RESUMEN

Objective: We describe the creation of a two-tier emergency response system with a nurse-led first responder program titled "MET-RN" (Medical Emergency Team-Registered Nurse) created for ambulatory settings supported by a critical care code blue team for escalation of care. This observational study evaluated the clinical characteristics and effects of a MET-RN program on the code blue response. Methods: A retrospective review of the MET-RN response data was assessed from January 2016 to June 2021. Data collected included time of call, call location, patient comorbidities, triage category (minor, urgent, or emergent), activation trigger, interventions performed, duration of the event, and patient disposition. In instances where the patient was admitted to the hospital, the discharge diagnosis and emergency department (ED) triage score were collected. Differences were tested using analysis of variance (ANOVA) F-tests, with Tukey post-hoc testing where applicable. Results: MET-RN responded to 6,564 encounters from January 2016 to June 2021. The most frequent trigger call was dizziness/lightheadedness, with a prevalence of 12.0%. 33.9% of the patients seen by MET-RN were transported to the ED for further evaluation. Establishing a MET-RN system led to an estimated median of 58.3% reduction in utilization of the code blue team per quarter. Conclusion: The creation of MET-RN first responder system enabled the ambulatory areas to receive minor, urgent, and emergent patient care support, leading to a decrease in utilization of the code blue team for the hospital. A two-tiered response system resulted in an improved allocation of hospital resources and kept critical care teams in high-acuity areas while maintaining patient safety.

RESUMEN

PURPOSE: The benefits of pharmacists' involvement in medical emergencies are well established, but optimal methods of training pharmacists for emergency response are unknown. The primary objective of this report is to describe the design and evaluation of a pharmacy resident medical emergency response training (PR-MERT) program for preparing trainees to respond to hospital medical emergencies, including cardiac arrest and rapid sequence intubation (RSI). SUMMARY: The PR-MERT program was a year-long longitudinal experience designed to prepare postgraduate year 1 pharmacy residents for medical emergency response. During the first month, the residents completed an orientation session that encompassed several lectures, certification by the American Heart Association in basic life support and advanced cardiovascular life support, standardized simulation scenarios, and mock medical emergencies. The trainees continued to utilize these skills and clinical knowledge through a longitudinal didactic lecture series, resident case conferences, and practice-based application by responding to real-life medical emergencies. Residents were assessed and coached throughout the program by clinical pharmacy preceptors and a "code coach" with extensive medical emergency response experience. After the year-long training, residents completed an anonymous survey assessing self-confidence and the structure of the program. The results showed improved confidence in medication selection and dosing, as well as anticipating the needs of the team and speaking up in cardiac arrest and RSI situations. Residents were satisfied with the training offered and structure of the program. CONCLUSION: The development of a PR-MERT program at an academic medical center was successful in achieving longitudinal learning objectives and improving residents' confidence in responding to medical emergencies. The implementation of a similar medical emergency training curriculum in inpatient pharmacy residency programs may be beneficial.

Asunto(s)

RESUMEN

Aim: Rapid response systems (RRS) are present in many acute hospitals in western nations but are not widely adopted in Asia. The influence of healthcare culture and the effect of implementing an RRS over time are infrequently reported. We describe the introduction a RRS into a Singaporean hospital and the barriers encountered. The efferent limb activation rates, cardiac arrest rates and unplanned intensive care unit (ICU) admissions are trended over eleven years. Methods: We conducted a retrospective observational study using prospectively collected data derived from administrative and Medical Emergency Team (MET) databases. Results: The RRS used a MET with a single parameter track and trigger and physician led efferent limb. Barriers encountered included clinical leadership buy-in, assembling and equipping the efferent team, maintaining a non-punitive mindset, improving accessibility to MET and communicating the impact of the MET. Over an 11-year period with 488,252 hospital admissions, MET activation rates increased from 1.6/1000 admissions (2009) to 14.1/1000 admissions (2019). Code blue activations and unplanned ICU admission rates decreased from 2.9 to 1.7 and from 8.8 to 2.0/1000 admissions, respectively over the 11 years. There were associations between increasing MET activation rate and reduction in code blue activations (p = 0.013) and unplanned medical ICU admission rates (p = 0.001). Conclusion: Implementing, sustaining and continued improvement of an RRS in Singapore is possible despite challenges encountered. With increasing activation rates over a decade, there were reductions in cardiac arrest rates and unplanned medical ICU admissions.

