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Welcome to the second installment of our three-part series on improving clinical performance and outcomes for in-hospital cardiac arrest (IHCA).

In Part 1, we discussed Code Blue Readiness, exploring how clinical teams can optimize factors that impact outcomes before IHCA occurs, including prevention, training, and crash cart preparation. And in Part 3, we’ll learn how post-cardiac arrest care and post-event debriefing can help improve patient outcomes in the short- and long-term after Code Blue events.

But first, we’ll take a deep dive into Code Blue Response: Optimizing clinical performance during in-hospital cardiac arrest by increasing efficiency, implementing cardiopulmonary resuscitation (CPR) best practices, and capturing critical data in the moment.

Code Blue Response Consideration 1: Time to Treatment

Every Code Blue responder knows that starting treatment as soon as possible after cardiac arrest is critical to patient survival. 

  • Each minute of delay in starting resuscitation can lead to a 7-10% drop in successful outcomes.1
  • The survival rate drops from 17.1% to 14.7% when CPR is initiated more than 2 minutes after arrest.2

But evidence shows that the time it takes to progress from one intervention to the next also directly impacts outcomes:

  • Survival drops >3% whenever time between CPR initiation and defibrillation or epinephrine administration reaches 3 minutes…2
  • …and another 2% once that gap reaches 6 minutes.2

This suggests that clinicians need to focus on optimizing the speed and efficiency of the entire Code Blue response.

Key takeaways

  • Alert designated responders of the Code Blue immediately.
  • Begin resuscitation ASAP — ideally the instant cardiac arrest occurs.
  • Unplug items on the crash cart from the wall before transporting it to avoid delays caused by falling or broken equipment.
  • Avoid impeding other clinicians or blocking important resources when accessing medications, supplies, and equipment on the cart.
  • Use defibrillation as early as feasible when cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia.3
  • Administer epinephrine as soon as feasible for nonshockable rhythms, or if initial defibrillation attempts for shockable rhythms fail.3
  • Ensure team members promptly and efficiently communicate information regarding patient status, interventions, and next steps.

Code Blue Response Consideration 2: CPR Quality

Multiple aspects of CPR quality have been shown to impact cardiac arrest survival:

  • Chest compressions are often delivered at rates much lower than the recommended range of 100-120 compressions per minute. In one study, the return of spontaneous circulation (ROSC) rate fell from 75% in the quartile where chest compression rates were the highest to just 42% in the quartile where they were lowest.4 
  • When rescuers compressed at a shallower depth (<38 mm), survival to hospital discharge fell 30%.5

In addition, inconsistencies in CPR practices are likely at least partially responsible for the significant variability in IHCA survival. According to the American Heart Association’s Get with the Guidelines – Resuscitation program data:

  •  The adult IHCA survival rate is 12 – 22%, while 33 – 49% of pediatric patients survive to hospital discharge.
  • >20% of IHCA patients survive if arrest occurs between 7AM and 11PM, while only 15% survive if arrest occurs overnight, between 11PM and 7AM. 

It’s critical for clinicians to consistently adhere to CPR best practices to ensure optimal Code Blue outcomes.

Key takeaways

According to the American Heart Association (AHA), responders should prioritize the following 5 CPR quality attributes, listed in order of importance to survival6:

  • Minimize interruptions in chest compressions, targeting a chest compression fraction (CCF) higher than 80%.
  • Maintain a chest compression rate of 100-120 per minute.
  • Ensure compression depth is ≥2” (≥50 mm) for adults, and ⅓ of the anterior-posterior dimension of the chest for pediatric patients (typically 1.5” (4 cm) in infants and  2” (5 cm) in children).
  • Avoid leaning on the chest between compressions to allow full recoil.
  • Avoid excessive ventilation, targeting fewer than 12 breaths per minute with minimal chest rise.

The AHA also recommends monitoring CPR quality and the patient’s physiological response, such as cerebral perfusion pressure (CPP), aortic diastolic pressure (ADP), end-tidal carbon dioxide (ETCO2), in real time so that responders can adapt care accordingly:

  • A nationwide survey of 130 hospitals found that tracking CPR compression interruptions increased hospitals’ odds of being in a higher IHCA survival category by two fold.7

Code Blue Response Consideration 3: Event Documentation

While a sense of urgency drives every Code Blue response, documenting each event is essential. The lack of high quality, comprehensive data on the treatment of IHCA is one of the main reasons survival rates remain so low.

Not only does event documentation help to guide and optimize treatment in the moment, it provides valuable information that hospitals and clinicians need to identify trends, spot gaps, and optimize care over time.

Key takeaways

  • Designate one member of the response team as the scribe or recorder  who will be in charge of documenting the event.
  • Choose a documentation method that allows for mobility. The scribe will need to move around to achieve the best vantage point without interfering with clinical interventions.
  • Document information in an analysis-friendly format that is easy to access and review afterward.
  • Document all important  information in real time so the team does not have to rely on recall:
    • Patient status, including vital signs, rhythm, and responsiveness
    • Time to CPR, defibrillation, epinephrine, and other interventions
    • CPR quality, including interruptions, rate, and ETCO2
    • Details about medications used, such as type, dosage, when they were administered, and patient response
    • Vascular access and airway management details
  • Provide feedback in real time on CPR quality and medication dosing based on best practices and hospital protocols.

Optimize Your Code Blue Response with Nuvara®

Nuvara’s advanced resuscitation solutions are designed to help clinicians improve IHCA care and outcomes.

CoDirector® Software provides:

  • In-the-moment clinical intervention assistance to help clinicians monitor CPR quality, determine medication dosing, and adapt care in the moment
  • Real-time electronic scribing for more efficient, effective documentation
  • A systematic approach to customize and standardize protocols and unify documentation processes across the hospital

The EMMIT® Emergency Care System provides all the benefits of CoDirector Software, plus:

  • Quick-to-Care design features, including a breakaway plug and instant responder alerts
  • A fast-access storage design that enables efficient, secure access to medications, supplies, and equipment — including RSI drugs

Related Articles

Make critical decisions with confidence

Although every Code Blue response is different, following proven guidelines and best practices is the key to optimizing in-hospital cardiac arrest outcomes for more patients. Learn more about how solutions from Nuvara can help responders make critical decisions with confidence.


  1. Simpson KH. 5th Ed. 2. Vol. 97. London, UK: The Resuscitation Council; BJA; 2006. Advanced Life Support.
  2. Bircher NG, Chan PS, Xu Y. Delays in cardiopulmonary resuscitation, defibrillation, and epinephrine administration all decrease survival in in-hospital cardiac arrest. Anesthesiology. 2019;130:414-422.
  3. American Heart Association 2015 Guidelines for CPR & ECC.
  4. Abella BS, Sandbo N, Vassilatos P, et al. Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation. 2005;111:428-434.
  5. Stiell IG, Brown SP, Christenson J, Cheskes S, Nichol G, Powell J, Bigham B, Morrison LJ, Larsen J, Hess E, Vaillancourt C, Davis DP, Callaway CW; Resuscitation Outcomes Consortium (ROC) Investigators. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med. 2012; 40:1192–1198.
  6. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128:417-435.
  7. 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.