RAJIV GANDHI UNIVERSITY OF HEALTH SCIENECES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE

CANDIDATE AND

ADDRESS

Ms. JOLLY JOHNSON A

GOLDFINCH COLLEGE OF NURSING

NO.150/24, KODIGEHALLI MAIN ROAD,

MARUTHI NAGAR, BANGALORE-560092

2 NAME OF THE

INSTITUTION

GOLDFINCH COLLEGE OF NURSING.

NO.150/24, KODIGEHALLI MAIN ROAD,

SAHAKARNAGAR POST, BANGALURU-560092

3 COURSE OF THE

STUDY AND THE

SUBJECT

MSc NURSING

MEDICAL-SURGICAL NURSING

4 DATE OF ADMISSION

TO THE COURSE

30-06-2012

5 TITLE OF THE TOPIC“A study to assess the effectiveness of structured

teaching programme on knowledge regarding

organized Crash Cart System among staff nurses

working in selected hospitals at Bangalore”.

6.0 BRIEF RESUME OF INTENDED WORK

6.1 INTRODUCTION

“People who are always taking care of their health are like misers who are hoarding a

treasure which they have never spirit enough to enjoy”.

~Laurence Sterne

Emergency Nursing is a nursing specialty in which nurse’s care for patients in the

emergency or critical phase of their illness or injury. In contrast to practically every other

specialty of nursing, in which a patient arrives with a diagnosis applied by a physician and

the nurse must manage the patient's care according to that diagnosis, emergency nurses work

with patients in whom a diagnosis has not yet been made and the cause of the problem is not

known. Emergency nurses frequently contact patients in the emergency department before the

patient sees a physician. In this situation, the nurse must be skilled at rapid, accurate physical

examination, early recognition of life-threatening illness or injury, the use of advanced

monitoring and treatment equipment, and in some cases, the ordering of testing and

medication according to "advance treatment guidelines" or "standing orders" set out by the

hospital's emergency physician staff. Emergency nurses most frequently are employed in

hospital emergency departments, though they may also work in free-standing urgent care

clinics2.

   Crash cart is a specially designed trolley, used for transporting and dispensing

medicines and equipments at the emergency site for participating in life saving measures.

Crash carts are located in areas of patient care in case of a life-threatening occurrence.

Physicians, nurses, pharmacists, and respiratory therapists must become familiar with the

contents of this cart. It contains necessary equipments to handle an emergency. A crash cart is

enabling healthcare providers to manage medical emergencies easily and confidently3. 

The cart is characterized by being easily movable and readily accessible into all sides

of the cart for quickly viewing and removing equipment and drugs during a crisis. The first

cardiac crash cart was created at Bethany Medical Center in Kansas City, Kansas. One of the

doctor’s fathers fabricated the first crash cart. It contained an Ambu bag, defibrillator

paddles, a bed board and endo tracheal tubes. A crash cart or code cart (crash trolley in UK

medical jargon) is a set of trays/drawers/shelves on wheels used in hospital emergency rooms

for transportation and dispensing of emergency medication/equipment at site of

medical/surgical emergency for life support protocols like Advanced Cardiac Life

Support/Advance Life Support (ACLS/ALS), Pediatric Advanced life Support [PALS] to

potentially save someone's life1.

The contents of a crash cart vary from hospital to hospital, but typically contain the

tools and drugs needed to treat a person in or near cardiac arrest. These include but are not

limited to:

Monitor/defibrillators and suction devices

Advanced Cardiac Life Support (ACLS) drugs such as Epinephrine, Atropine,

Amiodarone, Lidocaine, Sodium bicarbonate, Dopamine, and Vasopressin

First line drugs for treatment of common problems such as: Adenosine, Dextrose,

Diazepam or Midazolam, Epinephrine, Naloxone, Nitroglycerin, and others

Drugs for rapid sequence intubation: Succinylcholine or other paralytic agents like

Pancoronoum , a sedative  drugs such as Etomidate or Midazolam; endotracheal tubes

and other intubating equipment

Vascular access devices – Intra Venous(IV) Cannulae, Drip sets [Micro and Macro],

IV fluids [Normal Saline(NS), Lactated Ringer(RL), Hydroxy ethyl starch 

Other drugs and equipment as chosen by the facility2.    