RESUMEN

INTRODUCTION: The purpose of this study was to assess if implementing a code role delineation intervention in an emergency department would improve the times to defibrillation and medication administration and improve the nurse perception of teamwork. METHODS: A quantitative quasi-experimental study used a retrospective chart review to gather data. A pre- and post-test measured nurse perception of teamwork in a code using the Mayo High Performance Teamwork Scale (MHPTS) after a code role delineation intervention using a paired samples t-test. Pearson r correlations were used to determine relationships between nurse participant (N = 30) demographics and results of the MHPTS scores. RESULTS: A significant increase in teamwork was noted in 5 of the 16 items on the MHPTS regarding improved communication and identified roles in a code: the team leader assures maintenance of an appropriate balance between command authority and team member participation (t = -5.607, P < .001), team members demonstrated a clear understanding of roles (t = -5.415, P < .001), team members repeat back instructions and clarifications to indicate that they heard them correctly (t = -2.400, P = .029), all members of the team are appropriately involved and participate in the activity (t = -2.236, P = .041), and conflicts among team members are addressed without a loss of situation awareness (t = -2.704, P = .016). There was significance between total pre- and post-test scores (t = -3.938, P = .001). DISCUSSION: Implementation of code role delineation identifiers is an effective method of improving teamwork in a code in an emergency department setting.

Asunto(s)

RESUMEN

In-hospital cardiac arrest resuscitation training often happens in silos, with minimal interprofessional training. The aim of this study was to implement and evaluate a simulation-enhanced, interprofessional cardiac arrest curriculum in a university hospital. The curriculum ran monthly for 12 months, training interprofessional teams of internal medicine residents, nurses, respiratory therapists, and pharmacy residents. Teams participated in a 90-min high-fidelity simulation including "code blue" (30 min) followed by a 30-min debriefing and a repeat identical simulated "code blue" scenario. Teams were tested in an unannounced mock Code Blue the following month. Advanced Cardiac Life Support (ACLS) algorithm adherence was assessed using a standardized checklist. In-hospital cardiac arrest (IHCA) incidence and survival was tracked for 2 years prior, during, and 1 year after curriculum implementation. Team ACLS-algorithm adherence at baseline varied from 47% to 90% (mean of 71 ± 11%) and improved immediately following training (mean 88 ± 4%, range 80-93%, p = .011). This improvement persisted but decreased in magnitude over 1 month (mean 81 ± 7%, p = .013). Medical resident self-reported comfort levels with resuscitation skills varied widely at baseline, but improved for all skills post-curriculum. This simulation-enhanced, spaced practice, interprofessional curriculum resulted in a sustained improvement in team ACLS algorithm adherence.

Asunto(s)

RESUMEN

PURPOSE: The literature supports interval simulation training as a means of improving nurses' cardiopulmonary resuscitation (CPR) skills. The aim of this project was to improve the time-to-task skills in single-rescuer basic life support (BLS) in an outpatient surgery center through interval simulation training. DESIGN: Quality Improvement project. METHODS: Twenty-nine nursing staff were included in this pretest/post-test within subjects interventional design quality improvement project. A 2-minute pretest cardiac arrest simulation was performed in the outpatient surgery center where time-to-task and quality of CPR data were collected. The pretest was followed by a lecture and CPR training. Three months later, the simulation was post-tested in an identical scenario with measures of time-to-task and quality of CPR. FINDINGS: The mean times for code bell activation and initiation of CPR decreased significantly following the interval simulation training (P < .05). A clinically significant decrease was seen in the mean time-to-task placement of a backboard on code team arrival. CONCLUSIONS: Interval simulation training is an effective means of maintaining CPR skills in the outpatient surgery center setting.

