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The Implementation of Pediatric Quarterly Mock Codes and its Impact on Resuscitation Skills Compliance

Published:September 21, 2020DOI:https://doi.org/10.1016/j.pedn.2020.09.005
      Editor’s Note
      In the following contribution, the authors present their plan to ensure the pediatric staff remained prepared to care for the unstable child during a crisis by adhering to the guidelines established by Pediatric Advanced Life Support (PALS). They deemed that being competent in this skill was even more critical at their small hospital without a pediatric ICU than a large academic pediatric hospital with multiple ICUs. It is the unexpected events that test the nurses' knowledge and ability to intervene with confidence.
      Changing the review requirement from every other year or even every year to quarterly enabled the staff to gain confidence in their skills and respond to a code without panic, drawing on their knowledge and practice via simulation and debriefing experiences.
      It is a good reminder that no institution is too small nor does a code happen only in the ICU; children decline very rapidly and when they do, they need immediate intervention. Being able to implement PALS resuscitation skills according to PALS algorithms can make a real difference in patient survival.

      Introduction

      In-hospital pediatric codes have markedly low survival rates. According to
      • Andreatta P.
      • Saxton E.
      • Thompson M.
      • Annich G.
      Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates.
      , data illustrates that pediatric patients have a 27% survival rate to discharge following an in-hospital cardiopulmonary arrest. 34% of those that do survive will have some type of neurological deficit post arrest (
      • VanVoorhis K.T.
      • Willis T.
      Implementing a pediatric rapid response system to improve quality and patient safety.
      ). Delays in providing appropriate Pediatric Advanced Life Support (PALS) skills lead to poorer outcomes (
      • American Heart Association
      Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
      ). Since pediatric codes on non-critical care units are infrequent, medical personnel have limited experience caring for unstable pediatric patients. This limitation places a significant burden on the staff to remain proficient in the skills required to competently care for the unstable child.

      Background

      Inpatient pediatric cardiopulmonary arrests are infrequent events in this ten bed Pediatric Unit within a small regional hospital. Current hospital requirements are for each registered nurse who cares for pediatric patients to complete PALS training every two years, as recommended by the American Heart Association (AHA). It is also a mandated hospital wide educational requirement that registered nursing participate in one mock code scenario each year. However, the literature advocates that this standard be challenged. Inpatient pediatric registered nurses should be the experts in performing PALS resuscitation skills system wide, Thus, when a pediatric emergency arises it is the expectation that, in collaboration with other staff members, these nurses can implement PALS measures without delay.
      Initiation of this study began in 2017 when baseline PALS resuscitation skills compliance rates were measured on the inpatient unit at a dismal 40%. These results suggested that if a child were to have a cardiopulmonary arrest on this pediatric unit, nursing staff would only be 40% compliant in resuscitating the patient according to PALS algorithms. Although these healthcare professionals are PALS certified and expected to participate in annual mock code scenarios, this percentage implies a gap between acquired knowledge and accurate performance of skills during annual mock codes.

      Overview of the literature

      Renewal of PALS certification is required every two-years by the AHA and is recommended nationwide by most hospitals for staff caring for pediatric patients. However, knowledge retention of this information has been shown to deteriorate after only four months. In 2008,
      • Hunt E.A.
      • Fiedor-Hamilton M.
      • Eppich W.J.
      Resuscitation education: Narrowing the gap between evidence-based resuscitation guidelines and performance using best educational practices.
      identified that both physicians and nurses do not perform CPR correctly as soon as four months following a CPR class. Findings from the literature suggest that biannual education is ineffective in adequately preparing clinicians in providing optimal resuscitation efforts (
      • Sahu S.
      • Latal I.
      Simulation in resuscitation teaching and training, an evidence-based practice review.
      ).
      According to
      • Odia O.
      • Medows M.E.
      • Oluwole I.
      Assessing the usefulness of a mock code curriculum.
      , studies done in children's hospitals show that this gap can be bridged by more frequent simulation sessions that facilitate an overall increase in readiness to perform in codes and an increase in confidence levels. Using pediatric mock code simulations for review demonstrated a decrease in fears and anxiety related to resuscitation, improved communication, and increased the knowledge and familiarity with pediatric resuscitation guidelines. In 2008,
      • Hunt E.A.
      • Walker A.R.
      • Shaffner D.H.
      • Miller M.R.
      • Pronovost P.J.
      Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: Highlighting the importance of the first 5 minutes.
      claimed that these outcomes can be directly correlated to improved performance of resuscitation skills. However, there remains insufficient evidence that more frequent pediatric mock code simulations improve PALS skills compliance rates.

