When researchers at the University of Pennsylvania (UPenn) in Philadelphia studied cardiac arrests in non-ICU settings at three urban teaching hospitals, they found CPR quality was worse at night.
The rate of chest compressions at night varied more than during the day, and was often well below the level required for adequate blood circulation. In addition, rescuers at night paused longer when alternating between chest compressions and defibrillator shocks.
Feedback is Crucial
Study co-author Marion Leary, BSN, RN, an MICU nurse and assistant director of clinical research at the Center for Resuscitation at UPenn, shared some explanations for the research findings.
"The over-arching issue is that CPR quality is complex, and depends on human beings who may not perform well under pressure, especially if they are sleep-deprived at night," she said. "The goal is to have a well-trained, highly-functioning team with nurses doing CPR or giving meds, physicians leading the code, and respiratory therapists managing the ventilation."
"CPR is one of those clinical activities you have to perform over and over to maintain competency," said Leary, adding one 2008 study found, on average, a non-critical care nurse participated in a code every 59 months and had not practiced CPR in 18 months.1 We can't reasonably expect floor nurses to perform quality CPR under those circumstances."
UPenn has started providing nurses in designated nursing units with ongoing feedback about their CPR performance.
Practice Makes Perfect
"It looks like a hockey puck that's placed on the spot on the patient's chest where hands should be during CPR, and connected to the defibrillator," Leary said. "Compressions are delivered over the sensor, allowing the defibrillator to display real-time data about compression depth and rate. As a nursing community, if we recognize there's a problem with CPR quality, especially at night, we can fix it."
The research findings about quality of CPR compressions resonated with Terry Fazziola, RN, CCRN, PCCN, nurse educator for the cardiovascular service line at Scripps Memorial Hospital La Jolla, CA.
"While we have not measured the depth of compressions with a device during actual CPR situations, I'm not surprised the study found gaps between the recommendations and the actual CPR delivery," she said. "We've found that education about cardiopulmonary resuscitation needs to be done regularly, and observation of Code Blues is key to ongoing success."
Fazziola described how her organization has implemented a comprehensive approach to ensure CPR is done correctly at all times. "We educate new staff about our specific Code Blue policy during orientation to the hospital, and have a high-fidelity simulation lab for Code Blue practice," she noted.
"During one of our learning fairs, we provided staff with a chance to do CPR on a model that gave them data about the depth and rate of their compressions," she continued. "Every year, we hold about 50 mock Code Blues on various shifts. We focus on how we can improve everyone's skill set, promote communication during codes, and run the code better, with emphasis on the importance of compressions."
The simulation lab allows team of clinicians to practice a specific cardiopulmonary resuscitation scenario, watch a recording of their performance, and talk about what they see on the recording. "The simulation lab is a safe zone designed for learning, and is not used for performance evaluation," Fazziola emphasized.
"We will use the simulation lab to teach and practice the American Heart Association's new 2010 guidelines that change the recommended depth of compression in adults from 1-1/2 to 2 inches. The new guidelines also recommend compressing at least 100 times per minute, rather than the previous target of 100 times a minute. Staff who can push faster and still maintain the right depth of compressions will be encouraged to do so."
Fazziola and her colleagues regularly review data from real Code Blue situations, including the number of codes, the percentage of patients who survive immediately after the code, and the percentage that are discharged alive. "While we don't compare data between night and day shifts, that's something we may consider doing in the future," she said.