Blog Post Beyond Stopwatches – The Importance of Timing in Code Blue Care

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.