TABLE 5

System Changes Made Through Iterative Simulation With Debriefing Training Process

TopicKnowledge or Resource GapsLessons LearnedSystem Changes
Crash cartLocation in the roomProviders need further training with the code cart because, again, ICU nurses often play this role at base facilityAdditional crash cart and code sheet orientation added in subsequent sessions
Midlevel providers are inexperienced with the drawing and administration of medicationsCode sheet is not easy to use for providersCritical care nurse responsible for crash cart medications
Not all providers are familiar with code sheetED nurses responsible for administration
pediatric advanced life support, advanced cardiac life support, and other best practice guidelines added to the cart on the new unit
Code sheet font was enlarged and sheet was simplified
DefibrillatorHow to turn it onNeed further training for providers before the opening because, typically, ICU staff at the base facility code team handle this roleAdditional defibrillator orientation and practice in subsequent sessions.
How to select synchronized modeICU physician should be able to view
AccessWho can place and IO?Need to make sure IO equipment is available on new unitAdditional IO and epinephrine practice in subsequent sessions
What IO equipment is needed and how to we flush them?Providers need further IO practicePharmacist on call or available
Epinephrine administration in anaphylaxisProviders need further training in epinephrine administration
Dosage and Pyxis knowledge is limited among providersAdditional pharmacy support needed
AirwayHard to mitigate intubation failures with telemedicineNeed airway training for HM providersAirway training required for HM providers
Which RSI protocol (ED, ICU, or anesthesia) is best for our setting?Need to have video laryngoscopy equipment so the ICU physician can help HM providersPurchase of video laryngoscope to allow for visualization by ICU physician and HM team leader
Need further discussions with ED, anesthesia, and others about RSI protocolRSI protocol adopted from the ED
Code Blue classificationCode Blue versus RRT in a setting without direct ICU supportCode Blue needs more strict criteria than typically because of lack of direct critical care supportCardiopulmonary arrest
>60 mL/kg normal saline bolus
Use of inotropes
Use of positive-pressure ventilation
Seizure >10 min (requires second dose of benzodiazepine)
IO placement
  • HM, hospital medicine; IO, intraosseous; RSI, rapid sequence intubation.