Code Labs: Expediting Laboratory Test Results During a Code

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1 Feature Code Labs: Expediting Laboratory Test Results During a Code Shannon K. Hurliman, RN, BSN, CCTN Kristin Paston, RN, BSN BACKGROUND Knowing a patient s laboratory picture is crucial in any code blue situation. Having no streamlined method for collecting and processing laboratory specimens during codes leads to staff frustration and critical delays in patient care. OBJECTIVE To simplify collection and testing of laboratory specimens during codes. METHODS Staff nurses led an initiative through which (1) code laboratory tests were placed in a computerized order set, thereby simplifying ordering; (2) prepackaged bags of supplies for the new order set were placed in each code cart; (3) the laboratory department supervisor began carrying a code pager to ensure that laboratory staff are prepared for incoming code labs ; (4) a protocol was created for laboratory staff to follow after receiving code labs; and (5) processes were developed for units that are not integrated in the organization s electronic ordering system. RESULTS The mean turnaround time (the time from when laboratory tests are ordered to when are posted) was reduced from 52.0 minutes to 31.3 minutes (P =.002). Laboratory staff improved their processing time (the time from when specimens are received by laboratory staff to when are posted) from 34.9 minutes to 21.5 minutes (P =.01). Survey responses indicated that staff across disciplines were significantly more satisfied with the new process. CONCLUSIONS Because the changes are basic, they can be implemented easily in any hospital setting to improve turnaround time for laboratory tests during codes. (Critical Care Nurse. 2011;31[5]:30-36) Obtaining laboratory during a cardiac arrest with code blue team intervention is imperative for achieving a good outcome for the patient. Timely response by the code team is crucial, 1 as minutes can be the key to preserving life, limb, and brain function during a code. The University of Colorado 2011 American Association of Critical-Care Nurses doi: Hospital had no streamlined method to collect and process laboratory specimens during a code situation, leading to staff frustration, delays in receiving laboratory, and ultimately delays in patient care. A staff nurse brought this issue up to the resuscitation committee after a code in which the nurse was pulled away from the team performing cardiopulmonary resuscitation to discuss laboratory specimens over the phone. Members of the Resuscitation Committee worked to evaluate the present system for laboratory testing during codes and to construct a more efficient process. Team members identified various points in the process that could be improved and implemented changes to shorten the turnaround time for getting of laboratory tests during a code. Methods Instituting a code lab order set within the hospital s computer system was the first step taken to improve turnaround time for laboratory test during a code. Our team of nurses, physicians, and laboratory staff determined which laboratory tests are pertinent to any code blue situation (Table 1). Once the order set was in place, employees familiar with our computer ordering system were easily able to order all pertinent laboratory tests during a code by making just a few simple keystrokes. Next, the team made certain that all necessary laboratory tubes were organized in the code cart. Bright green stickers that read Code Labs were affixed to each laboratory tube, flagging the tubes to ensure that laboratory staff would see and process them right away 30 CriticalCareNurse Vol 31, No. 5, OCTOBER

