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Cardiac Arrest in Ambulatory Surgery
MARCH 1987. VOL. 45, NO 3
AORN JOURNAL
Cardiac Arrest in Ambulatory Surgery THE MANAGEMENT PERSPECTIVE
Joan A. Uebele, RN
A
cardiac arrest in an ambulatory surgery unit is a rare emergency, but it is one that staff members and managers must be prepared to handle. Whether your ambulatory unit is freestanding or hospital-integrated, planning, practicing, and preparing are the keys to getting the best possible outcome from an emergency situation. When plans are made in advance of emergencies, the emergencies can be minimized or, perhaps, eliminated. Plans that anticipate emergencies allow the staff to function better when an actual emergency occurs.’ Ambulatory surgery personnel must understand that all patients are at risk of suffering a cardiac arrest during the intraoperative period.2 There are, however, individual variables that increase a patient’s probability of suffering a cardiac arrest, such as chronic or acute diseases, age, past history of heart problems, type of anesthesia being used, preoperative preparations, and unrecognized diseases or blood chemistry imbalances that relate to cardiac functioning. Between 70% and 95%of ambulatory surgery patients will receive a general anesthetic, which has higher risks than local anesthetics? For patients receiving a local anesthetic, the circulating nurse frequently becomes the person responsible for monitoring the patient during the intraoperative phase. The circulating nurse, however, has many responsibilities during surgery and cannot give his or her entire attention to the patient. In addition, data shows that outpatients are generally healthier than inpatients, so it is easy to understand that emergency preparedness is not a major ~ o n c e r n .Nationwide, ~ the number of 698
cardiac arrests occurring in ambulatory surgery settings is low so ambulatory surgery staff members do not have the opportunity to experience resuscitation on a regular basis; therefore, it is up to managers to establish the department protocols to manage a cardiac arrest, and to keep the staff prepared.
Design and Layout
A
manager’s first consideration in preparing for a cardiac emergency is the design and layout of the ambulatory surgery unit. One must develop a sound overall design based
Joan A. Uebele,RN,MS, is a practitionerlteacher for the OR at Rush-Presbyterian-St Luke? Medical Center, Chicago. She earned her diploma in nursing at Chicago Wesley Memorial Hospital, her bachelor of science degree in nursing at Northwestern Universi& Evanston, Ill, and her master of science degree in nursing administration at the University of Illinois, Chicago.
MARCH 1987. VOL. 45, NO 3
AORN J O U R N A L
on assessed needs, anticipated case load, optimal traffic patterns, patient comfort, and safety rather than just rearranging space.5 In the final design, one must consider the following factors. Adequate space is needed in the rooms to accommodate emergency equipment and personnel, Space requirements, both for the recovery room and for the operating room, are usually addressed in local building codes and in state hospital licensing acts. The design of the furniture for the recovery area must permit the delivery of emergency care. Recliners or stretchers must be evaluated for adequacy during an arrest. If spare parts are needed to adapt the furniture in an emergency, the parts must be accessible. In selecting furniture for the operating rooms, remember that standards and accessories used for OR beds in ambulatory surgery units must be the same as those used for inpatient surgery. Oxygen and suction (vacuum) outlets must be installed in each patient recovery space (Fig 1). For the patient’s emotional comfort, you may wish to minimize the hospital atmosphere by incorporating the oxygen/vacuum outlets into the room decor. Address issues of patient privacy in the design, especially if recovery takes place in cubicles separated only by curtains. How much privacy a unit can provide for other recovering patients in the unit during a crisis is important. A central storage area for emergency equipment and supplies must be built into your floor plan. Remember that sizes and shapes of equipment can change, so allow some flexibility in the space allotments. If the department has more than three operating rooms, there should be two emergency carts-one for the recovery area and one for the operating rooms. Ensure adequate department security during nonoperational hours. Borrowed emergency equipment and missing medications are hard to explain when needed in a life-threatening situation. Plastic security locks can easily be installed on emergency drug supplies to help monitor and control the use of emergency medications. Give careful consideration to the location of patient call buttons and pull cords, and to other 700
Fig 1. When designing a recovery room to handle cardiac arrest emergencies, oxygen and vacuum suction outlets must be installed close to each patient. ~~
~
emergency communication methods a staff member can use to summon assistance. Design and locate patient areas so they are easily accessible to nursing stations. Windows for viewing patient areas can be added to your design without totally compromising patient privacy. Prepare a checklist of questions to ask the staff while designing your health care facility.6(See “Questions Concerning the Design of a Health Care Facility.”) Nursing input can help design a unit that will be functional for daily patient care and for emergency situations. Finally, establish procedures for observing patients both preoperatively and postoperatively, as mandated by local building codes and state licensing acts as well as the Joint Commission on Accreditation of Hospitals (JCAH).’
AOHN J O U R N A L
Questions Concerning the Design of a Health Care Facility" 1. What, when, where, and how are functions to be performed in the facility'? 2. What functional spaces and dimensions are required in the new area? 3. What fixed equipment is required? 4. What environmental conditions are required? 5. What workloads and workflows are entailed? 6. What staffing patterns are needed? 7. What portable equipment will be necessary? 8. What communication and transportation networks are involved? 9. What intramural and extramural relationships are to be accommodated? 10. What -provisions should be made for possible future expansion or changes?
