I am joined again by my good friend, Joe Bellezzo, to discuss the nurse-led code. I've been doing this at my two shops for about a decade. Joe, along with his partners-in-crime Zack Shinar & Chris Ho, have set up a beautiful process for nurse led code management at their hospital, Sharp Memorial in San Diego.
Stuff Mentioned in the Podcast
- Here is the tactical-approach podcast from EDECMO.org
- EMCrit Intra-Arrest Management Lecture
- Podcast 191 – Cardiac Arrest Update
The SBM Nurse Leader Responsibilities
- Call for Epi q 5 minutes. Once A-line is in, decide on epi based on art line DBP<40
- Pre-announce the rhythm check 30 seconds beforehand
- Call for the rhythm check
- Act as the receiver for all requests from the team and assign people to get these tasks done
- Spur doc-leader based on timing of code and any thoughts that occur while having a non-task focused view of the code
Update:
CANLEAD Study on the Nurse-Led Code in simulation
Additional New Information
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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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… Read more »
great points!! you’ve touched on the major issue, new nurses and no time to train them. this is why we only ask for the 4 points (the first 4 of the 5 above)–all of which can be briefed in <30 seconds before the patient arrives. Give epi every 5 minutes, tell us 30 sec before rhythm check, announce the rhythm check, and assign nurses to get tasks done. No extensive on-boarding necessary (though it sure would be beneficial). A cheatsheet with those 4 points could easily be made and put on to the code sheets.
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!
do you folks have a formal protocol? if so, would you consider linking
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… Read more »
Shane-think we agree on everything but semantics. Now, I love arguing semantics and could do it for hours. Not sure there is much of a quibble here though. The term “leader” can mean many things, I would say a majority of “leaders” in our daily lives are carrying out rote roles. In our system there is a physician code-leader and a nurse code-leader, they Co-lead. There is no ambiguity or conflict in those 2 roles, they work in concert with each other and the team. I think the only place the semantics break down is if we have a preexisting… Read more »
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 think the RRT nurse should definitely take the helm as mentioned above. The med resident would be filling the System I role, though not as effectively as someone more experienced. And of course the RRT Nurse will likely be spurring most of that system I thinking when the doc forgets/doesn’t yet know.
The RRT nurse would be paralyzed if another code is called in the hospital while trying to lead this one. The question now is who is going to lead? The charge nurse or the nurse taking care of the pt who is currently coding?
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… Read more »
amazing comments as usual!!!!!
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?
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
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
Hi guys, ER Nurse living in Norway here. Doing my 14th year in Norway’s largest ED, but kinda new to EmCrit so I’m digging my way down through all the posts,.. We have had nurse-lead codes for the last ten years, and I just gotta say that it works great. We manage the defibrillator, we make sure everyone is following the routine, make sure other nurses are administering the meds – basically keeping order in the resusc team, so that the Team Leader physician can just work on the patient. A couple of things is very different in Norway though;… Read more »
great stuff–keep it coming
S. Vera (RRT RN major hospital in NY) @Fredrik Wennerstrom: would love to contact you about the “nurse-led code” in your hospital. Please reach out!. Thank you!!!
Thank you for sharing the podcast.