The Synergy to Reduce Codes: Structures Crumble Without a Foundation

Purpose:
A hospital introduced a series of changes to improve patient safety by decreasing code blue events on the medical/surgical units as well as promoting an overall culture of safety. The combination of culture and structure changes produced a steady decline in medical/surgical code blue events.

Significance:
The initiatives were evidence-based but not unique. What is unique is the synergy occurring as culture change fosters a collaborative interdisciplinary environment. Stakeholders work together and efforts sustain. Innovative training methods were used to foster this “right” culture.

Strategy and Implementation:
Prompted by the Institute for Healthcare Improvement (IHI) 100K Lives Campaign, the hospital's Rapid Response Team (RRT) began responding to calls in 2006. Code blue calls to the medical/surgical units decreased markedly over the next several months then leveled and sustained. The next effort directly aimed at reduction of code blue events on medical/surgical units came in 2010 with the introduction of the Pediatric Early Warning System (PEWS). A less dramatic reduction in code blue calls occurred after initial PEWS implementation, but a reduction none-the-less. A review of data shows that between RRT and PEWS, a series of changes produced a steady decline in the code blue rate: introduction of SBAR communication, development of “crucial conversation” skills, and changes in the structure of the medical residency program. Innovative and interdisciplinary training methods were used to implement PEWS and continue to be used for ongoing PEWS work.

Evaluation:
The code blue rate per 1000 patient days is tracked quarterly to measure success. In January 2006, the rate was 1.2/1000 patient days. By March 2012, is was decreased to less than 0.2/1000 patient days. Of importance: reductions have sustained consistently over time.

Implications for Practice:
Give value to who and what is important for the patient's care delivery and include them. Don't be afraid to table planning until stakeholder buy-in is secured. If evidence is strong, build culture then try again. Never forget to communicate well, especially the listening part.