Engaging Nurses in Code Skills to Promote Interdisciplinary Teamwork

Saturday, 21 July 2018

Melissa A. Pollard, DNP, CCRN, CEN, RN-BC, ARNP-BC, WCC
Professional Development and Clinical Support, Exeter Hospital, Exeter, NH, USA


In our small community hospital we have developed a robust simulation program that engages interdisciplinary teams to participate in low volume, high risk simulated situations. It is important to involve the disciplines one would call on in an actual emergency in the simulation to promote psychological reality as well as allow the simulation to progress as close to real life as possible to identify areas of success and challenges. Teamwork in emergency situations can be challenging, especially with ad hoc interdisciplinary teams.

An identified weakness in our current program was that mode code simulations were voluntary, scheduled simulations. While these have value in practicing technical skills and teamwork, the emotional urgency is difficult to induce. There are also challenges in getting the correct compliment of emergency responders, as these mock codes tend to be unit based, or groups from the same discipline participate together. As a result, there is not the opportunity to practice in unfamiliar groups that would be present in an actual code situation. This initiative is to institute over head announced Code Blue that bring the actual ad hoc code team for that day to the simulation. Only on arrival will they become aware that it is not an actual patient emergency, yet they are still required to complete the simulation and debriefing.


A priority in the simulation program is emergency situations involving high risk/low volume events, which in our hospital includes codes in the medical surgical area. One way to achieve engagement and produce system outcomes is to develop scenarios that challenge the team to use their knowledge and teamwork skills. This will engage an interdisciplinary team to recognize an emergency situation and provide care, allowing the facilitators to observe the skills and team dynamics. The debriefings promote input on areas for quality improvement, policy review, equipment recommendations, and opportunities for promoting teamwork and collaboration.

This initiative comes from review of code situations and the desire to reinforce new protocols developed, including the identification of code leader by lanyard, minimize overcrowding, and standardize the expectation of a debriefing following the event. While stakeholders verbalize buy in, these are noted to not yet be fully consistent in the current culture.

The planning committee first obtained permission from senior leadership to utilize overhead paging for these simulations, to promote reality. We then reach out to the clinical supervisor on the day we plan a mock code. This is to assess if staffing and current situations in patient care areas will allow the code team to respond without any impact to actual patient care, as well as to secretly reserve a patient room to set up our simulator prior to calling the “code”. We require an unoccupied room, ideally near the elevator or stairwell to allow undetected set up time. We also notify the emergency department, as at times there is only one provider on, and request they send the paramedic in place of the emergency room physician, which is the back up plan per our policy. This allows the hospitalist physician experience running the code, and the paramedics time to work with the code team outside of the ED. The team uses actual equipment from their area, to allow assessment of timing to obtain, and any issues with use. At times, if the code leader is someone from the planning team, we arrange to have them give an order that deviates from Advanced Cardiac Life Support protocol. If no one questions it, we then discuss the importance of giving input to the leader if they are deviating from established algorithms during the debriefing.


To date these mock codes have been well received. Participants acknowledge initially feeling stressed, and vaguely annoyed to be called to a simulation. However, in the debriefing, there is overwhelming feedback that this was more psychologically engaging, and more realistic due to the interdisciplinary team make up and dynamics. There has also been positive feedback that a post code debriefing had previously seemed daunting, but the benefit became more clear after the simulated event. There is ongoing struggle with overcrowding, but keeping data on the number of respondents arriving, versus actually being needed, will be useful in follow up code team planning.

These simulations also give an opportunity to reinforce the newest American Heart Association guidelines on effective compressions using the mannequin feedback. We continue to monitor for any adverse effects of alarm fatigue from the paging, and strive to hold these often enough to allow various team member the opportunity to participate, without over taxing our resources.