TITLE

CODE BLUE ADULT ACUTE CARE SITES CALGARY ZONE

DOCUMENT #

INITIAL APPROVAL DATE

HCS-31

May 7,2013

APPROVAL LEVEL

INITIAL EFFECTIVE DATE

Senior Vice-President, Calgary Zone

September 3, 2013

SPONSOR

REVISION EFFECTIVE DATE

Calgary Zone: Executive Leadership, Intensive Care

Unit Executive Council and Code Blue Committee

N/A

CATEGORY

NEXT REVIEW

Health Care and Services

May 7, 2016

If you have any questions or comments regarding the information in this policy, please contact Clinical Policy Department at
clinicalpolicy@albertahealthservices.ca. The Clinical Policy website is the official source of current approved clinical policies,
procedures and directives.

PURPOSE
To provide clear guidelines and direction on how to respond to any adult experiencing acute
physiologic compromise, airway threat, respiratory and /or cardiac arrest.
APPLICABILITY
Compliance with this policy is required by all Alberta Health Services employees, members of
the medical and midwifery staffs, students, volunteers, and other persons acting on behalf of
Alberta Health Services (including contracted service providers as necessary) at the Foothills
Medical Centre, Peter Lougheed Centre, Rockyview General Hospital, and South Health
Campus. This policy does not limit any legal rights to which you may otherwise be entitled.
POLICY STATEMENT
Basic life support measures (BLS) shall be initiated immediately for any person who
experiences acute cardiopulmonary distress. The interventions undertaken must be
FRQJUXHQWZLWKWKHSDWLHQWV*RDOVRI&DUH'HVLJQDWLRQLINQRZQ, in accordance with
Calgary Health Region (legacy) Advanced Care Planning: Goals of Care Designation . If
the Goals of Care Designation is not known, it should be considered to be R1. Basic life
support may include the use of an automated external defibrillator (AED) by trained first
responders.
A Code Blue should be initiated for acute physiological disturbances that require immediate
intervention.
A Code 66 should be activated if a response time of up to 15 minutes is deemed acceptable.

Alberta Health Services 2013

PAGE: 1 of 9

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

EFFECTIVE DATE
September 3, 2013

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
2 of 9

Goals of Care (GOC) assist the healthcare team in providing care consistent with patient
and family wishes. As such, Code Blue activation should be initiated for Resuscitative care
designations only (R1, R2, and R3).
For patients with a Medical or Comfort Goals of Care designation, a Code 66 is the most
appropriate response team to activate.
The Critical Care Code Blue Team is responsible for attending and conducting adult
resuscitations in the hospital. The activation systems, personnel, and equipment required to
respond to a Code Blue will vary depending on the location of the event and site (see site
specific resources).
,WLVWKHUHVSRQVLELOLW\RIERWKWKH&RGH%OXH7HDPDQGWKHSDWLHQWVSULPDU\QXUVHRU
designate to confirm the identity and Goals of Care Designation of the patient.
Families may be given the opportunity to be present during resuscitation if feasible and
EHOLHYHGWREHLQNHHSLQJZLWKWKHSDWLHQWVZLVKHV$VWDIISHUVRQ6RFLDO:RUNHU6SLULWXDO
Care worker, nurse, physician, registered respiratory therapist, etc.) will be present with the
family for support.
POLICY ELEMENTS
1.

Response Locations
1.1

Response locations vary from site to site within the Calgary Zone. (See site
specific resources for response locations.)

1.2

The Code Blue Team will respond to the location of the cardiac arrest.

1.3

)RU&RGH%OXHFDOOVRFFXUULQJRXWVLGHRIDVLWHVGHILQHGUHVSRQVHORcations, but
within a reasonable distance of the physical plant, dual activation of Emergency
Medical Services (911) and the Code Blue Team are required. The team needs to
exercise clinical judgment and common sense when responding to calls where
environment, scene control, or other circumstances may put the team or patient at
risk. If such concerns are raised and the team feels that they cannot provide an
advanced cardiac life support (ACLS) response safely, provision of BLS services
as first responders may be considered, if it is safe to do so, while awaiting
Emergency Medical Services.

