In-Hospital Defibrillation

Stewart JA. Reply to " A comparison of resuscitation skills of qualified general nurses and ambulance nurses in The Netherlands" [letter]. Heart & Lung. 1994;23(4): 359-360.

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Reply to " A comparison of resuscitation skills of qualified general nurses and ambulance nurses in The Netherlands."

John A. Stewart, RN, MA
Seattle, WA

In "A comparison of resuscitation skills of qualified general nurses and ambulance nurses in The Netherlands" (Heart & Lung, November/December 1993), Berden, et al. cite two references [1, 2] , in support of their statement that basic cardiopulmonary resuscitation (CPR) has been proven to improve survival after in-hospital cardiac arrests. However, neither of the cited articles actually supports that contention; in fact, neither says anything at all about the effect of CPR on survival. There is actually scant evidence in the medical literature of a beneficial effect of basic CPR on survival from in-hospital arrests. But there is a more fundamental problem with the article: it supports the common but mistaken belief that basic CPR is the correct initial intervention for unmonitored in-hospital cardiac arrests.

The term basic CPR is misleading. The procedure is not basic in the sense of being fundamental to in-hospital resuscitation efforts—it is appropriately performed to slow the slide into irreversible death when there is an unavoidable delay in providing definitive treatment to restore the circulation, as is common in out-of-hospital arrests (so it isn't really cardiopulmonary resuscitation—revival from apparent death—either). Basic may also connote easy, but the article by Berden, et al., adds to the long list of studies showing that performing basic CPR correctly is often anything but easy. And today it is harder to do in the first moments of a cardiac arrest than it was a few years ago: the use of a ventilatory barrier is now standard practice, and commonly used barriers (e.g., the pocket mask) can make performing effective one-person CPR very difficult, if not impossible. (The authors' emphasis on one-person CPR and mouth-to-mouth ventilation is therefore somewhat inappropriate in the context of in-hospital resuscitation.)

Improving basic CPR training of hospital nurses, then, is unlikely to affect in-hospital survival. If survival rates are to improve, training resources must be directed to the intervention that is most effective in saving lives. As most readers of this journal can probably gather from reviewing their personal experiences, and as extensive evidence in the professional literature confirms, defibrillation is the cornerstone of almost all successful resuscitations from full cardiac arrest. Nothing else in the ACLS arsenal even comes close in importance—defibrillation is the true basic CPR. And the success of defibrillation is extremely time dependent—seconds really do count.

Most hospital units today have a defibrillator close at hand, and general nurses are usually first on the scene of an unmonitored arrest. Consequently, these nurses are in a position to defibrillate at the earliest practicable moment. Hospital nurses who try to start ventilations or chest compressions when a defibrillator is readily accessible and not yet in use are neglecting the most essential intervention and substantially decreasing their patient's chance of survival. They may be acting in perfect accordance with hospital policy, but in terms of clinical effectiveness they are still utterly wrong. This conclusion has been supported by the American Heart Association for years, at least in general terms:

In the last decade, we have under-emphasized the role of prompt defibrillation. CPR should be initiated only when a defibrillator is not immediately at hand or after initial shocks have failed to restore spontaneous circulation. CPR should never be used as a substitute for definitive care. [3]

And the 1992 ACLS Guidelines advocate that "all personnel whose jobs require that they perform basic CPR be trained to operate and permitted to use defibrillators...." [4]  Reaching that goal—rather than upgrading BLS skills—should be the first priority of in-hospital resuscitation training.

The prospect of training hospital nurses to defibrillate raises many questions. Can existing manual defibrillators be used, or are automated external defibrillators a better choice?  Is a delay for rhythm identification clinically prudent, or might "blind" defibrillation after a careful pulse check be desirable to achieve the earliest possible shocks? These and other relevant questions will take time and experience to answer. But the question of whether to work toward the goal of rapid defibrillation for cardiac arrests in hospitals can and should be answered now—firmly in the affirmative. Our responsibility to our patients demands it.

REFERENCES

1. Tunstall-Pedoe H, Bailey L, Chamberlain DA, Marsden AK, Ward ME, Zideman DA. Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS study): methods and overall results. BMJ 1992;304:1347-51.

2. Bedell SA, Delbanco EF, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;30:569-76.

3. American Heart Association. Textbook of Advanced Cardiac Life Support. 2nd ed.; 1987 (quote from page 5).

4. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care, III: adult advanced cardiac life support. JAMA 1992;268:2199-2241 (quote from page 2199).

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