Kyollo
ASH/CRA/QL/07 CODE BLUE ANALYSIS FORM
(Not part of the case file-to be used for quality improvement)
(Those marked with is applicable for analysis of mock drills)
"Date &time of activating Code Blue: 30- 0l-2025
Admitting Consuitant R. RAJAEESH SAIVASTAvA
OI TH PuLMONARy EDEMA
Diagnosis:LRTI wITH RESPIRA TMOR4 TNSIDN 1TH SCITIS, ENTeRI
"Code Blke dctivate8 bù.
Reason for activating Code Blue: No pulCE, NO RESPOSC
PATIENT DETAILS:
1. Any Comorbid condition? Y/NIf Y- details:
2. Any significant pre code event such as surgeryiprocedure/high alert drug administration/Code Orange
activated?: Y/N If Y-details:
3. Could the cade have been avoided: Y/NI If Y-details
NO
EVENT:
1. "Notification / Paging: Code blue on PA system / tel call: S33
2. "Arival of team: 3:Spm. minutes
3. Compressions started in: | minutes
4 *initial rhythm: No RHYTM
5 Essential Intervention:
CPR/Defibrillation: CPR eo1TH DEfEA,
6. Airway: Ambu/ETT:
7 Defibrillator:
Joules/NA
OUR NETWORK: AMRITSAR|BANGALORE CHENNAI |
oVuS [Link] GURGAON | HYDERABAD | NEW DELHI | PUNE
rite to us
[Link]
ASHICTRL/IP/0018
Please Label Here
If label in not available, write
CODE BLUE
RUNNING SHEET Apollo Spectra
PL Name, IP NoUHID NG LIVE
Age, Sex, Date, Nane of'Treating 1"hysiciat
Date of Activation Patient Name Mek D .
Time of Activatian am/pm
IPNOUHID Malk ill Age Sex
D
Admiting Diagnosis Mce
Location (room/ward)
Activated by
DYes No
Was a hospital-wide resuscitation response activated?
Witnessed: J Yes No
Time of Initiation of BLS am/pm
Time of Initiation of ACLS am/pm
Response Time (Activation to Initiation)
Airway ! Ventilation Circulation
At Onsat Spantaneous Apnea Assited Firs: Docurmentd Rhythm
Time of First Assisted Ventilation Time Chest Compression were Started
ETT Intubation : Time Size Patient DefibrillatedYes Nol
By Whom If Yes : Time of first Shock
Bolus Dose Infusions Dobutaminedose / cc per
Dopamine
Time IRhythm Dose
Comments :
Le
E PeriphetallCenttal Line
BP
Chest tube, Vital
Slgns, Response to
Interventions
muns
|05
Tins
10
mins
mins /8
20
|mins
|30
mins
40
mins
60
Mmins
Outcome
Resuscitaion Event Ended at
eason Resuscitalion Ended, Status Alive Dead
Return of circulation æEforts Terminated
Dtedical Futility DAdvance Directives
Recorder's Name.
Recorder's Signature
Physician's Signature Maele De .1. Physician's Name
Team Members (Name & Signature) 2. DR RO
Ram 6 eelam
Apolo
ASH/CRA/QL/07
CODE BLUE ANALYSIS FORM
(Not part of the case file-to be used for quality improvement)
(Those marked with is applicable for analysis of mock drills)
"Date & time of activating Code Blue:
9-l-25
Admitting Consultant: Mak ill.
Diagnosis:
*Code Blue activated by:
"Reason for activating Code Blue:
PATIENT DETAILS:
1. Any comorbid condition? Y/N If Y- details:
2. Any significant pre code event such as surgery/procedure/high alert drug administration/Code Orange
activated?: Y/N IfY-details:
3. Could the code have been avoided: YIN If Y-details: NU:
EVENT:
1. "Notification / Paging Code blue on PA system / tel call: 33z
2. 'Arrival of team: minutes
3. *Cornpressions started in: l minutes
4. "Initial rhythm:
5. Essential Intervention: CPR/Defibrillation:
6. Airway: Ambu/ETT:
7. Defibrillator:
Joules/NA
OUR NETWORK: AMRITSAR| BANGALORE | CHENNAI | GURGAON I
HYDERALAD NEW DELH! | PUNE
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contactus([Link]
8. Vascular access: [Link]?: YIN: YES
9. Medications given -list:
10."Protocol followedYN: If N-details
11. "Equipment availableYIN: If N-details
12. *Team function goad ¥NE If N-details:
13. 'Safely precautions followed: Y/N: If N-details: yeS
LOIH ReTPIRATD Ry PATuec
14. "Documentation gone YN LRIT NTERIC
CARTED
15. Cause of Death:
RESPIRA TORY [Link]*,
*EVENT TIMES:
Collapse to beginning of CPR: 356prm
Collapse to first defibrillation: 4-olpm
Collapse to first epinephrine: 3:58 pM
Collapse to first atropine: N0
OUTCOME:
ROSC (Return of Spontaneous Circulation: YIN
DispositioaExpired/transferred to other hospitaldischarged alive: xeRED
Neuro Status:
Length of Stay:
Conducted by: Dr
Form filled by
Minaka
Analysis done by: Code Blu Comoile
8. Vascular access: Y/[Link]?: Y/N: Aodabicautonale
9. Medications given -list:
N-details
10. "Protocol followed: Y/N: If
N-details
11. "Equipment availableYN: If
Aetails:
12. "Team function good: YIN If
N-details:
13. *Safely precautions followed: Y/N: If
14. 'Documentation done: Y/N: p
15. Cause of Death:
*EVENT TIMES:
Collapse to beginning of CPR:
Collapse to first defibrillation:
Collapse to first epinephrine
Collapse to first atropine: No.
