Hey Scott and Joe, You guys mentioned in the podcast the lack of evidence and clinical outcomes data to support instituting this across the board. You guys also made a very reasonable and cogent argument for changing practice in the absence of clear evidence. I would humbly add, however, that there is preponderance of evidence in the Human Factors literature that would support such an approach to running a code. We know that stress, increases in work load (particularly things that uses a lot of brain power like diagnostic reasoning), and time pressure all result in decreased capacity to effectively process information (decreasing cognitive “bandwidth”). This cognitive overload results in increased errors, lapses in situation awareness, and decreases in prospective memory (remembering to do something in the near future). We also now understand that multitasking is largely a myth and what we end up really doing as rapid task-switching which can also be problematic. Finally, it is become clear that interruptions are also a source of error and lapses in concentration. (NOTE: I’m sure my friends in the human factors world can point out some additional issues as well) Codes, by their very nature, exhibit many of these aforementioned characteristics.… Read more »

Great discussion. I have been implementing some of these ideas with agreeable physicians in the last two years as a bedside ED nurse and I have received great feedback. It is a huge pet peeve of mine when I see an RN code recorder state all too timidly, “that’s two minutes, rhythm check,” followed by silence as physicians discuss the beyond-ACLS problems. A few seconds later, “are we doing a rhythm check?” Can’t handle it. As nurses we have to claim ACLS and own quality CPR, something we can do very well, so that ED physicians can do what they do best during a code. Now transitioning to the NP role, I look forward to advocating for nurse-led codes. Thanks for covering this and empowering nurses to take leadership. Another major barrier: Nurse educators are so overwhelmed with on-boarding new RNs (due to incredibly rapid turnover, 11.2 to 17.2% nationally from 2011 to 2015, see http://bit.ly/2v5bgmH ) that developing training for plans like these take a back seat… Nurse turnover is and will be one of the biggest challenges for urban EDs. So Scott, what barriers did you face with implementation? Do all your physician colleagues do nurse-led codes? John… Read more »

Hi Scott and Joe,

I am an Emergency Trained RN practising in Singapore. Thank you for the great podcast and it really spurs my thoughts on this Nurse-led Code. My team and I are trying to get buy in from our nurses on this. Thus, I would like to know what are the positive vibes do your nurses received from co-leading codes with physicians.

Sean Seah, BN, RN, Adv Dip in Nursing (Emergency)
Changi General Hospital, Accident & Emergency Department
Singapore
No conflicts of interest

Very interesting post. Any thoughts of how this dynamic could play out during in-hospital arrests where the nurses and docs are a) not co-located and b) do not train/simulate together and c) there is often little to no consistent attending oversight? I’ve wondered whether our rapid response nurse team should actually run these codes, rather than an on-call medicine resident who may have little experience in such situations.

I have always asked myself why nurses cannot apply ACLS and lead the code in the hospital and now this is the answer. Have you heard about ths being used in ICU?

I’m interested that you mentioned delaying defibrillation to place an arterial line. Isn’t timely defibrillation one of the only things that has evidence to improve outcomes? I feel like that should be prioritized over almost anything else, especially an arterial line. If you are cannulating for ECMO, I could understand not defibrillating but not just for an a-line

[…] use methods such as nurse led codes and well established […]

We are going live with this at UVM in September! There’s a lot of excitement about this in our department from both the nurses and physicians. It’s great to hear how other people are approaching this. Thanks!

This isn’t describing a nurse-led code. A(C)LS trains any person to call out the next guideline steps, as you are having the nurse do, which is an excellent idea to cognitively offload the person who is actually leading the arrest – which is actually the physician, as you repeatedly reaffirm during the podcast. Nice branding (I’m sure ‘nurse-led’ really helps with some CRM and having buy-in from the nursing staff) but the name is actually misleading. Your described technique is well-known to pilots, who will often have the First Officer fly the plane in an emergency, so that the Captain can concentrate on the more complex management, without being bogged down in the simpler mechanical task of manipulating the aircraft. DÓI: nurse on cardiac arrest teams for 10 years (led (in the true sense) plenty of arrests as a nurse, until a superior mind could provide higher-level guidance), now qualified as a physician, and still leading arrests! I think you have taken the phraseology too far – to the point where CRM will suffer as a consequence of not understanding who the leader actually is (I was certainly confused, until I heard during your podcast that the nurse wasn’t actually… Read more »