Abstract of thesis entitled

Transcription

1 Abstract of thesis entitled Evidence based protocol of nurse initiated use of automated external defibrillator for in-hospital patients after cardiac arrest Submitted by Tsoi Lam Lai For the Degree of Master of Nursing At the University of Hong Kong On July 2014 Abstract In-hospital cardiac arrest is a common situation in Hong Kong. Yet, the survival to discharge rate is only 5%. Early defibrillation is showed important to improve the survival rate. According to the American Heart Association, the integration of Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) use is proposed to provide rapid resuscitation in recent year. Promoting first responders Nurses to provide automated external defibrillation is one of the method to provide early defibrillation in the resuscitation process. This dissertation aims at developing an evidenced-based guideline on nurse initiated use of automated external defibrillator for in-hospital patients after cardiac arrest. The objectives are to conduct a search on the existing best evidence of the nurses initiated use of AED, perform a critical appraisal on the literature, and develop guidelines for

2 the nurses initiated use of AED. In addition, assessment of the implementation potential of the proposed guidelines, and developing the implementation and evaluation plan are included in this dissertation. A systematic search was performed using three electronic databases including Pubmed, CINAHL Plus and the Cochrane Library by 29 th July Seven cohort studies are selected from thousands of the literature according to the inclusion and exclusion criteria. Data was extracted and showed in the evidence table. The level of evidence of each study was graded according to the Scottish Intercollegiate Guidelines Network framework. After performing the critical appraisal and data synthesis of the selected studies, it is concluded that nurses initiated use of AED can improve the survival to discharge rate after in hospital cardiac arrest. The implementation potential including transferability, feasibility and the cost/benefit ratio of the innovation was assessed. It was found that the innovation is feasible and beneficial to the cardiac arrest patients. After that, the implementation plan involving communication process between the stakeholders, initialization and sustaining the evidenced-based practice were discussed. A pilot study was carried out in order to identify any difficulties in implementing the innovation. A comprehensive evaluation plan concerning the patient outcomes, health care provider outcomes and system outcomes were evaluated after the pilot testing.

3 To conclude, nurse initiated automated external defibrillation is worthwhile to implement in hospital in Hong Kong. It is expected that there will be improvement in the resuscitation process and the survival to discharge rate of cardiac arrest patients after the implementation of the nurse initiated automated external defibrillation in hospital.

4 Evidence based protocol of nurse initiated use of automated external defibrillator for in-hospital patients after cardiac arrest by Tsoi Lam Lai BNurs (HKU) A thesis submitted in partial fulfillment of the requirements for the Degree of Master of Nursing at the University of Hong Kong July 2014

5 Declaration I declare that this thesis represents my own work, except where due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualifications. Signed. Tsoi Lam Lai i

6 Acknowledgements I would like to give special thanks to my supervisor Dr. Janet Wong for her significant help, guidance, and support throughout the past two years. In addition, I would like to thank my family members, my classmates for their accompany and encouragement in the entire process. Last but not least, I have to sincerely thank my fiancé Mr Chan Ka Ho, who has been providing me with support, understanding and love throughout these years. ii

7 Table of Contents Declaration... i Acknowledgement.ii Table of Contents..iii List of Appendices.v Abbreviations vi Chapter 1 Introduction 1.1 Background Affirmation of the Needs Objectives and Significance...4 Chapter 2 Critical Appraisal 2.1 Search and Appraisal Strategies Results Summary and Synthesis of Data Potential Innovation...16 Chapter 3 Implementation potential 3.1 Target Setting Transferability of findings Feasibility Cost/ Benefit Ratio of the innovation.23 Chapter 4 Evidence-based guidelines 4.1 Aims/Objectives/Target group Grades of recommendation Recommendation 29 Chapter 5 Implementation Plan 5.1 Communication Plan Pilot Study Plan Evaluation Plan...39 Chapter 6 Conclusion.44 Reference.45 iii

8 List of Appendices Appendix A Search History...48 Appendix B Table of evidence...49 Appendix C Methodology checklist...54 Appendix D Grade of Recommendation (Scottish Intercollegiate Guideline Network, 2008)...69 Appendix E Material Cost of implementing proposed innovation...70 Appendix F Evaluation form of survival to discharge rate for cardiac arrest patients after using automated external defibrillation 71 Appendix G Assessment form of using AED by nurses...72 Appendix H Timeline for implementation of nurse initiated AED program 73 Appendix I Flow chart of implementation of nurse initiated AED..74 iv

9 Abbreviations AED Automatic external defibrillator AHA American Heart Association APN Advanced Practice Nurse COS Chief of Service CPR Cardiopulmonary resuscitation DOM Department Operational Manager NO Nurse Officer RN Registered Nurse SIGN Scottish Intercollegiate Guideline Network SMO Senior Medical Officer VF Ventricular fibrillation VT Ventricular tachycardia WM Ward Manager v

