UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: CODE BLUE POLICY
Effective Date: January 2007 Approval: See Authorization
Supersedes Policy Date: none Contact: Clinical Staff Education
Reviewed August 2008 July 2009 October 2010 October 2011 February 2013
To provide immediate medical attention and treatment to any person in cardiopulmonary arrest at the University of
Wisconsin Medical Foundation (UWMF) TRANSFORMATIONS 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).
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.
1. INITIATION OF A CODE BLUE
a) The first person to discover someone in cardiopulmonary arrest will:
1. Establish unresponsiveness, assess for Do Not Resuscitate bracelet/jewelry.
2. Summon help:
Activate ‘Code Blue’ pad in procedure room #1 or #2.
Press #51 from all other phones and announce “CODE BLUE and LOCATION” three times.
3. Administer CPR as necessary.
4. APPROPRIATE STAFF 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.
In the event of a second code, the receptionist will summon the next closest Code Cart (if available)
to the emergency and announce the same as above.
2. RESPONDING CRASH CART AND STAFF
a) ALL AVAILABLE STAFF will respond to a Code Blue.
b) CODE CART will come from Pre-Post Room.
c) If needed the glucometer will be brought from the Pre/Post op area.
3. CODE BLUE TEAM MEMBER RESPONSIBILITIES
a) CODE DIRECTOR – (THE FIRST MD/PA/NP) 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 – PRE-POST STAFF will bring cart to the scene during Operating Room
hours and CLINIC STAFF will bring cart to the scene outside of Operating Room hours. Turn on the
Philips Heartstart MRx monitor/defibrillator using AED mode, apply cardiac fast patches to patient, and
operate the Heartstart MRx monitor/defibrillator. Defibrillate when order given by Code Director or if prompted
by the unit.
d) IV – (PA/NP/RN) -Secure IV line and administer medications as needed.
e) MEDICATIONS – (NP/ PA/RN) Draw up and administer meds; call out meds and dose to Code Director
f) AIRWAY – (ANY CPR CERTIFIED STAFF) Secure airway, bag or set up oxygen tank and tubing. Set up
suction- If suction is needed.
g) COMPRESSSIONS – (ANY CPR CERTIFIED STAFF) (1 or 2 PERSONS) Obtain vital signs, or administer
compressions if needed
h) RECORDER – (ANY STAFF) (1 PERSON) Record all pertinent data (i.e. vitals, meds, time of events), stand
by medication nurse (to properly record names of meds given); Have records copied to send with patient if
i) RUNNER – (ANY STAFF) be available to obtain any needed supplies/personnel, locate, direct and keep
j) TRAFFIC DIRECTOR – (ANY STAFF) keep area clear of nonessential personnel.
NOTE: The above roles/responsibilities are a guideline. They may be divided, combine or can be
interchangeable when the number of personnel is limited.
4. 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) Patient’s UWHealth Clinical Summary (in Chart Review) will be printed off Health Link and accompany patient
d) Copy of EKG/ECG sent with patient (if available) and if ECG/EKG not electronically filed, fax to Emergency
Department for advanced care.
e) Copy of Code Summary from Philips Heartstart MRx defibrillator.
5. 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
call switchboard to have “Code Blue - - All Clear” announced.
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).
6. EVALUATION OF CODE BLUE
a) The first person to witness the event should complete the PSN report within 24 hours.
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 Department.Manager.
WRITTEN BY: Amy Johnson, RN, MSN, Clinical Staff Educator
REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
REVIEWED BY: Anne Buol, Transformations Administrative Director, 2013
AUTHORIZATION AND ANNUAL REVIEW:
Medical Director Date
Clinic Manager Date