What Happens During a Code in the ER?

What Happens During a Code in the ER?

When a patient is described as having “coded,” this generally refers to cardiac arrest. In such a case, urgent life-saving measures are indicated. This can happen within and outside of medical facilities. The benefit of the occurrence in a professional health care setting is that policies and guidelines are in place to address this life-threatening crisis. What follows is the perspective of responding to a code from an ER nurse.

Just as every patient is different, so is every code. The causes and outcomes of every code have to do with the characteristics of the patient in question: the history of present illness and, of course, their comorbidities. Timothy Wrede, RN, is a long-time emergency and critical care nurse in the suburbs of New York City, as well as a former EMT who has seen his fair share of codes. According to Wrede, nothing matters during a code so much as the team that responds to it. “It is imperative to ensure that a good team of doctors, nurses, and ancillary staff are working together efficiently in order to achieve resuscitation of spontaneous circulation (ROSC),” says Wrede. 

According to Wrede, a veteran of level-I trauma care, when it comes to staffing a code, less is more. Studies suggest that thirteen is the maximum number of personnel participating in an effective code. Included in this number are professionals that go beyond those immediately at the bedside, such as pharmacy, lab, and spiritual services. “There’s nothing worse than 25 people crammed into a patient room trying to coordinate resuscitation,” according to Wrede. For him, the minimum is five ‘in the box’, or in direct proximity to the patient, as well as one team member ‘outside of the box’. “One doctor, three nurses, and two aides are more than sufficient to obtain or sustain an airway while maintaining a clear line of vision of the patient, the patient’s monitor, and other team members,” he says. This consists of one nurse on either side of the patient responsible for gaining peripheral IV access, administering IV medication, and obtaining blood samples for lab work. The code recorder, usually an RN, documents everything that occurs, including every medication given, timing, team actions, compressions, defibrillation, and patient response. 

Wrede’s description of the ideal code team is very similar to the American Heart Association’s recommendation for high-quality CPR teams.  It includes a “triangle” of providers doing chest compressions, defibrillating, breathing for the patient, and providing medications, in addition to a code recorder and a physician outside of the triangle.  The physician acts as a team leader by making high-quality treatment decisions, providing feedback, and overseeing team actions.

For Wrede, the most important times for a code are before and after it.  Having a competent team with pre-assigned roles, as well as the opportunity to review and debrief afterward to improve the process continuously, and allow for best patient outcomes. Many hospitals address this by establishing a code team that arrives every time a code is called, with well-established roles, and protocols. Wrede’s experiences describe codes in the ED, although codes are generally run the same regardless of where they take place. The biggest difference is the patient context.

When Nurse Staffing Lags, So Does ED Performance

When Nurse Staffing Lags, So Does ED Performance

Fewer nurses on staff linked to increases in length of stay

Ask a nurse and they will tell you that staffing levels matter. Now a study in the Western Journal of Emergency Medicine supports that popular opinion, providing further evidence to make the case for nursing’s role in achieving healthcare outcomes and metrics.

“Our study provides additional data that may help providers further engage hospital administration to supply adequate nurse staffing that allows EDs [emergency departments] to better achieve performance goals and improve the patient experience,” the researchers wrote. “This analysis is a pivotal step in identifying and ensuring appropriate nurse staffing to optimize ED quality metrics.”

In the retrospective observational review of the electronic health record database from a high-volume, urban public hospital, researchers compared nursing hours per day with door-to-discharge length of stay, door-to-admission length of stay (LOS), and the percentage of patients who left without being seen.

From January to December 2015, more than 100,000 patients were seen in the ED at an average of 290 visits each day. During this time, the ED had an average of 465 nursing hours worked per day.

The researchers found that regardless of daily patient volume, occupancy, and ED admission rates, days in the lowest quartile of nursing hours experienced a 28-minute increase per patient door-to-discharge LOS when compared with the highest quartile of nursing hours.

However, door-to-admit LOS showed no significant change across quartiles.

There was an increase of nine patients per day that left without being seen by a provider from the lowest to highest quartile of nursing hours.

The authors concluded that lower staffing rates contribute to a statistically significant increase in wait time for patients, which then impacts how many patients receive treatment each day.

In addition to the clear patient safety and patient satisfaction issues around failing to receive timely treatment, the decrease in patients seen can also impact throughput metrics and decrease the overall revenue of facilities.

This story was originally posted on MedPage Today.

Nurses Not Immune to Stress from Disaster

Nurses Not Immune to Stress from Disaster

Two reports find that RNs are both personally and professionally affected by natural disasters

That includes nurses.

“When both personal life and professional life are impacted by an adverse event, as occurred in Superstorm Sandy, stress can exponentially increase,” said Victoria H. Raveis, PhD, director of the Psychosocial Research Unit on Health, Aging, and the Community at NYU College of Dentistry. “The responsibilities associated with the profession of nursing add additional demands that increase the risk for role conflict when a disaster occurs.”

