The Red Code, an example of a rapid response system

J. Ricardo Navarro*, Viviana P. Castillo**

* Profesor asociado de Anestesiología, Universidad Nacional de Colombia, Bogotá, D.C., Colombia. E-mail: navarrop@telmex.net.co

** Estudiante de postgrado de Anestesiología, Universidad Nacional de Colombia, Bogotá, D.C., Colombia

Recibido: enero 25 de 2010. Enviado para modificaciones: enero 28 de 2010. Aceptado febrero 16 de 2010

Introduction: Rapid response systems or emergency codes, are multidisciplinary teams aiming at preventing cardiopulmonary arrests and death.

Objective: To highlight the importance of implementing rapid response systems such as the red code, for the management of complications in obstetric patients.

Methodology: Article Review based on the literature from PubMed, Science Direct, Ovid Databases.

Results: The origin of these codes dates back to the first cardiopulmonary resuscitation teams, when during the 1930´s, some measures began to be implemented for an immediate management of cardiac arrest by trained resuscitation staff. Later on, during the 80´s, the availability of the external automated defibrillator at pre-hospital care units led to the advancement in the administration of electrical therapy prior to the patient´s arrival at the hospital. Currently these practices and training in resuscitation are broadly disseminated including recommendations of obligatory compliance at pre-hospital and hospital emergency rooms. Based on these experiences, resuscitation groups specialized in managing patients with obstetric hemorrhage have been established and a decrease in mortality of these patients has been recorded.

Conclusions: With evidence showing that several deaths were the result of adverse events and medical complications, the idea of implementing rapid response systems as an efficient strategy to reduce morbimortality now resurfaces. This was the foundation for the emergence of the red code in Colombia, in an attempt to reduce maternal mortality from obstetric hemorrhage.

Key Words: Emergency Medicine, Rapid Response Teams, Resuscitation, Code Blue (Source: MeSH, NLM)

Emergency codes or rapid response systems are human teams with specific roles that anticipate or prevent cardio-respiratory arrest and death of the patients (1).

Despite the development of Health Care Emergency Services with rapid advanced vital support response, the survival outcomes in terms of survival following cardiac arrest outside the hospital environment are poor (2); this is due to the lack of training in basic resuscitation maneuvers of both witnesses and first-responders and delayed administration of pre-hospital defibrillation, despite the fact that the automated external defibrillator was made publicly available in 1979 (2,3).

Those responsible for the training of health care workers in resuscitation and for organizing these rapid response systems, were instructors formally trained in resuscitation that used the simulation equipment and obtained positive survival results in patients at the ER. Resuscitation codes are universal and arise as an alert mechanism to provide basic resuscitation services at the pre-hospital and specialized (advanced) hospital level. Success in terms of survival rates is due to widespread education and teamwork. Currently, the idea of developing emergency codes is re-emerging as a strategy addressed to reduce mortality from adverse events secondary to health care services (1,4).

In Colombia, the red code was born under the same premises: as a way to rapidly respond, in a hospital environment, for the prevention and control of complications derived from obstetric bleeding that represents the second cause of maternal mortality in the country.

The purpose of the article was to do a review of the rapid response systems and the red code in our country.

DEFINITIONS OF RAPID RESPONSE SYSTEMS OR EMERGENCY CODES

The rapid response system is a multidisciplinary team that anticipates and prevents cardio-respiratory arrest and death of the patients (1,4). The reason behind the organization of these teams is that 80 % of cardiac arrests are preceded by an extended period of time - around 6 to 8 hours (5) - of physiological instability, called condition C. If a rapid response is available at this phase of the crisis by a group of people with pre-determined roles, condition A which is the cardio-pulmonary arrest, shall be avoided. Once the patient goes into cardiac arrest, the code blue must be activated, when the prognosis of the clinical situation deteriorates (figure 1) (1,6).

