Crash Cart Research Articles

Intrapartum Maternal Cardiac Arrest: A Simulation Case for Multidisciplinary Providers.

Cardiac arrest in pregnancy is rare. Advanced Cardiovascular Life Support courses rarely address interventions specific to obstetric patients, and knowledge gaps are frequent among providers. The Society for Obstetric Anesthesia and Perinatology and American Heart Association have published guidelines regarding management of cardiac arrest in pregnancy, and interdisciplinary simulation training has been advocated to reinforce key management points for this clinical scenario. In situ multidisciplinary simulation training was implemented for anesthesia and maternal fetal medicine fellows and obstetric nurses at our hospital. The case was amniotic fluid embolism in a 35-year-old parturient at term. The patient had a witnessed seizure before cardiovascular collapse. Learners were expected to initiate high-quality cardiopulmonary resuscitation and perform a perimortem cesarean delivery within 5 minutes while demonstrating clear communication with each other. The case required a labor room, high-fidelity mannequin, defibrillator, code cart, cesarean section instruments, and simulated medications and intravenous fluids. Participants comprised two obstetric anesthesia fellows, three maternal fetal medicine fellows, and three obstetric nurses. Positive feedback about the training and increased perceptions of self-efficacy were received. Potential systems issues were detected and corrected because of the training, highlighting the value of in situ drills. We found it challenging to implement more frequent multidisciplinary sessions, but participants found the experience highly rewarding. We hope to expand the training to all physicians and nurses covering the unit on a regular basis. Modified scenario versions are being used for nursing-only and obstetric resident-only simulations during protected teaching time for those services.

Pharmacology, Part 3B: Less Commonly Used Interventional Medications and Adjunctive Medications in General Nuclear Medicine.

The understanding of key principles in pharmacology is essential to the clinical and research nuclear medicine practitioner. The scope of practice of the nuclear medicine technologist requires understanding of the indications, contraindications, warnings, precautions, proper use, drug interactions, and adverse reactions for interventional and adjunctive medications. This article is the companion to the third in a series of articles that aims to enhance the understanding of pharmacologic principles relevant to nuclear medicine. This article will build on the introductory concepts, terminology, and principles of pharmacology explored in previous articles in the series. Specifically, this article will focus on the pharmacologic principles associated with less commonly used interventional medications and adjunctive medications encountered in general nuclear medicine practice. Future articles will address the pharmacology related to nuclear cardiology, the emergency crash cart, and contrast media associated with CT and MRI.

Pharmacology, Part 3A: Interventional Medications in Renal and Biliary Imaging.

Pharmacology principles provide key understanding that underpins the clinical and research roles of nuclear medicine practitioners. Indeed, the scope of practice of the nuclear medicine technologist demands knowledge and understanding of indications, contraindications, warnings, precautions, proper use, drug interactions, and adverse reactions for each medication to be used. This article is the third in a series of articles that aims to enhance the understanding of pharmacologic principles relevant to nuclear medicine. This article will build on the introductory concepts, terminology, and principles of pharmacology explored in the first 2 articles in the series. Specifically, this article will focus on the pharmacologic principles associated with interventional medications encountered in renal and biliary imaging. A companion article (part 3B) will examine the less commonly used interventional medications in general nuclear medicine and prototype adjunctive medications. Future articles will address the pharmacology related to nuclear cardiology, the emergency crash cart, and contrast media associated with CT and MRI.

A Four-Stage Method for Optimizing and Standardizing a Crash Cart Configuration

OCCUPATIONAL APPLICATION An optimized crash cart configuration was developed through the use of human factors principles and by involving front-line users of crash carts in the design process from start to finish. The crash cart configuration was spread to four rural health care sites and received positive post-evaluation scores by clinical staff. The methodology used to develop the standardized crash cart, and the template for the configuration of the crash cart, can be adopted or adapted for use at any health care facility and can help in the mitigation of human error. Specifically, disorganized and/or inconsistent crash carts pose a patient safety risk due to the fact that retrieval of items may be delayed during critical situations. Implementing a tested, standardized crash cart configuration can increase the usability of the carts, which has significant patient safety implications during time-sensitive incidents such as code blue events.

