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Operating Room Codes Redefined

A Highly Reliable Model Integrating the Core Hospital Code Team

Caruso, Thomas J. MD*; Rama, Asheen MD*; Knight, Lynda J. MSN; Gonzales, Ralph Cer.A.T.; Munshey, Farrukh MD; Darling, Curtis MD*; Chen, Michael MD*; Sharek, Paul J. MD§

doi: 10.1097/pq9.0000000000000172
Individual QI projects from single institutions

Introduction: Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles.

Methods: A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver—a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff.

Results: The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management.

Conclusions: The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

From the *Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, Calif.

Lucile Packard Children’s Hospital Stanford, Palo Alto, Calif.

Department of Anesthesiology, Perioperative Medicine and Pain Management, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

§Division of General Pediatrics and Hospitalist Medicine, Department of Pediatrics, University of Washington, Seattle Children’s Hospital, Seattle, Wash.

Received for publication December 17, 2018; Accepted March 28, 2019.

Published online April 12, 2019.

To cite: Caruso TJ, Rama A, Knight LJ, Gonzales R, Munshey F, Darling C, Chen M, Sharek PJ. Safety Report: Opening the Door to Operating Room Codes—A Redesigned, High Reliable Model that Integrates the Core Hospital Code Team. Pediatr Qual Saf 2019;3:e172.

Corresponding author. Address: Thomas J. Caruso, MD, Department of Anesthesiology, Perioperative and Pain Medicine, 300 Pasteur Drive, 3rd Floor, Room H3584, MC 5640 Stanford, CA 94305–5640, PH: 650-723-5728,

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Compendium date: May/June, 2019

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An intraoperative cardiac arrest, also known in some settings as a “code blue,” is defined as an event during the care of an anesthesia care team that requires cardiopulmonary resuscitation with closed or open chest compressions.1 Intraoperative arrests are a low volume, high-risk event with an approximate incidence of 7 in 10,000 noncardiac adult surgeries.2 The pediatric perioperative population is at a higher risk than adults, with an incidence of 22 arrests in 10,000 noncardiac surgeries and an incidence of 127 arrests in 10,000 pediatric cardiac patients.1,3 Compared with intraoperative codes, the incidence of in-hospital pediatric cardiac arrests occur at a rate of approximately 8 in 10,000 patients.4 Despite a higher incidence of pediatric intraoperative cardiac arrests, the likelihood of any one anesthesiologist experiencing a code is rare compared with the in-hospital code team that is composed of a smaller group of providers that routinely respond to rapid response and code events throughout the hospital. Multidisciplinary code teams, in particular, those including intensive care specialists, have been associated with reduced adverse events, mortality, and mean duration of hospital stay.5 Despite this, intraoperative codes are traditionally managed by available and often variable operating room (OR) personnel, missing the benefit of the out-of-OR hospital code team which has more experience with team management of cardiac arrests. Typical respondents to out-of-OR codes include anesthesiologists, intensive care physicians and nurses, pharmacists, and respiratory therapists.

Significant efforts have been directed toward improving the management of perioperative arrests using high-fidelity simulation, crisis resource skill training, and cognitive aid checklists.6 Although establishing consistent team roles, clear, closed-loop communication, and simulations has been shown to improve outcomes, standardized methods for initiating intraoperative code responses have not been reported.7 Most ORs utilize paging systems to notify available perioperative providers, resulting in inefficient and often chaotic responses.8 To help ameliorate this chaos, perioperative providers undergo continuing education, including the American Heart Association Advanced Life Support certifications, to help prepare code respondents to control the intraoperative crises during an intraoperative cardiac arrest.

At our institution, the intraoperative emergency response system included multiple different methods to activate codes depending on time and day of the week. The number and type of responders also varied. Because the official hospital policy was not being reliably followed, the chief nursing officer and vice president of medical affairs chartered a quality improvement project. The goal of this quality improvement initiative was to optimize patient safety by standardizing the code response system. The aims were to simplify the emergency response activation, standardize respondents, and predefine associated roles to optimize communication, preparedness, and timeliness during OR code blues.

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This quality improvement project was performed at Lucile Packard Children’s Hospital Stanford, a freestanding, 365 bed academic, pediatric hospital in Northern California. The hospital has 16 ORs and 12 non-OR settings, including ambulatory procedure rooms and interventional suites. The intervention included both the OR and non-OR settings. The educational phase of the study occurred from April 2018 to June 2018. The institution serves a racially diverse population and provides perioperative services to approximately 13,500 perioperative patients each year. The anesthesia and surgical providers include academic faculty, fellows, residents, nurse practitioners, nurses, surgical technicians, and physician assistants. As a quaternary care trauma center with neonatal, pediatric, and cardiovascular intensive care units, the surgical population ranges from complex neonates to ambulatory procedures on healthy children. All nurses and anesthesiologists are required to have advanced cardiac life support or pediatric advanced life support certification.

