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Aurora St. Luke's Medical Center

Presentation Notes

Quality Improvement podium presentation at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Background: Previously established workflow processes for the documentation of all code events occurred on the paper code log. ICU nurses had been trained in the use of the code narrator within the electronic health record, but utilization and adoption of this function was low. A pilot was developed with Code Teams to streamline the code response documentation process with a focus on improving the use of the code narrator in order to accurately track resuscitation performance and outcomes.

Local problem: Code narrator utilization in the ICUs averaged 65% in the 1st quarter of 2021.

Method: The plan do study act (PDSA) cycle was used to pilot changes for a designated code narrator role assignment and code narrator use. Code champions were designated within the intensive care units, who were members of the code response team. The pilot included a re-education of the code narrator functionality (Fall 2021) and monthly meetings of champions to provide clinical feedback. Based on initial feedback one ICU unit was assigned the role of the code narrator in the response team. Information and roll out was brought to area council chairs to get buy in and support.

Results/Conclusions: Results of the pilot showed an increase average code narrator use in ICUs to 83% (2nd quarter), 76% (3rd quarter) and 85% (4th quarter).

Implications for practice: Pilot work provided baseline resuscitation data and increased documentation with improved code narrator use. Future work and expansion of this project will include the assignment of the code narrator role to all ICU nurses on the code response team and increased monitoring of Get with the Guidelines® Resuscitation outcomes for other improvement opportunities.

Document Type

Oral/Podium Presentation




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