*H. S. Rowland, B. L. Roland, Nursing Administration Handbook, second ed (Rockville, MD: Aspen Systems Corp, 1985) 63.
Stafing Concerns
A
second management responsibility related to dealing with cardiac arrests concerns the department staffing patterns and the availability of other trained professionals to provide assistance. Whatever staff scheduling system is used, the manager should assess the skills of the personnel in the department, and should plan for at least two persons certified in cardiopulmonary resuscitation (CPR) to be present until the last patient is discharged. This could include the anesthesiologist or other physician or a medical director qualified in resuscitative techniques. The JCAH standards specifically identify the need for trained personnel to be available while patients are present.8 The more physically isolated the ambulatory unit is from other support systems, the more self-reliance a manager must plan into the staffing patterns.
MARCH 1987, VOL. 45. NO 3
A cardiac arrest can occur anytime from admission to discharge; therefore, staff personnel must be available and prepared for emergency care at anytime during the patient's stay. For optimal patient safety, all department personnel should know the cardiac arrest protocols, and all registered nurses should be CPR certified.
Orientation and Education
A
third responsibility of management is staff orientation and continuing education related to CPR procedures, patient assessment, drug administration, and documentation. Staff preparation begins with orientation to the unit. As a prerequisite to employment, a manager may require that nurses have experience in the postanesthesia care unit, operating room, or critical care unit, and be CPR certified, all of which would provide a good foundation for responding to a cardiac arrest. The orientation must include a thorough review of emergency protocols and a review of specific emergency equipment and drug preparations. Pediatric equipment and adaptors and drug dosage calculations per weight should be available for quick reference to eliminate the need for complex calculations. A checklist of employee competencies should be documented and put on file with the employee's personnel record. The JCAH requires employees to be oriented and prepared for work on their unit. In addition, all continuing education activities during the year must be d o ~ u m e n t e d . Ongoing ~ evaluations of each employee will reflect any observation made of employee performances during an actual emergency situation. The requirements for CPR certification can be met within your department if you have a CPR instructor on staff. Annual CPR recertification is mandated by the American Heart Association and by the JCAH, and is a professional responsibility of each nurse according to the American Nurses' Association Code for Nurses.'" Managers should schedule a review of the emergency protocols at least twice a year. An excellent means of practicing resuscitation 70 1
AOHN J O U R N A L
MARCH 1987, VOL. 45, NO 3
Emergency policies, protocols, and procedures serve as guidelines for actions when an emergency occurs. is to schedule mock codes for the staff.l' Once a mock code format is developed, it can be used on a regular basis to review the skills and teamwork needed to handle a cardiac arrest.
Equipment
B
udgeting for purchasing and maintaining emergency equipment is a fourth management responsibility. A manager's selection will be limited by budget, by the availability of an item, and by any requirements for standardization of emergency equipment. If children are treated in the unit, a range of sizes of pediatric equipment-defibrillator accessories, blood pressure cuffs, laryngoscope blades, and Ambu masks-will also be needed.'* Equipment required for cardiac arrest management includes: defibrillator with paddles, cardiac monitor, recorder for monitor, oxygen gauges and portable oxygen, suction regulators and portable suction, laryngoscopes, and blood pressure c~ffs/manorneters.~~ After the initial purchase of equipment, managers must be aware of replacement needs, of changes in the standards of equipment in use, and of the availability and cost of preventative maintenance agreements. The equipment should be evaluated by a biomedical engineer when brought to the hospital, and on an annual basis. The biomedical engineer can also be consulted before purchasing the product. When selecting new and replacement equipment, the manager should consider both patient and staff safety. There is a concern for electrical safety and for the spread of communicable diseases when providing emergency care; equipment can be selected with these concerns in mind. Operating instructions should be attached to all emergency 702
equipment, particularly because it is used so infrequently. Managers should also be aware of equipment recalls by the manufacturer. The hospital biomedical engineer or risk manager should have a record of the recall history on new equipment considered for emergency use. If not, a monthly publication on hospital device alerts can be obtained through the American Hospital Association. Your need for emergency equipment will depend on the availability of other emergency support systems within your immediate environment.