10 Chapter 1 Introduction 1.1 Background Health care providers aim at providing the best and holistic care to patients with the goal of efficiently and uneventfully discharging them. Unfortunately, unexpected changes of the patients conditions may occur. One of the critical conditions is cardiac arrest. Cardiac arrest defines as the cessation of the heart to provide adequate oxygenated blood flow to the body (Torpy, Lynm, & Glass, 2006). In the United States, it is estimated that people result from death following sudden cardiac arrest per year (Capucci et al., 2002) and the survival to discharge rate of cardiac arrest is only 17% according to The National Registry of Cardiopulmonary Resuscitation in 2003 (Peberdy et al., 2003). In Hong Kong, there are 6316 cases died from heart disease which is 15.0% of the total mortality (Department of health, 2011). According to Yap et al. (2007), the in-hospital cardiac arrest survival to discharge rate is only 5 % in one of the teaching hospitals in Hong Kong. Interventions including early recognition of patients at risk of cardiac arrest, prompt and better in-hospital resuscitation and early defibrillation are important to improve survival rate (Sandroni, Nolan, Cavallaro, & Antonelli, 2007). Defibrillation is demonstrated as an effective electrical shock to restore a normal heart rhythm in patients who are undergoing ventricular fibrillation (VF) or ventricular tachycardia (VT) and delay the deterioration of patients conditions from VF to asystole. In the 1

11 United States, delayed defibrillation conditions are commonly happened in 30.1% of the cardiac arrest patients in a study and it is associated with a lower survival to discharge rate at around 22.2% (Chan, Krumholz, Nichol, & Nallamothu, 2008). If defibrillation is administered rapidly, the outcome of cardiac arrest due to VF or pulseless VT is better than those due to asystole or pulseless electrical activity (PEA) (Chan et al., 2008). Therefore, the integration of Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) use is proposed by the American Heart Association to increase the survival rate (Link et al., 2010). 1.2 Affirming the needs My local setting is a medical and geriatric ward in a public hospital. Nurses are usually the first responders to cardiac arrests patients. In my setting, nurses will start CPR immediately as long as there is no Do Not Resuscitation raised by the patients or the relatives. CPR can prolong VF and delay the onset of asystole so that it extends the time of implementing defibrillation. However, if CPR is solely performed without defibrillation, it is not able to terminate VF and restore a normal rhythm. The current practice in general wards nowadays is to perform early CPR to maintain adequate blood flow to vital organs. After the resuscitation team arrived, the physicians will provide the manual defibrillation to the patients. However, it usually takes a few 2

12 minutes before the physicians arrived. One study in a Hong Kong hospital showed that the mean arrival time of resuscitation team or time to defibrillation is around 5 minutes (Yap et al., 2007). As the preferred time of starting defibrillation is not more than 3 minutes, it is showed that there is a delay in defibrillation in general wards (Link et al., 2010). To improve the survival to discharge rate of the cardiac arrest patient, early defibrillation should be promoted. One of the methods to shorten the time to defibrillation is to allow the first responders Nurses to perform defibrillation in hospitals. Although nurses spend the most time with patients compare with the other health care providers, the defibrillation in resuscitation is mainly performed by physicians only in Hong Kong. Nurses initiated defibrillation by using manual defibrillator or automatic external defibrillator (AED) is not widely adopted in general wards in Hong Kong hospitals (Lee & Low, 2010). There are no well developed guidelines for nurses to implement defibrillation in general wards. 3

13 1.3 Study objectives and significance The recommended time from VF to defibrillation is less than 3 minutes (Link et al., 2010) and the delay in defibrillation will decrease the survival rate by 10% every minute (Marenco, Wang, Link, Homoud, & Estes, 2001). Waiting a response team to perform defibrillation is one of the factors that will result in delayed time to defibrillation and low survival rate of in-hospital sudden cardiac arrest (Cusnir et al., 2004). Therefore, there is a need to promote nurse as a first responder to perform defibrillation by using AED for cardiac arrests patients. AED is a defibrillator which could analyse patients cardiac rhythm automatically and deliver shocks if indicated (Liddle, Davies, Colquhoun, & Handley, 2003). The AED technology is advanced and showed improvement in effectiveness and accuracy (Marenco et al., 2001). Nurse led defibrillation by using AED which is beneficial to patient could be promoted (Kenward, Castle, & Hodgetts, 2002). It could improve the survival to discharge rate. Therefore, increase the satisfaction of patients and their family members. Apart from that, extending nurses role in defibrillation could promote the professionalism in nursing (Lee & Low, 2010). 4

14 The research question of this study: The effectiveness of nurse initiated automated external defibrillation to improve the survival to discharge rate for in hospital cardiac arrest patients in general wards? The objectives of this study are: a. To review systematically the current literatures on the use of automated external defibrillators for cardiac arrest patients, nurses role in performing defibrillation b. To conclude and synthesis the evidence from the selected literatures c. To assess the implementation potential of nurse initiated automated external defibrillation in general wards in Hong Kong d. To translate the reviewed evidence and develop an evidence-based practice guideline on nurse initiated automated external defibrillation e. To work out a systematic training program for nurses for the use of automated external defibrillations f. To prepare an evaluation plan of the nurse initiated automated external defibrillation guideline and the training program 5

