Public Health Literacy and Emergency Department Utilization in Saudi Arabia: A Cross-Sectional Study.

Purpose: Health literacy (HL) is the degree in which individuals are able to access, comprehend, and use publicly available health resources and services. A previous study was done in the Kingdom of Saudi Arabia (KSA) assessing the prevalence of HL, the study shows that almost half of KSA residents had limited HL. Most studies that show the level of HL and its relationship to emergency department (ED) utilization were conducted outside KSA. This study aims to assess the association between HL and utilization of ED services and to estimate the prevalence, factors, and outcomes of low HL in KSA. Patients and methods: A cross-sectional study was conducted among 903 participants in KSA over a period of 2 months (April and May 2023) using an online survey. Participants were asked about sociodemographic characteristics (age, sex, nationality, marital status, education, work status, income), associated factors (chronic diseases, psychiatric disorders, Covid-19 infection, Covid-19 vaccination, ED visits), and Health Literacy (read, access, understand, evaluation, decision). A health literacy instrument for adults (HELIA), which consists of the previously mentioned five subscales, was used to estimate the level of HL and its association with the risk factors. Results: Almost 529 (58.58%) and 374 (41.42%) had limited HL and adequate HL, respectively. Participants with limited HL were mostly aged 35-45 years (61.7%), men (p < 0.05) (68.9%), divorced (65.9%), non-Saudi (69.6%), and had elementary level of education (66.7%). Participants with adequate HL had master's and PhD degree (48.1%), were healthcare students or graduates (62.8%, p < 0.05), had an income >30 thousand riyals (55.6%, p < 0.05), were previously infected with COVID-19 (43%), and did not visit ED in the preceding year (42.3%). Conclusion: A high prevalence of low HL among KSA residents was observed. There was no significant difference in ED utilization between participants who had adequate and limited HL.

Application of Automated External Defibrillators Among the Public: A Cross-Sectional Study of Knowledge, Attitude, Practice, and Barriers of Use in Saudi Arabia.

Background: The likelihood of survival of an out-of-hospital cardiac arrest quadruples with the rapid application of basic life support (BLS). The public's ability to perform cardiopulmonary resuscitation (CPR) and use automated external defibrillators (AEDs) is extremely important. This study aimed to assess the public knowledge, attitudes, and practices (KAP) of utilizing AEDs and to understand barriers to AED application. Methods: We conducted a cross-sectional study from March 1-30, 2022. An electronic questionnaire was constructed and validated to measure the KAP for public AED utilization and its barriers. Results: Of the 406 participants, 244 (60.10%) were males. Male respondents had 17% less knowledge and poorer attitude towards using an AED as compared to female respondents. Knowledge and attitudes on using AEDs were low (70.7%) among Saudi nationals compared to those of foreign nationals. Those who were BLS/CPR trained had a 2.5 times greater understanding and willingness to use AEDs in public than those who were not. Barriers to AEDs in CPR/BLS-trained participants were: (1) accidentally hurting the victim (14.3%), (2) duty as a bystander to just call the ambulance and wait for help (12.1%), (3) never taught what to do (n = 41, 18.4%), (4) did not want to be scolded if performed wrong (3.1%), and (5) never witnessed such a situation (51.6%). Conclusion: There is a strong association between knowledge of and willingness to use AEDs in emergency situations among the public. Misconceptions about AEDs hinder their use. This calls for urgent training programs through accessible technology to reach the public.

Impact of COVID-19 on pediatric emergency fellowship training in Saudi Arabia.

OBJECTIVES: To assess the impact of the COVID-19 pandemic on the academic and clinical processes of pediatric emergency medicine (PEM) fellowship training held by the Saudi Commission for Health Specialties (SCHS). METHODS: A cross-sectional, nationwide, survey-based study was conducted between June and December 2020. PEM program directors as well as fellowship trainees were eligible. The collected data were under the following domains: (1) sociodemographic and work-related characteristics; (2) impact of the COVID-19 pandemic on patient flow and PEM procedures; (3) impact on emergency skills and competence; (4) impact on academic performance; and (5) attitudes toward PEM practice and potential solutions. Monthly reports of PEM visits and procedures were also collected from program directors. RESULTS: A total of 11 PEM program directors and 42 fellows responded. During the pandemic, the number of total ED visits decreased by 70.1%, ED inpatient admissions fell by 57.3%, and the number of intraosseous need insertion and lumbar puncture procedures fell by 76.7% and 62.3%, respectively; the temporal differences in the median frequencies were statistically significant. The pandemic has influenced the knowledge acquisition and leadership skills of one-third of program directors (36.4% and 27.3%, respectively) and the skills and competence of fellows (31.0%). The majority of directors and fellows showed that online classes/webinars were useful (100% and 95.2%, respectively), and there was no need to extend the current fellowship training to compensate for learning deficits (62.7% and 78.6%, respectively). The importance of dedicated modalities to fill in the training gap increased by 62.5% of program directors and 35.7% of fellows. CONCLUSION: The COVID-19 pandemic had significant effects on clinical procedures and academic activities in the PEM fellowship program. The impact was consistently perceived across PEM program directors and fellows. Technology-driven solutions are warranted to mitigate the expected learning and clinical deficits due to reduced clinical exposure.