6.2 NEED FOR THE STUDY

“Take care of your body with steadfast fidelity. The soul must see through these eyes

alone, and if they are dim, the whole world is clouded”.

- Johann Wolfgang Von Goethe

A “Crash Cart” is a mobile, compact cart, equipped with various medical aid tools

(used mainly for cardiac emergencies). The cart consists of items such as a defibrillator,

medications, a suction pump, and other life-saving equipment. Each floor of the Detroit VA

has a “Crash Cart” that is used only in the event of a Code Blue Emergency. These days, the

Cart is very organized, but not too long ago, this was not the case3.

In past years, there have been various issues with efficiency and organization of

the “Crash Carts”. The two main issues prior to its reinvention and revamping, were that (1)

the materials on the cart were not easily found, and (2) there were no clear instructions on

how to use critical items on the crash cart. There were also issues with over-stuffing of items,

and the excessive shifting of various items when the cart was on the move, or even when the

drawers of the cart were opened and shut.  Knowing that the most critical aspects of the

“Crash Cart” organization were time and access to materials, the Detroit VA’s Systems

Redesign Team was asked to help. The team lives by what they call the “5 S’s”:  Sort,

Strengthen, Shine, Standardize, and Sustain. The Detroit VA’s Systems Redesign Team will

take an issue or problem, break it down to its core elements, and then sort those elements.

Once that is done, they figure out where exactly these elements can be improved upon, and

become the most effective. Once that is developed, they then figure out how to organize it in

the neatest and cleanest way. They then make the things they sorted, strengthened and shined,

the more effective way of doing things, in other words, it becomes the new standard. Finally

once the first “4 S’s” are complete, it comes down to simply sustaining that standard, as well

as always striving to better it, improve upon it and update it4.

In collaboration with Renee Peterson, Assistant Chief of Nursing Services, the

Detroit VA’s Systems Redesign Team revamped the cart to what it is today. They brought

down the cumbersome number of 37 items to a more manageable 23. Using various bins

within the medical drawers, the issue of sliding and the mixing up of various medical tools

and medicine was addressed. They also made it significantly easier for the medical tools to be

relocated by labeling where every single item goes directly on the cart. The cart is also loaded

with various instruction books for first responders. Not only are the lives of clinicians made

easier, but the improvements make for better care for our Veteran patients4.These

improvements will make using the carts more effective, and more efficient. The Systems

Redesign team says that when actually timed, nurses using the cart cut their action time

drastically4.

Organizing a crash or code cart requires knowing the progression of the

"Advanced Cardiac Life Support" process, established by the American Heart Association.

Crash carts, found in most health care facilities, have five, seven or nine drawers containing

supplies used when responding to a life-threatening emergency. Found in strategic locations

throughout the hospital or health care facility, crash carts should be easily accessible to health

care providers, inventoried, and restocked on a regular basis5.

The investigator had come across many incidents in his experience in nursing

profession where many nurses were not having Knowledge regarding crash carts is very

important that emergency nurses should develop the skills regarding organization, uses and

care of crash carts in hospitals. Hence, from these instincts the investigator was motivated

and planned for doing awareness programme with the help of a teaching material5.

6.3 REVIEW OF LITERATURE

Review of literature for the present study is explained under the following headings,

1) Literature related to knowledge of staff nurses on Crash cart trolley.

2) Literature related to self-instructional module.

3) Literature related to general information regarding Crash cart trolley.

1.

