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The weakest link in the chain of survival?
The weakest link in the chain of survival? Author: E. M a r i e Wilson, R_N,MPA, Westbrook, C o n n e c t i c u t
ebruary is Heart M o n t h - - a good time to look at all the places you frequent to see if y o u will be taken care of well w h e n you have your heart attack. Could the local hospital be the w e a k e s t link in your chain of survival? Lonnie G.,* a 53-year-old woman, w a s recovering from a right h e m i c o l e c t o m y on the medical-surgical nursing unit. Although she h a d some v a g u e discomfort in her chest a n d back, she did not think too m u c h of it. After all, she h a d b e e n through so m u c h t h a t some a c h e s and pains were to be expected. When a s u d d e n s p a s m of p a i n s w e p t over her, she s w i t c h e d on her call light and waited. By the time her nurse r e a c h e d the bedside, the pain w a s excruciating. Then her heart stopped. Her nurse m a d e the "Code Blue" call and started CPR. Then at 2 AM, he w a i t e d for help to come. In this hospital, that m e a n t from the e m e r g e n c y department, at the other end of the building, three floors down.
F
A l m o s t all i n - h o u s e c a r d i a c emergencies occurred on the m e d i c a l - s u r g i c a l floors. Lonnie G. died, b u t the m e m o r y of this night did not. Some of the ED staff b e g a n to c o m p a r e the hospital's r e s p o n s e to Lonnie's cardiac arrest with the c o m m u n i t y ' s r e s p o n s e to similar incidents. During the last few years some of the ED staff h a d b e e n actively c a m p a i g n i n g with the local volunteer EMS a n d fire d e p a r t m e n t s to provide a better r e s p o n s e to potential cardiac p a t i e n t s in the community. In their c a t c h m e n t area they h a d a t t e n d e d meetings, lobbied town officials, and s o u g h t any m e a n s to convince the EMTs that there was a better w a y to help people in their towns. As a result fire d e p a r t m e n t first responders had b o u g h t s e m i a u t o m a t i c external defibrillators (SAEDs), trained firefighter medical response t e c h n i c i a n s and *A pseudonym. E. Marie Wilsonis Principal, Riverside Solutions. J Emerg Nurs 1998;24:69-70. Copyright © 1998 by the Emergency Nurses Association. 0099-1767/98 $5.00 + 0 18/9/87018
EMTs to use them, and instituted simultaneous disp a t c h of fire and a m b u l a n c e responders to potential cardiac calls. During the first 3 years of the program some of their patients m a d e it to the e m e r g e n c y d e p a r t m e n t alive, but none survived to discharge; the d a m a g e had b e e n too great.
B e c a u s e t h e n u r s i n g staff m e m b e r s w e r e already certified in CPR, t h e total training t i m e w a s a b o u t 2 h o u r s to a c h i e v e c o m p e t e n c e . The next step w a s to a d d the A d v a n c e d Life Support c o m p o n e n t to the response teams. Again, the ED staff p r e p a r e d the way, arguing for a param e d i c i n t e r c e p t program that would provide a param e d i c to m e e t with the ambulance, usually within 15 m i n u t e s of dispatch, to a c c o m p a n y the p a t i e n t to the hospital while a d m i n i s t e r i n g prehospital A d v a n c e d Cardiac Life Support (ACLS). Many w o n d e r e d if such a program w a s feasible for this large, rural area covering 11 towns a n d more than 30 fire and a m b u l a n c e companies. Nevertheless, the volunteer responder consortium p a r t n e r e d with the hospital a n d an i n t e r e s t e d private EMS provider to institute a p a r a m e d i c intercept response program, centrally b a s e d in the area, and simultaneously d i s p a t c h e d to all life-threatening m e d i c a l e m e r g e n c i e s , a c c o r d i n g to p r e s e t protocols. During the p a s t 4 years, several p a t i e n t s in cardiac arrest in the field have survived to d i s c h a r g e from the hospital. The s a m e ED staff m e m b e r s who h a d helped promote the cardiac response program in the community b e g a n to look within their own institution. Their study m a d e t h e m realize that their in-house response w a s not as efficient as t h a t in the community. Although they could provide ACLS m e a s u r e s within the 15-minute window, the lack of a quick first response severely c o m p r o m i s e d their patients. Why couldn't the hospital provide as well for its patients and visitors as the community? If the volunteer responders could formulate a response plan and train their people, couldn't the hospital do the s a m e ?
