Introduction
A critical appraisal for the Direct Practice Improvement (DPI) Project, including ten strategic points, will be developed. This DPI project includes a list of systematic statements with the help of which practitioners can improve their understanding of the use of capnography during resuscitation and contribute to the promotion of effective services for patients in a coronary care unit (CCU). A patient’s condition may suddenly get worse, and nurses should respond quickly to stabilize the patient’s health and avoid a fatal outcome (Dioso, 2014; Jaffe, 2017). In these guidelines, capnography is defined as a method to measure the level of ETCO2 and control resuscitation caused by the return of spontaneous circulation (ROSC) due to a heart attack (Bullock, Dodington, Donoghue, & Langhan, 2017; Langhan, Shabanova, Li, Bernstein, & Shapiro, 2015; Tobi & Amadasun, 2015). The main feature of this DPI project and the ten strategic points for the prospectus is the evaluation of capnography’s effectiveness as a resuscitation process among the patients in a CCU setting.
The proposal under discussion focuses on different aspects of the project, starting with the identification of a broad topic and concluding with a clear choice of a data analysis approach. It is supported by personal evaluations and the findings from credible studies on the topic. In general, this paper aims to assess the ten-point strategic proposal on the use of capnography during resuscitation of patients in CCUs through the prism of 6 domains and 23 statements, as well as provide an overall guideline assessment and clarify if the author managed to take all the necessary preparatory steps for writing a serious research project.
Domain Table
Domain 1. Scope and Purpose
The overall objective(s) of the guideline is (are) specifically described
Comments
The guidelines under consideration contain clear goals and key tasks. In the section “Broad Topic Area”, the author introduces the field and explains the process under discussion to illustrate the importance of this project. There is also a section with a clearly defined purpose statement: gaining an understanding of the essence of capnography and the efficacy of this monitoring process for CCU patients. The discussion of long-term goals, such as the prevention of health complications due to cardiac attacks and the reduction of ROSC, is developed (Mader, Coute, Kellogg, & Harrism, 2014). Lowering the risks of coronary perfusion pressure (CPP) and the Lazarus phenomenon can also be promoted with capnography (Hamrick et al., 2017; Kuisma et al., 2017). In general, the objectives and goals of the study are very detailed in the guideline. The author uses brief facts and sufficient headings to introduce the project and makes sure they all correspond with the frames of the chosen field.
The health question(s) covered by the guideline is (are) specifically described
Comments
The main research question that is covered by the guideline is if the implementation of time capnographers for patients in a coronary care unit may influence the efficacy of a resuscitation process and the transition to ROSC compared to non-use of this intervention. This question meets the criteria of a standard PICO question with the target population (CCU patients), intervention (capnography), comparison (non-use of capnography), outcome (resuscitation process efficacy), and setting (CCU). Though there is no clear answer to this particular question, the author of the guideline develops a good plan on how to make the necessary preparations, what sources have to be used, and when it is necessary to gather the material. All important definitions are given through the guideline, including the essence of capnography and associated conditions, such as cardiac arrest, cardiopulmonary resuscitation (CPR), the Lazarus phenomenon, and ROSC. In total, this section meets the reader’s expectations about the questions that can be raised in discussions about health improvement.
The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described
Comments
The description of the population is given in the guideline. Although the author does not focus on such aspects as race, sex, and age, special attention is paid to the participants’ clinical conditions and the severity of a disease. For example, the decision to cooperate with patients is based on such inclusion criteria as the diagnosis of cardiac arrest, hospitalization, and length of stay of patients in the CCU setting during the intervention. In addition, special attention is given to the exclusion criteria. Patients who are in rehabilitation, have high levels of ETCO2, or have already experienced the Lazarus phenomenon cannot participate in the intervention. The results of such an investigation can be ineffective or subjective. In fact, the population item is well written and described in the chosen guideline. It is clear who the main patients are, what problems they can have, and what conditions should be identified in a particular setting.
Domain 2. Stakeholder Involvement
The guideline development group includes individuals from all relevant professional groups.
