Skilled management of cardiopulmonary resuscitation, or responding to a “code blue,” is widely considered an important training objective during internal medicine residency. Gaining proficiency in managing a code blue typically depends on event-based experiential learning. In this issue of Academic Medicine, Mickelsen and colleagues report their use of schedule-based stochastic simulation estimates matched with observed code blue data to model the number of annual opportunities a first-year resident has to participate in code blue events. Their data offer compelling evidence that trainees in 2008 had much less opportunity (83% less) to participate in code blue events than did their predecessors in 2002. Mickelsen and coinvestigators speculate that this reduction could be attributable to quality improvement initiatives that may have reduced the total number of code blue situations, as well as to duty hours restrictions that reduced the residents' overall availability to participate. The authors of this commentary discuss the general influence of secular trends on educational needs, and they describe possible strategies to compensate for less “in-the-field” exposure by maximizing the “learning yield per event” and using simulation training methods. Finally, the authors consider the question of whether code blue training remains an appropriate goal for general medicine trainees in the face of evolving trends in health care systems.
Dr. Yang is director of inpatient quality, Silverman Institute for Healthcare Quality and Safety, Beth Israel Deaconess Medical Center, and assistant professor, Department of Medicine, Harvard Medical School, Boston, Massachusetts.
Dr. Howell is director of critical care quality, Silverman Institute for Healthcare Quality and Safety, Beth Israel Deaconess Medical Center, and assistant professor, Department of Medicine, Harvard Medical School, Boston, Massachusetts.
Correspondence should be addressed to Dr. Howell, Critical Care Quality, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215; telephone: (617) 632-7687; fax (617) 632-0369; e-mail: email@example.com.
Editor's Note: This is a commentary on Mickelsen SR, McNeil RB, Parikh PP, Persoff J. Reduced resident “code blue” experience in the era of quality improvement: New challenges in physician training. Acad Med. 2011;86:726–730.
Cardiac arrests fascinate us, as a profession and a society. You can scarcely flip channels during primetime without stumbling across cardiopulmonary resuscitation, defibrillation, or some other aspect of resuscitation. Two observations are particularly striking about onscreen “code blue” events. First, they are astoundingly frequent: A New England Journal of Medicine study of U.S. medical shows noted 60 occurrences of code blue events in 97 episodes1; a similar BMJ study noted 55 cardiac arrests in 64 episodes.2 Second, trainee physicians are very often the ones performing CPR. Whether you are watching House, Scrubs, Grey's Anatomy, or the venerable E.R., you are likely to see resident physicians performing key roles in cardiac arrest resuscitations.
Those telegenic resident physicians might be surprised by the results of Mickelsen and colleagues'3 study in this issue of Academic Medicine. Those of us responsible for training the next generation of real-life physicians who will be resuscitating our most desperately ill patients should not be surprised, but we should pay attention. Should we worry? In this commentary, we focus on three key elements of integrating Mickelsen and colleagues' findings into the body of knowledge of resident training: (1) how new hospital practices and residency requirements may affect traditional training paradigms, (2) how training programs might adapt to the changes and effects, and (3) whether every program needs to adapt to the changes in the same ways and to the same extent.
How Does This Study Add to Our Knowledge of Resident Training for Code Blue Events?
This study asked and answered an important question: What has happened to resident experience in cardiac arrest training over the past several years—since resident schedules have changed (sometimes dramatically) and since quality improvement has taken center stage in many teaching hospitals?4 Because no prospective data existed on individual resident exposure to code blue events, the authors used a hybrid approach of real, observed data (i.e., how many arrests occurred) and resident-schedule-based stochastic simulation to derive a probabilistic model of trainee opportunity to participate in code blue resuscitations. They found that the predicted number of code blue events that a resident would attend annually fell by 83% between 2002 and 2008, a reduction that is both clinically and statistically significant. Two primary components accounted for this decrease: (1) an overall fall in code blue rates, from 12 to 3.8 per 1,000 admissions (∼68% reduction), and (2) a change in the resident code team coverage schedule, designed to accommodate duty hours requirements. (Another possibility is that residents spent fewer aggregate hours in the hospital, but to disentangle the exact number of hours from the specific staffing change undertaken in the authors' institution is difficult.)