2 Table 1 Laboratory tests to order during a code blue cardiac arrest Complete blood cell count Basic metabolic panel Troponin level Magnesium level Phosphorus level Ionized calcium level Arterial blood gas analysis Prothrombin time/international normalized ratio Activated partial thromboplastin time (Figure 1). We also worked to organize the specimen tubes in a user-friendly way, prepackaged in a biohazard bag that could easily be sent down to the laboratory. The biohazard bag in each code cart was stocked with a bright green flyer that was developed to ensure further that laboratory staff would recognize the specimens as coming from a code blue. This flyer also included a place for the bedside clinician to write a nonpager callback number so that laboratory staff could communicate directly with the providers caring for the patient. Last, a code pager was assigned to the laboratory shift supervisor to make certain that the laboratory staff are always alerted to code situations and ready to process the specimens in the most efficient manner possible. Because some patient care areas (eg, diagnostic imaging areas) do Figure 1 Green Code Labs stickers and biohazard bags provided along with necessary tubes for collecting specimens for laboratory tests. not have access or training to use our hospital s computerized ordering system, an alternative process was developed. We developed a specific code lab requisition form that is stocked in the code carts in these units (Figure 2). Staff in these areas affix a patient identification label to the bright green code lab requisition form and include it with the blood specimens sent to the laboratory. These measures ensured that all of the hospital s care areas were included in this quality improvement initiative. Additional adjustments had to be made for units that run codes but do not activate the code blue paging system (eg intensive care units, cardiac catheterization laboratory). Because the pager system is Authors Shannon K. Hurliman is a charge nurse in the solid organ transplant unit and Kristin Paston is the director of the life support program at the University of Colorado Hospital in Denver. Corresponding author: Shannon K. Hurliman, RN, BSN, CCTN, University of Colorado Hospital, 1635 Aurora Court, Aurora, CO ( shannon.hurliman@uch.edu). To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. not activated when codes are called in those areas, the laboratory shift supervisor is not alerted and cannot notify the laboratory staff to be prepared for incoming code lab specimens. To manage this variation, we placed a laboratory phone number on the bright green laboratory flyer in the prepackaged code lab bags in each code cart so that staff in those areas can place a call to alert the laboratory staff to the code blue before the specimens arrive in the laboratory (Figure 1). Because of the large scale of this hospital-wide system change, a significant amount of staff education was conducted in a variety of departments to ensure that all personnel were aware of the project and knew how to incorporate the changes into their practice. A PowerPoint presentation was distributed (Tables 2 and 3), followed with a reminder howto information sheet to be sure all staff remained on track with the project (Table 4). In addition, a code lab testing protocol was developed for the laboratory staff that delineated CriticalCareNurse Vol 31, No. 5, OCTOBER

3 Figure 2 Code lab requisition form stocked in the code carts. Courtesy of University of Colorado Hospital, Denver, Colorado. 32 CriticalCareNurse Vol 31, No. 5, OCTOBER

4 Table 2 Information used in PowerPoint presentation to educate staff about the changes with code labs Main changes to the code lab process Lab shift supervisor carries code pager Code lab order set placed in Care Manager Lab tests included in the order set are CBC, BMP, troponin, magnesium, phosphorus, ionized calcium, ABG, PT/INR, PTT Bright green Code Labs stickers and Code Labs sheet added to code cart Abbreviations: ABG, arterial blood gas analysis; BMP, basic metabolic panel; CBC, complete blood cell count; PT/INR, prothrombin time/international normalized ratio; PTT, partial thromboplastin time. Table 3 Information used in PowerPoint presentation to educate staff about the changes in the process of calling codes Code labs process Call a code per usual process (dial x85555) Have the PSC order Code Labs order set in Care Manager Use lab vials in code cart, affix bright green Code Lab stickers, place in biohazard bag, and insert Code Lab sheet; label specimens with either the lab stickers (printed from Zebra printer) or patient bar code stickers Tube specimens to lab at tube station #132 or #142 Call lab supervisor to alert him/her of code situation Abbreviation: PSC, patient service clerk. precisely what steps should be taken from the moment the laboratory shift supervisor s code pager alarmed until the laboratory specimens were processed and the were called back to the bedside clinician. This project was initially brought to the Resuscitation Committee in January 2007, and we spent from January to June 2007 planning our improvement strategy. In June 2007, our facility moved campuses and the laboratory implemented a new automated processing system. Because of the move, project implementation was delayed, which allowed us the time to fine-tune the process to meet the needs of our new facility. Because this process change was within our current computer and hospital system, no significant cost was incurred to implement this initiative. Training of hospital staff about the changes was done on-site during work hours by 2 employees who were involved in the project and then rolled out hospital-wide by our educators and leadership staff. Results Two outcomes were measured to determine how successful the code lab project was: (1) turnaround time for of laboratory tests and (2) staff satisfaction with the code lab project. Our primary outcome was to determine whether the changes made to the code lab process helped improve efficiency in laboratory turnaround times during a code situation. Data on turnaround times were collected at baseline and after implementation. The baseline data set from before the code lab project was obtained by reviewing code blue records and data from the automated laboratory system from August through December This period was after our hospital had moved campuses and also after the laboratory had instituted a new automated laboratory system. We assessed 2 aspects of turnaround time: (1) the time elapsed from when the laboratory tests were ordered in the computer to when the were posted on the computer, and (2) the time elapsed from when the laboratory received the specimens to when the of the laboratory tests were posted on the computer. Potassium level was used as the final indicator that all test were posted because measurement of potassium level takes the longest to process. Of the 20 patient encounters from before the code lab project that were assessed, 8 had standard code blood specimens collected and were further evaluated. The 12 that were omitted from the analysis had no time data available or had only samples for arterial blood gas analysis collected. After the code lab project was instituted in January 2008, data were collected in a similar manner, with code blue and laboratory data from March through July 2008 being reviewed. Twenty patient encounters were eligible, 15 of which had appropriate data for evaluation. To assess the difference in total turnaround times from before to after the code lab project, we calculated the time difference between when the laboratory tests were ordered in our computer system and when were posted. This time range captured the full effect of the CriticalCareNurse Vol 31, No. 5, OCTOBER