      Project purpose

      The purpose of this project was to evaluate whether implementing pediatric quarterly mock codes, in a small inpatient pediatric unit within an adult hospital, increased staff nurse compliance rates on implementing PALS skills.

      Setting and design

      As pediatric rapid responses and/or codes are rare on non-critical units, when an emergency occurs, anxiety among staff is high. Currently, no Pediatric Intensive Care Unit (PICU) capabilities are housed in this rural hospital facility. There are multiple children's hospitals within a 30-mile radius that facilitate transport when necessary. Ability to stabilize a pediatric patient in a life-threatening situation exists with the use of heated high flow oxygen therapy, positive pressure ventilation, and mechanical ventilation capabilities. Pediatric hospitalists also partner with clinical staff to provide patient care 24 h per day.
      Prior to this project, pediatric nurses were required to participate in one mock code annually. The purpose of the Improvement Project was to increase compliance with PALS skills during a pediatric code by increasing mock codes to quarterly. Three mock codes were available per quarter and nurses were responsible for attending at least one each quarter.
      The focus of the mock code scenarios was to make them realistic by utilizing past pediatric emergencies as scenarios. Current supplies and equipment were used including a fully stocked code cart. A grant was received to purchase a high-fidelity, interactive pediatric mannequin. The mock codes were held in a patient room on the pediatric unit and the expectation was for nurses to complete the actionable items in real time.
      A primary nurse was chosen, given a scenario, and taken into a patient room. An embedded participant played the role of the mother and provided the patient's history leading up to the illness. The educator observed for PALS criteria using our recording tool (Image 1), operated the mannequin, and provided patient symptoms and status updates to help drive their resuscitation response. When the primary nurse calls for help, the other nurses participating in the mock code respond as appropriate. The scenario is then carried out to cover all learning objectives listed. A short debriefing is then held post-resuscitation where the code scenario is reviewed. The steps taken during the code, including successes and areas that need improvement, are also discussed. All members involved in the scenario verbalize a takeaway from their personal experience. PALS resuscitation skills compliance measures are not discussed at the time of debriefing.

      Implementation

      There are a few keys to success for implementing mock codes on any nursing unit. One is to have the facilitator team composed an Educator, Clinical Manager, and Clinical Nurse Specialist (CNS) contribute to and be present for all mock codes. The educator at our hospital is also the PALS instructor, which is especially helpful for content knowledge. She partners with our Pediatric Unit clinical manager to write the mock code scenarios each quarter. Since care is also provided for women's health on this nursing unit, one quarter each year is dedicated to an adult mock code. This is helpful for any pediatric nursing unit that might need to resuscitate a parent or visitor.
      Commitment from leadership was evidenced by supporting staff to work with their unit practice council to grow their idea of offering quarterly mock codes. In addition, leadership made these drills mandatory, as part of annual competencies. Early planning and scheduling for the entire year enhanced compliance as staff scheduled times that were convenient to their working schedules. Scenarios were offered around staff meetings to decrease time spent driving to and from the hospital during their ‘off’ time plus staff were paid to lessen the burden of attending.
      To make mock codes as realistic as possible, staff are encouraged to familiarize themselves with the code cart and use tangible supplies. It is helpful that the supplies and equipment in all code carts in the hospital system are identical, making it seamless and decreasing time searching for supplies. Expired code cart supplies are given to the education department to be used in simulation situations helping to provide realism.
      Facilitators use a simulation planning worksheet to quantify mock code simulations (Fig. 1). A list of learning objectives and goals for the simulation is developed to describe background content for each scenario. Facilitators use this worksheet to guide the scenario, and re-direct participants as needed if straying from the written objectives. The worksheet is a helpful tool when including providers into the simulations by giving them an overview of end goals for each activity. Finally, the worksheet allows other facilitators to step in and lead a mock code when needed by giving them a complete guide of the overall scenario.
      In planning the implementation of the pediatric simulations, it was necessary to create a recording tool to assess the participant's critical thinking and clinical skills during simulated emergency events (Fig. 1). One of the primary goals of the Pediatric Unit Management team, Educator, Clinical Nurse Specialist, and the Pediatric Unit Practice Council was for staff to follow the AHA PALS standards during critical events. Therefore, the PALS systematic approach and algorithms were utilized as the gold standard to evaluate the staff's performance.
      The PALS recording tool was developed to note when staff identified the simulated patient's signs and symptoms and the timeliness and appropriateness of their interventions. Standardizing the evaluation of each simulation according to PALS standards was imperative. Even though specific objectives varied with each quarter's simulation, each session needed to be evaluated as objectively as possible.
      This tool was also used as a reference for debriefing. During the debriefings, nurses were encouraged to assess themselves against the appropriate PALS algorithm and identify areas of compliance as well as opportunities for improvement. This approach allows for the pediatric staff to better understand and affirm the importance of using PALS written resources with every critical event.
      The recording tool was used to assess data in an objective format to set goals and benchmarks for improving performance for meeting PALS standards. These same key components were reviewed and scored from information collected on the tool from every simulation session. Each step was quantified and measured on levels attributed to the specific action items taken. A percentage was then formulated based on the entire code scenario. For example, recognition of symptoms and calling a code blue are objectives that are met or not met; whereas medication and joules calculations are correct or incorrect based on patient weight. Timing of interventions were measured as being in the correct sequence and implemented at the correct time and would be deemed as correct or incorrect. A combined total is then calculated after scoring all action items of the mock code drill.

