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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

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 29th

July 2013. 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.

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.

“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

i

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

ii

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.

iii

Table of Contents

Declaration……………………………………………………………........................ i

Acknowledgement…………………………………………………………………….ii

Table of Contents……………………………………………………………………..iii

List of Appendices…………………………………………………………………….v

Abbreviations…………………………………………………………………………vi

Chapter 1 Introduction

1.1 Background………………………….…………………………………………….1

1.2 Affirmation of the Needs…………………………………………………………..2

1.3 Objectives and Significance………………………………………………….........4

Chapter 2 Critical Appraisal

2.1 Search and Appraisal Strategies…………………………………………………..6

2.2 Results……………………………………………………………………………10

2.3 Summary and Synthesis of Data…………………………………………………13

2.4 Potential Innovation……………………………………………………………...16

Chapter 3 Implementation potential

3.1 Target Setting…………………………………………………………………….18

3.2 Transferability of findings………………………………………………………..19

3.3 Feasibility………………………………………………………………………...20

3.4 Cost/ Benefit Ratio of the innovation…………………………………………….23

Chapter 4 Evidence-based guidelines

4.1 Aims/Objectives/Target group…………………………………………………...27

4.2 Grades of recommendation………………………………………………………28

4.3 Recommendation…………………………………………………………………29

Chapter 5 Implementation Plan

5.1 Communication Plan……………………………………………………………………..32

5.2 Pilot Study Plan…………………………………………………………………………..36

5.3 Evaluation Plan…………………………………………………………………………...39

Chapter 6 Conclusion……………………………………………………………….44

Reference…………………………………………………………………………….45

iv

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

v

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

1

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 350000 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

2

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

3

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.

4

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).

5

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

6

Chapter 2 Critical Appraisal

2.1 Search and appraisal strategies

2.1.1 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 29th

July 2013. 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.

7

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),

2129-2136.

2. 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), 1229-1236.

3. 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), 416-422.

8

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), 1712-1718.

5. 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),

1537-1542.

7. 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), 846-852.

2.1.2 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

9

participants characteristic, intervention, comparison, outcome measure and results of

the literatures were all shown in the table of evidence.

2.1.3 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.

10

2.2 Results

2.2.1 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).

2.2.2 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.

11

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 11695 (Chan

et al., 2010).

2.2.4 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

12

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).

2.2.5 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).

13

(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., 2006. 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

14

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

15

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

16

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

17

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 20-30 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).

18

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.

19

3.2 Transferability of the findings

3.2.1 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.

3.2.2 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

20

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.

3.2.3 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.

21

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.

22

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.

23

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.

3.4.1 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

24

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.

3.4.2 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.

3.4.3 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

25

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.

3.4.4 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

26

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$1,696,240.

3.4.5 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.

27

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.

4.1.1 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.

28

4.1.2 Intended users

The intended users of this protocol are all registered nurses, advanced practice

nurses in medical and geriatric unit

4.1.3 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.

29

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;

30

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++)


The training program should be consists of more than 20 sessions and last for six

months (Zafari et al., 2004) (2++).

31


The annual assessment of AED use should be performed to ensure nurses’ proficiency

in using AED (Zafari et al., 2004) (2++).

32

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

5.1.1 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.

5.1.2 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

33

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

34

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.

35

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

36

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

5.2.1 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.

5.2.2 Ethical consideration

Concerning the ethical issue in the pilot study, an ethical approval will be obtained

from the Hospital Clinical Research Ethics Committee.

5.2.3 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

37

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.

5.2.4 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.

5.2.5 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

38

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.

39

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.

5.3.1 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

40

correlated in this innovation and should be evaluated.

System outcomes

To measure the system effectiveness, cost of using this innovation should not be

neglected. Resources cost including buying defibrillators, training cost should be

calculated. It is believed that stakeholders will provide support if the system outcomes

are effective. Therefore, this part of evaluation is important.

5.3.2 Nature of clients to be involved

As this innovation is carried out in the medical and geriatric unit in the targeted

hospital, therefore the target group will be patients aged above 18 years old, who

suffered from cardiac arrest in the medical and geriatric unit. For those having

implantable cardioversion defibrillator will be excluded.

