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Medical Education

Reducing Entropy: Redefining Response to Cardiopulmonary Arrest in a Level 1 Trauma Center through Simulation Training

Dr. Reddy ( is a hospitalist with the University of South Florida and the chief quality fellow at Tampa General Hospital.

On May 10, 2020, the Los Angeles Times reported the death of 62-year-old Celia Marcos, a charge nurse who rushed in to respond to a cardiac arrest in a patient suffering from COVID-19.3 She passed away from complications of the disease 14 days later. Her death, along with those of the hundreds of other healthcare workers around the world, highlights the need to balance and prioritize the health and safety of our team members without sacrificing the quality of care we provide for our patients in this new healthcare environment.

Survival to discharge of patients suffering in-hospital cardiopulmonary arrest (IHCA) at our institution has averaged between 20-25% over the past 2 years, which is average for medical centers globally.1 Staff members quoted problems with disorganized response, overcrowded rooms, and poor post-code transitions of care. Previous interventions, done independently over the course of the last two years, included introducing post-code debriefs, designating the code leader with a red hat, and advising the assignment of code roles to unit staff. Team members were incentivized with coffeeshop gift cards or meals gifted to the unit. These interventions and incentives however, failed to sustain any changes in processes or outcomes.

The onset of the COVID-19 pandemic, however, brought a new sense of urgency in improving the processes surrounding cardiac arrest care. As an always-busy safety-net county hospital and quaternary care center, we could not afford to improvise when it comes to patient and staff member safety. A Critical Care/Code Blue committee comprised of providers from Emergency Medicine, Internal Medicine, Pulmonary/Critical Care Medicine, Anesthesia, Rapid Response Team, Nursing, and Pharmacy was formed soon after news of the first cases in the United States came to light to create protocols for critical care situations where there would be high risk for virus aerosolization. We named the new response to our IHCA in COVID-19 patients the “Code 100.”


Code 100

The Code 100 process emphasized limiting the number of responders to highly trained individuals who would have proper PPE while keeping as much of the equipment outside negative pressure rooms as possible. We developed use of a “Staff Assist” call button rather than the Code Blue call button on COVID-19 units to prevent the normal code team from responding. The crash cart would remain outside the room, and each member of the code team was responsible for bringing essential equipment (medication box with a set number of pre-dosed code medications, the defibrillator, the airway box, with a HEPA filter, the glidescope, and ventilator). A gate keeper and pharmacist outside the room would convey additional materials into the room as needed.

In mid-March, a patient being treated for COVID-19 suffered cardiac arrest while he was being lain prone in our ICU. Given education earlier the same day, team members were outfitted in proper Personal Protective Equipment (PPE). No team members ultimately contracted the virus because of this patient’s care. However, fears around safe and effective treatment of these patients still abound. While we had filmed simulated versions of the new processes, videos alone were not enough. Literature notes positive correlation between simulation training and better outcomes for IHCA.2, 4 However, the uniqueness of the situation at hand was the urgency of training team members to properly care for known COVID-19 patients, without sacrificing the care of known negative or undifferentiated low risk patients due to fears of transmission.

The simulation training we designed originally encompassed the new Code 100 process, emphasizing the need for our team members to protect themselves with proper PPE, the donning and doffing of which takes valuable time, rather than responding immediately to a code in the hardwired way that all healthcare workers are taught to do. We eventually extended the use of high-level PPE for core code responders to IHCA in the undifferentiated, asymptomatic population in accordance with professional society guidelines. Partnering with the University of South Florida Center for Advanced Learning and Simulation and the Tampa General Hospital education department, we started with Just-In-Time training for staff on our COVID-19 designated units in late March and then expanded to other areas of the hospital from April to May 2020 with once-weekly sessions, including nursing, physicians, respiratory therapists, and pharmacists. Each simulation was recorded for immediate debrief. A post-simulation survey obtained feedback regarding the training process. We then debriefed with unit managers on units where true Code Blue events were called for feedback regarding the impact of training on implementing the new processes. Over 500 team members, including nurses, providers, respiratory therapists, and pharmacists have been trained so far.


