Document Title: CPR POLICY Document ID: Issue No:07
1 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
CONTROL OF THE MANUAL / POLICY
Holder: The holder of the copy of this manual / policy is responsible for maintaining it in good and safe condition
and in a readily identifiable and retrievable manner. The holder of the copy of this Manual / policy shall maintain
it in status by inserting latest amendments as and when the amended versions are received.
Issuing: Senior Quality Executive is responsible for issuing the amended copies to the copyholders, the
copyholder should acknowledge the same and he /she should return the obsolete copies to the Senior Quality
Executive.
Review: The manual / policy is reviewed annually or after any process changes and is updated as relevant to the
hospital policies and procedures. Review and amendment can happen also as corrective actions to the non-
conformities raised during the self-assessment or assessment audits by accreditation bodies. Every revision is
logged and tracked. Revision history is recorded on the document header.
Responsibility:
Designation Responsibility
Deputy Quality Manager Overall control and coordination of document management
Department Heads Review, request updates, and ensure department-level control
Senior Quality Executive Maintain master list, issue documents, archive old versions
Distribution: The manual / policy with original signatures is considered as ‘Master Copy’, and the photocopies
of the master copy for the distribution are considered as ‘Controlled Copy’. Only controlled copies (hard copy or
digital) are distributed.
Obsolete Documents: Obsolete versions are stamped “OBSOLETE” and archived. They must be removed from
circulation immediately to prevent accidental use.
Retention Period: All controlled documents and records are retained for a minimum of 5 years (or as per
regulatory requirement).
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
2 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
DISTRIBUTION LIST
Copy Mode of Date of
Department/ Unit Designation/ Recipient
Number distribution distribution
1 Quality Department Deputy Quality Manager Soft Copy 01-06-2025
2 Medical Admin Medical Superintendent I Soft Copy 01-06-2025
3 Nursing Admin GM Nursing Soft Copy 01-06-2025
4 All ICUs Nursing In-charge Soft Copy 01-06-2025
5 All Wards Nursing In-charge Soft Copy 01-06-2025
6 Cath Lab Cath Lab In-charge Soft Copy 01-06-2025
7 Dialysis Dialysis In-charge Soft Copy 01-06-2025
8 Operation Theatre OT Manager
Soft Copy 01-06-2025
All OT In-charge
9 Radiology Department Radiation Safety Officer Soft Copy 01-06-2025
10 Medical Technologist MT In-charge Soft Copy 01-06-2025
11 Pathology Department Lab Director Soft Copy 01-06-2025
Central Sterile Supply
12 CSSD In-charge Soft Copy 01-06-2025
Department
13 Bronchoscopy Department Bronchoscopy In-charge Soft Copy 01-06-2025
Gastroenterology Consultant
14 Soft Copy 01-06-2025
Department Gastroenterologist
15 Human Resources AGM HR Soft Copy 01-06-2025
16 Emergency Department HOD Emergency Soft Copy 01-06-2025
17 Pharmacy Department Supply Chain Manager Soft Copy 01-06-2025
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
3 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
AMENDMENT SHEET
Sl. Date of Reviewed &
Amendment details Reason for amendment
No amendment approved by
1. Reviewed but no changes required - 12-12-2019
2. Modification of Code Blue Team As per Requirement 18-12-2020
3. Modification of Terms of Reference As per Requirement 16-12-2021
4. Modified of Crash Cart Policy As per Requirement 20-12-2022
5. Reviewed but no changes required - 24-12-2023
6. Reviewed but no changes required - 21-12-2024
Added CPR Protocol and PALS
7. - 18-05-2025
Protocol
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
4 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
TABLE OF CONTENTS
SI. NO TOPIC PAGE NO
1. Introduction 5 of 16
2. Policy 5 of 16
3. Procedures for code blue structure and response 5 of 16
4. Recognizing and announcing code blue 5 of 16 - 6 of 16
5. Code Blue team responsibilities 6 of 16 -7 of 16
6. CPR termination 7 of 16
7. Code Blue documentation 7 of 16
8. CPR training 8 of 16
9. CPR Committee 8 of 16
10. CPR Committee Responsibilities 8 of 16
11. Terms of reference 8 of 16 - 10 of 16
12. Crash Cart policy 10 of 16
13. CPR Protocol 11 of 16 - 12 of 16
14. PALS Protocol 13 of 16
15. Annexure 14 of 16 - 15 of 16
16. Abbreviation 16 of 16
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
5 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
INTRODUCTION:
The purpose of Life Support is to maintain adequate ventilation and circulation for saving a patient’s life
and provide continuity of patient care in a safe, integrated patient care environment in case of
cardiopulmonary arrest in hospital.