February 1998 69
JOURNAL OF EMERGENCY NURSING/Wilson
T h e ED d i r e c t o r led t h e way, c o n v i n c i n g h o s p i t a l a d m i n i s t r a t i o n that, a l t h o u g h t h e r e w a s a t i m e l y o r g a n i z e d r e s p o n s e s y s t e m , it d i d n o t c o n t a i n all t h e c o m p o n e n t s n e c e s s a r y to c a r e for c a r d i a c arrest. H e c i t e d t h e A m e r i c a n H e a r t A s s o c i a t i o n ' s "Chain of Survival ''1 w h i c h calls for: • Early a c c e s s • Early CPR • Early defibrillation • Early ALS m e a s u r e s After m a n y d i s c u s s i o n s a n d m e e t i n g s t h e d i r e c tor w a s e n c o u r a g e d to m e e t w i t h m e d i c a l a n d nursi n g staffs to find a w a y to d e c r e a s e t h e r e s p o n s e t i m e for t r a i n e d r e s p o n d e r s . A t their initial m e e t i n g s t h e following facts w e r e stated: 1. A l m o s t all i n - h o u s e c a r d i a c e m e r g e n c i e s occ u r r e d on t h e m e d i c a l - s u r g i c a l floors. 2. P a t i e n t s a n d visitors w e r e v i c t i m s of c a r d i a c episodes. 3. T h e e m e r g e n c y d e p a r t m e n t w a s staffed b y A C L S - t r a i n e d p e r s o n n e l at all t i m e s . 4. T h e m e d i c a l - s u r g i c a l units w e r e a t t h e far e n d of t h e h o s p i t a l from t h e e m e r g e n c y d e p a r t m e n t . 5. W h e n c a r d i a c a r r e s t o c c u r s , a n e q u i p p e d t r a i n e d r e s p o n d e r is n e e d e d w i t h i n 4 to 6 minutes. It b e c a m e clear t h a t i n c r e a s e d r a t e s of survival of i n - h o u s e c a r d i a c a r r e s t d e p e n d e d on t r a i n i n g a n d e q u i p p i n g p e r s o n n e l on t h e m e d i c a l - s u r g i c a l u n i t s to i n t e r v e n e until m o r e h i g h l y t r a i n e d p e r s o n n e l could r e s p o n d from t h e e m e r g e n c y d e p a r t m e n t . T h e h o s p i t a l p u r c h a s e d SAEDs for e a c h of t h e t h r e e m e d i c a l - s u r g i c a l units. A n i n s t r u m e n t a t i o n t e c h n i c i a n a l r e a d y m a i n t a i n e d all of t h e ED a n d preh o s p i t a l defibrillators, so t h e n e w o n e s w e r e a d d e d to his responsibility, e l i m i n a t i n g t h e n e e d for a serv i c e c o n t r a c t . All n u r s i n g staff w e r e t r a i n e d in u s e of t h e SAEDs in c l a s s e s h e l d d u r i n g w o r k hours or in i n d i v i d u a l tutorial s e s s i o n s . B e c a u s e t h e n u r s i n g staff m e m b e r s w e r e a k e a d y certified in CPR, t h e total t r a i n i n g t i m e w a s a b o u t 2 h o u r s to a c h i e v e competence.
