Hospital Name: Hahnemann University Hospital Applicant: Cindy Marino [email protected] Title of Initiative: Closing the Code Team Gap Abstract (Please limit this description to 250 words) The American Heart Association has Get with the Guidelines Resuscitation Recognition Measures in place to acknowledge hospitals that demonstrate at least 85% compliance with specific measures. It is critical for hospitals to continue to improve time to first chest compression and time to first shock in order to improve patient safety efforts and increase the chances of saving a patient’s life. Our organization’s shared governance structure provides a forum where our team is engaged and empowered to create change. Our committees, councils, and task forces serve as a venue for staff to participate and provide input. The hospital Critical Care Committee is an organizational decision-making group. There is a vast array of multidisciplinary representation on this organizational committee. During the monthly hospital Critical Care Committee meeting, the topic of nurses and physicians needing mock codes to improve skills and confidence during actual patient code situations was discussed. The Chief Medical Officer (CMO) expressed the need for mock codes to be conducted on a monthly basis so telemetry and medical-surgical nurses have a greater understanding of the importance of immediate initiation of cardio-pulmonary resuscitation (CPR) and defibrillation for our patients. Therefore, the CMO asked that a subcommittee be formed to develop a mock code program at the hospital to improve and promote an organizational culture of patient safety, teamwork, and collaboration. What were the goals of your initiative? Two goals were set by the Critical Care Committee that would enhance patient safety and improve organizationwide practice. 1. Increase time to first chest compression ≤ 1 minute from our baseline data of 98% 2. Convert defibrillators to automatic external defibrillator (AED) setting for all areas in the hospital outside of the intensive care unit (ICU) setting thereby increasing the time to first shock ≤ 2 minutes from our baseline data of 75% What were your initiative's baseline data and the results of your initiative? During a Critical Care Committee meeting in 2012, a gap was identified with time to first chest compression being less than or equal to 1 minute and time to first shock of less than or equal to 2 minutes. The committee discussed there being a lack of confidence among staff with cardiopulmonary resuscitation and the need to improve these skills among the nurses and physicians in the telemetry and medical-surgical units. Though baseline data demonstrated we were above the national average for academic medical centers (AMC) in the two resuscitation measures, there was still room for improvement which could have drastic, beneficial effects on patient safety during patient code events. Baseline data for 2011 for time to first chest compression ≤ 1 minute was 98.1% in 2011 compared to 95.8% for academic medical centers. Baseline data for 2012 for time to first shock ≤ 2 minutes was 75% in 2011 compared to 69.6% for academic medical centers. The following plan of action was implemented throughout 2012 and 2013 to achieve sustainable results of improvement for patient safety and promote an organizational culture of safety and teamwork. Our hospital participates in the American Heart Association Get with the Guidelines Resuscitation Program and is compared nationally to academic medical centers that also take part in this program. A total of 729 hospitals participate in the program. Since implementing the organization-wide mock codes across different practice settings, time to first chest compression ≤ 1 minute in adult and pediatric patients has improved significantly. We achieved our goal of improvement by attaining 99% in 2012 from 98.1% in 2011 and continued to sustain the improvement in 2013 with by reaching 100% for time to first chest compression ≤ 1 minute in adult and pediatric patients. We exceeded our goal in 2012 and 2013 for time to first shock ≤ 2 minutes. We improved significantly from 75% in 2011 to 100% in 2012 and 2013. Due to the organization-wide efforts, time to first chest compression ≤ 1 minute reached 100% in 2013 and time to first shock ≤ 2 minutes significantly increased from 75% to 100% in 2013. Due to our success with the Get with the Guidelines Resuscitation program measures to improve patient safety, quality of care, and outcomes, our organization was recognized and received the Silver Resuscitation Award from the American Heart Association for 2013. This was one level up from the Bronze award received in 2012. Our organization was invited to present at the American Heart Association’s Regional Workshop “Strive to Revive: Overcoming Challenges of In-Hospital Resuscitation” on May 3, 2013. We presented on Closing the Code Team Gap. Describe the interventions that were instrumental in achieving the results for your initiative. At the meeting the Associate Chief Nursing Officer (ACNO), announced that the nursing directors of the Heart Failure Telemetry, Cardiac Intensive Care Unit, Progressive Care Unit and Medical Intensive Care Unit, would take the lead in organizing