Introduction
Emergency codes at hospitals are instrumental for alerting staff about different urgent situations. “Code blue” is a hospital emergency indicator that enables a facility-wide response and identifies a patient who requires immediate resuscitation or medical attention due to respiratory or cardiac arrest. Within the context of the Ministry of Health and Prevention of the United Arab Emirates, the implementation of effective emergency code practices aligns with the innovation health strategy. The Ministry is committed to instilling the concepts or principles of innovation in alignment with the best international standards at all strategic, organizational, and operational levels [1]. Therefore, code blue response improvement should be considered a part of the quality improvement process that enhances patient outcomes.
The decision to improve the application code blue indicator at the facilities under the Ministry of Health and Prevention stems from the need to enhance the overall performance of hospitals’ code teams under an evidence-based quality improvement plan. Besides, non-medical skills of the healthcare team, such as leadership, communication, the coordination of tasks, and interactions have shown to play as much of a role during the process of code response as medical skills [2].
The importance of such skills signifies that if any of them are lacking, possibly because resuscitation is not a frequent occurrence that all team members are regularly experiencing, or because of high-stress levels, the effectiveness of the code response may be limited. It is crucial to facilitate a quality improvement initiative at the Ministry of Health and Prevention to ensure that healthcare teams possess all necessary medical and non-medical skills when responding to code blue.
Case Description
The quality improvement case is concerned with the need to enhance the process of debriefing after the implementation of code blue at hospitals. Debriefing is concerned with discussing the actions that have been carried out and encouraging reflection on the ideas, opinions, and skills involved in the clinical event. It is intended for improving future performance, the quality of patient care, and health outcomes, as well as decreasing the influence of stress linked to the event. Because resuscitation is complex, time-critical, and emotionally stressful both for staff and their patients, debriefing is an essential part of the process.
The staff of the facilities governed by the Ministry of Health Prevention has shown to miss out on the debriefing component of code blue implementation. It is essential to address this process and facilitate consistent and effective debriefing after resuscitation to ensure that the team discusses all relevant issues and identifies both failures and successes. Improving the quality and frequency of debriefing procedures at hospitals is necessary to address the challenges at several levels, such as individual, team, and system levels.
If left unresolved, the issue of the absence of debriefing after code blue can lead to several adverse implications. Specifically, the staff may not make the desired conclusions based on what had occurred during a code blue incident because they do not have a framework for communicating post-process and reflecting upon the challenges endured. In addition, it is necessary to recognize the fact that code blue procedures could be emotionally and physically draining for the staff, but this remains unacknowledged as compared with dramatic or “newsworthy” events that are more likely to evoke support for workgroups.
The issue can be improved with the help of carrying out brief interventions, such as incident stress debriefing (CISD) or general debriefing practices when exposed to a stressful code blue event. A leadership initiative is needed for bringing staff members together and acknowledging shared distress, affirm the challenges endured by the emergency team, and help them develop best practices to be introduced in the future.
Critical Analysis of Systems and Processes
Organizational Culture
The key challenge to address within the organizational culture system as related to code blue debriefing is the fact that healthcare is characterized by a highly fragmented professional division of labor, in which every individual has a distinct role. The organizational culture of the facility that aims to improve debriefing practices and UAE hospitals under the Ministry of Health and Prevention should eliminate dysfunctional hierarchies and tensions between integration and specialization [3].
The fragmentation of work is challenging in the case of blue code-related debriefing because it enables fundamentally different professional interests within the team. As a result of that, there is a tendency toward conflict and contestation among team members to the detriment of quality improvement. Thus, in instances where the organizational culture of hospitals enables care fragmentation and competition between healthcare personnel, it is integral to make changes that would facilitate collaboration and mutual support.
Leadership
For both code blue implementation and the subsequent debriefing process, the identification and training of effective leaders is an important step toward quality improvement. According to research, even minor periods of instruction in leadership skills could improve trainees’ skills in simulated code blue environments [4]. Leadership instructions can not only improve nurses’ resuscitation skills but also lead to more effective CPR performance, which is an essential factor highlighted in the revised ACLS guidelines. Leadership instruction processes include deciding what should be done, telling colleagues what they should do, making short and clear statements, as well as ensuring adherence to the ACLS practices.
When it comes to debriefing, a leader should be in charge of organizing a meeting and inviting the multidisciplinary team of professionals who were involved in the code blue response event. A leader will also identify other staff members who were not involved in the code blue event but should participate in the debriefing for future preparation and training. During the debriefing process regarding the implemented code blue emergency response, the leader will take up a role of a facilitator with subject expertise who will support team members’ engagement, alert to differences in the perspectives and emotions, emphasize teamwork, as well as foster team development of solutions for performance issues.
Networks and Communication
Depending on the needs and qualities of the interdisciplinary team, the debriefing can range in timing when it is being carried out. A hot debriefing occurs immediately after the event and requires the instant attention of the team to engage in the discussion. The benefits of communicating immediately after the code blue event include the team availability, a greater variety of clinical staff, the minimization of recall bias, the possibility to address urgent issues as soon as possible, as well as the increased emotional motivation to participate [4].
Warm debriefing is a type of communication that takes place hours after the code blue event, and it’s carried out when quantitative data is already available, teams are more emotionally ready, a location can be reserved, and staff can complete the relevant post-code tasks and allocated time for the debrief. Cold debriefing takes place days or weeks after an event and allows for longer and deeper discussion to take place, although it can be difficult to gather staff back together.
