In-Hospital Defibrillation

This editorial (together with the article "Defibrillation training for general unit nurses" in the same journal issue) was my first publication. The journal reference is:

Stewart JA. Beyond code teams: early defibrillation by nurses for in-hospital cardiac arrests. Journal of Emergency Nursing. 1992;18(6): page 491.

This copyrighted material may only be used personally and may not be distributed further. All rights reserved. Copyright 1992, Mosby-Year Book, Inc.

Beyond code teams: early defibrillation by nurses for in-hospital cardiac arrests

John A. Stewart, RN, MA
Seattle, WA

The management of out-of-hospital cardiac arrests has changed dramatically in recent years because of increased emphasis on the goal of early defibrillation. During the past decade, numerous EMT-Defibrillation (EMT-D) programs across the country have separated defibrillation from the larger body of Advanced Cardiac Life Support (ACLS) knowledge and skills to bring this most essential lifesaving intervention to the cardiac arrest victim as rapidly as possible. By empowering EMT-Ds to defibrillated before ACLS-trained paramedics arrive, emergency medical services (EMS) systems with EMT-D programs have significantly increased survival rates [1].

In contrast to this trend in out-of-hospital treatment, the approach to in-hospital resuscitation has not changed significantly in the past decade. Typically, only nurses in certain specialty areas are authorized to defibrillate on their own initiative, and defibrillation training usually remains a part of broader ACLS training. Acute care general hospitals commonly provide ACLS to general units by means of "code teams," composed primarily of staff from critical care areas, who use crash carts and defibrillators located on the various units.

A fresh look at the response to in-hospital cardiac arrests is long overdue. The code team approach is analogous to EMS systems in which defibrillation is not performed until paramedics have arrived. Defibrillation is often delayed in codes on general units, despite the ready availability of defibrillators. The most obvious cause of delay is the time required for the code team to reach the scene, but significant delays also occur after the code team arrives [2, 3]. Code team leaders must quickly try to get a "global" grasp of the situation on arrival at the scene. In doing so they are often occupied, even if only briefly, by important but nevertheless secondary concerns, such as establishing IV access and--perhaps most frequently--evaluating the adequacy of basic CPR. A certain degree of "tunnel vision," directed toward cardiac monitoring and rapid defibrillation, is needed in the first minutes of the resuscitation effort.

Hospitals should adopt an approach to in-hospital codes that parallels EMT-D programs in the out-of-hospital setting. A cadre of trained nurses on general units throughout the hospital, authorized to defibrillate on their own initiative, could reach arrest victims much more quickly. Perhaps more importantly, they could provide the mental focus necessary to ensure that monitoring and defibrillation are performed as rapidly as possible, thus giving patients their first, best chance of survival [4].

Developing effective defibrillation training for general unit nurses presents a significant challenge. Some of the major training issues are addressed in "Defibrillation training for general unit nurses" in this issue.

The link between early defibrillation and survival is now beyond dispute. The American Heart Association recently issued a position statement emphasizing the central importance of early defibrillation for in-hospital as well as out-of-hospital resuscitation [5]. A serious commitment to early defibrillation for hospitalized victims of cardiac arrest promises to save many lives. The time for change is now.

REFERENCES

1. Eisenberg MS, Horwood,BT, Cummins RO, Reynolds-Haertle R, Hearne TR. Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med 1990;19:179-86.

2. Buechler D. Code blue evaluation. Nurs Manage 1982;13(5):25-8.

3. Sullivan MJJ, Guyatt GH. Simulated cardiac arrests for monitoring quality of in-hospital resuscitation. Lancet 1986;2:618-20.

4. MacKintosh AF, Crabb ME, Brennan H, Williams JH, Chamberlain DA. Hospital resuscitation from ventricular fibrillation in Brighton. BMJ 1979;1:511-3.

5. Emergency Cardiac Care Committee, American Heart Association. Statement on early defibrillation. Circulation 1991;83:2233.

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