Code Team Members Research Articles

Mind the gaps: Building communication bridges during medical codes

We describe the development and implementation of a program to identify and address gaps in code response at Memorial Sloan Kettering Cancer Center (MSKCC), a tertiary cancer center in New York City. The program aimed to assess the challenges faced by Rapid Response Team (RRT) and Medical Code Team (MCT) members, classify these challenges into medical knowledge/skills or team functioning/communication categories, develop a plan to address the identified challenges, and evaluate its effectiveness within the RRT/MCT teams. Based on survey responses and ongoing quality assurance (QA) reviews the two main challenges identified were chaos or crowd control and role identification. A tailored simulation-based training session was designed and implemented, leading to improved crowd management and the establishment of an ongoing training program.

Abstract 10327: Protected Mock Codes Using In-situ Simulation in Times of the COVID-19 Pandemic

Introduction: Our hospital faced an uphill battle with increasing clinical emergencies, a surge of patients, and compliance with the new regulations during the COVID-19 pandemic. Thereby, the code blue team developed a protected code blue protocol to minimize the infectious risk of the code team members and provide efficient management of emergencies during a lifesaving situation. Objectives: This project aimed to help the core team members to practice the new protected code blue protocol using in-situ simulation. The drills might improve the self-confidence of the code team members in performing their role, clear identification of themselves, effective communication skills, and teamwork. Methods: The mock code team developed different scenarios and ran the drills in 17 departments in different shifts within 8 weeks. A convenience sample of 269 staff participated in the drills. Participants included physicians, respiratory therapists, nurses, and other disciplinary staff. A debriefing was conducted to identify areas of improvement. Participants completed an evaluation form during the debriefing. The form included questions using a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) to rate the variables. Descriptive statistics and the Pearson correlation coefficient were used to test the hypotheses. Results: Out of the 269 participants, 125 staff completed and returned the evaluation form. The mean overall rating of the protected mock codes was 4.184 at a scale from 1 (very poor) to 5 (excellent) with a standard deviation of .827. The Pearson correlation coefficient ( r ) between the overall rating of the training and the amount of self-confidence in performing their role was .697 ( p =.000); clear identification of themselves was .329 ( p = .000); effective communication skills was .500 ( p = .000); and teamwork was .526 ( p = .000). Limitations: The project was conducted in a teaching hospital. The results might not apply to different care delivery settings. Conclusions: The findings of this project demonstrated that in-situ simulation improved the self-confidence of the code team members, communication skills, and teamwork in performing the protected code blue protocol for a COVID-19 suspected or confirmed patient with cardiac arrest.

Can hospital adult code-teams and individual members perform high-quality CPR? A multicenter simulation-based study incorporating an educational intervention with CPR feedback

AimsA multicenter simulation-based research study to assess the ability of interprofessional code-teams and individual members to perform high-quality CPR (HQ-CPR) at baseline and following an educational intervention with a CPR feedback device. MethodsFive centers recruited ten interprofessional teams of AHA-certified adult code-team members with a goal of 200 participants. Baseline testing of chest compression (CC) quality was measured for all individuals. Teams participated in a baseline simulated cardiac arrest (SCA) where CC quality, chest compression fraction (CCF), and peri-shock pauses were recorded. Teams participated in a standardized HQ-CPR and abbreviated TeamSTEPPS® didactic, then engaged in deliberate practice with a CPR feedback device. Individuals were assessed to determine if they could achieve ≥80% combined rate and depth within 2020 AHA guidelines. Teams completed a second SCA and CPR metrics were recorded. Feedback was disabled for assessments except at one site where real-time CPR feedback was the institutional standard. Linear regression models were used to test for site effect and paired t-tests to evaluate significant score changes. Logistic univariate regression models were used to explore characteristics associated with the individual achieving competency. ResultsData from 184 individuals and 45 teams were analyzed. Baseline HQ-CPR mean score across all sites was 18.5% for individuals and 13.8% for teams. Post-intervention HQ-CPR mean score was 59.8% for individuals and 37.0% for teams. There was a statistically significant improvement in HQ-CPR mean scores of 41.3% (36.1, 46.5) for individuals and 23.2% (17.1, 29.3) for teams (p<0.0001). CCF increased at 3 out of 5 sites and there was a mean 5-s reduction in peri-shock pauses (p<0.0001). Characteristics with a statistically significant association were height (p=0.01) and number of times performed CPR (p=0.01). ConclusionCode-teams and individuals struggle to perform HQ-CPR but show improvement after deliberate practice with feedback as part of an educational intervention. Only one site that incorporated real-time CPR feedback devices routinely achieved ≥80% HQ-CPR.

