Skip to main content

key takeaways

  • Code Blue teams that are formed ad hoc may be at a disadvantage compared to pit crew or pre-formed teams.
  • Clearly defining roles, standardizing the team’s equipment and setup, and establishing a shared mental model can help ad hoc Code Blue teams perform at their best.

Several studies have demonstrated the advantages of having a dedicated, pit-crew style Code Blue team trained and specialized to respond to in-hospital cardiac arrest (IHCA).1,2 But the reality is that the pit crew approach is resource-intensive and unrealistic at many hospitals.3

As a result, it’s common for hospitals to use ad hoc Code Blue teams instead. This means that when a code is called, team members are arriving from different areas of the hospital, with different skillsets and backgrounds, and forming in the moment to respond to a high-stakes medical emergency.4

This approach — necessary as it may be — poses challenges for hospitals and Code Blue teams alike. How can ad hoc teams work together effectively and cohesively when they are forming as the code unfolds? And how can hospitals ensure that clinicians have the skills and comfort level to perform optimally alongside team members they may have met mere minutes ago? Not surprisingly, studies show that ad hoc teams are at a disadvantage compared to pre-formed teams and may perform worse in areas like uninterrupted cardiopulmonary resuscitation (CPR) and time to defibrillation.3,5

The good news: While it may be challenging, fostering an effective team dynamic with an ad hoc approach can be done. Keep reading as we cover 3 key strategies that hospitals can use to support ad hoc Code Blue teams and elevate both individual and team performance.

Strategy 1: Clearly define roles

Role overlap, confusion, and poor communication are common problems that can plague ad hoc Code Blue teams. Clear role allocation is essential to overcoming these challenges. Here’s how to make it happen:

  • During mock codes and training exercises, include a strong focus on team roles during cardiac arrest: documentation, medications, airway, cardiopulmonary resuscitation, etc.
  • Swap these roles often during training.4 Not only does this foster team cohesion by introducing clinicians to roles and perspectives they may be less familiar with, it also ensures that team members have the skills to step into different roles if needed.4 That flexibility is an undeniable asset for ad hoc Code Blue teams.
  • During the code, assign roles upfront and make sure it is clear who is responsible for what tasks. This is often the job of the team leader.

The bottom line: Ad hoc Code Blue teams don’t have the opportunity to train extensively as a pre-formed group prior to the event. But when all team members share a common training background — one that is strongly role-focused — the team will still be able to function at a high level.

Strategy 2: Standardize setup and equipment

From the composition of the team to unexpected changes in a patient’s status, there are plenty of variables that are outside clinicians’ control as a Code Blue unfolds. In these kinds of scenarios, it’s helpful to think about what is within the team’s control — typically aspects of the environment, setup, and equipment — and standardize those whenever possible.4 For example:

  • Don’t underestimate the importance of crash cart standardization. Make sure tools and medications are reliably stored in the same spot, every time. Clinicians should know exactly where to go to access the item they need.
  • Some teams may even find it useful to standardize where team members are positioned relative to the patient: code team leader, documenter, CPR nurse, etc.4 This can be established and practiced often during mock codes/simulations until it becomes second nature.

The bottom line: The ability to rapidly adapt to ever-changing circumstances is a crucial skill for all Code Blue responders, and especially members of ad hoc teams. To help ground team members and free up the mental capacity needed to execute this skill well, keep the team’s environment, set up, and equipment as consistent as possible.

Strategy 3: Establish a shared mental model

For all Code Blue teams, but particularly those that form ad hoc, getting everyone on the same page is crucial. This is where having a shared mental model comes in. Essentially, that means the team has a common understanding of what the situation is and where the team is headed. A critical care director that we spoke to as part of our interview series said it best: “There needs to be a homogeneous understanding of where you want to drive patient care during this very high-stakes scenario, and that drive has to be understood by everybody.

A pre-brief is one strategy for establishing a shared mental model.6 The details of the pre-brief will vary depending on the situation and how much time is available, but it’s often led by the team leader and includes the following:4,6

  • Sharing what is known about the patient (e.g., status, underlying etiology)
  • Discussing the immediate plan (i.e., where the team is headed in the first 5 minutes or so of the code)
  • Assigning team roles and tasks
  • Asking the team for feedback/input: Is there anything we’re missing?

Of course, the specific circumstances will determine how much time the team can realistically devote to the pre-brief. For example, emergency department teams may have prior notice of a patient’s arrival and can gather to discuss beforehand. For an IHCA patient who unexpectedly deteriorates, there is little to no advance notice. But even when time is limited, it’s crucial to have a brief conversation in the beginning of the code about what is happening and where the team is headed.4,6


Keep learning

For more insight into Code Blue team dynamics, hear from a critical care director about effective Code Blue teams, training, and leadership.


  1. Spitzer CR, Evans K, Buehler J, et al (2019). Code blue pit crew model: A novel approach to in-hospital cardiac arrest resuscitation. Resuscitation, 143, 158–164.
  2. Peltonen V, Peltonen L, Rantanen M, et al (2022). Randomized controlled trial comparing pit crew resuscitation model against standard advanced life support training. Journal of the American College of Emergency Physicians Open, 3(3).
  3. Nallamothu BK, Guetterman TC, Harrod M, et al (2018). How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? A qualitative study. Circulation, 138(2):154-163.
  4. Alvarez A, Bucks C, Cline PB. High Performance Resuscitation Teams: Time Zero Series Online CME Course. Mayo Clinic School of Continuous Professional Development.
  5. Hunziker S, Johansson AC, Tschan F, et al (2011). Teamwork and leadership in cardiopulmonary resuscitation. Journal of the American College of Cardiology. 57(24).
  6. Purdy E, Alexander C, Shaw R, Brazil V. (2020) The team briefing: Setting up relational coordination for your resuscitation. Clin Exp Emerg Med, 7(1).
The information provided in this article is strictly for the convenience of our customers and is for general informational purposes only. Publication by Nuvara does not constitute an endorsement. Nuvara does not warrant the accuracy or completeness of any information, text, graphics, links, or other items contained within this document. Nuvara does not guarantee you will achieve any specific results if you follow any advice in the document. It may be advisable for you to consult with a professional such as a lawyer, doctor, nurse, business advisor, or professional engineer to get specific advice that applies to your specific situation.