Say No to Code Blue, Say Yes

to EWS in Hospital Setting

dr. Hendri Pangestu, Sp.An., KIC

28 juli 2019
Jika di umumkan atau alaram di
aktifkan (“code blue at…” ) maka
sekelompok dokter, perawat, spesialis
(code blue team) serentak
meninggalkan yang sedang dia Code Blue
kerjakan dan beranjak ketempat Saving Lives at a
dimana terjadi code blue Moment's Notice

Kode biru (code blue) adalah Late?

jika petugas medis menemukan
keadan pasien dalam keadaan
tidak merespon (tidak bernafas
dan atau jantung berhenti
berdenyut)
EMERGENCY CODES USED IN HOSPITALS
 Profil:
LT 4000 m2
LB 52000 m2
35 lantai

Padat penduduk dan banyak nya RS membuat bengunan RS bervariasi

Berbentuk vertikal
 Pasien yang masuk ICU dengan tidak terencana (code blue)
memiliki hubungan dengan mortality
3.5

2.5

2
yes mortality
1.5
no mortality
1

0.5

0
terencana tdk
terencana

Changi General Hospital 2013

 Proses terjadinya sakit kritis
☠
Post op, Redistribution blood flow to vital
Partus, PEB, organ (saving Heart & Brain)
HELLP,
Infection, Early Sign &
perdarahan, Symptom Compensation; Fail/ decomp C Death
Trauma dll Preserve brain and heart O
Onset of D
illness Compensatory phase E
Tachypnea Depends on; Blue
Tachycardia • Age Bradycardia late?
Hypertension Hypotension
 pH • Severity of illness
Alkalosis
Lactate • Preexisting disease Severe
CRP
Leucocyte  Normal Acidosis

Where were should we? ? EWS

1950
PETER SAFAR
to Pengendalian jalan napas
KOUWENHOVEN
Kompresi jantung tertutup
1960 & Pernapasan buatan

1974 American Heart Association

Cardiopulmonary Resuscitation (CPR)

1993 International Liaison Committee

on Resuscitation (ILCOR)

The Guidelines 2000 Conference, held in Dallas

2000 in February 2000 was the world’s first international conference
assembled specifically to produce international
resuscitation guidelines.
Bill Montgomery of the AHA was elected Co-chair of ILCOR,
together with Petter Steen of the ERC.
 1992 : ILCOR = International Liaison Comittee on
Resuscitation
The worldwide distribution of these guidelines will be enhanced by
publication in an official journal of the AHA, Circulation, and the official
journal of the European Resuscitation Council, resuscitation. Circulation
and Resuscitation will publish the International Guidelines 2000 as a
statement that strongly merits the description “international.” Publication
of the guidelines is the product of these councils:

➢ American Heart Association

➢ Australian Resuscitation Council
➢ European Resuscitation Council
➢ Heart and Stroke Foundation of Canada
➢ New Zealand Resuscitation Council
➢ Resuscitation Councils of Latin America
➢ Resuscitation Councils of Southern Africa
2015 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Science With Treatment Recommendations
Dallas, Texas
February 1–3, 2015

American Heart Association (AHA)

Australian and New Zealand Committee on
Resuscitation (ANZCOR)
European Resuscitation Council (ERC)
Heart and Stroke Foundation of Canada (HSFC)
Inter American Heart Foundation (IAHF)
Resuscitation Council of Asia (RCA)
Resuscitation Council of Southern Africa (RCSA)
 International Liaison Committee on Resuscitation (ILCOR)

1. American Heart Association (AHA)

2. European Resuscitation Council (ERC)
3. Heart and Stroke Foundation of Canada (HSFC)
4. Australian and New Zealand Committee on Resuscitation
(ANZCOR)
5. Resuscitation Councils of Southern Africa (RCSA)
6. Inter American Heart Foundation (IAHF)
7. Resuscitation Council of Asia (RCA)

CODE
ACLS BLUE

New Paradigma
IHCA In Hospitals Cardiac Arrest And
OHCA Out Hospitals Cardiac Arrest
IHCA VS OHCA
 Penyebab Henti Jantung
• Etiologi
– Cardiac (primer) → Out of Hospital Cardiac Arrest
(OHCA)
• Serangan Jantung (MCI)
• Kelainan jantung lain
– Non-Cardiac (sekunder) → Intra Hospital Cardiac Arrest
(IHCA)
• Internal
– Severe Pneumonia, Septic Shock, etc
• External
– Trauma hemorrhage, Intoxication etc

Nolan J. ERC Guidelines for Resuscitation 2005-introduction. Resuscitation. 2005; 67 (suppl1):S3-S6

