Problem

One of the current problems with intraoperative resuscitation is the lack of organization. More precisely, there is often times no clear recognition of defined roles and responsibilities for members participating in an intraoperative code (nursing, surgery, and anesthesia, etc.).^1–3 At our institution, we have quality and safety officers who review each intraoperative code event with the anesthesia team members to identify areas for improvement. Recurring themes included the need to more clearly identify who the code leader was and added burden on anesthesia technicians who are asked to leave the operating room (OR) to retrieve medications or refill the medication drawer within the anesthesia workstation.

Solution

The “Perioperative Pharmacy Attendance for Intraoperative Codes” safety initiative attempts to tackle this problem by addressing the role of “medication procurement, compounding, and time recording.” Pharmacists can quickly assess and provide dosing recommendations for medications not in the Advanced Cardiovascular Life Support (ACLS) algorithm that providers may have to utilize when there are drug shortages.⁴ Previously these responsibilities were delegated to the anesthesia attending who was also in charge of running the code; this led to an overburdened code leader. Pharmacist attendance also allows anesthesia professionals to perform alternative tasks during a code, as they are usually responsible for running the code.^1,2 The anesthesia team and nursing staff can more efficiently procure equipment and supplies because the pharmacy team is now responsible for obtaining the medications.

Initiating the Program

At our institution, adding the perioperative pharmacists to the intraoperative code response team was relatively seamless as they already had a familiarity with and thorough knowledge of where medications are stocked, appropriate concentrations for mixing, and proper doses (Table 1). Prior to the initiation of the program, all OR Pharmacists were ACLS-certified and oriented to the locations of the ORs and off-site locations (e.g., OB suite, Radiology, Endoscopy, and the Cardiac Catheterization Lab). Additionally, we created a travel bag of emergency medications as well as additional agents not usually stocked in the anesthesia workstation to be brought by the responding pharmacist (Table 2). This code bag may facilitate faster medication procurement and can be utilized in lieu of the large bulky code cart. This ensures reduced clutter in some of the smaller ORs and helps maintain a sterile surgical field/back table. This standardized, travel-size code bag is restocked after every code event by the responding pharmacist and is available across all operating rooms, OB suites, and off-site locations.

Table 1: Potential benefits of having perioperative pharmacist attend Intraoperative Codes/Rapid Response Events

Timely medication procurement and compounding

ACLS Medication (epinephrine) dose, timekeeping, and adherence

Differentiation of roles to allow anesthesia staff to perform alternative tasks (establish airway, lines, etc.)

This addition closely follows the inpatient model of code response

Familiarity with drug dosing and concentrations

Recommendation of alternative agents during drug shortages

 

Table 2: Proposed contents of travel code bag
DRUGS:	NON-DRUG ITEMS:
Epinephrine 1 mg	IV Tubing
Atropine 1 mg	MGH Emergency Manual
Dilute Epinephrine (10 mcg/ml)	Stop Watch for Time Keeping
Amiodarone (150 mg/100 mL bag)
Vasopressin (20 units/mL)
Sodium Bicarbonate 50mEq/50mL
Sugammadex 200 mg/2 mL
Calcium Chloride 10% 10 mL
Albuterol (MDI) with Metered Dose Inhaler (MDI) adapter
Insulin (1 unit/ml)
Common Anticoagulant reversals
ACLS = Advanced Cardiovascular Life Support; MGH = Massachusetts General Hospital.

An unintended benefit of creating this program was the identification of the lack of standardization within perioperative codes; therefore, we created an interdisciplinary Intraoperative Code Committee (Surgery, Anesthesia, OR Nursing, Quality and Safety Nursing, and Pharmacy) to define standardized roles during code responses and review all intraoperative codes.

Logistics

When there is an intraoperative code or emergent event, a broadcast call of “Anesthesia STAT OR” is made over Vocera® (voice activated communication system, San Jose, California). The OR pharmacists also carry this communication system and thus are alerted of an intraoperative code. Two pharmacists respond to the code (one from the post-anesthesia care unit [PACU] and one from the central OR pharmacy), bringing the portable emergency drug bags. Upon arrival at the OR, the pharmacists announce their presence to the code leader to ensure close looped communication. If the pharmacists need additional drugs or supplies, they communicate back to the central OR pharmacy to procure any supplies. After the code or emergent event concludes, the pharmacist working in the central OR pharmacy restocks both portable emergency drug bags and ensures they are returned to their storage locations (one in the PACU and one in the central OR pharmacy)

For smaller community hospitals without the resources to provide an intraoperative pharmacist the addition of a travel-size “code bag” may amplify the code team’s preparedness. This bag, as described previously, would contain all the relevant code medications in a more compact form. For hospitals without an OR Pharmacy satellite, perioperative leadership can reach out to pharmacy leadership to determine whether pharmacists attend codes in other areas of the hospital and whether this service might be extended to the OR environment. This dialogue may uncover areas for improvement and may lead to adoption of a similar model as our institution.

Reception and Tracking Success

At first glance, this safety initiative was well received by both anesthesia professionals and OR pharmacists. Therefore, we plan on formally evaluating satisfaction among the team members and investigate the time it takes to procure necessary drugs outside of the usual ACLS algorithm. Furthermore, our team will track adherence to the ACLS algorithm, time recording, and the incidence of medication errors during code situations.

Data on the location of the code, length of the code, time to respond to the code, medications given during the code, and any other issues related to personnel encountered during the code are being collected in a HIPAA compliant database. The database is used at our monthly Intraoperative Code Committee meeting to discuss opportunities for improvement, perform quality and safety analysis, and allow for other scientific research. We hope that these evaluations will further perpetuate adoption of this initiative in our own institution and validate it for other institutions.

 

Dr. Dalia is an assistant professor of Anesthesiology at Harvard Medical School in the Department of Anesthesia at Massachusetts General Hospital, Boston, MA.

Dr. Chowatia is a perioperative pharmacist in the Department of Pharmacy at Massachusetts General Hospital, Boston, MA.

Dr. Oliver is the manager of Perioperative Pharmacy Services in the Department of Pharmacy at Massachusetts General Hospital, Boston, MA.

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The authors have no conflicts of interest as they relate to this article.

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References

1. Prince CR, Hines EJ, Chyou PH, et al. Finding the key to a better code: Code team restructure to improve performance and outcomes. Clin Med Res. 2014;12:47–57.
2. Moitra VK, Gabrielli A, Maccioli GA, et al. Anesthesia advanced circulatory life support. Can J Anaesth. 2012;59:586–603.
3. Moitra VK, Einav S, Thies KC, et al. Cardiac arrest in the operating room: Resuscitation and management for the anesthesiologist: Part 1. Anesth Analg. 2018;126:876–888.
4. Johnson PN, Mitchell-Van Steele A, Nguyen AL, et al. Pediatric pharmacists’ participation in cardiopulmonary resuscitation events. J Pediatr Pharmacol Ther. 2018;23:502–506.