15 2.1 Search and appraisal strategies Chapter 2 Critical Appraisal Identification of studies After formulating the research question, a systematic search of literatures were done by using the three electronic databases including Pubmed, CINAHL Plus and the Cochrane Library by 29 th July The keywords were (1) automated external defibrillator or automated external defibrillation or AED ; (2) In-hospital cardiac arrest or in-hospital resuscitation ; (3) survival to discharge The combination of three groups of keywords was used in the above three electronic databases. A total of 75 literatures were found in the three electronic data bases. After screening the titles and abstract of these 75 literatures, 12 literatures were manually screened the full text according to the inclusion and exclusion criterion. Finally, 5 were selected from Pubmed. There were 4 relevant articles chosen from CINHAL Plus, but two of them were duplicated with those in Pubmed and removed. Regarding the search in the Cochrane Library, there were 6 relevant studies retrieved after combining the three groups of the keywords. However, none is selected after screening the title and abstract. Apart from that, reference lists of the selected articles were screened but there were no relevant articles. Finally, 7 relevant articles were selected from the three electronic databases according to the following selection criterion. The details of search history are shown in Appendix A. 6

16 Inclusion criteria: 1. Study participants should be the in hospital cardiac arrest adult patients 2. Intervention group is using automated external defibrillation 3. Study designs are cohort studies, case control studies or randomised control trails. 4. One of the outcome measures is using survival to discharge rate Exclusion criteria : 1. Study participants with implantable cardioversion defibrillator 2. Intervention group received automated external cardioversion defibrillator monitoring The selected 7 articles are as follow: 1. Chan, P. S., Krumholz, H. M., Spertus, J. A., & et al. (2010). AUtomated external defibrillators and survival after in-hospital cardiac arrest. JAMA, 304(19), Forcina, M. S., Farhat, A. Y., O'Neil, W. W., & Haines, D. E. (2009). Cardiac arrest survival after implementation of automated external defibrillator technology in the in-hospital setting. Crit Care Med, 37(4), Gombotz, H., Weh, B., Mitterndorfer, W., & Rehak, P. (2006). In-hospital cardiac resuscitation outside the ICU by nursing staff equipped with automated external defibrillators The first 500 cases. Resuscitation, 70(3),

17 4. Källestedt, Marie-Louise Södersved, Berglund, Anders, Enlund, Mats, & Herlitz, Johan. (2012). In-hospital cardiac arrest characteristics and outcome after defibrillator implementation and education: from 1 single hospital in Sweden. The American Journal of Emergency Medicine, 30(9), Kloppe, Cordula, Jeromin, Andre, Kloppe, Axel, Ernst, Monika, Mügge, Andreas, & Hanefeld, Christoph. First Responder for In-Hospital Resuscitation: 5-Year Experience with an Automated External Defibrillator-Based Program. The Journal of Emergency Medicine(0). 6. Smith, Roger J., Hickey, Bernadette B., & Santamaria, John D. (2011). Automated external defibrillators and in-hospital cardiac arrest: Patient survival and device performance at an Australian teaching hospital. Resuscitation, 82(12), Zafari, A. Maziar, Zarter, Susan K., Heggen, Vicki, Wilson, Patricia, Taylor, Regina A., Reddy, Kiran,... Dudley, Jr Samuel C. (2004). A program encouraging early defibrillation results in improved in-hospital resuscitation efficacy. Journal of the American College of Cardiology, 44(4), Data Extraction The selected 7 relevant literatures were summaries to form a table of evidence as showed in appendix B. The details of bibliographic citation, study design, study 8

18 participants characteristic, intervention, comparison, outcome measure and results of the literatures were all shown in the table of evidence Appraisal strategies The Scottish Intercollegiate Guidelines Network (SIGN) checklists (SIGN, 2008) were used to assess the quality of the research studies. Among different methodology checklists, checklists 3 for cohort studies were used for the identified studies. The checklist is divided into two sections including internal validity and overall assessment of the studies. The level of evidence is finally graded as ++, + or 0. The meanings of the codes are described as below: High quality (++): Majority of criteria is met. Little or no risk of bias is noted. Results are unlikely to be changed by further research. Acceptable (+): Most criteria are met. Some flaws in the study with an associated risk of bias were found, Conclusions may change in the light of further studies. Low quality (0): Either most criteria not met, or significant flaws relating to key aspects of study design. Conclusions are likely to change in the light of further studies. 9

19 2.2 Results Study Design All of the 7 identified studies were cohort studies. No randomizations were done in all of the studies. Among the 7 cohort studies, three of them were retrospective design (Forcina, Farhat, O'Neil, & Haines, 2009; Gombotz, Weh, Mitterndorfer, & Rehak, 2006; Kloppe et al., 2013). The other four were prospective design (Chan, Krumholz, Spertus, & et al., 2010; Källestedt, Berglund, Enlund, & Herlitz, 2012; Smith, Hickey, & Santamaria, 2011; Zafari et al., 2004) Level of evidence Using the SIGN checklists for the quality assessment for the 7 identified cohort studies, two of them were grade as ++ high quality, which means that majority of the criteria were met and no or little risk of basis (Chan et al., 2010; Zafari et al., 2004). The other five were grade as + acceptable, which indicates that some flaws in the study with an associated risk of bias were indentified (Forcina et al., 2009; Gombotz et al., 2006; Källestedt et al., 2012; Kloppe et al., 2013; Smith et al., 2011). The details of checklist are shown in appendix C. 10

