Trigger Code Blue Checklist

Designation Name Date

Nurse 1 : RN Ward
Nurse 2 : RN Scenario Title
Nurse 3 : AN
Facilitator (s)

Nurse Rapid Escalation Trigger Criteria Met Not Met

Recognize change in clinical status
Inform and get support within unit promptly
Implement primary support measures eg O2, protect airway
Conduct relevant physical assessment :
Respiratory Assessment :
 Check respiratory rate, depth and pattern. Auscultate lungs
Cardiovascular Assessment
RN in  Check pulse & check capillary refill.
charge Abdominal Assessment
 Auscultate abdominal sounds. Palpate area for pain or tenderness
Neurological Assessment
 Perform Glasgow Coma Scale. Check pupils & check motor power
Pain Assessment
Escalate using trigger protocol. Communicate information using SBAR
Delegate tasks to team
RN 2 Inform RN in charge promptly – change in clinical status, response to treatment
Assist in implementing support measures
Monitor and assess patient’s clinical status in appropriate frequency
AN Inform RN in charge promptly – change in clinical status, response to treatment
Assist in implementing support measures
Monitor and assess patient’s clinical status in appropriate frequency
Responder Code Blue Criteria Met Not Met
1st Situation Awareness: Check for danger.
Responder Check for responsiveness
Press Code Blue button
(RN/AN) Remove pillow & position patient supine
A Open airway. Head tilt chin lift
B Check breathing: Head tilt chin lift. Look for chest rise
C Check pulse
Perform 30 compressions. Depth at 4-6 cm at 100 - 120/min
Communicate using SBAR to team
 1st responder and 2nd responder perform compression to ventilation 30:2
 Perform 5 cycles CPR. Key phrase 2 Min UP.
 Switch when tired.
2nd Place cardiac board.
Responder Select correct size oropharyngeal airway, measure and insert.
(AN/RN) Set up air viva and set O2 at 15L. Place at head of bed. Key phrase Air Viva UP
Set up suction apparatus. Set suction pressure at 80-120mmHg. Key phrase Suction UP

TCB Checklist/17May18/v3
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Nurse Code Blue Criteria Met Not Met
2nd Remove headboard.
Responder  1st responder and 2nd responder perform compression to ventilation 30:2
(AN/RN)  Perform 5 cycles CPR. Key phrase 2 Min UP.
(90 secs)  Switch when tired

2nd Inform team “Code Blue Team Activated”

Responder Set up AED
(RN)  Prepare patient’s chest. Apply multifunction pads correctly
(4 mins )  Ensure no one is touching the patient during analysis
 Safety measures – ensure no one is in contact with patient during defibrillation
Set up 3 Lead ECG. Key phrase ECG UP
Prepare resuscitation drugs. IV Adrenaline 1:10,000 X1. Key phrase Drugs UP
Prepare intubation tray
 Prepare laryngoscope with appropriate size blade. Check light source.
 Prepare requisites for ETT intubation (ETT, ETT introducer, adhesive tapes)
 Key phrase ETT UP
Set IV line & start IV Normal Saline
1st DR Arrive. Communicate to Dr using SBAR
Responder Assist DR with intubation.
(RN) Ventilate 1 breath every 10 compressions
2nd  Turn defib to manual Lead II.
Responder  Assist Dr with – defibrillation & intubation – suction patient’s mouth.
(RN)  Setup ETCO2
 Prepare resuscitation drugs
RNs Demonstrate knowledge of resuscitation drugs
Team Post Resuscitation Care
 Ensure adequate O2 perfusion. Monitor ETT placement
 Monitor vital signs every 5 mins. Assess neurological status. Check pupils
 Perform 12 Lead ECG, CXR & blood investigations
 Demonstrate knowledge of drug infusion eg Dopamine /anti arrhythmic drug
 Prepare patient for transfer to ICU once stabilized
Team Documentation
 Complete Cardiac Arrest Registry Form. Fax a copy to Medical Affairs
 Keep Cardiac Arrest Registry Form & ECG rhythm strip in the case notes.
Team Management Met Not Met
Team Promptly intervene with appropriate intervention
Communicate vital information throughout among the team
Continuous patient monitoring and assessment
Able to perform tasks as delegated

Remarks (Skills, Knowledge, Communication & Teamwork

RN 1

RN 2
Prep time: ____mins

AN Prep time____secs

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