Knight Lynda Improving

8/3/2019 Knight Lynda Improving

1/33

Improving Code Team Performance

and Survival Outcomes: Implementation of Pediatric Composite

Resuscitation Training

Lynda Knight, RN, CCRN, CPN 1

Julia Gabhart, MD 1,2

Karla Earnest, RN, MSN 1

Stephanie Wintch, RN, BSN 1

Erin Augustine, MD1

Michael Chen, MD 1,2 Deb Franzon, MD 1,2

1Lucile Salter Packard Childrens Hospital 2Stanford University School of Medicine


2/33

Implementation of Pediatric

Composite Resuscitation Training Background Study Overview

Preliminary Data QI Lessons Discussion Points

Questions


3/33


4/33

Background

Implementation of a Rapid Response Team (RRT) decreased code events outside the ICU by 71%

Ongoing resuscitation training is imperative

Paul Sharek, et al. JAMA, Nov. 2007. LPCH.

Improved patient outcomes =Less code team experience


5/33

Background

Educational interventions should be ongoing, focusedon improving performance, quality of care, andmaintaining competency.

CHOP: Donoghue AJ et al., Pediatr Emerg Care , Mar 2009 Boston: Allan CK et al., J Thorac Cardiovasc Surg , Sep 2010

Simulation of crisis can identify targets for educational intervention to improve CPA resuscitationoutcomes.

K Daniels et al., Simul Healthc . 2008.

Pediatric simulation is associated with improvementin CPA survival rates.

P Andreatta et al. Pediatr Crit Care Med, June 2010.


6/33

Hypothesis

Composite Resuscitation Team Training isassociated with:

Improved survivalDecreased morbidity

Improved team communicationImproved code performance

following pediatric cardiopulmonary arrest(CPA).


7/33

Objectives

Primary Outcome Variable: Survival to discharge.

Secondary Outcome Variables: Morbidity

Admission and discharge Pediatric Cerebral PerformanceCategory scores.

Code performance/meeting AHA guidelines

2 minutes to rhythm check during chest compressions.


8/33

Research Questions

Will implementationof CompositeResuscitation Team

Training result in: Increased patientsurvival to discharge?

Improved performance

of multi-disciplinaryCode Team members? Decreased morbidity ?


9/33

Methods IRB approval waived

312- bed freestanding, quaternary care, academic childrenshospital

Examined all CPA events for which hospital code teamresponds.

Participants: all members of the code team. PICU/CVICU Attendings and Fellows All RNs, including Nursing Supervisor Pediatric Housestaff Hospitalists Respiratory Care Specialists Pharmacists Social Workers Security

Ongoing training from January 2010-June 2011 Required by HR for staff PALS and/or mandatory MD training sessions


10/33

InterventionComposite Resuscitation Team Training

Institution-specific Code Roles Video

PALS training : Zoll, EZ I/O, Broselow Cart

New code sheet and Quality Code Review Form

Familiarization with high-fidelity manikin

Code blue scenarios and debriefings approximately twicemonthly (January 2010-June 2011). 14 code simulations to date; anticipate 30.


11/33

Insert movie of simulation here


12/33


13/33


14/33

LPCH Quality Code Blue Review Form For Quality Purposes Only DO NOT Place in Medical Record Send to LPCH Code Committee, Quality Management, Mail Code 5893

Patient Name Event Date and Time Medical Record Number Event Location Code Blue: Pediatric Adult

211 Code Blue Response: Delay Pager issue(s) Other (specify) _________

Was Rapid Response, OB STAT, or Anesthesia ASAP called first? Yes No

Interventions: Chest Compressions Defibrillation Cardioversion Intubation

Cardiac rhythm at time of call: NSR ST SVT Bradycardia VTach w/ pulse VTach w/o pulse Vfib PEA AsystoleDid cardiac rhythm change? NSR ST SVT Bradycardia VTach w/ pulse VTach w/o pulse Vfib PEA Asystole

Brief History of events leading up to code: _____________________________ ___________________________________________________________________ Cardiopulmonary Resuscitation CPR Quality: (If no chest compressions, skip this section) Chest Compressions: Delay No back board Other (specify) __________ Were pulses checked with compressions? Yes No Was arterial line diastolic pressure used to monitor compression quality? Yes No

Not Applicable (arterial line not in place)

Defibrillation(s): Energy level lower / higher than recommended? Yes No Staff knowledgeable of defibrillator operation? Yes No Delay with pad, paddle, or cable placement? Yes No Other (specify) __________

Vascular Access: Was peripheral line obtained? Yes No Already present Was I/0 attempted? Yes No Was central line attempted? Yes No Already present

Airway: Aspiration related to provision of airway Multiple intubation attempts (# attempts: ________) Delayed recognition of airway misplacement/displacement Other (specify) __________


15/33

Medications: Was Emergency Medication Report available? Yes No Delay in code medication availability? Yes No Correct selection, dose, route? Yes No (specify) _________

Was dwindle epi given during compressions? Yes No

Leadership: Was a single Team Leader clearly identified? Yes No Was there a d elay in identifying a Team Leader? Yes No

