Towards early defibrillation--a nurse training programme in the use of automated external defibrillators

Hospital-wide first-responder automated external defibrillator programme: 1 year experience

The first year experience with a hospital-wide first-responder automated external defibrillator (AED) programme implemented in a 683-bed University Hospital is reported. Throughout the hospital, 14 "AED access spots" were identified which could be easily reached from all wards and diagnostic rooms within 30s. AEDs were installed (Lifepak 500; Medtronik PhysioControl Corp., Redmond, USA, equipped with a Biolog 3000i portable ECG monitor; Micromedical Industries Ltd., Labrador, Australia). Within 3 months, 120 medical officers, 750 nurses, and 50 administrative or technical staff underwent a 2h training programme. An AED was applied and activated by nurses/medical staff before the cardiac arrest team arrived in 27 of 33 cases (81.8%) of witnessed cardiac arrest. The median time from onset of the emergency call to the activation of the AED (record of ECG) was on average 2.1 min (range 1.0--4.5 min). In 18 of 27 cases in which the AED was installed promptly, the primary arrest rhythm was either VT or VF, and the AED delivered a shock. For this subgroup, the rate of return of spontaneous circulation and the rate of discharge at home were 88.9 and 55.6%, respectively. This encourages us to extend the concept of first-responder AED-defibrillation throughout our hospital.

Skill acquisition and retention in automated external defibrillator (AED) use and CPR by lay responders: a prospective study

This prospective study evaluated the acquisition and retention of skills in cardio-pulmonary resuscitation (CPR) and the use of the automated external defibrillator (AED) by lay volunteers involved in the Department of Health, England National Defibrillator Programme. One hundred and twelve trainees were tested immediately before and after and initial 4-h class; 76 were similarly reassessed at refresher training 6 months later. A standardised test scenario that required assessment of the casualty, CPR and the use of on AED was evaluated using recording manikin data and video recordings. Before training only 44% of subjects delivered a shock. Afterwards, all did so and the average delay to first shock was reduced by 57 s. All trainees placed the defibrillator electrodes in an "acceptable" position after training, but very few did so in the recommended "ideal" position. After refresher training 80% of subjects used the correct sequence for CPR and shock delivery, yet a third failed to perform adequate safety checks before all shocks. The trainees self-assessed AED competence score was 86 (scale 0-100) after the initial class and their confidence that they would act in a real emergency was rated at a similar level. Initial training improved performance of all CPR skills, although all except compression rate had deteriorated after 6 months. The proportion of subjects able to correctly perform most CPR skill was higher following refresher training that after the initial class. Although this course was judged to be effective in teaching delivery of counter-shocks, the need was identified for more emphasis on positioning of electrodes, pre-shock safety checks, airway opening, ventilation volume, checking for signs of a circulation, hand positioning, and depth and rate of chest compressions.

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

INTRODUCTION

The outcome from in-hospital cardiac arrest has improved little since the implementation of cardiopulmonary resuscitation 40 years ago. Early defibrillation improves survival following ventricular fibrillation and pulseless ventricular tachycardia. The emergence of automatic external defibrillators and advisory defibrillators has been heralded as the answer to defibrillation delays in-hospital.

AIM

To locate and evaluate the evidence supporting automatic external defibrillator use in-hospital on general wards.

METHOD

A systematic review of indexed and grey literature to identify primary research.

RESULTS

Fifteen in-hospital automatic external defibrillator studies were located, five met the inclusion criteria.

CONCLUSIONS

There is limited primary research evaluating automatic external defibrillators in-hospital. Manual defibrillators remain the most commonly used device for in-hospital defibrillation. Automated external defibrillators offer an alternative to manual defibrillation providing they have a screen and manual override capability, and the technology for pacing is close to hand. For in-hospital automatic external defibrillator programmes to be effective a change in nursing philosophy must occur, and defibrillation must become an expected rather than an extended nursing role.

