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Ineffective Compressions

Nurses   (952 Views 18 Comments)
by beekindRN beekindRN, ASN, RN (Member)

beekindRN is a ASN, RN and specializes in ICU.

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I participated in a code yesterday that was textbook. Everything went as expected, but the overall prognosis for the patient was extremely poor. This was her fourth (and seemingly endless) code in just a couple hours. 

My question is we had two nurses who were absolutely jackhammering their compressions. I thought it quietly but didn't say anything, as I'm a new nurse and didn't want to argue during a code and potentially compromise quality care. I also accepted that our efforts were most likely futile anyways. However, an aide who is in nursing school later pulled me aside and noted that these compressions seemed incorrect. She provided slow, deep compressions and even started she was humming "Stayin' Alive" to maintain a proper beat. She was berated briefly during the code by a nurse for performing "tired" compressions due to her "slow" rate, but I thought she allowed for complete chest recoil and maintained an even, appropriate rhythm. 

Next time, how do I address incorrect compressions professionally and appropriately? 

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hi. well i think its first important to nicely but assertively recommend someone else to do the compressions appropriately during the code because the main focus at that moment is to keep the patient alive. after the code, privately talk to the person and let them know. of course show sympathy and openness when telling them and dont make them feel like its their fault by saying "you you you." i hope that helps. 

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Silently count/time the compressions being delivered and then report the real-time rate out loud. "your rate is about 1xx; you're going just a little too fast."

However, regarding your observation of the aide, I've never seen adequate compressions that I would describe as "slow." Stayin' Alive is one of those cute little things someone figured out, but remember that in the absence of music playing there's really no reason think people will independently sing it to themselves at the recorded tempo.

There is a study that utilized the song/music, it had 15 participants. And they trained using the music. And they felt like it helped them later when they did compressions without the music.

Do you not use feedback pads or at least a metronome? These are way more effective than neat ideas, IME.

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beekindRN is a ASN, RN and specializes in ICU.

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1 hour ago, JKL33 said:

Silently count/time the compressions being delivered and then report the real-time rate out loud. "your rate is about 1xx; you're going just a little too fast."

However, regarding your observation of the aide, I've never seen adequate compressions that I would describe as "slow." Stayin' Alive is one of those cute little things someone figured out, but remember that in the absence of music playing there's really no reason think people will independently sing it to themselves at the recorded tempo.

There is a study that utilized the song/music, it had 15 participants. And they trained using the music. And they felt like it helped them later when they did compressions without the music.

Do you not use feedback pads or at least a metronome? These are way more effective than neat ideas, IME.

We do not have access to feedback pads, but are the process of introducing them at our facility. I thought the aide's compressions were well timed, as I was recording and literally watching the clock. Her compressions to me did not seem slow, but a couple other nurses said she was going much slower than everyone else and seemed tired. I love your recommendations on recording the time. Thank you!

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inthecosmos has 3 years experience as a BSN, RN and specializes in Varied.

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Feedback pads and mannequins have significantly improved my compressions. 

You could talk to your one-up (direct manager) and see if there's a way to best handle this.  I am candid with my manager regarding the responses to codes, which are sometimes lacking in my area.  We are a step-down unit and still have ACLS-certified nurses who are not consistent with their code response.

Our code team is pretty vicious, if someone isn't doing compressions correctly, it's immediately addressed.  If you're fearful of doing this, perhaps discussing it with your manager or clinical educator may assist.

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Crash_Cart has 11 years experience and specializes in ER OR LTC Code Blue Trauma Dog.

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During a code forget about "staying alive" and watch the cardiac monitor instead.

The cardiac monitor will give you the best visual feedback possible in terms of measuring the performance of your compressions.  

Ask me how I know this. 🙂

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Edited by Crash_Cart

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5 hours ago, beekindRN said:

I thought the aide's compressions were well timed, as I was recording and literally watching the clock. Her compressions to me did not seem slow, but a couple other nurses said she was going much slower than everyone else and seemed tired.

You described them as slow in the OP. If you actually timed them and know they were at an appropriate/recommended rate, that's perfect (and more objective than noting that someone is humming Stayin Alive - 😉🙂).

