New Knowledge, Innovation & Improvements

In Med-Surg Telemetry Units, the management and outcomes of a Code Blue (cardiac arrest or medical emergency) event rely, among other processes, on clear role delineation to improve communication and team dynamics. Many nursing units still operate without clear role delineation during a Code Blue response. This lack of defined roles can lead to confusion, delays in life-saving interventions, and poor patient outcomes.  

Racquel Agamata MSN, RN, PCCN, Nursing Professional Development Specialist, conducted an evidence-based practice (EBP) project to inquire on the evidence behind assigning Code Blue role delineation before the shift change, comparing it to the current practice where roles are not pre-assigned in Med-Surge Telemetry Units.  

Clinical Question 

To define the scope of literature search, the PICO question was “How does role delineation (role assignment) at the beginning of a shift affect the efficiency of Code Blue response in a Med-Surg Telemetry Unit compared to no role assignment? 

Search Strategy 

To gather relevant evidence, an organized search strategy was employed across multiple databases such as PubMed, Ovid, CINAHL, Cochrane Database using the search terms Code Blue, Role Assignment, Role Delineation, Cardiac Arrest, Efficiency in Emergency Response. Search Techniques includes Keyword, Title, MeSH Terms, Reference Mining. A total of 7 articles were reviewed, all included in the body of evidence for analysis. 

Evidence Synthesis 

The literature review consistently supports the idea that role delineation improves team efficiency during Code Blue events. The following key findings emerged from the evidence: 

• Clarity and Efficiency: Pre-assigned roles eliminate confusion, allowing team members to act immediately without delays in task allocation. 

• Enhanced Communication: Role delineation streamlines communication, enabling quicker decisions and more efficient interventions. 

• Timely Interventions: Assigning roles ensures critical tasks like airway management, CPR, and medication administration are performed promptly. 

• Improved Coordination: Clear roles improve team dynamics, maximizing skill utilization and task execution efficiency. 

Practice Recommendations 

Based on the evidence reviewed, several practice changes are recommended to improve Code Blue response efficiency: 

1. Pre-Assigned Roles: Assign roles during shift handoff to ensure preparedness.
2. Color-coded systems: Use visual cues for quick role identification.
3. Staff Engagement: Involve team members in the role assignment process.
4. Equipment Readiness: Ensure crash carts and medications are easily accessible.
5. Ongoing Education: Train staff on role delineation and Code Blue protocols.
6. Mock Drills: Conduct regular practice drills with post-event critiques.
7. Feedback Loops: Gather staff input to refine the process.

In the September 2024 issue of the Outpatient Surgery Magazine, OR Excellence Awards Edition, the Racho Cordova- Eye Surgery Center received an Honorable Mention to recognize their impactful work.  

The Rancho Cordova Eye Surgery Center, a two-room facility specializing in cataract surgery, practice change by switching from single-use to multi-use eye drops, dramatically reducing waste and costs—all without compromising patient outcomes. 

Previously, the facility used single-use eye drop vials to dilate patients’ pupils in the preoperative area. However, only a fraction of the medication—an average of three drops per bottle—was used before the remainder was discarded. To mitigate this practice’s cost and environmental impact, leaders and staff began exploring alternatives. Unnecessary waste of perioperative eye drops inflates the cost of ophthalmic surgeries, increases the carbon footprint, and worsens periodic drug shortages. 

In June 2023, the center transitioned to multi-use vials, a move that has proven successful. Before the switch, the facility used an average of 132 single-use vials weekly. By October 2023, that number had dropped to just 47 multi-use vials per week, a reduction of 85. 

“After implementing our multi-use drops policy and evaluating data over four months, we found that bottle ordering decreased by 63% and costs decreased by 53.3%,” says Haley Murphy, BSN, RN, Assistant Nurse Manager. “Most importantly, we did not observe any significant spike in infections or complications during this period.” 

The benefits extended beyond cost savings and waste reduction. When patients must dilate their pupils at home before surgery, they often face added costs for purchasing full bottles of eye drops at the pharmacy. Additionally, arriving at the facility with dilated pupils can create safety concerns, such as difficulty reading consent forms. By using multi-use drops onsite, the center ensures patient safety while addressing the national shortage of dilation drops and reducing the large amount of plastic waste generated by single-use vials. 

“This initiative highlights the importance of nurse involvement in cost-saving decisions within health care to maintain the highest quality standards in the clinical setting,” says Murphy. She adds that the highly skilled nursing team at Rancho Cordova has been instrumental in refining this process and other innovative programs. The team’s efforts, led by nurses, benefitted the facility and served as a model for other local health care facilities seeking to implement similar strategies. 