20 2.2.3 Characteristics of the study participants In 5 out of the 7 studies, the study populations with cardiac arrest were indentified in general patient care areas outside intensive care units (Chan et al., 2010; Gombotz et al., 2006; Källestedt et al., 2012; Kloppe et al., 2013; Smith et al., 2011).There were two studies included the cardiac arrest patients in intensive care units and emergency departments (Forcina et al., 2009; Zafari et al., 2004). Only one study s participants were from different hospitals (Chan et al., 2010). Others were all from single hospital. The demographic and characteristics of the study participants including some medical histories were compared in all studies. There were no significance differences on the baseline characteristic between the intervention and control group in all studies. The initial rhythms of cardiac arrest were also clearly documented in all of the studies. The number of participants were ranged from 166 (Smith et al., 2011) to (Chan et al., 2010) Interventions and Control All of the studies used AED as the intervention group. Four of the studies mentioned education program or staff training as part of the intervention (Forcina et al., 2009; Källestedt et al., 2012; Kloppe et al., 2013; Zafari et al., 2004). However, there were differences in the education and training programs in training hours and 11

21 assessment. Furthermore, different comparison groups were used among the seven studies. Two studies used standard defibrillators as the comparisons group (Forcina et al., 2009; Zafari etal., 2004). Three of the studies compared the outcome before the deployment of the automated external defibrillators and after it (Chan et al., 2010; Källestedt et al., 2012; Smith et al.,2011). One study compared the automated external defibrillators used on VT or VF patients and non-vt/vf patients (Gombotz et al., 2006) while one study did not mention any comparison group (Kloppe et al., 2013) Outcome measures (1) Survival to discharge All of the studies used the survival to discharge rate as the main outcome measures. There were two statistically significant results. One showed that survival to discharge rate decreased 3% with the use of AED (p<0.01) (Chan et al., 2010) while one showed increased 7.9% in the survival to discharge rate on AED group (p=0.001) (Zafari etal., 2004). Other results were not satistically significance on surivival to discharge rate (Forcina et al., 2009; Källestedt et al.,2012; Smith etal.,2011). Two studies showed the survival to discharge rate with the AED use is higher in VT/VF patients (Gombotz et al., 2006; Kloppe et al., 2013). 12

22 (2) Rate of return of spontaneous circulation (ROSC) The Rate of returen of spontaneous circulation (ROSC) were reported in five studies (Chan et al., 2010; Forcina et al., 2009; Gombotz et al., 2006; Kloppe et al., 2013; Smith et al., 2011). One of the study showed that the ROSC were higher with the deployment of AED (p=0.02) (Smith et al.,2011). The ROSC were also higher in VT/VF patients with the AED used as showed by Gombotz et al., The remaining three studies showed that the results of ROSC were not satistically significance. (3) Cerebral performance scale score (CPC) Two studies reported the CPC score (Källestedt et al., 2012; Zafari et al., 2004). 95% of the survivors after the AED use had CPC score 1 which indicated that the patients were consious and alret with normal function or only slight disability (p<0.001) (Källestedt et al., 2012). Zafari et al.,(2004) showed no satistically significance in the neurological outcome. Apart from that, one study did not mention the method to measure the nuerological disablilty at discharge (Chan et al., 2010) 2.3 Summary and synthesis Two studies compared the use of automated external defibrillation(aed) and 13

23 without the use of AED. One study showed that the survival to discharge rate was decreased 3 % with the AED use (p<0.01) (Chan et al., 2010) while another one showed survival to discharge rate was significantly increased 7.9% with the use of AED and training program (p=0.001) (Zafari et al., 2004). There were another three studies comparing implementing of AED use and manual defibrillator showed insignificant results on survival to discharge rate. (Forcina et al., 2009; Källestedt et al., 2012; Smith et al.,2011). The insignificant results were probably due to poor study design. Besides, there were different results between VT/VF patients and non VT/VF patients. Two studies both showed that the survival to dsicharge rate is higher in VT/VF patients with AED used. After summarising the results, it was found that there are different results among 7 studies. There are two statiscally significant results (Chan et al., 2010; Zafari et al., 2004). In these two studies, there were contradictory findings. According to Chan et al.,(2010), the survival to discharge rate was decreased with the AED use. The study paritcipants from this study were from 204 acute hospitals. Therefore, there was a variety in resuscitation protocol among different hospitals. No systematic and consistent training programs on AED use were implemented in the study. The negative results might probably due to poor training of the hosptial staffs in using 14

24 AEDs. On the contrary, another study showed that the survival to discharge rate was increased significantly with 7.9% (Zafari et al., 2004). This study was conducted in one single hosptial. Systematic training programs were provided and clearly mentioned in the study. The dramatically increase in survival to discharge rate after the training program and implementation of the use of AED was noted. From these two results, it was showed that the importance of systematic training in the success of AED implementation. As stated before, there were different designs of education programs mentioned in four studes. There are difference in the hours of training, length of program and assement (Forcina et al., 2009; Källestedt et al., 2012; Kloppe et al., 2013; Zafari et al., 2004). The design of the training program could influence the effectiveness of implementation of AED use. All of the four studies suggested that the program content should be included both the theorectic and practical training. Zafari et al., (2004) suggested longer and extensive trainings with 70 sessions of hands-on trainings in one year. Moreover, the annual assessment of the use of AED was included in this study but which was not mentioned in other studies. The well design of the training program with extensive hands-on training could contribute to the significant results in the study (Zafari et al., 2004). Thus, the design of the training 15