1.4

In the event that an area which routinely manages their Code Blue responses
internally requires resuscitation assistance, the site Code Blue Team is to be
activated.

1.5

In the event that a Code Blue is called in a magnetic resonance imaging (MRI)
area, resuscitation efforts must be taken outside of the magnetic resonance
imaging room as the magnet will cause items to become hazardous projectiles,
creating a patient and staff hazard.

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

2.

EFFECTIVE DATE
September 3, 2013

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
3 of 9

Initiating a Code Blue

2.1

First responder:
a)

initial patient assessment;

pulselessness,
apnea, and/or
presence of other life threatening condition requiring immediate
intervention.

2.2

2.3

2.4

b)

call for HELP;

c)

if not known, verify the Goals of Care to confirm resuscitation status;

d)

activate site Code Blue response (e.g., depressing Code Blue button, dial 600,
pull call bell); and

e)

if indicated, initiate BLS procedures.

Second responder:
a)

activate site Code Blue response if not completed by the first responder; and

b)

assist with BLS procedures if indicated.

Unit/clinic staff:
a)

assign staff member to remain at the entrance to the area to direct the Code
Blue Team to the location of the Code Blue;

b)

clear the route for Code Blue Team arrival; and

c)

bring airway management bag to the Code Blue location (see site specific
resources).

Switchboard Operator:
a)

iI&RGH%OXHORFDWLRQLVRXWVLGHRIDVLWHVGHILQHGUHVSRQVHORFDWLRQGLUHFW
caller to dial 9-911 to activate Emergency Medical Services; and

b)

site specific variations of overhead announcements and internal pager

activations (see site specific resources).

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

3.

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
4 of 9

Code Blue Team Personnel

3.1

3.2

4.

EFFECTIVE DATE
September 3, 2013

The critical care interprofessional Code Blue Team may include:

a)

physicians;

b)

registered nurses;

c)

nurse practitioners;

d)

Emergency Department paramedics;

e)

registered respiratory therapists;

f)

health care aides/nursing attendants/licensed practical nurses; and

g)

health care students under direct supervision.

Other personnel expected to attend:

a)

patient care area primary care registered nurse/licensed practical nurse or

designate;

b)

available unit staff;

c)

area manager/designate;

d)

Protective Services personnel (see site specific resources); and/or

e)

Electrocardiogram (ECG)/Cardiology Technologist.

Responsibilities and Expectations

4.1

Physician lead/designate:
a)

The Intensive Care Unit (ICU) attending physician/designate will direct the
Code Blue team and be responsible for the overall management of the
resuscitation. Designates may include Fellows, outreach physicians,
ICU/Critical Care Unit (CCU) residents, ICU bedside physicians and ICU
nurse practitioners. Other physicians, such as additional residents or attending
physicians, at the discretion of the Code Blue team leader, will serve as
resource persons and will perform or assist with procedures, such as airway
management and obtaining central venous access.

b)

The role of the Code Blue team leader may be delegated to another more
experienced physician team member.

c)

It is the responsibility of the Code Blue team leader to make decisions

regarding basic and advanced life support. This includes airway management,
vascular access, ordering of medications, and ultimate disposition of the

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

EFFECTIVE DATE
September 3, 2013

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
5 of 9

patient. The team leader may delegate procedural tasks to other members of
the team (capturing airway, obtaining vascular access, etc).
d)
4.2

,IUHVXVFLWDWLRQDWWHPSWVDUHXQVXFFHVVIXOLWLVWKH&RGH%OXHWHDPOHDGHUV
responsibility to terminate the code.

