UNIVERSITY HEALTH NETWORK

PRESENTS

PROTECTED CODE BLUES

A STAFF TRAINING VIDEO
• AT UHN A “PROTECTED CODE BLUE” WILL BE CALLED WHEN A PERSON UNDER
INVESTIGATION OR A PATIENT CONFIRMED TO HAVE A KNOWN OR EMERGING
VIRAL ILLNESS SUFFERS A RESPIRATORY OR CARDIAC ARREST

• MAINTAINING INFECTION CONTROL PROCEDURES IS CRITICAL TO

PROTECT STAFF AND PREVENT THE SPREAD OF ILLNESS IN HOSPITAL
DURING ALL ATTEMPTS TO RESUSCITATE PATIENTS

• THIS VIDEO WILL REVIEW PROPER PROCEDURES FOR STAFF TO FOLLOW IN THE
EVENT OF A CODE BLUE ON PATIENTS SUSPECTED OR CONFIRMED TO HAVE
KNOWN OR EMERGING VIRAL RESPIRATORY INFECTIONS ON INPATIENT UNITS
ACTIVATION
 CALLING THE PROTECTED CODE BLUE
• THE CODE MUST BE ACTIVATED BY CALLING EXTENSION 5555 AND STATING “PROTECTED CODE
BLUE” AND IDENTIFYING THE LOCATION.  

• FOR TGH AND TWH, SWITCHBOARD WILL PAGE THE CODE BLUE TEAM AND MAKE AN OVERHEAD
ANNOUNCEMENT, CALLING “PROTECTED CODE BLUE,” ALONG WITH THE LOCATION.

• FOR PM, UHN SWITCHBOARD WILL ALSO NOTIFY SINAI HEALTH SYSTEM SWITCHBOARD AND NOTIFY THEM
OF THE LOCATION OF THE PROTECTED CODE BLUE AT PM.

• IN THE EMERGENCY DEPARTMENTS, A PROTECTED CODE BLUE WILL ONLY BE CALLED FOR ADMITTED
PATIENTS WHO ARE UNDER INVESTIGATION OR CONFIRMED TO HAVE AN EMERGING ILLNESS
• IN THE INTENSIVE CARE UNITS, ALL PROTECTED CODE BLUES WILL BE RESUSCITATED BY THE ICU TEAM
AS PER USUAL EXISTING CODE BLUE RESUSCITATION PRACTICES ·       
ARRIVAL AT THE SCENE OF THE
CODE
 PROTECTED CODE BLUE
PERSONAL PROTECTIVE
EQUIPMENT

RED BOX LOCATED ON EACH INPATIENT WARD

AT TIME OF CODE
MUST BE BROUGHT TO THE PATIENT’S ROOM
REMAINS IN HALLWAY
 PROTECTED CODE BLUE
PERSONAL PROTECTIVE EQUIPMENT
 PERSONAL PROTECTIVE EQUIPMENT
(PPE)

HEALTH CARE WORKERS MUST USE THE FOLLOWING PPE DURING A

PROTECTED CODE BLUE:
• LEVEL II GOWN (YELLOW, NON-STERILE, FLUID RESISTANT, LONG SLEEVED)
• EXTENDED CUFF GLOVES
• THEIR FIT-TESTED N95 RESPIRATOR
• FULL-FACE SHIELD WITH PROTECTIVE DRAPE
• HAIR NET IF DESIRED IF HAIR IMPEDES VISION/INTUBATION FIELD
 PROPER PPE DONNING SEQUENCE
• 1. HAND HYGIENE:
• TO BEGIN, REMOVE JEWELLERY AND WATCH, IF APPLICABLE.
• TIE LONG HAIR WITH AN ELASTIC OR BOUFFANT CAP.
• WASH HANDS WITH ALCOHOL BASED SANITIZER BY RUBBING HANDS FOR A MINIMUM OF 15 SECONDS.
• ENSURE COVERAGE BETWEEN FINGERS, AROUND AND UNDER NAILS, ON PALMS, BACK OF HANDS, AND
WRISTS. CONTINUE RUBBING UNTIL DRY.