5 Table 4 How-to information sheet provided to remind staff of new procedures after PowerPoint presentation Type of unit Care manager Non care manager Instructions 1. Call a code by dialing x This will alert the laboratory shift supervisor. 2. PSC OR RN: Order Code Lab panel in care manager. The code labs MUST be entered into care manager. 3. Draw code labs in appropriately labeled Code Lab vacutainers stocked in the code cart. Use the laboratory zebra labels that print as your guide to what tubes to collect. Be sure to mix all samples by inversion 5 times as you collect them. 4. Label lab samples with zebra labels. 5. **IF THE CODE RESPONSE IS NOT ACTIVATED BY PAGER** but the code cart is accessed, call the lab supervisor (extension listed on green Code Labs sheet) as they have not been alerted by the pager system. 6. Place properly labeled code labs in biohazard bag with lime green Code Labs sheet BE SURE TO WRITE A NONPAGER CALL-BACK PHONE NUMBER. Results will be called immediately as each test is completed, and pager numbers ARE NOT acceptable. 7. Tube to 132 or Call a code by dialing x This will alert the laboratory shift supervisor. 2. Draw code labs in appropriately labeled Code Lab vacutainers, stocked in the code cart. You will need to collect: 1 green top with gel, 1 purple top, 1 blue top, and 1 blood gas syringe. Be sure to mix all samples by inversion at least 5 times as you collect them. 3. Label lab samples with patient s stickers (from admissions, found in chart) 4. Use the lime green code panel lab requisition form. OTR (4/08) DOD BE SURE TO WRITE A NONPAGER CALL-BACK PHONE NUMBER. Results will be called immediately as each test is completed, and pager numbers ARE NOT acceptable. 5. **IF THE CODE RESPONSE IS NOT ACTIVATED BY PAGER** but the code cart is accessed, call the lab supervisor (extension listed on green Code Labs sheet) as they have not been alerted by the pager system. 6. Tube to 132 or 142 Abbreviations: PSC, patient service clerk; RN, registered nurse. code lab project with all its components. At baseline, the mean laboratory turnaround time was 52.0 (SD, 4.74) minutes; after the code lab project, the mean time was 31.3 (SD, 3.84) minutes. The F statistic established the lack of homogeneity of the variance, so a Student t test for unequal variances was used to test the significance of the difference between the times. The t test indicated that the mean turnaround time was significantly less (P=.002) after the project than at baseline. Next, we assessed whether the laboratory staff had improved their processing time since the code lab project was instituted. To do this, the time difference between when the laboratory specimens were received in the laboratory and when the test were posted was calculated. Mean time at baseline was 34.9 (SD, 4.34) minutes and after the project was 21.5 (SD, 3.0) minutes. Using the F test, we again found that the t test for unequal variances should be computed. The t test indicated that the laboratory had significantly (P=.01) improved its turnaround processing time. As a secondary outcome measure, an electronic survey was distributed before the code lab project started to determine how satisfied Table 5 Questions used on the survey about satisfaction with procedures for ordering laboratory tests during a code blue 1. On a scale of 1 to 4, a please rate your overall satisfaction with the way laboratory tests are handled in a code situation. 2. On a scale of 1 to 4, please rate your satisfaction with the quickness of laboratory test in a code situation. 3. On a scale of 1 to 4, please rate your satisfaction with the appropriateness of laboratory tests being ordered during a code situation. a Scale: 1 = poor, 2 = fair, 3 = good, 4 = excellent. 34 CriticalCareNurse Vol 31, No. 5, OCTOBER

