Reducing preventable harm and death associated with in-hospital cardiac arrest (IHCA) is a big — yet achievable — goal. First, you’ll need to make sure you’ve built the best Code Blue response team possible. Then, per The Joint Commission’s new resuscitation requirements, hospitals will need to collect important data about every IHCA event, and have an interdisciplinary committee review that data to identify and suggest opportunities for improvement.
But once a potential quality improvement area has been pinpointed, how does the committee assess which course of action is best? How do they determine whether that course of action is working? And, most of all, how do they ensure these quality improvement (QI) initiatives are universally adopted and upheld over the long term? Here are 4 ways to make sure your resuscitation quality improvements stick.
1. Tackle One Improvement at a Time
Before you can make resuscitation quality improvements stick, you’ll need to figure out which areas are in need of improvement and address only one at a time with thoughtful, practical changes. This helps to ensure the results of any interventions are measurable.
First, per the latest requirements from The Joint Commission, the resuscitation committee should regularly review and observe trends in data collected and/or stored after each resuscitation event, such as from1:
- Cardiopulmonary arrest (CPA) forms
- Responder feedback
- Post-arrest documentation
- Debriefs
- Get With The Guidelines®-Resuscitation database
- Any other repository used at your institution
Guidance in Action
For example, let’s say the resuscitation committee has reviewed data from these sources and noticed a tendency toward overcrowding at Code Blue events. This is a relatively common issue that can negatively impact outcomes by making it harder for responders to access the patient for critical interventions. Throughout this article, we’ll explore how an institution might devise and cement quality improvements for this type of issue.
Once an area for improvement has been identified, every member of the resuscitation committee should have input on opportunities to solve the issue as well as specific interventions that might help. All members have unique and valuable perspectives based upon their own departments and roles on the response team.
Guidance in Action
Carrying through our overcrowding example, let’s say the resuscitation committee discussion reveals two opportunities for improvement:
- Two respiratory therapists (RTs) are showing up for every event in case intubation is necessary. Even when it’s not necessary, one RT is always utilized.
- Local staff who initiated basic life support (BLS) measures aren’t leaving the room once the resuscitation response team arrives.
Through further discussion, the committee decides to recommend a multi-pronged approach to address the issue:
- Work with RT leadership to ensure only one RT arrives at each resuscitation event. This could be as simple as a quick discussion.
- Upon arrival at every event, the code team leader (or a delegate, such as a nursing supervisor, director, or manager) should make an announcement along the lines of, “Anyone not on the code team or directly interacting with the patient, please exit the room.”
2. Spread the Word
After a single improvement area has been identified and the resuscitation committee has come to a consensus on how to move forward, it’s time to educate Code Blue responders, as well as all general staff and departments about the proposed change(s). Here are a few quick tips on how best to accomplish this:
- Try to allow six weeks to get the word out before official implementation.
- Education efforts may include:
- All-staff emails and posters in various units and departments
- Reinforcement during mock codes
- Discussion at leadership meetings, unit huddles, or any other planned gathering of relevant staff (even those not focused specifically on resuscitation)
- Coverage at individual and team training events and interdisciplinary education and/or communication sessions
Each of these touchpoints should cover the reasoning behind the change to encourage buy-in as well as clear, simple information about the impending process improvement(s).
Guidance in Action
For our overcrowding example, one education initiative might look like an all-staff email that explains:
- IHCA patients whose rooms are overcrowded tend to have worse outcomes
- Crowding at resuscitation events can prevent responders from accessing the patient and/or emergency equipment and makes effective communication between responders more difficult
- Although they will need to stay nearby for hot debrief, it’s OK for initial responders to leave and/or assist with other needs outside the room once the code team arrives, the primary initial responder hands off responsibility to the code team leader, and there are enough team members present to support advanced cardiac life support (ACLS)
- What to expect regarding the new announcements from code team leaders or delegates during live events
Regular education should also continue after the new practice is launched to ensure the greatest chance of successful, long-term adoption.2
3. Collect Data & Follow Up
As resuscitation quality improvements are officially implemented, make sure responders continue to collect the same data they did prior to the QI initiative (including items outlined by the latest requirements from The Joint Commission), and perhaps also start collecting any new data that’s relevant to the initiative that wasn’t being collected before.
Guidance in Action
For our overcrowding example, in addition to documenting whether the event was crowded or whether anyone had trouble accessing the patient, equipment, or supplies, teams could also take note of whether or not the proposed announcement was made by code team leadership.
