Developing a Code Blue Simulation Experience in Labor and Delivery

Over 700 women die each year due to pregnancy and delivery complications and most of these maternal deaths could have been prevented. It is imperative that Labor and Delivery nurses are prepared for a medical emergency to provide the best care possible. The purpose of this continuous improvement project was to develop a Code Blue simulation experience to increase Labor and Delivery nurses' comfort, competence and confidence in a Code Blue medical emergency. The pre-survey consisted of three demographic questions followed by eight informational questions to assess the nurses' perception of their role in a Code Blue as well as their perceived skill level. The 34 nurses in the Labor and Delivery department were divided into four groups to attend one day of the Bi-Annual Skills training. Labor and Delivery nurses participated in Code Blue simulation training which allowed the nurses to experience their role in a Code Blue situation. Roles and responsibilities were determined by the manager and learning specialist in Labor and Delivery with input from the Code Blue team at the hospital facility. Debriefing provided opportunities for expression of concerns, accomplishments and ways to improve. The post-survey consisted of the same questions as the pre-survey and demonstrated an increase in the nurses' comfort level, competence and confidence in a Code Blue situation. The majority of nurses at 70.5% responded they were strongly not confident, somewhat not confident or neutral to the question of how confident they felt in a Code Blue situation. Only 29.4% felt somewhat confident or strongly confident. Post-survey results showed 88.3% felt somewhat confident and strongly confident. In regards to competence, 58.8% felt strongly not competent, somewhat not competent and neutral with 35.3% feeling somewhat compete and only 5.9% feeling strongly competent. Post-survey results showed an increase to 41.2% feeling strongly competent with 50% feeling somewhat competent and 8.8% at neutral. The largest margin was Developing a Code Blue Simulation Experience 3 82.3% who felt strongly not comfortable, somewhat not comfortable and neutral in how comfortable they felt in a Code Blue situation. Only 17.6% felt somewhat comfortable or strongly comfortable. Post-survey results showed 85.3% felt somewhat comfortable and strongly comfortable. Comparison results from pre-survey and post-survey demonstrate that simulation training is an effective method of nursing education to improve the skills of the Labor and Delivery nurse.

Running head: Developing a Code Blue Simulation Experience Developing a Code Blue Simulation Experience in Labor and Delivery Georgette Louise White The University of Utah College of Nursing 1 Developing a Code Blue Simulation Experience 2 Abstract Over 700 women die each year due to pregnancy and delivery complications and most of these maternal deaths could have been prevented. It is imperative that Labor and Delivery nurses are prepared for a medical emergency to provide the best care possible. The purpose of this continuous improvement project was to develop a Code Blue simulation experience to increase Labor and Delivery nurses' comfort, competence and confidence in a Code Blue medical emergency. The pre-survey consisted of three demographic questions followed by eight informational questions to assess the nurses' perception of their role in a Code Blue as well as their perceived skill level. The 34 nurses in the Labor and Delivery department were divided into four groups to attend one day of the Bi-Annual Skills training. Labor and Delivery nurses participated in Code Blue simulation training which allowed the nurses to experience their role in a Code Blue situation. Roles and responsibilities were determined by the manager and learning specialist in Labor and Delivery with input from the Code Blue team at the hospital facility. Debriefing provided opportunities for expression of concerns, accomplishments and ways to improve. The post-survey consisted of the same questions as the pre-survey and demonstrated an increase in the nurses' comfort level, competence and confidence in a Code Blue situation. The majority of nurses at 70.5% responded they were strongly not confident, somewhat not confident or neutral to the question of how confident they felt in a Code Blue situation. Only 29.4% felt somewhat confident or strongly confident. Post-survey results showed 88.3% felt somewhat confident and strongly confident. In regards to competence, 58.8% felt strongly not competent, somewhat not competent and neutral with 35.3% feeling somewhat compete and only 5.9% feeling strongly competent. Post-survey results showed an increase to 41.2% feeling strongly competent with 50% feeling somewhat competent and 8.8% at neutral. The largest margin was Developing a Code Blue Simulation Experience 3 82.3% who felt strongly not comfortable, somewhat not comfortable and neutral in how comfortable they felt in a Code Blue situation. Only 17.6% felt somewhat comfortable or strongly comfortable. Post-survey results showed 85.3% felt