SAED: Can we Improve the In-Hospital: Chain of Survival?

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A presentation as a requirement for the Graduate Diploma in Critical Care Nursing - University of Canberra, 2005

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  • Specialist trained medical, nursing and paramedical staff have traditionally used manual defibrillators within clinical institutions and within the pre-hospital care environment. Defibrillator technology has since advanced to the current models of semi-automatic external defibrillators. Semi-automatic external defibrillator is described as an: “ automatic external defibrillator which provides the operator with an audible or visual prompt to discharge the defibrillator to deliver a shock to a victim when it recognises a shockable rhythm” Semi-automatic external defibrillators can be use by lay persons without any prior medical knowledge or knowledge of the semi-automatic external defibrillator machines. This was evident within a group of sixth-grader children who were able to efficiently use semi-automatic external defibrillators within a simulated cardiac arrest. The semi-automatic external defibrillator, once attached to the patient undertakes a process of rhythm recognition and advises the user to ‘shock’ the patient or to ‘continue cardio-pulmonary resuscitation’. Therefore, removing the need for the user to analyse cardiac rhythms and make decisions based on their findings.
  • Within the Australian pre-hospital care environment, survival from cardiac arrest is reported at approximately ten percent. As a result of low survival rates, the pre-hospital arena has seen increased efforts to improve the chain of survival particularly through the introduction of public access defibrillation programs.
  • Caffrey, et al demonstrated that the strategic planning and positioning of semi-automatic external defibrillators within three Chicago airports had a significant impact of patient survival rates.
  • Semi-automatic external defibrillators were positioned within a ninety second walk from any point within the airport terminals, therefore, providing a maximum three minutes walk from the patient to the defibrillator and return. Over a two year period, eighteen patients with ventricular fibrillation were defibrillated. The overall survival rate was fifty-six percent; this survival rate was increased to sixty-seven percent among patients where defibrillation was achieved within the first five minutes from collapse.
  • Other public access defibrillation programs, mimic similar results. Wassertheil, demonstrate that defibrillators at large public gatherings, such as, the Melbourne Cricket Ground and the Melbourne Shrine of Remembrance, improved survival rates following cardiac arrest. Of twenty-eight patients who had a cardiac arrest, seventy-one percent were discharged from hospital. In ninety-three percent of these cases defibrillation was achieved within the first five minutes of collapse.
  • In-Hospital cardiac arrest survival rates remain at best at 10%
  • Many clinical institutions have introduced Medical Emergency Teams in an attempt to reduced Intensive Care Unit admissions and identify critically ill patients within the non-critical care environment. Medical Emergency Teams respond to non-critical care ward areas when called by staff as a result of a patients physiological condition [see table 1]. This ‘calling criteria’ outlines physiological parameters that predict a patient is deteriorating and possibly in a pre-arrest state.
  • Many clinical institutions have introduced Medical Emergency Teams in an attempt to reduced Intensive Care Unit admissions and identify critically ill patients within the non-critical care environment. Medical Emergency Teams respond to non-critical care ward areas when called by staff as a result of a patients physiological condition [see table 1]. This ‘calling criteria’ outlines physiological parameters that predict a patient is deteriorating and possibly in a pre-arrest state.
  • Demonstrated that Medical Emergency Teams are effective in reducing Intensive Care Unit admissions, patient length of stay and adverse patient outcomes
  • In addition, Cretikos and Hillman state that Medical Emergency Teams facilitate a co-ordinated approach to the critically ill patient located outside designated critical care areas.
  • Spearpoint, et al describes a semi-automatic external defibrillator program within the West London Hospital Precinct. Prospective clinical data was used to demonstrate an increase in survival rate to approximately eighty percent. In the majority of these cases, defibrillation was achieved within two minutes from the onset of an arrhythmia and prior to adjunct therapy such as external cardiac compressions or ventilation. When adjunct therapies were used survival rates reduced to forty-one percent, possibly due to an associated time delay to defibrillation.
  • Coady describes a first-responder semi-automatic external defibrillator program within the Royal Sussex County Hospital, a four-hundred and thirty bed general hospital with an average of two-hundred and fifty cardiac arrests per year. Traditionally, manual defibrillation was performed within the hospital with a forty-one percent survival rate. Since the introduction of a first-responder semi-automatic external defibrillation program, survival rates have increased to fifty-five percent, a statistically insignificant, however, possibly a clinically significant improvement. Coady suggests that due to the first-responders reluctance to use the semi-automatic external defibrillators, only a slight increase in survival rates was evident, suggesting that acceptance from first-responders is important in the implementation of a semi-automatic external defibrillator program.