By sharing its protocols and results with local leaders, Rancho Cordova Eye Surgery Center demonstrated how operational changes driven by frontline staff can lead to impactful, sustainable improvements in patient care and resource management. 

During an ischemic stroke, every minute untreated results in the loss of 1.9 million neurons. This makes timely treatment essential, particularly for patients who qualify for Endovascular Stroke Treatment (EST), which aims to restore blood flow to the brain. A team of nurses, physicians, technicians, and other ancillary members worked together on a quality improvement project in the Sacramento Emergency Department (ED) focused on reducing the time between patient arrival and Neurointerventional Radiology (NIR) treatment by redesigning the flow and processes.  

As a Comprehensive Stroke Center, the hospital must have efficient processes and systems in place to support the needs of patients seeking advanced neurologic care due to stroke. The project’s goal was to decrease the Door-In-Door-In (DIDI) time, the interval from ED arrival to NIR, to under 65 minutes for at least 35% of qualified patients. Previously, this target was not being met, and barriers to faster treatment were identified.  

“One major adjustment we made was keeping patients in the CT suite to assess for large vessel occlusion rather than sending them back to the ED. This simple change allowed staff to remain with the patient, reducing delays and ensuring a seamless transfer to NIR,” shares Christine Swanson, BS, ADN, RN, Staff Nurse II, Emergency Department. “We also implemented direct access to the EST phone line, which significantly improved communication and speeded up report handoffs for faster patient transport.  We educated ED staff on the locations of Neuro IR supplies and streamlined workflows for both business and after-hours operations. These changes have made a meaningful impact on efficiency and patient outcomes.” The project has reduced delays and ensured more efficient care, helping to meet the <65-minute DIDI goal and faster EST times.  

Hospital throughput is the movement of patients from admission to discharge, ensuring they receive timely, appropriate care at every stage of their hospital stay. An efficient throughput process affects clinical outcomes and many other aspects of care, such as care experience and cost of care, as documented in numerous studies.  

“When a patient transfer is delayed within the hospital, it creates a ripple effect. For example, a backlog in the Emergency Department (ED) leads to longer wait times for community members seeking emergency care. Delayed discharges result in fewer available beds for incoming patients. Holding patients in the Operating Room (OR) because the Post-Anesthesia Care Unit (PACU) bed is not ready can also affect the patient’s recovery from anesthesia,” explains Carri Carson, BSN, RN, Assistant Director, Sacramento Emergency Department. “Hospital throughput is a complex process requiring close collaboration across multiple departments.”   

The hospital has prioritized initiatives to optimize the throughput process. Sacramento’s throughput core team is at the forefront of leading this work. The team is composed of interdisciplinary leaders who work together to identify barriers, implement strategies, and monitor outcomes. The throughput team’s leadership has positioned the hospital as a benchmark for throughput efficiency. Dorothy Vergel MSN, RN, CCRN, Nurse Manager, Post Anesthesia Care Unit shared an example of improvement led by clinical nurses, “when we started our PACU to Floor process improvement, clinical nurses from PACU and the inpatient units collaborated that led to a streamline in the hand-off and escalation process to reduce delays in patient transfers. It did not only reduce delays but also increased staff satisfaction.” 

In 2024, key metrics have consistently outperformed regional and local benchmarks, including ED-to-Floor, OR-to-PACU, and PACU-to-Floor times. “Our success highlights the strong culture of interdisciplinary collaboration in our hospital,” says Kristin Davis, MSN, RN, House Supervisor. “My role in coordinating bed placement relies on the efficient work of every team member—clinical nurses, physicians, pharmacy staff, lab personnel, bed control staff, house supervisors, Patient Care Coordinators, nurse leaders, transport, and housekeeping. Everyone contributes to the process, and our results reflect that teamwork.”   

Key Throughput Achievements in 2024:   

• ED to Floor: The percentage of patients admitted in less than 60 minutes rose from 9% in 2023 to 32% in 2024. The average time patients spent waiting to be moved to a hospital room was 178 minutes in 2023. In 2024, this average wait time decreased to 110 minutes, representing a 38% reduction. 

• OR to PACU: Achieved less than 15 minutes from “time zero,” with only three total holds in 2024, (total of 25 minutes).  

• PACU to Floor: Reduced the time from inpatient order release to bed placement by 45% compared to 2023, moving closer to the goal of 60 minutes.  

Nurses have been instrumental in optimizing workflows and ensuring efficient systems. Tim Hutchinson, MSN, RN, Hospital Operations Director, underscores this impact: “The leadership and advocacy of clinical nurses at the bedside is helping drive these processes efficiently while keeping our patients safe.” By leveraging their expertise and collaboration, nurses continue to lead meaningful change that enhances patient care and strengthens operational excellence.