Policies and Procedures
E
mergency protocols, policies, and procedures are the fifth area of responsibility for managers. Protocols, policies, and procedures serve as guidelines for actions when specific events occur. It is critical to have these written and reviewed by the staff members before an emergency occurs. Having the staff members participate in the development of emergency protocols and in the placement and selection of emergency equipment is a sound management tactic. The JCAH requires the policies and procedures to be reviewed annually and revised to reflect changing standards of practice.I4 Policies relating to cardiac arrest prevention and management should include the following: patient selection criteria that defines what American Society of Anesthesiologist(ASA) level will be accepted for surgical scheduling (ASA levels I and I1 are appropriate for ambulatory surgery. If ASA level 111patients are accepted, the potential for problems increases.9, a definition of admission requirements related to anesthesia use, a detailed list of emergency protocols for staff reference, with particular attention to
AORN JOURNAL
MARCH 1987. VOL. 45, NO 3
If strict admission criteria are established and followed, a manager can expect fewer patients with cardiac problems. the communciation system for summoning help, procedures for maintenance and daily checks of emergency equipment, 0 procedures for restocking emergency carts and for checking outdated drugs and supplies, procedures for admitting/transferring patients into the hospital for inpatient care, how patient charges for emergency equipment and supplies will be reported, discharge criteria related to the various types of anesthesia used in your unit (The surgeon will be more specific for additional discharge criteria when doing the postoperative orders.), and protocols for handling a death in the unit. When considering other written policies to include in your unit manual, a review of the JCAH guidelines will be helpful. When planning for care of the ambulatory patient, remember that the same standards of care apply to both outpatients and inpatients.
Risk Factors
U
'nderstanding the risk factors and warning signs related to cardiac arrests will help the staff prevent or treat those conditions in the ambulatory setting. For instance, if the general health of the patient population that the ambulatory surgery unit serves is above average, one can expect fewer surprises related to undiagnosed disease conditions. If, however, the unit treats a large proportion of elderly patients, a manager can anticipate a higher risk of cardiac arrests. A manager should also know which procedures make up 80%of the caseload, and analyze those for potential cardiac arrest risk factors. Historical data and departmental statistics will be the best source for that information. If a manager finds
that many myringotomies are performed, children with acute upper respiratory infections must be carefully screened because respiratory arrest in children is one of the chief predisposing events for cardiac arrest.'6 Also, by knowing the statistics on types of anesthesia used, a manager can anticipate potential problems associated with anesthesia. Factors such as tobacco smoking, diabetes mellitus, hypertension, and hypercholesterolemia are known to put patients at greater risk of having heart disease. Patients who have had a cardiac arrest within the past 12 to 24 months or who have suffered a myocardial infarction within the past year are at highest risk. Factors such as those should be assessed on admission and be reported in the history and physical record to establish the patient's potential for problems. If strict admission criteria are established and followed, a manager can expect fewer patients with cardiac problems. According to studies, the causes of sudden cardiac deaths include arteriosclerotic heart disease, primary myocardial disease, mitral valve prolapse, and long Q-T intervals. In some cases, no structural heart disease was found indicating an episode of spontaneous ventricular tachycardia/fibrillation as the cause of death. The precipitating factors leading to arrests included myocardial ischemia/infarction, congestive heart disease, electrolyte imbalances, medications, and neural fa~t0rs.l~ Two occurrences reported in the literature relating to arrest situations have significant implications for ambulatory staff members. The first describes a pediatric patient who unexpectedly suffered a cardiac arrest when anesthesia was administered. A follow-up study showed that the child was prepped with two enemas before his rectal biopsy surgery, causing hypocalcemia and hyperphosphatemia. The electrolyte imbalance was not assessed on admission and the patient had gone to surgery as ASA level I.(* 703
MARCH 1987, VOL. 45, NO 3
AORN J O U R N A L
In some cases, the success of CPR has been unrealistically dramatized by the media, creating high expectations for a positive outcome. In the second incident, the patient died from a cardiac arrest induced by hypokalemia related to diuretic therapy.I9 These two cases illustrate that obscure aberrations can produce unexpected problems in the ambulatory surgery patient.
Summary
P
reventing cardiac arrests requires constant vigilance on the part of the entire perioperative team. In the preoperative phase, physicians must make careful patient selections based on the patients’ risk factors, and cancel the cases or admit the patients if problems are found. In the intraoperative phase, the anesthesia personnel must carefully monitor vital signs, observe tissue perfusion, replace fluids, position the patient to maximize vital functions, and carefully select the anesthetic agents. In the postoperative phase, nurses must carefully observe and monitor the patient, especially highrisk patients, and take any necessary precautions. They must also explain instructions to the patient regarding complications after discharge. Although a manager may establish careful patient selection criteria, the day may come when the staff members must respond to a cardiac arrest in the ambulatory surgery unit. When it does, management of the patient must be the first priority. The staff members must correctly diagnosis the problem, send for assistance, perform CPR, mobilize equipment, oxygen, and medications, control traffic, document interventions, and record patient responses. In an ambulatory setting, there is a high probability that family members or friends will be with the patient. A nurse should be delegated to take them to a quiet area away from the immediate crisis, and provide information and emotional support. Frequent reports will help them cope with the crisis. Public awareness and knowledge about CPR 704