  • Hanefeld, et al describes a first-responder semi-automatic external defibrillator program that was instituted in a six-hundred and eighty-six bed university hospital in Germany. Previously, defibrillation was performed by a cardiac arrest team that was activated via a central communications centre, similar to the current situation at The Canberra Hospital. Hanefeld, states in 18/27 (66.6%) of cases a shockable rhythm was initially recorded and therefore a shock was delivered by the first-responder. Return of spontaneous circulation occurred in 16/18 (88.9%) cases, discharge from the Intensive Care Unit in 11/18 (61.1%) cases and discharged from hospital 10/18 (55.6%) cases. On average, defibrillation was achieved 2.6 minutes prior to the arrival of the cardiac arrest team.
  • Recommendations for future include research in the areas
  • SAED: Can we Improve the In-Hospital: Chain of Survival?

    1. 1. Semi-Automatic External Defibrillation: Can we Improve the In-Hospital Chain of Survival? Jamie Ranse Registered Nurse Graduate Diploma in Critical Care Nursing
    2. 2. Chain of Survival Australian Resuscitation Council, 1997, ‘Early Defibrillation’ , Australian Resuscitation Council Policy Statements Manual , no. 11.7.1, Melbourne, Australia.
    3. 3. Chain of Survival Australian Resuscitation Council, 1997, ‘Early Defibrillation’ , Australian Resuscitation Council Policy Statements Manual , no. 11.7.1, Melbourne, Australia.
    4. 4. Semi-Automatic External Defibrillator <ul><li>Various products all use the same principles </li></ul><ul><li>1 – 2 – 3 step process </li></ul>“ audible or visual prompt to discharge the defibrillator and deliver a shock when it recognises a shockable rhythm” Australian Resuscitation Council, 1997, ‘Early Defibrillation’ , Australian Resuscitation Council Policy Statements Manual , no. 11.7.1, Melbourne, Australia.
    5. 5. Semi-Automatic External Defibrillator Royal Phillips Technology, 2005, http://www.phillips.com.au/index.html
    6. 6. Semi-Automatic External Defibrillator Royal Phillips Technology, 2005, http://www.phillips.com.au/index.html
    7. 7. Semi-Automatic External Defibrillator Royal Phillips Technology, 2005, http://www.phillips.com.au/index.html
    8. 8. Pre-Hospital Chain of Survival <ul><li>In Australia survival from a pre-hospital cardiac arrest is approximately 10% </li></ul><ul><li>Efforts to strengthen the Chain of Survival </li></ul>Australian Resuscitation Council, 1997, ‘Early Defibrillation’ , Australian Resuscitation Council Policy Statements Manual , no. 11.7.1, Melbourne, Australia.
    9. 9. Pre-Hospital Chain of Survival <ul><li>Chicago Airports </li></ul>Caffrey SL, et al., 2002, ‘Public Use of Automated External Defibrillators’, New England Journal of Medicine , vol. 347, no. 16, pp. 1242 – 1247.
    10. 10. Pre-Hospital Chain of Survival 56% 67% Caffrey SL, et al., 2002, ‘Public Use of Automated External Defibrillators’, New England Journal of Medicine , vol. 347, no. 16, pp. 1242 – 1247.
    11. 11. Pre-Hospital Chain of Survival Melbourne Shrine of Remembrance Melbourne Cricket Ground 71% Wassertheil J, et al, 2000, ‘Cardiac Arrest Outcomes at the Melbourne Cricket Ground and Shrine of Remembrance Using a Tired Response Strategy – a Forerunner to Public Access Defibrillation’, Resuscitation , vol. 44, pp. 97 – 104.
    12. 12. In-Hospital Chain of Survival <ul><li>In-hospital cardiac arrest survival rate is approximately 10% </li></ul>
    13. 13. In-Hospital Chain of Survival Medical Emergency Teams (MET) <ul><li>Objective: </li></ul><ul><li>Identify critically ill patients </li></ul><ul><li>Recognise deterioration </li></ul>Cretikos M & Hillman K, 2003, ‘The Medical Emergency Team: Does it Really Make a Difference?’, Internal Medicine Journal , vol. 33, pp. 511 – 514.
