Software alerts doctors to crisis before a ‘Code Blue’ is called

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Ten years ago, critical care doctor Alison Fox-Robichaud would hear “Code Blue” on the public speakers in Hamilton General Hospital’s intensive care unit every day.

She says the announcement, which signals that a patient has lost vital signs or is crashing toward death, made her wonder, “What went wrong; what did we miss?”

Fox-Robichaud, an associate professor of medicine at McMaster University in Hamilton, started an effort to eliminate Code Blue calls in 2006, when there were nearly 400 at Hamilton General. Many Code Blue patients require CPR, and only 25 per cent of those who lose a heartbeat will ever get it back. Only three per cent of patients whose heart stops on a general ward will leave the hospital alive.

‘Failure to rescue’

Known in the medical community as “failure to rescue,” Code Blue cases are the second-costliest acute care claim for Canadian hospital insurers after child birth complications.

The reason insurance companies pay out? More often than not, hospital staff could have recognized that a patient was deteriorating long before they became critically ill.

‘I get frustrated when I have to have a difficult conversation with a family because we had a gap in care.’ – Alison Fox-Robichaud, critical care physician, Hamilton General Hospital

“I get frustrated when I have to have a difficult conversation with a family because we had a gap in care,” Fox-Robichaud said.

Patients who deteriorate in hospital usually have gradual changes in their vital signs — heart rate, blood pressure and oxygen level — that must be recognized early so doctors can intervene before it’s too late.

“Vital signs are the basis of what we do,” Fox-Robichaud said. But busy workloads mean vital signs might be collected only twice per shift, and often, medical staff “don’t stop and think about what they mean.”

An internal 911 system

In 2006, the Ontario Ministry of Health funded rapid-response teams in many of the province’s hospitals, and today, they are recommended in hospitals throughout Canada and the U.S. The teams consist of an ICU doctor, an ICU nurse and a respiratory therapist who respond to Code Blue alerts throughout the hospital.

Still, after Hamilton General set up its team, Code Blue rates dropped only marginally.

“If you didn’t know a patient was deteriorating, you didn’t know to call the team,” said Jim McDonald, a registered nurse with the rapid-response team at Hamilton General.

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The hospital partnered with IBM to create a computer program that scans vital signs and calculates a warning score to identify patients who are at risk of dying so that doctors can intervene early and avoid a Code Blue crisis. (Cory Ruf/CBC)

Fox-Robichaud then developed a warning score based on a patient’s vital signs: the more abnormal the vital signs, the higher the score. The idea was that a high score would prompt a call to the rapid-response team.

This year, Fox-Robichaud partnered with IBM to create a computer program that scans vital signs and calculates the warning score automatically. Now, when the new screening process detects a score of six or more, it triggers a pager warning to the members of the rapid-response team.

“For every 3.4 people we recognize to have a score of six or more, we save one life [by intervening early],” said Fox-Robichaud.

But there were some initial challenges with the electronic system. Frequent inputting of vital signs into the computer system increased workload and was often put off until later in the day, and nurses often didn’t add up the points assigned to various vital signs to determine a patient’s warning score.

McDonald said he would sometimes show up at a dying patient’s bedside and wonder, “Why didn’t they call us sooner?

The Sick Kids model

​While Hamilton General is the first hospital in Canada to fully integrate an electronic early warning score with a rapid-response team, similar work has been happening at the Hospital For Sick Children in Toronto. There, pediatric ICU doctor Chris Parshuram and Kristen Middaugh, who oversees the hospital’s bedside early warning system, have been working for a decade on identifying children at risk of deterioration.

The team has developed a six-level warning score based on vital signs, similar to what Fox-Robichaud has done but specific to children. Since 2014, Sick Kids has been using a paper-based version of it, whereby vital signs are written down, and a corresponding score is manually calculated.

Now, it’s launching an electronic version that will allow vital signs to be entered into a computer. A colour-coded warning score will alert the health care team to clinical changes and suggest timely interventions.

The program will alert bedside nurses to “put down their pens and call for assistance” if the score is dangerously high, said Middaugh.

A trial of the electronic early warning system is underway, with results expected in the new year. Asked whether it has reduced the number of patients who deteriorated or needed to be transferred to the ICU, Parshuram said, “Absolutely.”

“It’s definitely improving patient safety,” he said.

The paper-based version of the Sick Kids system has been replicated by children’s hospitals in parts of Europe, New Zealand and North America.

‘It’s the future’

“I think it’s the future,” Dr. James Downar, an associate professor of critical care at the University of Toronto and an intensive care doctor at the University Health Network, says of the Hamilton system.

“We aren’t perfect, and there are times computers can do a better job at recognizing complex patterns over time.”

He cautions that humans at a patient’s bedside can pick up on details, such as skin colour and mental alertness, that computers can’t.

Integrating early warning scores is a national priority for the Canadian Patient Safety Institute. Carla Williams, CPSI’s patient safety improvement lead, says programs like the one at Hamilton General “are getting traction in the country” because “failure to rescue is a problem on the rise.”

CPSI is compiling evidence from programs like Hamilton’s and will share it with hospitals across the country in the spring.

Success, but still more work to do

An added benefit of instituting a rapid-response team in hospitals is that it allows for more opportunities to have conversations with families and patients about what measures they want to be taken if the patient’s condition deteriorates. Some opt for palliative care and forego medical intervention, and that accounts for some of the decrease in the number of Code Blue calls.

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Fox-Robichaud demonstrates bedside monitoring on a dummy at Hamilton General Hospital. (Andy Hincenberg/CBC)

The numbers suggest Fox-Robichaud’s efforts are paying off. Today, it’s rare to hear a Code Blue blared overhead at Hamilton General. Only 54 have been activated this year, compared to the 400 that Fox-Robichaud observed in 2006 when she started examining the Code Blue approach.

But there is still work to do to achieve Fox-Robichaud’s vision of “a hospital without Code Blues.”

Patients sometimes deteriorate in busy emergency departments or in ambulances, for example, and there are times, such as overnight, when nurses are reluctant to wake a patient to do the vital sign checks on which the system relies.

Fox-Robichaud says she is testing hand-held devices and wireless monitors attached to sleeping patients to try to account for some of those scenarios.

“Getting to zero Code Blues is going to be hard work, but we can get there,” she said.

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Software alerts doctors to crisis before a ‘Code Blue’ is called

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