NEW YORK NURSE: September 2008
by Joely Johnson
A nursing home resident is making her way down a hall using a walker. In an instant, she collapses to the floor, a victim of sudden cardiac arrest (SCA). SCA is often associated with ventricular fibrillation, an abnormal quivering rhythm that makes the heart unable to pump blood properly. The traditional emergency response would be to begin cardiopulmonary resuscitation (CPR) in hope of keeping the resident alive until she could be taken to a hospital. Today, automated external defibrillators (AEDs) offer an additional emergency treatment. AEDs are FDA-approved portable devices that can shock an unsteady heart back into beating normally.
Used in combination with CPR, these devices can greatly increase survival rates when they are readily available in places where SCA tends to occur. According to New York State law, health clubs, places of public assembly, and public schools with more than 1,000 people must have an AED on the premises.
Currently only the five boroughs of New York City are legally required to have defibrillators in long-term care facilities. Although nursing homes in other locations are not obliged to have an AED on hand, many do. “Some facilities, however, are waiting to spend the money until it becomes a mandate,” said Sam Zuckerman, president of Be Safe, Inc., an emergency preparedness training company and AED distributor.
Simply having one AED on-site is not enough – particularly if the long-term care facility is a large one. The American Heart Association recommends that an AED be placed within three minutes of reaching any patient. The state echoes this general recommendation. If you work in a 10-story nursing home, however, one AED unit located on the fifth floor will not be sufficient to meet this recommendation for all of your residents.
Accessibility also means the AED is available around the clock – despite the fact that they cost $800 to $2,000, depending on the model. Securing your defibrillator in the nursing office may protect it from curious residents or deter potential theft, but it will be rendered useless during the night shift. “By law, AEDs must not be locked up,” said Zuckerman. The units can instead be stored in cabinets that sound an alarm when the door is open. This serves two purposes: First, others who hear the alarm will know the AED is being moved. And, if a nurse who is alone on a floor accesses the defibrillator during an emergency, leaving the door open allows the alarm to act as a summons for help. Defibrillator cabinets can also be hardwired to call the facility’s security office or local emergency number.
New York City regulations stipulate that nursing home personnel must be trained to use an AED, including CPR certification. And although Zuckerman says, “if you can find the button, you can use the machine,” specialized training guarantees that nurses will know how to use the particular machine located at their facility. “People can get confused by the different AED models out there,” he said. Providing AED training every few months also insures that all staff members will be aware of the exact location of the devices.
As of September 2007, easily visible signage is required to promote AED awareness and ensure accessibility. New York’s Public Access Defibrillator (PAD) program means that anyone trained in CPR has the right to use an AED in an emergency. Generally one sign is placed at the main entrance of a facility, stating a defibrillator is available and noting the location. Other signs should be placed throughout the building and a three-dimensional sign, legible from either end of the room or hallway, should be located above the AED cabinet or storage spot.
Defibrillator units are battery-operated and normally require little to no servicing. Batteries and gel-containing electrode pads should have a shelf life of two to three years, depending on the model. A frequent maintenance program is still very important, according to Zuckerman. Simply put, if the batteries are dead or the electrodes have corroded, the unit will be of no help.
"Like checking a code cart, a nurse should be assigned to note that the green charge indicator light is illuminated during each shift and that the expiration date has not been reached." In one facility, Zuckerman said, staff members actually removed the batteries from an AED unit to stop a periodic beeping sound – which was the signal that the unit was no longer charged and needed servicing. For reasons like this, it's wise to have an extra battery on hand.
In a long-term care facility, it is likely that a number of residents will have do not resuscitate (DNR) orders, prohibiting the use of a defibrillator in the event of cardiac arrest. When an AED is available, it’s especially important to know which patients have a DNR – and which do not. Not providing necessary defibrillation can result in a loss of licensure. You may want to suggest a review of how patients with a DNR are identified in your facility: Consider requiring easily identified color-coded bracelets or creating a simple and accessible photo book of patients and their DNR status.