BETH ISRAEL DEACONESS HOSPITAL NEEDHAM

CLINICAL PRACTICE MANUAL

Title: Emergency Care and Equipment Cardiopulmonary Resuscitation (Code Blue)
Policy #:
PURPOSE: To provide hospital employees and medical staff with guidelines for initiating and
administering cardiopulmonary resuscitation.
POLICY:
A.

B.

C.

Code Blue
A Code Blue response is initiated to activate the code blue (Resuscitation Team) to assist
in the treatment of a patient found to be in either cardiac or respiratory arrest, or a patient
that has the potential to arrest without proper intervention.
Initiation and Administration of Cardiopulmonary Resuscitation (CPR).
1.
CPR shall be initiated for a patient who suffers a cardiac or respiratory arrest unless
the patient has a written medical order which states "DO NOT RESUSCITATE" or
an explicitly written medical order to withhold one or two of these interventions.
See Hospital Policy on Withholding, Withdrawing, or Limiting Life Sustaining
Treatment including CPR.
2.

The employee or medical staff member who has received instruction and
demonstrated competence in defibrillation and CPR who witnesses the arrest or
finds the patient shall initiate defibrillation if indicated or administer CPR until a
defibrillator is available.

3.

All hospital personnel who provide direct patient care are required to obtain
their BLS training every 2 years.

Code Blue Team

Members of the Code Blue team shall include the following individuals:
Critical Care Nurse
Respiratory Therapist
Nursing Supervisor or Nursing Director/Designee
South 2 Nurse
Emergency Physician
Emergency Nurse
Hospitalist/In-house Physician
Medical Day Care Nurse

D.

Testing of Pagers
Pagers will be tested daily at 14:00pm. The following pagers will be tested: Critical
Care RN, Respiratory Therapist, Nursing Supervisor, South 2 RN, Emergency
Physician, Emergency RN, Medical Day Care Nurse and the Hospitalist/In-house
MD. If there is no response from a pager(s), MASCO will contact BIDNeedham.

IMPLEMENTATION
1

To activate a Code Blue response

1.

Any employee who witnesses a patient arrest or finds a patient needing immediate
medical assistance may initiate a Code Blue.

2.

The employee or medical staff member who has received proper instruction in CPR
and/or defibrillator who witnesses the arrest or finds the patient shall:
a.
Assess the patient's responsiveness
b.
Call Code Blue in accordance with item #3 below
c.
Initiate defibrillation if indicated or CPR in accordance with the American
Heart Association guidelines and continue CPR until relieved by the Code
Blue Team.

3.

To activate the Code Blue system, the employee or medical staff member shall:
a.
Dial 3-3737 internally (when dialing from an outside line 781-453-3737)
and request a Code Blue be called, state name of the Campus
(Needham), state whether the code is for an Adult or Pedi (age 8 and
under), state location of emergency (Department and room), name of
caller and call back number.
b.

If the medical emergency is outside the hospital building this will be defined
by all property including sidewalks, driveways, parking lots and ambulance
on property the caller will activate 3-3737 and request that the Needham
emergency response unit (Needham EMS/Fire 1-781-444-0142 ) be
called to the location of the incident.

4.

Upon notification of Code Blue, the operator will audibly page Code Blue (Adult or
Pedi), location and room , three times.

5.

Activate the Code Blue Response team pagers with Code Blue (Adult or Pedi),
location and room.

To cancel a Code Blue response

a.
b.
c.

Dial 33737
State Cancel Code Blue in Needhamwith location.
The code blue team will be paged by MASCO to notify team members of this
cancellation. In addition, overhead paging will state Cancel
Code Blue with location three times.

