Is the “July effect” real and does and does it impact the safety of hospitalized patients? – Incidence of code blue events and critical care response team activations at the beginning versus the end of the academic year
CCCF ePoster library. Spring J. Oct 2, 2017; 198172; 37
Dr. Jenna Spring
Dr. Jenna Spring
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Is the “July effect” real and does and does it impact the safety of hospitalized patients? - Incidence of code blue events and critical care response team activations at the beginning versus the end of the academic year

Spring, Jenna1; Hawryluck, Laura1

1Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada.


Many articles have been published in the medical literature and lay media regarding a perceived decrease in patient safety and increase in medical errors following the housestaff changeover that occurs at academic hospitals each July. Whether this so called “July effect” is real remains controversial; however, differences in the rates of failure to recognize or rescue a deteriorating patient have not been previously explored. The implications of such failures may have a significant safety impact on some of the sickest hospitalized patients. Most hospitals have instituted processes whereby patient deterioration leads to activation of the Critical Care response team (CCRT) to resuscitate and stabilize on the ward, or to speed the process of ICU admission. To ensure such teams are effective, the literature evaluates both frequency of team activations and cardiac arrest rates as a measure of failure to rescue.
The primary objective of this study was to determine whether there is a difference in the rate of code blue events and CCRT activations at the extremes of the academic year (May/June vs. July/August). The patient outcomes of these events were also examined.
In this retrospective cohort study, we identified code blue events and CCRT activations occurring on the wards between May and August for the 2011-2015 calendar years at two major teaching hospitals. Only code blue events classified as cardiac or respiratory arrests were included.  CCRT activations were recorded regardless of reason for consultation. Code blue events and CCRT activations were grouped into two time periods for the purposes of the analysis: May/June and July/August. The outcome of interest for code blue events was in-hospital mortality, while for CCRT consults it was need for transfer to a higher level of care. 
There were 181 code blue events that met inclusion criteria for the study. The code blue event rate per 1000 admissions was 2.79 in May/June and 4.17 in July/August (p = 0.007, Chart 1) corresponding to a rate ratio of 1.50 (95% CI 1.10-2.04). Code blue events were more likely to occur on medical services in July/August (79.4% vs. 63.5% in May/June, p=0.028) and there was a trend towards increased in-hospital mortality (82.2% vs. 68.9% in May/June), but this did not reach statistical significance (p=0.056). Most code blue events occurred after 5pm in both study periods (56.8% in May/June vs. 53.3% in July/August, p=0.756).
In terms of CCRT consults, there were 1996 included in the study. The activation rate per 1000 admissions was 34.67 in May/June and 41.89 in July/August (p < 0.005, Chart 1) with a rate ratio of 1.21 (95% CI 1.11-1.32). The primary reason for CCRT consultation is outlined in Chart 2. There was no difference in outcome with 33.1% of the patients transferred to an ICU or step-down unit in May/June vs. 35.3% in July/August (p=0.504). There was also no difference in the percentage of consults after 5pm (53.5% in May/June vs. 57.6% in July/August, p=0.076) or location with 64.1% of consults coming from medical wards in May/June compared to 64.7% in July/August (p=0.143).
Code blue events and CCRT consults are more likely to occur in July and August following the housestaff changeover at academic hospitals than in May or June. However, while the event rate is increased, there is no difference in the outcome of these events in terms of in-hospital mortality or transfer to a higher level of care.

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