Advanced life support skills undertaken by nurses--UK survey

Many nurses successfully complete the Resuscitation Council (UK), European Resuscitation Council, advanced life support (ALS) Provider Course. Acquiring ALS provider status is not necessarily a licence to practice and individual hospital policy determines which skills these nurses can then perform without direct medical supervision. This postal survey aimed to determine which ALS skills are utilised by nurse ALS providers working in a variety of clinical areas within acute hospitals in the UK. A questionnaire was sent to the Resuscitation Officer or Nursing Director of all acute hospital groups in the UK. Almost 261 (87%) of the questionnaires were completed and returned. Nurse ALS providers in 99% of coronary care units, 89% of intensive care units, and 88% of accident and emergency departments undertook manual defibrillation. The majority of hospitals ran compulsory in-house training sessions for intravenous cannulation. Laryngeal mask insertion by nurse ALS providers was permitted in 19% of coronary care units and in the wards of 16% of the responding hospitals. Tracheal intubation by nurse ALS providers working in coronary care units, intensive care units and emergency departments was permitted by 11% of the responding hospitals. This survey has demonstrated that many acute hospitals do not permit nurse ALS providers to use a number of the skills taught on the ALS provider course. General ward-based nurse ALS providers, in particular, are restricted in the ALS skills, they are permitted to use. It would be more efficient for nurses to be trained and assessed specifically in skills they are then permitted to use. Having been assessed in a given skill and achieved a nationally recognised standard, nurse ALS providers should be permitted to use it in clinical practice.

A strategy for nurse defibrillation in general wards

Reducing the delay to defibrillation has a major impact on chance of survival from cardiac arrest. A high proportion of cardiac arrests occur in general ward areas, and the teaching and application of defibrillation is as much a priority there as in high dependency areas. The patients most likely to survive in-hospital cardiac arrests are those whom return of spontaneous circulation had been achieved by the first responder. In most clinical areas the first responder is likely to be a nurse. Nurses in Brighton had been taught manual defibrillation for many years, but were often reluctant to use their skills. We introduced a course specifically designed for ward nurses, covering rhythm recognition and defibrillation, with the objective of training large numbers and making the skill so prevalent that it would become an accepted nurse procedure.

RESULTS

Ninety-eight nurses were trained during 1996. By the end of that year, nurses in general ward areas performed defibrillation in 80% of all cases where a shock was required at any time during the resuscitation attempt. However, only 3/25 (12%) of patients in a primary shockable rhythm were defibrillated before a member of the cardiac arrest team arrived. One hundred and forty-nine additional nurses were trained during 1997/8. By the end of this two year period there was no increase in the overall percentage of nurse defibrillations, but the number of patients in primary VF/VT defibrillated before the arrival of the cardiac arrest team had markedly increased to 17/37 (46%, P < 0.02). During this period the overall hospital survival to discharge from primary VF/VT showed a non significant improvement from 41 to 55%.

CONCLUSION

We believe that it is not sufficient simply to permit nurse defibrillation, it must be perceived as a routine skill within the environment of an acute hospital.

Automatic external defibrillators in the hospital as well?

When a cardiac arrest occurs in a non-intensive area of the hospital, the emergency response is not always adequate from the point of view of timeliness and technical quality. The aims of this study were evaluate an experimental programme to improve the CPR skills of staff operating in non-intensive areas of our general hospital and to test the usefulness of placing automatic external defibrillators (AEDs) within these areas. In the experimental phase, two AEDs were placed in 2 non-intensive wards of our hospital for 8 months. The staff of these wards received specific training in CPR and early defibrillation (CPR-D). The devices were used in 19 cases; for defibrillation in four cases of ventricular fibrillation (VF) (three patients were discharged alive from hospital), and for monitoring three supraventricular arrhythmias, one bradyarrhythmia and 11 cardiac rhythms during critical situations. In the implementation phase, four AEDs were indefinitely assigned to as many non-intensive awards. Periodical CPR-D courses and refresher exercises were run; the cardiology staff co-operated in the maintenance of the AEDs and in the registration of technical and clinical data. In the first period of this phase (9 months), AEDs were utilized in 24 cases by the ward-staff: in nine cases for VF (three patients were discharged alive from hospital) and in 15 cases for other rhythm detection in critical conditions. The number and the quality of these uses seem to confirm the favourable impact of the adoption of a more user-friendly defibrillator, such as an AED. The active co-operation between intensive and non-intensive staff was important to facilitate a quick activation of the chain of survival outside the intensive care units. We conclude that AEDs, which were developed for out-of-hospital use by non-physician operators, are suitable for use inside the hospital as well.