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    Runi Arundanti
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    Example for code blue form

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    © All Rights Reserved
    Download as PDF or read online from Scribd
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    491 views14 pages

    Code Blue Form

    Uploaded by

    Runi Arundanti
    Example for code blue form

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 14
    - @ STONY BROOK @N® UNIVERSITY MEDICAL CENTER Code Blue/Resuscitation Form (Quick Reference Guide for Documentation) . Date, time & patient’s weight must be recorded on top left of form. Re Attach patient label with correct location on each page of original and copy. 3. TIME: Note the time patient was found unresponsive. This is the Time Code Initiated (box on bottom left). Clock starts running from this time, not when code team arrives or CPR started. ‘* Only one clock/time to be used throughout the code! N S Continuously identify patient’s rhythm and record vital signs as appropriate to rhythm. (VS’s are to reflect the patient’s in the absence of compressions), Use other for PEA, Bradycardia, etc, New time=New line! 5. Pulse present? Record this every time! Chest Compressions? Record every time! 6. Document interventions (defibrillation, cardioversion, pacing) with energy settings (loules or MA). Remember: new timne=new line! © Document rhythm prior to and following electrical intervention, every time. * Check monophasic vs. biphasic Zoll, & internal vs. external Pacer. ~ . Document medication boluses and drips with dosage and route, i.e. Img IVP/ET/IO. Remember: New time=New Line! ~ . Witnessed: Check yes, only if you were in the room when patient became unresponsive. 9. Co-morbid conditions pre-arrest: Document patient’s pre-arrest state and any significant history. 10. Interventions already in place at time of arrest: Check off all interventions already in place prior to arrest. * Check Cardiac Monitor box, if patient was being monitored by telemetry prior to the code. Note date/time of intubation, when info is available Note location of IV access lines. Code Blue/Resuscitation Form (Quick Reference Guide for Documentation) 11, Procedures during resuscitation: This section is for interventions done during the code. * Circle blood products given. © Intubation: Give time, who inserted tube, size, cm lip? © ETT confirmation method: looking for two methods (Breath sounds, ECO2, CXR). 12. Type of Call: New=top of third page. Note times of all that applied. If ARC, note the time that Anesthesia was called. 13. Progress Note: Must be completed by the primary nurse, to include the events leading up to the code. 14, Post Code Blue / Resuscitation Information: Document the patient’s post-code blue condition, and who was notified, attending & family is responsibility of the Team Leader (Chief Medical Resident). * New boxes include Hypothermia Protocol initiated, and Autopsy Requested © Signatures required for Team Leader, Recording & Medication Nurses * All other team members present are to be legibly printed 15. Debriefing form on the back is completed by the team leader & RN © New: Was there an opportunity to call RRT prior to calling Code? © New: Code Cart # in box at bottom right 16. Other issues: Before separating otiginal from yellow copy, ensure that— © Event record is complete as/above items © The yellow copy is readable © White copy goes into the chart with mounted EKG Strips; yellow