The Impact of implementation of code blue nurse champion for cardiac arrests
Beverly Holland, MSN, MBA, RN, NEA-BC
Registered nurse with 34 years in acute care hospital settings
20 years in leadership roles
Clinical Education Department director
Involvement in ministry wide quality improvement
Code Blue committee
New employee orientation and Transition into Practice (TIP) RN onboarding
Cardiovascular disease is the primary cause of death resulting in 840,768 deaths in the United States (US) in 2017, with 379,133 due to cardiac arrest (Varini et al., 2019).
An estimated 209,000 in-hospital cardiac arrests (IHCA) occur each year in the US, with a survival rate of 24% (Andersen, Holmberg, Berg, Donnino, & Granfeldt, 2019).
Impacting factors for survival include:
skilled response by bedside nurses
skilled resuscitation team,
prompt initiation of cardiopulmonary resuscitation and defibrillation, and
organizational structures to support resuscitation care (Guetterman et al., 2018).
Survival and favorable outcomes for IHCA events are highly dependent on factors such as having a skilled resuscitation team in-house, prompt initiation of cardiopulmonary resuscitation (CPR) and defibrillation and established organizational structures to support resuscitation care. The Institute of Healthcare Improvement (IHI) recognizes the need for having a safety measure to assist healthcare professionals at the bedside in the prevention and identification of patient deterioration (IHI, 2008). Current evidence illustrates the variability in cardiac arrest survival in and out of the hospital, demonstrating a substantial opportunity to save lives (Bhanji, Finn, et al., 2015).
Rapid response systems and teams
Evidence Based Practice (Maglangit, 2015)
IHI 100,00 Lives Campaign (IHI, 2008)
Delays associated with high mortality
Early intervention, improves patient outcomes (Readron, Fernando, Maruphy, Rosenberg, & Kyeremantegn, 2018).
Rapid response systems are considered a powerful tool in patient safety (Jung et al., 2016). A rapid response team (RRT) is an evidence-based practice (EBP) that most hospitals in the country are utilizing (Maglangit, 2015). The RRT is one of the six initiatives that the IHI 100,000 Lives Campaign identified in 2004 (Mate, 2017). Delays in activating RRT calls are associated with high mortality, while early intervention during clinical deterioration can improve patient outcomes (Reardon, Fernando, Murphy, Rosenberg, & Kyeremanteng, 2018). Early RRT calls are associated with decreased mortality, while late calls are associated with increased patient morbidity and mortality (Jones, Moran, Winters, & Welch, 2013). Early requests for assistance allow identification of patients at risk of deterioration and target interventions to improve patient care (Maharaj, Raffaele, & Wendon, 2015). Recognition of altered physiological observations to complex process involves knowledge and experience (Guinane, Bucknall, Currey, & Jones, 2013).
Issues of delayed response and failure to notify the RRT are related to the inability to recognize patients’ deterioration and be associated with environmental factors. According to Jenkins, Astroth, and Woith (2015), recognition and addressing barriers can improve rapid response’ system safety culture and can have a positive impact on cardiac or respiratory arrests and mortality outside the intensive care unit (ICU). These barriers are related to perceptions that one has the necessary skills and abilities to perform or face issues or challenges related to navigation of the intra-professional and inter-professional hierarchies that lead to delays in activating the team when the patient condition deteriorates (Jenkins et al., 2015). Other possible system failures identified are multiple factors including delays in diagnosis and misdiagnosis (on physician’s side), inadequate interpretation of clinical symptoms, incomplete treatment, inexperienced staff, and patient management in appropriate clinical areas (Bagshaw et al., 2010 as cited in Jenkins et al., 2015).
The purpose of the project was to compare the impact of the implementation of the code blue nurse champion role in a select nursing medical-surgical division patient care department on nurses’ self-efficacy to initiate cardiac resuscitation and survival of IHCA.
The focused education for the code blue nurse champion role includes IHI rapid response education (IHI, 2008) and participation in cardiac arrest in situ simulation scenario (Liaw, Rethans, Scherpbier, & Piyanee, 2011).
Importance of the project
Survival depends on early recognition (Chang et al., 2018).
Literature indicates that adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016).
Interventions designed to improve the recognition and management of patient deterioration can improve learner outcomes when they incorporate medium to high-fidelity simulation (Connell et al., 2016).
When a nurse has self-confidence, recognizing, and responding appropriately to an emergency is increased (Horowitz, 2018).
Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016).
Patient safety is a hospital priority. Survival of cardiac arrest event depends on early recognition of the event and immediate response including activation of a “code blue” team and initiation of high-quality CPR (Chang et al., 2018). An integrative review of the literature revealed that CPR skills retention and poor-quality CPR remain a major challenge in the clinical setting. The findings have consistently demonstrated that the quality of CPR is directly related to survival outcomes. Literature indicates that adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016). CPR training helps individuals learn and apply cognitive, behavioral, and psychomotor skills then develop the self-efficacy to provide CPR when necessary (Bhanji, Finn et al.,2015; Horowitz, 2018). Nurses are often the first to activate the chain of survival when a cardiorespiratory arrest happens. It is crucial that nurses keep their knowledge and skills up to date, as well as attitudes to resuscitation are very important (Tiscar-Gonzalex, Blanco-Blanco, Gea-Sanchez, Molinuevo, & Moreno-Casbas, 2019). Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing, and responding appropriately to an emergency is increased (Horowitz, 2018). Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016).
Bandura’s self-efficacy (BSE) theory
Bandura (1982) defined confidence as “the perception that one is competent and capable of fulfilling particular expectations’” whereas self-efficacy is the personal judgment of “how well one can execute courses of action required dealing with prospective situations” (p. 122).
Confidence is important as it may influence the degree of self-efficacy experienced
Individuals are more likely to engage in behaviors if they have confidence in their ability to perform the task (Bandura, 1995).
Applying this theory, Participants that have received the training will potentially respond to patient deterioration with more confidence.
Theoretical Foundation (cont.)
The Transtheoretical Model (TTM)
Health behavior change involves progress through six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination
Focus on the individual’s decision making
Model of intentional change
Key assumption: people do not change behaviors quickly and decisively; instead, change in behavior, especially habitual behavior, occurs continuously through a cyclical process (Boston University School of Public Health [BUPH], 2019).
Based on the processes of change in TTM, behavioral change in the attitude stage facilitated by raising awareness, discussing relevant events and cases, and providing effective models, media campaigns, and group discussion opportunities (Keshmiri et al., 2017).
For nurses to move from the pre-contemplation to the termination stage, education needs to be effective, focusing on the harmful effects of “failure to rescue” [current state] and identify with the positive benefits of timely initiation of cardiac resuscitation.
Review of the literature
Relevant evidence supporting the implementation of the code blue nurse champion role to enhance staff efficacy and improve skills and knowledge in cardiopulmonary resuscitation (CPR)
Key words: cardiopulmonary resuscitation, survival, nurses’ self-confidence, IHCA, simulation, and RRT
Cardiopulmonary Resuscitation (CPR)
CPR knowledge by nurses
CPR performance and delivery by nurses
Confidence in performing CPR
Significance of simulation in nursing
The integrative literature noted relevant evidence supporting the implementation of the code blue nurse champion role to enhance staff efficacy and improve skills and knowledge in CPR. The main themes derived from the literature include Cardiopulmonary resuscitation (CPR) and simulation strategies. Three subthemes emerged from the literature, including CPR knowledge by nurses, CPR performance and delivery by nurses, and confidence in performing CPR.
