In Situ Code Blue Simulation Drills in a Developing Country: Challenges and Future Directions

Introduction: In-hospital cardiac arrest (IHCA) survival rates remain low in developing countries, with reported rates of 28.3% (adults) and 17.9% (pediatrics) at our tertiary care center in Pakistan. In-situ simulation (ISS) offers high-fidelity, experiential learning in actual clinical settings, yet its feasibility and impact in resource-limited settings are understudied. We hypothesized that implementing ISS mock code drills would improve team readiness, adherence to AHA guidelines, and CPR quality metrics in a developing country hospital.


Methods: This quasi-experimental pilot study was conducted at Aga Khan University Hospital (710 beds) from December 2023 to March 2025. We conducted 51 unannounced ISS mock codes across diverse hospital units, using high-fidelity manikins and realistic scenarios. Participants included resident physicians and rapid response nurses (BLS/ACLS-certified). Each drill involved 20–30 minutes of simulation followed by structured debriefing. Primary outcomes (technical skills, team dynamics) were assessed via a validated mock code documentation form aligned with AHA guidelines. Metrics included response times, CPR quality (e.g., compression fraction, defibrillation timing), and adherence to algorithms.


Results: Of 44 analyzed drills, specialty teams arrived within 3–5 minutes in 40.5% (cardiology), 66.7% (anesthesia), and 73% (medicine) of cases. Full AHA guideline adherence was low (14.3%), but individual metrics improved: compression fraction >81% (41.5%), timely defibrillation (22%), and post-ROSC care (79.5%). Team leadership was identified in 98% of drills, but role confusion persisted in 40%. Debriefing occurred in 50% of drills, highlighting strengths (e.g., crash cart readiness) and gaps (e.g., infection control). Longitudinal analysis showed improved response times (first vs. last drills: 44% vs. 89% arrival within 1 minute).


Conclusions: ISS mock codes are feasible in resource-limited settings and improve team readiness and select CPR metrics. However, systemic challenges (e.g., guideline adherence) and cultural barriers (e.g., hierarchical communication) limit full potential. Sustainable ISS programs require dedicated resources, structured debriefing, and institutional buy-in. Future studies should link ISS participation to real-world IHCA outcomes.