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Policy No.: E 3.1 Title: Code Blue – Medical Emergency Pages: 27

Originator(s): Professional Practice Office Initial Issue Date: March 2004 Owner: Professional Practice Office Next Review Date: June 5, 2015 Key Words: code blue, medical emergency, pool emergency, CPR, DNR

Effective Date: June 5, 2012

Reviewed by: Clinical Care Committee Approved by: Medical Advisory Committee

1.0 Purpose This policy is intended to outline CAMH’s response to medical emergencies and direct users to specific responsibilities and procedures at each of CAMH’s three sites and its satellite offices.

2.0 Persons Affected This policy applies to all staff, physicians, and affiliates of CAMH (hereafter referred to as staff); it also applies to students and volunteers as appropriate to the situation.

3.0 Policy

3.1 A Code Blue will be called in the event of a life threatening medical emergency that requires the immediate assistance of medical or clinical staff.

3.2 If necessary, life saving techniques will be initiated during a Code Blue. If there is a known client/patient code status of DNR, CPR should not be used. [Refer to PC 2.D.2 Do Not Resuscitate (DNR)].

3.3 Code Blue, Swimming Pool will be initiated to elicit an immediate medical response to serious medical emergencies and water accidents in the pool area at the Queen Street Site.

4.0 Definitions

Code Blue: The emergency code “designed to respond to a medical emergency, when a person is experiencing a real or suspected imminent loss of life” (OHA, 2008). Examples of life threatening medical emergencies include but are not limited to: airway compromise, circulation compromise including absent pulse and aspirations, cardiac and/or respiratory arrest, laryngospasm, seizure, choking, drowning, multiple injuries (spinal cord or cranial injuries), poisoning, shock, unconsciousness, hemorrhage, excessive bleeding, extensive burns, and suspected suicide. CPR (Cardiopulmonary Resuscitation): standardized medical procedures used to restart a heart and breathing when a person suffers cardiac or respiratory arrest. CPR involves the

DISCLAIMER: This material has been prepared solely for internal use at CAMH. CAMH accepts no responsibility for use of this material by any person or organization not associated with CAMH. No part of this document may be reproduced in any form for publication without the permission of CAMH. This is a controlled document. Any documents appearing in paper form are not controlled and should always be checked against the electronic version prior to use. The electronic version should always be considered the most current and accurate version. The most current version of this policy is in electronic format, found at http://insite.camh.net/policies/e_3_1_code_blue_medical_emergency-9322.pdf

http://insite.camh.net/policies/do_not_resuscitate_order-44187.pdf


Policy No.: E 3.1 Title: Code Blue – Medical Emergency Page No.: 2 of 27


initiation of a standardized algorithm that includes DABC-defibrillate, circulation, airway, and breathing. (The most important it two minutes of chest compression.) DNR Order (Do-Not-Resuscitate Order): the order which allows a client/patient with a life threatening illness or injury to forgo specific resuscitative measures that may keep him/her alive. These measures may include: chest compressions (CPR), assisted ventilation (breathing), endotracheal intubations, defibrillation, and cardiotonic drugs. The DNR order does not affect the provision of other emergency medical care, including treatment for pain (also known as comfort measures), difficult breathing, major bleeding or other conditions. The client/patient or substitute decision-maker may cancel the Do Not Resuscitate Order at any time (PC 2.D.2 Do Not Resuscitate Order)

5.0 Responsibilities

5.1 All Health Professionals • be aware of responsibilities for code response by time and location, including

equipment that must be taken to the scene, depending on area where he or she is working (refer to Appendix A: Code Blue Response)

• complete annual review of Code Blue policy and mandatory elearning • ensure CPR (with defibrillation) and first AID training are up to date as required

5.2 Admitting and Locating Services

• upon receiving the Code Blue call, announce three times: “Code Blue” and the location over the public address system

• notify appropriate personnel as per departmental procedures • when the RED Emergency phone hot line in the pool area is used (QS site only):

o Announce three times “Code Blue Swimming Pool”; o Notify appropriate personnel as per departmental procedures; o Wait to receive instruction to call 911 for ambulance.