Comments
In this project, individuals from several professional groups have to be involved. On the one hand, the use of capnography, the main intervention, has to be developed by professional nurses (Yen et al., 2016). In addition, doctors have to participate in discussions in order to read the results of the capnographer and make appropriate decisions. Finally, patients are the direct stakeholders who are defined in this guideline. All these members are from the local hospitals in New Jersey. In the Sample section, the number of patients (n=80) for the intervention is given. On the other hand, the role of the research group should not be ignored. The author develops a thorough literature review that serves as a solid background for the discussion of the chosen problem. However, neither names nor descriptions of any members are given, and this fact might be regarded as a considerable shortage of the DPI project. Still, the evaluation should also depend on the criteria given. In this case, the DPI project needs the introduction of the participants with no roles descriptions given.
The views and preferences of the target population (patients, public, etc.) have been sought
Comments
There is no specific section that introduces the preferences and views of patients and nurses. However, it is possible to gather some information from other sections such as “Methods”, “Literature Review”, and “Purpose Statement”. For example, patients, nurses, and other medical staff expect the possibility to monitor the level of ETCO2 with the help of the method of capnography and, as such, be able to reduce the number of negative healthcare outcomes. Nurses have to be ready for re-organization of their duties and improvement of the level of their knowledge about monitoring techniques and control of patients. Non-invasive techniques can improve the quality of a final decision and the necessity to implement ROSC or not as a part of capnography intervention (Venkatesh & Keating, 2017). Finally, the research group expects to identify the peculiarities of capnography by comparing the results between an experimental group and a control group and proving that the use of the technique is characterized by a number of positive outcomes.
The target uses of the guideline are clearly defined
Comments
The target users for this guideline are the CCU patients and nurses who participate in the monitoring processes. However, the topic of cardiac arrest and associated health changes and problems that may require the use of capnography techniques may also include such target users as cardiologists, registered nurses, and even the families of patients (as this method directly influences the improvement of the quality of life). Therefore, on the one hand, it is possible to say that the author of the guideline clearly introduces and describes the target population with their expectations and needs (Hassankhani, Aghdam, Rahmani, & Mohammadpoorfard, 2015). On the other hand, the list of potential users is not actually complete. Some general practitioners, emergency department staff, and specialized doctors may also be interested in the discussion of this topic and consideration of capnography as a good option for patients to avoid resuscitations and fatal incomes.
Domain 3. Rigour of Development
Systematic methods were used to search for evidence
Comments
There is no special section where a search strategy for evidence is mentioned. Despite the fact that the literature review introduces a solid part of the whole work, the author did not specify the names of databases and the types of studies used for analysis. Therefore, it is hard to give high scores for this point where the search of evidence matters. There were no time periods and no items given to simplify the search process. However, the author did identify the type of research and the methods that could be used to gather information regarding the offered intervention and expected outcomes, and described two theoretical perspectives (the Conceptual Model of Nursing and the Middle Range Nursing Theory of Self-Efficacy) as the methods to analyze nursing skills and understand the worth of capnography in the chosen setting (Lin, Guerguerian, Laussen, & Trbovich, 2015; Smith & Liehr, 2018). Regarding the chosen approach, it is wrong to state that the author did not use any search strategy. However, no results or process descriptions were implemented to the guideline.
The criteria for selecting the evidence are clearly described
Comments
Taking into consideration the fact that no clear search strategy was given, the evaluation of evidence selection has to be based on the chosen methods and samples in the study. In this case, the author succeeded in describing the inclusion and exclusion criteria for participants as a part of the intervention. Still, no definite recommendations for sources were given (e.g., the year of publication or the location of the studies). Looking through the list of sources chosen by the author, it is evident that only credible, peer-reviewed articles were used. For example, the article by Kodali and Urman (2014) helps to understand the essence of CPR and the necessity to measure carbon dioxide in the patient’s body. Kiekkas, Stefanopoulos, Konstantinou, Bakalis, and Aretha (2016) investigated capnography as a method to promote ventilator function. However, because the explanations of such a choice of sources for review were absent, it is impossible to give high ratings for this area.
The strengths and limitations of the body of evidence are clearly described
Comments
In this guideline, the author fails to develop the section with a clear description of the evidence’s strengths and limitations. Twenty studies were used in the literature review section, and a number of facts and statements were obtained from these sources. However, such aspects as study design, the relevance of
actual sources, and the direction of research were not properly discussed within the frames of this guideline. It is also hard to ascertain if the findings were biased or not. All the material seems to be descriptive by its nature instead of combining interpretations and evaluations. As a result, low ratings and the inability to find out the necessary information are observed in this part of the assessment.
