Nurse-driven protocols to treat pain, sedation, weaning from mechanical ventilation, and early urinary catheter removal have shown to improve patient outcomes and decrease costs.1-3 The bedside nurse is in the optimal position to implement early interventions that impact patient outcomes. The success of nurse-driven protocols requires administrative and organizational support both philosophically and financially. This article will describe the successful implementation of a nurse-driven resuscitation protocol and the process used to gain organizational support.
Protocols for management of in-hospital cardiac arrest are well established for medical and surgical patients in the American Heart Association Advanced Cardiac Life Support (ACLS) Guidelines.4 These guidelines are based on out-of-hospital arrest evidence and do not address the environmental differences of in-hospital arrests or the unique physiologic needs and potentially reversible causes of arrest in the cardiac surgical population. Cardiac arrest after cardiac surgery is an infrequent event, yet this postoperative complication is most greatly associated with mortality.5-7 The European Resuscitation Council (ERC) protocol provided a standard approach to resuscitation of this patient population.8 The differences between the ERC and ACLS resuscitation guidelines are subtle but distinct. Table 1 references the differences between the resuscitation guidelines.
Analysis of organizational historic cardiac arrest data in this patient population was required to determine if the ERC protocol fit the organization's population and the context of a community hospital in the United States. The review included all cardiac surgical patients who suffered an arrest from 2012 to 2014, to determine if the organization's population matched the population represented in the literature. Of the patients analyzed, 86% would have received different treatment based on the ERC guideline that could have potentially resulted in a different outcome.8 Organizational data reviewed matched the literature in day of arrest and location of arrest but differed in initial event.
Organizational data revealed an opportunity for improvement in survival to hospital discharge and incidence of arrest. In 2012-2014, the cardiac surgical patients who sustained an arrest had an average survival to discharge of 45% and an incidence of arrest of 2.67%. A review of the literature identified survival to discharge in this population of 45% to 69%9 and 50% to 83%5 with an incidence of arrest of 1.5%7 and 2.6% to 5.5%.5 Use of a standardized resuscitation protocol specific to cardiac surgical patients has the ability to improve survival to discharge and incidence of arrest.10,11 Based on the appraisal of the evidence, the authors determined the cardiac surgery resuscitation guideline (ERC) was valid, reproducible, and clinically applicable to the organization's context.12
Review of the Literature
A search was conducted using the following sources: PubMed, CINAHL, EMBASE, Joanna Briggs, TRIP, Web of Science, PsycINFO, and EBSCOhost to identify relevant studies from 1990 to present. Key words utilized in the search were as follows: cardiac surgery patient resuscitation, nurse-driven protocols, postoperative care of the care cardiac surgery patient, resuscitation protocols or guidelines, and cardiac arrest outcomes after cardiac surgery. Minimal research was available regarding the efficacy of resuscitation protocols specific to the cardiac surgical population or outcomes using the ERC guideline.8 The review of the literature produced 3 primary articles5-7 regarding cardiopulmonary arrest in the cardiac surgical patient population, 3 articles regarding the ERC guideline for resuscitation,8,10,13 a review of the science supporting the ERC guideline,14 and a prospective study assessing the benefit of early chest reopening at the bedside.11 The ERC guidelines for resuscitation8,13 adopted all of the evidence-based elements of the resuscitation protocol originally presented by Dunning et al.10 regarding a guideline for resuscitation in cardiac arrest after cardiac surgery resuscitation. The review of the literature guided the choice of interventions, units for implementation, education, and equipment needs for the project.
The purpose of the pilot project was to develop, implement, and evaluate a nurse-driven protocol for a single center based on the most current ERC resuscitation guideline.13 The key interventions of the new protocol were early epicardial pacing and defibrillation prior to chest compressions, early identification of causes of arrest, emergency resternotomy at the bedside, and treatment with low-dose epinephrine prior to arrest.13 The pilot was implemented in early February 2016 in a 12-bed cardiac intensive care unit in a tertiary care community hospital with 174 beds performing approximately 400 cardiac surgeries per year. The project was implemented after review by the institutional review board and deemed exempt. The pilot utilized the ERC resuscitation guideline13 prior to publication in the United States as a consensus statement by the Society of Thoracic Surgeons in 2017.15
To address the challenges of implementation and sustainability, an implementation science theory was chosen as the framework for the project. The authors chose the Practical, Robust, Implementation and Sustainability Model (PRISM) as it was specifically designed for healthcare as “a comprehensive model for translating research into practice.”16(p229) Key domains identified in the model for successful implementation of an evidence-based practice change are organizational characteristics (recipients) and perspectives (intervention), and implementation and sustainability infrastructure.16 Elements within these domains include strength of the evidence, barriers of the frontline staff, usability, adaptability, trialability, and reversibility.16 The feasibility for the practice change had to be addressed from the workflow, financial, and medical-legal perspectives.
