Example Of Effectiveness Of A Simplified Cardiopulmonary Essay
RESUSCITATION TRAINING PROGRAM FOR THE
NON-MEDICAL STAFF OF A UNIVERSITY HOSPITAL
Effectiveness of a simplified cardiopulmonary resuscitation training program for the non-medical staff of a university hospital
Part 1: Evaluation of “Effectiveness of a simplified cardiopulmonary resuscitation training program for the non-medical staff of a university hospital” by Hirose, Iwami, Ogura, Matsumoto, Sakai, Yamamoto, Mano, Fujino, and Shimazu.
The article gave a brief overview of the rapid-response system for in-hospital patients. It noted that although the primary recipients of the CPR training were the emergency medicine doctors and nurses, the first responders potentially were non-medical staff. Education for these employees and volunteers was not implemented. In 2010, the Consensus on Science and Treatment Recommendations Statement promoted 45-minute training for these individuals involving little or no instructor involvement compared to basic life-support courses led by an instructor. The authors conducted a study of the effectiveness of this type of CPR training in September of 2010. One year later, the quality of the skills were recorded by a CPR skill report system and the use of a questionnaire administered to the participants; the survey recorded their feelings of competency before and after training for CPR and the use of AED. It should be noted that mouth-to-mouth ventilation is harder to teach and a study by found that CPR without the technique were as effective as traditional CPR without ventricular fibrillation (Iwami et al., 2007).
The CPR training program lasted 45 minutes. Before the program began, the participants were given a survey for self-reporting on the respondent’s ability to administer chest compressions and use of an automated external defibrillator (AED). The questions consisted of “Can you check for a response?”, “Can you perform chest compression?”, and “Can you use an AED?”. The responses included “I can”, “I think I can”, “I don’t know”, and “I shouldn’t. More skillful people should.”. In addition, a skill test was administered consisting of the automatic recording of the number, depth, and interruption of chest compressions, The training kit was composed of a pad referred to as a personal training mannequin. Certified instructors supervised the class at a ratio of one instructor for every 10 to 20 participants. The instructions were provided by a DVD to provide continuity. After training using a mannequin, the survey was administered again to record changes in feelings of competency by the participants. The skill test was also administered again for comparison of technique prior to the training.
In the period from September 2011 through March 2013, the number of participants in the program was 161. Chest compressions technique was evaluated on 109 of the participants. The number of compressions was significantly greater before the training versus after: 110.8 per minute versus 94.2 per minute. Interruption of chest compressions was significantly shorter: 0.05 seconds per 30 seconds versus 0.89 seconds per 30 seconds. The mean depth of the compressions was significantly greater: 57.6 mm versus 9.4 mm. In regards to the survey, 159 participants responded following the training. The proportion who answered that they could positively or think they could perform the techniques increased significantly from before the training to after the training by over 61% for each skill. The Wilcoxon signed rank test was used for a comparison of the increased readings before the training and after.
In addition to the initial CPR and AED training, a re-training was performed approximately 12.7 months later. The results were over significantly higher in each of the skills from just before the re-training to just after. It was noted that based on the evaluation of skills prior to re-training, deterioration can begin in as little as 3 months. Therefore, it is recommended that re-training take place sooner than the one year criteria for this study. While the findings of the participants in the re-training class were higher before the class than participants before training in the class for the first time, they were still not adequate. A solution may be to evaluate skill levels for staff in 3-month intervals and recommend re-training for those individuals whose skills have deteriorated below the level of competency.
The conclusion of the study was that a 45-minute simplified CPR instruction program with practice on a mannequin improved the quality of the skills required for CPR and the perception of skill level by non-medical staff members attending the training. A recommendation was made for further study to address the best period of time before re-training to maintain skill levels and attitude of competency.
This article is of particular interest for staff in the operating room of health care facilities. Technical or mechanical staff is frequently in the operating room. Depending on the state, these individuals may not require certification. Medical assistants are not classified as non-medical staff. In the event of the need for a patient to require CPR, non-medical staff would not be the first people to perform it.
Part 2: Discussion of applications
Cardiopulmonary resuscitation (CPR) is an emergency procedure implemented as a life-saving measure for individuals experiencing cardiac arrest (Ilcor.org, 2013). The primary purpose is to prevent brain damage due to lack of oxygen. CPR is used in an effort to keep the patient stable until measures can be taken to restore spontaneous breathing and circulation.
