The Lahey Medical Center developed a mock code program using simulation to identify gaps in their code team's performance. In simulations, they found inadequate CPR due to shallow compressions and variability in teamwork strategies and adherence to ACLS guidelines, especially among first responders. The causes of these gaps seem related to poor performance of ACLS guidelines and ineffective teamwork. Moving forward, they plan to address the identified gaps through targeted simulations and training to improve code response.

1. Background: Survival to discharge following cardiopulmonary arrest remains
disappointingly low1
, despite a clear understanding of the pathophysiology
underlying such events2
. The act of a code team responding to these events and not
achieving optimum performance can be termed a “gap,” or incongruence between
actual and desired Code Blue response. These gaps may be caused by a variety of
factors and conditions, including a lack of sufficient training (individual or team
performance skills), lack of equipment or equipment that is sub-par, and logistical
problems, such as remoteness of location, difficulty reaching the patient, or
problems with transportation of equipment.
The Lahey Medical Center Code Committee has developed a mock code program to
investigate the nature of gaps in resuscitation performance by the interdisciplinary
Code Team. This has been done so that institutional changes may be enacted to
bridge observed gaps. This approach of analyzing system gaps using simulation
and crafting solutions has been conducted at other institutions with reasonable
success.3
Methods: Initially, perceived gaps are presented to the Code Committee, which
then plans and executes tailored mock code events for specific gap analysis. These
simulated Code Blue scenarios utilize a Laerdal SimMan 3G manikin. First
responders and members of the Code Team are instructed to respond to the
simulations as if to real codes. The Code Team is led through a structured debrief
following each mock code event, giving them an opportunity to voice concerns and
receive feedback regarding their teamwork behavior and adherence to standards of
care.
Using a novel evaluation tool based on current ACLS guidelines and TeamSTEPPS
criteria for teamwork behavior (Figure 1), mock code video footage, and data
recorded by the SimMan 3G (Figure 2), the performance of the Code Team is
evaluated.
USING SIMULATION TO PERFORM A GAP ANALYSIS OF
CODE BLUE RESPONSE
T. Howell Burke, Ben Guido, Darlene Bourgeois MSN RN, and Edwin Ozawa MD PhD
Lahey Hospital and Medical Center, Burlington MA
Figure 2. Code Blue team using a Laerdal SimMan 3G simulation
manikin with the transcript of code blue events at left.
Results: We have identified several important types of gaps in the code response. First,
inadequate CPR was performed in the majority of code simulations, typically due to shallow
compression depth. Preliminary results show that participants in codes vary widely in their use of
optimal teamwork strategy and their adherence to ACLS guidelines. These results suggest
furthermore that first responders, such as Medical Assistants and Medical Technicians, vary widely
in their adherence to BLS guidelines (Table 1). Many of the perceived causes of these gaps
seemed directly tied to the poor performance observed in adherence to ACLS guidelines or
members working together effectively as a team (Table 2).
Discussion: Members of the Code Team have voiced increasing support for the use of simulated
codes at Lahey Hospital. Moving forward, we anticipate that teamwork and standard of care
performance by the Code Team will improve with each simulation iteration. Furthermore, the
causes of gaps, such as location or educational constraints identified in successive iterations, will
allow simulations to be better tailored to improve Code Blue response. Continued Code Blue
simulation with the Code Team and more widespread training of medical paraprofessionals in BLS
could improve adherence to optimal teamwork strategy and BLS/ACLS guidelines.
Bibliography:
1. Kumar G, Nanchal R. Trends in survival after in-hospital cardiac arrest. N Engl J Med.
2013;368(7):680-681.
2. Sinz E, Navaro K. Advanced Cardiovascular Life Support Provider Manual. Dallas: American
Heart Association: USA; 2011.
3. Barbeito A, Bonifacio A, Holtschneider M, Segall N, Schroeder R, Mark J. In situ simulated
cardiac arrest exercises to detect system vulnerabilities. Simul Healthc. 2015;10(3):154-162.
Table 1. Evaluation of code team performance on teamwork and adherence to ACLS guidelines.
Figure 1. First Page of Sample Data Collection Form.
All results are summarized in an After Action Report, which is
presented to the Hospital’s Chief Medical Officer and Department
of Quality and Safety for review. The next step in this process will
involve actions being taken to bridge the observed gaps by
directly addressing their identified causes.
Table 2. Perceived gap rationale for each mock code and observed
mock code results.
Mock Code
Date/Location
Perceived Cause of Gap Associated Perceived
Concerns
Mock Code Observations
Neurology -
9/30/2015
Reduced after-hours clinic
staffing
Delayed first response
and code team arrival
Rapid establishment of
pulselessness; late first shock
Cardiology -
10/28/201
Inexperienced after-hours
clinic staffing
Delayed first response
and code team arrival
Pulselessness established too
late; late first shock
MRI - 12/18/2014 Isolated location;
inexperienced staff
Delayed first response
and code team arrival
Rapid establishment of
pulselessness; late first shock
Operating Room -
2/11/2015
Leadership, teamwork,
and task delegation
concerns
Delayed response; poor
teamwork and
collaboration
Rapid establishment of
pulselessness; timely first
shock;poor delegation of
tasks; sparing use of closed
loop communication
CCU - 3/11/2015 Busy location;
system-wide deficiencies
documenting code on
EMR
Commotion disrupting
resuscitative care or
teamwork; improper
code documentation
Effective teamwork; sparing
use of closed loop
communication; many
documentation errors
Lobby - 4/27/2015 No stationed providers Delayed first response
and code team arrival
Pulselessness established too
late
Inpatient Room -
6/1/2015
Common shift changes Delayed first response
and code team arrival
Pulselessness established too
late; late first assisted
ventilation