As mentioned above, the names of the emergency codes may mean different events and teams in various countries, hospitals or service; for example, the code blue is the immediate response system for Europe, Latin America and Australia, but this is not the case in some US cities where it is called mega code, while in some other places it´s code 99, code alpha, etc. (7,8).

The rapid response systems are made up by the following four components: (figure 2) (9,10).

1. Afferent component. Refers to the crisis detection and the code activation. It is the warning signal to which the group responds; for instance, code blue (cardio pulmonary arrest in Europe), red code (fire in Australia, obstetric bleeding in Colombia) and white code (cardiac arrest in children in New Jersey) (9). It is said that the term code blue was coined at the Bethany Medical Center, in Kansas City and from there it spread to China, Australia and Latin America (10). The people responsible for detecting and activating these signs have been nurses (11,12) who are also the pioneers in monitoring and appropriate functioning of the response systems around the world (13). Not in vain have the authors of this article suggested head nurses as the leaders of the red code.

The code is activated as per the clinical criteria formally established in the hospital; for instance, respiratory distress, systolic blood pressure below 80 mm Hg or over 180 mm Hg; respiratory rate over 36 per minute or less than 8 per minute, suicide attempt or postpartum bleeding over 1 000 ml, inter alia (table 1) (14)

2. Efferent component. This is the rapid crisis response by the medical emergency team (15,16). This group may be a separate team or the same resuscitation team that provides immediate stabilization in case of a situation of clinical deterioration. Their tasks are predetermined by the code (16). Most usually, these are people who work in intensive care or specialized areas, such as the experts in airway management (anesthesiologists, head and neck surgeons); experts in chest pain management (cardiologists, intensivists), etc. (17,18).

3. Evaluation component. This component takes care of measuring the results of the code actions, assesses the records or forms (completion of the forms is absolutely required) and takes action aimed at constantly improving the team´s response. Therefore, the evaluation component is responsible for training and education of all the system members (19,20).

4. Administrative component. preserves the code and provides the resources, including: drugs, equipment, labor, and motivational and psychological support (21).

As it can be seen, the rapid response systems are structured teams; but how did they originate and how did they spread?

To go over the history of codes we must go back into the history of the development of the cardio-pulmonary resuscitation teams and the code blue; this was the first model of this type of systems and has demonstrated positive impact over the patient´s morbi-mortality.

HISTORY OF THE ESTABLISHMENT AND DISSEMINATION OF THE CARDIOPULMONARY RESUSCITATION TEAMSCODE BLUES

The idea that the resuscitation techniques are useless if people are not trained to use them was what led Claude Beck - considered the forerunner of education and dissemination of cardio-pulmonary resuscitation systems - to spread the organization of these systems (22). Around 1930, Beck - chest and heart surgeon - and his coworker, Leighringer, received training in resuscitation to patients in "sudden arrest", at the Case Western Hospital of Cleveland. This knowledge spread to several hospitals in the United States. Dr. Beck, upon successfully resuscitating eleven patients with the use of several maneuvers, including defibrillation, concluded that a massive education program of cardio-pulmonary resuscitation had to be implemented.

Around 1950, these programs were made publicly available and resuscitation as a practice by non-health-care specialists at the pre-hospital level was simultaneously established (23). It was then noted that patient survival improved with the use of resuscitation; however, most cardio-pulmonary arrests occurred outside of the hospital environment.

In 1960, the introduction of medical practice inside ambulances was an invaluable life-saving contribution before the patient arrived at the hospital. Pantridge showed that by teaching resuscitation to ambulance doctors, patients with sudden death following acute myocardial infarction could be successfully resuscitated (24).