somewhat comfortable and strongly comfortable. Comparison results from pre-survey and post-survey demonstrate that simulation training is an effective method of nursing education to improve the skills of the Labor and Delivery nurse. Developing a Code Blue Simulation Experience 4 Introduction Problem Each day, approximately 830 women die worldwide as a result of pregnancy or pregnancy-related complications. In some cases, complications, that may have been present before pregnancy, become life-threatening during pregnancy and childbirth. Life-threatening complications related to pregnancy and childbirth include obstetrical hemorrhage, hypertensive disorders, infections, delivery complications, amniotic embolism and pre-existing conditions that worsen during pregnancy (WHO, 2018). Many of these complications can be prevented and are treatable. In the United States alone, over 700 women die each year due to pregnancy and delivery complications (Centers for Disease Control and Prevention, May 9, 2018). Yet before 1987, the United States had a significantly lower maternity mortality rate of just 6.6 deaths/100,000 live births. By 2006, that rate had climbed to 13.3 deaths/100,000 live births a year. By 2010, the mortality rate had jumped again, to 21/100,000 live births. Due to these increasing maternal mortality rates in 2010, United States ranked 50th out of 240 nations in the world in regards to maternal mortality (Edwards & Hanke, 2013). Solutions to maternal mortality are well-known, and the majority of maternal deaths can be prevented (Green, Rider, and Ratchliff, 2015). With skilled nursing care, the lives of women and babies can be saved before, during and after childbirth (WHO, February 16, 2018). Available Knowledge The American Heart Association (AHA) reports that rapid response teams increase the chance of positive health outcomes in obstetrical medical emergencies (Roth, Parfitt, Hering, & Developing a Code Blue Simulation Experience 5 Dent, 2014). Simulation drills have been noted to increase nurses' capability by improving their communication skills, knowledge base and self-confidence. Simulation provides an environment that allows nurses to practice critical situations within safe surroundings, thereby allowing for mistakes while providing opportunities for growth (Crowe, Ewart, & Derman, 2017). It is imperative that nurses who work in an intrapartum and postpartum setting have the knowledge and skills necessary to respond appropriately in an obstetrical medical emergency. In most cases of pregnancy-related complications before or after birth, it is the nurse who must initiate suitable clinical intervention in order to increase positive outcomes (Bittle, O'Rourke, & Srinivas, 2018). Rationale In order to perform a Code Blue in the maternity setting, it is important to have an effective Code Blue team that communicates well, is organized, and has expert knowledge and skills (Prince, Hines, Chyou, & Heegeman, 2014). However, in most cases, Code Blue team members do not know each other well, and in a lifesaving situation, this simple fact could prove detrimental to the patient and the outcome. When a Code Blue team responds to a code in the Labor and Delivery department, such unfamiliarity with each other could play a huge role in the success or failure of the resuscitation. It puts not only Code Blue team members at a disadvantage, but the labor and delivery nurses must also face the challenge of being thrust into a Code Blue team with whom they are unfamiliar. In the current hospital, staff nurses in Labor and Delivery are required to maintain certification in Basic Life Support (BLS) and Advanced Cardiac Life support (ACLS). These courses allow staff members to practice life support skills in a classroom under the direction of an instructor. However, the courses do not allow all Code Team members to practice together, Developing a Code Blue Simulation Experience 6 nor do they provide information concerning Code Team roles or definitions of the Labor and Delivery nurse. In addition, since staff members practice within a classroom, nurses are denied the opportunity to use equipment available in the workplace. Simulation education provides an opportunity for staff members to practice situational scenarios, which have been shown to increase nurse confidence, knowledge and communication skills (Gogle, 2017). Simulation allows for an environment that gives opportunity to explore reactions to varying scenarios in a non-threatening environment (Crowe, Ewart, & Derman, 2018). Specific Aims The purpose of this Doctorate of Nursing Practice (DNP) project was to develop a Code Blue simulation experience in an effort to increase Labor and Delivery nurses' confidence, competence and comfort in an emergency situation. Such simulation drills allow for Labor and Delivery nurses to practice scenarios while using the department's equipment in a space where the actual event may occur. The first objective was to assess the current comfort, confidence and competence of the nurses within the Code Blue situation. The second objective was to develop a simulated Code Blue situation for the Labor