copy must be submitted to the nursing office (via the NM/CNS or ADN on duty.) ‘Additional instructions & resources are on the back of the form ACLS algorithms removed from form, and laminated on side of cart New Documentation Records will be placed in a clear vinyl pocket on the outside of the crash carts by supply management with cart exchange (5 forms/cart) 17. Do not use the code blue event record as a frequent vital sign sheet. CMF, 11/5/10 act Patient Sticker Code Blue / Resuscitation Form @ ()pare: TIME: $]_8] a Code si Event Frat time recorded alge] | — eal old. ‘Use one “time source” throughout event. Vial 2 i g a i ge Patont Weight elel els El ae|t I ge] 3/8) a/ 4) Siegel eel eele Time Rhythm MUST be Documented 22/8 él lt 88] 45 [85 [eo @ Csinus Tvtach Civ-ib Llasystole LSvT| LY a TE oventicus taper Sober a EM Cratos Seach Saete Cages TST EY a Eisovencua t apol Cote EN EM Coho tach Stet Crenstre OT E Wtoventicuar 7 agonal Chater EN a Soham Cvtadh Sere Cestie TST] EY ay ‘Sovewauar™ agonal Dotter SN EM Sone ora St esate OTT EY ay Ee Keovetacasr agora) Lote Sy EM Seni Cech See Caysoe DOT] CY nM ikfovedous agora ome" BN EM shoe Sarach Cots Casto DOT] OY ey E ksoveticume apona omer SN eon Cake Cich Se-ae Cages ST] SY 7 1 Elidoventicir Uaponal “eter EN ON Cena vtech See C amee SST] OY ay idovenwtuir taponel eter ON EN Cana ceiach See Camatae COT] OY ay idoveticuar agonal Cleon EN EM Sha ach Sib C agatae OT] ay E Gover ago “etter oN SN She rach Seb Ceoatae TOT] BY ay rover agen etter EN EM pos Oe Cb cate SIT] TY ay E troventicuae agonal eter EM EM clams Cleach Sete agate OSM POY 4 ES keoventicum agonal eter an EM Sram each Sve Casta STF] OY ay El esovatacdar agora ate Su EM Sema oath See Cayetoe DOTY ay Soveniar agonal © ater EM Sx Sakae ach Ss Tatas DOT] SY ay Sidoveiciar 1 agonal © ober EM EM Esha rach See Casta SOT] OY + S idoventicuar 1 agora © ober Sw GN Esra ach Stee Clenatas CVT] OY acy taoenticia taper Clete Gn EM Cshos civah Ce-as Sagete OST] OY ay F elovnttouar 3 aponal i otor EM EN ame eich Sete agate DSM OY ay FE ktovencuar 7 agonal eter y EM Fe eas it ie eae eae Now cane Gast Gwtamie Geonace PR eared Te coon tewaeame ee Ne [Pv oye Oho —— ee ites ces No eoraaytane ces Oo [ra perogitenet ves CN EctmaedtinenaresCitnieewm [Sterne enero roe HART COPY Patient Sticker DATE: 2 Document Dose and Route IV/IO ETT Document Dose of Continuous IV Infusion : Els Het lt fe] | 2 pl etl: ples [be [Pe 2 Be) tele} ER] 8] |e 2/5 jee [Ee 2 el. | 2]ele|eel8] | 2 tetslebel teal £ e|2 AA HBT) ENE] He 2) 2 (3/2 | ea] 33 [8 Se [SeHle| Hal g [Be] 5 [2 ¢ ee = Be Conic sent) Aco Sener OR tet ones oe Pi pommel ED Platsets/ PRG / FFP ea (i) 1 evel 5 es epodal pow o et ne ects (ops fo - = ass Ceca Siete © tia ean cae] OW Aone Brrr = erserme ace O Peripheral fine ‘COther (specify) ETT Size; emiip:_ Arterial tine Sessa Comet aoa comer caw iacce Gamamten one | com Patient Sticker pre. I Cem Tae camnard Rapid Response (RRT) Cardiopulmonary Arrest (CPA) pulseless or pulse with inadequate [perfusion requiring Chest Compression & or Defibrillation ‘Acute Resp. Compromise (ARC) Absent, agonal or inadequate respiration that requires emergency ventilation Geren ens lo eo Fo tae eet ieee beens Expired 0 Survived ~ Transferred to: Time: Print C4) Autopsy Requestod ‘TEAM LEADER: If patient survived, Mental Status: (] Alert [J Lethargic (7 Comatose | Staff: If patient survived: Hypothermia Protocol initiated CIES C1 NO Notified: [Attending MD Nursing Office 71 Family, Recording Nurse Signature: ‘Medication Nurse