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The chief nursing officer and vice president of medical affairs chartered this project. A multidisciplinary quality improvement team of physicians, nurses, pharmacists, quality managers, and hospital code response team leaders led this initiative. Our initiative began with a stakeholder engagement phase that occurred over 4 weeks and ultimately led to a team that reviewed the background and current state of the variable ways in which code blue events could be initiated. We developed an A3 project plan as part of the quality improvement methodology. We developed the A3 through historical analyses of intraoperative arrests and perioperative staff interviews. Unstructured interviews of nurses, anesthesiologists, and surgeons were conducted by members of the quality improvement team to elucidate the current state to drive a needs assessment. Although a standard method for activating an intraoperative emergency response existed in policy, multiple homegrown pathways were identified, confusing practical application and potentially leading to suboptimal patient care. Based on staff interviews, a qualitative assessment determined that these homegrown pathways could lead to deficits in optimal communication, preparedness, and efficient responses to code blues. Different types of emergency responses included: anesthesia stat, anesthesia help, staff emergency, in-OR code, OR code blue, extracorporeal membrane oxygenation (ECMO) code, and a standard code blue (Table 1). Staff recognized the inconsistencies in code initiations, but supported the development of different pathways due to the variability of code respondents depending on the time of day. Another revelation was that anesthesiologists often assumed multiple roles, sometimes hindering the quality performance of competing assignments. Although cognizant of this practice habit, some reported difficulty in identifying other respondents with the requisite skill sets, particularly during nights and weekends due to a relative lack of redundant staffing during nights and weekends. OR nurses shared similar concerns regarding the ability to distribute competing nursing code roles on nights and weekends. Based on the current state analysis, a key driver diagram was developed to guide the interventions (Fig. 1).

Table 1

Table 1

Fig. 1

Fig. 1

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After several meetings and simulations performed in the OR (in situ simulations), the improvement team recognized a valuable key driver—a consistent activation process that initiated a standardized responding team, 24 hours a day, 7 days a week. The ability to activate a standard team provided efficient use of perioperative resources and eliminated the confusion identified by perioperative staff during the current state analysis. By utilizing core hospital code members routinely available outside of the OR during days, nights and weekends, standard respondents were identified (Table 2). Because anesthesiologists, surgeons, OR nurses, and surgical scrub technicians were consistently available, only a truncated group of out-of-OR code members were needed for intraoperative codes to provide consistent backup to OR members, particularly on nights and weekends (Table 2). Once we identified the respondents, code roles were preassigned (Table 3). Some roles, such as the anesthesiologist, were given multiple roles because there are consistently multiple anesthesiologists available, such as an attending and trainee. Also, given the dynamic, evolving needs of a code, an anesthesiologist may be reassigned by the code leader, such as switching from central line placement to medication administration after the central line is completed.

Table 2

Table 2

Table 3

Table 3

We simplified the emergency response activation process to a dichotomous system—OR code versus anesthesia help to reduce variability in respondents depending on the time of day. Activation of an OR code involved 2 steps: (1) calling the emergency response operator, who sent a page to the specialized out-of-OR code members and the perioperative code members and (2) sounding a unique, local, perioperative alarm by pushing a button located in the OR in which the arrest was occurring. Anesthesia help referred to any urgent, noncode scenario that required additional support, such as an unexpected difficult airway. Activation of the anesthesia help code involved 2 steps: (1) calling the anesthesia emergency phone that was carried by an available anesthesiologist who was not providing direct patient care and (2) sounding a unique, local, perioperative alarm located in the OR in which the help was needed. The development of the new code response system took approximately 8 weeks.

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Following interdepartmental electronic correspondence, several perioperative leadership meetings, and perioperative team education, we initiated the enhanced pediatric emergency response system. Stakeholder engagement and agreement was increased through active championing by frontline employees who are members of the perioperative quality improvement team and surgical, anesthesia, and perioperative nurse leaders. We displayed cognitive aids in each OR above the OR code and anesthesia help buttons to increase the visibility of the new process. The initial educational phase occurred over 2 months and also consisted of several components including 2 weeks dedicated to comprehensive training of OR staff.

After education, we conducted 4 daytime announced and 1 daytime unannounced in situ simulations that included the perioperative and out-of-OR code team members. Four attending anesthesiologists, 2 surgeons, and 6 nurses, including the OR nurse manager and assistant manager participated in these simulations. The purpose of these simulations was to educate the staff about the new process, ensure that activation of the code response team was reliable, and test system reliability and assignment of standard code roles. By conducting in situ simulations, we were able to observe possible barriers to implementation of the activation system that we could not easily identify in a sim-laboratory or discussion setting. Code team performance was not tested. Ongoing continuing education was scheduled to occur once monthly, corresponding to a 1-hour delayed OR start. Approximately, 7 perioperative members, including a surgical attending and resident, anesthesia attending and resident, 2 OR nurses and 1 scrub technician, and 5 out of the OR respondents were involved in the ongoing monthly simulations. The surgeons with the delayed OR start participated as the surgical representatives in the simulated code. The monthly simulations rotated between surgical service lines. We developed and administered a tool to assess knowledge retention of the process and associated roles by the perioperative staff to ensure adequate educational efforts. We measured our immediate results by a knowledge assessment which demonstrated high competency among perioperative staff.