Analysis of Emergency Department Use by Non-Urgent Patients and Their Visit Characteristics at an Academic Center.

Objective: We studied the extent and reasons for non-urgent emergency department (ED) visits in a single university hospital, their predictors, and patient outcomes to propose solutions suitable for Middle Eastern healthcare systems. Design: We conducted a retrospective review of electronic medical records, including all non- and less-urgent ED visits with complete triage records (levels 4 and 5 triage based on the Canadian Triage and Acuity Scale (CTAS) over one year. The data on patient demographics, visit characteristics, and patient disposition were analyzed using SPSS software. Setting: The study was conducted in the ED at King Abdullah Bin Abdul-Aziz University Hospital (KAAUH), a Saudi university hospital located within the campus of Princess Nourah Bint Abdulrahman University. Participants: A chart review was carried out for 18,880 patients with CTAS 4 or 5 visiting the KAAUH ED between July 2020 and July 2021. Additionally, a total of "11,857" patients with missing triage acuity or CTAS levels 1, 2, or 3 were excluded from the study. Results: The majority (61.4%) of the 30,737 ED visits were less-urgent or non-urgent. The most common reasons for non-urgent visits were routine examination/investigation (40.9%), medication refilling (14.6%), and upper respiratory tract infection/symptoms (9.9%). Most visits (73.4%) were during weekdays and resulted in the prescription of medication (94.2%), laboratory tests (62.8%), sick leaves (4.7%), radiology examinations (3.6%), and a visit to primary healthcare clinics (family medicine) within a week of the emergency visit (3.6%). Conclusion: Less- and non-urgent ED visits often did not need any further follow-ups or admission and represented a burden better managed by a primary healthcare center. Policymakers should mitigate unnecessary ED visits through public awareness, establish clear regulations for ED visits, improve the quality of care in primary healthcare centers, facilitate booking for outpatient department appointments, and regulate the systems of payment coverage/insurance and referral by other organizations.

Differences in acute pain perception between patients and physicians in the emergency department.

Background: Pain is a subjective complaint that comprises a vast majority of emergency department (ED) visits. Owing to its subjectivity, pain reporting is prone to variations that could impact patient care. We aimed to determine the extent of differences in pain rating-scores between patients and their physicians in the ED and impact on patient satisfaction. Methods: A prospective cross-sectional sample of eligible patients was recruited from two centers in Saudi Arabia. Pain scorings were performed using validated online questionnaires during patients' ED stay. Results: Pain rating scores by physicians was lower than that by patients (6.3 ± 2.0 versus 7.0 ± 3.1, p = 0.004). Additionally, severe pain rating (8-10 rating) was given less frequently by physicians compared with that by patients (26.0% versus 48.1%, p = 0.004). Comparing the ratings by physicians with those by patients, underestimation was observed in 70.1%, overestimation in 16.9%, and matching rating in 13.0% cases. The most frequent analgesic medication administered was paracetamol (79.2%), followed by diclofenac (26.0%), morphine (10.4%), and ketorolac (9.1%). The medications were administered mainly intravenously (87.0%) and, to a lesser extent, intramuscularly (31.2%). Majority of patients (62.5%) reported not to have sufficient pain relief after treatment. Conclusion: Most physicians tend to underestimate the level of pain perceived by their patients, which often leads to under-treatment and lower patient satisfaction. The present study revealed a significant difference in pain ratings between patients and physicians.

Testing for anosmia and ageusia in patients presenting to the emergency department with suspected coronavirus disease 2019 in Saudi Arabia.