Kouwenhoven, dean of the engineering school at Johns Hopkins University between 1939 and 1953, began studying about cardiac arrest and 31 years later published the complete external cardiac massage sequence (nowadays called thoracic compressions) combined with defibrillation to restore the heart rate. This event was necessary so that then, in 1961, Peter Safar organized and assembled the basic resuscitation techniques. Safar, who was trained as an anesthesiologist, established the ABCDEFGHI algorrhythm for basic care (ABC); for advanced care (DEF) and care following resuscitation (GHI). It should be highlighted that the ABC could be implemented at the extra-hospital level: A) patency of the airway, B) mouth-to-mouth respiration), C) external cardiac massage.

This algorhythm was initially taught by Dr. Safar to his students in the United States and then to members of the resuscitation team from around the world. In addition to being an outstanding professor of resuscitation maneuvers for doctors, Safar was worried about the training of paramedics and other non-doctors who would be part of the first resuscitation codes (25).

In the past, resuscitation practices were done among people themselves and this became an obstacle due to the high risk of transmitting infections through mouth-to-mouth respiration. At this point, the outstanding role of Asmund Laerdal comes into play. He was a toy manufacturer and the person that designed the Resusci Annie simulator in 1960, becoming one of the leaders in resuscitation and training in emergency codes around the world. The face of the Annie simulator was inspired by the face of a Parisian girl who drowned herself in the Seine River and after her death a mask was built with the mould of her face. Annie is not really Laerdal´s drowned daughter as has been claimed. This story is recorded in the suicide reports of the Seine, published in the book L´Inconnue de la Seine (24,25).

In 1961, Beck and Louis Horwitz instructed a group of rescuers in Cleveland with good results. However, the large-scale enactment of the code blue materialized in Seattle in 1970 thanks to Coob, Koppas and Einsenberg. They established a far-reaching education program for over 100 000 people, mostly paramedics, who were instructed in basic cardio-pulmonary resuscitation skills using 911 as hotline and achieved the expected successful results.

The official training in the immediate resuscitation codes took place in 1974. Between 1960 and 1980 resuscitation techniques were developed and finally in 1991, the American Heart Association (AHA) introduced the survival chain. This was the first code model with a considerable impact in reducing mortality. The Ontario Prehospital Advanced Life Support Study Group (OPALS) trial found an increased survival with the first three links of the code: activation (alert) of the system, basic resuscitation and early defibrillation (figure 3) (24).

RE-EMERGENCE OF THE RAPID RESPONSE SYSTEMS

The US Institute of Medicine published in 2000 the report: "To err is human: building a safer health system". They realized that there was a large percentage of deaths due to adverse events and lethal medical complications in hospitals; the estimate was 44 000 to 98 000 annual deaths in the United States. The report highlighted education, training and decision-making issues in health care professionals. Furthermore, there was a poor use of the technology available and confusing organizational processes.

The response to this report came from health care and health improvement institutions in the same country. They established the "safety culture" campaign in December 2004. The purpose of the initiative was to prevent over 100 000 deaths in 18 months and involved several American hospitals (27). Six changes were implemented to improve health safety: avoid medication errors, prevent acute myocardial infarction death, respirator associated pneumonia, central venous catheters infections and infections of the surgical wound, in addition to a novel idea that was the development of rapid response systems. The campaign´s report, dated June 14, 2006, claimed: "122 300 deaths were prevented in over 3 000 US hospitals" (28,29).

In the light of these positive results, emergency codes were developed and expanded worldwide. In Australia, the country where more studies have been completed to assess the various groups, the popularity of emergency codes hit its highest point; then these systems were used in the United States, the United Kingdom, Canada and more recently Scandinavia (30,31).

With the dissemination of the rapid response systems, in 2006 the International Liaison Committee on Resuscitation (ILCOR) prepared some guidelines based on expert opinions about the way in which these systems should be organized. The guidelines included recommendations about the make-up of the teams and their roles and offered a data recording template that would then be available to measure the results of the emergency medical system as well as for research purposes (32).

