As a healthcare professional, you’ve probably witnessed the chaos and confusion that ensue when a “code blue” is called for a patient in cardiac arrest. This emergency requires an urgent, organized response with immediate coordination of members of a highly capable interdisciplinary emergency resuscitation team.
At Oregon Health & Science University (OHSU), a Magnet® hospital, the code blue team may consist of staff who’ve never worked together before. Its six members include a physician team leader (a medical intensive care unit [ICU] fellow), an anesthesiologist, a respiratory therapist, and three critical care nurses. All team members except the respiratory therapist are certified in advanced cardiac life support (ACLS). OHSU policy defines the roles of each team member.
In 2008, nurse code-blue responders identified the need for additional training to improve patient safety and enhance code-responder nurses’ confidence and performance. The code RN development program was created in collaboration with the adult rapid response team and the simulation center. Through this training, staff identified the need for more clearly defined roles. The nurses identified three primary nursing responsibilities (called the 3D roles) that must be addressed in a code blue event—drugs, defibrillator, and documentation.
In 2009, OHSU recognized this innovative training and, understanding the need for high-stakes teams to train together, asked that the training become interdisciplinary. Consistent with Magnet principles, OHSU nurses often assume leadership roles in collaborative interprofessional activities to improve the quality of care, so this project fit in well with the organization’s culture.
With support from hospital administrators, an interdisciplinary committee was formed and cochaired by a nurse and physician. Committee members (physicians, nurses, respiratory therapists, and quality management and simulation specialists) developed a program of mock codes called simulated code interdisciplinary team training (SCITT). SCITT was officially launched in August 2009 for the purpose of training high-performing teams using crew resource management (CRM) strategies and ACLS algorithms to manage complex and dynamic crisis situations.
Evidence supports using simulations for cardiac resuscitation rehearsals to improve clinical team performance. Using a high-fidelity human patient simulator gives the SCITT team a chance to re-create a crisis scenario without endangering patients. Actual code team members participate in SCITT sessions—sudden, unanticipated, in situ code simulations followed by highly facilitated debriefings.
The immediate goal of SCITT is to identify and assess skill deficits and systems problems in emergency medical response. The longer-term goal is to improve code response by allowing code teams to practice the cognitive, technical, and behavioral skills necessary to manage these low-frequency but high-acuity events. Immediately after each mock code, the team is evaluated and gets feedback based on individual and team performance, focusing on the behavioral, cognitive, and technical skills specific to the resuscitation scenario.
SCITT sessions occur approximately twice a month and include both day and night shift staff. The hospital’s bed-flow manager allows SCITTs to take place in situ in various patient locations. Each scenario is specific to the unit location and patient population. SCITT sessions are paged to the OHSU code blue team through hospital operators as an “adult mock code blue.” Although participation is required and mandated, paging the sessions as mock codes gives a layer of safety to providers who may be engaged in other life-sustaining or emergency situations, which take precedence over training. Code team members are expected to triage the event, just as in a real code, by handing off or sending another provider to the mock code. Each SCITT session lasts about 1 hour and includes a 10-minute mock code.
After the session, a 30- to 40-minute debriefing and short session evaluation by participants are held. To maintain an interprofessional approach, the debriefing is done by a physician and nurse, each of whom has content expertise in either ACLS or CRM. The debriefing also includes a simulation specialist to assist with the manikin and two nurse actors who portray first responders. (See SCITT debriefings.)
Improvements over time
The Clinical Teamwork Scale used to measure elements of CRM uses a 0-to-10 scale for all categories (with 0 indicating poor and 10 indicating perfect). Baseline scores from 2009 ranged from 4 to 5.79 (average). After 2 years of training, all scores showed statistically significant improvements from baseline.
The critical action scale used to measure adherence to ACLS revealed that the code blue team correctly identified the cardiac rhythm 94% of the time—a significant improvement from a baseline adherence of 71% (p = .01). In addition, the team recognized the need for prompt defibrillation 82% of the time, compared to 47% at baseline (p = .005).
Simulation provides an excellent opportunity to mimic the intensity of critical events by practicing cognitive, technical, and behavioral skills with hands-on, real-time team training in a safe environment. At OHSU, SCITT has contributed to improved clinical and team-based performance as measured in mock codes over time.
System-level improvements have been identified through training, such as documentation, code-cart contents (based on practice and feedback), and the need for additional training on new equipment. The program has led to institutional support for RN code blue team members to function as code team leaders if they arrive on the scene before the physician code leader.
However, planning and facilitating SCITTs are time- and resource-intensive. Filling all the interdisciplinary roles to run a SCITT has been a challenge, especially on the night shift. We plan to continue twice-monthly SCITTs and have increased the scenario complexity based on actual case reviews from the code blue committee. We now have scenarios that incorporate a ventricular assist device, tracheotomy, pregnancy, massive hemorrhage, and ICU code blues. This project is approved by the institutional review board. We’re collecting data from actual code blue events to confirm that the training has translated to improved teamwork and clinical accuracy.
Field JM, Hazinski MF, Sayre, MR, et al. Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S640-56.
Guise JM, Deering SH, Kanki BG, et al. Validation of a tool to measure and promote clinical teamwork. Simul Healthc. 2008;3(4):217-23.
Seethala RR, Esposito EC, Abella BS. Approaches to improving cardiac arrest resuscitation performance. Curr Opin Crit Care. 2010;16(3):196-202.
Cynthia Perez is nurse manager for the cardiac and surgical ICU at Oregon Health & Science University (OHSU) in Portland and cochair of simulated code interdisciplinary team training at OHSU.