      Outcomes/Conclusion

      Implementation of quarterly mock codes on the Pediatric Unit increased staff nurse compliance on using PALS skills (Fig. 2). Through repetition, discussion, and practice of PALS skills, the pediatric unit staff nurse compliance rose to 98%, as compared to the initial 40% compliance with the, annual pediatric mock code requirement. This uptick in compliance aligns with
      • Auerbach M.
      • Kessler D.
      • Cooper-Foltin J.
      Repetitive pediatric simulation resuscitation training.
      findings.
      A decline in PALS skills compliance was exhibited during the fourth quarter of 2018. Staff nurses care for both women and children on the Pediatric Unit at our hospital. During the Third quarter of 2018, in situ adult mock code simulations were performed, leaving a six-month gap between PALS mock code simulations. The gap led to an 18% decrease in PALS skills compliance (Fig. 2).
      Future plans include continuing quarterly mock codes and analyzing PALS skill compliance over a three-year time frame. Observation of skills and nursing knowledge will continue to be monitored and evaluated as needed. A quantified measurement of specific PALS skills (e.g. chest compression rate and depth during CPR or carbon dioxide monitoring for effective bag-mask ventilation) will also be evaluated and analyzed for improvement.

      Implications

      Findings from the initial PALS skill compliance ratings demonstrated that the registered nurses on the pediatric unit were not proficient in their life-saving skills. Through teamwork, collaboration, communication and quarterly review, mock code proficiency improved considerably. Not only did compliance improve, qualitative data from post-evaluation forms showed a growth in confidence levels. Further unexpected qualitative findings included improved closed loop communication, teamwork, confidence in ability, just in time feedback, and clearly defining each participants' role.
      As previously stated, findings show that skills practiced in mock code simulations can be applied to real life scenarios and improve patient outcomes. Mock code simulations are based on real life scenarios and common types of pediatric patients. For example, an infant with bronchiolitis, a school-aged child with an appendicitis, or an adolescent with asthma exacerbation.
      Through experience, deficiencies in practice were identified and corrected by streamlining and standardizing processes in providing life-saving care. For example, patient rooms are small and poorly designed for quick entry, especially with a large code cart. Patient rooms have a rocking chair, which can provide comfort to a crying infant and is important in soothing the smallest patients. However, in a code situation, these rockers are a barrier to care, as they are typically located between the patient door and patient bed or crib. Through this experience, rockers have been removed from the room prior to pulling in the code cart- creating more room and leaving space for the code cart to be stationed near the action during life-saving measures.
      In addition, improvements to the code cart are continuously being made based on participant feedback, provided at the end of each simulation. Feedback was immensely valuable. An example of this was the addition of a step stool to the code cart to allow shorter nurses to provide better quality chest compressions.
      The most valuable addition to our code cart was the use of PALS algorithm cards. Through repetition, the code leader innately grabs the PALS algorithm cards. Once a cardiac rhythm is identified, the type of algorithm necessary is determined, ensuring that the best treatment is provided.

      Summary

      Implementing in situ quarterly pediatric mock codes increased staff nurse compliance using PALS skills. After implementing rounds of quarterly scenarios, compliance rose to 98%. Plans include continuing quarterly mock codes and analyzing compliance over a three-year timeframe. Quarterly in situ mock code simulations can be an effective in increasing PALS skill compliance and staff confidence. Skills practiced in these simulations can be applied to real life scenarios and improve patient outcomes.

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