COMPRESS INTERVENTION: QUALITY IMPROVEMENT IN CODE TEAM PERFORMANCE, EVALUATION, AND ASSESSMENT IN COMMUNITY HOSPITAL

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Code team is essential to respond to acute changes in patient clinical condition to prevent morbidity and mortality due to cardiopulmonary arrest. Effective code team is paramount especially in the community hospital as an effective team will save life efficiently and to reduce the morbidity and mortality. To achieve this, members of effective code team must be proficient in knowledge and skills and are effective in communication. To increase the overall performance and effectiveness of our hospital’s code team, we developed and implemented “COMPrESS” intervention, which stands for Code Team Member Performance Restructuring, Evaluation and Assessment METHODS: COMPRESS intervention is developed based on theory of planned behaviour and health belief model, which spanned over a 6-month period. In this intervention, various measures have been taken which include fixing a defined number of code team members, clearly identification of the roles of each member, evidence based knowledge assessments and education, initiation of training and education events (which includes Algorithm display, ACLS training and quarterly review lectures and exam) and surprise mock codes. To measure the effectiveness of the intervention, pre-intervention and post-intervention performances were collected by designated, unbiased and structured questionnaires. In addition, code team members knowledge and skills were also assessed by surprised multiple choice questions test and mock codes. Qualitative (NViVO analysis) and quantitative analysis (descriptive statistic, Fisher’s Exact test and Wilcoxan Sum Rank test) were used to identify the differences in the percentage of pre- and post-intervention survey. Post-intervention, there is significant improvements in the code team members knowledge and their confidence in the skills specific to their roles. In addition, there is small improvement seen in code team structure with regards to defined numbers of participant, clarity of the role and time to transport of the patient to next level of care. RESULTS: COMPrESS intervention improves code team members self-confidence, performance, knowledge and skills as well as to maintain team performance, confidence and cohesiveness, which enable the members to run the code in an organized, safe and effective manner. COMPrESS intervention has greatly improved several key areas that may impact the cohesiveness and functioning of the team. The improvement in the code team performance is beneficial not only to the team members but also able to reduce morbidity and mortality, improving patient’s quality of life as well as to reduce healthcare cost CONCLUSIONS: COMPrESS intervention that we developed may serves as a model for other community hospitals to improve their code team performance. CLINICAL IMPLICATIONS: Improvement in physician performance,quality of patient care, better patient outcomes and reduced health care cost with COMPress intervention. DISCLOSURES: No relevant relationships by Kok Hoe Chan, source=Web Response No relevant relationships by Battah Hamdi, source=Admin input No relevant relationships by Muhammad Hussain, source=Web Response No relevant relationships by Muqueet Kadri, source=Web Response No relevant relationships by Sudha Lagudu, source=Web Response No relevant relationships by Saraswathi Lakkasani, source=Web Response No relevant relationships by Ujjwala Murari, source=Web Response No relevant relationships by Bhavik Patel, source=Web Response No relevant relationships by Lakshmi Durga Sriramulu, source=Web Response No relevant relationships by Divya Mounisha Thimmareddygari, source=Web Response No relevant relationships by Radhika Vala, source=Web Response

Initiation and Assessment of Timekeeping Roles During In-Hospital Cardiac Arrests to Track Rhythm Checks and Epinephrine Dosing.

