Code Blue

Erin Stiefel, Monique Sandoval & Vivianne Sanada

GNRS 586: Leadership and ManagementJanet Wessels, MSN, RN, PHN

July 15, 2015

Background❖80 y.o. male❖Hx: CAD, HTN & Schizophrenia❖Admitting diagnosis: hallucinations & anxiety ❖Unit: inpatient psychiatric ❖Hospital day 2: sudden onset of confusion,

bradycardia & hypotension❖Pt lost consciousness & a “code blue” was called❖Inpatient psych unit is adjacently located to a

major academic medical center ❖Code team within the main hospital was

activated❖Part of code team had never been to psych unit❖The two buildings connect on 4th floor

Background❖Senior resident & intern used the only route they

knew of to get to the inpatient psych unit ❖Upon arrival, patient pulseless & apneic with O2

mask on❖Chest compressions / ventilatory support not yet

initiated ❖Resident & intern began CPR with bag-valve-mask❖Monitor leads incompatible with stickers placed on

the patient ❖Patient remained pulseless with an uncertain rhythm

& O2 sats remained 80%❖O2 was connected, but never turned on by RN ❖Code status was revealed as DNR, without

documentation❖Resuscitation efforts were continued by some at this

point ❖Son was called confirming DNR ❖Efforts were stopped & patient died moments later

MethodsManpower

Machines

Material

Delayed initiation of CPR

Incompetent Psych RN

Unfamiliar Resident/Intern

Code blue P & P

Lead RN and role delegation

Incompatible monitor leads (equipment)

Oxygen valve misuse

Electronic Health Record- Code Status

Confirming code status/documentation

Available policy / procedure in place

Inadequate SBAR

Root Cause Analysis

Lack of policy standardizing code team activation response criteria & guidelines

Inadequate orientation to hospital campus

Team unfamiliar with quickest route to inpatient psych unit

Code team arrival time was delayed

Delay in initiation of CPR

Root Cause AnalysisThere was a significant delay in the patient receiving CPR due to a lack of protocol outlining training guidelines & standardization criteria for code team.

Problem: lack of protocol outlining training guidelines & standardization criteria for code team, ultimately resulting in a delayed initiation of CPR.

PLANDecrease code blue team response time, increasing

initiation of CPR

DOImplement protocol

standardizing code team activation response criteria &

guidelines

ACTStandardized code blue

protocol implementation in hospitals nationwide

STUDYMake predictions, implement

interventions & make adjustments based on outcomes

PDSA

PDSA: Aim Reduce designated hospital code

blue team response time per call to under 3 minutes from time of overhead code call to unit arrival for 100% of code blue incidents within 6 months.

PDSA: PlanTasks Person

ResponsibleWhen Where

Establish performance measures including bi-annual CPR training for all staff members as well as ACLS training for all medically trained hospital staff.

Department managers, hospital supervisors

Planning stage - within 1 month

Throughout hospital setting

Orient all new & existing code team members as well as conduct bi-annual practice mock codes to measure CPR initiation time.

Hospital CPR committee / supervisor of code team

New & existing employee training implementation - within 1 week

Entire hospital campus

Standardize equipment throughout hospital campus to prevent ergonomic issues.

Department managers / hospital supervisors / code team supervisors

Prior to implementation - within 3 weeks

Entire hospital campus

Establish daily crash cart checks per unit.

Unit / department managers

Planning - within 1 week

Entire hospital campus

PDSA: PlanPrediction Measures to determine if

prediction succeedsMock code blues will take place during the training sessions and 100% of the codes will have CPR initiated within 3 minutes of the overhead code call.

Was CPR initiated right away? CPR initiation within 3 minutes of the overhead code call will be measured during the mock code blues. Training attendance will be collected via sign in sheets. Schedules will be based upon attendance & pass rates of mock codes.

SBAR will be efficiently communicated from primary RN within 1 minute of code team arrival.

Was all pertinent patient information communicated to carry out the code successfully? SBAR communication within 1 minute of code team arrival will be measured during mock code.

Equipment compatibility across hospital campus will be 1000%.

Is all equipment throughout hospital campus compatible? Equipment compatibility of 100% will be measured during mock codes.

Crash cart checks will result in 100% of crash carts being fully stocked.

Are all essential supplies fully stocked? Essential supplies / code materials will be given a pass / fail score upon mock code completion.

