Mock Code: A Code Blue Scenario Requested by and Developed for Registered Nurses

The use of simulation in medical training is quickly becoming more common, with applications in emergency, surgical, and nursing education. Recently, registered nurses working in surgical inpatient units requested a mock code simulation to practice skills, improve knowledge, and build self-confidence in a safe and controlled environment. A simulation scenario using a high-fidelity mannequin was developed and will be discussed herein.


Introduction
Simulation-based medical education is an evolving field that allows trainees to practice skills, expand knowledge, and build self-confidence in a safe and controlled environment with no risk to patients [1]. Through the use of a high-fidelity mannequin simulator, participants can practice clinical skills, and the mannequin will respond in accordance with the students' actions or inactions [2]. Recently, registered nurses working in surgery inpatient units expressed interest in participating in a simulation, in particular, a Code Blue scenario. The Quality, Patient Safety, and Risk Management Department of Eastern Health (EH) echoed staff concerns and approached the Clinical Learning and Simulation Centre (CLSC) for support. This technical report describes a unique collaboration between EH, a teaching hospital in St. John's, and the CLSC, a simulation center based in Memorial University. After the EH nurse educator met with the CLSC staff, it was felt that practicing a code in a safe, simulated environment would be a means to improve provider confidence and ultimately improve patient safety. Targeted learning objectives for this scenario were developed, focusing on the recognition of the deteriorating patient, team approach to care, timely and appropriate Code Blue response initiation, effective patient care, and clear communication techniques. Therefore, this scenario was designed for registered nurses working in each of the surgery units at EH, including orthopedics, neurosurgery, urology, and general surgery/plastics/burns. was developed ( Table 1) and submitted to the high-fidelity curriculum coordinator. The mannequin was then programmed, and the necessary tools for the simulation were developed and supplied.

Pre-Scenario
You are a registered nurse working in a surgery inpatient unit. You are rounding on your patients.

Reason for admission
Sarah Pratt is a 59-year-old female electrician who underwent bilateral total knee replacements three days ago. She is alert and oriented to person, place, and time.  To ensure a smooth experience for the learners, the team involved conducted a dry run of the scenario. Checklists based on the current guidelines [3][4][5] were developed and used during the scenario to provide an overall assessment of trainee competency ( Table 2). Also, the mannequin was able to provide feedback on the quality of compressions (e.g., depth, rate) and ventilation (e.g., seal, rate, saturation). The high-fidelity curriculum coordinator and the highfidelity educator at the CLSC, along with the nurse educator from EH, facilitated the scenario and participated in the subsequent debriefing.

Pre-briefing
A pre-briefing was held with all learners before the case. Learners were given a brief orientation to the simulation lab and the mannequin. The limitations of the simulation were reviewed, in particular, addressing technical issues with the mannequin and resource availability. The fiction contract -the agreement between the participants and instructors to proceed as if the simulation is real while simultaneously acknowledging that it is not -was readdressed [6]. Finally, trainees were advised that the case is strictly formative.

Case
This simulation scenario began with the patient in a surgical unit. She was sitting in bed, diaphoretic, with 40% O2 via venturi mask. The chart was placed on the overbed table for the nurse to review. About three minutes into the scenario, the patient stated that she was not feeling well and that she felt weak and short of breath. At this time, the nurse was expected to repeat the vitals. Sats dipped a little, the heart rate increased, and the blood pressure dropped. Then, in about 30 seconds, the patient arrested. The nurses participating had to initiate a Code Blue, provide effective respirations with BVM, start compressions, bring the crash cart to the bedside and apply pads, start timing for effective switch out of CPR, as well as record events. Once all the tasks were performed, the clinical educator entered the room portraying the role of the resident. The resident took over the team lead role and followed the cardiac arrest algorithm. Once the first dose of epinephrine was given, the client had a return of spontaneous circulation (ROSC).
Blood pressure and oxygen saturation readings were available when requested by the trainee. Visual feedback (looking for the chest to rise) therefore became important in this scenario.
A video (Video 1) showing a complete run-through of the scenario is included. It is intended to provide a step-by-step approach to the case.

Debriefing
Following the conclusion of the scenario, learners are provided with a formal debriefing. Care is taken during the debriefing to ensure that the number of debriefers is limited such that the debriefer-to-learner ratio does not exceed 1:1. The debriefing should be led by an experienced educator. The principles of good judgment and frame discovery should be central to the process. The points covered in the debriefing session are included in Table 3.
How did you feel throughout the simulation experience?
What went well in this simulation?
What did not go well in this simulation?
Were you satisfied with your ability to work through the simulation?
If you were able to do it again, how would you have handled the situation differently?
Was there effective closed loop communication?
Do you think there was effective use of delegation? Why or why not?
Is there anything else you would like to discuss?

Post-scenario didactics
After the debriefing, a didactic session was held. During this session, instructors were able to address any learning needs, and trainees were given the opportunity to strengthen the knowledge gained through the simulation exercise. Points covered in the didactics included being aware of the proper procedure when you come upon a patient with cardiac arrest, the importance of effective communication during stressful situations, and describing staff actions as response. Learners were asked to identify ways to improve staff response and patient care during a Code Blue scenario. The mannequin used in the scenario was also programmed to be able to determine the effectiveness of the compressions and airway management, so that was discussed where appropriate. A video (Video 2) showing the correct way to draw up epinephrine was included for further learning.

Discussion
This scenario was designed to increase the comfort level of registered nurses in Code Blue situations. It has been shown that nurses-both recent graduates and highly skilled, experienced nurses-respond with anxiety during a code. This anxious response results in delays in initiating cardiopulmonary resuscitation, regardless of responder experience. Under these high-stress conditions, they were also observed to struggle with the equipment-the arrest cart, defibrillator, and BVM device. In some instances, it was noted that the backboard placement was not correct, compressions were not effective, and ventilations were not adequate [7]. High-fidelity nursing simulation, while it does not replace working with patients, provides the opportunity for participants to learn technical skills and build confidence with no risk to the patient [8].