DNP: Direct Practice Improvement (DPI) Project Proposal Chapter 1

Submitted by

Beverly Holland

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

July 7, 2020

GRAND CANYON UNIVERSITY

The Impact of the Implementation of Code-Blue Champions for Cardiac Arrest

by

Beverly Holland

Proposed Comment by Author: Please note that this page will change with your final DPI manuscript development. Make sure you begin to use the DPI Project Template after obtaining IRB approval.

July 7, 2020

DPI PROJECT COMMITTEE:

Eleanor Hall, PhD, RN, Manuscript Chair

Sherri Mendelson, PhD, RN, Committee Member

Abstract

The project is based on Bandura's Self Efficacy (BSE) theory and Transtheoretical model TTM) of intentional behavior change. Nurses’ level of perceived self-efficacy, i.e., level readiness to implement resuscitation interventions is linked to their confidence in performance of American Heart Association (AHA) Basic Life Support (BLS). The Transtheoretical model (TTM) focuses on decision-making of the individual. In this project, a quantitative methodology will be used to analyze the impact of the implementation of a designated code blue nurse champion on nurses’ self-efficacy to initiate resuscitation efforts and patient survival of IHCA.

Data Results: Identify the population and the sample size. Briefly describe the approach for data analysis and results of statistical tests. State whether the results were statistically significant and include numeric values.

Implications: Conclude the abstract with one to two statements describing how the results of your project directly impacted practice at your site, and recommendations for what should be done in the future based on the findings of the project.

Keywords: Cardiopulmonary resuscitation, basic life support, code blue, in hospital cardiac arrest, nurse self-efficacy, rapid response team

Table of Contents Chapter 1: Introduction to the Project 9 Background of the Project 13 Problem Statement 19 Purpose of the Project 21 Clinical Question(s) 25 Advancing Scientific Knowledge 27 Significance of the Project 30 Rationale for Methodology 32 Nature of the Project Design 35 Definition of Terms 38 Assumptions, Limitations, Delimitations 42 Summary and Organization of the Remainder of the Project 45 Chapter 2: Literature Review 49 Theoretical Foundations 53 Review of the Literature 57 Theme 1 59 Theme 2 60 Summary 64 Chapter 3: Methodology 67 Statement of the Problem 68 Clinical Question 69 Project Methodology 71 Project Design 73 Population and Sample Selection 75 Instrumentation or Sources of Data 78 Validity 79 Reliability 80 Data Collection Procedures 81 Data Analysis Procedures 83 Potential Bias and Mitigation 86 Ethical Considerations 89 Limitations 91 Summary 93 References 95 Appendix A 108 Appendix B 147 Appendix C Error! Bookmark not defined.

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Cardiovascular disease is the primary cause of death resulting in 840, 768 in 2017, with 379, 133 deaths due to cardiac arrest (Varini et al., 2019). The American Heart Association’s (AHA) 2020 Impact Goals are to improve the cardiovascular health (CVH) of all Americans by 20% while reducing deaths attributable to CVDs and stroke by 20% (Varani et al., 2020). An estimated 209,000 in-hospital cardiac arrests (IHCA) occur each year in the United States (US), the survival rate of 24% (Andersen, Holmberg, Berg, Donnino, & Granfeldt, 2019). Key elements of success include early identification of at-risk patients combined with timely interventions to prevent deterioration of cardiac arrest (Andersen et al., 2019). Such identification might occur through an early warning system triggered by specific vital sign abnormalities, a scoring system based on multiple criteria, or staff concern (Andersen et al., 2019). Survival of and favorable outcomes from IHCA are highly dependent on factors such as skilled resuscitation team, prompt initiation of cardiopulmonary resuscitation and defibrillation, and organizational structures to support resuscitation care; nurses are an integral part of IHCA response (Guetterman et al., 2018).

At the project site, the rolling 12-month data for IHCA indicates that 44.6% of cardiac arrests occurred outside of the Intensive Care Unit (ICU), of which 59.60% occurred in the medical-surgical division (i.e., outside of ICU and Progressive Care Unit (PCU) equating to 5.16 per 1,000 discharges. For the month of May 2020, the incidence rate per discharges of IHCA in the medical surgical areas/units was 6.08 per 1,000 discharges. Survival to discharge of cardiac arrest is 30%, higher than the national average of 20% (Andersen et al., 2019).

Patient survival of cardiac arrest events depends on early recognition of the event and immediate response including activation of a “Code Blue” team and initiate high quality cardiopulmonary resuscitation (CPR) (Connell et al., 2016). Code blue, for the purpose of this project, is the phrase utilized to describe a medical emergency event at the project facility in which the patient has no pulse and is not breathing in or in cardiac arrest. Cardiac arrest is defined by the AHA (2016) as a malfunction in the heart causing an irregular heartbeat and disruption of blood flow to vital organs. The project site Code Blue committee notes appropriate patient placement as a factor outside of ICU IHCA; patients are sicker than their level of care placement. Whenever the rapid response team (RRT) is activated, patients are treated then transferred to a higher level of care. However, the author noted that 38% of codes occurring outside of the ICU had a rapid response within the previous 24 hours. Unexpected cardiac arrest is perhaps the most serious and clinically important adverse event.

Clinical nursing staff often provides suboptimal CPR during IHCA due to inadequate skills retention (Maiken, Castren, Nurmi, & Niemi-Murola, 2016; McHugh et al., 2016; Saramma, Raj, Dash, & Sarma, 2016), including a delay in the recognition of clinical deterioration with a resulting delay in the initiation of CPR (Andersen et al., 2019). Staff hesitation in initiating CPR is associated with a perceived low level of confidence in their ability to perform (Makinin et al., 2016). Numerous recent studies have reported similar findings of a connection between the confidence level of the nurse and the nurse’s performance of CPR on a patient (Adcock, Kuszajewski, Dangerfield & Muckeler, 2020; Herbers & Heaser, 2016; Makinen et al., 2016). A rapid response system (RRS) is considered one of the most powerful tools available to be used in the hospital for patient safety, where advanced nursing care and expertise are brought quickly to the patient's bedside (Simmes, Schoonhoven, Mintjes, Fikkers, & van der Hoeven, 2013). The author identified the existence of a “failure to rescue” patient care issue, i.e., a delay by medical-surgical nurses in the recognition and intervention of clinically deteriorating patients, with resultant delayed activation of the RRT.

High-quality CPR is critical for survival from cardiac arrest. Most providers in hospital settings have infrequent opportunities to perform CPR to maintain a level of proficiency (Panchal, Norton, Gibbons, Buehler, & Kurz, 2020), leading to a hesitancy to initiate CPR (Maiken et al., 2016). Nursing education and training designed for early recognition and management of patient deterioration can improve learner outcomes by using medium to high-fidelity simulation as an educational intervention (Connell et al., 2016). Deliberate practice and integration of teamwork skills in the time-pressured clinical environment provide great realism. They are a precious resource to improve participants' confidence and knowledge and identify latent threats and system issues that compromise patient safety (Greer et al., 2019; Czekajlo & Dabrowska, 2017). Staff not working in critical care areas may not have the needed knowledge, skills and experience in treating critically ill patients. However, they are instrumental in implementing a timely and appropriate intervention to prevent further deterioration and thereby reduce mortality and morbidity, because timely deployment most often depends on staff nurses (Massey, Chaboyer, & Anderson, 2017).

A quantitative quasi experimental methodology is selected for this project to assess the effectiveness of implementation of the code blue nurse champion role to improve IHCA survival. The educational intervention was aimed at identification of code blue champions using simulation and a communication framework. Champions then use their knowledge, attitudes and skills to improve nursing practice in their units and departments (Banks & Trull, 2012). The methodological approach identifies if targeted education on rapid response makes a difference in nurses’ timely recognition of patient deterioration and if appropriate action impacts survival of IHCA. Given that the purpose of the project is to determine the effectiveness of training on survival following IHCA, measurement is based on numerical data to derive a potential cause and effect. Secondarily, an evaluation of nurses reported self-efficacy to initiate and perform high quality CPR is measured pre and post training sessions. The intent of the intervention is to educate selected staff as code blue champions.

The following chapter discusses the background of the project categorized by problem statement, purpose, clinical questions, advancing scientific knowledge, and significance, rationale for selecting quantitative pretest-posttest design, definition of terms, assumptions, limitations, delimitations, and summary of the project. A detailed literature review including theoretical foundation is presented in Chapter 2 which illustrates the depth of the problem, the contributing factors, and the solution to the identified problem. Literature review aided the primary investigator in identifying other studies and was the basis for this project’s themes and subthemes. Chapter 3 discusses the methodology, the rationale for using that methodology and the nature of the design that was used for this project. Population, instrument used, data collection, data analysis, and ethical consideration will be also the subject of discussion in this chapter. Chapter 4 discusses data analysis and Chapter 5 discusses the conclusion and outline plan for future use of the project.

