Code blue for all unresponsive patients.

Analysis of the issues covered
Code blue should be contacted immediately for all unresponsive patients. Calling for help and initiation for help should be
done simultaneously. One of the issues identified in this case study is delayed in the response of code blue code due to poor call out
systems. The code team member should call out loudly for help through the facility-wide response system. In this technology, the
nurse should have pressed the Blue code push button to ensure that the code blue team were notified accordingly (Bayramoglu et al.,
2013). As the nurse in charge waits for code blue team, he or she should initiate CPR (Clarke, Apesoa-Varano, & Barton, 2016). The
code team are expected to introduce themselves as they arrive as well as and their roles statements such as “Am Mr. J. and will take
document” or “I’ll take the airway” which helps in ensuring there is clear role differentiation. The service user physician should be
contacted immediately. According to Price, Applegarth & Price (2012), the healthcare provider should first assess the patient dangers
and risks before they start the air management. This was not done in the case study and violated the ARC guide four which states that

the patient’s mouth should be opened and head slightly turned downwards to remove the airways (Australian Resuscitation Council,
2008).
An ineffective cough indicates a severe obstruction. In this case, if the patient is responsive, the healthcare provider should
give about five back blows, and if still, it is ineffective, they should give at least five chest thrusts (McInnes et al., 2012). This article
states that for all unresponsive patients, the healthcare should send for help and start CPR immediately. Similarly, guideline 5
recommends that all patients who are breathing abnormally or are unresponsive require being resuscitated. The first thing when
assessing breathing, the rescuers should check for movement around the chest (lower part) and abdomen (upper part). They should
check for the exhalation through the patient’s oral cavity or nose, and feel the movement of air in the patient’s mouth or nose. The
guide recommends a ratio of compressions to rescue breaths as 30:2 (Australian Resuscitation Council, 2008).
According to this article, the first nurse to respond should start saving the patient’s life by performing chest compressions
immediately (100 compressions per minute). Although important, the nurse should not wait for backboard , they should start chest
compressions as it can be put in place later when the code team arrives. The switching the compressor roles in the case study is
present but it took quite a long time than that recommended by ARC guide 6 which is approximately after 2 minutes. To maintain the
quality, the ventilations ratio should be maintained at 30:2 (Castelao et al., 2013). This is supported by Guide 6 which recommends
that interruptions to chest compressions should be minimized. The best location to perform the compressions is the sternum- the
lower half part of it. The healthcare provider’s heel is placed at the central part of the chest and put the other hand on top it. The

recommended rates of compressions are 100 to 120 compressions per minute which are about two compressions per second. The
guide also outlines on the quality of compressions ( which is identified as poor in the case study) where it suggests that depth of
compressions should be “at least 2 inches (5cm) with complete chest recoil after every compression” this helps the heart to re-fill
completely by the next round of compressions. The number of interruptions should be minimized to ensure maintain the quantity and
quality of compressions (Eroglu et al., 2014).
According to the article, the patient should be given 2 ventilations for every 30 seconds of oxygen-bag-mask device assisted
ventilation. The oxygen level should be set to the flow meter 15 L/min, and where applicable, the reservoir should be fully open
ensure that the patient gets 100% oxygen for each breath. One strength observed in the study is the fact that bag-mask device is best
done by two blue code team members where one open the airway to fasten the mask on whereas the second one squeezes the oxygen
bag. Also, the article states that defibrillation is very critical and that the use of placement hands-free defibrillation pads is a safer
option than hands held defibrillation paddles (Girotra et al., 2012; Prince et al., 2014). The article states that the deployment of
automated external defibrillators (AED) should be used as soon as possible as it reduces mortality and morbidity associated with
cardiac arrest caused by either ventricular fibrillation or ventricular tachycardia (Australian Resuscitation Council, 2008).

The compressions should resume immediately after delivering shock even with a normal heart rhythm as it will not provide enough
cardiac output that will ensure adequate perfusion. It is recommended that 2 minutes the cardiac rhythm should be assessed after 5
cycles of a CPR (Merchant et al., 2014). The use of vasopressors in cardiac arrest is recommended only when there are no high-quality

