In-Hospital Defibrillation

This letter was written in response to an article in the January 1994 issue of Resuscitation. The article reported positive results from a study of performance of a group of nurses in simulation testing after they had received brief training in AED use. I took that as an opening to promote early in-hospital defibrillation by nurses in general (with or without AEDs).

Reprinted from Resuscitation, 28(1), Stewart JA, Defibrillation by nurses, pages 71-72, 1994, with kind permission from Elsevier Science Ireland Ltd., Bay 15K, Shannon Industrial Estate, Co. Clare, Ireland.

Defibrillation by nurses

To the Editor:

I was pleased to read "Student nurses can defibrillate within 90 seconds" by McKee, et al., in the January issue of Resuscitation. The study indicates that training nurses to use automated external defibrillators (AEDs) is not particularly difficult or time consuming. This is important information because it adds to the impetus for meaningful action to address the pervasive problem of delayed in-hospital defibrillation. I wish to add a couple of points related to the article.

The training time for the tests of remote retention in the study was significantly greater than the three hours of initial training because the time required for early tests and feedback is properly considered as additional training time for subsequent tests. The authors acknowledge this indirectly ("Some loss of skills is apparent...but reinforcement leads to an improvement...at 3 and 6 months."), but a more explicit statement together with an estimate of time required for the retesting and feedback would have been helpful. Accurate reporting of training time is necessary for meaningful comparison with other training programs.

More importantly, I am concerned that readers of the article may come away with the impression that nurse-initiated defibrillation on general units is feasible only with AEDs. I don't doubt that "the main reason given for restricting defibrillation to doctors is the perceived need to ensure correct identification of the rhythm" and that use of AEDs removes this objection, but I believe that the objection itself should be questioned on two counts. First, it contains the implicit assumption that training general unit nurses to recognize ventricular fibrillation (VF) is not feasible. The impracticality of such training seems to be supported by the length of manual defibrillation courses for EMTs--10 to 16 hours for initial training is common--but these courses typically devote much time to rhythm analysis skills irrelevant to the basic problem of recognizing VF. Studies suggest that properly focused initial training in manual defibrillation, including positive identification of VF, can be much shorter [1,2].

Second, there is good reason to question a policy requiring identification of VF before shocking an arrested patient and to advocate a policy of "blind" defibrillation instead. Identification of VF, whether by a human caregiver or an AED, delays defibrillation for at least a few seconds, and if artifact confuses the picture the delay can be long enough to decrease significantly the probability of success. Requiring rhythm identification also delays general improvement in the delivery of defibrillation by making it easier to rationalize the currently accepted approach--based on the unsubstantiated assumption that the necessary training in rhythm identification is impractical and/or the somewhat more plausible contention that equipping hospitals with AEDs is too expensive and basically redundant.

A policy of blind defibrillation could save lives by hastening defibrillation without compromising patient safety. There is no evidence that countershocks cause harm to patients in non-VF cardiac arrest [3], and neurologically intact survival in such instances is extremely rare in any case. The extremely remote possibility (no documented cases in the literature after some thirty years of external defibrillation) of a patient not in cardiac arrest dying from an inappropriate shock exists even if rhythm identification is required or if AEDs are used--and the best line of defense against that possibility is, as always, good basic assessment of the patient.

I think that the case for nurse-initiated defibrillation was really made long ago with the simple observation that success of defibrillation is highly time-dependent, together with documentation of the dismal survival rates from cardiac arrests on general units. Work on this problem has been ongoing at a few sites for many years, unfortunately without much notice from the larger medical community--most notably the successful manual defibrillation program started in 1970 at Royal Sussex County Hospital in Brighton, England [4]. The authors of the present article have, however, added some important material to the large body of research that directly or indirectly supports defibrillation by nurses. Let us hope that this issue soon reaches "critical mass" and that researchers and caregivers begin to give the serious problem of delayed in-hospital defibrillation the attention it deserves.

1. Bradley K, Sokolow AE, Wright KJ. A comparison of an innovative four-hour EMT-D course with a "standard" ten-hour course. Ann Emerg Med 1988; 17: 613-619.

2. Stewart JA. Defibrillation training for general unit nurses. J Emerg Nurs 1992; 18: 519-524.

3. Kern KB, Ewy GA. Clinical defibrillation: optimal techniques. In Tacker WA Jr. Defibrillation of the Heart: ICDs, AEDs, and Manual. Mosby-Year Book, St. Louis, 1994.

4. MacKintosh AF, Crabb ME, Brennan H, Williams J, Chamberlain DA. Hospital resuscitation from ventricular fibrillation in Brighton. BMJ 1979; 1: 511-513.

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