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Service Delivery Innovation Profile

Immediate Post-Event Debriefing Improves Multiple Aspects of Response to Codes and Increases Staff Satisfaction


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Snapshot

Summary

Immediately following each cardiopulmonary resuscitation code, responders at the Chillicothe VA Medical Center review the event using a debriefing tool to gather pertinent information, discuss team performance and key processes (e.g., availability and functionality of supplies, medications, and equipment), and identify safety issues and opportunities for improvement. Quality improvement staff review findings from each debriefing and decide on appropriate followup steps, which are often initiatives designed to address identified problems. The program has improved overall performance in handling cardiopulmonary resuscitation codes, generating fast response times, reducing the frequency of equipment-related issues, improving success with first-time intubations, and enhancing communication and teamwork. This success has, in turn, improved staff satisfaction.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation trends in code response time, frequency of equipment issues, success rates for first-time intubation attempts, and staff satisfaction, along with anecdotal staff reports on the quality of teamwork and communication.
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Developing Organizations

Chillicothe VA Medical Center
Chillicothe, OHend do

Date First Implemented

2008
July

Problem Addressed

Poor communication and lack of teamwork cause many medical errors and deaths. These problems can have particularly dire consequences when a patient codes and needs cardiopulmonary resuscitation (CPR). Medical team debriefings after a CPR code can be effective in improving communication and teamwork going forward, but many hospitals—especially smaller ones—do not use them.
  • Poor communication and teamwork, leading to errors and death: Communication problems represent the leading cause of preventable patient deaths. Lack of teamwork among health care workers often causes such communication problems and is associated with one-fourth of all medical errors.1
  • Especially when patients code: Communication problems and other issues such as unavailable or nonworking equipment constitute particular challenges when a patient experiences a cardiopulmonary arrest. This highly complex, high-pressure, time-sensitive situation requires all team members to work together and communicate effectively to save the patient's life.
  • Unrealized potential of debriefings: A medical team debriefing immediately after a CPR code event can provide team members with the opportunity to review the experience, develop a shared understanding of events, discuss lessons learned, and make suggestions for improvement.2 Research has shown that debriefings after simulation training or a real event can improve teamwork and patient safety. Yet, many hospitals—particularly small ones where such events occur infrequently—do not have a formal way of identifying or addressing these challenges.3 For example, the Chillicothe VA Medical Center experiences only about 15 CPR codes annually and did not have a formal debriefing process in place before implementation of this program.

What They Did

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Description of the Innovative Activity

