A newly graduated RN, Janey, finds a patient unresponsive, without a pulse, and apneic. Does she know how to respond? Janey calls for help. An overhead page announces “Code Blue,” a code that is commonly used to initiate an emergency team response to a cardiopulmonary arrest. It is time now for Janey to start cardiac compressions and provide breaths until the code team arrives.
In the United States, Basic Life Support (BLS) or cardiopulmonary arrest training, is required for in-hospital direct care providers, including nurses, respiratory therapists, physiotherapists, occupational and speech therapists, patient care assistants, and case managers, and should have prepared Janey to respond in a timely and appropriate manner. The problem is BLS training alone does not guarantee competence. It has been well-documented that cardiopulmonary resuscitation (CPR) skills deteriorate over time, and repetition is needed to ensure ongoing competency (American Heart Association [AHA], 2015). Although a Code Blue response involves more than basic CPR, immediate high-quality CPR and rapid defibrillation is essential to survival (AHA, 2015). The challenge for professional development educators is to develop local Code Blue training that addresses ongoing and team-based competency in both BLS and Advanced Cardiac Life Support (ACLS). This column describes a team-based teaching plan for BLS-focused Code Blue training and offers recommendations for subsequent ACLS-focused training.
BLS-focused Code Blue training involves all team members and is initiated as a part of hospital orientation and repeated at regular intervals. This training begins with a review of CPR, code roles, rhythm identification, automated external defibrillator (AED) use, and crash cart use. The training culminates with a scenario that begins with Code Blue activation and initiation of CPR, and ends with the use of the AED or hands-free defibrillation via the crash cart monitor. Overall program goals are to actively engage staff using technology that 1) will allow feedback on skills performance and 2) will simulate a Code Blue scenario in a hospital setting.
This 60-minute interprofessional exercise is offered to 10 to 12 participants during hospital orientation or as part of a skills day, followed by on-unit 15-minute BLS-focused code scenarios. Simulation objectives are that participants will be able to:
Demonstrate use of a 5-minute technique to learn the contents of a crash cart.
Demonstrate how to set up and safely use an AED.
Demonstrate cardiac compressions of sufficient depth and rate that allow chest recoil.
Demonstrate appropriate use of a bag-valve mask or manual resuscitator.
Identify the various roles required to efficiently run a Code Blue.
Demonstrate application of various code roles when presented with a code scenario (Figure 1).
Code role positions are listed in priority order. The Code Leader is initially an RN who coordinates the cardiopulmonary resuscitation response. After arrival of the Provider, leadership transfers, and this RN monitors the crash cart and use of the defibrillator/monitor. The Primary Nurse is one of the code team members. The additional helper is directed by the Code Leader. Staff who are not required for the code return to the nursing unit.
Identify three heart rhythms that require activation of the Code Blue system.
Many aspects of the Code Blue response are the responsibility of nurses or respiratory staff (defibrillation, rhythm recognition, and crash cart use), yet all team members are included. The focus of this training activity is on a rapid first response, and every team member needs to know what such a response should look like.
The AHA (2015) requires use of feedback devices in BLS training. This simulation uses the Quality CPR (QCPR) learner app. This free app allows live monitoring and summative feedback on compression rate, depth, full release, and ventilation volume when used with QCPR capable mannequins (Laerdal Medical, 2019). For this simulation, only compression rate, depth, and full release are monitored. Presimulation preparation includes learners downloading the QCPR learner app on their smartphone.
Table 1 outlines the teaching plan for the Hospital Orientation Training. Stations are set up in the classroom, and a room on a nursing unit is used for the final scenario practice to add to the realism. All participants receive a code role handout and code role position diagram (Figure 1).
Teaching Plan for Hospital Orientation Code Blue Team-Based Simulation
After reviewing the objectives, a rhythm simulator is used to practice lethal rhythm identification. The educator demonstrates QCPR app use, as well as one- and two-person bag-valve mask ventilation followed by participants' return demonstration. Participants are instructed to complete 2 minutes of uninterrupted CPR using the QCPR app to allow them to experience the effort required for effective CPR. Crash cart review and AED/hands-free defibrillation demonstration and practice follow. The Code Blue role discussion is augmented by a diagram of suggested code role positions (Figure 1). The final step is a team response to a Code Blue scenario using a lifelike full-body CPR capable manikin that ends when the AED is successfully deployed. The scenario is repeated to allow everyone to participate.