Did Team Leader perform tasks, e.g. intubation? Yes No

If yes, did Team Leader designate new Team Leader? Yes No Was Team Leader knowledgeable of equipment? Yes No

Was Team Leader k nowledgeable of medications/protocols? Yes No

Protocol Deviation: BLS NRP PALS ACLS (specify) __________ Code Roles Clearly Identified:

Team Leader Respiratory Therapist Code Cart RN Bedside RN Pharmacist SecurityICU RN Event Manager USA

Recorder Nursing Supervisor Runner Responsibilities carried out for each role: Yes No (specify) __________

Clear communication used, e.g. Closed-loop communication: Yes No

Universal Precautions followed by all team members:Gloves Mask Gown

Crowd Control: Successfully managed by Event Manager, Nursing Supervisor, and Security? Yes No

Documentation: Signature of code team leader on CPR Record? Yes No Documentation complete on CPR Record? Yes No Quantros Report submitted? Yes No

Equipment: Available and easily accessible? Yes No Functioning properly? Yes No

Post-code debriefing was led by whom? ____________ List debriefing points addressed for this event:

Comments:

Report Completed By: Print Name_____________ Signature____________


16/33

Study Support

Expectation of participation set &information disseminated Faculty meetings Electronic reminder

Trainees engaged and eager (ICU Fellows) Positive feedback reinforced utility Appreciation of effort with realistic

simulation


17/33

Training and scenariosUseful and realistic


18/33

Data Collection Study population: Patients sustaining in-hospital CPA with

resuscitation Inclusion criteria: Any CPA event to which the hospital code

team responds Exclusion criteria:

Event did not meet NRCPR criteria No code record available

Data Source: Code Sheet Documentation in the medical record or NRCPR data

Control period January 1, 2006, through December 31, 2009;n=167

Comparison period July 1, 2010 through June 30, 2011; projected n = 40


19/33

Additional Data Collection

Mock code performance For comparison with actual CPA outcomes During intervention period

CPA documentation Scored for comparison between control and

comparison periods Intervention impact on code performance vsdocumentation


20/33

CodeDocumentation

Quality

True

Code

Performance


21/33

Data Analysis:

Demographic Data

Age

Gender Ethnicity Admission diagnosis Location of code event Admission PCPC scores


22/33

Data Analysis Analysis of primary & secondary outcome

variables Discrete variables via Chi-squared test Variables with more than one possibility of occurring

per code event via ANCOVA

Secondary analyses Simulation outcome versus actual CPA outcome Documentation quality of control vs intervention period

All analyses with SAS Enterprise Guide


23/33

Study CPA Events

Comparison Period31

Code Blue Events

242 Excluded

Not CPA events, our teamdid not respond, not

NRCPR criteria

12 Excluded

Not CPA events, our teamdid not respond, not

NRCPR criteria

28 Excluded

No Code Blue Record

5 Excluded

No Code Blue Record

167 CPA Events

(136 Patients)

Control Period437

Code Blue Events

14 CPA Events

(10 Patients)


24/33

#Admitswith CPAevents

#CPAevents

MeanPCPC atadmit

MeanPCPC atd/c

Survival toDischarge(%)

2 mincontinuousCCs (%)

< 1 min toCC of HR


25/33

#Admitswith CPAevents

#CPAevents

MeanPCPC atadmit

MeanPCPCat d/c

SurvivaltoDischarge(%)

2 mincontinuousCC (%)

< 1 minto CC of HR


26/33

1.81.9 3.53.6

45

66

0

10

2030

40

50

60

70

AdmitPCPC DC PCPC Survival%

Preliminary Data

Control PeriodComparison Period

Preliminary difference in Survival to Discharge

Significant?


27/33

01020

30405060708090

100

CC 1 Minfrom

HR


28/33

Simulation data trends toward correlation with Comparison data

0102030405060708090

100

CC 1 Minfrom

HR


29/33


30/33

Lessons Learned

Code documentation issuboptimal Future project: residents as

recorder.

Team performance hindered by lack of familiarityBroselow Carts Focused code-cart training

initiated

Subjectively, simulationshave improved code team

performance, communication

In-situ simulation revealedsystem weaknesses Unit-specific Code Blue

processes Security staff

Code cart locations

Simulation idiosyncrasies Suspending disbelief

difficult

Variable use of debriefingtool


31/33

Discussion

Data and subjective experience consistentwith the literature

Preliminary data encouraging Survival to discharge, morbidity Code performance/AHA guidelines

Code documentation quality a confounder


32/33

Part of Our Research Team


33/33

LPCH Innovations In Patient Care Grant, which funds thisresearch

All Code Team members who participated in theComposite Resuscitation Training and in-situ mock codes

Michael Chen, M.D. Amy Nichols, EdD, Director of Center For NursingExcellence for her help with study design and ongoingsupport

Alex McMillan, Ph.D., and Raymond Balise, Ph.,D., fromSPECTRM at Stanford University for their support in dataanalysis and study design.

Support from NRCPR (Get with the Guidelines) Staff and

F lt

Acknowledgements

Documents

Knight Lynda Improving