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Newsletters > NIHE Talks Health August 2010
NIHE Talks Health August 2010

Aug 5, 2010

*Look for the coupon in this newsletter good for 5% off any order. Good for any registration place till August 30, 2010.
Is Your AHA ACLS, PALS, BLS, or NRP due to expire or do you need the full Provider class? We have lots of NO STRESS classes throughout California everyday as well as, the only AHA online BLS, AHA online ACLS, and AHA online PALS that will get you an AHA card.
New locations opening in 2010. San Jose, CA and Sherman Oaks, CA, & Temecula, CA.
Upcoming ACLS, PALS, BLS, & NRP classes in: San Francisco, CA; Sacramento, CA; Loma Linda/Colton, CA, Torrance, CA, Fremont, CA; Walnut Creek, CA; Vacaville, CA; Culver City, CA; Pasadena, CA; San Jose, CA; Sherman Oaks, Ca; & Temecula, CA. Check out our website: www.nationalhearted.com for dates and times. Always get your AHA card the day you complete the class.
NEW ACLS & PALS Prep Courses Featured on our Website
If you need a little help preparing for your upcoming ACLS or PALS class check out our website, www.nationalhearted.com and click on the "Online CE" page for some great NEW ONLINE CE courses. ACLS Prep and PALS Prep cover how to identify the EKGs needed so that you can use the algorithms appropriately. They are great for not only preparing for your ACLS or PALS class but also, for follow-up to reinforce what you learn at the class. There are also, some great online courses about stroke.
Do you need even more help to prepare for your ACLS or PALS class?
If you want a text that covers not only what to do during a code, check out the ACLS In Depth and PALS In Depth Home study Courses available at www.nationalhearted.com . Get CE credit for being the best prepared student in the class. Also, available, buy just the textbook as a reference text: ACLS Study Guide and PALS Study Guide. These textbooks have all details on why as well as what to do during resuscitation. Go to our product page Buy Books and Products Now to buy the ACLS and PALS Study Guides and go to the Home Study CE to get the ACLS In Depth and PALS In Depth home study courses good for Nursing CE. CA Provider #13886.
Earn Extra Money in Your Spare Time as an AHA Instructor
Nurses, Paramedics, EMTs, & Respiratory Therapists—Become an American Heart Association Instructor and teach for us in your spare time or start your own business teaching AHA classes. It is easy to get started quickly and be qualified to start teaching AHA courses for us. If you decide to start your own business we will be happy to mentor and assist you to be successful. Call us at 909-824-0400 or go online to Become an AHA Instructor to get started making good money in your spare time today.
American Heart Association New Guidelines for 2010
AHA will publish their new guidelines for resuscitation for 2010 in October 2010 in their scientific journal. National Institute for Healthcare Education will include a summary of these for healthcare providers in the Fall 2010 edition of NIHE TALKS HEALTH newsletter. Don't miss out get your free subscription today at www.nationalhearted.com

This Month’s Featured Article on Health
Increasing Survival From In-Hospital Cardiac Arrest
The goal of this course is to identify the essential components of the rapid response team (RRT) and the theory behind their implementation. We will also, discuss the process of developing and implementing RRTs and ways to evaluate their performance. Upon completion of this course the student will be able to:
1.    Provide the rationale for RRTs.
2.   Discuss the steps to implement an RRT.
3.   Describe the methods to evaluate an RRT.
4.   Describe the composition of an RRT.

