Innovative Use of AED by RNs and RTs During In‐Hospital Cardiac Arrest: Phase II
CAEP Edmonton June 2015
Justin Godbout MD Candidate, BSc
Christian Vaillancourt MD, MSc Hannah Buhariwalla MD Candidate, BScH
Cynthia Penner CHIM
Rina Marcantonio CCHRA
Department of Emergency Medicine
Ottawa Hospital Research Institute
University of Ottawa, Ottawa, ON
Funded by Department of Emergency Medicine
The Mach‐Gaensslen Foundation of Canada
No conflict of interest
Background
2010 Resuscitation Guidelines recommend that defibrillation be performed rapidly (< 3 min)
A health record review at The Ottawa Hospital (Phase I) identified long time intervals before defibrillation in non‐
critical care areas (≥ 11 min)
Background
All TOH defibrillators have an automated external defibrillator (AED) mode
Until recently, registered nurses (RNs) and respiratory therapists (RTs) could not use AEDs
The Ottawa Hospital finished implementing a medical directive allowing RNs and RTs to use AEDs in September, 2013
Objectives
To evaluate the benefits of a rapid defibrillation program allowing RNs and RTs to use TOH defibrillators in AED mode during in‐hospital cardiac arrests
To evaluate two implementation strategies (Phase III funded by TOHAMO)
Methods
Design: Before‐after health record review
Setting: The Ottawa Hospital campuses / clinics
Population: (20‐month before; 7‐month after)
Inclusion
All in‐hospital cardiac arrest patients for which resuscitation was attempted (no DNR)
Re‐arrest following prehospital ROSC
Exclusion
Simple in‐hospital (ED) continuation of prehospital arrest care
Methods
Intervention:
All RNs and RTs have basic CPR+AED training
Educators rolled‐out the AED medical directive using “usual practices” (Phase II)
Included didactic and video support + hands‐on
Case Identification: Health record analysts, ICD‐10
Data Collection: Investigators reached consensus on a standardized and piloted data collection tool based on the Utstein reporting guidelines for in‐hospital cardiac arrests
Methods
Source documents: Electronic medical records
ED records of treatment
RACE records of treatment
Cardiac arrest records
All medical records and nursing notes
Primary Outcome Measure: Time to 1st shock
Secondary Outcome: Implementation of program
Analyses: Simple descriptive and t‐test statistics
Patient Characteristics Before
N (%) n=195
Mean Age (yrs)[range]
Male Sex Witnessed arrest
Initial rhythm
PEA
VF/VT
Asystole
AED no shock
Unknown
Mean arrest to team arrival (min)
ROSC
Survival to Hospital Discharge
Discharged Home
After n=75
68 [18‐96] 69 [19‐95]
121 (62.1) 48 (64.0)
137 (70.3) 54 (72.0)
76 (39.0)
52 (26.7)
41 (21.0)
‐
25 (12.8)
3:17
127 (65.1)
48 (24.6)
25 (52.1)
28 (27.3)
20 (26.7)
18 (24.0)
2 (2.7)
8 (10.7)
1:55
46 (61.3)
17 (22.7)
13 (76.5)
Cardiac Arrest Location
N (%)
ED
Medicine ward
ICU/CCU
Surgical ward
OR
Dialysis
Diagnostic imaging
Other
Before n=195
51 (26.2)
43 (22.1)
39 (20.0)
20 (10.3)
20 (10.3)
5 (2.6)
5 (2.6)
12 (6.2)
After
n=75
22 (29.3)
20 (26.7)
13 (17.3)
7 (9.3)
4 (5.3)
1 (1.3)
0 (0.0)
8 (10.7)
Cardiac Arrest Etiology
N (%)
Respiratory
MI/Ischemia/Arrhythmia
Metabolic/Sepsis
Bleeding
Unknown
Other
Terminal
Before n=195
58 (29.7)
42 (21.5)
28 (14.4)
26 (13.3)
20 (10.3)
16 (8.2)
5 (2.6)
After
n=75
19 (25.3)
19 (25.3)
10 (13.3)
9 (12.0)
7 (9.3)
3 (4.0)
8 (10.7)
Mean Time to First Shock (min)
15
10
10:54
8:13
5
0
Before (n=42)
After (n=23)
Mean difference 2:41 min; p = 0.30
An AED Was Used in 4 Cases (After group)
Discussion
We successfully implemented a program allowing RNs and RTs to use AEDs during in‐hospital cardiac arrest (AED medical directive)
There were lost opportunities to use an AED in most locations, possibly because previously‐identified facilitators and barriers were not addressed
AEDs were mostly used in non‐critical care areas, where Code Blue team usually takes longer to arrive
When an AED was used, the time interval between recognition of cardiac arrest and first shock delivery was much closer to the recommended guidelines
Limitations
Missing data (time of events)
Possible under‐reporting of AED use when no shock was advised
Hawthorne effect? Faster code team arrival
Decreased time to first shock despite limited implementation of AED med. dir.
Conclusions
The use of AEDs by RNs and RTs, could potentially lead to a significant reduction in time to first shock and improved survival outcomes (need larger study)
Our current implementation strategy did not appear to result in optimal use of AEDs in all locations
Time to 1st Shock for In‐Hospital Cardiac Arrests (n=21)
Locations
Medicine
Surgery
ICU
Rehab
ED
OR
Average time in Minutes
0:11
0:10
0:08
0:07
0:06
0:06
% of all Arrests
22.5
9.2
18.3
0.8
27.5
10.8