The number of clients is determined by the study design, primary outcome and

analysis method. The data will be collected randomly in the cardiac ward. The

primary outcome of the study is the survival to discharge rate. The evaluation aim is

to estimate the survival to discharge rate after the implementation of nurse initiated

automated external defibrillation. Therefore, a “CI for one proportion” will be used as

the method of analysis. According to Zafari et al (2004), the sigificant difference of

the survival to discharge rate after using nurse initiated automated external

41

defibrillation is 7.9%. The margin of error will be set as 0.08. Using the 95%

confidence interval and the worst case (pi=0.5), the sample size is 150 patients after

computerize by the online java programme (Lenth, 2012). It is estimated that a year is

needed to recruit 150 patients.

5.3.3 Data collection and analysis

Patient outcome

The survival to discharge rate is the patient outcome. It will be record in a

evluation form until the patient discharge or death. To estimate the survival to

discharge rate, CI for one porportion will be used as the method of analysis with using

95% confidence interval.

Healthcare provider outcome

(1) Nurses’ satisfaction level

For nurses who have already performed the automated external defibrillation

according to the evidence based guidelines, a self-admisterated questionaire will be

distributed for the nurses to assess their satisfaction level. A five point Likert Scale

will be used to evaluate their satisfaction level. The data will be collected and analysis

every two month. A t-test will be used to analysis the satisfaction level in order to

compare the changes of satisfaction level every two month.

42

(2) Nurses’ confidence and competency

Knowledge and skills of performing automated external defibrillation will be

assessed and observed by the APNs of the work force group. The details will be

recorded in the audit form. The perceived confidence level will also be documented

and analysis by using a t-test to compare any increase in confidence level after several

sections of hands-on trainings.

System outcome

Document all the expenditure of buying the automated external defibrillators and

training cost. Comparison between the actual cost and the budge plan should be made

annually.

5.3.4 Basis for an effective change of practice

To determine whether the change of practice is effective, some criteria such as

achievement of defined outcomes, substantial clinical benefits and evaluation of staff

compliance to the innovation are essential.

According to the reviewed literatures, the survival to discharge rate of using

automated external defibrillator by nurses increased around 8% after extensive

training program (Zafari et al., 2004). It is a statistically significant. Therefore, the

new guidelines will be considered to be effective if the survival to discharge rate of

43

cardiac arrest patients increased more than 8 %.

Apart from the primary outcome, there are other factors affecting the effectiveness

of the new guidelines. The perceived knowledge and confidence in performing nurse

initiated automated external defibrillation will be targeted to achieve 80% or above. It

is targeted that 100% of nurses finished the training program of using AED. Also, the

compliance rate of the new guidelines is targeted more than 80%.

5.3.5 Modification and measures to sustain the change

In order to have improvement after the evaluation, the report of the evaluation will

be given to the stakeholders including the SMO, DOM, WM, APNs in the work force

group. They will provide constructive comments for improving the evidence based

guidelines and long term implementation of nurse initiated AED.

To sustain the change, sharing of successful stories through nursing forum is

necessary to encourage all staff to sustain and support the implementation of the

innovation.

44

Chapter 6 Conclusion

To conclude, early defibrillation is correlated to the suvival to discharge rate in

hospital cardiac arrest. Nurses as the first respsonders can be the one who perform the

defibrillation before the arrival of the physicians. It can shorten the time of

defibrillation. The evidenced-based guidelines on nurse initiated defibrillation is well

supported by the best existing evidence.With the systematic training of the use of

automated external defibrillator, nurses can perform the defibrillation confidently and

proficiently on cardiac arrest patients. Thus, the survival to discharge rate can be

increased. Owing to the positive influence on patients’ suvival and hgih

implementaion potential of this innovation, it is worthwhile to introduce nurse

initiated automated external defibrillation for cardiac arrest patients in Hong Kong.

45

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48

Appendix A :Search History

Search Pubmed CINAHL PLUS Cochrane Library

Using the keyword

#1“Automated

external defibrillator

or automated external

defibrillation or

AED”, number of

studies searched

9813 733 399

Using the keyword

#2 “In-hospital

cardiac arrest or

in-hospital

resuscitation” ,number

of studies searched

2698 307 344

Using #1and #2,

number of studies

searched

81 307 8

Using the keyword

#3 “survival to

discharge”, number of

studies searched

20132 360 1744

Using #1 and #2 and

#3, number of studies

searched

26 43 6

After screening the

title and abstract,

number of studies

retrieved

8 4 0

After reading the full

text, number of

studies selected

5 2 0

49

Appendix B: Table of evidence

Bibliographic

Citation

Study

Design

Number of

Patients

and Subject

Characteristics

Intervention Comparison Data collection

period

Outcome Measure Result

Chan et al.,

2010

Cohort

study

(++)

11695 hospitalized

patient with cardiac

arrest in 204acute

care hospitals in

general wards.