the mock code process and house-wide conversion to AED mode. To fulfill the implementation of this organization-wide process a mock code task force was formed that developed a comprehensive plan for an organization-wide mock code process and AED conversion. In the task force’s first meeting for plan development to achieve the goals they considered the process to implement the mock codes. The table below identifies the topic and the correlating process decided upon. Topic Process Frequency and timing of mock codes Mock codes would be held twice a month on Monday afternoons at 1pm and on nightshift by Dana. Location of the mock codes Mock codes would begin on a designated floor and the subcommittee would work their way down. Using a manikin A manikin would be placed in a patient bed to provide true to life experience with proper placement of defibrillator pads to a patient’s chest. Code Cart The Staff Education department’s code cart is different from the code carts on the nursing floors. It was decided to use the code cart on the floor so staff has the opportunity to see the layout of their code cart since that would be the code cart the staff would utilize, therefore helping make the scenario more realistic. Nursing Director Involvement The nursing director of the floor where the mock code was identified to be held would be contacted by the member of the mock code team to pinpoint an empty room. It was also the expectation that the nursing director would be present during the mock code. Physician Involvement About a week before the mock code a triage Resident would be contacted and informed of the date, time, and location of the scheduled mock code. It would be communicated that a Resident physician would need to be present to help run the mock code. The triage Resident is responsible for ensuring a Resident physician from the code team arrives to run the mock code. Evaluation Tool Developed a mock code evaluation tool observing critical steps such as, start of chest compressions within 60 seconds, placing the defibrillator pads, and shocking the patient within 2 minutes. Role of Subcommittee Members One person would be the designated time keeper; 4 other individuals would observe CPR compressions, air way management, turning on the automated external defibrillator (AED), and proper pad placement. Mock Code Debriefing Post mock code debriefing would be done to praise the positive actions the staff took and to work on areas of improvement, such as goal of initiating CPR within 60 seconds, placing defibrillator pads and shocking within 2 minutes. The task force later met to finalize the process for their first mock code that would occur on one of the cardiac telemetry floors. The implementation process of the mock code event included: • The nursing director identifies an empty patient room for the mock code to occur • Thirty minutes prior to starting the mock code, the committee meets in the empty patient room and places the manikin on the patient bed • Mock code evaluation checklist is distributed to the team • Quick discussion on elements to focus on are reviewed: calling a code, initiation of CPR, placing the defibrillator pads, and turning on the AED • A member of the mock code team would pull the emergency light in the patient’s room. Someone would come on the intercom and ask, “Can I help you?” A member of the mock code team would answer, “The patient is not responsive, something is wrong, we need help.” • As soon as someone entered the room the stopwatch was started. • The mock code committee would explain a Situation-Background-Assessment-Recommendation (SBAR) patient scenario tailored to the nursing floor the mock code was conducted on. For example, the Surgery Special Care unit would have a surgical or trauma patient scenario, the OB Services floor would have a scenario involving a patient who just delivered a baby, and the Interventional Cardiology floor would have a cardiac scenario. • Below is a SBAR scenario example of a nurse communicating to a physician about a patient in ventricular tachycardia. The subcommittee focused heavily on initial nurse response and quickly starting CPR and defibrillation if needed. The goal was to have several elements already accomplished by the time the code team arrived. S – I was notified by the telemetry tech that the patient was in ventricular tachycardia, I found the patient unresponsive. B – The patient was admitted 1 day ago with acute myocardial infarction, has been pain free, previous telemetry rhythm was normal sinus rhythm, and vital signs stable. Patient is scheduled for a cardiac cath this morning. A – The patient was found with no pulse and morning lab shows potassium 2.8. R – CPR started and patient has been defibrillated. Recommend continuing CPR, repleting potassium, and contacting the Cardiology fellow. • Our yellow, hand-off communication tool was filled out with a past medical history, chief complaint of what brought the patient in to the hospital, what labs were drawn, and what tests were completed. The staff would read the hand-off tool at the beginning of the code. The nursing flow sheet would have the vital signs information, documented lab results, and patient assessment, basically, just enough information to