Resuscitation: Case Study

Resuscitation
Resuscitation

Resuscitation: Case Study

Part 1: Code Blue educational video from the Regina Qu’Appelle Health Region.

Time sequenceIssue notedcodecomments
0-22 seconds  Breach of Australian Resuscitation Council Guidelines:  BARCG- Guideline 2 priorities in an emergency        Finds Mr. Smith unresponsive. Fails to follow the Guide 2 BLS algorithm because she failed to assess danger, but she assessed the airway, as she is seen checking for the escape of air from the patients mouth or nose as recommended by guide 5.  Implications: Delay in resuscitation processes increases the risk of reduced cardiac output to the brain due to poor compressions.

 
Time 3.26Poor technical skills  PTS – BARCG Guide 6 & 8Chest compressions inadequate as recommended by Guide 6. The recommended chest compressions are 30 chest compressions followed by two breaths.
The chest compressions are slow than required by Guide 8. “A good CPR should deliver chest compressions over the lower half of the sternum at a depth of 5 cm” (ARC guide 8). Long pauses in CPR before shock delivery. Guide 6 discourages long pauses and distractions during a CPR Implications: Long pauses, distractions, slow and inadequate chest compressions lower the chance of  patient’s survival
Poor Non-Technical skills PNTS
Time 0.30Situation awarenessPNTS- SA The nurse did not press the emergency push button system to call for help immediately and instead used the overturn
Implications: Delayed response  by the code blue team
Time 0.30 secs Time 2.26 minutesDecision makingPNTS- DMDelay in full code response. The team arrived 2 minutes later after the call alert Implications: This led to delay important activities such as defibrillation. However, the rest of the decisions such as medication, hyperventilation and defibrillation activities went on well once the code blue captain arrived.
Time 3.36Task managementPNTS-TMCompressors for more than five cycles. One compressor was working for almost 5 minutes which is too long for a compressor. According to Guide 5, “the compressor roles approximately after 2 minutes or after five cycles of compressions and ventilations at a ratio of 30:2 so as to maintain the quality of compressions” (ARC guide 5).  However, other task management processes such as airway positioning, nasopharyngeal airway placement, bag-valve mask ventilation were correctly performed.
Time 5.28   Time 12.55CommunicationPNTS- comm  Occasionally fails to use the closed up communication which leads to miscommunications. For instance, at minute 12.55, the recorder had missed recording the endotracheal tube particulars due to poor communication strategy.
  The team used the SBAR technique to report the patient’s medical history to the code blue team leader. All the information was recorded including all the medication administered and other CPR outcomes such as cardiac rhythm before a shock was delivered. This is vital for future references.
 TeamworkPNTS-TeamNo introduction was done by the team members, but they delegated the resuscitation duties appropriately. The team consisted of a coordinator, compressor nurse, airway manager, nurse in charge of defibrillator, captain/leader and crash cart manager.
 LeadershipPNTS- LeadershipThe leader failed to evaluate the BLS on arrival. However, Mr. Sellinger (the code captain) performed his tasks effectively including identification of cardiac rhythm, initiation of ACLS protocol, and evaluation of the protocol reviewed the code blue documentation form and signed the code blue form after completing the code blue.

PART 2: Analysis of the issues covered

Code blue should be contacted immediately for all unresponsive patients. Calling for help and initiation for help should be done simultaneously.  One of the issues identified in this case study is delayed in the response of code blue code due to poor call out systems. The code team member should call out loudly for help through the facility-wide response system. In this technology, the nurse should have pressed the Blue code push button to ensure that the code blue team were notified accordingly (Bayramoglu et al., 2013).

As the nurse in charge waits for code blue team, he or she should initiate CPR (Clarke, Apesoa-Varano, & Barton, 2016). The code team are expected to introduce themselves as they arrive as well as and their roles statements such as “Am Mr. J. and will take document” or “I’ll take the airway” which helps in ensuring there is clear role differentiation. The service user physician should be contacted  immediately.

According to Price, Applegarth & Price (2012), the healthcare provider should first assess the patient dangers and risks before they start the air management. This was not done in the case study and violated the ARC guide four which states that the patient’s mouth should be opened and head slightly turned downwards to remove the airways (Australian Resuscitation Council, 2008).