Adult code cart redesign: Clinical implications.

Adult code cart redesign: Clinical implications.

P097: Making emergency room crash carts useful

Introduction: Human factors are a neglected when it comes to crash cart design and function. Using observational assessments and in-house surveys, the process improvement team found that staff use of the crash carts in the University of Alberta ED had significate redundancy, inefficiency and often leading to confusion during use. The process improvement team assessed the layout of the adult crash cart and redesigned the cart format based on observational problems/inefficiencies staff had during resuscitations. It was hoped that staff found the new design more efficient and effective during resuscitations when compared to the old cart. Methods: To effect change, the Rapid result change theory method was utilized to implement the new crash cart prototype. The model was used to evoke excitement and staff participation in front line process improvement. With input from senior staff, the cart was redesigned and placed in resus area where it stood the greatest chance of being used frequently. Once a prototype crash cart had gone live, surveys, based on a 7 point Likert scale compared the old and new cart systems. The resus area housed both old and new carts to facilitate the comparison. The survey assessed 6 domains; visibility of the medications, locating medications, overall organization, time savings, mixing medications and comfort level of using each cart. Results: After the trial, the surveys were collected and analyzed using T-test; the results were significant. There was an overwhelming positive result within all domains when comparing the two carts. There was mean difference ranging from 1.7 to 3.5 comparing when comparing the two carts to each domain. Conclusion: The results were so positive; all seven carts were changed to the same format. The overall impact of the new cart design saved time in both application and turnaround time in restocking.

Noteworthy Professional News

Noteworthy Professional News

Using simulation with interprofessional team training to improve RRT/code performance

Abstract Early recognition of and response to changes in patients' conditions are a National Patient Safety Goal. Rapid Response Teams (RRTs) are one safety strategy aimed at early recognition of signs and symptoms of clinical deterioration and reduction in rates of cardiopulmonary arrest and death in hospitalized patients. Mock codes and RRTs are another strategy for improving outcomes.The Corporal Michael J. Crescenz VA Medical Center(CMCVAMC) used data from the American Heart Association National Registry of Cardio-Pulmonary Resuscitation to create an interprofessional, collaborative program using simulation. The program included: review of emergency responses and hands-on sessions with crash cart equipment, airway management, and BLS skills, followed by a mock RRT and Code with debriefing. Participants in this quality improvement initiative were nurses, physicians, anesthetists, pharmacists, and respiratory therapists. They evaluated the simulation as a positive learning experience. Staff and patient outcomes were improved after the program. The program engaged staff and promoted interprofessional collaboration that may ultimately improve the quality of patient care.

Identifying and Managing Intraoperative Arrhythmia: A Multidisciplinary Operating Room Team Simulation Case.

Resuscitation of a critically ill patient is challenging for both novice learners and experienced health care providers. During a critical event, not only is it important to identify the correct underlying diagnosis, it is equally crucial that the appropriate Advance Cardiac Life Support algorithm, medications, and defibrillator modality are implemented. This scenario features a 56-year-old female who presents for excisional biopsy of an inguinal lymph node to evaluate lymphadenopathy concerning for lymphoma. Intraoperatively, she goes into cardiopulmonary arrest. Participants must identify and manage three different scenarios: (1) ventricular fibrillation, (2) unstable ventricular tachycardia, and (3) bradycardia, including the use of the defibrillator. Weekly simulation sessions were conducted in the in situ simulation operating room at Massachusetts General Hospital. Surgical residents, anesthesiology residents, nurses, and surgical technicians participated in a multidisciplinary operating room team. Each approximately 60-minute session included an orientation, the case, and the debriefing. Equipment included a simulation operating room with general surgery supplies, general anesthesia equipment, a high-fidelity SimMan patient simulator, a code cart, and a defibrillator. Ninety-one multidisciplinary participants completed this scenario from September to December 2015. Participants reported that the scenario was applicable to their clinical practice (96%), promoted teamwork skills (88%), and encouraged interprofessional learning (94%). Intraoperative cardiac arrest is a devastating event that can result in poor patient outcomes if the care team is not thoroughly prepared for crisis management. This simulation case scenario was implemented to train multidisciplinary learners in the identification and management of such an event.

