The 12-year-old leukemia patient had been hooked up to chemotherapy for only a few minutes when she began having problems. First, she said her skin was itchy. Then, she complained of back pain. Soon, she was having trouble breathing.
Within minutes, she was experiencing cardiac arrest. She was having a severe allergic reaction to the chemotherapy agent, and the nurse knew exactly what to do: Call a code blue, which activated an emergency pediatric code team.
Practice Makes Perfect
It sounds like a simple call for a nurse, but what happens in the first few minutes after a patient’s heart suddenly stops-before all the specialists arrive-can make a critical difference between life and death. At the Bass Childhood Cancer Center at Lucile Packard Children’s Hospital Stanford, we rarely see a child in cardiac arrest or a code blue.
But if we do, we are ready. That’s because we practice our resuscitation skills several times a year, thanks to a new hospital-wide, cutting-edge program that provides lifesaving practice.
The Revive Initiative at Stanford Children’s Health provides the opportunity to practice skills that are essential in these infrequent but high-risk events. And, in an uncanny coincidence, several of the medical staff who responded to the 12-year-old patient described at the start of the article had actually taken part in a mock simulation that day-just hours before and a few rooms down from where the girl had been receiving chemotherapy.
“It was very eerie that the scenario we simulated that morning was the exact situation that happened that afternoon,” says James Trietsch, DO, a doctor of osteopathic medicine at Stanford Children’s Health who was at both the morning simulation and the code blue incident. “The nurses identified right away that the patient was deteriorating, and they immediately activated the pediatric code team.”
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Keeping Skills Fresh
California law requires all registered nurses to complete a 2-day course in pediatric advanced life support and CPR once every 2 years. But studies show that employees don’t often retain much of what they learn in infrequent training because they aren’t putting their skills to use in real-life scenarios. Fortunately, cardiac arrest is a rare occurrence in pediatric patients. But this means there isn’t a lot of on-the-job practice, either.
To ensure these skills are always fresh, the hospital-under Revive leadership Felice Su, MD, Deborah Franzon, MD, Michael Chen, MD, and myself-conducted research in 2010 to examine pediatric resuscitation team training of nurses, physicians, pharmacists and respiratory therapists inside the hospital. Our research showed that the training program was associated with improved team performance and survival outcomes. The training now includes all hospital first responders.
The demonstrable success of the training prompted hospital administrators to launch the Mobile Simulation Resuscitation Program. As a result of the extensive growth of this continuous quality improvement program, leadership rebranded it the Revive Initiative.
Revive interventions consist of simulation training as a team, familiarization with emergency equipment and communication skills, monthly Rapid Response Team/Code Blue reviews, and formal debriefings of actual events.
“The program exemplifies synergy at its best,” says Franzon, a clinical associate professor of pediatrics and critical care at the Stanford University School of Medicine.
“Each of these training components comes together in just the right way to improve team members’ confidence and competence, and to save lives.”
The hospital has a team of well-trained “code” and emergency specialists who respond within 5 to 10 minutes, but Knight says another goal of Revive is to educate the physicians, nurses and staff members who are most likely to be closest to the patient when a real-life emergency occurs on what they should do before the code team arrives.
The First 5 Minutes
Our research makes it clear that the first 5 minutes of a code are the most important. If the first responders don’t initiate basic life support right away, the chance of having the most optimal neurological outcome decreases with every minute that passes.
Physiologically, this patient would not have survived with such a good neurological outcome without the first responders immediately performing high-quality CPR.
Each week, my team would move from unit to unit in the hospital, first setting up a skills station. That’s where the medical staff members practice such things as high-quality chest compressions on mannequins, working with defibrillators and locating emergency equipment in the code carts. Toward the end of each week, a mock simulation occurs. The staff knows to expect it, but they are not told when it will occur.
Since starting the program in 2014, 90% of the nursing staff and 50% of the medical staff have been through the skills sessions, and many participated in the unit mock codes.
Krysta Schlis, MD, an oncologist at the Bass Center, was the treating physician for the patient mentioned at the start of this article. She arrived in the patient’s room just as she began having trouble breathing.
Photo courtesy Bass Childhood Cancer Center
Within 2 minutes, Schlis was unable to find a pulse and Schlis and another doctor began chest compressions and maintained the girl’s breathing through a bag mask device. Within seconds, a nurse manager from the Bass Center arrived along with the crash cart, which includes a defibrillator and other emergency medical equipment needed for a resuscitation event. Another nurse recorded the event on code documentation.
Schlis commented that the mock simulations, both earlier in the day and those rehearsed in the months before, allowed the first responders who came to the room to stay calm and focused on what they were supposed to do before the emergency response team arrived.
“Most codes are very chaotic, but this was the best I’d ever seen. It was very calm, and it was clear who was in charge and what everyone was supposed to be doing,” Schlis said.
“I think the fact that we had done a lot of mock codes and had been practicing these rare incident skills, including the one that morning facilitated by the Revive Initiative, saved that girl’s life. There is no question in my mind.”
Lynda Knight is the Revive Initiative program director at Stanford Children’s Health in Palo Alto, Calif.