MULTIDISCIPLINARY REVIEW OF CODE EVENTS IN A HEART CENTER

作者：Blankenship Angela C; Fernandez Richard P; Joy Brian F; Miller Julie C; Naguib Aymen; Cassidy Steven C; Simsic Janet; Phelps Christina; Harrison Sheilah; Galantowicz Mark; Yates Andrew R^*

来源：American Journal of Critical Care, 2016, 25(4): E90-E97.

DOI：10.4037/ajcc2016302

Objective To identify a cause for clinical deterioration, examine resuscitation efforts, and identify and correct system issues (thus improving outcomes) via a multidisciplinary code-review process soon after cardiopulmonary arrest.
Methods Retrospective analysis of code events in a tertiary pediatric heart center from September 2010 to December 2013 and review of surgical-cardiac data from January 2010 to December 2013.
Results A multidisciplinary team reviewed 47 code events, 16 of which (34%) were deemed potentially preventable. At least 2 issues were identified during 66% (31/47) of cardiopulmonary arrests reviewed. Key issues identified were related to communication (62%), environment/culture/policy (47%), patient care (including resuscitation, 41%), and equipment (38%). About 60% of reviewed arrests resulted in educational initiatives (eg, mock code, in-service education) and 47% resulted in a new policy or modification of existing policy. Less common were changes in equipment (32%) or modification of staffing needs (11%). Changes most frequently occurred in the unit specific to the event (68%) but some changes occurred throughout the Heart Center (32%) or across the hospital system (13%). Survival to discharge after cardiopulmonary arrest has improved over time (P = .03) to 81% for cardiac surgical patients in our center.
Conclusion A multidisciplinary code-review committee can identify deficiencies and lead to educational initiatives and improvements in care. When coupled with a hospital-wide "code blue" review process, these changes may benefit the institution as a whole.

• 出版日期2016-7