Failure of the circulation for a few minutes might lead to irreversible cerebral damage with hypoxic injury.
Delay even within that time will lessen the eventual chances of a successful outcome of the patient.
Emphasis must therefore be placed on rapid institution of life support.
POLICY:
Resuscitation team should respond within seconds of any "CODE BLUE" call, anywhere in the hospital.
A weekly roster of code blue team with a back up team is available in each ward.
Life Support in CHPL will be provided by qualified personnel of theteam.
The Healthcare providers in CHPL should adhere to the current BLS,ACLS guidelines.
PROCEDURES:
CODE BLUE STRUCTURE AND RESPONSE:
Team Members of the Code Blue Team will be divided as Team A and Team B for back up as per weekly
roster.
ACLS trained Critical Care Registrar /Senior Residenton-duty is the Code Blue Team Leader for Adult
Codes.
ACLS trained Physician on-duty is the Code Blue Team Member for all Codes.
ICU Technologist.
ACLS trained Medical/Critical Care Technologists on-duty is aCode Blue Team Member for all Codes.
Ward in-charge Nurse is a Code Blue Team Member for Codes in his/her ward.
Staff Nurse of the coded patient is a Code Blue Team Member.
RECOGNIZING AND ANNOUNCING CODE BLUE:
The First Responder has to do these steps systematically:
Assess the victim's response.
Then check pulse & breathing simultaneously.
For an unresponsive victim, shout loudly, "CODE BLUE".
Call the Emergency number (8000), orinstruct another member of staff to call if available.
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
6 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
Instruct the operator: "Code Blue: Adult/ Pediatric
Start – BLS
Example: Dial 8000 - "Code Blue -The location..."
Acquire the CPR Board put on the bed or put the bed on the CPR board and start CPR.
Other Healthcare providers will bring the crash cart and assist as appropriate.
2 rescuer CPR continues until the hospital Code Blue Team arrives.
Switchboard operator has to do these steps systematically:
Announces the Code Blue through the overhead paging system, Repeated thrice.
Example: Dial 8000 - "Code Blue -The location..."
CODE BLUE TEAM RESPONSIBILITIES:
Cardiac monitor/ Defibrillator is connected to allow rhythm based ACLS management.
As per ACLS protocol ACC to AHA the CPR must be organized around 2 minutes of uninterrupted CPR.
First responder on the scene leads the code until theCode Blue Team leader arrives.
TEAM LEADER:
The ACLS/PALS Code Blue Team leader may transfer the leadership over to a more experienced
physician.
The ACLS/PALS Code Blue Team leader assigns the Code Blue team members with clear roles and
responsibilities.
The ACLS/PALS Code Blue Team leader monitors individual performance of the Code Blue Team
members and provides assistance and guidance to the team members.
The ACLS/PALS Code Blue Team leader ensures high quality CPR and early appropriate defibrillation.
After ROSC (Return of spontaneous circulation), the Code Blue Team leader should notify the ICU Staff
and the coded patient is then escorted by the Resident on duty to the ICU if bed is available.
The Code blue team leader should hand over the case to the treating team for continuity of care.
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
7 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
RESIDENT ON-DUTY:
The Code Blue Team Members assist in providing high quality CPR and early defibrillation.
PHYSICIAN ON-DUTY:
ACLS Trained Physician on-duty has to establish and maintain secured airway.
ACLS Trained Physician on-duty helps in gaining access to circulation (peripheral or central venous or
intra osseous circulation).
RESPIRATORY THERAPIST:
Respiratory Therapist assists in the management of airway andventilation.
INCHARGE NURSE:
Ward in-charge nurse records the events in the CPR Record Form and alerts the team every 2 minutes.
In charge nurse ensures all Code members arrive on time.
STAFF NURSE:
Other Nursing personnel respond to Code Blue calls in their unit and assist in 2 rescuer CPR and drug
administration, to be responsible for IV insertion & medication.
CPR TERMINATION:
In the event of ROSC (Return of spontaneous circulation) being unachievable, it is highly recommended that the
Code Blue Team Leader seeks consensus from all the Code Blue Team Members before CPR is terminated,
however the final decision to terminate the CPR remains with the Code Blue Team Leader as per guidelines.
CODE BLUE DOCUMENTATION:
The CPR Record Sheet is completed by the Recorder of the Code Blue Team. This is a real time Recording.
The Code Blue Team Leader reviews and signs the sheet.
The CPR Record Sheet is kept in the patient's medical records.
A copy of this sheet is also forwarded to the CPR Committee.
