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  • Quality of hospital personnel training
  • Adherence to evidence-based protocols
  • Code Blue data collection
  • Implementation of quality control and case review mechanisms

Due to persistently poor outcomes nationwide, in-hospital cardiac arrest (IHCA) has become a growing focus for influential healthcare entities, such as the American Heart Association (AHA) and the Institute of Medicine (IOM). These organizations point out that while many providers struggle to meet IHCA survival goals, others are exceeding them, demonstrating that thousands more deaths can be prevented each year with implementation of best practices.

The latest group to join the call is The Joint Commission (TJC), America’s premiere healthcare standards-setting and accrediting body. On June 18, 2021, TJC issued new and revised resuscitation requirements for hospitals and critical care facilities. These updates are intended to maximize patient survival and optimize neurological outcomes by reducing unnecessary variations in practice and encouraging more proactive and responsive approaches to resuscitation and post-resuscitation care.

These requirements apply to the hospital accreditation program and will go into effect January 1, 2022. Keep reading to learn exactly what the new standards are and a few ways you could start preparing for them now.

TJC Updates Regarding Resuscitation Education & Training – PC.02.01.11


An evidence-based training program(s) is used to train staff to recognize the need for and use of resuscitation equipment and techniques.


The hospital provides education and training to staff involved in the provision of resuscitative services. The hospital determines which staff complete this education and training based upon their job responsibilities and hospital policies and procedures. The education and training are provided at the following intervals:

  • At orientation
  • A periodic basis thereafter, as determined by the hospital
  • When staff responsibilities change

Note 1: Topics may cover:

  • Resuscitation procedures or protocols
  • Use of cardiopulmonary resuscitation techniques, devices, or equipment 
  • Roles and responsibilities during resuscitation events

Note 2: The format and content of education and training are determined by the hospital (for example, a skills day, a mock code).

(See also HR.01.01.01, EP 1; HR.01.05.03, EP 1)

Our Findings

This update was likely inspired by the growing body of evidence linking CPR quality and speed of interventions to IHCA survival:

  • A nationwide survey of 130 hospitals found that tracking CPR compression interruptions increased hospitals’ odds of being in a higher survival category by two fold.1
  • Each minute of delay in resuscitation can lead to a 7 – 10 percent drop in successful outcomes.2
  • Recent research shows that delays in not only CPR but defibrillation and epinephrine administration can decrease IHCA survival.3

The more skilled and practiced Code Blue teams are, the more effectively and efficiently they will be able to respond to in-hospital cardiac arrest events.


The AHA offers thorough guidance for resuscitation training and education, such as:

  • Encourage and/or empower team members to take an adult ACLS course. Studies show that teams with at least one ACLS-trained member have better patient outcomes.
  • Incorporate a practice & mastery learning model for resuscitation training. Evidence suggests that this improves skill acquisition and performance.
  • Provide booster training to supplement mass learning. Brief, frequent sessions focused on repetition of prior content can improve retention of CPR skills.
  • Conduct simulation-based “in-situ” training. New evidence shows that training in the actual environment can improve speed and team performance as well as IHCA patient survival and neurological outcomes.

TJC Updates Regarding Post-Cardiac Arrest Care – PC.02.01.20


The hospital develops and follows policies, procedures, or protocols based on current scientific literature for interdisciplinary post–cardiac arrest care.

  • Note 1: Post–cardiac arrest care is aimed at identifying, treating, and mitigating acute pathophysiological processes after cardiac arrest and includes evaluation for targeted temperature management and other aspects of critical care management.
  • Note 2: This requirement does not apply to hospitals that do not provide post–cardiac arrest care.

The hospital develops and follows policies, procedures, or protocols based on current scientific literature to determine the neurological prognosis for patients who remain comatose after cardiac arrest.

  • Note 1: Because any single method of neuroprognostication has an intrinsic error rate, current guidelines recommend that multiple testing modalities be incorporated into organizations’ routine procedures and protocols to improve decision-making accuracy.
  • Note 2: This requirement does not apply to hospitals that do not provide post–cardiac arrest care.

The hospital follows written criteria or a protocol for inter-facility transfers of patients for post–cardiac arrest care, when indicated.

Our Findings

IHCA is one of the leading causes of not only preventable death but also serious conditions associated with post-cardiac arrest syndrome, from neurologic injury to myocardial dysfunction to reperfusion injury. Studies suggest that close monitoring and treatment may increase the likelihood of continued survival and optimal neurologic recovery after cardiac arrest.4,5 These requirements from The Joint Commission could help hospitals more consistently achieve improved outcomes.


Consider standardizing the following post-cardiac arrest care measures, as appropriate6-8:

  • Ensure patients are transferred if needed to a facility capable of providing comprehensive post-cardiac arrest care.
  • Identify and treat the precipitating causes of the initial arrest.
  • Implement targeted temperature management to optimize neurological recovery in appropriate patients.
  • 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.

TJC Updates Regarding Code Blue Data Collection – PI.01.01.01


The hospital collects data on the results of resuscitation.


