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Keep the beat: Preventing out-of-hospital cardiac arrests

Monday July 11, 2011
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Deaths from coronary heart disease have been on the decline for the past several years, with one major exception: out-of-hospital cardiac arrest. Few communities have been able to significantly reduce the number of these usually deadly events that strike 235,000 to 325,000 people in the U.S. each year, according to a recent consensus report on strategies to improve OHCA survival released by the American Heart Association.

The report points to regional variations in treatment as one of the problems. "There are big disparities," said Michael Sayre, MD, associate professor for emergency medicine at The Ohio State University and a coauthor of the report, "Implementation Strategies for Improving Survival After Out-of-Hospital Cardiac Arrest in the United States," published May 16 in the journal Circulation.

"Some communities have survival rates of 3%, other communities have five times that number. The difference represents tens of thousands of lives lost," Sayre said.

Through their efforts in the hospital and community, nurses can help to prevent some of these deaths, according to resuscitation experts.

Bundle of care

At the Hospital of the University of Pennsylvania in Philadelphia, a protocol that bundles care measures has doubled OHCA survival rate from 22% to 50% since it was initiated in 2005, said Marion Leary, RN, BSN, assistant director of clinical research for the Center for Resuscitation Science at UPenn. The hospital sees about four OHCA patients a month.

"Anytime a cardiac arrest comes through the ED, our resuscitation team is notified," Leary said. The team includes Leary, another nurse and two ED physicians. "We don't code the patient, but we help the team determine eligibility for therapeutic hypothermia." The AHA's 2010 guidelines for post-cardiac arrest care recommend therapeutic hypothermia for eligible adult patients who can't follow commands after return of spontaneous circulation because it improves survival and neurological recovery.

The ICU physician selects the appropriate treatments from an order set based on the protocol developed by resuscitation experts. Leary and the ED physicians provide consultative services primarily during the ED and ICU phases, although they follow patients through discharge so they can track cognitive status, looking for neurological impairment.

Leary credits self-appointed hypothermia "champions" for the success of that part of the protocol. "They attend one of the quarterly resuscitation science training sessions we have, and then act as the point person in their unit," she said, adding hypothermia is only one part of the treatment plan, which includes symptom management and interventional cardiology for eligible patients.

"You need a strong nurse advocate and a physician champion to put a protocol in place," Leary said.

To ensure the protocol is kept current, a core group of physicians from emergency medicine and UPenn's five ICUs, critical care and ED nurses and pharmacists meet quarterly to review it.

Leary encourages nurses who are frustrated by barriers to improving OHCA care to continue to be an advocate for patients. In the case of therapeutic hypothermia, she said, "When people have a patient survive that they didn't think would, they quickly get on board."

Give the brain a chance

Leary and Sayre urge nurses and physicians to be patient when assessing functional status. "Right after cardiac arrest, there is no way to tell if the patient in a coma is going to wake up," Sayre said. "They can have severe neurological dysfunction with no response to pain, and a week later they can be talking to you."

For patients who receive therapeutic hypothermia, Sayre said he waits until 72 hours after return of spontaneous circulation before assessing neurological function. "You don't want to withdraw care too early," he said.

Sayre also said it's important to continue to be aggressive with treatment, even in the face of discouraging signs. "We've heard stories of patients who didn't go to the cath lab because they were in a coma," he said.

The big three

How can nurses in the hospital advocate for better treatment of OHCA? Beth Mancini, RN, PhD, FAAN, associate dean of the college of nursing at The University of Texas at Arlington, whose research focus is resuscitation, said it comes down to three main strategies: "Deliver high-quality CPR; ensure they have the evidence so they can facilitate the implementation of proven therapies such as therapeutic hypothermia; and continually monitor performance measures — and share that information both internally to their hospitals and externally with registries — to consistently improve care."

Families of patients with cardiac risk factors receive CPR training as part of a UPenn program, Leary said. "Families are so thankful for it. We use the CPR Anytime kit so they can take it home and train other family members and friends. It takes some of the pressure off families to know others are trained in CPR." The Family & Friends CPR Anytime kit (cpranytime.org) is available for $34.95 from the AHA. The kit, which includes a DVD and a manikin, offers a 20-minute lesson on CPR and choking relief.

A resource for nurses interested in monitoring is Get With the Guidelines — Resuscitation, another AHA program. Although the program focuses on in-hospital resuscitation events, the information and recommendations also would be helpful in OHCA, Mancini said. OHCA monitoring data should be shared with prehospital staff such as paramedics, she said.

Mancini said she sees nurses as responsible for cultivating prevention within their communities. Although not every nurse will choose to become a CPR instructor, all nurses can embrace the goal of educating the community, whether that community is a city, region, church, club or any other regular gathering of people.

"Nurses can simply spread the word about hands-only CPR," she said. "Just tell people when they witness an adult who suddenly becomes unresponsive to 'Call 911; put your hands in the middle of the chest and push hard and fast.' Some CPR is better than no CPR."

Cynthia Saver, RN, MS, is president of CLS Development Inc., Columbia, Md.


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How to boost OHCA survival

AHA's "Implementation Strategies for Improving Survival After Out-of-Hospital Cardiac Arrest in the United States," offers improvement elements for five system components: medical leadership, community, 911/EMS dispatch, EMS and hospital.

The hospital elements are:

• Specialized center for treating post-cardiac arrest patients

• Multidisciplinary post-cardiac arrest care treatment plan

• Early percutaneous coronary intervention

• Therapeutic hypothermia

• Early hemodynamic optimization

• Reliable early prognostication of functional outcome

• Automated implantable cardioverter-defibrillator placement

The full report can be found online at circ.ahajournals.org/content/123/24/2898.full