Skip to main content

In-hospital cardiac arrest (IHCA) is one of the leading sources of preventable harm and death in hospitals today. But beyond the obvious danger to patients, poor IHCA performance also impacts organizational aspects of many hospitals, including efficiency, reputation, regulatory compliance, and risk management.

Yet compared to other scenarios that result in preventable harm and death, relatively little effort is focused on improving Code Blue outcomes, which have all but stagnated for nearly a decade.1,2

The good news is that research suggests the opportunity for improvement is substantial. Many healthcare systems and providers are already meeting or exceeding the same improvement goals that seem so out of reach for others.3–5

Keep reading to learn more about the prevalence and impact of IHCA on healthcare systems today, the evidence for potential improvement, and Code Blue best practices that can be implemented at every level of the organization to make a real difference for patients, clinicians, and hospitals.

4 reasons hospitals should focus on Code Blue care

1. The problem is bigger than you may realize.

According to data published prior to COVID-19, only one in four of the 292,000 U.S. adults who experience in-hospital cardiac arrest each year survive to hospital discharge.1,6 This troubling figure is primarily due to:

  • Insufficient awareness regarding the prevalence, impact, and solutions that could increase Code Blue survival
  • A lack of comprehensive, high-quality data that could fuel evidence-based improvements in IHCA care

Beyond mortality, IHCA patients are also at risk for developing neurologic or reperfusion injury, myocardial dysfunction, or other serious conditions that can impact quality and duration of life after cardiac arrest. So, in short, the stakes couldn’t be higher.

2. Experts urge a more concerted effort.

The AHA’s Get with the Guidelines®-Resuscitation (GWTG-R) registry regularly publishes evidence-based guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). In 2010, they set a highly achievable 10-year goal of 35 percent for IHCA survival — yet a decade later, we’re still falling well short of that in the U.S. overall.1,2

Furthermore, the Institute of Medicine (now the National Academy of Medicine) published findings in 2015 on how to improve what it termed “unacceptably low” survival rates and quality of life following cardiac arrest. It called for a national focus on advancing resuscitation research and improving outcomes in this critical area.4

3. Improvement is possible.

The AHA considers its 35 percent IHCA survival rate goal achievable in part because many hospitals are already achieving it. In fact, research shows there is significant variability in Code Blue outcomes. Even when patient case mix and other hospital attributes are comparable, some providers are more than four times as likely to resuscitate IHCA patients.3–5,7

This level of variability indicates poorer outcomes are the result of disparities in care rather than any complexities inherent to the treatment of in-hospital cardiac arrest. Unfortunately, as is all too common, minorities and low-income patients seem to be hardest hit by these disparities.4,5,7,8

But on the bright side, we know there are specific steps hospitals and clinicians can take to improve IHCA outcomes.

4. Hospitals have a lot to gain—or lose.

Poor Code Blue performance can harm your organization in several key areas.

Patient outcomes
Every hospital exists, first and foremost, to help people. Considering the magnitude of the impact of in-hospital cardiac arrest on patients, caregivers, and communities, optimizing Code Blue outcomes should be a top priority for every healthcare system — especially those striving to establish themselves as leaders.

Risk & liability
Studies clearly show that many IHCA deaths and other poor outcomes can be prevented.2–5 Hospitals may be liable for failing to follow established Code Blue best practices, mitigate known risks, maintain regulatory compliance with medication and care delivery, and address issues that consistently result in sub-optimal care.

High IHCA mortality rates. Litigation. Gaps in processes, training, and innovation. Slow adoption of systems that could improve clinical performance. Any low stat or administrative misstep can harm a hospital’s reputation, and, in turn, funding opportunities, standing in the community, and popularity with patients in choosing their care.

Operational efficiency
Manual processes, legacy technologies, and poor data management create inefficiencies that waste clinicians’ valuable time and limit improvements throughout every phase of Code Blue care. From pen-and-paper crash cart checks and event documentation, to inconsistent and outdated reporting and debriefing practices, to de-centralized management of medications, supplies, and equipment — the opportunities for increasing efficiency are numerous.

Code Blue best practices

So what are hospitals with higher IHCA survival rates doing right? According to a nationwide survey of data from 130 hospitals participating in the AHA GWTG-R program, there are three key practices that can make a significant difference3:

1. Monitor for interruptions in chest compressions.

The study found that hospitals that tracked compression interruptions had more than two-fold greater odds of being in a higher survival category than those that didn’t.

