322-0267 CODE BLUE rev 06-10
322-0267 CODE BLUE rev 06-10
322-0267 CODE BLUE rev 06-10
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<strong>CODE</strong> <strong>BLUE</strong> RECORD<br />
Pre-arrest Diagnosis________________________________________<br />
SITUATION<br />
Date:<br />
BACKGROUND<br />
Time Code Called:<br />
Found by:<br />
Condition Found: Unresponsive Pulseless Apneic<br />
Other:<br />
Witnessed: Yes No<br />
Intubation Time: ETT Lip cm: CL / IV / IO / EJ<br />
Other:<br />
Placement Time:<br />
Physician in charge: Primary RN: Recorder:<br />
Location / Unit:<br />
CPR Started:<br />
ASSESSMENT<br />
RECOMMENDATIONS<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
RESUSCITATION OUTCOME<br />
Recovery TIME STOPPED _____________ BP _____________ HR _____________ RR _____________ SPO2 _____________ RHYTHM ______________<br />
RECEIVING UNIT ICU Other<br />
Expired TIME: PMD NOTIFIED:<br />
Signatures: Physician: ____________________________________________________ RT: __________________________________________________________<br />
ICU RN: ______________________________________________________<br />
Primary Nurse: ________________________________________________<br />
FORM <strong>322</strong>-<strong>0267</strong> Rev. 6/<strong>10</strong> (PART 1 OF 2)<br />
Original chart copy Xerox copy to QM Xerox copy to ICU NM<br />
<strong>CODE</strong> <strong>BLUE</strong>
<strong>CODE</strong> <strong>BLUE</strong> RECORD<br />
Pre-arrest Diagnosis________________________________________<br />
SITUATION<br />
Date:<br />
BACKGROUND<br />
Time Code Called:<br />
Found by:<br />
Condition Found: Unresponsive Pulseless Apneic<br />
Other:<br />
Witnessed: Yes No<br />
Intubation Time: ETT Lip cm: CL / IV / IO / EJ<br />
Other:<br />
Placement Time:<br />
Physician in charge: Primary RN: Recorder:<br />
Location / Unit:<br />
CPR Started:<br />
ASSESSMENT<br />
RECOMMENDATIONS<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
Time: ECG Rhythm HR BP Resp<br />
O2/BVM<br />
CPR<br />
Defib<br />
Joules<br />
Pacer<br />
Epinephrine<br />
½ 1 amp<br />
Atropine<br />
½ 1 amp<br />
Amiodarone<br />
_____ mg<br />
Other<br />
RESUSCITATION OUTCOME<br />
Recovery TIME STOPPED _____________ BP _____________ HR _____________ RR _____________ SPO2 _____________ RHYTHM ______________<br />
RECEIVING UNIT ICU Other<br />
Expired TIME: PMD NOTIFIED:<br />
Signatures: Physician: ____________________________________________________ RT: __________________________________________________________<br />
ICU RN: ______________________________________________________<br />
Primary Nurse: ________________________________________________<br />
FORM <strong>322</strong>-<strong>0267</strong> Rev. 6/<strong>10</strong> (PART 1 OF 2)<br />
Original chart copy Xerox copy to QM Xerox copy to ICU NM<br />
<strong>CODE</strong> <strong>BLUE</strong>
POST ARREST CQI<br />
REVIEW BY <strong>CODE</strong> RN<br />
Pre-arrest Diagnosis________________________________________<br />
Instructions: Complete this tool immediately following the code and forward to the ICU Nurse Manager<br />
Date __________________________ Time __________________ Code Status ____________________________________<br />
Describe what happened: ________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
BLS: __________________________________<br />
Time code called<br />
______________________<br />
Time BLS initiated ______________________<br />
Airway<br />
Breathing<br />
Yes ______ No ______<br />
Yes ______ No ______<br />
Circulation<br />
Yes ______ No ______<br />
Physician notified<br />
Yes ______ No ______<br />
ACLS: ________________________________<br />
Code Team arrived in a timely manner<br />
Monitor attached and rhythm identified<br />
Yes ______ No ______<br />
Yes ______ No ______<br />
ACLS Protocol followed<br />
Crowd Control initiated<br />
Yes ______ No ______<br />
Yes ______ No ______<br />
Family notified<br />
Yes ______ No ______<br />
Describe opportunities for improvement in the Code Blue process, including patient care prior to arrest:<br />
________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
Identify any safety/concerns from this code event: __________________________________________________________<br />
________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
______________________________________ ______________________________________ ________________________________<br />
RECORDER SIGNATURE DATE/TIME<br />
______________________________________ ______________________________________ ________________________________<br />
TEAM LEADER SIGNATURE DATE/TIME<br />
______________________________________ ______________________________________ ________________________________<br />
ICU MANAGER REVIEW SIGNATURE DATE/TIME<br />
Code Blue Evaluation Tool - Not part of the permanent record<br />
FORM <strong>322</strong>-<strong>0267</strong> Rev. 6/<strong>10</strong> (PART 2 OF 2)<br />
ATTACH CARBON COPY OF <strong>CODE</strong> <strong>BLUE</strong> FORM<br />
POST ARREST CQI REVIEW<br />
BY <strong>CODE</strong> R.N.
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