The Difficulty of Improving Code Blue Performance

The Difficulty of Improving Code Blue Performance
Written by Sarah Bryant with excerpt from Dr. Brian Ross

The Reality of Code Blue

Any healthcare professional is undoubtedly familiar with the chaos that ensues when a patient enters cardiac arrest. A clean, methodical approach and accurate documentation are essential to creating the best chance of resuscitation, but training for these “code blue” situations can be extraordinarily difficult.

The staff members involved in a code blue event have three key responsibilities: drugs, defibrillator, and documentation.

Unfortunately, code blue situations are sudden and unanticipated. In many environments, the code blue team is composed of members who have not worked together previously. The team is not always experienced with codes, and some equipment may not be present or function efficiently. Often, records are taken on paper, and simple mistakes can be difficult to avoid. Medication might be ordered but never administered. An essential dose could be ill-timed or missed. Occasionally, an entire paper record might be misplaced.

This excerpt written by Dr. Ross, the Chief Medical Officer at Format Health, illustrates a classic code blue situation:

“Imagine, if you can, 35 years of being called STAT, any time of the day or night, to the bedside of patient who is 3 minutes into a cardiac arrest. The patient’s family is standing in the hallway crying – holding on to each other.  You know very little about the patient. The one solace you take in the moment is that the patient is an adult and not a pediatric patient. Pediatric patients take the emotion and tension to a whole other level.

The people who have responded with you look familiar, some you know well, others you have never met. You know that over the next 15-30 minutes the decisions both you and your team make, and the care you deliver, will make the difference between the patient living or dying. You know that the care you provide will be judged by published guidelines and best practice.

You ask yourself –

  •  can you remember those guidelines and the critical steps required in this patient’s care during the confusion and cacophony of noises of a code blue response,
  •  will you be able to keep track of everything you do: where you are in the list of things that need to be done, the orders that you have given, the orders that have been completed and those that are still pending, and
  •  will the record of this patient’s care be immediately available to you if you need to follow the patient into a critical care unit or need to transition the patient’s care to a handoff intensive care team.

The team forms up to begin the code blue response and a team member steps to your side and announces they will be the ‘recorder.’ You look, and the person has a pen in hand and piece of paper attached to a clip board.  The pace is fast, the environment, at least to the unschooled, looks chaotic at best. You say to yourself, “Well here we go again.” Then to the team, “OK team, let’s get started.”

Things move quickly.  You are struck several times during the code by hearing the team ask questions like –

  •  “Have we given the epinephrine yet?”
  •  “Is it time to ‘shock’ the patient?”
  •  “Did we remember to check CO2 after placing the endotracheal tube?”
  •  “Should we change out the person giving chest compressions?”
  •  “How long ago did we give that epinephrine?”
  •  “Have we thought of the reason this may have happened – the 6H’s and 6T’s?”

With each question the recorder looks at the sheet on the clipboard and does their best to answer the questions. Time and time again, the recorder would express frustration over their ability to keep up with the pace of the code blue as well as track all the critical management decisions that were made.  The recorder would often leave the code blue hoping they would never be asked to be the recorder again.

The code blue ends with the patient having return of circulation and now you have to put the story together to hand off the patient’s care to the intensive care unit team.”

Potential Solutions

Fortunately, there are some steps that can be taken to better prepare for code blue events. An article from American Nurse Today outlines efforts by Oregon Health & Science University (OHSU) to improve their code blue training through regular simulations.

OHSU recognized the need for teams to train together and become interdisciplinary in their efforts. Their team was given regular, mock codes and then evaluated on their response to each resuscitation scenario. By evaluating team response, the OHSU was able to steadily improve its training, documentation methods, code-cart content organization, and identify the need for additional training equipment.

This article provided by the Marshfield Clinic, courtesy of the National Center for Biotechnology Information, documents an attempt to completely restructure a code blue team system in order to create a more effective team approach. Methods included a long education period, mock codes, and improved data collection methods. The conclusion of the study suggested that team performance improved with better organization, clearly identified roles, and frequent practice.

Of course, targeted and continuous training for code blue staff is ideal. However, every code blue situation is high-stress and time sensitive. In order to adequately train for a code blue event, simulations are an undisputed necessity. Realistically, many facilities are unable to provide the resources and time required to create effective training simulations.

Format Health’s pioneer product Event Doc: Code Blue offers better code blue performance in the form of an intuitive, digital interface that records and guides code blue documentation. In-system checks search for common mistakes and offer reminders at timed intervals for each dose of epinephrine and additional compressions. Issues with illegible handwriting are eliminated, and the documentation of each code blue event can be immediately delivered to intensive care unit.

The Conclusion

Restructuring, training, and software changes are all viable options for improving code blue response. Each effort to improve code blue performance can assure better data collection, reduce liability risk, and improve overall care quality. Furthermore, code blue improvements can greatly reduce the stress level of all staff members involved in each event.

The measures taken are often a question of what time and resources can be provided. Often, creating concrete roles for each team member, code familiarity, and accurate documentation are key components. If approached carefully, each of these can be relatively low-cost options that can have major impacts on code blue performance.