4.09 Medical Emergency Response ‐ Digestive Health Center (DHC)
Category: UWHC Departmental Policy
Policy Number: 4.09
Effective Date: September 25, 2013
To establish policies for the provision of Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS) and other
medical emergency care (such as ACLS) at UW Health Digestive Health Center (DHC).
Clinical staff will provide BLS and triage medical emergencies, responding with staff from the immediate area. If
the ACLS team is available and that level of care is deemed necessary it will be provided. A medical emergency
response team within the DHC shall be activated using the emergency response system. The goal is to resuscitate
and stabilize the patient for immediate transport to the Emergency Department (ED) via ambulance. There are two
types of responses at the DHC: Medical Response and Code Blue.
A. Medical Response: This is indicated for non-life threatening situations.
1. Activate the Medical Response within the building by dialing 262-0000.
2. Let paging know that you have a Medical Response. Give them the location of the emergency
(Digestive Health Center), floor and room number.
3. Physician of the day or designee and endoscopy care team leader or designee must respond to
the Medical Response.
4. Bring the Medical Response Bag and/or BLS cart to the location of the individual.
5. If appropriate, patients may be taken to an exam room.
6. If the patient is assessed to need transport to the ED, call the appropriate transport option. A list
is kept in the code binder located on the BLS cart (Appendix 1).
7. Patient’s condition will be assessed by appropriate medical personnel. If deemed emergent,
activate Code Blue immediately as shown below.
B. Code Blue: This is indicated for a life threatening emergency. Pushing a “Code Blue” button activates the
care team workstation’s Nurse Call system. Activate a Code Blue anytime a life threatening event is
occurring. Employees are encouraged to activate Code Blue as needed and are encouraged to err on the
side of safety if trying to determine whether or not to activate this level of response. Any staff member at
any time may dial 911; however, the decision to dial 911 is usually made after the patient has been
assessed by the Code Blue response team.
1. Activating “Push for Help” Buttons and “Pull for Help” Cords:
a. “Push for Help” and “Pull for Help” emergency alarm switches are located throughout the
building including all restrooms, prep/recovery rooms, phlebotomy bays and endoscopy
b. Activating a “Push for Help” button or “Pull for Help” cord places the individual in voice
contact with a staff member somewhere in the building, which is usually an area that is
proximate. Staff are made aware of a “Push for Help” button or “Pull for Help” cord
being activated by answering a console (a special, dedicated phone used to answer
“Push for Help”, “Pull for Help”, and “Code Blue” buttons), which has an audible
alarm/ring as well as text information that provides the person answering the console
with information specific to the type of call (i.e. “Staff Assist”; “Bath”; or in some cases
“Code Blue”) and the area and location of the button or cord that was
activated. Activating a “Push for Help” button or a “Pull for Help” cord does not
initiate a medical emergency response, and does not activate an external
response with the Dane County 911 system.
c. By placing the person that activates a “Push for Help” button or “Pull for Help” cord in
voice contact with a staff member, the staff member will make a decision to address the
problem/issue at the local level without activating a building response or a decision will
be made to activate a building response (Code Blue response or Medical Response). If a
“Push for Help” button or “Pull for Help” cord is activated and the staff member
answering the console does not get a response from the person who activated the
button or cord, the staff member answering the console must immediately check on the
patient and activate the appropriate medical emergency response as needed.
2. Activating “Code Blue” Buttons:
a. If a decision is made to activate the Code Blue response, a “Code Blue” button must be
b. Pushing a “Code Blue” button activates the Code Blue medical emergency response
system at the local level only, i.e. at the care team workstation.
c. You must activate Code Blue within the building by dialing 262-0000.
d. Let paging know that you have a Code Blue. Give them the location of the emergency
(Digestive Health Center), floor and room number.
e. DHC staff must call 911. Please give them:
i. Your Name
ii. Address: UW Health Digestive Health Center, 750 University Row, Madison WI
3. Code Blue Team:
a. A Physician of the day will be scheduled and identified Monday through Friday. The
Medical Director, Director and Access Manager shall ensure that a Physician of the day is
assigned and responds to medical emergencies as needed.