Novel Approach to Emergency Departments' Pediatric Readiness Across a Health System.

A gap analysis of emergency departments' (EDs') pediatric readiness across a health system was performed after the appointment of a service line health system pediatric emergency medicine (PEM) quality director. A 55-question survey was completed by each eligible ED to generate a weighted pediatric readiness score (WPRS). The survey included questions regarding volume, ED configuration, presence of a pediatric emergency care coordinator (PECC), quality initiatives, policies and procedures, and equipment. Surveys were completed from June 1 to November 12, 2016.Analysis of variance was used to compare the 4 groups of EDs based upon their annual pediatric volume as a continuous measure (low, <1800 visits; medium, 1800-4999 visits; medium-high, 5000-9999 visits; high, >10,000 visits). The Fisher exact test was used to compare the 4 groups for the remaining categorical variables represented as frequencies and percentages. A result was considered statistically significant at the P < 0.05 level of significance. There were a total of 16 hospitals (after the exclusion of the children's hospital, the hub for pediatric care in the health system, and 1 adult-only hospital) with the following pediatric capability: 7 basic (no inpatient pediatrics), 7 general (inpatient pediatrics, with/without a neonatal intensive care unit), and 2 comprehensive (inpatient pediatrics, pediatric intensive care unit, and a neonatal intensive care unit). In 12 EDs, adults and children are treated in the same space. These EDs see a total of 800,000 annual visits including 120,000 pediatric visits. Two low pediatric volume EDs had a median WPRS of 69, range of 62 to 76 (national median, 61.4); 6 medium pediatric volume EDs had a median WPRS of 51, range of 42 to 81 (national median, 69.3); 4 medium-high pediatric volume EDs had a median WPRS of 69.3, range of 45 to 98 (national medium, 74.8); 4 high pediatric volume EDs had a WPRS score of 84.5, range of 58 to 100 (national medium, 89.8). There were 4 sites with PECCs: 1 medium-high volume and 3 high volume, with a median WPRS of 98.5, range of 81 to 100 (national medium, 89.8). Two low-volume EDs have Neonatal Resuscitation Program training for nurses (P < 0.0083). One medium-high volume ED requires specific pediatric competency evaluations for advanced level practitioners staffing the ED. Pediatric-specific quality programs are present in the 2 low volume EDs, 3 of the 6 EDs in the medium group, 3 of 4 EDs in the medium-high group, and all 4 high volume hospitals. After the implementation of the health system PEM quality director, all EDs have a doctor and nurse PECC with a median WPRS of 81. In additiona, a committee was formed with the following key stakeholders: PECCs, pediatric nursing educators, pediatric quality, pharmacy, obstetrics, behavioral health, and neonatology. The committee is part of the health system quality program within both pediatrics and emergency medicine and is spearheading the standardization of code carts and medications, dissemination of pediatric clinical guidelines, and the development of a pediatric quality program across the health system. Pediatric emergency care coordinators play an important role in ED readiness to care for pediatric patients. In a large health system, a service line PEM quality director with the support of emergency medicine and pediatrics, a committee with solid frontline ED base, and a diverse array of stakeholders can foster the engagement of all EDs and improve compliance with published guidelines.

The Emergency Department Crash Cart: A systematic review and suggested contents.

As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart (EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council (ERC) guidelines for resuscitation, and the 2013 American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) 9th edition. There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.