has greatly increased since it was first used in 1960. By 1977, some 12 million Americans had been CPR-trained and some 53 million more were awaiting training.20 In some cases, however, the success of CPR has been unrealistically dramatized by the media, which has created high expectations for a positive outcome. These beliefs need to be tempered by the nursing staff by answering family questions honestly, and by being available to them during the resuscitation efforts. Attention must also be given to other patients recovering in the area, especially if patient cubicles are only separated by curtains. These patients can be moved to other areas and assured by a nurse that the crisis is being handled, and that their needs will be cared for during the crisis. Visitors and families of other patients should not be allowed to witness the resuscitation efforts. A nurse who calmly cares for the other patients can reduce their anxiety levels. Once the patient has been resuscitated and stabilized, he or she should be transferred to the coronary care unit. There should be enough emergency equipment available to both transfer the patient and handle another emergency. After a cardiac arrest incidence, a completed incident report documenting the details of the incident is usually required by risk management both for liability and quality control. Other chart documentation should be added to the patient’s record. A full report must be made to the coronary care nurses receiving the patient in the hospital. There is always the chance that resuscitation efforts will not be successful. In that case, the staff members must care for the family and minister to their needs for support. A chaplain, priest, or social worker should be called for assistance. Staff members also are responsible to follow through with procedures following a death in the unit. Within a week of the emergency, the manager should evaluate the performance of the team. What problems were recognized? Did the procedures
AORN JOURNAL
MARCH 1987, VOL. 45, NO 3
work as intended? Was equipment adequate for the event? Were drug doses easy to administer? Was the emergency communicated quickly enough to summon assistance? A manager should identify weaknesses in the procedures and implement the needed changes. A review of the incident can be therapeutic for all personnel and improve performances next time. In addition, documenting the evaluation and changes is a necessary part of the quality assurance program as mandated by the JCAH. Finally, management must look to the future. Expansion of the unit will come as caseloads increase, and with that will come the need for more emergency equipment. Also, the types of cases may change as new physicians bring their practices to the unit. Surgeries may become more complex, increasing the risk and probability of cardiac arrest. Protocols must be reviewed and revised as these new developments occur. Although the demand for ambulatory surgery services is expanding faster than the changes can be accommodated, the basic priority remains 0 constant-that of quality patient care. Notes 1. H M Donovan, Nursing Service Administration: Managing the Enterprise (St Louis: C V Mosby Co, 1975) 51. 2. C B Yanick, S Lavery, “Intraoperative cardiac arrest: Nursing implications,” AORN Journal 41 (February 1985) 404-413. 3. B T Allen, “Anesthesia and ambulatory surgery,” Journal of the American Association of Nurse Anesthetists 52 (June 1984) 306. 4. N Burden, “Emergency preparedness in the ambulatory setting: Medical emergencies,” Journal of Post Anesthesia Nursing 1 (May 1986) 133. 5. B J Stevens, The Nurse as Executive, third ed (Rockville, MD: Aspen Systems Corp, 1985) 308. 6. AHC/86 Ambulatory Health Care Standards Manual (Chicago: Joint Commission on Accreditation of Hospitals, 1985) 27. 7. H S Rowland, B L Roland, Nursing Administration Handbook, second ed (Rockville. MD: Aspen Systems Corp, 1985) 63. 8. AHC/86 Ambulatory Health Care Standarh hfanuul,26. 9. Ibid 23. 10. ANA Code for Nurses, publ. no. (3-132 (Kansas
City: American Nurses Association, 1978). 1I . C Matson, B Spears, “Simulated cardiopulmonary arrest: A planned learning experience,” Focus on Critical Care 12 (June 1985) 19-21. 12. P S Auerbach, S A Budassi, eds, Cardiac Arrest and CPR: Assessment, Planning, and Intervention, second ed (Rockville, MD: Aspen Systems Corp, 1983) 165. 13. Yanick, Lavery, “Intraoperative cardiac arrest: Nursing implications,” 4 16. 14. AMH/86 Accreditation Manual for Hospitals
(Chicago: Joint Commission on Accreditation of Hospitals, 1985) 60. 15. Allen, “Anesthesia and ambulatory surgery,” 305. 16. A L Harwood, ed, Cardiopulmonary Resuscitation (Baltimore: Williams and Wilkins, 1982) 134. 17. R F Malacoff, “Sudden cardiac death: Helping those at risk survive,” Postgraduate Medicine 75 (March 1984) 269. 18. J C Reedy, G T Zwiren, “Enema-induced
hypocalcemia and hyperphosphatemia leading to cardiac arrest during induction of anesthesia in an outpatient surgery center,” Anesrhesiology 59 (December 1983) 578-579. 19. B E Sobel et al, Electrophysiological Mechanisms Underlying Sudden Cardiac Death (Mt Kisco, NY: Futura Publishing Co, Inc, 1982) 93. 20. Harwood, ed, Cardiopulmonary Resuscitation, 160.
Suggested reading Gordon, J M; Hurowitz, E. “Cardiopulmonary resuscitationof the elderly.”Journal ofthe American Geriatric Society 32 (December 1984) 930-934. Lewis, J K et al. “Outcome of pediatric resuscitation.” Annals ofEmergency Medicine 12 (May 1983) 297299. Sommers, M S. “Creating a therapeutic environment during cardiopulmonary resuscitation.” Focus on Critical Care 12 (June 1985) 22-29. Stephenson, H E. Cardiac Arrest and Resuscitation, fourth ed. St Louis: C V Mosby Co, 1974, 175191.
