title: Quality improvement utilizing in-situ simulation for a dual-hospital pediatric code response team.
abstract: OBJECTIVE
  Given the rarity of in-hospital pediatric emergency events, identification of gaps and inefficiencies in the code response can be difficult. In-situ, simulation-based medical education programs can identify unrecognized systems-based challenges. We hypothesized that developing an in-situ, simulation-based pediatric emergency response program would identify latent inefficiencies in a complex, dual-hospital pediatric code response system and allow rapid intervention testing to improve performance before implementation at an institutional level.
  
  
  METHODS
  Pediatric leadership from two hospitals with a shared pediatric code response team employed the Institute for Healthcare Improvement's (IHI) Breakthrough Model for Collaborative Improvement to design a program consisting of Plan-Do-Study-Act cycles occurring in a simulated environment. The objectives of the program were to 1) identify inefficiencies in our pediatric code response; 2) correlate to current workflow; 3) employ an iterative process to test quality improvement interventions in a safe environment; and 4) measure performance before actual implementation at the institutional level.
  
  
  RESULTS
  Twelve dual-hospital, in-situ, simulated, pediatric emergencies occurred over one year. The initial simulated event allowed identification of inefficiencies including delayed provider response, delayed initiation of cardiopulmonary resuscitation (CPR), and delayed vascular access. These gaps were linked to process issues including unreliable code pager activation, slow elevator response, and lack of responder familiarity with layout and contents of code cart. From first to last simulation with multiple simulated process improvements, code response time for secondary providers coming from the second hospital decreased from 29 to 7 min, time to CPR initiation decreased from 90 to 15 s, and vascular access obtainment decreased from 15 to 3 min. Some of these simulated process improvements were adopted into the institutional response while others continue to be trended over time for evidence that observed changes represent a true new state of control.
  
  
  CONCLUSIONS
  Utilizing the IHI's Breakthrough Model, we developed a simulation-based program to 1) successfully identify gaps and inefficiencies in a complex, dual-hospital, pediatric code response system and 2) provide an environment in which to safely test quality improvement interventions before institutional dissemination.
authors: MassGeneral Hospital for Children, 175 Cambridge Street, CPZS-5, Boston, MA 02114, USA. Electronic address: pyager@partners.org.
authors: Phoebe
authors: P
authors: Yager
authors: Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
authors: Corey
authors: C
authors: Collins
authors: Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
authors: Carlene
authors: C
authors: Blais
authors: Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
authors: Kathy
authors: K
authors: O'Connor
authors: Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
authors: Patricia
authors: P
authors: Donovan
authors: Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
authors: Maureen
authors: M
authors: Martinez
authors: MassGeneral Hospital for Children, 175 Cambridge Street, CPZS-5, Boston, MA 02114, USA.
authors: Brian
authors: B
authors: Cummings
authors: Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
authors: Christopher
authors: C
authors: Hartnick
authors: MassGeneral Hospital for Children, 175 Cambridge Street, CPZS-5, Boston, MA 02114, USA.
authors: Natan
authors: N
authors: Noviski
mesh_terms: D001900:Boston; D016887:Cardiopulmonary Resuscitation; D002648:Child; D017598:Efficiency, Organizational; D004635:Emergency Medicine; D057209:Hospital Rapid Response Team / Q000458:organization & administration*; D006801:Humans; D010372:Pediatrics; D058996:Quality Improvement
keywords: Education; Emergencies; Quality improvement; Simulation