A team of medically trained professionals have approximately four minutes upon receiving a page to administer life-saving techniques to a patient experiencing coding, which is heart or respiratory failure. When a physician arrives at a patient's bedside, a dedicated team of professionals and a fully stocked code cart need to be ready and waiting to ensure the best patient outcome.
According to Marc Zubrow, M.D., director of critical care, Christiana Health Care System, New Castle County, Del., "Time is of the essence, as you want to apply the maximum amount of medical therapy to a patient within four minutes from the time a code is called to have a positive patient outcome."
More than a year ago, Kathy Johnson, R.N., nurse manager of MICU at Christiana, expressed a need to improve the existing code cart process. She discussed with me problems regarding the current practice and offered great ideas for improving it. Following our discussion and her request for support in this project, I offered my assistance enthusiastically.
I began by learning about emergency response, the supplies necessary, stakeholders, and how supplies and equipment are used during a code.
The following account details Christiana's existing process, problems incurred and an innovative process used to improve the procedure.
Issues a la carte
Christiana Care Health System is one of the Mid-Atlantic's largest, private not-for-profit health systems. It operates two acute care facilities and one extended care facility totaling 1,100 beds.
But, despite Christiana's clinical excellence, there are times when patients in the hospital can and do experience critical heart or respiratory failure, referred to as a code blue. In 2002, Christiana experienced 596 code blue events.
The process of responding to a code blue takes place as follows. A nurse or physician notifies telecommunications that a patient is coding. Immediately, the operator broadcasts an alert on the overhead paging system.
At the same time, alpha pagers are delivering the message to the multidisciplinary team assigned to respond. A dedicated team of trained physicians, and respiratory and nursing staff respond immediately in a precisely coordinated call to action with one goal--to restore breathing and/or heart rate as quickly as possible.
Several problems existed with the code blue process. When a cart was delivered, a parallel process had to occur, which was the placement of a backup cart to replace the code blue cart that was removed for the code. The dual process sometimes created confusion and delays in vital emergency response.
Stocking the carts was also a problem for nursing. Nurses with no materials management training or expertise from various units were restocking code carts.
Restocking would take 20 minutes or longer, depending on the time it took to determine the number of supplies used, the difficulty in locating replacement supplies and how many interruptions a nurse would encounter while restocking.
Johnson says, "Nurses spend many hours restocking supplies, troubleshooting electrical and clinical equipment, updating and replacing stock, and tracking the location of carts mobilized to cover multiple areas. This takes nurses away from patients' bedsides."
Multiple locks without numbers were being used to secure the carts, but this practice didn't meet the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Oakbrook Terrace, Ill.
According to JCAHO, the pharmacy department must control security and access to the drugs as well as the integrity of a cart.
In the old system, plain yellow plastic locks were kept secure, locked up with the narcotic stock on every nursing unit (every nurse had to have access to replacement locks).
However, the pharmacy department could not track what lock was placed on which cart because there were no numbers or identifiers on the locks. JCAHO representatives said that while there was some control of the cart with the yellow lock, there were hundreds of locks in the system that no one could track, including any that were broken or replaced.
In the beginning
Johnson reviewed the problems with the carts, supplies and delivery process. She wanted the materials management department to take responsibility for stocking and distributing the carts, thus freeing nurses from this responsibility.
She asked that a storage solution be developed that was consistent with the drawer system used for storing and securing medications. Finally, she asked that a design be created for a simple, yet effective delivery system.
Improvement in the process required careful examination. The Fifth Discipline is a book by Peter Senge. In it he states, "Systems thinking is a discipline for seeing integration, a framework for seeing patterns and interrelationships."
His book helped me develop a picture of the entire process and an understanding of how it worked in the eyes of each stakeholder (physicians, nurses, pharmacists and respiratory therapists).
In a 1998 Quality Management in Health Care article, Ray Seigfried, senior vice president of clinical and materials management services and pioneer of systems thinking at Christiana, wrote: "In a systems universe, there is no value to a separate component because any component's real value is only in its ability to work together."
To broaden my knowledge, Johnson invited me to join the Code Blue Committee where I heard, firsthand, the problems with the existing code cart process from both clinical and logistical perspectives.
I met Zubrow and Elizabeth Wykpisz, vice president of cardiovascular critical care services, and realized quickly the critical importance of the emergency response process. She set clear goals for achieving improvement in the process as follows:
- Increased timeliness related to arrival of the code cart to a patient's bedside
- Decreased variation in restocking resulting in less missing and/or wrong supplies related to a centralized stocking process
- JCAHO compliance related to locking and lock-tracking system (decrease in the number of locks from three to one)
- Improved nurse productivity. Because of time constraints, they aren't required to restock the code carts.
With a better understanding of the existing process, and with clear goals and expectations, I moved forward.