• announce three times “Code Blue and Location All Clear” with direction that the code is over

• announce three times “Code Blue and Location Cancelled” with direction to cancel or if false alarm

• when there are two Codes called simultaneously, announce “Code Blue 1…” or Code Blue 2…” (e.g. “Code Blue 2 Unit 1 - 1” or “Code Blue 2 Cancelled”).

• document communications regarding Code Blue and file a Code Report as per departmental procedures.

5.3 Hospitalist (Duty Doctor after hours)

• announce presence and assume role of team leader as needed • initiate 911 call and give report that emphasizes the threatening nature of the

emergency i.e. non breathing, unconscious • Determine:




- the degree of resuscitation to be continued on site - when to transport the victim to an acute care facility - when the Code Blue situation has ended - when to cancel a code or a 911 call

• complete documentation including a progress note, transfer summary, and Form 11 (Transfer to Public Hospital) as necessary

• complete notification of: o Attending Physician o Substitute Decision Maker/Next of kin o Coroner (if the attempts to resuscitate are not successful)

5.4 Nursing Staff (responsibilities may be shared among nursing staff who respond)

• retrieve or delegate retrieval of emergency equipment and glucometer from designated locations

• lead the code until physician and response team arrives • initiate a call 911 if the physician is not immediately available • coordinate/assign a nurse to record time and actions taken on Code Blue Response

Record kept on the cart • delegate a staff in the area to access and/or print the Client/Patient Profile from

TREAT as necessary and if time allows • direct Admitting and Locating Services when Code Blue is all clear or cancelled • delegate Security/other staff to meet and direct the ambulance attendants to the Code

site, if necessary • arrange for a staff to escort if person is to be transferred to a general hospital when

appropriate • prepare documentation for the transfer, if necessary • complete SCORE report • document process and outcomes in client/patient’s health record • replenish emergency cart after use

5.5 Security

• respond to the scene of all Code Blue emergencies • assist with re-routing of traffic and crowd control • meet EMS and escort to location of emergency • bring the medical emergency cart as stipulated in Appendix A • contact and communicate with Admitting and Locating Services operator by walkie-

talkie or cell phone

5.6 Manager or APN/C (of After Hours Manager) • lead a debrief of the Code Blue



6.0 Procedures 6.1 Assignment of the Code Manager

6.1.1 At the beginning of each shift/day on an inpatient unit, the Charge Nurse/Team Lead will assign/reassign nursing staff to Code Blue. It is recommended that an experienced clinician be assigned this role. This person will also respond to Code Blue called in assigned areas as outlined in Appendix A: Code Blue Response.

6.1. 2 Staff in non-clinical areas may also identify who will act as the Code Manager or respond to Code Blue in assigned areas if this is practical.

6.2 Initiation of Code Blue

Russell Street (RS) Site

College Street (CS) Site

Queen Street (QS) Site

Satellite Sites

Any staff Call 5555 to be connected to Admitting and Locating Services (A & L) at CS site. State code blue, site, and exact location. If the person’s condition appears critical, instruct A & L staff to call 911. Remain on the line if 911 is called. If you are alone, yell for help.

Call 5555 to be connected to A & L at CS site. State code blue, site, and exact location. If the person’s condition appears critical, instruct A & L staff to call 911. Remain on the line if 911 is called. If you are alone, yell for help and initiate CPR.

Call 5555 or press Emergency Alarm Button or use key access panel. All methods will connect to A & L at QS site. State code blue, site, and exact location. If the person’s condition appears critical, instruct A & L staff to call 911. Remain on the line if 911 is called. If you are alone, yell for help. .

Call 5555 to connect automatically to 911. State location and type of emergency.

Admitting and Locating Services (A & L; formerly known as Switchboard)

Announce code Blue and location three times on public announcement (PA) system at the RS site. (After hours announce at both RS and CS). Radio security. After hours, page Resident and

Announce code Blue and location three times on PA. Radio security. After hours, page Resident and nursing supervisor. Call 911 if needed.

There will be a 20 second delay as the fire panel warns up; in this period A&L will radio security. Once the fire panel has warmed up, announce code Blue and location three times on PA. Radio Security. Page Hospitalists during day and duty doctor

n/a



Russell Street (RS) Site

College Street (CS) Site

Queen Street (QS) Site

Satellite Sites

nursing supervisor. Call 911 if needed.

and nursing supervisor after hours. Call 911 if needed.

