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Welcome to the third and final installment of our blog series on optimizing factors that impact outcomes before, during, and after Code Blue events. In Parts 1 and 2, we covered Readiness and Response, discussing how clinical teams can best prepare for and administer in-hospital cardiac arrest (IHCA) care.

Now, we’ll take a look at what providers and hospitals can do after Code Blue events — including optimizing post-cardiac arrest care and implementing “hot” and “cold” debriefs — to improve outcomes in the short- and long-term.

Code Blue Review Consideration 1: Post-Cardiac Arrest Care

According to pre-COVID-19 data, the average survival-to-hospital-discharge rate for all U.S. adults who experience IHCA is 25.8%.1 But even among patients who achieve ROSC, that figure increases only marginally, to 32% – 54%.2 This indicates that surviving the initial arrest episode is merely the first hurdle on the path to prolonged survival.

IHCA patients suffer from a number of life-threatening conditions associated with post-cardiac arrest syndrome. These include neurologic injury, myocardial dysfunction, and reperfusion injury — not to mention the persistent acute and chronic pathology that may have precipitated arrest in the first place. 

Clinicians must provide proper monitoring and specialized care to optimize outcomes and ensure the best chance of survival to hospital discharge for these patients.

Key takeaways3-5

  • Transport the patient to an appropriate critical care unit capable of providing comprehensive post-cardiac arrest care.
  • Identify and treat the precipitating causes of the initial arrest to prevent recurrence.
  • Implement targeted temperature management to optimize neurological recovery for adults with non-shockable rhythms and no internal bleeding who remain comatose. ASAP after ROSC, target 32 – 36°C and maintain for at least 24 hours.
  • Optimize hemodynamics to ensure organ perfusion & oxygenation.
  • Provide respiratory support targeting oxygen saturation of 92 – 98%.
  • Provide multimodal rehabilitation assessment & treatment as needed.
  • Implement comprehensive, multidisciplinary discharge planning.
  • Assess patients and caregivers for anxiety, depression, post-traumatic stress, and fatigue.

Code Blue Review Consideration 2: “Hot” Debriefs

The American Heart Association recommends incorporating regular debriefing sessions into the Code Blue care cycle. These sessions can inform evidence-based improvements​ and drive hospital-wide standardization of best practices​ — which is likely why they are associated with improved IHCA survival and outcomes.3

There are two types of debriefs — “hot” and “cold.” During “hot” debriefs, the response team convenes immediately after each event to review the details of the case. This gives clinicians the opportunity to fill in gaps in documentation, analyze what went right or wrong, consider performance individually and as a team, and identify opportunities & strategies for improvement.

Unfortunately, “hot” debriefs are often not detailed or data-driven. Capturing comprehensive, accurate information during the code can be cumbersome — plus scribes typically don’t have the time or resources they need to analyze what data they do have in time for the debrief. In these cases, clinicians see little value in sticking around once a code is completed.

Key takeaways

  • Ensure information presented is useful, meaning data-driven, and performance-based.
  • Include data that impacts outcomes most, such as CPR quality indicators, time between interventions, and details about types and doses of medications administered — all correlated to patient response.
  • Conduct sessions immediately after Code Blue events so the details of the event are still fresh.
  • Provide debriefs in an analysis-friendly format that is easy to review & gain insight from.
  • Give each member of the response team space to share information, ask questions, and provide input.

Code Blue Review Consideration 3: “Cold” Debriefs

During “cold” debriefs, larger stakeholder groups review all of the Code Blue cases that occurred across the facility or hospital system within a set period of time, such as the previous month or quarter. Reviewers need comprehensive, high-quality data to spot trends, vet best practices, and implement system-wide, evidence-based improvements to optimize Code Blue outcomes over time.

Key takeaways

  • Conduct sessions every three months or less. One study showed that hospitals that reviewed cases at least quarterly had more than four-fold greater odds of being in a higher IHCA survival category than those that reviewed less frequently.6
  • Designate a resuscitation champion to identify gaps in care, spearhead quality improvement, advocate for additional resources, and promote IHCA quality monitoring. Hospitals with a recognized resuscitation champion had nearly 3-fold greater odds of being in a higher IHCA survival category.6
  • Include diverse stakeholders, such as Code Blue responders, a Code Blue committee, or other task forces and decision makers in charge of process improvements.
  • Review early warning scores and the latest relevant scientific literature in addition to the information included in debrief reports.
  • Establish a reporting & accountability structure to drive continual improvements and make the best use of debriefing sessions.

Optimize Code Blue Review with CoDirector® Software

CoDirector Software from Nuvara® provides the insights clinicians and hospitals need to improve IHCA performance & outcomes over time with:

  • Facilitated “hot” debriefs that automatically provide a precise, quantified, instructive snapshot of the response team’s performance
  • Detailed, automated, and easily accessible “cold” debrief reports to drive system-wide improvements
  • The ability to automatically document quality indicators, analyze & benchmark clinical performance, and mitigate liability and risk
  • Continual aggregation and analysis of facility-wide event data to uncover trends and new opportunities to enhance care over time
  • Insight-rich reports that provide a single, shared, comprehensive view of Code Blue operations — and how to improve them


Improve performance before, during, & after IHCA

From setting response teams up for success to supporting resuscitation best practices to facilitating system-wide improvements over time, learn how Nuvara can help optimize clinical performance for every Code Blue event.


  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. Carr BG, Kahn JM, Merchant RM, Kramer AA, Neumar RW.Inter-hospital variability in post-cardiac arrest mortality. Resuscitation. 2009; 80:30–34.
  3. American Heart Association Guidelines for CPR & ECC: 2020 Updates.
  4. Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: Post-Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S768-S786.
  5. Callaway CW, Donnino MW, Fink EL, et al Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 suppl 2):S465-S482.
  6. 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.