 Etiology of OHCA
(Out-of-hospital Cardiac Arrest)

Nolan J. ERC Guidelines for

Resuscitation 2005-introduction.
Resuscitation. 2005; 67 (suppl
1):S3-S6
Representatives from Europe at the
International Consensus Conference
held in Dallas, USA, in January 2005
(Germany), (UK), (Israel), (Austria), (Belgium), (France), (Sweden),
(Italy), (Spain), (Netherlands), (Norway), (Finland), (Denmark), (Czech
Republic), (Norway).
• Section 1. Introduction
• Section 2. Adult basic life support and use of
automated external defibrillators
• Section 3. Electrical therapies: Automated
external defibrillators, defibrillation,
cardioversion and pacing
• Section 4. Adult advanced life support
• Section 5. Initial management of acute
• coronary syndromes
• Section 6. Paediatric life support
• Section 7. Cardiac arrest in special
circumstances
• Section 8. The ethics of resuscitation and
end-of-life decisions
• Section 9. Principles of training in
resuscitation
 2005 2010 2015
Section 1. Introduction 1. Executive summary; 1. Executive summary
Section 2. Adult basic life support 2. Adult basic life support and use 2. Adult basic life support
and use of automated external of automated external and automated external
defibrillators defibrillators; defibrillation.
Section 3. Electrical therapies: 3. Electrical therapies: automated 3. Adult advanced life
Automated external external defibrillators, support.
defibrillators, defibrillation, defibrillation, cardioversion and 4. Cardiac arrest in special
cardioversion and pacing pacing; circumstances.
Section 4. Adult advanced life 4. Adult advanced life support; 5. Post-resuscitation care.
support 5. Initial management of acute 6. Paediatric life support.
Section 5. Initial management of coronary syndromes; 7. Resuscitation and
acute 6. Paediatric life support; support of transition of
coronary syndromes 7. Resuscitation of babies at birth; babies at birth.
Section 6. Paediatric life support 8. Cardiac arrest in special 8. Initial management of
Section 7. Cardiac arrest in special circumstances: electrolyte acute coronary
circumstances abnormalities, poisoning, syndromes.
Section 8. The ethics of drowning, accidental hypothermia, 9. First aid.
resuscitation and end-of-life hyperthermia, asthma, 10. Principles of education in
decisions anaphylaxis, cardiac surgery, resuscitation.
Section 9. Principles of training in trauma, pregnancy, electrocution;
11. The ethics of
resuscitation 9. Principles of education in resuscitation and end-of-
resuscitation; life decisions
10. The ethics of resuscitation and
end-of-life decisions.
 Section Adult advanced life support
Prevention of in-hospital
cardiac
arrest 2005
1. The problem
2. Nature of the deficiencies in
acute care
3. Recognising the critically ill
patient
4. Response to critical illness
5. Appropriate placement of
patients
6. Staffing levels
7. Resuscitation decisions
8. Guidelines for prevention of
in-hospital cardiac arrest
Prevention of in-hospital
cardiac
arrest 2010
1. The problem
2. Nature of the deficiencies
in the recognition and
response to patient
deterioration
3. Education in acute care
4. Monitoring and
recognition of the
critically ill patient
5. Calling for help
6. The response to critical
illness
7. Appropriate placement of
patients
8. Staffing levels
9. Resuscitation decisions
10. Guidelines for prevention
of in-hospital cardiac
arrest
Prevention of in-hospital
cardiac
arrest 2015
1. The problem
2. Nature of the
deficiencies in the
recognition and
response to patient
deterioration
3. Education in acute care
4. Monitoring and
recognition of the
critically ill patient
5. Calling for help and the
response to critical
illness
6. Appropriate placement
of patients
7. Staffing levels
8. Resuscitation decisions
9. Guidelines for
prevention of in-
hospital cardiac arrest
We need to question focus on cardiac arrest teams and
look how we prevent deterioration to critical
illness/arrest; look to changing/merging to/with rapid
response teams? Good to see we support the model of
RRT.
Pembaruan pedoman AHA 2015 untuk CPR dan ECC

→EWS

Pengawasan
dan
pencegahan
 STANDAR NASIONAL AKREDITASI RUMAH SAKIT
Edisi 1,
STANDAR PELAYANAN BERFOKUS PASIEN
• BAB 1. AKSES KE RUMAH SAKIT DAN KONTINUITAS PELAYANAN (ARK)
• BAB 2. HAK PASIEN DAN KELUARGA (HPK)
• BAB 3. ASESMEN PASIEN (AP)
• BAB 4. PELAYANAN DAN ASUHAN PASIEN (PAP)
• BAB 5. PELAYANAN ANESTESI DAN BEDAH (PAB)
• BAB 6. PELAYANAN KEFARMASIAN DAN PENGGUNAAN OBAT (PKPO)
• BAB 7. MANAJEMEN KOMUNIKASI DAN EDUKASI (MKE)

