Rethinking Code Blue Teamwork

All Code Blue events are intense, demanding events where a patient’s life hangs in the balance. But for the clinicians who respond, some events are harder to move past than others. Sometimes it’s about the outcome: a particularly complex case, a patient that couldn’t be saved. Unquestionably, it’s mentally and emotionally draining to respond to a medical emergency where adults have, at best, only a 1 in 4 chance of survival.¹

But many times, it’s about more than just the medical specifics or the final outcome.² Maybe the team just didn’t click that day. Or there were too many people in the room, a lack of clarity surrounding roles, and a group that splintered off into multiple directions during the code and never got back on track. Team members may find themselves replaying the events in their head afterward, wondering how it might have gone differently.

It’s normal for cases to vary in difficulty and complexity. But if these kinds of team dynamics have become a pattern, it may be time to rethink what’s working in Code Blue teamwork at your hospital — and what isn’t. In this blog, we’ll discuss 4 key shifts — in mindset, approach, or team dynamics — that may be just what your hospital needs to revitalize your Code Blue team and take performance to the next level.

Individual –> Team

It sounds simple, but the shift in mindset from individual to team can be a gamechanger in a world in which medical training is largely focused on the individual practitioner.²

Of course, individual skillsets are important. During a Code Blue, each team member must be prepared to execute their individual clinical skills quickly and under immense pressure. But it’s also true that Code Blues are team events, and outcomes — good or bad — are never the result of one individual’s actions alone.

As one critical care director we interviewed observed, “I don’t think one single individual impacts survival in a cardiac arrest. Cardiac arrests are scenarios that require coordination, and coordination involves many players.”

But what does that shift look like in practice? Here are some ways to embrace a team-focused mindset, regardless of your specific role in Code Blue events:

• As a team member, think beyond developing your individual skills alone. How are you performing within the team? Are you communicating clearly, using simple, closed-loop communication during events? Are you speaking up when you have concerns or notice something that others may have missed during a code?
• As a team leader, are you modeling the kind of behavior that best supports team cohesion and synergy? This can look like: demonstrating calm during chaos, being receptive to feedback and input, and sharing key information with the team.
•  As a member of administration or hospital leadership, make sure to put adequate resources into building a  mock Code Blue training program. Of the many benefits this program will yield, it will give Code Blue responders ample opportunity to practice together and build their skills as a team.

Focusing on adverse outcomes –> Learning from all events

The benefits of debriefing are well known, but hospitals often struggle to do it consistently.³ And we get it: With all the competing priorities and demands clinicians juggle on a daily basis, taking time to debrief after every code may seem far-fetched. Great in an ideal world, but not practical in reality. As a result, it’s common for many hospitals to only debrief for cases with the worst outcomes.

But while it’s crucial to learn from failures, to do so exclusively is problematic for a few reasons:

• Debriefs will start to get a bad reputation as blame sessions. Team members may go in feeling automatically defensive, which creates tension and reduces learning.
• Your hospital will miss out on the insights that come from analyzing events that went well. What was working when the team performed at its best — and how can your hospital apply that knowledge in future events?²  This kind of analysis can be just as useful as looking at the cases that didn’t go according to plan.
• To do this, get into the habit of performing hot debriefs after every event until it becomes second nature. And for more in-depth cold debriefs, consider cases at both ends of the spectrum to maximize learning.

Command-control –> Collaboration

At many hospitals today, it’s common for Code Blue teams to be organized using a command-control leadership approach.² Typically, that looks like one leader — often a more senior, experienced clinician — who is in charge of the team and has ultimate decision-making authority. There are all kinds of benefits of this leadership style for emergency events:

• Reduces the confusion that can occur if no clear leader emerges
• Keeps the team focused on the same goals and objectives
• Helps avoid role overlap because the team is taking direction from one person

Plus, Code Blue team members often have varying degrees of skills and experience. When a patient’s life is at stake, it simply makes sense to have a more experienced clinician steering the team.

That said, there are some drawbacks too. Most importantly, studies have shown that these kinds of hierarchical team structures can inhibit psychological safety.^4,5 In other words, team members may feel less comfortable speaking up when they have a concern — which is the last thing you want in a life-or-death medical emergency.

The solution? Prioritize a culture of collaboration, even within the traditional command-control leadership model. This can look like:

• Asking other team members for input.
• Recognizing team members when they do speak up or voice a concern.
• Having the team leader voice key observations and strategy out loud to improve information exchange and increase collaboration.

Deceptively simple, these strategies are subtle but powerful. Over time, they’ll help increase the psychological safety of the team without losing the benefits that come from command-control leadership.

Hands-on leadership –> Hands-off leadership

Here’s a fact that may surprise you: Studies show that leaders who are more hands-on during the code are often less effective.⁶

At first blush, this might seem counterintuitive. But it makes sense when you consider that one of the most essential tasks of the code leader is to determine the underlying cause of the arrest.⁷ To do this well, the leader needs to step back, gain perspective of the situation, and integrate multiple sources of information. Exactly the kind of high-level thinking that’s tough to pull off if the leader is simultaneously engaged in a hands-on task.

Another benefit to consider: A hands-off leadership approach also frees up the leader to devote more energy to managing the team. For example, the leader can spot and troubleshoot team-based obstacles, such as role confusion or team members performing their individual tasks but forgetting to report back to the larger group. These are the types of issues that can prevent the team from operating effectively but might otherwise go unnoticed.

Of course, the leader’s ability to adopt a hands-off approach will depend greatly on the complexity of the case and the resources of the team. And it doesn’t mean that leader should always avoid direct involvement in the code. But when possible, shifting to an “intervene as needed” approach can give the leader the time and space he or she needs to step back, take stock of the situation, and gain perspective of the overall clinical picture — and this can yield surprising benefits for the entire team.