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Department: Heart Matters

COVID-19 code blue

Chu, Ruby PhD, RN, CCRN

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doi: 10.1097/01.NME.0000694208.21083.38
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In the US, approximately 350,000 out-of-hospital cardiac arrests occur every year, with a 12% survival rate. On the other hand, 209,000 people experience an in-hospital cardiac arrest annually, with a 24.8% survival rate. Cardiopulmonary resuscitation (CPR) is an important emergency measure to save lives.

Cardiac arrest is a concern for COVID-19 patients. For those who are critically ill, mortality is high, specifically with increasing age, comorbidities, and cardiovascular disease. Because CPR is a procedure that generates aerosolized particles, there's a risk of virus transmission; however, CPR shouldn't be delayed because this will deprive the patient of lifesaving measures. There's also a chance that during the high stress of resuscitation efforts, infection control won't be maintained. Due to these concerns, some hospitals instituted a policy not to initiate CPR until the patient was intubated. Additionally, the overwhelming surge of COVID-19 cases caused many hospitals to have a shortage of ventilators, ICU beds, and personal protective equipment (PPE).

New interim guidelines

The American Heart Association (AHA), in collaboration with other organizations, created interim guidelines for intervention and treatment of patients with suspected or confirmed COVID-19 experiencing a cardiac arrest. The new guidelines provide strategies that require a different process and approach than usual.

Limit provider exposure. Ensure that the patient's COVID-19 status is communicated to the healthcare team. Healthcare professionals and coworkers must limit unnecessary virus exposure by wearing PPE before entering the patient's room. Moreover, only essential personnel should be present in the room. The use of a mechanical compression device instead of manual compression is recommended to limit the number of providers in the patient's room.

Ventilation and oxygenation. Prioritize ventilation and oxygenation interventions to lower risks of aerosolization, such as the use of a HEPA filter when available. The new recommendation is to intubate the patient as early as possible after obtaining a shockable rhythm. Then inflate the endotracheal tube (ETT) cuff and connect the ETT to a ventilator using a HEPA filter to decrease the risk of aerosolization. Consider video laryngoscopy for successful intubation. Additional guidance is to use a bag-valve mask with a HEPA filter maintaining a tight seal or a non-rebreather oxygen mask covering the patient's mouth. For delayed intubation, use a bag-valve mask with a HEPA filter or manual ventilation with a supraglottic airway device. If the patient is intubated, avoid disconnecting the ventilator circuit.

Consider resuscitation appropriateness. It's important to address the patient's care goals. Develop policies for clinicians to make critical decisions for COVID-19 patients during CPR based on age, comorbidities, and severity of illness.

Protected code blue

The evolving COVID-19 pandemic has created challenges during resuscitation efforts, requiring modification of processes and practices to protect healthcare workers from aerosolized virus transmission. A protected code blue (PCB) framework can help minimize staff exposure when managing a patient with COVID-19 who's experiencing a cardiac arrest. In 2003, the PCB model was developed when numerous healthcare workers died from exposure to acute respiratory syndrome.

In preparation for the PCB, team members don full PPE, including an N95 mask, face shield, gown, gloves, and head cap. With everyone in full PPE, it's hard to identify team members and their roles. One identification strategy to prevent confusion is to use stickers indicating team member roles. The PCB guiding principle is to minimize the number of team members in the room.

Team A, consisting of the physician team leader, the anesthesiologist, the primary nurse, the second nurse, and the ICU nurse, is inside the patient's room. The door will remain closed during the code. A voice-activated device can be used to effectively communicate with PCB team members outside the patient's room, known as Team B.