• 2. GOWN
• TAKE A FLUID RESISTANT ISOLATION GOWN FROM THE ISOLATION CART.
• PERFORM A VISUAL INSPECTION TO ENSURE THERE IS NO DAMAGE.
• WHEN PUTTING ON THE GOWN, ENSURE THAT BOTH THE NECK AND MID-BACK TIES ARE TIED AS
TIGHTLY AS POSSIBLE SO THAT CLOTHING IS FULLY COVERED AND GOWN DOES NOT DRAPE
WHEN PROVIDING CARE.
 PROPER PPE DONNING SEQUENCE

• 3. RESPIRATOR
• SELECT YOUR FIT-TESTED N95 RESPIRATOR. IF YOU HAVE LONG HAIR, TIE YOUR HAIR BACK WITH A HAIR TIE OR BOUFFANT CAP BEFORE
PUTTING ON THE RESPIRATOR.
• PLACE THE RESPIRATOR OVER YOUR NOSE AND MOUTH. PULL THE BOTTOM ELASTIC OVER YOUR HEAD FIRST AND PLACE IT ON THE BACK OF
YOUR NECK ON BARE SKIN. THEN PULL THE TOP ELASTIC OVER AND PLACE IT AT THE CROWN OF YOUR HEAD.
• WITH YOUR FINGERS, FIRMLY MOLD THE METAL STRIP AROUND YOUR NOSE TO ENSURE THE RESPIRATOR IS SEALED TO YOUR FACE.
• PERFORM A SEAL CHECK BY QUICKLY INHALING AND EXHALING. IF YOU FEEL AIR ESCAPING AROUND THE EDGES OF THE RESPIRATOR, MOLD
THE METAL STRIP AROUND YOUR NOSE AGAIN TO ADJUST THE FIT.

• 4. FACE SHIELD
• TAKE A FACE SHIELD WITH A BIB. IF THERE IS A FILM, PEEL OFF THE FILM.
• PLACE THE FOAM STRIP ON YOUR FOREHEAD AND PULL THE ELASTIC AROUND THE BACK OF YOUR HEAD. ENSURE THAT THE FOAM STRIP IS
ON THE MIDDLE OF YOUR FOREHEAD SO THAT THE FACE SHIELD SITS PROPERLY ON YOUR FACE.
• PINCH THE BIB TO ENSURE YOUR CHIN AND NECK ARE PROPERLY SHIELDED
 PROPER PPE DONNING SEQUENCE

• 5. GLOVES
• PUT ON YOUR EXTENDED CUFF GLOVES. PULL THE GLOVES OVER THE CUFFS OF THE
GOWN SO THAT YOUR WRISTS ARE FULLY COVERED.
 

• 6. ID BADGE
• TAKE THE ID BADGE THAT CORRECTLY IDENTIFIES YOUR ROLE FROM THE SAFETY
LEADER
• PIN THE ID BADGE TO YOUR GOWN
• YOU ARE NOW READY TO ENTER THE ROOM
 DESIGNATED SAFETY LEADER

• A DESIGNATED SAFETY LEADER – USUALLY THE CHARGE NURSE OR DESIGNATE- WILL ASSESS EACH CODE
BLUE TEAM MEMBER FOR ANY BREACHES IN DONNING PPE

• THE SAFETY LEADER WILL MAINTAIN A STAFF ENTRY LOG TO DOCUMENT NAMES AND CONTACT INFORMATION
FOR ALL STAFF ENTERING THE ROOM

• THE SAFETY LEADER WILL ENSURE ANY VISITORS PRESENT AT THE TIME OF THE CODE EXIT THE ROOM
AND FOLLOW PROPER DOFFING PROCEDURES

