Introduction
The quality of care in coronary care units (CCUs) has undergone considerable changes and improvements. Many methods are available to achieve positive results, avoid cardiac complications, and predict deaths or other negative health outcomes in patients. In this prospectus of a direct practice involvement (DPI) project, the idea of using capnography during cardiopulmonary resuscitation (CPR) of patients in the CCU will be developed to evaluate its efficacy on recovery dynamics and the associated level of patient satisfaction regarding care. This topic is worth investigating because while various treatment scenarios have already been developed, nurses still demonstrate uncertainty in using this method to monitor patients’ end-tidal carbon dioxide (ETCO2) levels. In their studies, Lin et al. (2017), Novais and Moreira (2015), and Pantazopoulos et al. (2015) proved the need for volumetric or another type of capnography for patients having bronchoscopy sedation, post-surgery anesthesia, and defibrillation. The need to develop similar research from new perspectives and under different conditions is evident. This DPI project will focus on the use of capnography during cardiac arrest.
Background of the Problem
Patients may ask for professional help for different reasons and under various conditions. The nurse’s task is to examine people and record their vital signs, ensuring readiness to provide effective care. Carbon dioxide (CO2) is a major product of metabolism that is transported via perfusion or expelled via ventilation, and nurses must know how to monitor the ETCO2 level (Dioso, 2014; Duckworth, 2017). If ETCO2 levels are poorly or incorrectly measured, the patient’s condition may worsen quickly, and the process of resuscitation can be a challenge. One possible outcome is the return of spontaneous circulation (ROSC), when nurses and other medical staff must monitor the duration of the condition and any changes in a patient (Bullock, Dodington, Donoghue, & Langhan, 2017). Fatal results are possible even if the staff is properly prepared and all preventive measures are taken (Israel, 2014; Kuisma et al., 2017). Therefore, it is vital to learn methods that can be applied in a CCU and fill in any existing gap in practice.
Capnography is offered as a possible measurement tool in resuscitation that helps to evaluate coronary perfusion pressure (CPP) and track any changes in coronary blood flow. Cardiac arrest results in approximately 1,000 deaths per day in the United States, and nurses must take a number of steps, including the promotion of CPR and control of ROSC (Edelson et al., 2014; Kodali & Urman, 2014; Mader, Coute, Kellogg, & Harrism, 2014). Normal levels of ETCO2 are between 35 and 45 mmHg, and capnography indicates when remarkable changes occur, provoking new cardiac problems, poor ventilation functioning, and abnormal chest compressions (Kiekkas, Stefanopoulos, Konstantinou, Bakalis, & Aretha, 2016; Liu, Poon, & Tsui, 2016; Sheak et al., 2015; Venkatesh & Keating, 2017). The use of capnography has already been successfully researched in patients with chronic hypercapnic respiratory failure because of hypoventilation, severe hypothermia, or metabolic changes (Cereceda-Sánchez & Molina-Mula, 2017; Chhajed et al., 2016; Darocha et al., 2017). Nurses must continue to improve their knowledge regarding cardiac arrest, capnography, and quality of care in order to avoid potential gaps and shortfalls in their practice.
Theoretical Foundations and Review of the Literature/Themes
An understanding of theoretical foundations is a critical step in developing the DPI project. This will facilitate identifying the characteristics of resuscitation and the use of capnography in a CCU. Two middle-range theories will be applied in the chosen context: the conceptual model of nursing (CMN) and the middle-range nursing theory of self-efficacy (NTSE). The literature review is another stage of the DPI project where the researcher must be able to find sufficient applicable material and will divide the discussion into several logical themes, enhancing knowledge of the practical use of capnography in nursing care.