A national survey of MRI safety practices in Ghana

ObjectiveThe aim of the present study was to assess current MRI safety practices among MRI facilities in Ghana, and their compliance with the 2013 American College of Radiology (ACR) guidance document on MR safe practices. Material and methodsA questionnaire developed from the 2013 ACR Guidance Document was used to collect information on magnetic field strengths, MR safety policy and compliance, patient screening, emergency preparedness, infection control, MRI safety accessories, equipment safety, signage and barriers, report of adverse incidents, and access and communication. ResultsOut of the 13 MRI facilities identified, response rate of 92% was obtained. Six (50%) facilities indicated they have MRI safety policy and have it present and readily available to facility staff. Five (42%) facilities indicated they have handheld magnets, and 1(8%) has ferromagnetic detection system. Only one (8%) had crash carts. Seven (58%) facilities have zone 4 clearly marked with a red light and lighted sign stating “The Magnet is On”. One (8%) recorded projectile incident and fire outbreak. Eight (67%) facilities have direct visual observation of access corridors to zone IV. ConclusionThere was compliance in some areas of MRI safety practice, however there were some shortfalls which need to be addressed. We therefore recommend improvement in the following areas: (1) establishment, implementation, and maintenance of current MRI safety policy, (2) patient screening, (3) provision of training and routine drills on emergency response protocols with documentations, (4) emergency preparedness, and (5) provision of colour codes for equipment used within MRI environment.

A “Neurological Emergency Trolley” reduces turnaround time for high-risk medications in a general intensive care unit

ObjectivesTo reduce medication turnaround times during neurological emergencies, a multidisciplinary team developed a neurological emergency crash trolley in our intensive care unit. This trolley includes phenytoin, hypertonic saline and mannitol, as well as other equipment. The aim of this study was to assess whether the cart reduced turnaround times for these medications. Research methodology/designIn this retrospective cohort study, medication delivery times for two year epochs before and after its implementation were compared. Eligible patients were identified from our intensive care unit screening log. Adults who required emergent use of phenytoin, hypertonic saline or mannitol while in the intensive care unit were included. Groups were compared with nonparametric analyses. Setting33-bed general medical-surgical intensive care unit in an academic teaching hospital. Main outcome measuresTime to medication administration. ResultsIn the pre-intervention group, there were 43 patients with 66 events. In the post-intervention group, there were 45 patients with 80 events. The median medication turnaround time was significantly reduced after implementation of the neurological emergency trolley (25 vs. 10minutes, p=0.003). There was no statistically significant difference in intensive care or 30-day survival between the two cohorts. ConclusionThe implementation of a novel neurological emergency crash trolley in our intensive care unit reduced medication turnaround times.

Rolling-refresher simulation improves performance and retention of paediatric intensive care unit nurse code cart management.

IntroductionPaediatric Intensive Care Unit Nurses (PICU RNs) manage the code cart during paediatric emergencies at the Children’s Hospital at Dartmouth-Hitchcock. These are low -frequency, high-stakes events.MethodsAn uncontrolled intervention study with 6-month follow-up. A collaboration of physician and nursing experts developed a rolling-refresher training programme consisting of five simulated scenarios, including 22 code cart skills, to establish nursing code cart competency. The cohort of PICU RNs underwent a competency assessment in training 1. To achieve competence, the participating RN received immediate feedback and instruction and repeated each task until mastery during training 1. The competencies were repeated 6 months later, designated training 2.ResultsThirty-two RNs participated in training 1. Sixteen RNs (50%) completed the second training. Our rolling-refresher training programme resulted in a 43% reduction in the odds of first attempt failures between training 1 and training 2 (p=0.01). Multivariate linear regression evaluating the difference in first attempt failure between training 1 and training 2 revealed that the following covariates were not significantly associated with this improvement: interval Paediatric Advanced Life Support training, interval use of the code cart or defibrillator (either real or simulated) and time between training sessions. Univariate analysis between the two trainings revealed a statistically significant reduction in first attempt failures for: preparing an epinephrine infusion (72% vs 41%, p=0.04) and providing bag-mask ventilation (28% vs 0%, p=0.02).ConclusionsOur rolling-refresher training programme demonstrated significant improvement in performance for low-frequency, high-risk skills required to manage a paediatric code cart with retention after initial training.

