence can lead to improved performance for medicalprofessionals in resuscitation and subsequently increased survival.[14 15] Nurses' confidence and perceived technical and non-technical skills during patient clinical emergencies havebeen shown to be enhanced following simulation.[16] Such training should be based on inhospital scenarios and current evidence-based guidelines, including the recognition of sickpatients, and should be taught using simulations of a variety of cardiac arrest scenarios. This will ensure that the training reflects the potential situations that nurses may face inpractice.[17]

However, there is lack of sufficient data about changes in performance after the implementation of nurse-initiated defibrillation.[18 19] Some studies support the concept but they havefailed to compare the outcomes objectively after implementing this technique.[2022]

The aim of the current study was to determine the capability of nurses to identify VF and VT rhythms on an ECG and carry out subsequent defibrillation on their own as soon as theyidentify and confirm cardiac arrest.

The results may affect the emphasis of nurses' undergraduate and postgraduate training including ECG interpretation and defibrillation skills, which in turn may impact our currentpatient management practice.

MethodsStudy DesignThe study protocol was approved by the ethics committee from the Survey and Behavioural Research Ethics of the Chinese University of Hong Kong. This was a prospective cohortstudy to determine the capability of emergency department (ED) nurses to recognise VF or pulseless VT correctly and their willingness to perform defibrillation immediately. Allnursing staff in the ED of the Prince of Wales Hospital in Shatin including nursing officers, registered nurses and enrolled nurses were invited to attend a 90-min teaching sessionabout ECG interpretation and defibrillation skills. The teaching session was conducted by an assistant professor (GNC) in our department. Prince of Wales Hospital is the only tertiarycentre in the New Territories East Cluster in Hong Kong. There are approximately 375 resuscitation cases monthly including 25 cardiac arrest cases in the year 2009. Although allpatients in cardiac arrest will be recognised and resuscitation initiated by nursing staff, the definitive care of all resuscitation cases is currently provided by medical practitioners. Allregistered nurses in the department undergo regular refresher training in BLS and frequently use it in practice.

Participants were asked to complete a questionnaire (see supplementary appendix 1, available online only) just before the teaching session. The questionnaire consisted of 10questions; each included an ECG rhythm for identification and the decision for defibrillation. Correct answers for both parts scored one mark for the question and therefore the totalmarks for the questionnaire were 10. The teaching session focused on the identification of rhythms in cardiac arrest and defibrillation skills. It was followed by a practical session topractice defibrillation, using full monitor/defibrillators (not automated external defibrillators). The accuracy of CPR was also assessed, based on the American Heart Association BLS(2005) guidelines in an attempt to standardise skills. A 30:2 ratio with a compression depth of 1.5 to 2 inches was the aim for all participants.

Participants were invited to repeat the same assessment on the same set of ECG (see supplementary appendix 2, available online only) 12 weeks after the teaching session. Theteaching sessions were mandatory for the nursing staff, and they were required to attend one of the teaching sessions unless there was a special reason for their absence.Participation in the study was voluntary. The accuracy rate for the recognition of VF and/or VT before and after teaching and the confidence in performing defibrillation was calculatedand compared.

Statistical Analysis


2 of 9 05/03/2015 00:29

Nurses were grouped into two groups for data analysis: group one comprised nursing officers and advanced practice nurses, whereas group two consisted of registered nurses andenrolled nurses.

Correct answers for both ECG interpretation and defibrillation decisions scored one point for each question (maximum score of 10 for each part). The sum of the two scores wascalculated and halved so that the scores had a maximum of 10 to allow comparison with the original scores. The combined score reflects their ability to give appropriate treatment topatients in cardiac arrest with a shockable rhythm. The differences in mean scores between pre-teaching and post-teaching questionnaires of all nurses were calculated. The paired-samples t test was used to analyse the pre-teaching and post-teaching score of each nurse. The mean time in years from completion of the ACLS course to the current study wasrecorded and the means of the two groups were compared using a two-sample t test.

ResultsFifty-one nurses attended the teaching session and all 51 pre-teaching questionnaires were collected (figure 1). Not surprisingly, the nurses in group 1 had more experience ofworking in the ED. Those in group 2 had less experience, which was more evenly distributed (). Overall, 14 (27.4%) nurses had not completed an ACLS course. The mean number ofyears after completing an ACLS course was 8.3 (SD 4.2; range 114 years). Group 1 had a mean of 9.9 years since completing an ACLS course and group 2 had a mean of 6.3years since completing an ACLS course, which was a statistically significant difference (p=0.0019, two-sample t test). A total of 43 post-teaching questionnaires was collected withnine from group 1 and the remainder from group 2. Two nurses from group 1 and six nurses from froup 2 did not complete the post-teaching questionnaire because they were onvacation at that time or had left the department.

