Code Team Performance (1).pdf

7/30/2019 Code Team Performance (1).pdf

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Ca n y o u im p r o v e t h e

p e r f o r m a n ce o f y o u r c o d e

t e a m ?

Heather Brasset, RN, BSNKaren LeComte, MSN, RN, CNCCP(C)

Pediatric Critical Care Program

British Columbias Childrens Hospital


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Project Team Members

Vena Camenzuli BSN, RN (CNC)Gord Krahn RT (Research and Quality)

Mark Chalmers RT (ECLS coordinator)Sandy Pitfield MD (Pediatric Intensivist)

Mona Singal MD (Pediatric Intensivist)

And the PICU staff


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To quote Dickens

It was the best of times, it wasthe worst of times, it was theage of wisdom, it was the age

of foolishness

And we will definitely get back to these points!!


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Imagine if you will

An aviation team interviewing a code blue team


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In your code blue scenarios

Is everyone involved standing in the same placeeach time?

Is the equipment and supplies available in the samefashion each time?

Do individuals assume standard roles?Are standardized procedures and instructions used?

If things go wrong, does a systematic checklist getused to correct the error?

is the most junior person on your teamacknowledged with credibility if s/he reportssomething is wrong?


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Theyd be back to exercise and

vitamins(in no time!)


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The best of times Lots of expertise

Team of experts vs.expert team

Good people who wantto do the right thing

Intentions vs actions

site wide improvementsrecently implemented

Survey

Perceptions vs realities

we can do better


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System Strengths Resuscitation

training BLS, PALS, ACLS

Team credentialsestablished

Patientcustomizedmedication sheets

Emergency medspre calculated andconfirmed onadmission


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Site wide improvements Resuscitation

notification process

Crash cart reduction &standardization

Reduced drug wastageand standardized drug

kits Resuscitation record

updated

Communicationstrategies (site widedistribution/media site)

Site mock codes


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Policy Updated Engagement of practice leader to clean up

numbers of code blue policies there were 8 that we knew about!

More show up all the time in individualprograms as do additional crash carts!

WOP cleaning up this process.

Goal = one policy for code blue site wide


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Site wide mock codes How will we know we

have made an

improvement? Improved performance

(roles, communication,activation) during realresuscitation situations

What changes ideas dowe have? Regular schedule of mock

codes (wards & PICU)

Process improvements(templates, roles defined,engagement of hospitalstaff, evaluation and datacollection)


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Improvements Majority of scheduled mocks

have been completed

(improvement from ~ 50%anecdotally)

Attitude towards participationimproved (and continues to

do so) Value of insitu mocks and

using simulator have beenidentified by various teams

Improvements in team workand communication havebeen the most recognizedbenefit of mock codes bothon ward and in PICU


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Improvement Ideas Roles

Role clarity situational awareness by asking for help

In the PICU getting CN and A&R to bedside Communication

Closed loop Use of SBAR

Treatment delays

Time to establish stable airways (intubation) Calling resuscitation team

Procedures/skills Vascular access ECLS activation

By the Mock Code facilitators: acceptanceof the realism of the situation Orientation to the simulation (some participants still pretending to give

meds, call physicians, etc.) to reinforce expectations and enhancerealism


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Challenges with mocks Making it a priority/mandatory learning

experience (not getting lost in thebusyness)

Realism People assigned to role needs to participate

otherwise role confusion occurs Improvements gained in having people

perform in true roles Participation

Continues to be culture of optional by someteam members

Increase numbers of participants

Feedback/debriefing Identifying and closing performance gaps

Timing Creating opportunities for night shift scenarios


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Resuscitation Questionnaire In a resuscitation situation:

I am comfortable with my role on the resuscitation team I am comfortable and confident with documentation I am able to accurately prepare medications I am able to effectively provide chest compressions

I am able to effectively maintain an airway and ventilatea patient I am comfortable in identifying patients who are

deteriorating

I can mobilize a resuscitation team to a patients bedspot I am familiar with PALS algorithmns


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Resuscitation Questionnaire In the resuscitation situations that I have been

involved in the PICU there was: Clear roles and responsibilities established

Clear messages delivered

Closed loop communication occurring Knowledge sharing amongst the team

Individual awareness of each members limitations

Appropriate interventions Re-evaluation and summarizing occurring

Respect amongst team members


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Resuscitation Questionnaire Which skills would you most benefit to

review: Bag/mask ventilation

Ventilation with ETT

Chest compressions Medication preparations

Vascular access

Communication documentation


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The worst of times Repeat the same mistakes

and failure to recognize how could be better Same issues surfaced during codes (patient safety

events and moral distress)

Team of experts vs. expert team Lots of expertise yet, team functioning could improve

Critical mistakes were made

Process Standardization required!!