RRT Description
Most hospitalized patients who suffer cardiac arrest do not survive to discharge. Hospitals that have implemented an early identification of need and intervention program have reported an increase in survival rates. Medical emergency teams (METs) and Rapid Response Teams (RRTs) are the two most common terms for the teams that have been put together to implement this early intervention. In this course we will be discussing the RRTs. They are most commonly composed of a variety of disciplines usually including at least a critical care nurse, a respiratory therapist, and a physician.
The concept of the RRT is being implemented in various countries around the world, including but not limited to the United States, Australia, India, and Great Britain. In this course, we will look at the history of this concept, the evidence supporting the further implementation of RRTs, and discuss recent studies that have challenged the efficacy of RRTs. Also included, is a how-to guide that will allow a nurse to implement a RRT program that will best fit with her institution. Even though many hospitals now require all of their RNs to be ACLS certified, the RRT program offers essential support to the non-critical care nurse that does not participate in running a code very often.
According to the National Registry of Cardiopulmonary Resuscitation only 17% of in-hospital cardiac arrest patients survive to discharge. In many countries around the world, healthcare policymakers are attempting to institute changes that will increase this rate of survival. Historically, resuscitation/code teams have been activated by the patient’s nurse when the patient experiences cardiac or respiratory arrest.
Many studies have looked at which pre-arrest warning signs, when identified early by the patient’s caregivers and treated effectively, would increase survival rates. Often these warning signs were observed and documented, but not acted upon. Respiratory difficulty and neurologic and mental status deterioration are the most common of these signs. Researchers have also, investigated why the staff failed to intervene when they observed and documented this deterioration.
“Failure to rescue” is the term associated with this phenomenon. It is a grouping or constellation of events that frequently result in undesirable patient outcomes ending in cardiac arrest. Failure to rescue may be the result of an inexperienced nurse failing to identify the subtle signs and symptoms of deterioration. If this slide into cardiac arrest is not halted and reversed the patient may deteriorate to a point of crisis that may have been averted if identified early and treated. Communication breakdowns can also, result in failure to rescue. In one study that evaluated the quality of patient care prior to an unexpected ICU admission, one frequent cause was that the nurses did not recognize the clinical indicators that were predictive of pre-arrest conditions or if they did recognize them did not communicate them to the medical personnel.
In Australia and Great Britain in the mid 1990’s the concept of the MET was established. Later the Institute for Healthcare Improvement started its 100,000 lives campaign, with the RRT as one of its foundational principles. These teams vary in composition, but their goals is the same: early recognition of pre-arrest conditions and early intervention to reverse the treatable conditions. Many studies indicate that this has resulted in fewer cardiac arrests occurring outside the ICU and mortality rates have improved.
Early Australian studies looked at the effect of the MET concept on patient outcomes. They evaluated mortality rate, cardiac arrest rate, and length of hospital stay. Results varied somewhat, but there was a general trend of improved patient outcomes, particularly in surgical patients. Mortality improved but there were conflicting results in length of stay.
The largest study to date , the Medical Early Response Intervention and Therapy (MERIT) trial randomized 23 Australian hospitals to a MET intervention group or a group using a standardized approach, such as code blue, to patient emergency situations. The goal of the study was to determine whether MET reduced cardiac arrests and mortality rates. The MERIT research team postulated that the similar results from both groups (MET and the control group)might have been due to the control hospitals’ using a MET style of treatment even though they had not formalized it and called it that. Ultimately, this team of researchers questioned whether further study was needed as so many hospitals are using the MET approach whether they call it that or not, and so a control group would be difficult to form.
A post-hoc analysis published in 2009 identified a phenomenon of early emergency team calls that occurred during the MERIT trial. This analysis revealed that in all hospitals involved in the study, both control and study, there was a significant reduction in the rate of adverse events as the amount of early emergency calls increased. Adverse events were defined as unexpected cardiac deaths, overall cardiac arrests, and unexpected deaths.
The first International Conference on Medical Emergency Teams met in 2005. Experts on critical care, patient safety, hospital medicine, and METs came from around the world to analyze the data and define a systematic approach to reducing in-hospital cardiac arrests. At this conference the components of the rapid response system were defined as: an afferent component, an efferent component, a patient safety/process improvement component, and an administrative component. The afferent arm consists of recognizing a crisis by means of activation criteria (such as unstable vital signs) and calling in the RRT. The efferent arm is the rapid response by a team to deliver care to the patient prior to cardiac arrest. The patient safety arm is the evaluation process to gain insight into the problems in practice that allowed the patient to reach a crisis in the first place. It also, evaluates the effects of the response system on patient outcomes. The administrative arm refers to the hospital administration’s role in supporting the culture change to make RRT’s possible. While team design and labels may vary from one institution to the next, the key components of all early response teams are similar to the International Conference on Medical Emergency Team system.
Subsequently, the International Liaison Committee on Resuscitation (ILCOR) published their consensus statement giving guidelines for the analysis of rapid response systems. These guidelines include parameters for monitoring rapid response systems, reporting outcomes, and conducting research on rapid response systems. Standardized data collection tools were included for use globally so that outcome analysis would be standardized.
After the publication of the MERIT study data criticism of MET and RRT systems has occurred. Some researchers questioned the methodology of the MERIT trial and the interpretation of that data. One group of authors concluded after a systematic review of MET published studies that at best there is only weak evidence supporting METs. They recommended that further study be done using a large, randomized control group to determine if the cost of a MET team or a RRT was repaid with an increase in positive outcomes. Until this is done, this group concluded that the use of financial and staff resources would be better spent on other patient safety mechanisms.
Currently, the Joint Commission now requires that hospitals have in place a process to provide early detection of patient decline and treatment of that decline. Therefore, it is unlikely that the proposed large study including a randomized, large control group is not currently possible in the United States. The methodology of the single study mentioned previously, was different. This study was designed to evaluate care outside of the ICU and it did see a significant decrease in negative outcomes outside of the ICU.