The methods for formulating the recommendations are clearly described
Comments
There is no separate section where clear recommendations are given in the guideline. However, final decisions and the methods on how to analyze data and answer the research question can be found throughout the paper. It is recommended that nurses be prepared for rearrangement of their roles and the use of a multimodal approach to improve decision-making in hospitals (Lui, Poon, & Tsui, 2016). In addition, the expected outcomes of capnography on nurses and patients were discussed in the literature review, explaining that nurses could learn how to interpret the results of capnography (Pantazoloulos et al., 2015) or how to control chest compressions during cardiac arrest (Sheak et al., 2015). Quantitative data analysis tools were recommended to detect the difference between the well-being of patients whose conditions were monitored with the help of capnography and those using standard techniques. The results of the Wilcoxon signed-rank test and a paired t-test influenced final recommendations.
The health benefits, side effects, and risks have been considered in formulating recommendations
Comments
In the Problem Statement section, the main benefits of the implementation of capnography in the CCU setting were described. The possibility to improve care quality and monitor patients can be achieved as a result of capnography. Strong evidence taken from credible sources was used to prove these improvements. For example, Kalmar et al. (2018) indicate the necessity to measure the stroke volume index to predict possible cardiac outcomes. Such clinical indicators as pulse pressure, heart rate, and blood pressure have to be evaluated during resuscitation (Kalmar et al., 2018). The patient’s status may be clearly defined in case various technologies are used during monitoring (Lin et al., 2017). Harmful side effects of capnography were not recognized because of the nature of the chosen intervention. The goals to decrease the number of lethal outcomes and survive the Lazarus phenomenon could be achieved and defined as the health benefits of the chosen guideline for both patients and nurses.
There is an explicit link between the recommendations and the supporting evidence
Comments
There is a link between the recommendations and the evidence chosen by the author. The guideline user can easily identify the facts in order to support his/her understanding of the recommendations. For example, it is stated that medical staff continue to face some problems when having to use capnographers in hospitals and explain the changes in ETCO2 levels (Hamrick et al., 2017; Kiekkas et al., 2016). The outcome is to improve nurse awareness of the peculiarities of the offered technique and read the results properly. The expectation to improve the quality of care can be supported by the evidence taken from the article written by Hassankhai et al. (2015) about self-efficacy and learning motivation. It is important for nurses to appreciate the benefits to be gained in their work, and this guideline discusses the conditions under which the knowledge of capnography and its effects can be improved.
The guideline has been externally reviewed by experts prior to its publication
Comments
The process of publication of the chosen guideline is complex and consists of several stages. Therefore, it is necessary to make sure that a group of experts can review the project and share their opinions on its development. In this case, the target population of the study, including patients and nurses, will certainly share their opinions about the need for this guideline, the importance of the
intervention, and a discussion of capnography as the main method to monitor the ETCO2 level. Nurses have to take several tests before and after the intervention in order to demonstrate what they know about capnographers and what they want to know. Patients, in their turn, can explain their attitudes to the change of care and the possibility to achieve greater positive health outcomes. Finally, teachers and editors have to read the paper before its publication to give their recommendations on how to improve its structure, grammar, and other aspects of the academic work.
A procedure for updating the guideline is provided
Comments
The guideline under consideration is a part of a project proposal with the aim of discussing future steps and expected outcomes. Therefore, without clear conclusions being achieved, and the results being observed, it is hard to leave any firm recommendations for future research. The evaluation of this part of the work can be developed in two ways: on the one hand, no future recommendations were given by the author; on the other hand, the author succeeded in discussing the updating of procedures. As a result, neither agreement nor disagreement can be offered for this section due to the nature of the work done and the goals to understand what kind of improvements may be achieved if capnography is
implemented. The publication date remains unknown, and as soon as it is published, new evidence can be gathered in order to understand what new knowledge should be used to be able to offer a new vision of the problem and its solution.