Table 1. Nurses' ED working experience (n=51)

ED working experience NO (n=8) APN (n=3) RN (n=36) EN (n=4)20 years 1 0 0 0


3 of 9 05/03/2015 00:29

ACLS course taken 7 3 27 0

ACLS, advanced cardiac life support; ED, emergency department.


4 of 9 05/03/2015 00:29


5 of 9 05/03/2015 00:29

Figure 1.

Percentage of emergency department nursing staff by grade (n=51). APN, advanced practice nurse; EN, enrolled nurse; NO, nursing officer; RN, registered nurse.

For ECG scores, there were no statistically significant changes in either group after teaching. For defibrillation scores, there was an overall improvement in the defibrillation decision(absolute mean difference 0.42, p=0.014). This is largely due to the improvement in group 2. When looking at the combined scores, performance was also improved by the teaching(absolute mean difference 0.465, p=0.046) ().

Table 2. Comparison of pre and post-training scores between groups

GroupPre-training ECG score Post-training ECG score

p Value*MeanSD (percentiles) MeanSD (percentiles)Group 1 (n=9) 9.330.707 (910) 90.866 (810) 0.180

Group 2 (n=34) 8.51.33 (710) 8.850.821 (89.25) 0.128

All nurses 8.671.267 (810) 8.880.823 (810) 0.269

GroupPre-training defibrillation score Post-training defibrillation score

p Value*Mean (percentiles) Mean (percentiles)Group 1 9.440.726 (910) 9.220.667 (910) 0.480

Group2 8.851.048 (810) 9.440.613 (910) 0.005

All nurses 8.981.012 (810) 9.40.623 (910) 0.014

Absolute difference (95% CI)

0.42 (0.068 to 0.769)

Group Pre-training total mark (combined answers) Post-training total mark (combined answers) p Value*Group 1 90.866 (810) 8.561.13 (7.59.5) 0.194

Group 2 7.821.359 (79) 8.530.896 (89) 0.009

All nurses 8.071.352 (79) 8.530.935 (89) 0.046

Absolute difference (95% CI)

0.465 (0.013 to 0.917)

* Paired-samples t test.


6 of 9 05/03/2015 00:29

Besides the objective data analysis, the nurses reported to have benefitted from the teaching. Two-thirds (67%) of nurses became more confident in managing patients withshockable rhythms.

DiscussionNurses are vitally important in patient care. They are usually the first responder to any physiological changes in hospital patients. In VF and pulseless VT, time is the most crucialfactor for survival. The shorter the time from arrest to defibrillation, the better the survival rate will be.[23] A delay in defibrillation time of 1 min can greatly decrease the chances ofsurvival.[10 24 25]

Traditionally in Hong Kong and elsewhere, doctors play an important role in managing patients with cardiac arrest, especially during defibrillation. However, the survival rate is higher ifdefibrillation is done at an early stage by nurses before the arrival of a resuscitation team.

Dwyer et al [21] stated that nurses are confident enough to initiate defibrillation if they are permitted to do so. However, most of the studies lack local data to support this practice inHong Kong. The presence of at least one person with ACLS training has been shown to increase both short-term and long-term survival following cardiac arrest.[26] However, Smithet al [27] and Madden[28] stated that there is dramatic decline in ACLS and BLS skills retention for nurses within the certification period, and ACLS skills degrade more quickly.Re-education of resuscitation can affect nurses' knowledge and skills,[29] and such training should be provided as often as possible to prevent skills deterioration betweenupdates.[17] Therefore, regular concise refreshing training may be beneficial. The fact that more senior nurses (group 1) had a longer interval between ACLS training and this studyevaluation may help to explain the difference in scores observed between groups 1 and 2, but these differences were not statistically significant. Nevertheless, this suggests thatregular ACLS training is of benefit to all levels of staff, not just 'junior' nursing staff.

The results of our study are encouraging. Apart from better decision making, the nurses became more confident when facing cardiac arrests due to VF or pulseless VT. Effortsshould be made to have regular training for frontline nurses to keep them well equipped to face these clinical challenges. Nurses should be authorised to defibrillate independentlywithout direct medical supervision. The resuscitation committee in this hospital has started to emphasise the involvement of nurses in resuscitation. Meanwhile, resuscitation stillpredominantly relies on doctors, but nurse-initiated defibrillation is under consideration and may be launched in the near future. Policies will clearly vary from hospital to hospital, butour experience of this short training programme suggests that nurses are capable of achieving high knowledge scores in this important area of practice. Furthermore, nurse-initiatedresuscitation should be subject to a centralised case review process to provide feedback to staff involved in resuscitation and for clinical audit.

Our study mainly focuses on ED nurses who are relatively familiar with cardiac arrests. Nevertheless, there is still room for some improvement both in ECG interpretation anddefibrillation decision making. This study could be extended in the future to nurses in different specialities for comparison.

In conclusion, we found that nurses improve in defibrillation decision-making skills and confidence after appropriate brief, focused in-house training.

ReferencesPeberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the National Registry ofCardiopulmonary Resuscitation. Resuscitation 2003;58:297308.