• ONCE THE CODE TEAM ENTERS THE ROOM, THE DOORS WILL BE CLOSED

• YOU WILL NOT BE ALLOWED TO ENTER THE PATIENT’S ROOM UNLESS YOU ARE WEARING
APPROPRIATE PPE

• THERE WILL BE NO EXCEPTIONS UNDER ANY CIRCUMSTANCES

 THE CODE
INPATIENT HOSPITAL WARD SETTINGS
 INSIDE THE ROOM- PEOPLE

THE PROTECTED CODE BLUE TEAM INSIDE THE ROOM SHOULD BE LIMITED TO THE FOLLOWING PERSONNEL:

• ONE CODE BLUE TEAM LEADER (GIM SENIOR MEDICAL RESIDENT OR CICU RESIDENT OR MSNICU
FELLOW)
• ONE (1) ANESTHETIST STAFF ON-CALL
• ONE (1) GIM CODE BLUE JUNIOR RESIDENT
• ONE (1) TO TWO (2) RTS
• TWO (2) IN PATIENT UNIT NURSES INCLUDING THE NURSE CARING FOR THE PATIENT, FOR PATIENT
INFORMATION/CHARTING AND TIMEKEEPING/CPR
• ONE RESUSCITATION NURSE TO DELIVER CODE MEDICATIONS
 INSIDE THE ROOM- EQUIPMENT
THE FOLLOWING EQUIPMENT SHOULD BE BROUGHT INTO THE ROOM FOR RESUSCITATION:
• DEFIBRILLATOR
• CODE BLUE CRASH CART MEDICATIONS TRAY
• INTUBATION BOX AND MCGRATH OR OTHER VIDEO LARYNGOSCOPE
• INTRAOSSEOUS (IO) INSERTION DRILL AND NEEDLE IF NEEDED

• THE CODE BLUE CRASH CART ITSELF REMAINS OUTSIDE THE PATIENT ROOM IN THE
HALLWAY
• ANY ADDITIONAL EQUIPMENT NEEDED WILL BE PASSED TO THE CODE TEAM BY THE RN OUTSIDE
THE ROOM
• AT PM, RN DESIGNATE WILL REMOVE PCB MEDICATIONS FOR PYXIS AND HAND THEM OFF TO
SHS PCB TEAM LEADER
 OUTSIDE THE ROOM--PEOPLE
THE PROTECTED CODE BLUE TEAM OUTSIDE THE ROOM SHOULD BE LIMITED TO THE FOLLOWING PERSONNEL:

• ONE (1) SAFETY LEADER

• ONE RN TO OBTAIN ITEMS FROM THE CODE BLUE CART REQUIRED BY THE TEAM AND PROVIDE SUPPORT IN CASE A TEAM
MEMBER MUST LEAVE THE ROOM

• ONE (1) INPATIENT WARD RN TO ACT AS A RUNNER

• ONE (1) SECURITY OFFICER TO CONTROL ANY CROWDS AND HELP LIMIT ENTRY OF NON-HEALTH CARE PERSONNEL INTO
THE ROOM

• ONE (1) TRANSPORTATION SERVICES TEAM MEMBER TO PROVIDE ASSISTANCE WITH TRANSFER OF BLOOD SAMPLES TO
THE LAB

• ADMINISTRATOR ON-SITE (AOS) ON CALL

• MRP OR DELEGATE TO PROVIDE ANY ADDITIONAL PATIENT INFORMATION AS REQUIRED BY THE CODE TEAM
 MODIFICATIONS TO ACLS

• APPLY TAVISH MASK (IF NOT ALREADY IN PLACE) OR AMBU-BAG TO THE

PATIENT BUT DO NOT INITIATE MANUAL BAGGING

• IF, IN VERY RARE CASES, A PATIENT NEEDS TO BE ASSISTED WITH BAG MASK
VALVE (BMV) VENTILATION, SMALL TIDAL VOLUMES SHOULD BE APPLIED.