Emergency Equipment
If the Code Blue is in a non-patient care or public access area within the hospital, the nurse
supervisor or designated personnel will obtain a monitor/defibrillator from the nearest
location and bring it to the Code Blue site.
2

Roles and Responsibilities During a Code Blue

1. Nursing staff members in the unit/area/department shall bring the closest
emergency cart and the monitor/defibrillator to the room or location of the Code
Blue. (See section IV A. Code Carts)
2. Medical staff member(s) shall serve as the Code Blue Team leader
3. The Medical staff member(s) will determine when sufficient staff is present to assist
with the Code Blue and shall direct the members in defibrillation/monitoring,
administration of medications, airway management, IV access, CPR and
documentation.
4. Administrative Supervisor/Clinical Director/Manager
a.
Provide oversight and direction of nursing activities as necessary to assure
proper documentation of events, preparation of intravenous fluids and
medications, delivery of specimens to laboratory, procurement of blood
products, etc.
Disposition of the Patient
1.
2.

If CPR was successful and unless otherwise ordered by the physician, the patient
shall be transferred to the ICU accompanied by a critical care nurse, nursing
director/nursing supervisor, primary nurse and a physician as indicated.
If CPR was not successful, the nursing staff shall provide post mortem care and
transfer the patient to the morgue.

Documentation of CPR
The Resuscitation Flowsheet shall be completed by the designated code team
recorder. The physician and medication nurse signature is required on the flowsheet.
A copy is placed in the medical record and one copy is sent to the Emergency
Services Medical Director.
Return/Replacement of Used Equipment
1.

Emergency Cart
a.
The contents of the Emergency Cart will be checked immediately following
the Code Blue and replacement supplies obtained.
Monday Friday (0700-1500) from Central Supply (3-5222)
(1500-0700), weekends and holidays - from Nursing
Supervisor (Pager ID: 97801)
b.

Replacement medications should be obtained from the Pharmacy

Monday Friday (0700-1700) from pharmacy

(1700-0700) from Nursing Supervisor.
Weekends and Holidays (0700-1500) from pharmacy
(1500-0700) from the Nursing Supervisor
c.

Reusable equipment should be returned to the decontamination

area in the Emergency Department as per protocol.

d.

When all replacement items have been obtained and the contents have been
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e.
2.

3.
4.

5.

checked, the code cart is secured with breakaway lock. Record date, time,
lock number and signature of nurse who performed the check on the code
cart checklist.
See section of the code cart exchange procedure/process.

Monitor/Defibrillator
Clean the monitor/defibrillator (especially the paddles), return it to its designated
location, and ensure that the battery is charging. Ensure that all supplies are
readily available including defibrillation pads, monitor, electrodes, monitor strip
paper, external pacemaker and pacemaker pads etc.
ECG Machine
Clean and replace any needed supplies. Return to its designated location.
Respiratory Therapy/Airway Management Equipment
Respiratory Therapist will ensure that any replacement respiratory equipment has
been obtained, e.g., ambu bag, 02 masks, cannulas, and CO2 detectors in
collaboration with the nurse.
Code Process Review
The intent is for the medical team leader to review the process issues after
the Code Blue is terminated.

EMERGENCY EQUIPMENT, LOCATION AND INSPECTION

Code Carts
1.
2.

3.
4.

The contents of the Emergency Code Carts will be determined by the Beth
Israel Deaconess Hospital, Needham Emergency Services Committee.
A Code Cart Inventory List of approved supplies will be on each code cart.
This inventory list will be evaluated by the Committee biannually.
Suggestions to change the inventory list will be brought to the Emergency Services
Committee for approval. No new items should be added to the code cart without
approval.
The Nursing Director/Clinical Manager or his/her designee is responsible for ensuring
that the Emergency Code Cart is in place and in usable condition at all times.
Location: Emergency Code Carts are located in the following places:
1.
2.
3.
4.
5.
6.
7.

8.

ICU ( 1Adult)
South Two (1 Adult)
Emergency Department (2 Adult , 1 Pedi) - available to Lab, Rehabilitation
Medicine
Operating Room (1 Adult, 1 Pedi)
PACU (1 Adult) available to Same Day Surgery
Radiology Department (1 Adult)
Medical Day- (1 Adult)-(1 Pedi)-Available to Cardiology and Ambulatory
Services.

Operating Room:
a.
A Code Tackle Box contains medications and supplies for intubation. The
Tackle Box may be transported to any area of the hospital by anesthesia
personnel responding to the code.
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b.