 An ineffective cough indicates a severe obstruction. In this case, if the patient is responsive, the healthcare provider should give about five back blows, and if still, it is ineffective, they should give at least five chest thrusts (McInnes et al., 2012). This article states that for all unresponsive patients, the healthcare should send for help and start CPR immediately. Similarly, guideline 5 recommends that all patients who are breathing abnormally or are unresponsive require being resuscitated.

The first thing when assessing breathing, the rescuers should check for   movement around the chest (lower part) and abdomen (upper part). They should check for the exhalation through the patient’s oral cavity or nose, and feel the movement of air in the patient’s mouth or nose. The guide recommends a ratio of compressions to rescue breaths as 30:2 (Australian Resuscitation Council, 2008).

According to this article, the first nurse to respond should start saving the patient’s life by performing chest compressions immediately (100 compressions per minute). Although important, the nurse should not wait for backboard , they should start chest compressions as it can be put in place later when  the code team arrives. The switching the compressor roles in the case study is present but it took quite a long time than that recommended by ARC guide 6 which is approximately after 2 minutes.

To maintain the quality,  the ventilations ratio should be maintained at 30:2 (Castelao et al., 2013). This is supported by Guide 6 which recommends that interruptions to chest compressions should be minimized. The  best location to perform the compressions is the sternum- the lower half part of it. The healthcare provider’s heel is placed at the central part of the chest and put the other hand on top it. The recommended rates of compressions are 100 to 120 compressions per minute which are about two compressions per second.  

The guide also outlines on the quality of compressions ( which is identified as poor in the case study)  where it suggests that depth of compressions should be “at least 2 inches (5cm) with complete chest recoil after every compression” this helps the heart to re-fill completely by the next round of compressions. The number of interruptions should be minimized to ensure maintain the quantity and quality of compressions (Eroglu et al., 2014).

 According to the article, the patient should be given 2 ventilations for every 30 seconds of  oxygen-bag-mask device assisted ventilation. The oxygen level should be set to the flow meter 15 L/min, and where applicable, the reservoir should be fully open ensure that  the patient gets 100% oxygen for each breath. One strength observed in the study is the fact that bag-mask device is best done by two blue code team members where one open the airway to fasten the mask on whereas the second one squeezes the oxygen bag.

Also, the article states that defibrillation is very critical and that the use of placement hands-free defibrillation pads is a safer option than hands held defibrillation paddles (Girotra et al., 2012; Prince et al., 2014). The article states that the deployment of automated external defibrillators (AED) should be used as soon as possible as it reduces mortality and morbidity associated with cardiac arrest caused by either ventricular fibrillation or ventricular tachycardia (Australian Resuscitation Council, 2008).

The compressions should resume immediately after delivering shock even with a normal heart rhythm as it will not provide enough cardiac output that will ensure adequate perfusion. It is recommended that 2 minutes the cardiac rhythm should be assessed after 5 cycles of a CPR (Merchant et al., 2014). The use of vasopressors in cardiac arrest is recommended only when there are no high-quality CPR. It is important to be extra cautious when administering a drug. This is because miscommunication is a common issue which often leads in the administration of incorrect drug doses or medications.

This can be prevented by using “closed loop” method of communication (Segon et al., 2014; William et al., 2016). For instance, when a nurse receives an order to inject some medicine, they should repeat the information of drug prescribed out loud, inject it and then announce it again after administration (Price et al., 2012). This method was used in some instances, but in the instance that it was absent, the recorder was prone to miss out some key aspects; for example, in this code blue simulation, the recorder had missed recording the endotracheal tube measurements.

The article suggests that an effective code blue team should have leader who controls the all the procedures and efforts of resuscitation. They communicate with the staff involved and evaluate the cardiac rhythm of a patient. Mr. Sellinger is the team captain of the case study and was standing in a position such that he could effectively see all of the resuscitation procedures and efforts. If the organization allows, the family member can be allowed into the room. It is also important to ensure that the information is well recorded.

In the case study, the recorder is shown documenting all the resuscitation process. However, it is important to understand that documentation process is done according the healthcare facility’s policy (McEvoy et al., 2014; Sahin et al., 2016). The recorder should remind the code team when time for a specific task has elapsed and must record all the activities taking place including the medicines prescribed. The article also suggests that all clinical areas should grant quick access to equipment such as blood glucose, blood pressure, and equipment of pulse oximetry and other equipment so as to effectively manage a deteriorating patient (Clarke, Carolina Apesoa-Varano, & Barton, 2016).

