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key takeaways

  • Only 1 in 4 adults survive in-hospital cardiac arrest yearly in the United States. Although improvement is possible with better application of best practices, most hospitals struggle to move the needle.
  • Top strategies to improve Code Blue response include: using mock codes, prioritizing crash cart safety, switching to electronic documentation, improving CPR quality, and debriefing after every code.

In 2010, the American Heart Association (AHA) set a goal to increase the in-hospital cardiac arrest (IHCA) survival rate to 35%.1 This target wasn’t selected at random, of course. It’s a goal the AHA knew to be achievable because some hospitals were already meeting it — even exceeding it — with adherence to best practices. But as a nation, we’re still falling short, with survival rates persistently hovering around 25%.2 And for hospitals that aren’t close to the 35% target, it can seem daunting to even think about getting there. Where to begin? What areas to focus on first?

The answer, of course, will look different at every hospital. But to start, we rounded up 5 of our best tips for improving Code Blue response. From training to crash cart readiness to documentation, keep reading to learn top areas that often hold hospitals back — and actionable tips to improve.

1. Practice with mock codes

Why it matters

Even the most seasoned clinicians find it tough to keep skills fresh between codes. Clinicians receive Advanced Cardiac Life Support (ACLS) training every 2 years, but studies show that knowledge starts to diminish within months if not used or reinforced.3 And skill decay isn’t the only problem. The emotional aspect of responding to a life-threatening emergency needs to be considered as well. Codes are innately high-stress, high-stakes, fast-paced events, which can make it even harder for responders to recall relevant information and apply it in the moment.

The good news? Mock codes can help. Practicing in a simulated environment allows teams to apply skills regularly. And that repetition is exactly what clinicians need to build muscle memory, manage nerves, and feel confident and focused during an emergency. Mock codes also give teams the opportunity to work together and clarify roles in practice sessions. This can help reduce cognitive overload during an emergency, freeing up mental energy for each team member to focus on their specific role during the code.

Tips to improve Code Blue response

  • Commit to a regular schedule for mock codes (monthly is a good target).
  • Decide whether high-fidelity, low-fidelity, or a mix of the two is best for your hospital.
  • Include all members of the code team, if possible.
  • Collect and review data on each code to reinforce learning.

2. Prioritize crash cart readiness

Why it matters

Crash cart readiness is not always top of mind when it comes to improving IHCA outcomes. With so many pressing demands on staff members’ time, mistakes and oversights are common when it comes to repetitive, manual tasks like cart checks.

But this comes at a cost. In 2017, The Joint Commission (TJC) reported that crash carts often contain “hidden issues” (think: missing medications, damaged equipment, drained batteries) that can adversely affect patient safety.4 And the problem isn’t going away. As of 2022, TJC surveyors are still reporting crash cart mismanagement as one of the top clinical problems they encounter.

Tips to improve Code Blue response

  • Standardize crash cart organization. Every second counts in a code. Reducing unnecessary variation in cart contents and organization means team members can easily access what they need — when they need it.
  • Automate as much as possible. Manually checking and restocking carts is time consuming and error prone. Invest in technology, like The EMMIT® Emergency Care System from Nuvara®, that help automate these processes for you.
  • Make it a priority. Track crash cart inspections to ensure they happen as frequently as they should. At every debrief, determine if there were any issues with missing or disorganized supplies. Report these findings back to your hospital’s resuscitation champion or resuscitation committee so they can be tracked and addressed on a hospital-wide level.

3. Switch to electronic documentation

Why it matters

Accurate documentation affects every aspect of Code Blue care: from the patient’s individual care, to hospital-wide performance outcomes, to the data that some hospitals submit to national registries for benchmarking.

But scribes aren’t given the tools and resources they need to do the job properly. With most hospitals still relying on pen-and-paper documentation methods, scribes can’t keep up, handwriting is often illegible, and the quality of the documentation (as well as the data derived from it) suffers.

Fortunately, there’s good news too. Studies show that digital and electronic forms of documentation significantly reduce common problems like errors, omissions, and illegibility.5,6 It’s a matter of more hospitals adopting and utilizing the technology.

Tips to improve Code Blue response

Paper documentation isn’t working, but it can still be challenging to switch to a different method — especially when it comes to a high-stakes event like cardiac arrest. Smooth the transition with these tips:

  • Prioritize ease-of-use when selecting an electronic documentation tool. If the tool isn’t flexible and intuitive, scribes may resort to old, paper-based methods during the code and update the electronic record afterward. This is a problem your hospital wants to avoid: Double documentation wastes time and increases error.
  • Get staff buy-in. Involve scribes/nurses in the decision-making process when choosing which technology to invest in. They know the challenges of documentation better than anyone and can provide valuable feedback on what features matter most. They can also help train other staff and get buy-in once the new technology is rolled out.
  • Think outside the box. Don’t settle for the electronic version of the existing paper template your hospital uses. An electronic tool can — and should — provide much more. Nuvara’s CoDirector® Resuscitation Software, for example, goes well beyond the fill-in-the-blank template hospitals are accustomed to using. It keeps teams on track with in-the-moment guardrails that align with ACLS/Pediatric Advanced Life Support (PALS) algorithms, plus software prompts to ensure the right information gets recorded.
  • Practice.  Provide training sessions when the new tool is rolled out and for any new staff who are hired afterward. Use the tool in mock codes to give scribes ample opportunity to practice and become comfortable with the technology.