Security During regular hours, 1 staff to bring equipment to the scene; 1 meet EMS at entrance.

1 security staff respond to the scene and bring equipment if necessary; 1 meet EMS at entrance.

Respond to scene and meet EMS at entrance.

n/a

Staff responsible for attending

Section 6.0 outlines specific responsibilities for all staff. Refer to Appendix A: Code Blue Response to identify which codes you are responsible for responding to and equipment that you must bring to the scene.

6.2 Initiation of Code Blue Swimming Pool (Queen Street Site)

• the lifeguard or other personnel lifts the RED emergency phone from its cradle (two such RED phones installed in the pool area - in the pool office and the pool deck)

• The special “hot line” alerts Admitting and Locating Services • NB: the red emergency phone should be used for Pool Emergencies only. The regular

phone is to be used: o If a psychiatric emergency occurs (follow Code White procedure) o For all other medical emergencies (follow Code Blue procedure)

• If transfer to a general hospital is required, the client/patient should not be removed from the pool area until the ambulance arrives.

• If the client/patient has been diagnosed as a possible Central Nervous System (head, neck or spinal) injury, the client/patient should be kept immobile until the ambulance crew takes over. In water, the portable spinal board (head immobilizer) reserved for this purpose is used.

6.3 Documentation

• The Code Blue will be fully documented in the progress notes of the client/patient’s health record. Documentation will include:

o A description of the event that led to the Code Blue o A description of the interventions implemented and the client/patient’s response

to those interventions o Outcome of the Code Blue

• One copy of the Code Blue Response Record will be filed to the client/patient health record; one copy will be forwarded to the Quality and Patient Safety Department.

• The Code Blue will also be documented in the SCORE system.



6.4 Immediate Post-Event Debriefing

• The manager or APN/C (or After Hours Manager) will lead a debrief in order to: o ensure the emotional, psychological and physical well being of staff,

client/patients, and witnesses to the event o provide a supportive and educational process where staff and client/patients are

assisted with their reactions to the event o offer additional support/resources to staff, such as, Health, Safety, and Wellness

Services, Employee Assistance Program (EAP) and Spiritual Care Services 6.6 Replenishment of Equipment

See PC E 3.3 Emergency Medical Equipment 6.7 Death

All feasible emergency efforts are implemented until relieved by the EMS or death is pronounced. In the event of a death, no matter the cause, DO NOT disturb the environment. Proceed according to PC 2.D.1 Death of an Inpatient.

7.0 References

Ontario Hospital Association (OHA). (2008). OHA emergency management toolkit: Developing a sustainable emergency management program for hospitals. OHA: Toronto.

8.0 Links/Related Documents

8.1 CAMH Policies and Resources AHR 3.14.3 Management of Incidents, Errors, and Adverse Events AHR 3.14.15 Incident Reporting E 3.3 Emergency Medical Equipment

PC 2.D.1 Death of an Inpatient PC 2.D.2 Do Not Resuscitate Order (DNR)

PC 2.D.6 Reporting and Disclosure of Critical Incidents Code Blue Response Record

9.0 Review/Revision History

Date Revision No.

Revision Type

Reference Section(s)

March 2004

1.0

New policy n/a

October 2006

2.0 Minor Updated procedures, responsibilities, links

December 3.0 Moderate Reformat; addition of specific responses by

http://insite.camh.net/policies/e_3_3_emergency_medical_equipment-65168.pdf

http://insite.camh.net/policies/death_of_an_inpatient-37166.pdf

http://insite.camh.net/policies/ahr_3_14_3_management_incidents-22524.pdf

http://insite.camh.net/policies/ahr_3_14_15_incident_reporting-22470.pdf

http://insite.camh.net/policies/e_3_3_emergency_medical_equipment-65168.pdf

http://insite.camh.net/policies/death_of_an_inpatient-37166.pdf


http://insite.camh.net/policies/pc_2_d_6_reporting_and_disclosure_of_critical_incidents-6789.pdf

http://insite.camh.net/forms/clinical_forms/38555_F0197-20040628.html



Date Revision No.