• AVOID ALL PROCEDURES THAT INCREASE RISK OF TRANSMISSION

DUE TO AEROSOLIZATION SUCH AS NON-INVASIVE VENTILATION
(BIPAP) AND HIGH-FLOW OXYGEN THERAPY (E.G. OPTIFLOW).
 MCGRATH VIDEO LARYNGOSCOPES
BROUGHT ON ARREST CARTS TO SITE OF
CODE
 INTUBATION– KEY POINTS
• INTUBATE PATIENTS EARLY AND HOLD CPR DURING INTUBATION TO MINIMIZE AEROSOLIZATION OF
PARTICLES AND INCREASE INTUBATION SUCCESS.

• THE STAFF ANESTHESIOLOGIST (OR EXPERIENCED ED/ICU PHYSICIAN IN RESPECTIVE DEPARTMENTS) IS

THE IDEAL INDIVIDUAL TO PERFORM INTUBATION.

• RAPID SEQUENCE INTUBATION, UNLESS THE PATIENT IS IN A FULL ARREST STATE, IS RECOMMENDED IN ORDER
TO AVOID COUGHING AND AEROSOLIZATION.

• VIDEO LARYNGOSCOPE SHOULD BE USED TO ASSIST INTUBATION AND ETCO2 USED TO CONFIRM POSITION

• AFTER INTUBATION IMMEDIATELY APPLY A FILTER BETWEEN THE ENDOTRACHEAL TUBE AND THE
RESUSCITATION BAG OR THE VENTILATOR CIRCUIT TUBING
 IF STAFF ANESTHESIA IS NOT
AVAILABLE
IN THE UNLIKELY EVENT THAT THE STAFF ANESTHESIOLOGIST (OR EXPERIENCED
ED/ICU PHYSICIAN) IS NOT READILY AVAILABLE TO PERFORM INTUBATION, AN RT
MAY PROCEED WITH INTUBATION IF THE FOLLOWING CONDITIONS ARE MET:

1. RT IS TRAINED AND COMPETENT TO PERFORM ENDOTRACHEAL INTUBATION

(AS DETERMINED BY THE RESPIRATORY THERAPY DEPARTMENT)
2. THE PATIENT DOES NOT HAVE ANY FEATURES PREDICTIVE OF A DIFFICULT
AIRWAY IN THE OPINION OF THE RT
3. THE PATIENT IS UNCONSCIOUS AND APNEIC
THE END OF THE CODE
 EXITING THE ROOM

• TEAM MEMBERS SHOULD CLEARLY COMMUNICATE TO EACH OTHER A PLAN

REGARDING EXITING THE ROOM

• DOFFING SHOULD OCCUR IN AN ORDERLY AND STEPWISE FASHION SO

AS NOT TO CONTAMINATE ONE ANOTHER.

• IDEALLY, THE JUNIOR MEDICINE RESIDENT OR CODE TEAM LEADER SHOULD

REMAIN IN THE ROOM DURING THE DOFFING OF OTHER TEAM MEMBERS TO
ATTEND TO THE PATIENT.
DOFFING PPE
 DOFFING PPE

• THE DESIGNATED SAFETY LEADER WILL ENSURE ALL TEAM MEMBERS

FOLLOW PROPER PPE DOFFING PROCEDURES

• THE HIGHEST RISK OF CONTAMINATION OCCURS DURING DOFFING

• TAKE THE TIME YOU NEED TO DOFF AND DISPOSE OF YOUR PPE SAFELY
 DOFFING PPE-- LOCATION

ALL DOFFING SHOULD OCCUR INSIDE THE

PATIENT’S ROOM OR ANTEROOM

DOFFING SHOULD NOT OCCUR IN THE HALLWAY

 DOFFING PPE
ID BADGE
• REMOVE YOUR ID BADGE AND TOSS IT IN THE GARBAGE

GLOVES
• FIRST, REMOVE YOUR GLOVES USING THE GLOVE-TO-GLOVE, SKIN-TO-SKIN TECHNIQUE. PINCH ONE GLOVE AND PULL
THE GLOVE DOWN AND AWAY WITH YOUR OTHER GLOVED HAND. GATHER THE REMOVED GLOVE INTO YOUR GLOVED
HAND.
• WITH YOUR BARE HAND, PUT YOUR FINGERS UNDER THE GLOVE OF YOUR OTHER HAND AND PULL DOWN AND AWAY.
• THROW GLOVES IN THE GARBAGE BIN. IF YOU THINK YOU MAY HAVE CONTAMINATED YOUR HANDS WHILE REMOVING
YOUR GLOVES, YOU CAN PERFORM HAND HYGIENE AT THIS TIME.

