The Lifesaver team (L-R): SSN Nor Syamsul Nazly Bin Mohamed Said, NSCU, co-leader; ANC Huang Na, Ward 56; ANC Lim Choon Chai, leader, NDU; and ADN Jonathan Sim, facilitator, from Nursing Administration. Not pictured are ADN Teo Lee Wah, NSCU; NC Sun Xia, Ward 44; and SSN Sivaranjini Siva, Short Stay Unit.

Code blue refers to an emergency situation in a hospital in which a patient is in cardiac or respiratory arrest. When code blue is activated, a team of healthcare professionals comprising doctors and nurses (known as the code blue team) will be responsible to render immediate care to the patient.

Confidence matters
As first responders of the code blue team, nurses play an important role in delivering care in a fast and accurate manner within the first few minutes of a patient’s collapse, and can bring about positive outcomes for the patient.

“Basic Cardiac Life Support (BCLS) course and Life Support Course for Nurses (LSCN) are the two essential training courses, and the training certificates are valid for two years only. Certified nurses will need to undergo reassessment to keep their skills relevant,” shared Assistant Nurse Clinician (ANC) Lim Choon Chai from Nursing Development Unit (NDU), also the leader of quality improvement team, Lifesaver. He stressed that the stringent criteria for the courses is to ensure participants meet the competency level to deliver the right care to the patient.

Critical skills competency programmes like BCLS and LSCN is designed to validate knowledge and skills but does not provide learning opportunities in a real clinical setting.
From a survey conducted by the team, it was noted that almost half of nurses in NHCS expressed the lack of confidence in their ability to lead a team in managing a code blue scenario. While recognising that about 15% of respondents were new to the organisation, the team believes that gaining experience can build up their confidence over time.

“The tricky part is that though you’ve passed the courses, the knowledge and confidence may diminish if there’s no opportunity to practice,” shared co-leader Senior Staff Nurse (SSN) Nor Syamsul Nazly Bin Mohamed Said from the Nursing Specialty Care Unit (NSCU).

Continuous practice helps
“An average of 25 minutes was taken to complete a resuscitation – this was what we discovered through eight mock sessions of code blue activations,” said SSN Syamsul. Not only was the timing not acceptable, more observations were noted such as staff and processes being disorganised and poorly coordinated during the resuscitations, unfamiliarity of the emergency medical equipment and lack of quality chest compression. Through further analysis, the Lifesavers team identified the key root causes which included role uncertainty during medical emergencies and a lack of clear guidelines to follow when responding to these situations. 

Following that, the Lifesavers implemented an in-situ simulation training to better make use of available resources, “Regular simulations allow our nurses ample opportunities to practice in order to retain and refresh their skills and knowledge. To make the training more realistic, the ECG simulator is used to simulate a code blue right beside the patient’s bedside.”

The team also set their goal to complete a resuscitation within 10 minutes, in accordance to the American Heart Association’s (AHA) guidelines and Institute for Healthcare Improvement’s (IHI) standards.

Hitting the mark
With a realistic and interactive simulation programme in place, progress was remarkable.

The realistic training environment propelled nurses’ confidence in handling code blue scenarios.
“The guidelines provide clarity, thus helped increase nurses’ skills and confidence in responding to emergency situations. We are very proud to attain our goal of 10 minutes for the time taken to complete a code blue procedure,” shared Assistant Director of Nursing (ADN) Jonathan Sim who facilitated the team’s progress.

“Through the project, our nurses have gained confidence in delivering better critical care in a code blue scenario, and as confidence increased, staff morale and teamwork improved too!” beamed team member, ANC Huang Na from Ward 56.
For their excellent improvement initiative, the Lifesaver received the Gold award at the Team Excellence Symposium, part of the Innovation & Quality Circles (IQC) movement organised by the Singapore Productivity Association.