TABLE 4

Systems Issue Identified Specific to MRT and Code Blue Process

AreaIssues Identified in Simulation and DebriefingDiscussionPhase of Training
Roles and responsibilitiesWho does airway?There is going to be an airway physician proceduralist, but can this person precept an HM physician, APRN, or resident through procedure?III
Who is team leading?Can the HM physician defer to the ICU physician? If so, what role will the HM physician then fill? What action can the HM physician take if the ICU physician takes over or team members defer to the ICU rather than the HM physician? The airway doc (ED, ICU, or anesthesia) will also have experience running codes, so it is vital that there is communication at the team level about who is leading the resuscitationIII, IV
“Runners” need to be identifiedThe charge nurse should ideally designate this because it cannot always be the patient care assistant because sometimes things need to be retrieved from PyxisIII, IV
Another person needed at the PyxisSomeone logged in and ready to get supplies (medications, equipment) out and deliver it to the bedside teamIII
Documentation of careNeed a defined person to document care during Code Blue events and RRTs, especially with regards to timing of medications and other interventions.III
Defibrillator setupWho will be responsible for defibrillator setup if a code is not called, and thus a paramedic is not there (eg, a patient in supraventricular tachycardia who needs cardioversion)?III
Clarify the role and responsibilities of the (1) charge nurse and (2) critical care nurses at the satellite campusDiscussed the charge nurse being placed next to the team leader with the following responsibilities: documenting, helping the physician team leader maintain situation awareness, identifying and assigning missing roles and responsibilities (eg, runners)I/II, IV
Who should be doing bedside assessments and reassessments during emergencies?Possible role for APRN?IV
What is the role of the ED paramedic?They have expertise in cardiopulmonary resuscitation (here pertaining to chest compressions) and the use of a defibrillator, which most other disciplines do not, so it’s recommended that they run the defibrillator and “coach” providers doing cardiopulmonary resuscitation (here pertaining to chest compressions)IV
What is the role of the ED nurse?Ideally, the ED nurse should go to the bedside (not to the code cart) and deliver medications and fluids.IV
The majority of the staff do not know each other, including what their discipline and role isIdentified need to use stickers (like at the main campus ICU and ED) to allow better role definition when personal protective equipment is in placeIV
CommunicationSurgical patientsIf RRT or Code Blue is called on surgical patient, how will surgical APRN be contacted?III
Clarification of “calling a code” criteriaAt minimum, a code will be called for cardiopulmonary arrest or near arrest state; respiratory failure (defined as any use of positive pressure), any planned intubation, circulatory failure (defined as >60 mL/kg nasal saline given in short time period [<60 min]), and any use of inotropes, chronotropes, or vasopressors. The team further questioned whether a code should be called for any use of a crash cart? Any intraosseous placement? Seizure activity: any, >1 min, or >5 min? With no resolution despite first antiepileptic drug?I/II, III
Activating RRTWhat phone no. is to be called for RRT and does the activation of an RRT at the satellite campus get relayed to the ICU at the main campus?I/II
Communicating with transport servicesCan the calling of a Code Blue be immediately sent to transport to make them aware of the potential need for moving the patient to the main campus? Does every code patient (if they survive) need to be moved to the main campus?I/II
Need to develop process of communication to support services during emergencies (specifically, radiology, laboratory, blood bank, and pharmacy)Which provider will handle these phone calls?I/II
Positioning of the team leaderIn relation to equipment (ie, telemedicine screen) and team (ie, nurses at code cart), the physician team leader needs to stand where he or she can see the patient, monitor, telemedicine screen, and code cartIV
Staff assist versus RRTAssist button is in the room (next to Code Blue button) and when pushed, it will alert the unit coordinator but does not go to pagers; an RRT has to be called by phone because there is no RRT buttonIV
Need to develop telemedicine consultation processIncluding the expected response time for the ICU physician, the scripting of the initial conversation (ie, who at the satellite campus is going to share the team’s mental model with the ICU physician), what responsibilities and authority the ICU physician has, and who they will be talking to at the satellite campus (eg, 1 person, entire team)I/II
ResourcesPharmacy consultationDuring evening or night and weekend shifts when a pharmacist is unable to attend a code or RRT, is it possible for the team to include the pharmacist via speaker phone?III
Code sheetProviders need training on this. Can the font be larger? Can the form be simplified?III
AlgorithmsNeed for pediatric advanced life support and advanced cardiac life support as well as other best practice algorithms (eg, seizure, anaphylaxis), to be placed on the code cartIII, IV
EquipmentIs there a need for an “RRT kit”?Suggested supplies include normal saline, stopcocks, intravenous fluid tubing; use of a rolling Pyxis or kits; portable suction; respiratory bagIII
Video laryngoscopeRecommended for providers to allow visualization by team leader and ICU physician during intubation attempts; this was purchased and thus training and implementation strategies need to be put in placeIII
Airway BoxNeed to develop an “airway box” because there is not a critical airway team or cart at the satellite campusIV
  • APRN, advanced practice nurse; HM, hospital medicine.