A Code Leader is assigned. The individual who finds the patient unresponsive and pulseless activates the Code Blue response and begins compressions. Participants choose an appropriate role on arrival. The Code Leader ensures that all roles are in process and reassigns roles as needed. A designated observer monitors for AHA (2017) compliance: time to CPR initiation (60 seconds) and to defibrillation (120 seconds). Debriefing occurs at the end of each scenario using the Plus-Delta model, emphasizing what went well and what was missed, and reviewing time target achievement for CPR and defibrillation.
Repetition is needed to make basic responses (assess, call for help, head down, remove pillow, start CPR, place backboard, and apply AED) automatic to improve response time. The initial 60-minute training should be augmented with random BLS-focused Code Blue 15-minute scenarios on a set schedule coordinated by the nurse educator and administrative unit staff. It is important to include a few minutes for debriefing. Reflection on the experience will enhance knowledge retention (INACSL, 2016).
Outcomes, Challenges, and Future Directions
For participants during hospital orientation, outcomes depend in part on their experience levels. Are they an intensive care unit nurse, a new graduate, a medical-surgical nurse, or a patient care assistant with 20 years of experience? What kind of experience have they had with a Code Blue? Despite these variations, observations as a nurse educator in a long-term acute care facility, and as faculty involved in simulation with undergraduate nursing students, have demonstrated a high engagement in all components. In the interprofessional simulation, participants gain an appreciation of the roles played by each other during a Code Blue and have an opportunity to practice collaboration. By the end of the simulation and debriefing, code responses are more automatic, team responses are smoother, and CPR and defibrillation targets are met.
Use of the QCPR app reinforces the effort needed for effective CPR and fosters a new appreciation of the BLS requirement to change compressors every 2 minutes. Anecdotal observations and participant comments suggest an increased comfort with interprofessional initiation of the Code Blue event. Based on observed weaknesses, subsequent training should emphasize early deployment of the CPR backboard, following AED prompts for application, and increased practice with hands-free defibrillation. Potential measures of long-term team training success are achievement of targets for CPR and defibrillation during actual Code Blues and initiation of effective CPR by patient care assistants as first responders.
High-quality effective CPR and early defibrillation is a high priority. Adequate performance during orientation BLS-focused Code Blue training and in subsequent random scenarios serves as the foundation for advancement to ACLS-focused Code Blue training. This training features scenarios derived from ACLS algorithms and includes intravenous medication administration, code documentation, RN-physician report, advanced rhythm analysis, and debriefing regarding Code Blue effectiveness.
A Code Blue is a sporadic, emergent life-threatening event that requires a rapid coordinated team response. Ongoing training is needed for direct care providers in hospitals to produce and maintain competency given the event's high risk and unpredictable occurrence. The first few minutes of cardiopulmonary arrest are critical in determining patient outcomes (AHA, 2015). Professional development educators must develop local Code Blue training that addresses BLS competency as wells as ACLS skills. This column featured a plan for 60-minute BLS-focused Code Blue team-based training during hospital orientation/skills day and subsequent 15-minute unit-based BLS-focused scenarios. BLS-focused Code Blue training implemented with interdisciplinary team members targets improving Code Blue response time and CPR quality. All staff need to be prepared to meet the challenge of a Code Blue event.
Teaching Plan for Hospital Orientation Code Blue Team-Based Simulation
|Content||Time (Minutes)||Equipment||Training Notes|
|Introduction||5||• Tablet rhythm simulator||• Lethal rhythm review|
| • Objective review|
| • Rhythm review|
|Station I CPR||15||• 3 QCPR capable manikins||• Compressions – 3 pairs|
| • Compressions with QCPR app||• Bagging – 3 pairs|
| • Bag-valve mask||• 3 manikins and 3 bag-valve masks||• When complete rotate|
| One person|
| Two persons|
|Station 2 crash cart/AED||15|
| • Cart review||• Cart review: categorize by drawer, e.g., 1) IV push drugs, 2) Respiratory, 3) IV supplies, 4) IV drips, 5) Procedure trays|
| • AED/hands-free defibrillation demonstration and practice||• AED simulator, programed to shock x 1||• Cart practice: e.g., epinephrine in what drawer?|
|• 1 manikin|
|Station 3 code roles||10||Code role handout||Didactic|
| • See Figure 1|
|Station 4 code scenario||15||• Life size, CPR capable manikin||• Patient post-MI|
| • Split into 2 groups of 5 to 6||• Hospital bed||• Primary nurse in the room; monitor alarms-VT|
| • One group does scenario, other group observes/monitors||• Tablet rhythm simulator showing VT||• Check response-none, 0 pulse, apneic|
| • Debriefing:||• Observer:||• Call Code Blue, CPR, shock x 1,|
| What went well|| Time to CPR||then stop|
| What was missed|| Time to defibrillation|
| • Switch groups and repeat|