A comparative study of code blue records : Nursing2020 Critical Care

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A comparative study of code blue records

Whitcomb, John J. PhD, RN, CCRN, FCCM; Hahn, Cayla BSN; Sumner, Ivey BSN; Shelley, Kirk BSN; Hunnicutt, Taylor BSN

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doi: 10.1097/01.CCN.0000471260.40048.0d
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In Brief

Cardiopulmonary arrest is a major health problem claiming 350,000 to 450,000 lives per year in the United States. The survival rate has increased to 49% with the use of automated external defibrillators (AEDs) by lay personnel in settings outside the hospital environment.1 However, there are no reliable national statistics on survival from in-hospital cardiopulmonary arrest because reporting varies for each U.S. treatment facility and there's no comprehensive reporting system.1

Furthermore, a preliminary study of resuscitative outcomes over a 48-month period demonstrated there were 122 data points not documented and, of those, 64 were critical elements, such as cardiac rhythm at time of arrest, time to first shock, time of first responder arrival, and length of arrest.2

This pilot study focused on a new way to document cardiac arrest. The study was conducted at a local hospital in Greenville, S.C., after receiving Institutional Review Board approval. Two different systems were used simultaneously to document cardiac arrests (code blues). One was the current charting system, which was the hospital's standard documentation computer. According to staff nurses, this system was difficult to use during an emergency due to page layout. The second system was a new handheld electronic device maintained in the ICUs and CCUs.

When a code blue was called, the clinical coordinator, who was on duty and responsible for attending all codes, used the handheld device to document the cardiac arrest from beginning to end. One unique feature of the handheld device was that it was electronically synched with the defibrillator.5 It had the ability to record information such as the cardiac rhythm, time the cardiac arrest began, number of shocks delivered, and shock intervals. For this pilot study, no subjects who required cardiopulmonary resuscitation (CPR) were found in a shockable rhythm, therefore this aspect of the handheld device couldn't be evaluated.

This pilot study provided support for using the handheld device to increase the accuracy of cardiac arrest documentation because the events were recorded in real-time. Data were then compared to determine what events were or weren't documented. This information could be used to look for patterns that correlate to survival rates and potentially create new protocols that improve patient outcomes.


The purpose of this comparative pilot study was to describe the clinical characteristics, documentation, and outcomes of a cardiac resuscitative event associated with code blue team responses using a handheld electronic device.

A retrospective chart review or cardiac arrest sheet review was conducted over a 3-month period and compared to the data collected with the handheld electronic device from the same cardiac arrests that occurred in the ICU and CCU. The two data collection techniques were compared to determine which method of documentation captured the event more comprehensively and accurately.


Patients ranged in age from 40 to 83 years with 5 males and 3 females. Co-morbidities included hypertension, diabetes mellitus, chronic obstructive pulmonary disease, heart failure, end-stage renal disease, coronary artery disease, and morbid obesity. Hospital length of stay ranged from 1 to 16 days.

Initial CPR was started 14 to 20 seconds from the onset of arrest. The first I.V. epinephrine dose was administered 38 to 56 seconds from the start of the arrest. Only two subjects survived the arrest and no subjects survived to hospital discharge. The length of arrests ranged from 3 minutes to 49 minutes. The cardiac rhythm most commonly documented was pulseless electrical activity (PEA). (See Get with the guidelines.)


Overall, the handheld electronic device provided a more detailed description of the cardiac arrest event versus the standard electronic charting. The standard electronic charting was difficult to use because of the way it was set-up within the system and the multiple pages that needed to be scrolled and used. The handheld device was much easier to document the events in real time because of the touch screen and time stamping ability. In comparing the two methods of documentation, greater detail was obtained with the handheld device, increasing data collection by 50% in terms of when CPR was started, when medications were given, and over sequence of the code events.


Limitations for this pilot study included the small sample size. There were only 8 cardiac arrests in the study location. The low number was due to family meetings on quality of life issues and many patients and their families chose a do-not-resuscitate order.


This pilot study, comparing a commercial handheld electronic device to standard electronic charting, demonstrated that there's an easier way to document a cardiac arrest. More studies need to be conducted that would help improve protocols and guidelines that dictate how a cardiac arrest is documented. Having more information on patient outcomes during and post-cardiac arrest could help researchers understand which interventions have the best outcomes. This could increase the survival rate of patients experiencing cardiac arrest.4

Get with the guidelines

The AHA has developed a collaborative quality improvement program called Get with the Guidelines: Resuscitation (GWTG-R). This program is intended to help providers improve adherence to evidence-based care of patients who experience an in-hospital resuscitation event or received post-cardiac arrest care. The events could have occurred following an in-hospital or out-of-hospital event in the adult, pediatric, or neonatal population.

The program collected data from hospitals across the United States to provide feedback on their resuscitation practices and patient outcomes as well as to help develop new evidence-based guidelines.1 The GWTG-R includes recognition measures, quality measures, reporting measures, medical emergency team actions, and descriptive measures.3


1. American Heart Association Get with the Guidelines: Resuscitation www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelines-Resuscitation/Get-With-The-Guidelines-Resuscitation_UCM_314496_SubHomePage.jsp
2. Whitcomb JJ, Seawright J, Wadsworth R, et al. A retrospective study evaluating response time and survival from a cardiopulmonary arrest: a creative inquiry project with undergraduate nursing students. Dimens Crit Care Nurs. 2013;32(1):50–53.
3. Allan N, Bell D, Pittard A. Resuscitation of the written word: meeting the standard for cardiac arrest documentation. Clin Med. 2011;11(4):348–352.
4. Kaye W, Mancini ME, Truitt TL. When minutes count—the fallacy of accurate time documentation during in-hospital resuscitation. Resuscitation. 2005;65(3):285–290.
5. Zoll Medical Corporation. CodeNet Resuscitation Data Management System. www.zoll.com/medical-products/data-management/code-net-resuscitation-system/
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