Take it further: Set response teams up for success.

    • Improve operational efficiency and ensure regulatory compliance by standardizing, digitalizing, and/or automating cart checks and inventory management for medications, supplies, and equipment.
    • Reduce risk by focusing on prevention, using early warning score systems to identify at-risk patients,9 increasing monitoring of deteriorating patients, and training teams to stabilize patients prior to arrest.
    • Hold regular mock code training to ensure clinicians are prepared to act quickly and provide the best care in an IHCA emergency.

2. Review cardiac arrest cases often.

Hospitals that reviewed cases at least quarterly had more than four-fold greater odds of being in a higher survival category than those that reviewed less frequently. But it’s difficult to review data that isn’t collected or organized with analysis in mind — and even more difficult to glean actionable insights from it.

Take it further: Focus on data collection.

    • Standardize, and if possible digitalize Code Blue event documentation and reporting processes across your hospital to increase efficiency and ensure compliance with reporting regulations.
    • Implement “hot” debriefs that allow responders to review their performance immediately following each event, as well as “cold” debrief sessions, where larger groups analyze hospital-wide performance at least quarterly to improve outcomes over time.
    • Safeguard your hospital’s reputation by joining a national cardiac arrest registry as soon as possible. A 2018 study showed that increased duration of GWTG-R participation was associated with improved quality of IHCA care.10

3. Designate a resuscitation champion.

Hospitals with a recognized resuscitation champion had nearly three-fold greater odds of being in a higher survival category. Generally, these individuals are responsible for:

  • Spearheading quality improvement initiatives
  • Identifying and responding to gaps in resuscitation care
  • Advocating for acute and post-resuscitation care resources
  • Promoting IHCA as part of the hospital’s quality monitoring portfolio

Take it further: Create a reporting structure for continual improvement.

    • Establish a Code Blue committee to review IHCA cases monthly. 
    • The committee should report data to the Patient Safety council, who will identify trends and opportunities for improvement.
    • The council should regularly share recommendations with the Hospital Board, ensuring continued support over time.

What else can your organization do to improve clinical performance and outcomes for in-hospital cardiac arrest?

  • Embrace new systems and technologies that can expand clinicians’ opportunities to improve care — especially those that digitalize, integrate, assist, and/or automate key steps of the Code Blue care process.
  • Follow the latest AHA guidelines for CPR and ECC. These include best practices for adult, pediatric, and neonatal life support, plus guidance on resuscitation education science and optimizing systems of care.
  • Adopt the Institute of Medicine’s Strategies to Improve Cardiac Arrest Survival. These include establishing robust data collection and dissemination practices, education and training, improving delivery and quality of resuscitation and post-arrest care, and more.

Related Articles

How can we help?

Improving every aspect of in-hospital cardiac arrest care is critical for patients, clinicians, and hospitals. See what Nuvara® is doing to address known, underlying factors that impact clinical performance before, during, and after Code Blue events.


  1. 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.
  2. Neumar RW. Doubling cardiac arrest survival by 2020: achieving the American Heart Association impact goal. Circulation. 2016;134:2037-2039.
  3. 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.
  4. IOM (Institute of Medicine). 2015. Strategies to improve cardiac arrest survival: a time to act. Washington, DC: The National Academies Press.
  5. 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.
  6. 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.
  7. Merchant RM, Berg RA, Yang L, et al. Hospital Variation in Survival After In‐hospital Cardiac Arrest. Journal of the American Heart Association, American Heart Association. 31 Jan. 2014. doi: 10.1161/JAHA.113.000400.
  8. Neagle JT, Wachsberg K. What are the chances a hospitalized patient will survive in-hospital arrest? The Hospitalist. 2010 Sept; 2010(9). Available at: Accessed December 12, 2020.
  9. Nishijima I, Oyadomari S, Maedomari S, et al. Use of a modified early warning score system to reduce the rate of in-hospital cardiac arrest. J Intensive Care. 2016; 4 (12). doi: 10.1186/s40560-016-0134-7.
  10. Andersen LW, Holmberg MJ, Berg KM, et al. In-hospital cardiac arrest: a review. JAMA. 2019 March; 321(12): 1200-1210.