Elsevier

Resuscitation

Volume 143, October 2019, Pages 158-164
Resuscitation

Simulation and education
Code blue pit crew model: A novel approach to in-hospital cardiac arrest resuscitation

https://doi.org/10.1016/j.resuscitation.2019.06.290Get rights and content

Abstract

Background

Mortality from in-hospital cardiac arrests remains a large problem world-wide. In an effort to improve in-hospital cardiac arrest mortality, there is a renewed focus on team training and operations. Here, we describe the implementation of a “pit crew” model to provide in-hospital resuscitation care.

Methods

In order to improve our institution’s code team organization, we implemented a pit crew resuscitation model. The model was introduced through computer-based modules and lectures and was reemphasized at our institution-based ACLS training and mock code events. To assess the effect of our model, we reviewed pre- and post-pit crew implementation data from five sources: defibrillator downloads, a centralized hospital database, mock codes, expert-led debriefings, and confidential surveys. Data with continuous variables and normal distribution were analyzed using a standard two-sample t-test. For yes/no categorical data either a Z-test for difference between proportions or Chi-square test was used.

Results

There were statistically significant improvements in compression rates post-intervention (mean rate 133.5 pre vs. 127.9 post, two-tailed, p = 0.02) and in adequate team communication (33% pre vs. 100% post; p = 0.05). There were also trends toward a reduction in the number of shockable rhythms that were not defibrillated (32.7% pre vs. 18.4% post), average time to shock (mean 1.96 min pre vs. 1.69 min post), and overall survival to discharge (31% pre vs. 37% post), though these did not reach statistical significance.

Conclusion

Implementation of an in-hospital, pit crew resuscitation model is feasible and can improve both code team communication as well as key ACLS metrics.

Introduction

There are at least 200,000 in-hospital cardiac arrests (IHCA) each year in the United States,1 and hospital survival following an IHCA is estimated to be 15–30%.2, 3, 4, 5 Though some degree of mortality reflects patients’ underlying disease, inadequate resuscitation also likely contributes to decreased survival.6, 7, 8, 9, 10 For example, in a study completed by Ornato et al., resuscitation errors were noted in 40% of cases presenting in ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT) and in 27% of cases with an alternative presenting rhythm.10 Errors in resuscitation were associated with decreased rates of return of spontaneous circulation (ROSC) and survival to hospital discharge.

In an effort to minimize errors, a number of training techniques have been utilized to improve resuscitation practices. These include the implementation of ACLS training and the utilization of resuscitation simulation sessions.11, 12, 13, 14, 15, 16 However, knowledge of ACLS and adherence to established algorithms is not enough. The presence of leadership skills, prior leadership training, and utilization of more directive statements are associated with better cardiac arrest simulation performance,17, 18, 19 while inadequate communication and lack of leadership behaviors have been associated with poorer outcomes during cardiac arrest scenarios.20, 21

In addition to strong communication and leadership skills, team function and organization are also important when managing critical care scenarios. One way that many first responders deal with the inherent chaos of emergency situations is by utilizing a “pit crew” model when responding to cardiopulmonary arrests.22, 23, 24, 25 Recently, Hopkins et al. included a pit crew model and team training as part of their “best practices” protocol when responding to out-of-hospital cardiac arrests (OHCA).25 In this study, patients treated in the post-intervention period had higher survival to hospital discharge and better neurologic outcomes in the form of higher cerebral perfusion category scores. Similarly, in an earlier retrospective cohort analysis of OHCA, team-focused CPR was associated with improved survival with good neurologic outcome compared to standard CPR.26

Team training and communication are also an area of focus for in-hospital cardiopulmonary resuscitation.27, 28 The American Heart Association (AHA) 2013 consensus statement recommended that providers utilize a coordinated team response with “specific role responsibilities”.29 Though the guideline did not detail exactly how many roles there should be or what the responsibilities should include, it did endorse utilizing a pit crew model in order to ensure high quality CPR and to minimize pauses in compressions.

Despite this recommendation, descriptions of in-hospital resuscitation teams with specific roles and responsibilities are lacking. The aim of this quality improvement initiative was to improve code team communication and organization through the development of a pit crew model for resuscitation. Here we describe our institution’s development and roll-out of that model and a retrospective comparison of pre- and post-implementation metrics.

Section snippets

Patients

All patients who had a true cardiopulmonary arrest (CPA) at the main campus of our tertiary care, academic medical center were included in this quality improvement project. Data were reviewed for all events pre-intervention (April 2013–December 2013) and post-intervention (October 2014–June 2015). The main goal was to improve team communication and function with a secondary goal to improve resuscitation metrics. Since all data obtained were de-identified and were collected under the auspices of

Results

There were exactly 159 cardiopulmonary arrest events at our medical center in both the pre-intervention (April 2013–December 2013) and post-intervention (October 2014–June 2015) time periods. Each time frame included three quarters of code events with a nine month gap during the intervention period. The automatically recorded data elements from the Information Warehouse were the most complete, but there were still omissions due to incomplete charting of the bedside staff during some events.

Discussion

Lack of clear code team organization and communication is a frequently cited problem within true code and mock code events.30, 31 In order to improve this aspect of code blue resuscitation, more emphasis should be placed on educating code team members about specific roles and responsibilities.

Though utilization of a pit crew model was suggested in the 2013 AHA consensus statement on CPR quality, there are few examples of how this can be implemented in the literature. Most of these examples are

Conclusions

This study represents one of the first adoptions of the pit crew model as part of the coordinated response to in-hospital cardio-pulmonary arrests. By better defining code team roles and responsibilities, we have laid the foundation for ongoing improvement of our code team’s organization and communication and, ultimately, patient outcomes.

Conflicts of interest

None.

Acknowledgments

We would like to thank the members of the code blue and emergency response team (Code Blue/ERT) committee who helped with the implementation of the pit crew model. There was not any funding obtained for this research.

References (32)

Cited by (20)

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    The systematic review published by ILCOR recognises that the evidence in support of this recommendation comes from studies of mostly moderate to very-low-certainty certainty, mainly non-randomised controlled trials.49 The majority of these studies associated with system performance improvement found that interventions to improve system performance improved system level variables and skill performance of basic life support (BLS) and advanced life support (ALS) in actual resuscitations,50–61 leading to improved clinical outcomes following out-of-hospital or in-hospital cardiac arrest. Several studies showed improved survival to hospital discharge52,54,56,57,61–70 and survival with favourable neurological outcome at discharge.52,54,61–65,68–71

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    The quality of guideline-based care was associated with survival to discharge and favorable neurologic outcome, while the participating hospitals in the US varied in quality of care significantly.4 There were three studies evaluating modified CPR training programs for IHCA patients.18,28,33 One study proposed a “pit crew” model, clearly allocating each member in the team with a specific responsibility for resuscitation.33

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