    14. 14. In-Hospital Chain of Survival Medical Emergency Teams (MET) <ul><li>Objective: </li></ul><ul><li>Identify critically ill patients </li></ul><ul><li>Recognise deterioration </li></ul><ul><li>Aim: </li></ul><ul><li>Reduce ICU admissions </li></ul><ul><li>Reduce respiratory and cardiac arrest </li></ul>Cretikos M & Hillman K, 2003, ‘The Medical Emergency Team: Does it Really Make a Difference?’, Internal Medicine Journal , vol. 33, pp. 511 – 514.
    15. 15. In-Hospital Chain of Survival Medical Emergency Teams (MET) Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, et al., 2004, ‘Prospective Control Trial of Effect of Medical Emergency Team on Postoperative Morbidity and Mortality Rates’, Critical Care Medicine , vol. 32, no. 4, pp. 916 – 921. <ul><li>ICU admissions </li></ul><ul><li>Patient length of stay </li></ul><ul><li>Adverse patient outcomes </li></ul>
    16. 16. In-Hospital Chain of Survival <ul><li>ICU admissions </li></ul><ul><li>Patient length of stay </li></ul><ul><li>Adverse patient outcomes </li></ul><ul><li>Coordinated approach </li></ul><ul><li>Survival from in-hospital cardiac arrest remains at approximately 10% </li></ul>Cretikos M & Hillman K, 2003, ‘The Medical Emergency Team: Does it Really Make a Difference?’, Internal Medicine Journal , vol. 33, pp. 511 – 514. Medical Emergency Teams (MET)
    17. 17. In-Hospital Chain of Survival First-Responder Semi-Automatic External Defibrillator Programs
    18. 18. In-Hospital Chain of Survival <ul><li>West London Hospitals, England </li></ul><ul><li>Multidisciplinary Hospitals </li></ul><ul><li>~ 1200 beds </li></ul><ul><li>Delayed Defibrillation </li></ul><ul><li>Semi-Automatic External Defibrillation </li></ul>Spearpoint KG, McLean CP & Zideman DA, 2000, ‘Early Defibrillation and the Chain of Survival in ‘in-Hospital’ Adult Cardiac Arrest; Minutes Count’, Resuscitation , vol. 44, pp. 165 – 169. 41% 80%
    19. 19. In-Hospital Chain of Survival <ul><li>Royal Sussex Hospital, England </li></ul><ul><li>430 Beds general hospital </li></ul><ul><li>250 Cardiac Arrests per annum </li></ul><ul><li>Manual defibrillation </li></ul><ul><li>Semi-Automatic External Defibrillators </li></ul>Coady EM, 1999, ‘A Strategy for Nurse Defibrillation in General Wards’, Resuscitation , vol. 42, pp. 183 – 186. 41% 55%
    20. 20. In-Hospital Chain of Survival <ul><li>St Josef Hospital, Germany </li></ul><ul><li>636 Beds </li></ul><ul><li>18/27 (67%) initial rhythm shockable </li></ul><ul><li>16/18 (89%) return of circulation </li></ul><ul><li>11/18 (61%) discharged from ICU </li></ul><ul><li>10/18 (56%) discharged home </li></ul><ul><li>2.6 minutes quicker </li></ul>Hanefeld C, Lichte C, Mentges-Schroter I, Sirtl C & Mugge A, [in press - 2005], ‘Hospital-Wide First-Responder Automated External Defibrillator Programme: 1 Year Experience’, Resuscitation . 56%
    21. 21. Recommendations <ul><li>Implementation of In-Hospital First-Responder Semi-Automatic External Defibrillator Programs </li></ul><ul><li>Research </li></ul><ul><ul><li>Compliance and barriers </li></ul></ul><ul><ul><li>Australian perspective </li></ul></ul><ul><ul><li>Increase current literature </li></ul></ul><ul><li>Education </li></ul><ul><ul><li>Basic Life Support </li></ul></ul><ul><ul><li>Public Access Defibrillator Programs </li></ul></ul>
    22. 22. Questions?
    23. 23. Semi-Automatic External Defibrillation: Can we Improve the In-Hospital Chain of Survival? Jamie Ranse Registered Nurse Graduate Diploma in Critical Care Nursing

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