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AORN JOURNAL
Cardiac Arrest in Ambulatory Surgery THE MANAGEMENT PERSPECTIVE
Joan A. Uebele, RN
A
cardiac arrest in an ambulatory surgery unit is a rare emergency, but it is one that staff members and managers must be prepared to handle. Whether your ambulatory unit is freestanding or hospital-integrated, planning, practicing, and preparing are the keys to getting the best possible outcome from an emergency situation. When plans are made in advance of emergencies, the emergencies can be minimized or, perhaps, eliminated. Plans that anticipate emergencies allow the staff to function better when an actual emergency occurs.’ Ambulatory surgery personnel must understand that all patients are at risk of suffering a cardiac arrest during the intraoperative period.2 There are, however, individual variables that increase a patient’s probability of suffering a cardiac arrest, such as chronic or acute diseases, age, past history of heart problems, type of anesthesia being used, preoperative preparations, and unrecognized diseases or blood chemistry imbalances that relate to cardiac functioning. Between 70% and 95%of ambulatory surgery patients will receive a general anesthetic, which has higher risks than local anesthetics? For patients receiving a local anesthetic, the circulating nurse frequently becomes the person responsible for monitoring the patient during the intraoperative phase. The circulating nurse, however, has many responsibilities during surgery and cannot give his or her entire attention to the patient. In addition, data shows that outpatients are generally healthier than inpatients, so it is easy to understand that emergency preparedness is not a major ~ o n c e r n .Nationwide, ~ the number of 698
cardiac arrests occurring in ambulatory surgery settings is low so ambulatory surgery staff members do not have the opportunity to experience resuscitation on a regular basis; therefore, it is up to managers to establish the department protocols to manage a cardiac arrest, and to keep the staff prepared.
Design and Layout
A
manager’s first consideration in preparing for a cardiac emergency is the design and layout of the ambulatory surgery unit. One must develop a sound overall design based
Joan A. Uebele,RN,MS, is a practitionerlteacher for the OR at Rush-Presbyterian-St Luke? Medical Center, Chicago. She earned her diploma in nursing at Chicago Wesley Memorial Hospital, her bachelor of science degree in nursing at Northwestern Universi& Evanston, Ill, and her master of science degree in nursing administration at the University of Illinois, Chicago.
MARCH 1987. VOL. 45, NO 3
AORN J O U R N A L
on assessed needs, anticipated case load, optimal traffic patterns, patient comfort, and safety rather than just rearranging space.5 In the final design, one must consider the following factors. Adequate space is needed in the rooms to accommodate emergency equipment and personnel, Space requirements, both for the recovery room and for the operating room, are usually addressed in local building codes and in state hospital licensing acts. The design of the furniture for the recovery area must permit the delivery of emergency care. Recliners or stretchers must be evaluated for adequacy during an arrest. If spare parts are needed to adapt the furniture in an emergency, the parts must be accessible. In selecting furniture for the operating rooms, remember that standards and accessories used for OR beds in ambulatory surgery units must be the same as those used for inpatient surgery. Oxygen and suction (vacuum) outlets must be installed in each patient recovery space (Fig 1). For the patient’s emotional comfort, you may wish to minimize the hospital atmosphere by incorporating the oxygen/vacuum outlets into the room decor. Address issues of patient privacy in the design, especially if recovery takes place in cubicles separated only by curtains. How much privacy a unit can provide for other recovering patients in the unit during a crisis is important. A central storage area for emergency equipment and supplies must be built into your floor plan. Remember that sizes and shapes of equipment can change, so allow some flexibility in the space allotments. If the department has more than three operating rooms, there should be two emergency carts-one for the recovery area and one for the operating rooms. Ensure adequate department security during nonoperational hours. Borrowed emergency equipment and missing medications are hard to explain when needed in a life-threatening situation. Plastic security locks can easily be installed on emergency drug supplies to help monitor and control the use of emergency medications. Give careful consideration to the location of patient call buttons and pull cords, and to other 700
Fig 1. When designing a recovery room to handle cardiac arrest emergencies, oxygen and vacuum suction outlets must be installed close to each patient. ~~
~
emergency communication methods a staff member can use to summon assistance. Design and locate patient areas so they are easily accessible to nursing stations. Windows for viewing patient areas can be added to your design without totally compromising patient privacy. Prepare a checklist of questions to ask the staff while designing your health care facility.6(See “Questions Concerning the Design of a Health Care Facility.”) Nursing input can help design a unit that will be functional for daily patient care and for emergency situations. Finally, establish procedures for observing patients both preoperatively and postoperatively, as mandated by local building codes and state licensing acts as well as the Joint Commission on Accreditation of Hospitals (JCAH).’
AOHN J O U R N A L
Questions Concerning the Design of a Health Care Facility" 1. What, when, where, and how are functions to be performed in the facility'? 2. What functional spaces and dimensions are required in the new area? 3. What fixed equipment is required? 4. What environmental conditions are required? 5. What workloads and workflows are entailed? 6. What staffing patterns are needed? 7. What portable equipment will be necessary? 8. What communication and transportation networks are involved? 9. What intramural and extramural relationships are to be accommodated? 10. What -provisions should be made for possible future expansion or changes?