Objectives:Compliance to advanced cardiac life support algorithm is low and associated with worse outcomes from in-hospital cardiac arrests. This study aims to improve algorithm compliance by delegation of two separate code team members for timing rhythm check and epinephrine administration in accordance to the advanced cardiac life support algorithm.Design:Prospective intervention with historical controls.Setting:Single academic medical center.Patients:Patients who suffered in-hospital cardiac arrest during study period were considered for inclusion. Patients in which the advanced cardiac life support algorithm or new timekeeper roles were not used were excluded.Interventions:Two existing code team members were delegated to time epinephrine and rhythm checks.Measurements and Main Results:Primary endpoint was deviations from the 2-minute rhythm check or 3- to 5-minute epinephrine administration. Each deviation outside allotted time intervals was counted as one deviation. However, instances in which multiple intervals passed were counted as multiple deviations. Algorithm adherence was analyzed before and after intervention. Secondary endpoints included return of spontaneous circulation rate, time until first dose of epinephrine, and anonymous survey data. Thirteen pre intervention in-hospital cardiac arrests were compared with 13 in-hospital cardiac arrests post. Prior to intervention, the median deviation per in-hospital cardiac arrest was 5 (interquartile range, 3–7) versus 1 post (interquartile range 0–1; p = 0.0003). The median time until first dose of epinephrine was administered pre intervention was 5 minutes (interquartile range, 0–4) versus post intervention median of 0 (interquartile range, 0–0; p = 0.02). Pre-intervention return of spontaneous circulation rate was 46.1% versus 69.2% post. Surveys demonstrated advanced cardiac life support providers felt time keeping roles made it easier to track epinephrine administration and rhythm checks and improved team communication.Conclusions:Two separate timekeeper roles during in-hospital cardiac arrests improved algorithm compliance, code team function, and was favored by code team members. Timekeeper roles may be associated with improved rates of return of spontaneous circulation and less time until the first dose of epinephrine was administered. This study is limited by small sample size and single-center design.

Culture and personal influences on cardiopulmonary resuscitation- results of international survey

BackgroundThe ethical principle of justice demands that resources be distributed equally and based on evidence. Guidelines regarding forgoing of CPR are unavailable and there is large variance in the reported rates of attempted CPR in in-hospital cardiac arrest. The main objective of this work was to study whether local culture and physician preferences may affect spur-of-the-moment decisions in unexpected in-hospital cardiac arrest.MethodsCross sectional questionnaire survey conducted among a convenience sample of physicians that likely comprise code team members in their country (Indonesia, Israel and Mexico). The questionnaire included details regarding respondent demographics and training, personal value judgments and preferences as well as professional experience regarding CPR and forgoing of resuscitation.ResultsOf the 675 questionnaires distributed, 617 (91.4%) were completed and returned. Country of practice and level of knowledge about resuscitation were strongly associated with avoiding CPR performance. Mexican physicians were almost twicemore likely to forgo CPR than their Israeli and Indonesian/Malaysian counterparts [OR1.84 (95% CI 1.03, 3.26), p = 0.038]. Mexican responders also placed greater emphasison personal and patient quality of life (p < 0.001). In multivariate analysis, degree of religiosity was most strongly associated with willingness to forgo CPR; orthodox respondents were more than twice more likely to report having forgone CPR for apatient they do not know than secular and observant respondents, regardless of the country of practice [OR 2.12 (95%CI 1.30, 3.46), p = 0.003].ConclusionsIn unexpected in-hospital cardiac arrest the decision to perform or withhold CPR may be affected by physician knowledge and local culture as well as personal preferences. Physician CPR training should include information regarding predictors of patient outcome at as well as emphasis on differentiating between patient and personal preferences in an emergency.

Abstract 248: Initiation and Assessment of Timekeeping Roles During In-Hospital Cardiac Arrests to Track Rhythm Checks and Epinephrine Dosing

Introduction: Compliance to ACLS cardiac arrest algorithm is low and associated with worse outcomes from in-hospital cardiac arrests (IHCA). Reasons for non-compliance include reduced communication due to chaotic nature of IHCAs and difficulty timing epinephrine administration and rhythm check intervals. Hypothesis: Delegating two separate code team members for rhythm and epinephrine timing will increase adherence to ACLS algorithm during IHCAs. Methods: This is a pre-post interventional study of IHCAs at a single academic medical center. Two stopwatches were placed on all code carts and two new timekeeping roles were created. Education was provided to staff regarding the alteration of existing code team member roles for the use of stopwatches. Algorithm adherence was analyzed pre and post implementation of timekeeper roles. Deviation from the 2-minute rhythm check or 3-5-minute epinephrine administration was counted as one deviation. Anonymous surveys were delivered to evaluate providers perceived benefits of timekeeper roles for IHCAs. Results: Data from 13 pre intervention IHCAs were compared to 12 IHCAs post intervention. The initial rhythm was PEA/asystole in 69% pre-intervention vs 83% post intervention. Prior to implementation 82 deviations vs. 11 deviations post implementation occurred (p=0.006). The mean time until first dose of epinephrine was administered pre intervention was 2.3 ± 3.3 minutes vs 0.4 ±1 minute post. Pre-implementation ROSC rate was 53.8% vs. 66.7% post intervention. Surveys were delivered to 100% of code team members post intervention, with a 79% response rate. Surveys demonstrate providers felt time keeping roles made it easier to track epinephrine administration and rhythm checks. On a Likert scale, 78% of providers “strongly agree” that the use of timekeeping roles and devices improved code team communication. Conclusion: Two separate timekeeper roles during IHCAs improved algorithm compliance, code team function and communication, and was favored by code team members. Timekeeper roles may be associated with improved rates of ROSC and less time until the first dose of epinephrine is administered. This study is limited by its small sample size, single center and requires validation.