6 staff members were with the current processes for ordering, processing, and obtaining of laboratory tests during a code situation. Clinical nurses, patient service clerks, and nurse managers on the medicine, transplant, general surgery, pulmonary, cardiac intensive care, and surgical intensive care units were asked to complete the survey. Laboratory staff were also included in the survey; however, laboratory staff instituted the code lab project processes before the survey launch because of patient safety concerns with processing laboratory tests during a code blue, thereby masking their true satisfaction with the project. The survey consisted of 3 questions related to the handling, turnaround time, and appropriateness of laboratory during a code blue (Table 5). Participants were asked to rank these on a scale from 1 for poor to 4 for excellent. The mean score for each question stratified by 4 groups intensive care nurses, medical/surgical nurses, patient service clerks, and laboratory staff was computed. The baseline satisfaction data demonstrated that the intensive care nurses were the least satisfied with the current process. The medical/surgical nurses were moderately satisfied and the patient service clerks had only 3 responders. After the project was implemented, we queried the same groups to determine satisfaction with the code lab processes after the changes specified in the code lab project were instituted. The showed significantly higher scores after the code lab project (Figure 3, Table 6). The survey after the code lab project had a much lower response A B C D E Figure 3 Scores on the code lab satisfaction survey for (A) intensive care unit nurses, (B) medical/surgical nurses, (C) patient service clerks, (D) laboratory staff, and (E) overall. Scale: 1 = poor, 2 = fair, 3 = good, 4 = excellent. project (n = 20) project (n = 8) project (n = 21) project (n = 16) project (n = 3) project (n = 3) project (n = 68) project (n = 37) project (n = 112) project (n = 68) CriticalCareNurse Vol 31, No. 5, OCTOBER

7 Table 6 Comparison of of survey from before and after code lab project Question Quickness of 3. Statistic Before After Before After Before After a N Degrees of freedom t P (2-tail) a Scale: 1 = poor, 2 = fair, 3 = good, 4 = excellent. rate. We believe that the lower response rate reflects underlying satisfaction with the project and a subsequent lack of interest in responding. Overall, 85% of responders after the project thought that the code lab process had improved in the past 6 months. Discussion Knowing a patient s laboratory picture is a crucial element in any code blue situation. By decreasing turnaround time for getting of laboratory tests, code team participants and the team leader are able to make more effective treatment decisions, directly affecting patient care during a code event. This nurseled initiative has led to system-wide functional and practice changes including quicker screens for ordering laboratory tests, the laboratory supervisor carrying a code pager, To learn more about laboratory values in the critical care setting, read Comparison of Glucose Point-of-Care Values With Laboratory Values in Critically Ill Patients by Shearer et al in the American Journal of Critical Care, 2009;18: Available at and laboratory specimens being packaged in the code cart more efficiently. The outcome has been overwhelmingly positive, from the viewpoints of clinicians and patients. The strategies implemented resulted in significantly faster processing of laboratory test and significantly improved the overall turnaround time for laboratory test during codes. In addition, staff across disciplines showed that they were significantly more satisfied with the new process for code labs. Because the process changes are basic, they can be easily implemented in the hospital setting to improve turnaround time for laboratory test during codes. CCN Now that you ve read the article, create or contribute to an online discussion about this topic using eletters. Just visit and click Submit a Response in either the full-text or PDF view of the article. Financial Disclosures None reported. Reference 1. Field JM, ed. Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: American Heart Association; CriticalCareNurse Vol 31, No. 5, OCTOBER