Introductory page
Dear __________,
We are conducting a research study evaluating provider experiences caring for adult patients suffering an in- hospital cardiac arrest. We appreciate your completing the following brief survey. Study results will guide future projects to improve cardiac arrest resuscitation quality and patient outcomes after cardiac arrest. Your responses will not be linked to identifying information about you.
Sincerely,
Ithan Peltan, MD, MSc
* Question asked only of physicians
† Question asked only of nurses
** Question is asked only of clinicians who indicate that they may play a leadership role on the Code Blue team
‡ Question asked only of physicians who indicate that they may play a leadership role on the Code Blue team
§§ Question asked only of attending physician
Cardiac arrest response involvement
1. Do you participate (or expect to participate) in the response to a cardiac arrest (a “Code Blue”) at an Intermountain Healthcare hospital at least once every 24 months?
Yes
No
Only consider cardiac arrests of adult patients
2. Select the one hospital where you are most likely to participate in cardiac arrest responses
Alta View
American Fork
Bear River Valley Hospital
Cassia Regional Medical Center
Cedar City (Valley View) Hospital
Delta Community Hospital
Dixie Regional Medical Center
Fillmore Community Hospital
Garfield Memorial Hospital
Heber Valley Medical Center
Intermountain Medical Center
LDS Hospital
Logan Regional Hospital
McKay-Dee Hospital
Orem Community Hospital
Park City Medical Center
Primary Children’s Hospital
Riverton Hospital
Sanpete Valley Hospital
Sevier Valley Hospital
The Orthopedic Specialty Hospital (TOSH)
Utah Valley Regional Medical Center
3. Select all hospital settings where you might participate in a cardiac arrest response.
£ Inpatient medical or surgical ward
£ ICU
£ ED
£ OR
£ PACU
£ Obstetric ward/labor & delivery
£ Cardiac catheterization lab (“cath lab”)
£ Other procedural area (i.e. interventional radiology)
£ Other hospital area (i.e. lab, cafeteria, radiology, outpatient clinic) Select all that apply
4. Select the one hospital setting where you are most likely to participate in a cardiac arrest response.
Inpatient medical or surgical ward
ICU
ED
OR
PACU
Obstetric ward/labor & delivery
Cardiac catheterization lab (“cath lab”)
Other procedural area (i.e. interventional radiology)
Other hospital area (i.e. lab, cafeteria, radiology, outpatient clinic)
* Question asked only of physicians
† Question asked only of nurses
** Question is asked only of clinicians who indicate that they may play a leadership role on the Code Blue team
‡ Question asked only of physicians who indicate that they may play a leadership role on the Code Blue team
§§ Question asked only of attending physician
Cardiac arrest response role
5. When participating in a cardiac arrest
response, what are all the roles you might be called upon to perform?
£ Team leader
£ Informal assistant to code team leader*
£ Formal assistant to code team leader*
£ Nurse leader†
£ Recorder†
£ Perform chest compressions
£ Administer medications
£ Prepare medications
£ Manage ventilation, bag/mask
£ Perform intubation
£ Perform other invasive procedures (i.e. central line placement)*
£ Draw labs
£ Surgeon during OR code*
£ Other/role task Select all that apply
6. When participating in a cardiac arrest response, what one role would you be most likely to perform?
Team leader
Informal assistant to code team leader*
Formal assistant to code team leader*
Nurse leader†
Recorder†
Perform chest compressions
Administer medications
Prepare medications
Manage ventilation, bag/mask
Perform intubation
Perform other invasive procedures (i.e. central line placement)*
Draw labs
Surgeon during OR code*
Other/role task
* Question asked only of physicians
† Question asked only of nurses
** Question is asked only of clinicians who indicate that they may play a leadership role on the Code Blue team
‡ Question asked only of physicians who indicate that they may play a leadership role on the Code Blue team
§§ Question asked only of attending physician
Cardiac arrest response experience
In the past 12 months, how many times did you…
0 times 1-2 times 3-6 times 7-11 times 12 times or more7. Participate in an adult cardiac arrest resuscitation?