and Delivery staff. The third objective provided an opportunity to implement a simulation training for the labor and delivery nurses. An evaluation of the nurses' confidence, competence and comfort after participating in a Code Blue simulation was the fourth objective. Developing a Code Blue Simulation Experience 7 Methods Context The 145-bed hospital located in Cache Valley, 80 miles northeast of Salt Lake City, serves residents of northern Utah, southeastern Idaho, and western Wyoming. The hospital is a not-for-profit, full-service facility, with a level three trauma center and level two-B maternity services. Approximately 2600 babies are delivered each year, and the facility delivers pregnant patients with moderate-to-severe maternal-fetal comorbidities. The facility does not have a neonatologist, and the required gestational age for delivery is 32 weeks and greater. If a patient is stable with less than 32 weeks gestation, or if a patient has severe maternal-fetal comorbidities, the patient will be transferred to a hospital with a higher level of care capability. The Labor and Delivery unit includes 12 labor rooms, 3 antepartum rooms, 2 operating rooms, and a 2-bed post-anesthesia care unit. Couplet nursing care is provided in the 35-bed mother/baby unit, and a special care nursery (SCN) provides care for babies above 32-weeks' gestation, with a nurse practitioner providing care 40 hours a week. Perinatologists and neonatologists are available through telehealth for consultation, and the medical department has a 24/7 hospitalist service. Participants in this study included 34 nurses that work in Labor and Delivery. All nurses included certification in basic support certification (BLS), advanced life support (ALS) and certified electric fetal monitoring (C-EFM). The simulation drills were developed using the best evidence from both current literature and previous simulation drills in Labor and Delivery. A team of nurses that serve on the Labor Developing a Code Blue Simulation Experience 8 and Delivery education committee met to develop simulation scenarios for a bi-annual skills update. Interventions A pre/post survey consisting of three demographic questions and eight nursing assessment questions using the Likert scale was developed by the author and approved by the project committee faculty member, as well as the IRB committee. • What is your age? • How many years have you been a registered nurse? • How many years have you been a Labor and Delivery nurse? • Do you believe the Labor and Delivery nurse has a specific role in a Code Blue? • Please rate your understanding of the Labor and Delivery nurses' role in a Code Blue. • Please rate your understanding of the other Team members' roles in a Code Blue. • Do you feel it would be helpful to better understand your role in a Code Blue? • Do you feel simulation training would be helpful to better understand your role in a Code Blue? • How confident do you feel in a Code Blue situation? • How competent do you feel in a Code Blue situation? • How comfortable do you feel in a Code Blue situation? Survey questions were distributed by the facility's Research Electronic Data Capture (REDCap) through the nurses' work e-mail. In the second week of February, nurses received a notification in their work e-mail requesting that they complete a survey. The introduction letter provided information concerning Developing a Code Blue Simulation Experience 9 the project and the option to participate or not participate (See Appendix A). The nurses could complete the survey in advance, or they could select to compete the survey on Skills Day, just before the simulation drills. The 34 participating nurses were divided into four different sections, and each nurse was assigned a Skill Day to attend: February 13, February 21, February 26, or March 6. On Skills Day, after an introduction to objectives, the nurses participated in a simulation drill in a Labor and Delivery room. Code Blue roles were defined and discussed. An emergency room nurse was present to provide in-depth information regarding the role of the Labor and Delivery nurse in a Code Blue, the placement of the Code Blue team in the room and their responsibilities (Appendix B). Nurses were required to actively participate in the Code Blue simulation drill. After the simulation drill, debriefing opportunities allowed for nurses to converse concerning positive and negative aspects of the drill. Nurses completed a post-survey after Skills Day was completed. Study of Interventions The theoretical framework used to develop the simulation drills involves Malcom Shepherd Knowles's Learning Theory. The four principles of this theory are as follows: adults take an active role in learning, adults use experiences from their past in order to learn, adults learn from practical applications that relate to work, and adults learn from working on solving problems, rather than remembering information (Pappas, 2013). By using a simulation drill to train Labor and Delivery staff in the appropriate response to a Code Blue, nurses on the unit will have a greater understanding of their role and will better understand