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Code blue Do you know what to do?

By Jan
By J
Ja
Janet
an
anet
net
et E.
E. Jackson,
Jac
Jackso
Ja
ackso
a kso
on,
n, MS,
MS
MSS,, RN,
RN
N, and
and Amy
my S.
my S. Grugan,
Gruga
Grug
ug
ga
an,
n, MSN,
MSN
MS
SN, RN
SN RN

MANY HEALTHCARE FACILITIES have implemented rapid re-

sponse teams (RRTs) in response to the Institute for Healthcare
Improvement’s 100,000 Lives Campaign.1 By addressing a patient’s
deteriorating clinical status before a full-blown crisis, RRTs may
reduce in-hospital cardiopulmonary arrests or “codes,” typically
called code blues.2 Consequently, although nurses in hospitals are
required to have basic life support training, they may have few
opportunities to practice these skills before needing to perform
them on a patient in crisis. This lack of practice makes it difficult
to maintain proficiency.3
It’s been estimated that after a code blue is called, 3 to 5 minutes
may elapse before the code team arrives at the bedside.4 Because
those minutes are critical to the patient’s survival, even nurses on
non-ICU units need to be proficient at responding to a code blue
and using resuscitative equipment and skills. This article reviews the
appropriate actions and interventions clinicians must perform dur-
ing a code blue in adults with a focus on the nurse’s role. It also dis-
cusses the importance of ongoing education and hands-on training,
including participation in mock codes, to keep nurses’ skills sharp.

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Initiating a code blue should be sufficient for several
A code blue in adults should be minutes after the onset of cardiac
called immediately for any patient arrest in a patient with a patent
who’s unresponsive, apneic, and/or upper airway.5 Research studies
pulseless. Under American Heart support the delay of airway manage-
Association (AHA) guidelines, calling ment and institution of ventilations
for help and initiating CPR should until additional help arrives.7
be done simultaneously.5 Protocols
for summoning a code team vary Airway manager
depending on facility policy; all staff While the first responder begins
should be familiar with the procedure compressions, a second responder
for calling a code blue in their facility. manages the airway. Using AHA
Calling out loudly for help is the guidelines:
initial request for assistance, and lo- • give the patient two ventilations for
cally responding assistants are desig- every 30 compressions using the
nated to formally call the code blue bag-mask device attached to an oxy-
through the facility-wide response gen source. Most patient rooms have
system.6 While awaiting members of a bag-mask device immediately avail-
the hospital-wide code team to arrive, able, typically located at the head of
a nurse should initiate CPR and other the bed.
interventions. Members of the code • set the oxygen level on the flow
team should identify themselves and The key to running an meter at 15 L/min and, if appli-
their role upon entering the room cable, fully open the reservoir on
effective code blue is the
with statements such as “I’ll take the the bag-mask device to ensure that
airway” or “I’ll document.” A staff quality and timeliness of each breath is delivered with 100%
member at the nurses’ station should the interventions. oxygen.
contact the patient’s healthcare pro- • bag-mask device ventilation is most
vider as soon as the code is called. effective when performed by two
The key to running an effective compressions per minute; the beat of trained and experienced providers.
code blue is the quality and timeli- the Bee Gees’ tune “Staying Alive” is One provider opens the airway and
ness of the interventions. Early, high- just the right cadence for the effective seals the mask to the face while the
quality CPR and rapid defibrillation, timing of compressions.8 Don’t wait other squeezes the bag.5
if indicated, before advanced cardio- for a backboard to be placed to begin • make sure each compression of the
vascular life support (ACLS) inter- compressions; it can be placed when bag causes the chest to rise (a tidal
ventions are two essential principles additional personnel arrive who will volume of approximately 600 mL
in beginning the resuscitation phase. then switch compressor roles approxi- delivered over 1 second). An oropha-
Despite the fact that healthcare pro- mately every 2 minutes (or after about ryngeal airway can be placed to help
fessionals with advanced education 5 cycles of compressions and ventila- ensure airway patency when deliver-
and training know the pathophysiol- tions at a ratio of 30:2) to prevent de- ing ventilations with a bag-mask
ogy behind cardiopulmonary arrest, creases in the quality of compressions. device.
in the heat of the moment they often Make sure the depth of chest com- • during CPR, minimize interrup-
forget that the most important first pressions is at least 2 inches (5 cm) tions in compressions when deliver-
step is restoring perfusion through with complete chest recoil after each ing ventilations.
effective chest compressions. The compression to allow the heart to fill • although ventilation with a bag-
AHA has put forth the mantra of completely before the next compres- mask device is acceptable during
“push hard and fast” in their by- sion. Minimize the frequency and CPR, be prepared to assist a qualified
stander CPR program.7 duration of interruptions in com- anesthesia provider with endotra-
Starting with the compressor, the pressions to maximize the number of cheal intubation because there are
following discussion outlines the role compressions delivered per minute.9 times when ventilation with a bag-
of each member of the code blue team. Chest compressions cause air to be mask device is inadequate.5
expelled from the chest and oxygen Continuous waveform capnogra-
Compressor to be drawn into the chest due to the phy, in addition to clinical assess-
The first healthcare provider to re- elastic recoil of the chest. Because ment, is considered to be the most
spond assumes the role of “compres- ventilation requirements are lower reliable method of confirming and
sor” and immediately begins chest than normal during a cardiac arrest, monitoring correct endotracheal tube
compressions at a rate of at least 100 oxygen supplied by passive delivery placement.5

