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Over 200,000 patients die each year in the U.S. as a result of in-hospital cardiac arrest (IHCA).1 And despite evidence that many of these deaths could be prevented with consistent implementation of best practices, many hospitals still struggle to reach the American Heart Association’s IHCA survival goal of 35%.2-5

One of the primary factors impacting Code Blue outcomes is a lack of comprehensive, high-quality data that clinicians and hospitals can use to drive process improvements. That’s why it’s so important for responders to collect data on every IHCA event.

Not only does documentation help hospitals analyze and optimize system-wide practices over time, it can also provide valuable information to guide in-the-moment improvements in CPR quality and adherence to hospital protocols. Here are five tips to help ensure your hospital’s Code Blue documentation practices are as effective as possible.

1. Get to Know the ILCOR Documentation Guidelines

The International Liaison Committee on Resuscitation (ILCOR) outlines the gold standard for resuscitation registry documentation, including the data collection form and cardiopulmonary arrest documentation criteria.6,7

In 2019, an ILCOR task force released an updated Utstein Resuscitation Registry Template for IHCA, which delineates several groups of data elements and classifies information within those groups as either “core” or “supplemental.”

  • Core items enable reasonable comparisons between systems and are considered essential for quality improvement programs.
  • Supplementary items are considered useful for research purposes, in combination with core variables.

 

Simplified ILCOR Resuscitation Registry Data Collection Template for IHCA7

(See full text and details here.)

2. Assess Your Hospital’s Current Documentation Practices

Review whatever data is routinely collected during actual in-hospital cardiac arrest cases at your institution, and compare it against the ILCOR requirements outlined in item 1 above. Carefully consider and make note of the following:

What data is missing, if any? Are missing items considered “core” or “supplementary”?

How can your institution start collecting the missing data points? Consider holding a brainstorming session with Code Blue response teams and other key stakeholders to come up with practical solutions. For example:

  • Responders may not have access to continuous end-tidal carbon dioxide monitoring, but could they use a colorimetric detector?
  • Do your hospital’s data collection methods ensure staff are best equipped to perform this critical task? Is one member of each response team designated as the scribe or recorder? Is documentation digitized and user-friendly?

Can you prioritize missing items based on other criteria, such as updated requirements from The Joint Commission, which will go into effect January 1, 2022? These guidelines specifically call for the collection and/or review of8:

  • Timeliness of the staff’s response
  • CPR quality
  • Post-cardiac arrest care measures
  • The number and location of cardiac arrests (e.g. ambulatory area, telemetry unit, or critical care unit)
  • The outcomes of resuscitation (e.g. return of spontaneous circulation (ROSC) and survival to discharge)
  • Transfer to a higher level of care

3. Implement a Quality Improvement Intervention

Now that you have a better understanding of what data points you need to be focusing on, it’s time to tell the teams who are actually responsible for collecting the information: Code Blue responders. Meaningful change cannot happen unless they realize there is an issue and receive guidance on how to resolve it. In short, they don’t know what they don’t know.9 

Provide feedback on documentation practices in whatever way works best for your clinical teams and your institution, such as: 

  • Emails. Sometimes the simplest method of communication is also the most effective. Regular digital summaries of how actual documentation compares to best practices and expectations can help ensure the information is easy to access and reference — and that it sticks through repetition.
  • Report cards. That said, we’ve all experienced inbox fatigue. If your team members are overloaded with digital communications, perhaps put together something more tactile, like a physical checklist that clearly shows at a glance where documentation is succeeding and what areas still need work.
  • Staff meeting presentations. It can also be helpful to offer input in a setting that is more open to group discussion and problem solving. Be sure to share feedback at meetings where specific responders named on documentation forms are present and/or in units where Code Blue events are most likely to occur.

4. Collect Data, Review Results, and Re-evaluate10,11

Once Code Blue responders have received appropriate education on the IHCA data they should be collecting, give them a reasonable amount of time and/or a set number of cases in which to implement these new practices. Then review cases against previous practices as well as against the ILCOR requirements.

Was there any improvement? 

If not, consider implementing a more significant intervention:

  • Reinforce the Joint Commission requirements and how those may impact your organization’s accreditation status.
  • Escalate the issue by looping in overarching quality and safety department heads.

If there was improvement, great! Let staff know what they did right as well as any areas that are still lacking. Either way, be sure to maintain surveillance of IHCA data collection.

5. Write It Up

Every institution struggles with cardiac resuscitation documentation for one reason or another. Some are still using slow, manual, or outdated data collection processes. Others may not be reviewing cases often enough to realize they are missing key data points. But whatever the case, writing up and submitting your own successful intervention techniques for presentation or publication can go a long way toward helping other institutions solve their own issues.12,13

By coming together to address the pervasive lack of Code Blue data, we’re also taking perhaps the most important step toward improving overall IHCA outcomes — and, ultimately, saving more lives.

