Emergency Medicine Uganda: THE FIRST 5 MINUTES: Resuscitation strategies in a children’s hospital for better outcomes

THE FIRST 5 MINUTES:

Resuscitation strategies in a children’s hospital for better outcomes

……………….Uganda with scarce expert human resource. We realized we can get a nurse to the patients’ bedside in 5 seconds, whereas it may take 5 minutes or more to get a doctor ……………… So it is imperative that they are competent enough to initiate appropriate management …………………

The dream of many a health worker-in-training seems stereotyped – fast paced, adrenaline-full, life-on-the-edge moments where the life of another is in your hands, big or small though they may be. Here your knowledge and skill comes to the fore and oh how good you are at this. Knowing that one wrong move and they are gone, one great heroic decision and you pulled this life back from the ever welcoming clutches of death and his mate, the grave! It all makes for a greatly significant contribution to the lives of mankind and you are right in the middle of it. Of course, we are always the heroes and everyone looks with great admiration like it is the famous Hercules riding back home triumphantly from one of those fierce battles and subsequent great Greek victories that required the supernatural to intervene.

Reality is somewhat different, I found; Okay, majorly different: Knowledge chooses this exact moment to desert you and your hands somehow lose that fine-motor skill they seemed to be good at just a few hours ago. Sometimes it is a shouting and/or screaming match, other times it is a frenetic running around – not knowing where many things are – the mask, ambubag, laryngoscope blade, defibrillator or the inability to get a team together to save this life for a myriad of reasons.

And then there are those times when it is just not clear what it is we are doing – we may shock asystole/PEA or fail to shock VF (ventricular fibrillation). Just sometimes, one or two of us in the team may run away from the sight of that defibrillator (yes we do get scared sometimes after all it shocks the patients and if used improperly, the user/resuscitator too). Well, the defibrillator may have stopped working or UMEME chose this moment to load shed and we are unable to start the backup generator (okay this is because there is no fuel).

Or worse still, epinephrine is out of stock, and amiodarone has not been stocked in the last 6 months (we had other priorities; it has nothing to do with poor planning!).

Many things can go wrong, and one of the key determinants of a successful resuscitation is the competencies (knowledge, skill and attitude) of the resuscitation team. Survival from any emergency (life threatening illness) is dependent on a well-oiled team that knows what and when to do what needs to be done. The team is well-prepared and mostly ready for any eventualities like a Formula One servicing team. Training in life support courses i.e. basic and advanced life support will give these teams the knowledge they need to be able to perform appropriately¹. Additionally odds of survival from a cardiac arrest seem to increase if the health worker who discovered the patient is actually trained in Life Support².

Unfortunately, these skills suffer significant attrition a few weeks after training³ and thus the care that is usually offered to those patients who have “coded” (had a cardiopulmonary arrest) is laden with many worrying problems – delays and deviations from recommended guidelines⁴. We start compressions late (say 1.5 minutes after this was indicated) or request defibrillators late (4.3 minutes after defibrillation was needed). As Hunt et al. (2008) state, “future educational and organizational interventions should focus on improving the quality of care that is delivered during the first 5 minutes of resuscitation, emphasize BLS and early defibrillation”.

Life Support Training to Improve In-Hospital Cardiac Arrest Survival:

With this in mind, it therefore makes sense, that the team that would be instrumental in improving in-hospital survival from cardiopulmonary arrest is the nursing team, especially in the context of Uganda with scarce expert human resource. We realized we can get a nurse to the patients’ bedside in 5 seconds, whereas it may take 5 minutes or more to get a doctor to the said patients’ bedside. So it is imperative that they are competent enough to initiate appropriate management for these patients teetering on the edge of life and death.

This therefore became part of the strategy at our hospital – to build a nursing team that can provide appropriate resuscitation care in the “first 5 minutes”, before the arrival of other members of the team.

Consequently, since 2008/2009 a requirement for continuing work at the hospital is a minimum certification in BLS (the American Heart Association’s Basic Life Support) and additionally mandatory PALS (Pediatric Advanced Life Support) certification for those who work in what we call ICU.

Also, attending mock code is a requirement – each of our nurses are required to attend at least one a month; where we will practice BLS, effective teamwork and communication, knowledge of AHA algorithms and management of common Ugandan illness and disease in a typical neurosurgical patient at our hospital and whatever is necessary to ensure that the first 5 minutes are clockwork effective.

How will this have helped?

Anecdotally, we can say the incidences of “the patient changed condition and died” are a “Never Event” and so are those deaths that seem to occur mostly in the middle of the night that make you ask the question “what happens in the night?” The team available is competent enough to keep these little children alive.

Additionally, we see the incidences of sudden, unplanned admission to ICU from the ward going down (I should have gotten numbers for this).

Besides, with this improved knowledge and skill, we find our nurses able to detect the deteriorating patient much earlier than the alert from a cardiac and/or respiratory arrest. That is the first link in the pediatric chain of survival i.e. prevention, is greatly enhanced.

So if you want to improve survival in your hospital – you may need to look at the first 5 minutes and you will see a nurse at the bedside. Improve their competencies to provide high quality and safe care and you just may see much better outcomes – almost guaranteed.

References

Grant, E. C., Marczinski, C. A. & Menon, K. 2007. Using Pediatric Advanced Life Support in pediatric residency training: does the curriculum need resuscitation? Pediatric critical care medicine. 8:433-439.
Dane, F. C., Russell-Lindgren, K. S., Parish, D. C., Durham, M. D. & Brown Jr. T. D. 2000. In-hospital resuscitation: association between ACLS training and survival to discharge. Resuscitation. 47:83-87.
Soar. J., Monsierus, G. K., Balance, J. H. W., Barelli, A., Biarent, D., Grief R., Handley A. J., Lockey, A. S. et al. 2010. European resuscitation council guidelines for resuscitation 2010. Section 9. Principles of education in resuscitation. Resuscitation. 81:1434-1444.
Hunt, E.A., Walker, A.R., Shaffner, D. H., Miller, M. R. and Pronovost, P. J. 2008. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. Pediatrics. 121 (1):e34-e43.