An Emergency Department Nurse-Led Educational Intervention of Bystander Hands-Only Cardiopulmonary Resuscitation in the Homeless Community

Sunday, 30 July 2017

Caroline Warren, BSN, RN, CHES
Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
Diana Lyn Baptiste, DNP, MSN, RN
Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD, USA


An estimated 360,000 out-of-hospital cardiac arrests (OCHAs) occur each year in the United States. Individuals living in low socioeconomic neighborhoods and members of the homeless population are at a higher risk for death due to cardiovascular complications. Homeless individuals experience cardiovascular deaths at a higher rate due to inequities related to a lack of access to preventative and routine health care. According the U.S Department of Housing and Urban Development, there are 7,856 individuals who are without homes in Maryland. Of the individuals experiencing homelessness in Maryland, 22% are considered habitually homeless and demonstrate a high burden of disease including chronic health problems, substance abuse, and mental illness. Cardiovascular disease and related complications are the leading cause of death in the state of Maryland, stimulating concern for the how healthcare professionals manage this problem among the homeless who are disproportionately affected.

The aim of this community-based health education project was to evaluate the feasibility of the implementation of an emergency nurse-led bystander cardiopulmonary resuscitation (CPR) education program for homeless adults in Baltimore. The goal of our education program was to address individual and community health needs by providing instruction of best practice with hands-only CPR to homeless individuals in a transitional setting. We conducted a pilot evaluation of the implementation of hands-only bystander CPR education sessions in the East Baltimore Homeless Community aimed at developing strategies for future sustainable emergency nurse-led programming.


We conducted a pilot evaluation of the implementation of hands-only bystander CPR education sessions in a homeless shelter aimed at developing strategies for future sustainable emergency nurse-led programming. The setting for this study was a low barrier emergency shelter located in Baltimore, Maryland that offers services to more than 275 adults. This shelter is managed by Catholic Charities of Baltimore and sponsored by the city of Baltimore. Residents of the shelter are encouraged to attend classes like this bystander CPR education session by the on-site counseling staff and are incentivized for their attendance through the shelter’s self-sufficiency development programming. The class size was limited to 10 participants so they each could have their own CPR manikin. Our Institutional Review Board deemed this study as non-human subject research and exempt from review.

Instruction was provided by volunteer registered nurses who practice in the adult emergency department in a Level One urban academic medical center that sees 70,000 patients annually. Instructional methods were based on the program American Heart Association’s (AHA) Hands-Only CPR curriculum. Hands-only CPR is to be implemented when a teen or adult collapses in an everyday setting and then a trained bystander can initiate the two basic steps which includes starting compression-only CPR (i.e. no mouth-to-mouth breaths are administered). The education program delivered to participants was based on teaching two basic steps to responding to a cardiac arrest, 1) call 911, and 2) “push hard and fast at the center of the chest.” Nurses first demonstrated hands-only methods on manikins and provided real-life scenarios in which OHCAs can occur. A focus of this program was to gain the participant’s trust of emergency services with the instruction given by emergency nurses who could advocate to create a culture of health and promote a change to increase community safety.


A total of 52 people were trained over seven sessions with the emergency nurse volunteer instructors. Each session lasted for 30 minutes, with a total of 10 volunteer impact hours. Our highest attendance was during the code blue alert months October through March. A total of 32 participants attended during code blue months while 20 attended during non-code blue months. A 64% difference in attendance was apparent. Attendance was lower during the warmer months, when residents were typically less likely to participate in community-based education programs at the shelter.


The AHA Hands-Only CPR curriculum is simple to teach and designed for populations with varying levels of health literacy. The straightforwardness of the hands-only course allows for the educators to specifically target people who live in low-income neighborhoods and communities with an increased risk to die from cardiac arrest. Attendance to this program in-house at the shelter was voluntary, but there was some internal motivation for attendance. We discovered that while many residents where interested in attending the session, the timing often created a scheduling conflict with their other required programs. Through this experience, we learned that it is important to consider the time of the day so that residents can attend other required programs and obligations to shelter rules. Further investigation is necessary to explore learning outcomes, knowledge and attitudes among the participants receiving the hands-only bystander CPR education.