Breaking the 'Code' for Emergency Response
By Dan Meyers
There’s a lot of data to support changes Children’s Hospital Colorado made in how it calls and responds to “codes,” that is, when a patient needs emergency help to breathe.
But the charts and numbers really add up to this:
“We figure we saved six lives this year,” says Emily Dobyns, a professor of pediatrics at the University of Colorado School of Medicine and medical director of the ICU at Children’s Colorado.
Dobyns, co-chair of the hospital’s code committee, knows that in the relentless math of emergency response, the more codes there are outside the ICU, the more kids who die. On the other floors at the hospital, about one in four survive the conditions that led to a code. In the ICU, about four out of five make it.
So the idea is to get the kids at greatest risk of a code into the place where they have the best chance of surviving it.
Children’s, in the last three years, has cut the number of codes outside the ICU by more than half, from 0.6 per thousand admissions to 0.24. That translates into those lives Dobyns figures were saved.
How’d the hospital do it? It adopted numerous changes in structure, rules and culture. Also those candies called Lifesavers proved to be true lifesavers—but more on that later.
Five years ago, Children’s began a systemic effort to reduce code rates. That was helped along by a national effort by the Child Health Corporation of America, a business alliance of children’s hospitals, to push nationally for improvements in pediatric health care.
Out of all this came the hospital’s Rapid Response Team: a group with the expertise needed to treat patients who may be heading for a code.
The code literally is what comes across the pagers of the team when its needed: “Code blue, hospital room …” That text produces a purposeful scramble. Its recipients know that a patient likely will require measures including chest compression, electric shock and/or advanced airway support.
But the hospital broadened its efforts beyond that team. Among those changes: Nurses on the inpatient units were better trained to pick up signs of trouble. The hospital began to dig into codes to see if they were preventable.
Children’s adopted what it calls a Pediatric Early Warning System that rates patients on a scale of 0–3 in cardiovascular, respiratory and neurological function. A total score of four or more triggers the Rapid Response Team. The hospital analyzed its data and found a four or more meant the child was 30 times more likely to need a code than a three. So four and above requires a visit from the rapid response team.
The family of a patient can activate the team if they see their child doing poorly or if they feel their concerns are going unheard.
Debriefing after a code proved to be hugely valuable, and not just for squeezing out errors.
“You realize how hard it is on the younger providers when a code happens,” Dobyns says. “You go into this to make a difference and help kids. You think, ‘Where did I screw up?’ It’s reassuring when they realize they didn’t, or that next time this happens they can approach the issue in a different way.”
While the hospital’s results are good, they can’t be taken for granted. This year, the code rate edged up, though only about a third of the events were preventable.
“I think we’ve been successful,” Dobyns says. “We’ve made some huge interventions that saved kids.”
And the Lifesavers?
“We found there was resistance to calling the rapid response team,” Dobyns says. “Some people looked at it as sign of their own failure. So we went out and got rolls of Lifesavers. We put ribbons on them plus a note that said ‘Thank you for being a lifesaver.’”
Call for the team, get a roll of Lifesavers.
“I thought that was the stupidest thing we could possibly do,” Dobyns says with a laugh. “But it worked. It made a huge difference.”