1. Literature related to knowledge of staff nurses on Crash cart trolley.

A study was conducted on intensive care unit nurses knowledge of the Crash cart

trolley. The investigator administered 31 multiple choices question to 168 intensive care

unit nurses from 15 institutions. The mean score was 57% correct. Although 90%of

intensive care unit nurses correctly identify the equipments should be measured, only 61%

were able to measure it correctly, and answer to this practical question varied. The results

of the study indicated that formal training, frequency and exposure to the Crash cart

trolley and professional certification in critical care correlated with better score on the

questionnaire. Additional research is needed on a larger scale to validate these findings

and determine if critical care nurses' knowledge of Crash cart trolley is sufficient to

maintain quality standards of safety and optimal patient care.9

An article was published on assessment of critical care nurses' knowledge of the

Crash cart arrangement. A 37-question multiple-choice examination that tested

knowledge regarding the use of the Crash cart trolley was administered to a group of

nurses, attending a national conference (New Orleans, LA), who preregistered for a

hemodynamic workshop. Two-hundred sixteen nurses completed the questionnaire. The

mean test score was 16.5 +/- 5.7 (48.5%). The study concluded that a wide variation in

the understanding of the use of the Crash cart trolley exists among nurses using this

device in the care of seriously ill patients. The results indicate that current teaching

practices regarding the Crash cart trolley need to be re-evaluated and specific

credentialing policies need to be considered.10

An article was published on expert critical care nurses' use of Crash cart

trolley. This paper reports one component of a study, which used a concept attainment

framework to determine what data 8 expert critical care nurses in relation to Crash cart

trolley used. In addition, participants used few clinical assessment attributes, but collected

a large number of attributes, which they arranged around three to five central concepts

and took a broad view of hemodynamic assessment. One participant did not display many

of the decision-making features normally associated with an expert practitioner. In

conclusion, expert critical care nurses process an immense amount of data in a short space

of time. Evidence suggests not all nurses who practice in the field for a lengthy period

reach the level of an expert.12

2. Literature related to the effectiveness of structured teaching programme.

A study was conducted to determine the effectiveness of structured teaching

programme for nurses on organization of selected emergency drugs to critical care units

by using Crash cart trolley. Findings of the study revealed that the mean pre-test

knowledge scores of nurses on organization of emergency drugs were 22.47, which was

found to be inadequate. There was an increase in the post test knowledge after the

administration of self instructional module.13

An evaluative study was conducted on the effectiveness of self-instructional

module on selected drugs used in critical care units. The pre-test mean percentage

knowledge of nurses was found to be less than 50 %( 49.92%).Findings of the study

indicated that nurses were not adequately equipped with the knowledge on selected drugs.

An increased knowledge score has obtained after the administration of self instructional

module.14

3. Literature related to general information regarding Crash cart trolley.

A study was conducted on knowledge of Crash cart trolley is a basic

emergency medications often utilized to guide therapeutic interventions, especially in

critically ill patients. 391 critical care nurses practicing in various critical care specialties

were invited to participate in the study. The response rate was 17.4% (n = 68). The

participants were asked to complete an 18-item and total scores ranged from 11.1% to

61.1%. Literature on nurses’ knowledge of hemodynamic monitoring is limited, but

several studies, published and unpublished, indicate a general knowledge deficit in use of

crash cart trolley. Because of these research findings, in this article, we focus on areas of

particular knowledge deficit related to essential Crash cart trolley is a basic emergency

medications .15

A descriptive study was conducted, in Finland, to assess the knowledge regarding

use of crash cart trolley medication calculation skills of nurses and self-evaluation of nurses

on it. The result shows that 70% nurses have sufficient skills and 95% of the nurses have

mathematical skills. Moreover, 79% have sufficient knowledge on conversions, solution

calculation (50%), tablet calculation (95%), weight calculation (77%), and infusion rate

calculation (73%).The analysis revealed that the youngest nurses (20-29 years) have adequate

skills, and where as the oldest (50-59 years) have less skill. According to above study

Investigator concludes that the pharmacological skills of the nurses seemed to be inadequate.5

A qualitative study was conducted, in Australia, to explore nursing roles in crash

cart trolley knowledge and nurse’s perception of related education, needed to prepare them

for practice. The finding of the study shows that the, nurses have a limited understanding of

crash cart trolley, and are dissatisfied with pre-registration teaching of the subject, but

recognize the need for emergency knowledge in practice.4

6.4 STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of structured teaching programme on knowledge

regarding organized Crash Cart System among staff nurses working in selected hospitals at

Bangalore”.

