1. Code Blue, Code Blue!!!! What’s a nurse to do?
Unit V
How many of you have seen a Code Blue yet? Did any of you participate in the code?
What do you do first in a Code Blue situation?
Stay calm. Take a deep breathe and let your nursing skills take over. To an outsider, codes make look chaotic and disorganized.
But to the educated eye, a code blue progresses through and orderly series of events, and each team member has their distinct role.
Most hospitals require their nurses to be ACLS certified – special training through AHA

2. Objectives
Discuss cardiac emergency to include the use of the crash cart and the importance of BLS
Identify Rapid Response Team and Code Blue Team

3. Patient Emergency
50 % patients who code exhibit warning signs up to 6 hrs prior to arrest
RRT consists of ICU nurse, RT, sometimes MD, and bedside nurse
RRT at bedside within minutes to assess patient
When do you call for a code? –
Studies have shown almost ½ of all patients who code show warning signs up to 6 hrs prior to coding: HR <45 or >125, RR <10 or > 30, CP, AMS
Well lets look first at some warning signs:
This is why your assessment skills are so necessary when evaluating what’s going on with your patient.
Most hospitals have a Rapid Response Team. The goal = get the patient the help he needs in order to prevent a code blue.
A rapid response team aims to recognize warning signs sooner and prevent patients from arresting.
Rapid-response teams enable nurses, other patient-care staff patients, or their visitor to notify a team of experts who will respond to a patient whose condition appears to be worsening. The signs of decline can be as subtle as a nurse sensing that a patient just doesn’t ‘‘look right.’’ TJC mandates patient access
RRT = ICU nurse, RT, sometimes MD, bedside nurse – respond within few minutes

4. Criteria for calling RRT
Change in heart rate (<40 or >130)
Change in Systolic BP (<90 or >200)
Change in resp. rate (<8 or >24) or threatened airway or change in SaO2
Change in mental status
New, repeated, or prolonged seizures
UO <50mL/4 hours
Failure to respond to treatment to an acute problem/symptom
Nurse, patient, or family member is concerned
Changes can be acute or gradual!
Recognizing vital signs trends and changes is CRUCIAL! , AMS, UO
It takes a more perceptive nurse to anticipate and prevent a code, than to run a code well.
The criteria for calling RRT facility specific can be any of the following:
Change in heart rate (<40 or >130)
Change in SBP (<90 or >200)
20% change in HR or rhythm change
Change in resp. rate (<8 or >24) or threatened airway
Change in SaO2 (< 90), or failure to respond to treatment
Significant bleed
Change in mental status – (new onset confusion, slurred speech)
New, repeated, or prolonged seizures
Failure to respond to treatment to an acute problem/symptom
Staff member concerned or worried about patient

5. What to Do I Do If I Think My Patient is in trouble?
Tell nurse responsible for patient’s care (also clinical instructor) immediately of changes in patient’s condition
Rapid Response Team (RRT) team – can be called as soon as the nurse identifies changes in the patient’s condition
Reassess the patient frequently

6. Calling Code Blue Determine unresponsiveness Call out for help
Push Code Blue button at the head of bed or
Pick up the phone and dial______
Identify the emergency – Code Blue
Identify the location and the room #
Note time using the clock in patient’s room
If you are the one to find the patient, your first responsibility is to assess LOC to determine unresponsiveness.
Call out loudly, “I need help in room 202”, as soon as you have established unresponsiveness.
When someone answers tell them to call a code or push the Code blue button. Make sure you know what the number is at your hospital for a code blue. At Mercy the number is 7777 for all emergencies.
Make sure you note the time using the clock in the patient’s room.
Remember that the patient’s primary nurse must remain in the room with the patient until the end of the code.

7. Prior to the Code Team Arriving
Start CPR
Circulation
Airway
Breathing
Defibrillation (AED only)
Obtain the Crash Cart/AED
Remove extra furniture from the room
Unit Secretary will:
Page Chaplain for Family support
Call attending MD
Chart to Room
After establishing unresponsiveness:
Start chest compressions per new BLS guide lines.
Then what? Place your finger on the carotid artery and check for a pulse. And look if chest rises
Second responder will bring in emergency equipment to be brought to the room. Where do we find the emergency equipment? On the crash cart.
The second responder then begins two person CPR with the first responder. The code blue team should arrive within 2-3 minutes of calling the code or sooner.
If the coding patient is in a room with another patient move that patient to another room. The code team will need the chart so it must be with the patient.

