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Improving Code Team Performance and Survival Outcomes: Implementation of Pediatric Composite Resuscitation Training

Lynda Knight, RN, CCRN, CPN1 Julia Gabhart, MD1,2 Karla Earnest, RN, MSN1 Stephanie Wintch, RN, BSN1 Erin Augustine, MD1 Michael Chen, MD1,2 Deb Franzon, MD1,2

Salter Packard Childrens Hospital 2Stanford University School of Medicine

Implementation of Pediatric Composite Resuscitation Training

Background Study Overview Preliminary Data QI Lessons Discussion Points Questions


Paul Sharek, et al. JAMA, Nov. 2007. LPCH.

Improved patient outcomes = Less code team experience

Implementation of a Rapid Response Team (RRT)

decreased code events outside the ICU by 71%

Ongoing resuscitation training is imperative

Educational interventions should be ongoing, focused on improving performance, quality of care, and maintaining 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 resuscitation outcomes.
K Daniels et al., Simul Healthc. 2008.

Pediatric simulation is associated with improvement in CPA survival rates.

P Andreatta et al. Pediatr Crit Care Med, June 2010.

Composite Resuscitation Team Training is associated with: Improved survival Decreased morbidity Improved team communication Improved code performance following pediatric cardiopulmonary arrest (CPA).

Primary Outcome Variable:
Survival to discharge.

Secondary Outcome Variables:

Admission and discharge Pediatric Cerebral Performance Category scores.

Code performance/meeting AHA guidelines

2 minutes to rhythm check during chest compressions. <1 min from HR <60 to chest compressions. <3 min from recognition of VT/Pulseless VF to shock.

Clear identification of Team Leader.

Research Questions
Will implementation of Composite Resuscitation Team Training result in:
Increased patient survival to discharge? Improved performance of multi-disciplinary Code Team members? Decreased morbidity?

IRB approval waived 312-bed freestanding, quaternary care, academic childrens hospital Examined all CPA events for which hospital code team responds. 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

Composite 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 twice monthly (January 2010-June 2011).
14 code simulations to date; anticipate 30.

Insert movie of simulation here

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 Medical Record Number

Code Blue:

Event Date and Time Event Location



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 Asystole Did 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) __________

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 delay 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 knowledgeable 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 Security ICU 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? 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:

Yes No

Report Completed By: Print Name_____________


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

Training and scenarios Useful and realistic

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

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 vs documentation

Code Documentation Quality

True Code Performance

Data Analysis:
Demographic Data
Age Gender Ethnicity Admission diagnosis Location of code event Admission PCPC scores

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

Study CPA Events

Control Period 437 Code Blue Events
242 Excluded

Comparison Period 31 Code Blue Events

12 Excluded

Not CPA events, our team did not respond, not NRCPR criteria
28 Excluded No Code Blue Record 167 CPA Events (136 Patients)

Not CPA events, our team did not respond, not NRCPR criteria
5 Excluded No Code Blue Record 14 CPA Events (10 Patients)

Preliminary Control Period Data

<3 min to first Shock #Admits Mean Mean Survival to 2 min < 1 min to from initial with CPA #CPA PCPC at PCPC at Discharge continuous CC of HR Pulesless events events admit d/c (%) CCs (%) <60 (%) VT/VF (%) 43 of 48 2009 42 60 1.73 1.58 19 of 42 (45) (89) 2 of 3 (66) 9.22 of 40 4.12 18 of 38 (47) (23) 3.73 of 28 4.22 13 of 28 (46) (13) 12.75 of 33 4.07 12 of 28 (42) (39) 30.5 of 40 (76) 14.5 of 19 (76) 23 of 33 (69)

2008 2007 2006

38 28 28

42 31 34

1.79 2.11 1.67

3 of 5 (60) 1 of 6 (17) 7 of 15 (46)

Increased number of CPA events in 2009

Increase in acuity with expansion of PICU, CVICU, SCT Unit NRCPR inclusion despite missing Code Record

Variation between years in performance outcomes

Kappa measurement, single reviewer to re-examine data

Preliminary Comparison Period Data:

July 1-September 31
Survival to 2 min Discharge continuous (%) CC (%) < 1 min to CC of HR <60 (%) <3 min to first Shock from initial Pulesless VT/VF (%) Team Leader Clearly Id'd (%)

#Admits Mean with CPA #CPA PCPC at events events admit Sum, Percent or Average (JulySeptember)

Mean PCPC at d/c




6.66 of 14 3.6 6 of 9 (66) (47)

12.86 of 14 (92) 1 of 2 (50)

5 of 14 (36)

Projected Comparison Period Data size: 40-50 CPA events Initial Team Leader Identification data disappointing

Preliminary Data
70 60 50 40 30 20 10 0 66 45 Control Period Comparison Period 1.8 1.9 Admit PCPC 3.5 3.6 DC PCPC Survival %

Preliminary difference in Survival to Discharge Significant?

Preliminary Data
100 90 80 70 60 50 40 30 20 10 0 CC 1 Min from HR<60%

Control Period Comparison Period 2 Min CC <3 Min to Shock

Initial NRCPR Process Variable outcomes encouraging Code Blue Report quality, simulation trends essential to interpretation

Simulation vs Actual Code Data

100 90 80 70 60 50 40 30 20 10 0 CC 1 Min from HR<60%

Team Leader Clearly Identified Simulations: 91%

Actual Codes: 36%

Control Period Comparison Period Simulation 2 Min CC <3 Min to Shock

Simulation data trends toward correlation with Comparison data

Lessons Learned
Code documentation is suboptimal
Future project: residents as recorder.

In-situ simulation revealed system weaknesses

Unit-specific Code Blue processes Security staff Code cart locations

Team performance hindered by lack of familiarity Broselow Carts

Focused code-cart training initiated

Simulation idiosyncrasies
Suspending disbelief difficult Variable use of debriefing tool

Subjectively, simulations have improved code team performance, communication

Data and subjective experience consistent with the literature Preliminary data encouraging
Survival to discharge, morbidity Code performance/AHA guidelines

Code documentation quality a confounder

Part of Our Research Team

LPCH Innovations In Patient Care Grant, which funds this research

All Code Team members who participated in the Composite Resuscitation Training and in-situ mock codes
Michael Chen, M.D. Amy Nichols, EdD, Director of Center For Nursing Excellence for her help with study design and ongoing support Alex McMillan, Ph.D., and Raymond Balise, Ph.,D., from SPECTRM at Stanford University for their support in data analysis and study design. Support from NRCPR (Get with the Guidelines) Staff and Faculty