Transcript Improving Code Team Performance and Survival Outcomes

Revive Initiative at Stanford Children’s
Health
Synergy Pediatric Resuscitation
Program
Lynda J. Knight RN, MSN, CPN
Presenter Disclosure
Information
Lynda J . Knight, MSN, RN
Improving Code Team Performance and Survival
Outcomes: Implementation of Pediatric
Resuscitation Team Training
FINANCIAL DISCLOSURE:
 No Financial Disclosures
UNLABELED/UNAPPROVED USES
DISCLOSURE:
 NONE
“the interaction or cooperation
of two or more organizations
…to produce a combined effect
greater than the sum of their
separate effects”
The IOM Report
June 30th, 2015
“A national
responsibility exists to
improve the likelihood of
survival and favorable
neurologic out- comes
following a cardiac
arrest. This will require
immediate changes in
cardiac arrest reporting,
research, training, and
treatment.
The IOM Report
June 30th, 2015
•
•
•
Should adopt formal, continuous
quality improvement programs for
cardiac arrest response that assign
responsibility, authority, and
accountability within each
organization
Implement core technical and nontechnical training, simulation, and
debriefing protocols to ensure that
EMS and hospital personnel can
respond competently to both adult
and pediatric cardiac arrests; and
Actively collaborate and share data
to facilitate national, state, and local
benchmarking for quality
improvement.
The IOM Report
June 30th, 2015
• Should adopt formal,
continuous quality
improvement
programs for cardiac
arrest response that
assign responsibility,
authority, and
accountability within
each organization
Code Committee
Code Committee reviews RRT & Codes monthly and
identified:
Practice variability
Best practice standards not met consistently
Role Confusion and Crowd Control issues
Hesitation in timely escalation of deterioration
Incomplete documentation and “hot”debrief
Lack of confidence and competence due to low
incidence events
The IOM Report
June 30th, 2015
• Implement core
technical and nontechnical training,
simulation, and
debriefing protocols to
ensure that EMS and
hospital personnel can
respond competently to
both adult and pediatric
cardiac arrests; and
What we know about training in
teams
The challenges of pediatric
resuscitation team training
Low frequency < 50 year
High acuity: 40% Survival
Possible Team Configuration highly
variable: > 300,000
✓Frequent
✓All team
members
Guideline Adherence & Team
performance not quantified
✓In own
environment
PALS Training every 2 years
✓Measurable
Simulation environment limitations
Pediatric resident resuscitation skills
improve with practice and coaching
Time to Initiation of Chest Compressions
Gold Standard
}
3-fold increase
E.A. Hunt et al. / Resuscitation 85 (2014) 945–951
In situ mock codes save lives
after
Real codes
before
Mock Codes
Andreatta P, et al. Peds Crit Care Med .
12(1) , January 2011, p 33-38.
Could in situ training of all team members
Improve survival and team performance?
✔
✔
✔
✔
✔
✔
Knight L, et al. Crit Care Med: Volume 42(2)
February 2014, p 243-251
Results: Composite, in-situ resuscitation team
training improves code team performance and
outcomes
Outcome
Pre intervention
Intervention
OR (CI)
Survival to discharge after
CPA
50/124
(40.3 %)
28/46
(60.9%)
cOR=2.30
(95% CI, 1.154.60)
23/64
(35.9%)
cOR-2.14
(95% CI, 1.153.99)
0.11
P = 0.37
Adherence to Resuscitation 38/138
Standard Operating
(20.8%)
Performance (AHA
Guidelines)
Mean increase in Pediatric
Cerebral Performance
Category score
0.27
Knight L, et al. Crit Care Med: Volume 42(2)
20%
15%
In situ simulation with debrief uncovers
latent Errors
Knight L, et al. Crit Care Med: Volume 42(2)
February 2014, p 243-251
IMSH 2015 Simmy Award
• Add video
In-Situ Unit Schedule
Revive Part 1
Individualized, Tailored Learning
• All units and locations within the footprints of LPCHS
are divided into 15 groups
• A “ Resuscitation Week” is conducted on one of these
areas every week providing:
 unit specific emergency skill training
 interprofessional in-situ mock codes
 formalized debriefing
• Evaluate, Revise, Begin again
• Strengthens skills, communication, and team dynamics
• Build confidence and competence
Revive Part 1
Individualized, Tailored Learning
• High fidelity manikin'splasma TV and videotape
capability for conducting
QI/educational debriefings
• Small and mobile (so easy
to get in and out)
• Staff and faculty learn within
their own clinical
environment
Revive Part 2
Team Training Unannounced In-Situ Mock Codes
•
•
Monthly in-situ un-announced mock
codes in locations where
Code
Teams respond and perform as an
actual event
Pre-defined Learning objectives:
– Clear code roles and responsibilities
– Effective communication and team
dynamics
– Identified system errors or process
improvements
•
Code Team performance assessed
– PALS, NRP, ACLS, AHA Gold
Standard
– Equipment competency and effective
communication
•
Formalized Debrief
Shannon video
The IOM Report
June 30th, 2015
• Actively collaborate and
share data to facilitate
national, state, and
local benchmarking
for quality
improvement.
PEDIATRIC/NEONATAL CODE BLUE and RAPID RESPONSE 5 minute TEAM DEBRIEFING GUIDE
Goal: The goal of a debriefing is to: 1) improve the quality of medical care provided at LPCH. 2) Any staff member present may document the debrief 3)
Hospitalist/ANS leads on acute care units; PICU/CV Attending/Charge Nurse/ANS lead in ICU’s 4) This is not a “blaming” session and everyone’s
participation is encouraged and appreciated.
