BETH ISRAEL DEACONESS HOSPITAL – NEEDHAM
CLINICAL PRACTICE MANUAL
Titl
e:
Em
erge
ncy
Car
e
and
Equ
ipm
ent
Car
dio
pul
mon
ary
Res
usci
tati
on
(Co
de
Blu
e)
Poli
cy
#:
PU
R
P
O
S
E
:
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.
POLICY:
A.
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.
B.
C.
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:
4
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.
IMP
LEM
ENT
ATI
ON
To activate a Code Blue response
1.
A
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3.
To activate the Code Blue system, the employee or medical staff member shall:
a
.
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32
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To
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Cod
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resp
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e
a.
Dial
337
37
b.
Stat
e
“Ca
ncel
Cod
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Blu
e in
Nee
dha
34
m”
wit
h
loca
tion
.
c.
The
cod
e
blue
tea
m
will
be
pag
ed
by
MA
SC
O to
noti
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tea
m
me
mbe
rs
of
this
can
cell
atio
n.
In
add
itio
n,
over
hea
d
pagi
ng
will
stat
e
35
“Ca
ncel
Cod
e
Blu
e
wit
h
loca
tion
”
thre
e
time
s.
Em
erge
ncy
Equ
ipm
ent
I
f
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C
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B
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e
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s
36
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37
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38
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40
C
o
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B
l
u
e
s
i
t
e
.
Rol
es
and
Res
pon
sibil
ities
Dur
ing
a
Cod
e
Blu
e
1. N
u
r
s
i
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g
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t
a
f
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41
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42
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45
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3. T
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48
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49
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50
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51
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.
4
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52
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53
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54
p
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55
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56
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c
57
t
s
,
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t
c
.
Dis
posi
tion
of
the
Pati
ent
1
.
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f
C
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a
n
d
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n
58
l
e
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t
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59
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60
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61
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65
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70
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72
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73
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84
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86
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/
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.
2
.
M
o
n
89
i
t
o
r
/
D
e
f
i
b
r
i
l
l
a
t
o
r
Clea
n
the
mon
itor/
defi
brill
ator
(esp
ecial
ly
the
pad
dles
),
retur
n it
to
its
desi
gnat
ed
loca
tion,
and
ensu
re
that
the
batt
90
ery
is
char
ging
.
Ens
ure
that
all
sup
plie
s are
read
ily
avai
labl
e
incl
udin
g
defi
brill
atio
n
pads
,
mon
itor,
elect
rode
s,
mon
itor
strip
pape
r,
exte
rnal
pace
mak
er
and
pace
mak
er
pads
etc.
91
3.
Clea
n
and
repl
ace
any
need
ed
sup
plie
s.
Ret
urn
to
its
desi
gnat
ed
loca
tion.
ECG Machine
4.
5.
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.
ICU ( 1Adult)
South Two (1 Adult)
Emergency Department (2 Adult , 1 Pedi) - available to Lab, Rehabilitation
92
4.
5.
6.
7.
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.
8.
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.
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.
93
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 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 unit’s 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.
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.
94
3.
Inspections:
1.
Biomedical Equipment Safety tests occur quarterly by a private vendor.
Location of Emergency Phones:
1.
2.
3.
4.
5.
6.
7.
Emergency Department
ICU
South 2
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
95