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
8 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
STAFF CPR TRAINING REQUIREMENTS:
All Healthcare providers are required to have BLS training and should hold a valid BLS certificate.
The Code Blue Team Members are required to have ACLS training and should hold valid certificates.
The BLS, ACLS certification is renewed every two years.
CPR COMMITTEE:
Medical Superintendent II
Registrar, Critical Care
HOD Emergency
Sr. General Manager Nursing
Anesthesiologist
Quality Manager
Deputy Quality Manager
Infection Control Nurse
In charge, MT
HR Executive (Quality)
Chairperson- Medical Superintendent II
Convener- Registrar, Critical care
Frequency- Monthly and as & when required
Quorum: Minimum 70% of members
The chairman shall have the authority to invite any non-member to attend the meeting, if it is deemed fit in relation
to any matter being/ or to be deliberated by the committee.
CPR COMMITTEE RESPONSIBILITIES:
Reviews all completed Code Blue forms, and implements or recommends corrective actions.
Reviews crash cart contents and drugs, and recommends additions or deletions to the contents.
Reviews and updates CPR Policy and Procedure as required based on regularly collated data any evidence-
based guidance.
To Ensure training for all staff on CPR and to ensure that they understand their roles and responsibilities.
TERMS OF REFERENCE:
Agenda
Agendas for the meeting shall be prepared by the convener in consultation with the chair person and signed by
the chair. Then it is sent to all committee members and other experts. The agenda shall be sent to all at least 2
days before the scheduled meeting.
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
9 of 16 CH/ NABH/POLICY/CPR/24
Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
A meeting shall be called even by an oral / telephonic communication in case of an emergency meeting. A
justification for the emergency meeting has to be given.
Minutes
•Shall be prepared by the convener
•MOM is sent to the chairperson for the approval.
•After the approval of the minutes by the chairperson, the approved minutes are circulated within 2 days of the
meeting to all the committee members and the person concerned for implementation.
•A copy of the agenda and minutes of every meeting shall be kept at the quality department.
Role of Chairperson
Acts as a liaison between the CPR committee members and the hospital administration.
Receives all the surveillance reports and information pertaining to CPR/Code blue, initiate necessary action
based on the reports.
Keep oneself abreast with the recent developments in the field.
Role of Convener
•Prepare the agenda for the next meeting.
•Submission for approval of agenda by the chairperson.
•Inform the committee members regarding the next meeting at least 2 days before the meeting.
•The minutes of meeting shall be prepared by the convener.
•Get the approval of minutes by the chairperson.
•Circulate the agenda approved by the chair person to the members and the concerned persons.
•To maintain all records (as per list) related to the committee.
•Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting
signature from all the concerned members.
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
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16 Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
Decision making
•A thorough discussion of the agenda shall be done by the committee members and based on their suggestion and
recommendations the issue shall be weighed. Also as and when needed any kind of trial study may be performed
and based on the outcome of it the committee will decide on that issue.
•The decision of the committee will be finally taken by a majority vote and that shall be implemented.
Records to be maintained
1. List and details of all members
2. The TOR of the committee
3. Copy of all agendas, minutes of all meeting
4. Attendance sheet
5. Copy of any other correspondence to the committee members or non-members
6. Copy of any study conducted for the sake of the committee
CRASH CART POLICY:
Refer to: CH/ NABH / POLICY / CRASH CART /60
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
11 of CH/ NABH/POLICY/CPR/24
16 Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
CPR Protocol:
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
12 of CH/ NABH/POLICY/CPR/24
16 Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
13 of CH/ NABH/POLICY/CPR/24
16 Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
PALS Protocol:
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
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16 Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
ANNEXURE
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
15 of CH/ NABH/POLICY/CPR/24
16 Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
Document Title: CPR POLICY Document ID: Issue No:07
16 of CH/ NABH/POLICY/CPR/24
16 Classification: Internal Department Name: Critical Care
Date of Implementation 15-11-2018 Date of Revision 18-05-2025
ABBREVIATIONS:
ICU Intensive Care Unit
OT Operation Theatre
CPR Cardiopulmonary Resuscitation
PALS Pediatric Advanced Life Support
BLS Basic Life Support
ACLS Advanced Cardiovascular Life Support
MOM Minutes of Meeting
TOR Terms of Reference
NABH National Accreditation Board for Hospitals and Healthcare Providers
IV Intravenous
IO Intraosseous
Name Designation Signature Date
Approved by: Dr. Satabdi Sadhukhan Medical Superintendent-II 18-05-2025
Prepared by: Dr. Sharmistha Chatterjee In charge Critical Care 18-05-2025
