Next Generation is a Brigham Clinical & Research News column penned by students, residents, fellows and postdocs. If you are a Brigham trainee interested in contributing a column, email us. This month’s column is written by Michael Senter-Zapata, MD, an innovation fellow in the Healthcare Transformation Lab at Massachusetts General Hospital and a staff hospitalist in the Hospital Medicine Unit at Brigham and Women’s Hospital.

It was a Tuesday, a “switch day” for Brigham and Women’s Hospital (BWH) Internal Medicine interns. Every other Tuesday, all interns would rotate to a new medical service and begin caring for a new panel of patients. This particular Tuesday, I was joining the medical intensive care unit (MICU) for the first time. Nerves were running high, and I did not know what to expect. Nothing could have prepared me for the day ahead.

A nurse ran into the resident workroom and shouted, “The patient next door lost a pulse!” The patient, Ms. G, had been improving and was extubated the day before. She was elderly with a cardiac history but was showing signs of improvement.

Senior resident, Deepa Manjunath, MD, and I sprinted to the patient’s room to find a nurse already performing chest compressions and others busy getting the code cart and placing several more IVs. I got in line to take over chest compressions and watched as Deepa, who was leading the code, held the attention of the room as she directed the team. I admired her poise despite the chaos. However, I noticed that she kept glancing down at her phone in between relaying orders. “What was she looking at?” I asked myself.

Once things had settled, Deepa and I debriefed the code and brainstormed reasons why Ms. G “crashed.” I asked Deepa for advice on how best to lead codes myself and she pulled out her phone. She opened a mobile iOS application designed to help code leaders stay organized amidst the mayhem. The app displayed a stopwatch and tracked metrics like CPR cycles, medications given shocks administered and other information input by the code leader. However, the app’s interface was outdated, disorganized and made for a confusing user experience.

A Hectic Code Environment

In between all of the codes that day, I reflected on the overall experience as an intern who was brand new to the hectic code environment. I realized that if two codes occurred at the same time, I was clinically underprepared to lead a code team. As is customary for graduating medical students, I completed a day-long American Heart Association (AHA) course on advanced cardiovascular life support (ACLS) at the end of my fourth year at Washington University in St. Louis. At the end of that training session, I was given a series of AHA pocket cards that contained several arrow-based pictograms with algorithmic approaches to common code scenarios. However, the cards were printed in miniscule font, could be overwhelming to new code leaders to decipher and could be easily lost. Now almost a year later, my skills were rusty, and I realized that a substantial knowledge and experience gap existed for new resident code leaders.

I envisioned a new app designed for trainees that could decrease code-related anxiety, decision fatigue, and cognitive load while increasing adherence to AHA guidelines and improving outcomes. I pictured an app that broke down the existing ACLS algorithmic pictograph into a series of simple screens that walked novice users through appropriate management and implemented a checklist system, similar to those used in the aviation and surgical fields, in addition to haptic reminders about when, how and how often to perform crucial interventions. A search of the Apple iOS App Store at the time revealed apps that focused on either the organizational components or the existing pocket card algorithms, but none intertwined the two concepts or implemented a guided, step-by-step approach to the ACLS algorithm. As a result, I decided to develop my own.

From Idea to App

During a short break between intern and junior year of residency, I built a very rudimentary version of my guided app. However, I soon needed assistance and met Dylan Neel, an MD-PhD student in the Harvard–MIT Health Sciences and Technology Program, who taught himself to code. I also reached out to my program director, Joel Katz, MD, for advice, and he emphasized that he and the Brigham were eager to supply the resources and collaboration to turn my idea into reality.

Dylan and I spent the next several months making pictographs and flowcharts of our new code-running app and decided to study its utility as a medical education tool. We enlisted two of our faculty mentors to oversee the project, and with their guidance, we received several research grants during this time to study the app’s impact on resident education and patient care.

By January 2021, Dylan had developed a fully working app prototype, and we began phase I of our study where we collected early feedback data from BWH Internal Medicine residents. The response was overwhelmingly positive.

Collaborating with Colleagues

After being introduced to the Brigham Digital Innovation Hub (iHub), I pitched the project idea at their open innovation studio and received wonderful support, which included a suggestion to collaborate with colleagues at the Healthcare Transformation Lab (HTL) at Massachusetts General Hospital (MGH) who had published a now award-winning ACLS mobile app several months after I began my project and were already collaborating with the AHA.

After several months of working with the HTL, I was accepted to their 2022-2023 Healthcare Innovation Fellowship program. Since July, Dylan and my MGH HTL mentor, Jared Conley, MD, PhD, MPH, and I have continued improving the ACLS app and have begun a randomized control trial at the BWH STRATUS Center for Medical Simulation to assess the app’s efficacy. We aim to publish our trial results in the spring of 2023 and later widely disseminate the app.

The project has been a wonderful example of the collaborative spirit championed across Mass General Brigham. My team and I were met with enthusiastic support and graciously given the resources needed to succeed. Many BWH and MGH mentors believed in the project’s potential, and it has been a pleasure and honor to develop this app alongside them.

Ultimately, I hope this project will grant every clinician in the world access to improved, evidence-based and guided ACLS management so they may feel confident and prepared to deliver the best possible care to patients like Ms. G.

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