Cardiovascular disease is the primary cause of death resulting in 840,768 in 2017, with 379, 133 deaths due to cardiac arrest (Varini et al., 2019). The American Heart Association’s (AHA) 2020 Impact Goals are to improve the cardiovascular health (CVH) of all Americans by 20% while reducing deaths attributable to CVDs and stroke by 20% (Varani et al., 2020). The total prevalence of CVD in the United States (US) from 2013 – 2016 is 48% for all populations and genders (Virani et al., 2020); mortality is significant at 7%; 53% attributed to males, while 48% are females (Virani et al., 2020). Reported total healthcare costs related to CVD for the year 2014 – 2015 are $351.2 billion (Virani et al., 2020), shedding light on the financial burden of CVD.

For deaths attributable to CVD, selection of the single most likely underlying cause can be difficult when several significant comorbidities are present, as is often the case in the elderly population (Virani et al., 2020). However, cardiac arrest, whether expected or unexpected, results from disease processes linked with CVD (Andersen et al., 2019). An estimated 290,000 in-hospital cardiac arrests occur each year in the United States (US), the survival rate of 24.8% (Andersen et al., 2019). Key elements of success include identification of at-risk patients combined with early interventions to prevent deterioration of cardiac arrest (Andersen et al., 2019). Such identification might occur through early warning systems triggered by specific vital sign abnormalities, a scoring system based on multiple criteria, or staff concern (Andersen et al., 2019). Survival and favorable outcomes for IHCA are highly dependent on several factors, such as skilled resuscitation team, prompt initiation of cardiopulmonary resuscitation and defibrillation, and organizational structures to support resuscitation care; nurses are an integral part of IHCA response (Guetterman et al., 2018). The Institute of Healthcare Improvement (IHI) recognizes the need for having a safety measure to assist healthcare professionals at the bedside in the prevention and identification of patient deterioration (Institute of Healthcare Improvement [IHI], 2008). Current evidence illustrates the variability in cardiac arrest survival in and out of the hospital, demonstrating a substantial opportunity to save lives (Bhanji, Finn, et al., 2015).

For IHCA, provider-dependent determinants of survival are early defibrillation for shockable rhythms and high-quality cardiopulmonary resuscitation (CPR) (Bhanji, Donoghue, et al., 2015). Nurses are most likely first responders to witness an IHCA and provide treatment (McHugh et al., 2016). Furthermore, when rescuers respond slowly, survival is lower; early initiation of CPR links with improved outcomes for both out-of-hospital and in-hospital cardiac arrest (Bircher, Chan, & Xu, 2019). Therefore, CPR training for all hospital personnel has been mandatory in hospital systems for decades, facilitating the rapid identification and management of cardiac arrest before the arrival of the cardiac arrest team. Quality of chest compressions and CPR, in general, are associated with better outcomes in patients with cardiac arrest (Varani et al., 2020). Nurses do not deliver high-quality resuscitation skills in actual clinical settings (Saramma et al., 2016). Makinen et al. (2016) note that nurses (N=185) are hesitant to start CPR, which is associated with a perceived low level of confidence in their ability to perform. Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback (Saramma et al., 2016) and bolstering nurses' knowledge to enhance their self-efficacy in mastering skills (N=206 nurses) (Saramma et al., 2016). McHugh et al. (2016) discuss the impact of the professional nursing environment. A key consideration is facilitating a professional practice environment, ensuring training methodologies embeds professional practice concepts (i.e., team training, structural empowerment, e-learning methods access to up-to-date training methodologies) (McHugh et al., 2016). Research identifies an opportunity to re-evaluate traditional CPR education to identify inefficiencies and bolster confidence (McHugh et al., 2016).

Acquisition and retention of resuscitation skills are significantly better with novel training approaches compared to traditional methods (Saramma et al., 2016). Saramma et al. (2016) note that using different teaching techniques enhances nurses' knowledge, skill, attitude, and overall confidence to initiate timely CPR and save lives. High-quality CPR is critical for survival from cardiac arrest, but many providers in hospital settings have infrequent opportunities to perform CPR to maintain proficiency (Panchal, Norton, Gibbons, Buehler, & Kurz, 2020). In-situ simulation offers acute care nurses an opportunity to practice life-saving techniques in the clinical setting without patient harm. Simulation as a safety strategy focuses on the development of positive attributes and productive capacities that underpin safety performance. Simulation is oriented to improving safety through recognizing and responding to environmental disruptions (Greer et al., 2019). Offering nursing staff secured time to practice the technical and nontechnical skills necessary for effective teamwork can potentially reinforce and improve knowledge retention, skill acquisition, confidence levels, and self-efficacy (Greer et al., 2019). Nurses’ self-efficacy with a timely response to IHCA is a critical link to the delivery of AHA BLS recommendations with the outcome of survival of cardiac arrest.

Rapid response systems (RRS) are considered a powerful tool in patient safety (Jung et al., 2016). Rapid response team (RRT) is an evidence-based practice (EBP) that most hospitals in the country are utilizing (Maglangit, 2015). The RRT is one of the six initiatives that the Institute of Healthcare Improvement (IHI) “100,000 Lives Campaign” identified in 2004 (Mate, 2017). The concept of implementing the rapid response system, also known as RRT or Medical Emergency Team (MET), is simply to bring critical care expertise at the patient's bedside (or when needed) (Institute of Healthcare Improvement, 2008). The initiative seeks to prevent patient deaths and to improve patient outcomes. The team's goals are to recognize early signs of deterioration and prevent avoidable code events (Barrett, Hawdon, Wade, & Reeves, 2017). According to Lee, Bishop, Hillman, and Daffurn (1995), RRTs were developed "to promote rapid assessment and treatment of patients whose clinical condition was deteriorating but were not in shock or cardiac arrest" (p. 183). The team helps detects any significant clinical deterioration at the earliest opportunity, therefore, quickly addressing the issue (s) and preventing further deterioration (Maglangit, 2015). Despite its known value in preventing patient's deterioration and improving outcomes, there is still mixed information on its effectiveness in decreasing patient transfers to the ICU and decreasing the number of hospital codes (Maglangit, 2015).

Delays in activating RRT calls are associated with high mortality, while early intervention during clinical deterioration can improve patient outcomes (Reardon, Fernando, Murphy, Rosenberg, & Kyeremanteng, 2018). Early RRT calls are associated with decreased mortality, while late calls are associated with increased patient morbidity and mortality (Jones, Moran, Winters, & Welch, 2013). Early requests for assistance allow identification of patients at risk of deterioration and target interventions to improve patient care (Maharaj, Raffaele, & Wendon, 2015). Recognition of altered physiological observations to complex process involves knowledge and experience (Guinane, Bucknall, Currey, & Jones, 2013).

Issues of delayed response and failure to notify the RRT are related to the inability to recognize patients` deterioration and be associated with environmental factors. According to Jenkins, Astroth, and Woith (2015), recognition and addressing barriers can improve rapid response` system safety culture and can have a positive impact on cardiac or respiratory arrests and mortality outside the intensive care unit (ICU). These barriers are related to perceptions that one has the necessary skills and abilities to perform or face issues or challenges related to navigation of the intra-professional and inter-professional hierarchies that lead to delays in activating the team when the patient condition deteriorates (Jenkins et al., 2015). Other possible system failures identified are multiple factors including delays in diagnosis and misdiagnosis (on physician's side), inadequate interpretation of clinical symptoms, incomplete treatment, inexperienced staff, and patient management in appropriate clinical areas (Bagshaw et al., 2010 as cited in Jenkins et al., 2015).

According to Massey et al. (2017), an adequate education, appropriate knowledge, and skills are required to aid in the identification of the deteriorating patient and helps provide prompt, timely, and appropriate intervention to prevent further deterioration and possibly death. Additionally, a well-planned education program aimed at making nursing staff thoroughly familiar with the purpose and process of the rapid response team, the development of clear-cut calling criteria, and the involvement of key stakeholders, including nurses, in the design and implementation of the rapid response team can alleviate issues concerning delays of activating the rapid response team (Massey et al., 2017). However, Maglangit (2015) note that RRT education alone revealed negative correlation and no significance on the nurses’ confidence level (N=28) in activating team. Meanwhile, pre and post-test results showed that RRT education increased nurses’ confidence level in activating the team.

Considering that early interventions could save lives, issues concerning delays in calling the rapid response team do exist. The recognition of physiological observations and response to complex processes involves knowledge and experience, and early intervention and escalation of care are essential (Guinane et al., 2014). Earlier intervention improves patient's survival (Jenkins et al., 2015). Banks and Trull (2012) implemented a process improvement strategy. The strategy educates code blue champions by using simulations and a communication framework. The champions then use their education to improve practice in their departments (Banks & Trull, 2012). The authors note findings demonstrated that nurses’ report increased confidence and competence in managing a code blue situation, and patient outcomes reflect the improvement in skills; code blue champions on each unit and reported a 74% survival rate compared to the national average of 44% (Banks & Trull, 2012).

The clinical staff is often providing suboptimal CPR due to inadequate skills retention (Makinen et al., 2016; McHugh et al., 2016; Saramma et al., 2016), recognition of clinical deterioration leading to delay initiating CPR (Andersen et al., 2019), and hesitation to start CPR, which is associated with perceived low level of confidence in their ability to perform (Adcock et al., 2020; Makinen et al., 2016). Greig, Elliot, Parboteeah, and Wilks (1996) defined CPR skills retention as retaining the capacity to perform CPR effectively at a certain point in time after CPR training.