b. The Code Blue team shall be composed of the following members:
i. Anesthesiologist (if available)
ii. ACLS certified Physician of the day
iii. ACLS certified Nurse Clinician
iv. ACLS certified Nurse Care Team leader (if available)
v. BLS certified Medical Assistants / Endoscopy Technicians
vi. Manager (if available)
vii. Pharmacist (if available)
c. The Code Blue team responds to all Code Blue responses within the DHC. For arrests
occurring in the DHC parking lot call BOTH 262-0000 for BLUE CART AND 911 for
Madison FIRE/RESCUE and give location of individual.
d. When possible, call paging or 911 from a DHC landline instead of a personal cell phone.
4. Responsibilities of the Code Blue team:
a. Physician of the day:
i. Coordinate and direct the entire resuscitation effort if Anesthesiologist is not
ii. Order the administration of appropriate drugs and fluids.
iii. Evaluate the EKG and direct the treatment of dysrhythmia.
iv. Support efforts by the Manager or Care Team Leader to limit the number of
people in the area and dismiss personnel no longer essential for continuation of
v. Decide when to terminate efforts.
vi. Review and sign Resuscitation Report.
vii. Complete the blue cart note in the patient’s electronic medical record (EMR)
(utilize Smart Note or individual note).
viii. Coordinate and direct the immediate post-resuscitation review session.
ix. Provide follow-up contact and information to patient's family and attending
physician regarding resuscitation effort.
b. ACLS Certified Nurse Clinician:
i. Stay in the room to provide information regarding appropriate patient history
and the events leading to the arrest.
ii. Assist with CPR if needed.
iii. Administer drugs and therapies per ACLS protocol.
iv. Assist with bedside procedures.
v. Ensure patient is being ventilated with high concentration oxygen until
vi. Assist Anesthesiology in intubation and ventilation.
vii. Assist in the transfer of patient/victim to the ED.
viii. After initial stabilization procedures are complete, and upon mutual agreement
with emergency response team, return to their respective work area.
ix. Review the Resuscitation Report for accuracy.
c. Anesthesiology (or other qualified provider):
i. Coordinate and direct the entire resuscitation effort.
ii. Establish and maintain airway and ventilation.
iii. Assess effectiveness of basic life support, pupils, carotid pulse and breath
d. Medical Assistant and/or Endoscopy Technician:
i. Help take the blue cart (ACLS cart) from the cart closet closest to the
patient. Cart closet is locked with badge access.
ii. Plug in the electrical system of the blue cart into an appropriate electrical
iii. Procure additional equipment, as necessary.
iv. Bring extra standard precaution supplies to site of the blue cart.
v. Assist as needed.
vi. Assist in CPR.
vii. Assist in obtaining vital signs.
viii. Assist in clearing hall for transfer of patient to the ED.
ix. Restock the blue cart and verify contents and order additional supplies if
needed following conclusion of the resuscitation effort.
e. Care Team Leader:
i. Responsible for performance of basic life support until Physician members of
the code team arrive.
ii. Clear hall and room for arrival of blue cart and code team.
iii. Responsible for continuation of patient care services on nursing unit.
iv. Assist community EMS (911), if possible.
v. Take phone lab reports and share with others on the code team.
vi. Assume responsibility for family notification and support.
vii. Notify patient's Attending physician (if not present).
viii. Document summary of events preceding the arrival of the code team on
patient’s progress note.
ix. If pharmacy is not present, act as recorder for the resuscitation on the
x. Assist in identification of support or debriefing needs of staff involved in
resuscitation effort and work with Nurse Manager to contact resources to meet
needs for family and/or staff support.
i. Prepare medication in accordance with the Pharmacy Policy 6.5 and as directed
by the Attending physician.
ii. Maintain the Resuscitation Report as the recorder.
a. All emergent patients must be transported by fire/rescue to the ED after evaluation by a
b. Non-emergency transport can be arranged using the list kept in the code binder located
on the BLS cart.