guide the staff through the mock code. • The staff is told this is a code situation and to proceed with what you would do during a patient code • The code would be called by the staff as an actual code, not a mock code. This was a benefit because it would provide information on how long it took the code team to arrive on the unit and if all of the members of the code team showed up. The mock code would run for about five to ten minutes, depending on how long it took the staff on the floor, as well as the code team, to arrive. Immediately following the mock code, a debriefing session would be held. Staff was told their timing related to establishing unresponsiveness, airway, starting chest compressions, placing the defibrillator pads, and calling the code. The staff would be commended for what was done correctly and informed on areas of improvement. Staff would also ask questions during the debriefing about items in the code cart as well as specifics to recording information on the code 99 documentation form. After each mock code the committee would compare notes and fill out the evaluation tool. A copy of the completed tool would be sent to the ACNO and the director of the unit. At each Critical Care Committee meeting the information provided included a brief summary of how many mock codes were done, discussed areas for improvement (such as nurses operating the AED), and the team work displayed from the health care team. After a few mock codes a common theme was noted – staff were intimidated by the AED. They did not understand how it worked and their responsibility in using it. Therefore, the Critical Care Committee made a decision that would change practice organization-wide. All areas outside of the ICUs would have the LifePak defibrillators automatically set to AED mode when turned on so staff would be able to shock a patient easier and faster if needed. The task force members developed an AED education tool. All staff was educated on the tool either by the nursing director or clinical educator/manager of the unit, with support from the Staff Education department. This education is now a part of new hire nursing orientation. The Clinical Quality department had oversight for physician education. As mock codes were continued, an increase in confidence in the use of the AED was noticed. How can this initiative be replicated through the region? (Please limit this description to 100 words.) Our improvements increased the safety for our patients. The mock codes provided more education and confidence to our staff working throughout the hospital practice settings and to our physicians, which in turn created a quicker response by the healthcare team in providing initial shock by the AED and faster initiation of chest compressions for the patient in a code situation. With our detailed structure and processes, any organization can replicate our innovative plan of action for their patient population, ultimately improving the organizational culture for patient safety awareness, teamwork, and collaboration. Explain how the initiative demonstrates innovation (Please limit this description to 100 words.) The mock code process takes education for the healthcare team on code management to the next level by introducing multidisciplinary mock code scenarios into everyday practice. Utilization of a life-like manikin to simulate a true to life code situation with a patient at an unannounced time and location on the nursing unit allowed for healthcare providers to enter into a situation unaware and armed with critical thinking skills to complete the code process. Debriefing sessions following each mock code scenario provided invaluable feedback to healthcare team members for improving patient safety. How does this initiative demonstrate collaboration with other providers within the continuum of care? (Please limit this description to 100 words.) The multidisciplinary representation on the Critical Care Committee contributed to effective collaboration and decision-making at the hospital-level. The nursing directors of the Heart Failure Telemetry, Cardiac Intensive Care, Progressive Care and Medical Intensive Care units on the mock code task force worked diligently to develop the organization-wide mock code process and AED conversion. In collaboration with the CMO, ACNO, and other members of the Critical Care Committee, our innovative process led to the achievement of sustainable results of improvement in patient safety during patient code events. Explain ways in which senior leadership exhibited commitment to the initiative (Please limit this description to 100 words.) Our Critical Care Committee identified a gap with time to first chest compression and time to first shock, and recognized a lack of confidence among staff with cardiopulmonary resuscitation. The need to improve these skills among the nurses and physicians in the telemetry and medical-surgical units was apparent, and our hospital-wide initiative to improve patient safety was driven by our ACNO and CMO. They supported the development of the mock code task force to spearhead this initiative. Their emphasis on quality patient care and safety propelled our organization toward practice changes that contributed to improved outcomes for patients.