Broad Topic Area
The topic area of this Direct Practice Involvement (DPI) Project includes any improvements that can be made in the coronary care unit (CCU) on the basis of capnography being one of the possible methods to monitor the well-being of patients. The process of resuscitation is complex, and medical staff members have to be prepared to take any necessary steps, as well as recognize the various scenarios of threat development. This DPI project helps to develop a framework that ensures control over the levels of end-tidal carbon dioxide (ETCO2) is possible. Cardiac outputs of patients in a CCU setting and decreased mortality rates have to be investigated. In addition, special attention should be paid to the level of awareness of capnography among nurses, and their readiness to apply this technique to the patients in the CCU.
Literature Review
Background of the Problem/Literature Gap
Nurses are responsible for monitoring and taking care of patients regardless of any individual’s condition, need, and expectations. A patient’s condition may worsen anytime, and nurses have to be ready to respond quickly and apply all the necessary standards and skills for resuscitation (Dioso, 2014). Resuscitation outcomes may be improved in a variety of ways, and the measurement of ETCO2levels 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. Although this tool helps to measure the coronary perfusion pressure (CPP) rate, there is a lack of opportunities to track the changes in the patient’s coronary blood flow and ETCO2levels (Hamrick et al., 2017; Pantazopoulos et al., 2015).
Therefore, it is necessary to investigate the peculiarities of the process of using capnography in order to create a sustainable environment for patients with cardiac arrests and be able to predict the worst possible outcomes.
Theoretical Foundations
Positive outcomes in understanding the process of resuscitation and the worth of capnography as the main monitoring tool can be achieved in terms of the application of two middle-range theories. The aim of the chosen theoretical approach is to combine the need for interdisciplinary communication and specific nursing skills, and understand the benefits and challenges of capnography.
The Conceptual Model of Nursing (CMN) is based on the idea of multidimensional analysis that includes the necessity to deal with a variety of tasks, also known as multi-tasking, and sustained prolonged monitoring (Lin, Guerguerian, Laussen, & Trbovich, 2015). The chosen framework allows to complete tasks at the necessary level, requiring conscious shifts in attention and defining the types of work that should be done: concurrent, dual, parallel, interleaved, or sequential (Yen et al., 2016).
The Middle Range Nursing Theory of Self-Efficacy (NTSE) promotes the idea of the development of competent relationships between nursing and medical staff members regarding two main components – self-efficacy expectations and outcome expectations (Smith & Liehr, 2018). This framework makes the researchers pay special attention to such aspects as care, education, competency, and the level of professionalism in order to predict behavioral outcomes (Smith & Liehr, 2018).
The combination of these two perspectives provides a good opportunity to study the significance of capnography during resuscitation in patients in the CCU setting from the point of view of coordinating nurses’ actions, controlling the available data, and decision-making. The chosen frameworks should help to improve the existing guidelines, cover the lack of nursing knowledge about capnography, and encourage compliance with hospital standards.
Review of Literature Topics with Key Concepts
Cardiac Arrest and Cardiopulmonary Resuscitation (The Lazarus Phenomenon)
Cardiac arrest is one of the most urgent emergencies in a CCU. It is characterized by high rates of mortality because of poor prognosis and 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). According to Kodali and Urman, Cardiopulmonary resuscitation (CPR) is a spontaneous and personal call that is required to be developed by nurses and other medical staff to deal with cardiac arrest.
Regardless of the fact that a number of advances are associated with CPR, the chances of survival are still only 10-20% of patients (Pantazopoulos et al., 2015). According to the existing resuscitation guidelines, chest compressions have to be delivered “at a rate of at least 100 min-1and a depth of at least 50 m” (Sheak et al., 2015).
Resuscitation is the method that promotes the ROSC (Mader, T. J., Coute, Kellogg, & Harrism, 2014), but if it occurs after CPR, the nurses use the term “the Lazarus phenomenon,” also known as autoresuscitation (Kuisma et al., 2017). It is important to follow clear and step-by-step guidelines to monitor this situation (10-minute monitoring is recommended before calling the time of death). To avoid the number of negative outcomes during CPR because of cardiac arrest, the measurement of expired carbon dioxide (CO2) is recommended (Kodali & Urman, 2014). Capnography is one of the available tools to complete this task.