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Age of wisdom Resuscitation research

Resuscitation education

Simulation


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What we know Crisis event simulation identifies targets for

educational interventions to improve outcomesDaniels, et al. Simulation in Healthcare, 2008

Simulation is associated with improvements insurvival rates following cardiopulmonary arrestAndreataa, et al. Pediatric Critical Care Medicine, J une 2010

Performance improvement, quality of care andmaintaining competency should be the focus ofeducation of resuscitation teams


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Age of foolishness What are we waiting for ??

We know what works andyetsomebad habits still prevailed


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Team Survey Quiz designed to

highlight the updateon new PALSguidelines and closesome performance

gaps Prize was a new

PALS card!

questionnaire plan was to compareself ratings toobservations


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Observations Self ratings

Always or almost always

comfortable with Role

Documentation

Chest compressions

a/w and ventilation

Identifying patients who aredeteriorating

Mobilize resusc team tobedside

Familiar with PALS algorithm

What we observed

Roles were often ambiguous

and people were multitaskingoutside their particularassumed role

Documentation didnt meet thestandard and processes were

deviated from Chest compressions (rate and

depth deviations from BLSstandards

Medications

Dribble epi (diluted) Meds to patient posed issues


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Observations Survey

In resuscitation situations that

I have been involved inusually and most of the time Clear roles and

responsibilities Clear messages Knowledge sharing

Aware of each teammembers limitation Appropriate interventions Re evaluation and

summarizing Respect amongst team

not very often Closed loop communication

What we observed Roles need standardization

Communication was less thanideal as an observer Not all on the same page Summarizing ought to be

more frequent Respect is never an issue

when you are observed butgossip and post event recallby team members suggestsrespect doesnt alwaysoperate when adrenaline ispumping through your viens


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Observations Survey

Skills most beneficialto review

Bag mask ventilation

Vascular access

communication

What we observed

All resuscitation skills

had performanceissues/gaps thatrequired addressing

Simulations revealedsystem weaknessesthat requiredaddressing


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Who do we need? Standard code team

organization was required Physician team leader

Airway/Ventilation

Compressions (andcompression relief)

Bedside Nurse Recorder

Med/fluid nurse # 1

Med/fluid nurse #2

Team leader nursing Runner

Communication relay


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Standardized Roles Standard roles

defined Placement

determined by priority

of proximity to patient standard placement

of each team member

to keep them focus ontheir role


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Name tags everyone


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Standard Roles Standard roles

assigned in the pre-brief

Time provided for

team members tofamiliarize self withrole


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Closing gaps role clarity and fixingsome challenges


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Reduce delays Get the right people

to the scene Standard process

Assigned tocommunication teammember

J ob aide created


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Why fight the crash cart? Configuration of

monitor/defibrillator

Awkward for staff to work

Poor visualization by teamleader when teamaccessing drawers

** team performance washindered by crash cart

orientation


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Make it your friend!! Orientation of

monitor/defibrillatoradjusted

Monitor positionedtowards patient

Drawers facing outfacilitated betteraccess by team

Med team betteraccess to cart


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The case against practice creep?

What was dribble epi allabout?

epinephrine to 1: 100 000

Close the gapValidation of understanding

(quiz)

conversations


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Use of Simulation Experiential

Learning

High fidelitysimulation PALS scenarios

Recreatedeteriorating childand arrest

scenarios (casebased specific toour unit)


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Use of Simulation Focus on low

incidence, high risksituations Cardiac ECLS

Teamworkcompetenciesimproved

Communication

Reflection Requests for additional

simulation work


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Moving forward Audits Quality review

Audits for qualityduring mockscenarios

Inform the project


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Moving forward training video

Specific code blueroles reviewed

Zoom in on each role

Positive examples ofcommunication

Focused on teamfunction


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Lessons Learned Things take time change requires patience and persistance

Would you just leave the monitor the way it is!!

Low incidence, high risk scenarios

Most valued simulation learning Realistic high fidelity simulations appreciated most

Communication, communication, communication Skill development of communication skill = improved outcomes and

respect amongst team

Small changes = some big wins Positive feedback reinforced utility

Debrief requires a skilled facilitator Quality questions Performance gaps

Reflection and critical thinking


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Thank You!!

Heather Brasset [email protected]

Karen LeComte [email protected]


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Code Team Performance (1).pdf

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