OBJECTIVE: This study investigated the role of objective olfactory dysfunction (OD) and gustatory dysfunction (GD) testing among patients with suspected coronavirus disease 2019 (COVID-19) who presented with respiratory symptoms. METHODS: A prospective, blinded, observational study was conducted in the emergency units of two tertiary hospitals. Participants were asked to identify scents in the pocket smell test (PST) and flavors in four different solutions in the gustatory dysfunction test (GDT). We assessed the level of agreement between objective findings and self-reported symptoms. We evaluated the diagnostic accuracy of chemosensory dysfunction for diagnosing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. RESULTS: Of 250 participants, 74 (29.6%) were SARS-CoV-2-positive. There was slight agreement between self-reported symptoms and objective findings (kappa = 0.13 and 0.10 for OD and GD, respectively). OD assessed by the PST was independently associated with COVID-19 (adjusted odds ratio = 1.89, 95% confidence interval, 1.04-3.46). This association was stronger when OD was combined with objective GD, cough, and fever (adjusted odds ratio = 7.33, 95% confidence interval, 1.17-45.84). CONCLUSIONS: Neither the PST nor GDT alone are useful screening tools for COVID-19. However, a diagnostic scale based on objective OD, GD, fever, and cough may help triage patients with suspected COVID-19.

Post-acute COVID-19 condition in Saudi Arabia: A national representative study.

BACKGROUND: Many survivors of COVID-19 have developed symptoms and diseases similar to those observed after severe acute respiratory syndrome (SARS). Therefore, this study aimed to characterize the symptoms that appear after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been eradicated and to determine their relationship with COVID-19 severity. METHODS: This multicenter, retrospective cross-sectional study was conducted in all eligible confirmed cases of SARS-CoV-2 infection from Saudi Arabia. Study participants were randomly selected using computerized random sampling from a population of 314,821 patients. Descriptive statistics were used to describe baseline demographic data and clinical characteristics. Categorical variables were presented as counts and percentages, while continuous variables were presented as means and standard deviations. RESULTS: Approximately 70% of patients were found to have five or fewer symptoms simultaneously. Late symptoms (in the ongoing symptomatic COVID-19) occurred in 225 (22·5%) patients with the most common late symptoms being loss of smell, loss of taste, fatigue, shortness of breath, and cough (52·4%, 31·1%, 11·5%, 10·2%, and 8·9% of patients with late symptoms, respectively). We also found that the presence of acute symptoms of COVID-19 and admission to the hospital were significant independent predictors of the post-COVID-19 condition. CONCLUSION: Saudi patients with COVID-19 develop a wide range of symptoms, similar to those observed and reported in other countries. The loss of smell, the loss of taste, shortness of breath, and fatigue were the main persistent symptoms. Regular follow-up of COVID-19 survivors is highly recommended to minimize the burden of the post-acute COVID-19 condition and improve the quality of life of patients.

Attitudes and Preparedness of Non-Frontline Physicians in Saudi Arabia Toward the COVID-19 Pandemic.

OBJECTIVE: This study assesses the attitudes (willingness) and preparedness of non-frontline physicians across different specialties in the Kingdom of Saudi Arabia (KSA) toward the management of hospitalized coronavirus disease (COVID-19) patients. METHODS: This cross-sectional study conducted between April 15, 2020, and May 5, 2020, included 6209 physicians working in KSA. An electronic questionnaire was designed and validated for the assessment of 3 categorical outcome variables, namely, attitudes, confidence, and knowledge levels. Pearson's chi-square test was used for comparing the distribution of the proportions of these 3 categorical variables. RESULTS: Most participants (63.2%) were willing and prepared to treat COVID-19 patients. A significantly large proportion of participants specializing in anesthesiology (78.2%) had higher knowledge levels, followed by those from plastic surgery (71.1%), pediatrics (69.7%), and obstetrics and gynecology (69.1%) (P < 0.0001). Lower confidence levels were found for airway management skills (38.1%), particularly among dermatologists and radiologists. CONCLUSION: Higher knowledge levels about personal protective equipment (PPE) use and confidence in airway management skills were proportionally related to the level of willingness to participate in COVID-19 patient management. There is an urgent need to train doctors from certain specialties on PPE use and airway management to enable their frontline support of severely ill COVID-19 patients.

Preventing SARS-CoV-2 transmission in the emergency department by implementing a separate pathway for patients with respiratory conditions.