Immediately following each CPR code, those who responded review the event using a debriefing tool to gather pertinent information, discuss team performance and key processes (e.g., availability and functionality of supplies, medications, and equipment), and identify safety issues and opportunities for improvement. Quality improvement staff review findings from each debriefing and decide on appropriate followup steps, which are often initiatives designed to address identified problems. Key steps in the debriefing process are outlined below:
  • Immediate gathering of responders after event: Immediately following a code that requires CPR, responders and other relevant individuals meet in a quiet place on the unit to initiate the debriefing process. Responders paged for the CPR code (and who therefore participate in the debriefing) vary by time and day of the week that the code occurs, as outlined below:
    • For codes during administrative hours: When a CPR code occurs during normal administrative hours (Monday through Friday between 7:30 a.m. and 4 p.m.), code responders include at least one physician, a physician assistant, the associate chief nurse, a nurse manager, a surgical care unit nurse, a telemetry/intensive care unit (ICU) nurse, a respiratory therapist, the chaplain, and fire and police department personnel.
    • For codes at other times: During other times, responders include the nursing, medical, and psychiatric officers on duty; staff nurses from the ICU and acute medicine departments; a respiratory therapist; and fire and police department personnel. The chaplain can be paged if necessary.
  • Debriefing guided by a communication tool: Once the CPR code is finished, the nurse manager retrieves the debriefing tool, a double-sided form stored on the code supply cart that guides the discussion and helps to document the group's feedback. The nurse manager first notes the time that the following events occurred: calling of the code, the team's arrival, and completion of the code. The team then uses the tool as outlined below:
    • Review of questions on key issues: The team reviews 20 questions listed on the tool that cover key topics such as the notification process; patient condition and code status; availability and functionality of supplies, medications, and equipment; and the success of interventions, including cardiac rhythm determination, intubation, airway establishment, and intravenous access. Sample questions include:
      • Was the announcement on the pager clear?
      • Was the patient's code status identified before the code started?
      • Was intubation equipment readily available, including the guide scope?
      • Was the airway managed appropriately?
      • Were (family and staff) emotional issues handled effectively?
      • Was there effective leadership?
    • Additional discussion and documentation: After answering the questions, the team uses the descriptive section of the tool to discuss and document other important issues, including physician, nurse, and respiratory therapist satisfaction with the code response (ranked on a 5-point Likert scale) and any safety breeches, unanticipated events, problems, and recommendations for improvement. Information provided in March 2014 indicates that a spreadsheet with the Likert scale results, as well as the number of codes and the areas within the facility that can be improved upon, is maintained by the quality facilitator.
  • Review by quality improvement facilitator and committee: The nurse manager signs the tool and sends it to the hospital's quality improvement facilitator, who reviews the safety issues and recommendations. As necessary, the quality facilitator follows up with responders for more details and then discusses the experience, potential problems, and solutions during the organization's bimonthly CPR Committee meeting.
  • Development of quality improvement initiatives: Committee members discuss the debriefing findings and decide on necessary followup steps, which often involve designing and implementing new quality improvement initiatives. Examples include the following:
    • New equipment purchases: The hospital purchased glide scopes for intubation and blind-insertion airway devices, which have been placed on all code supply ("crash") carts. Respiratory therapists trained all physicians on glide scope use. In addition, the hospital ordered different sized intubation tubes, added carbon dioxide detectors to the intubation trays, and placed crash carts and automatic external defibrillators in several additional locations.
    • Speeding up and improving first-attempt intubation: The hospital designated respiratory therapists as first-line intubators (meaning that they can initiate intubation even if the physician has not yet arrived) and made stronger sedatives available to increase the likelihood that intubation would be successful on the first attempt.
    • Training on equipment: As needed, physicians, nurses, and respiratory therapists receive training on the proper use and maintenance of equipment from a nurse manager, supply department staff member, or respiratory therapist. For example, respiratory therapists train physicians on the use of glide scopes and intubation equipment, and they train nursing staff on oxygen delivery systems, hand-held nebulizers, and electrocardiograms. Nurse managers require annual competency updates by the staff to identify areas in need of improvement, and nursing staff provide education to all new hires about the proper use of equipment.
    • Code simulations: The hospital purchased a simulation mannequin so that teams can practice CPR code response; a nurse educator runs a simulated "mock code" once a month. Mock codes are staged at unannounced locations throughout the hospital and the staff are unaware that they are mock codes until they arrive on the scene. The mock code has been successful as a teaching tool for staff members working on units that may experience a code situation once every 1 or 2 years and has helped to create a positive atmosphere. The nurse educator running the mock codes reports the results/findings to the nurse manager of the unit. This nurse educator has developed a "Mock Code Blue Audit Sheet" (adapted from an audit sheet used at another VA facility), which incorporates a point system to reflect the appropriateness of participant responses to the simulated code blue (i.e., initiation of CPR, intubation, etc.), adherence to best practices, and her general observations. A post mock code blue debriefing is held to help staff improve in areas such as drug/shock sequence, ensuring that a recorder is assigned, and accurate hand-off information to the code team when they arrive. Information provided in March 2014 indicates that hospital staff continue to make improvements based on the findings from code simulations.

Context of the Innovation

The 297-bed Chillicothe VA Medical Center, part of the United States Department of Veterans Affairs (VA) medical system, provides medical, mental health, and nursing home services to veterans living in south-central and southeastern Ohio. The medical center treated 4,287 inpatients in fiscal year 2010, during which it experienced 16 codes where patients required CPR. The impetus for the debriefing program came from the VA's National Center for Patient Safety, which initiated a Medical Team Training program in 2007. This program trains staff at VA hospitals to adopt and/or develop initiatives to improve teamwork and communication, often leading to better patient outcomes. At its onsite Medical Team Training session in May 2008, Chillicothe VA Medical Center leaders identified the CPR code process as an opportunity for improvement, because such events occurred relatively infrequently in the hospital, the response process had never been formally analyzed or standardized, and multiple intubation attempts commonly occurred during these events.

Did It Work?