8. Lead an adult cardiac arrest resuscitation?**
Consider all possible roles and hospital environments you indicated above
when answering the following questions.
Disagree Disagree StronglyNeither Agree nor
Disagree Agree
Strongly Agree
9. I feel confident leading cardiac arrest resuscitations**
10. I feel confident participating in cardiac arrest resuscitations
11. I feel my resuscitation team(s) have the skills and
knowledge needed to respond to cardiac arrest events effectively
12. I have difficulty thinking clearly during cardiac arrest
resuscitations
13. My resuscitation team(s) have difficulty working together
effectively or smoothly
14. I worry that I will make errors during cardiac arrest
resuscitations
15. I worry that my resuscitation team(s) will make errors
during cardiac arrest resuscitations
16. If I lead a cardiac arrest resuscitation on a weekday, at least
one other physician will be present to provide assistance
‡ 17. If I lead a cardiac arrest resuscitation on a night or on a
weekend, at least one other physician will be present to provide assistance
‡
* Question asked only of physicians
† Question asked only of nurses
** Question is asked only of clinicians who indicate that they may play a leadership role on the Code Blue team
‡ Question asked only of physicians who indicate that they may play a leadership role on the Code Blue team
§§ Question asked only of attending physician
Demographics
18. What is your primary specialty?
§§If you fit into >1 specialty category, choose the specialty in which you are most likely to participate
in a cardiac arrest resuscitation.
Please choose "hospitalist" if you are a primary care physician who sees inpatients primarily while working as a hospitalist (as opposed to also seeing outpatients at the same time)
Critical care (medical)
Critical care (surgery/trauma)
Critical care (anesthesia)
Critical care (neurology)
General surgery
Hospitalist
Internal medicine (outpatient & inpatient)
Other medical subspecialty
Cardiothoracic surgery
Other surgical subspecialty
Family medicine
Emergency medicine
Anesthesia
Obstetrics & gynecology
Neurology
Other specialty
19. How old are you?
†_____
20. What percentage of your clinical time is spent caring for inpatients, ED patients, or patients in hospital-based procedural or post-procedural areas (i.e. cath lab, OR,
PACU)?*
Click bar above and then drag to set response21. How many years have you been a nurse?
†_____
22. Are you currently certified in ACLS
(advanced cardiac life support)?
Yes No23. Have you participated in a cardiac arrest
simulation or “mock code” within the last year?
Yes
No
Answer "no" if the only cardiac arrest simulation you participated in was a "mega code" station during ACLS training
.
0% 50% 100%
* Question asked only of physicians
† Question asked only of nurses
** Question is asked only of clinicians who indicate that they may play a leadership role on the Code Blue team
‡ Question asked only of physicians who indicate that they may play a leadership role on the Code Blue team
§§ Question asked only of attending physician
Error text (incompatible unit reported)
WAIT
You selected “______” as the setting where you are most likely to participate in a cardiac arrest response, but you did not select
"_______" as one of the settings where you might be part of the cardiac arrest team.
Please reconcile your answers above before continuing.
Error text (incompatible code team roles reported)
WAIT
You selected “______” as the role you are most likely to play in a cardiac arrest response, but you did not select "_______" as one of the roles you might play on the cardiac arrest team.
Please reconcile your answers above before continuing.
Error text (missing data)
STOP
You're almost done, but at least one required question in the ______ section still needs an answer.
Completion text (ineligible provider due to lack of code participation or ineligible hospital/unit)
Thank you!
Based on your responses, you have provided all required information. Thank you for participating in this survey, _____. Please click the "Submit" button below to record your response and be entered to win an Amazon gift card.
Completion text
Thank you!
Thank you for participating in this survey, ______. Please click the "Submit" button below to record your response and be entered to win an Amazon gift card.
