In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal, because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing, and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate code blue recording systems seems to primarily serve a risk reduction tool. It is that for sure, however, it is important not to loose site of the first two critical functions of an accurate code blue record: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. It was through an unfortunate series of events that the whole problem of inadequacy of code blue records and the poor quality of data was recognized.

Upon further exploration, this problem was found to be a universal issue across most healthcare organizations large and small.  The code blue work flow process can certainly be improved in most healthcare organization.  However until the problem of accurate rapid data acquisition and seamless secure handling of data so that it can be immediately uploaded into the medical record is solved, the care of patients during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during code blue events.

In-hospital cardiac arrests (code blues) occur across the U.S. in both large and small healthcare facilities, and the outcomes are usually quite disappointing. The percentage of the 200,000 patients who experience in-hospital cardiac arrest every year and survive to discharge is surprisingly low [only 17% – 20% according to the Society of Hospital Medicine]. However, upon reflection, this may not be surprising. The patients who experience in-hospital cardiac arrest are often in fragile, medical condition with multiple co-morbidities that only complicate their cardiac status.

Improving the care for code blue patients is a complex and multifaceted issue. When a patient experiences a cardiac arrest, the need for immediate high quality care directed by published guidelines, grounded in high quality science, is obvious. Equally as important as well established care guidelines is the capture of the care that is provided cardiac arrest patients. Ensuring that the event is well documented and that the documentation is immediately available for post-arrest patient care is essential.

The timing of every medication, every procedure, and, in fact, every patient care intervention becomes critical to improving patient outcomes. The AHA has recognized the importance of careful timing of many of the life-saving cardiac arrest interventions, such that, a number of their published practice guidelines are based on very careful timing of their execution.

The consequence of increased emphasis on placing timing requirements on patient management decisions is that the job of the code blue recorder is complicated exponentially. Not only does the recorder now need to accurately capture the events of the code blue, but now they are also tasked with tracking multiple timed and recurrent critical medication and management actions.

An additional consequence of now tracking timed management actions is that the patient record degrades as the recorder is distracted from the duties of capturing the patient care to ‘watch the clock’.

The Event

How has the recording aspect of code blues changed with the advent of emphasis on the importance of very accurate timing of the provisions of cardiac arrest care.

During a cardiac arrest, guidelines, in part, suggest that:

1. Epinephrine should be delivered at 3-5 minute intervals.
2. Chest compressions must be delivered at a rate of 100-120 per minute.  
3. The person providing compressions should be rotated every two minutes to ensure that the compressor does not tire and the patient continues to receive adequate CPR.
4. Compressions may frequently be paused to take vitals, administer defibrillatory shocks, facilitate endotracheal intubations when managing patients with difficult airways, but compressions should never be paused for longer than 10 seconds.
5. Defibrillation shocks should be delivered every 2 minutes.

Unfortunately, a provider tasked to record code blue care is frequently unable to track all of these time-based interventions during the fast-paced and high-stress situation. How does one keep one’s eye on multiple clocks and at the same time generate an accurate code blue record?

In response to this dilemma, some hospital systems have begun deploying two recorders to code blues – one to actually document the event for the patient record and another to keep track of the timing. Two recorders can be challenging in small spaces, where crowd control is already an issue. It also requires more staff to meet the need (which becomes costly). However, there are relatively few options available to improve timing of critical interventions, and it is clear that keeping time is essential to providing the best care possible for the patient.

It is strongly suggested that the recorder do nothing but document the event.

Distracting the recording provider with anything other than the record can greatly degrade the patient record and thus patient care, and there are often too many distractions during a code blue response. There are critical communications between the physician lead and the response team and between the code blue leader and the patient’s family. A family member is often in the room and understandably distressed. Often, too many nurses respond to the overhead code alarm and the room might crowd. One team member might be attempting to control the crowd. Another might be securing a patient’s belongings. The list goes on.

The average code doesn’t last for long. It ends as soon as the patient is successfully resuscitated or when the physicians present believe there is nothing more that can be done for the patient and the patient does not survive.

A new code blue recording system has recently come on the scene – RevitalPro – a intuitive, mobile, easily used device developed by Format Health out of Seattle Washington.

