The Clinical Nurse Leader as Risk Anticipator:

Optimizing the Completion and Accuracy of the Code Blue Recorder Sheet
Cathy Morano, RN BSN
Abstract Specific Aim Code Blue Recorder Revised Code Blue Sheet
Sheet Completion
A small community hospital in northern California
Evaluation Tool Post
implemented a practice improvement project in critical care
units to optimize best practices surrounding a “code blue”
The Critical Care Unit will optimize the completion and
and Accuracy
event. In-Hospital Cardiac Arrest (IHCA) is a high-risk
process of care that requires tremendous resources to deliver
accuracy of the code blue recorder sheet documentation
to 90% by July 31, 2017.
Jan 2017 to June 2017 Training
an efficient, safe, and cost-effective service. The code blue
recorder sheet summarizes the whole patient care event; this JAN FEB MAR APRIL MAY JUNE
necessitates careful documentation. As a risk anticipator, the
unit clinical nurse leader identified suboptimal variation in Kotter’s 8 Step Change CODE BLUE FOCUSED AREAS:

Was the code outside ICU?

2017
n=6
17%
2017
n=0
0%
2017
n=8
12%
2017 n=
4
100%
2017
n= 6
0%
2017
n= 8
50%
documentation after a microsystem assessment. This led to a
practice change project and targeted educational Model If code is outside ICU, did patient
survived?
Is the patient under Hospitalist
100% N/A 100% N/A N/A Yes

67% N/A 66% 100% 100% 100%

intervention for code blue recorders. Fifteen staff members care?

were identified from every shift to cover all IHCA events. Recorder Sheet completed? 17% N/A 38% 17% 67% 50%
Cardiac:
Baseline data indicated that the completion and accuracy of Type of the Code: Cardiac or 83% -
Cardiac N/A
75% -
Cardiac
50% Cardiac:
Cardiac: 75%
Respiratory:
Respiratory? Respiratory: 100%
the code blue documentation were critically low. A literature 17% - Resp 25% - Resp
50%
25%

Was CPR in progress upon arrival

review revealed best practices with an evidenced-based of the team?
100% N/A 100% 100% 100% 100%

educational approach including thorough assessment and Did patient survive? 67% N/A 66% 75% 50% 90%

responsiveness to staff learning needs and preparedness, Was the patient discharged alive? 0% N/A 66% 75% 0% 80%
Was there an RRT called prior to
enhancing knowledge and building confidence to impact the code?
0% N/A 0% 25% 0% 0%

patient care outcomes. Results of the educational intervention Was ACLS algorithm followed
40% N/A 88% 75% 67% 50%
appropriately?
demonstrated significant improvements in team member Was the Critique form
50% N/A 50% 0% 33% 30%
confidence in the skills specific to their role and completed?
Was this case referred for Risk
20% N/A 33% N/A 50% 0%
responsibilities. Completion and accuracy data indicated that review?
Was this a reportable event? 0% N/A 0% 0% 0% 0%
the rate improved from the baseline of 17% to 67% over the
two-month period of training. Clearly, in high acuity and high-
risk events such as IHCA, unit leaders need to carefully define
Selected References
the division of labor, role clarity, staff learning needs to
Results
implement, and maintain best practices in code blue
documentation.
Keywords: in-hospital cardiac arrest, focused training,
Power Point Carpico, B. & Jenkins, P. (2011). Resuscitation review to improve nursing performance

Presentation
during cardiac arrest. Journal for Nurses in Staff Development, 27(1). 7-12
recorder, documentation doi:10.1097/NND.0b013e 3182061ca7
Chan, P. S., Krein, S. L., Tang, F., Iwashyna, T. J., Harrod, M., Kennedy, M., …Nallamothu,
B. K. (2016). Resuscitation practices associated with survival after in-hospital cardiac arrest.
Journal of American Medical Association Cardiology, 1(2), 189-197. doi:

Global Aim Statement Why do we need a Code Team?

•Efficient and
safe
How to be an effective member?
•Be organized
•Proficient with knowledge
10.1001/jamacardio.2016.0073
Clarke, S., Apesoa-Verano, E.C., & Barton, J. (2016). Code blue: methodology for a qualitative
study of teamwork during simulated cardiac arrest. British Medical Journal, 6:e009259
and skills doi:10.1136/bmjopen-2015-009259
•Saves lives
•Able to apply standardized Prince, C. R., Hines, E. J., Chyou, P. H., & Heegeman. (2014). Finding the key to a better code:
•Reverse process code team restructure to improve performance and outcomes. Clinical Medicine
clinical death •Effective communication Research, 12(1-2), 47-57. doi: 10.3121/cmr.2014.1201
We aim to improve the completion and accuracy of the •Limit disability •Practice to maintain skills Resuscitation Central Documentation. (2017). Hospital Code Documentation: Why Document a
documentation for all in-hospital cardiac arrest (IHCA) •Clear identification of team Patient’s Resuscitation Event? Retrieved from
member roles and
events. The process begins when Code Blue is announced responsibilities
http://www.resuscitationcentral.com/documentation/hospital-code-data/

via overhead pager indicating the location of the patient The Recorder
identified as having respiratory, cardiac or both (also known •Document the entire resuscitation
as cardiopulmonary) arrest. The process ends after the code process
blue recorder sheet and critique form is completed. By
working on this process, the educational intervention in
•Knowledgeable of the ACLS algorithm
•Reminds the Team Leader of the time,
name and dose of last medication
conjunction with the revised code blue recorder sheet administered
•Document cardiac rhythm and code
contents will lead into the improvement of the assigned summary strips
team member as the Code Blue Recorder to complete the •Document airway management
recorder sheet completely and accurately according to the •Complete Vital signs documentation
•Document start and end time of the
sequence of the IHCA event, in compliance with American
event
Heart Association (AHA) standard guidelines. •Indicates patient disposition
•Obtains Team Leader signature
•Completes the critique form
The benefits of a complete code blue
recorder sheet:
•Data help determine performance
improvement priorities
Acknowledgements
•Data collected are used to monitor the
stability of existing processes
•Data will help determine if AHA guidelines Special thanks:
are being followed To my supportive husband, Gary Morano
•It provides information that can guide To my preceptor, mentor, & Director, Viki Ardito
continuing care for the patient
To our supportive professor & coach, Dr. Cathy Coleman
•It helps to answer questions the family may
have about the event, reducing the risk for
litigation