8. Once the code team arrives
Do not stop CPR when the first team member arrives
Continue until someone is ready to take over
Once the code blue team arrives advanced cardiac life support protocols are initiated. Each team member has a specific job.
Go to next slide

9. Code Team & Their Roles
Hospitalist or ER doctor– team leader – intubation, gives orders
Critical Care Nurse – gives meds
Supervisor / Staff nurse – documents
Respiratory therapist – assists respirations, may intubate as well
Lab – ABG, BMP, CBC
NA –CPR, brings crash cart and chart, help with other patients
Chaplain - assist with taking family to quiet location
Student – CPR, observation
Members of the code team: ED MD or other responding MD, ICU nurse, unit supervisor, staff nurse, RT, Lab, CNA, chaplain, security
Team Leader: Usually a physician directs and coordinates the resuscitation efforts, but an ACLS certified nurse can run a code until the physician arrives. The team leader usually stands at the foot or head of the bed. She needs a clear view of the patient to make sure that procedures and assessments are performed rapidly and accurately.
Defibrillator Operator: A physician or ACLS nurse actually delivers the shock. Most victims of cardiac arrest die of lethal arrhythmias. Rapid defibrillation is the key to survival.
AEDs in hospitals.
Intubationist: This is usually a physician or respiratory therapist. Assist with setting up of equipment and having suction available.
Medication Nurse: Establishes and maintain IV lines, calculate drug dosages, prepare and administer drugs and fluids.
Staff nurse: give info to MD (next slide), documentation
Lab, CNA, chaplain, student

10. What the Code Team Needs to Know
Current Diagnosis / Recent Treatments or Procedures
Events Leading Up to Code
Recent Meds
Primary MD
Code Status
Other Pertinent History: Allergies, MRSA Status, Diabetic, Cardiac, respiratory history, etc.
Current Diagnosis / Recent Treatments or Procedures
Events Leading Up to Code
Recent Meds
Primary MD
Code Status
Other Pertinent History: Allergies, MRSA Status, Diabetic, Cardiac, respiratory history, etc.

11. Post – Code Responsibilities
Patient’s nurse gives report to
receiving nurse
Family Care
Code Summary printed
EKG Strips charted
Completed Code Sheet signed by physician in charge of the code
Code Evaluation completed and sent to Risk Management
Cart Exchange
Documentation
The final phase of the code blue is the winding down phase. Efforts are now aimed at maintaining the victim in stable condition until he can be transported to a critical care bed, or deciding to terminate the code. If patient is being transferred then the patient’s primary nurse gives report to the receiving nurse. Primary nurse should accompany her patient to the ICU.

12. Documentation Patient assessment ECG rhythm (strip)
Notification of MD, orders received
Treatments initiated & patient response, post treatment rhythm (strip)
If transferred, mode of transport, transfer note, receiving unit bed number, receiving nurse
All of this will need to be documented in the patient’s record.

13. The Crash Cart Example Top O2 tank, portable suction, ambu bag
Defibrillator
Intubation equipment
Possibly meds
O2 tank, portable suction, ambu bag
Front drawers and
Side drawers
Meds
IV equipment + fluids
Resp supplies
Trays
Misc (gloves, sutures, flashlight, batteries)
Example
As soon as the crash cart arrives place the CPR board under the patient (need to break lock to open cart). On the top of the crash cart is the defibrillator, defibrillator pads, electrodes, possibly meds and respiratory drawer. Some hospitals keep the respiratory equipment in what looks like a tackle box.
The front drawers contain meds, IV equipment, fluids and trays (i.e. central line), resp supplies like non-rebreather mask, suctioning equip).

14. Emergency Medications
Oxygen
Epinephrine
Amiodarone
Atropine
Adenosine (Adenocard)
Diltiazem
Digoxin
Lidocaine
Magnesium Sulfate
Dobutamine
Dopamine
Narcan
Remind students that they will NOT be giving medications in a code situation, however, they are responsible for knowing in what situations that these medications will be used and what the expected outcomes and side effects are of the medications.
The top drugs used in a code are epinephrine, amiodarone, and atropine.

15. Do Not Resuscitate Full code or No Code Documentation on chart of
MD order
MD discussion with patient / family
Chart labeled
MAR labeled
What if family changes their mind??
What about Directed Code Status? Patient may not want CPR or intubation but does want arrhythmias treated.

16. Student’s Role in a Code
Assessment / reassessment
Notify nurse immediately of changes in the patient’s status
Perform CPR
Observe during the Code
Help with patient’s family