25 program on AED use should be extensive with hands-on trainings. Study design is usually one of the factors that may affect the results. Three studies showed there was no significant difference in survival to discharge rate when comparing AED use with no AED use (Forcina et al.,2009; Källestedt et al., 2012; Smith et al.,2011). There were some underlying reasons. First, there were not enough sample size in two of the studies (Källestedt et al., 2012; Smith et al.,2011). Secondly, the survival to dischage rate might be influenced by the resuscitation team response in hospitals and the post resucitation care. One of the studies showed that the median time of CPR team arrival was 2 minutes (Forcina et al.,2009). It was already a fast response which prevented the opportunity for defibrillation by first responders using AED. The inability of first responders to use the AED quickly or effectively may have contributed to the insignificant result. Furthermore, some studies showed that survival to discharge rate with the AED use is higher in VT/VF patients (Gombotz et al., 2006; Kloppe et al., 2013). Therefore, recording of patients intial cardiac arrest rhythm was suggested in the future pilot study. 2.4 Potential innovation According to the best evidence availiable on this topic, systematic training 16

26 programs on the implemention of AED use in hospitals for caridac arrest patients is essential (Zafari et al., 2004). Nureses as the first respsonders should perform CPR and apply the AED before the phsicican arrival to shorten the time to defibrillation. To effectively implement that, the training of proper use of AED is of great importance to implement the AED program. The details of the training programs should be well designed and intensive with hands-on training. The program should be consist of both theoretic and pratical trainings. The hours could be from 2-3 hours per sessons. It is recommanded that there is sessons in six months. The annaul assessment of AED use for nurses should be implemented to ensure the effective use of AED (Zafari et al., 2004). 17

27 Chapter 3 Implementation potential In the previous two chapters, literatures were reviewed and the results showed the significance and affirming needs of implementing nurse initiated automated external defibrillation. In this chapter, implementation potential, feasibility and the cost-benefit ratio of the innovation will be discussed. Therefore, the transferability of research findings into practice could be successful by developing evidence based guidelines. 3.1 Target Setting The nurse initiated automated external defibrillation program is proposed to the medical and geriatric unit in one of the public hospitals. There are 12 medical and geriatric wards in the designated hospital. The numbers of beds are around 480 in total. The patients admitted to the unit are all with medical problems, most of them have history of cardiac disease or other medical diseases. Cardiac arrest is a critical condition with only 5% survival to discharge rate in hospital in Hong Kong. Registered Nurses and Advanced Practice Nurses take care of the patients most of time in the ward. They are usually the first responder to patients with cardiac arrest. Nurse initiated automated external defibrillation which shorten the time of defibrillation could be benefit to the cardiac arrest patients in the medical and geriatric wards. 18

28 3.2 Transferability of the findings Target population This program are proposed to in hospital patients with cardiac arrest aged 18 or above admitted in the medical and geriatric wards. Patients with implantable cardioversion defibrillator were excluded. In the reviewed studies, participants are in general wards in 5 out of 7 research studies (Chan et al., 2010; Gombotz, Weh, Mitterndorfer, & Rehak, 2006; Källestedt, Berglund, Enlund, & Herlitz, 2012; Kloppe et al., 2013; Smith, Hickey, & Santamaria, 2011). They are all aged 18 or above. The baseline characteristic of the patients including age, gender, race, and medical history were compared. No significant differences were found between the intervention and control group in all studies( Chan et al., 2010; Gombotz et al., 2006; Källestedt et al., 2012; Kloppe et al., 2013; Smith et al., 2011). The target population in the research articles is similar to those in the clinical setting in terms of age and baseline characteristic. Thus, it is highly transferable to the target setting Philosophy of care The philosophy of care in the medical and geriatric unit is patient-centered care which aims at improving quality of life of patients, with the mission serving the community through seamless care, continuous education and the advancement of the 19

29 Science of Medicine. In this nurse initiated automated external defibrillation program, it provides rapid life saving interventions in order to increase the survival to discharge rate. It is a patient-centered and seamless care that optimizes the patients survival chance in cardiac arrest. The survivors after in hospital cardiac arrest could have good quality of life (Elliott, Rodgers, & Brett, 2011). Therefore, the innovation is fundamentally consistent with the prevailing philosophy in the target setting Number of patients benefit This innovation is benefit for cardiac arrest patients without Do Not Resuscitate order in the medical and geriatric unit. There are more than 50 cardiac arrest patients needed resuscitation every month in the medical and geriatric unit. Therefore, this innovation could be benefit for a large amount of patients in long term. 3.3 Feasibility To successfully implement this innovation, there are several factors including organization climate, administration support, staff attitude, staff training and resources availability should be taken into consideration. 20

