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doi: 10.1097/01.NURSE.0000369869.05928.5a

What's the 4-1-1 on "the first five"?

Tasota, Frederick J. MSN, RN; Clontz, Amy MSN, RN; Shatzer, Melanie MSN, RN; Dongilli, Tom

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Frederick J. Tasota is critical care clinical specialist and Amy Clontz is trauma clinical specialist at the University of Pittsburgh Medical Center-Presbyterian University Hospital, Pa. Melanie Shatzer is administrative director of nursing discovery and innovation at the University of Pittsburgh Medical Center-St. Margaret's Hospital. Tom Dongilli is director of operations for the Peter M. Winter Institute for Simulation Education and Research.

After a patient's cardiac arrest, but before the medical emergency team arrives ... It's a crucial 5-minute window of time. Do you know what to do?

CAN YOU HANDLE a cardiac emergency until the medical emergency team (MET) arrives? To improve crisis response, our facility developed a program to prepare first responders to intervene appropriately. Here's why and how we did it.

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Dire need

Clinical observation, mock codes, and code reviews demonstrated that non-MET personnel—often the first to identify and respond to medical emergencies—weren't consistently prepared to provide key interventions, including early defibrillation with an automatic external defibrillator (AED).

To date, the emphasis in our institution has been on the MET, with well-developed initiation criteria, sustained use over time, a crisis team-teaching course at an affiliated simulation center, and in-house mock codes (cardiac arrest) to evaluate team response.

But non-MET first responders are key. Research shows that early problem recognition, rapid responder activation, appropriate initial intervention, and rapid defibrillation are key components in the chain of survival for hospitalized patients in cardiac arrest.1 Unfortunately, in-hospital delays in defibrillation are common nationwide, with more than 30% of patients with lethal cardiac dysrhythmias not defibrillated until more than 2 minutes after recognition.2

Also, a high percentage of cardiac arrests occur outside ICUs (180 in our institution in 2006), and patient survival hinges on first-responder actions.2 Direct observation and review of responses by non-ICU staff in our institution revealed opportunities to:

* standardize first-responder behaviors before MET arrival

* review nurse-initiated AED use

* standardize mock code teaching to improve staff performance in crisis situations.

Little objective data on performance and teaching for first responders exists. However, the importance of educated personnel performing basic life support (BLS) and initiating early defibrillation is well documented. AED use should be considered a routine skill for all nurses after appropriate classroom and hands-on education.3,4

Orientation for non-ICU staff in our hospital includes education about basic cardiac dysrhythmias, MET activation, and BLS. In addition, non-mandatory education includes unit-based mock codes and crisis team teaching.

Interestingly, while attending BLS class, we also discovered that our AED education reviewed only devices found in public areas, but not the cardiac monitors or defibrillators with built-in AEDs available on each unit's emergency cart. Taking this information into consideration, we determined that our emergency teaching was inadequate because we continued to observe disorganization and skill uncertainty among first responders before MET arrival.

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Our rationale

Our team, composed of three clinical nurse specialists and the director of operations at an affiliated simulation center, cited the following reasons for teaching first responders:

* enhance critical thinking and motor skills

* improve early problem recognition

* eliminate inconsistent or inappropriate initial interventions

* standardize key responses

* empower decision making

* improve communication

* complement the MET

* promote safety from the onset of a patient crisis.

On the basis of this rationale, we developed a simulation-based program to decrease staff anxiety related to crises and facilitate completion of key resuscitative tasks before MET arrival. We initially provided crisis teaching with simulator-center assistance for new nurses during orientation. Before using simulation experts, we informally addressed the hospital's MET response, briefly reviewed the emergency cart, and practiced mock codes with a low-tech manikin. High-fidelity human patient simulators displaying human characteristics and responding to interventions let us enhance simulated emergencies. Our team soon recognized that this was a win-win opportunity. New staff appropriately interacted in the nonthreatening, yet realistic, environment created with the human patient simulator and the emergency scenarios. Although not all participants had hands-on learning, all were involved in observation and post-scenario debriefing sessions. Evaluations were overwhelmingly positive.

