Objectives: Identify the changes that have been made to the Code Blue Record ( for pilot at the BGH site) Discuss the importance of documentation during a Code Blue Event from a risk management as well as a data collection perspective Describe completion guidelines for each section of the form
Code Blue Documentation The Code Blue Record is to reflect the care a patient received during a Cardiac Arrest or an Acute Respiratory event Times of all assessments/interventions should be entered using a single watch or clock as the event timer The official documentation of what occurred at the event needs to be documented on the Code Blue Record during the event. Progress notes should be utilized to document pre event & post event care but NOT to REdocument items already recorded on the form
Code Blue Documentation Form
Code Blue Data Collection Get With the Guidelines - Resuscitation (GWTG-R) The GWTG-R is an evidence based, quality improvement program that Buffalo General Hospital subscribes to Its purpose is to evaluate and improve emergency team response, effectiveness of resuscitation & post resuscitation care Our Code Blue data is entered into the database and we can assess ourselves related to other like facilities This also meets a Joint Commission requirement for evaluating Code Blue Responses
Code Blue Data Collection Get With the Guidelines - Resuscitation (GWTG-R) GWTG-R Measures: Rapid Response Team events-medical Emergency Team or MET Acute Respiratory events-acute Respiratory compromise or ARC events ( example-unplanned intubations) Codes-Cardiopulmonary Arrests or CPA
Code Blue Documentation Form Record the patient s name and medical record number in the designated area of the record. The patient s PLUE label should also be placed in this section Remember-each page of the carbonized document must be labeled
Code Blue Documentation Form. The Top Section of the Code Sheet The ONLY section of the form that may be completed immediately after the event. A. Date/Time Event Recognized The date/time that the event was recognized should be recorded in this space. B. Location Record the location of the patient at the date/time that the event was recognized. C. Witnessed Indicate yes if the patient was directly observed by someone (can be family, lay bystander, employee or health care professional) at onset of event (differs from monitored). D. Age, Weight, and Height (Length) Record the patient s data in the appropriate space. E. Was a hospital-wide resuscitation response activated? Indicate if a hospital-wide resuscitation was called via the switchboard operator
Code Blue Documentation Form Illness Category- Enter the most appropriate illness category at the time of the event onset. Medical-Cardiac Patient with a primary diagnosis of medical illness that is cardiovascular at the time of the event. Medical-Noncardiac Patient with a primary diagnosis of medical illness at the time of the event that is not cardiovascular. Surgical-Cardiac Patient who is post-operative following cardiac surgery at the time of the event. Surgical-Noncardiac Patient who is pre-operative or post-operative with a surgical illness as the primary diagnosis that is not cardiac surgery at the time of the event. Newborn Infant in delivery suite or newborn nursery without other primary diagnosis. Obstetric Obstetric patient (before, during or after delivery) at the time of the event. Trauma Patient with single or multiple trauma as the primary diagnosis at the time of the event. Other (visitor/employee) Neither in-patient nor outpatient, but a visitor or employee at the time of the event.
Condition when need for Chest Compression/defibrillation was identified? Pulseless Indicate if the patient was pulseless when the need for chest compressions and/or defibrillation was identified. Pulse (Poor Perfusion) Indicate if the patient had a pulse when the need for chest compressions and/or defibrillation was identified. Did the patient with a pulse become pulseless? Indicate yes if the patient had a pulse at onset of chest compressions and/or defibrillation but became pulseless during the event. Patient Conscious at Onset Indicate yes if the patient was conscious at the beginning of the event.
Indicate all monitors present at onset. ECG Cardiac monitoring in the form of telemetry (central and/or bedside) monitoring. Pulse Ox. Pulse oximeter in the form of telemetry (central and/or bedside) monitoring. Apnea Apnea/bradycardia monitor in the form of telemetry (central and/or bedside) monitoring.
Airway/Ventilation Section must be recorded during the event for greatest accuracy. At onset Indicate the patient s respiratory status when the need for emergency assisted ventilation, chest compressions, and/or defibrillation was recognized. Spontaneous Breathing without mechanical assistance Apneic Not breathing spontaneously Agonal Gasping (Ineffective) SLOW respirations Assisted Mechanical ventilation being provided Time of First Assisted Ventilation Enter the time that emergency assisted ventilation (noninvasive or invasive) was first initiated during the event. Ventilation Select each type of ventilation/airway used during the event. There is no limit on the number of types that may be selected. Bag-Valve-Mask Bag/valve/mask ventilation provided (should be selected even if patient had ETT or tracheotomy in place during the entire event). Endotracheal Tube Endotracheal tube in place or placed during the event. Tracheotomy Tracheostomy tube in place or placed during the event. Other If Other is selected, provide the name(s) of the other airways used.
Intubation: Time, Size and by Whom If an invasive airway was inserted or re-inserted during the event, enter the time of achievement, not when the first attempt was made. Also, record the size of the invasive airway and the name of the person who successfully intubated the patient. Confirmation Method Method (s) of confirmation used to ensure correct placement of invasive airway. Indicate all that were used. Auscultation Indicate if the presence of equal bilateral breath sounds was confirmed. Exhaled CO2 Indicate if expired CO2 detector such as capnography, colorimetric, etc. was used to confirm placement. Other If Other is selected, provide the name(s) of the other method(s) used to confirm placement.