Patient Experience: Satisfaction Data
Because code blue activation at hospitals is not a frequent occurrence, the interdisciplinary team leader can collect patient satisfaction data after the event. This data is necessary for understanding whether the patient has had a positive experience when it comes to emergency care delivery. The data can be collected with the help of a questionnaire that will be later used as one of the sources for data analysis during a debriefing session with an interdisciplinary team. Patient satisfaction rates are needed to evaluate because they can point to the overall effectiveness and the effects of the blue code implementation at UAE hospitals, with the possibility to compare and contrast data between facilities.
Resources, Monitoring, Evaluation, and Feedback
Considering the mission of the Ministry of Health and Prevention to facilitate high levels of innovation on a country-wide basis, the resources provided for improved debriefing sessions should be advanced. An evaluation tool used for measuring the outcomes of the debriefing process implemented post-code blue should include core team indicators. Important indicators include the quality of communication, the number of observations, knowledge sharing, issue identification, problem-solving, analysis, and summarizing. A debriefing tool can be developed to suit the needs and peculiarities of the interdisciplinary team involved in the code blue response process.
The tool should include the clear messages and roles of the team members during the debriefing and mention all relevant observations that occurred during the debriefing [5]. The tool developed by American Heart Association can be used as an example and implemented at the UAE facilities. Since standardizing is challenging for the majority of settings, the tool may be used by leaders and facilitators to have the same structure for the debriefing meetings and promote an evidence-based method of inquiry [6]. Besides, although a standardized tool cannot be applied fully to each debriefing situation, it facilitates a mandatory needs assessment and summary to be made at the end of the session. This point is essential because it allows comparing the conclusions of previous debriefing sessions on code blue responses and the outcomes of subsequent interventions to see whether the solutions are implemented.
Champions
Industry leaders in healthcare quality improvement and evidence-based practice should play a significant role in initiating the implementation of regular debriefings at the UAE hospitals. The Emirates Cardiac Society, the Big Heart Foundation, Gulf Heart Association, and others should lead the quality improvement by communicating the expectations of not only care but also post-intervention assessment. The Ministry of Health and Prevention will be responsible for overseeing whether the interdisciplinary teams at UAE hospitals meet the standards of quality by measuring patient outcomes at the facilities subject to the interventions.
Recommendations
The critical analysis of systems and processes has shown that there is significant evidence to suggest that the implementation of the debriefing for code blue emergencies is a necessary quality improvement step [3]. The use of assessment tools will yield both qualitative and quantitative data on team performance along with code documentation and evaluation. The data documented, discussed, and analyzed during debriefings will be fundamental to use on checklists or forms to offer consistency during recurrent team discussions.
Thus, depending on the facility and the needs of an interdisciplinary team, a format of the debrief will be agreed upon within a certain timeframe, followed by the implementation stage [7]. The outcomes of implementation will be measured with the help of a team dynamics debriefing tool that would include the quality of communication within the interdisciplinary group and identify a need for improvement.
The recommended quality improvement is possible to implement within 12 months because code blue is not a frequent occurrence. It will take some time for the team to adjust to the debriefing and test different formats before establishing a structured process that will be carried out every time after an emergency response [8]. A possible limitation of the project is the possibility of collecting data throughout different facilities due to the difference in the way debriefing is approached. The potential for future quality improvement and research projects involves collecting more data and information from code blue teams, including patient survival outcomes, which would be highly beneficial [9]. Also, it is possible to introduce mock codes held at facilities to increase teams’ preparedness for emergencies.
Conclusion
To conclude, it should be mentioned that the proposed quality improvement initiative is intended to affect healthcare organizations as a whole while also their workers and patients separately. Ultimately, the results of the quality improvement initiative will show whether the introduction of regular and effective debriefing procedures after code blue influences team communication, emergency preparation, and the overall knowledge and skills of the nursing team. With the help of the Ministry of Health and Prevention support, it is expected to increase the preparedness and training of personnel to respond to code blue and engage in collaborative problem-solving during debriefing.
References
- United Arab Emirates Ministry of Health and Prevention. Innovation health strategy. MOVAP. 2021. Web.
- Karia C, Hughes A, Carr C. Uses of quick response codes in healthcare education: a scoping review. BMC Med Edu. 2019; 19: 1-14.
- Clarke S, Apesoa-Varano, R, Barton J. Code blue: methodology for a qualitative study of teamwork during simulated cardiac arrest. BMJ Open. 2016; 6(1): e009259.
- Williams K-L, Rideout J, Pritchett-Kelly S, McDonald M, Mullins-Richard P, Dubrowski A. Mock code: a code blue scenario requested by and developed for registered nurses. Cureus. 2016; 8(12): e938.
- Sawyer T, Loren D, Halamek L. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? Journ Perinatol. 2016; 1-5.
- Salik I, Paige J. Debriefing the interprofessional team in medical simulation. StatPearls. 2020. Web.
- Sevotte J-C, Welch-Horan B, Mullan P, Piazza J, Ghuysen A, Szyld D. Development and implementation of an end-of-shift clinical debriefing method for emergency departments during COVID-19. Adv Simul (Lond). 2020; 5: 32.
- Corey P. The effectiveness of adult and pediatric code blue simulation-based team trainings. Scholarworks. 2016. Web.
- Holcomb J. Improving survival rates in patients suffering cardiac arrest with specialized resuscitation teams: an integrative review. Digitalcommons. 2020. Web.