Reference no: EM133330508

An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxiety. On hospital day 2, he had sudden onset of confusion, bradycardia, and hypotension. He lost consciousness, and a "code blue" was called.

The inpatient psychiatry facility is adjacent to a major academic medical center. Thus, the "code team" (comprising a senior medical resident, medical intern, anesthesia resident, anesthesia attending, and critical care nurse) within the main hospital was activated. The message blared through the overhead speaker system, "Code blue, fourth floor psychiatry. Code blue, fourth floor psychiatry."

The senior resident and intern had never been to the psychiatry facility. "How do we get to psych?" the senior resident asked a few other residents in a panic. "I don't know how to get there except to go outside and through the front door," a colleague answered. So the senior resident and intern ran down numerous flights of stairs, outside the front of the hospital, down the block, into the psychiatry facility, and up four flights of stairs (the two buildings are actually connected on the fourth floor).

Upon arrival minutes later, they found the patient apneic and pulseless. The nurses on the inpatient psychiatry ward had placed an oxygen mask on the patient, but the patient was not receiving ventilatory support or chest compressions. The resident and intern began basic life support (CPR with chest compressions) with the bag-valve-mask. When the critical care nurse and the rest of the code team arrived, they attempted to hook the patient up to their portable monitor. Unfortunately, the leads on the monitor were incompatible with the stickers on the patient, which were from the psychiatry floor (the stickers were more than 10 years old). The team did not have appropriate leads to connect the monitor and sent a nurse back to the main hospital to obtain compatible stickers. In the meantime, the patient remained pulseless with an uncertain rhythm. Moreover, despite ventilation with the bag-valve-mask, the patient's saturations remained less than 80%. After minutes of trying to determine the cause, it was discovered that the mask had been attached to the oxygen nozzle on the wall, but the oxygen had not initially been turned on by the nursing staff. The oxygen was turned on, the patient's saturations started to rise, and the anesthesiologist prepared to intubate the patient. Chest compressions continued.

At this point, a staff nurse on the psychiatry floor came into the room, recognized the patient, and shouted, "Stop! Stop! He's a no code!" Confusion ensued-some team members stopped while others continued the resuscitation. Although a review of the chart showed no documentation of a "Do Not Resuscitate" order, the resuscitation continued. The intern on the team called the patient's son, who confirmed the patient's desire to not be resuscitated. The efforts were stopped, and the patient died moments later.

Questions

1. What parts of this scenario really caught your attention? 

2. Identify ways to educate hospital staff about how to activate code teams.

3. You are selected for an improvement team in response to this event. Draw a fishbone diagram with all possible failure points and contributing factors related to the core problem you have identified. 

4. What recommendations would you make? Consider:

• Standardization of equipment
• BLS/CPR for the First Responder training
• Assessing the environment and all equipment upon entering the scene

5. Where is communication likely to break down at the code site?

• Who should be notified in the event of a patient code?
• How can you make Do Not Resuscitate orders available and effective?