Ergonomically Flawed Electrode Design Can Create Delays in Defibrillation

摘要

Introduction Time is the most important factor affecting survival from ventricular fibrillation cardiac arrest.1 Defibrillation survival decreases by 7-10% for every additional minute of delay.2 Consequently, international guidelines now endorse a goal of only 2-4 minutes from collapse until defibrillation for in-hospital cardiac arrests.2 Cardiac arrest teams are designed to coordinate a timely response, especially to ventricular fibrillation arrest. Unfortunately, excessive delays may occur because the team may be slow to transport, set up, or activate defibrillation equipment. Delays in defibrillation should be viewed for what they are -- a perilous source of medical error. Intuitively one would expect to attribute most defibrillation delays to human error. However, the tremendous impact that flawed equipment design has on medical system error in general is now being increasingly recognized.3 We seek to demonstrate through the following series that flawed defibrillation electrode design can lead directly to intolerable defibrillation delays. Case Reports Our institution uses either Quik-Combo? (Medtronic, Redmond WA) defibrillator electrodes or Padpro? defibrillator electrodes (model 2516 Padpro LLC, Ann Arbor MI) hooked up to a Lifepak? 12 defibrillator (Medtronic, Redmond WA). Unlike the Quik-Combo, the Padpro electrodes require a customized plug adaptor to be connected in series between it and the Lifepak 12 therapy cable (see figure 1). We determined that medical staff confusion over the Padpro and its additional adaptor created unjustifiable delays in defibrillation for two patients.