Digital records are difficult to work with during a code, and a dedicated function should exist that prints a package from the EPR for codes.
PROBLEM
Electronic medical records make it difficult for the Code Blue team to do their job.
The Code Blue team is called to resuscitate critically ill patients. Sometimes their task follows a standard resuscitation algorithm, such as resuscitating a pulseless patient, and requires little external information. Often however the patient has developed a new acute problem, such as hypoxia or hypotension, and requires urgent management. In order to troubleshoot and treat the code team needs to know the patient’s medical history and course in hospital.
Electronic medical records have made it quite difficult to quickly learn about a patient during a code; especially, when compared to the prior standard of the paper chart[1].
First, a computer usually is not inside the patient’s room during a code, which makes accessing the record difficult. Someone from the team has to leave the code to read about the patient from another room. They are unable to quickly relay the information or answer any questions that arise. Sometimes a portable computer on wheels is brought into the room, where it gets in the way and takes up space.
Second, if there is a computer already in the room, it is often turned off, located in an awkward location given the surrounding chaos, and impossibly slow to log into. This all creates unnecessary delays.
Third, during a code a paper chart can be quickly flipped through. Its individual components (medications, progress notes, labs, EKGs, etc) can be separated, passed around, and viewed in parallel by multiple team members. A paper chart is the “gold standard” for quickly reviewing a patient’s history.
The electronic medical record is slow to navigate. Information is stored in discrete tabs and different windows. It is difficult to view multiple sources in parallel. Electronic notes take longer to skim through because of the length of the notes. Key information is lost among the clutter created by ‘copy-paste’. These problems are only amplified when viewing electronic records via a tablet or smart device.
One way around this is to print records from electronic chart. However, using the standard built in print function in the electronic record it is a time consuming process, and produces a very large stack of paper that is difficult to navigate efficiently.
PROPOSAL
All electronic health records should be built with a “Code Blue: Print Button”.
When a code is called, the unit clerk opens the patient’s record and presses the “Code Blue: Print Button”. It does several things.
1. All items in the print cue are placed on hold. The Code Blue document is spooled to top print priority.
2. A cohesive package with a table of contents, pagination, and headings is printed [2]. This is important to make the document easy to sort through.
3. The order of the documents is the same at every code.
4. The document is printed in two sections. Therefore Part 1 will be finished printing prior to the Code Team’s arrival. Part 2 soon after. The document is prioritized from most important to least.
5. The specific contents of the package can be curated by each hospital. The system should include a variable algorithm to calculate how far back to pull information from based on the quantity of information obtained.
An example of a Code Blue Package may include:
PART 1
Index
Single Cover Page Demographic Summary:
– Resuscitation status & living will details
– Language spoken
– Close relatives & their contact information
– Religious affiliation & end of life wishes
– Contact information of the attending physician
– Isolation status. Transmissible infections.
Active Data
– Vital trend
– Medications administration list (in table form). Allergies.
– Recent labs (displayed in table form)
– Patient Problem List
– Entrance History and Physical.
– Recent progress notes
– Prior EKGs (report and original)
PART 2
Past History
– Current vascular access on the patient. Prior failed access sites.
– Prior anesthesia assessments and notes detailing intubation attempts.
– All notes from prior codes
– All consultant letters
– All procedure and operative notes
– Implanted hardware details
– Home medication list
– CXRs (report and image)
– Summary of prior reports such as: CT/MRI/nuclear imaging, Pulmonary Function Test, EEGs
FUTURE OPTIONS
A Code Blue Button integrated into the EPR has benefits other than acting as a fancy print function. It can be used to automatically notify personal, order test, and re-allocate hospital resources.
Thanks to Robert Schmidt, and Liam Black for reading drafts.
[1] Some may argue that the ward staff can provide information to the code team. This is more optimistic than the standard. When responding to codes on the surgical ward, often the surgical team is in the OR. After hours there is not ward staff around. More frequent resident signs overs means staff are less likely to have the patient’s history memorized. Furthermore, relying on memory only increases the chance of recall errors in high stress situations.
[2] Ideally there should also be along the right edge margins