There are no national guidelines or standards for resuscitation facilities or training in NHS hospitals. And even though both the King’s Fund and the Clinical Negligence Scheme for trusts require the provision of resuscitation training, no content is specified.
VOL: 97, ISSUE: 08, PAGE NO: 42
Vicki Leah, MSc, RN, is resuscitation officer, Darent Valley Hospital, Dartford, Kent
Although a great deal of attention has been paid to the formulation of standard guidelines for both basic and advanced resuscitation training, there is little literature on the most appropriate form of in-hospital resuscitation (Cummins et al, 1997).
The number of resuscitation officers has increased over the past 10 years and most hospitals now have a resuscitation service. But the content of resuscitation training is usually decided by the hospital’s resuscitation officer, influenced by the Resuscitation Council’s guidelines on basic and advanced life support (Handley et al, 1998; Nolan and Gwinnutt, 1998; Robertson, 1997).
An important part of a typical two-hour resuscitation training session for nurses is instruction in basic life support (BLS). This type of training usually forms an important part of standard resuscitation training, with most staff doing a recommended annual update.
Basic life support in hospital
The BLS guidelines were designed to enable lay bystanders to give initial cardiopulmonary resuscitation (CPR) after a collapse in the community. They were not intended for use in hospitals and are not the most appropriate sequence of actions for a nurse to take after the collapse of a patient on a ward.
The ‘chain of survival’ in hospital is different from that in the community (Kaye and Mancini, 1996), so teaching strict BLS guidelines to nurses is inappropriate and may even harm patients by increasing the time before a definitive intervention is made (Liddle and Carr, 1998).
A collapse in hospital differs from one in the community in a number of ways. If a patient becomes unresponsive in hospital there will be a nurse in the vicinity who can call for and receive immediate medical help. There will never be only one nurse available, so it can be assumed that:
- At least two people are available to treat the patient;
- Most patients who arrest have been seriously ill beforehand and should already be under close observation and monitoring;
- The cause of the cardiac arrest can be more readily identified and treated.
With all cardiac arrests, survival is most likely in patients with ventricular fibrillation so early monitoring and defibrillation is a priority. It is, therefore, ideal for the first responder to be in a position to provide definitive treatment. With new technology, such as automated external defibrillators, definitive treatment by all nurses should be possible for all patients in a shockable rhythm.
A hospital algorithm
A suggested algorithm for the initial management of cardiac arrest in hospital is shown in Fig 1. When a patient collapses on a ward the nurse should first shout for help, then assess whether the patient is responsive.
If the patient is unresponsive, the nurse should check for a pulse while other staff members are arriving. If a pulse can be felt, the rapid response team should be called, MOVE (Monitor to include a full set of observations, Oxygen, Venous access, 12-lead Electrocardiography) should be performed and the assessment/treatment of the patient continued.
If there is not a definite pulse, the cardiac arrest team should be called. If only two members of staff are present they should both leave the patient: one should call the arrest team while the other fetches an automated external defibrillator, which is usually part of the cardiac arrest trolley. The defibrillator should be turned on and the nurse should follow the voice prompts. Defibrillation and CPR should be carried out as instructed. This ensures that all patients in a shockable rhythm (ventricular fibrillation/pulses ventricular tachycardia) receive early defibrillation.
CPR should be performed with oxygen administration through a pocket mask or bag-valve mask with reservoir. A two-person technique is used, with the person doing chest compressions squeezing the bag. The third person to arrive should confirm that the oxygen is connected and turned to 10L and that the suction is turned on and placed at the head of the patient.
The ward staff should then consider the possible cause of the cardiac arrest. One nurse should be designated to give a handover to the cardiac arrest team leader, preferably the nurse who knows most about the patient’s medical condition and social history. The patient’s medical notes should be located and drugs should be prepared.
Once the anaesthetist takes over the management of the airway, the nurse who was managing the airway should prepare the equipment for intubation. After the arrival of the cardiac arrest team, the nurses should be able to continue to help by anticipating the needs of the team. This involves knowing the cardiac arrest treatment algorithms and recording events contemporaneously.
If no rapid response team system is in place it may be appropriate to call the cardiac arrest team for every patient who is unresponsive after a collapse. This would modify the algorithm shown in Fig 1: assessment of the pulse would occur at the same time as the cardiac arrest team is called.
Even if the patient is not in cardiac arrest, sudden unresponsiveness requires the immediate attendance of a senior member of the medical team. The concept of a specific cardiac arrest team may be outdated because it is often called too late. Many hospitals have a rapid response team which includes an anaesthetist and an intensive care unit nurse. This is complemented by a hospital policy which dictates that all nurses registered for six months or more are trained to defibrillate using automated external defibrillators.
The rapid response team is called if the patient becomes seriously ill, pre-empting a deterioration that may require cardiac resuscitation. To help nurses make that decision, a risk assessment is carried out. According to the patient-at-risk system, which assesses variables such as heart rate, respiratory rate and level of consciousness, patients with a score of less than three are at risk and need to be reviewed by the medical or rapid response team.
Departures from standard protocols
Checking for a safe environment may be important if a patient collapses in the community but is not necessary in a hospital training programme and wastes valuable time. All standard health and safety procedures should be followed in the event of an arrest in a bathroom or if the patient is on the floor, for example. Health care professionals all have a responsibility to ensure that the clinical area is safe.
Gasping respiration is common when patients collapse in hospital (Clark et al, 1992). If nurses assume that the patient is breathing this can lead to a delay in diagnosis because, according to standard BLS protocols, a breathing patient is not in cardiac arrest. Nurses who work in hospitals must have the clinical skills to differentiate between the two and act accordingly.
If a patient collapses in hospital his or her pulse should be checked immediately. The cardiac arrest team should be called if a definite pulse cannot be located. Airway manoeuvres are performed later in the sequence as part of ventilation with oxygen.
Pocket masks, which are not expensive, should be kept in all clinical and non-clinical areas. Mouth-to-mouth ventilation should therefore not be necessary in a hospital.
It must be emphasized that oxygen should be used whenever ventilation is performed. For this reason it and a suction apparatus should be available in all patient areas. A system that can be used to store and move oxygen, a suction apparatus and a defibrillator to non-clinical areas should also be readily available.
This algorithm is simple and pertinent to hospitals in which standard BLS guidelines still conform to the universal resuscitation algorithm. Its simple format takes less time to teach, allowing instruction on other important in-hospital topics, such as recognition of patients who are at increased risk and audit of the outcomes of cardiac arrest.
The use of the algorithm in the context in which the nurse works should be emphasised throughout training, so the teacher must be familiar with the activity and routines of each clinical area.
The BLS algorithm for resuscitation, which was designed for use by lay people, is not wholly appropriate for the management of patients who collapse in hospital. It is, however, widely taught to nurses. Hospital resuscitation training should reflect the reality of the clinical situation when a patient collapses in a hospital.