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Considering that in-hospital cardiac arrest (IHCA) survival rates continue to fall well below target goals, hospitals should empower Code Blue teams in every way possible to confidently and consistently deliver the highest standard of resuscitation response.

Clinicians typically complete a range of required training, including biennial Basic Life Saving (BLS) and cardiopulmonary resuscitation (CPR). But muscle memory can start to dissipate within weeks of these sessions.

That’s why the American Heart Association (AHA), National Academy of Medicine, and The Joint Commission have all recommended that hospitals provide additional, ongoing resuscitation training, such as in situ IHCA simulations. Keep reading to learn five key steps to running a successful mock Code Blue program in your hospital.

1. Recognize the need for mock Code Blues

In-hospital cardiac arrest is one of the most significant contributors to overall mortality in hospitals today. It claims hundreds of thousands of lives each year in the U.S. alone, including 75 percent of adults who experience it, according to data collected prior to COVID-19.1,2 

But compared to other scenarios that result in preventable harm and death, relatively little effort is focused on improving Code Blue outcomes.2,3 This is likely because IHCA is most often the result of some other condition rather than a primary cause of death itself. Yet research shows that process and performance improvements could prevent many of these deaths, bringing the national survival rate closer to the AHA’s goal of 35%.2-6

Why mock Code Blues?

In short, because they work. Data shows that these simulated hospital emergency sessions can improve:

  • Response times and efficiency7
  • Staff confidence and competency7,8
  • Team performance8,9 
  • Patient survival8,10
  • Neurological outcomes9

The bottom line

​​Code Blues are the ultimate high-stakes hospital emergency scenarios. Successful outcomes depend so heavily on timely response from highly skilled personnel that there’s essentially no such thing as “too much training.” Regular in situ mock codes are an extremely effective way for interdisciplinary teams to build high-risk skills in a safe yet realistic environment.

2. Choose a director to run your program

Selecting the right person to run your mock Code Blue program is one of the most important determinants of success. If your hospital has a resuscitation champion, they would likely either take point on this initiative or be responsible for finding a candidate. Whatever the case, look for a program director who is:

  • Focused, organized, and detail-oriented. There’s a fair amount of schedule wrangling and planning involved, so pick someone who isn’t squeamish around color-coded spreadsheets.
  • Motivated and passionate. Your program director should deeply believe in the value of the mock Code Blue program and have no trouble getting others to buy into your hospital’s need for it.
  • Available and accountable. Even the most capable candidate can’t run a successful program if they don’t have the bandwidth. Be sure to discuss time and effort commitment beforehand.
  • Energetic and outgoing. Select someone with excellent communication skills, as they will be responsible for not only starting and running the program but also training others to maintain it.
  • Flexible and open-minded. Although your director should have a solid baseline of expertise in resuscitation, they will need to continuously absorb and incorporate the latest evidence-based best practices into the program.

3. Make a plan that sets mock codes up for success

From when you schedule mock Code Blues to the procedures and processes practiced during each one, thorough planning is of the utmost importance. Be sure to consider the following key points.

Training events should be short, sweet, and frequent. 

  • Clinicians have hectic schedules, so keeping mock Code Blues short will help ensure they are able to attend, enjoy, and really learn from each experience.11
  • Holding sessions monthly will give more responders the opportunity to attend regularly and keep their skills sharp between biennial required training.

Hold sessions in actual patient treatment areas.

  • In situ simulation provides a more realistic training environment and can positively affect learning outcomes as well as patient outcomes.9
  • Watch out for potential risks, such as mixing training supplies with real medical supplies.

Focus on your hospital’s protocols and expert recommendations.7,10

  • Attendees should walk away ready to respond to IHCA events in accordance with industry standards, such as the AHA’s Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, as applied through the protocols of your institution.
  • These sessions should give staff the opportunity to review response team roles and responsibilities and work hands-on with your hospital’s emergency equipment — especially any newly implemented systems.

4. Collect data on every mock code

Event documentation is an essential part of every IHCA response — and it’s even more important during training. Not only does it help clinicians practice for collecting key data points during hectic live events, it’s also the best way for responders to analyze and understand their performance and strive for improvements where needed.

Tips for event documentation

  • Designate one member of the team as the scribe or recorder.
  • Use a method that allows the recorder to move around the room as needed.
  • Choose an analysis-friendly format that’s easy to access and review afterward.
  • Get as much info as possible during the code to avoid relying on recall.
  • Provide feedback on CPR and medication dosing in real time to help guide the code response toward best practices and hospital protocols.

