Practice makes perfect


A 78-year-old woman is admitted to Rouge Valley Centenary (RVC) with pneumonia. Two days later, as she lies in her hospital bed, her nurse notices that she appears disoriented. When she examines her, she sees that the patient is having trouble breathing. She presses the call bell to call for help, and finds the patient is unresponsive. After checking the patient’s airway and pulse, she quickly reaches over to the phone behind the bed, and asks locating to call a code blue – a hospital emergency code for a cardiac arrest. Seconds later, the call is announced over the hospital’s loud speaker system.

Within moments, a physician, nurses and registered respiratory therapists (RRT) from the hospital’s cardiac arrest team rush into the room, donning masks, gowns and gloves, one pushing a crash cart. As beads of sweat drip down their faces, two nurses from the unit take turns administering CPR on the patient. The heart rate monitor perched beside the patient’s bed shows that her heart is not beating. One of the two nurses from the cardiac arrest team injects the patient with medications to help restart the heart, while the other keeps watch on the heart monitor. An RRT manages the patient’s airway.

Lined up around the patient room, clinical practice leaders (CPLs) peer at their stop watches, keeping track of how quickly the nurses respond to the emergency call. Luckily, today’s event is an exercise – a mock code blue. The patient in question is a practice mannequin. The exercises are designed to be as realistic as possible, in order to enhance the response skills and build the confidence of staff, so that they’re prepared for an actual situation.

While code blue calls are a way of life at most health-care facilities, clinical leadership at Rouge Valley Health System (RVHS), a two-hospital system with hospital campuses in east Toronto and west Durham region, regular practice to enhance and improve staff members confidence in their ability to respond is important.

“We found that we needed to bring up our staff members comfort level. We see this as a learning opportunity and a chance for development,” explains Karen Mayne, director, quality, risk and professional practice. It’s important that everyone already knows what to do, so that there isn’t a panic during a real code blue. It’s important that they already know what to expect from their other team members.”

Regular mock code blue exercises had already been in place at RVHS. But in 2009, they were redesigned so that staff could be coached through the process, rather than be critiqued at the end of the process. Errors can be corrected immediately, and staff members feel much less intimidated when they address questions or concerns in front of their peers.

“What we’re doing now is ingraining right behaviour rather than critiquing wrong behaviour. We redesigned the process because we observed that critiquing did not improve practice, or emphasize team building. We wanted to enhance learning and not derail the process,” explains Dianne Tomarchio, CPL, intensive care unit (ICU) and corporate Safer Healthcare Now! champion at RVC.

The exercises, which take place 12 times each year – six times at each hospital

campus – are planned by the hospital’s Advanced Cardiac Life Support (ACLS) instructor team. They can take place in any area throughout the hospital, from clinical areas such as the emergency department or birthing unit, or in non-clinical areas such as the front lobby. So that all clinical areas of the hospital are covered, each unit also conducts their own mock codes, which are led by the floor’s clinical educator.

Participants include CPLs; RRTs; physicians; unit staff; and the cardiac arrest team. If it is a code pink where a child goes into cardiac arrest, the neo-natal intensive care unit (NICU) and paediatrics, teams are also involved.

At the end of each exercise is a debriefing session where CPLs leading the exercise can give feedback to the participants. Staff members also have an opportunity to provide feedback to the CPLs. The idea is that by providing coaching throughout the exercise, staff can take a more systematic approach during a real code blue exercise. The ACLS instructor team then conducts its own debriefing session, discussing what worked and what didn’t work.

The exercises also help to create standard work for real code blue events, helping to ensure that patients are getting the highest quality of care in the event of a cardiac arrest. It’s also a way to improve the quality of care patients receive from RVHS staff during a real code blue.

“The mock code is also a quality assurance for our entire organization. And the style is very effective. We can correct any bad behaviour at the source, so that it doesn’t happen to a patient,” says Amer Syed, manager/CPL, respiratory therapy.

So far, the feedback from staff has been positive. “I thought it was very helpful and definitely increased my confidence. I feel like I could actually deal with a code blue situation,” says Melissa Szabo, a registered nurse at RVHS.