June 10, 2019By Lance Baily

Johns Hopkins Children’s Center Uses CODE ACES2 & Simulation to Improve CPR Quality

In 2013, Johns Hopkins Children’s Center started developing a new approach to CPR—Coaching, Objective‐Data Evaluation, Action‐linked phrases, Choreography, Ergonomics, Structured debriefing, and Simulation (CODE ACES²). The children’s hospital recently published research on the approach, which increased achievement of excellent CPR based on American Heart Association guidelines from 19.9% of resuscitation events to 44.3%! Let’s take a closer look at how medical simulation is improving CPR outcomes via this HealthLeaders article review by Christopher Cheney, of the new John Hopkins CODE ACES² program.

More than 6,000 children have in-hospital cardiac arrest annually and most do not survive to discharge. Starting quality CPR quickly is crucial to improving those outcomes, which is why Johns Hopkins Children’s Center staff now reliably starts chest compressions within 10 seconds. Lead author of the research, Elizabeth Hunt, MD, MPH, PhD, director of the Johns Hopkins Medicine Simulation Center and an associate professor at Johns Hopkins University School of Medicine, told HealthLeaders recently:

“The idea is to teach in medicine similar to how world class chess players, athletes and musicians train—to practice the right way over and over again while getting feedback from an expert mentor. This also helps our resuscitation team to decrease variability. Under the CODE ACES² approach, a debriefing is held after every cardiac arrest to review challenges that the resuscitation team encountered and identify any deviations from best practices.”


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Johns Hopkins Children’s Center used pre- and post-event “room diagramming” to attain the best room layout for a patient in cardiac arrest. Pre-event room diagrams include the location of surgeons, nurses, chest compressors, and defibrillators. The diagram plans were practiced in monthly resuscitation simulations. Unnecessary furniture and equipment were removed.Room diagrams drawn after an event are part of data presented at debriefings.

A CODE‐ACES² debriefing takes about 45 minutes and starts with a privacy and confidentiality acknowledgement. The debriefing features clinical data analysis, review of peer-to-peer debriefing forms, examination of relevant therapy such as pharmacy, and critiques of CPR quality.

The optimal position of the CPR coach opposite from the chest compressor was determined through simulations, along with the positioning for the code team leader and defibrillator. Simulation has helped perfect other facets of the CODE‐ACES² approach such as placement of the backboard.

Fore more, read the full HealthLeaders article entitled “7-Component CPR Model Improves In-Hospital Resuscitation of Children“. Read the JAMA research article entitled “Improved Cardiopulmonary Resuscitation Performance With CODE ACES²: A Resuscitation Quality Bundle” by Betsy Hunt et al.


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The research was a prospective observational study of quality of chest compressions (CC) during pediatric in‐hospital cardiac arrest associated with development and implementation of a resuscitation quality bundle. Objectives were to: 1) implement a debriefing program, 2) identify impediments to delivering high quality CC, 3) develop a resuscitation quality bundle, and 4) measure the impact of the resuscitation quality bundle on compliance with American Heart Association (AHA) Pediatric Advanced Life Support CC guidelines over time.

The findings concluded that CODE ACES² was associated with progressively increased compliance with AHA CPR guidelines during in‐hospital cardiac arrest!


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