Advertisement

Code team restructuring during COVID-19: A modified pit-crew approach

      To the Editor,
      Every day there are more infections and deaths attributed to the ongoing COVID-19 pandemic. Due to the severity of respiratory failure associated with the disease, cardiopulmonary arrest is not uncommon in these patients. Recent estimates suggest the mortality following a cardiopulmonary arrest is 87–100%.
      • Shao F.
      • Shuang X.
      • Ma X.
      • et al.
      In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China.
      • Sheth V.
      • Chisti I.
      • Rothman A.
      Outcomes of in-hospital cardiac arrest in patients with COVID-19 in New York City.
      Given the infectious nature of COVID-19 in the setting of limited resources including both personnel and equipment, health systems have been forced to reconsider previously established resuscitation practices. In the spring of 2020, the American Heart Association, and the International Liaison Committee on Resuscitation published additional guidance for providers when responding to cardiopulmonary arrest patients with known or suspected COVID-19 and during the pandemic in general.
      • Edelson D.P.
      • Sasson C.
      • Chan P.S.
      • et al.
      Interim guidance for basic and advanced life support adults, children, and neonates with suspected or confirmed COVID-19: from the emergency cardiovascular care committee and get with the guidelines.
      • Nolan J.P.
      • Monsieurs K.G.
      • Bossaert L.
      • et al.
      European Resuscitation Council COVID-19 guidelines executive summary.
      Prior to the onset of the pandemic, we had instituted a Pit Crew Model for responding to in-hospital cardiac arrests at our institution.
      • Spitzer C.R.
      • Evans K.
      • Buehler J.
      • Ali N.A.
      • Besecker B.Y.
      Code blue pit crew model: a novel approach to in-hospital cardiac arrest resuscitation.
      In the spring of 2020, we adapted our model in order to minimize the number of personnel in the room, prioritize provider safety, and preserve equipment and resources. Specifically, we combined the roles of timekeeper and monitor operator, instructed that the crash cart and pharmacist should be located outside of the room (in order to minimize contamination and subsequent cleaning), and introduced a new role of “room safety monitor.” The room safety monitor should be positioned immediately outside of the patient room and is charged with controlling and limiting access to the room, managing supply and equipment inflow, and observing safe donning and doffing procedures of personnel (See Fig. 1).
      Fig. 1
      Fig. 1Pit Crew Model prior to COVID-related modifications (left) and following modifications (right). The modified, COVID-specific Pit Crew Model combines the timekeeper and monitor (defibrillator) operator roles, repositions the crash cart and pharmacist outside of the room, and adds the role of a room safety monitor.
      In addition to the implementation of this adapted COVID-19 Pit Crew Model, we also modified other aspects of our institution’s code blue protocol. Event activations included notification of the unique isolation requirements to ensure appropriate protective equipment was donned prior to entering the room. In accordance with interim guidance from the American Heart Association,
      • Edelson D.P.
      • Sasson C.
      • Chan P.S.
      • et al.
      Interim guidance for basic and advanced life support adults, children, and neonates with suspected or confirmed COVID-19: from the emergency cardiovascular care committee and get with the guidelines.
      we also prioritized early intubation, paused chest compressions when necessary in order to intubate, and promoted oxygenation and ventilation strategies that minimized aerosol generation.
      Since the creation of our new COVID-19 Pit Crew Model, steps have been taken to educate providers about the modified process, evaluate the new structure, and assess adherence to process changes and isolation precautions. These included frequent communication with stakeholders and an in-situ mock code event.
      By making slight modifications to our already-existing Pit Crew Model for in-hospital cardiac arrest management, our institution was able to make quick, effective changes to our resuscitation practices that promoted patient and provider safety as well as preservation of personal protective equipment. Due to the dynamic and evolving COVID-19 knowledge base, future approaches will require real-time assessment of resuscitative quality metrics, continued adaptation of resuscitation team structure, ongoing educational initiatives, and incorporation of best practices as they evolve.

      Conflicts of interest

      None.

      Acknowledgments

      We would like to thank the members of the Code Blue Quality Committee who aided with the development and implementation of this model. There was not any funding obtained for this quality initiative.

      References

        • Shao F.
        • Shuang X.
        • Ma X.
        • et al.
        In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China.
        Resuscitation. 2020; 151: 18-23
        • Sheth V.
        • Chisti I.
        • Rothman A.
        Outcomes of in-hospital cardiac arrest in patients with COVID-19 in New York City.
        Resuscitation. 2020; 155: 3-5
        • Edelson D.P.
        • Sasson C.
        • Chan P.S.
        • et al.
        Interim guidance for basic and advanced life support adults, children, and neonates with suspected or confirmed COVID-19: from the emergency cardiovascular care committee and get with the guidelines.
        Circulation. 2020; 141: e933-e943
        • Nolan J.P.
        • Monsieurs K.G.
        • Bossaert L.
        • et al.
        European Resuscitation Council COVID-19 guidelines executive summary.
        Resuscitation. 2020; 153: 45-55
        • Spitzer C.R.
        • Evans K.
        • Buehler J.
        • Ali N.A.
        • Besecker B.Y.
        Code blue pit crew model: a novel approach to in-hospital cardiac arrest resuscitation.
        Resuscitation. 2019; 143: 158-164