Practicing Code Simulations Helps Improve Patient Care, Response Time
By Lucy S. Witt, MD, MPH
and Joyce Akwe, MD, MPH, FACP
Chief of Hospital Medicine
Atlanta Veterans Administration Health Care System
DECATUR, Ga. – “Call a Code-99!” – a phrase that immediately gets most clinicians’ hearts racing. Codes are often chaotic, complex and require coordination among a, sometimes, large team of staff members. Clearly identifying the role of each team member, their responsibilities and bedside position may improve the success of a code situation. Simulation is an effective way to test interventions aimed at improving real life outcomes. Recently the Atlanta Veterans Administration Health Care System (VAHCS) used simulation to do just that.
Despite recognition of the necessary elements for successful resuscitation, the American Heart Association reports that in 2016 only 24.8% of those suffering cardiac arrest in a hospital setting survived (American Heart Association, 2016). Time to medical intervention and quality of chest compressions are well documented, crucial aspects of a successful code. However, other qualities like demonstrative leadership, clear communication, effective team member interaction and succinct task completion may also contribute to patient outcomes (Meaney, Bentley, Mancini, Christenson, Bhanji, et al., 2013).
To improve the performance of code teams at the Atlanta Health care System, a multidisciplinary team of motivated stakeholders from across the hospital was formed. This team identified the necessary roles for a successful code and the responsibilities each participant should undertake. It then completed hospital wide training for staff on their potential roles in a code situation.
Identification badges detailing specific roles and their responsibilities, as well as a chart with suggested bedside positioning were created. These badges and the associated training were tested using mock codes all over the hospital. These simulated codes were timed, and a debriefing took place after each event. It was found that participants felt that these mock codes had improved communication, less over-crowding and clearer leadership when compared to other code situations they had been a part. The average time to medical intervention, defined as administration of a code drug or administration of a shock, also improved. Previously, mock code time to medical intervention was 2 minutes, 46 seconds. During this simulated intervention, the time to medical intervention improved to 2 minutes, 3 seconds.
This intervention was based on a similar study completed by Prince et. al. In that study, Prince and colleagues also found that more clearly defined roles, responsibilities and bedside positioning, along with mock code training, improved their real-life code communication and decreased time to medical intervention (Prince, Hines, Chyou, Heegeman, 2014).
The Atlanta VA Health Care System project helps prove that a similar strategy can be applied within a VA health care system. The next steps include incorporating identification badges and positioning into real-life code situations, as well as analyzing participants attitudes afterward, as well as time to medical intervention. It is hoped that the results found in simulated codes will be replicated to improve the time to medical intervention, code outcome and the care delivered to our Veterans; again, proving the utility of simulation.
 American Heart Association. (2016). Heart Disease and Stroke Statistics - Statistical Update. http://cpr.heart.org/AHAECC/CPRAndECC/General/UCM_477263_Cardiac-Arrest-Statistics.jsp.
 Meaney P., Bentley, J., Mancini M., Christenson, J., de Caen A, Bhanji, F., et al. (2013). Cardiopulmonary resuscitation quality: Improving cardiac resuscitation outcomes both inside and outside the hospital. A Consensus Statement from the American Heart Association. Circulation, p. 417-35.
 Prince, C.R., Hines, E.J., Chyou, P.H., Heegeman, D.J. (2014). Finding the key to a better code: code team restructure to improve performance and outcomes, Journal of Clinical Medical Research, 57, p. 12-47, doi: 10.3121/cmr.2014.1201.