Nurses play an integral role in initiating and delivering CPR; therefore, consideration of their role as the first responder is critical. Makinen et al. (2016) found that nurses are hesitant to start CPR, which is associated with a perceived low level of confidence in their ability to perform. Nurses lacking confidence are more hesitant to respond during resuscitation, and thus have a lesser chance for the highest potential and beneficial patient outcomes according to Herbers & Heaser, 2016. The research identifies an opportunity to re-evaluate traditional CPR education to identify inefficiencies to bolster confidence in nurses. McHugh et al. (2016) discussed the CPR competency knowledge of nurses and the impact of the professional nursing environment. Key considerations include facilitating a professional practice environment and ensuring training methodologies embed professional practice concepts (i.e., team training, structural empowerment, and access to up-to-date training methodologies) (McHugh et al., 2016).
CPR skill retention is not a new concept. The frequency of competency renewal to ensure retention of skills has been explored (Hernandez-Padilla et al., 2015). A positive association is noted between self-efficacy and knowledge (i.e., higher self-efficacy is associated with increased knowledge), with significantly higher self-efficacy among nurses who correctly perform chest compressions (Dudzik et al., 2019). Results suggest that the development of practical psychomotor skills and ability are achieved through training and real-time feedback (Massey et al., 2015; Saramma et al., 2016), bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills. Kallestedt et al. (2012) revealed that education and additional training positively affected nurses’ knowledge and attitudes towards performing CPR.
Cardiac arrest is a significant health problem, with thousands of patients suffering from cardiac arrest each year in North America (Lin et al., 2018). Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016). The use of simulation to enhance CPR skill acquisition and confidence has been identified as an effective methodology (Brennen et al., 2016; Cheng et al., 2015; Gonzalez et al., 2016; Horowitz, 2018; Lim et al., 2018). Several studies sought to address the effect of manikin simulators in translation to real-life emergencies (Adams et al., 2016; Curren et al., 2015; Lin et al., 2018; Niles et al., 2017). In-situ mock code simulation intervention programs that focus on the critical first five minutes of a cardiac arrest have demonstrated improved nursing responses to IHCAs (Herbers & Heaser, 2016).
The identified outcomes of simulation assist in development of this DPI. The use of simulation manikins is a precise objective assessment of high-quality CPR, specifically ECC (Brennan et al., 2016); visual instructor observations is not consistent to validate performance. The use of in situ methodology offers a modality of training to evaluate clinical team’s performance in procedures without direct patient interaction (Sullivan et al., 2015). Repetitive brief in situ simulation improves nurse’s performance of timely compressions initiation and defibrillation in cases of IHCA (Sullivan et al., 2015) and nursing staff confidence in managing a crisis event (Adcock et al., 2020). The in situ simulation modality provides awareness of latent safety threats that may not otherwise be prevented in a real-life scenario (Greer et al., 2019).
Does the implementation of a code-blue nurse champion role, as a cardiac arrest first responder, improve nursing self-efficacy and knowledge to initiate cardiac resuscitation and survival of IHCA patients when compared to current practice among adult medical surgical patients in an acute care hospital in California over four-weeks?
Q1: Does the implementation of a code blue nurse champion role increase survival of IHCA?
Q2:Does educational training consisting of IHI rapid response education, and cardiac arrest in situ simulation for code blue nurse champions increase self-efficacy and knowledge in responding to cardiac arrest?
This project is based on the following overall question—
Sub questions include…
One Group quasi-experimental design
Assess the effectiveness of implementation of the code blue nurse champion role to improve IHCA survival
Identify if the additional training makes a difference in nurses’ timely recognition of patient deterioration and if appropriate action impacts the survival of IHCA
A quantitative methodology was selected for this project to discover through statistical analysis quantifiable, objective data related to the implementation of code blue nurse champion role on nurses’ self-efficacy to respond cardiac arrest and survival of IHCA. This methodology was chosen over qualitative methodology because of the need to collect numerical data on IHCA and nurses’ self-efficacy to assess for significance; whereas qualitative cannot be tested for significance (Polit & Beck, 2012). A quantitative quasi-experimental design was selected for this project to assess the implementation of the code blue nurse champion role to improve IHCA survival. The specific design was chosen for translating research into a specific nursing unit to determine if translation of research works at a local level using a convenience sample. This strategy educates code blue champions by using rapid response education and simulations. The champions then use their education to improve practice in their units and departments (Banks & Trull, 2012). The data from the identified instrument and IHCA code data are reported quantitatively. Descriptive statistics were utilized to determine the relationship between variables or the significance of group differences or the effect of an intervention.