Asunto(s)

RESUMEN

Background and Aims: Code blue is a rapid response system developed for emergency resuscitation and stabilization of any sudden cardiac arrest (SCA) within a hospital. Literatures on outcome and factors predicting mortality from SCA in the Emergency departments (EDs) of India is scant. Material and Methods: This retrospective cohort study included all patients above the age of 15 years who had a code blue declared in the ED between the months of January 2018 and June 2019. Factors related to the sustained return of spontaneous circulation (ROSC) and mortality were analyzed using descriptive-analytic statistics and logistic regressions. Results: This study included 435 patients with a male predominance of 299 (69%). The mean age was 54.5 (SD - 16.5) years. Resuscitation was not attempted for 18 patients because of the terminal nature of the underlying disease. The majority were in-hospital cardiac arrests (74%). The nonshockable rhythm included pulseless electrical activity (PEA) (85.5%) and asystole (14.5%) cases. Shockable rhythms, that is, pulseless ventricular tachycardia/ventricular fibrillation were noted in only 10% (43/417) of cases. ROSC was attained in 184 (44.1%) patients, among which 56 (13.4%) were discharged alive from the hospital. Multivariate logistic regression analysis showed CPR >10 min (odds ratio [OR]: 13.58; 95% CI: 8.39-22.01; P < 0.001) and female gender (OR: 1.89; 95% CI: 1.13-3.17; P = 0.016) to be independent risk factors for failure to achieve ROSC in ED. Conclusion: The initial documented rhythm was nonshockable in the majority of the cases. CPR duration of more than 10 min and female gender were independent risk factors for failure to achieve ROSC in the ED. Nonshockable rhythms have a poorer outcomes than that of shockable rhythms.

RESUMEN

Background: Critical events are common at community hospitals, yet physicians who lead them have had varying levels of training and involvement during their residency and professional development. Little is known about the impact of simulation to improve performance during inpatient critical events among community hospitalist physicians. Objectives: To determine if hospitalist physicians reported sustained performance improvement regarding critical events as a result of simulation. Methods: Physicians at a community hospital in Northern California participated in critical event simulation over one year. Self-assessment surveys (scale 1 through 5) were collected before, after, and at 1-month post-simulation. Differences in survey scores and post-simulation trends in total composite survey scores over a 1-month period were compared among participants. Results: From February 2018 through February 2019, 25 of 32 eligible physicians (78%) participated in the simulations. Most were trained in internal medicine (76%), practiced primarily hospital medicine (72%), and had previous experience of at least 5 critical events per year (68%). Participants reported increases in mean survey scores (knowledge +0.8, familiarity +1.0, communication +1.2, technical skills +1.0) which were sustained at one month post-simulation (knowledge +0.8, familiarity +1.0, communication +1.3, technical skills +0.9) (all p < 0.0001). At one month post-simulation, participants who were clinic-based and had <5 years of post-residency experience had higher composite survey score differences compared to those who were hospital-based and had ≥5 years of experience, respectively (p < 0.05). Conclusion: Simulation may lead to sustained performance improvement at critical events as reported by community hospitalist physicians. Further investigation is needed.

RESUMEN

OBJECTIVES: The primary aim was to define factors related to the return of spontaneous circulation (ROSC) after in-hospital cardiac arrest (IHCA), and the secondary aim was to determine factors related to 28-day mortality in patients admitted to intensive care unit (ICU) after ROSC. METHODS: In this retrospective study, we included the patients who suffered from IHCA in a tertiary hospital between July 2016 and April 2019. Pre- and post-resuscitation characteristics of the patients and event characteristics were defined to reveal the independent factors associated with ROSC and 28-day survival. RESULTS: A total of 254 patients (median age 73 years, 58.3% males) underwent cardiopulmonary resuscitation (CPR). The ROSC rate was 45.7%. Of all, 51 patients (median age, 63 years, 54.9% males) were admitted to in-hospital ICUs. The 28-day survival rate was 31.4%. The independent risk factors were chronic kidney disease (odds ratio [OR], 3.18, 95% confidence interval [CI], 1.37-7.19, P = 0.007), chronic obstructive pulmonary disease (OR, 2.84, 95% CI, 1.23-6.61, P = 0.015), asystole as an initial rhythm (OR, 2.94, 95% CI, 1.27-6.79, P = 0.012), multi-trauma-related complications (OR, 21.11, 95% CI, 4.71-94.69, P < 0.001), and septic shock (OR, 4.10; 95% CI, 1.16-14.54, P = 0.029) for ROSC; and a cerebral performance category score >2 (OR, 20.86, 95% CI, 2.74-158.65, P = 0.003), Acute Physiology and Chronic Health Evaluation II score >14 (OR, 7.58, 95% CI, 1.06-54.23, P = 0.044) for 28-day mortality. CONCLUSIONS: Independent risk factors related to ROSC and 28-day mortality were defined in the study. However, further studies are needed to devise new strategies for increased hospital discharge with preserved neurologic functions.