The hospital collects data on the following:

  • The number and location of cardiac arrests (for example, ambulatory area, telemetry unit, critical care unit)
  • The outcomes of resuscitation (for example, return of spontaneous circulation (ROSC), survival to discharge)
    • Note: Return of spontaneous circulation (ROSC) is defined as return of spontaneous and sustained circulation for at least 20 consecutive minutes following resuscitation efforts.
  • Transfer to a higher level of care
  • (See also LD.03.07.01, EP 2; PI.03.01.01, EP 22)

Our Findings

One of the largest factors impacting IHCA outcomes today is a lack of data to inform best practices:

  • There’s no national reporting requirement for IHCA data in the U.S.
  • The data that exists is not necessarily representative of or applicable to the full population.
  • Data collection is often still paper-based, relying on inconsistent, error-prone, manual processes.
  • Data is typically uploaded as a flat PDF, which is not searchable and makes analysis and reporting extremely difficult.
  • The number of gold-standard clinical trials focused on IHCA research is limited. 

The Joint Commission’s revised resuscitation requirements can help hospitals generate the high-quality, comprehensive data needed to support improvements in Code Blue care.


Knowing the importance of data collection and what data to collect is a great start. Now you need data collection strategies and methodologies that are feasible for every Code Blue team across your organization:

  • Designate one member of each response team as the scribe or recorder.
  • Choose a documentation method that allows for mobility. The scribe will need to move around for the best vantage point without interfering with interventions.
  • Document information in an analysis-friendly format that is easy to access, analyze, and report afterward.
  • Document information in real time so the team does not have to rely on recall.

TJC Updates Regarding Resuscitation Data Analysis – PI.03.01.01


An interdisciplinary committee reviews cases and data to identify and suggest practice and system improvements in resuscitation performance.

Note 1: Examples of the review could include:

  • How often early warning signs of clinical deterioration were present prior to in-hospital cardiac arrest in patients in non-monitored or non-critical care units
  • Timeliness of staff’s response to a cardiac arrest
  • The quality of cardiopulmonary resuscitation (CPR)
  • Post–cardiac arrest care processes
  • Outcomes following cardiac arrest

Note 2: The review functions may be designated to an existing interdisciplinary committee.

(See also PC.02.01.19, EPs 1 and 2; PC.02.01.20, EPs 1–3; PI.01.01.01, EP 10)

Our Findings

TJC likely included data analysis with an interdisciplinary committee in its resuscitation requirements because regular debriefing sessions are associated with improved IHCA survival and outcomes.6 Generally speaking, there are two types of debriefs — “hot” and “cold”:

  • “Hot” debriefs: The response team convenes after each event to review the details of the case and identify opportunities & strategies for improvement.
  • “Cold” debriefs: Larger groups review facility-wide Code Blue cases to spot trends, vet best practices, and implement enhancements system-wide.


There are a few steps hospitals can take to better facilitate regular data analysis sessions:

  • Identify and budget for resources to regularly prepare, analyze, and report on collected Code Blue data.
  • Provide debriefs in an analysis-friendly format that is easy to review & gain insight from.
  • Start structuring and standardizing debriefing processes, including cadence, participants, meeting and reporting formats, agenda, etc.
  • Conduct “cold” debrief sessions at least every three months to promote improved IHCA survival.1

Solutions That Can Help

In order to more confidently address all of The Joint Commission’s resuscitation updates, you can also take the following steps.

Designate a resuscitation champion to:

  • Spearhead quality improvement initiatives
  • Identify and respond to gaps in resuscitation care
  • Advocate for acute and post-resuscitation care resources
  • Promote IHCA as part of the hospital’s quality monitoring portfolio
  • Potentially improve IHCA survival1

Adopt CoDirector® Software from Nuvara®. With CoDirector:

  • Your hospital’s resuscitation algorithms and medication dosing protocols can be customized and easily updated system-wide for in-the-moment reference and guidance during cardiac arrest training and real events.
  • An interactive dashboard of automated timers enables clinicians to pace recurring actions and monitor CPR quality in the moment.
  • All interventions can be digitally documented in real time, including CPR and defibrillation — no double-entry or redundant steps needed.
  • Hospitals get out-of-the-box, automatic event reporting for key clinical quality indicators and exportable data for deeper data analysis.
  • “Hot” and “cold” debrief reports are automatically created.


See CoDirector Software in Action

As more advocacy groups come together in support of improved resuscitation practices, every hospital and clinical team must do their part to follow evolving recommendations, standards, and guidelines. See how Nuvara’s CoDirector Software can help you do exactly that.


  1. 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.
  2. Simpson KH. 5th Ed. 2. Vol. 97. London, UK: The Resuscitation Council; BJA; 2006. Advanced Life Support.
  3. 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.
  4. 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.
  5. Andersen LW, Holmberg MJ, Berg KM, et al. In-hospital cardiac arrest: a review. JAMA. 2019 March; 321(12): 1200-1210.
  6. American Heart Association Guidelines for CPR & ECC: 2020 Updates.
  7. 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.
  8. 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.
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