GOWN
• NEXT, REMOVE YOUR GOWN. UNTIE BOTH TIES AT THE NECK AND MID-BACK.
• CAREFULLY PULL GOWN FROM BEHIND SHOULDERS AND CAREFULLY DOWN YOUR ARMS, AWAY FROM YOUR BODY.
• FOLD GOWN INWARDS AND ROLL INTO A BALL AWAY FROM YOU. PLACE IN SOILED LINEN CART.

HAND HYGIENE
• PERFORM HAND HYGIENE FOR 15 SECONDS. RUB HANDS TOGETHER, ENSURING COVERAGE BETWEEN FINGERS,
AROUND AND UNDER NAILS, ON PALMS, BACK OF HANDS, AND WRISTS.
• CONTINUE RUBBING HANDS UNTIL DRY.
 DOFFING PPE
FACE SHIELD
• REMOVE FACE SHIELD BY GRABBING ELASTIC AT BACK OF HEAD. REMEMBER TO NOT TOUCH THE FRONT OF YOUR FACE
SHIELD WHEN REMOVING.
• PULL ELASTIC OVER HEAD AND PULL FACE SHIELD DOWN AND AWAY FROM YOUR FACE.
• PLACE FACE SHIELD INTO GARBAGE BIN.

RESPIRATOR
• REMOVE N95 RESPIRATOR BY PULLING BOTTOM ELASTIC UP AND OVER YOUR HEAD.
• NEXT PULL TOP ELASTIC OVER HEAD AND AWAY FROM YOUR FACE.
• DO NOT TOUCH THE FRONT OF THE RESPIRATOR.
• PLACE RESPIRATOR INTO GARBAGE BIN.

HAND HYGIENE
• AGAIN, PERFORM HAND HYGIENE FOR 15 SECONDS. RUB HANDS TOGETHER, ENSURING COVERAGE BETWEEN FINGERS,
AROUND AND UNDER NAILS, ON PALMS, BACK OF HANDS, AND WRISTS.
• CONTINUE RUBBING HANDS UNTIL DRY.
TRANSPORT TO THE ICU
 TRANSPORT TO ICU
• PATIENTS SURVIVING A PROTECTED CODE BLUE OUTSIDE OF THE ICU MUST BE TRANSPORTED AS SOON AS
POSSIBLE TO THE ICU.

• AS IN ALL CODE BLUES, PROCEDURES SHOULD BE DEFERRED UNTIL THE PATIENT ARRIVES IN THE ICU

• IN ORDER TO TRANSPORT THE PATIENT TO THE ICU, ANY CODE TEAM MEMBERS
ACCOMPANYING THE PATIENT THROUGH THE HOSPITAL MUST RE-DON PPE IN THE
HALLWAY

• THE TRANSPORT TEAM SHOULD IDEALLY CONSIST OF AT LEAST ONE (1) PHYSICIAN, ONE (1) RT, AND ONE (1)
RN.
 
•  THE SAFETY LEADER WILL ENSURE PROPER DONNING PROCEDURES ARE FOLLOWED
 TRANSPORT TO ICU

• IF THE PATIENT HAS NOT BEEN INTUBATED, THE TEAM MUST ENSURE A TAVISH O2 MASK IS
BEING USED IN ORDER TO REDUCE CONTAMINATION OF THE SURROUNDING ENVIRONMENT BY THE
PATIENT’S EXHALED BREATH

• SECURITY WILL BE RESPONSIBLE FOR CLEARING ALL NON-ESSENTIAL PEOPLE IN THE PATH OF
TRANSPORT OF THE PATIENT.