Code Blue Team registered nurses:

a)

ensure necessary equipment is available

bring the ancillary Code Blue supplies to the Code Blue location
(backpack); and/or
bring the crash cart as required (see site specific resources).

b)

co-ordinate/delegate roles
Manage crash cart: prepare medication, mix intravenous solutions,
manage defibrillator, etc. All crash carts are set up in a standard format
as determined by the Department of Critical Care Medicine, Calgary Zone
Code Blue Committee.
Documentation: Code Blue resuscitation and Quality Assurance. When
responsibility for documentation is delegated to another regulated health
care professional, the Code Blue registered nurse is responsible to review
the documentation with the delegated health care provider at the
completion of the code.
Patient Care: Responsible for direct patient care requirements during the
Code Blue including medication administration, intravenous initiation,
assisting with intubation and procedures.

4.3

Emergency Department paramedics (South Health Campus only):

a)

4.4

Responsible for direct patient care requirements during the Code Blue,
including managing the crash cart, preparing medications and delivering
shocks/cardioversions.

Registered respiratory therapists:

a)

Responsible for managing the patient's airway, oxygenation, ventilation and

obtaining/analyzing blood gases, under the direction of the team leader.

b)

Responsible for ensuring the difficult airway management cart (DAM) is

brought to the code when requested. Use of the DAM cart equipment is limited
to the ICU physicians/delegates, Emergency Department physicians or
Anesthesia physicians.

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

4.5

4.6

EFFECTIVE DATE
September 3, 2013

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
6 of 9

c)

If a second provider fails intubation, registered respiratory therapists will

automatically request the DAM cart be deployed to the code, and Anesthesia
paged stat if not already present.

d)

In the event an airway management bag was used, the registered respiratory
therapist will restock and place in the designated location.

Health Care Aide/Nursing Attendant/licensed practical nurse:

a)

Assist with bringing the crash cart to the site of the arrest (see site specific
resources).

b)

Perform chest compressions as directed.

c)

Assist with transport of patient to appropriate unit as necessary.

d)

Assist with crash cart cleaning and replacement as directed.

Patient care area staff:

a)

Perform BLS, including establishing an airway with equipment as available

until the Code Blue Team arrives.

b)

Direct the Code Blue Team to the location of the patient.

c)

Assist as directed throughout the resuscitation.

d)

Ensure the patient chart and workstation-on-wheels (W.O.W) are in the room.

e)

Clear any excess equipment or supplies and assist other patients away from
the area.

f)

Have the following information readily available for the Code Blue Team
patient identification and Goals of Care designation;
when was the patient last seen conscious and breathing (how long have
they been down);
what occurred just prior to the Code Blue; and
rHDVRQIRUWKHSDWLHQWVDGPLVVLRQ.

g)

Contact the family and attending physician if not already present.

h)

Accompany the patient on transport to ICU/Emergency Department or

appropriate department for a higher level of care.

i)

Document events preceding the Code Blue up and until the time the Code
Blue Team arrives.

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

4.7

EFFECTIVE DATE
September 3, 2013

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
7 of 9

Protective Services Personnel:

a)

Shall either
respond to all Code Blue calls (see site specific resources); or
respond to Code Blue calls at the request of the Code Blue Team.

4.8

b)

In the event of a unit, building, or site lockdown, a Protective Services officer

will attend the ICU to be on stand-by, in anticipation of a Code Blue, ready to
provide an escort for the Code Blue Team.

c)

Assist with way-finding.

d)

Assist with crowd control and safety concerns.

Electrocardiogram/Cardiology Technologist
a)

5.

6.

An Electrocardiogram/Cardiology Technologist will attend all Code Blue calls.

Documentation
5.1

All Code Blue events will be documented on the Resuscitation Record.

Documentation is completed using elapsed time.

5.2

Response time should be calculated and documented as the time elapsed

between Code Blue activation and arrival of the Code Blue Team.

5.3

It is the joint responsibility of all members of the Code Blue Team to complete and
sign the Resuscitation Record and the Code Blue Quality Assurance Review
Form.

5.4

The Code Blue Quality Assurance Review Form is to be filled out in collaboration
with all those present at the Code Blue.

