1. Code Blue Do you know what to do? Department of Clinical Education 2009

2. CODE BLUE • An IMPENDING or ACTUAL • CARDIAC/RESPIRATORY ARREST

3. How To Call A Code Inside Stony Brook Hospital • DIAL 321 from inhouse phone. • Identify yourself (give name) • Announce Code Blue for adults or Code Blue Pediatrics for a child • Indicate EXACT FLOOR, TOWER & ROOM NUMBER OF PATIENT • Example: Code Blue, T-16 North, room 240 • Wait for the operator to repeat and confirm location before hanging up. • Do not hang up on the operator, let them hang up on you.

4. Response System For Cardiac/Respiratory Emergencies occurring outside of main hospital • East Campus: HSC & Basic Science Tower • Call University Police at 333 or by dialing 632-3333 • University Police will contact EMS to respond • Off Site locations: Tech Park, Ambulatory Center • First person on the scene activate 911 to dispatch EMS ambulance

5. Adult Code Blue Team • Senior Medical Resident (team leader) • Anesthesiologist or Anesthesiology Resident • Respiratory Therapist • Unit Staff Nurse • ICU Nurse will respond as assigned • Primary RN stays with Patient!!!

6. ICU Nurse will respond as assigned: • 18S ( SICU) responds to 13N, 14N, 18N, 19N, 19S • 17S (MICU) responds to 17S ( dialysis ), 16S,16N,15N, 15S, 12S, 14S ( Endoscopy), 10N ( Adult Psychiatry), 12N (Antepartum) • ED responds to Level 1-4 (except burn and MRI) Maternity Center, 8N, 8S, 9N, 9S • CTICU responds to Burn, MRI • CCU responds to Level 5 including CACU • Nurse assigned to the patient will be present

7. Who arrives for a pediatric code? • Some members will include: • Pediatric Transport Resident • If Ped. Transport Resident is unavailable, the Senior Pediatric Urgent Care Resident • Pediatric Resident on Call for the ER will respond to codes in Pediatric Urgent Care • Unit Staff Nurse • PICU Nurse • Anesthesiologist • Respiratory therapist

8. Additional Staff Responders All Codes • Nurse Manager/Off Shift &/or designee • Transporter • Public Safety Officer for all codes in non-patient areas • Others involved: • Telephone operator, Unit Clerk, CNA, Distribution Services & Elevator transport

9. TEAM Responsibilities In A Code

10. NSC/ Secretarial support • Assure the Code Blue has been called • Calls code: 321 in Hospital • 911-out of hospital • Prepares forms & Labels • Makes phone calls/collects patient records as directed • Post Code: calls distribution services to return cart

11. NURSING ASSISTANTS/PCT • Assist with moving Code cart to the patient room • Listen & Follow Directives from the RN • Clean patient area post code • Help transport patient to ICU unit if needed

12. HOSPITAL ATTENDANT • Is an employee from Distribution Services • Responds to the unit with a new code cart • Returns secured used cart to central sterile

13. Telephone Operator • Once code is received, initiates code blue page over address system and repeats 3 times • Alert Code Blue team members via pocket pagers • Alert MICU, OR and Anesthesia • Alert the ED or nearest patient care area if public address system or back up pocket pagers should fail

14. MEDICAL DOCTORS • Senior Medical Resident takes charge & clears the area • If certified, may intubate patient • Administer emergency meds as needed • Notifies patients’ attending of arrest • Communicates with family at the earliest possible moment • Decides on termination of the code

15. MD’s Continued • Code Successful—initiate arrangement for transfer to critical care unit • Code Unsuccessful—pronounces patient’s death & refers to autopsy • Completes progress note and reviews/signs Code Blue Resuscitation Record • Authorizes all medication/interventions

16. Anesthesia • Proceed to area of code blue • Serve as 2nd/3rd rescuer until team assembles • Inserts ETT when indicated and verifies position with CO2 Detector • Assists in attaching ETT to ventilator • Remains with patient until RT is able to maintain respiratory function of patient

17. Respiratory Therapist • Establishes and maintains airway • Performs tracheal suctioning • Assists/performs intubation if certified • Provides adequate ventilatory support via manual resuscitator &/or mechanical ventilator according to MD orders • Maintain & monitor ventilatory status • Draw & analyzes ABG’s when indicated • Assist in transfer of patient as indicated

18. Clinician/Charge Nurse/Nurse Manager/ADN • Ensure Code Cart/defibrillator present • Ensure Code Team has responded • Assign responsibilities as needed • Code Cart/Medication Nurse • Documentation • Assist as needed • Removal of other patients & family members, crowd control, pt. transfer

19. Registered Nurse/Code Cart RN • Apply multifunction electrode pads • Prepare cart for use/opens cart • Puts intubation tray at patient’s head • Prepare & dispense emergency meds • Clearly announces name and amount of meds handed off • Prime IV tubing & make IV labels