Specifics on Methodology: PICOT
P=Acute Care Registered Nurses’; Hospitalized patients experiencing IHCA
I=Code blue nurse champion role
O=Improved nurse knowledge, self-efficacy [attitude] towards CPR; improved IHCA survival
T=During four weeks timeframe
|Variable||Variable Type||Level of Measurement|
|Code Blue Nurse Champion Role||Independent||Nominal|
|Patient survival IHCA||Dependent||Ratio|
|Nurses’ self-efficacy (attitude)||Dependent||Ratio|
|Nurses’ knowledge||Dependent||Interval Scale|
Specifics on Methodology
Code blue nurse champion role
Rapid Response Education (IHI, 2008)
Roles and Purpose
Patient Physiological Changes
Early Warning Signs of Deterioration
Cardiac arrest in-situ simulation
Based on AHA BLS and ACLS Standards
Identified apneic patient
Provide high quality CPR
Current RNs on 4 South Telemetry Nursing Department
Code blue nurse champions received education including IHI rapid response education and cardiac arrest in situ simulation. The participants were current RNs on a select patient care unit. The education provided to nurses was adapted from the IHI website. The education includes RRT composition, role, and purpose, patient physiological changes and early warning signs of deteriorating status, when to call RRT, how to call RRT, and the SBAR (Situation, Background, Assessment, and Recommendation(s)) communication that should be used during calls.
In-situ simulation was focused on responding to a deteriorating patient, specifically on cardiac arrest, team roles, prioritizing actions, and effective communication, inclusive of the role of RRT. Simulation scenario was based upon AHA BLS and ACLS standards for frontline responders (Liew et al., 2011). The staff identified the unresponsive, apneic adult patient, called the code, assess the carotid pulse, and provide high quality CPR. Additional responders arrived with the crash cart and AED, turned on AED and applied pads, analyzed rhythm, and safely defibrillated if the AED indicated a shockable rhythm. Responders set up oxygen and suction, appropriately communicated with the code team (e.g., through SBAR format), and prepared to assist physician provider with endotracheal intubation.
Specifics on Methodology (cont.)
HIPAA waiver form completed
Not intended to provide generalizable results
Pre and Post Survey confidentiality
Retrospective IHCA data: de-identified
CAEPCR Questionnaire: ERC 2010 guidelines
Small sample size: Participants (N=18) and IHCA
Short time frame
Although this is considered a quality improvement project, approval was obtained from the IRB of both the project site and Grand Canyon University, Phoenix, Arizona. The project received IRB exempt approval. Written informed consent was not required, the HIPAA waiver form was completed.
Confidentiality for the participants was maintained for both contribution in the project as well as their survey responses. Records were not obtained or kept on participants names. Participants were voluntary participating in the project; their attendance and completion of the survey served as their voluntary attestation for participation. The participants were asked to seal and place their completed pre and post survey tools in a marked envelope (pre-survey and post-survey) after completion. The survey did not have any participant’s identifying information; survey numeric coding is based on the participants’ individual determination. The cardiac arrest data included de-identified existing retrospective data. The data was not coded such that a link exists that could allow the source of the data to be re-identified. After the study was completed, survey results were shredded and disposed of in a protected hospital bin, per hospital policy.
No adverse consequences were expected to any of the participants during the project. Participants were informed that the findings of this project may help promote the code blue nurse champion role. The project proposed to add to the body of knowledge on simulation modality for nursing in healthcare organizations.
