Nursing facilities in the United States must reevaluate their procedures for cardiopulmonary resuscitation (CPR) attempts, according to a medical director and author of a new review published in JAMDA.
Changes may be necessary in order to match current evidence and community standards, especially involving the use of automated external defibrillators (AEDs), according to Rebecca D. Elon, MD, MPH, CMD, of Johns Hopkins School of Medicine in Baltimore.
Elon, who also serves as chief medical officer at FutureCare Health and Management Corp., based in Towson, MD, reviewed data about CPR outcomes in older adults and nursing facility settings. She found that although AEDs have been the standard of care for out-of-hospital cardiac arrest response in community settings over 20 or more years, adoption of AEDs varies in nursing homes and the number of U.S. facilities with the devices is unknown.
Federal regulations do not require that all federally supported nursing facilities have the capacity to provide on-site automated external defibrillation as part of their basic life support (BLS) protocols. But the use of AEDs may make a difference within the few minutes available to successfully perform resuscitation before permanent brain damage and irreversible death occur, Elon wrote.
Provider hesitancy, lack of data
Yet evidence is lacking about the deployment and outcomes of AEDs in nursing facilities, and much of what is known comes from international studies, she noted. In addition, cost-effectiveness studies regarding the deployment of AEDs have not considered the unique circumstances of nursing facility settings and residents.
“Concern over negative outcomes of the procedure is a factor that may explain the hesitancy of many providers to expand nursing facility CPR capacity by adding AEDs,” she wrote.
That said, new CPR standards, including the introduction of AEDs, may be warranted in these settings, Elon added. Recent research has found improved outcomes in a limited cohort with witnessed cardiac arrests, early bystander CPR and an initial amenable rhythm, who were shocked with an AED before the arrival of emergency medical services personnel.
In addition, clinical staff in nursing homes already are required to undergo BLS/CPR training that includes the use of AEDs, and providing them with the tools to implement their knowledge may not pose an additional burden, she noted.
A risk management tool
When properly done, including the use of informed consent, providing AEDs for nursing facility staff to use in their BLS/CPR protocols “might prove to be an important quality improvement intervention and risk management tool for nursing facilities,” Elon proposed.
Changes to standard of care in U.S. nursing facilities is unlikely without regulatory intervention, but Elon recommended that nursing home medical directors who wish to promote evidence-based medicine should analyze and discuss the following for their facilities:
- the facility’s current processes for determining and documenting code status,
- processes and outcomes of its current BLS/CPR procedures,
- the community standard of care, and
- the needs and wishes of the population being served by the facility.
This can help to determine “whether the status quo is appropriate or whether facility processes and procedures might need to evolve to improve outcomes,” Elon wrote. “The efforts of individual medical directors and teams within individual facilities and companies have the potential to raise the bar of current practice for the benefit of those we serve.”
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