OBJECTIVES: This study aimed to describe the development and implementation of a separated pathway to check and treat patients with a suspected/confirmed coronavirus disease 2019 (COVID-19) in the emergency department (ED) at King Abdullah bin Abdulaziz University Hospital in Riyadh. METHODS: We conducted a retrospective, descriptive longitudinal study from March to July 2020 by analyzing data of all confirmed cases of COVID-19 among ED visitors and healthcare workers in King Abdullah bin Abdulaziz University Hospital. RESULTS: During the study period, a total of 1,182 swab samples were collected for testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of which 285 (24.1%) tested positive. Of the 285 cases of confirmed SARS-CoV-2 infection, 18 were healthcare workers and 267 were patients. As a result of using the respiratory pathway for COVID-19 patients, the hospital managed to limit transmission of SARS-CoV-2 not only between patients but also between patients and healthcare workers, while also containing the pandemic. There were no cases of nosocomial SARS-CoV-2 infection recorded among the patients who visited the ED or the flu clinic. All confirmed cases were community acquired and patients were cared for under constrained measures. CONCLUSIONS: Implementing infection control measures and restricting those with respiratory symptoms to the ED pathway prevented nosocomial spread of SARS-CoV-2 infection in the ED.

Exploring the Prevalence and Patterns of Use of Sleep Aids and Stimulants Among Emergency Physicians and EMS Providers in Saudi Arabia.

PURPOSE: This study explores the prevalence and patterns of the use of pharmacologic sleep aids and stimulants among Saudi Arabia's emergency physicians (EPs) and emergency medical services (EMS) providers. PATIENTS AND METHODS: We adopted a descriptive, cross-sectional design. To collect data on the types and frequencies of sleep aids and stimulants used, we distributed a semi-structured, anonymous, web-based questionnaire to registered EPs, paramedics, and emergency medicine technicians (EMTs) in the Saudi Commission for Health Specialties. An internal consistency analysis showed good reliability (Cronbach's alpha=0.667) of the questionnaire. A subscale analysis confirmed the results-alpha values were 0.720 and 0.618 for the use of sleep aids and stimulants, respectively. RESULTS: Males and females represented 81.8% and 18.2%, respectively, of the valid sample of 669 participants. Respondents aged 25-34, 35-44, and 45-55 years represented 51.9%, 32.7%, and 10.2% of the sample, respectively. Results showed that a majority of the respondents (67.1%) used stimulants. Caffeine was the most common stimulant; caffeine and energy drinks were used by 65.9% and 17.2% of the respondents, respectively. Caffeine, energy drinks, nicotine, and ephedrine were used by 65.9%, 17.2%, 18.5%, and 17.3% of the respondents, respectively. The respondents who used at least one sleeping aid and those using only one and two sleeping aids accounted for 36.6%, 15.6%, and 9.7%, respectively. The most common sleeping aids antihistamines and marijuana were used on most days by 13.4% and 13.3% of the respondents, respectively. The average monthly number of night shifts (P = 0.025) significantly influenced sleep aid use. Respondents working in night shifts for 3-5 months or more than 7 days were more likely to use sleeping aids. CONCLUSION: Future research should enhance health workers' knowledge of the efficacy and safety of these medications and guide strategies to organize and reduce night shift work.

Protective Boxes to Prevent Airborne Transmission of SARS-COV-2: Hospital-Based Experiences and a Narrative Literature Review.

OBJECTIVE: Occupational safety in healthcare settings is an integral part of treating COVID-19. A growing body of evidence suggests that the inhalation of both respiratory droplets (>5 µm) and tiny aerosols (<5 µm) is a possible route of virus transmission. Recently, innovative barrier enclosures (aerosol boxes) have been designed to cover patients' heads while allowing the implementation of airway management procedures through fitted holes. The initial design has undergone a series of modifications to improve staff safety, operators' ergonomics, and the efficacy of airway procedures. METHODS: We reviewed the literature concerning different box modifications and provided an insight into our experience of using the box. Aerosol boxes have garnered the attention of clinicians who are frequently exposed to aerosols while performing aerosol-generating medical procedures, particularly endotracheal intubation. Current evidence comes from simulation-based studies rather than real-life clinical investigations. RESULTS: The reports indicated that the box has significantly reduced the diffusion of aerosols into the room; however, the operators have experienced difficulties in the maneuverability of airway devices. CONCLUSION: Aerosol boxes should be used for patients necessitating simple elective intubations after healthcare providers are adequately trained. Customized designs can be further made based on clinicians' experiences.