Improve Code Blue Documentation with Nuvara

In support of these strategies, hospitals can also adopt a more modern data collection solution, such as the Nuvara Emergency Care System. This innovative combination of user-centric hardware and purpose-built software:

  • Allows all interventions to be digitally documented in real time
  • Allows your hospital’s resuscitation algorithms and medication dosing protocols to be customized and easily updated
  • Provides an interactive dashboard of automated timers that enables clinicians to pace recurring actions and monitor CPR quality in the moment
  • Provides out-of-the-box, automatic event reporting for key clinical quality indicators and exportable data for deeper data analysis
  • Automatically creates both “hot” and “cold” debrief reports

Want to Learn More?

Learn how the Nuvara Emergency Care System can help ensure your hospital’s IHCA data collection processes are aligned with nationally and globally recognized standards and best practices.

References

  1. Andersen LW, Holmberg MJ, Berg KM, et al. In-hospital cardiac arrest: a review. JAMA. 2019 March; 321(12): 1200-1210.
  2. IOM (Institute of Medicine). 2015. Strategies to improve cardiac arrest survival: a time to act. Washington, DC: The National Academies Press.
  3. Chan PS, Krein SL, Tang F, et al. Resuscitation practices associated with survival after in-hospital cardiac arrest: a nationwide survey. JAMA Cardiol. 2016;1(2):189-197.
  4. Kronick SL, Kurz MC, Lin S, et al. Part 4: systems of care and continuous quality improvement. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(suppl 2): S397-S413.
  5. Neumar RW. Doubling cardiac arrest survival by 2020: achieving the American Heart Association impact goal. Circulation. 2016;134:2037-2039.
  6. Jacobs, I., Nadkarni, V., & ILCOR Task Force on Cardiac Arrest and Cardiopulmonary Resuscitation Outcomes. (2004, November 23). Cardiac arrest and cardiopulmonary resuscitation outcome reports: Update and simplification of the Utstein templates for resuscitation registries. Circulation, 3385–3397. https://doi.org/10.1161/01.CIR.0000147236.85306.15
  7. Nolan, J. P., Berg, R. A., Andersen, L. W., Bhanji, F., Chan, P. S., Donnino, M. W., Lim, S., Ma, M.-M., Nadkarni, V. M., Starks, M. A., Perkins, G. D., Morley, P. T., & Soar, J. (2019). Cardiac arrest and cardiopulmonary resuscitation outcome reports: Update of the utstein resuscitation registry template for in-hospital cardiac arrest: A consensus report from a task force of the international liaison committee on resuscitation (american heart association, european resuscitation council, australian and new zealand council on resuscitation, heart and stroke foundation of canada, interamerican heart foundation, resuscitation council of southern africa, resuscitation council of asia). Circulation, 140(18). https://doi.org/10.1161/cir.0000000000000710
  8. The Joint Commission. (2021, June 18). R3-report_resuscitation [PDF]. https://www.jointcommission.org/. Retrieved July 30, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3-report_resuscitation_hap_final_.pdf
  9. Mick, J. (2017). Call to action. Nursing, 47(4), 36–43. https://doi.org/10.1097/01.nurse.0000513603.03034.5c
  10. Shermon, E., Munglani, L., Oram, S., William, L., & Abel, J. (2017). Reducing dnacpr complaints to zero: Designing and implementing a treatment escalation plan using quality improvement methodology. BMJ Open Quality, 6(2), e000011. Retrieved July 30, 2021, from https://doi.org/10.1136/bmjoq-2017-000011
  11. Jones, P. G., & Miles, J. L. (2008). Overcoming barriers to in-hospital cardiac arrest documentation. Resuscitation, 76(3), 369–375. https://doi.org/10.1016/j.resuscitation.2007.08.021
  12. Kaplan, H. C., Provost, L. P., Froehle, C. M., & Margolis, P. A. (2011). The model for understanding success in quality (musiq): Building a theory of context in healthcare quality improvement. BMJ Quality & Safety, 21(1), 13–20. https://doi.org/10.1136/bmjqs-2011-000010
  13. Ogrinc, G., Mooney, S. E., Estrada, C., Foster, T., Goldmann, D., Hall, L. W., Huizinga, M. M., Liu, S. K., Mills, P., Neily, J., Nelson, W., Pronovost, P. J., Provost, L., Rubenstein, L. V., Speroff, T., Splaine, M., Thomson, R., Tomolo, A. M., & Watts, B. (2008). The squire (standards for quality improvement reporting excellence) guidelines for quality improvement reporting: Explanation and elaboration. Quality and Safety in Health Care, 17(Suppl 1), i13–i32. https://doi.org/10.1136/qshc.2008.029058
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