Signature: pon nie Se = cana 15%, DATE: o Patient Sticker TYPE OF CALL (all that apply) Time Call Initiated Rapid Response (RAT) (Cardiopulmor [perfusion requiring Chest Compression & or Defibrillation Arrest (CPA) pulseless or pulse with inadequate ‘Acute Resp. Compromise (ARC) Absent, agonal or inadequate respiration that requires emergency ventilation Rr Cy See aie eee D Expired © Survived ~ Tanefered to: Time: Autopsy Requested Reema crac ean ae eu If patient survived, Mental Status: © Alert (1 Lethargic Comatose | Staff: If pationt survived: Hypothermia Protocol initiated [YES C] NO. Notified: (Attending MD (3 Nursing Office Ci Family Recording Nurse Signature: Medication Nurse Signature: ‘Team Leader Signature: NURSE HANAGERIADNINU OFFICE Code Blue Debriefing Form “Confidential & required to be collected & maintained ‘pursuant to Public Health Law ‘Sections 2805 j,k and m and Education Law Section 6527" - Patient Sticker — This is not part of the Medical Record COMPLETE AND SEND Yellow copy of event record to the Nurse Manager; ADN or Nursing Office. Did the patient meet any of the following criteria within the 6 hour time frame prior to the code blue and an RRT was not called? (Chociall that apply — includes Pediato and Adul) ‘Sia Concem or “worry” about the patient ‘Acute Change in Blood Pressureiperfusion Tnereased Work of Breathing and any ofthe following: | ‘Acute change in Heart Rate ‘Worsening retractions "Tachycardia ‘Saturations < 90% despite oxygen Bradycardia ‘Uncontrolled seizures > 5 min (with altered breathing ‘Acute change in level of consciousness or agitation and/or cardiac function) Cyanosis Other Specify: Was there an opportunity to callun RRT prior to calling the Code Blue? YES or NO Piease Comment on the followings (Read carefully) NO. Coarrelive Rion Take ‘Was continuous end tidal CO2 monitoring used to monitor quality of CPR? If yes, was an end tidal CO2 value of >10 mmHg achieved? "Was arterial line diastolic pressure used to monitor compression quality? ‘Was a device or technology used to monitor compression quality? ‘Was a compression rate of about 100/minute maintained during CPR? ‘Were compressions interrupted (hands off period) for > 10 seconds at any time uring CPR? (Other than for interventions such as ET placement)? ‘Were compressions interrupted for >15 seconds (20 sec. for neonates) for interventions such as invasive alrway placement during CPR? ‘Did ventilation rate exceed 10/min (20 min for pediatric patients), excluding the initial confirmation of tracheal tube placement? ‘Was Overhead Hospital Wide Resuscitation call initiated? If yes, was there a delay? ‘Was induced Hypothermia initiated after retum of circulation achieved? | Personinel responding within 5 minutes? Physician Respiratory Therapist ‘Anesthesiologist TCU Nore ‘Nurse Manager /ADN Equipment Avaliable g ‘Ambu// Oxygen Laryngoscope Suction ‘Monitor / defibrillator [pacemaker ‘Medications Other (please write additional comments on back) ‘Time Code Blue Initiated: ‘Time Code Blue Ended: Medical ICU Residen/Code Biue Team Leader, PRINT Name: PGY-I, Print Nam PGY-2, Print Name: ‘Nurse caring for patient, Name: Code Cane ‘What recommendations, suggestions or criticisms docs the team have regarding sequence of events or conduct of the code? es Patient Sticker DATE (a) Document Dose of Continuous IV Infusion| Document Dose and Route IV/O ETT a eles| |e 3 al a Fletelftel gHHI 4] Elz g| E alg FHUMUHT RB ela g[d fila SHEEHY] [Bil E/E] erate Pane FFP oc (FP) Pulse Oxretry Cinteral poranent