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Program particulars

Lessons learned from this initiative and from real emergencies stimulated our team to broaden the scope of this interactive learning opportunity. While the idea evolved, we started taking the human patient simulator throughout the hospital, addressing needs for education related to nursing responsibilities in a crisis. After facilitating multiple sessions with staff nurses, the program was officially designated "First 5 Minutes," based on the desire to enhance crisis response in those moments preceding MET arrival. The hospital's own medical emergency response improvement team provided support, and we opened attendance to students, nurse assistants, therapists, technicians, and clericial support, because these staff members also provide valuable assistance during emergencies.

We offered program educational sessions day and night to accommodate different schedules and limited program length to 30 minutes to encourage participation. The curriculum was structured to promote learning and hands-on involvement for multiple learners at various experience levels. Specifically, content focuses on response to cardiac arrest and nurse-initiated defibrillation, but learner objectives and most hands-on activities apply to any patient crisis.

Educating non-ICU staff on emergency response and improving standardized behaviors begins with a brief overview of objectives and expectations, followed by an introduction to the human patient simulator and the environment where the scenario is conducted. Staff assume different roles, and the person initially assessing the "patient" receives a brief report of pertinent information. Staff are then asked to respond as they would in a real emergency.

After the initial scenario, we facilitate a lengthy debriefing of crisis response, positively reinforcing correct interventions, discussing priorities, reviewing equipment and sequence of interventions, uncovering errors, providing rationales, allowing hands-on practice, and eliciting participant responses. Commonly identified problem areas included assessing the ABCs, defibrillation, and performance of other key tasks that can facilitate patient-care during a crisis.

We then conduct a second scenario, with staff assuming different roles, followed by a shorter debriefing, any special situations, additional hands-on review, and questions. Before leaving, staff receive a handout listing key tasks to be initiated by first responders before MET arrival in any crisis.

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Spreading the word

To date, more than 300 staff members have participated in the program at our hospital, and data have been analyzed from 75 nurses consenting to:

* pre/post surveys assessing perceptions of simulation

* pre/post true/false tests assessing cognitive knowledge related to identifying crises and implementing appropriate measures.

See Nurses provide encouraging feedback for details.

Most important, performance of key tasks before MET arrival in the simulations improved and time to defibrillation was dramatically reduced. Nurse administrators now include "First 5 Minutes" as mandatory teaching for non-ICU staff, in addition to BLS retraining, and are including it in orientation for all new nurses.

In fall 2007, initiative adaptation throughout our regional health system began. Nurses at other locations have been educated as facilitators and are educating staff. Also, the program curriculum has been formalized by our team for use within and outside the system. The program template, combining traditional mock code scenarios with high-tech simulation, is basically all that's necessary for new facilitators to begin teaching others. Additional components important to facilitate successful program implementation include:

* a core group of knowledgeable facilitators, similar to our team, willing to dedicate time to conduct the teaching

* administrative champions willing to fully support the program.

The beauty of this safety initiative is that it provides an exciting educational experience adaptable for healthcare providers in any setting.

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Nurses provide encouraging feedback

The "First 5 Minutes" program proved an effective means of reviewing emergency measures and improving standardized behaviors during simulated crises.

* Participants who felt comfortable managing patients before MET arrival increased from 25% to 45%.

* Those who strongly agreed that the simulated experience would be realistic increased from 51% to 71%.

* Correct test answers improved by 45%. Correct answers related to knowledge of where intubation supplies were kept (a 73% increase), first action to take when assessing unresponsive patients (a 62% increase), and placement of cardiac monitoring electrodes versus defibrillator pads (a 45% increase).

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1. Callanan V, Nichol G, Valenzuela T, et al. The chain of survival. Proceedings of the International Guidelines 2000 Conference for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ann Emerg Med. 2001;37(Suppl 4):S5–S16.

2. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9–17.

3. Coady EM. A strategy for nurse defibrillation in general wards. Resuscitation. 1999;42(3):183–186.

4. Dwyer T, Williams LM, Jacobs I. The benefits and use of shock advisory defibrillators in hospitals. Internat J Nurs Pract. 2004;10(2):86–92.

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