1. TeamSTEPPS for Code Blue Teams: Piloting SBAR & CUS for Interprofessional Team Education
April 8, 2015

2. Rules of Engagement Audio for the webinar can be accessed in two ways:
Through the phone (*Please mute your computer speakers)
Through your computer
A Q&A session will be held at the end of the presentation
Written questions are encouraged throughout the presentation and will be answered during the Q&A session
To submit a question, type it into the Chat Area and send it at any time during the presentation
The lines may open for call-in questions during the Q&A session

3. Acknowledgements Project Sponsors Project Team Jim Battles, PhD (AHRQ)
Heidi King, MS (DoD)
Project Team
Health Research & Educational Trust (HRET)
Barb Edson (Project Director)
Chris Hund (Project Manager)
IMPAQ International
David Baker (Team Lead)

4. TeamSTEPPS Master Training
Two-day training course
Train-the-trainer approach
Prepares you to serve as a TeamSTEPPS Master Trainer by
Providing instruction on TeamSTEPPS tools and strategies
Providing an opportunity to develop and plan your TeamSTEPPS implementation
Prepares you to serve as a leader for implementing TeamSTEPPS within your organization

5. Upcoming TeamSTEPPS Events
Monthly Webinars
Scheduled through September 2015
Topics, speakers, and registration information will be posted on the portal
Register now for the May webinar: I-PASS: Integrating High Quality Handoffs into TeamSTEPPS and Hospital Care
Master Training Courses
Registration available for courses through August 2015
Online Course Availability
Not able to travel? TeamSTEPPS 2.0 Online Master Trainer Course now available
Register and enroll at:

6. Upcoming TeamSTEPPS Events (Cont’d)
Annual Conference
June 16-18, 2015
Denver, Colorado at the Westin Downtown Denver
Learn more and register for all events at

7. Help Line (312) Or

8. Today’s Presenters Ken Miller, RN, MSN, CCRN Edward Lee, MD
Simulation Education Program Coordinator
Department of Nursing Practice, Research, and Education
Edward Lee, MD
Assistant Clinical Professor, Hospitalist Section
UCLA Department of Internal Medicine
Chair, Code Blue QI Committee

9. Objectives
Provide an overview of Code Blue teams and interprofessional team education at UCLA
Describe the identification of the need for TeamSTEPPS tools among code blue team members
Describe how interprofessional code team training and TeamSTEPPS tools are being implemented
Present data measuring the effectiveness of the intervention

10. Code Blue Team Overview
Ronald Reagan UCLA Medical Center
Level I Trauma Center
520 Acute inpatient beds
6 different intensive care units (ICU)
Teaching hospital with 76 ACGME accredited programs and over 1000 physician trainees
Tertiary/quaternary referral center
High volume transplant center

11. Code Blue Team Overview
Code Blue Team Composition
Medical ICU Resident and Intern
Coronary Care Unit Resident and Intern
Anesthesia Senior Resident
Critical Care Transport RN
Pharmacist
Respiratory Therapist
EMT/Escort
Security, Chaplain, Bed Control
*Nurses from the affected unit

12. In-Situ Education 3-Minute Mock Codes
Emphasis on the first three minutes of a code
Objectives include the development of:
Leadership Skills
Role Designation
SBAR Communication
Early and High Quality Compressions

13. Interprofessional Education (IPE)
August 2012 – Begin advanced simulation training for internal medicine junior and senior residents. Sessions scheduled “just in time” prior to residents being on the code pager.
January 2013 – Sessions become interprofessional with med/surg nurses, ICU nurses, and critical care transport nurses.
July 2014 – Department of Anesthesia commits residents to the IPE sessions.

14. Interprofessional Education (IPE)
– 13 sessions
– 20 sessions
– Anticipated 25 sessions

15. Interprofessional Education (IPE)
3 Cases per Session (1/2 day)
Intracranial hemorrhage
Cardiogenic shock
Advanced arrhythmia
GI Bleed
Status Asthmaticus
Sepsis
Dual patient triage scenario
Debriefing after each case
Teamwork and communication
Medical decision making

16. Identifying Areas for Improvement
Sources of information
Personal experience in codes at UCLA
Informal survey of healthcare providers about issues related to teamwork and communication
Quality improvement committee reviews
Data from event reports
Observation of teams during IPE sessions

17. Identifying Areas for Improvement
Four Items Identified
Issue
Intervention
Key information not effectively shared
Team members not speaking up when problems are noticed
Orders not heard/completed
Team not “on the same page”

18. Identifying Areas for Improvement
UCLA became a TeamSTEPPS training center in early 2013, practically coinciding with the start of IP Code Team training
TeamSTEPPS provided the mental framework and vocabulary to better understand teamwork, helping us to more effectively train our providers

19. Identifying Areas for Improvement
Four Items Identified
Issue
Intervention
Effective Communication
SBAR
Advocacy and Assertion
CUS, Assertive Statement
Verify and Validate Information Exchange
Closed-Loop Communication
Shared Mental Model
Using the Huddle

20. SBAR Examples of the Problem
Code Team did not hear from primary MD that a patient with an intracranial bleed was taking Coumadin.
Primary MD did not feel comfortable with information relayed by nurse, leading to a delay in management of septic patient.

