Barriers to effective in-hospital resuscitation: lessons learned during implementation of a hospital-wide code system
Aims and objectives: To understand the barriers involved in effecting a hospital-wide code system and overcoming them during implementation.
Background: Improving survival after in-hospital cardiac arrest involves standardization of both defibrillation equipment and staff’s abilities during codes.
Design: Observational descriptive study.
Methods: Observational study of the situation existing before implementation of an effective in-hospital resuscitation system and description of the implementation process. Descriptive statistics were used.
Results: Prior to intervention, defibrillators were unstandardized, misused and often inaccessible. Basic and advanced life support training was suboptimal and poorly overseen. Codes were attended by curious bystanders and inappropriate staff; there was lack of clarity regarding roles and key interventions. A standard defibrillator model was purchased and gradually deployed throughout the hospital; these were configured to meet the unique requirements of each department. Training was restructured. Standard operating procedures were created for all resuscitations while an oversight mechanism was installed. Code teams were created by taking departmental workloads and clinical skills into consideration. A nurse resuscitation coordinator was appointed per department and a hospital-wide culture was fostered where nurses were responsible for the quality of CPR. Major limiting issues such as distrust of device accuracy and safety, knowledge gaps and problems at the device-user interface were identified and bridged.
Conclusions: Creation of an effective in-hospital code system requires thorough research into the culture and requirements of various hospital departments. Multiple barriers must be overcome to set this process into motion.
Relevance to clinical practice: Implementation of change requires more than a declaration from supervisors; it requires deep understanding of the existing culture of different departments to take effective root. Awareness of these often unacknowledged issues combined with the willingness to confront and overcome them are keys to success.