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Abstract

Introduction: Aggressive efforts to improve situational awareness including identifying and predicting patients at risk of getting sicker, developing mitigation and escalation plans and the like have lead to a substantial decrease in actual code events outside our ICUs. This has lead to a greater dependence on in situ simulation to maintain the skills of our code team. Because we are a large institution that draws code team members from different disciplines and departments it is not uncommon that each subsequent shift's code team is a unique combination of practitioners. Novel interactions between code team members who were unfamiliar with other members had the potential to lead to elements of an optimal response being overlooked, or double covered. We therefore looked at process improvement techniques to implement several key goals for team improvement. Methods: We developed a core set of improvement goals for our code team response, including, but not limited to, team member identification, pre-defined roles for all responders, awareness of those specific roles, performance of a medication pause to assure dosing accuracy, sharing the mental model and consistent and complete documentation. Specific roles for the individual members were stressed between events through liaisons to the units, or by face-to-face communication with the carriers of the code pagers each shift. Key elements of code roles were also written on the armband used for team member identification. Documentation was modified to enhance our ability to track implementation. We then tracked performance through frequent, in-situ, randomly called simulations over a four-month period. Simulations were always followed by debriefings that reiterated goals, stressed the core improvements, and provided direct feedback. Results: Over the course of four months we were able to bring the rate of pre-defined critical process elements occurring during simulation from 40% to 100%. Two late failures were able be tracked to specific process misses, which allowed for focused education and refinement of the process with higher level of reliability interventions. Semi-qualitative observation at actual code events that occurred during this period showed similar presence of the process improvements. Conclusions: Systematic and reinforced practice of improvement processes can demonstrate real change in code team performance during in situ simulation. Sustaining these changes beyond the specific improvement period, and determining effect on outcome of true code events will be important follow up studies.