4. Measure CPR quality

Why it matters

By now, clinicians are familiar with the criteria for — and the importance of — high-quality cardiopulmonary arrest (CPR) during a code. Plenty of studies have demonstrated the link between CPR quality and improved outcomes.7

But it’s more than just knowing what constitutes high-quality CPR when it comes to rate, depth, chest compression fraction, and ventilation. Execution is the challenging part. And without any kind of feedback device or aid, even the most experienced clinicians will struggle to accurately judge CPR quality in the moment.

Tips to improve Code Blue response

  • Use real-time feedback to guide CPR. Whether it is end-tidal carbon dioxide (ETCO2) readings or use of a CPR feedback device, the value of objective, real-time guidance can’t be overstated.
  • Analyze data afterward to improve. Review CPR quality data on an individual event level (at hot debriefs) and an aggregate level (at cold debriefs) to reinforce learning, spot patterns, and identify areas for improvement.
  • Consider alternate methods, like mechanical CPR, when appropriate.

5. Debrief after every event

Why it matters

Simply put, hot debriefs are one of the best ways to learn and improve. Since the event is still fresh and the entire team is usually available to participate, the topics discussed are more likely to stick. Studies back this up, showing that debriefing programs can improve outcomes.8,9 Plus, hot debriefs have the added benefit of reducing staff burnout and frustration. They allow team members to process and discuss what might have been an emotionally charged event — an important outlet that responders don’t often get.

The problem? Consistent hot debriefing is easier said than done. One study showed that only 14% of hospitals conduct hot debriefs frequently.10 If this sounds like your hospital, follow the tips below to improve consistency.

Tips to improve Code Blue response

  • Designate a leader to ensure hot debriefs happen after every event, regardless of the outcome. If debriefs only occur when something goes wrong during a code, they will start to earn a reputation as blame sessions.
  • Use a standardized format to reduce time and make the debriefing habit stick.
  • Make it worth your team’s while. The review must be data driven. The goal is for team members to receive actionable, useful information each time. Use whatever data is available immediately after the event: CPR feedback devices, ETCO2 readings, data from electronic documentation tools, etc.


We’re here to help

Nuvara is committed to helping hospitals improve Code Blue care. Our solutions offer:

  • Real-time, comprehensive electronic code documentation that’s intuitive and easy to use
  • ACLS/PALS algorithm guardrails to keep code teams on track during the code
  • Built-in analytics & access to data and performance insights immediately after the event
  • Streamlined crash cart processes: automated expiration alerts, digital cart inventory, built-in sensors to monitor cart access, and more


  1. Neumar RW. (2016). Doubling cardiac arrest survival by 2020: achieving the American Heart Association impact goal. Circulation, 134:2037-2039.
  2. Virani SS, Alonso A, Benjamin EJ, et al. (2020). Heart disease and stroke statistics 2020 update: a report from the American Heart Association. Circulation, 141: e139-156.
  3. Smith KK, Gilcreast D, & Pierce K. (2008). Evaluation of staff’s retention of ACLS and BLS skills. Resuscitation78(1), 59 65.
  4. The Joint Commission. (2017). Crash-cart preparedness. Quick Safety, 32:1-3. Available at: Quick Safety 32: Crash-cart preparedness | The Joint Commission
  5. Grigg E, Palmer A, Grigg J, et al. (2013, July 29). Randomised trial comparing the recording ability of a novel, electronic documentation system with the AHA paper cardiac arrest record. Emergency Medicine Journal, 1–7.
  6. Peace JM, Yuen TC, Borak MH, et al. (2014, Feb.) Tablet-based cardiac arrest documentation: a pilot study. Resuscitation, 85(2): 266-269.
  7. Meaney PA, Bobrow BJ, Mancini ME, et al. (2013). Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation, 128:417-435.
  8. Kessler DO, Cheng A, & Mullan PC. (2015). Debriefing in the emergency department after clinical events: a practical guide. Annals of Emergency Medicine, 65(6): 690-698. DOI: 1016/j.annemergmed.2014.10.019
  9. Sawyer T, Loren D, & Halamek LP. (2016). Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol, 36(6): 415-9.
  10. Malik AO, Nallamothu BK, Trumpower B, et al. (2020). Association between hospital debriefing practices with adherence to resuscitation process measures and outcomes for in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes. 13(11).
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