Enhancing Team Response to Intraoperative Emergencies

Patient mortality remains a serious risk during intraoperative emergencies such as airway complications or cardiac arrest. Improving outcomes in these high-stakes situations requires a well-coordinated, multidisciplinary team response.

At Children’s Hospital of Orange County (CHOC), part of Rady Children’s Health in Orange, California, perioperative and resuscitation leaders launched a quality improvement project to strengthen emergency response protocols in the OR. A cross-functional team with expertise in critical care, resuscitation, and perioperative services collaborated to bring diverse perspectives to the hospital’s perioperative code events.

Three experts in quality improvement—Marissa Tierney, RN, MSN, PCNS-BC, CCRN; Jennifer Hayes, MSN, RN, CCRN-K; and McKinleigh Mills, MSN, RN, CPN, CNL, CNS(c)—led a multidisciplinary initiative to enhance resuscitation practices during intraoperative emergencies.

By integrating house-wide and perioperative-specific code responders, the CHOC team significantly improved emergency response in the OR. This collaborative model required thoughtful coordination of clinical expertise and response techniques—without disrupting ongoing surgical procedures.

Here are two key strategies CHOC’s multidisciplinary team identified to improve intraoperative emergency response:

Strategy #1: How to Review and Refine Emergency Intraoperative Protocols

The team began by reassessing the entire emergency response process from end to end. They discovered that the escalation process for intraoperative emergencies was inconsistent—varying by time of day and day of the week. This variability led to confusion among staff and delayed or resulted in insufficient support during critical events.

Staff feedback confirmed the need for clearer protocols. Key areas for improvement included clarifying roles, enhancing communication, and ensuring that CHOC’s high resuscitation standards were reliably met.

In response, the team refined emergency protocols for two key scenarios:

Airway Emergencies. After review, the team chose to maintain the existing approach of requesting additional anesthesia support as needed. 

Cardiac Arrest. The team created a new protocol that involves the perioperative team being assigned specific code roles at the start of each shift. In the event of an emergency, team members receive instant push notifications on their work phones, allowing for an immediate internal response to support the initial resuscitation while waiting for the code team to enter the operative space.

“This structure facilitates a dual approach that enables surgical staff to stay focused on operative tasks, while the code team manages the resuscitation,” Tierney said.

Strategy #2: How to Integrate Team Training

“Practice, practice, practice” says Hayes. To improve execution during intraoperative emergencies, the team took a multifaceted approach that focused on building knowledge, skills, and confidence in both new and existing protocols.

“It’s not enough to have a protocol; teams need to feel comfortable executing it,” Hayes said. Simulation training remains a central part of their strategy to help staff build and maintain confidence.

Hands-on education sessions were delivered in a judgment-free environment, emphasizing communication and core skills such as resuscitation basics. Interdisciplinary simulation drills mirrored real-life scenarios, allowing team members to master roles, refine workflows, and identify areas for improvement.

This combination of refined protocols and regular team training has led to measurable changes in team response.

“When a real perioperative emergency occurs, responders now act quickly, clearly, and confidently,” Mills added.