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Code blue: Overcoming the fear

Castro, Maria Christabelle MSHA, BSN, RN, CCRN, NE-BC; Cruz, Milagros BSN, RN, CCRN; Briones, Ruben BSN, RN, RN-BC

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doi: 10.1097/01.NURSE.0000445763.18817.1c
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CARDIOPULMONARY emergencies are high-risk, low-incidence events in long-term care (LTC) units. Many nurses find responding to a cardiac arrest a stressful experience that invokes insecurity and fear. We were concerned that nurses at the Community Living Center (CLC), an LTC unit for veterans located next to the main hospital, weren't confident in their skills due to the low incidence of cardiopulmonary arrests in LTC settings compared with the main hospital.

The CLC is a homelike facility where veterans receive short- or long-term rehab, help with activities of daily living, and skilled nursing and medical care. We were concerned that RNs, LPNs, and unlicensed assistive personnel (UAP) at the CLC didn't meet the skills and competency expectations in a code blue. Because the CLC is a brisk 6- to 10-minute walk from the main hospital, responders to code blue situations and members of the critical care committee decided to assess the confidence of the CLC staff in code blue situations through simulation-based mock code drills. We implemented a two-phase educational program based on the latest evidence-based guidelines to improve nurses' responses to code blue situations and patient safety. We also extended simulation training to resident physicians and interns in the ICU who are part of the cardiac arrest team.

Guidelines and training

The American Heart Association last updated the CPR and emergency cardiovascular care guidelines in 2010 based on the evidence evaluation process. These guidelines continue to emphasize the importance of high-quality, effective chest compressions and early defibrillation.1

Studies of in-hospital staff performance show that retention of CPR skills is poor; as a result, training every 2 years is recommended.1 As with any skill, basic life support (BLS) and advanced cardiovascular life support (ACLS) skills require practice to ensure competence. When the quality of education is increased and training is more frequent, we believe CPR skills become natural and instinctive and resuscitation efforts are more effective, especially for frontline patient-care providers.

The ICU nurse of the cardiac arrest team from the adjoining hospital usually arrives first and can assess how the first responder, and in this case the CLC staff, performs BLS. The staff in the CLC is expected to provide BLS, and although they're trained in BLS, manikin training isn't quite the same as a real-life situation. They tended to stay in the background and watch the code blue due to a lack of confidence.

Starting with a survey

In December 2011, members of the critical care committee sent an online survey to 120 CLC nursing staff to find out the following:

  • Do they understand their role in a code blue?
  • Do they know how to operate the automated external defibrillator (AED)/defibrillator before the cardiac arrest team arrives?
  • Do they believe that BLS training is sufficient to enable them to -effectively and correctly participate during a code blue?

There were 96 respondents. (See Comparing results before and after education.) RNs, LPNs, and UAP were unsure of their role before the arrival of the cardiac arrest team, felt uncertain about operating the portable AED/defibrillator, and believed BLS training wasn't sufficient to boost their confidence. These survey results led us to the following questions:

  • Does BLS provider training adequately prepare nurses to respond to a code blue?
  • Does BLS training increase confidence in their ability to participate in a code?
  • Would increasing the frequency of BLS training from annually to quarterly improve retention of skills and competency?

Starting a program

In response to the survey, a simulation-based mock code program was developed. Its goals were to improve patient outcomes and increase healthcare team members' knowledge, competence, and confidence in emergency situations. Review of the literature and the use of simulation to reinforce healthcare members' roles and responsibilities in cardiac arrest and rapid response team situations supported the first-phase training.2,3 This phase covered BLS skills and competency and emphasized first and second responder roles.

The simulation program was conducted in two phases. The main focus of the first phase was the “First 5 Minutes,” the key component for improved patient outcomes: high-quality, effective CPR. It also focused on nurses' roles as first and second responders. Second-phase training covered practicing mock codes. For the training to be successful, realism is the key; the situation must closely mimic a real code blue.