70 Volume 24, Number 1
T o d a y w h e n t h e r e is a p o s s i b l e c a r d i a c e m e r g e n c y on a h o s p i t a l floor unit, t h e n u r s e is notified, t h e SAED is b r o u g h t to b e d s i d e , a n d t h e e m e r g e n c y d e p a r t m e n t is notified. T h e n u r s e a s s e s s e s a n d t a k e s t h e a c t i o n s w a r r a n t e d , i n c l u d i n g defibrillation a n d CPR. A p h y s i c i a n from t h e e m e r g e n c y d e p a r t m e n t r e s p o n d s w i t h a "crash cart" t h a t i n c l u d e s a 12-lead EKG m a c h i n e , c a p n o g r a p h y e q u i p m e n t , a n d c a r d i a c medications. The respiratory therapy department also r e s p o n d s to a s s i s t w i t h ventilation. A l t h o u g h t h e h o s p i t a l h a s k e p t no d a t a in t h e 5 years since the cardiac emergency response program s t a r t e d , one n u r s e c a n i d e n t i f y at l e a s t t h r e e p a t i e n t s w h o w e r e t r e a t e d w i t h defibrillation, t w o of w h o m r e c o v e r e d to d i s c h a r g e . A n u n d e t e r m i n e d a d d i t i o n a l n u m b e r r e c e i v e d t r e a t m e n t for early c a r d i a c e m e r g e n c y s y m p t o m s t h a t d i d n o t p r o g r e s s to c a r d i a c arrest. T h e staff a t t r i b u t e s t h e h e i g h t e n e d a w a r e n e s s of c a r d i a c s y m p t o m s a n d p r o m p t r e s p o n s e of t h e u n i t n u r s e s to t h e s e p a t i e n t s as t h e r e a s o n s for t h i s i m p r o v e m e n t in p a t i e n t o u t c o m e s . H o w a b o u t your h o s p i t a l ? A r e your o u t c o m e s a s g o o d a s your p r e h o s p i t a l p r o v i d e r s ' for c a r d i a c e m e r g e n c i e s ? If not, F e b r u a r y is a g o o d m o n t h - - h e a r t m o n t h - - t o b e g i n to b e p a r t of t h e solution to u n t i m e ly d e a t h s from c a r d i a c d i s e a s e .
Reference 1. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the "chain of survival" c o n c e p t - - a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee of the American Heart Association. Circulation 1991;83:1832-47.
Contributions for this column shouM be sent to E. M a r i e Wilson, RN, MPA, 35 Chapman Mill Pond Rd., Westbrook, CT 06498; phone (860) 669-4443; E-maik [email protected]; or Connie J. Mattera, RN, CEN, EMT-P, 6801 iV. Olcott, Chicago, IL 60631; phone (847) 618-4485.
ebruary is Heart M o n t h - - a good time to look at all the places you frequent to see if y o u will be taken care of well w h e n you have your heart attack. Could the local hospital be the w e a k e s t link in your chain of survival? Lonnie G.,* a 53-year-old woman, w a s recovering from a right h e m i c o l e c t o m y on the medical-surgical nursing unit. Although she h a d some v a g u e discomfort in her chest a n d back, she did not think too m u c h of it. After all, she h a d b e e n through so m u c h t h a t some a c h e s and pains were to be expected. When a s u d d e n s p a s m of p a i n s w e p t over her, she s w i t c h e d on her call light and waited. By the time her nurse r e a c h e d the bedside, the pain w a s excruciating. Then her heart stopped. Her nurse m a d e the "Code Blue" call and started CPR. Then at 2 AM, he w a i t e d for help to come. In this hospital, that m e a n t from the e m e r g e n c y department, at the other end of the building, three floors down.
F
A l m o s t all i n - h o u s e c a r d i a c emergencies occurred on the m e d i c a l - s u r g i c a l floors. Lonnie G. died, b u t the m e m o r y of this night did not. Some of the ED staff b e g a n to c o m p a r e the hospital's r e s p o n s e to Lonnie's cardiac arrest with the c o m m u n i t y ' s r e s p o n s e to similar incidents. During the last few years some of the ED staff h a d b e e n actively c a m p a i g n i n g with the local volunteer EMS a n d fire d e p a r t m e n t s to provide a better r e s p o n s e to potential cardiac p a t i e n t s in the community. In their c a t c h m e n t area they h a d a t t e n d e d meetings, lobbied town officials, and s o u g h t any m e a n s to convince the EMTs that there was a better w a y to help people in their towns. As a result fire d e p a r t m e n t first responders had b o u g h t s e m i a u t o m a t i c external defibrillators (SAEDs), trained firefighter medical response t e c h n i c i a n s and *A pseudonym. E. Marie Wilsonis Principal, Riverside Solutions. J Emerg Nurs 1998;24:69-70. Copyright © 1998 by the Emergency Nurses Association. 0099-1767/98 $5.00 + 0 18/9/87018
EMTs to use them, and instituted simultaneous disp a t c h of fire and a m b u l a n c e responders to potential cardiac calls. During the first 3 years of the program some of their patients m a d e it to the e m e r g e n c y d e p a r t m e n t alive, but none survived to discharge; the d a m a g e had b e e n too great.