The staff that does not work in critical care areas may not have the exact knowledge, skills and experience in treating critically ill patients, however, they are instrumental in implementing a timely and appropriate intervention to prevent deterioration and reduce mortality and morbidity because timely deployment most often depends on staff nurses (Massey et al., 2017). The rationale for many of these strategies on implementing a timely and appropriate intervention, according to Massey et al. (2017), is to prevent patients from deteriorating through providing education, informing staff, and providing them with the necessary skills. Due to their proximity to patients and familiarity with their clinical conditions, bedside nurses are ideally positioned to alert the RRT for anticipatory response and intervention (Connell et al., 2016). They are the first caregivers to identify the subtle changes in the patient’s condition, indicating clinical deterioration. They must be educated and trained to activate the rapid response system (RRS) preemptively and proactively (Jenkins, Astroth, & Woith, 2015). Currently, there exists a nursing practice issue of “failure to rescue” in the medical-surgical patient population, i.e., and a delay in recognition of patient deterioration resulting in the delayed activation of the RRT.

It is not well known if or to what degree the implementation of code blue nurse champion would impact nurses’ self-efficacy and survival of IHCA when compared to current practice among acute care registered nurses in community hospital in Southern California.

Patient safety and preventable in-hospital mortality remain crucial aspects of optimum medical care. Despite improvements in cardiopulmonary resuscitation and the availability of cardiac arrest teams, the risk of death from an IHCA remains significant (Virani et al., 2020). Many adverse events are related to a failure to recognize patient deterioration on the floor and provide appropriate, timely intervention (McHugh et al., 2016). Immediate action and resuscitation skill proficiency are essential to reduce morbidity and mortality resulting from an IHCA.

The purpose of this project is to compare the impact of the implementation of the code blue nurse champion role in a select nursing medical-surgical division patient care department on nurses’ self-efficacy to initiate cardiac resuscitation and survival of IHCA. The nurse champion role will be defined as a cohort of staff registered nurses on a medical-surgical unit. The nurse self-efficacy to initiate cardiac resuscitation will be measured pre and post education and training using the Basic Resuscitation Skills Self-Efficacy Scale (BRS-SES). Patient outcome of survival of IHCA in a medical surgical unit is measured by survival of cardiac arrest obtained through the organizations code blue data. Survival of cardiac arrest will be assessed through audits of cardiac arrest code sheets. A baseline of survival of cardiac arrest will be obtained. Following the intervention, a post determination will be assessed for the survival of IHCA.

Detection of early signs and effective resuscitation therapy during the cardiac arrest by nurses is influenced by various factors, such as work environment, resources, and value systems (Attin, Tucker, & Carey, 2016). Acquisition and retention of resuscitation skills were significantly better with novel training approaches than traditional methods (Halm & Crespo, 2018). The research recommended elements in the resuscitation educational paradigm include:

1. Training standards examined regularly

2. Contextual learning using simulators

3. Mastery learning that emphasizes delivery of the low dose, high frequency (LDHF) practice of critical skills

4. In-situ simulation in the clinical setting

5. Benchmarking outcome performance (Halm & Crespo, 2018).

One of the things that has been found is a code blue nurse champion. There is a gap in the research linking actual survival of IHCA with current activities for nursing activities with code blue. Therefore, the implementation of code blue nurse champion role could help them to receive more hands-on experience and equip them to provide timely and effective CPR during cardiac arrest. This DPI project will provide information to fill that gap, include evidence of the benefit in situ simulated CPR performance and self-efficacy. The project’s desired outcome measure of improved IHCA survival, indicative of timely resuscitative efforts, would illustrate the value of a novel practice change.

Prior studies have demonstrated that CPR quality is directly related to survival outcomes, suggesting that poor-quality CPR should be considered preventable harm (Wibrandt, Norsted, Schmidt, & Schierbeck, 2015). Evidence links quality CPR with positive cardiac arrest outcomes, ensuring effective CPR skill training is therefore paramount (Brennen, McGraw, & Brooks, 2016; Lin, Cheng, Grant, Currie, & Hecker, 2018; Kim, Park, & Shin, 2016; Ofoma et al., 2018). Ineffective CPR skills are identified as preventable harm (Halm & Crespo, 2018). Makinen et al. (2016) note that nurses (N=185) are hesitant to start CPR, which is associated with a perceived low level of confidence in their ability to perform. McHugh et al. (2016) discuss CPR knowledge of nurses. McHugh et al. (2016) discuss the impact of the professional nursing environment. Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback and bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills (N=206 nurses) (Saramma et al., 2016). A key consideration is facilitating a professional practice environment, ensuring training methodologies embeds professional practice concepts (i.e., team training, structural empowerment, of e-learning methods access to up-to-date training methodologies) (McHugh et al., 2016). Banks and Trull (2012) used Code Blue champions on each unit and reported a 74% survival rate compared to the national average of 44%.

The following question guides this quality improvement project: To what degree does the implementation of code-blue nurse champion role as cardiac arrest first responder impact the nursing self-efficacy to initiate cardiac resuscitation with survival of IHCA when compared to current practice among adult medical surgical patients in an acute care hospital in California over four-weeks?

The following clinical questions guide this quantitative project:

Q1: What is the impact of educational training for code blue nurse champion on nurses’ reported self-efficacy responding to cardiac arrest?

Q2: What is the impact of a code blue nurse champion on survival of IHCA?

The purpose of this project is to compare the impact of the implementation of the code blue nurse champion role in a select nursing medical-surgical division patient care department on nurses’ self-efficacy to initiate cardiac resuscitation and survival of IHCA. An estimated 290,000 in-hospital cardiac arrests occur each year in the United States (US), the survival rate of 24.8% (Andersen et al., 2019). High-quality CPR is critical for survival from cardiac arrest. However, many providers in hospital settings have infrequent opportunities to perform CPR to maintain proficiency (Panchal et al. 2015), leading to hesitancy to initiate CPR (Makinen et al., 2016). Educational interventions designed to improve the recognition and management of patient deterioration can improve learner outcomes when they incorporate medium to high-fidelity simulation (Connell et al., 2016). Deliberate practice and integration of teamwork skills in the time-pressured clinical environment provide great realism. They are a precious resource to improve participants' confidence and knowledge and identify latent threats and system issues that compromise patient safety (Greer et al., 2019; Czekajlo & Dabrowska, 2017).

An integrative review of the literature revealed that CPR skills retention and poor quality CPR remain a major challenge in the clinical setting. The findings have consistently demonstrated that the quality of CPR is directly related to survival outcomes. Literature indicates that adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016). CPR training helps individuals learn and apply cognitive, behavioral, and psychomotor skills then develop the self-efficacy to provide CPR when necessary (Bhanji, Finn et al.,2015; Horowitz, 2018). Nurses are often the first to activate the chain of survival when a cardiorespiratory arrest happens. It is crucial that nurses keep their knowledge and skills up-to-date, as well as attitudes to resuscitation are very important (Tiscar-Gonzalex, Blanco-Blanco, Gea-Sanchez, Molinuevo, & Moreno-Casbas, 2019). Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing, and responding appropriately to an emergency is increased (Horowitz, 2018). Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016).

The training for the code blue nurse champions includes the use of in-situ simulation on cardiac arrest scenarios. Simulation offers acute care nurses an opportunity to practice life-saving techniques in the clinical setting without patient harm. Simulation as a safety strategy focuses on the development of positive attributes and productive capacities that underpin safety performance. Simulation is oriented to improving safety through recognizing and responding to environmental disruptions (Greer et al., 2019). Offering nursing staff secured time to practice the technical and nontechnical skills necessary for effective teamwork can potentially reinforce and improve knowledge retention, skill acquisition, confidence levels, and self-efficacy (Greer et al., 2019). Nurses’ self-efficacy with a timely response to IHCA is a critical link to the delivery of AHA BLS recommendations with the outcome of survival of cardiac arrest. Implementing dedicated code blue nurse champions is a novel approach to improve recognition and response to deteriorating patients. Providing additional hand-on experience through cardiac arrest in-situ simulation could equip them to provide timely and effective CPR during cardiac arrest.

The project is based upon Bandura's Self Efficacy (BSE) theory and Transtheoretical model (TTM). Confidence is related to self-efficacy but is a distinct concept. Bandura (1982) defined confidence as “the perception that one is competent and capable of fulfilling particular expectations’ expectations” whereas self-efficacy is the personal judgment of “how well one can execute courses of action required dealing with prospective situations” (p. 122). Self-efficacy has been studied extensively in nursing in relation to how nursing interventions can influence a patient’s behavior to improve health outcomes (Lenz & Shortridge-Baggett 2002 as cited in Van Dyk, Siedlecki, & Fitzpatrick, 2016). Confidence is important as it may influence the degree of self-efficacy experienced. The Transtheoretical model (TTM) focuses on the decision-making of the individual and is a model of intentional change. The TTM operates on the assumption that people do not change behaviors quickly and decisively; rather, change in behavior, especially habitual behavior, occurs continuously through a cyclical process.