Through this case study, it is evident code training programs using simulation is beneficial and has been recommended by various healthcare institution organizations since 1999. This training will help the learners to improve cardiac resuscitation outcomes as it offers an opportunity  for  regular hands-on practice within the hospitals.  This also helps the team to understand the various roles and responsibilities expected during a full code. Along with continuing education and mock codes, the team members become confident in their responsibilities (Gutwirth, Williams, Boyle, & Allen, 2012).

References

Australian Resuscitation Council. (2008). Standards for Resuscitation: Clinical Practice and Education. Retrieved from  http://www.resus.org.au/clinical_standards_for_resuscitation_march08.pdf

Bayramoglu, A., Cakir, Z. G., Akoz, A., Ozogul, B., Aslan, S., & Saritemur, M. (2013). Patient-Staff Safety Applications: The Evaluation of Blue Code Reports. The Eurasian Journal of Medicine, 45(3), 163–166. http://doi.org/10.5152/eajm.2013.34

Castelao, E. F., Russo, S. G., Riethmüller, M., & Boos, M. (2013). Effects of team coordination during cardiopulmonary resuscitation: A systematic review of the literature. Journal of critical care, 28(4), 504-521.

Clarke, S., Apesoa-Varano, E. C., & Barton, J. (2016). Code Blue: Methodology for a qualitative study of teamwork during simulated cardiac arrest. BMJ open, 6(1), e009259.

Eroglu, S. E., Onur, O., Urgan, O., Denizbasi, A., & Akoglu, H. (2014). Blue code: Is it a real emergency? World Journal of Emergency Medicine, 5(1), 20–23. http://doi.org/10.5847/wjem.j.issn.1920-8642.2014.01.003

 Girotra, S., Nallamothu, B. K., Spertus, J. A., Li, Y., Krumholz, H. M., & Chan, P. S. (2012). Trends in Survival after In-Hospital Cardiac Arrest. The New England Journal of Medicine, 367(20), 1912–1920. http://doi.org/10.1056/NEJMoa1109148

Gutwirth, H., Williams, B., Boyle, M., & Allen, T. (2012). CPR compression depth and rate about physical exertion in paramedic students. Journal of Paramedic Practice, 4(2).

McEvoy, M. D., Field, L. C., Moore, H. E., Smalley, J. C., Nietert, P. J., & Scarbrough, S. (2014). The Effect of Adherence to ACLS Protocols on Survival of Event in the Setting of In-Hospital Cardiac Arrest. Resuscitation, 85(1), 10.1016/j.resuscitation.2013.09.019. http://doi.org/10.1016/j.resuscitation.2013.09.019

Merchant, R. M., Berg, R. A., Yang, L., Becker, L. B., Groeneveld, P. W., & Chan, P. S. (2014). Hospital Variation in Survival After In‐hospital Cardiac Arrest. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, 3(1), e000400. http://doi.org/10.1161/JAHA.113.000400

McInnes, A. D., Sutton, R. M., Nishisaki, A., Niles, D., Leffelman, J., Boyle, L., … Nadkarni, V. M. (2012). The ability of code leaders to recall CPR quality errors during the resuscitation of older children and adolescents. Resuscitation, 83(12), 1462–1466. http://doi.org/10.1016/j.resuscitation.2012.05.010

Price, J. W., Applegarth, O., Vu, M., & Price, J. R. (2012). Code Blue Emergencies: A Team Task Analysis and Educational Initiative. Canadian Medical Education Journal, 3(1), e4–e20.

Prince, C. R., Hines, E. J., Chyou, 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. http://doi.org/10.3121/cmr.2014.1201

Segon, A., Ahmad, S., Segon, Y., Kumar, V., Friedman, H., & Ali, M. (2014). Effect of a Rapid Response Team on Patient Outcomes in a Community-Based Teaching Hospital. Journal of Graduate Medical Education, 6(1), 61–64. http://doi.org/10.4300/JGME-D-13-00165.1

Sahin, K. E., Ozdinc, O. Z., Yoldas, S., Goktay, A., & Dorak, S. (2016). Code Blue evaluation in children’s hospital. World Journal of Emergency Medicine, 7(3), 208–212. http://doi.org/10.5847/wjem.j.1920-8642.2016.03.008

Williams, K.-L., Rideout, J., Pritchett-Kelly, S., McDonald, M., Mullins-Richards, P., & Dubrowski, A. (2016). Mock Code: A Code Blue Scenario Requested by and Developed for Registered Nurses. Cureus, 8(12), e938. http://doi.org/10.7759/cureus.938

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