Operating Room Codes Redefined: A Highly Reliable Model Integrating the Core Hospital Code Team.

Introduction:Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles.Methods:A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver—a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff.Results:The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management.Conclusions:The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

Code Team Structure and Training in the Pediatric Resuscitation Quality International Collaborative.

Code team structure and training for pediatric in-hospital cardiac arrest are variable. There are no data on the optimal structure of a resuscitation team. The objective of this study is to characterize the structure and training of pediatric code teams in sites participating in the Pediatric Resuscitation Quality Collaborative. From May to July 2017, an anonymous voluntary survey was distributed to 18 sites in the international Pediatric Resuscitation Quality Collaborative. The survey content was developed by the study investigators and iteratively adapted by consensus. Descriptive statistics were calculated. All sites have a designated code team and hospital-wide code team activation system. Code team composition varies greatly across sites, with teams consisting of 3 to 17 members. Preassigned roles for code team members before the event occur at 78% of sites. A step stool and backboard are used during resuscitations in 89% of surveyed sites. Cardiopulmonary resuscitation (CPR) feedback is used by 72% of the sites. Of those sites that use CPR feedback, all use an audiovisual feedback device incorporated into the defibrillator and 54% use a CPR coach. Multidisciplinary and simulation-based code team training is conducted by 67% of institutions. Code team structure, equipment, and training vary widely in a survey of international children's hospitals. The variations in team composition, role assignments, equipment, and training described in this article will be used to facilitate future studies regarding the impact of structure and training of code teams on team performance and patient outcomes.

Abstract 180: Nursing Roles for In-Hospital Cardiac Arrest Response: A Qualitative Study

Introduction: Survival and favorable clinical outcomes for in-hospital cardiac arrest (IHCA) are highly dependent on a skilled resuscitation team, prompt initiation of high quality CPR and defibrillation, and organizational structures to support resuscitation care. While nurses are generally involved in resuscitation efforts, the purpose of this study was to examine their specific roles and factors that affect their contributions during an IHCA response. Methods: We conducted a qualitative study at 9 hospitals participating in the AHA Get-With-The-Guidelines Resuscitation registry. Purposeful sampling was used to select hospitals that vary in terms of geography, academic status, and risk-standardized IHCA survival. Participants included nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, hospital administrators, and other staff, yet discussion of the nursing function was prominent across all stakeholder groups. Qualitative thematic text analysis was used to identify the distinct types of nursing roles in relation to IHCA and how these roles were supported across sites. Results: We conducted semi-structured interviews with 158 individuals at 9 hospitals. Nurses were identified as an integral part of the IHCA response at all sites, with three major IHCA nursing roles identified: bedside first responder, rapid response or code team member, and leader. There were distinct differences across sites in support for nurses in these different roles with regard to educational training and competency, organizational engagement, and empowerment (Table). Conclusion: Nurses are a critical component of effective IHCA response and processes, including diverse roles as bedside first responders, code team members, and leadership for resuscitation care. Mentoring and empowering frontline nurses and ensuring that clinical competency and training needs for IHCA care specific for nurses is essential for resuscitation care.

Structured redesign of a hospital-based code response team using Six Sigma tools and human factors principles to facilitate teamwork

Abstract Introduction Response to in-hospital cardiac arrest (a “code”) requires the coordinated efforts of a team of medical professionals in a high-stress, high-risk healthcare setting. This can lead to a chaotic situation. Excessive noise and confusion must be improved to deliver the most effective care. Purpose To develop a paradigm for efficient and effective code response. Methods An interprofessional team used Six Sigma tools to identify characteristics of an “ideal” process for the two identified phases of code response. Further discussion and application of human factors engineering principles produced a paradigm for the code response process. Discussion/conclusions The aim of this structured redesign of our institution's code response process was to reduce the amount of nonproductive noise and confusion during code response through clarification of roles and responsibilities of code team members. The application of engineering principles and interprofessional nature of the redesign group were vital to the successful redesign process.

