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Department

Comprehensive Clinical Care

Position/Job Title

Clinical Nurse Educator

Description

Background: There is evidence to support the use of implementing clinical debriefing programs in the hospital setting. Implementing a standard debriefing program for teams that care for patients in cardiac arrest is shown to improve outcomes, yet in practice most events are not debriefed. Many hospitals currently use a debriefing tool for traumatic clinical events. However, many of these debriefing programs are focused on the Emergency Departments and pediatric events. Hypothesis: Utilizing a standard debrief tool for inpatient clinical resuscitation (Code Blue) events can identify areas for quality improvement. Methods: A literature review was performed including articles that related to a debriefing process following inpatient Code Blues or other critical clinical incidents. Based on the literature, a formal debriefing tool that utilized a gather, analyze, summarize (GAS) model of Code Blue debriefing was created (American Heart Association, 2023). The tool requested staff to identify potential areas of improvement related to teamwork, medical management, and environment. This tool was presented to the critical care leadership team and was approved for initiation in the critical care setting. The form could be used either immediately after an event took place or at the earliest available time for the resuscitation group to meet. The Code Blue debrief form would then be gathered, findings input into a tracking document, and analyzed. The results were summarized and presented to the hospital Code Blue Committee to enact process changes and discuss areas of opportunity. After receiving positive feedback from nursing, providers, clinical unit leaders, nurse managers, and directors the Code Blue debrief process and tool was implemented throughout the inpatient departments in the hospital. Results: Upon analysis of the 66 Code Blue debriefs (from November 2023 through June 2024), largest opportunities for improvement included crowd control (20%), equipment availability (14%), and a lack of clear roles (12%). Based on this data, new processes were outlined to improve quality and efficiency of resuscitation events. To address crowd control a recommendation was presented to nursing Unit Based Council that outlined necessary team members and roles. The task of removing excess personnel from the event was designated to the code team. Mock codes continue to be performed on the unit and emphasized the importance of crowd control and clearly communicated roles. Conclusions: Based on the positive feedback from the interdisciplinary team, the Code Blue debrief tool will continue to be utilized to help improve our resuscitation event response.

Publication Date

4-15-2025

Keywords

Henry Ford Jackson Hospital Research Symposium, comprehensive clinical care, quality improvement

Let’s Talk About it: Utilizing a Code Blue Debrief for Inpatient Resuscitation Events

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