The most important factors for results are less interruptions of chest compressions, complete relaxation of pressure inbetween compressions, avoidance of excessive ventilation, compressions being of adequate depth, and compressions being fast enough (Meaney et al., 2013). Chest compressions should be at least 2 inches deep at the rate of at least 100 per minute (Mayoclinic.org, 2015). Breathing assistance with mouth-to-mouth resuscitation may be performed through the use of a device or by exhaling into the victim’s nose or mouth. The resulting elevation in CO2 levels may trigger spontaneous breathing. Recommendations place a higher priority on efficient compressions over artificial ventilation is a choice must be made. When first responders are non-medical, chest compressions are easier to learn and remember. However, CPR is not expected to restore cardiac function. It is a temporary action until an electric shock can be administered; this is called “defibrillation”. It is considered effect for pulseless ventricular tachycardia or ventricular fibrillation. CPR should be continued until further assistance arrives or until the patient is declared dead.
2. Literature Review:
(Bergum et al., 2015) conducted an observational study over a 4.5 year period on the underlying causes of cardiac arrest in hospital patients. In that time period, 302 incidences were examined to determine causes and if the emergency teams recognized the causes when responding. The findings were that 85 percent of the causes could be determined reliably and in 65 percent of the episodes, the emergency team correctly identified the cause. Cardiac-related causes were responsible for 60 percent of the episode and hypoxic causes accounted for 20 percent. Survival of the patients with cardiac episodes was 30 percent and 37 percent for patients with hypoxic episodes. In 48 percent of the episodes, the initial cardiac rhythm was pulseless electrical activity; 23% experienced asystole, and 27 percent experienced ventricular fibrillation or ventricular tachycardia. The percentage of patients that survived until they could be discharged from the hospital was 25 per cent. The amount of time until CPR was started was one minute.
The pros and cons of whether a family should be allowed to be present during CPR of a loved one have been debated since the idea was proposed in 1987 (Jabre et al., 2013). Several studies have indicated that having the family present decreased the amount of post-traumatic stress syndrome (PTSD) in the surviving members. The results of a study by Jabre et al. found that family members who did not watch CPR efforts were 60% more likely to experience PTSD than those who did not watch. They found stress levels were not increased in the response team and the duration of the CPR and the survival of the patient also appears to be incidental. The major concern on the part of the medical teams is of legal liability. In a survey of 432 health care professionals, concern about liability was recorded by 27%. However, studies of litigation after observation of CPR efforts reveal no lawsuits were filed. McClenathan ( 2002) believes this is due to a bonding between the care staff and the family in this dramatic time. If appropriate education has taken place, the family will understand at least a part of what is happening and a staff member may be present to assist in narrating the events as they happen in order to ease the stress of the situation.
A look at the statistics surrounding the issue of family admission to view a CPR effort yields interesting results. McLaughlin and Gillespie (2007) found that positive outcomes result with the family witnesses CPR, but the majority of emergency rooms either have not effectively set policies in place addressing this or they do not even have policies in place. Leung and Chow (2012) used a descriptive survey to evaluate attitudes of the families of patients who observed CPR efforts and hospital staff. They found that 94 percent want to be there again for a family member if the need arises, 74 percent felt it made accepting the loss easier, and 64 percent believed their presence was comforting to the patient. However, McClenathan, Torrington, and Uyehara (2002) surveyed critical care professionals and discovered 78 percent were opposed to family members present during CPR. Physician s were 80 percent against the practice, and 57 percent of nurses were, also. A short answer section found that they felt the patients confidentiality was violated, staff members would be distracted from their responsibilities from performance anxiety, and that family members would be exposed to psychological trauma.
Influential variables include sample size, whether or not the patient survived, the attitude of the family members stating they wanted to witness CPR efforts, location of the efforts (in hospital, emergency room, patient’s home, etc), and others. Of the family members who did not watch the CPR efforts, 12% stated they wished they had, and only 3% of the ones who observed said they regretted it. The conclusion is that family members can understand that every effort has been made to save their loved one without the mystery of being behind closed doors. It also offers them a chance for a last goodbye.
