Reduce Stress in Code Blue Events With Electronic Code Blue Documentation

What follows the chaos of a Code Blue event, the acquisition and handling of the Code Blue records, is nearly as important as managing the event itself. The patient record that is generated during a Code Blue has three critical functions:

  1. First and foremost, the record is not only a real-time patient management aid during the event but serves as a road map for post-event care.
  2. Second, the data collected serves as a rich source for directing quality improvement efforts.
  3. Thirdly, if acquired accurately, the record is the single best picture for reconstructing the event if risk management issues arise.

As a result, the record must be as accurate and complete as possible. It must be immediately available to the providers at all stages of patient care. Because the record provides vital reporting data for the organization, it is essential to eliminate lost records, avoiding transcription errors from paper to system databases, and ease archiving efforts and information retrieval. According to Emergency Medicine Journal¹, electronic documentation of Code Blue events captured 24% more critical information during a simulated medical emergency without loss in data quality. 

 An efficient Code Blue recording ‘instrument’ – be it paper or an electronic desktop system should be:

  • an utterly mobile device – Code Blues do not always happen in dedicated patient spaces
  • intuitive in its function – requiring little if any training to for the recorder to stay facile with its use
  • capable of rapid data acquisition
  • have seamless, secure upload to both the patient EMR as well as the organizational data repository

Real-Time Patient Management Tool

A valuable Code Blue documentation system and record would not only provide fast, efficient, complete, and accurate acquisition of data for the patient record, but, if possible, assist providers in making management decisions.

Unfortunately, in addition to poor timing of critical interventions, the records often contain inaccuracies, are grossly incomplete, and replete with errors. Most disturbing, paper code blue records are frequently lost on the way to the ICU and never make their way into the patient’s record. As a result of the paper handling process in many healthcare systems, code blue records are frequently unavailable for upload into the patient’s medical record until days after the event.

RevitalPro, a new tablet-based Code Blue documentation tool, does just that. The system, virtually effortlessly, allows rapid capture of management decisions and procedures in real-time and provides safety alerts and practice guideline prompts to the health care providers. At present, it appears to be the leading code blue data acquisition system available. 

Optimizing the cardiac arrest recording process – the paper record or electronic recording system – to work in parallel with the hospital’s Code Blue protocol should improve performance. By focusing on creating an accurately time-stamped record of management decisions with fewer distractions of data elements details which can be filled in later (such as patient conscious at onset, blood pressure at onset, etc.), errors can be minimized.

Finally, keeping the recording provider familiar with the paper record or a complicated electronic record-keeping system is challenging but critical for generating a high-quality Code Blue record and delivering high-quality patient care.

A record-keeping software, such as RevitalPro, can be used to produce a record more quickly and efficiently. Software options like RevitalPro provide the benefit of a typed, legible record which can be seamlessly uploaded to the EMR – thus eliminating the problem of transcribing a patient record from an illegible handwritten paper record.

RevitalPro provides a solution to many of the problems outlined above. It has built-in timers to help track dosage and compressions, safety alerts that assist providers in adherence to published guidelines, and direct, seamless, secure upload of the final document into the EMR. An article from the Journal of Emergency Medicine¹ found that RevitalPro reduced omission errors by 28% and redundant entries by 36% compared to paper recorders.

Quality Improvement

Code Blue events frequently leave the involved staff shaken and unsure of their performance. Debriefing has become an essential practice for improving staff response and overcoming staff apprehension toward Code Blue events. Discussing both team performance and individual roles with other responders can both reassure staff members and improve performance.

The record generated by RevitalPro provides an excellent tool for post Code Blue debrief.

Often, practice/rehearsal is what improves code response. Some institutions have code blue simulations available to improve performance. Participating in mock codes is ideal because the simulations can be oriented to an individual hospital’s policies. Mock events build confidence in potential code team members and encourage them to get involved. Furthermore, practice and debriefing efforts can improve timing and, thus, patient care efforts. The RevitalPro system is also an excellent tool to use during training/practice sessions (mock codes) to highlight what care was delivered well and what care might need improvement.