Abstract 239: The Effect of an Interdisciplinary Simulation Training Program on Translational Outcomes for In-Hospital Cardiopulmonary Arrests

Purpose: High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge, but few hospitals regularly track these metrics. Other studies have demonstrated significant improvements in survival after IHCA events following implementation of a dedicated code team training program. Therefore, we developed a unique curriculum for a Code Team Training (CTT) course, and evaluated its post-implementation effect on CPR quality and post-IHCA patient outcomes at our institution. Methods: CPR quality data was prospectively collected for quality improvement purposes once our institution had that capability, with 12-months pre-CTT and 21 months post-CTT. Pre-CTT data shaped the elements of the four-hour CTT course that included didactics, small group sessions, and high-fidelity simulation exercises. A total of 456 multi-professional code team members were trained in 22 courses. Data collection included CPR quality and translational outcomes for events where CPR was performed, except the ED. CodeNet® software was used for CPR quality measures, cardiac rhythm, defibrillation metrics, use of continuous waveform capnography, and pauses in compressions. Target metrics for CPR quality were based on 2015 AHA guidelines. Key translational outcomes measures included event location, ROSC, and survival to hospital discharge. Results: CPR quality was obtained from 140 of 230 (61%) in- and out-of-hospital pulseless adult cardiac arrest events over 33 months (50 [36%] before CTT and 90 [64%] following the first course). There was no significant difference between groups in terms of event location within the hospital nor initial event rhythm. A total of 116,908 chest compressions were evaluated. Median compressions in target rate improved from 32% before CTT to 49% after CTT (p&lt;0.05). When accounting for target rate and depth, the median compressions rate improved to 38% post-CTT compared to 31% pre-CTT (p&lt;0.05). While compression depth had a non-statistically significant decline (90.8% pre-CTT and 83.4% post-CTT), mean rate and median rate-in-target improved from 119.99 +/- 15.6 cpm and 32.4% pre-CTT to 113.7 +/- 16.1 cpm and 48.6% post-CTT (p&lt;0.05). The rate of ROSC improved from 60% (30 of 50) to 78% (70 of 90) after implementation of CTT (p=0.003), excluding IHCA in the ED. Index IHCA survival rate for our institution improved from 26% to 33% before and after CTT [p-value NS], which far surpasses the national average (23.8%). Conclusions: After the initiation of a CTT course that targets key code team member personnel, CPR quality significantly improved, which was associated with an increase in ROSC and a trend towards increased survival for in-hospital cardiac arrest patients.

The Effect of an Interdisciplinary Simulation Training Program on Translational Outcomes for In-Hospital Cardiopulmonary Arrests

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge, but few hospitals track these metrics. Small studies have demonstrated significant improvements in survival after IHCA events following implementation of a dedicated code team training program. We developed a Code Team Training (CTT) course for our institution, and evaluated its post-implementation effect on CPR quality and post-IHCA patient outcomes. METHODS: CPR quality data was prospectively collected from actual IHCA events for quality improvement purposes, with 12-months pre-CTT and 11 months post-CTT. Pre-CTT data shaped the elements of the four-hour CTT course that included didactics, small group sessions, and high-fidelity simulation exercises. 111 multi-professional code team members were trained in 10 courses. Data collection included CPR quality and translational outcomes for events where CPR was performed. CodeNet® software was used for CPR quality measures, cardiac rhythm, defibrillation metrics, use of continuous waveform capnography, and pauses in compressions. Key translational outcomes measures included event location, ROSC, and survival to hospital discharge. RESULTS: CPR quality was obtained from 150 of 303 (49.5%) in- and out-of-hospital pulseless adult cardiac arrest events over 23 months (63 [44.4%] before CTT and 87 [54.0%] following the first course). Total CPR time captured was 24 hours, 5 minutes, 32 seconds (146,449 chest compressions). There was no difference between groups in terms of event location within the hospital, initial event rhythm, or the proportion of events transmitted to CodeNet™ via WiFi. Of note, there were significantly more out-of-hospital arrests in the post-CTT group. Median compressions in target depth and rate was 31.9% [IQR 10.2-64.4] before CTT and 75.0% [IQR 53.0-83.4] after CTT (p=0.005). While compression depth remained similar (88.2% pre-CTT and 94.3% post-CTT), mean rate and median rate-in-target improved from 117.49 +/- 16 cpm and 29% pre-CTT to 109.5 +/- 13.8 cpm and 61% post-CTT (p=0.0006). Index in-hospital pulseless cardiac arrest survival rate for our institution improved from 28% to 36% before and after CTT [p-value NS], which far surpasses the national average (23.8%). ROSC also trended towards an improvement from 49% to 58% (p-value NS). Survival for out-of-hospital arrests also improved from 0% to 8% (p-value NS). CONCLUSIONS: After the initiation of a CTT program targeting key code team member personnel, CPR quality significantly improved, which translated into a nonstatistically significant trend towards increased survival for IHCA patients. CLINICAL IMPLICATIONS: IHCA is a relatively infrequent high-stakes event with a low national average for survival to discharge that has not significantly improved over the years even with increased knowledge and technical advances. Preliminary results from our pilot study demonstrate that implementation of a formal CTT program resulted in 10 additional lives saved over a 6-month span compared to pre-intervention standard-of-care. Ongoing research is currently evaluating the long term sustainability and exportability of our CTT program. DISCLOSURE: The following authors have nothing to disclose: John Hunninghake, Heather Delaney, Justin Reis, Matthew Borgman, Raquel Trevino, Renee Matos No Product/Research Disclosure Information