The implementation of the rapid response systems in various areas has been studied at length in many countries. Australia, leader in adopting, researching and submitting the results of the emergency codes systems (33), stood out in the evaluation of the rapid response teams in the short and long term (34). A few trials showed the significant reduction in the morbimortality of patients when these systems were implemented (35-38). Other studies (39) however did not find any major differences, as evidenced from the MERIT trial (34).

Nevertheless, it must be emphasized that any research work in this area is difficult to accomplish because of the random allocation of hospitals (that are constantly changing) (40,41), because these are behavioral studies, because of the inability to do blind studies, etc. Despite the fact that there is no level 1evidence in terms of the excellent results of the rapid response systems, there has been no proof about any negative impact of their implementation.

In conclusion, better quality studies are required, with a larger number of patients, that last longer, and with less biases (42).

THE EMERGENCE OF THE RED CODE IN COLOMBIA

Emergency codes began to be implemented in several countries. One of these models was the O system developed in the United States that emerged at a time when obstetric crisis were occurring (43). One of the goals of these crises was always that of controlling the obstetric hemorrhage (44). The development of emergency codes in response to maternal bleeding was been broadly accepted and has shown positive outcomes (44,45).

Following the same objectives of the rapid response systems, the red code emerged in Colombia in 2007.

Obstetric hemorrhage is the first cause of maternal death worldwide (46). In Colombia is second and in the Department of Antioquia, as in the rest of the world, is number one. Hence, Medellín became the city where the so-called red code was initially proposed. The code was promoted in 2009 by the Nacer group of the School of Medicine, University of Antioquia.

This training module emphasizes active management of birth in patients undergoing vaginal delivery and provides the guidelines for the aggressive management of hemorrhagic shock in the obstetric patient. This emergency code is supported by PAHO/WHO, USAID, the Governor´s Office of Antioquia and the University of Antioquia (affiliate of CLAP/SMR - Latin American Center of Perinatology, Women´s Health and Reproduction) and it has been strongly implemented throughout the country as of last year (47,48).

Consequently, the red code is a health-care team that emerges as a response to maternal bleeding in obstetric wards; its activation is intended to rapidly respond to this emergency condition and to reduce maternal mortality in the country (48,49).

A recent study developed in Bogotá at 2nd, 3rd and 4th level health-care institutions identified poor knowledge about the red code in the obstetric departments. The conclusion was that there were difficulties in socializing this code in the hospitals in the country (50). Probably the problem with the development of codes lies on the fourth component - the administrative aspect - and hence the recommendation is to have the Ministry of Social Protection act as the agency responsible for correcting these flaws that impact the morbimortality of obstetric patients.

In going over the history of the obstetric departments, the role of the head nurse is outstanding. The first maternity units in the United States emerged early in the second decade of the 20th Century and were established by midwives and doctors in some villages. An example of these units was Little House that operated in the forties under the direction of the sisters of the Holy Medical Mission. Then, in 1975, the first modern maternity center was established in New York with optimal economic, social and patient satisfaction results. Finally nurses got their accreditation at these centers in 1982 and guidelines and regulations were published for the adoption of maternity wards (51).

Since the time of Florence Nightingale (52,53), mid 20th Century, the job of the nurse in the hospital environment has been indispensable and even more so in the implementation of the immediate response codes. We are not exaggerating when we claim that the leader of the red code in the obstetric units should be the nurse. Nurses have a tradition of service, dedication and professionalism acknowledged in the medical filed as trustworthy professionals.

CONCLUSION

Emergency codes or rapid response systems are made up by teams of health-care professionals attempting to detect and do early intervention in the evolution of patients with hemodynamic instability. These codes are given different names in different places. In order to do a review of the history of emergency codes, we must make reference to the beginning of the first groups trained in cardio-pulmonary resuscitation and how they spread and became known around the world, with excellent results.

Presently, the concept of the rapid response system is re-emerging. In Colombia, the concept was also used for the creation of the red code and it should be socialized to achieve its key goal: reducing maternal morbimortality in the country.

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