Implementation Of Cardiopulmonary Resuscitation Research Articles

A Review of Regional Anesthesia in Infants.

Regional anesthesia provides effective anesthesia and pain relief in infants with age-specific data attesting to safety and efficacy. Regional anesthesia decreases exposure to opioids and general anesthetic agents and associated adverse drug effects, suppresses the stress response, and provides better hemodynamic stability compared to general anesthesia. Regional anesthesia can prevent long-term behavioral responses to pain. As a result, the overall number and variety of nerve blocks being used in infants is increasing. While neuraxial blocks are the most common blocks performed in infants, the introduction of ultrasound imaging and a better safety profile has advanced the use of peripheral nerve blocks. Infant-specific pharmacokinetic and pharmacodynamic data of local anesthetic medications are reviewed including risk factors for the accumulation of high serum levels of unbound, pharmacologically active drug. Bupivacaine accumulates with continuous infusion and 2-chloroprocaine can be used as an alternative. Local anesthetic systemic toxicity has the highest incidence in infants less than 6 months of age and is associated with bolus dosing and penile nerve blocks. Local anesthetic toxicity is treated by securing the airway, suppression of seizure activity and implementation of cardiopulmonary resuscitation. Administration of intralipid (intravenous lipid emulsion) is initiated at the first sign of toxicity. A high level of expertise in regional anesthesia is needed when treating infants due to their unique development.

Health care professionals' concerns regarding in-hospital family-witnessed cardiopulmonary resuscitation implementation into clinical practice.

In-hospital, family-witnessed cardiopulmonary resuscitation of adults has been found to help patients' family members deal with the short- and long-term emotional consequences of resuscitation. Because of its benefits, many national and international nursing and medical organizations officially recommend this practice. Research, however, shows that family-witnessed resuscitation is not widely implemented in clinical practice, and health care professionals generally do not favour this recommendation. To describe and provide an initial basis for understanding health care professionals' views and perspectives regarding the implementation of an in-hospital, family-witnessed adult resuscitation practice in two European countries. An inductive qualitative approach was used in this study. Finnish (n = 93) and Polish (n = 75) emergency and intensive care nurses and physicians provided written responses to queries regarding their personal observations, concerns and comments about in-hospital, family-witnessed resuscitation of an adult. Data were analysed using inductive thematic analysis. The study analysis yielded five themes characterizing health care professionals' main concerns regarding family-witnessed resuscitation: (1) family's horror, (2) disturbed workflow (3) no support for the family, (4) staff preparation and (5) situation-based decision. Despite existing evidence revealing the positive influence of family-witnessed resuscitation on patients, relatives and cardiopulmonary resuscitation process, Finnish and Polish health care providers cited a number of personal and organizational barriers against this practice. The results of this study begin to examine reasons why family-witnessed resuscitation has not been widely implemented in practice. In order to successfully apply current evidence-based resuscitation guidelines, provider concerns need to be addressed through educational and organizational changes. This study identified important implementation barriers for allowing families in critical care settings to be present during resuscitation efforts. These results can be further used in developing and adjusting clinical practice policies, protocols and guidelines related to family-witnessed resuscitation.

The comparision of Iranian Physician and Nurses attitudes towards Do- Not- Resusciate Orders

Abstract:Background and AimDecision making process about Do- Not-Resusciate (DNR) order is unique, since, it is the only treatmentdecision that should be taken in advance. Most physicians and nurses are not sure whether and when to makea decision about DNR order and its moral aspects. The current study is performed to compare and investigatenurses and physicians attitude about DNR order for patients in their final phases of life.Materials and MethodsIn this descriptive–comparative study, 152 physicians and 152 nurses have been studied. The samplingmethod was stratified sampling. The data gathering tools were a demographical questionnaire and a attitudequestionnaire about DNR order.ResultsThe nurses and physicians in this research with averages of 3.25 for nurses and 3.22 for physicians, had apositive attitude about DNR order. But there was no significant difference between the attitude average scoreof the physicians and nurses about DNR order (p>0.5). Nurses and physicians with experience ofparticipating in implementation of cardiopulmonary resuscitation and DNR order, had more positive attitudetoward DNR orderConclusionsThe findings suggest that there is no difference between the physician’s and nurse’s view about DNR order.Although there is a significant relationship between former experience of participating in implementation ofcardiopulmonary resuscitation and DNR order with positive attitude about DNR order.KeywordsCardiopulmonary resuscitation; Physician; Nurse, Attitude

Experience of Belgrade’s Emergency Medical Service in the implementation of cardiopulmonary resuscitation guidelines issued in 2010