She, along with colleagues at NYU Rory Meyers College of Nursing and NYU Dentistry, recently published two reports in the Journal of Nursing Scholarship that offer insights on emergency preparedness, recovery, and resilience. The studies were centered on nurses working at NYU Langone Health’s main hospital during Superstorm Sandy in 2012. Key themes that emerged were communication — both improving channels and the importance of connecting nurses with others during a crisis — and social support.

Preparedness Training Needed

To understand how nurses at NYU Langone were impacted before, during, and after the storm, the researchers conducted interviews and surveys with 16 nurses who participated in the mid-storm evacuation of more than 300 patients at the institution’s 725-bed Tisch Hospital due to high water levels.

Raveis and her team explored nurses’ experiences in disasters, assessed the nurses’ challenges and resources for carrying out responsibilities, and uncovered some lessons.

After the interviews, an online survey was sent to all RNs assigned to inpatient units at NYU Langone on the day of the storm. The researchers received 528 anonymous responses, including responses from 173 nurses who were part of the evacuation.

While some nurses had previous disaster training and experience, and a few of them reported feeling prepared during the storm and the resulting evacuation, many working the night of the storm lacked prior hands-on experience or deep knowledge of emergency preparedness.

This lack of comfort with emergency preparedness is not uncommon, noted Eric Alberts, corporate manager for emergency preparedness at Orlando Health in Florida.

“I’ve been going across the United States speaking about the PULSE [nightclub mass shooting] incident, and, unfortunately, we’re finding that a lot of hospitals don’t have an emergency plan,” he said.

“Or if they do, they don’t practice it. And if they do practice it, they’re not really practicing it — they’re just doing a flu shot campaign and calling it an exercise.”

Alberts recommended that hospital and health system leaders do a thorough evaluation of their disaster readiness: “Really look at your processes and your people and see what is available during emergencies. Emergency preparedness and healthcare looks and feels different everywhere you go. And then from that, look at what resources and people are able to help those individuals have a good, efficient, and effective plan.”

The researchers also called for more education and planning for future disasters and they recommend FEMA’s all hazards approach to disaster planning.

Personal Concerns Present

Communication was a challenge during Superstorm Sandy when access to electronic medical records, email, and phone communication was unavailable because of power loss.

RNs reported unlocking medication carts in anticipation of the power outage and handwriting medical summaries for patients being evacuated to other hospitals. Of the nurses surveyed, 72% reported that their primary mode of communication was talking face-to-face and 24% used personal cell phones.

The researchers also found that nurses had their own personal concerns during the storm, worrying about their families’ welfare and personal loss. And while many arranged for extended stays at the hospital before the storm, they reported feeling uncertain about leaving their families and later had trouble contacting loved ones.

The survey found that 25% of nurses suffered property damage or loss, and 22% needed to relocate after the storm. Some respondents reported psychological problems after the storm, including having disturbing thoughts (5%) and difficulty sleeping (4%).

Social support from co-workers, hospital leadership, and loved ones was cited as an important resource in helping nurses cope with the stress of the disaster.

“Our research also shows that maintaining good communication with peers and hospital leaders after the hurricane helped the nursing staff feel more connected and less stressed,” said another of the study coauthors, Christine T. Kovner, RN, PhD, professor of geriatric nursing at NYU Meyers.

This story was originally shared on MedPage Today.

Virtual Reality Enhances Ohio University School of Nursing Education

Virtual Reality Enhances Ohio University School of Nursing Education

The Ohio University College of Health Sciences and Professions’ School of Nursing is putting virtual reality to use in the classroom. Assistant professor Sherleena Buchman helped create a Narcan simulation during the 2018 spring semester. Since then, the initial video simulation has been transformed into a virtual reality simulation.

A 360-degree video was made from cameras surrounding the Narcan simulation, which features two college students discovering a friend experiencing an opioid overdose. Throughout the scene, the students call 911 and work together to help their friend by administering Narcan.

“Using virtual reality goggles, the person can turn around and see everything. It’s really amazing,” Buchman shared with the CHSP Newsroom. “When you look down, you can see them going through the bag looking for Narcan. If you hear a noise, you can turn your head to look in that direction to see what’s going on. It’s just like you were physically in the room.”

Buchman believes that as the simulation becomes more realistic, the students will learn even more than they could in a traditional nursing education setting. Currently, this simulation is only available in the university’s GRID Lab, but Buchman is working to have the simulation eventually available on all smartphones. The simulation will help students learn not only about Narcan and how to administer it, but how to view and think about addiction without a stigma.

“It leaves you with a feeling of ‘Wow, I just watched someone overdose and watched them come back,’” said Buchman. “The reactions viewers gave were interesting and emotional. They showed compassion as we sometimes don’t consider the side of the actual person who overdosed and the feelings of those that found them.”