oUTCOME:
of Spontaneous Circulation: YIN
ROSC (Return
Disposition: Expired/transferfed to other hospitaldischarged alive:
Neuro Status:
Length of Stay:
Conducted by: Dr Mlk il,
Form filled by Minet
Analysis done by: Code Ble Comm ttee
ASH/CTRLIP/0018
Pleave Label flere
If label
Pr Nam
Age, Sex Dt Name
n not
S No UIID
available, wTite
of Treating Physican
CODE BLUE
RUNNING SHEET Apollo Spectra
TOUCHING LIVES
Date of Activation
Time of Activation Patient NameMR. 8HRI- KR13HAN
355 am/pm PNo./UHIDSHIPy 6/Sy Ago8YLsex Madb
Location (room/ward) C
Activated by 3.560m f0&TAf£ Admitting DiagnosisRTI OITH
Was a hospital-wide resuscitation response activated? Yes No CA AD1T7H PoRTEtHYReR
Witnessed Yes No CHOdELI THIS| s.
Time of Initiation of BLS
3-52pm am/pm
Time of Initiation of ACLS
Response Time
3:55pro am/pm
(Activation to Initiation)
Airway IVentilation Circulation
At Onset Soontaneous Apnea Assiled First Documentd Rhythm
Time of First Assisted Ventilation Time Chest Comnpression were Started
ETT Intubation,: TimeZ02S Sizo sC1. Patient Defibrillatedes No
By Whom Doc7ok If Yes : Time of first Shock
Bolu: Infusions Dobutaminedase / cc per
Tirng Dopamine Commeents
Periphera/Centtal Line
BE t he Vital
Signs, Response to
lnterventions
mins R R
10
20
25
mins NIA
ins TA
50
mins
Rosuscitalon Event Ended at Outcome
Reason Resuscitation Ended Status Alive
O Return of circulation
O Med1cal Futilty U Eforts Terminated
Advance Directives
Recorder's Name
Miakol Recorder's Signature
Physician's Signature
1, Physician's Name
Team Members (Name &Signature) 2 UY
Hith
AlareadL
Kollo
ASH/CRA/QL/07 CODE BLUE ANALYSIS FORM
for quality improvement)
(Not part of the case file-to be usedfor
(Those marked with is applicable analysis of mock drills)
2- 23
"Date &time of activating Code Blue:
Admitting Consultant:
Diagnosis:
"Code Blue activated by:
"Reason for activating Code Blue:
No pulat no keaptnse
PATIENT DETAILS:
1. Any comorbid condition? YIN If Y- details:
JAauing kidny
2. Any significaDt pre code event such as surgery/procedure/high alert drug administration/Code Orange
activated?: Y/N If Y-details:
3. Could the code have been avoided: Y/N/ If Y-details: No
EVENT:
1. 'Notification / Paging: Code blue on PA system / tel call. 3
2. "Arival of team:. pn minutes
3. Compressions started in: minutes
4. "Initial rhythm: No
5. Essential Intervention:
CPR/Defibfillation:[PK +
yibaillaha
6. Airway: Ambu/ETT
mbu
7. Defibrillator:
Joules/NA
OUR NETVIORK: AMRITSAR| BANGALORE J CHENNAI |
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[Link] ir te t0 us
[Link]
8. Vascular access: Y/N. Adequate?: YIN:
9. Medications given -list:
10."Protocol followed: YIN: If N-details
11. 'Equipment available Y/N: If N-details
12. "Team function gooY/N: If N-details:
13. 'Safety precautions followed: Y/N: If N-details:
14. "Documentation done: Y/N:
15. Cause of Death:
*EVENT TIMES:
Collapse to beginning of CPR:
Collapse to first defibrillation:
Collapse to first epinephrine:
Collapse to first atropine:
OUTCOME:
ROSC (Return of
Spontaneous Circulation: YIN
Dispos1tion: Expired/transferred to other hospitalldischarged alive:
Neuro Status:
Length of Stay
Conducted by: Dr
Form filled by:
Miakl
Analysis done by Crll klue lomnitlee
ASHICTRUIP/0018
Please Label Here
CODE BLUE
If label in not available, write
P Name, IP [Link]
Age. Sex. Date. Nane of Treating Physician
RUNNING SHEET Apollo Spectra
TOUCHING LIES
Date of Activation:3-2-2
Time of Activation : ): bp
am/pm
Patient Name
Maek ill
Location (room/ward) B IPNO./UHID_Nek [Link] Sex
Aclivated by y:oSpn. t0AL Admiting Diagnosis Metle Dll
Was a hospital-wide resuscitation response activated? Yes DNo
Witnessed: Yes No
Time of Initiation of BLS
am/pm
Time of Initiation of ACLS
am/pm
Response Time
(Activation to Initiation)
Airway| Ventilation
Circulation
At Onset
Spontaneous Apnea Assited First Documentd Rhythm
Time of First Assisted Ventilation
Time Chest Compression were Started
ETT Intubation : Fime Size_ Pat1ent Defibrillated Yes No
By Whom Doclon If Yes: Time of first Shock
Holus Dose
Infusions dose cc per
Tirng
kuo,eidseg Comments
PetpheralCentral Line
BE Plucernent, I0
Signs Re
Inlerventions
mins
10
mins o
o 94D
20
il cheste
30
|ins
40
mins
|60
mins
Resuscitaion
Reason Ren Event Ended at40 on Outcome
Suscitation Ended
Slatus : HAlive
GReturn of circulation Dead
Medical Futility Etorts Terminated
Advance Directives
Recorder's Name Minakal
Physician's Signature
.Recorder's Signature
Hetk dull 1. Physician's Name
Team Members (ame &Signature) 2
_DR. K. M o r
Haigh
Aubkagt