Planning & Implementation
The first step to designing a RRT program for your institution is to review the literature and to identify problems with existing practice. Review the rates of cardiac arrest outside of your ICU and compare it to the rates at similar institutions with RRTs. Do the same with your rates for survival to discharge for post cardiac arrest patients. Once you have identified the need to improve cardiac arrest rate and to decrease mortality you can move on to the planning part of the process.
Decide what will be the makeup of your RRT and decide upon activation criteria. A typical RRT might include two or three of the following: ICU nurse, floor nurse, respiratory therapist, midlevel provider such as nurse practitioner or physician’s assistant, and an intensivist or anesthesiologist. Duties and responsibilities of the floor nursing staff and the RRT must be emphasized. Collaboration and communication between the two are essential to making this system work. Once the staff nurse identifies a patient concern she should communicate this to the charge nurse. They will collaborate and make a decision to call the RRT. The patient’s medical provider should be contacted just as they would without the RRT system in place.
The staff nurse should include the following in her report to the RRT: patient’s name and room number, current diagnosis, identified problem, vital signs, date of admission, past pertinent medical history, assessment findings such as LOC and lung sounds, resuscitation status, pertinent labs and medications, named assessment of the problem, and what interventions the nurse would like from the RRT and the medical provider.
Staff nursing responsibilities include: recognizing patient deterioration early, collaborating with the charge nurse, activating the RRT system and communicating the signs and symptoms of patient deterioration in a clear and concise manner, and contacting the patient’s medical provider and family. The RRTs responsibilities include: support and educate the floor nursing staff prior and during the event, assess and stabilize the patient, assist the floor nurse with communication, use critical care skills, and assist with transfer to a higher level of care if necessary.
As part of the initial planning process activation criteria for the RRT system must be decided upon. It is essential that data be collected ongoing and analyzed so that these criteria may be modified as necessary to maximize positive patient outcomes. After criteria are decided upon, they must be communicated to all the staff and ongoing education in these criteria is part of the RRT staff responsibilities. The most important activation criteria are: the patient’s nurse “feeling” that there is a subtle change or decline in the patient’s status. Other potential activation criteria may include: patient change in mental status, oxygenation less than 90% on supplemental oxygen, respiratory rate less than 8 or greater than 30, heart rate less than 40 or greater than 130, systolic blood pressure less than 90, acute bleeding, possible stroke, or seizures.
Once you have designed your RRT team, decided upon activation criteria, educated your staff and team as to their responsibilities and fully communicated all changes to all affected parties, you can begin to implement your RRT system. Ideally you should have a transition period with limited implementation to identify any flaws in your design. You may initially limit the service area to certain units of the hospital and you may also, limit by times of day or days of the week. Collect follow up reports from both the floor staff and the RRT team and analyze outcomes and make modifications to your RRT system design as needed. Increase your coverage as soon as possible as patient emergencies will occur in all parts of your hospital not just where you have implemented your system. The initial transition phase can end when you have your RRT system operating smoothly and enough staff has been trained to keep it operating.
The next step after full implementation is to continue to collect data on patient outcomes and compare the data from before RRT implementation to after RRT implementation. It is important to develop a tracking system that can be analyzed quickly. Data to be collected can include: number of cardiac arrests outside the ICU, hospital mortality, length of stay, length of stay after a cardiac arrest. It is also wise to include nursing staff outcomes such as staff satisfaction, staff retention, and nursing recruitment to increase nursing staff, especially floor nursing staff, compliance with the RRT system. Including key stakeholders such as the hospital medical director, the ICU medical director, and if applicable, the director of any medical residency program. If you have medical residents including them in the training, implementation, and debriefing as part of their ongoing training will benefit them and the RRT process. Plan to provide ongoing updates and refreshers for all your staff to increase efficiency in the RRT process.
Most studies indicate the implementation of the RRT system will benefit your hospital by reducing cardiac arrests outside of your ICU, shortening hospital stays, and decreasing mortality. The RRT system is one way to better utilize the financial and staffing resources in the hospital to increase positive patient outcomes. With careful planning and implementation the RRT system will save lives and increasing your nursing staff’s efficiency and morale.
1.    According to the National Registry of Cardiopulmonary only _____% patients survive to discharge after in-hospital cardiac arrest.
a.    5%
b.   12%
c.   17%
d.   23%
2.    METs were first established in:
a.    Great Britain
b.   Australia
c.   United States
d.   South Africa
3.    Some warning signs of imminent cardiac arrest may include:
a.    Respiratory rate less than 8
b.   Systolic blood pressure less than 90
c.   Seizures
d.   All of the above
4.    ILCOR stated in their consensus report that RRTs were too expensive and were not a good utilization of resources.
a.    True
b.   False
5.    The MERIT study was flawed according to some analysts due to the lack of a large randomized control group.
a.    True
b.   False
6.    The first step to developing an RRT system is to:
a.    Analyze need
b.   Identify team members
c.   Create an event analysis data collection tool
d.   Educate the nursing staff on the RRT process
7.    Initial implementation of the new RRT system should be limited in scope by time and area until flaws in the system can be worked out.
a.    True
b.   False
8.    An inexperienced nurse failing to identify the subtle signs of patient deterioration and thus act to halt a patient’s decline may result in an event called:
a.   Patient decline syndrome
b.   Nurse patient disconnect
c.   Patient compromise
d.   Failure to rescue
9.    Nursing outcomes should be included in RRT system analysis to increase nursing compliance.
a.    True
b.   False
10.   Including the hospital medical director and other senior hospital administrator’s in the RRT process is unnecessary and a waste of hospital staffing resources.
a.    True
b.   False
Increasing Survival for In-hospital Cardiac Arrest Patients Posttest
To get 2 hours CE (CA Provider #13886) for taking this course you must fill in the following and email it to pamela@nationalhearted.com You must get a score of 80% in order to pass.
RN License #_________________________________________
1.______ 2.______ 3.______ 4.______ 5.______ 6.______
7.______ 8.______ 9.______ 10.______