Prior studies have demonstrated that CPR quality is directly related to survival outcomes, suggesting that poor-quality CPR should be considered preventable harm (Wibrandt et al., 2015; Halm & Crespo, 2018). Evidence links quality CPR with positive cardiac arrest outcomes. Ensuring effective CPR skill training is therefore paramount (Brennen et al., 2016; Lin, Cheng, Grant, Currie, & Hecker, 2018; Kim et al., 2017; Ofoma et al., 2018). Ineffective CPR skills are identified as preventable harm (Halm & Crespo, 2018). Makinen et al. (2016) note that nurses (N=185) are hesitant to start CPR, which is associated with a perceived low level of confidence in their ability to perform. Both Maiken et al. (2016) and McHugh et al. (2016) discuss CPR knowledge of nurses and influence on resuscitation efforts. McHugh et al. (2016) discuss the impact of the professional nursing environment. Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback and bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills (N=206 nurses) (McHugh et al., 2016). A key consideration is facilitating a professional practice environment, ensuring training methodologies embeds professional practice concepts (i.e., team training, structural empowerment, of e-learning methods access to up-to-date training methodologies) (McHugh et al., 2016). Banks and Trull (2012) used Code Blue champions on each unit and reported a 74% survival rate compared to the national average of 44%.

The purpose of this quality improvement project is to compare the impact of the implementation of a code blue nurse champion role in a select nursing medical-surgical division patient care department on nurses’ self-efficacy to initiate cardiac resuscitation and survival of IHCA.

The success of a research quality improvement project is dependent on research questions and methods, which assist with topic relevance and clinical significance. Empirical research, related to evidence-based practice (EBP), is examined using the PICOT format for Direct Practice Improvement (DPI) projects (Ellis, 2019). 

The aim of the quantitative methodology is to predict, control, or explain theory testing. Quantitative research relies on statistical analysis to analyze data. Quantitative methods emphasize objective measurements and the statistical, mathematical, or numerical analysis of data collected, or by manipulating pre-existing statistical data using computational techniques (Fain, 2017). The method is used to test or confirm theories and assumptions. Two foundational aspects of a quantitative research project are for it to build on prior results or evidence and provides a basis for future research and discovery (Zaccagnini & White, 2017).

The purpose of quantitative methodology is to discover through statistical analysis cause and effect relationships. According to Klazema (2014) the overall goal of [quantitative] methodology is to convey numerically what is being seen in the research and to arrive at specific and observable conclusions. Descriptive statistics are utilized to determine the relationship between variables or the significance of group differences or the effect of an intervention.

The evaluation method used in this quality improvement project will use quasi experimental design. A quantitative quasi experimental design is selected for this project to assess the effectiveness of implementation of the code blue nurse champion role to improve IHCA survival. This strategy educates code blue champions by using simulations and a communication framework. The champions then use their education to improve practice in their units and departments (Banks & Trull, 2012). The methodological approach is used to identify if the additional training makes a difference in nurses’ timely recognition of patient deterioration and if appropriate action impacts survival of IHCA. Given that the purpose of the project is to determine the effectiveness of training on survival following IHCA, measurement is based on numerical data to derive a potential cause and effect. Secondarily, an evaluation of nurses’ reported self-efficacy to initiate and perform high quality CPR is measured pre and post training sessions.

The intent of the intervention is to educate selected staff as code blue nurse champion role. The participants are current registered nurses (RNs) on a select patient care unit. The RRT education provided to medical-surgical nurses is adapted from the Institute of Healthcare Improvement (IHI) website (See Appendix B). The education includes RRT`s composition, role, purpose, reason to call, when to call, how to call and the SBAR (Situation, Background, Assessment, Recommendation) communication that should be used during calls. In-situ simulation is focused on responding to a deteriorating patient, specifically on cardiac arrest, team roles, prioritizing actions, and effective communication, inclusive of the role of rapid response teams (RRT).

The nature of the project design chosen is a quantitative quasi-experimental design to assess the outcome effectiveness of implementation of code blue nurse champions. An unpaired t-test will be used to evaluate pre and post-intervention nurses' self-reported self-efficacy with resuscitation. The two measures need to be obtained from the same group of people at different times (Polit & Beck, 2012). This method is best used in situations in which the variables are not able to be changed by the investigator (Polit & Beck, 2012). Demographic data will be included stratifying the sample into less than two years or less of experience and greater than two years. Descriptive statistics include gender, age, education level, previous experience witnessing a cardiac arrest, performance of CPR on a live patient, and experience in use of automated external defibrillation (AED) device on a live patient.

IHCA survival of cardiac arrest data will be assessed comparing two months prior and two months following the one-month intervention. A rate will be obtained per 1,000 patient discharge before and after the intervention. A chi-square analysis will be used to determine if there is a significant difference between what was found [survival of cardiac arrest] and what would have been expected.

Nurses identified for the project will be randomly chosen in collaboration with the nurse manager. Equal representation from night shift (1900-0730) and day shift (0700-1930) will be included. This author intends to have a sample of 10 RNs involved in the project training for code blue nurse champion. The valid and reliable instrument to be used is the Basic Resuscitation Skills Self-Efficacy Scale (BRS-SES) by Hernandez-Padilla, Suthers, Fernandez-Sola, and Granero-Molina (2016). Objective data is collected from cardiac arrest data (survival of IHCA). Quasi-experimental, referred to as controlled trials without randomization, involves an intervention but lacks randomization (Polit & Beck, 2012). The characteristic of the design is the application of an intervention to establish a cause-effect relationship between two or more variables, without randomization (Polit & Beck, 2012.); groups are not assigned and the independent variable (s) is not manipulated.

Evaluating the quality of research is essential if findings are to be utilized in practice and incorporated into care delivery. Lincoln and Guba (1985) as cited in Noble and Smith (2015) offer alternative criteria for demonstrating rigor within qualitative research, namely truth value, consistency and neutrality, and applicability. Unlike quantitative researchers, who apply statistical methods for establishing validity and reliability of research findings, qualitative researchers aim to design and incorporate methodological strategies to ensure the ‘trustworthiness’ of the findings (Noble & Smith, 2015). It is imperative that all qualitative researchers incorporate strategies to enhance the credibility of a study during research design and implementation. Although there is no universally accepted terminology and criteria used to evaluate qualitative research, the authors outline some of the strategies that can enhance the credibility of study findings (Noble & Smith, 2015) such as:

1. Truth value: Utilization of reflective journal maintained and decisions documented. Representativeness of the findings in relation to the phenomena, for example “Semi-structured audio-recorded interviews allow for repeated revisiting of the data to check emerging themes and remain true to participants’ accounts of caring for patients with renal disease managed without dialysis” (p. 1).

2. Consistency / Neutrality: Achieve auditability through transparent and clear description of research process from initial outline, through the development of the methods and reporting of findings.

3. Applicability: Application of findings to others’ contexts that includes [for example] “rich detail of context, the renal setting, including the patients managed within the service, facilitates the evaluation of study conclusions and transferability to other renal units” (p. 1).

Among qualitative traditions commonly used in health sciences research (i.e., research about health care) are ethnography, grounded theory, phenomenology, and hermeneutics (Melnyk & Fineout-Overholt, 2015). Ethnography involves the study of a social group’s culture through time spent combining participant observation, in-depth interviews, and the collection of artifacts (i.e., material evidence of culture) in the informants’ natural setting. This appreciation of culture—drawing on anthropologic (i.e., human development) theory and practice—provides the context for a better understanding of answers to specific research questions (Melnyk & Fineout-Overholt, 2015).

The following terms are used in this scholarly project. The terms are identified according to the way in which they applied to this project.

Basic life support. Basic life support (BLS) is the foundation for saving lives following cardiac arrest. Fundamental aspects of BLS include immediate recognition of sudden cardiac arrest (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), and rapid defibrillation with an automated external defibrillator (AED) (Berg et al., 2010).

Cardiopulmonary disease. A family of disease states including coronary heart disease (CHD), heart failure [congestive heart failure (CHF)], stroke, and hypertension (Virani et al., 2020).

Cardiopulmonary resuscitation. Cardiopulmonary resuscitation (CPR) is the performance of chest compressions and ventilations. High-quality CPR includes compressions of adequate rate and depth, allowing full chest recoil between compressions, minimizing interruptions in chest compressions and avoiding excessive ventilation (Berg et al., 2010).

Clinical Significance. Clinical significance (also known as clinical relevance) indicates whether the results of a project are meaningful or not for several stakeholders. Statistical significance does not assure that the results are clinically relevant. Indeed, the use of significance testing rarely determines the practical importance or clinical relevance of findings (Armijo-Olivo, 2018).

Code blue. Hospital emergency code used to alert staff for various emergency situations to reduce in-hospital associated deaths. Code blue systems are communication systems that ensure the most rapid and effective resuscitation of a patient in respiratory or cardiac arrest. (Kaykisiz, Tongun, Sonmezsoy, & Guven, 2017). For purpose of this project, code blue activation is specific to cardiac arrest.

High fidelity. Life-sized computerized manikins with realistic anatomical structures that can mimic real-life situations (Kim et al., 2016). The manikins have embedded software and can be controlled by an external, handheld device.

In hospital cardiac arrest. Refers to a cardiac arrest that occurs within a hospital setting. For the purpose of this project, in-hospital cardiac arrests (IHCA) are inclusive only of those that occur outside of the emergency department (ED).

In-situ simulation. Comprised of team-based activities and occurs in patient care units with healthcare professionals in their own working environment. The intentional blend of simulation and real working environments means that in situ simulation brings simulation to the real working environment and provides training where people work (Sorensen et al., 2017). In situ simulation can be either announced or unannounced, the latter also known as a drill.