For this project to be successful, the cardiothoracic (CT) surgeons had to be engaged in the practice change early in the process. Their support was needed to proceed with approval within the organization and provide credibility of the protocol with the nurses. The data analysis of previous outcomes, ERC guidelines, and the proposed nurse-driven protocol were presented to the CT surgeons. The surgeons embraced the ERC guideline because it supported their clinical expert opinion regarding resuscitation in this patient population.
Discussions surrounding key elements of the resuscitation protocol specific to our organization had to occur because of the operations of a community hospital setting. The ERC guideline calls for emergency sternotomy within 5 minutes for all patients once chest compressions are initiated; however, in our hospital, the CT surgeon is on call but not physically present around-the-clock. After discussions with the surgeons, it was clear they may not always perform emergency sternotomy even if they were at the bedside. What they did desire was that the nurses be prepared to assist with an emergency sternotomy if they decided to do the procedure.
Once the CT surgeons approved the new resuscitation protocol with this modification, key organizational leaders were approached to elicit agreement with the practice change. As a next step, a deliberate process was followed to obtain approval through nursing and physician leadership groups. The CNO endorsement was essential for a successful translation of the evidence into practice. Philosophical and financial support was needed to promote the nurse-driven protocol and achieve improved patient outcomes. In order to elicit leadership support, the historical data along with the cost of equipment and education were presented.
The intervention domain of the PRISM model16 was very important for this project. All of the elements of the intervention domain were essential to the success of the practice change; however, the most important elements were workflow, addressing barriers, and equipment. Nursing focus groups were held to obtain input on workflow, equipment, and determine barriers. The nurses identified equipment needed to implement the resuscitation protocol including an adequate number of temporary pacemakers and defibrillators to facilitate the response time. The nurses determined the optimal workflow to provide the interventions in less than 1 minute. This workflow was taught in the classes. A scope of practice concern voiced by the nurses identified the need for specific orders for the resuscitation protocol. To standardize the nurse-driven protocol, orders to implement the early interventions were embedded in cardiac surgery order sets.
Potential barriers to implementation identified by the nurses included a lack of knowledge and the complexity of knowing when to perform either ACLS or the ERC protocol. To address lack of knowledge, the advanced practice RNs (APRNs) leading the project taught several courses to ensure adequate education for the nurses, providers, and resuscitation team members. Courses utilized lecture, skill stations, and patient scenarios to teach the resuscitation protocol. To address the need to perform 2 resuscitation protocols, posters of the protocol were placed in patient rooms as well as signage regarding activation of the code team. The visual cues were suggested by nursing and providers on the code team to help them quickly identify which resuscitation protocol was needed, either ACLS or ERC. Implementation of mock codes, rounding by the APRNs, and debriefings contributed to the sustainability of the practice change.
Planning and implementation of the project took approximately 18 months. There were many aspects of the project to address to ensure a smooth implementation. The PRISM model16 was used to develop an evaluation method. Both process and outcome measures were identified for this pilot project. The authors felt it was important to assess process metrics as the outcome metrics were affected by multiple variables other than the resuscitation protocol. The process metrics measured were time to intervention and accuracy of the intervention. The primary outcome measures were incidence of arrest and survival to discharge.
The evaluation component of the PRISM model uses the RE-AIM framework: reach, effectiveness, adoption, implementation, and maintenance.17 Successful implementation was determined on the evaluation of reach, effectiveness, and implementation. Reach refers to the number of individuals willing and able to participate in an intervention.17 This project had 2 categories to assess for reach: 1) the target population of cardiac surgical patients suffering a resuscitation event in the cardiac ICU who should receive the new resuscitation protocol and 2) the number of cardiac ICU nurses who received the training for the protocol. To evaluate the reach of the practice change, the percentage of cardiac surgical patients who suffered a resuscitation event in the ICU and received the new resuscitation protocol during the 36-month data collection period (2016-2018) was calculated. The goal was 100%. Reach for the cardiac surgical patients was 93%. Reach was also assessed by calculating the percentage of ICU nurses who participated in the class. Of the nurses caring for cardiac surgical patients in the ICU, 100% were trained to the new protocol.
