Effect of an Educational Intervention for Nursing Personnel on Emergency Inventory and Drugs Checklist of Resuscitation Trolley in a Tertiary Cardiac Center, Kathmandu.

Background and Aims: A crash cart is a trolley with emergency medicines and equipments required for medical emergencies. Nurses often witness cardiac arrest. They should be familiar with the placement of equipments and drugs in crash cart trolleys. Thus, this study was conducted to assess the effect of an educational intervention on knowledge of crash cart drugs and equipment management among nurses. Methods: This is a pre-experimental research design conducted at Shahid Gangalal National Heart Center, Kathmandu, Nepal. A simple random sampling technique was adopted. A semi-structured questionnaire was used to identify the knowledge of nurses. A standard checklist was used to observe crash cart trolleys. Pre and post test data was taken. Outcome variables included knowledge of crash cart trolleys organization and well organized crash cart in different wards. Data were analyzed to compare the knowledge before and after the intervention. Chi-square test, pair t-test, and linear regression multivariable model used for statistical analysis. Results: A total of 134 nurses were recruited in this study. The overall mean score of knowledge was significantly higher in post-intervention. The total knowledge mean score difference among nurses was -11.07, (p<0.001), drug content difference at crash cart was -16.85, (p<0.001), equipment content at crash cart was -24.42, (p<0.001).The linear regression showed significant improvement in knowledge at post-intervention (β; 0.928, 95% CI; 10.52, 11.57, p<0.001), when adjusted for age, education, work experience, working unit and CPR training. Conclusion: Knowledge and organization of crash cart was improved after educational intervention.


Introduction
A resuscitation trolley (Crash cart/ emergency trolley) is mobile trolley containing drugs and medical equipment to save life. 1 Resuscitation trolley is required in all patient care areas. 2 Nursing personnel should be familiar with crash cart content and location.Inservice education and orientation training is mandatory to up-to-date nursing staff on crash cart trolley. 3,4n UK, in-hospital incidence of cardiac arrest is 1 to 1.5/1000 hospital admissions.Most of the cardiac arrest (85%) occurs in admitted patients.Shockable rhythm is 17%.Return of spontaneous circulation (ROSC) is achieved in 53%, who are treated by the resuscitation team. 5ffective (cardio pulmonary resuscitation) CPR depends on the availability of well-stocked crash carts.Basic device failure, inadequate knowledge, lack of experience, and training on the crash cart are some of the key issues in resuscitation. 6Medication and material-related errors might occur during CPR that can increase morbidity and mortality 7 .Every hospital most have trained healthcare providers as well as adequate amount of essential equipment to deal medical emergency. 80][11] The incidence of cardiac arrest is high in cardiac hospitals.Therefore, crash cart and staff working in a cardiac center should always be ready to tackle cardiopulmonary resuscitation (whether it is in a critical care setting or a general ward).This study aimed to find out the baseline status of the crash cart observation of different inpatient ward, existing knowledge of crash cart management among the nursing staff and intervention as per requirement.

Inclusion criteria and Exclusion criteria
All the Staff nurses working at In-patient ward of SGNHC were included in the study.All the nursing supervisors, staffs on study / maternity leave, staffs working at outpatient department, operation theatre and catheterization laboratory were excluded in study.

Data collection tool/instruments
A semi-structured questionnaire was developed to identify knowledge of the resuscitation trolley among staff nurses.Consultation with subject expert was done (anesthesiologist, CPR expert, nursing supervisors, and cardiologist), observation of the existing crash cart was done and extensive literature review was done to develop the tool.The questionnaire was divided into two sections; part I: Socio-demographic questions, part II: Knowledge related Multiple Choice Questions of resuscitation trolley organization and management.A standard resuscitation trolley checklist of SGNHC was used to observe crash cart in different inpatient ward.

Validity and reliability
A Validity of the instrument was maintained by extensive literature review, consultation with the subject expert (Anesthesiologist, CPR instructor, nursing supervisors, and Cardiologist) and colleagues.Reliability of the instrument was maintained by pre-testing the questionnaire in participants with 10% sample in similar characteristics and setting and they were excluded in the study.The instrument was modified and finalized as required.

Intervention
This study examined the effect of educational intervention among staff nurses on resuscitation trolley management and organization of crash cart in inpatient wards.Education was focused on: content of emergency trolley, organization of drugs on it, post-resuscitation crash cart maintenance, and emergency inventory checklist.A Power Point presentation was prepared.All the nursing staff working at in-patient wards were invited to attend the class.One-hour education session was done in the conference hall of the hospital for consecutive four days by the research team.A demonstration was done for organization of drugs and equipment on a crash cart.

Statistical analysis
Data were analyzed using chi-squared test and pair t-test to identify the difference between the crash cart drug and inventory management before and after intervention.Associated factors with knowledge were examined by using linear regression (multivariable analysis) model.Percentage difference between pre-intervention and post-intervention group was calculated by using percentage difference calculator.To calculate total knowledge score, participant's responses were recoded.Recoded variables were computed to total knowledge score.Same process was followed for total drug and equipment content in crash cart.