Medical surgical division. Refers to inpatient nursing care departments within an acute care hospital that care for patient’s not requiring intensive care or step down level of care. Typically patients cared for within this division are diagnosed with a medical condition (e.g., asthma, diabetes, congestive heart disease) that requires hospital care. Patients may also be surgical patients recovering from surgical procedures (e.g., gallbladder removal, colon surgery, appendectomy). The division does not include obstetrics, perioperative, or emergency room care.

Participants. For the purpose of this project, participants are defined as registered nurses who take part in the code blue nurse champion project. The participants actively interact with the simulator and education.

Rapid response team. A rapid response team (RRT) is a hospital based team that is alerted by a staff member to alert other staff for help when a patient’s vital signs have fallen outside set criteria (Jung et al., 2016)

Self-efficacy. Perceived self‐efficacy is concerned with people's beliefs in their ability to influence events that affect their lives. This core belief is the foundation of human motivation, performance accomplishments, and emotional well‐being (Bandura, 1997, 2010). Unless people believe they can produce desired effects by their actions, they have little incentive to undertake activities or to persevere in the face of difficulties (Bandura, 2010). Whatever other factors may serve as guides and motivators, they are rooted in the core belief that one can make a difference by one's actions.

Scenarios. Scenarios use a script or planned series of events based on a disease process that will occur [in the simulation experience] (Sorensen et al., 2017).

Simulation. Simulation-based clinical education refers to a variety of activities using patient simulators, including devices, trained persons, lifelike virtual environments, and role-playing, not just handling manikins (Kim et al., 2016).

Assumptions. The following assumptions are present in this project:

1. Acute care nursing staff may be irresolute about their role and the role of RRTs creating further delay in immediate response times. 

2. Acute care nurses are not fully confident in early recognition. 

3. Nursing staff education and establishment of a designated code blue nurse champion each shift will improve early recognition of patient decline as well as early response and therefore, a decrease in poor patient outcomes.

4. Nurses working in the medical surgical division will be interested in participating and provide honest feedback.

5. The instruments [survey] are independent of one another. All participants will complete the survey independently of each other.

6. The participants will be working in the department during the study period and not floated off department. The intent is to have a trained code blue nurse champion working every day and night shift.

Limitations. The following limitations are present in this project:

1. The first limitation is the short timeframe. The four-week timeframe limits the number of IHCA to assess for survival.

2. The survey was a participant’s perception. There is no objective measurement to assess participants’ actual performance changes.

3. The number of participants is based on the investigator and nurse manager’s opinion to determine the best coverage over 24 hours, seven days a week. The desire is to ensure that there is a code blue nurse champion working every day and night shift.

Delimitations. The following are delimitations present in this project:

1. One delimitation is the sample was one of convenience. The sample will come from one nursing department at the project site. Having more diverse location(s) may be a more accurate sample of the population as a whole (Polit & Beck, 2012).

2. There are numerous research studies on nursing and medical students using simulation to develop self-efficacy, but there are few on practicing nurses using simulation to increase self-efficacy to improve performance in high-risk situations, specifically cardiac arrest response. This investigator intends to provide more information on the corollary of in-situ simulation in increasing nurses’ self-efficacy.

3. Research is focused on improving nurses’ ability to perform high quality CPR, but there is a gap in the literature focusing on medical-surgical nurses’ capability to recognize patient deterioration and initiate resuscitation care. The delivery of CPR at an individual nurse level may be infrequent resulting in decreased knowledge and skills. The code blue nurse champion role is a novel approach to focus education on a dedicated group of nurses rather than direct the education and training to all nurses in a medical surgical division.

Cardiovascular disease is a primary cause of death resulting in 840,768 deaths in 2017, with 379,133 deaths due to cardiac arrest (Varini et al., 2019). The AHA's 2020 Impact Goals are to improve the cardiovascular health (CVH) of all Americans by 20% while reducing deaths attributable to CVDs and stroke by 20% (Varani et al., 2020). For deaths attributable to CVD, selection of the single most likely underlying cause can be difficult when several significant comorbidities are present, as is often the case in the elderly population (Virani et al., 2020). However, cardiac arrest, whether expected or unexpected, results from disease processes linked with CVD (Andersen et al., 2019). An estimated 290,000 in-hospital cardiac arrests occur each year in the United States (US), with a survival rate of 24.8% (Andersen et al., 2019).

The IHI recognizes the need for having a safety measure to assist healthcare professionals at the bedside in the prevention and identification of patient deterioration (IHI, 2008). Current evidence illustrates significant variability in cardiac arrest survival in and out of the hospital, demonstrating a substantial opportunity to save lives (Bhanji, Finn, et al., 2015). For IHCA, provider-dependent determinants of survival are early defibrillation for shockable rhythms and high-quality cardiopulmonary resuscitation (CPR) (Bhanji, Donoghue, et al., 2015). Nurses are most likely first responders to witness an IHCA and provide treatment (McHugh et al., 2016; Tíscar-González et al., 2019). Furthermore, when rescuers respond slowly, survival is lower; early initiation of CPR links with improved outcomes for both out-of-hospital and in-hospital cardiac arrest (Bircher et al., 2019). Therefore, CPR training for all hospital personnel has been mandatory in many hospital systems for decades, facilitating the rapid identification and management of cardiac arrest before the arrival of the cardiac arrest team. Quality of chest compressions and CPR, in general, are associated with better outcomes in patients with cardiac arrest (Varani et al., 2020). Nurses do not deliver high-quality resuscitation skills in actual clinical settings (Saramma et al., 2016). Makinen et al. (2016) note that nurses (N=185) are hesitant to start CPR, which is associated with a perceived low level of confidence in their ability to perform. McHugh et al. (2016) discuss the impact of the professional nursing environment. Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback (Saramma et al., 2016) and bolstering nurses' knowledge to enhance their self-efficacy in mastering skills (N=206 nurses) (Saramma et al., 2016).

Acquisition and retention of resuscitation skills are significantly better with novel training approaches compared to traditional methods (Saramma et al., 2016). Rapid response team (RRT) is an evidence-based practice (EBP) for early response to patient deterioration that most hospitals in the country are utilizing (Maglangit, 2015). Considering that early interventions could save lives, issues concerning delays in calling the rapid response team exist. The recognition of physiological observations and response to complex processes involves knowledge and experience, and early intervention and escalation of care are essential (Guinane et al., 2014). Earlier intervention improves patients’ survival (Jenkins et al., 2015). According to Massey et al. (2017), adequate education, appropriate knowledge, and skills are required to aid in the identification of the deteriorating patient and help provide prompt, timely, and appropriate intervention to prevent further deterioration and possibly death. Educational interventions designed to improve the recognition and management of patient deterioration can improve learner outcomes when they incorporate medium to high-fidelity simulation (Connell et al., 2016).

Due to their proximity to patients and familiarity with their clinical conditions, bedside nurses are ideally positioned to alert the RRT for anticipatory response and intervention (Connell et al., 2016). Currently, there exists a nursing practice issue of “failure to rescue” in the medical-surgical patient population, i.e., a delay in recognition of patient deterioration, resulting in a mortality of 5.16 per 1,000 patient discharges. For the month of May 2020, the incidence of IHCA in the medical surgical division was 6.08 per 1,000 discharges. In situ simulation demonstrates sustained positive impact upon the real world implementation of rapid response to patient deterioration (Connell et al., 2016). A novel approach is proposed that includes educational (inclusive of in-situ simulation and components of RRT (IHI, 2008) interventions to improve recognition and management of patient deterioration under the auspices of code blue nurse champions. Patient outcomes to be evaluated include survival of IHCA.

The review of the literature provides guidance for developing this project. This chapter presents a discussion of the literature related to cardiac arrest and nurse’s ability and confidence to respond to patient deterioration and perform high quality CPR during in hospital cardiac arrest (IHCA). There are numerous studies related to nurses’ performance and training methods of high quality CPR. Simulation is explored as a methodology as an effective training strategy. The framework to guide this project is Bandura's Self Efficacy (BSE) theory and Transtheoretical model (TTM). The following chapter presents a discussion on the theoretical framework for the quality improvement project. The instrument used is the Basic Resuscitation Skills Self-Efficacy Scale (BRS-SES) by Hernandez-Padilla et al., 2016.

The following chapter includes a comprehensive review of the literature search was performed using the following electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL) with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews, PubMed, and Clinical Key. Keywords used in the Boolean or phrase search were: cardiopulmonary resuscitation, survival, nurses, nurse’s self-confidence, in hospital cardiac arrest, and rapid response teams. The following limiters were used: English only, full text, academic journals, clinical trial, and year ranges from 5 to 40 years.

The incidence of IHCA in the medical surgical setting pose distinct challenges for acute care nurses. Many providers in hospital settings have infrequent opportunities to perform CPR to maintain proficiency (Panchal et al. 2015), leading to hesitancy to initiate CPR (Makinen et al., 2016). Research confirms that traditional basic life support (BLS) courses do not translate into high-quality resuscitation skills (Niles et al., 2017). There is increasing awareness of the factors inhibiting nurses from escalating care for patients who deteriorate (Massey et al. 2014 as cited in Massey et al., 2015). However, why non-critical care nurses fail to recognize and respond to patient deterioration has not been extensively studied (Massey et al., 2015). Nurses play an integral role in the initiation and delivery of CPR, and consideration of their role as the first responder is critical. Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing, and responding appropriately to an emergency is increased (Horowitz, 2018).

