Clinical Audit

Clinical Audit Title: Clinical evaluation of Code Blue cases announced in hospital
Audit Lead(s) /
Dr. Balram Yadav
Designation

Ward / Department Hospital Wide

Start Date 01/07/2023 Estimated Finish Date 31/07/2023

Background / Rationale to the Clinical Audit

(a brief history to the project)
CPR was originally developed to save the lives of people dying unexpectedly when acute myocardial infarction
(AMI) caused sudden cardiac arrest in ventricular fibrillation – ‘hearts too good to die’. As awareness of CPR
increased and resuscitation equipment became more widely available and more portable, attempts at CPR
became very common in situations other than a sudden cardiac arrest due to AMI. When a person dies the
heartbeat and breathing cease, so the distinction between cardio respiratory arrests that is sudden and
unexpected and cardio respiratory arrest that occurs in the context of death from an advanced and irreversible
cause is not always made. As a result CPR has been attempted commonly in people who are gravely ill, and for
whom attempts to re-start their heart either would not work (subjecting them to violent physical treatment at
the end of their life and depriving them of a dignified death) or might restore their heart function for a brief
period and possibly subject them to a further period of suffering from their underlying terminal illness
(prolonging the dying process without prolonging life). The study by the project Confidential Enquiry into
Patient Outcome and Death found that CPR was attempted in hospitals in many people for whom there was
little or no likelihood of benefit, yet no anticipatory decision had been considered or made about CPR.
Clinical Audit Aim / Objectives
(Overall purpose of the project - e.g. improve, enhance, ensure, change, obtain)
1. The results of research into the benefits of introducing a MET are variable, although evidence for their benefit is
increasing.
2. A system of pre-emptive ward care, based predominantly on individual or teams of nurses known as critical care
outreach, has developed
3. Encouraging research into methods of resuscitation to create new knowledge
4. Leading evidence synthesis of published research to guide contemporary practice
5. Studying resuscitation teaching techniques
6. Establishing appropriate guidelines for resuscitation procedures
7. Promoting the teaching of resuscitation using the established guidelines which remains a key
implementation strategy of evidence based guidelines
8. Establishing and maintaining standards for resuscitation
9. Fostering good working relations between all organisations involved in resuscitation
10. Producing and publishing training aids and other literature concerned with the organisation of
resuscitation and its teaching.
 Method

Will the project Retrospective

be……….
How will cases be All sample of reported Code blue – CPR events
selected
From what time
period will cases be 1st July – 31sr July 2023
drawn from?
What is the target cases of reported CPR
sample size?
Is the target sample All cases within a specified time period
size…….
All cases within a specified time period
Data Source
Audit all cardiac arrests, ‘false arrests’, unexpected deaths and unanticipated
Other (please ICU admissions, using a common dataset. Audit the antecedents and clinical
specify)
responses to these events.
Work Plan
Planned Planned
By Whom By Whom
Date Date
Dr. Balram
Start audit 01/07/2023 Report written Mr Pradeep 05/08/2023
Yadav
Action plan
Data collected Mr. Kailash Dr. Balram
31/07/2023 agreed & 05/08/2023
by Chand yadav
completed
Findings Dr. Balram
Dr. MK Bohra 01/08/2023 Report submitted 05/08/2023
reviewed by yadav
Support required from Clinical Audit

None Case Note Audit y Assistance with report y

Questionnaire / Audit tool Analysis of data y Assistance with presentation

Other :
 Although the data on the effects of outreach care are also inconclusive, it has been suggested
that outreach teams may reduce deaths, ICU admissions and readmissions, and increase
survival.
 Regular monitoring and early, effective treatment of seriously ill patients appear to improve
clinical outcomes and prevent some cardiac arrests.
 Prevention of in-hospital cardiac arrest requires staff education, monitoring of patients,
recognition of patient deterioration, a system to call for help and an effective response.
 Commitment and Support
I agree to take responsibility for ensuring that the audit is completed, reported and an action plan is
devised to implant recommendations arising from the audit.
Signature of person taking responsibility

Name Dr. Balram Yadav

Date 05/08/2023

This has been agreed with the clinical audit lead for the speciality:

Analysis :
During the process of Clinical audit of CPR, the following data as were found

Table 1
case no Total
time of
CPR (in
Total time of CPR (in min)
min) 35
1 30 30
25
2 10
20
3 12 15 Total time of CPR
10 (in min)
4 15
5
21 0
5 1 2 3 4 5