Domain 4. Clarity of Presentation
The recommendations are specific and unambiguous
Comments
The guideline contains the recommendations that are based on the goals and expectations. There is a clear recommendation that is given in the paper: to use capnography as a method to monitor the level of ETCO2 and normalize patients’ conditions during resuscitation. Associated outcomes were also properly identified, including the improvement of the quality of care, the decrease in lethal outcomes, and increase in nurse motivation. These outcomes also identify the relevant population with specific clinical indicators (cardiac attack) and within specific settings (CCU). It is clear to whom each recommendation has to apply, including the improvement in quality of care (patients) and increased awareness (nurses). In addition, the contribution to this guideline to the general public is evident because all readers can use it as a solid foundation to their independent investigations. In general, all recommendations are specific and unambiguous due to the presence of clear evidence that supports the discussion and the description of the participants who are directly involved in the chosen healthcare processes.
The different options for management of the condition or health issue are clearly presented
Comments
Several options for management of the chosen cardiac condition that may require resuscitation are suggested in the project. A multimodal approach that should be applied to decision-making in hospitals is promoted (Lui et al., 2016). The authors underline that rearrangement of the current priorities is inevitable and include direct participation of the nursing staff. For example, the use of capnography should not be only based on following appropriate instructions. It is also important to encourage nurses and promote the development of necessary skills, as well as their monitoring changes under different conditions. Capnography has to be incorporated with such steps as the assessment of chest compression levels and circulation status (Pantazopoulos et al., 2015). In addition, the choice of the Middle Range Nursing Theory of Self-Efficacy underlines the importance of patient education and medical competency that help predict various behavioral outcomes.
Key recommendations are easily identifiable
Comments
There is no special section that contains clear and easy identifiable recommendations. The point here is that the author does not focus on defining recommendations at this stage of work. Rather, the task is to develop a solid theoretical background and introduce a plan of work that can be followed. It is wrong to take points away because of the absence of the required section. Rather,
it is better to investigate the paper where these recommendations are mentioned. In the summary of the literature review, there are clear statements explaining why capnography should be thoroughly studied, and what the role of nursing staff can be. Resuscitation threats must be recognized in the hospital setting, new tools have to be introduced and learned, and the evaluation of vital signs should never be neglected by nurses. These recommendations seem to be enough to promote nurse education and the improvement of knowledge levels.
Domain 5. Applicability
The guideline describes facilitators and barriers to its applications
Comments
The implementation of the guideline is well described in the methods and data collection section. The author mentions that the application of capnography in a CCU setting is characterized by certain benefits and challenges, but there are no special documents and examples of how to take the necessary steps. The evaluation developed by Kiekkas et al. (2016) shows that the gaps in understanding capnography can challenge many nurses and patients. Hamrick et al. (2017) state that the lack of control of the ETCO2 level and the inability to give a clear explanation of its changes create additional problems. However, the situation can be improved through increasing the quality of care, motivation of nurses, and promoting self-efficacy (Hassankhani et al., 2015). In general, this project contains enough information about challenges and facilitators and informs the reader about how to apply the method of capnography in a CCU setting.
The guideline provides advice and/or tools on how the recommendations can be put into practice
Comments
There are many ways of how the use of capnography by nurses can be put into practice. In this project, clear and effective recommendations are given through the description of the data collection methods. In the literature review, the guideline provides several pieces of advice on why capnography should not be ignored in the CCU. Then, special attention is paid to the participation of people, divided into several groups, and the need to compare the results in order to prove the urgency of the offered technique. Pre-trial achievements have to be taken into consideration and used to prove the levels of progress in the post-intervention period. The ability to measure the ETCO2 level in patients with cardiac arrest can reduce the number of fatal outcomes in patients (Langhan et al., 2015). All these facts show how the chosen method can be developed in real-life settings.
The potential resource implications of applying the recommendations have been considered
The potential resource implications of applying the recommendations have been considered
Comments
On the one hand, the document under evaluation includes a proposal of a project that has to be developed regarding the existing problems, and it is hard to talk about its future resource implications without obtaining certain results and observing the outcomes that can provide comment on the effectiveness of capnography.