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Results

The program has improved overall performance in handling CPR codes by generating fast response times, reducing the frequency of equipment-related issues, improving success with first-time intubations, and enhancing communication and teamwork. This success has led to higher levels of staff satisfaction.
  • Fast response time: Between implementation of the program in the fourth quarter of 2008 and the second quarter of 2010, teams responded to nearly every CPR code within 5 minutes (the hospital's stated goal), with only one response taking longer than 5 minutes. Of 51 codes at the facility since 2008, only 4 had response times greater than 5 minutes (all were less than 7 minutes).
  • Fewer equipment-related issues over time: Shortly after implementation, a variety of equipment-related issues arose, including an automatic external defibrillator not being available, tubing not fitting the oxygen tanks, and a suction canister exploding after a caregiver did not release an air pressure valve. However, during the first two quarters of 2010, no such issues occurred, suggesting that identified equipment issues to date have been resolved. Since 2008 there have been some equipment issues such as missing code blue sheets, sharps containers, IV starter kits, missing glide scope covers, and other missing equipment on the crash carts; all problems have been remedied by the supply department.
  • More successful first-time intubations: Over the time period outlined above, the frequency of successful first-attempt intubations by respiratory therapists has increased and now most intubations are successful on the first try. Before implementation, successful intubation sometimes required between three and eight attempts. The number of intubation attempts has greatly decreased to between one and three attempts with successful intubation.
  • Improved communication and teamwork: Team members report that teamwork and overall communication have improved as a result of the debriefing process, including the team becoming more cohesive and accepting of each other's input. Communication has continued to improve as the team uses the post-code debriefing discussion.
  • Higher staff satisfaction: Physician, nurse, and respiratory therapist satisfaction has trended upward over time, increasing from roughly 3.5 to 4 during the fourth quarter of 2008 to 4.5 during the second quarter of 2010 (on a 5-point Likert scale). Staff satisfaction has been maintained at a rating of between 4 and 5 with nearly all code blues.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation trends in code response time, frequency of equipment issues, success rates for first-time intubation attempts, and staff satisfaction, along with anecdotal staff reports on the quality of teamwork and communication.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Assignment of team leader: Hospital leaders assigned the quality improvement facilitator to lead the effort to improve the CPR code process.
  • Selection of quality improvement team: A hospital cardiologist and the quality improvement facilitator selected staff to join a multidisciplinary quality improvement team.
  • Creation of debriefing form: Based on the Medical Team Training program and their own knowledge of key steps in CPR code response, the quality improvement team created a form to guide the postcode debriefing process.
  • Staff education: The quality improvement facilitator educated the nurse managers and supervisors, while a chaplain educated the other chaplains individually. The training focused on teamwork during CPR codes and the code debriefing process. Trainees also viewed a 10-minute video provided by VA Medical Team Training representatives that highlighted the importance of teamwork during code debriefing and presented various debriefing scenarios. The nurse managers and the chaplain then provided education to physicians, nurses, and other frontline staff.
  • Program rollout: Use of the form and the debriefing process began in July 2008. Early on, CPR code responders provided feedback about the form and the process to the quality improvement facilitator.
  • Ongoing modification of form: The form has had iterative revisions in response to user suggestions.

Resources Used and Skills Needed

  • Staffing: The initiative requires no new staff; existing staff integrate the debriefing into their regular responsibilities.
  • Costs: Program development did not require any financial outlay. Although ongoing operation of the program also does not entail any expenses, the hospital has purchased various types of equipment in response to the suggestions that have come out of the debriefings, as described earlier.
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Funding Sources

Chillicothe VA Medical Center
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Tools and Other Resources

A copy of the medical center's debriefing tool can be found in the following article:
Percarpio KB, Harris FS, Hatfield BA, et al. Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training program improves the cardiopulmonary resuscitation code process. Jt Comm J Qual Patient Saf. 2010;36(9):424-9, 385. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Hold debriefing immediately: Holding the session right after the CPR code ensures that the experience remains fresh in everyone's mind and that all involved providers can participate.
  • Encourage input from and respect for all team members: The nurse manager leading the debriefing process should actively encourage all team members to offer feedback with regard to problems and opportunities for improvement, including ideas that may seem small or trivial. The nurse manager should also remind participants to be patient and respectful as they listen to colleagues' feedback, especially because individual CPR code response team members will vary from event to event.
  • Store debriefing form on crash cart: Initially, nurses elected to print the form from the nurse manager's computer instead of storing it on the crash cart, as they thought it would get missed among the other crash cart forms. However, having the form readily available and accessible to everyone has proven to be more efficient.
  • Assign accountability for responding to forms: One individual should be accountable for reviewing the debriefing forms and presenting key findings to senior leaders, thus allowing the hospital to act on the response team's recommendations in a timely manner.

Sustaining This Innovation

Take action on team recommendations: Hospital leaders should play a critical role in sustaining the code debriefing process by taking action on code team recommendations. This involvement reinforces to team members that patient safety and improved patient outcomes are hospital priorities and makes them more likely to remain engaged in the process and continue offering suggestions for improvements.

More Information

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Contact the Innovator

Fonda Harris, RN, MSN, QIF, MSSCL
Quality Improvement Facilitator
Chillicothe VA Medical Center
17273 State Route 104
Chillicothe, OH 45601
(740) 773-1141 ext. 7988
E-mail: fondasherri.harris@va.gov 

Innovator Disclosures

Ms. Harris has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Percarpio KB, Harris FS, Hatfield BA, et al. Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training program improves the cardiopulmonary resuscitation code process. Jt Comm J Qual Patient Saf. 2010;36(9):424-9, 385. [PubMed]

Footnotes

1 TeamSTEPPS™: Creating a safety net for your healthcare organization: guide to action. Agency for Healthcare Research and Quality. June 2008.
2 Dunn E. White Paper: NCPS Medical Team Training Program. U.S. Department of Veterans Affairs National Center for Patient Safety. July 2007.
3 Percarpio KB, Harris FS, Hatfield BA, et al. Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training program improves the cardiopulmonary resuscitation code process. Jt Comm J Qual Patient Saf. 2010;36(9):424-9, 385. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 02, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 10, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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