A few methodological issues warrant comment. First, stochastic simulation is an interesting and reasonable approach to the question at hand. Instead of a simple point estimate, it gives us a sense of the uncertainty around the “answer.” Although the results of the simulation seem both plausible and robust, we would have welcomed seeing both more technical detail about the simulation and a fuller discussion of the rationale for some of its assumptions. For example, if the authors had access to the specific timing of code blue occurrences, as opposed to just monthly averages, they might have been able to shed some light on the importance of overnight or weekend duty to code blue exposure for resident physicians. Second, the comparison the authors draw against national resuscitation rates is probably not especially robust. The authors' data result from a registry of clinical code blue records; the billing-based data against which they compare may well capture a meaningfully different patient population. Previous work has found major problems relying on billing data to identify cardiac arrest.5,6
Additionally, we would have welcomed more detail both about what kinds of interventions (such as rapid response teams) were associated with such a dramatic and sustained reduction in cardiac arrests and about how these may be related to resident training. Finally, we note that the first-year residents' diminished exposure to code blue events, in the face of a declining number of such events per month, was compounded by the program's choice to preserve a “traditional” code blue staffing scheme. The institution asked residents to respond to code blue calls only during their 24-hour on-call shifts (as well as their ICU and emergency room shifts), rather than preserving or increasing residents' total “available hours to respond” to a code blue by distributing code blue staffing opportunities across other shifts during their inpatient rotations. Nonetheless, these are relatively minor issues and do not detract from the report's primary point: Residents are not seeing as many code blue events as they used to.
Secular Trends Profoundly Influence Educational Needs
The first key lesson from this report is that secular trends in code blue incidence are and will continue to deeply affect how we train residents. Although this could be an isolated issue at the authors' institution, experience (including at our own institution) indicates it is probably more widespread. Four years ago, presaging Mickelsen and colleagues' work, our hospital's CEO wrote:
One side effect of this improved coordination of care and the decrease in frequency of “code blue” events is that we now need to use our simulation center to train more of our interns, residents and nurses so they can get enough experience resuscitating patients! What a lovely problem to have.7
We have, of course, seen this educational pattern before. When the two of us began training, medical educators felt that the ability of every graduating internist to show competency in the inpatient management of HIV's panoply of complications was absolutely critical. HIV was then primarily an inpatient disease: Our attendings expected us to see plenty of cerebral toxoplasmosis, Pneumocystis, and Cryptococcal meningitis. Inpatient management of HIV-related diarrhea was so common that hospitals had clinical pathways in place for its management.8 Today, the landscape has changed dramatically: HIV is a largely outpatient disease, and this has radically altered training. Some examples are even more extreme. The 1892 edition of Osler's Principles and Practice of Medicine mentions measles at least 62 times; neither of us has ever even seen a case. Procedures can suffer this fate as well. For decades, many considered pulmonary artery (PA) catheterization to be a core skill for critical care physicians. However, in a single decade, PA catheter use in U.S. ICUs declined by more than two-thirds,9 a secular trend that has reshaped training and practice.10 Mickelsen and colleagues' work raises the possibility that we may see similar challenges with code blue training in the future.
How Do We Cope With Less In-the-Field Exposure?
