29 March 2018

Code blue system in hospitals

Code blue is perhaps the most popular codes used in hospital for managing emergency situation. Code blue is a code given to identify and communicate that a medical emergency, of the nature of cardiac arrest, has occurred and the patient needs to be attended immediately for life saving measures. (Other codes - Code Pink, Code Red). Since it deals with the life threatening situation, swift and coordinated action by a team of professionals is of paramount importance. This calls for designing and implementing a highly efficient system, which can work in round the clock and can cover entire hospital. This posts elaborate on all considerations that should be made while designing a code blue system. Also check code blue form and crash cart checklist along-with this post.

1.       Forming of a code blue team: The code blue team is at the core of entire system. This is a team of trained professionals who can competently provide life saving measures to a patient under medical emergency. Following are the roles required within the team with a suggested person who could be given that role. Hospitals can however, modify this as per their staffing structure and hospital’s layout
Who can perform
Calling (activating) the code
This can be any one who identifies the situation and activates the code blue. As it could be any healthcare staff they are not a part of code blue team
Initial action before the code blue team reaches on the spot – This includes bringing patient’s medical record, bring the crash cart trolley, positioning the patient and start with CPR
This can be done by the caller of the code along with other secondary nurse available in the area. (In a hospital all nurses and healthcare staff should be trained on basic life support and CPR)
Airway management, bag mask ventilation, suctioning of the airway and assistance to anaesthesia in case of intubation
A doctor, preferably from ICU or anaesthesia department
Application of defibrillator pads, ensuring proper position of the patient
Nurse 1 (preferably from critical care department). This person can also be given role of recording the events for future analysis.
Continuation of CPR measures, use of defibrillator, conducting anaesthesia or intubation if required.
A doctor, preferably from anaesthesia department
Preparation and handing over medication from the cart
Nurse 2
Putting in IV and administering medication received from crash cart
Nurse 3
Leading the team, taking quick decisions, manage situation and help with defibrillator, anaesthesia and intubation part
Team leader – generally a physician from critical care or emergency department

*  The team members should be identified and they should be communicated about their roles during code blue.
*  The team should consist of at-least 5 members to effectively handle critical functions
*  At-least one member in the team should be certified in ACLS. All members in team should be trained in BLS.

2.       Number of code blue teams – Since the code blue team is required round the clock, the number of teams should be at-least 3 to cater for in each shift. In case of large hospitals, multiple teams can be formed with their specified coverage area

3.       Communication of code – One essential objective of code blue system is to ensure that every code blue team member should immediately get to know about the occurrence of the medical emergency. There are several ways in which this could be done

a.       Calling number and announcement: In this there is a dedicated internal telephone number (like 1111 or 99) which is used only for informing code blue. The number when dialled rings at telephone operator (or a dedicated place with round the clock presence of a person who will receive the call). The instrument that receives the call from dedicated number is exclusive and will never be busy with any other line. A standard statement is used for communicating code blue, such as ‘Code blue – ward no. 22’. The receiver of the call (the telephone operator) also has a public announcement system. As soon as he receives a code blue call, he announces the same in public announcement system and all code blue team members, wherever they are working, get to know about the code. As soon as they here the announcement they immediately move towards the location and perform their role. One objective of code blue system is to ensure that code blue team reach the point of event quickly (within 1 minute) of .

b.       Pager system: In this all code blue team members on duty carries a pager. There is a dedicated telephone number as explained above. Instead of making a public announcement the receiver of code blue call just page it to all team members at one go. The pager beeps indicating to holder that a code has been called
c.       Push button switch: In this, a code blue switch is installed in each patient area. The switch when pressed sends an indication to all code blue team member about the location where the emergency has occurred

4.       Crash cart – Crash cart is a trolley that consist of all necessary medicines, equipment and instruments that may be required for carrying out BLS and ACLS measures. Clickhere to get the list of items in crash cart and other requirements related toits management

5.       Trainings – There are two types of training that is required. One for the code blue team members and one for all healthcare staff in the hospitals

a.       For code blue team – The code blue team should be trained on following
                                                                                       i.      Orientation to code blue system
                                                                                     ii.      The communication system under code blue
                                                                                   iii.      Crash cart and its usage
                                                                                   iv.      Basic life support techniques, including CPR
                                                                                     v.      At-least one member to be trained and certified in Advanced Life Support technique
b.       For all other staff
                                                                                       i.      Orientation to code blue system
                                                                                     ii.      When and how to activate code blue
                                                                                   iii.      Basic Life support including CPR
                                                                                   iv.      Familiarization with crash cart

6.       Mock drill: Since code blue requires a highly coordinated activity mock drill of code blue should be done regularly to ensure that the system is functioning. For mock drill, a nurse assume that a patient has collapsed and activates code blue. An observer is placed to observe and record everything that happens on activation on code. The observations are then reviewed to identify if every thing happened as planned or whether there was deviation. Based on mock drill findings, necessary training are provided

7.       Documentation of code blue event It is important to document critical actions and happenings during the code blue event. These records are used for multiple purpose, including doing a post-event analysis. One of the team member take the role of the recorder. A standard form that captures necessary data should be used for documenting each code blue event.

8.       Post event analysis: A post event analysis should be done for each code blue event to assess if everything required was done and if there were any major or minor deviations from the code blue protocol

9.       Quality indicators: Few indicators that can be used for evaluating whether or not the code blue system is working efficiently and effectively, are given below

a.       Average time to respond – The time from activation of code blue till the time when the 1st member of code blue team reach on spot
b.      Outcome percentage – Percentage of patients’ survived out of total who went under cardiac arrest
c.       Non- compliance rate – Percentage of non-compliance to standard process of code blue system
d.      Failure to activate – Percentage of times when code blue was not activated, when required