Cardiopulmonary arrest in primary care clinics: more holes than cheese: a survey of the knowledge and attitudes of primary care physicians regarding resuscitation

BackgroundPatients experiencing pre-arrest symptoms may first refer to their primary care physician. The study's aim was to determine the likelihood that a patient undergoing out-of-hospital cardiac arrest will receive appropriate resuscitation efforts in a primary care clinic in a country with a directive that clinics maintain resuscitation equipment and physicians undergo periodic resuscitation training.MethodsAn anonymous, 23-question online cross-sectional survey was created and administered to primary care physicians working in community clinics (10/1/2015-5/3/2015). Recruitment was accomplished by posting a link to the survey to all physicians listed as registered Society of Family Medicine members and in other online forums dedicated to residents and board-certified specialists in family medicine in Israel. The primary outcome measure was the proportion of respondents whose responses indicate that they fulfill all conditions for performing resuscitation.ResultsOf approximately 2400 potential respondents, 185 replied to the survey; the study's findings should be viewed as preliminary. Respondents' characteristics were generally similar to those of the study population, but respondents had a higher rate of family medicine specialists.Respondents were mostly female (n = 108, 58%) Israeli graduates who have practiced medicine for > 10 years (72%, n = 134). 55% (n = 101) had undergone basic life support (BLS) training within < 2 years.Although just 5% (n = 10) estimated call-to-Emergency Medical Service (EMS) arrival time to their clinic to be <5 min, only 64% (n = 119) knew the telephone number for summoning EMS. Most confirmed the existence of a resuscitation cart in their clinic (85%, n = 157); 68% confirmed the presence of a defibrillator (n = 126). Most respondents were aware of the location of the defibrillator in their clinic (67%, n = 123), stated its accessibility during working hours (63%, n = 116), and 56% (n = 103) knew how to use it. Only 28% of the questionnaires indicated that all requirements for mounting an effective BLS response had been fulfilled.ConclusionsThe study suggests that many primary care clinics are under-equipped and their physicians are under-prepared to initiate life-saving services. Steps must be taken to rectify this situation. In addition, to develop more reliable estimates of the phenomena reported in this preliminary study, these issues should be re-examined in the context of a high response rate physician survey.

Tips to Improve Success Rate of Intubation: A Standardized Rapid Sequence Intubation Protocol Attached to the Resuscitation Cart.

The purpose of this study was to determine whether the implementation of a standardized rapid sequence intubation (RSI) protocol easily accessed on the resuscitation cart increased the success rate of intubation and reduced intubation-related complications in the emergency department (ED). This work was a retrospective study of patients who were intubated in the ED between February 2006 and June 2007. The RSI protocol and a dosage cross-table were attached to the resuscitation cart beginning in January 2007. Intubated patients before and after application of the protocol were sorted into two groups: pre-intervention and post-intervention. A total of 147 patients were enrolled in the study, including 72 patients in the pre-intervention group and 75 patients in the post-intervention group. After application of the standardized protocol prompted on the resuscitation cart. The adherence rates to pre-treatment agents (69% vs. 90%; p < 0.01) and neuromuscular blocking agents (NMBA) (72% vs. 90%; p < 0.01) significantly improved. The first-attempt success rate was 57 of 72 (79%) in the pre-intervention group versus 70 of 75 (93%) in the post-intervention group (p = 0.016). The time to intubation did not differ signifi cantly, but the preintervention group had a higher percentage of prolonged time to intubation (13% vs. 3%; p = 0.029). The implementation of a standardized RSI protocol did not induce signifi cant adverse effects. Our study demonstrated implementation of a standardized RSI protocol, improved clinician adherence to the RSI, increased success of first-attempt ED intubation and led to a decline in the rate of prolonged time to intubation.

