Implementation of a Code Nurse in the Emergency Department

Aim: : The emergency room (ER) is a complex and fast-paced work environment with an increasing patient census and more complex diagnoses requiring numerous healthcare team members. This quality improvement (QI) aims to examine the efficacy of implementing a novel role such as a Code Nurse in preventing further deterioration and ensuring the best outcomes among critically ill patients.

Framework:: The authors used PDCA (Plan-Do-Check-Act) to guide the project's planning and implementation. The project will utilize a code nurse responsible for monitoring quality metrics and reporting opportunities for education or process improvements to successfully meet reportable metrics to specific accrediting bodies to clinical nurse specialist (CNS), managers, and director.

Setting:: The project site is a 443-bed non-academic hospital, a specialty center for Burn, Comprehensive Stroke, STEMI, and treats 90,000 patients a year.

Stakeholder Team:: The ER director, CNS, and stroke coordinator with staff input, developed the framework and job description of the code nurse. The CNS provided education to code nurses focused on caring for critically ill patients safely, reducing metric fallouts, and preventing delay of care. The ER director, CNS, and managers will monitor the process and outcomes.

Methods: : The QI project is a quantitative study using a Code Nurse to improve patient outcomes in ER. The ER nursing leadership selected full-time expert nurses after an interview to cover the department 24 hours, 7 days a week. Criteria for selection include possession of ACLS, PALS, NIHSS, and certification in CEN, TNCC, or CCRN.

The code nurses received a didactic critical care review and a full-day rotation to ICU, IR, and cath lab. Their rotation's goal was to understand the ongoing care and potential complications that can occur when care in the ER is delayed.

The team developed a structured process to increase sepsis compliance with initiating bundles, reduce the time for door-to-cath lab, and decrease the time from door to Interventional Radiology (IR) for patients with stroke symptoms.

The project started in April 2022. The team monitored and examined the benefits of a code nurse by measuring the metrics from six prior and six months post-implementation.

Outcomes:: The sepsis bundle compliance increased by 4.9% in 6 months of implementation (pre-73.7%; post-78.6%). The STEMI door-to-cath lab reached 100% compliance post-implementation (pre-50%; post-100%). For acute ischemic stroke patients, IV thrombolytics hospital arrival to treatment time improved, decreasing by 5 minutes (pre-53 minutes; post-48 minutes). Hospital arrival to IR for endovascular thrombectomy eligible patients increased by 9 minutes (pre-90 minutes; post-99 minutes) from January 2022 to October 2022.

Implications:: Creating a Code Nurse position in ER is a patient-centered initiative that has shown significant improvement in patient outcomes. Code nurses are trained to respond to any critical event that occurs in the ER. As a result of exposure and repetition, they have refined their skills and have become more effective clinical experts at the bedside. We continue to analyze data every month and work to improve the scope of the code nurse.