Now able to intervene within seconds, intensive care nurses at UCHealth are preventing more cardiac arrests in heart surgery patients.
What’s the contributing factor?
UCHealth Medical Center of the Rockies’ adoption of Cardiac Surgery Unit-Advanced Life Support (CSU-ALS) protocol, which was only recently published and accepted in the United States.
“CSU-ALS enables nurses to administer a targeted treatment quicker,” said Melanie Roberts, a clinical nurse specialist for critical care at MCR. “Nurses are doing the right thing in seconds for the best outcomes.”
Work earns Magnet Nurse of the Year
In October 2017, Roberts was awarded 2017 National Magnet Nurse of the Year in empirical outcomes by the American Nurses Credentialing Center for her work in implementing CSU-ALS at UCHealth.
“This protocol and redesigned workflow allows nurses to take action within the 15 to 20 seconds that will prevent cardiac arrest in these patients,” she said.
Traditional life support methods (Advanced Cardiac Life Support or ACLS) — usually begin with chest compressions — don’t make sense for cardiac surgery patients, who are in an ICU where other life-saving interventions are immediately available.
These interventions, such as a pacemakers and defibrillators, may prevent the need for CPR and, in many cases, stop a full cardiac arrest from occurring, Roberts added.
In 2015, the year prior to CSU-ALS implementation at MCR, 73 percent of cardiac surgical patients who required resuscitation in the cardiac ICU needed chest compressions, whereas in 2016, the year after CSU-ALS became protocol, only 32 percent needed chest compressions, according to MCR data.
It’s evident that early intervention is key, Roberts said.
Then and now
Before the protocol, a patient who showed signs of cardiac arrest received CPR from a nurse until the pacemaker or defibrillator arrived. Now CSU-ALS gives nurses the tools and training to intervene immediately before the doctor gets there. The CSU-ALS protocol has unique interventions and calls on a special “cardiac surgery code team.” Measures include using temporary pacing wires or already-attached defibrillation pads, employing different standards for CPR depth, and even opening up the chest to get to the heart.
“We have to intervene immediately if we are going to prevent cardiac arrest,” Roberts said.
In the first year the CSU-ALS protocol was implemented, the percentage of patients who went into cardiac arrest decreased from 2.67 to 1.6 percent.
“Now nurses hook the patient up to a pacemaker and have defibrillators outside the room to use to restore the heart rhythm faster,” Roberts said. “Chest compressions help get a pulse back, but we don’t want to use chest compressions if we don’t have to.”
Patients who have undergone complex cardiac surgical procedures, such as open-heart surgery, have unique hemodynamics, she said. Compressions from CPR can cause serious issues, and ACLS-recommended medication has the potential to cause bleeding in these patients. ACLS guidelines don’t address this specific group, but CSU-ALS does.
CSU-ALS was developed in Europe in 2009 and approved by the European Resuscitation Council. But it was only recently that the Society of Thoracic Surgeons in the United States endorsed the guidelines.
Roberts presented CSU-ALS and UCHealth’s findings at the 2017 ANCC National Magnet Conference in Houston, Texas, in October. The Magnet Recognition Program, and its hospital designation, is a leading indicator of an organization focused on quality patient care, nursing excellence and innovations in professional nursing practice, according to its website. Its national conference is attended by more than 9,000 nurses and nursing executives, representing more than 20 countries.
“Many asked how I was able to do it here when the protocol was so new to the U.S. and such a complex practice change,” Roberts said.
Roberts shared her strategies, which included help from Susan Miller, a cardiovascular surgery nurse practitioner at MCR.
Roberts and Miller introduced the protocol to MCR management in 2014, presenting research that validated benefits for patients. They soon received the support of cardiothoracic surgeons, quality and code committees and senior leadership. Both nurses attended a CSU-ALS conference in 2014 and instructor training in 2015, becoming two of the first health care professionals in the United States certified to train others in CSU-ALS.
Then in 2016, Miller and Roberts trained more than 60 nurses and other members of the ICU cardiac team in CSU-ALS, and held monthly mock trainings to keep their skills sharp.
“Nurses embraced this new protocol once they proved to themselves they could do it,” Roberts said. “There is a strong positive reinforcement with CSU-ALS because when it’s needed, they see right away that it works.”
Roberts and her team continue to track and record data on CSU-ALS because there is limited published data on its use in the U.S., she said. She said UCHealth plans to implement it system-wide.
Roberts hopes that her recent recognition by Magnet will add momentum to CSU-ALS implementations, not only at UCHealth but across the country.
“We work really hard to be a Magnet-designated hospital,” Roberts said. “And it pushes us to do these types of projects and implement these innovative practices that empower our nurses and benefit our patients.”
Along with MCR, UCHealth Poudre Valley Hospital and UCHealth University of Colorado Hospital are Magnet-designated hospitals.