Their report describes an important and evolving challenge to the experiential learning model at the core of graduate medical training nationwide: How can training, proficiency, and mastery of critical skills be preserved in a setting where the frequency of “experience-based” learning opportunities is declining, possibly as a consequence of resident duty hours limits, patient safety interventions, and/or new technologies? To address this challenge, we should perhaps question the basic assertion that repeated “field-based” exposure to critical events such as code blue is in fact sufficient to derive proficiency in responding to such events; a number of previous studies suggest otherwise.11,12 Simply participating in a series of code blue events does not likely confer the multifaceted learning required to achieve proficiency, let alone mastery, of a complex skill such as code blue management. Too often missing from such field-based training experiences are two essential elements of effective experiential education: feedback and reflection. Notably, in their survey of residents across 13 internal medicine programs in Canada, Hayes and colleagues11 found that amongst respondents (most of whom reported participating in one to five code blue events per month for three to four months of the year), 49.3% disagreed that they had received adequate training to lead cardiac arrest teams in teaching hospitals; additionally, only 5.9% reported attending formal debriefing sessions, and just 1.3% reported routinely receiving performance feedback after cardiac arrests.
Undoubtedly, a useful goal for physician training programs (especially important as code blue events decline in frequency) will be to develop strategies to explicitly maximize the “learning yield per event” and thus create training experiences not solely reliant on sheer quantity or repetition for learning effect. Programs should focus on and develop strategies that maximize the overall learning yield by augmenting each direct experience with timely, effective feedback and structured opportunity for critical reflection. With respect to code blue management, such strategies to improve the learning yield that follows participation in actual event responses might include (1) standardized team debriefings after every code blue, during which all participants share feedback and reflect on the response event, (2) interrogation of defibrillator devices to provide residents with reports regarding the quality and timing of chest compressions, defibrillation, and medication delivery during actual resuscitation events, and (3) direct, event-based faculty supervision and feedback.
Finally, code blue response training in particular has been an intense and fruitful target of innovation in high-fidelity simulation-based education over the past decade. Several features of code blue responses make such training ideally suited to the simulation environment, including the rare and unpredictable nature of actual events, the high risk associated with “real-life” performance errors, the emphasis on interpersonal communication skills that can be readily rehearsed in the simulation environment, the algorithmic nature of the interventions which are easily amenable to scenario-driven instructional sessions, and the vulnerability to cognitive errors due to fixation, stress, and distraction that can be readily recreated using high-fidelity simulation. A number of recent studies13–15 suggest that carefully planned, high-fidelity simulation training programs can indeed improve proficiency in both technical performance of resuscitation skills as well as event leadership skills. Simulation programs that are most effective recreate critical features of actual events, allow “risk-free” rehearsal of core skills, use structured event debriefing strategies for facilitating detailed feedback and reflection, focus on behavior-based (rather than purely knowledge-based) instruction, and emphasize team dynamics. Although Mickelsen and colleagues aptly note that such simulation-based training interventions may prove too costly for individual hospitals or medical schools to support, the role of simulation is likely only to gain in importance for training for critical events, especially those with rare or unpredictable frequency such as code blue. Further, we are likely to see the creation, adoption, and spread of regional simulation training centers—in models similar to those currently in place for procedure-based subspecialty training.
The combination of (1) enhanced educational structure (with emphasis on feedback and reflection) to support real-life clinical experiences and (2) high-fidelity, simulation-based training programs allows for the possibility that proficiency and mastery of critical skills such as code blue management may be not only preserved (despite diminished real-life exposure) but also potentially improved as focus shifts from the quantity to the quality of learning experiences.
Is Code Blue Training an Appropriate Goal for General Medicine Trainees?
An implicit assumption of Mickelsen and colleagues' report is that medical residents should be trained to respond to cardiac arrest. Is this really the case? The authors show us that our trainees have already lost 83% of their exposure to code blue events. The pressures that created this situation will become only more pronounced. Hospitals continue to improve quality, with corresponding reductions in cardiac arrest16; more stringent duty hours regulations have already come into play. Moreover, that tele-ICU services and regionalization of critical care will play increasing roles in U.S. health care delivery in the future seems likely.17 These two factors—combined with the growing presence of 24 × 7 in-house ICU attendings in many teaching hospitals—will only further diminish trainees' code blue exposure.
