Multidisciplinary review of code events in a heart center

Objective To identify a cause for clinical deterioration, examine resuscitation efforts, and identify and correct system issues (thus improving outcomes) via a multidisciplinary code-review process soon after cardiopulmonary arrest. Methods Retrospective analysis of code events in a tertiary pediatric heart center from September 2010 to December 2013 and review of surgical-cardiac data from January 2010 to December 2013. Results A multidisciplinary team reviewed 47 code events, 16 of which (34%) were deemed potentially preventable. At least 2 issues were identified during 66% (31/47) of cardiopulmonary arrests reviewed. Key issues identified were related to communication (62%), environment/ culture/policy (47%), patient care (including resuscitation, 41%), and equipment (38%). About 60% of reviewed arrests resulted in educational initiatives (eg, mock code, in-service education) and 47% resulted in a new policy or modification of existing policy. Less common were changes in equipment (32%) or modification of staffing needs (11%). Changes most frequently occurred in the unit specific to the event (68%) but some changes occurred throughout the Heart Center (32%) or across the hospital system (13%). Survival to discharge after cardiopulmonary arrest has improved over time (P =.03) to 81% for cardiac surgical patients in our center. Conclusion A multidisciplinary code-review committee can identify deficiencies and lead to educational initiatives and improvements in care. When coupled with a hospitalwide "code blue" review process, these changes may benefit the institution as a whole.