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A lifesaving skill

CPR practice boosts resuscitation success

Monday February 10, 2014
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As Marion Leary, RN, MSN, assistant director of clinical research at the University of Pennsylvania’s Center for Resuscitation Science in Philadelphia, pointed out, “cardiac arrest can happen at any time, anywhere.” When performed well, cardiopulmonary resuscitation boosts survival rates after those arrests occur.

“What the data tells us is that higher-quality CPR gives better patient outcomes,” said Beth Mancini, RN, PhD, NE-BC, FAHA, ANEF, FAAN, professor and associate dean for undergraduate studies in the nursing program at the University of Texas at Arlington. “Better CPR maximizes chances of survival.”

CPR quality is not always optimal even in healthcare settings, however. In 2013, the American Heart Association published a consensus statement, “CPR Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital,” which cited an “increasing body of evidence [indicating] that even after controlling for patient and event characteristics, there is significant variability in survival rates both across and within pre-hospital and in-hospital settings.”

“We have often presumed that qualified, educated health professionals would do CPR right and do it consistently because they want to, but the fact is we don’t always do it right and we don’t recognize when we do it wrong,” said Mancini, who with Leary was a coauthor of the consensus statement, published in June on the website of the journal Circulation.

“The data continually show that most people, including healthcare professionals, don’t perform CPR well,” Leary said.

According to data cited in the consensus statement: “In a hospital setting, survival is greater than 20% if the arrest occurs between the hours of 7 a.m. and 11 p.m., but only 15% if the arrest occurs between 11 p.m. and 7 a.m. There is significant variability with regard to location, with 9% survival at night in unmonitored settings compared with nearly 37% survival in operating room/post-anesthesia care unit locations during the day.”

Unfortunately, once patients experience an arrest, only about half are discharged from the hospital neurologically intact. “We can do better than that,” Mancini said. “The goal is not that we save everyone; the goal is to save as many as we can.”

Although geographic pockets of excellent bystander and hospital CPR exist, the consensus statement found the quality of CPR varies substantially. “The opportunity to improve the quality of CPR is without borders,” Mancini said. “Everyone can do better.”

Beth Mancini, RN
Real-time feedback

“CPR is a psychomotor skill with the intent to maximize blood flow, so you want to monitor that flow in real time,” Mancini said. One option is a monitor/defibrillator that provides information on CPR quality through visual or audio feedback. “When you compare the use of equipment to humans’ ability to know whether someone should be pushing deeper or faster, equipment beats us every time,” she said. Depending on the device, a monitor/defibrillator can measure compression depth, rate, chest recoil and time not compressing the chest.

If the hospital is unable to afford use of the devices throughout the facility, Mary Fran Hazinski, RN, MSN, FAAN, FAHA, professor at Vanderbilt University School of Nursing in Nashville, Tenn., and an international CPR expert, recommends placing them in higher-risk areas such as EDs and ICUs, and including them on resuscitation carts that are brought to the scene.

Though smaller hospitals and organizations that rarely have patients needing resuscitation might not be able to afford high-end equipment, less expensive feedback devices are available. Direct supervision also is useful. Leary suggests assigning someone on the response team to watch and give feedback on the quality of CPR. “One of the roles for nurses can be to run the CPR portion of the resuscitation effort,” she said, adding this step is “easy to implement and can make a huge difference in outcomes.”

Larger hospitals also can benefit from this strategy. “We try to put one person at the foot of the bed,” Hazinski said. “That person tracks CPR interruptions, looks at depth and rate of compressions and watches for the person’s hands coming off the chest.”

Checking the pulse, a commonly used technique for assessing CPR quality, is not recommended because of inaccuracy.

Tom LeMaster, RN
Practice makes perfect

While the AHA issues provider cards for two years, that renewal cycle might not be frequent enough for individuals, especially those who perform CPR infrequently, to maintain their competency, Mancini said. The emphasis is on more frequent assessment of skill performance and remediation when needed.

Mancini said deterioration of CPR skills can occur in as little as 30 to 60 days, making regular practice vital. “Practice helps develop that muscle memory and to know the desired rhythm,” Hazinski said. “The better you perform CPR, the better you can identify when it’s compromised.”

In the busy healthcare environment, it takes creativity to find practice time for staff. Mancini suggests taking a manikin on a quarterly or monthly basis to units where CPR is performed less often and having staff perform a short two-minute review. Another option is to have kiosks where staff can independently perform CPR using online training.

