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Surviving Your First Code

Anderson, Amanda MPA, MSN, RN

AJN The American Journal of Nursing: July 2019 - Volume 119 - Issue 7 - p 56–61
doi: 10.1097/01.NAJ.0000569456.04788.17
Transition to Practice

This column is designed to help new nurses in their first year at the bedside—a time of insecurity, growth, and constant challenges—and to offer advice as they learn what it means to be a nurse. This article prepares new nurses for their first code, describes what happens during a code, and reviews the responsibilities of the resuscitation team.

This article prepares new nurses for their first code, describes what happens during a code, and reviews the responsibilities of the resuscitation team.

Amanda Anderson works in administration for the Mount Sinai Health System in New York City. She is also on the editorial board and a contributing editor of AJN. Contact author: The author has disclosed no potential conflicts of interest, financial or otherwise.



Something was wrong with my patient. When I saw him that morning, he'd been calm, almost too quiet. A few hours later, he was struggling with the ventilator and pulling on the tubing, heart rate and blood pressure sky-high. His vitals returned to baseline within five minutes, then dipped below his 12-hour trend in 10. I was worried but didn't know exactly why.

A few minutes later, as morning rounds began, I told the attending my concerns. She looked at my patient's vitals and said, “Normotensive—nothing to complain about here.” But moments later, I watched as my patient's heart rate continued to drop by 10s, until he was asystolic, and we were calling a code. My first.

Resuscitation is an event many novice nurses feel ill prepared for. In their qualitative study on medical–surgical nurses’ experiences as first responders during such events, Hart and colleagues found consistent themes of inexperience-based fear.1 One nurse admitted, “As a new nurse, having a deteriorating patient can be scary. I had confidence that I knew who to notify but beyond that I was looking for cues… to help me navigate the next steps.”

Although learning the complex skills of advanced cardiac life support (ACLS) may feel overwhelming to a new graduate who is already overloaded with new information and experiences, there are still ways novice nurses can prepare for these emergencies. This article will prepare new nurses for their first code, review what happens during a code, and introduce the typical roles on a resuscitation team.

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Follow your gut. Many nurses have gut feelings or premonitions of doom when anticipating their first code. Patricia Benner's seminal book, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, is full of narratives from experienced nurses who had “a feeling” something wasn't right with their patient, and then followed their gut and averted disaster.2 Whether you're a nursing veteran or new to the profession, you're certain to experience this phenomenon—acknowledge and explore it.

Review data and trends. While not every gut feeling materializes, it's important to take the time to think each one through. Does your patient look different? Have her vital signs changed? His speech? Look closely at details you noted during earlier assessments, paying attention to signs of circulatory changes, like skin mottling; to neurological differences, like subtle confusion; or to respiratory needs that increase ever so slightly. Signs your patient is becoming more dependent on medication, oxygen, or fluid may be indicative of something more ominous, like a myocardial infarction or sepsis.

Prepare for the worst. Although some emergencies take us by surprise, you'll find that by preparing for worst-case scenarios, you'll be more likely to prevent them. For example, never receive a post-op patient from the operating room without noting to check for internal bleeding, and always watch patients with exacerbations of chronic obstructive pulmonary disease for signs of developing pneumonia. Is your diabetic patient developing hypoglycemia because the breakfast trays are late? Is your postfall patient on neuro checks?

Figure 1.

Figure 1.

Take nothing personally. Once you feel ready to take an ACLS class, you'll watch a video of a code team resuscitating a patient. The team is quiet, steady, composed. This is how a code should be: each person assuming one role, waiting for the leader to direct the action based on the ACLS algorithm (see Figure 1). In reality, however, this is not always the case; and when chaos hits, your primary concern should be for the safety of the patient, not for your feelings.

In many codes, the room is crowded and noisy. Sometimes the code leader is ignored, and strong words can be exchanged. As the novice, focus on what you feel confident doing, and take no offense when more experienced nurses or providers ask you to step back. Focus on your purpose (to perform basic life support [BLS]) and your goal (to help safely resuscitate the patient) and save any criticisms for the postcode debrief. It's okay to feel upset after your first code. But if your feelings are jeopardizing the team's resuscitation efforts, you need to ask to leave the scene.

Do one thing at a time. In a code setting, there will be many voices, instructions, and questions, and when it's your first time, every one of them will feel important. Unless you work in a facility where the resuscitation team has assigned roles, assume each role is up for grabs and work with your colleagues to adopt whichever you feel most confident in. If you take on a role no one else is doing, simply announce it. Say, for example: “I'm managing the cart.”

If you're working on one request or performing one function, continue with it, so long as it's not overridden by the code leader or supervisor. And if you've been asked to prepare a bag of iv fluid for infusion and also to run and check on a bed in the ICU, quickly finish the first task before moving on to the next.

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The American Heart Association (AHA), whose resuscitation guidelines are the standard, specifies that a code team should include both a code leader to direct the effort and supportive personnel working together to achieve resuscitation using closed-loop communication.3 (In closed-loop communication, the recipient of a message repeats it back for confirmation by the sender, so that both have the same understanding of what was said.) A 2015 study by O'Donoghue and colleagues that surveyed both medical–surgical and critical care nurses at a level 1 trauma center found that a majority claimed to “often” have clearly defined roles in code situations, many self-assigning their roles.4 Additionally, a qualitative study based on interviews with clinical and administrative staff at nine hospitals found clearly defined roles in resuscitation teams to be a key characteristic of high-performing teams.5

Table 1

Table 1

Familiarity with team members’ roles can help new nurses navigate their first code. Even if you're simply a bystander, learning the attributes of each role will help you understand the inner workings of the team and where you might fit in. What follows is a brief review of each role on a code team (see Table 1 for an overview).

Code leader. The code leader is responsible for guiding the team through the ACLS algorithm and for minimizing interruptions in chest compressions.3 The leader synthesizes a vast amount of information during a code, and issues directions based on her or his appraisal of the situation. The leader is typically a health care provider (in the hospital setting, a physician or NP).

Key actions. The leader of a code communicates. Whether inquiring about the events that led up to the resuscitation or instructing support personnel in the actions to take, the leader must be clear and concise in all interactions. AHA guidelines require that any communication from or to the leader be closed-loop communication.3 For example, when a code leader says, “Push 1 milligram of epinephrine iv now,” the expectation is that the person manning the patient's iv access sites will “close the loop” by replying, “1 milligram of epinephrine administered.” It is also the leader who decides whether the patient can still be resuscitated or it's time to “call the code.” A code centers on the leader's commands and the team's response to those commands.

Tips for growth. As a novice nurse, it's unlikely you'll be code leader in a hospital setting, but you can prepare for the role by observing leaders during codes. Pay attention to how leaders are identified, who fills this role, and whether they do or don't succeed, and why. And if you work the night shift with a minimal staff, or do home care nursing in a remote setting, follow BLS steps until someone certified or more experienced in ACLS management arrives to lead.

Primary (or medication) nurse. The primary nurse is the nurse assigned to the patient. On a unit with a rapid response team, the primary nurse remains on site in case there are questions about patient presentation and subsequent decompensation. When there isn't a rapid response team or the team isn't available, the primary nurse typically mans the patient's iv access sites and delivers medications.

Key actions. The primary nurse communicates the patient's condition to the code leader and to the providers attending the code. Clear, brief, succinct, and problem-specific communication is necessary, as are details about the medications or therapies the patient received prior to decompensation. For example, if a patient went into asystole after a period of nausea and chest tightness that wasn't relieved by nitroglycerin, it's important to start with this. The primary nurse also starts iv infusions during the code. If your unit policy forbids RN administration of certain medications, know this prior to a code and whether this policy applies during emergencies.

Tips for growth. The best way to prepare for being primary nurse during a code is to be an organized, highly attuned nurse every day. Use communication tools—such as SBAR (Situation, Background, Assessment, Recommendation)—whenever speaking with providers so you can practice presenting important patient information succinctly. Organize your patient's room, ensure her iv access, and arrange your documentation as if an emergency is just around the corner. If you consistently label your access sites, organize your iv tubing, and make sure your patient's room is safe and clutter-free every day, you'll have no problem assuming the primary nurse role at your patient's side in the event of a code.

Code cart controller. Code cart control is a skill that comes with experience and practice. The code cart controller needs to know what's in the code cart and be able to dispense it quickly, while at the same time announcing each medication she or he is preparing out loud to a frenzied group.