Date/time: ___________________________
Code Blue: Neonatal � Pediatric �
Adult �
Patient name and MRN ____________________________________________
OR
Rapid Response Call �
ECMO Call �
VAD call � Pediatric Stroke call �
If debriefing was not conducted, why? � Team constraints � Team dispersion � Team declined � Other_________________
Thinking about team performance in this emergency event:
Identify what went easily (check all that apply):
Communications were closed-loop, clear and heard; reports were in SBAR format
Everyone knew what the emergency was (shared mental model)
Team Leader was identified; leadership was clear; TL did not perform a task
R-series ETCO2 and CPR feedback used to determine compression effectiveness and Return of Spontaneous Circulation
(ROSC) by CPR Monitor
Comments: __________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
___________________________________________________________________________________________________
Identify what was challenging?
Communication issues
Members on the team were not aware of what was going on (No Situational Awareness)
There was no clear leadership (ONE Clear team Leader)
No Crowd Control provided by Event manager and/or Charge Nurse
Deviations from PALS /ACLS/ NRP algorithms (Explain)
Compressor was not replaced every 2 minutes, No CPR Monitor Role
Delay in obtaining access (Explain)
Comments: __________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
___________________________________________________________________________________________________
Thinking about this pediatric/neonatal emergency, identify system issues that need improvement (Check all that apply)
Operator or Pager Issues
Equipment issues
Medications issues
Crowd Control Issues
Delays in transporting the patient (within the hospital)
Push back to make the RRT call
If RRT could have been called earlier
Comments: __________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Code Roles in an emergency
Event Manager assigned code roles; Ensured key members have armbands on upper arms; Assisted with Crowd Control;
Primary RN stayed at bedside, performed ABC’s; available for communication
Recorder documented and prompted TL on algorithm and reconciled med documentation with pharmacist
 CPR Monitor placed pads, prompted TL on 2 min.rythmn checks, Zoll CPR feedback; ETCO2; rotated compressors
 Team Leader checked and signed Code Record and participated in debrief
Pharmacist announced arrival; given a table to work; established who was TL; provided the weight and algorithm being followed and offered Broselow
Tape if no weight available
Hospitalist at code cart and manage defibrillator; Facilitated debriefs outside the ICU’s
Outcome Measures
N= 164 (1st Rollout)
Mock Codes: Relevant to Practice
N= 182 (2nd Rollout)
53%
STRONGLY AGREE
AGREE
NEUTRAL
DISAGREE
STRONGLY DISAGREE
79%
45%
21%
1%
0%
1%
0%
0%
0%
0%
10%
20%
30%
40%
1st Rollout
50%
60%
70%
80%
90%
100%
2nd Rollout
Mock Codes: Beneficial in Own Clinical Environment
STRONGLY AGREE
AGREE
NEUTRAL
DISAGREE
STRONGLY DISAGREE
N= 163 (1st Rollout)
60%
79%
N= 182 (2nd Rollout)
39%
21%
1%
0%
0%
0%
0%
0%
0%
10%
20%
30%
40%
1st Rollout
50%
2nd Rollout
60%
70%
80%
90%
100%
Participant Evaluation Results – Program Overall
N= 160 (1st Rollout)
N= 176 (2 Rollout)
Program Overall: Valuable Experience
nd
49%
STRONGLY AGREE
79%
49%
AGREE
21%
NEUTRAL
1%
0%
DISAGREE
1%
0%
STRONGLY DISAGREE
0%
0%
0%
10%
20%
30%
40%
1st Rollout
50%
2nd Rollout
60%
70%
80%
90%
100%
Facilitator Evaluation Results – Realism &
Collaboration
Skill Station - High Fidelity Mobile Cart Created
Realistic Environment for Simulation
STRONGLY AGREE
N=30
40%
AGREE
53%
NEUTRAL
3%
SOMEWHAT DISAGREE
3%
DISAGREE
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Skill Station - Unit Collaboration
Easy Among Other Disciplines
STRONGLY AGREE
90%
100%
N=34
23%
AGREE
59%
NEUTRAL
9%
SOMEWHAT DISAGREE
9%
DISAGREE
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Revive Initative at Stanford Children’s Health
 Mobile Simulation Ongoing Team
training
 Rapid Response Initiative/PEWS work
 Policies and protocols in regards to a
deteriorating child and emergency
response
 Research (Single & Multi- Centered)
examining measurable survival and
program outcomes
 Get with The Guideline -Resuscitation
Quality International Database
contributor
 Resuscitation/Code Committee actual
code and RRT reviews/education
 Examining Real Time CPR feedback
 International organizational participation
and presentations
 Outreach
Next steps ……
• We will identify gaps in CPR performance during
simulated codes compared to AHA standards,
differences in CPR performance during simulated
codes compared to actual CPA events, and differences
in CPR performance during simulated codes
compared to student and facilitator perceptions of
performance.
• We will conduct two in-hospital simulated codes
weekly over a 6-month period collecting data for seven
parameters from the defibrillator (compression rate,
depth, fraction, and percent in target, ventilation rate
and longest pre- and post-shock pause).
Next steps….
•
Each simulated code participant (students and
facilitator) will complete a post-event survey to assess
their perceptions on whether the CPR performed met
AHA standards.
• To identify gaps in CPR performance, we will compare
data-driven feedback from the defibrillator for each
simulated code to AHA standards, data-driven
feedback obtained during actual CPA events during
the same 6-month period, and the student and
facilitator survey results. We will use these results to
restructure and optimize our simulation education
program with emphasis on addressing the gaps
identified.