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Out-of-hospital cardiac arrests: how primary care staff can improve outcomes

cardiac arrest


A practice nurse is more than capable of managing a cardiac arrest at least until paramedics arrive.

Dealing with an out-of-hospital cardiac arrests can be traumatic for staff. Elaine Francis, a registered nurse with 10 years of cardiology experience, highlights the critical role of a practice nurse as a highly skilled first responder, including the challenges involved, and describes how practices can contribute to the better distribution and uptake of defibrillators in the community.

The first few minutes after a cardiac arrest are crucial – out-of-hospital cardiac arrests (OHCAs) have historically poor survival rates in the UK, with around 8% of people achieving hospital discharge after an OHCA. The UK does not perform as well as comparable nations1 but education and public-access defibrillation have improved results significantly. Survival rates are four times higher with early public-access defibrillation.2

However, OHCA outcomes dipped during 2020.3 It is not clear whether this was a direct result of Covid infection, fewer people present to begin treatment, or a natural reluctance of bystanders to begin potentially aerosol-generating compressions during a viral pandemic.4 It remains to be seen whether bystander CPR returns to a positive trend as and when the pandemic recedes.

OHCAs that occur in primary care have significantly better outcomes than those taking place in other non-acute settings.

Cardiac arrest in primary care

Primary care professionals are no strangers to emergency situations. GP practices have frequent contact with patients who have multiple comorbidities and who are therefore at relatively high risk of an acute medical emergency. Practices also see people with serious acute problems who have been unwilling to attend emergency care settings – such patients are also likely to be at an elevated risk of an acute event.5 In addition, patients living with long Covid may be at higher risk and display cardiac symptoms.

The occurrence of out-of-hospital cardiac arrests (OHCA) during primary care visits is, however,  relatively low.6,7 Nevertheless, due to the vital importance of swift action, staff should be trained to respond and lifesaving equipment should be readily accessible.

OHCAs in GP practices have better outcomes than those elsewhere8 – just the presence of a GP improves survival rates.9 Practice nurses are in a similar position – a highly skilled immediate first responder able rapidly to deploy an automated external defibrillator (AED) offers the best chance of identifying a shockable rhythm.10

The practice nurse in a cardiac arrest

Nurses’ learning styles are overwhelmingly practical and exposure-driven11, and life-support skills wane naturally with lack of practice.12 Cardiac arrests can be traumatic for staff13, especially if they feel the required skills are not well honed.

As a minimum, nurses experience basic life support training throughout pre-registration education and every year of their career. However, an emergency, time-critical cardiac arrest can be physically and emotionally punishing to all responders.

A practice nurse’s primary role in such situations is to improve the patient’s chances of recovery. Although a cardiac arrest is a naturally high-stress situation, the role of any trained attendant is to follow a protocol that has been learned and practised regularly. But a practice nurse will also be crucial in managing the actions and emotions of others present during the emergency. 

Managing a cardiac arrest: role of the practice nurse

A practice nurse is more than capable of managing a cardiac arrest at least until paramedics arrive. A nurse can recognise an arrest and begin appropriate treatment, including ensuring more help is on its way.

An effective intervention also involves assessing and realising the limitations of the situation, including making best use of the skills of the other staff present. A nurse attached to a practice is in the perfect position to coordinate the staff – knowing, for example, who can take over chest compressions, who can attach and use an AED, who can make a calm and efficient phone call to emergency services, and who can usher other patients to a safe place.

Defibrillation is often something people feel unsure about carrying out, but AEDs are designed for anyone to use. They have basic diagrams, voice prompts and safeguards, and they are meant for the general public. By virtue of working in a surgery and dealing with unwell members of the public, every member of staff at a GP practice should be confident to initiate their use, although clearly regular training refreshers will help.

If early arrest management is successful and the patient has return of spontaneous circulation, early post-arrest care is second nature to nurses. Monitoring vital signs, blood sugars, maintaining a patient’s dignity and stress levels are the very essence of nursing practice.

Increasing the use of AEDs

The NHS shift towards integrated care systems, giving more control to local health and social care providers, local councils and other authorities, offers the chance to improve access to defibrillators.