the steps needed to ensure the best health outcomes (Roth, Parfitt, Hering, & Dent, 2014). While a Code Blue in the Labor and Delivery unit is very rare, in order to address a Code Developing a Code Blue Simulation Experience 10 Blue effectively, nurses must have an understanding of ACLS algorithms, Code Team roles, and the Labor and Delivery role in this emergency situation. Measures The simulation drill was developed by the Labor and Delivery education team under the direction of the author, the emergency room nurse and a unit learning specialist. A Labor and Delivery Code Blue Placement Chart was shared in the classroom setting before the simulation drill (Appendix B), and the roles of the Code Blue team were discussed. By using the Labor and Delivery unit patient room, nurses were able to practice an emergency mock code with the existing equipment in the Labor and Delivery unit. The Code was used to provide an opportunity for each nurse to participate as a member of a Code Blue team. Team members' roles were identified and explained by the education team. After each drill, debriefing sessions were held to allow for feedback and to review what went well and what went wrong within the simulation. Analysis Obstetric emergencies such as cardiac arrest are rare within the Labor and Delivery department, but when such an emergency occurs, all members of the interdisciplinary team must communicate and work together effectively. Practicing emergency skills has become a new alternative to classroom teaching (Gogle, 2017). Such simulation drills provide an opportunity for nurses to learn in a risk-free environment. The purpose of this quality improvement project was to develop a Code Blue simulation experience that allows for an opportunity to increase Labor and Delivery nurses' confidence, competence and comfort in an emergency situation such as a Code Blue. Developing a Code Blue Simulation Experience 11 Quantitative research data was collected through a REDCap survey tool. A pre-survey was administered via computer before simulation training in the Labor and Delivery department. After simulation training, a post-survey was administered. Descriptive statistics were used to collect and interpret the survey data. Ethical Considerations For this quality improvement project, approval was obtained prior to implementation from the Institutional Review Board (IRB) at the facility corporate office. The survey was submitted and also approved. All nurses in the Labor and Delivery department were given the opportunity to participate by completing the survey before the simulation training. While participation was optional, nurses may have felt compelled to complete the survey as their manager requested that they complete the survey. As a result, their responses may have been adapted to meet the intended responses. If the survey was completed within the hospital, nurses were paid by the hospital to complete the pre-survey and post-survey, possibly altering the responses as well. Results Within the Labor and Delivery department, 34 nurses completed the pre- and post-survey, for a 100% response rate. Demographic information was obtained with regards to the characteristics of the department. While two members of the staff, or 5.9%, were between 18-24 years old, the majority of the staff, or 52.9%, fell between 25-34 years of age. Three nurses, or 8.8%, were between the ages of 55-64 (Figure 1). Of the 34 nurses in Labor and Delivery, 15 nurses, or 44.1%, had less than five years' experience as a registered nurse. This demographic was followed closely by the number of Developing a Code Blue Simulation Experience 12 nurses with less than ten years' experience: 8 nurses, or 23.5%. This means the total number of nurses with less than ten years' experience was 23 nurses, or 67.6% (Figure 2). Cardiopulmonary Resuscitation (CPR) training is required every two years. Evidence suggests that any advances made during life support and basic skills training decrease after initial training. However, frequent practice of CPR skills will increase successful application of performing CPR or ACLS (American Heart Association, July 7, 2017). Due to the relative inexperience of the Labor and Delivery team, it follows that it would be beneficial to consistently work to improve the skills needed to effectively perform as a member of the Code Blue team. The third demographic question that was asked relates to the Labor and Delivery experience of the nurses. The data closely resembles the data obtained with regard to each nurse's years of experience as a registered nurse. This is perhaps due to the fact that within the past several years, many nurses have resigned in order to pursue careers in other areas of nursing. Of the 34 nurses in the Labor and Delivery department, 16 nurses have less than five years' experience, for a total of 47.1%. Combined with the additional nurses from the six to tenyear group, 25 nurses, or 73.6%, have fewer than ten years' experience as a Labor and Delivery nurse. The department also includes three nurses with 36-45 years' experience, with the most senior nurse having between 41-45 years' experience (Figure 3). The demographics of the Labor and Delivery department shows a team of nurses that have less than ten years of experience. Thus, another advantage of simulation training is that it allows for each nurse to participate in a Code Blue and make mistakes without the anxiety of injuring a live patient (Durham & Alden, 2008). Simulation drills provide an opportunity for nurses accustomed primarily to learning via technology to immerse themselves in a learning activity that helps to determine and clarity roles in an emergency situation. Simulations in the Developing a Code Blue Simulation Experience 13 clinical setting provide opportunities to learn that are consistent with adult learning theory (Durham & Alden, 2008). All nurses would benefit from exposure to a Code Blue event especially because it is not seen often in Labor and Delivery. When a patient is unresponsive, apneic, or does not have a pulse, a Code Blue should be called. Within any hospital facility, the Code Blue team will arrive within three to five minutes. It is imperative that the Labor and Delivery nurses know their roles in this medical emergency (Jackson & Grugan, 2015). In order to have an effective Code Blue team, the team must have effective communication skills, must be organized, must know the roles of the team, and must be competent in their knowledge and skills (Prince, Hines, Chyou, & Heegeman, 2014). Following the demographic questions in the survey, the first question addressed the issue of whether the Labor and Delivery nurse believed they had a specific role in a Code Blue. The nurses in the department had never participated in a Code Blue situation geared toward the resuscitation of a pregnant patient or a post-partum patient though their previous experience included ACLS certification every two years with other members within the hospital. The majority of the nurses responded that they felt they had a role in a Code Blue in the pre-survey. Further questions provided more information on whether they understood that role. Nurses somewhat agreed: 44.1% and 41.2% strongly agreed that they have a specific role in a Code Blue for a total of 85.3%. In the post-survey after simulation training, an increase in the strongly agreed category was noted at 88.2%. (Figure 4 and 5). During the intrapartum or postpartum period, emergencies can occur in a rapid sequence. The Labor and Delivery nurse must perform ongoing maternal-fetal assessment and be prepared for a medical emergency (Curran, 2003). To be successful in a Code Blue situation, the Labor and Delivery nurse must understand their role in a Code Blue, as well as the role of other team Developing a Code Blue Simulation Experience 14 members. Even with a inexperienced Labor and Delivery nurse team one to two nurses did respond they had an understanding of the roles in a Code Blue. The majority of nurses responded with a fair or good understanding of their role, as well as other team members during a Code Blue (Figure 6 and 7). The next two questions addressed the perception of the nurse with regards to understanding their role in a Code Blue as well as their perception of simulation training. Studies show that simulation training is frequently being used and has proven to be effective in increasing the quality of care during a resuscitation (Baker & Tyler, 2011). Data from the presurvey shows an engaged staff with the majority of nurses willing to learn their role in a Code Blue and also willing to participate in a simulation training to achieve that understanding. Data did show one nurse who strongly disagreed with the concept of simulation training and learning the role of the Labor and Delivery nurse in a Code Blue (Figure 8 and 9). The last three questions centered around the confidence, competence, and how comfortable the Labor and Delivery nurse felt concerning their role in a Code Blue situation (Figure 10 and 11). The simulation training provided an opportunity for nurses to practice resuscitation skills in order to increase their capability in a Code Blue medical emergency. Practicing BLS in a classroom does not allow for the nurse to practice CPR in a real working environment with a Code Blue team and the appropriate equipment. Evidence shows that simulation training improves the confidence of nurses during a Code Blue medical emergency (Smith, 2018). Developing a Code Blue Simulation Experience 15 Discussion Summary A key finding in the study provided information concerning the level of experience within the Labor and Delivery department. More than half of the nurses were 34 years of age or younger and 14 nurses had just 0-5 years of experience. If the level were raised to 10 years of experience, the number grew to 23 nurses. This data shows a need to develop processes to educate less experienced nurses in effective ways that help them grow in their nursing role. In 2018, a major report concluded that post-partum hemorrhage (PPH), cardiovascular and coronary conditions, infection, and cardiomyopathy caused the majority of maternal deaths in the United States (Slomski, 2019). These deaths may have been the result of unsuccessful