21. SBAR
Poor communication noted during nurse-to-primary MD communication and during primary MD-to-Code Blue Team communication
Intervention – SBAR
Situation―What is going on with the patient?
Background―What is the clinical background or context?
Assessment―What do I think the problem is?
Recommendation―What would I recommend?

22. Assertive Statement, CUS
Examples of the Problem
While waiting for norepinephrine drip to be prepared, the anesthesia resident fails to suggest bolusing pressors despite having drugs available.
Team leader reads EKG as non-STEMI. Another team member clearly sees that the EKG shows a STEMI, but fails to speak up.

23. Assertive Statement, CUS
Failure to “speak up” when mistakes or delays in care were noticed by a team member
CUS
Concern
Uncomfortable
Safety issue
Creating a culture of collaboration
Team training facilitates the notion that all team members are important and have contributions to make

24. Closed Loop Communication
Examples of the Problem
Vitamin K is ordered by MD, but is not clearly communicated to anyone, resulting in the drug not being given to the patient.
Arterial blood gas ordered by MD, but nobody took responsibility thus the blood was not sent. This was only realized when results were later requested, only to discover that the ABG was never done.

25. Closed-Loop Communication
Communication, particularly orders, often not clearly directed
Closed-Loop Communication

26. Huddle – Shared Mental Model
Examples of the Problem
Providers physically segregate based on specialty
Providers cognitively segregate based on tasks (Ex – airway team only communicating with each other)
Anesthesia resident nearly gives succinylcholine for induction because he was not aware that the team was considering increased intracranial pressure

27. Huddle – Shared Mental Model
Teams tend to self-segregate into groups (silos) resulting in poor communication between providers
Huddle
Brief, ad-hoc “meeting” to regain situation awareness and bring everyone back to a shared mental model
Effective for discussing critical events/actions
Breaks down silos by encouraging cross communication

28. Implementation Team training works, but only if you do it!!
Get institutional buy-in
Identify champions from each provider group
Train the trainers
Motivate providers to participate
A simulation center is helpful, but not required!

29. Implementation Get institutional buy-in Patient outcomes
Financial considerations (risk management)
Reportable data
Educational needs of training programs

30. Implementation Identify champions from each provider group
Understanding of politics/motivations
Understanding of schedules, practical barriers
Understanding of areas for improvement
Important for curriculum design to ensure that key competencies are being addressed

31. Implementation Train the trainers
All instructors take a 2-day simulation instructor course
Most instructors have participated in a TeamSTEPPS course
Structured debriefing is used by all instructors and addresses teamwork/communication first
Model behaviors – describe and demonstrate the skills

32. Implementation Motivate providers to participate Mandatory
Offer CME or CE credits
Show outside data – Everyone wants to improve
Pilot in certain areas then show gains to more resistant areas to get buy-in
Peer pressure/Word of mouth

33. Barriers Encountered Time (participants and instructors)
Support from institution
Participation from some groups
Scaling to the entire health system

34. Measuring Progress
2012 – Began collecting data on teamwork and communication using 5 questions included on our event reporting system
Was a code leader clearly evident throughout the code?
Was information consistently shared among team members?
Were the workload and tasks appropriately distributed between team members?
Did team members communicate effectively with one another?
Rate the overall teamwork during the code.

35. Measuring Progress Limitations
Not a validated questionnaire
Event reports on codes are completed by nurses
Subjective rating scale
Bias – nurse who completes the report was also present during the resuscitation
Positive response – defined as an answer of 4 or 5 on 1-5 scale or “Yes” to Yes/No questions

36. Measuring Progress

37. Measuring Progress What about patient outcomes?
Caveat - Many quality improvement projects related to resuscitation were initiated between 2012 to current

38. Measuring Progress

39. Summary
Interprofessional team training is an important part of Code Blue Team performance
TeamSTEPPS concepts are effective at teaching teamwork skills and creating a culture of mutual support
Pick specific skills to emphasize that are relevant to your Code Blue Teams – We emphasize SBAR, CUS, Closed-Loop Communication, and Huddles
Barriers to progress exist, but can be overcome!

40. Summary
In hospital cardiac arrest outcomes can be improved!!!!

41. Questions and Answers

42. Thank You!
For more information, please contact our team at: