The Journal of Continuing Education in Nursing

Teaching Tips 

Simulation-Based Learning During COVID-19: A Teaching Strategy for Protected Code Blues

Sarabeth Silver, RN, MN; Nely Amaral, RN, BScN, VAQS; Diana Heng, RN, MN, CNCC(C); William Mundle, RN, MN, CMSN(C)


In light of the COVID-19 pandemic and uncertainties around risk of transmission, urgent hospital resuscitation (also known as “Code Blue”) efforts are needed, pivoting to protect health care workers. This article provides teaching tips for “Protected Code Blues.” [J Contin Educ Nurs. 2020;51(9):399–401.]


In light of the COVID-19 pandemic and uncertainties around risk of transmission, urgent hospital resuscitation (also known as “Code Blue”) efforts are needed, pivoting to protect health care workers. This article provides teaching tips for “Protected Code Blues.” [J Contin Educ Nurs. 2020;51(9):399–401.]

When the World Health Organization announced a global pandemic and national and provincial governments in Canada mandated a stop to elective surgeries, a 32-bed surgical unit in a Toronto, Ontario, hospital quickly responded to become a designated surgical COVID-19 unit for general internal medicine patients. The change in patient population, the uncertainties around COVID-19, and the pandemic prompted changes to the Code Blue response.

The concept of a Protected Code Blue (PCB) first emerged in Ontario during SARS-CoV, the first pandemic of the 21st century (Public Health Ontario, 2020). From the pandemics, a restructured response to cardiac arrests put health care providers' safety before patient outcomes (McIsaac et al., 2020). Initially, at the Mount Sinai Hospital campus of Sinai Health, a PCB was initiated for patients who tested positive for or were confirmed as having COVID-19 (McIsaac et al., 2020). When clear that asymptomatic transmission was occurring in the community, all Code Blues in the hospital were identified as being protected. Moving to a PCB required a shift in clinicians' mentalities and workflow. Prior to COVID-19, Code Blues generated an immediate team response, with up to 15 individuals. In contrast, now during PCB the aim is to limit individuals in the room to those who are necessary (i.e., an experienced anesthesiologist or emergency department physician for intubation, a critical care nurse, and a respiratory therapist to assist) (McIsaac et al., 2020). Figure 1 illustrates a diagram of clinicians involved in a PCB.

Protected Code Blue response personnel inside and outside of patient room.Note. ED = emergency department; ICU = intensive care unit; MD = medical doctor; RRT = registered respiratory therapist; RN = registered nurse; PPE = personal protective equipment. Copyright 2020 by Sinai Health. Reprinted with permission.

Figure 1.

Protected Code Blue response personnel inside and outside of patient room.

Note. ED = emergency department; ICU = intensive care unit; MD = medical doctor; RRT = registered respiratory therapist; RN = registered nurse; PPE = personal protective equipment. Copyright 2020 by Sinai Health. Reprinted with permission.

During these high-adrenaline and emotionally charged situations, staff tend to omit steps due to the rapid cadence with every second counting (Ryzner & Kujath, 2018). As the intention of the PCBs is to protect health care providers, careful attention to donning and doffing of personal protective equipment (PPE) is critical. Proper donning and doffing of PPE and excellent hand hygiene practices are paramount to mitigate the transmission of COVID-19 through direct contact, respiratory droplets, and potential aerosolization (Public Health Ontario, 2020). To facilitate these changes in practice for health care providers during PCB, slower and mindful actions were encouraged. Imperative for staff safety during PCB was the introduction of a PCB monitor/supervisor role.

In the context of Code Blues, simulations provide opportunities for participants to cognitively rehearse, learn new skills and competencies, and build confidence while reducing stress, all without risk to patients or health care providers (Ryzner & Kujath, 2018; Williams et al., 2016). Although literature on simulated Code Blues exists, little is known about simulated PCBs. The purpose of this article is to provide teaching tips and lessons learned using PCB simulation in a designated COVID-19 surgical unit.

Education Through Mock PCBS

Introduction of a PCB was a change in practice for all team members responding to hospital Code Blues, including ward clerks, nurses, respiratory therapists, anesthesia, code team leader, porters (patient transport), security, support services, and unit leadership. To ensure that this rapid change in practice was embraced by clinicians, mock PCBs were organized to simulate the Code Blue response. Following a mock PCB, participants were expected to be able to:

  1. Appropriately respond as the first responder (i.e., apply an aerosol-filtering mask to the patient and start chest compressions).

  2. Designate a monitor/supervisor to identify and track clinicians entering the room, as well as limiting the number of individuals in the room. Ensure staff were safe to enter the room with appropriate donning of PPE and observing for unintentional breeches.

  3. Utilize new communication tools (i.e., baby monitors) and closed-loop communication.

With PCBs, the door must be closed as intubation of COVID-19 patients is an aerosol-generating medical procedure (Public Health Ontario, 2020). The closed door is a barrier to the code team response as a lack of visibility of the resuscitation process can hinder effective communication. To navigate around the closed door, baby monitors were introduced in all units for two-way communication between the code team personnel inside the room and the code team personnel outside the room. Closed-loop communication was emphasized to repeat back and verify exchange of information, as clear communication was difficult when staff wore N95 respirators and face shields.

Implementation Strategy

A total of 14 mock PCBs occurred over the course of 6 weeks in several inpatient medical–surgical units. Arrangement of these simulations required engagement of a variety of hospital personnel, including switchboard and locating services, security, critical care response team, respiratory therapy, anesthesia, support services, patient flow and admitting, risk management and emergency preparedness, and senior leadership from administration, nursing education, and professional practice and quality. To elicit a natural response to a PCB situation, participants in the unit were unaware of the mock code until an overhead announcement was made, with the exception of the first responder being notified 5 minutes prior for cardiopulmonary resuscitation and PCB initiation.

The two mock PCBs in the COVID-19 surgical unit had two different groups of staff nurses, all with similar years of experience. All staff were educated on donning and doffing practices, changes in Code Blue policies and procedures, and the key roles specific individuals play in the event of a PCB. Huddles and communication around PCB occurred regularly in the weeks leading up to the mock PCBs. Informal prebriefs were held for both groups of staff prior to each mock PCB with unit leadership. The immediate steps in a PCB response were reviewed to ensure that all staff were familiar with the changes from usual practices. A more cohesive and thorough response was provided by the group who had a prebrief the day prior, compared with the group who had their prebrief a week prior to the mock PCB.

After the mock PCBs, the Code Team Leader, who was also the Chief Medical Resident, facilitated a team debrief with all participants who were present. The debriefs included more than 20 individuals and were held around the central unit communication station. The debriefs were opportunities to discuss what went well and areas for improvement in a supportive environment (Williams et al., 2016). Immediately after these larger group debriefs, an additional reflective debrief with only the ward nurses encouraged a more meaningful discussion to clarify expectations and processes with their peers and immediate unit leadership. Although many of the staff found the large group debrief helpful and informative, time was limited. Therefore, a need for further discussions was identified (Table 1).

Tips for Coordinating Simulated Protected Code Blues (PCB)

Table 1:

Tips for Coordinating Simulated Protected Code Blues (PCB)


In both simulations, the role of the first responder was an eye-opening experience for all nurses. Prior to this pandemic, once a first responder initiated a Code Blue, several team members arrived at the patient's bedside to assist within seconds. However, with a PCB, the second and all subsequent individuals entering the room needed to be donned in droplet and contact protective equipment, as well as an N95 respirator, before they were able to enter the room and assist, which could take several minutes (Public Health Ontario, 2020). Despite being only a simulation, both first responders expressed discomfort with assuming the role, and while only alone for a few minutes, both described it feeling like an eternity before they received assistance. After these simulations, staff gained a deeper appreciation for the role of the first responder and the importance of escalation of care of any deteriorating patient in advance to prevent these situations.

Another key takeaway was the importance of the monitor/supervisor role. The monitor provides traffic control for those who can enter the patient room and ensures no sequence of PPE donning is omitted or rushed. Not all staff were accustomed to this role during an emergency response. The initial designation of a monitor in both mock PCBs was unclear and delayed during the unit-level response. By bringing the PCB to life through simulation, it allowed for a better understanding of the necessity and value of this role that was further discussed during the debriefing sessions.

Overall, these mock PCBs allowed staff to practice their response to a Code Blue for COVID-19 patients in a safe environment. The experience from SARs-CoV had left many nurses fearful for their own safety when caring for patients during a pandemic, especially amidst the uncertainty with COVID-19. Staff nurse Iliana Kraleva-Rachkova, RN, BScN (Hons), CMSN(c), CON(c), said:

The mock PCB really helped to reduce anxiety; we got to see in real life what to do and learned what to do better.

The importance of staff safety during this unprecedented time is paramount. Staff needed time adjusting to the fact that during a PCB, diligent attention to their safety and providing the best care to the patient were also required. With all the enhancements to practice becoming a new normal, it is essential that staff learn these changes, with an effective and safe method of doing so through simulation.


  • McIsaac, S., Wax, R. S., Long, B., Hicks, C., Vaillancourt, C., Ohle, R. & Atkinson, P. (2020). Just the facts: Protected code blue—cardiopulmonary resuscitation in the emergency department during the coronavirus disease 2019 pandemic. Canadian Journal of Emergency Medicine, 1–4. doi:10.1017/cem.2020.379 [CrossRef]
  • Public Health Ontario. (2020). IPAC recommendations for use of personal protective equipment for care of individuals with suspect or confirmed COVID-19.
  • Ryzner, D. M. & Kujath, A. S. (2018). Low-fidelity code blue simulation on the orthopedic unit. Orthopedic Nursing, 37(4), 230–234 doi:10.1097/NOR.0000000000000475 [CrossRef] PMID:30028424
  • Williams, K. L., Rideout, J., Pritchett-Kelly, S., McDonald, M., Mullins-Richards, P. & Dubrowski, A. (2016). Mock code: A code blue scenario requested by and developed for registered nurses. Cureus, 8(12), e938 doi:10.7759/cureus.938 [CrossRef] PMID:28123919

Tips for Coordinating Simulated Protected Code Blues (PCB)

Engage all key stakeholders in planning and preparing for the PCB

Prebrief a day or two before with the group involved in the mock PCB

Have a hands-on review of new equipment (i.e., baby monitors)

Avoid informing staff of mock simulation timing to elicit a more natural response

Ensure the role of the monitor/supervisor is visible and present during mock

Debrief following simulation, with additional smaller debriefs to reinforce key learnings and promote further discussions


Ms. Silver is Clinical Nurse Specialist, Surgery and Oncology, Ms. Amaral is Director, Nursing Quality and Practice, and Magnet Program Director, Ms. Heng is Nursing Unit Administrator, Surgery and Oncology, and Mr. Mundle is Manager, Quality and Performance, Surgical Services and Urgent and Critical Care, Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada.

The authors have disclosed no conflicts of interest, financial or otherwise.

Address correspondence to Sarabeth Silver, RN, MN, Clinical Nurse Specialist, Surgery and Oncology, Mount Sinai Hospital, Sinai Health, 600 University Avenue, Room 1132, Toronto, ON, Canada M5G 1X5; email:


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