RESUMEN

Background: High-quality cardiopulmonary resuscitation (HQ-CPR) focuses on improving heart and brain blood perfusion. The evaluation of HQ-CPR included depth, frequency, rate of chest compressions, and the occurrence of chest recoil between two chest compressions. Staff performing CPR may not be performing HQ-CPR since it is influenced by individual stamina, physical strength, and lack of target marker. We aimed to study the impact of 100 times per minute rate vs. 120 times per minute CPR rate on the depth and percentage of depth-on-target done by trained staff on a manikin. Methods: This was a cross-over randomized control study. The subjects were anesthesiology and intensive care residents in a tertiary teaching hospital in Indonesia, all certified to perform advanced life support. The subject was asked to perform both CPR of 100 and 120 times per minute after a period of one-day rest. The standardized adult manikin was used, and the depth of CPR was measured using a pad-sensor attached to the manikin, and the results were transferred to recording software. Analysis was done using the chi-square analysis, and p < 0.05 was considered statistically significant. Results: A total of 35 subjects were included. The results showed that the average compression depth at 100 times/minute was more statistically superficial than the 120 times/minute treatment (5.210 ± 0.319 vs. 5.430 ± 0.283, p = 0.007). In contrast, the compression depth-on-target percentage was significantly higher at a speed of 100 times per minute (37.130 ± 10.233 vs. 18.730 ± 7.224, p = 0.0001). Conclusion: One hundred times per minute CPR resulted in a statistically significant lower compression depth, although not clinically significant, with a statistically significant higher percentage of compression depth-on-target than 120 times per minute CPR.

RESUMEN

BACKGROUND: Code Blues allow a rapid, hospital wide response to acutely deteriorating patients. The concept of frailty is being increasingly recognised as an important element in determining outcomes of critically ill patients. We hypothesised that increasing frailty would be associated with worse outcomes following a Code Blue. AIMS: To investigate the association between increasing frailty and outcomes of Code Blues. METHODS: Single-centre retrospective design of patients admitted to Frankston Hospital in Australia between 1 January 2013 and 31 December 2017 who triggered a Code Blue. Frailty evaluation was made based on electronic medical records as were the details and the outcomes of the Code Blue. The primary outcome measure was a composite of hospital mortality or Cerebral Performance Categories scale ≥3. Secondary outcomes included the immediate outcome of the Code Blue and hospital mortality. RESULTS: One hundred and forty-eight of 911 screened patients were included in the final analysis. Seventy-three were deemed 'frail' and the remainder deemed 'fit'. Seventy-eight percent of frail patients reached the primary outcome, compared with 41% of fit patients (P < 0.001). Multivariable analysis demonstrated frailty to be associated with primary outcome (odds ratio = 2.87; 95% confidence interval (CI) 1.28-6.44; P = 0.01). A cardiac aetiology for the Code Blue was also associated with an increased odds of primary outcome (OR = 3.52; 95% CI 1.51-8.05; P = 0.004). CONCLUSIONS: Frailty is independently associated with the composite outcome of hospital mortality or severe disability following a Code Blue. Frailty is an important tool in prognostication for these patients and might aid in discussions regarding treatment limitations.