Definition of Capnography
Capnography is defined as the promotion of ventilator function which aims to measure exhaled CO2partial pressure. The use of this method makes it possible to maintain the normal level of ETCO2,between 35 and 45 mmHg, and prevent its decrease to 10 mmHg or increase to more than 45 mmHg (Kiekkas, Stefanopoulos, Konstantinou, Bakalis, & Aretha, 2016).
Capnography has to be included within the available set of the device to monitor changes in patients in a short period of time. It is a non-invasive technique, and its use can help control the trend of ETCO2partial pressure in addition to the readiness for making a final decision about implementing ROSC (Venkatesh & Keating, 2017).
As well as cardiac problems, capnography can also be used as a method to control and predict hypoventilation that depends on such factors as respiratory drive and muscle tone (Lin et al., 2017). It is effective in measuring the stroke volume index and cardiac outcome as the main possible achievement (Kalmar et al., 2018). There are four main steps of capnography: “inspiratory baseline, expiratory upstroke, expiratory plateau, and inspiratory downstroke” (Kiekkas et al., 2016, p. 40).
Clinical Indicators of Capnography
Cardiopulmonary resuscitation is one of the main applications for capnography when the absence of cardiac outcome and the inability to stabilize the pulmonary blood flow are observed. This method of help may be offered to patients in the Intensive Care Unit or the Emergency Department.
Capnography may be used to rescue patients when such factors as central vascular resistance, pulse pressure variation, blood pressure, heart rate, and the level of ETCO2 are evaluated (Kalmar et al., 2018). According to Kiekkas et al. (2016), low values of ETCO2 may also be signs of hyperventilation or hyperthermia in patients. The evaluation of the arterial pressure and its analysis in terms of ETCO2 can also signal problems such as sepsis or partial obstruction of airways (Kiekkas et al., 2016).
The promotion of safety in patients is one of the major tasks for medical staff, and special attention is recommended to be paid to obese patients, those who have chronic pulmonary diseases, or who have survived abdominal operations (Kiekkas et al., 2016).
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).
Types of Capnography
The decision to use capnography depends on a variety of factors. This method may be classified into time and volume capnography, given the fact that CO2concentration may be plotted against time or expired volume (Kodali & Urman, 2014).
Volume capnography is based on using special equipment that records CO2 concentration in regards to the expired volume to estimate the dead space (Jaffe, 2016). Time capnography is a frequently used technique that is based on infrared technology to analyze CO2, its absorbing qualities, and concentration (Kodali & Urman, 2014). Time capnography can be of two types: side-stream (disposal tubing and a T-piece adapter that has to be placed between the breathing circuit and endotracheal tube) and main-stream (an adapter is placed between the breathing circuit and the endotracheal tube) (Kodali & Urman, 2014).
Side-stream cartographers are mostly used due to their advantage in helping even non-intubated patients, whilst main-stream capnography has to be applied immediately after endotracheal intubation (Liu, Poon, & Tsui, 2016). As a result, capnography should also be defined as clear evidence of the correct placement of an endotracheal tube and the possibility to avoid negative outcomes and deaths of patients who suffer cardiac arrest (Kodali & Urman, 2014).
Nursing Knowledge of Capnography
The success of capnography depends on the level of knowledge about this technique nurses, and other medical workers have. 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 capnographers and measure the levels of ETCO2, they must also understand how to interpret the available readings and various waveforms (Kiekkas et al., 2016). The lack of knowledge about capnography directly influences the quality of care that may be offered to a patient in a hospital. Ventilation and circulation are the processes that undergo considerable changes in situations where nurses fail to determine the changes in ETCO2 levels.