*H. S. Rowland, B. L. Roland, Nursing Administration Handbook, second ed (Rockville, MD: Aspen Systems Corp, 1985) 63.
Stafing Concerns
A
second management responsibility related to dealing with cardiac arrests concerns the department staffing patterns and the availability of other trained professionals to provide assistance. Whatever staff scheduling system is used, the manager should assess the skills of the personnel in the department, and should plan for at least two persons certified in cardiopulmonary resuscitation (CPR) to be present until the last patient is discharged. This could include the anesthesiologist or other physician or a medical director qualified in resuscitative techniques. The JCAH standards specifically identify the need for trained personnel to be available while patients are present.8 The more physically isolated the ambulatory unit is from other support systems, the more self-reliance a manager must plan into the staffing patterns.
MARCH 1987, VOL. 45. NO 3
A cardiac arrest can occur anytime from admission to discharge; therefore, staff personnel must be available and prepared for emergency care at anytime during the patient's stay. For optimal patient safety, all department personnel should know the cardiac arrest protocols, and all registered nurses should be CPR certified.
Orientation and Education
A
third responsibility of management is staff orientation and continuing education related to CPR procedures, patient assessment, drug administration, and documentation. Staff preparation begins with orientation to the unit. As a prerequisite to employment, a manager may require that nurses have experience in the postanesthesia care unit, operating room, or critical care unit, and be CPR certified, all of which would provide a good foundation for responding to a cardiac arrest. The orientation must include a thorough review of emergency protocols and a review of specific emergency equipment and drug preparations. Pediatric equipment and adaptors and drug dosage calculations per weight should be available for quick reference to eliminate the need for complex calculations. A checklist of employee competencies should be documented and put on file with the employee's personnel record. The JCAH requires employees to be oriented and prepared for work on their unit. In addition, all continuing education activities during the year must be d o ~ u m e n t e d . Ongoing ~ evaluations of each employee will reflect any observation made of employee performances during an actual emergency situation. The requirements for CPR certification can be met within your department if you have a CPR instructor on staff. Annual CPR recertification is mandated by the American Heart Association and by the JCAH, and is a professional responsibility of each nurse according to the American Nurses' Association Code for Nurses.'" Managers should schedule a review of the emergency protocols at least twice a year. An excellent means of practicing resuscitation 70 1
AOHN J O U R N A L
MARCH 1987, VOL. 45, NO 3
Emergency policies, protocols, and procedures serve as guidelines for actions when an emergency occurs. is to schedule mock codes for the staff.l' Once a mock code format is developed, it can be used on a regular basis to review the skills and teamwork needed to handle a cardiac arrest.
Equipment
B
udgeting for purchasing and maintaining emergency equipment is a fourth management responsibility. A manager's selection will be limited by budget, by the availability of an item, and by any requirements for standardization of emergency equipment. If children are treated in the unit, a range of sizes of pediatric equipment-defibrillator accessories, blood pressure cuffs, laryngoscope blades, and Ambu masks-will also be needed.'* Equipment required for cardiac arrest management includes: defibrillator with paddles, cardiac monitor, recorder for monitor, oxygen gauges and portable oxygen, suction regulators and portable suction, laryngoscopes, and blood pressure c~ffs/manorneters.~~ After the initial purchase of equipment, managers must be aware of replacement needs, of changes in the standards of equipment in use, and of the availability and cost of preventative maintenance agreements. The equipment should be evaluated by a biomedical engineer when brought to the hospital, and on an annual basis. The biomedical engineer can also be consulted before purchasing the product. When selecting new and replacement equipment, the manager should consider both patient and staff safety. There is a concern for electrical safety and for the spread of communicable diseases when providing emergency care; equipment can be selected with these concerns in mind. Operating instructions should be attached to all emergency 702
equipment, particularly because it is used so infrequently. Managers should also be aware of equipment recalls by the manufacturer. The hospital biomedical engineer or risk manager should have a record of the recall history on new equipment considered for emergency use. If not, a monthly publication on hospital device alerts can be obtained through the American Hospital Association. Your need for emergency equipment will depend on the availability of other emergency support systems within your immediate environment.