PDSA: DOCode Team: Protocol implementation

❖ Bi-annual skill competency testing ➢ New hire & existing code team orientation➢ Mock codes / simulations➢ Adherence to response time standards ➢ Map routes for entire hospital campus ➢ Equipment standardization / function tests ➢ Crash cart checks ➢ SBAR training ➢ Code status documentation checklist ➢ EHR training: code status

❖ Time frame: 6 months of orientation, training & mock codes in order for protocol to be implemented in daily practice

PDSA: StudyPrediction Outcome

CPR will be initiated within 3 minutes of overhead code call by arrival of code blue team in 100% of code blue incidents.

Code team arrival averaged at 5 minutes, rather than 3.

Upon code team arrival primary RN will delegate roles within 1 minute of arrival.

Role delegation lasted 2 minutes on average.

Bedside RN will deliver adequate SBAR while code team is beginning role tasks, within 1 minute of arrival.

SBAR was clear, succinct, and beneficial to the code team.

Code team will debrief & discuss problem areas to address for success of future codes.

Debrief sessions helped identify areas for improvement and allowed the code team to focus on individual areas of weakness to make adequate policy improvements.

100% of hospital staff will pass BLS skills checks, 100% of code team will pass mock code blue simulation checklist.

100% of hospital staff passed the BLS skills check, 85% of code team passed mock code blue simulation due to arrival time.

PDSA: Study Problem Solution

Code team arrival averaged at 5 minutes, rather than 3.

Increase time frame to 9 months to allow staff to become accustomed to new protocol

Role delegation to initiation of tasks took longer than the 1 minute goal

Code team will have role delegation by manager at beginning of shift rather than during code

Summary of findings:● Implementing the new protocol has been successful at

reducing the time it takes the code blue team to arrive to code calls

● Our aim of reducing code blue team response time per call to under 3 minutes for 100% of code blue incidents was not quite reached

● The 6 month time frame may not have been enough time to allow the staff to become accustomed to the new protocol

PDSA: Act❖Standardized code blue protocol

implementation in hospitals nationwide ❖Based on study outcomes reducing adverse

code events❖Code blue team protocol will include:

➢hospital campus orientation➢emergency route tour of hospital campus ➢equipment standardization & checks ➢simulated mock code blues ➢decrease in time from overhead code call to CPR initiation ➢SBAR training ➢skill competency testing

Stakeholder Analysis Internal (unit) stakeholders

Management

Nurse Managers

Psych Nursing Staff

The “Code Team” Senior Medical Resident Medical Intern Anesthesia Resident Anesthesia Attending Critical Care Nurse

External stakeholders Patient Family / pts loved ones (son) Academic medical center Insurance companies Other hospitals

Force Field Analysis

Save lives & improve outcomes by limiting

future errors

Financial implications for increasing good outcomes

Repercussions for continued errors

JCAHO

Training push back / staff attitudes

Limited resources

Cost

Decrease code blue team response time to under 3 minutes from overhead call to arrival, ultimately increasing initiation of CPR. Documented in code report in EHR.

Forces FOR Change (Driving Forces)

Forces AGAINST Change (Resisting Forces)

Availability / time

ReferencesAdams, B. D., Carr, B., Raez, A., & Hunter, C. J. (2009). Cardiopulmonary resuscitation in

the combat hospital and forward operating base: use of automated external defibrillators. Military Medicine, 174(6), 584-587.

Guidelines 2000 for Cardiopulmonary Resuscitation and emergency cardiovascular care.

Part 4: the automated external defibrillator: key link in the chain of survival. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. (2000). Circulation, 102(8 Suppl), I60-I76.

Lanfranchi, J. A. (2013). Instituting code blue drills in the OR. AORN Journal, 97(4),

428-434. doi:10.1016/j.aorn.2013.01.017

Mullen, L., & Byrd, D. (2013). Using simulation training to improve perioperative patient

safety. AORN Journal, 97(4), 419-427. doi:10.1016/j.aorn.2013.02.001

Qureshi, S. A., Ahern, T., O'Shea, R., Hatch, L., & Henderson, S. O. (2012). A standardized

code blue team eliminates variable survival from in-hospital cardiac arrest. The Journal Of Emergency Medicine, 42(1), 74-78. doi:10.1016/j.jemermed.2010.10.023