Resuscitation team perceptions of family presence during CPR.

The literature supports family presence during cardiopulmonary resuscitation (CPR) and its many perceived benefits for patients and their families. It also suggests that, overall, health care professionals are supportive of this practice. There have not been any published studies to date that have looked at the perception of family presence from the multidisciplinary resuscitation or code team's perspective. The purpose of this study was to describe the multidisciplinary care provider's understanding and perceived barriers of family presence during CPR in an academic medical center. This study is a quantitative, exploratory, descriptive study that utilized survey methodology. The sample included all members of an urban academic medical center's resuscitation response team. The study findings reveal that, overall, code team members feel that family members should be allowed to remain at the bedside during CPR but that challenges exist including education deficits and mixed feelings that may result from family presence; the study participants caring for neonates and children were more favorable to family presence during CPR than their adult counterparts. Barriers remain related to family presence during resuscitation. Education is needed for all members of the health care team to facilitate collaborative changes in resuscitation practices. Education should include information regarding institutional policies, methods for incorporating family members into the code process, and interventions to support the psychosocial needs of family members.

Improving Code Team Performance and Survival Outcomes

To determine whether implementation of Composite Resuscitation Team Training is associated with improvement in survival to discharge and code team performance after pediatric in-hospital cardiopulmonary arrest. We conducted a prospective observational study with historical controls at a 302-bed, quaternary care, academic children's hospital. Inpatients who experienced cardiopulmonary arrest between January 1, 2006, and December 31, 2009, were included in the control group (123 patients experienced 183 cardiopulmonary arrests) and between July 1, 2010, and June 30, 2011, were included in the intervention group (46 patients experienced 65 cardiopulmonary arrests). Code team members were introduced to Composite Resuscitation Team Training and continued training throughout the intervention period (January 1, 2010-June 30, 2011). Training was integrated via in situ code blue simulations (n = 16). Simulations were videotaped and participants were debriefed for education and process improvement. Primary outcome was survival to discharge after cardiopulmonary arrest. Secondary outcome measures were 1) change in neurologic morbidity from admission to discharge, measured by Pediatric Cerebral Performance Category, and 2) code team adherence to resuscitation Standard Operating Performance variables. The intervention group was more likely to survive than the control group (60.9% vs 40.3%) (unadjusted odds ratio, 2.3 [95% CI, 1.15-4.60]) and had no significant change in neurologic morbidity (mean change in Pediatric Cerebral Performance Category 0.11 vs 0.27; p = 0.37). Code teams exposed to Composite Resuscitation Team Training were more likely than control group to adhere to resuscitation Standard Operating Performance (35.9% vs 20.8%) (unadjusted odds ratio, 2.14 [95% CI, 1.15-3.99]). After adjusting for adherence to Standard Operating Performance, survival remained improved in the intervention period (odds ratio, 2.13 [95% CI, 1.06-4.36]). With implementation of Composite Resuscitation Team Training, survival to discharge after pediatric cardiopulmonary arrest improved, as did code team performance. Demonstration of improved survival after adjusting for code team adherence to resuscitation standards suggests that this may be a valuable resuscitation training program. Further studies are needed to determine causality and generalizability.

