Code - PowerPoint Presentation

Slide1

Code Blue

Erin Stiefel, Monique Sandoval & Vivianne SanadaGNRS 586: Leadership and ManagementJanet Wessels, MSN, RN, PHNJuly 15, 2015Slide2

Background

80 y.o. maleHx: CAD, HTN & SchizophreniaAdmitting diagnosis: hallucinations & anxiety

Unit:

inpatient psychiatric

Hospital

d

ay 2:

s

udden 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

c

ode team had never been to psych unit

The two buildings connect on 4th floorSlide3

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 onChest compressions / ventilatory support not yet initiated Resident & intern began CPR with bag-valve-mask

M

onitor 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 Slide4

Methods

ManpowerMachinesMaterial

Delayed initiation of CPR

Incompetent Psych RN

Unfamiliar Resident/

Intern

Code

b

lue P & P

Lead RN and

r

ole

d

elegation

Incompatible monitor

l

eads (

equipment

)

O

xygen valve

misuse

Electronic Health Record- Code Status

Confirming

c

ode

s

tatus

/

documentation

Available policy

/

p

rocedure

in place

Inadequate SBARSlide5

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 Slide6

Root Cause Analysis

There was a significant delay in the patient receiving CPR due to a lack of protocol outlining training guidelines & standardization criteria for code team. Slide7

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

DO

Implement protocol standardizing code team activation response criteria & guidelines

ACT

Standardized code blue protocol implementation in hospitals nationwide

STUDY

Make predictions, implement interventions & make adjustments based on outcomes

PDSASlide8

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. Slide9

PDSA: Plan

TasksPerson ResponsibleWhenWhereEstablish 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 Slide10

PDSA: Plan

PredictionMeasures 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.Slide11

PDSA: DO

Code Team: Protocol implementationBi-annual skill competency testing New hire & existing code team orientationMock codes / simulationsAdherence 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 Slide12

PDSA: Study

PredictionOutcomeCPR 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.Slide13

PDSA: Study

ProblemSolutionCode team arrival averaged at 5 minutes, rather than 3.Increase time frame to 9 months to allow staff to become accustomed to new protocolRole delegation to initiation of tasks took longer than the 1 minute goalCode 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 Slide14

PDSA: Act

Standardized code blue protocol implementation in hospitals nationwide Based on study outcomes reducing adverse code eventsCode blue team protocol will include: hospital campus orientationemergency 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 Slide15

Stakeholder Analysis

Internal (unit) stakeholdersManagementNurse 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 Slide16

Force Field Analysis

Save lives & improve outcomes by limiting future errors Financial implications for increasing good outcomesRepercussions 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 Slide17

References

Adams, 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