On the other hand, this project includes recommendations for additional resources to be applied in hospitals at the moment of intervention. Specialized staff have to participate in the promotion of the chosen monitoring method. New equipment (a capnographer) is also properly discussed by the author. Still, this document cannot gain many points in regard to shedding light on the types of cost or other economic evaluations. The reader cannot determine how much money needs to be spent to deal with patients’ cardiac problems or calculate the difference between treatment and prediction costs.
The guideline presents monitoring and/or auditing criteria
Comments
The use of capnographers for cardiac patients has to be based on proper measurement of all vital signs. Although there are no specific documents and appendices to explain how monitoring criteria should look like, the general aspects are outlined within the guideline. It is expected to maintain the normal ETCO2 level, between 35 and 45 mmHg, and avoid its decrease up to 10 mmHg, or increase to about 45 mmHg (Kiekkas et al., 2016). In addition, the peculiarities of chest compression are identified in the guideline so that nurses can get an idea of what kind of help and results should be expected. Considering the chosen goal and methods of data discussion and evaluation, this information seems to be enough for monitoring patients and to define their potential cardiac complications.
Domain 6. Editorial Independence
The views of the funding body have not influenced the content of the guideline
Comments
This project actually depends on the participation of external funding programs and organizations that can support the idea of capnographers in CCU settings. Help that may be offered in terms of this guideline includes some financial contributions to buy capnographers for as many local hospitals as possible and promoted training programs for nurses. In addition, organizational improvements can be required to strengthen the content of the guideline and make it available to the general US public. In this guideline, no names or support statements are included. Funding bodies do not perform a serious role in the promotion of the guideline, and all responsibilities are divided between the developers of the project and its direct participants. Finally, there is no discussion about how potential funding bodies can influence the development and understanding of recommendations for nurses.
Competing interests of guideline development group members have been recorded and addressed
Comments
In this project proposal, members of the development group do not find it necessary to define their competing interests and discuss how to meet their expectations and professional needs. No description of competing interests is given. Neither is any mention given to clear methods on how these disagreements can be sought. Finally, developers’ interests are not found to be crucial for the creation of a guideline process and the introduction of recommendations that may be offered to a reader. At the same time, it is also important to mention that there is no explanation as to how a development group was formed. This observation can be explained by evaluating the goals of the guidelines and expected outcomes. The task is not to talk about the needs of researchers and facilitators, but to prove that capnography is an effective monitoring method for patients and nurses.
Overall Guideline Assessment
Rate the overall quality of this guideline
I would recommend this guideline for use
Notes
The overall guideline assessment should show the possible levels of quality of all the recommendations given by the developers. Regarding the evaluations made, it is possible to say that this guideline has to be recommended for use in local hospital settings with some modifications. For example, special attention should be paid to the development of editorial independence of the text. In this project, the role of potential funding bodies is not described. The possible ways to secure enough funding for the successful implementation of capnography in CCU settings remains unclear. The practice of monitoring patients’ vital signs and ETCO2 levels can help to save many lives and predict negative outcomes of resuscitation. Cardiac problems continue to affect millions of people worldwide, and if the government can participate in the solution to this issue, its role should be properly discussed.
In addition, the quality of evidence has to be improved in this guideline. There are many credible sources that were used to discuss the chosen problem
and clarify what has already been done in the field, and what improvements can be observed in the near future. However, the reader fails to understand how the developers gather information, choose databases, and evaluate the studies. Therefore, it is necessary to develop an additional section with a description of the evidence search and to identify all strengths and limitations. The peculiar feature of this improvement is that it does not take much time or serious effort. The author of the guideline just has to share the steps that they have already taken and guide potential researchers on how to organize evidence collection for the chosen topic. As it stands, the quality of the guideline is high, but several clarifications can make it achieve the highest possible rating.
Conclusion
In general, the creation of this critical appraisal for the chosen practice guideline about the implementation of capnography for patients in CCU settings helps to reveal both strong and weak aspects of the recommendations. It is not enough to just create a proposal and proclaim its importance for a number of hospitals and medical workers. The proposal should contain certain elements and meet specific goals to be recognized and put into practice. Despite some shortages in the project, its overall assessment remains high with several recommendations to be followed. This guideline turns out to be a solid basis for a strong healthcare intervention with the goal to reduce the number of fatal outcomes among cardiac patients and increase the quality of care nurses and other medical staff can offer in hospitals.
References
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