The Healthcare Providers’ Role during Code Blue
Krizza was busy reviewing the chart of her patient when she hears an announcement on the hospital’s speakers. “Code blue..code blue..” She immediately heads to her Clinical Instructor after assessment to ask about what Code Blue is and what have nurses got to do with it.
In nursing, you will are never too sure of what happens next, one minute you’re having a “chill duty,” the next you are bombarded with tons of admissions. One moment the patient is okay, the next minute he is on cardiac arrest. When times like this happens what do the nurses do? What is the role of nurses when it comes to code blue situations?
Initiating a code blue
Code blue is usually used to specify a patient requiring resuscitation or otherwise in need of immediate medical attention, frequently as a result of a respiratory or cardiac arrest.
In this case, a code blue team responds to the situation by providing initial emergency care and/or CPR when necessary.
A code blue in adults should be called straightaway for any patient who’s unresponsive, apneic, and/or pulseless. Under American Heart Association (AHA) guidelines, calling for help and initiating CPR should be done simultaneously. The protocols for calling a code team differ depending on facility policy; however, all staff should be acquainted with the procedure for calling a code blue in their facility.
- Calling out loudly for help is the initial request for assistance, and locally responding assistants are assigned to formally call the code blue through the facility-wide response system.
- While awaiting members of the hospital-wide code team to arrive, a nurse should initiate CPR and other interventions.
- Members of the code team should identify themselves and their role upon entering the room by using statements such as “I’ll take the airway” or “I’ll document.”
- A staff member at the nurses’ station should contact the patient’s healthcare provider as soon as the code is called.
- The compressor
- The first healthcare provider to respond assumes the role of “compressor” and immediately begins chest compressions at a rate of at least 100 compressions per minute
- Don’t wait for a backboard to be placed to begin compressions; it can be placed when additional personnel arrive who will then switch compressor roles approximately every 2 minutes (or after about 5 cycles of compressions and ventilations at a ratio of 30:2) to prevent decreases in the quality of compressions.
- Make sure the depth of chest compressions is at least 2 inches (5 cm) with complete chest recoil after each compression to allow the heart to fill completely before the next compression.
- Minimize the frequency and duration of interruptions in compressions to maximize the number of compressions delivered per minute. Chest compressions cause air to be ejected from the chest and oxygen to be drawn into the chest due to the elastic recoil of the chest.
- Because ventilation requirements are lower than normal during a cardiac arrest, oxygen supplied by passive delivery should be sufficient for several minutes after the onset of cardiac arrest in a patient with a patent upper airway.
- Airway manager
While the first responder begins compressions, a second responder manages the airway. Using AHA guidelines:
- Give the patient two ventilations for every 30 compressions using the bag-mask device attached to an oxygen source. Most patient rooms have a bag-mask device immediately available, typically located at the head of the bed
- Set the oxygen level on the flow meter at 15 L/min and, if applicable, fully open the reservoir on the bag-mask device to ensure that each breath is delivered with 100% oxygen.
- Bag-mask device ventilation is most effective when performed by two trained and experienced providers. One provider opens the airway and seals the mask to the face while the other squeezes the bag.
- Make sure each compression of the bag causes the chest to rise (a tidal volume of approximately 600 mL delivered over 1 second). An oropharyngeal airway can be placed to help ensure airway patency when delivering ventilations with a bag-mask device.
- During CPR, minimize interruptions in compressions when delivering ventilations.
- Although ventilation with a bag-mask device is acceptable during CPR, be prepared to assist a qualified anesthesia provider with endotracheal intubation because there are times when ventilation with a bag-mask device is inadequate
- Defibrillator manager
Rapid defibrillation for “shockable rhythms,” which are pulseless ventricular tachycardia and ventricular fibrillation, is life-threatening, and the ability to recognize a shockable rhythm is a required skill. Vascular access, drug delivery, and advanced airway placement shouldn’t cause interruptions in chest compressions or delay defibrillation.5
- Placement of hands-free defibrillation pads versus traditional handheld defibrillation paddles is recommended as a safer option and allows for more rapid defibrillation. The patient should be connected to a 3- or 5-lead cardiac monitor; if the hands-free pads have monitoring capabilities, they can be used to monitor the cardiac rhythm. Often both methods of cardiac monitoring are used during a code.
- Nurses should be trained in dysrhythmia recognition and ACLS or have an expert on the clinical unit immediately available to help them identify dysrhythmias. If no expert is immediately available, consider using the automated external defibrillator (AED) function on the defibrillator, if available, to ensure early defibrillation when indicated before the code team arrives.
- Because defibrillators are manufactured as either monophasic or biphasic, the nurse must know which type of defibrillator is on the unit. A monophasic defibrillator is generally set to deliver 360 joules for defibrillation, and a biphasic defibrillator is initially set to deliver between 120 and 200 joules, depending on the manufacturer’s recommendations.
- Once a shockable rhythm is identified, the defibrillator manager sets the energy level on the defibrillator, as directed by the team leader, using “closed loop” communication to ensure understanding of the order before defibrillation. Using this technique, the team leader gives the order, such as “defibrillate with 200 joules,” the defibrillator manager repeats, “Charging to 200 joules.” The defibrillator manager then announces the delivery of 200 joules after the shock is delivered.
- As soon as the shock is delivered, resume chest compressions immediately; don’t delay resumption of chest compressions to recheck the rhythm or pulse. Even resumption of a normal heart rhythm won’t initially produce enough cardiac output for adequate perfusion, so CPR should continue.
- After about 5 cycles of CPR (about 2 minutes), ending with compressions, the cardiac rhythm should be checked during the change of compressor roles. If an organized electrical rhythm is present, check for return of spontaneous circulation (ROSC) by checking the carotid pulse.
- Crash cart manager
The crash cart manager should be located on the same side as the patient’s venous access and have room to open the crash cart drawers for easy access to the contents.
ACLS guidelines support early administration of vasopressors in cardiac arrest, but medications are secondary to high-quality CPR and rapid defibrillation, when indicated.
- Use caution when administration of medications during a code blue; miscommunication is a common problem leading to administration of incorrect medications or doses during codes.
- It’s also helpful if crash carts are stocked consistently across the facility.
- Code Team Leader
The code team leader guides resuscitation efforts, communicates with all team members, and monitors the patient’s cardiac rhythm. He/she needs to be in a position to successfully observe all aspects of the resuscitation efforts. This role may be taken by a physician or an advanced care provider.
- The recorder
The recorder documents the entire resuscitation process. Documentation during a code blue differs from facility to facility as well as different electronic health record systems have specific methods for code documentation.
- During the code, the recorder reminds the code team leader every 2 minutes when it’s time for a compressor role switch and the time, name, and dose of the last medication administered.
- It’s also important for the recorder to document the cardiac rhythm before a shock is delivered and that compressions were immediately resumed after the shock.
- The recorder also notes that 100% oxygen is being delivered and that the patient has good rise and fall of the chest with ventilations.
- Assessment findings such as end-tidal CO2 values should be recorded.
- Print cardiac rhythm strips or the code summary from the monitor/defibrillator for the patient’s medical record.
- Clearly identify all documentation with the patient’s name, date of birth, medical record number, and date and time.
- Note the time that resuscitation efforts were discontinued, patient disposition, and time of death if applicable.