Emergency resuscitation training saves lives—even the same day

The 12-year-old leukemia patient had been hooked up to chemotherapy for only a few minutes when she began having problems. First, she said her skin was itchy. Then, she complained of back pain. Soon, she was having trouble breathing. Within minutes, she was suffering from cardiac arrest. She was having a severe allergic reaction to the chemo and the nurse knew exactly what to do: call a code blue, which activated an emergency pediatric code team.

It sounds like a simple call for a nurse, but what happens in the first few minutes after a patient’s heart suddenly stops – before all the specialists arrive – can make a critical difference between life and death. Doctors and nurses at the Bass Childhood Cancer Center at Lucile Packard Children’s Hospital Stanford rarely see a child in cardiac arrest, also known as a code blue. But if they do, they are ready. That’s because they practice their resuscitation skills several times a year, thanks to a new hospital-wide, cutting-edge program that provides lifesaving practice.

The Revive Initiative at Stanford Medicine Children’s Health provides the opportunity to practice skills that are extremely important in these infrequent but high-risk events. And, in an uncanny coincidence, several of the medical staff who responded to the 12-year-old had actually taken part in a mock simulation that day – just hours before and a few rooms down from where the girl was receiving chemo.

“It was very eerie that the scenario we simulated that morning was the exact situation that happened that afternoon,” said James Trietsch, DO, a doctor of osteopathic medicine doctor at Stanford Medicine Children’s Health who was at both the morning simulation and the code blue incident, which happened last April. “The nurses identified right away that the patient was deteriorating and they immediately activated the pediatric code team.”

California law requires all registered nurses to complete a two-day course in pediatric advanced life support (PALS) and CPR once every two years. But studies show that employees don’t often retain much of what they learn in infrequent training because they aren’t using the skills enough. Moreover, cardiac arrest is fortunately a rare occurrence in pediatric patients, but this means there isn’t a lot of on-the-job practice, either.

To ensure these skills are always fresh, the hospital — under the guidance of Lynda Knight, RN, MSN; Deborah Franzon, MD, medical director of the pediatric ICU; and Michael Chen, MD, anesthesiologist — conducted research in 2010 examining this pediatric resuscitation team training, which trained nurses, doctors, pharmacists and respiratory therapists inside the hospital. The research proved the program was associated with improved survival, and now has grown to include all hospital first-responders.

That led to hospital administrators launching the Mobile Simulation Resuscitation Program (MSRP). Due to the extensive growth of this patient safety program, it’s been rebranded as the Revive Initiative. Revive interventions consist of simulation training as a team, familiarization with emergency equipment and communication skills, monthly Rapid Response Team/Code Blue reviews, and formal debriefings of actual events.

“The program exemplifies synergy at its best,” said Franzon, a clinical associate professor of pediatrics – critical care at the Stanford University School of Medicine. “Each of these individual training components come together in just the right way to improve team members’ confidence and competence, and to save lives.”

The hospital has a team of well-trained “code” and emergency specialists who respond within 5-10 minutes, but Knight said the additional goal of Revive is to also educate the doctors, nurses and staff who are most likely to be closest to the patient when a real-life emergency occurs and before the code team arrives.

“Research makes it clear that the first five minutes of a code are the most important,” Knight said. “If the first responders don’t initiate basic life support right away, the chance of having the most optimal neurological outcome decreases with every minute that passes. Physiologically, this patient would not have survived with such a good neurological outcome without the first responders performing high quality CPR immediately.”

Each week, Knight and her team move from unit to unit in the hospital, first setting up a skills station. That’s where the medical staff practice such things as chest compressions on mannequins, working with defibrillators, and locating emergency equipment in the code carts. Towards the end of each week, a mock simulation occurs that the staff knows to expect, but are not told when it will occur. Since starting the program in 2014, 90 percent of the nursing staff and 50 percent of the medical staff have been through the skills sessions, and many participated in the unit mock codes.

Krysta Schlis, MD, an oncologist at the Bass Center, was the girl’s doctor and arrived in her room just as she was having trouble breathing. Within two minutes, Schlis was unable to find a pulse and Schlis and another doctor began chest compressions and maintained the girl’s breathing through a bag mask device. Within seconds, a nurse manager from the Bass Center arrived along with the crash cart, which includes a defibrillator and other emergency medical equipment needed for a resuscitation event, while another nurse recorded the event on code documentation.

Schlis said the mock simulations, both earlier in the day and those rehearsed in the months before, allowed the first responders who came to the room to stay calm and focused on what they were supposed to do before the emergency response team arrived.

“Most codes are very chaotic, but this was the best I’d ever seen. It was very calm and clear who was in charge and what everyone was supposed to be doing,’’ Schlis said. “I think the fact that we had done a lot of mock codes, practicing these rare incident skills, including the one that morning, facilitated by the Revive, saved that girl’s life. There is no question in my mind.”