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Introduction: Code teams respond to cardiopulmonary arrest (CPA) events and must be able to act immediately as a team to effectively manage these emergencies. Teamwork amongst the code team during these responses are critical for efficient and effective resuscitation actions. Code team members are trained and skilled to respond to CPA events, but are often deficient in teamwork skills during resuscitation. Findings from previous research at the study organization to assess teamwork perception by code team members showed deficits in perception of teamwork related to leadership, communication, and mutual team support. The purpose of this study was to determine the effect of a two-hour training program using simulation, debriefing, and review of Crew Resource Management principles related to CPA events on perception of teamwork of code team members. Methods: The study was conducted in one large tertiary teaching hospital. Code team members who routinely respond to CPA events were invited to participate in a two-hour teamwork training program. A pre-test, post-test design was used for the study. A sample of resident physicians (MDs), nurses (RNs), and respiratory therapists (RTs) participated in a two-hour teamwork training program for CPA events. After informed consent, subjects participated in a mock CPA event in a simulation lab while being evaluated for teamwork skills by trained observers. After the simulation, subjects and observers rated teamwork performance during the simulation using the Team Emergency Assessment Measure (TEAM) tool on a 1–4 scale, including a global rating (1–10 scale). Next, a debriefing of the event was done, followed by a didactic presentation with group discussion on teamwork skills during CPA emergencies, using Crew Resource Management and TeamSTEPPS principles. Key areas of emphasis were on leadership, communication, and mutual support during CPA events. Subjects then participated in a second simulation of a different CPA event and were encouraged to use principles they had just learned in the program. Immediately following, subjects and observers again rated teamwork performance using the TEAM tool and completed evaluations on the program. Results: Seventy-three code team members participated in the study: 18 MDs (25%), 23 RNs (32%), and 30 RTs (41%) in small groups over a 12 week period. Significant improvement in the average TEAM score was noted by both participants and observers after the teamwork training program. Participants’ mean TEAM pre-test score was 3.3 and post-test score was 3.7 (p<.001) on a 1–4 scale. Observers’ mean scores improved from 3.0 to 3.7 (p<.001). Participants’ global rating score (1–10 scale) increased from 7.7 to 8.8 (p<.001) and observers’ global rating scores increased from 7.3–9.0 (p<.001). While observers rated the TEAM scores significantly lower than those of participants on the 1st simulated event, no differences were found after the 2nd simulation evaluation or on either of the global ratings (p<.05) Participants rated the simulation and training program as being beneficial, effective, enjoyed interprofessional team learning, and supported incorporating team training in future CPA training. Conclusions: A two-hour teamwork training program incorporating simulation and teamwork principles improves perceptions of teamwork from both trained observers and code team members. It was possible to incorporate teamwork principles into a two-hour training session versus a longer workshop program on team training. The program was effective in conveying key concepts relating to teamwork during CPA events in an interprofessional learning environment and participants were able to learn from each other, respecting contributions and roles from members of the code team. While long term retention of concepts and sustainability was not assessed in this study, a potential area for study on how team training for CPA events translates into behaviors during actual CPA emergencies may enhance knowledge in this area of practice.

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Introduction: Through enhanced situational awareness and mitigation plans, the frequency of Code Events in our institution has decreased dramatically in recent years. The code team thus has less experience in actual codes and depends more upon simulation to assure maintenance of a high-performing team. In situ simulation with randomly called mock-codes is a mainstay of training and testing the system’s ability to respond. Process goals during code events including use of mental modeling, effective positioning of code team members/equipment, and clear communication of patient information are vital components of an effectively run medical code. Using in situ simulation and deliberate practice incorporating these features over the last 6 months, we have demonstrated a significant improvement in simulated code performance. Despite these advances, we hypothesize that there remains even more room for team improvement and efficiency. The modification of standard simulation based training techniques may thus further improve code team performance. Methods: Randomly called mock code events were performed at our institution in varying locations. Following the arrival of all code team members and allowing them time to assume their pre-assigned roles, a pause was performed. During this, observation of each code team member’s location and the location of vital equipment (defibrillator, ‘crash’ cart) was recorded. If sub-optimally positioned, the members and/or equipment were repositioned and the code event resumed. Other variables recorded during the pause included the number of staff in the room without defined roles, the number of staff performing roles outside of their defined scope, and the presence/absence of a medication pause or team leader mental model. Following completion of the mock code, coaching specific to each component was performed by the simulation team, and a survey was handed out to assess self-perceived value of the pause intervention. Results: During each simulation, >1 code member was found to be improperly positioned for their assigned role during the pause. Several participants were found in the room without clearly defined roles including an additional 13 participants during one event. Of those participants without defined roles, a tendency existed for them to perform roles clearly designated to code team members and potentially outside of their scope. 89% of code team members felt more confident in obtaining their proper position during code events based upon the post-code questionnaire. Conclusions: Utilization of a ‘mid-code event pause’ during medical simulation allows for a real-time recognition of suboptimal conditions during simulated code events and has great potential for improving basic process goals. Further research is needed to assess the impact of this intervention upon such relevant patient outcomes as efficacy of CPR, time to defibrillation, and time to establishment of IV/IO access.