Part of the process
While researching management gurus and theories at Penn State University, University Park, Pa., I read The Knowledge Creating Company written by Ikujiro Nonaka and Hirotaka Takeuchi.
Their five-phase model of an organizational, knowledge-creating process was extremely helpful and effective. The concept is that with each phase, a natural learning process leads to the development of the next phase.
Phase 1--Sharing tacit knowledge: Sharing tacit knowledge is a critical step for furthering knowledge. This process helps build mutual trust.
I began by spending quality time talking to stakeholders, carefully listening, learning and understanding the code blue process, and gaining knowledge about what each clinician contributes during a code.
This enabled me to gain the clinicians' trust and also their acceptance of new ideas about the cart system. It was important to incorporate their ideas and suggestions into the prototype.
Phase 2--Creating concepts: The team, through discussions and reflection, formed a shared mental model. Specific concepts are formed from words and phrases from the shared tacit mental model.
With every aspect of the code cart design and function, we were discussing the concept of the cart being user-friendly in transport and mobility as well as while in use.
It couldn't be too large or cumbersome, and it needed to contain the prescribed items and equipment in an organized and logical fashion. The new cart delivery process needed to be simple and easy to execute.
Phase 3--Justifying concepts: New concepts created by the team need to be justified to determine if they are truly worthwhile.
Early in the process, certain ideas regarding cost and functionality needed to be discussed. One such idea was spending money to buy new defibrillators for all 64 new carts.
A new defibrillator costs approximately $7,000. This would result in replacing 20 to 30 usable defibrillators that were on the existing carts.
Without question, new defibrillators would be more appealing, however, it was not necessary to replace the existing units because they worked fine. This provided a means to invest in other costly supplies and custom cart design.
Phase 4--Building an archetype: An archetype is realized when the justified concepts are made tangible and concrete.
The committee carefully developed a list of criteria for the new code cart, including color and height. They defined the list of items to be included in the cart, and how the items would be grouped.
We researched bins and drawers that would afford the best supply organization and functionality without neglecting aesthetics. The number of drawers on the cart were determined as well as the location of the necessary supplies and equipment for maximum efficiency and dependability.
The code cart delivery algorithm received equal attention. To make the existing complex system simple required careful concentration and discussion for each step. We needed to envision the whole process while focusing on single steps. By placing code carts in every nursing unit, the code team could sprint to the code location with their hands unencumbered.
Phase 5--Cross-leveling knowledge: Once knowledge has been transformed into an archetype, it can trigger new knowledge in the form of cross leveling, which means to apply the outcome from one project to another.
One of the early ideas was to use custom fabricated trays to organize the items on the code carts, similar to medication trays used by the pharmacy department. Custom fabricated trays with dividers fit nicely into drawers or carts, and the unique dividers and accessories effectively organize small or medium items (e.g., lab tubes, syringes).
They are easy to adjust when making product changes because dividers and inserts slide and snap off to accommodate varying product dimensions.
We revisited our initial reason for looking at the bin system (syringe drawer stocking). As a result, we reviewed product usage data with a goal of standardizing syringe bins and making them more functional.
Cross-leveling the knowledge gained from the code blue process helped to expand the knowledge in completing the syringe drawer project.
In the end
By mid-October 2002, we had successfully implemented 64 new code carts. The team that developed the new process stocked, inspected and delivered each cart to its location.
It was a collective and collaborative effort. We received excellent and timely ancillary support from maintenance, clinical engineering, transportation and purchasing.
In a letter of appreciation to the implementation committee, Zubrow states, "I would like to commend and congratulate you on the coordination and implementation of the new code cart delivery system. It is evident that this involved a great deal of strategic planning, innovation and teamwork to roll out a plan that greatly impacts our patients. The seamlessness in which this was accomplished has proven to me that great things can be accomplished with great people."
Regarding the new process, Wykpisz says, "The design of the code cart and process has exceeded my expectations."
She says this process serves several functions including:
- Supporting compliance with JCAHO standard 8.1
- Ensuring security for the contents of the code cart (e.g., medications)
- Ensuring necessary equipment is stocked and maintained with attention to expiration dates
- Centralizing stocking functions to ensure the integrity of supplies and to free nursing staff for other clinical responsibilities
- Placing items according to groupings (e.g., respiratory equipment) and providing redundancy to support timely availability of equipment
- Providing equipment personnel with enhanced responsibility and participating as a vital member of the code blue process.
I felt a great sense of pride that materials management was instrumental in helping to create a new code cart process that would be used by the four-minute heroes at Christiana. In a post-implementation Code Blue Committee meeting, Zubrow says, "I arrived at a code location before the team arrived, and because the cart was already there, I immediately began attending to the patient." In the past, he would have been waiting for the cart and the team to arrive.
Charles Neikam is director of logistics at Christiana Health Care System, New Castle County, Del.
This article first appeared in the December 2003 issue of Materials Management in Health Care.
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