Honing the details

Prescheduled training was coordinated with one or more nurse managers so it wouldn't involve staff overtime. Because small groups were found to be more effective, interactive, and informal, classes were arranged for groups of four or five participants.

First-phase training. The goal for this phase was to provide training for 100% of frontline direct patient-care providers. Two instructors were present. To accommodate staff on all shifts, training was provided at various times when unit activities were usually less hectic. The training location was a hospital bed in an unoccupied patient room with a training crash cart, defibrillator, and a low-fidelity manikin.

All participants got an opportunity to operate the equipment. They were encouraged to open crash cart drawers and supplies, put things together, and check equipment for proper functioning. For real-time cardiac monitoring, a volunteer was connected to the monitor so responders could practice correct electrode placement and troubleshooting equipment. Defibrillator pads were applied to a manikin. For chest compressions, “push hard, push fast” was emphasized by review and a return demonstration.

First-phase training was completed with 90% staff participation. At the end of each education session, a case scenario was provided and participants were encouraged to critique each other's performance. Participants could identify what went well and what needed improvement.

Figure. C
Figure. C:
omparing results before and after education

Discussion among participants of the simulation activity as well as a posteducation survey showed that staff appreciated the hands-on training and gained confidence in operating the equipment and in performing as first and second responders. They've also acknowledged that the “First 5 Minutes” training classes helped them feel better prepared and more confident about actively participating during a code blue.

Second-phase training. The goal for this phase was to evaluate staff knowledge, skills, competency, and implementation of their roles and responsibilities as first and second responders.

Two trainers coordinated with the nurse managers in CLC to make sure an empty room would be available for a mock code conducted on their units. They also collaborated with the hospital switchboard operator to announce a code blue overhead so that the cardiac arrest team located in the adjacent hospital could respond. Once the hospital cardiac arrest team arrived at the scene, they were informed that it was a mock code. The CLC staff then proceeded with the mock code. After each mock code, debriefing was conducted.

For subsequent mock codes, the overhead page for the cardiac arrest team wasn't activated so as not to interrupt patient care.

Encouraging outcomes

Both phases were completed within 1 year. A follow-up survey using the same questions revealed that mock codes improved staff's perceived performance and that nurses believed that the mock codes were helpful. They felt more confident in their roles and demonstrated increased comfort with the equipment.

About 4 months after the completion of training, an actual code blue was called in CLC. The responding cardiac arrest team from the adjacent hospital applauded the CLC staff's effort and efficiency, and this was reflected in the debriefing. The first and second responders performed exactly what was expected of them when the cardiac arrest team arrived at the scene. A mock code is now conducted quarterly in CLC.

Expanding the program

Having seen the successful outcome of simulated training, the trainers began to look internally to the cardiac arrest team in the adjacent hospital. Resident physicians and interns in the ICU rotate monthly. They're part of the cardiac arrest team if they're on-call for the day. Although they're required to complete ACLS training, most of them haven't assumed the team leader role in a real code blue. In response, the trainers also began to conduct simulated code training for physicians rotating to the ICUs monthly, focusing on their roles and responsibilities when a code blue is called. They assume the roles of team leader, airway management, or chest compressor and are asked to perform each role during the simulation.

Postcode debriefing quarterly reviews showed that after the code blue simulation training, actual code blue situations were conducted more efficiently with less confusion with role designation and improved communication among members of the cardiac arrest team.


1. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S640-S656.
2. Woollard M, Whitfield R, Newcombe RG, Colquhoun M, Vetter N, Chamberlain D. Optimal refresher training intervals for AED and CPR skills: a randomised controlled trial. Resuscitation. 2006;71(2):237–247.
3. Woollard M, Whitfeild R, Smith A, et al. Skill acquisition and retention in automated external defibrillator (AED) use and CPR by lay responders: a prospective study. Resuscitation. 2004;60(1):17–28.
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