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Defibrillator manager
In addition to compressions, the Safety guidelines for defibrillation
only other therapy proven to in- • Know your monitor/defibrillator.
crease survival is defibrillation.9 • Know where the defibrillation cables and pads are kept.
Rapid defibrillation for “shockable • Use hands-free defibrillator pads whenever possible.
rhythms,” which are pulseless ven-
• Make sure defibrillator pads are fully in contact with the patient’s bare chest.
tricular tachycardia and ventricular
• The pad marked “sternum” should be below the right clavicle in the midclavicular
fibrillation, is critical, and the abil-
line (right anterior chest wall position).
ity to recognize a shockable rhythm
is a required skill. Vascular access, • The pad marked “apex” should be placed between the fourth and fifth intercostal
space on the left anterior axillary line (left axillary position).
drug delivery, and advanced airway
placement shouldn’t cause inter- • If necessary, pads may be placed anteriorly on the right side of the patient’s ster-
ruptions in chest compressions or num and posteriorly below the left scapula and lateral to the spine.
delay defibrillation.5 • If the patient has an implanted pacemaker, position pads so that they’re not
Placement of hands-free defibrilla- directly over the device.
tion pads versus traditional handheld • Don’t place pads on top of a transdermal medication patch. Remove the patch
defibrillation paddles is recommend- and wipe the area clean before applying a defibrillator pad.
ed as a safer option and allows for • Ensure that oxygen flow isn’t directed across the patient’s chest.
more rapid defibrillation. The patient • Announce “Charging defibrillator to (specified number of joules)” and press the
should be connected to a 3- or defibrillator charge button.
5-lead cardiac monitor; if the hands- • When the defibrillator is fully charged, announce “I am going to shock on three,”
free pads have monitoring capabili- then count and announce “ALL CLEAR.” Chest compressions should continue until
ties, they can be used to monitor the this announcement is made.
cardiac rhythm. Often both methods • After visually confirming all staff is clear of the patient and bed, press the defibril-
of cardiac monitoring are used dur- lator shock button.
ing a code. • Immediately after the shock is delivered, resume CPR beginning with compressions.
Nurses should be trained in dys-
• Make sure defibrillator supplies are restocked and the defibrillator is plugged into
rhythmia recognition and ACLS or
the wall outlet for recharging after code is complete.4
have an expert on the clinical unit
immediately available to help them
identify dysrhythmias. If no expert team leader gives the order, such Crash cart manager
is immediately available, consider as “defibrillate with 200 joules,” Most units have a crash cart or code
using the automated external defi- the defibrillator manager repeats, cart available for use in resuscitation.
brillator (AED) function on the defi- “Charging to 200 joules.” The defi- The crash cart contains emergency
brillator, if available, to ensure early brillator manager then announces medications and equipment, such as
defibrillation when indicated before the delivery of 200 joules after the a monitor/defibrillator or AED and
the code team arrives. shock is delivered. (See Safety airway adjuncts.
Because defibrillators are manu- guidelines for defibrillation.) ACLS guidelines support early
factured as either monophasic or As soon as the shock is deliv- administration of vasopressors in car-
biphasic, the nurse must know ered, resume chest compressions diac arrest, but medications are sec-
which type of defibrillator is on the immediately; don’t delay resump- ondary to high-quality CPR and rapid
unit. A monophasic defibrillator is tion of chest compressions to defibrillation, when indicated.5 Use
generally set to deliver 360 joules recheck the rhythm or pulse. caution when administration of med-
for defibrillation, and a biphasic Even resumption of a normal heart ications during a code blue; miscom-
defibrillator is initially set to deliver rhythm won’t initially produce munication is a common problem
between 120 and 200 joules, enough cardiac output for ade- leading to administration of incorrect
depending on the manufacturer’s quate perfusion, so CPR should medications or doses during codes.10
recommendations.5 continue.5 After about 5 cycles of One way to prevent miscommunica-
Once a shockable rhythm is CPR (about 2 minutes), ending tion is using “closed loop” communi-
identified, the defibrillator man- with compressions, the cardiac cation, as described earlier. (This
ager sets the energy level on the rhythm should be checked during method should be used for every
defibrillator, as directed by the the change of compressor roles. If intervention during a code, not just
team leader, using “closed loop” an organized electrical rhythm is medication administration.) For ex-
communication to ensure under- present, check for return of spon- ample, the nurse who receives an
standing of the order before defi- taneous circulation (ROSC) by order to administer a medication
brillation. Using this technique, the checking the carotid pulse. repeats the medication name and