There are a number of ethical considerations associated with the use of CPR on patients in various circumstances. For example, an emergency room staff may perform aggressive resuscitative efforts on a patient without consent from a legal representative of the patient (McElroy, 2012). Although the use of CPR may be in opposition with the beliefs of the patient, it is in his best interest that efforts be taken to save his life without waiting for confirmation of consent. Some people have a request for Do Not Resuscitate (DNR). In the case of a cardiac arrest, they don’t want CPR performed. This is a common request in senior care facilities and hospitals where patients have given thought to the possibility they may have a short time to live. The decision not to perform CPR is commonly made in a situation where the patient is terminal and even with continued treatment death is not too far away (Hensley, 2005). Unless there is some circumstance where the patient needs have a last visit or conclude some business, there should be no ethical problem with allowing a patient to die. Another situation is where a chronically ill patient would survive with severe suffering. The decision to perform CPR is made by weighing the benefits against the burdens of the outcome. Patients are unique in their assessments. At this point, a truthful conversation is in order. Telling the patient unrealistic predictions for cure or the remaining length of his life is not ethical.
Advertisements by the Heart Association and other similar organizations encourage non-medical staff members to learn CPR in order to play a part in saving lives outside a medical facility. Television programs and movies have left the general public with the idea the CPR is effective and without consequences. However, the statistics regarding survival following CPR efforts are far from encouraging (Cooper, Cooper and Cooper, 2006). In an article discussing the history and current practices of CPR, Cooper et al. (2006) found that from January 2000 to March 2004, only 17 percent of the patients requiring CPR either as an inpatient or outpatient survived. The possibility of survival decreases by 7 percent to 10 percent for each minute of untreated ventricular fibrillation (Cummins et al., 1991). The diagnoses of the patients is also relevant. In a series of 14 studies, only 13.5 percent of patients who required CPR survived to hospital discharge (Ebell and Afonso, 2011). Of those numbers, patient with cancer had a discharge rate of 5.8 percent and with metastatic cancer, none survived to discharge. The rate was 25 percent for patients whose only problem was a myocardial infarction. If the patient was in the intensive care, one study showed the discharge rate was 11 percent and the other was 5 percent. Dialysis patients were only 8 percent. The highest rate of survival to discharge for all patients receiving CPR while in the hospital was 25 percent.
In addition to low survival rates for patients receiving CPR, there are associated injuries. Many patients successfully resuscitated suffer from mediastinal hemorrhage, fractured ribs, aspiration pneumonia, and sternum fractures. Approximately 10 percent of patients remain in a vegetative state secondary to hypoxia. Roine, Kajaste and Kaste (1993) interview 155 survivors of CPRS and found that after three months, 60 percent has moderate to severe cognitive impairment; at one year post-CPR, the number remained at 48%.
In response to education that the use of an AED increases chances for survival, the devices have been installed in high-traffic areas such as office buildings, shopping malls, and airports (Caffrey et al., 2003). Interestingly, it has been found that the fastest response times by trained staff has been in casinos (Valenzuela et al., 2000). The environment is confined and the presence of an alert staff on security cameras results in a mean response time of 4.4 minutes from collapse to the first shock delivery. In addition, the survival until hospital discharge is 75 percent if the initial shock was given before 3 minutes had passed. This type of information shows improvement in survival is significant with the use of an AED (Bunch, Hammill and White, 2005).
Effective team dynamics are crucial during the operation of a CPR effort (Nursingpub.com, 2009). Communication is of the utmost importance. The leader of the team should use a closed loop form with the other team. When the leader gives an assignment, the other team member confirms the message was understood. Confirmation tells the leader when that task is completed. A calm attitude provides clear communication, also. Clear annunciation helps, and team members should question an instruction if they are not sure what was said or meant. If efforts do not seem to be effective, it is acceptable for the team leader to ask for other suggestions. Personal experience or intuition may provide insight to the situation. Each member of the team should know his responsibilities in the context of the operation of the unit. It is the job of the team leader to be sure person understands his or her tasks. It is essential a team member know they have the ability to perform the task assigned; otherwise, the leader should be notified. In this respect, it is important each team member know his limitations and informs the leader of them. New skills have no place in a life-saving operation. In the event an action occurs at an unusual time, suggestions should be given tactfully with respect to everyone involved. Mutual respect is very important when people work together in high-stress situations. At the conclusion of the CPR activity, regardless of the outcome, the team leader is responsible for monitoring the status of the patient, evaluating the interventions performed, and assessing findings.
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