Simultaneous Code Blue

6.1

Simultaneous Code Blue occurs when a Code Blue is called while another one is
still underway.

6.2

A second Code Blue team will respond to the simultaneous call. Code Blue Team
members will be assigned to a second Code Blue Team by the nurse
clinician/designate and the charge-registered respiratory therapist. The Code Blue
team physician leader will assign a physician or designate to direct the second
team.

6.3

The same process will be followed in the event of a third simultaneous Code Blue.

6.4

Members of the second and subsequent Code Blue Teams vary from site to site
(see site specific resources).

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

7.

8.

9.

EFFECTIVE DATE
September 3, 2013

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
8 of 9

Code Blue Response When Elevator Unavailable and in Emergency Situations

7.1

If the elevators cannot be used because of elevator malfunction or an emergency

situation such as Code Red, the Code Blue Team will take the stairs to the location
and proceed with the resuscitation. This may require the manual transport of
resuscitation equipment.

7.2

If the patient requires transport to the ICU or another patient care area and the
elevators remain unavailable, the Code Blue Team leader will decide on the risk
and benefit of transporting the patient up or down stairs versus continuing to
provide ACLS on location until the elevators become available.

7.3

,QWKHHYHQWRID&RGH5HG6WDWXV2QHRFFXUULQJLQWKHVDPHORFDWLRQDVWKH
Code Blue, the Code Blue Team will follow the direction of Protective Services and
the Calgary Fire Department.

Code Blue Response During Unit, Building or Site-wide Lockdown

8.1

In the event a Code Blue is called during activation of a unit, building, or site-wide
lockdown, the Code Blue team will follow the direction of Alberta Health Services
Protective Services and Calgary Police Services personnel.

8.2

When a Code Blue occurs in the same location as a lockdown, the Code Blue
team members will need to be escorted by Calgary Police Services and Alberta
Health Services Protective Services to the activating area.

Patient Disposition Following Code Blue

9.1

If the patient is to be transferred from the Code Blue location to a critical care area:
a)

Patient will be monitored on a cardiac and oxygen saturation monitor at all

times.

b)

Patient will be accompanied by a registered nurse and registered respiratory

therapist at all times, and physician/nurse practitioner when deemed
necessary.

c)

The nurse from the sending unit must accompany the patient and give report
to the receiving nurse.

9.2

If the patient is not already admitted and requires ICU care, the patient may be
admitted directly to the receiving unit. In the event that a bed is not readily
available, or this is not unit practice, the Code Blue Team will collaborate with the
receiving nurse clinician/designate to determine the preferred location for the
patient.

9.3

If the patient expires at the code and is not an inpatient, the deceased may be
transported to ICU for post-mortem care prior to disposition to the morgue. Other
locations may also be acceptable (Emergency Department, ward bed, etc).

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.

TITLE
CODE BLUE ADULT ACUTE CARE SITES - CALGARY ZONE

10.

EFFECTIVE DATE
September 3, 2013

DOCUMENT #
HCS-31

POLICY - LEVEL 3
PAGE
9 of 9

Crash Cart Management

10.1

Following use, the crash cart must be sent to Distribution for restocking.

10.2

Any equipment removed from the crash cart for patient transport must be returned
to Distribution separately (e.g., defibrillator, back board, etc).

10.3

The crash cart and reusable equipment must be cleaned before being sent to
distribution. The responsibility for this varies by site (see site specific resources).

10.4

The process to replace a used crash cart with a new one varies by site (see site
specific resources).

10.5

Crash carts will be checked every 24 hours or as designated see site specific
resources and crash cart checklist/responsibilities.

REFERENCES
Alberta Health Services Resuscitation Record (Form #00535)
Alberta Health Services Code Blue Quality Assurance Review (Form #00534)
Former Calgary Health Region Advanced Care Planning: Goals of Care Designation #1635

If you have any questions or comments regarding the information in this policy, please contact clinicalpolicy@albertahealthservices.ca. The Clinical
Policy website is the official source of current approved clinical policies, procedures and directives.