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After a needs assessment, the team identified several problems that included the lack of a standardized activation method for an intraoperative emergency response, the assumption of multiple roles by anesthesiologists during the nights and weekends, and the challenge of assigning all appropriate nursing roles during nights and weekends (Table 4). After education and simulation sessions were conducted, we administered the knowledge assessment tool to perioperative staff (n = 52/54). Test takers were OR nurses. We targeted nurses because they are the main care providers that activate the code or anesthesia help pathways. The average score was 96%, and 100% of participants answered that they felt comfortable performing their designated role during an intraoperative code. Anecdotal reports of subsequent intraoperative codes indicate that the process is now reliable with less variability in code initiation and respondents. Ongoing monthly simulations (6) with perioperative staff have helped retain familiarity and understanding with the emergency response system. Approximately, 7 perioperative members, including a surgical attending and resident, anesthesia attending and resident, 2 OR nurses and 1 scrub technician were involved in the ongoing monthly simulations.

Table 4

Table 4

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Quality improvement methodology including utilization of an A3 project plan and key driver diagram was utilized to assess and redesign the perioperative emergency response systems (Fig. 1).9 The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. This project was initiated by the chief nursing officer and vice president of medical affairs in response to an identified need to optimize responses to OR codes. Ongoing simulations with perioperative personnel continue to optimize the process. Review of subsequent OR codes reflects an improved initiation process and management. There were no unintended consequences reported by perioperative providers. However, they may arise, including unavailable PICU providers and sterility concerns with multiple respondents entering the OR. Overlapping or duplicate roles need to be carefully managed by the code leader as they could lead to confusion. Also, the lack of familiarity of the perioperative environment from non-OR respondents may require ongoing consideration.

Despite the historical tradition of intraoperative codes being managed by OR care teams, given increasing case complexities and pressure for efficient staff models, a multidisciplinary approach to intraoperative codes that include out-of-OR respondents should be considered. Most intraoperative arrests are managed inefficiently.8 During the day, unnecessary personnel respond to OR codes, hindering performance.8 The resulting imbalance of personnel in the OR with the code can result in limited resources for patients in the other ORs. Contrary to the abundance of help available during the day, intraoperative codes that occur on nights and weekends often face the opposite problem of limited OR staff availability, resulting in unfilled code roles.

Outcomes following cardiopulmonary arrests are significantly different depending on the time of day and whether the code occurred during the weekend.10–13 The use of standard resuscitation teams may optimize outcomes in patients with cardiac arrest.14 Given the variability of OR code responders during typical intraoperative arrests, a focused group of OR code providers supplemented with a subset of out-of-OR code respondents offers a reliable and standardized team with predefined roles even during nights and weekends.15 The reliability requires a consistent activation that is virtually always responded to by the predetermined team. Despite the potential to increase in the total number of respondents to an intraoperative code, having a dedicated group of respondents that routinely respond to code events throughout the hospital provided experience and role clarity. The results of our intervention were an appropriate increase in the number of available respondents on nights and weekends and a net decrease in the number of respondents during the day.

There were several limitations to this project. Due to the infrequency of intraoperative arrests, this project was unable to show a decrease in morbidity, although the methods used to design the proposed OR code team have been well studied and shown to be effective. The objective measures of this study were limited to a knowledge assessment by the OR nurses which showed a high competency level for code roles and the emergency response activation. Nurses were targeted for the assessment, as they are the primary activators of the emergency response system. We provided the additional members of the code response team with knowledge assessments and feedback during simulation debriefing. Although simulations were not conducted during nights and weekends, they did include perioperative staff that work during nights and weekends. Also, our hospital’s centralized paging system may not be generalizable to other institutions that may rely on different activation response systems. However, the structure and formation of a standardized intraoperative code response team can still be applied, as evidence from our monthly ongoing simulations and our in situ simulations, which demonstrated a consistent activation of the emergency response system with appropriate respondent roles.

Furthermore, our institution includes a pediatric intensive care unit with night and weekend coverage. These in-house staff made it possible to create a standardized intraoperative code response team, which may be difficult to replicate in some hospitals without these resources. Also, the relatively rare incidence of intraoperative codes at our institution minimizes disruption to the out-of-OR respondents.

This improvement project describes a standardized method of activating the intraoperative emergency response with predetermined roles. Ongoing perioperative simulations provide opportunities for continued optimization. Future efforts will measure differences in morbidity and examine outcomes on nights and weekends compared with daytime arrests.

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The authors have no financial interest to declare in relation to the content of this article.

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