Data to collect12

  • Patient status, including vital signs, rhythm, and responsiveness
  • Time to defibrillation for pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) arrest
  • Time to Epinephrine for pulseless electrical activity (PEA) or asystole
  • Time to start of CPR or other initial interventions
  • CPR quality, including interruptions, rate, and end-tidal carbon dioxide (ETCO2)
  • Details about medications used, such as type, dosage, when they were administered, and patient response
  • Vascular access and airway management details

Notes about areas of potential improvement

  • Were responders able to easily navigate the necessary equipment? 
  • Were they able to use the defibrillator’s AED function without issue?

5. Debrief after each event

Similar to data collection, debriefing should be a part of every Code Blue, mock or real. This is where the data collected in Step 4 really comes into play and helps hospitals and clinicians improve both individual performance and system-wide best practices over time. In fact, data shows that regular debriefing sessions are associated with improved IHCA survival.5

“Hot” debriefs

  • The response team convenes immediately after each event to review the details of the case.
  • Clinicians fill in gaps in documentation, analyze what went right or wrong, consider performance individually and as a team, and identify opportunities & strategies for improvement.
  • During mock codes, this time is best spent discussing13:
    • Why there may have been missteps based on staff feedback 
    • Which effective practices should be reinforced
    • Adherence to institutional protocols 
    • Areas in need of improvement

“Cold” debriefs

While less relevant to mock code programs, “cold” debriefs are still an essential part of the real Code Blue care cycle:

  • Larger stakeholder groups review all of the IHCA cases that occurred across the facility or hospital system within a set period of time.
  • Reviewers spot trends, vet best practices, and implement system-wide, evidence-based improvements to optimize Code Blue outcomes over time.


Train smarter with Nuvara®

When it comes to Code Blue training, knowledge really is power. Learn how advanced resuscitation solutions from Nuvara can help give clinical teams the knowledge and situational awareness they need to save more lives.


  1. Holmberg MJ, Ross CE, Fitzmaurice GM, et al. Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019 July;12:1-8.
  2. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020 Mar;141:e139-e596.
  3. Neumar RW. Doubling cardiac arrest survival by 2020: achieving the American Heart Association impact goal. Circulation. 2016;134:2037-2039.
  4. IOM (Institute of Medicine). 2015. Strategies to improve cardiac arrest survival: a time to act. Washington, DC: The National Academies Press.
  5. Chan PS, Krein SL, Tang F, et al. Resuscitation practices associated with survival after in-hospital cardiac arrest: a nationwide survey. JAMA Cardiol. 2016;1(2):189-197.
  6. Kronick SL, Kurz MC, Lin S, et al. Part 4: systems of care and continuous quality improvement. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(suppl 2): S397-S413.
  7. Herbers, M. D., & Heaser, J. A. (2016). Implementing an in situ mock code quality improvement program. American Journal of Critical Care, 25(5), 393–399.
  8. Ngo, D. Q., Vu, C., Nguyen, T., Sotolongo, P., Talati, M., Zahabi, N., & Platt, K. (2020). The effect of mock code blue simulations and dedicated advanced cardiac life support didactics on resident perceived competency. Cureus. Retrieved July 29, 2021, from
  9. American Heart Association Guidelines for CPR & ECC: 2020 Updates.
  10. Nallamothu, B. K., Guetterman, T. C., Harrod, M., Kellenberg, J. E., Lehrich, J. L., Kronick, S. L., Krein, S. L., Iwashyna, T. J., Saint, S., & Chan, P. S. (2018). How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? Circulation, 138(2), 154–163. 
  11. Schneider, M., & Good, S. (2018). Meeting the challenges of nursing staff education. Nursing, 48(8), 16–17.
  12. Tofil, N. M., Lee White, M., Manzella, B., McGill, D., & Zinkan, L. (2009). Initiation of a pediatric mock code program at a children’s hospital. Medical Teacher, 31(6), e241–e247.
  13. Lee, J., Lee, H., Kim, S., Choi, M., Ko, I., Bae, J., & Kim, S. (2020). Debriefing methods and learning outcomes in simulation nursing education: A systematic review and meta-analysis. Nurse Education Today, 87, 104345.
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