Asunto(s)

RESUMEN

OBJECTIVE: Globally, previously determined teams activated by 'code blue' calls target rapid and organised responses to medical emergency situations. This study aimed to evaluate the cardiopulmonary resuscitation (CPR) conditions in Turkey. METHODS: A web-based survey was sent to anaesthesiologists in Turkey via email. The survey included 36 questions about demographic features and 'code blue' practices and procedures. RESULTS: A total of 180 participants were included. The mean working duration was 16.1±7.5 years. Of the anaesthesiologists who participated, 35% worked in university, 26.1% in education and research, 1.7% in city hospitals, 18.9% in state hospitals and 18.3% in private hospitals; 68.3% had CPR certification. There were code blue systems in 97.6% of the organisations. For code blue calls, 71.9% were activated by calling '2222'. There were 41.5% organisations with code blue teams of 3-4 people, whereas 26.7% had 2-member teams. Among call responders, 68.5% were anaesthesia technicians/paramedics, 60.7% were anaesthesiologists and 42.7% were anaesthesia assistants. In organisations, 66.3% regularly conducted code blue training. In total, 63.3% of the participants stated that the time to reach the location was nearly 2-4 minutes. During CPR, the use of capnography was 18.3%. Of the participants, 73.8% chose endotracheal intubation as priority airway device during CPR. CONCLUSION: Today, code blue practice is an important quality criterion for hospitals. This study shows the current status of 'code blue' according to the results of respondent data completing the survey. To prevent in-hospital cardiac arrest, a chain of preventive measures should be established, including personnel training, monitoring of patients, recognition of patient deterioration, the presence of a call for help system and effective intervention.

RESUMEN

BACKGROUND: Code Blue is a popular hospital emergency code that is used to alert the emergency response team to any medical emergency requiring critical care. By retrospectively studying Code Blue cases in a children's hospital, we looked for high-risk factors associated with survival and how to improve the effectiveness of Code Blue systems through training. METHODS: Data were collected on age, gender, department, diagnosis, time of Code Blue call activation, time between call and arrival of the Code Blue team, treatment details and outcome before and after the training process from January 2016 to December 2019. Chi-square test and logistic regression analysis were used to analyze the data. RESULTS: A total of 139 Code Blue cases from the period of January 2016 to December 2019 were retrospectively studied. The wards where Code Blues occurred most frequently were the infectious diseases ward (n=31, 22.3%), the hematology and oncology ward (n=30, 21.6%), and the cardiology ward (n=15, 10.8%). Age, inpatient status, time of arrival, the time of cardiopulmonary resuscitation (CPR), and the cause of shock were all risk factors for death. After the training, the arrival time and recovery time were significantly reduced (P<0.01). The proportion of patients who were transferred to the ICU had increased (P<0.05), and the proportion of deaths had decreased (P<0.01). The survival curve improved (P<0.05). CONCLUSIONS: It is very important to summarize the risk factors related to Code Blue. It is clear that the efficacy of the Code Blue events improved after training of the hospital staff in the Children's Hospital.

RESUMEN

Introduction: Acute respiratory distress syndrome (ARDS) is present in approximately 10% of ICU admissions and is associated with great morbidity and mortality. Prone ventilation has been shown to improve refractory hypoxemia and mortality in patients with ARDS. Methods: In this simulation, a 70-year-old male had been transferred to the ICU for ARDS and was undergoing scheduled prone ventilation as part of his care when he experienced a cardiopulmonary arrest secondary to a tension pneumothorax. Learners demonstrated how to manage cardiac arrest in a prone patient and subsequently identified and treated the tension pneumothorax that was the cause of his initial arrest. This single-session simulation for internal medicine residents (PGY 1-PGY 4) utilized a prone mannequin connected to a ventilator in a high-fidelity simulation center. Following the simulation, facilitators led a team debriefing and reviewed key learning objectives. Results: A total of 103 internal medicine residents participated in this simulation. Of those, 43 responded to a postsimulation survey. Forty-two of 43 agreed or strongly agreed that all learning objectives were met, that the simulation was appropriate for their level of training, and that their participation would be useful for their future practice. Discussion: We designed this simulation to improve learners' familiarity with prone cardiopulmonary resuscitation and to enhance overall comfort with cardiac arrest management. Postsimulation survey results and debriefings revealed that the simulation was a valuable education opportunity, and learners felt that their participation in this simulation would be helpful in their future practice.