Currently this simulation is only available for laymen, but Buchman is working on another version specifically for Ohio University’s nursing students that can be used as a teaching tool. She feels excited and grateful about her success with the simulations so far.

“It’s been a pretty amazing journey. I love technology, simulation and education and the students today have grown up with technology in their hands. This is a way we can impact them that’s familiar,” Buchman said. “It’s amazing to think that we can help create something that will help patients and help our community by impacting this generation of students and community members who see this and will be able to carry out these actions on their own.”

How a Nursing Career with VA Changed a Former Combat Medic’s Life

How a Nursing Career with VA Changed a Former Combat Medic’s Life

Jeffrey Ballard, R.N. and Army Veteran, began his medical career as an emergency medical technician (EMT). After gaining experience as a paramedic and a licensed practical nurse (LPN), he became a registered nurse in the Emergency Department at a Level 1 Trauma Center. He was deployed to Afghanistan two years later as an infantry medic, where he sustained injuries in combat. Following a year and a half of surgeries and physical therapy back home, Ballard returned to emergency nursing, but his struggle with PTSD prompted his departure within a year.

Ballard received care at the Manchester VA Medical Center, and he decided to continue his nursing career there. “I wanted other Veterans to have the same comfort I experienced,” he said.

Today, Ballard has been working with the VA for nearly five years and serves in a program that helps elderly Veterans maintain their independence. Working alongside compassionate nurses and caring for combat Veterans like himself has helped Ballard rediscover his passion and flourish in his career. With his experience, he’s been able to better understand and build trust with Veterans in a way that generates comfort and healing for both parties. Recently, Ballard won the title “Red Sox Nurse Hero of 2018” and was invited to throw a game-opening pitch at the historic Fenway Park.

VA offers Veterans not only life-changing care but also life-changing careers. Join our team and discover the unique rewards that come from serving our nation’s heroes. To get started, search for opportunities near you and apply today.

This story was originally posted on VAntage Point. 

Essential Training Helps VA Nurse Save a Life

Essential Training Helps VA Nurse Save a Life

VA Palo Alto nurse Karen Wall saved a woman’s life on a cross-country flight, applying the CPR techniques she learned and taught in a Basic Life Support class at her health care system.

Here is her account of the experience:

If you have ever wondered if it is a good idea to learn CPR, here is proof that it works. On August 11, 2017, I was returning home from a conference I had attended in Washington, D.C. During the Southwest flight from Baltimore to Las Vegas, I became involved in a medical emergency on board.

Whenever I travel, I always let the crew know I am a nurse in case anything happens where they need medical assistance. On this particular day, I was sitting in my seat relaxing with my shoes kicked off and talking with my seatmate, when I heard a commotion a couple rows behind me.

I heard the flight attendant say “Nurse!” I turned around, and she saw me and remembered who I was from boarding. She called me over and there was a lady in the window seat of the aisle passed out.

After grabbing my pocket mask from my carry-on (yes, I always have it with me), I went to her seat after the other people in the row cleared out. When I got to her, I tried to arouse her and get her to respond, but she was gray and cold, had vomited, was not breathing, and had no pulse when I checked her carotid artery.

I called a “code blue” and called for someone to get an Automated External Defibrillator (AED) while the flight attendant alerted the pilot so he could call for help on the ground. My seatmate, also a Veteran, jumped into the row as we worked to get the lady lying down in the row across the seats, as we had no other place that was flat enough to lay her out to begin CPR.

As we were doing this, suddenly two more registered nurses and a doctor came from their seats to help. One of the nurses (who also happened to be a VA nurse) began chest compressions (counting out loud) as I gave breaths—it was two-person CPR in action and by the book.

Once the AED arrived and was turned on, I applied the pads as directed by the AED and then plugged it in. The AED analyzed her and gave the shock just like I had recently learned in a Basic Life Support (BLS) class at work. We continued CPR and eventually got a pulse. She was breathing again! We monitored her vital signs, placed her on oxygen, and turned her on her side so she would not aspirate if she vomited again.

The pilot diverted the flight to Denver where we were met by EMT, who then took over the case and got her off the plane to take her to a hospital.

We need to continually practice our skills.

When I think of the many things I learn in class and the skills I not only learn for myself but also teach others as a BLS instructor, this experience reminded me that there is a reason we teach BLS and teach it the way we do. There is a reason for why we need to continually practice our skills and not take for granted it will never happen to us.

We never know when we will be “the one” who makes a difference in a person living or dying. When I had time to think back on the events of this day, it was as if we had taken the book out and literally followed the steps that lead to a positive outcome for real.

Never have I ever felt so proud to be a VA nurse than at the moment that passenger opened her eyes, looked at me, and smiled!


About the author: Karen Wall, EdD, RN-BC, OFS, LMFT, is a Geriatric & Dementia Care Coordinator at the Palo Alto VA Health Care System

This story was originally shared on VAntage Point. 

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