1.

Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006;295:507.2.

Skogvoll E, Isern E, Sangolt GK, et al. In-hospital cardiopulmonary resuscitation. 5 Years' incidence and survival according to the Utstein template. Acta AnaesthesiolScand3.


7 of 9 05/03/2015 00:29

1999;43:17784.

Herlitz J, Bang A, Ekstrom L, et al. A comparison between patients suffering in-hospital and out-of-hospital cardiac arrest in terms of treatment and outcome. J Intern Med2000;248:5360.

4.

Zoch TW, Desbiens NA, DeStefano F, et al. Short- and long-term survival after cardiopulmonary resuscitation. Arch Intern Med 2000;160:196973.5.

Dumot JA, Burval DJ, Sprung J, et al. Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. Arch Intern Med2001;161:17518.

6.

Khan NU, Razzak JA, Ahmed H, et al. Cardiopulmonary resuscitation: outcome and its predictors among hospitalized adult patients in Pakistan. Int J Emerg Med2008;1:2734.

7.

Chang SH, Huang CH, Shih CL, et al. Who survives cardiac arrest in the intensive care units? J Crit Care 2009;24:40814.8.

Krittayaphong R, Saengsung P, Chawaruechai T, et al. Early defibrillation: a key for successful outcome of in-hospital cardiac arrest. J Med Assoc Thai 2009;92(Suppl2):S15.

9.

Hazinski MF, Gonzales L, O'Neill L. Basic life support for healthcare providersmanual. Texas: American Heart Association, 2006.10.

Skrifvars MB, Saarinen K, Ikola K, et al. Improved survival after in-hospital cardiac arrest outside critical care areas. Acta Anaesthesiol Scand 2005;49:15349.11.

Boyde M, Wotton K. A review of nurses' performance of cardiopulmonary resuscitation at cardiac arrests. J Nurses Staff Dev 2001;17:24855.12.

Dane FC, Russell-Lindgren KS, Parish DC, et al. In-hospital resuscitation: association between ACLS training and survival to discharge. Resuscitation 2000;47:837.13.

Verplancke T, De Paepe P, Calle PA, et al. Determinants of the quality of basic life support by hospital nurses. Resuscitation 2008;77:7580.14.

Hoadley TA. Learning advanced cardiac life support: a comparison study of the effects of low- and high-fidelity simulation. Nurs Educ Perspect 2009;30:915.15.

Gordon CJ, Buckley T. The effect of high-fidelity simulation training on medical-surgical graduate nurses' perceived ability to respond to patient clinical emergencies. J ContinEduc Nurs 2009;40:4918.

16.

Hamilton R. Nurses' knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature. J Adv Nurs 2005;51:2889.17.

Herrera M, Lpez F, Gonzlez H, et al. [Results of the first year of experience of the cardiopulmonary resuscitation program "Juan Ramn Jimnez" Hospital (Huelva) [InSpanish]. Med Intensiva 2010;34:17081.

18.

Gombotz H, Weh B, Mitterndorfer W, et al. In-hospital cardiac resuscitation outside the ICU by nursing staff equipped with automated external defibrillatorsthe first 500cases. Resuscitation 2006;70:41622.

19.


8 of 9 05/03/2015 00:29

Competing interestsNone.

Ethics approvalThis study was conducted with the approval of the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong.

Provenance and peer reviewNot commissioned; externally peer reviewed.

Emerg Med J. 2012;29(1):24-27. 2012 BMJ Publishing Group Ltd & the College of Emergency Medicine

Stewart JA. Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest. Scand J Trauma ResuscEmerg Med2010;18:42.

20.

Dwyer T, Williams LM, Mummery K. Nurse-initiated defibrillation? Reality or rhetoric. Nurs Crit Care 2007;12:2707.21.

Eastwick-Field P. Introducing nurse-initiated management of cardiac arrest. Nurs Stand 1996;10:468.22.

Yap HY, Li Thomas ST, Tan KS, et al. Characteristics, management process, and outcome of patients suffering in-hospital cardiopulmonary arrests in a teaching hospital inHong Kong. Hong Kong Med J 2007;13:25865.

23.

Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA 2002;288:30358.24.

Larsen MP, Eisenberg MS, Cummins RO, et al. Predicting survival from out-of-hospital cardiac arrest. Ann Emerg Med 1993;22:16528.25.

Moretti MA, Cesar LA, Nusbacher A, et al. Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest. Resuscitation 2007;72:45865.26.

Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation 2008;78:5965.27.

Madden C. Undergraduate nursing students' acquisition and retention of CPR knowledge and skills. Nurse Educ Today 2006;26:21827.28.

Oh SI, Han SS. A study on the sustainable effects of reeducation on cardiopulmonary resuscitation on nurses' knowledge and skills. J Korean Acad Nurs 2008;38:38392.29.


9 of 9 05/03/2015 00:29

01 nurse defib

Documents