August Heart Healthy Recipes
Summer is here with all of its abundance. Let’s try some fast recipes so we can get out of the kitchen fast and get outside for some fun!

Fruit Smoothies
Banana sliced into small pieces
Handful of raw nuts
¼ tsp. Stevia
Berries ½ cup
1-2 cups ice
1 cup water
Place all ingredients in blender and blend till smooth. Makes 1-2 servings delicious smoothie. If you are unfamiliar with Stevia, it is a nature zero calorie sweetener you can find in your grocery store with the artificial sweeteners. It however, doesn’t stimulate your appetite like some artificial sweeteners do.

Pasta Stir Fry
Cook your favorite pasta aldente. Spaghetti, fettuccini, spirals, or whatever shape you like. Use a whole grain pasta for more nutrition and a lower glycemic index. While the pasta is cooking, chop and sauté one onion, two cloves of garlic, and one red bell pepper in 1 tsp olive oil. Add chopped broccoli, carrots, and mushrooms-one cup each and cover the pan and let steam with the onions and garlic for 8-10 minutes or until tender. Add cooked pasta and season with Bragg’s Aminos or soy sauce to taste. You can find Bragg’s Aminos at your health food store.
*The American Heart Association strongly promotes knowledge & proficiency in BLS, ACLS, & PALS & has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the American Heart Association. Any fees charged for such a course, except for a portion of fees needed for AHA course material, do not represent income to the Association.
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*The American Heart Association strongly promotes knowledge & proficiency in BLS, ACLS, & PALS & has developed instructional materials for this purpose.  Use of these materials in an educational course does not represent course sponsorship by the American Heart Association.  Any fees charged for such a course, except for a portion of fees needed for AHA course material, do not represent income to the Association.