Devolved control to those who understand the needs of their community has coincided with the addition of compulsory CPR training to secondary school curriculum across most of the UK. More people than ever before can be given the confidence and competence to offer immediate, life-saving support in those critical first few minutes of a cardiac arrest.

How surgeries can promote AED access

GP surgeries and clinics are well placed to recommend and support optimum local availability of AEDs. Decisions on where best to site the defibrillators will always benefit from local knowledge – who better than regional primary care professionals to assess population density, demographic risk, and accessibility?14 A vital consideration is the ability of the public to access and use them. Rural and hard-to-reach areas may have a low population and lower-risk demographic, but are likely to be further from any emergency responders.

Resuscitation Council UK’s quality standards recommend that all practices have an AED, and basic life support is usually the minimum level of first aid training for anyone in a clinical role in any setting. The location of the AED within a practice is also essential – time is of the essence, so easy access to vital equipment is critical.

This recommendation of a single in-house AED is a basic one, but the central role of GP practices in a community allows deeper involvement. A practice is a beacon of face-to-face care and support for its neighbourhood and everyone knows their nearest surgery. With that in mind, and considering that GP surgeries have specific opening times, perhaps practices are the ideal location for an external wall-mounted AED in addition to their in-house facilities.

The future of OHCA response

An Irish pilot programme that sent text alerts to GP volunteers to cardiac arrests in their vicinity has successfully increased rapid attendance of competent first responders to OHCAs.15 Rolling this out to other trained volunteers could further improve patient outcomes, since rapid, effective compressions and early defibrillation are key to survival and preserved function.17

Another model of OHCA response, trialled in Singapore, uses mobile technology. Trained first responders have an app that alerts them to OHCAs in their vicinity and the locations of AEDs18; off-duty primary care nurses could be valuable as voluntary first responders, improving outcomes and care in their community.

To complete relevant cardiovascular CPD modules for nurses, click here.

References

1. National Confidential Enquiry into Patient Outcome and Death. Time Matters. London: NCEPOD, 2021.

2. Bækgaard J et al. Use of public defibrillators linked to out-of-hospital cardiac arrest survival. Circulation 2017;136:954–965.

3 Scquizzato T et al. Effects of COVID-19 pandemic on out-of-hospital cardiac arrests: A systematic review. Resuscitation. 2020;157:241-247.

4 Mahase E and Kmietowicz Z. Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest. BMJ 2020;368:m1282.

5. Taber J et al. Why do people avoid medical care? A qualitative study using national data. J Gen Intern Med 2015;30:290-297.

6. Rashford S. Adult cardiac arrest in general practice. Aust Fam Physician. 2002 Sep;31(9):796-801.

7. Mitchell O et al. Out-of-hospital Cardiac Arrest in the Outpatient Clinical Environment. Circulation 2020;142:A243.

8. Bury, G et al. (2009). Cardiac arrest in Irish general practice: an observational study from 426 general practices. Resuscitation 2009;80:1244-1247.

9. Barry, T and Bury, G. Cardiac arrest resuscitation and its relevance to general practice. BJGP 2019;69;481-482.

10. Haskins B et al. Cardiac arrests in general practice clinics or witnessed by emergency medical services: a 20‐year retrospective study. Med J Aust. June 2021. Online ahead of print.

11. Mangold K et al. Learning Style Preferences of Practising Nurses. J Nurses Prof Dev. 2018;34:212-218.

12. Murphy M and Fitzsimons D. Does attendance at an immediate life support course influence nurses’ skill deployment during cardiac arrest? Resuscitation. 2004;62(1):49-54.

13. Spencer S et al. The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practices. Resuscitation 2019;142:175-81.

14. Chan, Timothy CY et al. Optimizing the deployment of public access defibrillators. Management Science 2016;62:3617-3635.

15. Barry T et al. General practice and cardiac arrest community first response in Ireland. Resuscitation Plus 2021;6:100127.

16. Kudenchuk P et al. Treatment and outcome of out-of-hospital cardiac arrest in outpatient health care facilities. Resuscitation. 2015;97:97-102.

17. Ming Ng W et al. myResponder Smartphone Application to Crowdsource Basic Life Support for Out-of-Hospital Cardiac Arrest: The Singapore Experience. Prehosp Emerg Care. 2021;25:388-396.