Effectiveness or efficacy refers to the impact an intervention has on important outcomes.17 The most important evaluation for a clinical practice change is effectiveness. Our goal was to improve survival to discharge and incidence of arrest. The data represent 36 months (2016-2018) for all cardiac surgical patients with a sternotomy. There were a total of 1059 patients with 60 resuscitation events and a survival to discharge of 73%. Prior to implementation of the resuscitation protocol, survival to discharge was an average of 45% (Table 2). The average incidence of arrest has been variable. There were other favorable outcomes that were unanticipated. The incidence of pulseless electrical activity arrest decreased from 47% to 8% from 2015 to 2018, and the need for chest compressions during the resuscitation event decreased from 82% to 20% in that same time period (Table 3).
Implementation refers to the nurse's compliance to the elements of the intervention protocol. Each resuscitation event was reviewed concurrently for accuracy and timeliness of the interventions provided. In summary, when the new resuscitation guideline was implemented, 98% of the time the correct intervention was delivered within the expected timeline of 60 seconds or less.
Discussion and Clinical Implications
Empowering nurses through a nurse-driven cardiac surgery resuscitation protocol increased survival to discharge and decreased the need for potentially harmful chest compressions. Ensuring nurses have the tools to implement a nurse-driven protocol such as equipment, orders, and knowledge is vital to success. Corporate, physician, nursing, and team endorsement was necessary to implement the protocol and for successful adoption and sustainability. Analysis of the process measure of time to intervention validated that nurses could intervene with the appropriate intervention in less than 1 minute. This also supported the necessity for the nurse-driven protocol without which timely intervention could not occur. Many nonacademic organizations do not have a CT surgeon present 24/7. The new evidence-based, nurse-driven protocol allowed a standardized response to be implemented by the nurses. Based on the results, it was determined the new resuscitation protocol would be continued in the cardiac ICU and expanded to the intermediate care unit as well as another hospital within the system.
There were several lessons learned during the implementation of this project. As we analyzed outcome data, it became clear that there were multiple variables affecting a patient's overall survival, not just the protocol for resuscitation. The current state of resuscitation science requires resuscitation protocols be evaluated based on survival to discharge for efficacy. This form of evaluation assumes all patients are rescuable from cardiac arrest, which is not the case. Based on the severity of illness, for some patients cardiac arrest is part of the trajectory of their illness, not a reversible complication. For these reasons, other data were analyzed such as incidence of particular events and need for chest compressions. This facilitated leadership's understanding that survival to discharge alone was not the only important outcome.
Each resuscitation event was evaluated, and debriefings were held after each emergency sternotomy. These were both very effective tools to identify issues or barriers the nurses faced. Some of the issues identified included calling the wrong code team, restocking of the emergency heart cart, role confusion, and unfamiliarity with equipment. This directed further steps to improve the processes. Charge nurses underwent additional training in order to successfully lead the team, a daily heart cart checklist was implemented to ensure equipment was stocked, and ongoing mock code training included heart surgery patient scenarios.
Recommendations based on this experience encompass 3 areas: data, organizational endorsement, and sustainability. The analysis of historical data and relating those data to the evidence-based protocol in the context of the organization are needed to determine if the intervention is appropriate for the specific patient population. Ongoing data collection is vital to determine compliance with the protocol, to maintain support from leadership, and to evaluate efficacy of the new intervention. Organizational endorsement can be difficult because of the multidisciplinary nature of resuscitation. It is key to the success of the project to engage key stakeholders early in the process and gain their support for the practice change. Enlisting both nursing and medical providers to review workflow and determine the necessary changes to implement the new protocol is important. Sustainability requires continued effort of the key clinical experts. Debriefing or reviewing each resuscitation event provides the opportunity to identify issues or barriers and the opportunity to continually improve the process. Ongoing education and training are necessary and can be accomplished through mock codes on a biyearly basis. Routine reeducation should be planned for all members of the resuscitation team.
As APRNs, it is our responsibility to ensure our patients receive the most current evidence-based care in coordination with other team members. Implementation of a new resuscitation protocol is complex and requires a systematic process to engage the team and ensure all aspects of the new protocol are addressed. Using a systematic approach to change practice was effective in this setting and may be helpful for others as they implement new standards and protocols.
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