20. Code Cart Nurse continued • Charge defibrillator as per team leader order • Distribute supplies as needed from code cart (bld. specimen tubes, ABG kits, etc.) • At the end of the code, return all non-disposable items (ie. O2 flow meter & suction) back to the used cart & LOCK • Ensure cart exchanged/new & checked for completeness. Sign check sheet

21. Nurse Recorder • Document code activities, assessments and time performed on the CPR Documentation Record • Can report on medications given including dose and time • Writes progress note on CPR Documentation Record • Complete code Blue Debriefing report and attach to copy of Documentation record • Place white copy of code blue sheet on patients’ chart along with all EKG strips or “complete disclosure” record • Send yellow copy to NM/ADN for review and forward to nursing office

22. Additional Nurse/designee • Get suction equipment set up and ready for use • Starts IVs/draws blood as needed • Administers meds as directed by team leader and calls out to Nurse Recorder • Assist with compressions • Assist team as directed

23. Code Team Positions • Coming soon—All staff members will be assigned Code positions daily • This will decrease confusion of roles and improve patient outcomes! • Training has begun on 16S

24. Pediatric Codes • Refer to Pediatric Unit for specific policy

25. PEDIATRIC CODE CART

26. How will you Repond?

27. A Person CollapsesPossible Cardiac Arrest • ASSESS responsiveness • ACTIVATE emergency response system 321

29. NOTE THE TIME! MilitaryTime Only 0700

30. CHECK for Airway, Breathing and Circulation

31. FOCUS: Basic CPR and Defibrillation • A= airway: open the airway • B= Breathing: check breathing, provide positive-pressure ventilations • C= Circulation: check circulation, give chest compressions • D= Defibrillation: assess for and shock/pulseless VT and V-Fib

32. Help is on the way • Senior Medical Residents • ( team leaders) • Anesthesiologist/ Resident • Respiratory Therapist

33. ACLS • A=Airway: place airway device as soon as possible • B=Breathing: confirm proper placement by PE • B=Breathing: confirm proper placement by • 2nd method - End-tidal CO2 - Esophageal detector devices B= Breathing: prevent airway device dislodgment: • Use ETT holder • Use proven tape and tie B= Breathing: monitor oxygenation and ventilation

34. ACLS • C= Circulation: establish IV access • C= Circulation: identify rhythm • C=Circulation: give rhythm and condition appropriate drugs. • D=Differential Diagnosis: search for and treat identified reversible causes.

35. The Code Cart has arrived!

36. Once The cart is here: • Get Ambu bag/ ambu patient • Attach ambu to 15L/02 • Roll patient-place on backboard and place pacer pads on • Place chest leads-ZOLL • Empty bottom drawer- equipment to head of the patient • Hook up suction • Prepare drugs • Document

37. DRAWER 1ACLS 1st Line Meds for 30-40 minute code • Adenosine • Amiodarone • Furosemide • Magnesium • Naloxone • Procainamide • Vasopressin • Lidocaine • Sodium Bicarbonate • Atropine • Epinephrine • Dextrose

39. DRAWER 2 • ABG kits • NG tube (salem sump) • 5 in 1 connector • Zoll pads • EKG paste/paper • Gauze/ tape • Pulse ox monitoring cables

40. DRAWER 3 • Venipuncture Supplies • Phlebotomy Supplies

41. DRAWER 4 • Emergency Cricothyrotomy Set • 2 Trachs • CO2 Detector • Suction Catheters (red rubber)

42. DRAWER 5 • IV solutions • IV tubings • Premixed Drips • Dopamine • Lidocaine

43. DRAWER 6 • Laryngoscope Box • Intubation Box • Suction set up • O2 Set up • Central Lines • 2 Triple Lumen Catheters • Bipolar Pacing Wire

44. ZOLL-Stat-Padz NOTE: WHEN PLACING PATIENT ON THE BACKBOARD PLACE stat-padz ON THE PATIENT! Place pads in anterior/posterior position (sandwich left side of heart) if possible Stat-padz will Monitor, Defibrillate and Pace as needed Connect to the Multifunction Cable

45. Paddles • Not recommended, but if used apply small chest electrodes to monitor rhythm • White to the right; • Smoke (black) over fire (red) on the left • MFC must be attached to paddles • Apply electrode gel to metal face • Place one paddle at apex & one paddle at the base of the heart

46. ZOLL • Turn ZOLL on ( GRAY ) • Gray area on ZOLL indicates monitor **In an emergency situation, threatened by a lethal arrhythmia (V. Fib, pulseless V. Tach) a LIP/ACLS certified RN/PA may perform defibrillation

47. TO DEFIBRILLATE • Think Red1,2,3 & MD order • Stat Padz or paddles • CHARGE ( default setting is 120 joules), use arrows up or down to change as per MD order • DISCHARGE • Numbers 1,2,3 match numbers on the ZOLL • “I’m clear, you’re clear, everybody clear??”

48. Ventricular Tachycardia

49. degenerating into V- Tach V- Fib

50. TO PACE OR CARDIOVERT • Think greenand MD order to transcutaneous pace • When cardioverting remember the sync mode (soft key on bottom) • Joules will automatically default back to 120 ( ready to treat a lethal arrythmia)