Mock codes in any organization are another effective tool not only for CPR quality but for improving overall resuscitation effectiveness. Hazinski said monitors/defibrillators that gauge CPR quality are part of mock code carts at Vanderbilt to help staff improve their psychomotor skills. “Practicing with the devices does improve performance,” she said. “You can turn off the audible after a few cycles and improvement is maintained.”

At Cincinnati Children’s Hospital, Tom LeMaster, RN, MSN, MEd, REMT-P, EMSI, program director for the Center for Simulation and Research, has found “in situ simulations,” similar to mock codes, useful for maintaining staff competence. He credits an element of surprise for making the simulations more effective. “We call the charge nurse a couple of hours ahead to be sure the timing will work, but the staff don’t know about the simulation until we walk in,” he said. “We will show up on an inpatient unit, in the ED or ICU or anywhere else in the hospital.”

Simulations pay off with more efficient and effective teams. “Even decreasing the time between the last compression and defibrillation and between defibrillation and resumption of CPR by a few seconds can dramatically increase effectiveness, but that takes a great deal of practice by the team,” Hazinski said.

Marion Leary, RN
Starting with students

Enhancing quality CPR begins with nursing students. “We need to have students learn and practice CPR across all our courses,” said Mancini, who added that simulation is a way to accomplish psychomotor expertise. “Students can have as many as four to six sessions of hands-on practice as part of their simulation experiences during the two years they are in the program.”

Hazinski said students look to faculty for direction as to what’s important in their coursework. Faculty “need to make it clear the high-quality CPR makes survival more likely,” she said. “Faculty also need to emphasize the need for quality indicators in this area and that they are important.” Students can monitor each other for effective CPR during simulations.

Professional responsibility

One of a nurse’s professional responsibilities is to provide quality CPR. “Know the guidelines and use them both in and out of the hospital setting,” Leary said.

“Nurses can make a difference during resuscitation,” she added. “If your facility doesn’t have CPR feedback devices or someone to direct CPR, step up and make that suggestion.”

LeMaster said finding a champion at a high level, such as the chief of the medical staff, is helpful. “It’s great to have the support of a department director, but you also need [someone] higher up,” he said. “That goes a long way.” He added that nurses also should coordinate efforts through quality departments since resuscitation is a patient safety issue.

“Nurses have to deeply understand concepts of process improvement and their role in it,” Mancini said. “CPR is one of the most important things we do. Because we don’t do it very often but it’s so important, we need to be sure our readiness is optimized. Wherever I work, I need to own that.”

Cynthia Saver, RN, MS, is a freelance writer and president of CLS Development, Inc. in Columbia, Md. Send comments to editor@nurse.com or post comments below.
Continued emphasis on high-quality CPR

The 2010 American Heart Association guidelines for CPR and emergency cardiovascular care emphasize the need for high-quality CPR, including:

• A compression rate of at least 100/min (a change from “approximately” 100/min).

• A compression depth of at least 2 inches (5 cm) in adults and a compression depth of at least one third of the anterior- posterior diameter of the chest in infants and children (approximately 1.5 inches [4 cm] in infants and 2 inches [5 cm] in children). Note that the range of 11⁄2 to 2 inches is no longer used for adults, and the absolute depth specified for children and infants is deeper than in previous versions of the AHA Guidelines for CPR and ECC.

• Allowing for complete chest recoil after each compression.

• Minimizing interruptions in chest compressions.

• Avoiding excessive ventilation.

Other important information from the 2010 AHA Guidelines:

• There has been no change in the recommendation for a compression-to-ventilation ratio of 30:2 for single rescuers of adults, children, and infants (excluding newly born infants). The 2010 AHA Guidelines for CPR and ECC continue to recommend that rescue breaths last approximately 1 second. Once an advanced airway is in place, chest compressions can be continuous (at a rate of at least 100/min) and no longer cycled with ventilations. Rescue breaths can then be provided at about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute). Excessive ventilation should be avoided.

• A change from A-B-C to C-A-B: The 2010 AHA Guidelines for CPR and ECC recommend a change in the BLS sequence of steps from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest compressions, Airway, Breathing) for adults, children, and infants (excluding the newly born). This fundamental change in CPR sequence will require reeducation of everyone who has ever learned CPR, but the consensus of the authors and experts involved in the creation of the 2010 AHA Guidelines for CPR and ECC is that the benefit will justify the effort.