CODE BLUE MANAGEMENT

PURPOSE
 To provide a more efficient and organized way of delivering cardiopulmonary resuscitation through a
coordinated team approach.
 To continuously improve survival of patients requiring cardiopulmonary resuscitation.
SCOPE
 All patients within the hospital, regardless of age, are covered by the Code Blue teams (adult and
pediatric).
 The Code Blue teams respond to and manage life-threatening emergencies while the emergency situation
continues. Examples of life-threatening emergencies include, but are not limited to:
− Cardiopulmonary arrest
− Acute respiratory failure or near-respiratory arrest requiring airway management.
− Sudden loss of consciousness
− Medical deterioration with high-risk of impending cardiopulmonary arrest.
POLICY
I. The Code Blue Team is group of doctors, nurses and other Healthcare Team that conduct Code Blue which
are assigned depending on the proximity to the patient with a life-threatening medical emergency and
time of the day. A monthly bulletin will be released for the list of doctors and daily assignment for the
members of the code team.
(Note: Multiple roles may be subsumed by a higher ranking team member as needed)

A. Adult Code Blue Team Roles

1. Team Captain
− Emergency Department (EMR) Resident on Duty / Senior Resident on Duty
− Cardiologist Attending Physician (with ACLS)
− Trained Nurse
2. Airway Specialist
− ER Resident on Duty
− Trained Nurse
− Trained Respiratory Therapist
3. Chest Compressor
− Nurse / Nurse Assistant / Auxiliary Service
4. IV Access Specialist
− Emergency Room Staff Nurse
5. Circulating Nurse
− (Nurse In-Charge/Senior Nurse in the unit)
6. Medication Nurse
− (Nurse-in-Charge)
7. Emergency Cart Nurse
− (ICU Nurse)
8. Recorder
− (ICU Nurse)
9. Liaison Officer
− (Supervisor/ Officer in Charge)
 B. Pediatric Code Blue Team
1. Team Captain (Chief Resident)
2. Airway Specialist (Chief Resident/Resident on Duty)
3. IV Access Specialist (Resident or IV Therapy Nurse)
4. Chest Compressor (BLS certified/ Nursing Auxiliary/ Trained Instructional Worker)
5. Medications Nurse (Intensive Care Unit Nurse]
6. Emergency Cart Nurse (Emergency Room Staff Nurse)
7. Recorder/ Circulating Nurse (Nurse In-Charge)

II. General Policy Guidelines

1. The performance of CPR is based on the latest international consensus guidelines adopted by the
institution.
2. CPR is performed to resuscitate a patient when reversibility of illness is possible.
3. CPR should only be started and stopped on a physician’s order [The default standing order is to start
CPR procedures unless a previous valid Do Not Resuscitate (DNR) order is present].
4. Performing CPR in the absence of a clinical indication or with no likelihood of success should be
avoided. The CPR team is not obligated to perform CPR when societal and scientific consensus
indicates the futility of the procedure (American Heart Association CPR Guidelines, 2015).
5. When possible, a DNR form should be executed with the patient’s surrogates well ahead of time when
a cardiac arrest is likely.
6. Monitoring/Inventory of each E-carts must only be performed every after code blue management

III. Terminating CPR Efforts

1. If resuscitation is unsuccessful
a. Stopping the resuscitation effort rests with the Team Captain, dependent on his/her knowledge of the
patient, the case, and the type of arrest.
b. Study data suggest certain timeframes when termination of resuscitation efforts may be considered.
− Due to the very poor chance of hospital survival, termination of resuscitation efforts may first be
considered after 15 minutes with no return of spontaneous circulation (ROSC) (Cooper and Evans,
2002).
− Due to the very poor chance of hospital survival, termination of resuscitation efforts may first be
considered after 10 minutes with no ROSC when age >60 and pre-existing pulmonary, renal or
cardiac disease are present (Schultz et al, 1996).
− Patients suffering asystole or pulseless electrical activity (PEA) have only a 10% chance of surviving
hospital stay (Peberdy, 2003).
− In the absence of mitigating circumstances, prolonged resuscitation is unlikely to be successful
(AHA, 2015).
c. Therefore, it is strongly recommended that resuscitation be stopped or not restarted when (all must
apply):
− All identifiable reversible causes for arrest have been addressed
− Quality of ACLS procedures is good, assessed by team leader
− Asystole or PEA persists for more than 45 min
d. A Do Not Attempt Resuscitation order or stop resuscitation order by the Team Captain or the
Attending Physician cannot be countermanded.
 e. Efforts must be ensured by an experienced physician to address family questions and concerns prior to
terminating resuscitation efforts (if Team Captain performs this function, he/she must endorse the
case to next Team Captain).
f. When resuscitation is successful
− Efforts should be directed towards the prevention of recurrence of arrest, stabilization of the
patient for ICU transfer, and initiating procedures to promote neurologically intact survival.
− Therapeutic hypothermia is suggested for all patients undergoing less than a cumulative of 60
minutes of CPR who are unable to follow commands after Return to Spontaneous Circulation
(ROSC). This procedure is recommended for any patient with a Glasgow Coma Scale (GCS motor
score <6 within a few minutes of ROSC (AHA, 2015).
− Surface cooling measures should be started immediately.
IV. Positions
− To be able to carry out the cardiopulmonary resuscitation procedures efficiently, the positions of
team members and location of the code cart and cardiac monitor in all types of room will follow
the layout of Ward Setup.