As the data is collected, you’ll want to follow up accordingly both immediately and over the long term:
Immediate followup
Resuscitation events acutely impact patient lives. After each event, there should be immediate follow up with the local staff and resuscitation team responders to discuss and reinforce the latest changes.
- Did teams follow the new guidelines?
- Did the changes have any impact on the response?
It’s especially important to follow up on any cases that didn’t meet new expectations to find out why.
- Was there a system failure?
- Were there new staff members involved who simply were not aware of expectations?
- Did responders simply forget or were they too distracted or stressed out to remember?
Checking in and reiterating expectations are crucial steps in maintaining any shift in practices.
Guidance in Action
Back to our example, it would be a great idea to specifically follow up in the short term with any staff who responded to the events that were initially considered overcrowded. Have they been able to easily implement the changes? Is the new process helping?
Long-term followup
Compare new data against pre-QI data to see if there’s any overall change. Depending on the volume of IHCA events at your institution, a couple of months’ worth of post-implementation data should be enough.
If you’re noticing a positive effect in some areas or departments but not others, this data can help you communicate with those department leaders and motivate them to support anyone on their team who is having trouble maintaining the practice change.
If there hasn’t been any improvement, that’s ok. It is incredibly valuable to learn that a specific change was not effective. Armed with more data and insight, the resuscitation committee will be better equipped to change gears and try something new. Better is better, no matter how you get there.
Guidance in Action
Over the long term, has overcrowding not improved? Talk to various staff members to find out why the recommended change isn’t working, and ensure that data can be accessed and used to help create a new, hopefully more successful intervention.
In all followup activities, be sure to focus on patients’ wellbeing. Emphasize how the actions of one can impact overall care and outcomes for many.
4. Celebrate Wins (Even Small Ones!)
After two or three months of consistent, direct feedback after every event, the change should have become standard practice for responders, and data will likely show the effect at least on some level.
Any measurable benefit whatsoever should be showcased to all staff to highlight the success of their efforts. You can start by showing data from individual events to local units as they improve (if relevant), and then also highlight improvements monthly, at six months, and at one year for comparison. This kind of positive reinforcement can also help staff remember and stay motivated to continue on with the new practice.
Guidance in Action
To finish up with our overcrowding example, it’s important to celebrate even individual events when there are no crowding issues. Then, over the long term, continually ask:
- Has overcrowding ceased or significantly dropped off after a month or two? Great! Celebrate!
- Do clinicians feel they are having an easier time accessing patients, supplies, and equipment during resuscitation events? Awesome! Celebrate that!
- Most importantly, is there any improvement in overall patient outcomes over the same time period? If so, this calls for a major celebration by all.
Remember, better is better! There’s no such thing as perfection, so all we can do is strive to keep improving for our patients — and ourselves.
How Can We Help?
Ongoing education and reinforcement, data collection, following up on outliers, and celebrating wins are impactful ways to maintain practice improvements for resuscitation events.3,4 CoDirector® Software from Nuvara® can help with:
- Real-time, digital data collection
- Automatic “hot” and “cold” debrief reports
- Built-in analytics that highlight areas in need of improvement
- Easy-access intervention protocols that can be customized based on evolving hospital policies and practices
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Nuvara’s CoDirector Software can help your hospital improve emergency response processes and comply with new resuscitation standards from The Joint Commission.
References
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Mannion, R., & Davies, H. (2018). Understanding organisational culture for healthcare quality improvement. BMJ, k4907. https://doi.org/10.1136/bmj.k4907
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Dudzik, L., Heard, D. G., Griffin, R. E., Vercellino, M., Hunt, A., Cates, A., & Rebholz, M. (2019). Implementation of a low-dose, high-frequency cardiac resuscitation quality improvement program in a community hospital. The Joint Commission Journal on Quality and Patient Safety, 45(12), 789–797. https://doi.org/10.1016/j.jcjq.2019.08.010
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Silver, S. A., McQuillan, R., Harel, Z., Weizman, A. V., Thomas, A., Nesrallah, G., Bell, C. M., Chan, C. T., & Chertow, G. M. (2016). How to sustain change and support continuous quality improvement. Clinical Journal of the American Society of Nephrology, 11(5), 916–924. https://doi.org/10.2215/cjn.11501015
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Van Heerden, C., Janse van Rensburg, E. S., & Maree, C. (2019). Action research as sustainable healthcare quality improvement: Advances in neonatal care emphasising collaboration, communication and empowerment. Action Research, 147675031989683. https://doi.org/10.1177/1476750319896839