Lessons Learned

While outcomes data such as Survival of Event of IHCA or Survival to Discharge after IHCA will lag for several months, we have seen improvement in team member level of comfort with responding to codes, especially on units where most nurses are BLS trained. Commonly, unit managers reported that IHCA events, when they happened, were more organized, with only essential people in the room. Furthermore, the inclusion of providers and pharmacists in the training encouraged a culture of camaraderie and teamwork. The multidisciplinary approach to process development, training, and information dissemination also served to collect more perspectives on the successes and pitfalls of this new process. The role of the pharmacist, for example, has been to have closed loop communication with the code leader and mix medications right in the patient’s room. With the code leader now speaking through a closed door and walkie-talkie to the recorder, the pharmacist now had the additional task of anticipating medication needs based on what was already used from the limited medication box taken into the room. Communication, more than anything else, took precedence. The team members who played the first responder during the simulations noted loneliness and anxiety while waiting for the rest of the code team to arrive. When one is the lone provider performing compressions inside the room without any external feedback, the very quiet two to three minutes it usually took for others to enter seemed like eternity. These feelings were assuaged by communication from the recorder over the walkie-talkie system. We incorporated the impact of this kind of team member support into future sessions.

Additionally, as we continue to provide training and obtain feedback, more requests for unit-specific and patient-specific scenarios arise. As the pandemic lingers, the leadership implemented viral testing for all patients admitted to the hospital. For example, one unit would like help simulating the care of obese patients on bariatric beds that are too large to move out of their doors with the patient still in them. Our Labor and Delivery unit would like for the mannequin to be that of a pregnant female and to include the neonatal resuscitation in their scenario. In service of these requests, we expanded scope on training and improvement efforts towards all inpatient resuscitations.

Changing both the process and mindset around code response at our institution came with the rapidly changing environment—we needed to update both the process and the training multiple times a day based on new CDC recommendations as well as updated literature. The learning and response within each simulation session embodies rapid cycle improvement, and each training and debriefing session resulted in process changes, as did actively seeking feedback from units that had Code Blues called. As our number of new COVID-19 cases plateau and the organization opens to higher censuses, we now focus on keeping the momentum generated in the creating and disseminating of these new processes. In the past, small rewards like gift cards and meals temporarily incentivized compliance. However, the current impetus to change and to sustain these changes appears driven by stories—both of successful outcomes and continued challenges. There is a feeling that team member input directly impacts patient care in a value-added way. The changes made reflect how our organization continues to evolve from a reactionary to proactive approach in quality improvement in health care, and how other organizations can adapt new processes and disseminate their use throughout the organization in a relatively short period of time.


  1. Andersen LW, Holmberg M, Berg K, et al. In-Hospital cardiac arrest: A review. JAMA. 2019 Mar 26;321(12):1200-1210. doi: 10.1001/jama.2019.1696.
  2. Josey K, Smith M, Kayani A, et al. Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest. Resuscitation. 2018 Dec;133:47-52. doi: 10.1016/j.resuscitation. 2018.09.020. Epub 2018 Sep 24.
  3. Karlamangala S. A nurse without an N95 Mask raced in to treat a ‘code blue’ patient. She died 14 days later. Los Angeles Times. presbyterian. Published May 10, 2020. Accessed June 15, 2020. (Subscription required to read full article.)
  4. Theilen U, Fraser L, Jones P, et al. Regular in-situ simulation training of paediatric medical emergency team leads to sustained improvements in hospital response to deteriorating patients, improved outcomes in intensive care and financial savings. Resuscitation. 2017 Jun;115:61-67. doi: 10.1016/j.resuscitation.2017.03.031. Epub 2017 Mar 28.


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