Procedure
Adult Code Blue
1. A “Code Blue” should be called for any patient who is UNRESPONSIVE and has:
− Absence of effective respirations, and/or
− Absence of pulse
2. A “Code Blue” can also be called when the medical staff attending to the patient believes that a
cardiopulmonary arrest is likely to occur. This includes emergent airway procedures and rapid clinical
deterioration.
3. Upon confirming the absence of effective respirations and/or a pulse, the nurse or resident DIALS the
number designated for Code Blue Team and starts BLS until code team arrives.
4. The Code Blue alarm is raised over the Public Address system, detailing the room (or clinical area) of the
patient, as well as whether it is a Pediatric or an Adult Code. No patient identifiers are used in the alarm.
Note: Staff and operators should “spell out” room numbers (e.g. “one-four-three-two” instead of
“fourteen-thirty-two”) to avoid confusion.
5. All available health care personnel near the site of the code should run to the code and start or assist BLS
until the ACLS team arrives. ACLS team shall respond within 5 minutes.
6. The Code Blue Team shall bring the defibrillator to the code location
7. Once the Code team arrives, the BLS team endorses the patient to the Team Captain. The first ACLS-
capable member of the team that arrives leads the resuscitation effort until the pre-assigned Team Captain
arrives. The (acting or actual) Team Captain assumes medical leadership of resuscitation. He also reviews
work designations and positions of the team members and decides which members of the resident staff
may leave the code.
8. The Team Captain runs the code according to standard resuscitation protocols, monitors resuscitation
quality and assesses patient’s response at least every 2 minutes and after each intervention given.
9. The Code Nurse prepares all medications; the Medication Nurse administers the medicines while the
Recorder Nurse writes down time and dose of medications as they are administered.
10. The ROD or Team Captain reports the case to the Attending Physician, then informs all Referral Attending
Physicians once released by the Team Captain and secures referrals, if applicable.
11. The nursing staff of the unit maintains the patient’s privacy by limiting traffic and by closing curtains or
doors. In clinical areas outside of patient’s rooms, effort is made to transport the patient if safely possible
to a more secure and private location.
12. Upon Return of Spontaneous Circulation (ROSC), vital signs are checked and recorded every 5 minutes or
more often if warranted, and after every intervention as deemed necessary by the Team Captain.
13. After >20 minutes of ROSC, Team Captain provides for post-resuscitation care until patient is transferred
and endorsed to the ICU. If pulselessness returns within this 20 minutes period, the Code clock is not
restarted. The second (or subsequent) arrest will then be considered as part of the previous arrest. If
pulselessness returns after 20 minutes, the patient is considered to have a new cardiac arrest and the
Code clock is restarted.
14. At the end of the resuscitation effort, the Team Captain counter-checks all his/her verbal orders with the
written record on Patient Chart and Cardio Pulmonary Resuscitation Checklist.
15. The Team Captain conducts debriefing session with the team together with Cardio Pulmonary
Resuscitation Checklist
16. After code activation, the Medication Nurse shall endorse the charges to the Nurse In-charge for charging
through GENESIS system.
17. Nurse In-Charge should provide duplicate copy of Cardio Pulmonary Resuscitation Checklist to Central
Supply Room for replacement of Supplies.
18. In the event of unresponsive patient/guest is in OPD MAB the patient should be brought to Emergency
Room by the OPD MAB staff.

Pediatric Code Blue

1. An arrest or near arrest situation is identified by the Resident on Duty or nurse. He/she calls for help.
2. The Code Team is activated by centralized paging.
3. The resident on duty or nurse begins CPR immediately while awaiting the arrival of the Code Team.
4. In the event that a member of the Code Team cannot immediately respond (as he/she is attending to
another critical patient), he/she must right away inform the code location of his whereabouts so that
back-up can be called.
5. Should any of the team members fail to respond within five minutes of code activation, another
message should be sent.
6. Upon arrival, Team Captain of the Code Team immediately briefs the members about the events
surrounding the code and proceeds to update the Attending Physician of his patient’s status. The
Resident on duty / Team Captain facilitates referral to other subspecialties as deemed necessary by the
Attending Physician.
7. The Team Captain assumes command of the code. The other members of the team shall make their
roles known to the Team Captain. They have already been identified and their roles assigned prior to
the start of their duty (for residents) or shift (for nurses). The Team Captain sees to it that the
maximum number of respondents is 7 and keeps extra personnel out of the way. He makes sure that
the highest standard of professionalism is exercised by the team members throughout the entire
duration of the code.
8. At the termination of resuscitation, the Recorder (who documents the code in real time using a
standard form) lets the Team Captain sign the In-Hospital Cardiopulmonary Resuscitation Checklist
after it has been properly accomplished. He/she then provides the Team Captain a copy of the In-
Hospital Cardiopulmonary Resuscitation Reporting Checklist and incorporates the original copy in the
 patient’s chart. The Team Captain’s copy will then be kept at a designated place for records purposes
and for future reference.
9. The Team Captain stays with the patient until transport to the ICU where he will endorse the patient to
the ICU team.
10. The Team Captain debriefs his team and reviews the conduct of resuscitation. The code is evaluated
using a standard form or checklist which shall become part of the team’s records.
11. The emergency cart is replenished and locked at the end of resuscitation. Monitoring and/or inventory
of Emergency cart in every station should be every after use.
12. In the event that immediate family members will request to be present during a code, only two (i.e.,
the parents or legal guardians) shall be allowed to remain in the area while the rest shall be ushered to
a waiting room. A facilitator (who, in this case, may be the Resident on duty or Staff Nurse or Nurse
Supervisor) shall stay with the parents to answer queries and lend moral support.
13. The Supervisor on Duty shall direct the flow of traffic inside the unit during the code.