Second Shift Holiday Neonatal Code -- A Recipe for Stress

Background: Obstetrical and neonatal staff felt extremely frustrated and stressed during a neonatal resuscitation.  Frustration and tension among code team members impacted communication and the team's effectiveness.

Case: A 31 year old multigravida patient presented via ambulance to labor and delivery at a community hospital with SROM of "muddy fluid" at 8 cm dilatation.  The patient was flailing her arms and legs uncontrollably complicating the accuracy of maternal and fetal pulses detection. Initial fetal heart tones were in the 50's and the maternal palpated pulses were in the 70's.  The obstetrician was notified immediately.  SVD of male infant was born limp and cynatotic.  The NICU staff was notified.  Unique nursing challenges during this code included:  door-to-delivery time 13 minutes, unassisted RN delivery, nightshift holiday with limited staffing, patient presented alone and physician call-to-arrival-time 30 minutes with no in-house OB physician presence.

The neonate required compressions, intubation, multiple epinephrine doses and fluid boluses during the 23minute code.  The team was frustrated at their inability to locate emergent supplies in a timely fashion from the newly initiated neonatal code box and their roles during the resuscitation.  Additional staff were required to assist.   The nursing supervisor and respiratory staff were not initially present during the code because the overhead code was not initiated. 

Important laboratory findings: 

Neonatal VBG @ 15 minutes:  pH <6.7, pCO2 <11.5, pO2 <25, Base Excess undeterminable.  The placental pathology report indicated acute choriamnionitis and the umbilical cord indicated acute funisitis and focal hemorrhage.

Conclusion: Multiple interdisciplinary debriefings were held to gather information and to support staff involved in the code.  Nursing/physician leadership identified system/process issues from these debriefings.   Strategies were developed to reduce staffs' frustration, tension and chaos felt during codes that included:  reassignment of code team member responsibilities, implementation of routine code drills that included staff from all shifts and all team member departments and the initiation of timed neonatal code box drills to increase code box familiarity.  Staff assisted in developing a code checklist that facilitated communication during and after a neonatal code. 

Staff felt more confident in their roles and responsibilities as code responders.  Team members' feel more effective, less stressed, and prepared for the unexpected.  Empowering staff and increasing knowledge does decrease frustration and tension during unaticipated and challenging neonatal codes.

Keywords: neonatal codes, team effectiveness