Purpose for the Program
Effective communication and collaboration among the clinical team is essential to optimize perinatal patient safety during the delivery of emergent care to a neonatal patient. In more than 80% of perinatal deaths and injuries, communication concerns have been identified by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) as the most frequent identified root cause. “Code Pink” was created to optimize outcomes and prevent failure to rescue.
Based upon the recommendation from the Joint Commission and needs assessment of the perinatal staff, a Midwestern level II family-birth center examined, developed, simulated, and then adapted an algorithm for the assignment of the procedural roles needed to provide care during a neonatal emergency, titled “Code Pink.”
Implementation, Outcomes, and Evaluation
The implementation of the Code Pink algorithm identifies specific procedural roles for the entire unit during a neonatal emergency. Within the algorithm there is a telephone triage to ensure that the ancillary departments are notified. The Code Pink algorithm also includes a shift assignment of the following procedural roles: fetal monitor watcher, medications/crash cart, chest compressions, recorder, airway, and runner. These roles are fulfilled by registered nurses who have completed the Neonatal Resuscitation Program (NRP). The role of “runner” is assigned to perinatal patient care assistants who have completed NRP.
To activate the Code Pink algorithm any staff member presses our staff emergency button, located in every room, which alerts every staff member's wireless telephone with the room number. The algorithm is then followed and all staff know their assigned roles of the Code Pink team, and if necessary staff will telephone ancillary departments, including respiratory, special care nursery, neonatology, and anesthesia.
The algorithm has been practiced and simulated numerous times, with each simulation focusing on interdisciplinary communication and role identification. Since the creation of the Code Pink algorithm/team there have been no role-based communication errors and no failure rescue events.
Implications for Nursing Practice
Adherence to the Code Pink algorithm provides for rapid intervention at the time of care when the patient, and other patients on the unit, need seamless and collaborative care. With the application of the Code Pink algorithm into nursing practice, patient care and staff communication of emergent roles and expectations are optimized. This organized, team-based care process has improved delivery of care through the creation of an algorithm and environment that is clearly focused on patient safety and communication among an entire staff during obstetric emergencies.