Key actions. The controller's main job is to select and distribute medications from the medication drawer to the primary (or medication) nurse, as ­ordered by the code leader. The controller's secondary but equally important job is to distribute anything else that's needed, from intubation equipment to suction devices to iv fluids or central line kits. If you feel ready to take on this role during a code, start by quickly breaking the lock and placing the medication drawer on top of the cart so you can begin distributing the medications. Some code teams use two people for this role—one dispensing the medications, the other distributing supplies. If this is the case on your unit, be sure to work in an orderly way, as two people in a crowded space can easily get in each other's way.

Tips for growth. To learn to control the code cart effectively, you must learn its contents. Most hospital nursing education departments have a simulation lab with an old code cart available to practice on. Another way to learn the contents of the cart is to be nosy whenever you see one open. If you write down the general content categories for each drawer and study them, you'll become familiar with them over time.

Chest compressor. The person who performs chest compressions has a very important role in a code. According to AHA guidelines, “Chest compressions are the key component” to successful resuscitation, and high-quality chest compressions significantly improve resuscitation outcomes.3 To ensure chest compressions are of the highest quality, a backboard, or a strong plastic board, is placed under the patient's back. Though the person in the room with the biggest muscles is typically the chest compressor, if you're first on the scene, you'll assume this role by default.

Key actions. The chest compressor has two important roles: to give high-quality chest compressions, and to let the team know as soon as she or he needs a break. Lacking the stamina to continue chest compressions is nothing to be ashamed of, and many people will be ready to relieve you.

Tips for growth. First, keep current with your BLS certification, and second, know that though doing chest compressions for the first time may feel scary, chest compressor is a vital role—one that, if done well, can contribute directly to your patient's survival.

Airway manager. If responders aren't already ­engaged in performing chest compressions, and before respiratory therapy arrives on the scene, it is the airway manager's job to start compressions and ensure that the patient's airway is patent and oxygen is flowing.

Key actions. The person responsible for airway management will use BLS skills to open the patient's airway and administer rescue breaths. An Ambu bag with oxygen should be applied as quickly as possible. If you're on a medical–surgical unit, you may not have an oxygen flow regulator on your patient's wall, in which case make sure to ask the code cart controller for one. If there is no wall oxygen at all, use the oxygen tank on the side of the code cart, or give rescue breaths with the Ambu bag using room air.

Manage the patient's airway until respiratory therapy arrives, including removing any secretions or vomit the chest compressions produce. Know to expect this and request a suction setup early. Low-level oral suctioning will also help to reduce the patient's risk of aspiration pneumonia during the code, and every anesthesiologist will request it before intubation, so think ahead.

Tips for growth. Familiarity with equipment and room setup is important. If you think your patient isn't doing well, set up an oxygen flow regulator and suction just in case. Learn to manage the Ambu bag and to create a close seal over an airway by asking to observe respiratory therapists or code teams during orientation.

Defibrillator manager. While some code teams bring and manage their own defibrillator, the novice nurse should still have a basic understanding of the device and how to use it.

Key actions. After coordinating with the code leader to halt chest compressions, the defibrillator manager applies the defibrillator pads to the patient's chest. This happens early in the code, and the code leader's cooperation is necessary to ensure minimal interruptions in chest compressions. Once the pads are in position, the defibrillator manager waits for the code leader's prompt to analyze the rhythm. If a shock is indicated by the machine or ordered by the code leader, the manager programs the energy levels (joules), and once the defibrillator is charged, prompts the team to “clear” the patient. Once the “all clear” is confirmed, the shock is delivered.

Tips for growth. As a novice not yet trained in ACLS, your use of the defibrillator will be limited. You can still familiarize yourself with it, however, by shadowing the charge nurse while she performs the shift's defibrillator and code cart security checks. This will give you some exposure to the buttons and dials, and if you perform the check yourself, which typically requires a test shock, you'll gain some dexterity as well.

A novice nurse can also play an important safety role during defibrillation attempts. The code team may not notice that the patient's oxygen tubing or iv line is dangerously close to someone on the team. In a high-functioning code setting, each voice counts. So, if you see something that may cause a shock to a teammate, say something.

Documenter/timekeeper. The person who documents the code charts ACLS actions and the patient's response to resuscitation efforts using specific code documentation. This role can help a new graduate nurse learn the ACLS algorithm as well as code documentation.