Theoretical foundations
In this quantitative project, two major variables for discussion must be noted. The first involves capnography as a nursing tool used to carry out certain duties. The CMN offers a good contribution to this foundation as it allows developing a multidimensional analysis of tasks, monitoring and defining the types of work to be performed (Lin, Guerguerian, Laussen, & Trbovich, 2015; Yen et al., 2016). Dependent variables, including patient satisfaction and the quality of recovery dynamics, may be evaluated in terms of the NTSE, the essence of which is to clarify the relationship between self-efficacy and outcome expectations (Smith & Liehr, 2018). This theory explains the value of care quality and its dependence on the level of professionalism that nurses demonstrate. The combination of models shows that the use of capnography requires not only an satisfactory level of knowledge but also the ability to identify and meet patients’ expectations as well as encourage compliance.
Review of the literature/themes
Cardiac arrest plays a crucial role in the study as a condition that requires the use of capnography. This phenomenon is explained as “the cessation of cardiac mechanical activity confirmed by the absence of a detectable pulse, unresponsiveness, and apnea” (Tobi & Amadasun, 2015, p. 132). Capnography and its main features must be clearly defined in the project as this tool promotes positive outcomes in resuscitation and effective measurement of the stroke volume index (Kalmar et al., 2018; Langhan, Shabanova, Li, Bernstein, & Shapiro, 2015; Turle, Sherren, Nicholson, Callaghan, & Shepherd, 2015).
Clinical indicators include its use in CCUs, patient safety, and evaluation of vital signs (Kiekkas et al., 2016). Nurses must be familiar with the available types of capnography because its use depends on many factors. Volume, time, and side-stream capnography are frequently used in CCUs (Jaffe, 2017; Nassar & Schmidt, 2016). Nursing awareness of capnography must be encouraged in conditions when ETCO2 levels remain unknown (Hamrick et al., 2017). Finally, patients and nurses may experience various outcomes after the use of capnography, and reorganization of care may be required.
Problem Statement
Taking into consideration recent findings in the field along with the background of the problem, a new statement must be developed for this DPI project. Despite significant contributions to the discussion of capnography, it is not known to what degree the use of capnographs can be effective in patients undergoing cardiac arrest during resuscitation in CCUs (Heradstveit & Hetne, 2014). In addition, it is important to investigate the level of knowledge of nurses who are responsible for performing capnography. Their task is not only to use the machine and check the level of ETCO2 but also to be ready to share the obtained information with other medical staff and apply the data in further diagnosis and treatment (Hassankhani, Aghdam, Rahmani, & Mohammadpoorfard, 2015; Lin et al., 2015). It is important for nurses to improve their understanding of capnography in the context of CCUs, especially in the case of patients during resuscitation.
Clinical Questions and Variables
The idea of this quantitative project is to investigate capnography as an opportunity to achieve positive health outcomes and predict cardiac complications. The research is organized to compare the conditions and results when capnography is used or is not used during resuscitation of patients in a CCU. The main PICO question is as follows: “In the patients of a coronary care unit (P), how will the implementation of time capnography (I), compared to non-use of this intervention (C), influence the efficacy of the resuscitation process and the transition to ROSC (O)? Taking into consideration the already-discussed problem statement and theoretical foundations, the intervention, capnography, must be defined as an independent variable in the project. The success of the resuscitation process depends on how well nurses monitor ETCO2 levels and achieve positive recovery dynamics after cardiac arrest. Finally, it is necessary to evaluate overall satisfaction with the quality of care offered to patients. In total, the study includes three dependent variables and one independent variable:
- DV1: recovery dynamics after cardiac arrest;
- DV2: effectiveness of ETCO2 level monitoring in CCUs;
- DV3: patient satisfaction;
- IV1: capnography.
Additional clinical questions are based on these variables and the necessity to discuss the basics of capnography in CCUs:
- How effective is capnography in monitoring ETCO2 levels among cardiac patients in CCUs?
- What is the relationship between recovery dynamics after cardiac arrest and patient satisfaction in the context of capnography use?