Revision Type

Reference Section(s)

2007 location and time October

2009 4.0 Minor Addition of links, updates based on

redevelopment March 2010

5.0 Minor Glucose tab 5mg removed from response because no longer available in Canada

May 2011 6.0 Moderate Reformat; update to RS and CS initiation and response by location and time; appendices

reduced and linked as forms June 2012 7.0 Moderate Addition of buildings and response for new

buildings; equipment moved to new policy Emergency Medical Equipment

February 2013

8.0 Minor Remove “Medical Staff STAT”



Appendix A: Code Blue Response

Russell Street Site

Staff Responsible for Response Staff Responsible for Transport of Emergency Equipment

Code Location Monday-Friday

08:30-16:30 hrs

Monday-Friday 16:30-08:30

hrs Weekends and Holidays

Monday-Friday 08:30-16:30 hrs


Weekends and Holidays

Location of Emergency

Equipment and AEDs

All Areas

• All nursing and medical staff in the RS buildings

• Hospitalist from CS

• RS Security

• CS Resident (2000-0800 hrs)

• all CS medical staff

• 1 nurse per inpatient unit at CS;

• RS Security (1 security member meets CS staff at RS south entrance to direct)

RS Security RS Security RS 2nd Floor by Security

NO CLINICAL SERVICES are provided at RS after 2000 hrs on weekdays, weekends or holidays



College Street Site



08:30-16:30 hrs







Equipment and AEDs

ER/EAU: Ground Floor Treatment Room

Ground Floor: Room G126A

4th Floor Treatment Room

5th Floor: Nursing Station

9th Floor: Treatment Room

All Areas

• 1 Nurse per inpatient unit

• Hospitalists • all available

medical Staff in proximity to code

• Security

• 1 Nurse per inpatient unit

• all available medical staff

• Security • CS Resident

(2000-0800 hrs)

Non inpatient: CS Security to transport equipment from G126A Inpatient: inpatient staff where code occurs

Non inpatient: CS Security to transport equipment from G126A Inpatient: inpatient staff where code occurs

10th Floor: Treatment Room



Queen Street Site Units 1 and 3



08:30-16:30 hrs







Equipment and AEDs

Unit 1 Inpatient

Units

• 1 Nurse per inpatient unit in units 3 and 1

• all available medical staff in proximity to code

• hospitalists • security


• duty doctor • After Hours

Manager (when on site and available)

• Security

Inpatient staff on Unit where code occurs


Unit 1-2, 1-3, 1-4, 1-5,

Unit 1-1 Forensic

Outpatient Service

and Unit 1 basement

• 1 Nurse per unit in units 3 and 1

• Hospitalists • Available

medical staff in proximity to code

• Security

• 1 Nurse per unit in units 3 and 1 Duty doctor After Hours Manager (when on site and available) Security

Forensic Outpatient Service

Unit 1-2 staff Forensic Outpatient Service Location (TBD)

Unit 3-4


• Hospitalists • All available


• Security




• Security

Unit 3-5 Unit 3-5 Unit 3-5



Unit 3 Inpatient

Units




• Security


• Duty doctor • After Hours


• Security



Unit 3-1, 3-2, 3-3, 3-5 Treatment Rooms



Staff Cafeteria, Mall, , Hallway from Mall to Unit 1



08:30-16:30 hrs







Equipment and AEDs

Staff Cafeteria,

Mall, Clothing

Shop







• Security

3-1 Staff 3-1 Staff Cupboard next to PACU office. Cupboard key located on Unit 3-1.