Policies and Procedures
E
mergency protocols, policies, and procedures are the fifth area of responsibility for managers. Protocols, policies, and procedures serve as guidelines for actions when specific events occur. It is critical to have these written and reviewed by the staff members before an emergency occurs. Having the staff members participate in the development of emergency protocols and in the placement and selection of emergency equipment is a sound management tactic. The JCAH requires the policies and procedures to be reviewed annually and revised to reflect changing standards of practice.I4 Policies relating to cardiac arrest prevention and management should include the following: patient selection criteria that defines what American Society of Anesthesiologist(ASA) level will be accepted for surgical scheduling (ASA levels I and I1 are appropriate for ambulatory surgery. If ASA level 111patients are accepted, the potential for problems increases.9, a definition of admission requirements related to anesthesia use, a detailed list of emergency protocols for staff reference, with particular attention to
AORN JOURNAL
MARCH 1987. VOL. 45, NO 3
If strict admission criteria are established and followed, a manager can expect fewer patients with cardiac problems. the communciation system for summoning help, procedures for maintenance and daily checks of emergency equipment, 0 procedures for restocking emergency carts and for checking outdated drugs and supplies, procedures for admitting/transferring patients into the hospital for inpatient care, how patient charges for emergency equipment and supplies will be reported, discharge criteria related to the various types of anesthesia used in your unit (The surgeon will be more specific for additional discharge criteria when doing the postoperative orders.), and protocols for handling a death in the unit. When considering other written policies to include in your unit manual, a review of the JCAH guidelines will be helpful. When planning for care of the ambulatory patient, remember that the same standards of care apply to both outpatients and inpatients.
Risk Factors
U
'nderstanding the risk factors and warning signs related to cardiac arrests will help the staff prevent or treat those conditions in the ambulatory setting. For instance, if the general health of the patient population that the ambulatory surgery unit serves is above average, one can expect fewer surprises related to undiagnosed disease conditions. If, however, the unit treats a large proportion of elderly patients, a manager can anticipate a higher risk of cardiac arrests. A manager should also know which procedures make up 80%of the caseload, and analyze those for potential cardiac arrest risk factors. Historical data and departmental statistics will be the best source for that information. If a manager finds
that many myringotomies are performed, children with acute upper respiratory infections must be carefully screened because respiratory arrest in children is one of the chief predisposing events for cardiac arrest.'6 Also, by knowing the statistics on types of anesthesia used, a manager can anticipate potential problems associated with anesthesia. Factors such as tobacco smoking, diabetes mellitus, hypertension, and hypercholesterolemia are known to put patients at greater risk of having heart disease. Patients who have had a cardiac arrest within the past 12 to 24 months or who have suffered a myocardial infarction within the past year are at highest risk. Factors such as those should be assessed on admission and be reported in the history and physical record to establish the patient's potential for problems. If strict admission criteria are established and followed, a manager can expect fewer patients with cardiac problems. According to studies, the causes of sudden cardiac deaths include arteriosclerotic heart disease, primary myocardial disease, mitral valve prolapse, and long Q-T intervals. In some cases, no structural heart disease was found indicating an episode of spontaneous ventricular tachycardia/fibrillation as the cause of death. The precipitating factors leading to arrests included myocardial ischemia/infarction, congestive heart disease, electrolyte imbalances, medications, and neural fa~t0rs.l~ Two occurrences reported in the literature relating to arrest situations have significant implications for ambulatory staff members. The first describes a pediatric patient who unexpectedly suffered a cardiac arrest when anesthesia was administered. A follow-up study showed that the child was prepped with two enemas before his rectal biopsy surgery, causing hypocalcemia and hyperphosphatemia. The electrolyte imbalance was not assessed on admission and the patient had gone to surgery as ASA level I.(* 703
MARCH 1987, VOL. 45, NO 3
AORN J O U R N A L
In some cases, the success of CPR has been unrealistically dramatized by the media, creating high expectations for a positive outcome. In the second incident, the patient died from a cardiac arrest induced by hypokalemia related to diuretic therapy.I9 These two cases illustrate that obscure aberrations can produce unexpected problems in the ambulatory surgery patient.
Summary
P
reventing cardiac arrests requires constant vigilance on the part of the entire perioperative team. In the preoperative phase, physicians must make careful patient selections based on the patients’ risk factors, and cancel the cases or admit the patients if problems are found. In the intraoperative phase, the anesthesia personnel must carefully monitor vital signs, observe tissue perfusion, replace fluids, position the patient to maximize vital functions, and carefully select the anesthetic agents. In the postoperative phase, nurses must carefully observe and monitor the patient, especially highrisk patients, and take any necessary precautions. They must also explain instructions to the patient regarding complications after discharge. Although a manager may establish careful patient selection criteria, the day may come when the staff members must respond to a cardiac arrest in the ambulatory surgery unit. When it does, management of the patient must be the first priority. The staff members must correctly diagnosis the problem, send for assistance, perform CPR, mobilize equipment, oxygen, and medications, control traffic, document interventions, and record patient responses. In an ambulatory setting, there is a high probability that family members or friends will be with the patient. A nurse should be delegated to take them to a quiet area away from the immediate crisis, and provide information and emotional support. Frequent reports will help them cope with the crisis. Public awareness and knowledge about CPR 704
