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Improving Code Team Performance
and Survival Outcomes: Implementation of Pediatric Composite
Resuscitation Training
Lynda Knight, RN, CCRN, CPN 1
Julia Gabhart, MD 1,2
Karla Earnest, RN, MSN 1
Stephanie Wintch, RN, BSN 1
Erin Augustine, MD1
Michael Chen, MD 1,2 Deb Franzon, MD 1,2
1Lucile Salter Packard Childrens Hospital 2Stanford University School of Medicine
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Implementation of Pediatric
Composite Resuscitation Training Background Study Overview
Preliminary Data QI Lessons Discussion Points
Questions
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Background
Implementation of a Rapid Response Team (RRT) decreased code events outside the ICU by 71%
Ongoing resuscitation training is imperative
Paul Sharek, et al. JAMA, Nov. 2007. LPCH.
Improved patient outcomes =Less code team experience
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Background
Educational interventions should be ongoing, focusedon improving performance, quality of care, andmaintaining competency.
CHOP: Donoghue AJ et al., Pediatr Emerg Care , Mar 2009 Boston: Allan CK et al., J Thorac Cardiovasc Surg , Sep 2010
Simulation of crisis can identify targets for educational intervention to improve CPA resuscitationoutcomes.
K Daniels et al., Simul Healthc . 2008.
Pediatric simulation is associated with improvementin CPA survival rates.
P Andreatta et al. Pediatr Crit Care Med, June 2010.
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Hypothesis
Composite Resuscitation Team Training isassociated with:
Improved survivalDecreased morbidity
Improved team communicationImproved code performance
following pediatric cardiopulmonary arrest(CPA).
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Objectives
Primary Outcome Variable: Survival to discharge.
Secondary Outcome Variables: Morbidity
Admission and discharge Pediatric Cerebral PerformanceCategory scores.
Code performance/meeting AHA guidelines
2 minutes to rhythm check during chest compressions.
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Research Questions
Will implementationof CompositeResuscitation Team
Training result in: Increased patientsurvival to discharge?
Improved performance
of multi-disciplinaryCode Team members? Decreased morbidity ?
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Methods IRB approval waived
312- bed freestanding, quaternary care, academic childrenshospital
Examined all CPA events for which hospital code teamresponds.
Participants: all members of the code team. PICU/CVICU Attendings and Fellows All RNs, including Nursing Supervisor Pediatric Housestaff Hospitalists Respiratory Care Specialists Pharmacists Social Workers Security
Ongoing training from January 2010-June 2011 Required by HR for staff PALS and/or mandatory MD training sessions
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InterventionComposite Resuscitation Team Training
Institution-specific Code Roles Video
PALS training : Zoll, EZ I/O, Broselow Cart
New code sheet and Quality Code Review Form
Familiarization with high-fidelity manikin
Code blue scenarios and debriefings approximately twicemonthly (January 2010-June 2011). 14 code simulations to date; anticipate 30.
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Insert movie of simulation here
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LPCH Quality Code Blue Review Form For Quality Purposes Only DO NOT Place in Medical Record Send to LPCH Code Committee, Quality Management, Mail Code 5893
Patient Name Event Date and Time Medical Record Number Event Location Code Blue: Pediatric Adult
211 Code Blue Response: Delay Pager issue(s) Other (specify) _________
Was Rapid Response, OB STAT, or Anesthesia ASAP called first? Yes No
Interventions: Chest Compressions Defibrillation Cardioversion Intubation
Cardiac rhythm at time of call: NSR ST SVT Bradycardia VTach w/ pulse VTach w/o pulse Vfib PEA AsystoleDid cardiac rhythm change? NSR ST SVT Bradycardia VTach w/ pulse VTach w/o pulse Vfib PEA Asystole
Brief History of events leading up to code: _____________________________ ___________________________________________________________________ Cardiopulmonary Resuscitation CPR Quality: (If no chest compressions, skip this section) Chest Compressions: Delay No back board Other (specify) __________ Were pulses checked with compressions? Yes No Was arterial line diastolic pressure used to monitor compression quality? Yes No
Not Applicable (arterial line not in place)
Defibrillation(s): Energy level lower / higher than recommended? Yes No Staff knowledgeable of defibrillator operation? Yes No Delay with pad, paddle, or cable placement? Yes No Other (specify) __________
Vascular Access: Was peripheral line obtained? Yes No Already present Was I/0 attempted? Yes No Was central line attempted? Yes No Already present
Airway: Aspiration related to provision of airway Multiple intubation attempts (# attempts: ________) Delayed recognition of airway misplacement/displacement Other (specify) __________
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Medications: Was Emergency Medication Report available? Yes No Delay in code medication availability? Yes No Correct selection, dose, route? Yes No (specify) _________
Was dwindle epi given during compressions? Yes No
Leadership: Was a single Team Leader clearly identified? Yes No Was there a d elay in identifying a Team Leader? Yes No
Did Team Leader perform tasks, e.g. intubation? Yes No