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dosage out loud before administering leader may direct them to wait out- ately resumed after the shock. The
it and then announces the medication side the room until further help is recorder also notes that 100% oxygen
name and dosage again after it’s been needed, help move the patient’s is being delivered and that the pa-
given.5 It’s also helpful if crash carts are roommate, or check on other patients tient has good rise and fall of the
stocked consistently across the facility. on the unit who may need assistance. chest with ventilations. Assessment
For example, all the I.V. epinephrine In many institutions, policy allows findings such as end-tidal CO2 values
should be located in the same drawer family presence during resuscitation should be recorded. Print cardiac
of all the crash carts in the facility. efforts; if so, family should be offered rhythm strips or the code summary
The crash cart manager should be the option of being in the room with a from the monitor/defibrillator for the
positioned on the same side as the staff support person. If no policy exists patient’s medical record. Clearly iden-
patient’s venous access and have or families don’t wish to be present, tify all documentation with the pa-
room to open the crash cart drawers they should be directed to a private tient’s name, date of birth, medical
for easy access to the contents. waiting area. A staff support person record number, and date and time.
should be available to stay with the Note the time that resuscitation efforts
Code team leader family and serve as a liaison between were discontinued, patient disposi-
The code team leader directs resusci- medical personnel and the family until tion, and time of death if applicable.9
tation efforts, communicates with all a patient disposition is determined.11
team members, and monitors the Postcode care
patient’s cardiac rhythm. The code The recorder Nurses need to prepare to transfer
team leader needs to be in a position The recorder documents the entire the patient for further stabilization or
to effectively observe all aspects of resuscitation process. Documenta- treatment. If the arrest was due to
the resuscitation efforts. This role tion during a code blue differs from cardiac causes, the patient may be
may be taken by a physician or an facility to facility. Different electronic taken to the cardiac catheterization
advanced care provider. health record systems have specific lab (if the facility has one) or to the
Because most patient rooms are methods for code documentation. ICU. Attach the monitor/defibrillator
relatively small, especially those with During the code, the recorder re- and continuously monitor the car-
two patient beds, it’s essential to man- minds the code team leader every 2 diac rhythm during transfer to the
age the space in the room. This may minutes when it’s time for a compres- designated unit. Someone who can
involve moving furniture or tempo- sor role switch and the time, name, effectively manage the airway should
rarily moving a patient’s roommate to and dose of the last medication ad- also accompany the team transferring
another room. Some people who re- ministered. It’s also important for the the patient. Handoff of care commu-
spond with the intention of helping recorder to document the cardiac nication should follow established
may not find a role that needs to be rhythm before a shock is delivered facility policy and procedure.
filled. In this case, the code team and that compressions were immedi- Patient care considerations include
optimizing ventilation, oxygenation,
and BP to maintain vital organ
Reviewing mock code skills perfusion. Patients may require an
• Initiate the code blue per facility policy. I.V. vasopressor such as epinephrine,
• Start CPR (one- and two-person rescuer). dopamine, or norepinephrine to ob-
• Position the bag-mask device and attach it to oxygen. tain and maintain a systolic BP of at
• Place the backboard. least 90 mm Hg. To optimize neuro-
• Bring the crash cart to the room.
logic function and improve the
chance of survival to hospital dis-
• Arrange the room for best patient and crash cart access.
charge, therapeutic hypothermia may
• Locate supplies and equipment on the crash cart.
be considered for patients with
• Attach ECG leads. ROSC who are unresponsive.5 The
• Attach defibrillation pads. pastoral care team, nursing supervi-
• Charge the defibrillator and defibrillate. sor, or charge nurse may need to
• Administer medications. contact the family if they weren’t
• Set up equipment for intubation (endotracheal tube, stylet, laryngoscope, suction). present at the time of the arrest and
• Set up continuous waveform capnography. inform them about the change in the
• Assume various roles. patient’s clinical status.
• Coordinate the code.
Postcode debriefing
• Collaborate with other healthcare team members (respiratory therapist, physician,
anesthesia provider, pharmacist, patient care technicians).3,5,6,11
At a convenient time after the code,
staff should gather for a debriefing