As a result, several important hypotheses can be developed for this qualitative project:
- H1: The use of capnography results in positive health outcomes in patients during resuscitation compared to non-use of the same tool.
- H2: In CCUs, capnography is an important tool for monitoring ETCO2 levels in cardiac patients.
- H3: Capnography is an effective tool to enhance positive recovery dynamics in patients who experience cardiac arrest.
Significance of the Project
The results of this project will show how capnography should be implemented in CCUs in order to stabilize the condition of patients who undergo cardiac arrest. Even though capnography helps to monitor and measure CO2, its implementation remains a poorly investigated topic due to a lack of nursing experience. If all the hypotheses are proved or partially proved, it may be recommended for all hospitals to turn attention to capnography during resuscitation. The improvement of nursing knowledge about the chosen technique can be promoted via the CMN with its multitasking and prolonged monitoring or via the NTSE with its expectations of self-efficacy. The same ideas may be extended in terms of qualitative or mixed methods projects by discussing capnography or resuscitation as phenomena in nursing practice. The health condition of patients who experience cardiac arrest will be stabilized and improved because nurses will be enabled to monitor vital signs effectively and predict cardiac complications in a timelier manner.
Rationale for Methodology
Quantitative methodology has been chosen for conducting this DPI project. The main task is to identify whether capnography can bring positive results in caring for patients undergoing cardiac arrest and if it is effective during resuscitation. The essence of a quantitative study is to gather large amounts of data from different individuals, relying on their attitudes toward care and knowledge about capnography (Austin & Sutton, 2014; Barnham, 2015; Heale & Twycross, 2015). The efficacy of capnography can be proved by means of well-calculated numbers and statistical results that will facilitate determining whether hypotheses should be accepted or rejected (Center for Innovation in Research and Teaching, n.d.b). To answer the PICO question, an experiment must be organized to collect measurable data and discuss results that are generalizable to a large group of people (Gunnell, 2016). The offered method does not require much time or money to be developed, and credible information will be used.
Nature of the Project Design
Based on the selected quantitative methodology, an experimental design must be applied to the discussion of the current research questions. This method can be quantitatively measured without introducing new ideas and discussing well-known phenomena (Center for Innovation in Research and Teaching, n.d.a). The already-known capnography technique will be used as the intervention in the experiment with optimal variable control and manipulation (ETCO2 levels, recovery dynamics by way of the number of fatal outcomes, and the quality of care through patient satisfaction levels). Randomized control trials will be used to investigate the effects of capnography on the treatment of patients experiencing cardiac arrest. In experimental designs, subjects are measured before and after a technique is applied (Stephanie, 2016). In this case, the participants will be divided into two groups where one has access to capnography and the other receives standard monitoring without capnography. The comparison of results after the intervention will prove or disprove the efficacy of capnography.
Purpose of the Project
The purpose of this quantitative DPI project with experimental (randomized control trial) design is to examine the degree to which capnography (independent variable) can be defined as effective in the improvement of care quality (dependent variable), recovery dynamics (dependent variable), and ETCO2 level monitoring (dependent variable) for patients undergoing cardiac arrest (participants) during resuscitation in CCUs (location). The independent variable should not be measured or changed during the project but must be defined as a technique to control exhaled CO2 partial pressure (Kiekkas et al., 2016). Nurses will be required to check their level of knowledge about capnography through the Nurses’ Knowledge about Capnography Test (NKCT). The dependent variables such as the recovery dynamics and ETCO2 levels will be measured by ordinal scales that allow comparison of the degree to which positive outcomes are achieved. Patient satisfaction with the quality of care will be measured via nominal scales with specifically characterized responses (“Satisfied,” “Neutral,” and “Dissatisfied”).