Key actions. Medication dose, CPR cycle, rhythm changes, and the level of joules in each shock are just a few of the details recorded by the person documenting the code. Other specifics are intubation times, airway sizes, physician names, and iv access attempts and successes. It's important to record everything that takes place in a resuscitation attempt, and a skilled documenter knows how to work quickly and use the code flowsheet efficiently.

If timekeeper is also part of the documenter role, this facet is of equal importance. A timekeeper documents each two-minute ACLS cycle, the length of time since the last dose of a medication, how long the current chest compressor has been performing compressions, and how much time has elapsed since the start of a code.

Tips for growth. Review a code flowsheet and familiarize yourself with its categories. Learn timekeeping by observation: if there's a code on your unit, jump in beside the experienced documenter, and compare your documentation with theirs afterward.

Runner. The runner stands to the side of a code and waits until something is needed but missing from the scene or the code cart. If the code leader wants a drug from the pharmacy or more protective gear, runners run and get them. Runners can also provide extra assistance at the scene, performing tasks like finger sticks or iv insertions.

Key actions. The runner waits until something is needed, announces they're going for it, and runs off. The ability to locate supplies, communicate to relevant personnel outside the code setting, and quickly return with a resolution are key to this role. If a code is complex, there may be several runners standing by.

Tips for growth. This is the perfect role for a new graduate nurse. Learn where supplies are kept and when to call for special equipment not housed on the unit. Ask seasoned nursing assistants, who tend to know supply sources and locations best. Also, practice iv insertion and phlebotomy as much as you can; you'll be invaluable during a code when labs are needed or lines are accidentally removed.

Crowd controller. An important but often overlooked role during a code is that of the crowd controller, which involves managing the number of people in the room, and more importantly, the presence of family or the relocation of roommates. Your hospital might leave it up to nursing leadership to assign this role, but if no one steps up to the plate, don't be afraid to jump in.

Key actions. The crowd controller assesses the resuscitation space and helps to reduce the number of people in it. If it's not a private room, this involves moving nonaffected patients and family members. If the coding patient's family is in the room, the controller offers support, answers questions, and supports them in their choice to either leave or stay during resuscitation. Research shows that family presence may be beneficial.3

Tips for growth. As a novice nurse, ushering nonessential people, including clinician bystanders, out of the resuscitation room may feel above your station. But being an active presence with family members and serving as their advocate in the code setting can be very rewarding. Most family members want to ask questions and understand the actions being taken and whether they cause pain. If, in this role, you hear family members request that resuscitation stop, share these sentiments with the code leader.

Cleanup crew. Your first code should teach you that resuscitation efforts wreak havoc on a patient's room. Even if you're hesitant to assume any of the other roles during a code, you can learn a lot by sticking around to help clean up afterward.

Key actions. If the resuscitation effort was successful, usually the patient is taken to the operating room or ICU for further care, leaving an empty, chaotic room. If the effort was unsuccessful, the primary nurse is left to manage not only the patient's remains and a chaotic room, but also a grieving family. Helping to clean up is a way to learn while also providing relief to a colleague. After a code, there's a risk that sharps and other biohazardous materials have been left behind. Cleanup starts with a quick sweep of the room. After safety is restored, pickup and organization efforts follow.

Tips for growth. Don't be afraid to change overflowing trash bags, sweep the floor of debris, and assist with linen changes as needed. In this role, you may get the rare opportunity to provide support to some of the most seasoned nurses, and you'll see that they, too, are still shaken by codes.

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While every nurse's first code can feel scary and unpredictable, it needn't be. If you take care to think ahead, prepare for the worst, and understand which roles you are able and ready to take on—as well as which you still need to practice and study for—you will be sure to succeed in one of nursing's most challenging events.

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1. Hart PL, et al Medical-surgical nurses’ experiences as first responders during deterioration events: a qualitative study J Clin Nurs 2016 25 21-22 3241–51
2. Benner PE From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing Company, Nursing Division; 1984.
3. Kleinman M, et al Part 5: Adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care Circulation 2015 132 18 Suppl 2 S414–S435
4. O'Donoghue SC, et al Nurses’ perceptions of role, team performance, and education regarding resuscitation in the adult medical-surgical patient Medsurg Nurs 2015 24 5 309–17
5. Nallamothu BK, et al How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? A qualitative study Circulation 2018 138 2 154–63
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