• SECURITY WILL HAVE A SERVICE ELEVATOR WAITING TO TRANSPORT THE PATIENT FROM THE
PROTECTED CODE BLUE LOCATION TO THE ICU.

• ENVIRONMENTAL SERVICES MUST FOLLOW BEHIND THE CODE TEAM AND CLEAN THE ELEVATOR
BUTTONS AND ANY VISIBLY CONTAMINATED SURFACES AFTER THE PATIENT HAS BEEN TRANSPORTED.
AFTER THE CODE
 AFTER THE CODE: CLEAN UP
• EXCESS MEDICATIONS MUST BE DISCARDED AT THE END OF THE PROTECTED CODE BLUE.

• STAFF PERFORMING PROCEDURES DURING THE CODE MUST ENSURE THAT CONTAMINATED DISPOSABLE EQUIPMENT
IS DISCARDED.

• ENVIRONMENTAL SERVICES WILL BE REQUIRED TO DISINFECT AND CLEAN THE ROOM AS PER USUAL PROTOCOL.

• ENVIRONMENTAL SERVICES MUST CLEAN THE ELEVATOR BUTTONS AND ANY VISIBLY CONTAMINATED SURFACES
AFTER THE PATIENT HAS BEEN TRANSPORTED.

• IN THE EVENT OF AN UNSUCCESSFUL RESUSCITATION, THE PATIENT’S REMAINS WILL BE REMOVED AS PER CARE
AFTER DEATH POLICY 3.30.003.
 SAFETY LEADER RESPONSIBILITIES
AT THE END OF THE CODE

• THE SAFETY LEADER WILL DOCUMENT ANY CHALLENGES THAT WERE OBSERVED/IDENTIFIED TO THE UNIT’S
NURSING AND MEDICAL LEADERSHIP.

• THE SAFETY LEADER WILL ENSURE ALL MULTI-USE EQUIPMENT AND MEDICAL DEVICES ARE PROPERLY
HANDLED AND DISINFECTED.

• ANY SINGLE USE ITEMS THAT ENTERED THE ROOM REGARDLESS OF IF IT WAS USED SHOULD BE DISCARDED

• RETURN PROTECTED CODE BLUE KIT TO STORES FOR RESTOCKING AND KEEP ANY UNUSED PPE IN
THE RED BOX
• RETURN THE MCGRATH LARYNGOSCOPE FOR CLEANING AND EXCHANGE AS PER UHN SITE POLICY
 IN THE EVENT OF STAFF
CONTAMINATION

STAFF WHO BELIEVE THAT THEY HAVE BEEN CONTAMINATED/EXPOSED

SHOULD
• IMMEDIATELY DECONTAMINATE AFFECTED AREAS IF POSSIBLE,
• PERFORM HAND HYGIENE,
• DON A SURGICAL MASK,
• REPORT TO THEIR SUPERVISOR
• PHONE OCCUPATIONAL HEALTH CLINIC FOR ASSISTANCE
CREDITS
 VIDEO SCRIPT AND CONTENT

• JOY LARNES NABARRETI RN

• LAURA HAWRYLUCK MD
• ALON VAISMAN MD
• JOHN GRANTON MD
 FILMING

TIM CHIPMAN
PRODUCTION COORDINATOR A/V SERVICES
THE MITCHENER INSTITUTE FOR APPLIED HEALTH SCIENCES
 SPECIAL THANKS TO

• JOSEPH BAIRD RN
• MICHELLE MCTAGGART RN
• AMANDA WALLACE RN
• KAILA WINGROVE RN, MN

• JENNIFER LEBLANC RT

• AHTSHAM NIAZI MD
• TAYLOR PETROPOULOS MD
• ELIZABETH WILCOX MD
 THANK YOU

• TWH ANESTHESIA DEPARTMENT

• TWH CRITICAL CARE TEAM

• TWH GIM TEAM