B e c a u s e t h e n u r s i n g staff m e m b e r s w e r e already certified in CPR, t h e total training t i m e w a s a b o u t 2 h o u r s to a c h i e v e c o m p e t e n c e . The next step w a s to a d d the A d v a n c e d Life Support c o m p o n e n t to the response teams. Again, the ED staff p r e p a r e d the way, arguing for a param e d i c i n t e r c e p t program that would provide a param e d i c to m e e t with the ambulance, usually within 15 m i n u t e s of dispatch, to a c c o m p a n y the p a t i e n t to the hospital while a d m i n i s t e r i n g prehospital A d v a n c e d Cardiac Life Support (ACLS). Many w o n d e r e d if such a program w a s feasible for this large, rural area covering 11 towns a n d more than 30 fire and a m b u l a n c e companies. Nevertheless, the volunteer responder consortium p a r t n e r e d with the hospital a n d an i n t e r e s t e d private EMS provider to institute a p a r a m e d i c intercept response program, centrally b a s e d in the area, and simultaneously d i s p a t c h e d to all life-threatening m e d i c a l e m e r g e n c i e s , a c c o r d i n g to p r e s e t protocols. During the p a s t 4 years, several p a t i e n t s in cardiac arrest in the field have survived to d i s c h a r g e from the hospital. The s a m e ED staff m e m b e r s who h a d helped promote the cardiac response program in the community b e g a n to look within their own institution. Their study m a d e t h e m realize that their in-house response w a s not as efficient as t h a t in the community. Although they could provide ACLS m e a s u r e s within the 15-minute window, the lack of a quick first response severely c o m p r o m i s e d their patients. Why couldn't the hospital provide as well for its patients and visitors as the community? If the volunteer responders could formulate a response plan and train their people, couldn't the hospital do the s a m e ?
February 1998 69
JOURNAL OF EMERGENCY NURSING/Wilson
T h e ED d i r e c t o r led t h e way, c o n v i n c i n g h o s p i t a l a d m i n i s t r a t i o n that, a l t h o u g h t h e r e w a s a t i m e l y o r g a n i z e d r e s p o n s e s y s t e m , it d i d n o t c o n t a i n all t h e c o m p o n e n t s n e c e s s a r y to c a r e for c a r d i a c arrest. H e c i t e d t h e A m e r i c a n H e a r t A s s o c i a t i o n ' s "Chain of Survival ''1 w h i c h calls for: • Early a c c e s s • Early CPR • Early defibrillation • Early ALS m e a s u r e s After m a n y d i s c u s s i o n s a n d m e e t i n g s t h e d i r e c tor w a s e n c o u r a g e d to m e e t w i t h m e d i c a l a n d nursi n g staffs to find a w a y to d e c r e a s e t h e r e s p o n s e t i m e for t r a i n e d r e s p o n d e r s . A t their initial m e e t i n g s t h e following facts w e r e stated: 1. A l m o s t all i n - h o u s e c a r d i a c e m e r g e n c i e s occ u r r e d on t h e m e d i c a l - s u r g i c a l floors. 2. P a t i e n t s a n d visitors w e r e v i c t i m s of c a r d i a c episodes. 3. T h e e m e r g e n c y d e p a r t m e n t w a s staffed b y A C L S - t r a i n e d p e r s o n n e l at all t i m e s . 4. T h e m e d i c a l - s u r g i c a l units w e r e a t t h e far e n d of t h e h o s p i t a l from t h e e m e r g e n c y d e p a r t m e n t . 