Some investigations show that the medical staff still face some problems in using cartographers because of the inability to have a clear explanation of why the level of ETCO2 is increased, and what may be done to improve the indicators (Hamrick et al., 2017). The quality of care and the level of knowledge nurses can gain closely connected with the chosen theoretical guidelines and clinical experiences (Hassankhani, Aghdam, Rahmani, & Mohammadpoorfard, 2015).
The goal of any DPI project is to improve nurses’ understanding of the matter and motivate them to develop and hone their best skills and traits. Hassankhani et al. (2015) recommend promoting self-efficacy as the major tool to increase learning motivation and underline the potential outcomes and expected results. Nurses have to want to improve their awareness about capnography because of the improvements that can be achieved in CCU settings.
Outcomes of Capnography on Nurses and Patients
Patients who have experienced cardiac arrest can receive high-quality care in the CCU in a short period of time. The rearrangement of the existing roles of nurses will be recommended. A multimodal approach to decision-medical in hospital settings should be promoted (Lui et al., 2016). Simultaneous usage of various technologies may considerably influence the patient status and increase the need for multimodal monitoring (Lin et al., 2015). Nurses will learn how to interpret the results of capnography and predict the cases of resuscitation in different care units (Pantazopoulos et al., 2015). Targets of intervention, as well as the types of capnography, are chosen with regard to available data and the history of diseases. The changes in ETCO2 levels are thoroughly controlled and predicted, leading to a significant decrease in lethal outcomes among patients with heart problems.
Summary
Cardiac arrests lead to increased cases when resuscitation is obligatory (Bullock et al., 2017). Resuscitation result in various unfavorable consequences for patients and nurses, including the decreased level of care, failure to read all important indicators, and even death. New tools have to be introduced and properly learned by the medical staff to improve the current situation.
Capnography is suggested as one of the possible additions to the already existing strategies that aim at addressing patients’ needs. Capnography makes it possible to control the changes in vital indicators.
The level of ETCO2 should be normalized and monitored among all inpatient hospitals. Nurses must improve their level of knowledge about this technique and be prepared to incorporate crucial improvements and innovations. In the CCU context, the re-organization of recent nurse duties and guidelines can be observed. The improvement of nurses’ skills and qualities is an expected outcome that results in the reduction of negative healthcare outcomes.
Problem Statement
While the analysis of the literature shows that capnography is a valuable technique in measuring the concentration of CO2, its implementation in the coronary care unit remains a poorly investigated issue despite its potential benefits such as the improvement of care quality and monitoring of patients’ well-being.
Clinical/PICO Questions
In the patients of a coronary care unit (P), how can the implementation of time cartographers (I) compare to non-use of this intervention (C) and influence the efficacy of a resuscitation process and the transition to ROSC (O)?
Sample
The collection of data for this DPI project depends on a properly defined sample. It is expected to identify clearly such aspects of work as the location of the setting, the population to work with, and the number of people to be involved in the research. At this moment, the following decisions are made:
Location: New Jersey;
Population: Two neighborhood cities which are characterized by an equal distance from the nearest primary care provider with a coronary care unit (with 15 beds in the unit and 109 beds in the whole hospital);
Sample: 80 participants will be included in the study to investigate the worth of capnography as the main method to control the level of ETCO2 during a period of six months. Ten registered nurses from the CCU will be staffed to promote the intervention.
Define Variables
There are two types of variables that will be used for this DPI project. On the one hand, there is one independent variable that should not be changed during the project. On the other hand, there are several dependent variables that have to be checked during and after the intervention.
Independent variable: a capnography tool.
Dependent variables: the recovery dynamics after cardiac arrests, the level of patient satisfaction about the quality of care, and the efficacy of ETCO2 level monitoring.
Methodology and Design
This project will be based on a quantitative methodology that is supported by a randomized controlled trial. This study design includes the participation of people who will be divided into two groups: experimental and control. It is expected that there will be a difference between the results obtained from the experimental group (the participants should undergo the intervention) and the control group (the participants do not receive the intervention). A qualitative process evaluation will be carried out in the chosen trial.