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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.

Abstract 187: Code Team Members’ Perception of Family Presence During Cardiopulmonary Resuscitation at an Academic Medical Center

INTRO: Despite increased acceptance, barriers remain for family presence during cardiopulmonary resuscitation (CPR). Few have focused on the entire code response team. Our objective was to determine the perceived role of family presence, its benefit to patients and/or the code team, and barriers to implementation. We hypothesized that perceptions of family presence would vary by team member role. Methods: We conducted an IRB approved survey at an urban academic Level 1 trauma center during August, 2012. Subjects were members of the adult or pediatric code teams, including chaplains, clinical care techs (CCTs), registered nurses (RNs), advanced practice nurses (APNs), physicians, pharmacists, patient equipment techs, security officers, and respiratory therapists. A convenience sample was asked to complete an online family presence survey tool adapted with permission from Nykiel et al. Most responses used a five point likert scale ranging from strongly disagree (1) to strongly agree (5). Results: Five hundred eighty-eight of 3000 staff responded. They were 78% RNs and 25% adult critical care. Seventy percent had participated in family presence situations. More RNs, physicians, CCTs, and chaplains felt that family presence during CPR was part of their job (mean 4.1, 3.6, 3.6, 4.2 respectively) compared to respiratory therapists, pharmacists, security, and patient equipment techs (mean 2.2, 2.0, 1.5 respectively). Similarly, more RNs, physicians, CCTs, and chaplains felt comfortable providing emotional support to family members during CPR (mean 3.7, 4.1, 3.3, 4.2 respectively) compared to respiratory therapists, pharmacists, security, and patient equipment techs (mean 2.8, 1.9, 2.0, 1.8 respectively). Overall, they felt family presence benefits the family (72%), patients (59%) and the code team (41%). Perceived barriers were lack of space, increased staff stress, staff objections, interruptions of care, and lack of identified support person (72, 68, 56, 48, 44% respectively). CONCLUSION: Code team members have varied perceptions about family presence during CPR depending upon their role. This suggests that specific education strategies for the entire code team may be necessary to improve the family presence experience.

Perceptions of Teamwork Among Code Team Members

Cardiopulmonary arrest (CPA) teams, known as code teams, provide coordinated and evidenced-based interventions by various disciplines during a CPA. Teamwork behaviors are essential during CPA resuscitation and may have an impact on patient outcomes. The purpose of this study was to explore the perceptions of teamwork during CPA events among code team members and to determine if differences in perception existed between disciplines within the code team. A prospective, descriptive, comparative design using the Code Teamwork Perception Tool online survey was used to assess the perception of teamwork during CPA events by medical residents, critical care nurses, and respiratory therapists. Sixty-six code team members completed the Code Teamwork Perception Tool. Mean teamwork scores were 2.63 on a 5-point scale (0-4). No significant differences were found in mean scores among disciplines. Significant differences among scores were found on 7 items related to code leadership, roles and responsibilities between disciplines, and in those who had participated on a code team for less than 2 years and certified in Advanced Cardiac Life Support for less than 4 years. Teamwork perception among members of the code team was average. Teamwork training for resuscitation with all disciplines on the code team may promote more effective teamwork during actual CPA events. Clinical nurse specialists can aid in resuscitation efforts by actively participating on committees, identifying opportunities for improvement, being content experts, leading the development of team training programs, and conducting research in areas lacking evidence.