New ED protocols dramatically improve survival rates of cardiac arrest patients
New ED protocols dramatically improve survival rates of cardiac arrest patients
Involvement of emergency nurses is 'crucial'
A 35-year-old patient was brought to the ED at Long Island College Hospital of Brooklyn (NY) in full cardiac arrest. His heart was successfully restarted, but he was in a coma and in danger of suffering brain damage. By lowering his body temperature, swelling of the brain was prevented, and the patient awoke from the coma with no lasting damage.
"Therapeutic hypothermia is an amazing science that can bring patients back from a potentially grave situation after arrest, with minimal neurological compromise," says Miriam Chapman, RN, nurse manager of the ED.
ED nurses also treated a young woman with a congenital heart defect whose life was saved using this technique. "It was so dramatic that CBS did a story on it," she recalls. "The day they came to our ED to shoot the story became a reunion of sorts between our patient and her husband, and the staff. And it was a most joyous occasion!"
A small but growing number of EDs are dramatically improving survival rates of cardiac arrest patients with cooling therapy. Hypothermia as a therapy for the treatment of cardiac arrest victims in the ED "really started to take off in the last year or so," says Benjamin Abella, MD, an assistant professor of emergency medicine at the University of Pennsylvania. "There is a real surge of interest in this."
Definitive research showing that hypothermia improves outcomes in cardiac arrests came out in 2002, says Abella, "but for a variety of reasons, implementation was quite slow."1 Although no hard data exist, he estimates that one-quarter to one-third of EDs are doing this therapy currently. "It's not the majority, but that number is changing rapidly," he says.
Nurses in the ED play a significant role in this therapy and can be champions for implementing it, Abella says. "In our hospital, we attribute a lot of the success of our clinical protocol to the participation of our nurses," he says. "Many of the subtleties of therapy, such as issues of temperature maintenance, nurses often pick up on sooner than physicians. So, their involvement is crucial."
At the Hospital of the University of Pennsylvania/ Penn Presbyterian Medical Center in Philadelphia, "we have seen the survival rate of post-cardiac arrest patients improve from 24% to 54% with the use of therapeutic hypothermia," reports Sandra Dietrich, RN, MSN, MHA, clinical director of emergency services. "Not only does this therapy improve survival, but it has been shown to decrease neurologic morbidity."
[Editor's note: To see the ED's hypothermia protocol, go to Penn Medicine's Center for Resuscitation Science's web site, http://www.med.upenn.edu/resuscitation/hypothermia. Under "News" click on "View hypothermia algorithm (PDF)." Also click on "Protocols" and University of Pennsylvania Post-Cardiac Arrest/Induced Hypothermia Order Set and University of Pennsylvania Nursing Hypothermia Protocol.]
Michael Lutes, MD, assistant professor in the Department of Emergency Medicine at Medical College of Wisconsin in Milwaukee, reports that his ED had two cases that made the local news. "These were relatively young patients who returned to their normal lives after undergoing resuscitation from cardiac arrest and therapeutic hypothermia," he says. (Editor's note: To read a story about the ED that ran in Milwaukee Magazine, go to www.milwaukeemagazine.com. Click on "archives" and then "View the magazine archive." Under "Health," click on "December 2008 — The Big Chill." To read a two-part story from the Milwaukee Journal-Sentinel, go to www.froedtert.com/MediaRoom/IntheNews. Under "In the News," click on "Archive Jan — June 2008." Under "Warming Up to Freezing," click on "cardiac arrest patients." To see a video clip from a local television station, click on "Archive July — Dec 2008." Under "Doctors Freeze Body to Ease Heart Attack Dangers," click on "dropping heart attack patients' core body temperature" and "Froedtert Hospital Freezes Patients To Save Their Lives.")
Reference
- Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Eng J Med 2002; 346:549-556.
Sources
For more information on the use of therapeutic hypothermia protocols by ED nurses, contact:
- Miriam Chapman, RN, Nurse Manager, Emergency Department, Long Island College Hospital of Brooklyn. E-mail: [email protected].
- Sandra Dietrich, RN, MSN, MHA, Clinical Director, Emergency Services, Hospital of the University of Pennsylvania/Penn Presbyterian Medical Center, Philadelphia. Phone: (215) 662-3965. E-mail: [email protected].
- Michael Lutes, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee. E-mail: [email protected].