pacer 2 tubated 2 Epearea pacer pb _ 2 tacheostomy a revenous lo. rraosseos (0) 2 Vasopreesare Ransectanouous | tation: © Ube vnc otter VE CIV Aeceas 8y Whore: Taner Pacer ETT Sie: ‘om Confirmation Method: Pace NURSE MANAGER/ADNINU OFFICE Peripheral oe Tone ape Atal Gena venous Acco, Additional Notes related to Quality Assurance and Quality Improvement Item Time: eres ee ‘Document time for each Itorvenion or notod change In condo. ATT “Th i Bs nS Coa Toa Caados vol GU Wa eK DOX lease wile HBS ‘dont hy. Docuant tne ayihm a romps an htervenion and net the yh tat eau fom an intervonion. The thytam rsuting fom en nervnton shoud be entered into nex tional ‘Note PEA: if te pate s identified as having PEA. please it tho cartac rit onthe monitor as fey ea et anno PEA, Example oss, satel ace ae wwe anyother. Tan hole tat ne pain hao vaable pube preset i ‘Note the presence or absence of a pulse. =] Nei i is Saco ganerTNTy Te HT NOL a aNRCRUEN WH RE ETTORE TET | Tate may be wi oF without pulse a8 ned ithe ules" column. ifthe patient has an A-line, noo the blood pressure during a pause In compressions ony and nat te blood — pressure resulting from compressions. ‘Document ether M for mechanical oF « aimbec tor portaieous ST z ‘Document Yes or No Hots [55 U6, BSSUFa The i OKT Tor ie Ui a ‘st joules, assure the chim box fled out for this te ioral ei etme th pacers aio ot a pa ar ed a aoe Tay HE HO sheet, document the mAmps and rate of pacing. ms ab i sig “Assure that Vital Signs and drips al tie code ends are listed. 5 an roe wit enc dss. Use ie Ylang Oe RDB aTaone, IV = avon ET= Mecteaons! niraessious Tafusions ‘Document the medication dose in millgrame, microgramé or unis unless documenting, Normal sane should be documented in mitre. Estimated ‘Document only patients areal was winessed. Wot winessed, document as unknown. Downtime STATE UNIVERSITY OF NEW YORK ' ST@NY BR@NWK ‘UNIVERSITY HOSPIEAL Patient Sticker Code Blue / Resuscitation Form ()) pare: TIME: Code Blue Event: First time recorded ls ‘taf inital recognition of event. ‘Use one “time source” throughout event. Patient Weight: [Cimonaphasle biphasic ‘D monophasi (1 biphasic Paced Aythm Cintra External ‘Cacioverson (ule) Blood Preseure Detibitation gous) Heart Rate Respiations 0, Saturation Time Rhythm MUST be Documented (hy Tainos Cvtach Sve Casystore DSVT] ) Ciicloventicular 1 agonal 0 other [D sinus] vtach Cl vf asystore C1 SVT] C ldloventicular © agonal C1 other sinus Ci v-tach 0 vtlb © asyetore C1SVT| Cr icoventicular 6 agonal U other sinus Ci wtach Cf asyetole OST D idioventicutar D agonal © other ED sinus Ci vtach Ci ib esysiore CSV 5 ioventricular © agonal Cl other sinus CO v-tach Cw © agystcie OST D iioventricular C1 agonal 1 other sinus 0 wach vb O asystole C1 SVT) 1 icioventicuiar Ci agonal_D other 7 sinus v-tach CI wtf Cr asystole OSV) 5 idoventiicular © agonal 5 other sinus 0 v-tach Cv C asysisle LIST D idoventicular 1 agonal C ether sinus O vtach 2 vf Cl asysioe OSV 5 idoventicuiar G agonal Gather sinus Cl wtach C1 vo Cr asystore C1 SVT ifoventicular C agonal © other [Ci sinus 0 v-tach Chet © asystole LTS Tiicioventricular G agonal D ather sinus Ci v-iach Cv Cl asystoie OST S icioventictiar © agonal Clother [esis Co v-tach CI wb C1 aayetole LT SVT | iieventrcular © agonal 5 other sinus Ci v-tach Cl v-tb D asyatore SVT Dr idioventicular 1 agonal 1 ether sinus Ci v-tach CI vb 2 aaystole DST D idoventicuiar 6 agonal 0 other sinus wtach O wt Cl esystele OST] CY ofc Puce Present? 2

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