Pediatric mock codes can improve care
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A newborn infant is brought to your ED in full arrest. You are unable to establish venous access. What do you do next? This scenario does not occur often in the ED. That’s exactly why you should practice in advance with pediatric mock codes, advises Lynne G. Callahan, RN, MICN, CNIV, pediatric liaison nurse and pre-hospital care coordinator at Cedars-Sinai Medical Center in Los Angeles. When Callahan did a retrospective chart review, she noted that the majority of the charts did not have weights in kilograms recorded. Nor did they have a color code noted from the Broselow Pediatric Emergency Tape.
Callahan has since implemented pediatric mock codes as part of the mandatory education for nursing staff. The goal is to reduce medication errors and improve patient care by using a team approach, she says. You must have the skills and tools to be ready for the most stressful of situations in the ED, Callahan stresses. "Unfortunately, when a pediatric patient comes to the ED in full arrest, the outcome is poor at best and they usually don’t survive," she says. "It’s important for the whole team to know they have done everything they could."
The ED has held three mock codes to date.
Although pediatric mock codes have been held for years at Christiana Care Health Services in Newark, DE, they were mainly geared toward physicians. "I worked hard to get nursing involved, because pediatric codes are few and far between," says David Salati, RN, pediatric care coordinator for trauma, emergency, and aeromedical services at Christiana Care.
Salati says that one or two mock codes are held in the ED each month. Pediatric codes are "low-frequency, high-risk" scenarios, he says, adding that 20% of the ED’s patient volume are children, but they only see about 40 pediatric cardiac arrests in a year. "With the size of our staff, it’s unusual for anyone to be involved in more than one a year," he says.
Here are items to consider when implementing pediatric mock codes:
• Pay special attention to dosages and equipment. Callahan says that mock codes increase familiarity with rarely used equipment and supplies, such as neonatal intubation kits. "Half your stress can be relieved if by the time the patient arrives, you are aware of all the tools you have to use, and everything is right there for you," she says.
During one mock code, an ED nurse was calling out medication doses using the hospital’s formulary while another nurse was looking at the Broselow tape and correcting the dosages. Callahan took the opportunity to explain that the dosages on the color-coded tape didn’t correlate with the hospital pharmacy dosages. She reminded nurses that she had developed a new medication book with all the formulary dosages correlating with the Broselow tape dosages, located in the color-coded pediatric crash cart. "This will reduce our medication errors," she says. "We can use the tape as the weight and a guideline, but we need to get our doses from the book."
Whether everything goes right during the code depends largely on the staff’s comfort level with the equipment, stresses Salati. "Doing mock codes gives people close to a real-world experience, with using length-based resuscitation tapes and getting the right size equipment to work for a given patient," he says.
After the mock codes, Callahan often reviews the location of all supplies in the pediatric color-coded crash carts. The top drawer contains all medications and intubation supplies, and the bottom drawer contains supplies for umbilical line access, she says. "Each drawer is coordinated with the weight of the child in kilograms."
• Every individual has a specific role. A checklist is used for every role involved in the pediatric mock code, including the ED attending physician, respiratory therapist, technicians, the neonatology attending, charge nurse, code team leader, and right and left nurses. (See Pediatric Mock Code Objectives and Pediatric Mock Code Checklist.) "All the players have a role that is defined for them, with critical elements for every role," says Callahan:
— The team leader makes sure the resuscitation room is set up and that the appropriate documentation forms are used.
— The right nurse has to make sure initial vital signs are obtained and done manually as opposed to electronically, to attempt vascular access, and administer and/or draw meds.
— The left nurse is responsible for placement of the Broselow tape and calling out the color code, and/or drawing up the weight in kilograms.
• Use scenarios that are high risk for errors. Callahan recommends using one of the following four scenarios for a pediatric mock code: sepsis, fluid resuscitation, cardiac arrest resuscitation, or airway resuscitation. (See Pediatric Mock Code/Resuscitation Case Scenario.) "Those are the most important things we deal with, that seem to involve a high error rate in calculation of drugs," she says.
Sources
For more information about pediatric mock codes, contact:
• Lynne G. Callahan, RN, MICN, CNIV, Cedars-Sinai Medical Center, Ruth and Harry Roman Emergency Department, 8700 Beverly Blvd., Los Angeles, CA 90048. Telephone: (310) 423-3335. Fax: (310) 423-0424. E-mail: [email protected].
• David Salati, RN, Pediatric Care Coordinator for Trauma, Emergency, and Aeromedical Services, Christiana Care Health Services, 4755 Ogletown-Stanton Road, Newark, DE 19718. Telephone: (302) 733-6793. Fax: (302) 733-1633. E-mail: [email protected].
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