1. Roberts, Melanie DNP, RN-BC, CNS, CCNS, CCRN


In this month's Magnet(R) Perspectives column, Melanie Roberts, DNP, RN-BC, CNS, CCNS, CCRN, critical care clinical nurse specialist at Medical Center of the Rockies (MCR) and Poudre Valley Hospital, discusses her efforts to implement the state-ofthe-art European Resuscitation Council (ERC) guideline for resuscitation of cardiovascular (CV) surgery patients. Her evidence-based initiative has improved quality of care and mortality rates among the CV surgery population at MCR. Dr Roberts' pioneering work earned her the 2017 National Magnet Nurse of the Year Award for Empirical Outcomes. She shares details of her innovative program and examines the value of implementing practice enhancements in a Magnet environment. She describes the importance of an interdisciplinary team effort to achieve success.


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In my role as a critical care clinical nurse specialist, I've spent more than 20 years looking at patient resuscitation data. Often, I'd think, "Is there a better way to do things for our cardiovascular (CV) surgery patients?"

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I found my answer in a conference session on the ERC guideline, Cardiac Surgery Advanced Life Support (CALS). The concept was simple but powerful: resuscitation of CV surgery patients should be different because these patients are different. I believed CALS could benefit our patients in a way traditional resuscitation could not. However, before I presented it as a possible practice change, I wanted to thoroughly understand all aspects of the process. I was getting my doctorate at the time, so I used the opportunity to learn about the science behind this advanced protocol.


It took a lot of work to get buy-in across the organization. My team and I reached out to our CV surgeons, other physicians, and hospital leadership. We asked, "What do you think of this protocol? Could it work for our patients?" We showed them the evidence. We showed them our patient data. We articulated the process and how we would train our cardiac ICU nurses to do 2 different resuscitation protocols on patients.


Once approved, we asked the nurses what they needed to make this work. They defined the workflow, we provided intensive education, and in early 2016, we became one of the 1st organizations in the state to implement CALS guidelines (called Cardiac Surgery Unit Advanced Life Support in the United States).


We took great care to ensure our nurses felt confident. We told them that, if they felt they couldn't do the new resuscitation, they could do what they did before. In the end, they didn't need to. Our nurses were so courageous and strong and embraced the new protocol and made it work.


How does CALS differ from traditional Advanced Cardiac Life Support? With CALS, the initial interventions must happen within 60 seconds of patients showing signs of cardiac arrest. Cardiovascular surgery patients are unstable by nature, so we hook them up to a pacemaker immediately after surgery. Defibrillators sit outside rooms so nurses can grab them quickly. Traditionally, epinephrine is given after chest compressions are started. In the CALS protocol, we give low doses of epinephrine when the blood pressure drops so the patient does not lose his/her pulse. If performed within 60 seconds, you can avert cardiac arrest before you have to do chest compressions, which can be inherently dangerous for CV surgery patients and can cause significant injury. Our nurses are able to perform the interventions in 10-20 seconds because everything is ready.


Initially, we saw a decrease in the incidence of cardiac arrest but did not see a survival-to-discharge benefit. However, in 2017, we achieved a survival-to-discharge rate of 70%, which is consistent with the literature. Only 25% of the patients needed chest compressions, compared with 73% of the patients before implementation.


It is a bold move to say you want to change a long-held nursing practice, but Magnet(R) hospitals are amenable to innovation. I believe the collegiality between nurses and providers is different in a Magnet organization. I'm not sure nurses could go to providers in other hospitals and say, "This is a good idea, what do you think?" However, in a Magnet environment, relationships are stronger and everyone is open to evidence-based ideas.


Although I led this project, I couldn't have done it without my team. Our nurses really embraced the new knowledge and made it work. I'm thrilled I received the Magnet Nurse of the Year Award, but it took the entire critical care interdisciplinary team to achieve success.