DETEKSI (MENGENALI) PERUBAHAN KONDISI PASIEN

Standar PAP 3.1
Staf klinis dilatih untuk mendeteksi (mengenali) perubahan kondisi pasien memburuk
dan mampu melakukan tindakan.
Maksud dan Tujuan PAP 3.1
Staf yang tidak bekerja di daerah pelayanan kritis/ intensif mungkin tidak
mempunyai pengetahuan dan pelatihan yang cukup untuk melakukan asesmen serta
mengetahui pasien yang akan masuk dalam kondisi kritis. Padahal, ,banyak pasien di
luar daerah pelayanan kritis mengalami keadaan kritis selama dirawat inap. Sering
kali pasienmemperlihatkan tanda bahaya dini (contoh, tanda-tanda vital yang
memburuk dan perubahan kecil status neurologisnya) sebelum mengalami
penurunan kondisi klinis yang meluas sehingga mengalami kejadian yang tidak
diharapkan

Ada kriteria fisiologis yang dapat membantu staf untuk mengenali sedini-dininya
pasien yang kondisinya memburuk. Sebagian besar pasien yang mengalami gagal
jantung atau gagal paru sebelumnya memperlihatkan tanda-tanda fisiologis di luar
kisaran normal yang merupakan indikasi keadaan pasien memburuk. Hal ini dapat
diketahui dengan early warning system (EWS).

Penerapan early warning system (EWS) membuat staf mampu mengidentifikasi

keadaan pasien memburuk sedini-dininya dan bila perlu mencari bantuan staf yang
kompeten. Dengan demikian, hasil asuhan akan lebih baik. Pelaksanaan early
warning system (EWS) dapat dilakukan menggunakan sistem skor. Semua staf dilatih
untuk menggunakan early warning system (EWS).
 The Process of Dying*
Primary ventricular
fibrillation
0 min
Primary Asystole

Alveolar anoxia 2-3 min Code blue

Asphyxia:
(Airway Obstruction) 5-12 min
(Apnea)
Circulatory Arrest
Exsanguination

Pulmonary Failure

Shock

Brain Failure
*Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and
future directions. Ann Emerg Med 22:324,1993
IHCA ( In Hospitals Cardiac Arrest )

To Act or process of
becoming worse
 Intensity of treatment

I
n
t
e
n I
s
HCU C
i IW
t HDU U
Home Hospital Ward ED
y

Cumulative delay and

Lost opportunity
NEWS

NEWS helps to identify clinical deterioration and outcome

improvement
Scores are readily available for nurses and providers that will
enhance the initiation of an intervention
NEWS provides a realistic tool for clinical decision-making
because the score includes a single physiological measure of
extreme value in addition to aggregate scores that activate
interventions
The NEWS and sepsis
• We recommend that sepsis should be considered in any patient
with a known infection, signs or symptoms of infection, or in
patients at high risk of infection, and a NEW score of 5 or
more –‘think sepsis’.

• We recommend that patients with suspected infection and a NEW

score of 5 or more require urgent assessment and intervention by
a clinical team competent in the management of sepsis and urgent
transfer to hospital or transfer to a higher-dependency clinical
area within hospitals, for ongoing clinical care.
Initial NEW score recorded in the ED and subsequent Initial NEW score and subsequent ICU admission
patient 30-day mortality in patients with sepsis (n = and/or mortality in patients with sepsis (n = 2,003).
2,003). Adapted with permission from BMJ Publishing Adapted with permission from BMJ Publishing
Group Ltd Group Ltd
 ward patient

Early recognition
deterioration in critically ill

EWS Scoring
EWS activation Monitoring chart

appropriated
treatment deterioration

ICU TEAM
ICU
transfer to high level
WITHOUT
of care
WALL
 KESIMPULAN

• Ada 2 “type” Cardiac Arrest yaitu In Hospital

Cardiac Arrest (IHCA) dan Out Hospital Cardiac
Arrest (OHCA)
• IHCA lebih “Poor OutCome” di banding OHCA
• Banyak kejadian henti jantung di rumah sakit
ditandai dengan peringatan dini yang dapat
diketahui lebih cepat sehingga bisa dicegah menjadi
lebih buruk.
 KESIMPULAN

•EWS dapat membantu dalam pencegahan IHCA

•EWS lebih awal melakukan intervensi dari “code
blue”
•Membawa sistem ICU ke luar area ICU
•Dapat dijadikan proses “learning by doing” untuk
para tetaga medis