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session to discuss the code. Partici- tions. This can be done through self- 4. Loucks L, Leskowski J, Fallis W. Spacelabs
Innovative Project Award winner—2008.
pants should be careful not to criti- study modules or by attending re- Megacode simulation workshop and education
cize each other’s performance but view sessions offered by staff educa- video—a megatonne of care and code blue: live
and interactive. Dynamics. 2010;21(3):22-24.
rather provide an objective review of tors. (See Reviewing mock code skills.)
5. Sinz E, Navarro K, Soderberg ES, eds. Advanced
things that went well and things that Cardiovascular Life Support: Provider Manual. Dallas,
could be improved. Newer staff A successful code TX: American Heart Association; 2011.
members may find their first code Recognizing that you’ll care for pa- 6. Huseman KF. Improving code blue response
through the use of simulation. J Nurses Staff Devel.
distressing, so provide support as tients who experience cardiopulmo- 2012;28(3):120-124.
needed. Areas for improvement are nary arrest, it’s important to know 7. Hazinski H, ed. BLS for Healthcare Providers:
ideal topics for staff education. the expected roles and responsibili- Student Manual. Dallas, TX: American Heart
Association; 2011.
ties during a code blue. Nurses need 8. American Heart Association. Hands-only CPR.
Maintaining knowledge to understand the multifaceted as- 2013. http://www.heart.org/HEARTORG/CPRAnd
ECC/HandsOnlyCPR/Hands-Only-CPR_UCM_
and skills pects of providing care during and 440559_SubHomePage.jsp.
A challenge for nurses is maintaining after a code blue as well as the im- 9. 2010 American Heart Association Guidelines for
resuscitation skills, especially if they portance of maintaining their resus- Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science. Dallas, TX: American
work on a unit where codes rarely citation skills to provide patients Heart Association; 2010.
occur. Participating in mock codes, with a better chance for survival. ■ 10. Institute for Safe Medication Practices.
reviewing crash cart contents, prac- Preventing medication errors during codes. Nurse
REFERENCES Advise-Err. 2011;9(9):1.
ticing setting up equipment, and
1. Institute for Healthcare Improvement. Overview 11. Dorney P. Code blue: chaos or control, an
attending staff development work- of the 100,000 Lives Campaign. http://www.ihi. educational narrative. J Nurses Staff Devel. 2011;
shops related to resuscitation can org/Engage/Initiatives/Completed/5MillionLives 27(5):242-244.
Campaign/Documents/Overview of the 100K
help staff maintain knowledge and Campaign.pdf.
Janet E. Jackson and Amy S. Grugan are assistant
skills. Static or high-fidelity mani- 2. Thomas K, VanOyen Force M, Rasmussen D, professors of nursing at Bradley University in
kins can be used for mock codes to Dodd D, Whildin S. Rapid response team: Peoria, Ill.
challenges, solutions, benefits. Crit Care Nurse.
provide realism. Before participating 2007;27(1):20-27.
The authors and planners have disclosed no potential
in mock codes, nurses should pre- 3. Hill CR, Dickter L, Van Daalen EM. A matter of conflicts of interest, financial or otherwise.
life and death: the implementation of a Mock Code
pare by reviewing CPR skills, facility Blue Program in acute care. Medsurg Nurs. 2010;19
policies, equipment, and medica- (5):300-304. DOI-10.1097/01.NURSE.0000463651.10166.db

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