Initiative Aims to Reduce In-Hospital Cardiopulmonary Arrests

In-hospital cardiopulmonary arrests (CPA) are a public health concern nationwide, with approximately 292,000 adult CPAs in the United States each year, according to a study in the American Heart Association’s Circulation journal. During the third quarter of 2019, the rate of in-hospital cardiopulmonary arrests (CPA) at Cleveland Clinic South Pointe Hospital was 4.89 per 1,000 patient days. The hospital’s interdisciplinary Code Blue Committee, which includes several nurses, reviewed the summary report of all CPAs.

“We realized that we called more code blues than rapid responses, and there were a lot of codes with initial rhythm as pulseless electrical activity,” says Nancy Hodge, MSN, RN, assistant nurse manager of the ICU and a member of the Code Blue Committee. “How could we prevent this from happening?”

Employing several tactics

The committee devised a multipronged approach to decrease the rate of in-hospital cardiopulmonary arrests, which featured the following:

• A revamped debriefing tool. “The original tool was a front-and-back page that asked for a lot of extra information,” says Jennifer Eklich, BSN, RN, CCRN, a clinical nurse in the ICU and a member of the Code Blue Committee. “So we made it simpler.”

The new one-page debriefing tool captures all the information required for reporting in the database for code blue reviews. Caregivers indicate whether they called a code blue, rapid response or concurrent event, and whether it was documented in the safety event reporting system. The tool also includes information on airway access, vascular access and chest compressions. “We check off items to see what we missed or could have done better, as well as what we did great,” says Hodge.

• Revision of caregiver roles and responsibilities. “During code blues and rapid responses, there can be a lot of confusion about who should do what – who is handling documentation, the defibrillator, medication,” says Eklich. Taking into consideration input from the Shared Governance Council, the Code Blue Committee updated the Code Blue and Rapid Response Policy so caregivers would better understand not only when to initiate a call, but also their roles and responsibilities.

In addition, the committee created green labels identifying each role – code supervisor, CPR and medication nurse – that caregivers assume when they enter the room. This helps ensure that everyone in the crowded room knows their job and the role of others.

• Equipment enhancements. Based on suggestions from frontline nurses, the Code Blue Committee placed tackle boxes on top of every crash cart to store a pulse oximeter device, extra EKG leads, defibrillator pads and other emergency tools. Each unit in the hospital received a tackle box, which also includes laminated instructions for maintenance and expiration dates for applicable supplies. “Now when there’s a rapid response, everything is readily available for caregivers,” says Hodge.
  
  
• Nursing education. Because South Pointe Hospital had more code blue calls than rapid responses, Hodge and a physician assistant educated staff on every unit, during both day and night shifts, about when to call a rapid response. They also reviewed equipment in the tackle box and crash cart and discussed the role of the patient’s primary care nurse, other unit caregivers and the code blue or rapid response team. Hodge, the physician assistant and Eklich also attended unit huddles throughout the first half of 2020 to further educate and remind nurses about the code blue/rapid response process and roles.
  
  
• A communication tool. The Code Blue Committee created a communication tool to remind nurses of the critical information to provide the operator, who places the overhead page during a code or rapid response. The tool uses the acronym LEAN.

L – Give the Location of the event

E – Specify whether the Event is a code blue or rapid response

A – Indicate if the patient is an Adult or child

N – Provide a Number to call back

• Mock simulations. During the second quarter of 2020, caregivers on all shifts and units participated in rapid response simulations. Afterward, the team reviewed what went well, what they needed to work on and what further education was required.

Results of the initiatives

After implementing these strategies, the in-hospital CPA rate at South Pointe Hospital decreased to 3.29 per 1,000 patient days during the third quarter of 2020 and 2.19 during the fourth quarter. The Code Blue Committee continues to review all codes and look for opportunities for improvement. Hodge and Eklich also continue to educate nurses, making presentations to newly hired nurses and the New Graduate Council.