ED nurses learn these new cardiac arrest interventions News 'went through the ED like wildfire' A young woman in her 30s in cardiac arrest was placed on a therapeutic hypothermia protocol, recently implemented at Long Island College Hospital in Brooklyn, NY. She eventually was transferred from the ED to the intensive care unit (ICU), and she eventually was discharged, but her outcome could have been much different if the protocol had not been used. "Months later, she returned to thank the staff. I could see the disbelief in their faces. Some didn't recognize her as the same patient and marveled at how well she looked," says Miriam Chapman, RN, nurse manager of the ED. "The recovery of that patient went through the ED like wildfire, validating the benefits of hypothermia treatment." Chapman says her job of training ED nurses in the new hypothermia protocol was made easier by the above case. "There is nothing like being a part of a success story," she says. However, Chapman says as with any new protocol, her initial challenges included soliciting interest, excitement, and avoiding the stigma of "just another hospital policy." Maintaining the competency level of ED nurses when hypothermia cases are so infrequent is Chapman's major challenge. "To maintain the competency level of the nurses, we hold spontaneous reviews of the equipment," she says. "The day charge may pull a nurse at random and ask him or her to set up the equipment." Also, the initial care of the cardiac arrest patient requires a 1-to-1 or 2-to-1 nurse ratio at a moment's notice. When the code is called, ED nurses stabilize the patient, start the protocol, and expedite the patient's transfer to the ICU as quickly as possible, so that the patient doesn't need to be in the ED for an extended time. The difficult part of training involved the use of new devices, such as the Alsius, a triple-lumen catheter that involves the entire health care team, and central line insertion, Chapman says. The Artic Sun, another device used in the protocol, is not invasive, but it requires large cooling pads to be placed by ED nurses. "The machine the pads are attached to require frequent inservices, to remember its detailed directions," says Chapman. "It is very complicated and, since you aren't using it every day, it is important to review often." Before a cardiac arrest patient is cooled, ED nurses at the Hospital of the University of Pennsylvania/Penn Presbyterian Medical Center in Philadelphia do the following interventions:
Next, IV fluids are infused, with the goal of maintaining the patient's core temperature between 32°C and 34°C for 24 hours. "ED nurses monitor the patient's core temperature, blanket temperature, and check for arrhythmias," says Sandra Dietrich, RN, MSN, MHA, clinical director of emergency services. [A "Tip Sheet" used by ED nurses with an equipment checklist and temperature chart is included.] ED nurses also perform a hemodynamic assessment, input and output, baseline and ongoing neurological exams, and pain assessment, Dietrich says. They also measure levels of sedation and agitation, she says. |
Criteria for Hypothermic Resuscitation of Cardiac Arrest Patients in the ED
Source: Hospital of the University of Pennsylvania/Penn Presbyterian Medical Center, Philadelphia. |
Equipment for Cooling Patients
Source: Hospital of the University of Pennsylvania/Penn Presbyterian Medical Center, Philadelphia. |
Take steps to prevent accidental rewarming Patient is at risk for serious complications While therapeutic hypothermia is quite safe for cardiac arrest patients in the ED, "it takes a lot of attention to detail to do well," cautions Michael Lutes, MD, assistant professor in the Department of Emergency Medicine at Medical College of Wisconsin in Milwaukee. "One of the biggest risks of therapeutic hypothermia is accidental rewarming," he says. If external methods of cooling are used, a lot of attention needs to be paid to the patient's core temperature so that the patient is kept in the ideal temperature zone, says Lutes. "Overcooling may place the patient at risk for serious complications such as atrial or ventricular arrhythmias, coagulopathy, and increased risk of infection," says Sandra Dietrich, RN, MSN, MHA, clinical director of emergency services at the Hospital of the University of Pennsylvania/Penn Presbyterian Medical Center in Philadelphia. "The nurse must closely monitor the patient for response to treatment." The patient's vital signs are monitored continuously via rectal temperature probe and esophageal probe, or temperature probe indwelling bladder catheter. "It is important to have plenty of cold 0.9% saline available — at least 6 to 8 liters," she says. Communication between ED and intensive care unit (ICU) nurses is critical. "The transition from ED to ICU needs to be smooth to prevent rewarming and to ensure that external cooling measures are maintained," says Lutes. Miriam Chapman, RN, nurse manager of the ED at Long Island College Hospital in Brooklyn, NY, says her ED's equipment monitors the core temperature of the patient and will automatically adjust to maintain a set therapeutic range (Coolgard 3000, manufactured by Irvine, CA-based Alsius Corp.). "For overwarming, you may add ice packs to the patient's torso or beneath the armpit, or cooling blanket above or below the patient," she says. "For overcooling, you may use hand and feet mittens, a Bair Hugger, or warm humidified air via a face tent." |
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.