30 3.3.1 Organization climate and administration support The climate in organization will have influence on the innovation implementation. In the designated hospital, the research utilization is strongly promoted. There is an evidence based practice coordinator in the hospital mainly responsible for reviewing current protocol base on updated research articles and coordinating all evidence base projects in all departments. In medical and geriatric department, some evidence based protocols are already developed and validated for use for example central venous catheter dressing and deep vein thrombosis prevention protocol. Therefore, the organizational climate is conducive to research utilization. Concerning the administration support on the nurse initiated automated external defibrillation, staff and administrators are positive towards this innovation. Nurse initiated manual defibrillation is already promoted in the designated hospitals in the intensive care unit. A research in the designated hospital showed that nurses are more confident in using automated external defibrillation compared with manual defibrillation (Hui, Low, & Lee, 2011). It is believed that nurse initiated automated external defibrillation which is easy to use compared with manual defibrillation will be supported by the administrator and staff. 21

31 3.3.2 Staff training and attitude There will be a change in practice in the medical and geriatric unit if nurse initiated automated external defibrillation is proposed. Nurses may think that it is their extended role to do so and they are usually resistant to change in this situation. Promotion and education on the needs and importance of nurses initiated defibrillation should be emphasized in the regular nursing forum or journal club. It will help to change the nurses attitude in providing defibrillation in resuscitation care. Most of the nurses already attended the Basic Life Support (BLS) courses. The use of automated external defibrillators is introduced in the course. Thus, most of the nurses are supposed to have basic knowledge of using the automated external defibrillators. The skills and confidence of using the automated external defibrillators are the main concern. Therefore, systematic training with hands-on trainings for six months are essential before the implementation of the program in order to build up nurses confidence and technical skills on using the AED. In this situation, nurses have to use their additional time or released from other practice activities to attend the training. It will increase their workload and decrease their rest time. Some nurses might be reluctant to do so. There might be some compensation for example: over-time compensation or study leave as a measure to solve this problem. 22

32 3.3.3 Availability of resources To implement this innovation, automated external defibrillators are the major equipments that need to be purchased. It will be the major expenditure in this program. Apart from that, there should be a 2 advanced practice nurses to provide the training sessions and coordinate the program. Neurological outcome and survival to discharge rate of cardiac arrest patients could be use as a clinical evaluation tool for the innovation. 3.4 Cost/Benefit ratio of the innovation To effectively implement the innovation, cost and benefit ratio of this innovation will be discussed Potential risk of implementing the innovation The cardiac arrest patients are the main target group of this innovation. These patients need urgent resuscitation. Nurse initiated automatic external defibrillation could be benefit for patients. On the other hand it also provides risks for patients. If the nurses are not confident or proficient to provide effective automatic external defibrillation, the compliance to this innovation is low. The risk of delay in defibrillation is still present. Apart from that, wrongly use of AED will do harm to 23

33 patient as it might further delay the defibrillation and hinder the resuscitation progress. Therefore, systematic training of nursing staffs and annual assessment of the use of AED for nurses is essential to ensure nurses proficiency in using AED Potential risk of not implementing the innovation According to the current practice, physicians will perform the manual defibrillation in medical and geriatric unit. There is usually a delay in defibrillation while waiting the physician arrival. Therefore, it will decrease the survival to discharge rate of cardiac arrest patients Potential benefit of implementing the innovation Nurse initiated automated external defibrillation could benefit patients, health care professions and health care system. It shortens the time of defibrillation. In current practice, the time from cardiac arrest to defibrillation by physician is around 5 minutes. After implementing the innovation, it is estimated that the time to defibrillation could be decreased to 3 minutes. There is at least 40% reduction of time to provide rapid defibrillation. It will increase the survival to discharge rate of cardiac arrests patients thus enhance the satisfaction of patients and families. For nurses, implementing nurse initiated automated external defibrillation will provide greater 24

34 autonomy for nurses. The professionalism of nursing will therefore be promoted. Furthermore, nurses will have higher job satisfaction while patients are more likely to survive and discharge (Kyller & Johnstone, 2005). The staff morale will therefore be improved Material Costs The AED devices are the main material cost. It costs around HKD $8000 each. There are 12 medical and geriatric wards in the designated hospital. To place one AED device in each ward, it costs HKD $96,000 for the AED devices in total. There are no extra nurses needed to operate the automated external defibrillators as all of the nurses in medical and geriatric wards need to be trained of using AED devices. Concerning the nursing training costs, there will be 2 advanced practice nurses to provide and coordinate the training sessions. The mean salary of an advanced practice nurse per month is HKD$ 49,495. The hourly paid is around HKD $ 248. To provide 20 sessions of training with 2 hours each session, the cost is HKD$19,840 for the trainers. As all registered nurses have to attend the training course, they will use their own time but compensate hours will be given for them. The mean salary of a registered nurse is HKD$32,760 per month. The hourly paid is HKD $164. The cost for trainee in the whole training course is HKD $6560 per registered nurse. There are 25