Nursing Knowledge and Attitude in Cardiorespiratory Arrest (CAEPCR) questionnaire (Tiscar-Gonzalez et al., 2019)
Three distinct sections
Socio-Demographic data ( 8 questions)
Knowledge of CPR (11 questions)
Attitude / Self-efficacy (12 questions)
Three Delphi rounds
Piloted on a test-retest basis with a convenience sample of 30 RNs (Tiscar-Gonzalez et al., 2019); psychometric characteristic confirmed by 347 nurses
The Knowledge and Attitude of Nurses in the Event of a Cardiorespiratory
Arrest (CAEPCR) questionnaire comprises of three sections: sociodémographique
information, theoretical and practical understanding, and attitudes of ethical issues.
The questionnaire was designed using the Delphi technique (three rounds). The
questionnaire was adjusted and it was piloted on a test-retest basis with a convenience
sample of 30 registered nurses. Psychometric characteristics were assessed by
a sample of 347 nurses using Cronbach’s alpha. Descriptive analysis was performed
to describe the sociodemographic variables and Spearman’s correlation coefficient
to assess the relationship between two scale variables. Pearson’s chi-squared test used to study the relationship between two categorical variables. Wilcoxon Mann
Whitney test and the KruskalWallis test were performed to establish relationships
between the demographic/work related characteristics and the level of understanding.
Descriptive Data: participants (N=18); outcome population (N=155); Socio-demographic data
CAEPCR Data analysis: Paired one tail t-test
Pre and Post Knowledge Total Score
Pre and Post Attitude Total Score
Spearman correlation: Pre- and Post-Knowledge, Pre- and Post-Attitude
IHCA data: Fischer’s Exact Test
Examine for differences in proportions for survival pre- and post intervention
Incidental outcome: RRT calls
Chi-Square association between pre- and post-implementation
In the following slides are the statistical results of the instrument and incidence of IHCA.
The sample population for this quality improvement project were registered nurses (RNs) at an urban acute care hospital in Southern California. A total of two training sessions were completed. Eighteen RNs volunteered to participate in the quality improvement project. Each participant attended one training session, which included IHI rapid response education (IHI, 2008) and cardiac arrest in-situ simulation scenario. The mean observations for age was 39.0 (SD = 10.61). Of note, participants (89%), reported that they feel confident to attend a CPR event; yet, 17% had never performed CPR.
A key noted response by participants was their reported ablity to attend a CPR event: 11% did not respond favorably.
Do you feel able to attend a CPR event?
Do you feel able to attend a CPR event Yes No 88.89 11.11
Patient Population: N=155
Gender: Female (n = 71), Male (n = 84)
Top Admitting diagnosis:
Hypoxia (n = 10)
Hispanic Females 40%
Non-Hispanic Females 10%
Hispanic Males 40%
Non-Hispanic Male 20%
End-Stage Renal Disease (n = 8)
Hispanic Female 75%
Hispanic Male 25%
Hyperkalemia (n = 5)
Non-Hispanic Female 100%
Hispanic Male 60%
Non-Hispanic Male 20%
The outcome population for this project were the patients admitted to 4 South nursing unit during the 30 days of implementation of code blue nurse champion. For the project period, there was a total of 155 patients discharged from 4 South (n = 71 females; n = 84 Males); four patients are noted to have deceased during their hospital stay. The patient outcome was survival of IHCA. The most frequent primary admitting diagnosis included hypoxia (n =10, 40% Hispanic females, 10% non-Hispanic female, 30% Hispanic male, and 20% non-Hispanic male.; end stage renal disease (n=8, 75% Hispanic female, 25% Hispanic males); and hyperkalemia (n=5, 100% non-Hispanic female, 60% Hispanic male, and 20% non-Hispanic male).
Outcome population (cont.)
|Length of Stay||5.02||.91|
The average LOS was 5 days. The majority of patients 97.4% were discharged home alive.
