Improving Response to Medical Emergencies in Ambulatory Care

Purpose: Many challenges arise when considering emergency response in an ambulatory care setting. After thoughtful assessment of an organization’s 30 practice sites in eastern Massachusetts, it was recognized that change was necessary to be more in line with ambulatory care evidence-based practice and ambulatory care professional association recommendations. Research indicates that patients who received basic life support (BLS) in a pre-hospital setting have higher survival rates and lower mortality rates than those who received advanced cardiac life support (ACLS) (Ann Internal Medicine, 2015; JAMA Intern Med, 2015).

Description: Management of medical emergencies at the multi-practice ambulatory care center included ACLS response with the use of code cart equipment and medications. Acknowledging the varying frequency in which emergencies that required this level of response occurred confirmed that change was necessary. When ACLS skills are infrequently used in practice, comfort and competence levels are low. Review of safety event reports revealed that common medical emergencies seen throughout the organization included minor medical events such as fainting, nausea, falls, seizures, and bleeding. The medical emergency response model shifted to focus on BLS, including first aid, automated external defibrillation (AED), and activation of emergency medical services (EMS) when needed.

This change required buy-in from key stakeholders including operational and clinical leaders, physicians, advanced practice clinicians, nurses, and other direct care employees. Policies were revised to anchor on the new model. The initial steps included the purchase and installation of 120 AEDs, with onsite training and requiring all direct patient care employees to receive American Heart Association (AHA) BLS certification, and additional training on handling other common medical emergencies. In order to replace code carts in most areas of care, 188 rapid response (RR) bags were deployed across the practice sites. The RR bags include supplies and medications to manage minor medical emergencies and initiate BLS. Due to the acuity of care provided by procedural and some specialty areas; certain departments, including urgent care, cardiac testing, endoscopy, and the special procedures unit will retain code carts and will be certified to provide an ACLS response. Using a standardized template that anchors on principles outlined in the policy, RR plans will be developed and implemented on a local site level.

Ongoing training is critical to ensure the knowledge and skills to recognize early signs and symptoms of a decompensating patient and manage minor medical emergencies are present. Mock events, which will be informed by common themes reviewed through the safety reporting system, will engage staff and allow for practice and further development of these essential skills.

Evaluation/outcome: Creating safe response to medical emergencies with the development of RR in a multi-location ambulatory care center requires a great deal of ongoing assessment and review. Measurable outcomes include posting local site plans centrally on the organization’s intranet after development and increasing staff preparedness and confidence to handle an event with the use of the RR bag. Feedback from staff on this model will be reviewed after every mock event. Safety events will be tracked to ensure appropriate response to a patient event.