Background

A leading cause of death in the United States is sudden cardiac arrest. Weaknesses in the traditional biennial BLS training methodology, resulting in poor cardiopulmonary resuscitation (CPR) skills, have been identified in the literature (Brennen et al.,2016; Makinen et al.,2016;). Evidence links quality CPR with positive cardiac arrest outcomes, thus ensuring effective CPR skill training is paramount (Brennen et al., 2016; Gonzalez et al., 2017; Lin et al.,2018; Kim et al., 2017; Ofoma et al., 2018). Current evidence illustrates the variability in cardiac arrest survival in and out of the hospital, demonstrating a substantial opportunity to save lives (Lin et al., 2018; Lund-Kordahl et al., 2019).

Nurses are often first line responders for patients who suffer from an IHCA during their hospital stay (Tíscar-González et al., 2019. Survival of cardiac arrest event depends on early recognition of the event and immediate response including activation of a “code blue” team to initiate high quality CPR (Connell et al., 2016). However, many providers in hospital settings have infrequent opportunities to perform or initiate CPR to maintain proficiency (Panchal et al. 2015), leading to hesitancy to initiate CPR (Makinen et al., 2016). Nurses’ self-efficacy with a timely response to IHCA is a critical link to the delivery of AHA BLS recommendations with the outcome of survival of cardiac arrest.

In-situ simulation offers acute care nurses an opportunity to practice life-saving techniques in the clinical setting without patient harm. Simulation as a safety strategy focuses on the development of positive attributes and productive capacities that underpin safety performance. Simulation is oriented to improving safety through recognizing and responding to environmental disruptions (Greer et al., 2019). Offering nursing staff secured time to practice the technical and nontechnical skills necessary for effective teamwork can potentially reinforce and improve knowledge retention, skill acquisition, confidence levels, and self-efficacy (Greer et al., 2019).

The medical surgical nurses at the project facility had similar skill deficiencies as reported in the literature. The author organizations’ code blue committee notes appropriate patient placement as a factor outside of ICU IHCA; patients are sicker than their level of care placement. When RRT is activated, patients are transferred to a higher level of care. However, only 38% of non-ICU codes had a rapid response within the previous 24 hours. Immediate action and resuscitation skill proficiency are essential to reduce morbidity and mortality resulting from an IHCA. Nurses are more willing to activate the team when they are knowledgeable and have more information about the team and RRT criteria (Maglangit, 2015).

Bandura’s Self Efficacy Theory. Bandura (1982) defined confidence as “the perception that one is competent and capable of fulfilling particular expectations’ expectations” whereas self-efficacy is the personal judgment of “how well one can execute courses of action required dealing with prospective situations” (p. 122). One’s own perception of self-efficacy contributes to an individual’s judgement of their ability to perform specific behaviors (Bandura, 1982). Confidence is important as it may influence the degree of self-efficacy experienced.

Self-efficacy has been studied extensively in nursing concerning how nursing interventions can influence a patient's behavior to improve health outcomes (Lenz & Shortridge-Baggett 2002, as cited in Van Dyk et al., 2016). Confidence is essential as it may influence the degree of self-efficacy experienced. Confidence means that an individual knows how to do something, but self-efficacy has to do with what an individual believes they can do with that skill. Individuals with high self-efficacy believe that a task is achievable and will recruit resources such as learning a new skill, seeking advice, and devoting additional time to accomplish the task (Pajares 2009 as cited in Van Dyk et al., 2016). Fundamentally, individuals with a high degree of self-efficacy believe that they can influence their environment and the course of their endeavors and, therefore, perceive the cost of attempting to accomplish a task worthwhile (Bandura, 1995). Further, individuals with high self-efficacy in a given area exert a higher level of effort and demonstrate a high persistence when approaching a difficult task than individuals with lower self-efficacy (Lunenburg 2011 as cited in Van Dyk et al., 2016).

Bandura’s Self-Efficacy theory provides an excellent framework to the concept of CPR skills retention and recent studies (Hernandez-Padilla et al., 2015; Horowitz, 2018, McRae et al., 2017). McRae et al. (2017) note nurse’s increase in self-efficacy to perform cardiac surgical resuscitation skills through the use of simulation training. Self-efficacy expectancy comes from previous experience with the behavior, vicarious experience, persuasion that they can perform the behavior, and physiological response to the experience or anticipation of the experience of performing an event (McRae et al., 2017). One’s perception of self-efficacy contributes to an individual’s judgement of their ability to perform specific behaviors. Individuals with less efficacy to perform the behavior either avoid the behavior or give up quickly on learning a skill whereas individuals with higher levels of self-efficacy are likely to persevere to master (McRae et al., 2017). In-situ simulation training presents an active learning experience that enhances skills mastery and self-perceptions as objective feedback motivates learners to enhance their skills and to role-play effective code management.

The Transtheoretical Model.The Transtheoretical Model (TTM) focuses on the individual's decision-making and is a model of intentional change. The transtheoretical model posits that health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations (Prochaska & Velicer, 1997). The TTM operates on the assumption that people do not change behaviors quickly and decisively; instead, change in behavior, especially habitual behavior, occurs continuously through a cyclical process (Boston University School of Public Health [BUPH], 2019). The TTM is not a theory but a model; different behavioral theories and constructs can be applied to various stages of the model where they may be most effective.

The TTM posits that individuals move through six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination (BUPH, 2019). For each stage of change, different intervention strategies are effective at moving the person to the next stage of change and subsequently, through the model to maintain the ideal stage of behavior (BUPH, 2019). To progress through the stages of change, people apply cognitive, affective, and evaluative processes. Ten processes of change are recognized, with some processes being more relevant to a specific stage of change than other processes (BUPH, 2019). These processes result in strategies that help people make and maintain change.

This section provides a broad, balanced overview of the existing literature related to the topic. It identifies themes, trends, and conflicts in methodology, design, and findings. It provides a synthesis of the existing literature, examines the contributions of the literature related to the topic, and presents an evaluation of the overall methodological strengths and weaknesses of the evidence. Through this synthesis, the gaps in evidence should become evident to the reader.

This section describes the literature in related topic areas and its relevance to the project topic. It provides an overall analysis of the existing literature examining the contributions of this literature to the field, identifying the conflicts, and relating the themes and results to the project. Citations are provided for all ideas, concepts, and perspectives. The investigator’s personal opinions or perspectives are not included.

The required components for this section include the following:

· Chapter 2 needs to be at least 20-25 pages in length. It needs to include a minimum of 50 scholarly sources with 85% of sources published within the past 5 years. Additional sources do not necessarily need to be from the past 5 years.

· Quantitative project: Describes each project variable in the project and discusses the prior evidence that has been done on the variable. Comment by Author: Please note that you may also use seminal works and other relevant literature that supports your topic concept.

· Discusses the various methodologies and designs that have been used to provide evidence on topics related to the project. Uses this information to justify the design.

· Relates the literature back to the DPI-project topic and the practice problem.

· Argues the appropriateness of the practice improvement project’s instruments, measures, or approaches used to collect data.

· Discusses topics related to the practice improvement project topic. This section may include (a) studies relating the variables (quantitative); (b) studies on related evidence-based research, such as factors associated with the topic; (c) studies on the instruments used to collect data; and (d) studies on the broad population for the project.

· Set of topics discussed in the Review of Literature demonstrates a comprehensive understanding of the broad area in which the project topic exists.

· Argues the appropriateness of the practice improvement project’s instruments, measures, or approaches used to collect data.

· Each section within the Review of Literature includes an introductory paragraph that explains why the particular topic was explored relative to the practice improvement project topic.

· Each section also requires a summary paragraph(s) that (a) compares and contrasts alternative perspectives on the topic, (b) provides a summary of the themes relative to the topic discussed that emerged from the literature, (c) discusses data from the various studies, and (d) identifies how themes are relevant to your practice improvement project topic.

· The types of references that may be used in the literature review include empirical articles, a limited number of practice improvement projects, peer-reviewed or scholarly journal articles, and books that are cutting-edge views on a topic, evidence-based research, or seminal works.

The body of a literature review can be organized in a variety of ways depending on the nature of the project. Work with your committee chairperson to determine the best way to organize this section of Chapter 2, as it pertains to your overall project design. This template organizes the evidence thematically, as illustrated below.

You may want to organize this section by themes and subthemes. To do so, use the pattern below.

Subtheme 1. Grouped findings related to Theme 1. Comment by Author: This heading is tagged with APA Style Level 4 heading [3.03].

Project 1 . Describe the clinical question(s), sample, methodology, and findings of this project. Comment by Author: Same as above. Make sure you are replacing “Project 1” with specific language. Do not include “Project 1” in the title as it is just a placeholder.

Project 2 . Describe the clinical question(s), sample, methodology, and findings of this project.

Project 3 . Describe the clinical question(s), sample, methodology, and findings of this project.

