MIXED BLESSING Using expired dantrolene, which can be physically demanding to reconstitute, helps make simulations as realistic as possible.

Are you confident your staff could handle a malignant hyperthermia crisis? Although you won't know for certain until they experience the pulse-pounding pressure of racing against time during an actual life-or-death event, you can organize realistic drills that have your staff run through the response protocols needed to save a stricken patient. Someday the call might come that puts all their training to the ultimate test. Here's how to make sure every member of your staff is prepared to react quickly and calmly when it does.

1 Tailor the learning
I'd never once participated in an MH simulation in my 16 years of OR nursing, let alone experienced an actual event. But a colleague of mine, Rebecca Albert, BSN, RN, has. Along with another colleague, Lee Ann Quave, MSN, RN, we decided it was time to identify gaps in our staff's understanding of MH and tailor our educational efforts and drills accordingly.

We used a variety of sources, including the National League for Nursing's simulation design template and material from AORN, and expanded on those to create our own drill. To establish a knowledge baseline, we administered a test before the simulation, while planning to re-administer it after. Not surprisingly, the test and subsequent simulations revealed numerous areas for improvement, not just for those who took part, but also for those of us who designed them.

2 Understand the warning signs
One of the deficiencies we found among staff members who thought they knew a fair amount about MH was the misconception that high temperature is one of the early signs. In reality, it's usually one of the later signs, following an increase in end-tidal carbon dioxide, rapid heartbeat, muscle rigidity and rapid breathing. And in our research, we learned that early recognition of symptoms is a huge factor in improving survival.

We also talked about complacency, about never letting our guard down. It's important to understand that, on average, patients who experience MH have had 6 uneventful anesthetic events before that initial crisis is triggered.

So we focused first on recognition and on what to do before the MH cart or toolbox arrives — like hyperventilating the patient, calling the Malignant Hyperthermia Association of the United States (MHAUS) hotline (800-644-9737), putting out a call for as many hands as possible to be available to provide help, packing the patient in ice, and discontinuing volatile anesthetic agents and succinylcholine.

Most simulations are done in the OR, but MH's warning signs might not manifest until hours after a procedure. In fact, the crisis that Ms. Albert faced started just as the procedure was being finished in the OR. The team was so close to the end that they quickly finished and transferred the patient to the recovery room, where they knew they'd have more help. Her experience made us realize that our education and initiative also needed to go beyond the procedure area to the PACU.

NEW MH WEAPON
Should You Add Charcoal Filters to Your MH Cart?

TRAP AND ABSORB The Malignant Hyperthermia Association of the United States suggests you prepare anesthesia machines for MH-susceptible patients with activated charcoal filters.

There's a relatively new tool in the malignant hyperthermia arsenal — activated charcoal filters that quickly trap and adsorb triggering agents that remain in the breathing circuit after flows of volatile anesthetics are cut off. The filters, which can quickly be inserted into the circuit's inspiratory and expiratory limbs, eliminate the need to disconnect and manually ventilate the patient, freeing the anesthesia provider to oversee and assist with the myriad other tasks involved in dealing with an MH emergency, and potentially reducing the number of additional staff needed.

The filters can also be used to quickly prepare anesthesia workstations in anticipation of MH-susceptible patients. In published tests (osmag.net/ra3hzn), the filters reduced trace volatile anesthetic concentrations to acceptable levels in less than 2 minutes, versus the "10 to 104 minutes of flushing normally required to prepare a machine used previously to deliver a volatile anesthetic."

The Malignant Hyperthermia Association of the United States (MHAUS) recommends maintaining a supply of the Vapor-Clean filters, which are manufactured by Dynasthetics (dynasthetics.com) and list for $599 for 8 pairs. The company says the filters can be used on any make and any model of anesthesia machine.

— Jim Burger

3 Know the roles
We also recognized that we needed to more clearly identify each individual's role during the crisis. Nurses are pretty good at walking into a situation, assessing what's going on and knowing where help is needed, but it's important to understand the very specific tasks associated with MH, so we'd prepared "badge buddies," which we handed out to participants to explain what to do and what to look for both before and after the cart arrived. Staff can also reference the badges during a real-life emergency so all assignments are covered and all emergency response steps are completed.

4 Be ready to reconstitute
Your staff has to know how to prepare dantrolene as quickly as possible for administration. We'd acquired some expired dantrolene from a sister facility, which was important because, again, we wanted the simulation to be as realistic as possible. We reconstituted 3 or 4 vials and found that mixing it was more challenging than staff members expected. I've heard of other facilities using substances like powdered drink mixes in drills, but those are made to dissolve pretty easily. I'm not sure they provide a realistic experience. By using expired dantrolene, we were able to see what it's really like without depleting all of our resources for future simulations. I can now say from experience, that it definitely takes more than one person to do the reconstituting and, ideally, more than 2, because it's a labor-intensive task.

THE BIG QUESTION
Do You Know Where Your Dantrolene Is Stored?

CMS data show that lack of malignant hyperthermia readiness is a persistent problem, according to a recent article in the American Journal of Health-System Pharmacy (osmag.net/hchzm6). Specifically, the data show that inspectors have cited various hospitals for inadequacies in staff training, reflected, by among other things, the inability of staff to find dantrolene quickly enough.

In fact, most problems cited by inspectors involve failing to have enough dantrolene on hand or failing to adequately train staff to find and administer the drug. CMS doesn't tell its surveyors how to assess MH preparedness, but it expects facilities to follow "current accepted standards of practice." The Malignant Hyperthermia Association of the United States (MHAUS) recommends that dantrolene be accessible within 10 minutes once a decision is made to treat a patient.

The report notes that facilities shouldn't be surprised if inspectors measure the distance between their MH carts and any areas where succinylcholine is administered to ensure that they aren't too far apart, or time whether a mock MH case could be treated in the recommended time frame.

— Jim Burger

5 Learn to communicate
As always seems to be the case, communication during our drills proved to be one of the most important challenges. That's another reason it's so important to practice in a setting that's as realistic as possible. If you practice like it's the real deal, you'll always identify opportunities for improvement.

Some needed communication improvements were very basic, like making sure everyone knows where the MH toolbox or cart is, knowing the best places to get large amounts of ice quickly and being aware of where the dantrolene is kept (see "Do You Know Where Your Dantrolene Is Stored?"). For example, some facilities have liter bags of fluids in the freezer ready to go, or a big ice machine where ice can be scooped out, particularly if they have a cardiac OR, since perfusion typically requires a lot of ice. But recovery room nurses or others who don't work in the cardiac OR may not know where that ice is. All of those facility-specific factors need to be addressed.

EASY REFERENCE "Badge buddies" help staff members understand what to do both before and after the MH cart arrives.

6 Consider a new code
Going forward, we're also talking about creating a special code — in addition to blue, red, yellow, black and so forth — for whenever there's an actual MH crisis. That would let people know more quickly what's going on and how they'll be expected to pitch in once they arrive. MH patients are going to eventually have to be taken to the ICU, but they're not necessarily going to be in cardiac arrest, which is what the assumption would be if a code blue is called. An MH crisis may require different kinds of responses.

Proven improvement
When we pre-tested staff members on their MH understanding, the average score was 46.6%. After the simulation, it was 80%. Meanwhile, the average self-rated knowledge and capability score zoomed up from 28% before the simulation to 88% after. Those improvements clearly demonstrate the value of running realistic drills. We hope we never have an MH crisis, but even more so, we want to be prepared if we do. After all our hard work, we know we're ready. OSM