Premenarchal Adolescent Female Ovarian Torsion: A Case of Delayed Diagnosis.

BACKGROUND Ovarian torsion is a rare surgical emergency in premenarchal girls. Early diagnosis and surgical detorsion are required to restore blood flow and limit tissue damage. CASE REPORT Here, we present a case of ovarian torsion and appendicitis in an 11-year-old premenarchal girl who presented to our emergency room with a 4-day history of right iliac fossa pain, limping, and fever. Upon initial evaluation in our hospital, her vital signs were stable and clinical examination revealed abdominal guarding and right lower quadrant rebound tenderness with positive Rovsing's sign. Abdominal ultrasound and computed tomography scans showed adnexal cysts and torsion, an inflamed appendix, and free fluid in the abdomen. Intraoperative findings included a twisted gangrenous ovary and an edematous appendix. The patient underwent emergency laparoscopic oophorectomy and appendectomy. CONCLUSIONS This case demonstrates that reactive appendicitis can occur secondary to inflammation of adjacent structures such as the ovary.

Simulation-Based Peer-Assisted Learning: Perceptions of Health Science Students.

OBJECTIVE: Since 2010, simulation-based learning has become increasingly popular as a well-recognized method of learning used by medical undergraduates in clinical settings. However, the relatively new concept of simulation-based peer-assisted learning has not yet been widely accepted, so it has not been well documented. Therefore, this study evaluated the perceived advantages of simulation-based peer-assisted learning among health professions students and interns and their acceptance of this new concept of learning from a student-instructor. METHODS: This was a pilot study conducted with 11 students in various health profession fields at Princess Nourah bint Abdulrahman University (PNU). The students were given a comprehensive lecture on simulation scenario development and were assigned to four separate interdisciplinary teams for a practical session on simulation scenario writing. Then, they each completed a questionnaire seeking their opinion concerning their experience and concept understanding. RESULTS: The results confirmed the advantages of interprofessional simulation-based peer-assisted learning as it helped in understanding the process as perceived by the study participants. All students expressed their willingness and enthusiasm to use simulation as a technique for peer-assisted learning. CONCLUSION: The study affirms the importance of developing student teachers' teaching skills at an institutional level. The future implementation of simulation-based peer-assisted learning is dependent on the students' awareness of the concept. By exploring a new dimension of medical education, the student teachers could expand their horizon of exposure to holistic case management and interactive learning and equip themselves with practical communication skills to excel in a real-world setting.

A Push-to-Talk Application as an Inter-Professional Communication Tool in an Emergency Department During the COVID-19 Pandemic.

OBJECTIVE: To assess the effects of using a smartphone-based push-to-talk (PTT) application on communication, safety, and clinical performance of emergency department (ED) workers during the COVID-19 outbreak. DESIGN: An observational, cross-sectional study. SETTING: ED in an academic medical center. PARTICIPANTS: All ED staff members, including physicians (consultants, specialists, residents, and interns), nurses, emergency medical services staff, technicians (X-ray), and administration employees. INTERVENTIONS: Eligible participants (n=128) were invited to fill out an online questionnaire 30 days after using a PTT application for sharing instant voice messages during the COVID-19 outbreak. MAIN OUTCOME MEASURES: Self-reported data related to communication, implementation of personal protective measures, and clinical performance at the ED were collected and analyzed on a 5-item Likert scale (from 5 [strongly agree] to 1 [strongly disagree]). Also, the proportions of favorable responses (agree or strongly agree) were calculated. RESULTS: Responses of 119 participants (51.3% females, 58.8% nurses, and 34.5% physicians; 90.4% received at least one notification per day) were analyzed. The participants had favorable responses regarding all domains of communication (between 63.0% and 81.5%), taking precautionary infection control measures (between 49.6% and 79.0%), and performance (between 55.5% and 72.3%). Receiving fake and annoying alerts and application breakdowns were the lowest perceived limitations (between 12.5% and 21.0%). CONCLUSION: The assessed PTT application can be generalized to other departments and hospitals dealing with patients with COVID-19 to optimize staff safety and institutional preparedness.

Use of In Situ Simulation to Improve Emergency Department Readiness for the COVID-19 Pandemic.

