Code blue is perhaps the most popular codes used in hospital for managing emergency

situation. Code blue is a code given to identify and communicate that a medical emergency, of
the nature of cardiac arrest, has occurred and the patient needs to be attended immediately for
life saving measures. Since it deals with the life threatening situation, swift and coordinated
action by a team of professionals is of paramount importance. This calls for designing and
implementing a highly efficient system, which can work in round the clock and can cover entire
hospital. This posts elaborate on all considerations that should be made while designing a code
blue system. Also check code blue form and crash cart checklist along-with this post.

1. Forming of a code blue team: The code blue team is at the core of entire system. This is a
team of trained professionals who can competently provide life saving measures to a patient
under medical emergency. Following are the roles required within the team with a suggested
person who could be given that role. Hospitals can however, modify this as per their staffing
structure and hospital’s layout

Role Who can perform

Calling (activating) the code This can be any one who identifies the situation and
activates the code blue. As it could be any healthcare
staff they are not a part of code blue team
Initial action before the code blue team This can be done by the caller of the code along with
reaches on the spot – This includes other secondary nurse available in the area. (In a
bringing patient’s medical record, bring hospital all nurses and healthcare staff should be
the crash cart trolley, positioning the trained on basic life support and CPR)
patient and start with CPR
Airway management, bag mask A doctor, preferably from ICU or anaesthesia
ventilation, suctioning of the airway and department
assistance to anaesthesia in case of
intubation
Application of defibrillator pads, ensuring Nurse 1 (preferably from critical care department). This
proper position of the patient person can also be given role of recording the events
for future analysis.
Continuation of CPR measures, use of A doctor, preferably from anaesthesia department
defibrillator, conducting anaesthesia or
intubation if required.
Preparation and handing over medication Nurse 2
from the cart
Putting in IV and administering medication Nurse 3
received from crash cart
Leading the team, taking quick decisions, Team leader – generally a physician from critical care
manage situation and help with or emergency department
defibrillator, anaesthesia and intubation
part

*  The team members should be identified and they should be communicated about their roles
during code blue.
*  The team should consist of at-least 5 members to effectively handle critical functions
*  At-least one member in the team should be certified in ACLS. All members in team should be
trained in BLS.
   

2.       Number of code blue teams – Since the code blue team is required round the clock, the
number of teams should be at-least 3 to cater for in each shift. In case of large hospitals,
multiple teams can be formed with their specified coverage area

3.       Communication of code – One essential objective of code blue system is to ensure that every
code blue team member should immediately get to know about the occurrence of the medical
emergency. There are several ways in which this could be done

a.       Calling number and announcement: In this there is a dedicated internal telephone number
(like 111) which is used only for informing code blue. The number when dialed rings at
telephone operator (or a dedicated place with round the clock presence of a person who will
receive the call). The instrument that receives the call from dedicated number is exclusive and
will never be busy with any other line. A standard statement is used for communicating code
blue, such as ‘Code blue – ward no. 22’. The receiver of the call (the telephone operator) also
has a public announcement system. As soon as he receives a code blue call, he announces the
same in public announcement system and all code blue team members, wherever they are
working, get to know about the code. As soon as they here the announcement they immediately
move towards the location and perform their role. One objective of code blue system is to
ensure that code blue team reach the point of event quickly (within 1 minute) of .

b.       Pager system: In this all code blue team members on duty carries a pager. There is a
dedicated telephone number as explained above. Instead of making a public announcement the
receiver of code blue call just page it to all team members at one go. The pager beeps
indicating to holder that a code has been called
c.       Push button switch: In this, a code blue switch is installed in each patient area. The switch
when pressed sends an indication to all code blue team member about the location where the
emergency has occurred

4.       Crash cart – Crash cart is a trolley that consist of all necessary medicines, equipment and
instruments that may be required for carrying out BLS and ACLS measures. 

5.       Trainings – There are two types of training that is required. One for the code blue team
members and one for all healthcare staff in the hospitals

a.       For code blue team – The code blue team should be trained on following
                                             i.      Orientationto code blue system
                                            ii.      The communication system under code blue
                                          iii.      Crash cart and its usage
                                          iv.      Basic life support techniques, including CPR
                                            v.      At-least one member to be trained and certified in Advanced Life Support technique

b.       For all other staff

                                             i.      Orientationto code blue system
                                            ii.      When and how to activate code blue
                                          iii.      Basic Life support including CPR
                                          iv.      Familiarization with crash cart

6.       Mock drill: Since code blue requires a highly coordinated activity mock drill of code blue
should be done regularly to ensure that the system is functioning. For mock drill, a nurse
 assume that a patient has collapsed and activates code blue. An observer is placed to observe
and record everything that happens on activation on code. The observations are then reviewed
to identify if every thing happened as planned or whether there was deviation. Based on mock
drill findings, necessary training are provided

7.       Documentation of code blue event – It is important to document critical actions and

happenings during the code blue event. These records are used for multiple purpose, including
doing a post-event analysis. One of the team member take the role of the recorder. A standard
form that captures necessary data should be used for documenting each code blue event.

8.       Post event analysis: A post event analysis should be done for each code blue event to assess
if everything required was done and if there were any major or minor deviations from the code
blue protocol

9.       Quality indicators: Few indicators that can be used for evaluating whether or not the code
blue system is working efficiently and effectively, are given below

a.       Average time to respond – The time from activation of code blue till the time when the
1st member of code blue team reach on spot
b.      Outcome percentage – Percentage of patients’ survived out of total who went under cardiac
arrest
c.       Non- compliance rate – Percentage of non-compliance to standard process of code blue
system
d.      Failure to activate – Percentage of times when code blue was not activated, when required