It should help to identify the peculiarities of the intervention (a capnography tool is applied) through a strong understanding of the chosen process and its progress within the frames of the trial. The peculiar feature of quantitative research methods in nursing research is the possibility to succeed in three different tasks. First, it is necessary to investigate the pre-trial achievements and study results (focusing on the results of the literature review). The second step is the analysis of the intervention process (introducing a capnography program to the chosen experimental group). Finally, the third step is the determination of the connection between the changes (the dynamics of the recovery process in CCU patients).
This experimental design has to be measured quantitatively, meaning that no new ideas and approaches are introduced. The task is to take the already known technique (capnography) and apply it to a certain group of people (CCU patients in one of the local hospitals). In the end, it is expected to receive accurate measurements of the ETCO2 levels in the patients with cardiac arrests and compare the results of their monitoring process in regard to the possibility of reducing the number of fatal outcomes and increase the quality of care. The latter can be defined through the level of satisfaction of patients who receive care during the intervention. In this project, a qualitative experimental research design should allow the researcher to prove the idea that capnography is characterized by positive effects on CCU patients.
Purpose Statement
The purpose of this qualitative research that is undertaken with a randomized controlled trial is to understand the possible efficacy of capnography to monitor resuscitation processes and promote the recovery dynamics among patients in the coronary care unit in New Jersey.
Data Collection Approach
The peculiar feature of the data collection approach in this project is the necessity to gather the material during the implementation of the intervention. Eighty patients will be divided into two groups. 40 of them will receive capnography as the main method to monitor the ETCO2levels. The other 40 patients will receive standard monitoring at the CCU setting.
The information about patients and their health conditions will be gathered from their cards after informed consent is obtained. The main inclusion criteria for patients are the diagnosis of cardiac arrest, hospitalization, and their presence in the CCU setting at the moment of the intervention. The exclusion criteria are rehabilitation, previously stated high levels of ETCO2, and the already survived Lazarus phenomenon.
Observation and monitoring are the chosen data collection methods in this study. Special portable capnography will be offered to the team to monitor any changes. An envelope with the final decision as to whether to use capnography or not is opened before the intervention, and the method of monitoring is followed. The primary outcome measure will include the status of patients (well-being) after the implementation of the intervention. The secondary outcome measure will be patient satisfaction with the technique and the level of knowledge of capnography among nurses.
The CCU staff should give their approval to check what they know about capnography before the intervention. Then, training on the interpretation of capnography must be received, and the NKCT will help to check the changes in nurse awareness of the technique. The nurses, who participate in this intervention, in their turn, will be obliged to take the Nurses’ Knowledge about Capnography Test (NKCT) to evaluate their level of knowledge (Kiekkas et al., 2016). This test should be taken before the intervention (pre-test) and after the intervention (post-test) so that the researcher can define the progress that is associated with the adoption of the technique.
Data Analysis Approach
The data analysis approach should be based on prior information about patients and the repeated measures design that is chosen for this trial. Eighty patients have to be observed fully, 100%, to detect the difference in their well-being. The data has to be entered into Excel, and the analysis will be developed using SPSS statistical software. All tests to compare the levels of ETCO2must be 2-sided with a specially identified p-value of <0.05 from the available patient characteristics and indicators. It is the only statistically significant factor in the study analysis. A Chi-square test will be used to indicate the main characteristics. Fifty percent of the nursing staff will be invited to monitor data as a part of a committee.
The goal of the data analysis is to test the idea that capnography is an effective tool to monitor significant factors of patients and to predict the development of a critical situation when ROSC will be inevitable. The level of nurses’ awareness of capnography and its effects on patients’ well-being will be analyzed using the results of the NKCT. A paired t-test can be appropriate to meet the goal of the study. Taking into consideration a small sample, a non-parametric approach will help to clarify the relationship between the variables. For example, the Wilcoxon signed-rank test will help to compare the outcomes among two related samples, match them, and identify the differences.
References
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