Automated

external

defibrillators

(AED) used in

cardiac arrest

patient

N=4515

AED was not

used

N=7180

From January

1,2000 and

August 26,2008

Primary outcomes:

(1)Survival to

discharge

Secondary outcomes:

(2)Rate of return of

spontaneous

circulation(ROSC)

for at least 20 minutes

(3)Rate of survival at

24 hours after cardiac

arrest

(4) neurological

disability at discharge

(1)AED used 16.3%

AED not used 19.3%

Effect size: -3(p<0.01)

(2) AED used 48.5%

AED not used 50.4%

Effect size: -1.9(p=0.56)

(3) AED used 33.7%

AED not used 36.6


(4) AED used 53.5%

AED not used 54.6%


50

Zafari et al.,

2004

Cohort

study

(++)

569 patients who

had an in-hospital

cardiac arrest with

resuscitation

attempted between

January 1,1995 and

June 30,2002

428 patients were

studied before the

program

implementation

1995-2000

141 patients was

studied after the

program

implementation

from June2001-

June 2002

Education and

manual

defibrillators used

in AED mode and

AEDs (June

2001-2002)

Monophasic

defibrillators

(January

1995-2000)

Before the

program

implement:

January 1,1995

and 2000

After the

program

implement:

June2001- June

2002

Primary outcome:

(1)Survival to

discharge

Secondary outcome:

(2)Neurological

outcome

1995-2000

(1) 4.9%

(2) 1.76±0.46

2001-2002

(1)12.8%

(2) 2.00±0.43

Effect size:

(1)7.9(p=0.001)

(2)0.24 (p=0.36)

Gombotz,

Weh,

Mitterndorfer,

& Rehak,

Cohort

study

(+)

439 cardiac arrest

patients in non

monitored areas of

the hospital

automated

external

defibrillators

on VT/VF

Automated

external

defibrillators

on non VF/VT

From April

2001 and

December 2004

outcome:

(1) survival to

discharge

(2)ROSC

AEDon VF/VT

patients:

(1) N=34, 54%

(2) N=63, 86%

51

2006 patients

N=73

patients

N=366

AED on non VF/VT

patients

(1)N=91, 25%

(2)N=193,53 %

Effect size: -19.0

Källestedt,

Berglund,

Enlund, &

Herlitz, 2012

Cohort

study

(+)

N=73 From

May 1, 2006, to

April 30, 2007

N=113 From April

1, 2009, to

December 31,

2010

(1) a systematic

education

of all health care

professionals in

cardiopulmonary

resuscitation and

(2) the

implementation of

18

automated

external

defibrillators.

Manual

defibrillation

by rescue

team

Before the

intervention:

From

May 1, 2006, to

April 30, 2007

After the

intervention:

April 1, 2009, to

December 31,

2010

outcome:

(1)Alive at

discharge

From Hospital

(2)Cerebral

performance

score among survival

Before the

intervention

(2006-2007)

(1)N=18,26%(p=0.51)

(2) N=9, 50%(p<0.001)

After the intervention

(2009-2010)

(1) N= 39,32%(p=0.51)

(2) N=50,95%(p<0.001)

Effect size:

(1)6.0(p=0.51)

(2)45(p<0.001)

Kloppe et al.,

2013

Cohort

study

(+)

Emergency call

463

outside intensive

care unit,

emergency

automated

external

defibrillators

(shocked

delivered)

no April 1, 2004

until

March 31, 2009

outcome:

survival to discharge

AED:

N=23,41%

52

department and

operation theatre

Witnessed cardiac

arrest event:126

N=56

Automated

external

defibrillators

(no shocked

recommend

group)

N=70

At the same time,

there are training

program for all

employee in

hospital

Smith,

Hickey, &

Santamaria,

2011

Cohort

study

(+)

N=82 From

8 November 2004

to 7 November

2007

N=84 From 7

November 2007, to

7 November 2010

automated

external

defibrillators.

N=82

No automated

external

defibrillators.

