UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: CODE BLUE POLICY
Effective Date: 9.13.2010 Approval: See Authorization
Supersedes Policy: None Contact: Clinical Staff Education
Reviewed 1.27.2011 2.15.2012 3.26.2013
PURPOSE: To provide immediate medical attention and treatment to any person in cardiopulmonary arrest at the
University of Wisconsin Medical Foundation (UWMF) Clinic site. The goal is to rapidly assess and begin transport of the
patient to the appropriate facility as soon as possible under the circumstances.
Basic Life Support (BLS): Recognition of cardiopulmonary arrest, access to the Emergency Medical Services (EMS)
system, and basic Cardiopulmonary Resuscitation (CPR).
POLICY: All UWMF clinic employees are responsible for knowing this procedure, their expected roles, use of emergency
equipment, and utilizing Standard Precautions while participating in a Code Blue.
PROCEDURE: Assess patient and summon help so interventions occur quickly and simultaneously:
I) INITIATION OF A CODE BLUE
a) The first person on the scene will assess patient and establish unresponsiveness.
b) Summon help. Page using #51 and announcing “CODE BLUE and LOCATION” three times.
c) Check for Do Not Resuscitate bracelet/jewelry.
d) Administer CPR as necessary.
e) Appropriate staff member will CALL 911.
NOTE: If the person is carrying a concealed weapon - alert the 911 dispatcher of the weapon and
request a police officer
DO NOT remove the gun; continue steps of CPR.
II) RESPONDING CRASH CART AND STAFF
a) All available staff will respond to a Code Blue.
b) Any available staff will transport the Code Cart.
c) Reception will meet ambulance at the front doors.
III) CODE BLUE TEAM MEMBER RESPONSIBILITIES
a) CODE DIRECTOR – (THE HIGHEST CREDENTIALLED STAFF MEMBER ON THE SCENE) the Code
Director will direct emergency efforts, and designate tasks to be performed. This person may relinquish this
role to another MD/PA/NP.
b) CHARGE PERSON – (THE FIRST NP/ PA/ RN) the Charge Person assists the Code Director in emergency
efforts by delegating tasks. This person may relinquish this role to another RN/NP/PA.
c) CODE CART TRANSPORTER – (ANY STAFF X’s 2) will bring the code cart to the location of the
d) IV NURSE – (Anesthesiologist /RN) will locate possible IV sites, set up and secure IV line and administer
medications as needed.
e) MEDICATION NURSE – (Anesthiologist /RN) will draw up and administer meds
f) AIRWAY – (ANY CPR CERTIFIED STAFF) will secure airway, bag or set up oxygen tank/compressor and
tubing. Set up suction and suction if needed.
g) COMPRESSSIONS – (ANY CPR CERTIFIED STAFF (2 PERSONS) will obtain vital signs, administer
compressions if needed and help maintain airway if needed.
h) RECORDER – (ANY CPR CERTIFIED STAFF) will record pertinent data (i.e. vitals, meds, time of events);
Have records copied to send with patient if transported.
i) RUNNER – (RECEPTION) will be available to obtain any needed supplies/personnel and direct ambulance
j) TRAFFIC DIRECTOR – (RECEPTION/COORDINATOR) will keep area clear of nonessential personnel.
NOTE: The above roles/responsibilities are a guideline. They may be divided and interchangeable when the
number of personnel is limited.
IV) PREPARING THE PATIENT FOR TRANSPORT BY AMBULANCE
a) Code Director or Charge person will notify receiving hospital and give report.
b) Copy of the UWMF Emergency Event Record will accompany patient.
c) Print off ‘Code Summary’ from Defibrillator to send with patient.
d) Print off patient’s UW Health Clinical Summary from HealthLink.
V) TERMINATION OF THE CODE BLUE
a) When the ambulance has arrived and care has been turned over to the EMS, the charge RN or designee will
announce overhead “Code Blue - - All Clear”.
b) The resuscitation must be stopped by physician’s order.
c) If the patient dies, the charge physician will note the time of death and the Recorder will document. The charge person will
contact the Coroner’s Office (Dane County - 284-6000)
VI) EVALUATION OF CODE BLUE
a) The first person to witness the event should complete a GENERATIONS FERTILITY CLINIC INCIDENT
REPORT FORM within 24 hours of event and send to: UWMF Safety Department Manager.
b) The clinic manger will coordinate a debriefing (if needed) with Clinical Staff Education department.
Debriefing form to be completed within 48 hours of debriefing and sent to: UWMF Safety
WRITTEN BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
REVIEWED BY: Elizabeth Albracht, Manager of Generations Fertility Care Clinic
Dan Lebovic, MD, Reproductive Endocrine & Infertility
REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator, 2012
AUTHORIZATION AND ANNUAL REVIEW:
Medical Director - Generations Date
Clinic Manager Date
Medical Director – UWMF Date