Firelands Regional Medical Center [FRMC] is a medium sized healthcare facility that

offers services across the continuum of healthcare including inpatient physical rehabilitation

[rehab] and psychiatric [psych] services in addition to medical-surgical [med-surg], oncology,

pediatrics, progressive, and intensive care units. As with many facilities throughout the country,

FRMC has been seeing an increase in patient acuity and co-morbidities amongst patients in med-

surg, rehab, and psychiatric units. The facility was also seeing a decrease in nursing knowledge

of proper response to medical emergencies and a delay in carrying out proper life-saving

measures when necessary.

The Problem

As previously stated, many units throughout the facility have been seeing an increase in

patient acuity and an increase in the number of medical emergency team [MET] calls as well as

an increase in the number of code blue emergencies. As a part of the code blue committee, this

nurse and her preceptor review documentation and response times of staff and have found that

treatments are sometimes delayed because of lack of recognition of early warning signs, or

while staff fumble with equipment and wait for specific orders rather than following advanced

cardiac life support [ACLS] algorithms. Upon review of ten code blue charts from the second

quarter of 2018, there were more than 10 events in which chest compressions were not initiated

within three minutes of cardiac arrest and defibrillations did not occur for up to ten minutes into

the event. There was a great need for an increase in how nursing staff are trained to recognize

and respond to medical emergencies throughout the facility.

The Solution
 As a potential solution to the problem, this graduate nursing student and her preceptor

performed research on the best methods to improve emergency response (Herbers & Heaser,

2016). It was decided that the best method would be to develop high-fidelity simulation training

classes for psych and rehab nurses. Med-surg, progressive care, and intensive care nurses already

take the simulation classes as a part of initial nursing orientation, but simulation was added onto

their bi-annual skills competency education days. To test the effectiveness of the education, in

situ mock codes were conducted on various nursing units at varying times of the day.

Methods

Clinical Judgment Classes

Clinical judgment classes were conducted as regularly scheduled for med-surg,

progressive care, and critical care nurses during initial nursing orientation processes. Students

completed the class only after successfully passing an electrocardiography [EKG] class.

Scenarios were designed to be specific to patient populations based on where the students

worked. Students were expected to identify cardiac arrthymias, determine proper response, and

anticipate treatment options for each scenario.

Clinical judgment classes were conducted and mandatory for all psychiatric and physical

rehabilitation nurses. Classes were offered at varying dates and times to meet the schedules of

staff. Both units have registered nurses [RNs] and licensed practical nurses [LPNs] on staff.

Non-licensed personnel, called orderlies at FRMC, were also encouraged to attend, but it was not

mandatory. This student and her preceptor developed scenarios that were meant to be specific to

patient populations that were seen in these nursing units. Requirements of patient care were also

based upon the experience and degree of practice of each student. The RNs from these units
were not required to take any EKG classes and none were ACLS certified. The LPN scope of

practice was also considered when conducting the classes (Prince, Hines, Chyuou, & Heegeman,

2014). No nurses were required to identify cardiac dysrrthymias, but were expected to be able to

identify that something was ‘not normal’.

The nurses in all of the clinical judgment classes took turns being the primary nurse of a

patient who was showing signs of deterioration. It was up to the nurse to perform the necessary

assessments, gather information, and make a decision as to whether the patient’s presentation

warranted a call to a physician, a call for the MET, or a code blue. Once an emergency response

was activated, the rest of the students acted as the other members of the response teams and

began life-saving measures.

All classes were taught with the American Heart Association’s Get with the Guidelines

[GWTG] recommendations in mind (American Heart Association, 2018). We specifically

focused on the student’s ability to have the patient ‘code ready’. Being code ready meant that in

the event of cardiac arrest, the nurses would begin CPR, perform bag-valve mask ventilations

[BVM], apply 2-lead EKG monitor, apply fast patches and connect them to the defibrillator, and

have the backboard under the patient. The goal was to promote early CPR and early defibrillation

in hopes of increasing patient outcomes.

In Situ Code Blue Events

This student and her preceptor formed a group with a nurse from the quality department,

an emergency room clinical nurse educator, and a critical care physician. The group worked

together to develop scenarios for the in situ events as well as determine debriefing topics with

those on the code team and us as a group. All scenarios involved a patient [high-fidelity
simulation mannequin] complaining of chest discomfort before going into a ventricular

fibrillation rhythm. During the events, those from this sub-committee would monitor the time it

took the staff to start chest compressions, BVM, and defibrillation. We would also pay close

attention to the timing of epinephrine administration. O’Brien (2015) conducted a similar study

using in situ code blue events and found that her staff met gals of initiating CPR within 1 minute

of cardiac arrest and defibrillation within 2 minutes in at least 85% of cases. FRMC shared

similar goals for our in situ code blue events.