treatments, medical errors, and/or lack of appropriate coordination of care surrounding the event. The pre-survey and post-survey demonstrated that Labor and Delivery nurses believe that they do have a specific role in a Code Blue medical emergency. The post survey showed that 30 out of 34 nurses strongly agreed that they have a role in a Code Blue. It is important that nursing staff believe they have a role in any medical event to best work toward coordination of care in a medical emergency such as a Code Blue. Further survey results showed that Labor and Delivery nurses felt it would be helpful to both understand their role in a Code Blue and perform simulation training to increase their skills for performing in a Code Blue medical emergency. For the simulation training to be effective, it is important for all staff members to be engaged and willing to learn. Pre-survey data showed that Labor and Delivery nurses felt they had a fair to good understanding of both their role in a Code Blue and the roles of other team members in a Code Developing a Code Blue Simulation Experience 16 Blue. After simulation training the response rate shifted to a good and very good understanding. Pre-survey data showed one nurse with a poor understanding, but the post-survey showed zero nurses with poor understanding. The focus of the pre-survey and post-survey focused on three questions: how comfortable the nurse felt in a Code Blue situation, how competent the nurse felt in a Code Blue situation and how confident the nurse felt in a Code Blue medical emergency. The pre-survey showed a wide variety of responses, from strongly uncomfortable, competent and confident to strongly comfortable, competent and confident. However, the post-survey after simulation showed a definite shift to greater understanding as nurses responded with an increase in how comfortable, competent and confident they felt during a Code Blue medical emergency. Interpretation Simulation training is currently used in many aspects of the corporate world and especially in health care. This type of training provides an environment that allows for nurses to practice real-life experiences, receive immediate feedback on performance, learn through collaboration with other nurses and staff members, and learn in a no-risk environment (Lindenberger, 2017). In 2014, a randomized, controlled trial was conducted by the National Council of State Boards of Nursing (NCSBN) to determine whether simulation training of nursing students was as effective as clinical hours in the hospital setting. Nursing students were divided into two groups. One group spent 25% of their clinical time in simulation training and 50% of the group spent their clinical time in simulation training. The results of the study showed that there was no difference in the NCLEX pass rate between the two groups (Aebersold, 2018). The trial showed that simulation training can be an effective method of education for nurses. Developing a Code Blue Simulation Experience 17 The second part of the trial included following the graduates into the work place to determine how well they performed in their new nursing positions. Managers reported no difference in nurses' performance, thus demonstrating that clinical hours can be successfully replaced by simulation training in a lab setting. The feedback provided by the students also demonstrated a willingness to learn by simulation training (Aebersold, 2018). The pre-survey allowed the nurses to express their thoughts on the role of the Labor and Delivery nurse in a Code Blue situation as well as how comfortable, confident and competent they felt when it came to a Code Blue. The responses rating the efficacy of simulation training included 28 nurses who strongly agreed to its efficacy, five nurses who somewhat agreed and one who remained neutral. The results demonstrated a willingness by the nurses to learn and grow in their Code Blue skills by using simulation training. Even though maternal codes are rare in Labor and Delivery, nurses must be prepared for any medical emergency. It is important for each nurse to understand the ACLS algorithm, as well as the skills necessary to participate in a Code Blue (Roth, Parfitt, & Brewer, 2015). This continuous improvement project demonstrated an increase in the understanding of the role of the Labor and Delivery nurse in a Code Blue as well as an increase in nurse competency levels, confidence levels and comfort levels in a Code Blue medical emergency. The data showed that simulation training does indeed align with current research studies which show that simulation training is beneficial in nurse education. Limitations The continuous improvement project was completed in one Labor and Delivery department with only 34 participants with varying degrees of experience. The Code Blue drill performance could have been influenced by various factors, such as the experience level of each Developing a Code Blue Simulation Experience 18 nurse participating. The Skills Update was held on four different dates, each a week apart which may have increased the level of performance of nurses in later simulation training, due