has greatly increased since it was first used in 1960. By 1977, some 12 million Americans had been CPR-trained and some 53 million more were awaiting training.20 In some cases, however, the success of CPR has been unrealistically dramatized by the media, which has created high expectations for a positive outcome. These beliefs need to be tempered by the nursing staff by answering family questions honestly, and by being available to them during the resuscitation efforts. Attention must also be given to other patients recovering in the area, especially if patient cubicles are only separated by curtains. These patients can be moved to other areas and assured by a nurse that the crisis is being handled, and that their needs will be cared for during the crisis. Visitors and families of other patients should not be allowed to witness the resuscitation efforts. A nurse who calmly cares for the other patients can reduce their anxiety levels. Once the patient has been resuscitated and stabilized, he or she should be transferred to the coronary care unit. There should be enough emergency equipment available to both transfer the patient and handle another emergency. After a cardiac arrest incidence, a completed incident report documenting the details of the incident is usually required by risk management both for liability and quality control. Other chart documentation should be added to the patient’s record. A full report must be made to the coronary care nurses receiving the patient in the hospital. There is always the chance that resuscitation efforts will not be successful. In that case, the staff members must care for the family and minister to their needs for support. A chaplain, priest, or social worker should be called for assistance. Staff members also are responsible to follow through with procedures following a death in the unit. Within a week of the emergency, the manager should evaluate the performance of the team. What problems were recognized? Did the procedures
AORN JOURNAL
MARCH 1987, VOL. 45, NO 3
work as intended? Was equipment adequate for the event? Were drug doses easy to administer? Was the emergency communicated quickly enough to summon assistance? A manager should identify weaknesses in the procedures and implement the needed changes. A review of the incident can be therapeutic for all personnel and improve performances next time. In addition, documenting the evaluation and changes is a necessary part of the quality assurance program as mandated by the JCAH. Finally, management must look to the future. Expansion of the unit will come as caseloads increase, and with that will come the need for more emergency equipment. Also, the types of cases may change as new physicians bring their practices to the unit. Surgeries may become more complex, increasing the risk and probability of cardiac arrest. Protocols must be reviewed and revised as these new developments occur. Although the demand for ambulatory surgery services is expanding faster than the changes can be accommodated, the basic priority remains 0 constant-that of quality patient care. Notes 1. H M Donovan, Nursing Service Administration: Managing the Enterprise (St Louis: C V Mosby Co, 1975) 51. 2. C B Yanick, S Lavery, “Intraoperative cardiac arrest: Nursing implications,” AORN Journal 41 (February 1985) 404-413. 3. B T Allen, “Anesthesia and ambulatory surgery,” Journal of the American Association of Nurse Anesthetists 52 (June 1984) 306. 4. N Burden, “Emergency preparedness in the ambulatory setting: Medical emergencies,” Journal of Post Anesthesia Nursing 1 (May 1986) 133. 5. B J Stevens, The Nurse as Executive, third ed (Rockville, MD: Aspen Systems Corp, 1985) 308. 6. AHC/86 Ambulatory Health Care Standards Manual (Chicago: Joint Commission on Accreditation of Hospitals, 1985) 27. 7. H S Rowland, B L Roland, Nursing Administration Handbook, second ed (Rockville. MD: Aspen Systems Corp, 1985) 63. 8. AHC/86 Ambulatory Health Care Standarh hfanuul,26. 9. Ibid 23. 10. ANA Code for Nurses, publ. no. (3-132 (Kansas
City: American Nurses Association, 1978). 1I . C Matson, B Spears, “Simulated cardiopulmonary arrest: A planned learning experience,” Focus on Critical Care 12 (June 1985) 19-21. 12. P S Auerbach, S A Budassi, eds, Cardiac Arrest and CPR: Assessment, Planning, and Intervention, second ed (Rockville, MD: Aspen Systems Corp, 1983) 165. 13. Yanick, Lavery, “Intraoperative cardiac arrest: Nursing implications,” 4 16. 14. AMH/86 Accreditation Manual for Hospitals
(Chicago: Joint Commission on Accreditation of Hospitals, 1985) 60. 15. Allen, “Anesthesia and ambulatory surgery,” 305. 16. A L Harwood, ed, Cardiopulmonary Resuscitation (Baltimore: Williams and Wilkins, 1982) 134. 17. R F Malacoff, “Sudden cardiac death: Helping those at risk survive,” Postgraduate Medicine 75 (March 1984) 269. 18. J C Reedy, G T Zwiren, “Enema-induced
hypocalcemia and hyperphosphatemia leading to cardiac arrest during induction of anesthesia in an outpatient surgery center,” Anesrhesiology 59 (December 1983) 578-579. 19. B E Sobel et al, Electrophysiological Mechanisms Underlying Sudden Cardiac Death (Mt Kisco, NY: Futura Publishing Co, Inc, 1982) 93. 20. Harwood, ed, Cardiopulmonary Resuscitation, 160.
Suggested reading Gordon, J M; Hurowitz, E. “Cardiopulmonary resuscitationof the elderly.”Journal ofthe American Geriatric Society 32 (December 1984) 930-934. Lewis, J K et al. “Outcome of pediatric resuscitation.” Annals ofEmergency Medicine 12 (May 1983) 297299. Sommers, M S. “Creating a therapeutic environment during cardiopulmonary resuscitation.” Focus on Critical Care 12 (June 1985) 22-29. Stephenson, H E. Cardiac Arrest and Resuscitation, fourth ed. St Louis: C V Mosby Co, 1974, 175191.
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