New guidelines will revamp ED nursing care of cardiac patients
Recommendations require 'change in mindset'
If a patient in your ED goes into cardiac arrest, would your goal be to get the defibrillator to the patient as quickly as possible — even if that means delaying continuous cardiopulmonary resuscitation (CPR)?
If so, you're not in compliance with new guidelines from the American Heart Association (AHA) for emergency cardiovascular care.1
Previously, early defibrillation was the priority, with CPR considered as the intervention to perform only until definitive treatment occurred. "The evidence now suggests that it is only with adequate and continuous CPR that defibrillation can be successful," says Barbara Weintraub, RN, MSN, MPH, APN, CEN, manager of pediatric emergency services at Northwest Community Hospital in Arlington Heights, IL. "The ED nurse's main goal now is to ensure that CPR continues in as uninterrupted a manner as possible."
The new AHA guidelines will affect ED nurses in many ways, but are simpler overall, says Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, clinical educator for the ED at Children's Memorial Hospital in Chicago. For example, nurses no longer need to determine the range of atropine dose for bradycardias or determine ejection fraction status for patients with tachycardias, she explains. "Overall, the new guidelines simplify treatment, with fewer drugs and interventions to learn, and put the focus back on the basics of CPR," she says.
Do continuous CPR
The research indicates that the more continuous the chest compressions, the better the coronary perfusion, says Weintraub. For this reason, the AHA now recommends rescuers do the following:
- For an adult patient with one or two rescuers prior to advanced airway placement: Deliver 30 compressions to two breaths. Push fast and hard.
- For an adult patient with one or two rescuers following advanced airway placement: Deliver continuous compressions at rate of 100 per minute without pause for ventilation, and deliver one ventilation every six to eight seconds.
- For an infant or child with one rescuer: Deliver 30 compressions to two breaths. Push hard and fast.
- For an infant or child with two rescuers: Deliver 15 compressions to two breaths.
The delivery of one shock followed by five cycles/two minutes of CPR is another significant change for the ED, Steinmann says. "This will require more staff members to actually be involved in doing CPR," she explains. "The need to organize resuscitative care around the two-minute/five-cycle will require conscious planning."
The guidelines recommend limiting interruptions in chest compressions to 10 seconds whenever possible. "This is definitely an in-hospital issue, as we have more technology to distract us from making sure the basics are covered," says Steinmann. In the ED, nurses have to address intubation, central lines, drawing labs, obtaining X-rays, echocardiograms, and blood gasses, she explains.
The focus on uninterrupted CPR will require a change in mindset, says Steinmann. "Previously, we were primarily focused on interventions with CPR only when compressions did not interfere with other activities."
According to the new guidelines, maintaining adequate coronary perfusion is the key to improving the patient's chances of survival. "This means that the emphasis in a pulseless arrest situation has moved to the CPR component," says Weintraub. "CPR should
be initiated immediately and continued up until a brief monitor rhythm check is undertaken. CPR should then be resumed immediately."
The new CPR rate is physically demanding, because it requires you to push hard and fast with 30 compressions in fewer than 23 seconds, says Steve Rasmussen, RN, CEN, clinical coordinator for the ED at Virginia Commonwealth University Medical Center in Richmond, VA. "This requires frequent rescuer changes to maintain proper speed and depth due to fatigue," he notes.
In the past, when a patient was found unconscious and pulseless, you would call for help, apply an automated external defibrillator, and use a sequence of up to three shocks without interposed chest compressions, Rasmussen says. "Now you call for help, do CPR, shock once, and immediately continue CPR for two minutes before checking for a pulse," says Rasmussen. (See box below for steps to follow in the ED.)