This system is the best code blue documentation system currently on the market. The system provides the code blue recorder with an interface that is exceptionally intuitive, easily used, designed around the workflow of a code blue. The system’s interface was designed with the user in mind such that its use requires little to no initial training or continual in-service training. In addition, the system provides automatic critical timers and safety alerts based on established guidelines. The timers and alerts have basically eliminated the need of the recorder to watch the clock or a stopwatch, and thus, attend exclusively capturing the most complete, detailed, accurate patient record possible.

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

•  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
•  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
•  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

•  “Have we given the epinephrine yet?”
•  “Is it time to ‘shock’ the patient?”
•  “Did we remember to check CO2 after placing the endotracheal tube?”
•  “Should we change out the person giving chest compressions?”
•  “How long ago did we give that epinephrine?”
•  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product RevitalPro: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.

In-hospital cardiac arrest situations, “code blues,” can be sudden and disorienting for the care providers involved. Typical code blue events last only a few minutes, but the actions taken by the providers during that time play an essential role in patient outcomes.

Preparing for a quick, high-stress situation can be difficult.

Learning the code protocol at your facility and familiarizing yourself with the code blue documentation sheet can save valuable time during the event.

Nurse Nacole Riccaboni, an ICU nurse and influential nursing blogger, recounted the events of her first code blue:

“It was 2011, and I was doing an initial head to toe assessment, and I experienced my first code blue. He said his chest was hurting and that he couldn’t breathe. Before I could even get the phone up to my ear to call The Rapid Response Team, he yelled, “I’m dying” and just stopped moving. He went limp, his eyes rolled back, and he just stopped moving! It wasn’t like on television. There was no dramatic music or signals. He just was talking one minute and not the next. I wasn’t mentally prepared for that. I checked for a pulse, hit the code blue button, and immediately started cardiopulmonary resuscitation (CPR). Dozens of people soon ran into the room to help me. And by “helping me,” I mean running the code because I froze. I felt like it was my fault and I must have missed something for this to happen. I couldn’t get out of my own head.

I was just doing CPR, not counting or following the algorithm. It took the charge nurse yelling, “Nacole! Look at me and do this right!” for me to get it together and hear the support team’s instructions. When you’re learning basic life support or even advanced cardiac life support, you don’t learn about the human element of the process. Doing CPR on a mannequin is very different than doing it on a person. When you press down on a person, you feel the bones and their organs resistance. Often orifices leak and ooze, and it can be a very traumatic process. The human element can distract you, and you may forget the algorithms and tasks needed at specific times frames. That’s why code leaders and recorders are so crucial. One person can’t do it all. It takes a team to save a life.

The most significant action during a code blue is quality CPR. As nurses, we are often the first person at the bedside and the first person to initiate CPR. We must provide high-quality chest compressions in order to give our patients a chance at survival. There are five critical components of high-quality CPR:

• minimize interruptions in chest compressions,
• provide compressions of adequate rate and depth,
• avoid leaning between compressions, and
• avoid excessive ventilation.

High-quality CPR is often undervalued due to bedside monitors and gadgets, but it’s the single most important function during a code situation. If I could give any advice to nurses during code blues, it would be to know how to properly deliver high-quality chest compressions. I wrote a paper on CPR during my undergraduate program, and I remember this excerpt,

“External chest compressions provide approximately 20-25% of baseline cardiac output, with 10-20% of normal cerebral perfusion. This degree of vital organ perfusion can provide reasonable salvage for 15 minutes.”

(Trauma, 7e – Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano)

I keep that in mind during each code. If high-quality CPR can only provide 20-25%, image how low the cardiac output suboptimal CPR provides, if any.

When you are in a code blue situation, understand that the return of spontaneous circulation with unimpaired neurologic function unimpaired is the primary goal. Strive towards achieving this objective with utilizing proper cardiac arrest algorithms and by knowing the H’s and T’s. The H’s and T’s of advanced cardiac life support (ACLS) is a mnemonic used to help recall the major contributing factors related to:

• asystole,
• pulseless arrest including (PEA),
• ventricular fibrillation (VF), and
• pulseless ventricular tachycardia (VT).

Often during a code, the team reviews these causes an in attempt to improve the patient’s outcome. When a person goes into cardiopulmonary arrest, there often isn’t an apparent cause. As nurses, we obviously review a patient’s history, along with laboratory and diagnostic findings. But the cause often eludes us, and that’s where the H’s and T’s come into play. The code team works as a unit making sure each Hs/Ts is evaluated, and the appropriate intervention is implemented.