N=84

Before the

intervention:

8 November

2004 to 7

November 2007

After the

intervention:

November

2007, to 7

outcome:

(1) survival to

discharge

(2)Return of

Spontaneous

Circulation

Before the intervention

(1) N=15,19%(p=0.56)

(2) N=29,35%(p=0.02)

After the intervention

(1) 18 ,22%(p=0.56)

Effect size: 3.0(p=0.56)

(2)45,54%(p=0.02)

Effect size 19.0(p=0.02)

53

November 2010

Forcina,

Farhat,

O'Neil, &

Haines, 2009

Cohort

study

(+)

561 patients,

emergency

department patients

and outpatients

undergoing

diagnostic or

therapeutic

procedures who

suffered a cardiac

arrest with a CPR

attempt

Automated

External

Defibrillator

(AED)

N=284

Standard

defibrillator

N=277

1 year before

introduction of

AED

(September

11,2003 to

September

10,2004)

And 1 year after

complete

deployment of

AEDs and staff

training (March

9,2005 to

March8, 2006)

Primary outcome:

(1) survival to

discharge

Secondary

Outcomes:

(2) rate of ROSC

(3)CPR survival

(4)24-hour survival

(1)AED used 18%

Standard defibrillator :23%

Effect size: -5(P=0.09)

(2)AED used 67%

Standard defibrillator :70%

Effect size:-3 (p=0.54)

(3)AED used 60%

Standard defibrillator : 61%

Effect size: -1 (p=0.78)

(4)AED used 36%

Standard defibrillator : 42%

54

Appendix C: methodology checklist

S I G N

Methodology Checklist 3: Cohort studies

Study identification (Include author, title, year of publication, journal title, pages)

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), 846-852.

SECTION 1: INTERNAL VALIDITY

In a well conducted cohort study: Does this study do it?

1.1 The study addresses an appropriate and clearly focused question. Yes

SELECTION OF SUBJECTS

1.2 The two groups being studied are selected from source populations that are

comparable in all respects other than the factor under investigation.

Yes

1.3 The study indicates how many of the people asked to take part did so, in each of the

groups being studied.

Yes

1.4 The likelihood that some eligible subjects might have the outcome at the time of

enrolment is assessed and taken into account in the analysis.

Does not

apply

1.5 What percentage of individuals or clusters recruited into each arm of the study

dropped out before the study was completed.

Not applicable, as drop out

rate is not applied in this

study

1.6 Comparison is made between full participants and those lost to follow up, by

exposure status.

Does not

apply

55

ASSESSMENT

1.7 The outcomes are clearly defined. Yes

1.8 The assessment of outcome is made blind to exposure status. If the study is

retrospective this may not be applicable.

Does not

apply

1.9 Where blinding was not possible, there is some recognition that knowledge of

exposure status could have influenced the assessment of outcome.

No

1.10 The method of assessment of exposure is reliable. Yes

1.11 Evidence from other sources is used to demonstrate that the method of outcome

assessment is valid and reliable.

Yes

1.12 Exposure level or prognostic factor is assessed more than once. No

CONFOUNDING

1.13 The main potential confounders are identified and taken into account in the design

and analysis.

Yes

STATISTICAL ANALYSIS

1.14 Have confidence intervals been provided? Yes

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimise the risk of bias or confounding?

High Quality(++)

2.2 Taking into account clinical considerations, your evaluation of the methodology used,

and the statistical power of the study, how strong do you think the association between

exposure and outcome is?

associated

2.3 Are the results of this study directly applicable to the patient group targeted in this

guideline?

Yes

56

S I G N



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), 1537-1542.







Yes



Yes



Does not

apply



Does not apply


exposure status.

Does not

apply

ASSESSMENT




Does not

apply



No

57




No


CONFOUNDING


and analysis.

Yes





Acceptable (+)




strong


guideline?

Yes

58

S I G N



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), 2129-2136.







Yes



Yes



Does not

apply



Not applicable, as drop

out rate is not applied in

this study


exposure status.

Does not

apply

ASSESSMENT




Does not

apply

59



No




Yes

1.12 Exposure level or prognostic factor is assessed more than once. Does not

apply

CONFOUNDING


and analysis.

Yes





High Quality(++)




associated


guideline?

Yes

60

S I G N



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), 416-422.







Yes



Yes



Does not

apply





this study


exposure status.

Does not

apply

61

ASSESSMENT




Does not

apply



No




Yes


CONFOUNDING


and analysis.

Yes


1.14 Have confidence intervals been provided? No, for the

outcome

survival to

discharge

rate



Acceptable (+)




associated


guideline?

Yes

62

S I G N



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), 1229-1236.







Yes



Yes



Yes





this study


exposure status.

Does not

apply

ASSESSMENT




Does not

apply

63



No




Yes


CONFOUNDING


and analysis.

Yes





Acceptable(+)




associated


guideline?

Yes

64

S I G N



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.







Does not

apply

Only one

group



Yes



Does not

apply



Does not apply


exposure status.

