Direct-care nurse perceptions of barriers to code reduction on an inpatient pediatric medical unit

Purpose:
To explore nurses' perceived barriers to early clinical intervention for code reduction on the inpatient medical unit. This study was done to verify suspicions that there may be unidentified barriers that sometimes prevent nurses from escalating the patient to a higher level of care.

Background/Significance:
There are limited studies describing the complexities of recognizing and responding to clinical deterioration from the nursing perspective. Consistently and effectively detecting and acting upon patient deterioration is a complex issue. Children's Hospital tracks all codes in the organization and has identified the medical unit as one of the areas with the highest number of codes. Many targeted efforts have been made with staff on this unit, we have seen significant decreased in codes since.

Methods:
Qualitative interviews were completed with 10 nurses from the inpatient medical unit by a nurse cultural anthropologist. The interviews elicited detailed narratives of nurses' experiences with successful and unsuccessful early intervention efforts and perceived barriers to code reduction. Interviews were transcribed by a transcriptionist and then de-identified. Transciptions were then analyzed for themes and patterns using Atlas.ti software for qualitative analysis.

Results:
Detailed examination of nurse experiences revealed local factors that facilitate and inhibit timely transfer of critical patients to the Intensive Care Unit (ICU). This presentation shares the story behind the study, discusses its methodological challenges and opportunities, and presents findings in the context of current literature on RRTs and code prevention. Nurses identified themes such as the impact of nurse assertiveness training, house staff lack of understanding of nursing, pressures placed on this medical unit when the ICU is full, and unit cultural beliefs that impede engaging the RRT.

Conclusions and Implications for Practice:
Findings will be used to direct new interventions and research aimed at improving processes and outcomes to enhance patient safety. This information will help drive further QI initiatives at our organzation around code reduction.