COVID19 & CODE BLUES

Please note that ALL patients are presumed to be PUIs/COVID positive if they are having an RRT / Code Blue called on them and thus you MUST wear an N-95 and face shield during these encounters
See RR/CODE GUIDE for most updated information and necessary phone numbers for RR and Code Blue/Stroke/Heart.
Response Team and Roles
  • Code Leader: MICU/SICU/ED attending, MICU fellow, or MICU resident.

    • Leads code

  • Compressor: Nurse or MD.

    • Provides CPR

  • Nurse: MICU/SICU/ED nurse.

    • Administers medications, draws blood, and physically operates defibrillator

  • Airway manager: Anesthesia, MICU, or ED attending.

    • Obtains advanced airway

  • Respiratory therapist: Outside or inside the room depending upon scenario (as below).

  • Code recorder: Nurse or MD

  • Gofer: Nurse or MD

    • retrieves items not already in the room

 

PPE
  1. N-95s + face shields + gown + gloves are required for all encounters of a Code Blue or RRT. N-95s should be obtained from the chiefs office at the start of each call day and carried with the call team everywhere. Code Blue carts also have N-95s availble as well.

  2. The team should ensure all members entering the room have proper PPE as suggested by hospital guidelines (N-95 mask, eye-shield, gown and gloves). If proper PPE is NOT available, DO NOT go into the patient’s room even if it delays CPR.

  3. PAPR /CAPR or PPE as described above is a must for airway (intubating the patient) person

  4. PPE should be doffed prior to exiting the patient room

 

CODE Materials:
  1. The code cart will be brought to the room but left outside. Items to be removed from the cart and carried into the room include:

    1. Top two medication trays

    2. Defibrillator and pads

    3. Backboard

  2. Resident team will be responsible for bringing: personal PPE

  3. Critical care nursing will be responsible for bringing:

    1. Intraosseous kit

    2. Video laryngoscope (from MICU)

    3. Saline flushes

  4. RT will be responsible for bringing:

    1. Nonrebreather

    2. Ambu bags with viral filter

    3. Transport ventilator (Hamilton-MR1 ventilator)

    4. Breathing tube

    5. Easy Cap

  5. Anesthesia will be responsible for bringing:

    1. Intubating medications

    2. Laryngoscope blade and stylet

 

 

CODE BLUE ON AN INTUBATED PATIENT

Inside the Room: Code leader, Compressor, Nurse

Outside the Room: Gofer, RT, Recorder, Safety Officer

  1. Code Leader assigns roles on arrival to the Code Blue to ensure only appropriate personnel enter the room. Code leader will be inside the room for the code.

  2. Compressor provides chest compressions as per CPR guidelines.

    1. DO NOT disconnect patient from ventilator. Increase FiO2 to 100%.  

  3. Critical care or ER nurse administers medications, draws blood, and physically controls defibrillator.

  4. Code recorder remains outside the room.

    1. Attempt to minimize number of times the door is opened. Communication with those inside the room should be via walkie-talkies which will arrive with the PPE bag.

  5. Code Gofer outside the room to bring supplies/medications as needed. If possible, these should be handed across the threshold of the room in a bin which should remain thereafter inside the room.

    1. Code cart will remain outside the room

    2. Attempt to minimize the number of times the door is opened.

  6. RT outside room donned in preparation for assisting
    with any ventilator needs

 

CODE BLUE ON AN NON-INTUBATED PATIENT

Inside the Room: Code leader, Compressor, Nurse, Airway Manager, RT

Outside the Room: Gofer, Recorder, Safety Officer

  1. Code Leader assigns roles on arrival to the Code Blue to ensure only appropriate personnel enter the room. Code leader will be inside the room for the code.

  2. Compressor provides chest compressions as per CPR guidelines.

    1. A surgical drape should be placed loosely over the face of non-responsive patients prior to inception of CPR in order to minimize aerosolization.

  3. RT will be in the room with proper PPE assisting in intubation

    1. NO AMBU bagging of patient before an endotracheal tube is in place. Instead, place a non-rebreather mask on patient’s mouth and nose while awaiting an advanced airway.

  4. Airway manager will intubate the patient wearing appropriate PPE.

    1. This may occur in any patient room irrespective of negative-pressure status

  5. Critical care or ER nurse administers medications, draws blood, and physically controls defibrillator.

  6. Code recorder outside the room the room.

    1. Attempt to minimize number of times the door is opened. Communication with those inside the room should be via walkie-talkies which will arrive with the PPE bag.

  7. Code Gofer outside the room to bring supplies/medications as needed. If possible, these should be handed across the threshold of the room in a bin which should remain thereafter inside the room.

    1. Code cart will remain outside the room

    2. Attempt to minimize the number of times the door is opened.

 

TRANSPORTING PATIENTS AFTER A CODE
  1. A transport team will transfer the patient to the ICU consisting of

    1. Respiratory therapist

    2. Critical care nurse

    3. MICU resident / Intern

  2. Ideally the three members should be different from the ones running the code in appropriate PPE

  3. In case a new team member is not available, then the one in the room must doff PPE as recommended, wash hands and don new PPE before transporting the patient

  4. The patient must have an established airway with an ET tube with a bacterial/viral filter and will be transported on a transport ventilator.

  5. Wipe down the bed and transport equipment with appropriate wipes (70% ethanol or bleach containing).

  6. Cover the patient with a clean sheet with the transport equipment under the sheet.

  7. If the code team members are not accompanying the patient, they will follow hospital guidelines for removing PPE and washing hands.

 

Other Recommendations:
  1. An updated LST note must be documented on all covid-19 positive and PUI

  2. For known Covid-19 patients with multi-organ failure, early involvement of palliative care and ethics team is highly recommended so that discussions can be carried out with next of kin regarding code status.

 

RAPID RESPONSE

Inside the Room: Rapid response leader, Critical Care Nurse, RT, Floor Nurse (if already inside room)

Outside the Room: Floor nurse (if not already inside room), Gofer

  1. Rapid response leader assigns roles on arrival to the event to ensure only appropriate personnel enter the room. Rapid leader will be inside the room for the event.

  2. Critical care or ER nurse administers medications, draws blood, obtains IV access, and otherwise assists.

  3. RT will be inside room to assist with respiratory needs.

    1. NO AMBU bagging of patient without advanced airway.

    2. HFNC may be administered in a negative pressure room or in a standard room with a surgical drape placed over the patient’s face. When transporting on HFNC, patient’s face must be draped with surgical drape.  

  4. Gofer outside the room to bring supplies/medications as needed. If possible, these should be handed across the threshold of the room in a bin which should remain thereafter inside the room.

    1. Attempt to minimize number of times the door is opened.

    2. If patient is decompensating, have a low threshold to upgrade to Code Blue to bring Airway Management and ICU providers.