Table 2
case no Cardio version
1 1 Cardioversion
1.2
2 0
1
0.8
3 1
0.6
0.4 Cardioversion
4 1
0.2
5 1 0
1 2 3 4 5
 Table 3
case no intubation

1 1
Intubation
1.2
2 0
1
3 0 0.8
0.6
4 0 Intubation
0.4
5 1 0.2
0
1 2 3 4 5

Table 4
case no establishing
new IV line Establishing new IV line
1 0 1.2
2 1 1
0.8
3 0
0.6 Establishing new IV
4 0 0.4 line
5 0 0.2
0
1 2 3 4 5

Table 5
Case Adrenaline
no Adrenaline
1 1
1.2
1
2 1 0.8
0.6
3 1 Adrenaline
0.4
4 1 0.2
0
5 1 1 2 3 4 5
 Table 6
case no SBC
1 1 SBC
1.2
2 0
1
3 1 0.8
0.6
4 1 SBC
0.4
5 1 0.2
0
1 2 3 4 5

Table 7
case no Atropine
1 2 Atropine
2 2 2.5

3 1 2
4 1 1.5
5 2 1 Atropine

0.5

0
1 2 3 4 5

Table 8
case no outcome of CPR
(death - 0 ,
recovery - 1)
Outcome of CPR
1.2
1
1 0
0.8
2 1
0.6
3 1 Outcome of CPR
0.4
4 1
0.2
5 1
0
1 2 3 4 5
Recommended strategies for the prevention of avoidable cardiac arrests and inappropriate
CPR attempts

1. Ensure that people with symptoms suggestive of acute coronary syndromes are assessed
and treated appropriately without delay.
2. Ensure that people with symptoms that may indicate a risk of cardiac arrest (e.g.
unexplained syncope) receive prompt assessment that includes an ECG and, where
appropriate, are referred for prompt assessment by a heart rhythm specialist.
3. Ensure that people with conditions that may indicate a risk of cardiac arrest (e.g.
complete heart block, severe left ventricular impairment, severe aortic stenosis,
hypertrophic cardiomyopathy) receive prompt specialist assessment and appropriate
treatment.
4. In hospitals, place critically ill patients and those at risk of rapid deterioration in areas
where the level of care is matched to the seriousness of each patient’s condition.
5. Monitor such patients regularly using simple vital-sign observations (e.g. pulse and/or
heart rate, blood pressure, respiratory rate, conscious level, temperature and SpO 2).
6. Match the frequency and type of observations to the severity of illness of the patient.
7. Ensure that the hospital has a clear policy that requires a timely, appropriate, clinical
response to deterioration in a patient’s clinical condition.
8. Introduce into each hospital a clearly identified system for response to critical illness.
This will vary between sites, but may include an outreach service or resuscitation team
(e.g. CODE BLUE TEAM) capable of responding to acute clinical crises. The service
must be available 24 hours per day.
9. Ensure that all clinical staff are trained in the recognition, monitoring, and management
of critically ill patients, and that they know their role in the rapid response system.
10. Empower staff to call for help when they identify a patient at risk of deterioration or
cardio respiratory arrest.
11. Ensure that all policies on CPR decisions are based on current national guidance, and
ensure that all clinical personnel understand it.
12. Identify those fully informed patients who do not wish to receive CPR, those patients for
whom cardio respiratory arrest is an anticipated terminal event and for whom CPR would
be inappropriate, and those patients who have lost capacity in whom a decision not to
attempt CPR is in their best interests.
 Conclusion:

All Conclusion considerations, discussions and decisions about CPR must be recorded fully and
clearly, together with details of the reasons for any decision. Such decisions should also be
communicated clearly, where necessary in writing, to all those involved in the patient’s care. It is
recommended that decisions about CPR (and about other elements of emergency care and
treatment) are recorded on a standard form. Such a form should remain in all the Department to
the Staff at all times and be kept in a place where it will be accessible immediately by anyone
needing to refer to it in an emergency. store documented decisions about CPR the systems used
must be accessible immediately by all those who may need to see the records, must be secure and
must be responsive to any reversal of the recorded decision.

Clinical Auditor Clinical Audit Lead

Dr. MK Bohra Dr. Balram Yadav

Sign Sign

Date: 08/08/2023 Date: 08/08/2023