35 around 240 registered nurses in the medical and geriatric unit. To train all registered nurses for the AED use, the total cost will be HKD$1,574,400 in total. Apart from that, there are still printing material and maintenance cost of AED. The details of the material cost will be list in appendix E. In total, the cost of implementing nurse initiated automated external defibrillation would be HKD$1,696, Nonmaterial costs In this program, nurses have to receive extra training. Therefore, there is a possibility of increase nursing workload. Some of the junior staffs may not be confident enough to provide the defibrillation and thus they will be stressful. After comparing the cost and benefit ratio, the innovation is still worthwhile to be implemented. It is a significant resuscitation care for cardiac arrest patients although it is an expensive innovation which costs HKD$1,696,240. This innovation aims at rapid life-saving and increasing the survival to discharge rate would outweigh the cost. 26

36 Chapter 4 Evidence-based guidelines After summaries all available evidence and evaluating the implementation potential, an evidence-based guidelines is necessary to be developed before implementing the innovation. 4.1 Aims/Objectives/Target group The aims of this evidence-based guidelines is to provide nurses a clear and evidence based guidelines about the resuscitation care for cardiac arrests patients in medical and geriatric ward by providing automated external defibrillation The objectives are to: 1. Summarize the updated and exiting evidence of nurses initiated automated external defibrillation 2. Develop and standardize clinical practice procedures for nurses in providing automated external defibrillation 3. Increase the survival to discharge rate of cardiac arrest patients in medical and geriatric unit. 27

37 4.1.2 Intended users The intended users of this protocol are all registered nurses, advanced practice nurses in medical and geriatric unit Target group Patients aged 18 or above who admitted to the medical and geriatric unit and suffer from cardiac arrest 4.2 Grades of recommendation The SIGN s Grades of Recommendation 2008 is used to indicate the grades of evidence of this protocol. However, it does not imply any level of clinical significance. Details of grading were shown in appendix D. 28

38 4.3 Recommendation Recommendation 1 (Grade B) Cardiopulmonary resuscitation (CPR) is recommended to be performed immediately once patients suffer from cardiac arrest Evidence: Survival to discharge rate is twice in patients with cardiac arrest who received CPR within first minutes after collapse compare with those CPR started later (Herlitz, Bång, Alsén, & Aune, 2002) (2++). Recommendation 2 (Grade A) Nurses should apply the automated external defibrillator to cardiac arrest patients before the physical arrival within three minutes. Evidence: i) Application of AED for in hospital cardiac arrest patients would increase the survival to discharge rate (Zafari et al., 2004) (2++) especially for those with VT/VF patients (Kenward, Castle, & Hodgetts, 2002) (1++, 2+, 2+). There is also an improvement in rate of return of spontaneous circulation (Gombotz et al., 2006; 29

39 Kloppe et al., 2013) (2+,2+) and cerebral performance scale score (Smith et al.,2011) (2+). ii) The time of performing defibrillation is recommended to be with in three minutes in cardiac arrest patients. It is related to high survival rate (Herlitz et al., 2005) (2++). Recommendation 3.0 (Grade B) Systematic training including theoretic and hands-on training of AED use should be provided for nurses before implementing nurse initiated automated external defibrillations Evidence: Training and education is a key step of successfully implementing AED use in hospital (Forcina, Farhat, O'Neil, & Haines, 2009; Källestedt et al., 2012; Kloppe et al., 2013; Zafari et al., 2004) (2+,2+,2+,2++) Recommendation 3.1 (Grade B) The training program should be consists of more than 20 sessions and last for six months (Zafari et al., 2004) (2++). 30

40 Recommendation 3.2 (Grade B) The annual assessment of AED use should be performed to ensure nurses proficiency in using AED (Zafari et al., 2004) (2++). 31

41 Chapter 5 Implementation plan After finalizing the evidence based guidelines, the implementation plan will be discussed in this chapter. The communication plan followed by the pilot study will be developed for implementing the evidence based guidelines. After that, the evaluation plan will be described to evaluate the effectiveness of the proposed guidelines. 5.1 Communication plan Identify potential stakeholders Before implementing the evidence based guidelines, communication with potential users is the initial step. First of all, it is important to identify all the stakeholders who are affected by the proposed changes. In this proposed innovation in medical and geriatric unit, the stakeholders are Chief of Service (COS), Department of Manager (DOM), Ward Manager (WM), Nurse Officers (NOs)/Advanced Practice Nurses (APNs) and ward nurses Communication process and initiation of change Nurse Officers (NOs)/Advanced Practice Nurses (APNs) NOs and APNs play an important role in clinical setting. They are responsible to initiate and participate in evidence-based practice and nursing research, coordinate and implement new initiatives to make quality improve in health care. Therefore, NOs 32

42 and APNs are the first parties that should be approached. The evidence of the nurse initiated automated external defibrillation from the literatures will be showed to them and explain the affirming needs to initiate the change. After that, the evidence-based guidelines will be clearly described to them as well. The NOs and APNs are expected to provide feedbacks and suggestions. The proposer of the innovation will make some improvements on the evidence based guidelines of nurse initiated AED. This process will last for 4 weeks. Chief of Service (COS), Department of Manager (DOM), Ward Manager (WM) After consulting the senior nurses (NOs and APNs), the evidence based guidelines should be more comprehensive. At this stage, the proposer will be more confident in presenting the innovation and the guidelines to the administration parties. The ward manager should be approached firstly. It is essential to gain the approval and agreement from the ward manager before approaching other higher administrators. A preliminary meeting will be held with ward manager to present about the exiting problem of the defibrillation in the clinical setting, the affirming needs to make changes according to the best evidence from the literatures and most importantly the proposed evidence based guidelines which could improve the nursing care in resuscitation process for the sake of patients. After gaining the approval from the ward 33