Introduction. Implementation of cardiopulmonary resuscitation (CPR) is defined by the unified 2010 Guidelines for CPR. Objective. This paper presents the experience of Belgrade’s Emergency Medical Services (EMS) in the implementation of out-of-hospital (OH) CPR according to the new, 2010 Guidelines.Methods. A retrospective study design was used. We recorded OH CPR and analyzed four variables: patient gender and age, arrest location, bystander witnessed arrest, and arrest rhythm (shockable – group I, non-shockable – group II). The study also looked at implementation and follow-up of CPR, therapy, CPR duration, EMS reaction time, and patient outcome (Return of Spontaneous Circulation [ROSC] or death). Results. Of 794 OH CPR attempts, 136 (17%) patients with field ROSC were transported to hospital admission (HA) (22% group I, 78% group II). ROSC at HA was sustained in 64 (47%), and unsustained in 72 (53%) patients. Among the patients with ROSC on HA, 47% had spontaneous breathing and 5% fully regained consciousness. The ROSC rate was higher after arrest occurring at home (P<0.001). No statistical significance between the groups regarding the following analyzed variables was found: patient gender, age, onset time (day or night shift), bystander witnessed arrest, ROSC, breathing and consciousness at HA. In all patients, intravenous (IV) access was established. Atropine was administered in 28 (21%) group II patients. Adrenaline was administered in 71% of patients and withheld in 29% of patients due to hospital closeness or sustained ROSC. By HA, 46% were successfully intubated. The average response time in group I was 8.1±4.0 minutes, in group II 6.8 ± 4.4 minutes. A highly significant association (p<0.01) was found between CPR duration and ROSC at HA (26.23 min – ROSC vs. 14.46 min – no ROSC).Conclusion. Study results indicate the significance of the new Guidelines for CPR in the everyday practice of Belgrade’s EMS teams. Continual training increases the quality of administered CPR measures and the rate of patients with ROSC at HA. New studies would contribute to the disclosure of weak links in the survival chain after OH CPR in Belgrade.

Using snowball sampling method with nurses to understand medication administration errors

We aimed to encourage nurses to release information about drug administration errors to increase understanding of error-related circumstances and to identify high-alert situations. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Snowball sampling was conducted to recruit participants. A semi-structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Eighty-five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one-third of total errors. Among 259 actual errors, 83.8% resulted in no adverse effects; among remaining 16.2%, 6.6% had mild consequences and 9.6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double-check procedures by colleagues and nurses responsible for errors; reporting rates were 62.5% (162/259) vs. 50.7% (35/69) and only 3.5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High-alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high-alert situations. Strategies for reducing drug administration errors by nurses are suggested. Survey results suggest that nurses should double check medication administration in known high-alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non-reprimanding atmosphere, helping to establish standard operational procedures for known high-alert situations.

Cognitive dissonance theory applied to CPR, DNAR, and the practice of slow codes

Cognitive dissonance theory holds that inconsistencies in our thinking or between beliefs and actions generate mental discomfort. This motivates efforts to reduce the inconsistencies by adapting behaviours or thoughts to make them more consistent with one another. This article demonstrates how the theory can be applied as a framework to understand internal conflicts which health professionals may experience when they encounter inconsistencies between their principles and practice, in the implementation of cardiopulmonary resuscitation and ‘do-not-attempt-resuscitation’ orders. The author suggests that the discomfort generated by these conflicts has been a motivating factor in the emergence of so called ‘slow codes’ (cardiopulmonary resuscitation efforts intentionally conducted too slowly or not long enough to be successful). Interventions are suggested that may help prevent the occurrence of slow codes.

Influence of guidelines on CPR decisions: an audit of clerking proforma

We audited documentation rates and implementation of cardiopulmonary resuscitation (CPR) decisions for patients admitted under the Department of Elderly Care Medicine, Mayday University Hospital, Croydon, as new guidelines and a proforma were introduced. For the first audit, data were collected from 75 departmental discharges. Following introduction of a proforma, six point prevalence audits were performed of all elderly care inpatients. Consultant documentation improved from 27/75 (36%) to 102/109 (94%), 135/148 (91%), 133/140 (95%), 96/119 (81%), 148/157 (94%) and 167/169 (98%) in audits 2, 3, 4, 5, 6 and 7 respectively. The percentages of decisions that were Do Not Attempt Resuscitation (DNAR) were 64% 72%, 45%, 68% and 62% in audits 3 to 7 respectively. For audit 5 our guidelines required discussion with patient before making a DNAR order, whereas the guidelines applicable for the other audits did not stipulate discussion. The fall in documentation rates and proportion of CPR decisions that were DNAR in audit 5 were statistically significant. There was no significant difference in age, diagnosis, cognitive function or disability between patients in those audits (3-7) when these parameters were recorded. Introducing a proforma significantly improved CPR decision documentation. Obligatory discussion with a patient before issuing a DNAR order was associated with a fall in documentation of decisions.