6.5. OBJECTIVES OF THE STUDY

1. To assess the pretest knowledge scores of Staff Nurses on Organized Crash cart

system

2. To develop and implement structured teaching programme on Knowledge of Staff

Nurses on Organized Crash cart system

3. To assess the effectiveness of structured teaching programme on knowledge of Staff

Nurses on organized crash cart system in terms of posttest knowledge scores.

4. To find out the association between knowledge scores with their selected socio

demographic data.

6.6. OPERATIONAL DEFINITIONS

1. Assess: It is the organized, systematic and continuous process of collecting data and the

statistical measurement of knowledge regarding organized crash cart system by structured

questionnaire.

2. Effectiveness: It refers to the feedback brought about by the nurses after

structured teaching programmes. It is measured in terms of significant gains in the posttest.

3. Structured teaching programme: In this study, it is systematically developed programme

with teaching aids, designed to impart knowledge, regarding organized crash cart system

among staff nurses.

4. Knowledge: In this study, it refers to the awareness and understanding regarding

organized crash cart system among staff nurses by structured questionnaire.

5. Crash cart: In this study, a crash cart is a trolley for storing life saving equipment and

drugs in a hospital emergency room, Intensive care unit, clinics and other areas.

6. Staff nurses: In this study, Registered nurses are health care providers who provide patient

care, training with a scope of practice.

7. Hospitals: It refers to an institution providing medical and surgical treatment and nursing

care for sick and injured.

6.7. ASSUMPTION

1. The nurses will not have adequate knowledge regarding organized crash cart system

2. The nurses will be expressing their willingness to learn and understand about

organized crash cart system

3. The nurses will gain knowledge after the administration of intervention.

6.8. DELIMITATION

1. The sample size was delimited to 60 staff nurses.

2. The study period was delimited for 4 weeks.

3. The sample was delimited to staff nurses who are presented in selected hospitals at

Bangalore.

4. The study was delimited to staff nurses present during the study.

6.9. HYPOTHESIS

H1∙ There is a significant difference in pre test and posttest knowledge of nurses.

H2∙ There is a significant association between then demographic characteristics and the

posttest knowledge in nurses.

7.0 MATERIALS AND METHODS

7.1 SOURCES OF DATA

Research Design : Experimental, One group pre test and Post test

design

Setting of the study : selected hospitals at Bangalore

Population : staff nurses

Sampling technique : Simple random sampling technique

Sample size : Sample size will be 60

Sampling Criteria:

INCLUSION CRITERIA

Those who are willing to participate in the study.

Staff nurse, who know to speak, read and write in English or Kannada.

Staff nurses who completed GNM and BSc Nursing Course.

Available during the period of data collection

EXCLUSION CRITERIA

Staff nurses those who are not available at the time of study

Staff nurses who completed ANM, MSc and PhD in nursing.

7.2 METHODS OF DATA COLLECTION

After obtaining the permission from the concerned authorities, the investigator will

introduce her/him to the study subjects and explains the purpose of study. The data will be

collected by using structured questionnaire.

Description of the tool : Structured questionnaire

Tool-1

Part-A : Proforma for collecting demographic data

Part-B : Structured questionnaire to assess the knowledge of staff

nurses on organized crash cart system

Tool-2 : Structured teaching programme regarding organized crash

cart system

Methods of Data analysis and interpretation

Pre and posttest scores of knowledge will be analyzed through the following

technique.

Descriptive statistics: Mean, standard deviation, range and mean score percentage will

be used to quantify the level of knowledge before and after structured teaching programme.

Inferential statistics: Paired t-test will be use to examine the effectiveness of

structured teaching programme by comparing the pre- test and post- test score.

Chi-square test will be worked out to determine the association of socio-demographic

factors of staff nurses with pre-test knowledge.