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Follow these steps for patients in cardiac arrest Based on new American Heart Association guidelines, here are the steps that would occur if a patient was found collapsed in the hospital lobby, says Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, clinical educator for the ED at Children's Memorial Hospital in Chicago: — A code is called, and the automated external defibrillator (AED) from the area is placed on the patient as cardiopulmonary resuscitation (CPR) is in progress. A shockable rhythm is noted and the AED provides one shock. — Immediately after the shock has been delivered, rescuers begin chest compressions and continue CPR for two minutes/five cycles of compressions/ventilations at which time the AED will reanalyze the rhythm and a pulse check can be done. — When the code team arrives and the manual defibrillator is available, the patient is attached to the monitor, disposable defibrillator pads are applied, and the rescuers complete the cycle of compressions/ventilations. — The rhythm is checked and if the patient is still in ventricular fibrillation (VF), the biphasic manual defibrillator is immediately charged to 200 joules to deliver the next shock (360 for a monophasic defibrillator). Immediately after the shock is delivered, chest compressions are resumed, without a pulse check or rhythm analysis. Ventilations are continued with a self-inflating bag connected to an oxygen source. —The team begins to look for intravenous access and prepares to intubate, but intubation will not be attempted until the current set of compression/ventilation cycle is completed. |
Educate nurses
Since many ED nurses have "grown up" with the old system, change may not be easy, says Rasmussen. "It will take a lot of positive reinforcement to initiate this rollout," he says.
This year's changes take basic life support (BLS) and advanced cardiac life support (ACLS) in a very different direction than past AHA updates, says Alisa Murchek, associate director of nursing for critical care and emergency services at University of Illinois Medical Center at Chicago. "These changes will necessitate a huge change in some of the general principles we have ingrained in our practice," she says.
For example, she notes that three stacked shocks of increasing voltage have been part of ACLS and pediatric advanced life support (PALS) practice for more than a decade. "Changing this practice to a single shock followed by two minutes of CPR will not come naturally to ED nurses," says Murchek. "We are really going to have to work hard to internalize this."
At the University of Illinois Medical Center, all BLS instructors are teaching the new guidelines, and all ACLS instructors have obtained competencies in the new material, says Murchek. "Our BLS instructors are nurses, so they face the task of re-educating and then observing real-time clinical practice to ensure all staff are following the new BLS ratios in an arrest situation," says Murchek. "Our ED nurses will need to ensure that they recertify in ACLS and BLS as soon as possible."
To ensure compliance with the new AHA guidelines, ED nurses at Children's were given a mandatory CPR update. "We have also posted the new algorithms in our code books as ready references," says Weintraub.
At Children's, a bulletin board was posted in the ED highlighting the changes in PALS, BLS, and ACLS. "We discussed the changes at our all-day ED education days, and the new changes have been incorporated into all our resuscitation classes," says Steinmann.
At Covenant Healthcare in Saginaw, MI, ED nurses officially are being taught the new CPR method by the education department when they are due for CPR recertification. "In the meantime, we have already 'trained' our entire ED staff via a memo, as well as providing numerous AHA skills books throughout the department," says Marc Augsburger, RN, BSN, manager of the emergency care center. "That way, they are knowledgeable of the changes and how to operate for the future."
Reference
1. Hazinski MF, Nadkarni VM, Hickey RW, et al. Major changes in the 2005 AHA guidelines for CPR and ECC: Reaching the tipping point for change. Circ 2005; 112:206-211.
Sources
For more information about the new American Heart Association guidelines, contact:
- Marc Augsburger, RN, BSN, Manager, Emergency Care Center, Covenant HealthCare, 900 Cooper Ave., Saginaw, MI 48602. Telephone: (989) 583-6259. Fax: (989) 583.7181. E-mail: [email protected].
- Alisa Murchek, Associate Director of Nursing, Critical Care and Emergency Services, University of Illinois Medical Center at Chicago, 1740 W. Taylor St., Suite 1600, M/C 722, Chicago, IL 60612. Telephone: (312) 996-9898. Fax: (312) 996-7335. E-mail: [email protected].
- Steve Rasmussen, RN, CEN, Clinical Coordinator, Emergency Department, Virginia Commonwealth University Medical Center, 1250 E. Marshall St., Richmond, VA 23298. Telephone: (804) 828-7330. E-mail: [email protected].
- Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS. Clinical Educator, Emergency Department, Children's Memorial Hospital, 2300 Children's Plaza, Box 66, Chicago, IL 60614. Telephone: (773) 975-8764. [email protected].
- Barbara Weintraub, RN, MSN, MPH, APN, CEN, Manager, Pediatric Emergency Services, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: [email protected].
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