If yes, did Team Leader designate new Team Leader? Yes No Was Team Leader knowledgeable of equipment? Yes No
Was Team Leader k nowledgeable of medications/protocols? Yes No
Protocol Deviation: BLS NRP PALS ACLS (specify) __________ Code Roles Clearly Identified:
Team Leader Respiratory Therapist Code Cart RN Bedside RN Pharmacist SecurityICU RN Event Manager USA
Recorder Nursing Supervisor Runner Responsibilities carried out for each role: Yes No (specify) __________
Clear communication used, e.g. Closed-loop communication: Yes No
Universal Precautions followed by all team members:Gloves Mask Gown
Crowd Control: Successfully managed by Event Manager, Nursing Supervisor, and Security? Yes No
Documentation: Signature of code team leader on CPR Record? Yes No Documentation complete on CPR Record? Yes No Quantros Report submitted? Yes No
Equipment: Available and easily accessible? Yes No Functioning properly? Yes No
Post-code debriefing was led by whom? ____________ List debriefing points addressed for this event:
Comments:
Report Completed By: Print Name_____________ Signature____________
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Study Support
Expectation of participation set &information disseminated Faculty meetings Electronic reminder
Trainees engaged and eager (ICU Fellows) Positive feedback reinforced utility Appreciation of effort with realistic
simulation
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Training and scenariosUseful and realistic
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Data Collection Study population: Patients sustaining in-hospital CPA with
resuscitation Inclusion criteria: Any CPA event to which the hospital code
team responds Exclusion criteria:
Event did not meet NRCPR criteria No code record available
Data Source: Code Sheet Documentation in the medical record or NRCPR data
Control period January 1, 2006, through December 31, 2009;n=167
Comparison period July 1, 2010 through June 30, 2011; projected n = 40
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Additional Data Collection
Mock code performance For comparison with actual CPA outcomes During intervention period
CPA documentation Scored for comparison between control and
comparison periods Intervention impact on code performance vsdocumentation
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CodeDocumentation
Quality
True
Code
Performance
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Data Analysis:
Demographic Data
Age
Gender Ethnicity Admission diagnosis Location of code event Admission PCPC scores
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Data Analysis Analysis of primary & secondary outcome
variables Discrete variables via Chi-squared test Variables with more than one possibility of occurring
per code event via ANCOVA
Secondary analyses Simulation outcome versus actual CPA outcome Documentation quality of control vs intervention period
All analyses with SAS Enterprise Guide
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Study CPA Events
Comparison Period31
Code Blue Events
242 Excluded
Not CPA events, our teamdid not respond, not
NRCPR criteria
12 Excluded
Not CPA events, our teamdid not respond, not
NRCPR criteria
28 Excluded
No Code Blue Record
5 Excluded
No Code Blue Record
167 CPA Events
(136 Patients)
Control Period437
Code Blue Events
14 CPA Events
(10 Patients)
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#Admitswith CPAevents
#CPAevents
MeanPCPC atadmit
MeanPCPC atd/c
Survival toDischarge(%)
2 mincontinuousCCs (%)
< 1 min toCC of HR
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#Admitswith CPAevents
#CPAevents
MeanPCPC atadmit
MeanPCPCat d/c
SurvivaltoDischarge(%)
2 mincontinuousCC (%)
< 1 minto CC of HR
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1.81.9 3.53.6
45
66
0
10
2030
40
50
60
70
AdmitPCPC DC PCPC Survival%
Preliminary Data
Control PeriodComparison Period
Preliminary difference in Survival to Discharge
Significant?
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01020
30405060708090
100
CC 1 Minfrom
HR
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Simulation data trends toward correlation with Comparison data
0102030405060708090
100
CC 1 Minfrom
HR
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Lessons Learned
Code documentation issuboptimal Future project: residents as
recorder.
Team performance hindered by lack of familiarityBroselow Carts Focused code-cart training
initiated
Subjectively, simulationshave improved code team
performance, communication
In-situ simulation revealedsystem weaknesses Unit-specific Code Blue
processes Security staff
Code cart locations
Simulation idiosyncrasies Suspending disbelief
difficult
Variable use of debriefingtool
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Discussion
Data and subjective experience consistentwith the literature
Preliminary data encouraging Survival to discharge, morbidity Code performance/AHA guidelines
Code documentation quality a confounder
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Part of Our Research Team
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LPCH Innovations In Patient Care Grant, which funds thisresearch
All Code Team members who participated in theComposite Resuscitation Training and in-situ mock codes
Michael Chen, M.D. Amy Nichols, EdD, Director of Center For NursingExcellence for her help with study design and ongoingsupport
Alex McMillan, Ph.D., and Raymond Balise, Ph.,D., fromSPECTRM at Stanford University for their support in dataanalysis and study design.
Support from NRCPR (Get with the Guidelines) Staff and
F lt
Acknowledgements