Inside the patient's room (Team A):

  • The first responder is often the primary nurse, who enters the room in full PPE and places a face mask or covering on the patient's mouth before initiating chest compressions. Passive ventilation, such as use of a non-rebreather mask with 15 L/minute oxygen flow, is used. To prevent aerosolization, manual ventilation isn't performed. When the physician team leader arrives, he or she directs the code blue and provides guidance on when to terminate the code.
  • The anesthesiologist manages the patient's airway by performing the intubation. The new guidelines encourage early intubation by a highly qualified person with the best chance of successfully intubating the patient or use of video laryngoscopy to minimize aerosolization. If intubation is delayed, use a bag-valve mask with a HEPA filter seal tightly on the patient's face. Pause chest compressions during intubation.
  • The second nurse brings the code cart, leaving it outside the patient's room. He or she removes the equipment from the code cart (defibrillator/monitor and backboard) and brings it into the patient's room, attaching the pads, turning on the defibrillator, following the prompts, and placing the backboard under the patient. After two cycles of CPR, the second nurse will relieve the primary nurse of chest compressions.
  • The ICU nurse brings the prepared medications bag inside the patient's room and manages the defibrillator. If the patient is experiencing ventricular fibrillation, the ICU nurse will immediately shock the patient. He or she will insert an intraosseous line if the patient has no I.V. access, give emergency medications, and record events. Lastly, the mechanical chest compression device is placed on the patient's back.

Additional team members outside the patients' room include another backup compressor nurse, the nursing supervisor who acts as the “gatekeeper,” a nurse who acts as a runner, and a respiratory therapist.

Outside the patient's room (Team B):

  • The backup compressor nurse in full PPE will go inside the patient's room when needed to relieve the second nurse.
  • The nursing supervisor monitors room access and ensures strict donning and doffing of PPE.
  • The nurse runner obtains additional equipment or supplies, maintains crowd control, and supports the family.
  • The respiratory therapist is the backup person to relieve the anesthesiologist managing the airway.

After achieving return of spontaneous circulation, the patient will be transported to the ICU accompanied by limited code team members while maintaining strict contact precautions. One staff member accompanies the patient during transport to clear the hallway. Equipment should be decontaminated based on CDC guidelines. The PCB team must discard PPE carefully and perform hand hygiene.

Nurses and other healthcare personnel on the frontline must take extra precautions to protect themselves. The challenge is to make sure patients experiencing a cardiac arrest, whether COVID-19 positive or not, are given the best chance of survival without compromising the safety of staff members who will be taking care of other patients. The key points to remember are to ensure PCB team members wear appropriate PPE when in the patient's room, minimize bag-valve mask ventilations, perform early intubation, and designate a gatekeeper to monitor proper donning and doffing of PPE.

Learning every day

The COVID-19 outbreak has generated concerns over how to respond to patients experiencing a cardiac arrest. Healthcare workers must take extra precautions and follow the AHA's new interim guidelines for COVID-19. Organizing an ethics team can help determine whether patients will require resuscitation or a do-not-resuscitate order during hospitalization. Evidence-based criteria, as they become available, will help the ethics team make rational decisions about patients with COVID-19 who are deteriorating.

key points


Limit provider exposure

  • Don PPE.
  • Only allow essential personnel in the patient's room.
  • Use a mechanical chest compression device.
  • Communicate the patient's COVID-19 status to the healthcare team.

Ventilation and oxygenation

  • Defibrillate to a shockable rhythm and then intubate the patient right away.
  • Minimize failed intubation attempts.
  • Consider video laryngoscopy.
  • If necessary before intubation, use a bag-valve mask device with a HEPA filter.
  • Use a non-rebreather mask covered by a surgical mask for passive ventilation.
  • Avoid disconnecting the closed ventilator circuit.

Consider resuscitation appropriateness

  • Address the patient's care goals.
  • Develop a facility policy to guide resuscitation care.


American Heart Association. AHA cardiac arrest statistics.
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      McIsaac S, Wax RS, Long B, et al. Just the facts: protected code blue—cardiopulmonary resuscitation in the emergency department during the coronavirus disease 2019 pandemic. CJEM. 2020;1–4.
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