to the fact the nurses knew more about the process and expectations. Several nurses did not have ACLS certification, whereas some nurses had years of experience in maintaining their ACLS certification. Another limitation was the requirement for nurses to participate in the Code Blue simulation training. The pre-survey and the post-survey were not required but participation in the drill was a mandatory part of the nurses' yearly education training. Conclusion Even though Code Blue situations are rare in Labor and Delivery, it is important for nurses to be prepared for any medical emergency event. By participating in simulation training nurses can gain a better understanding of their role in a Code Blue, as well as actively practice their role. Simulation training has been proven to be an effective method of education that allows nurses to practice in a controlled environment without harm to an actual patient. With women's mortality rates in the United States increasing, it is imperative that Labor and Delivery nurses act and prepare for any type of medical emergency. Simulation training provides an avenue for nurses to utilize ACLS skills, improve communication skills, and work with a Code Blue team. The simulation training provided at the Skills Update sessions enhanced the skills of the Labor and Delivery nurses to prepare them for any type of medical emergency, thereby ensuring the safest and best care for mom and baby. Developing a Code Blue Simulation Experience 19 Acknowledgments Thanks to Julie Balk and Teresa Garret, my respected professors, for their guidance and help in developing and completing this continuous improvement project. The project changed direction many times but the finished project is exciting and helpful. I am deeply indebted to Greg Snow who is an expert at REDCap and was very patient with all my problems and questions. He was so kind and always willing to help, regardless of my (sometimes inconvenient) timing. Thank you to my two Learning Specialists, Jeanine Bouknight and Keana Grover, for their dedication in running the simulation training and making it a worthwhile experience for the nurses in Labor and Delivery. A very special thanks to my staff in Labor and Delivery. They are truly wonderful nurses that give their best every day for our patients and their families. They strive to keep their patients safe and give the best care possible. Last but not least, thank you to my family for their love and support, and extra thanks to Luke for his help with the graphs. I could not have done it without you supporting me every inch of the way. Developing a Code Blue Simulation Experience 20 References Aebersold, M., (2018, April 3). Simulation-based learning: no longer a novelty in undergraduate education OJIN: The Online Journal of Issues in Nursing, 23(2). American Heart Association (July 7, 2017). https://cpr.heart.org/idc/groups/ahaeccpublic/@wcm/@ecc/documents/downloadable/ucm_496707.pdf Baker, A., & Tyler, A. (2011, September). Taking code blue education to the units. Nursing2011, 41(9), 14-17. Bittle, M., O'Rourke, K., & Srinivas, S. K. (2018). Interdisciplinary skills review program to improve team responses during postpartum hemorrhage. JOGNN, 47, 254-263. Crowe, S., Ewart, L., & Derman, S. (2018). The impact of simulation-based education on nursing confidence, knowledge and patient outcomes on general medicine units. Nurse Education in Practice, 29, 70-75. Curran, C. A. (2003, May). Intrapartum emergencies. JOGNN, 32(6), 802-813. Durham, C. F., & Alden, K. R. (2008). Enhancing patient safety in nursing education through patient simulation. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Edwards, J. E., & Hanke, J. C. (2013, October/November). An update on maternal mortality and morbidity in the United States. Nursing for Women's Health, 17, 376-388. Gogle, J. (2017, February/March). Using simulation-based learning to prepare for a potential cardiac emergency on the labor unit. Nursing for Women's Health, 21, 21-27. Green, M., Rider, C., & Ratcliff, D. (2015). Developing a systematic approach to obstetric emergencies. JOGNN, 44, 677-682. Jackson, J. E., & Grugan, A. S. (2015, May). Code blue: Do you know what to do? Nursing2015, 45(5), 34-39. Developing a Code Blue Simulation Experience 21 Lindenberger, J. (2017). 8 top benefits of training simulations in the workplace. Retrieved from https://www.lindenbergergroup.com/8-top-benefits-training-simulations-workplace/ Prince, C. R., Hines, E. J., Chyou, P., & Heegeman, D. J. (2014, March 25). Finding the key to a better code: code team restructure to improve performance and outcomes. Clinical Medicine and Research, 1-19. Roth, C. K., Parfitt, S., & Brewer, M. (2015, February 2015). Effectiveness of an obstetricsbased advanced cardiac life support education program. JOGNN, 44(4), 518-526. Roth, C. K., Parfitt, S. E., Hering, S. L., & Dent, S. A. (2014, October/November). Developing protocols for obstetric emergencies. Nursing for Women's Health, 18, 379-390. Slomski, A. (2019, March 13). Why do hundreds of US women die annually in childbirth? JAMA, 1-3. Smith, L. R. (2018). Improving cardiopulmonary