Sterile internal paddles are kept in a designated area for use with the
Operating Room Defibrillator Unit.

Code Cart Medication:

1.

The Pharmacy is responsible for the contents and inspection procedures of the
emergency medications on all Code Carts.
2.
The Pharmacist will:
a.
Conduct monthly inspections of the emergency medications and replace
any medications that are outdated.
b.
Provide a system to ensure the integrity of the medications between
periods of inspection on all code carts.
Code cart Inspections:
1.

All code carts are to be inspected daily when area is open by the Clinical
Manager /Charge Nurse or their designee
Frequency of inspection:
a. ICU/Emergency Department /Radiology/South 2 are checked daily.
*Operating Room/*PACU//*Ambulatory Services daily (*denotes only during
hours of operation)
2.
All Code Carts are locked.
3.
The cart checklist (located on the code cart clipboard) should be signed and
dated by the person performing the inspection to document the integrity of the
break away lock, the inventory and expiration dates are current.
4.
After a code, the code cart is promptly restocked and secured, ready for use. If
any supplies are unavailable, the nursing administration supervisor should be
notified.
5.
Supplies are to be used in emergency situations only.
6.
Numerated locks are obtained only from Pharmacy.
Code Cart Exchange:
The purpose of the code cart exchange is to have a fully stocked adult
code cart available at all times for backup or exchange during a medical
emergency/code blue. The exchange cart will be available and accessible
at all time.

Procedure/Process:

During a code blue or an emergency situation when an adult code

cart has been opened, a staff member from central supply/or
designee will be instructed,by the department,to bring the
exchange cart to the appropriate location. Off shift,weekends or
holidays, the nursing supervisor/or designee will share this
responsibility
The additional code cart will be stored in central supply when not
in use
Once the exchange cart arrives on the unit, nursing will verify that
5

the numerated lock is intact. If the lock is not intact, nursing will
then open the code cart and review the content list and replace the
items accordingly. Nursing will contact the phamacy/designee to
review the medication content list. The code cart will then be
locked using a brackaway numbered lock.
Nursing will place the units defibrillator, ACLS Guide Book/binder
and the clip board from the used code cart onto the new cart
The used code cart will be sent to central supply for restocking.
Central supply will immediately restock the used items and call the
pharmacy to restock the used medications.
Items will be replaced using the code cart content list .
Once all items are replaced, the code cart will then be locked using
a numerated brackaway lock found in the pharmacy or in the pyxis.
The lock number will be documented on the code cart check list.
Off shifts,weekends and holidays, nursing/nursing
supervisor/designee will replace the used items on the code cart.
The fully stocked code cart will then be sent to central supply for
storage or be reused on their unit.
While the exchange code cart is in storage, the lock integrity will
be checked daily and documented by central supply on the code
cart checklist. The nursing supervisor will share this responsibility
on weekends and holidays.
If the code cart is found unlocked, the responsible person will go
through the code cart ensuring that all items are present.
At the end of the month, nursing from MDC/designee, will open the
cart and verify the expiration date and content of the code cart.
Expired items will be removed and replaced. Pharmacy will be
responsible for the verification of medication. Numerated lock will
be replaced and documentation according to policy.

Defibrillator/Monitor Check:
1.
2.

3.

Routine Checks:
1.
All defibrillators have daily checks by a staff member during hours
of operation.
Defibrillator/Pacing Checks:
1.
Manufacturers guidelines are followed per model specification..
2.
The Code Cart check list should be signed and dated by person performing the
Defibrillator checks.
Inspections:
1.
Biomedical Equipment Safety tests occur quarterly by a private vendor.

Location of Emergency Phones:

1.
2.
3.

Emergency Department
ICU
South 2
6

4.
5.
6.
7.

Medical Day Care

Cardiology
PACU
Radiology

Inspections of Emergency Phones:

1.

Effective Date:
Last Revision Date:
Updated:

The Emergency Phones are tested monthly by maintenance. A logbook will be

maintained.

May 1996
March 15, 2004, April 14, 2004, June 1, 2005, Dec.2005
Dec.13,2005