Recognising and responding to deteriorating patients is very essential for preventing and mitigating mortality in any healthcare facility. Hospitals across the globe have implemented code-blue activation calls to handle such critical situations like cardiac arrests. However, in spite of all the protocols in place whenever there is a deterioration of patients in the critical care areas there is utter chaos.
This with a lot more discussion on the causes, challenges and impact of the code blue situation was the thrust of the panel discussion at the FE Care Tech Summit 2022 in Hyderabad on the evening of Monday, July 18th. Organised by Financial Express.com in partnership with Dozee, the focus of the discussion was on “Code Blue Events in Non-ICU Setups: A Must Stop Chaos”.
During this discussion, the panelists talked about the reasons for such chaos and how it can be prevented, the role of Rapid Response Team (RRT), and the importance of nursing in such critical situations. The panel comprised: Dr. Padmaja, HOD Anesthesia, NIMS; Dr Sateesh Kumar Kailasam, Group Director-Emergency Medicine, Medicover Hospitals and Dr. M Prakasamma, Executive Director, ANSWERS and the discussion was moderated by Bobby Ramesh, Director of nursing, Continental Hospital.
Dr. Padmaja highlighted the importance of empowering nurses and residents to take immediate action in such situations and handle the patients properly. She also talked about the importance of training which is required to prevent the Code Blue situation.
On the current system of handling code-blue situations, Dr. Padmaja, HOD, Anaesthesia, NIMS, said: “The code blue in as ward in a “never event” that should never happen. This typically happens when either we are in a hurry to shift an unoptimised patient because of the need for an ICU bed. The non-ICU wards are usually unmonitored areas. Unless we have a system in place we cannot prevent it. So ours is a two-tier system layer where we have the nurses monitoring the patients and also residents who are under training monitoring. So, we started with training these nurses and residents to recognise these early warnings. This took a lot of time and the process is still underway. Until Dozee was installed in the hospitals it was all manual monitoring. So, identifying those patients who require frequent monitoring by using this new scale took some time for us. This actually changed a lot of things for us. We have started implementing the new scores in the ward and also so the nurses, as well as the resident, understood which patients require more frequent monitoring and which patients can probably be left unmonitored. So, this new score has made a lot of change to the incidences of the code blues in the ward.”
Dr. Padamaja stressed that to prevent such a Code Blue situation it is extremely important that we empower our nurses to directly contact the RRT.
Dr. Padmaja also said: “The next that made a difference was the rapid response team. The most important thing was when we empowered the nurses to call the rapid response team directly. Until then being an academic institution there was a lot of hierarchy. So, the nurses had to inform the resident, the resident had to inform the senior resident, and the senior resident had to inform the faculty, then they would take a call whether to shift to the ICU or do whatever is required. So, when we could break the hierarchical system and empower the nurses that led to a decrease in the code-blue situation in the ward. These two changes made a lot of difference. The other is again being able to monitor the patients in the non-ICU areas. Dozee did make a lot of difference.”
Meanwhile, Dr. Sateesh Kumar Kailasam emphasised that for the effective utilisation of RRTs, the nurses have to support by intimating about the critical patients in their wards, proactively the rounds have to be carried out by the response team members to assess the condition of the patients. So, if any patient is deteriorating they can be quickly transferred to the ICU before Code Blue happens.
On why such chaos happens irrespective of the presence of code-blue protocols and how helpful is rapid response team, Dr. Sateesh said: “Yes we have a lot of protocols, but when we have a real scenario every patient is different. We see sudden cardiac deaths happen in non-critical areas because the monitoring is not as much as it is there in the ICUs. A code-blue event is a lot of things. First is identification. What is the attrition rate of the nurses? We have to train nurses every month. Then alerting. One day the PA system will work, the second it may not work. Then getting a crash cart, many hospitals don’t have crash carts on every floor. Everyone needs to know the access to crash-cart. Every floor may not have a defibrillator. And the code team arrives. Although the protocols and checklists are there, they take it to their heart and they should have a passion to treat their patients when there is a code blue in the wards. As we know the doctor-to-patient and nurse-to-patient ratio is low. We need more doctors first, then we need trained doctors. I think early warning signs are the most important tool.”
During the panel discussion, Dr. M Prakasamma highlighted the importance of At-Home Care to prevent such situations. She also talked about the roles and challenges of public health.
On the role of public health to avoid panic situation-like code blue Dr. M Prakasamma said: “As a public health professional, I can only say that we had gone through a national code-blue situation and that is where we all need to come in. It’s not just one patient or one hospital, but the entire country of more than a billion people who went into a situation of code-blue and the chaos created by a pandemic and how it threw our country off-balance. We have a very large public health system in India. In fact, I had to argue with many countries that ours is one of the best systems. Everything is there, down from the village level to the tertiary level. We have the best doctors and every technology coming into India. We have nurses who go all over the country and serve and we have the best technicians. However, we went into chaos. First, during this chaos home is where health starts, the nutrition starts where the mother looks for signs and symptoms, and the care starts. Now with COVID-19, we have technology going into homes. The public has become tech-savvy for their own health. I have been part of the global health workforce alliance by WHO. There is a need to do health workforce management in India. There is a need for an integrated health system.”
After a Code-Blue activation call in a hospital, when the response team is able to resuscitate the patient, there is a sense of joy among the staff. The panelist also discussed about the tremendous pressure on the Code-Blue team.
On the psychological impact of Code Blue on the team, Dr. Padmaja said: “Being on a code-blue team can be very stressful. It is a very responsible job to revive someone who is arrested. One of the major stresses is that the person who is in the ward has started the revival process or they are waiting for you. I think one thing that can actually mitigate this stress is if we train our nurses to start the CPR process while the code-blue team is arriving rather than waiting for the team.”
Dr. Padmaja also mentioned that to certain extent stress can be relieved especially in non-critical areas other than the wards the staff present there should also be trained to respond to such situations. During the discussion, the experts pointed out that while the doctors are in command, it is the nurses who execute the care plan. However, the role of nurses is not often given importance or credit.
On the importance of nursing in a critical patient care situation, Dr. Prakasamma said: “Nurses are the heart of the hospitals. FE and Dozee are doing a great job of acknowledging the role of nurses. A nurse is the only person who does all the jobs. She is the caretaker, she is the coordinator of patient care and she is also the custodian of patient care. Yes, technology is attractive and glamorous but there are some things, the critical core of nursing that no machine can do.”
On the role of technology in preventing code-blue situations, Dr. Satish said: “Thanks to COVID-19 we have become more tech-savvy. If there is an app or any software that can help a doctor see the status of all the patients and then they can direct a nurse or doctor or connect to the primary consultant that make everything easier and we can prevent a lot of Code Blues. Code-blue should not happen if a strong RRT team is there. Code-Blues will not happen if there is a technological way to streamline the communication between the doctors, patients and nurses. Hospitals that have EMR have smoother process.”