Asunto(s)

RESUMEN

Description Starting intern year comes with its own challenges and learning opportunities, especially in a pandemic. In this paper I reflect on one such situation. The code and passing of a particular patient earlier this year taught me many lessons and it has impacted the type of physician I aspire to be.

RESUMEN

OBJECTIVE: To assess the rates of serious medical issues on psychiatry wards by determining the rate, indication and outcomes of rapid response calls. METHOD: Using retrospective file review, information regarding rapid response calls during an 8-month period was analysed. RESULTS: Seventy-two rapid response calls were recorded; 7.5% of the admissions involved a rapid response call. Of patients who required a rapid response call, 88.6% had medical comorbidities. Also, 29.2% of rapid response calls required transfer to another ward. CONCLUSIONS: Patients on psychiatry wards frequently require urgent medical intervention. Improved collaboration and service planning between general medical and psychiatric service is required to improve clinical care and outcomes for this high-risk group.

Asunto(s)

RESUMEN

BACKGROUND: Prompt identification and management of patients having clinical deterioration on wards is one of the key steps to reduce in-hospital cardiac arrests (IHCA). Our organization implemented a novel Automated Code Blue Alert and Activation (ACBAA) system since 1st March 2018. METHODS: We conducted a retrospective before-and-after ACBAA system implementation study in JurongHealth Campus (JHC) of National University Health system (NUHS), Singapore. In JHC, code blue can be activated by both manual activation and ACBAA system activation from 1st March 2018. The ACBAA system will be activated when any of the pre-defined peri-arrest criteria is met. The primary outcome of the study was the incidence of IHCA. The secondary outcome included return of spontaneous circulation (ROSC) of IHCA and in-hospital survival to home discharge of code blue activation. OUTCOMES: The incidence of IHCA per 1000 hospital admissions after-ACBAA system implementation was 14.6% lower than before-ACBAA system though not statistically significant [relative risk (RR): 0.86, 95% confidence interval (CI) 0.55-1.34, P > 0.05]. Compared to the before-ACBAA system period, the after-ACBAA system period had a trend for higher rate of survival to home discharge after IHCA (RR: 2.13, 95% CI 0.65-6.93, P > 0.05) with good neurological outcome. CONCLUSIONS: Implementation of a novel ACBAA system has shown a trend in reducing IHCA incidence. In the era of digitalised healthcare system, the ACBAA system is practical and advisable to implement in order to reduce IHCA. Further studies are required to validate the criteria for peri-arrest code blue activation.

Asunto(s)

Asunto(s)

RESUMEN

Emergency medical services (EMS) is called for a 65-year-old man with a 1-week history of cough, fever, and mild shortness of breath now reporting chest pain. Vitals on scene were HR 110, BP 135/90, SpO2 88% on room air. EMS arrives at the emergency department (ED). As the patient is moved to a negative pressure room, he becomes unresponsive with no palpable pulse. What next steps should be discussed in order to protect the team and achieve the best possible patient outcome?

Asunto(s)

RESUMEN

PURPOSE: The objective of this study was to identify the characteristics and tasks vital for individuals to successfully navigate a proactive rapid response role at a quaternary children's hospital. DESIGN AND METHODS: A qualitative thematic analysis of open-ended interviews was utilized to define the essential characteristics and functions of a WATCh (Watch, Assess, Triage for Children) nurse. The sample included both WATCh nurses and other healthcare providers that work with WATCh nurses. RESULTS: Effective WATCh nurses are excellent communicators with advanced skills who are experienced, confident, and visible. They work as an extension of the nurse and as a care facilitator for high-risk children, advocate, and educator. CONCLUSIONS: A more proactive approach is essential for successful pediatric rapid response teams in hospital settings to prevent patient decompensation and code blue events. This study has identified that a successful program requires defined tasks and essential role characteristics. PRACTICE IMPLICATIONS: Implications for integration into practice include a defined selection process and training program for the WATCh nurse role to provide standardization and consistency. Experience was identified as an essential characteristic for the role but an exact amount was not defined. Strong communication skills are also necessary and while training can help supplement the characteristic, a certain level of personality and confidence should be identified in potential candidates. Training will need to include not only practice skills, but also personal skills to be an effective role in the institution.

Asunto(s)