Does not

apply

ASSESSMENT




No



No

65




No


CONFOUNDING


and analysis.

No


1.14 Have confidence intervals been provided? No



Acceptable (+)




Moderate associated


guideline?

Yes

66

S I G N



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), 1712-1718.







Yes



Yes



Does not

apply



Does not apply


exposure status.

Does not

apply

67

ASSESSMENT




Does not

apply



Can’t say

1.10 The method of assessment of exposure is reliable. Can’t say

No validity

and

reliability of

CPC as a

measure of

cerebral

function

after CA



Can’t say Survival of

discharge

rate was

indicated


CONFOUNDING


and analysis.

yes Including

patient’s

characteristic

between two

group of

patients




68


Acceptable(+)




Moderate associated


guideline?

Yes

69

Appendix D: Grade of Recommendation (Scottish Intercollegiate

Guideline Network,2008)

Grade Statements

A At least one meta analysis, systematic review, or RCT rated as 1++, and

directly applicable to the target population; or

A systematic review of RCTs or a body of evidence consisting

principally of studies rated as 1+, directly applicable to the target

population,

and demonstrating overall consistency of results

B A body of evidence including studies rated as 2++, directly applicable

to

the target population, and demonstrating overall consistency of results;

or

Extrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to

the target population and demonstrating overall consistency of results;

or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

70

Appendix E: Material Cost of implementing proposed innovation

(In six months)

Item Amount calculation Price (HKD)

AED 12 $8000 x 12units $96,000

Nursing

staff(trainer)

for 40 hours

training

workshop

2 mean salary of

APN per hour x 2

staffs x 40 hours

$248x 2x 40

$19,840

Nursing

staff(trainee)

for 40 hours

training

workshop

240 Mean salary of RN

per hour x 240

staffs x 40 hours

$164x240x40

$1,574,400

Printing

material(course

notes)

240 $0.5x 4pages x

240staffs

$480

Maintenance

cost of AED

12 $500 x 12 units $6000

Total $1,696,240

71

Appendix F: Evaluation form of survival to discharge rate for

cardiac arrest patients after using automated external defibrillation

Patient Name:__________________ Patient ID no:_________________

Sex:__________ Age:__________ Ward__________

Resuscitation process:

Patient’s Diagnosis: ____________

Date of cardiac arrest: ____________

Time of cardiac arrest: ____:_____hrs

Time of commencement of resuscitation: ____:______hrs

First Doctor arrival at: _______:______hrs; Name of the doctor:____________

Second Doctor arrival at ______:______hrs; Name of the doctor:____________

Initial ECG rhythm when cardiac arrest: _____________

Commencement of automated external defibrillation by nurses: Yes No

Time of commencing automated external defibrillation by nurse: _____:_____hrs

Immediate outcome:

CPR ended at ______:_______hrs

AED ended at ______:_______hrs

Transferred to : ICU CCU Ward_____

Certified death at ______:______hrs

Outcome:

Survival till Day ___, ___/____/___(Date) Discharge date:______________

Death on:_______________

72

Appendix G: Assessment form of using AED by nurses

Procedure Yes No N/A Remark

1. Turn on the AED

2. Attach defibrillation pads on

patient’s skin in correct position

3. Don’t touch the patient during

rhythm analysis by AED

4. State “everybody clear” if AED is

going to deliver the shock

5. Continue CPR

Compliance percentage:____________

Assessor:__________________ Assessor’s signature:_____________

73

Appendix H: Timeline for implementation of nurse initiated AED program

Year 2015 (month) 2016 2017 2018

1 2 3 4 5 6 7 8 9 10 11 12 3 6 9 12 3 6 9 12 3 6 9 12

Preparation period

(teaching materials, recruit

team member in the work

force group, promotion of

the innovation)

Communication with

stakeholders

Pilot study

Pilot study evaluation and

review

Implement the large scale

innovation

Training program

Data collection and

analysis

Evaluation and final report

of the program

74

Appendix I: Flow chart of implementation of nurse initiated AED

Assess patient

↓

Unresponsive, not breathing, no pulse

↓

Activate Emergency Response

(Call for help, get AED, start CPR immediately)

↓

Start use of AED, Press AED on/off button to assess rhythm by nurses

↓

AED indicates a shockable arrhythmia

↓

Defibrillate up to 3 times

↓

Check breathing and pulse

if absent

↓

Perform CPR for 2 minutes

Check breathing and pulse

↓

When doctor arrives, connect pads to manual defibrillator if necessary

and continue resuscitation process

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