7.3 Does the study require any investigation or intervention to be conducted on the

patients or other human being or animals? If so, please describe briefly.

Yes. Structured teaching programme will be conducted as an intervention to the nurses.

7.4 Has Ethical Clearance been obtained from your institution in case of the above?

Yes, ethical clearance has been obtained from the institution.

7.5. ETHICAL COMMITTEE

Title of the topic

A study to assess the effectiveness of structured teaching

programme on knowledge regarding organized Crash

Cart System among staff nurses working in selected

hospitals at Bangalore.

Name of the candidate Ms. Jolly Johnson A

Course and the subject MSc Nursing in Medical Surgical Nursing

Name of the guide Prof. Paulraj S

Ethical committee Approved

8.0 REFERENCES

1. Black JM. Medical surgical nursing. 7th ed. Philadelphia: Elsevier Publications; 2004.

2. Gladstone J. Drug Administration Errors: A study into the factors underlying the

occurrence and reporting of drug errors in a District General Hospital. Journal of

Advanced Nursing. 1995; 22:628-637.

3. Swapna Naskar Williamson. Emergency Nursing: The need for clinical specialization.

The Nursing Journal of India April2002; LXXXXIII (4):78-9

4. Robin D.Dennison. A Medication safety education programme to reduce the risk of

harm caused by medication errors .The Journal of Continuing Education in

Nursing2007; 38(4): 176-83.

5. Brunner, Suddarth. Textbook of medical surgical nursing. 11th ed. Philadelphia:

Lippincott Publishers; 2008.

6. Sharan D. Repetitive strain injuries. Available from:

URL: http://www.emergencymedicinemims.com/articles_details.php?id=16

7. King RL. Nurses perception On Their emergency Educational Needs. Journal of

Advanced Nursing 2004; 45(4): 392-400.

8. Niemi Hg, Hupli M. Kilpi HL, Puukka P. Medication Calculation Skill of Nurse in

Finland. Journal of Advanced Nursing 2003; 12: 519-28.

9. Guy J Persaud J, Davies E, Harvey D. Drug Errors: What Role Do Nurses And crash

carts have in minimizing the Risk? Journal of Child Health Care 2003; 7(4): 277-90.

10. Baker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL.emergency Medication

Error Observed In 36 Health Care Facilities. Achieves of Internal Medicine 2002;

162: 1897-1903.

11. O’shea E. Factors Contributing To emergency Medication Errors: A Literature

Review. Journal of Clinical Nursing 1999; 8: 496-5 04.

12. Rozario J.M. a study to Asses the knowledge and practices of Nurses in the

Administration of Selected emergency Intravenous drug in Intensive Care units.

Master of Science in Nursing Dissertation; SNDT Women’s University. SNDT

College Of Nursing; Bombay, 1994.

13. Balasaraswathy(1995). A study to determine the effectiveness of self-instructional

module for nurses on administration of emergency drugs to critically ill patients of

selected hospitals in Mangalore. Master science in nursing, Mangalore university.

14. Sams L. M(1997). Effectiveness of structured SIM on selected drugs used in

CCU,for the staff nurses working in these units in selected hospital of

Karnataka.Unpublished MSc thesis. Manipal academy of higher education, Deemed

University.

15. Beate H, Elizabeth J Bridges. Monitoring emergency Intra Arterial Blood Pressure:

What

You May Not Know. Crit Care Nurs. 2007; 22: 60-79.

9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE It is a vital area in the field of emergency

medicine. So studies like this will enhance

the knowledge of staff nurses

11 NAME AND DESIGNATION

11.1 GUIDE Prof. PAULRAJ S

.

11.2 SIGNATURE

11.3 CO-GUIDE-

11.4 SIGNATURE

-

11.5 HEAD OF DEPARTMENT

Prof. PAULRAJ S

11.6 SIGNATURE

12 12.1 REMARK OF THE

CHAIRAN AND PRINCIPAL

The study is feasible and also improves the

knowledge of staff nurses

12.2 SIGNATURE