When Buffalo Bills safety Damar Hamlin collapsed on the field in early January, thousands in attendance and millions more tuning in to Monday Night Football watched as emergency personnel rushed to save the young man’s life. First responders had to administer CPR and shock Hamlin’s heart back into rhythm using a defibrillator after he’d gone into cardiac arrest.
It was a riveting and distressing event that made front page news, highlighting the efforts the emergency personnel took to treat Hamlin on the field and later at the hospital.
Whether on a football field or in the operating room (OR), a cardiac arrest can be a catastrophic event. It is essential to identify the cause, in which body cavity the precipitating event occurred, and the appropriate corrective actions that must be taken.
The surgeon must determine if the cause is an improperly placed endotracheal tube, a malfunctioning endotracheal tube, a tension pneumothorax, a tension mediastinum, an anesthetic gas failure, drug-induced anaphylaxis, an intracranial event, or massive exsanguination. Each of these scenarios requires a different response.
These events may occur once in a decade or once in a career. Simulating this kind of catastrophe and educating the surgeon and team on how to respond appropriately in a controlled environment has real benefits.
A recent study published in The Joint Commission Journal on Quality and Patient Safety—“Intraoperative Code Blue: Improving Teamwork and Code Response Through Interprofessional, In Situ Simulation,” by Gregory Wu, MD, and coauthors—examined the topic of cardiac arrest, also known as a code blue, for incidents that occur in the OR.
“Although an intraoperative cardiac arrest is uncommon, it can be a catastrophic event that requires special considerations not seen in code blues on nursing units,” the study authors wrote.
Code blues can stem from several different factors, and the positioning of the patient can complicate matters for the healthcare team. This makes it imperative that the OR team is trained on proper response measures—in both technical and nontechnical skills, as well as the process needed to provide the best resuscitation measures for the patient.
The study authors argued that in situ simulation—simulation conducted in the work environment, such as a patient care unit as opposed to an offsite location—has the potential to improve team performance. As part of the study, the authors assessed the effects of in situ simulation on code response, teamwork, communication, and comfort in intraoperative resuscitations.
“Simulation provides the benefit of interprofessional and team-based training, which is important in a perioperative code, when the cumulative performance of the team likely has greater impact than the capabilities of any one individual,” according to the authors. “The benefits of simulation in code training also include the use of in situ learning, in which learning can be addressed on the individual, team, unit, and organizational levels.”
The study followed a team working in the OR of a community hospital located in New Jersey during a 4-month period in 2021, comprising:
- 21 perioperative nurses
- 7 anesthesiologists
- 7 surgical technologists
- 4 patient care technicians
The group ran through a code blue scenario twice, with technical skills being measured by “time-to-tasks” and nontechnical skills assessed using the Team Emergency Assessment Measure (TEAM) instrument. The team members self-reported comfort in skills prior to the program and again after the simulation training ended. The simulations were recorded and later reviewed for comparison.
The study showed:
- A decrease in time to compressions (by 14 seconds, a 53.5% improvement) and to defibrillation (by 49 seconds) between the two simulations
- Significant improvements in confidence levels of certain CPR-related technical skills
- Statistically significant improvements in TEAM scores in the two teams that performed lowest in the pre-debrief simulation (p <0.05)
The study authors concluded that in the operative setting, “in situ simulation training was associated with improvement in technical skills of individuals and teams, with significantly improved teamwork in teams that required the most training.” However, they noted that long-term effects needed additional research.
“In the rare event of an intraoperative code, perioperative individuals and teams need to be equipped with the technical skills, nontechnical skills, and confidence to provide the best resuscitative measures for the patient,” the study authors explained. “In the operative setting, where time and space for training are limited, the use of just 1 hour of in situ simulation training has been shown to improve technical skills of individuals and teams, with significantly improved teamwork in teams that required the most training.”
The authors found “simulation also provided insight into the status of code blue arrests, which allowed us to make local and systemwide changes in policies, OR environment, and code culture to overall improve the quality of intraoperative codes and increase patient safety.”
Frequent nontechnical, skill-specific simulation training with a formal debriefing for retention and the continued maintenance of skills will benefit the OR team when faced with an intraoperative cardiac arrest.
Disclaimer
The thoughts and opinions expressed in this article are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the ACS.
