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You’d think that if you’re going to suffer a sudden cardiac arrest (SCA), the best place to have it is in the hospital. And while that may be true, one hospital in Providence, RI, has discovered there’s always room for improvement. Ten years ago, the typical time from discovering the victim to initial shock at The Miriam Hospital was seven to 10 minutes; today, it’s about two minutes. The difference? Today there are 22 automated external defibrillators (AEDs) at Miriam, and every nurse on staff is trained in their use as a first responder.
The idea of AEDs on airplanes and at large public events seems like good common sense, but wouldn’t they be a bit redundant in a hospital setting? Not at all, insists Sandy Sawyer-Silva, RN, MSN, CCRN, nurse manager of the intensive care unit (ICU) at Miriam. "An AED is, in fact, not redundant in a hospital — it’s a first-line device for SCAs," she asserts. "It is estimated that between 85% to 90% of all sudden cardiac death is due to shockable rhythms, so the faster you can get the device to patients and shock them, the greater the likelihood of survival."
The literature seems to bear her out. Here are just a few examples:
• SCA survival rates approach 90% in coronary care units, which typically are well-equipped with manual defibrillators and highly skilled operators.1
• Each minute of delay between the onset of an arrest to defibrillation decreases the chance for survival by 10%.2
• Defibrillation delays in hospitals can be attributed to outmoded hospital protocols that require nurses — often the first to respond to a patient in distress — to administer CPR, call for the defibrillation team, and wait.3
"About 15 years ago, we did a time study and looked at how long it took us to deliver the first shock," Sawyer-Silva recalls. "We were stunned to find that even nurses and residents trained in advanced cardiac life support took seven to 10 minutes to get off the first shock — and this is a small hospital [242 beds], where you don’t have to go very far. With AEDs we can successfully and repeatedly get three successive shocks off in less than two minutes from the time the person is found."
The Miriam currently uses the Agilent Heartstream FR2, from Palo Alto, CA-based Agilent Technologies. "It’s a new model we’ve had for the past six months," notes Sawyer-Silva. They are present throughout the hospital, on every medical surgical unit, in the clinic, and in the outpatient operating room in the building across the street. "Every nurse knows how to use them; they’re very simple to use — designed, in fact, for use by nonhealth care individuals," she says. "It does everything but walk the dog."
The device is applied to patients who meet three criteria: There is no pulse; they are not breathing; and they are otherwise completely unresponsive. "Once that’s established, you push the on-off’ button," Sawyer-Silva explains. "Then, the device will tell you to attach electrodes to the patient’s bare chest; diagrams on the electrodes show you where to apply them. Literally, a 10-year-old could do it.
"Once that’s done, the AED will tell you to plug the pads into the flashing yellow lights on the device. Then it will say, Analyzing heart rhythm; do not touch patient.’ All this takes about 15 seconds. If it detects a rhythm it can’t shock, it tells you to check the patient, who may now have a pulse," she continues. "If not, you proceed with CPR. Or the machine will say shock advised, push orange button.’ Immediately after the patient is shocked, the device reassesses, tells you to stand back, and will deliver up to three shocks," Sawyer-Silva adds. All the shocks, she explains, are 150 jewels, rather than successively stronger. "Older devices did that, but this is more advanced technology," she observes.
All nurses who join Miriam are trained in the use of the AED as part of their orientation. In fact, all health care providers — physical and respiratory therapists, nuclear medicine technicians, and so forth, have to take health care provider CPR, which includes use of the AEDs. Anyone so trained can be a first responder. There is no need for inservice follow-up, Sawyer-Silva says. "We did a retention study a few years ago, and nurses were able to use the device within three to six months without any additional training."
Sawyer-Silva says she is firmly convinced the AEDs have saved many lives that might otherwise have been lost. "Each minute before arrest is recognized represents another 10% likelihood of not surviving," she notes. "So, if we’re there in two minutes, that increases the likelihood of survival to 80%. I’m a real believer in this." She estimates the AEDs are applied at The Miriam approximately 20 times a month.
The hospital’s original AEDs were provided by Laerdal Company, a Swedish distributor that was later acquired by Agilent. "But we looked at all the brands that are available today — and there are many," she says. "Our team chose the Heartstream FR2 because they thought it was the simplest to use and had features they wanted. The size was right. The directions were clear; all the features were superior. We believe that simplicity absolutely reduces time to application," Sawyer-Silva says. The less time you have to think about things, the better it is — especially in a stressful situation."
1. Carruth JE, Silverman ME. Ventricular fibrillation complicating acute myocardial infarction: Reasons against the routine use of lidocaine. Am Heart J 1982; 104:545-550.
2. Cummin RO, et al. Ann Emerg Med 1989; 18:1,269-1,275.
3. Kaye W, et al. Organizing and implementing a hospital-wide first-responder automated external defibrillation program: Strengthening the in-hospital chain of survival. Resuscitation 1995; 30:151-156.
For more information, contact:
• Sandy Sawyer-Silva, RN, MSN, CCRN, ICU Nurse Manager, The Miriam Hospital, 164 Summit Ave., Providence, RI 02906. Telephone: (401) 793-3520.