5. W h e n c a r d i a c a r r e s t o c c u r s , a n e q u i p p e d t r a i n e d r e s p o n d e r is n e e d e d w i t h i n 4 to 6 minutes. It b e c a m e clear t h a t i n c r e a s e d r a t e s of survival of i n - h o u s e c a r d i a c a r r e s t d e p e n d e d on t r a i n i n g a n d e q u i p p i n g p e r s o n n e l on t h e m e d i c a l - s u r g i c a l u n i t s to i n t e r v e n e until m o r e h i g h l y t r a i n e d p e r s o n n e l could r e s p o n d from t h e e m e r g e n c y d e p a r t m e n t . T h e h o s p i t a l p u r c h a s e d SAEDs for e a c h of t h e t h r e e m e d i c a l - s u r g i c a l units. A n i n s t r u m e n t a t i o n t e c h n i c i a n a l r e a d y m a i n t a i n e d all of t h e ED a n d preh o s p i t a l defibrillators, so t h e n e w o n e s w e r e a d d e d to his responsibility, e l i m i n a t i n g t h e n e e d for a serv i c e c o n t r a c t . All n u r s i n g staff w e r e t r a i n e d in u s e of t h e SAEDs in c l a s s e s h e l d d u r i n g w o r k hours or in i n d i v i d u a l tutorial s e s s i o n s . B e c a u s e t h e n u r s i n g staff m e m b e r s w e r e a k e a d y certified in CPR, t h e total t r a i n i n g t i m e w a s a b o u t 2 h o u r s to a c h i e v e competence.
70 Volume 24, Number 1
T o d a y w h e n t h e r e is a p o s s i b l e c a r d i a c e m e r g e n c y on a h o s p i t a l floor unit, t h e n u r s e is notified, t h e SAED is b r o u g h t to b e d s i d e , a n d t h e e m e r g e n c y d e p a r t m e n t is notified. T h e n u r s e a s s e s s e s a n d t a k e s t h e a c t i o n s w a r r a n t e d , i n c l u d i n g defibrillation a n d CPR. A p h y s i c i a n from t h e e m e r g e n c y d e p a r t m e n t r e s p o n d s w i t h a "crash cart" t h a t i n c l u d e s a 12-lead EKG m a c h i n e , c a p n o g r a p h y e q u i p m e n t , a n d c a r d i a c medications. The respiratory therapy department also r e s p o n d s to a s s i s t w i t h ventilation. A l t h o u g h t h e h o s p i t a l h a s k e p t no d a t a in t h e 5 years since the cardiac emergency response program s t a r t e d , one n u r s e c a n i d e n t i f y at l e a s t t h r e e p a t i e n t s w h o w e r e t r e a t e d w i t h defibrillation, t w o of w h o m r e c o v e r e d to d i s c h a r g e . A n u n d e t e r m i n e d a d d i t i o n a l n u m b e r r e c e i v e d t r e a t m e n t for early c a r d i a c e m e r g e n c y s y m p t o m s t h a t d i d n o t p r o g r e s s to c a r d i a c arrest. T h e staff a t t r i b u t e s t h e h e i g h t e n e d a w a r e n e s s of c a r d i a c s y m p t o m s a n d p r o m p t r e s p o n s e of t h e u n i t n u r s e s to t h e s e p a t i e n t s as t h e r e a s o n s for t h i s i m p r o v e m e n t in p a t i e n t o u t c o m e s . H o w a b o u t your h o s p i t a l ? A r e your o u t c o m e s a s g o o d a s your p r e h o s p i t a l p r o v i d e r s ' for c a r d i a c e m e r g e n c i e s ? If not, F e b r u a r y is a g o o d m o n t h - - h e a r t m o n t h - - t o b e g i n to b e p a r t of t h e solution to u n t i m e ly d e a t h s from c a r d i a c d i s e a s e .
Reference 1. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the "chain of survival" c o n c e p t - - a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee of the American Heart Association. Circulation 1991;83:1832-47.
Contributions for this column shouM be sent to E. M a r i e Wilson, RN, MPA, 35 Chapman Mill Pond Rd., Westbrook, CT 06498; phone (860) 669-4443; E-maik [email protected]; or Connie J. Mattera, RN, CEN, EMT-P, 6801 iV. Olcott, Chicago, IL 60631; phone (847) 618-4485.