CPR. It is important to be extra cautious when administering a drug. This is because miscommunication is a common issue which
often leads in the administration of incorrect drug doses or medications. This can be prevented by using “closed loop” method of
communication (Segon et al., 2014; William et al., 2016). For instance, when a nurse receives an order to inject some medicine, they
should repeat the information of drug prescribed out loud, inject it and then announce it again after administration (Price et al., 2012).
This method was used in some instances, but in the instance that it was absent, the recorder was prone to miss out some key aspects;
for example, in this code blue simulation, the recorder had missed recording the endotracheal tube measurements.
The article suggests that an effective code blue team should have leader who controls the all the procedures and efforts of
resuscitation. They communicate with the staff involved and evaluate the cardiac rhythm of a patient. Mr. Sellinger is the team captain
of the case study and was standing in a position such that he could effectively see all of the resuscitation procedures and efforts. If the
organization allows, the family member can be allowed into the room. It is also important to ensure that the information is well
recorded. In the case study, the recorder is shown documenting all the resuscitation process. However, it is important to understand
that documentation process is done according the healthcare facility’s policy (McEvoy et al., 2014; Sahin et al., 2016). The recorder
should remind the code team when time for a specific task has elapsed and must record all the activities taking place including the
medicines prescribed. The article also suggests that all clinical areas should grant quick access to equipment such as blood glucose,
blood pressure, and equipment of pulse oximetry and other equipment so as to effectively manage a deteriorating patient (Clarke,
Carolina Apesoa-Varano, & Barton, 2016).

Through this case study, it is evident code training programs using simulation is beneficial and has been recommended by
various healthcare institution organizations since 1999. This training will help the learners to improve cardiac resuscitation outcomes
as it offers an opportunity for regular hands-on practice within the hospitals. This also helps the team to understand the various roles
and responsibilities expected during a full code. Along with continuing education and mock codes, the team members become
confident in their responsibilities (Gutwirth, Williams, Boyle, & Allen, 2012).

References
Australian Resuscitation Council. (2008). Standards for Resuscitation: Clinical Practice and Education.

Bayramoglu, A., Cakir, Z. G., Akoz, A., Ozogul, B., Aslan, S., & Saritemur, M. (2013). Patient-Staff Safety Applications: The
Evaluation of Blue Code Reports. The Eurasian Journal of Medicine, 45(3), 163–166..34

Castelao, E. F., Russo, S. G., Riethmüller, M., & Boos, M. (2013). Effects of team coordination during cardiopulmonary resuscitation:
A systematic review of the literature. Journal of critical care, 28(4), 504-521.

Clarke, S., Apesoa-Varano, E. C., & Barton, J. (2016). Code Blue: Methodology for a qualitative study of teamwork during simulated
cardiac arrest. BMJ open, 6(1), e009259.

Eroglu, S. E., Onur, O., Urgan, O., Denizbasi, A., & Akoglu, H. (2014). Blue code: Is it a real emergency? World Journal of
Emergency Medicine, 5(1), 20–23.

 Girotra, S., Nallamothu, B. K., Spertus, J. A., Li, Y., Krumholz, H. M., & Chan, P. S. (2012). Trends in Survival after In-Hospital
Cardiac Arrest. The New England Journal of Medicine, 367(20), 1912–1920.

Gutwirth, H., Williams, B., Boyle, M., & Allen, T. (2012). CPR compression depth and rate about physical exertion in paramedic
students. Journal of Paramedic Practice, 4(2).

McEvoy, M. D., Field, L. C., Moore, H. E., Smalley, J. C., Nietert, P. J., & Scarbrough, S. (2014). The Effect of Adherence to ACLS
Protocols on Survival of Event in the Setting of In-Hospital Cardiac Arrest. Resuscitation, 85(1),
10.1016/j.resuscitation.2013.09.019.

Merchant, R. M., Berg, R. A., Yang, L., Becker, L. B., Groeneveld, P. W., & Chan, P. S. (2014). Hospital Variation in Survival After
In‐hospital Cardiac Arrest. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, 3(1),
e000400.

McInnes, A. D., Sutton, R. M., Nishisaki, A., Niles, D., Leffelman, J., Boyle, L., … Nadkarni, V. M. (2012). The ability of code
leaders to recall CPR quality errors during the resuscitation of older children and adolescents. Resuscitation, 83(12),
1462–1466.
Price, J. W., Applegarth, O., Vu, M., & Price, J. R. (2012). Code Blue Emergencies: A Team Task Analysis and Educational Initiative.
Canadian Medical Education Journal, 3(1), e4–e20.

Prince, C. R., Hines, E. J., Chyou, P.-H., & Heegeman, D. J. (2014). Finding the Key to a Better Code: Code Team Restructure to
Improve Performance and Outcomes. Clinical Medicine & Research, 12(1-2), 47–57.

Segon, A., Ahmad, S., Segon, Y., Kumar, V., Friedman, H., & Ali, M. (2014). Effect of a Rapid Response Team on Patient Outcomes
in a Community-Based Teaching Hospital. Journal of Graduate Medical Education, 6(1), 61–64.

Sahin, K. E., Ozdinc, O. Z., Yoldas, S., Goktay, A., & Dorak, S. (2016). Code Blue evaluation in children’s hospital. World Journal of
Emergency Medicine, 7(3), 208–212

Williams, K.-L., Rideout, J., Pritchett-Kelly, S., McDonald, M., Mullins-Richards, P., & Dubrowski, A. (2016). Mock Code: A Code
Blue Scenario Requested by and Developed for Registered Nurses. Cureus, 8(12), e938.

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