Circulation Section A. First Rhythm Requiring Compressions Record the rhythm identified via ECG monitor when patient with a pulse first received compressions during the event. B. First PULSELESS Rhythm Record the first rhythm identified when the patient became pulseless. -For the unmonitored patient, select the rhythm first identified when monitor was applied. -For a monitored patient, the rhythm may be validated from the central monitor console (including use of full disclosure) C. Compressions Describe the method used to provide chest compressions during the event. Indicate all that apply. Manual Manual chest compressions were delivered during the event. Device - If Device is selected, provide the name (s) of the device (s) used to provide chest compressions. None Chest compressions were not required during the event. D. Time Chest Compressions Were Started Record the time that the first chest compressions were started.
CPR Compression Device Currently Kaleida Has one device located at DeGraff Hospital The ZOLL AutoPulse is a external non-invasive cardiac support pump that moves more blood, more consistently than is possible with human hands.
Documentation of the event A. Time Record the time of each intervention/procedure. B. Breathing Indicate the respiratory rate in the first half of the box if the patient spontaneous respirations. Indicate with a check mark in the second half of the box if the patient is receiving assisted ventilation (invasive or non-invasive). C. Pulse Indicate the heart rate in the first half of the box if the patient has a spontaneous pulse. Indicate with a check mark in the second half of the box if the patient is receiving chest compression (manual or mechanical). NOTE: If the patient with a pulse is receiving chest compressions, both boxes should be completed.. D. BP Indicate the patient s blood pressure (BP) if present. Leave the box blank if BP is not obtainable. E. Rhythm Identify the rhythm displayed on the monitor after each set of 5 cycles of CPR and prior to interventions.
. Circulation Section-continued Impedance Threshold Device Used? Indicate if an Impedance Threshold Device was used at any time during the event. AED Applied Indicate if an Automated External Defibrillator (AED) was used. Note: If an AED was applied during the event, enter the time AED was applied. Defibrillator Type Indicate if the defibillator is monophasic or biphasic. Pacemaker On Indicate if a pacemaker (transcutaneous or internal) was functioning during the event. Record the type of device under the comments section.
Impedance Threshold Device Goal: Enhance the negative pressure (or vacuum) in the chest during the decompression phase of CPR in order to return more blood to the heart. ResQPOD: ResQ Pod is a small valve placed on the end of a breathing tube that increases blood flow during CPR. Early studies with these devices indicate significant improvement in life-sustaining blood flow to the heart and brain during CPR compared to CPR alone with out the devices. The results include improved survival rates and a trail is expected in 2009 at Kaleida Health
Defibrillation D represents defibrillation (unsynchronized) and C represents synchronized cardioversion. Joules Record the number of joules used for each shock. Medications Boluses Circle the route of the medication at the top of the column and document all drugs administered as a bolus with the dose (example-1mg). Any drug not listed but administered should be recorded in the available blank space with the dose and route documented as stated above. Infusions Document all continuous infusions, recording the time started and the rate in ml per hour. The concentration of the infusion and the route (IV or IO) should be recorded under the drug name at the top of the column. Any infusion not listed but administered should be recorded in the available blank space with the rate (ml) per hour and the concentration/route documented as stated above.
Comments The comment section should be used to document procedures, interventions, lab results, patient s response to interventions, additional medications/infusions administered that could not be documented in the medication section Chest tube inserted
Additional appropriate comments When CPR was being performed: Was a compression rate of about 100 per minute maintained? Were compressions interrupted for more than 10 seconds at any time Did the ventilatory rate ( of assisted ventilations) exceed 10 per minute ( 20 per minute in pediatrics) CPR interrupted for 15 seconds to intubate
The abbreviations at the bottom of the form must be used to enter cardiac rhythms, IV route/site and as indicated
Code Outcome A. Time Resuscitation Event Ended Record the time chest compressions stopped and did not resume because it was either the beginning of the sustained (>20 min) return of circulation or because of other reasons indicated below under Reason resuscitation ended. B. Reason Resuscitation Ended Select the reason that the resuscitation event ended from the list below. Survived - Return of Circulation (ROC) >20 min. Return of spontaneous pulse, including with pacemaker or extracorporeal membrane oxygenation (ECMO), with good perfusion that was sustained for > 20 minutes. Died: Efforts Terminated, No Sustained ROC Patient did not respond to Advanced Life Support (ALS), unable to achieve a sustained ROC. Died: Medical Futility Advanced Life Support (ALS) was terminated because of medical futility, such as end stage disease or organ failure. Died: Advanced Directives Patient had an advanced directive in place that limited the extent of advanced life support procedures. Died: Restrictions by Family There were restrictions placed by the family of the patient, i.e., family requested that the event be terminated.
Devices Using the designated columns, enter the time and site of insertion; size and type of device and name of individual performing the procedure for: Intravenous (IV) and /or intaosseous (IO) devices Central Line Placement NG Nasogastric tube placement Other Any other line placement such as transvenous pacemaker, indwelling catheter, etc. Team Members At least 4 Code Team members in additional to the recorder and Code Team leader may sign as participating during the event.
Signatures The Recorder & Code Captain or Charge Physician must thoroughly review and sign the record in the appropriate places. Following the Code, the recorder, patient nurse and Charge MD should review the documentation for accuracy and completeness
Quality: Any quality improvement issues related to personnel, equipment, medication should be indicated here. Be specific in description of the issue. Example, equipment delay in obtaining transcutaneous pacer, light bulb in laryngoscope not working; medication inadequate supply of epinephrine. This portion of the form (pink copy) is NOT a permanent part of the medical record
Summary The code documentation form is a record of your patient assessment and the interventions performed during a cardiac or respiratory arrest. The form should be completed in any patient area where a code is called for an acute respiratory event or a cardiac arrest Complete documentation on the form during the emergency also assists in data collection which can ultimately assist us as an institution in improving patient outcomes after respiratory & cardiac arrests