At Sutter Roseville Medical Center, a suburban California facility, 80,000 patients pass through its emergency department (ED) every year.

“We are a STEMI [ST-elevation myocardial infarction] center, primary stroke center with thrombectomy capability, and a level II trauma center,” shares Andrea Perry, RN, MSN, CNL, CEN, CPEN, the ED’s clinical nurse leader. “We’ve developed several alerts over the years to expedite evaluation and care delivery for these patients.”

However, a few years ago, staff grew increasingly concerned about all the sick patients who do not fall neatly into one of the buckets established to trigger a quick response.

“Our providers were concerned that these patients did not warrant the same priority as those falling into the various alert categories. Nursing staff echoed these sentiments,” Perry explains.

For instance, while the CT scanner would be cleared immediately for a stroke or a trauma patient, that might not be the case for someone who experienced a fall, was on a blood thinner, and possibly in danger of a head bleed. If the individual was a medical patient, that person likely would not receive such a quick response, Perry reports.

In 2016, the ED began working on a new alert process designed to ensure these medical patients not covered by the alerts already in place would receive the same type of rapid, timely response that the other alerts trigger. The resulting approach, dubbed “code critical,” has proven successful at accelerating care to a broad category of critically ill patients.1

Additionally, the step-by-step improvement process has helped ED staff clean up one of their other alert processes, making it more efficient and effective.

From the start, ED leaders were determined to take their time in developing the process because they understood it could significantly affect their department. They wanted to ensure all the kinks were worked out and all the details were in place prior to implementation.

“It helped that both our provider group and our nurses felt the need for a change. They were then part of the process development, running the experiments and observing the outcomes,” says Perry, noting the ED used traditional Lean processes in its quality improvement efforts. “This made it so much easier to implement the final process because there was already staff ownership.”

In the initial project stages, developers learned the hospital had a web-based secure messaging system that was used to trigger the pagers of catheter lab personnel when a STEMI patient presented for care. However, staff wondered if this system could do more. They did not want to contribute to alarm fatigue or to saturate the hospital staff with more calls to action via the hospital’s overhead intercom system.

Fortunately, the developers discovered this system could be customized to send messages or alerts in multiple ways to different stakeholders, depending on each individual’s personal preference. For instance, when a “code critical” patient comes in, an ED staff member could electronically trigger the alert with one step. That alert would be communicated to all the relevant staff via preferred medium.

Different versions of the alert could be sent, too, depending on whether the individuals involved needed to rush to a specific bed in the ED or just needed to be aware that a “code critical” patient was in the ED. A nursing supervisor might not need to physically respond, but nonetheless needs to be aware that an intensive care unit (ICU) bed might be needed soon.

Consequently, developers designed two types of activations, all of which could be triggered with a single action: a “for your information” type of alert, and an alert that instructs the receiver to come now.

Perry says the web-based, secure messaging approach offers multiple advantages over a traditional pager system. Under the old approach, a staff member wishing to trigger an alert would call the hospital operator. The operator would page the alert on the hospital’s intercom system and send the page (using a code) to the specific team members needed.

“First, there is the potential for distortion of the message with the extra step of calling the operator to activate,” Perry observes. “In addition, we experience issues all the time with providers not receiving pages, with the antenna going down or with people who don’t have pagers being somewhere in the hospital where they can’t actually hear the page.”

ED phlebotomists may miss such alerts when drawing blood in the lobby where the overhead alerts are not announced, Perry offers.

“We had frequent issues where their pagers would fail, and [staff] would have no idea that a critical patient had arrived,” she says. “Providers would frequently ask for other methods of notification, such as receiving a text or call, but those options were unavailable. Using a secure-message system ... solved both of these issues.”

Under the secure-messaging approach, staff will activate the alerts themselves so the alerts will go out faster. There is less chance for the message to be distorted since there are fewer people involved in the communications chain, Perry notes.

“In addition ... contact information can be updated extremely easily, whereas updates to our pager system were onerous,” she adds.

Perry acknowledges the ED has experienced several network outages that complicate the department’s ability to send alerts using a web-based program. Nevertheless, an alternative pathway usually is available.

“[When] the hospital’s network is down, our cell providers usually aren’t,” she notes. “We are able to use our personal devices to send out alerts in a timely fashion when our computer systems fail.”

With physicians and nurses seeking a change in the way alerts were activated, the ED did not experience many roadblocks in convincing staff to embrace the change to a secure-messaging approach. However, ED leaders did find that implementing the “code critical” workflows necessitated a need for additional nursing staff. Certainly, asking for additional staff is challenging.

“Thankfully, we collected data showing not only the volume of alerts, but also the impact the activations were having on timely patient care delivery,” Perry says. “That combination of data helped our administration see the need for additional resources.”

Specifically, Perry assembled pre-implementation data on all patients who likely would have triggered a “code critical” alert if that process had been in place in the second quarter of 2016. She excluded any patients who triggered other existing codes, such as sepsis, trauma, or STEMI.

Perry compared the preimplementation data to patients who triggered a “code critical” alert in the second quarter of 2017, after the new process had been implemented.

There were significant improvements in response times in the post-implementation group, with door-to-doctor times slashed by 60%, door-to-lab draw times down by 76%, door-to-intubation times lower by 59%, and time-to-imaging cut by almost 50%. Furthermore, “code critical” patients requiring admission to an ICU arrived there 20% faster than similar patients from the pre-implementation group.

When revisiting the data in the second quarter of 2018, Perry reports the improvements mostly were sustained. In some cases, there were additional improvements over 2017. She notes it took longer for patients to move upstairs in 2018 due to some patient surge issues.

The use of the “code critical” alert has increased steadily. Perry says when the ED went live with the approach in 2016, it was averaging about 40 of these alerts per month. Today, the ED averages 121 “code critical” alerts per month. Additionally, the ED has implemented the same process to its stroke alert procedure, and the department is achieving similar time-to-treatment gains.

Facilities may be experiencing similar time-to-treatment challenges regarding medical patients, or other patient groups may not be receiving the kind of timely care their conditions warrant.

Perry suggests including frontline staff early in any proposed improvement process.

“Get a group together that includes ED nurses and providers, and [staff members from] pharmacy, diagnostic imaging, respiratory therapy, laboratory, and any other [personnel] you think may need to respond,” she advises. “Have them be part of the solution. They will know about issues and barriers that leadership may not. They’ll bring innovative solutions to the table.”


  1. Perry A. Code critical: Improving care delivery for critically ill patients in the emergency department. J Emerg Nurs 2020;46:199-204.