INTRODUCTION: During the world-wide coronavirus disease 2019 (COVID-19) outbreak, there is an urgent need to rapidly increase the readiness of hospitals. Emergency departments (EDs) are at high risk of facing unusual situations and need to prepare extensively in order to minimize risks to health care providers (HCPs) and patients. In situ simulation is a well-known method used in training to detect system gaps that could threaten safety. STUDY OBJECTIVES: One objective is to identify gaps, test hospital systems, and inform necessary modifications to the standard processes required by patients with COVID-19 presenting at the hospital. The other objective is to improve ED staff confidence in managing such patients, and to increase their skills in basic and advanced airway management and proper personal protective equipment (PPE) techniques. METHODS: This is a quasi-experimental study in which 20 unannounced mock codes were carried out in ED resuscitation and isolation rooms. A checklist was designed, validated, and used to evaluate team performances in three areas: donning, basic and advanced airway skills, and doffing. A pre- and post-intervention survey was used to evaluate staff members' perceived knowledge of ED procedures related to COVID-19 and their airway management skills. RESULTS: A total of 20 mock codes were conducted in the ED. Overall, 16 issues that posed potential harm to staff or patients were identified and prioritized for immediate resolution. Approximately 57.4% of HCPs felt comfortable dealing with suspected/confirmed, unstable COVID-19 cases after mock codes, compared with 33.3% beforehand (P = .033). Of ED HCPs, 44.4% felt comfortable performing airway procedures for suspected/confirmed COVID-19 cases after mock codes compared with 29.6% beforehand. Performance of different skills was observed to be variable following the 20 mock codes. Skills with improved performance included: request of chest x-ray after intubation (88.0%), intubation done by the most experienced ED physician (84.5%), and correct sequence and procedure of PPE (79.0%). CONCLUSION: Mock codes identified significant defects, most of which were easily fixed. They included critical equipment availability, transporting beds that were too large to fit through doors, and location of biohazard bins. Repeated mock codes improved ED staff confidence in dealing with patients, in addition to performance of certain skills. In situ simulation proves to be an effective method for increasing the readiness of the ED to address the COVID-19 pandemic and other infection outbreaks.

Reversal of Digital Ischemia with Phentolamine After Accidental Epinephrine Injection.

BACKGROUND Accidental finger-stick injuries have been reported with epinephrine autoinjectors, such as EpiPen and EpiPen Jr, and can result in necrosis and digital ischemia. However, long-term adverse effects are very rare. The treatment for accidental finger-stick injuries is controversial and includes intra-arterial injections of vasodilating agents, topical vasodilators, and supportive management as needed. CASE REPORT Here, we report a case of a 26-year-old pharmacist who injected herself accidentally with an EpiPen on the tip of her index finger. Warm water and nitroglycerine gel did not alleviate her symptoms. After three hours, phentolamine was injected around the necrotic area, and the skin normalized. CONCLUSIONS All health professionals should be trained in how to handle epinephrine autoinjectors safely. Phentolamine may be efficacious in treating accidental finger-stick injuries from epinephrine autoinjectors.

Longitudinal exploration of in situ mock code events and the performance of cardiac arrest skills.

INTRODUCTION: In hospital cardiac arrest (IHCA) affects 200,000 adults in the United States each year, and resuscitative efforts are often suboptimal. The objective of this study was to determine whether a program of "mock codes" improves group-level performance of IHCA skills. Our primary outcome of interest was change in CPR fraction, and the secondary outcomes of interest were time to first dose of epinephrine and time to first defibrillation. We hypothesized that a sustained program of mock codes would translate to greater than 10% improvement in each of these core metrics over the first three years of the program. METHODS: We conducted mock codes in an urban teaching hospital between August, 2012 and October, 2015. Mock codes occurred on telemetry and medical/surgical units on day and night shifts. Codes were managed by unit staff and members of the hospital's "Code Blue" team, and data were recorded by trained observers. Data were summarized using descriptive statistics, and repeated measures outcomes were calculated using a mixed effects model. RESULTS: Fifty-seven mock codes were included in the analysis: 42 on Medical/Surgical units and 15 on Telemetry units. CPR fraction increased by 2.9% per six-month time interval on Telemetry units, and 1.3% per time interval on Medical/Surgical units. Neither time to first epinephrine dosing nor time to defibrillation changed significantly. CONCLUSIONS: While we observed a significant improvement in CPR fraction over the course of this program of mock codes, similar improvements were not observed for other key measures of cardiac arrest performance.