Last but not least, know the patient (if your patient has the cardiopulmonary arrest, of course). If you’re just there to help, assist in any way you can. Common questions during a code are:

• Was the event witnessed?
• Was the patient found down?
• What was the initial rhythm displayed?
• What time did the code start?
• Vital signs pre-event?
• Most recent laboratory and diagnostics?

These details are what providers and the team will need. Yes, the patient doesn’t have a pulse, that’s of the utmost importance but what lead up to the event is just as important. Does the patient have a cardiac history? Who is the next of kin? All these questions play a role during the code blue process. And only the nurse assigned to the patient has these answers. So, be available and be ready. Use the team but remember, you are the point of contact during this event. You are the only one with this knowledge.

A code blue event is a singular episode packed with many moving components. This is why a team is crucial to a patient’s survival. Often nothing could have been done to avoid the cardiopulmonary arrest development. So instead of folding inward and collapsing in on yourself, focus on saving the patient. Know the background, the cardiac arrest algorithms, how to perform high-quality CPR, each team member’s role and your H’s and T’s. Being prepared is all we can do and when the time comes, implement that awesomeness to the best of your ability.”

Nurse Nacole recalls the angst that many new nurses feel during their first several code blues. Study, preparation, and simulated training are key to effectively responding to in a code blue event. Sufficient training and preparation tools such as these inexpensive mini-cardiovascular cards help to build familiarity with essential cardiac elements. These cards cover: beta blockers, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), and antianginal medications.

Recognizing the key factors can certainly help in preparation for a code blue. Understanding what questions are going to be asked, preparing for the quick pace, studying H’s and T’s, and practicing high-quality CPR are excellent activities for care providers.

Notes make for excellent preparation. It’s a good idea to ensure that your notes are small and portable for those quick, break room reviews. Continuous study will build confidence and ensure you feel well prepared.

If you have some code blue prep ideas or would like to share your first code blue experience, we encourage you to comment below!

What follows the chaos of a code blue event, the acquisition and handling of the code blue records, is nearly as important as the management of the event itself. The patient record that is generated during a code blue has three critical functions:

1. First, and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
2. Second, the data collected serves as a rich source for directing quality improvement efforts.
3. Thirdly, the record, if acquired accurately, is the single best picture for reconstructing the event if risk management issues arise.

As a result, it is imperative that the record be the as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval.

To this end, the recorder should not be distracted during the acquisition of the code blue data. Other tasks, such as tracking timed events, stopwatches, or ‘clock watching’ are common distractions. In addition, an efficient code blue recording ‘instrument’ – be it paper or a desk top electronic system should be:

• a completely mobile device – code blues do not always happen in dedicated patient spaces
• intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
• capable of rapid data acquisition
• have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real Time Patient Management Tool

A valuable code blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Post event, if return of circulation (ROSC) is achieved, the patient is frequently transferred to higher level of care, often on a ventilator. An integral part of real time patient management is making the code blue record immediately available to the transition team at the end of the code.

The team must understand what caused the cardiac arrest, and how the patient was managed. Without a record of the drugs administered or some assessment of the 6h’s (hypovolemia, hypoxia, hydrogen ion, hyperkalemia, hypokalemia, and hypothermia) and 6t’s (toxins, tamponade, tension pneumothorax, thrombosis: myocardial infarction, thrombosis: pulmonary embolism, and trauma), intensive care may be unable to provide the post resuscitation care that patient needs for long-term survival.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and so never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently not available for upload into the patient’s medical record until days after the event.

RevitalPro, a new code blue documentation tool developed by Format Health in Seattle does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available.

Optimizing the cardiac arrest recording process – the paper record or electronic recording system –  to work in parallel with the hospital’s code blue protocol should improve performance. By focusing on creating an accurately time stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record keeping system is difficult, but critical for generating a high quality code blue record as well as delivering high quality patient care.

A record-keeping software (such as RevitalPro: Code Blue) can be used to produce a record more quickly and efficiently. Software options such as RevitalPro provide the benefit of a typed, legible record which can be seamlessly upload to the EMR – thus eliminating the the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro: Code Blue provides a solution to many of the problems outlined above as it has  built-in timers to help track dosage and compressions, safety alerts that assist providers adherence to published guidelines, and immediate, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine recounts a study in which RevitalPro reduced omission errors by 28% and redundant entries by 36% as compared to paper recorders.

Quality Improvement

Code blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an important practice for both improving staff response and overcoming staff apprehension toward code blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generate by RevitalPro provides an excellent tool for post code blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to