Bacterial Contamination and Disinfection Status of Laryngoscopes Stored in Emergency Crash Carts

ObjectivesTo identify bacterial contamination rates of laryngoscope blades and handles stored in emergency crash carts by hospital and area according to the frequency of intubation attempts.MethodsOne hundred forty-eight handles and 71 blades deemed ready for patient use from two tertiary hospitals were sampled with sterile swabs using a standardized rolling technique. Samples were considered negative (not contaminated) if no colonies were present on the blood agar plate after an 18-hour incubation period. Samples were stratified by hospital and according to the frequency of intubation attempts (10 attempts per year) using the χ2-test and Fisher exact test.ResultsOne or more species of bacteria were isolated from 4 (5.6%) handle tops, 20 (28.2%) handles with knurled surfaces, and 27 (18.2%) blades. No significant differences were found in microbial contamination levels on the handle tops and blades between the two hospitals and two areas according to the frequency of intubation attempts. However, significant differences were found between the two hospitals and two areas in the level of microbial contamination on the handles with knurled surfaces (p<0.05).ConclusionsProtocols and policies must be reviewed to standardize procedures to clean and disinfect laryngoscope blades and handles; handles should be re-designed to eliminate points of contact with the blade; and single-use, one-piece laryngoscopes should be introduced.

Use of Simulation to Improve Cardiopulmonary Resuscitation Performance and Code Team Communication for Pediatric Residents

Cardiorespiratory events are infrequent in pediatric teaching hospitals but can lead to significant morbidity and mortality. Clear communication within the response team prevents delays in action and allows all team members to contribute to providing optimum management. This resource was developed to simulate high-acuity and low-frequency events for pediatric residents. The scenario options are recurrent supraventricular tachycardia, prolonged QT syndrome, myocarditis, and respiratory syncytial virus bronchiolitis. The simulation is best performed in a simulation center with audio- and video-recording capabilities but could also be performed in situ in the pediatric intensive care unit or emergency room. Necessary personnel include a simulation technician and two instructors. A code cart, mock medications, and defibrillator with hands-free pads appropriate for the mannequin are necessary supplies. Critical actions include initial survey and intervention, rhythm recognition, cardiopulmonary resuscitation (CPR), use of defibrillator, and administration of anti-arrhythmic medications when needed. At the conclusion of the scenario, a formal debriefing with learners using structured feedback is performed. These cases have been used with groups of pediatric or emergency medicine residents approximately 16 times over the past 3 years. Learners have reported that participation increased their confidence and comfort with management of cardiorespiratory events and that communication technique practice improved their teamwork and sign-out skills. Rhythm recognition and CPR performance scores during the simulation scenarios improved, with subjective improvement during actual cardiorespiratory events. This resource advances learner knowledge of Pediatric Advanced Life Support algorithms and teamwork communication and identifies learner knowledge and management deficits.

Accuracy of Prefilled “Code Cart” Epinephrine Syringes for Direct Administration of Small Doses

Accuracy of Prefilled “Code Cart” Epinephrine Syringes for Direct Administration of Small Doses

Utilization of emergency crash cart system in the hospital among nursing students

Knowledge regarding utilization of emergency crash cart system in the hospital is very important as the emergency nurses should develop the skills regarding organization, uses and care of crash carts in the hospitals. In this situation, the nurse must be skilled at rapid, accurate physical examination, early recognition of life-threatening illness or injury, the use of advanced monitoring and treatment equipment. Quasi experimental one group pre-test and post-test design with evaluative approach was used. Study was carried out in selected Nursing Colleges in Mysore, using simple random sampling. 100 4th year B. Sc. Nursing students were selected. Data was collected by a self-administered questionnaire which includes demographic data, and 30 items. Self-instructional module was administered after assessing the pre-test. A post test was conducted after 7 days with same tool. Findings reveal that the among 100 students majority 47(47%) of them were in the age group between 22–25 yrs. 52(52%) were females, and 37(37%) of them were got information from Class Teachers. Pre test revealed that 4th year B. Sc. Nursing students were having low level of knowledge with a mean score of 18.35. After giving Self-instructional module post test score increased to 23.69, which shows the effectiveness of Self-instructional module. It has been found that variables like age, sex and source of information shows there is a significant association with post-test knowledge level.