In a concluding paragraph, provide a synthesis of the evidence studies presented in Subtheme 1. Discuss the strengths and weaknesses of each project, as well as the variables, instrumentation, and findings of each project as they relate to each other and use the findings of the studies in the subtheme to build an argument for your project. Discuss what is missing or how the design or methodology could have changed in studies to improve the quality of the project. Discuss inconsistencies or gaps that emerge in the evidence providing opportunity for additional projects. Provide a transition sentence to the next subtheme.

Subtheme 2. Grouped findings related to Theme 1.

Project 1 . Describe the Clinical question[s], sample, methodology, findings Comment by Author: This heading is tagged with APA Style Level 5 heading [3.03].

Project 2 . Describe the clinical question[s], sample, methodology, findings)

Project 3 . Describe the clinical question[s], sample, methodology, findings

Provide a synthesis of the evidence in the subtheme as suggested above. Continue repeating this pattern with other evidence findings that fit with Theme 1 and then provide an overall synthesis of the evidence for Theme 1. Repeat this pattern for the next major theme in your literature review and continue repeating as needed.

Chapter 2 can be particularly challenging with regard to APA format for citations and quotations. Refer to your APA manual frequently to make sure your citations are formatted properly. It is critical that each in-text citation is appropriately listed in the References section.

For a quote within a quote, use a set of single quotation marks. [4.08]. As a rule, if a quote comprises 40 or more words, display this material as a freestanding block quote. Start formal block quotes on a new line. They are indented one inch in from the left margin. The entire block quote is double-spaced. Quotation marks are not used with formal block quotes. The in-text citation is included after the final punctuation mark. [6.03]. Below is an example of a block quote: In an important biography, The First American: The Life and Times of Benjamin Franklin, historian H. W. Brands writes: Comment by Author: Caution! Make sure you do not overuse titles in the literature review. You can use them in certain instances, but do not rely on them to convey content.

In February 1731, Franklin became a Freemason. Shortly thereafter, he volunteered to draft the bylaws for the embryonic local chapter, named for St. John the Baptist; upon acceptance of the bylaws, he was elected Warden and subsequently Master of the Lodge. Within three years, he became Grandmaster of all of Pennsylvania's Masons. Not unforeseeable he—indeed, this was much of the purpose of membership for everyone involved—his fellow Masons sent business Franklin’s way. In 1734 he printed The Constitutions, the first formerly sponsored Masonic book in America; he derived additional [printing] work from his brethren on an unsponsored basis. (Brands, 2000, p. 113)

This section restates what was written in Chapter 2 and provides supporting citations for key points. It synthesizes the information from the chapter using it to define the “gaps” in or “project needs” from the literature, the theories or models to provide the foundation for the project, the problem statement, the primary clinical question, the methodology, the design, the variables or phenomena, the data collection instruments or sources, and population. It then provides a transition discussion to Chapter 3.

Overall, this section should:

· Synthesize the information from all of the prior sections in the literature review and use it to define the key strategic points for the project.

· Summarize the gaps and needs in the background and introduction and describe how it informs the problem statement.

· Identify the theories or models describing how they inform the clinical questions.

· Use the literature to justify the design, variables, data collection instruments or sources, and population to be evaluated.

· Relates the literature back to the DPI-project topic and the practice problem.

· Build a case (argument) for the project in terms of the value of the project and how the clinical questions emerged from the review of literature.

· Explain how the current theories, models, and topics related to the project will be advanced through your project.

· Summarize key points in Chapter 2 and transition into Chapter 3.

This section should help the reader clearly see and understand the relevance and importance of the project to be conducted. The Summary section transitions to Chapter 3 by building a case for the project, in terms of project design and rigor, and it formulates the clinical questions based on the gaps and tensions in the literature. Comment by Author: Use INSERTPage Break to set new page for new chapter. Do not use hard returns to get there.

Chapter 3 documents how the project is conducted in enough detail so that replication by others is possible. The introduction begins with a summary of the project focus and purpose statement to reintroduce the reader to the need for the project. This can be summarized in three or four sentences from Chapter 1. Summarize the clinical questions in narrative format, and then outline the expectations for this chapter.

Remember, throughout this chapter depending on where you are in your project, the verb tense must be changed from present tense (proposal) to past tense (DPI Project manuscript). Furthermore, consider will happen during data collection and analysis as it is planned here. Sometimes, the DPI project protocol ends up being modified based on committee, Academic Quality Review (AQR), or Institutional Review Board (IRB) recommendations. After the practice project is complete, make sure this chapter reflects how the project was actually conducted.

This section restates the problem for the convenience of the reader. Copy and paste the Statement of the Problem from Chapter 1. Then, edit, blend, and integrate this material into the narrative. Change future tense to past tense for DPI Project manuscripts.

This section restates the clinical question(s) for the project from Chapter 1. The following clinical questions guide this quantitative project:

Q1:

Q2:

Q3:

It then presents the matching of the variables. This discussion includes the independent variable (intervention or practice change) and the dependent variable (outcome of the DPI) (see Table 1)

Table 1

Characteristics of Variables

Note: Add notes here = (Creswell & Creswell, 2018).

The section also briefly reviews the approaches to collecting the data to answer the clinical questions. (see Figure 1)

Figure 1. Approaches to collecting the data to answer the clinical questions

Between-subjects (or between-groups) designs include different people or data in each collection so that each person is only in one group or the other. Within-subjects (or repeated-measures) design include the same person in all collections both before and after the intervention.

The section should describe the instrument(s) or data source(s) to collect the data for each variable. It also discusses why the design was selected to be the best approach to answer the clinical question(s).

This section describes the methodology for the DPI project and explains the rationale for selecting this quantitative methodology. It also describes why this methodology was selected as opposed to the alternative methodologies. (see Table 2) DPI projects are typically quantitative due to the nature of measuring a practice improvement.

Table 2

Type of Methodology and Rationale for Selecting It

Note: Quantitative methods are recommended for DPI projects due to feasibility and clinical relevance associated with the measurement of a practice improvement.

Reference: Creswell, J.W. & Creswell, J.D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.) Thousand Oaks: CA. Sage Publications.

This section should elaborate on the Methodology section (from Chapter 1) providing the rationale for the selected project method (e.g. quantitative). Arguments are supported by citations from articles and books on methodology or design. It is also proper in this section to outline the predicted or expected results in relation to the clinical questions based on the existing literature. Describe how the method selected supports the attainment of information that will answer the clinical questions.

This section elaborates on the nature of the Project Design section from Chapter 1. In most DPI projects, a quasi-experimental design is the recommended due to measurement of a direct practice improvement. If other methods are considered, it should be discussed with your chair/committee including the capacity to measure a practice improvement and time frame needed to complete it.

This section includes a detailed description of, and a rationale for, the specific design for the project. Quantitative designs include descriptive, correlation, quasi-experimental, and experimental designs (Creswell & Creswell, 2018). Each associated with an approach to the data being collected. See Appendix B for an algorithm to assist with design determination. Designs involving a practice change or intervention are either a quasi-experimental or experimental type. However, an experimental design is usually not feasible for a DPI due to the requirement for randomization and manipulation of the intervention within and between the project groups to address the statistical assumptions.

This section further describes how it aligns to the selected methodology indicated in the previous section. Additionally, it describes why the selected design is the best option to collect the data to answer the clinical need for the project.

The section explains exactly how the selected design will be used to collect data for each variable. It identifies the specific instruments and data sources to be used to collect all of the different data required for the project. Arguments are supported by citations from articles and books on DPI project method or design. This section should specify the independent, dependent, or classificatory variables, as appropriate. These variables should be defined in Chapter 1. Be sure to relate the variables back to the clinical questions. A brief discussion of the type of data collection tool chosen (survey, interview, observation, etc.) can also be included in this section as related to the variables. Collecting data using an instrument may require a consent versus collecting data from the EHR may require a HIPAA waiver. These considerations should be addressed later in the proposal.

This section discusses the setting, total population, project population, and project sample. The discussion of the sample includes the project terminology specific to the type of sampling for the project. This section should include the following components:

· Describes the characteristics of the total population and the project population from which the project sample (project participants) is drawn.

· Describes the characteristics of the project population and the project sample.

· Clearly defines and differentiates the sample for the project versus the number of people completing instruments on the project sample.

· Describes the project population size and project sample size and justifies the project sample size (e.g., power analysis) based on the selected design.

Clearly defines and differentiates between the number for the project population and the project sample versus the number for the people who will complete any instruments. Details the sampling procedure including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population.

Describes the informed consent process, confidentiality measures, project participation requirements, and geographic specifics.

· Discusses the intervention protocol to answer the clinical question(s).

· If subjects withdrew or were excluded from the project, you must provide an explanation. This would be added for the final manuscript and would not be present in the proposal.

This section fully identifies and describes the types of data that will be collected, as well as the specific instruments and sources used to collect those data (tests, questionnaires, interviews, databases, media, etc.). Discuss the specific instrument or source to collect data for each variable or group. Use subheadings for each data collection instrument or source of data and provide a copy of all instruments in an appendix.

If you are using an existing instrument, make sure to discuss in detail the characteristics of the instrument. For example, on a preexisting survey tool describe the way the instrument was developed and constructed, the validity and reliability of the instrument, the number of items or questions included in the survey, and the calculation of the score as appropriate.