Risk Management

At first glance, an accurate Code Blue recording system seems to serve as a risk reduction tool primarily. Indeed, it is essential not to lose sight of a precise code blue record’s first two critical functions: patient care and quality improvement.

Risk reduction was the genesis for the development of the RevitalPro system. Through an unfortunate series of events, the problem of inadequacy of Code Blue records and the poor quality of data was recognized.

Upon further exploration, this problem was a universal issue across most healthcare organizations, large and small. The Code Blue workflow process can undoubtedly be improved in most healthcare organizations. However, until the problem of accurate, rapid data acquisition and seamless, secure handling of data can be immediately uploaded into the medical record is solved, patients’ care during cardiac arrests will still miss the mark. The RevitalPro system seems to solve many of the glaring problems that face acquisition and handling of patient care information during Code Blue events.

Code Blue Legal Issues


At some point, every medical professional will wonder about the legal ramifications of an in-hospital cardiac arrest (code blue). Code blue events happen quickly, and documenting the entire occurrence may be difficult.

Unfortunately, if the documentation doesn’t exist, it isn’t easy to prove that the team provided adequate care.

Lawsuits are uncommon, but the risk is considerable. When patient outcomes are unfavorable, that risk increases. Patients experiencing in-hospital cardiac arrest are often already in fragile condition. The percentage of patients who survive to discharge is surprisingly low (only 17% – 20%, according to the Society of Hospital Medicine¹).

When a code blue does have a negative outcome, the patient’s family may find comfort in the documented proof that the highest quality care was provided.

An accurate documentation of timing is crucial. It’s important to know when each dosage is administered and when the next should occur. Usually, the documenter also keeps time. The following list includes critical timing elements:

  1. Epinephrine should be delivered at 3-5 minute intervals.
  2. The person providing compressions should be rotated every two minutes to ensure that the patient receives adequate CPR.
  3. Defibrillation shocks should be delivered every 2 minutes.
  4. Compressions may be frequently paused to take vitals, administer defibrillatory shocks, and facilitate endotracheal intubations when managing patients with difficult airways. However, compressions should never be paused for longer than 10 seconds.

Ensuring these elements are accurately represented in the record establishes the essential proof of care.

HIPAA Compliance

It is also essential to ensure that the record makes it where it needs to go. Even a thorough document won’t improve your organization’s legal standing if no one can find it.

Approximately 30% of code blue paper charts are lost before they are transcribed into an EMR. Any event in which a medical record containing sensitive patient information disappears constitutes a HIPAA violation.

The code blue record also contains pressing information for the intensive care providers who accept the patient after the event. The documentation needs to follow the patient as quickly as possible, or your facility may not be providing adequate patient care.

The Signature

This is an item that is frequently overlooked. The code leader must sign the code blue record.

Without that signature, any medication administered during the code blue event was given without a prescription. This constitutes its legal issue.

The signature also provides anyone who views the document with proof that the event was overseen by a trained professional. This is especially necessary during code blue events because cardiac arrest situations tend to be chaotic. It’s far too easy for a dosage to be poorly timed or missed completely without a practiced, guiding hand.

Changing the Documentation Method

Changing the documentation method is generally done at an organizational level. If your organization uses paper documentation, refining that recording document to fit best the environment’s flow could improve your code blue records’ quality.

Because code blue events are often fast-paced, the documentation sheet must be as intuitive as possible. It is a good practice to go over the forms with the practicing nurses or code blue team to ensure the form follows the hospital’s code blue protocol as closely as possible. Simulations can be run to refine the document’s layout further.

In many cases, an electronic documentation method is a better solution. RevitalPro offers built-in timers and standard dosage defaults to help recorders create an accurate record and allow the code leader to keep precise time.

RevitalPro also offers immediate upload of the record to be quickly accessed by intensive care after the event. Immediate upload also ensures that the document is immediately available to provide the patient’s family and is directly accessible by risk management.

Electronic documentation methods also remove the need to transcribe written records into an EMR. Issues associated with illegible handwriting or lost documents are also avoided.

Brian Ross, PhD, MD

Brian Ross, PhD, MD

Professor Emeritus, Department of Anesthesiology and Pain Medicine, University of Washington