Broad Topic Area
The topic of the Direct Practice Improvement (DPI) Project is the use of capnography during resuscitation in the Intensive Care Unit (ICU), with a focus on nurses’ adoption of this tool. The wellbeing of patients greatly depends on the information collected about them during their hospitalization. The process of resuscitation is complex, and it requires nurses to possess great knowledge of tools that can help guide it. Cardiac outputs of the patients in the ICU setting require investigation, opening up the question of how the unit can decrease mortality rates. This DPI Project intends to address the gap in the current literature, which shows that capnography has been considered for use during resuscitation, and its benefits have been shown. Nevertheless, as research indicates, nurses are often still hesitant to utilize this support in their procedures. Thus, the project aims to address nurses’ knowledge of capnography and their preparedness to apply this technique in the ICU setting.
Literature Review
Background of the Problem/Gap
Resuscitation is a challenging process that requires nurses to possess sufficient skills and respond quickly to any change in a patient’s condition. Resuscitation outcomes may be improved in a variety of ways, and the measurement of ETCO2 levels is a crucial step within this activity (Langhan, Shabanova, Li, Bernstein, & Shapiro, 2015). The return of spontaneous circulation (ROSC) during a heart attack may lead to fatal outcomes in different patients, including children, and it is essential for medical staff to employ accurate time management strategies (Bullock, Dodington, Donoghue, & Langhan, 2017; Kuisma et al., 2017). Capnography is one of the possible methods to measure the level of ETCO2 during resuscitation, but not many hospitals use it to improve patients’ outcomes.
Capnography has been used in clinical settings for over four decades. It was developed as a tool that helps monitor coronary perfusion pressure (CPP) and blood flow during anesthesia (Cereceda-Sánchez & Molina-Mula, 2017). However, this initial purpose is not the only one, where capnography has been found useful. In particular, the use of this tool for assistance during cardiopulmonary resuscitation (CPR) has been widely researched (Heradstveit & Heltne, 2014; Whitaker & Benson, 2016; Wright, 2017). The first evidence of studies looking at capnography during CPR shows was published in the 1970s, and the most recent findings were published only two years ago. Works by Turle, Sherren, Nicholson, Callaghan, and Shepherd (2015) and Sheak et al. (2015) shown that this tool could be a valuable addition to the practice. In the first works, the use of capnography was the main subject, considering its potential benefits for resuscitation outcomes and patient wellbeing.
Nevertheless, many nurses still express a level of uncertainty when discussing the use of capnography due to the potential lack of knowledge and reduced awareness (Leppink, O’Sullivan, & Winston, 2016). Thus, the question arises of whether the nurses’ knowledge of capnography affects the use of capnography in the described procedure. Some recent studies demonstrate the crucial role of educating nurses to introduce capnography on the management of cardiac arrest. Such authors as Dioso (2014), Duckworth (2017), Israel (2014), and Jaffe (2017) describe the training process and highlight the role of training in overcoming barriers about capnography use and meeting high standards of care quality. These investigations demonstrate that the gap in research has shifted from debating the benefits of capnography during CPR to the issue of the nurses’ role in applying this tool in a clinical setting.
Theoretical foundations/conceptual framework
For this DPI Project, Lewin’s change theory is chosen as the main theoretical foundation. The model was introduced by Kurt Lewin in the 1940s, and it is still considered one of the major change-related approaches in business and research. Lewin’s change theory is simple in its structure; it poses that every change project is conducted in three stages – unfreeze, change, and refreeze (Lewin, 1951). These steps are meant to prepare participants for change and help them to make the new additions or revisions to the system permanent. This theory was selected as its use is supported by a large number of healthcare research articles (Udod & Wagner, 2018). Its focus on employees as facilitators of change is crucial for this DPI Project that considers nurses’ use of capnography as the center of the investigation – it explains the connection between nurses’ knowledge, their adoption of capnography, and clinical uncertainty.
Review of the literature/themes
The following list of themes represents the summary of examined literature:
Cardiac Arrest and Cardiopulmonary Resuscitation: Cardiac arrest is characterized by high rates of mortality because of poor prognosis, and it leads to more than 1000 deaths per day in the United States (Pantazopoulos et al., 2015). Tobi and Amadasun (2015) use the following definition for this concept: “the cessation of cardiac mechanical activity confirmed by the absence of a detectable pulse, unresponsiveness, and apnea” (p. 132). Cardiopulmonary resuscitation (CPR) is a spontaneous and personal call, and the measurement of expired carbon dioxide (CO2) is recommended to lower the rate of negative outcomes (Kodali & Urman, 2014; Kuisma et al., 2017).
The Definition of Capnography: Capnography is defined as the promotion of ventilator function, which aims to measure exhaled CO2 partial pressure (Kiekkas, Stefanopoulos, Konstantinou, Bakalis, & Aretha, 2016). It is a non-invasive technique, and its use can help control the trend of ETCO2 partial pressure in addition to the readiness for making a final decision about implementing ROSC (Venkatesh & Keating, 2017). Capnography must be included within the available set of the device to monitor changes in patients within a short period of time.
Clinical Indicators of Capnography: Capnography implementation may be provided within the Intensive Care Unit or the Emergency Department. Capnography may be used to rescue patients when such factors, such as central vascular resistance, pulse pressure variation, blood pressure, heart rate, and the level of ETCO2, are evaluated (Kalmar et al., 2018). Although capnography is not the only method in detecting changes in ETCO2 or respiratory depression, this method is regarded as more effective and easier in comparison to other approaches such as pulse oximetry (Kiekkas et al., 2016).