Instrumentation
The NKCT is a questionnaire intended to evaluate nurses’ level of knowledge about the tool of capnography. It is recommended that participating nurses take this test before and after the intervention to identify whether progress can be identified in terms of capnography use and its effects on recovery dynamics (Kiekkas et al., 2016). In this project, the data collection method will be quantitative observation. The same instrument has already been applied in various fields, including technology, education, health care, and psychology (Campbell, 2017; Guo et al., 2016; Katz-Buonincontro & Anderson, 2018). The larger the sample size, the more credible and valid the results of observations (Bhat, 2019). Questionnaires provide an easy and practical way to ask questions and receive definite answers that can be applied in further discussions (Flanagan, Greenfield, Coad, & Neilson, 2015; Kłak, Mińko, Siwczyńska, & Samoliński, 2015; Marques et al., 2014; Rowley, 2014). Patients will be given a questionnaire to gather their opinions about the quality of care and the effectiveness of capnography as a monitoring tool in treatment.
Data Collection Procedures
In the chosen quantitative observations and questionnaires, quantitative data obtained during the implementation of the intervention is a core issue. Quantitative data collection is based on the decisions made and the level of involvement on the part of the participants (Hannigan, 2018; Watson, 2015). Observation of 80 patients will be carried out during the implementation of the offered intervention. Participants will be divided into two groups: experimental and control. Forty patients will be monitored with the help of a time capnograph (the experimental group), and the other 40 patients will be monitored using standard methods (the control group; avoiding capnography). The division into groups will be random, depending on the results documented in an envelope (there will be one envelope for each patient with the name of a tool to be used to be opened during an intervention). Ten nurses will take tests to check their level of knowledge about capnography and to share their opinions about recovery dynamics and ETCO2 level monitoring.
By means of a questionnaire after the intervention, patients who survive cardiac arrest will share their opinions about capnography along with an overall impression about the care offered during resuscitation and effects experienced after cardiac arrest. In general, patients would likely find it difficult to explain the value of capnography for measuring CO2 levels, and that is why the opinions of nurses by way of the NKCT tests are anticipated to be informative and effective sources of quantitative information.
Data Analysis Procedures
Participants will include 80 patients undergoing cardiac arrest, 40 of which will receive capnography to monitor the ETCO2 level. Information about patients will be stored in an Excel spreadsheet for further analysis using SPSS statistical software. A Chi-square test will be used to identify and analyze the characteristics of the participants and achieved results (Ali & Bhaskar, 2016). Two-sided statistical tests with p-value <0.05 must also be developed (Leppink, O’Sullivan, & Winston, 2016). Five nurses will be responsible for monitoring patients and evaluating the value of capnography versus not using this tool. This quantitative project includes three hypotheses and three questions for statistical analysis. The first question and the hypothesis about the effectiveness of capnography use in patients during resuscitation will be analyzed via SPSS. The second question and hypothesis about ETCO2 level monitoring by means of capnography will be analyzed via an Excel spreadsheet. The third question and hypothesis about recovery dynamics will be analyzed via SPSS. Inferential analysis such as correlation will help in describing the relationship between the chosen variables, and a descriptive statistical analysis of the frequency of fatal and positive care outcomes will be conducted.
Ethical Considerations
Ethical concerns must be properly identified and explained in quantitative research. These include norms for conduct and the ability to differentiate where right and wrong steps are taken, addressing such concepts as honesty, objectivity, and respect (Sanjari, Bahramnezhad, Fomani, Shoghi, & Cheraghi, 2014; Zyphur & Pierides, 2017). Such ethical concerns as voluntary participation, fabrication of information, and safety of participants will be solved by having a local Institutional Review Board provide oversight. Informed consent will be offered to every participant with an explanation of the goals and details of the project. Potential participants must learn the essence of this DPI project before they give their approval. They may also withdraw from the research study at any time without giving reasons. The personal data of the participants will be protected due to such issues as confidentiality and anonymity. A system of codes will be developed to avoid using actual names or even mentioning the gender or age of a participant.
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Appendix A
Appendix B
Variables/Groups, Phenomena, and Data Analysis
Table 1. Quantitative Studies.