Pre and Post Knowledge Total Score
One tail t-test
Homogeneity of Variance:
One tailed Wilcoxon signed rank
Pre and Post Attitude Total Score
One tail t-test
Homogeneity of Variance:
One tailed Wilcoxon signed rank
Spearman Rho correlation coefficient
The CAEPCR questionnaire included three sections: Sociodemographic data, knowledge, and attitude. Pre-intervention, participants completed the eight sociodemographic section. A one-tailed paired samples t-test was conducted to examine whether the mean difference of Pre- Knowledge Total Score and Post- Knowledge Total Score was significantly different from zero.
Homogeneity of Variance. Levene’s test was conducted to assess whether the variances of Pre- Knowledge Total Score and Post- Knowledge Total Score were significantly different.
A one-tailed Wilcoxon signed rank test was conducted to examine whether there was a significant difference between Pre- Knowledge Total Score and Post- Knowledge Total Score. The one-tailed Wilcoxon signed rank test is a non-parametric alternative to the paired samples t-test and does not share its distributional assumptions (Polit & Beck, 2012).
The attitude section were 12 likert scale questions, responses were on a Likert scale of one to five (i.e., 1 = strongly disagree, 2 = slightly disagree, 3 = neither agree nor disagree, 4 = slightly agree, and 5 = strongly agree). A total high score was 60, with a minimum score of 12. A one-tailed paired samples t-test was conducted to examine whether the mean difference of Pre- Attitude Total Score and Post- Attitude Total Score was significantly different from zero.
Homogeneity of Variance. Levene’s test was conducted to assess whether the variances of Pre- Attitude Total Score and Post- Attitude Total Score were significantly different.
A one-tailed Wilcoxon signed rank test was conducted to examine whether there was a significant difference between Pre- Attitude Total Score and Post-Attitude Total Score. The one-tailed Wilcoxon signed rank test is a non-parametric alternative to the paired samples t-test and does not share its distributional assumptions (Polit & Beck, 2012).
For this quality improvement project, Spearman rho (rs) correlational coefficient was used to determine the relationship between Pre-Attitude Total Score, Post-Attitude Total Score, Pre-Knowledge Total Score, and Post-Knowledge Total Score. A Spearman rho correlational coefficient is a statistical measure of the strength of a monotonic relationship between paired data (Polit & Beck, 2012).
Data analysis: IHCA
Fischer’s Exact Test of Independence
Identify if proportions for survival are different pre and post intervention
The de-identified information included deidentified IHCA data four weeks prior to the intervention and four weeks post the intervention. Data elements included data of cardiac arrest, location (nursing unit), and outcome of event (i.e., survival or deceased). Data was analyzed using a Fischer Exact test of Independence to determine if proportions for survival are different pre- and post-intervention (i.e., code blue nurse champion role).
Data analysis: RRT
Determine association between code blue nurse champion role implementation and RRT calls
Results: Pre and Post Knowledge
F (1, 34) = 0.14, p = .715
Wilcoxon Signed Rank:
V = 9.00, z = -1.73, p = .958
A one-tailed paired samples t-test was conducted to examine whether the mean difference of Pre- Knowledge Total Score and Post-Knowledge Total Score was significantly different from zero. The result of the one-tailed paired samples t-test was not significant based on a confidence level of 0.05, t (17) = -1.84, p = .959, indicating no difference in mean scores. This finding suggests the difference in the mean of Pre-Knowledge Total Score and the mean of Post-Knowledge Total Score was not significantly different from zero. The mean of Pre-Knowledge Total Score (M = 8.67, SD = 1.4) was not significantly lower than the mean of Post-Knowledge Total Score (M = 9.00, SD = 1.37).
The result of Levene’s test for equality of variance were not significant based on a confidence level of 0.05, F (1, 34) = 0.14, p = .715. The results suggest that it is possible that the mean Pre- Knowledge Total Score and Post-Knowledge Total Score were produced by distributions with equal variances, indicating the assumption of homogeneity of variance was met.
A Wilcoxon signed rank test was …