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by Sandra Sawyer Silva, RN, CCRN, nurse manager of the intensive care unit and chairperson of the CPR review committee at The Miriam Hospital. (Published October 9, 2001, Nursing Spectrum)
This scenario has occurred countless times over the past 10 years at The Miriam Hospital, Providence, RI, where we have installed AEDs in all areas of the hospital except critical care. Why would a teaching hospital use a device designed for lay responders? Not As Good As We ThoughtSince 1979, The Miriam Hospital has had an in-house Advanced Cardiac Life Support (ACLS) program. All medical residents and nearly every critical care nurse, has completed the American Heart Association (AHA) program for ACLS. Because a large number of our caregivers were trained in ACLS, we expected our survival to discharge rates for cardiac arrest victims to be higher than the national average. While our data did reveal a higher survival to discharge rate, we still felt there was opportunity for improvement. In 1985, we collected data from all areas outside of critical care to determine the average length of time until the first defibrillatory shock was delivered to patients with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Despite 24-hour, ACLS-trained house staff medical coverage and a relatively small hospital, it took an average of seven to 10 minutes to deliver the first shock on a med/surg unit. This finding surprised us. Try, Try AgainOur goal was to reduce the time to first defibrillation to four minutes. Our first corrective action was to train all of the nurses on the cardiac telemetry units to perform manual defibrillation using a conventional defibrillator. We repeated our time study several months after the training was completed and found that there was no significant improvement. We conducted attitudinal surveys of the nursing staff and discovered that despite the training, the nurses still did not feel comfortable delivering a shock in the absence of a physician. Our next attempt to improve the time to defibrillation was to redesign our code team. The redesigned team was more efficient, but the time to first defibrillation did not improve. Success At LastIn 1990, William Kaye, MD, then director of critical care medicine, suggested equipping the hospital with three AEDs. He was active in both national and international resuscitation practice and was convinced that the use of AEDs would improve our time to first defibrillation. Physicians and nurses initially viewed the use of AEDs with skepticism. Despite the resistance, Kaye organized a pilot program to install six AEDs on two 30-bed telemetry units. All of the nurses on the telemetry unit participated in a two-hour training program that combined discussion of defibrillation theory and the actual use of an AED. After the training, all of the nurses were able to perform a three-shock defibrillation sequence using the AED in less than 2 minutes. The same nurses were retested in three to six months. Nearly all (95%) of the nurses were able to demonstrate the skill without further instruction.1 These nurses were the same group we had trained to use the conventional defibrillator. Attitudinal surveys about AED use found that these nurses were now much more likely to use it. In fact, they felt empowered by the AEDs because they could provide life-saving treatment without a physician being present. The pilot program lasted 18 months. It proved to be so successful that we installed AEDs in all noncritical care areas of the hospital in the fall of 1991. Kaye and the resuscitation committee continued to monitor and analyze arrest data. Analysis of arrests where the AED was used on the original pilot units for the period from 1991 to 1995 revealed an amazing improvement. Patients with VT/VF arrests on whom the AED was used, had a 60% survival to discharge rate. Clearly the speed at which these patients were defibrillated was the significant factor. A Pilot Becomes A StandardKaye has retired, but his legacy remains with The Miriam Hospital being the first hospital in the world to use AEDs on hospitalized patients. We have improved our time to first defibrillation to two minutes or less in noncritical care areas, and we have a survival-to-discharge rate for VT/VF victims that is consistently above the national average. We think those statistics speak volumes. Many other hospitals have instituted their own AED programs. The 2000 guidelines published by the American Heart Association now recommend AED use in hospitals. It also has incorporated AED training into the Healthcare Provider BLS program.2 Since the use of AEDs in the hospital has a positive effect on patient outcomes, all 22 of our aging AEDs were replaced with new, state-of-the-art biphasic AEDs. We are committed to the two-tiered approach to defibrillation - it's just better patient care. *Name has been changed. References
Article copyright Nursing Spectrum
Nurse Wire (www.nursingspectrum.com). |
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