Outcomes

Throughout the practicum experience, three in situ code blue events were held, all with

similar results. In all three events, there was a delay in performing BVM from nursing staff. All

of the nursing staff waited for the respiratory therapist to arrive to initiate respiratory support. In

these events, it was identified that the respiratory therapists required additional training in BVM

techniques and compression-to-ventilation ratios. In the first two events, the respiratory

therapists failed to remove the pillows from behind the mannequin’s head and was therefore not

getting good chest rise with ventilations. In the third event, the respiratory therapist was

providing one supplementary breath via ambu-bag every two to three seconds causing the

mannequin’s abdomen to become distended with air. All three respiratory therapists performed

rescue breathing during chest compressions despite the patient not being intubated. Also, in all

events, there was only one respiratory therapist performing the BVM and found it difficult to

obtain a proper seal with the mask against the mannequins face.

In two of the three scenarios, chest compressions were initiated within one minute of the

mannequin becoming unresponsive. In the third event, the nurse stated that she could not begin
chest compressions until the crash cart and code team arrived. In that event, it was roughly 2 ½

minutes before compressions were initiated. In all three events, the nurses provided adequate

chest compressions in terms of depth and rate, but did not perform them in sync with the

respiratory therapist at a 30 compression – 2 ventilation ratios.

In all three scenarios, it took more than seven minutes for defibrillation to occur. There

was a delay in rhythm recognition as the nursing staff did not pause compressions for

ventilations or to check a cardiac rhythm. Some staff expressed feeling uncomfortable

defibrillating patients while waiting for the physician to arrive, despite those on the code team

being ACLS certified. There was also confusion as to an appropriate joule setting to defibrillate

the mannequin in one of the events as the physician ordered to ‘defibrillate at maximum joules’

and not follow ACLS algorithms.

In one of the scenarios, a dose of epinephrine was administered before any defibrillations

occurred. In the other two events, epinephrine was given after the first defibrillation. Both of

these scenarios go against ACLS guidelines for the administration of epinephrine for refractory

ventricular fibrillation (American Heart Association, 2018).

Areas for Future Improvement

The overall goal of the clinical judgment classes and in situ code blue events was to

improve nursing emergency preparedness and improve patient outcomes during code blue

situations. What was found during the in situ code blue events was that education should be

expanded to include ancillary departments, like respiratory therapy to reinforce proper

resuscitation methods. It was also evident that further clinical judgment and code readiness

simulation classes would be beneficial as none of the nurses performed compression-to-

nurses and physicians need to be had regarding when to administer epinephrine for patients in

ventricular fibrillation.

After all of the in situ code blue events, surveys were sent to those who participated

asking whether or not they found the exercise beneficial and if there was anything they would

change regarding the event. Out of the 75 surveys that were returned, only one person found the

event uneventful and their rationale for that was because the event occurred during his or her

lunch break. The rest of the survey participants expressed that the events were helpful to put

their knowledge and skills to the test for times between clinical judgment and ACLS classes.

Some participants asked for warning before the events and for a medical history for the fake

patient.

Since expanding the clinical judgment classes to psych and rehab nurses and starting the

in situ code blue events, the time from recognition of cardiac arrest to time of CPR initiation and

defibrillation in real patients has decreased. From four inpatient code blue charts that this

student reviewed with her preceptor, CPR was initiated within a minute of recognition of cardiac

arrest. Of the four, only one patient was found to be in a shockable rhythm, identified as

pulseless ventricular tachycardia, and the patient was defibrillated six minutes into the code blue.

This shows that while staff response during the in situ simulated code blue events did not meet

the requirements, staff performance in real-life emergences has improved.

American Heart Association. (2018). Get with the guidelines- Resuscitation. Retrieved from

http://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-

with-the-guidelines-resuscitation/get-with-the-guidelines-resuscitation-clinical-tools

Herbers, M. D., & Heaser, J. A. (2016). Implementing an in situ mock code quality improvement

program. American Journal of Critical Care, 25(5), 393-400. doi:10.4037/ajcc2016583

O'Brien, M. A. (2015). The use of mock code training in improving resuscitation response.

Walden University. Retrieved from scholarworks.waldenu.edu/dissertations/1607/

Prince, C. R., Hines, E. J., Chyuou, P. H., & Heegeman, D. J. (2014). Finding the key to a better

code: Code team restructure to improve performance and outcomes. Clinical Medicine &

Research, 12(1-2), 47-57. doi:10.3121/cmr.2014.1201