PEDIATRIC CODE STANDARDIZATION
The team performed a needs assessment that included where pediatric
patients are currently cared for and where they are anticipated to
be cared for in the future. Four key areas were identified: personnel,
equipment, education/training, and policies.
Appropriate equipment and medications were provided to those areas
to ensure efficient access in the event they are needed.
The pharmacy developed an updated pediatric dosing sheet, which
was placed in the infant resuscitation drug kit (IRDK) and the new
Broselow bags/carts. This was color-coded to meet standardization
with Broselow bags/carts.
The Value of a ‘Near Miss’: Pediatric Code Redesign
In 2017, a Pediatric Code activation occurred in the ultrasound area of
UAB Hospital. Although the patient ultimately required no treatment,
process failures were noted when the incorrect emergency response
team arrived and delays in pediatric supplies occurred. In truth,
a Pediatric Code is a rare event at UAB, with only five activations
between 2011 and 2016. The near miss was referred to the Patient
Safety department for review, and the Patient Safety Committee
chartered a team to be formed to review the process. The team had
interprofessional representation that included experts in pediatric
care, neonatal care, the Emergency Department, the UAB pharmacy,
Materials Management, the Office of Interprofessional Simulation, the
UAB Call Center, the Department of Quality and Patient Safety, and
members of UAB’s emergency response team. This team had a goal
of formalizing/standardizing procedures for Pediatric Codes, to make
sure equipment was available where needed, to train staff, and to
standardize policies.
Policies were comprehensively reviewed, and revisions were made with
input from the Resuscitation Committee and the Neonatal Team. There
was standardization of equipment naming and contents, location of
equipment, and response teams in six different policies.
The Office of Interprofessional Simulation conducted in-situ simulation
codes, identified gaps in the process, and corrected these through
education. Follow-up simulation demonstrated significant improvements
in personnel response and equipment availability.
Targeted education was performed for the MET Team, the pharmacy,
the neonatal and pediatric emergency response teams, and the
Emergency Department. Targeted education to specific units with
new/additional equipment was performed, and refresher education on
calling a Pediatric Code was done for all staff.
www.uabmedicine.org
17