If you are using a source of data, discuss the detail on how the source of data was accessed, the validity and reliability of the source of data and how the information was collected and stored. If the learner is acquiring data from medical records or databases, e.g. electronic health records including being provided a delimited database of data, this access and permission should be specified and how the identifiable patient information is being protected within the project. A HIPAA waiver may be specified.

This section describes and defends the procedures used to determine the validity of the data collected. Validity refers to the degree to which a project accurately reflects or assesses the specific concept that the investigator is attempting to measure. Ask if what is actually being measured is what was set out to be measured. As an investigator, you must be concerned with both external and internal validity.

For this section, provide specific validity statistics found in the literature for quantitative instruments, identifying how they were developed. NOTE: Learners should not be developing any quantitative instruments without permission from the DNP department.

This section describes and defends the procedures used to determine the reliability of the data collected. Reliability is the extent to which an experiment, test, or any measuring procedure is replicable and yields the same result with repeated trials. For this section, provide specific reliability statistics for quantitative instruments, identifying how the statistics were developed from the literature.

This section details the entirety of the process used to collect the data. Describe the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project. The key elements of this section include:

· A description of the procedures for project sample recruitment, sample selection, and assignment to groups (e.g. comparison versus intervention).

· A description of the procedures for obtaining informed consent and for protecting the rights and well-being of the project sample participants, as well as those completing instruments on them.

· A description of the procedures adopted to maintain data securely, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed.

· A description of the procedures for data collection, including how each instrument or data source was used, how and where data were collected, and how data were recorded.

· An explanation of the independent and dependent variables (if applicable), and how the resulting change in those variables is measured (if applicable),

· An explanation of how variables were compared (if applicable).

This section provides a step-by-step description of the procedures to be used to conduct the data analysis. The key elements of this section include:

· A description of how the data were collected and organized for each variable or group.

· A description of the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analyses.

· Demonstration that the project analysis is aligned to the specific project design.

· A description of the clinical question(s).

· A detailed description of the relevant data collected and analyzed for each stated clinical question.

· A description of how the raw data were organized and prepared for analysis. Provides a step-by-step description of the procedures used to conduct the data analysis.

Figure 2. Parametric statistics for analysis of ratio or interval level dependent variable (Creswell & Creswell, 2018)

The independent variable within a quasi-experimental design will be most be a nominal or categorical level variable identifying the sample or group associated with the intervention. It is the dependent variable’s level of measurement which will direct the type of statistical analysis e.g. parametric versus non-parametric. If the dependent variable is a ratio, interval, the test to be used would be a parametric one. If the dependent variable is an ordinal or nominal level, a non-parametric test would be used.

Figure 3. Non-parametric statistics for analysis of nominal or ordinal level dependent variable (Creswell & Creswell, 2018)

Bias in sampling can occur. A sampling method is called biased if it systematically favors some outcomes over others. The following example shows how a sample can be biased, even though there is some randomness in the selection of the sample.

Example:

If my project employs an intranet survey and there are people who meet the criteria but do not have access to the internet to take the survey, I will miss all those people who met the criteria for participation!

Here are some common sources and consequences of bias:

Convenience samples:

Sometimes it is not possible or not practical to choose a random sample. In those cases, a convenience sample might be used. Sometimes it is plausible that a convenience sample could be considered as a random sample, but often a convenience sample is biased. If a convenience sample is used, inferences are not as trustworthy as if a random sample is used.

Bias may be present in data collection. While collecting data for the DPI, there are numerous ways by which the Learners may introduce bias to the project. If, for example, during patient recruitment, some patients are less or more likely to participate in the project such sample would not be representative of the population in which

this project is done (Roush, 2020). In that case, these subjects who are less likely to enter the study will be underrepresented and those who are more likely to enter the study will be over-represented relative to others in the general population, to which conclusions of the study are to be applied to (Roush, 2020). This is what we call a selection bias. To ensure that a sample is representative of a population, sampling should be random, i.e. every subject needs to have equal probability to be included in the DPI. It should be noted that sampling bias can also occur if sample is too small to represent the target population. For example, if the aim of the DPI is to assess the if motivational interviewing in psychiatric patients improves medication adherence the Learners may only be able to recruit otherwise healthy, stable patients during a regularly scheduled well check-up. By recruiting only well patients and the inability to use all psychiatric clients that can consent this is another bias.

Bias can also occur in the data analysis right? We often are only looking at data that gives preference to answering the clinical question. If the data is misrepresented or not fully reported or even manipulated this is a bias (Fox & Lash, 2020). Comment by Author: Make sure all citations are entered in the reference list as the reviewers will check all citations and references for accuracy.

Bias may occur in the data interpretation. It is imperative to run the correct statistical analysis (Fox & Lash, 2020). The data must be correctly analyzed and presented as is. Do not report only what was significant or discuss what was not significant. Consider a project where your pre and post-knowledge test for nurses did not show a statistical significance in using the tool. However, if the tool decreased readmission rates by 50% was it clinically significant? This observation should be discussed in detail.

This section discusses the potential ethical issues surrounding the project, as well as how human subjects and data will be protected. The key ethical issues that must be addressed in this section include:

· Identify how any potential ethical issues will be addressed.

· Provide a discussion of ethical issues related to the project and the sample population of interest, institution, or data collection process.

· Address anonymity, confidentiality, privacy, lack of coercion, informed consent, and potential conflict of interest.

· Demonstrate adherence to the key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, practice or patient problem, and clinical questions.

· Discuss how the data will be stored, safeguarded, and destroyed.

· Discuss how the results of the project will be published.

· Discuss any potential conflict of interest on the part of the investigator.

· Reference IRB approval to conduct the project, which includes subject recruiting and informed consent processes, in regard to the voluntary nature of project.

· Include the IRB approval letter with the protocol number, informed consent/subject assent documents, site authorization letter(s), or any other measures required to protect the participants or institutions in an appendix.

While Chapter 1 addresses the broad, overall limitations of the project, this section discusses in detail the limitations related to the DPI project approach and methodology and the potential impacts on the results. This section describes any limitations related to the methods, sample, instrumentation, data collection process, and analysis. Other methodological limitations of the project may include issues with regard to the sample in terms of size, population and procedure, instrumentation, data collection processes, and data analysis. This section also contains an explanation of why the existing limitations are unavoidable and are not expected to affect the results negatively.

Here you need to consider potential limitations and delimitations, which could impact your proposed project’s implementation. Are the nursing staff resistant to change? Is there currently a culture inherent in the site where the use of evidence-based practice is openly used/welcomed by staff? What strategies might you use to overcome any barriers you might face? How will you capitalize upon any facilitators you have identified?

This section restates what was written in Chapter 3 and provides supporting citations for key points. Your summary should demonstrate an in-depth understanding of the overall project design and analysis techniques. The Chapter 3 summary ends with a discussion that transitions the reader to Chapter 4. Comment by Author: Use INSERTPage Break to set new page for the reference list.

Adcock, S., Kuszajewski, M. L., Dangerfield, C., & Muckler, V. C. (2020). Optimizing Nursing Response to In-Hospital Cardiac Arrest Events Using In Situ Simulation. Clinical Simulation in Nursing. doi: 10.1016/j.ecns.2020.05.006

Andersen, L. W., Holmberg, M. J., Berg, K. M., Donnino, M. W., & Granfeldt, A. (2019). In-hospital cardiac arrest: a review. Jama, 321(12), 1200-1210. doi:10.1001/jama.2019.1696

Ellis, P. (2019). Evidence-based practice in nursing. Learning Matters. Retrieved from https://books.google.com/books?hl=en&lr=&id=hnWKDwAAQBAJ&oi=fnd&pg=PP1&dq=Evidence+based+practice+Ellis,+2019&ots=prvUEMHpVw&sig=-g_pMBlkvFy1DKZzXoMZSpG_7MI

Fain, J. A. (2017). Reading, understanding, and applying nursing research. FA Davis.

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Rapid Response Education

Components of RRT Membership:

MD –Emergency physician, Anesthesia, and/ or Hospitalist

RRT Members Are Skilled In:

Why Use RRT?

codes or intervene earlier number of codes

When To Activate RRT?

Staff uncomfortable with patient situation

Or

recent narcotic/sedative administration, hypoglycemia/hyperglycemia)

Failure to respond to treatment

How To Activate RRT?

RRT will assist with assessment & management of pt & pt's nurse will be responsible for calling MD, meds., & intervention unless they require specialized skills

How To document and Methods To Document RRT Calls

An RN's note & appropriate patient care flow sheets will document patient status leading to activation of RRT. Followed by “See RRT notes for interventions”.

SBAR Communication

(Situation, Background, Assessment, Recommendation)

Purpose of SBAR: provides clear, concise, pertinent information to MD

Situation:

• Respiratory status ☐

• Vital signs (VS) ☐

• Cardiac status ☐

• Mental status ☐

• Other ☐

Background:

Assessment:

Recommendations/Response:

Response – patient condition in response to interventions

Reference:

Institute for Healthcare Improvement. (2008). Measures: Deploy Rapid Response

Teams. Retrieved June 23, 2020, Retrieved from

http://www.ihi.org/resources/Pages/Measures/MeasuresRapidResponseTeams.asp