Code Leadership

Pandemonium, chaos, yelling, disarray, and arguing are not the words that I would use to describe a “code blue” in the pediatric intensive care unit (ICU). In fact, contrary to what you would see on TV, running a “code blue” is often calm and eerily quiet. Why is this the case? Well, one reason is code leadership. Running a code is an example of leadership. During the code, one sees the many nuances of leadership compressed into a relatively brief time period amongst a team of highly trained, healthcare professionals.

A ”code blue” in the pediatric intensive care unit ICU is usually an event measured in minutes to maybe an hour or more depending on the circumstances. But, most of the time, the acute phase of the “code blue” is usually less than 30 minutes in length. If you ask any of the participants in the code, they will tell you that time seems to slow down, and the experience feels much longer than the time recorded on the code log.

In most instances, medical interventions during the “code blue” are aimed at correcting an event where a child’s heart stops functioning properly and/or a child is having severe breathing problems which need to be corrected. Some supportive measures include chest compressions to keep the heart pumping, giving medications to stimulate the heart’s activity and function, assisting with breathing, and many other actions to support the heart and lungs of a child to prevent them from dying. Upon reflection, the most important parts of the “code blue” are not the medical interventions by themselves as much as the coordinated effort to deliver those interventions. Each medical professional is skilled at delivering medical care, but saving a child’s life cannot be solely accomplished through individual contributions. It is the teamwork and orchestration of all the individual activities that save lives.

The surprising number of leadership lessons that are infused into a “code blue” is impressive. It is a microcosm of the larger professed leadership concepts touted while running a large company, a championship professional sports team, a hospital, or any other large collaborative effort to succeed in any given endeavor. Nevertheless, the small scale and limited time interval shouldn’t cause one to underestimate the importance of leadership during a “code blue” event.

A primary focus during a “code blue” event is the division of labor. Each healthcare professional knows their role upon entering the code event. The primary roles include the recorder, medication preparer, bedside nurse, chest compressor, airway manager, others who support the team in various functions, and the code captain. Each role is critical to delivering optimal care to give a child the best chance for survival.

First, the recorder is often a nurse charged with writing down each intervention and medication given as well as documenting the exact time that they were provided. Why is this important? During a code, it is nearly impossible to remember all the medications that were given, how many times they were given, and when they were given. Documenting when chest compressions were started and stopped, when a patient was defibrillated and with how much electricity, when a child was intubated, and when and what other events occurred are not details that the team should be responsible for remembering during a high-stress and intense situation. It is ultimately important to put a comprehensive picture together of what has been done during the code in the team’s mind by being reminded of all the events that have taken place during the code. So, the recorder documents all the details so that the actions can be referenced by the team in real time during the code to decide what to do next.

Next, a medication nurse or a pharmacist prepares the medications that are being delivered. It takes time and attention to detail to determine the correct medication requested, medication dose (especially with kids where almost all medications are dosed based on the weight of the patient), dilution, concentration, and where and how a medication can be administered. Giving the wrong medication, medication dose, or medication preparation can be the difference between life and death during these critical events.

The bedside nurse is another key player during the code. The bedside nurse administers the medications prepared by the medication nurse or pharmacist. He or she also is responsible for making sure that vital signs, such as heart rate and blood pressure, are obtained either manually or through the monitoring devices during the code. There is also care for intravenous access, obtaining blood for testing, checking for physical exam findings, and other patient care-related activities. If the patient has been in the hospital or the ICU for a while, the bedside nurse is usually the person who has been caring for that individual and knows that patient’s medical history better than the other staff participating during the code. Knowing the patient’s medical history is important, so the medical team can identify potential causes for the “code blue”, avoid potential pitfalls in the delivery of care, and design the best care plan under the given circumstances.

The chest compressor is a critical member of the code team, in the event of a cardiac arrest. The chest compressor role is usually filled by multiple individuals who take turns performing the duties. Nurses, physicians, respiratory therapists, and any other medical personnel who have been trained in cardiopulmonary resuscitation (CPR) can participate. It is critical to keep the heart pumping by externally squeezing the heart by pushing on the chest, but it is exhausting. Because of the intensity and rapidity of the compression activity, an individual usually can sustain the activity for about 5-10 minutes before the efficacy of their efforts starts to wane. So, it is important to rotate individuals to perform optimal compressions for as long as the patient needs them.