It comes down to participants doing their best and accepting feedback (even the questioning/clarifying and corrective types) professionally. They have no business being involved if they can't receive real-time feedback like an adult. And those offering feedback also just deliver it in a professional, straight-forward manner.

When the aide was critiqued, that would've been a good time to call out her rate as well, since you say you happened to have an idea what it was. Just announce it right out, as recorders announce things in codes: "Compression rate is about 105/min."

Announce the floggers' rates the same way: "Compression rate is about 140."

I hope these two didn't think they were in some kind of competition. Kind of sounds like it. It's so very unattractive when people use compressions as an opportunity to ??? I don't even know what their goal is...display some kind of CPR Extraordinaire prowess, I guess. 🙄 Woopdee-doo. Just do it correctly.

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11 hours ago, Crash_Cart said:

[...]

The cardiac monitor will give you the best visual feedback possible in terms of measuring the performance of your compressions.

Ask me how I know this. 

Do tell.  Other than rate, which is only one component, how does the cardiac monitor tell you anything at all about the "performance of your compressions."

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Crash_Cart has 11 years experience and specializes in ER OR LTC Code Blue Trauma Dog.

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12 hours ago, chare said:

Do tell.  Other than rate, which is only one component, how does the cardiac monitor tell you anything at all about the "performance of your compressions."

A cardiac monitor provides a direct measurement of your compression performance.

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Davey Do has 35 years experience and specializes in Psych, CD, HH, Admin, LTC, OR, ER, Med Surge.

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This is such a good discussion and it's nice to be able to relate to something that is medical in nature without me being  puzzled, scratching my head and saying, "Whaaa?"

And I learnt a few things, like about the cardiac monitor, the metronome, and feedback pads!

Years ago, WRMC didn't have CPR manikins with feedback for the practical portion of our BLS renewal. Instead, we had a rather elderly nurse educator who would call out directions like "Harder! Faster!"

One nurse complained that she felt like she was listening to the soundtrack from some geriatric porno flick.

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5 hours ago, Crash_Cart said:

A cardiac monitor provides a direct measurement of your compression performance.

How, exactly?  Please be specific, and provide credible source.

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adventure_rn is a BSN and specializes in NICU, PICU.

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Ooh, I love this topic (we've done a ton of QI projects about this in my unit).

During our compressions, as we cycle through 'compressors,' the job of the person who isn't actively compressing is to watch the monitor and give feedback about compression speed and depth.

Nearly all of our patients have arterial lines. From the a-line you can determine the rate and the depth/effectiveness/pulse generation. The rate as read on the a-line should give you the compression rate. You can assess the depth/intensity/recoil of the compressions by looking at the BP on your a-line. In a perfect code, the BP that you generate with your compressions should be equivalent to your ideal BP (120/80). If you're going to overboard, your a-line BP is going to be way higher. If you're getting tired, it's going to be lower. If you're not getting enough chest recoil, your pulse pressure is going to be super narrow. You can also figure out the rate from just the EKG (assuming they aren't in some crazy rhythm) or just the pulse-ox (assuming your compressions are generating enough force to give you a decent pulse), but they aren't as accurate and don't really tell you about blood pressure.

I thought it was amazing during my first code that I had somebody there telling me, "Ok, your rate is good, try to go a little deeper," or, "your blood pressures are starting to drop--are you getting tired or do you need to switch out?"

You ask how to address this--perhaps during a debrief after the code? We actually address it on my unit by doing a formal code review every month where we look over staff accounts (everybody involved fills out a QI survey) as well as minute-by-minute rhythm strips and vital signs. It's a great learning experience, which is how we implemented the compression feedback model I described.

My unit (pediatric cardiac) frequently codes kids who are fresh out of heart surgery with tons of suture lines all over their hearts. We did have issues with people getting overzealous doing compressions (especially on little infants whose BP should be 60/30) and had a few kids who hemorrhaged from busted cardiac suture lines. The way we addressed it was by implementing our monthly code review.

Edited by adventure_rn

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