Nursing Knowledge of Capnography in Resuscitation: The success of capnography depends on the level of knowledge about this technique nurses would possess in the implementation of the tool. Despite certain benefits of the chosen tool, the literature review proves that there are some gaps in understanding capnography and its benefits to patients and hospitals (Kiekkas et al., 2016). It is not enough for nurses to learn how to use capnography and measure the levels of ETCO2, they must also understand how to interpret the available readings and various waveforms (Kiekkas et al., 2016).
Outcomes of Capnography on Nurses and Patients:The quality of care and the level of knowledge nurses can gain are closely connected with the chosen theoretical guidelines and clinical experiences (Hassankhani, Aghdam, Rahmani, & Mohammadpoorfard, 2015). By learning how to interpret the results of capnography, nurses also increase their ability to predict and guide the cases of resuscitation in different care units (Pantazopoulos et al., 2015). The outcomes of using capnography are invaluable for this DPI Project, as they are an indicator of successful change.
Problem Statement
It is not known to what degree the implementation of an evidence-based intervention for the use of capnography at an acute care hospital in the Northeastern U.S. would impact the rate of use of capnography use during CPR, when compared to current practice among adult ICU patients undergoing cardiopulmonary resuscitation in the ICU over a four week period. The research discussed in the literature review shows the crucial role capnography can play in the outcome of resuscitation (Hassankhani et al., 2015; Kiekkas et al., 2016). It also demonstrated that the lack of awareness about this tool among nurses, which is likely to impact their preparedness to employ capnography during CPR (Hassankhani et al., 2015). It is vital to address this problem and see whether a change project positively influences nurses’ actions as well as patient outcomes related to cardiac arrest and resuscitation.
Clinical Questions, Hypotheses, and Variables
The central clinical question that guides this project is: To what degree does implementation of an evidence-based intervention on use of capnography during cardiopulmonary resuscitation, lead to increased use of capnography during cardiopulmonary resuscitation when compared to current practice, among adult ICU patients in an acute care hospital setting in the Northeastern U.S within a four week period?
Sample (and Location)
- Location: Northeastern U.S. hospital
- Population adult ICU patients and nurses in an acute care hospital setting in the Northeastern U.S.?
- Sample: 60-100 patients.
Patients who experienced cardiac arrest and underwent cardiopulmonary resuscitation (with and without the use of capnography) in the ICU.
Exclusion Criteria
- Pediatric patients (under 18 years old).
- Patients who underwent resuscitation outside of the project’s period.
- Patients who underwent resuscitation outside of the ICU.
Variables
Independent variable – implementation of an evidence-based intervention on the use of capnography during cardiopulmonary resuscitation.
Dependent variable – number of cases of cardiopulmonary resuscitation where capnography is used.
The use of capnography during cardiopulmonary resuscitation means the application of capnography techniques to track patients’ ETCO2 levels during CPR (Pantazopoulos et al., 2015). This variable will be documented using the EHR data from the facility. Nurses’ adoption of the tool depends on their awareness about capnography techniques and benefits, as well as their competence with regards to technical equipment use and ETCO2 levels interpretation (Pantazopoulos et al., 2015). Thus, the implementation of the intervention is considered the main independent variable which should influence the nurses’ use of capnography.
Methodology and Design
The chosen methodology for the project is quantitative, and the DPI project will employ a quasi-experimental design. This design is selected because it will allow the investigator to assess the unit’s outcomes and nurses’ knowledge before and after the intervention. This is consistent with the clinical question that aims to show the effect of a change project – the data from two points in time will show improvements and answer the clinical question. The sample will include patients who had cardiac arrest and underwent resuscitation in the ICU during the project’s period.
Purpose Statement
The purpose of this quantitative, quasi-experimental project is to determine to what degree the implementation of capnography during cardiopulmonary resuscitation (CPR) when compared to the current practice would increase the use of capnography during CPR for adult ICU patients at an acute care hospital in the Northeastern United States. The chosen quantiative methodology will result in a data set that can be presented for further investigation. This project will contribute knowledge about nurses’ use of capnography and their preparedness to apply this tool during CPR in the ICU. The results of the project will provide additional support for the use of capnography and show whether change projects are effective in increasing the use of capnography. Moreover, they will add data about patient outcomes in the discussed conditions.
Data Collection Approach
The main data collection method that will be used for the project is the Nurses’ Knowledge on Capnography Test (Kiekkas et al., 2016; Nelson, 2018). The chosen tool is validated by researchers, and it has been used in similar projects prior to this one (Kiekkas et al., 2016). The NKCT will be applied in a controlled environment to determine the participating nurses’ level of knowledge in relation to capnography. Apart from that, data about instances of capnography and patient outcomes will be gathered from the EHR. Data about capnography use will focus on the fact of using capnography during resuscitation. Moreover, the facility will provide demographic information about patients, such as their age, gender, and ethnicity. No contact with patients will be made as the facility will provide aggregate data from their records.
Data Analysis Approach
The quality improvement project sample includes patients who experienced cardiac arrest and underwent resuscitation under investigation in the period considered in the project. Adult patients in the ICU will be considered for the quality improvement. The unit was chosen as stated in the clinical question, and the location (the Northeastern U.S. states) was selected due to the investigator’s outreach. The sample is expected to be around 60-100 patients, and the response rate will be 100% due to the fact that the data will be obtained from records. Nurses who take part in the project will receive structured surveys based on the Nurses’ Knowledge about Capnography Test (NKCT), and the investigator will also collect the hospital’s records about resuscitation and patient outcomes for comparison. Some information about the patients will be collected for basic descriptive statistics – age, gender, and ethnicity.
The proposed data collection methods will be first discussed with the participating hospital to ensure that the organization agrees to provide the requested data. Then, the procedures will be submitted for the IRB review. The patient’s and nurses’ data will be anonymized to avoid privacy concerns.
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