6. AED and Cart Locations:
a. Lower floor
i. AED – By room 011
b. First floor
i. AED – By the lab waiting area
ii. BLS cart – room 105A
c. Second floor
i. AED – By the hospitality area
ii. ACLS cart – room 268
d. Third floor
i. AED – By the reception area
ii. ACLS cart – room 303A
7. Restocking, Care and Maintenance of the Carts and AED Following a Resuscitative
a. Refer to Nursing Patient Care Policies 14.27 and 14.30 for direction on restocking.
b. A Medical Assistant will be responsible for restocking the cart immediately after the code
or medical response.
c. Pharmacy will be responsible for double checking the cart and replacing the drug box.
d. Obtain BLS/ACLS cart lock replacements from pharmacy or designee ensuring proper
sign out procedure.
e. In the case of a subsequent event, there are two ACLS carts located within the
DHC. One may be used as a backup if necessary.
f. All backup supplies may be retrieved from the clean supply room located on the second
floor – room 223.
8. Blue Cart Review: Each resuscitation effort should be reviewed by the DHC medical emergency
response team. Whenever possible, this review will take place immediately upon completion of
the resuscitation effort. All medical emergency response team members should attend each
review session if possible. Completed Resuscitation and Review Forms (including name of
Physician of the day) will be forwarded to the Resuscitation Review Committee for review. The
review meeting will address the following items:
a. To identify correctable problems with equipment, procedures or performance.
b. To insure accuracy and completeness of Resuscitation record.
c. To hear and discuss differences of opinion within the Team.
d. To report problems and recommendations to the Resuscitation Committee.
1. Complete documentation on HealthLink (HL) SBAR form and any necessary documentation to
Resuscitation Report Form #1280007 which is found in the code binder on the blue cart with the
assistance and information obtained from the first and second responder.
2. When the patient is transported to the ED of choice, an SBAR report must be called to them and
the Resuscitation Report form should be faxed to the receiving facility.
3. Obtain the SBAR form from HL by doing the following:
a. Click on the visit navigator. On the menu bar, select SBAR from clinic.
b. Click on the create note.
c. To print note, go back to chart review, select office visit from today, then print.
4. A copy of the Resuscitation Report and verbal report will also be given to the EMS prior to
5. Request a UWHC Medical Record number for those who do not already have one and add
complete documentation to the HL SBAR form. To obtain a medical record number call: 608-890-
5387 or 608-261-1600.
1. Mock Codes/Evaluation: Facility emergency "mock codes" will be carried out periodically and
documented as part of the department’s emergency response drills. All Medical Response/Code
Blue responders will participate in these drills.
2. The Emergency Action Plan will be part of a new employee's orientation at DHC. The UWHC
Risk Management Department and the Blue Cart Committee will approve the emergency action
plan and subsequent changes. The plan will be reviewed and evaluated by the DHC Emergency
Medical Committee. The medical emergency plan will be included in the DHC Orientation Manual,
on-line, and in the building policy and procedure.
IV. FORMS USED
Resuscitation Report UWH #1280007— reviewed monthly by Peer Review sub-committee of Resuscitation Review
AHA NRCPR v4.0 - CPA Data Collection Form
Administrative Policy 8.23 - Do Not Resuscitate/No CPR Order
Administrative Policy 8.13 - Cardiopulmonary Resuscitation Response Team
Hospital Departmental Policy 14.27 – Maintaining and Securing the Emergency Response Carts
Hospital Departmental Policy 14.30 – Maintenance of the Automated External Defibrillator (AED) Heartstream F-2
and Lifepak 12 Defibrillator
Administrative Policy 8.24 - Guidelines for Treating Patients When They Refuse Medical Treatment
Administrative Policy 8.25 - Guidelines for Decisions to Limit Life-Sustaining Medical Treatment
Administrative Policy 7.36 - Emergency Response Teams
Administrative Policy 7.12 – Emergency Assessment at UWHC Facilities
VI. WRITTEN AND APPROVED BY
DHC Medical Directors
DHC lead Physicians
DHC Leadership Team
VII. REVIEWED AND APPROVED BY
UWHC Safety Program Director
Ambulatory Policy and Procedure Committee
Deborah D. Tinker, MSN RN CENP, Director, Ambulatory Nursing