While compressions are important to keep the heart pumping, the heart muscle will not function on its own without oxygen. The muscle requires blood with oxygen to contract and squeeze appropriately. With untrained bystanders in out-of-hospital CPR, it is encouraged to perform only chest compressions because there is a better willingness to start CPR by bystanders if they only have to perform chest compressions, bystanders usually provide low-quality mouth-to-mouth ventilation, and attempting mouth-to-mouth ventilation has the detrimental effect of interrupting chest compressions too long during ventilation periods. In the hospital setting, however, providing assisted breathing during CPR is the standard of care. A special mask with an air-pumping bag is used to push air into the lungs to assist with breathing or a breathing tube (endotracheal tube) is placed into the trachea through the mouth to attach an air-pumping bag to push air into the lungs as well. The activity of managing the airway is usually performed by a specially trained physician or respiratory therapist.

There are also other healthcare personnel who provide important services during the “code blue”. There are personnel who run the blood samples to the lab for testing, obtain intravenous access to administer medications, help obtain vital signs, bring supplies that are requested, call other hospital members if more specialized services are required, control the number of individuals in the area to make sure that there is enough space for those directly participating in patient care, and any number of other essential tasks during the code. There is also staff, such as social workers and clergy, who provide emotional and spiritual support to family members during the time of grave uncertainty while their critically ill child is being cared for by the medical team.

Finally, the code captain, usually a physician, is responsible for orchestrating the code by coordinating all the activities previously mentioned. The code captain is the leader of the code team and is responsible for trying to identify what caused the patient’s decompensation and how to stabilize and treat the child. He or she is responsible for ordering tests, deciding which medications or treatments to administer, when to start and stop compressions, and many other required duties during the resuscitation process. However, as a leader of a code, the job entails listening to the team as much as directing what needs to be accomplished. This is where code leadership starts and sets the tone for the team during an extremely stressful and high-stakes situation.

Knowing the code-team members and their responsibilities helps lay the foundation for understanding what is involved in code leadership. Everyone on the code team is a healthcare professional who is highly trained and knows their role. They do not need to be told how to perform their duties and certainly should not be micromanaged while performing them. Each team member needs to trust one another and their abilities. But, they all require coordinated interactions to reach their optimal performance under the most critical of circumstances. This is where code leadership enables the team to reach its high level of functioning.

The ability of the code captain to listen and observe what is happening creates an environment where all members feel comfortable expressing their ideas and feel heard. The team should not only feel comfortable communicating with the code captain, but also between themselves. Empowering each member of the team to contribute brings out the best in everyone, especially the code captain. The pharmacist or medication nurse expresses that a particular medication dose needs to be adjusted because of other medications the child has been taking. The recorder tells the team that the last dose of epinephrine was given 5 minutes ago, and it is time to give another dose. The bedside nurse relays that the patient had a history of being on blood thinner medication for a blood clot in the leg and she is concerned that the patient is at risk of bleeding into his/her brain. The staff member managing the breathing mentions that there is more resistance to pushing air into the lungs and there may be a mucous plug in the endotracheal tube. These are common types of comments that may be relayed during this critical event. Each piece of offered information may alter a medical decision to potentially save a child’s life, just like omitted information may cause the entire team to overlook potential life-saving interventions with devastating consequences. But, the staff may only offer the information if they feel that the leader is willing to receive it and they can freely communicate amongst themselves in a respectful, controlled, and collaborative environment.

Creating a receptive and collaborative environment is crucial during a “code blue” event, but communication is equally important. Being clear and concise with communication prevents miscommunication and potential errors in management. An effective method of communication during a code is closed-loop communication. Repeating back what was told or asked of you ensures that the correct information was received. Team members should not rely on guessing or reading the minds of each other to convey needs or wants during critical events. Time is of the essence and miscommunication not only creates errors but also causes delays which is a luxury that critically ill patients do not have during a “code blue” event.

While there are other aspects of code leadership, knowing one’s role during the code, exercising trust amongst and respect for the abilities of team members, creating a non-threatening environment that empowers comments and input, listening, communicating effectively, and collaborating are important and necessary leadership features within a code team. The code captain is the leader of the team and orchestrates the “code blue”, but each member must display leadership characteristics as well. The code team is a team of leaders who display the many nuances of leadership during the compressed time period of a code as they work towards the singular and well-defined goal of saving a child’s life.

What are other important leadership principles that you can add and which do you think are the most important, either in this scenario or any other environment that requires leadership?

If you are a healthcare professional, what other leadership elements have you witnessed during the running of a "code blue"?