resuscitation skills using unit-based simulation (Doctoral dissertation). Retrieved from http://web.b.ebscohost.com/ezproxy.lib.utah.edu/ehost/detail/detail?vid Developing a Code Blue Simulation Experience 22 Appendix A Introduction Letter Developing Code Blue Simulation for the Labor and Delivery Nurse The purpose of this study is to develop a Code Blue simulation experience in an effort to increase Labor and Delivery nurses' confidence, competence and comfort in an emergency situation. We are completing this study to determine whether or not simulation training will improve the nurses' confidence, competence and comfort in a Code Blue situation. I would like to ask you to complete a brief computer survey. Data obtained is maintained on an encrypted computer system. Your answers are kept confidential and will be viewed only by the researcher Georgette White. If you have any questions or if you feel you have been harmed by this research, please contact Georgette White, Labor and Delivery manager at Logan Regional Hospital at Intermountain Healthcare. Phone number is 435-770-1998. If you have questions regarding your rights as a research subject, or if problems arise which you do not feel you can discuss with the Investigator, please contact the Intermountain Institutional Review Board at 1-800-321-2107 or by email at [e-mail]. It should take 15 minutes to complete the questionnaire. Participation in this study is voluntary. You may choose not to take part. You may choose not to finish the questionnaire or to omit any question you prefer not to answer without penalty or loss of benefits. By returning this questionnaire, you are giving your consent to participate. I appreciate your willingness to consider participation in this study. https://intermountainhealthcare.org/redcapsurveys/surveys/?s=XRNXKNNFEL http://j.mp/2Dqbw1B Developing a Code Blue Simulation Experience 23 Appendix B Labor and Delivery Code Blue RT/Airway 1.Assist with airway procedures 2. Ask for ETCO2 3.Maintain oxygenation and ventilation 4.Obtain ABGs/artlines Anesthesiologist 1. Airway ER/RN Medication Lead Assist 1.IV patency 2.Medicaitons CPR CPR L&D/RN 1.Start CPR until Code team arrives 2.Gives report 3.Massage uterus 4.Assist Obstetrician 5.Stays in room Staffing/Crowd Control 1.Ensure that only the appropriate team members are in the room 2.Monitor who goes in/out for CPR rotation, 2 in room with rest outside of door PPH Cart Code Cart ICU/RN Defibrillator 1.Usually first code member to arrive- Stay team lead until ER/MD arrives. 2.Attach defibrillator. Shock if indicated 3.Give team lead report to ER/MD 4.Establish another/initial IV line 5.Stay with defibrillator and help with pulse checks &rhythm checks every 2 minutes 6. Monitor quality of CPR ER/MD Team Lead 1.Gets Report from ICU and L&D RN 2.ACLS Runs Code 3.Intubation unless delegates to RT or Anesthesia 4.Calls out rhythm at pulse Obstetrician MCU /RN Recorder 1.Record event of Code 2.Report 2 minutes intervals to team lead Surgical RN 1.Obtain ultrasound, glideslope, and CPR stool 2.Assist with Code In the hallway to assist as needed CPR Phlebotomy Social Worker EKG Radiology Developing a Code Blue Simulation Experience Figures Figure 1: Age of Labor and Delivery Nurses 24 Developing a Code Blue Simulation Experience Figures Figure 2: Years of Experience as a Register Nurse 25 Developing a Code Blue Simulation Experience Figures Figure 3: Years of Experience as a Labor and Delivery Nurse 26 Developing a Code Blue Simulation Experience 27 Figures Figure 4: Code Blue Simulation Pre-Survey 20 15 10 5 0 Strongly Disagree Somewhat Disagree Neutral Somewhat Agree Strongly Agree Do you believe the Labor and Delivery nurse has a specific role in a Code Blue? Figure 5: Code Blue Simulation Post-Survey 35 30 30 25 20 15 10 5 1 0 1 2 Strongly Disagree Somewhat Disagree Neutral Somewhat Agree 0 Strongly Agree Do you believe the Labor and Delivery nurse has a specific role in a Code Blue? Developing a Code Blue Simulation Experience 28 Figures Figure 6: Code Blue Simulation Pre-Survey 25 20 15 10 5 0 Poor Fair Good Very Good Please rate your understanding of the Labor and Delivery nurses' role in a Code Blue? Please rate your understanding of the other team members' roles in a Code Blue Figure7: Code Blue Simulation Post-Survey 25 20 15 10 5 0 Poor Fair Good Very Good Please rate your understanding of the Labor and Delivery nurses' role in a Code Blue. Please rate your understanding of the other Team members' roles in a Code Blue. Developing a Code Blue Simulation Experience Figures 29 Developing a Code Blue Simulation Experience 30 Figures Figure 10: Code Blue Simulation Pre-Survey 20 15 10 5 0 Strongly Not Somewhat Not Neutral Somewhat Strongly How comfortable do you feel in a Code Blue situation? How competent do you feel in a Code Blue situation How confident do you feel in a Code Blue situation? Figure 11: Code Blue Simulation Post Survey 20 15 10 5 0 Strongly Not Somewhat Not Neutral Somewhat How comfortable do you feel in a Code Blue situation? How competent do you feel in a Code Blue situation? How confident do you feel in a Code Blue situation? Strongly