Hallway from Mall to Unit 1




• Security




• Security

3-1 Staff 3-1 Staff Unit 3-1 Treatment Room



Areas outside Units 1 and 3, Swimming Pool, Area Outside of Unit 1 and 3, Stores, Kitchen



08:30-16:30 hrs

Monday-Friday 16:30-08:30 hrs Weekends and

Holidays




Location of Emergency Equipment and AEDs

Area outside of Unit 1 and 3 (former parking

lot)







• Security

3-1 Staff 3-1 Staff Unit 3-1 Treatment Room

Queen Street

Swimming Pool and Pool area




• Security • Lifeguard




• Security


CAMH Kitchen

located in basement

(take elevator beside

outpatient Pharmacy)




• Security




• Security




Units 2 and 4



08:30-16:30 hrs







Equipment and AEDs

Unit 4-1, lobby,

basement and main entrance of Unit 4

(excluding ECT)







• Security

Unit 4-2 Staff Unit 4-2 Staff Unit 4-2 Treatment Room

Unit 4-1 ECT

• 1 Nurse per unit in unit 4



• Security

N/A ECT staff N/A ECT Suite

Unit 4-4 & 4-5







• Security



Unit 4-4 and 4-5 Treatment Rooms



Units 2 and 4 continued, Parking, Grounds Building



08:30-16:30 hrs







Equipment and AEDs

Unit 2 (excluding basement)







• Security

Inpatient staff on Unit where code occurs (Unit 2-2, 2-3, 2-4, 2-5)


Unit 2-2, 2-3, 2-4, 2-5 Treatment Rooms

Unit 2 Basement







• Security

Unit 2-2 Staff Unit 2-2 Staff Unit 2-2 Treatment Room

Shaw parking

lot, Unit 2 and 4

parking, Grounds Building







• Security

Unit 2-2 Staff Unit 2-2 Staff Unit 2 1st Floor Mailroom



Units 2 and 4 continued, Child Care Centre, Patient Advocate, Pharmacy, Hallway from Unit 2 to Mall



08:30-16:30 hrs







Equipment and AEDs

Childcare Centre, Patient

Advocate Library

Pharmacy, Hallway to Mall from

Unit 2,







• Security

Unit 4-2 Staff Unit 4-2 Staff Unit 4-2 treatment room

Partial Hospital. Program







• Security

Partial hospitalization Staff

Partial hospitalization Staff

Partial hospitalization Treatment Room



West Wing and Grounds Building



08:30-16:30 hrs







Equipment and AEDs

All Areas

• 1 Nurse per inpatient unit in White Squirrel Way



• 1 Nurse per unit in AIM and Medical Withdrawal



• Security

AIM staff AIM Staff 40 WSW



White Squirrel Way



08:30-16:30 hrs


Holidays


hrs




60 WSW

• 1 Nurse each from building 30, 40, 50, 60


• hospitalists • security • APN/Cs and

Managers

• 1 designated nurse responder from medical unit (30, 40 or 50)

• Evening PA (1630 to 2030)

• 1 Nurse from MAP • duty doctor • After Hours


• Security • APN/Cs and

managers as available

Addiction Program Day PA Medical withdrawal unit staff to bring glucometer to all codes in WSW

Designated Nurse responder from medical unit (30, 40 or 50) Medical withdrawal unit staff to bring glucometer to all codes in WSW

1st level 60 WSW

1st Floor 30, 40 50

WSW




Managers









1st level 60 WSW



White Squirrel Way Continued



08:30-16:30 hrs


Holidays


hrs




2nd Floor 30, 40, 50

WSW




Managers









Emergency Cart and defibrillator: 50 WSW Grab & Go bag: 2nd level 30 WSW

3rd Floor 30, 40, 50

WSW




Managers









Emergency Cart and defibrillator from 50 WSW Grab & Go bag from 3rd level 50 WSW



White Squirrel Way Continued



08:30-16:30 hrs


Holidays


hrs




4th Floor 30, 40, 50

WSW




Managers









Emergency Cart and defibrillator from 50 WSW

WSW parking lot

and backyard


• 1 Nurse from Unit 1-4, 1-5, and 1-3

• Medical staff from WSW buildings




• 1 Nurse from Unit 1-4, 1-5, 1-2, 1-3



• Security



Emergency Cart and defibrillator from 60 WSW Grab & Go bag from 3rd level 30 WSW



80 Workman Way grounds and parking surrounding building



08:30-16:30 hrs







Equipment and AEDs

Pace (1st Floor),

Geriatric Assessment Unit A (2nd

Floor), Geriatric

Assessment Unit B (3rd Floor) Unit,

CYF Inpatient Unit (4th

Floor)