43 manager, a formal meeting should be held with the COS and DOM. In the meeting, the proposer will give a presentation with the content of the existing problem, the significance of initiating the innovation, the feasibility of the evidence based guidelines and the cost-benefit ratio of implementing the innovation. This presentation is the key to gain the support from the administration parties. The process of this important stage will take about 6 weeks. Ward nurses All ward nurses in medical and geriatric unit are responsible to carry out the innovation. As there are over two hundred ward nurses in the whole unit, sharing sessions should be held to disseminate the evidence based guidelines to all nurses. There should be four sharing sessions held in different time slots in order to achieve higher attendance. During the sharing sessions, the details of the new innovation will be demonstrated by the proposer. Information sheet of the proposed evidence based guidelines will also be distributed. All nurses are allowed to provide comments and suggestions. They are also encouraged to raise questions and concerns as they are the one who carry out the innovation. A webpage of the new innovation will be set up for more information and collection of comments and suggestions. It is estimated that this process will last for 6 weeks. 34

44 5.1.3 Formulate a work force group After getting consensus from all different parties, a work force group can be formulated to facilitate and guide the changes before the pilot test. This group includes 1 Senior Medical Officer (SMO), 1 WM, 2 APNs/NOs, 4 Registered Nurses (RNs) and the evidence based guidelines proposer. The senior medical officer will act as an advisor. The remaining staffs are responsible for facilitating the change, providing training to other ward nurses and publicity of the new innovation. After forming a work force group, the facilitation of the change will be more efficient. First of all, a time table will be set. A training program has to be developed. The selected members (2 APNs and 4 RNs) in the work force group will provide the training for the remaining nursing staffs later. They are from the cardiac unit and proficient in using AED. They will be leading the change and providing training on the use of automated external defibrillator for all nursing staffs in the medical and geriatric unit. For sustaining the change, the positive attitude towards the new innovation is important. The work force group will keep promoting the new guidelines with clear vision and sharing successful stories. There will also be some new audit forms to 35

45 assess nurses competence in performing the automated external defibrillation and the compliance with the new guidelines. The revision of the new guidelines will be in a regular basis. 5.2 Pilot study plan Objective: The pilot study is a small scale test in order to assess the feasibility of a new innovation to be conducted in a large scale. The possible difficulties and technical problems could be revealed in the pilot study. Therefore, the evaluation of the pilot study is essential to modify the new guidelines before the implementation of the real program Ethical consideration Concerning the ethical issue in the pilot study, an ethical approval will be obtained from the Hospital Clinical Research Ethics Committee Design, Setting and Sample The pilot test will be carried out by the work force group in the cardiac ward in medical and geriatric unit. Before the pilot study, the members of the work force group will provide four sessions of 2 hours extensive training program including 36

46 hands-on training to all nurses in the cardiac ward in one month. The primary outcome will be the survival to discharge rate of cardiac arrest patients receiving the nurse initiated automated external defibrillation. It will be compared with the baseline data before the implementation of the innovation in the selected ward. The convenience sampling method will be used. Patients with the implantable cardioversion defibrillator will be excluded. It is expected about 20 eligible participants will be recruited in three months. Data including the initial cardiac arrest rhythm will be recorded Primary outcome measures (1) Survival to discharge rate of cardiac arrest patients The survival to discharge rate will be recorded using the evaluation form (appendix F) and compared with the baseline in the selected ward Secondary outcome measures (1) Nurses compliance to the new guidelines Observation of nurses compliance to the new guidelines by the work force group members will be done during the pilot study. Questionnaires will be distributed to the nurses and unstructured interview will be conducted to collect feedback from the 37

47 nurses. (2) Effectiveness of the training program The effectiveness of the training program will be assessed by providing a multiple choice quiz for the trainee after the training sessions. Apart from that, return demonstration and audit of using the automated external defibrillators will be performed (appendix G). The qualitative and quantitative methods are adopted in the data collection process. The details of the data collection and analysis will be shown in the evaluation part. 38

48 5.3 Evaluation plan An evaluation plan could reflect the effectiveness of the nurse initiated automated external defibrillation in the local setting. By data collection and analysis, it will provide scientific data to the stakeholders in order to successfully implement the innovation in the future. In the following parts, the outcomes will be identified followed by the nature of clients to be involved. After that, data collection and analysis will be discussed Identifying outcomes Patient outcomes According to the literatures reviewed, the survival to discharge rate will be used as the primary outcome to assess the clinical benefit of nurse initiated automated external defibrillation for the cardiac arrest patients. Healthcare provider outcomes Nurses are encouraged to provide nurse initiated defibrillation before doctors arrival. It may increase their workload and stress therefore their satisfaction level should be evaluated. Nurses confidence and competency to carry out the defibrillation after training should be evaluated to ensure the innovation is appropriately implemented. Nurses job satisfaction, competency and confidence are 39