In this context, when most of our trainees will not end up practicing critical care medicine, does retaining code blue management as an educational goal for a medical residency continue to make sense? In the end, we both think “yes” is the right answer (at least in 2011). Understanding the sometimes brutal nature of a resuscitation seems like a critical educational goal for the future primary care physician, geriatrician, oncologist, hepatologist, and heart failure specialist (among others) as our society moves toward more explicit and reliable discussions of end-of-life care in the outpatient setting. Moreover, running a resuscitation is not just the province of the intensivist: In today's world, hospitalists across the country provide a tremendous amount of critical care. However, we are cognizant of the fact that future generations may look back and think that this is actually an outrageous position. Brass and Kendell's18 1961 article is particularly instructive in this regard:
Reluctance to perform an immediate and unsterile thoracotomy when even the diagnosis of cardiac arrest might be in doubt is understandable.... The opportunity for resuscitation must therefore occur frequently in hospital practice, both in the wards and in outpatient and casualty departments. Because of the vital time factor it will generally be a house officer who is presented with this opportunity. We therefore believe it should be the duty of all resident staff to acquaint themselves with the basic principles of cardiac massage. The only apparatus needed is a scalpel....
Few of us today would argue that all internal medicine and family practice residents must be competent in emergent thoracotomy and open cardiac massage. Will future educators look back at cardiac arrest management in the same way? Mickelsen and colleagues' report raises this possibility, but only time will truly tell.
Dr. Howell is partly supported by the Physician Faculty Scholars Program of the Robert Wood Johnson Foundation (grant #66350).
1 Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996;334:1578–1582.
2 Gordon PN, Williamson S, Lawler PG. As seen on TV: Observational study of cardiopulmonary resuscitation in British television medical dramas. BMJ. 1998;317:780–783.
3 Mickelsen SR, McNeil RB, Parikh PP, Persoff J. Reduced resident “code blue” experience in the era of quality improvement: New challenges in physician training. Acad Med. 2011;86:726–730.
4 Aronson MD, Neeman N, Carbo A, et al. A model for quality improvement programs in academic departments of medicine. Am J Med. 2008;121:922–929.
5 Hsia DC. Accuracy of Medicare reimbursement for cardiac arrest. JAMA. 1990;264:59–62.
6 De Bruin ML, van Hemel NM, Leufkens HG, Hoes AW. Hospital discharge diagnoses of ventricular arrhythmias and cardiac arrest were useful for epidemiologic research. J Clin Epidemiol. 2005;58:1325–1329.
8 Jones SG. Implementing a multidisciplinary HIV diarrhea critical pathway in the acute care setting. J Assoc Nurses AIDS Care. 1997;8:59–68.
9 Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993–2004. JAMA. 2007;298:423–429.
10 Rubenfeld GD, McNamara-Aslin E, Rubinson L. The pulmonary artery catheter, 1967–2007: Rest in peace? JAMA. 2007;298:458–461.
11 Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: A survey of internal medicine residents. Crit Care Med. 2007;35:1668–1672.
12 Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293:305–310.
13 Perkins GD. Simulation in resuscitation training. Resuscitation. 2007;73:202–211.
14 Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med. 2006;21:251–256.
15 Hunziker S, Bühlmann C, Tschan F, et al. Brief leadership instructions improve cardiopulmonary resuscitation in a high-fidelity simulation: A randomized controlled trial. Crit Care Med. 2010;38:1086–1091.
16 Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: A systematic review and meta-analysis. Arch Intern Med. 2010;170:18–26.
17 Nguyen YL, Kahn JM, Angus DC. Reorganizing adult critical care delivery: The role of regionalization, telemedicine, and community outreach. Am J Respir Crit Care Med. 2010;181:1164–1169.
18 Brass PR, Kendell RE. Successful cardiac massage after myocardial infarction in a casualty department. BMJ. 1961;1:26–29.