• 1 nurse per unit on PACE, GAUA, GAUB, Inpt CYF, Unit 2 and 4






• Security



PACE Location with GA Access GAUA, GAUB, CYF Inpt Treatment Rooms

Basement and Parking







• Security

PACE Staff GAUA PACE Location with GA Access



80 Workman Way continued



08:30-16:30 hrs







Equipment and AEDs

CYF Outpatient

and Courtyard (1st Floor)







• Security

CYF outpatient staff bring Grab and Go and AED PACE staff brings emergency cart

CYF outpatient staff bring Grab and Go and AED GAUA

Emergency Cart: PACE Location with GA Access Grab and Go and AED: CYF location

CYF Day Hospital

(4th Floor)







• Security

CYF Day Hospital bring Grab and Go and AED CYF inpatient staff bring emergency cart

CYF Day Hospital bring Grab and Go and AED CYF inpatient staff bring emergency cart

Emergency Cart: CYF Inpatient Treatment Room Grab and Go and AED: CYF Day Hospital



80 Workman Way continued



08:30-16:30 hrs







Equipment and AEDs

CYF Interview

and Admin Rooms (5th

Floor)







• Security

CYF 5th Floor Staff bring Grab and Go and AED CYF inpatient staff bring emergency cart


Emergency Cart: CYF Inpatient Treatment Room Grab and Go and AED: CYF 5th Floor location

CYF Interview

and Admin Rooms (6th

Floor)







• Security



Emergency Cart: CYF Inpatient Treatment Room Grab and Go and AED: CYF 6th Floor location



100 Stokes Street, grounds and parking surrounding building



08:30-16:30 hrs



Monday-Friday 08:30-

16:30 hrs




Equipment and AEDs

Basement, 1st Floor, 2nd Floor, 5th Floor

(excluding Health, Safety

Wellness), 6th Floor, 7th

Floor

• 1 nurse per unit in 80 Workman Way and Unit 1, Addiction Medicine, Mood Outpatient, and Health, Safety and Wellness



• 1 nurse per inpatient unit in 80 Workman Way and Unit 1



• Security

Security Addiction Medicine Service to bring glucometer

Security Geriatric Assessment Unit to bring glucometer

2nd Floor location

Addiction Medicine

(3rd Floor), Health, Safety,

Wellness (5th Floor)

• 1 nurse per inpatient unit in 80 Workman Way, Addiction Medicine, Mood Outpatient, and Health, Safety and Wellness



• 1 nurse per inpatient unit in 80 Workman Way



• Security

Staff in area where code occurs (Addiction Medicine, Health, Safety and Wellness)

Inpatient staff on Unit where code occurs Geriatric Assessment Unit to bring glucometer

Addiction Medicine, Health, Safety and Wellness Services



100 Stokes Street Continued



08:30-16:30 hrs




16:30 hrs




Equipment and AEDs

Mood and Anxiety

Outpatient Service and Research (4th Floor)

• 1 nurse per inpatient unit in 80 Workman Way, Addiction Medicine, Mood Outpatient, and Occupational Wellness



• 1 nurse per inpatient unit in 80 Workman Way



• Security

Addiction Medicine Addiction Medicine Service to bring glucometer

Security Geriatric Assessment unit to bring glucometer

Addiction Medicine 2nd Floor location



101 Stokes Street



08:30-16:30 hrs




16:30 hrs




Equipment and AEDs

All Areas

• 1 nurse per clinical unit in Addiction Medicine, Mood Outpatient, Units 3 and 1


• hospitalists • security • Available OT

staff in proximity to code

• 1 nurse per clinical unit on Units 3 and 1



• Security

Security Unit 1-2 to bring glucometer

Security Unit 1-2 to bring glucometer

ADL Suite



Tunnels



08:30-16:30 hrs




16:30 hrs




Equipment and AEDs

Tunnels: Half by

Cafeteria

• 1 nurse per unit in Units 3 and 4



• 1 nurse per unit in Units 3 and 4



• security

Security Security Unit 3-1 Treatment Room

Tunnels: Half by 100

Stokes Street

• 1 nurse per inpatient unit in Addiction Medicine, Mood Outpatient



• 1 nurse per inpatient unit in GAUA, GAUB, CYF



• security

Security Security 1st Floor location by Security