CPR training
Yes 67 (50.0) No 67 (50.0) Table 2 represents the knowledge of crash cart management among the nursing personnel in both groups.A higher proportion of nursing staff in the post-intervention group had greater knowledge of crash cart placement, drugs, equipments placement, and safety Nepalese Heart Journal 2023; Vol.20(2), 19-26 checks of the equipment used in resuscitation of the patient.A higher percentage difference was observed in almost all the questions regarding crash cart management in the post-intervention group.The highest percentage difference was seen in maintenance of crash cart (182.3),contents of the drawer (177.4), and safety check of equipment (173.2%).The proportion of knowledge in the post-intervention group was significant with p<0.001.Table 3 represents the percentage differences in knowledge of resuscitation trolley organization after educational intervention among nursing staff.A total of 14 crash cart trolleys were observed.We had seen up to 200% differences in post-intervention crash cart drugs and contents management.However, no percentage difference was observed in some items.Such as, defibrillator and oxygen cylinder placement were not kept as instructed by checklist protocol.Likewise, inj.Aminophylline, inj.Phenobarbitone was 0% in the crash cart before and after an intervention.Most of the other items were updated in the crash cart after educational intervention.Crash cart contents and equipment changed significantly (p<0.001).

ITEMS
Define number   Table 4 shows the total difference in mean score of knowledge and crash cart organization pre-and post intervention crash cart management.Total knowledge difference was significantly seen in post-intervention, with mean knowledge of 10.71(1.91) in pre-intervention and 21.76 (2.45) in post-intervention group.Likewise, total drugs and equipment in the crash cart also was observed updated significantly with post-intervention mean was 23.28 (1.20), and 26.78 (1.3) p<0.001

Discussion
Updated resuscitation trolley is crucial for care of critical emergency in all inpatient wards.Its importance is even more if the health care center is tertiary cardiac center.Unlike developed countries, its importance is often underestimated in developing countries like Nepal.Many hospitals do not have a protocol/ guideline of crash cart organization.The main reason for conducting this study is to assess the current knowledge of nurses on crash cart management followed by education intervention and follow up of post intervention crash cart organization.
In this study, nurses from the post intervention group had better knowledge regarding crash cart and inventory management.The resuscitation cart and equipment management was also observed improved in the post intervention phase.
The nurses from post intervention group had greater of right placement of crash cart at their unit, drugs and inventory placement on it, and safety check of emergency equipment.Similar study conducted by Lamkhede showed significantly increased knowledge level among nurses in post intervention. 14n this study, the post intervention group knew how to keep drugs and equipment in an organized manner so that it could be found easily.The percentage difference in post intervention was increased.Similar kind of increment on knowledge was seen in the study conducted by Makkar and Madaan in New Delhi. 15mmon fault in resuscitation equipment, drugs used in cardiopulmonary resuscitation can have grave consequence, so they should be checked for their functioning condition. 6Knowledge of safety check of equipment also increased with educational intervention among nurses in this study.They checked the equipment before their shift start every time.
Regarding the resuscitation equipment and drug organization in crash cart trolley, the post intervention crash carts observation was found well organized. 4Almost all the drugs items and equipment were found in designated area in the crash cart during post intervention observation.Drawers were labeled clearly.Standardized layout of drawers was found in crash cart of different inpatient wards. 16lear labeling and organization of drugs in a crash cart decreases the chances of medication error during CPR. 7ome drugs like inj Metoprolol, Inj Aminophylline were not found on crash cart in pre and post intervention phase because hospital store and dispensary had not supplied these drugs.Some airway adjuncts like bougie, nasopharyngeal airway, bite block and laryngeal air mask was not there in crash in both phase because these items were lacking at hospital store supply. 17he resuscitation trolley was customized so the defibrillator and oxygen cylinder was kept in different trolley in an accessible place not in a crash cart in both pre-post interventions.There was no locking system in the resuscitation trolley, so the trolley was unlocked all the time but different literature recommended that the crash cart trolley should be locked all the time except in CPR. 18esuscitation council of UK states that resuscitation trolley needs to lock all the time except in emergency, this standard protocol was not found in this study. 5CPR training, age, and working unit were seen less likely associated with knowledge of crash cart, drug and inventory management but education intervention was seen significant.

Limitation of the study
This study had no control group which may affect the interpretation.This is a one-time pre-post intervention study so it is difficult to generalize.

Conclusion
Knowledge of crash cart organization help nursing staffs to initiate cardiopulmonary resuscitation promptly in medical emergencies.This study updated knowledge of crash cart organization to initiate early resuscitation.Knowledge of crash cart organization was improved and well organized crash carts were found in inpatient wards after educational intervention.

Table 2 Pre-intervention and post-intervention knowledge of respondents on resuscitation trolley management Questionnaire Item
Nepalese Heart Journal 2023; Vol.20(2), 19-26 PDiff = percentage difference between pre-intervention and post-intervention group.

Table 5
shows a multiple linear regression model to assess the effect of intervention on knowledge of crash cart management and adjusted for age, education, working unit, and CPR training.The model showed significant improvement in knowledge at post-intervention as compared to pre-intervention (β; 0.928, 95% CI; 10.52, 11.57, p<0.001).There was no significant association of education, age, working unit, and CPR training in crash cart management.