Cases & Commentaries

Code Blue—Where To?

Commentary By Bruce D. Adams, MD

The Case

An 80-year-old man with a history of coronary
artery disease, hypertension, and schizophrenia was admitted to an
inpatient psychiatry service for hallucinations and anxiety. On
hospital day 2, he had sudden onset of confusion, bradycardia, and
hypotension. He lost consciousness, and a "code blue" was

The inpatient psychiatry facility is adjacent to
a major academic medical center. Thus, the "code team" (comprised
of a senior medical resident, medical intern, anesthesia resident,
anesthesia attending, and critical care nurse) within the main
hospital was activated. The message blared through the overhead
speaker system, "Code blue, fourth floor psychiatry. Code blue,
fourth floor psychiatry."

The senior resident and intern had never been to
the psychiatry facility. "How do we get to psych?" the senior
resident asked a few other residents in a panic. "I don't know how
to get there except to go outside and through the front door," a
colleague answered. So the senior resident and intern ran down
numerous flights of stairs, outside the front of the hospital, down
the block, into the psychiatry facility, and up four flights of
stairs (the two buildings are actually connected on the fourth

Upon arrival minutes later, they found the
patient apneic and pulseless. The nurses on the inpatient
psychiatry ward had placed an oxygen mask on the patient, but the
patient was not receiving ventilatory support or chest
compressions. The resident and intern began basic life support (CPR
with chest compressions) with the bag-valve-mask. When the critical
care nurse and the rest of the code team arrived, they attempted to
hook the patient up to their portable monitor. Unfortunately, the
leads on the monitor were incompatible with the stickers on the
patient, which were from the psychiatry floor (the stickers were
more than 10 years old). The team did not have appropriate leads to
connect the monitor and sent a nurse back to the main hospital to
obtain compatible stickers. In the meantime, the patient remained
pulseless with an uncertain rhythm. Moreover, despite ventilation
with the bag-valve-mask, the patient's saturations remained less
than 80%. After minutes of trying to determine the cause, it was
discovered that the mask had been attached to the oxygen nozzle on
the wall, but the oxygen had not initially been turned on by the
nursing staff. The oxygen was turned on, the patient's saturations
started to rise, and the anesthesiologist prepared to intubate the
patient. Chest compressions continued.

At this point, a staff nurse on the psychiatry
floor came into the room, recognized the patient, and shouted,
"Stop! Stop! He's a no code!" Confusion ensued—some team
members stopped while others continued the resuscitation. Although
a review of the chart showed no documentation of a "Do Not
Resuscitate" order, the resuscitation continued. The intern on the
team called the patient's son, who confirmed the patient's desire
to not be resuscitated. The efforts were stopped, and the patient
died moments later.

The Commentary

Although it was ultimately discovered that this
patient did not want resuscitation, many things went awry in this
case, including a significant delay in possible defibrillation. In
any cardiac arrest, time to defibrillation (Tdefib) is
the single most important variable associated with survival, as
mortality increases up to 10% for each additional minute of delay
in defibrillation.(1)
Great strides in improving the "chain of survival" have been
achieved for both in-hospital and out-of-hospital cardiac arrest,
from early access to emergency services to early CPR to early
defibrillation.(2) In
this case, there were delays in locating the patient, problems with
the equipment, and inadequate CPR training of the psychiatry staff.
Some of these errors can (and do) occur in cardiac arrests on
medical wards and other inpatient care areas. Yet the location of
this arrest—outside the main hospital—doubtless led to
the poor technique, inadequately trained personnel, and
malfunctioning equipment that we observed here. Hospital cardiac
arrest teams ("code blue" teams) are accustomed and trained to
manage just that—"code blues" on admitted inpatients
within the usual confines of the hospital walls. Once code
blue teams are forced to leave those familiar borders, they are
literally "out of their comfort zone." The environment now is as
medically austere as that an ambulance paramedic experiences when
he resuscitates a patient 4 miles away from the hospital.

Responding to Cardiac Arrest in Outlying Areas
of the Hospital Complex

For hospitals in the United States, the Joint
Commission states that "Resuscitation services [must be] available
throughout the hospital."(3) The
statement "throughout the hospital" is crucial. It implies that
equipment, supplies, oxygen, and medical personnel must all be
present and ready to respond to cardiac arrest—not just in
emergency departments (EDs), intensive care units, and wards but
also in the "soft" areas, such as this inpatient psychiatry
facility. Given this standard, it is likely that this case would
represent a sentinel event in
the Joint Commission's eyes.

Joint Commission standards are not the only
regulations governing the requirement to competently manage
cardiopulmonary arrests throughout health care institutions. The
Emergency Medical Treatment and Active Labor Act (EMTALA), a
federal statute best known for governing the transfer of patients
between hospitals, also specifically outlines the responsibilities
of hospitals to provide emergency medical services. According to
EMTALA, hospitals are required to provide emergency medical
services to all patients "within the hospital."(4)

EMTALA specifically obligates the hospital
when the emergency presents outside of the main hospital, as in
this case, under two of its provisions:

  • Even when not physically located in the main
    hospital building, hospitals must provide screening and emergency
    stabilization for any medical condition in nearby
    psychiatric units. The relevant language is: "EMTALA requires that
    a hospital's dedicated emergency department would not only
    encompass what is generally thought of as a hospital's emergency
    room, but would also include other departments of hospitals, such
    as labor and delivery departments and psychiatric units of
    hospitals."(4) So
    the law actually considers the psychiatric unit legally (if not
    medically) to be on par with a full trauma center ED. This
    requirement underscores that psychiatric units must have robust
    training, equipment, and activation protocols for life-threatening
  • An actual request by or on behalf of the
    individual wherever a prudent layperson would believe, based on the
    individual's appearance or behavior, that the individual needs
    emergency medical examination or treatment.(4,5) While the actual care required is not dictated, the
    government does expect the hospital to either immediately arrange
    transport of the stricken individual to the ED or to "send out a
    crash team of physicians and nurses to the individual on

The Hospital Campus

In 2000, Centers for Medicare & Medicaid
Services (CMS) expanded the responsibility of the hospital to
respond to any emergency presentation on the hospital campus or at
any provider-based off-campus facility of the hospital. What is
known as the "250-yard rule" arose from the definition of campus
found in the Code of Federal Regulations section 413.65:

"Campus means the physical area
immediately adjacent to the provider's main buildings, other areas
and structures that are not strictly contiguous to the main
buildings, but are located within 250 yards of the main buildings,
and any of the other areas determined on an individual case basis
by the CMS regional office, to be part of the provider's

In 2003, CMS clarified and narrowed the
hospital's responsibility to respond to emergencies outside of the
main hospital. The current legal state is dynamic, but the 250-yard
zone continues to apply when defining the hospital campus.
Note, however, that CMS is the ultimate judge of where that zone

Hospitals should err on the side of caution by
developing with legal assistance appropriate policies to cover
emergencies throughout the hospital campus.

Managing Cardiopulmonary Arrests in Public
(Non–Patient-Care) Areas of the Hospital

About 1% of all in-hospital cardiac arrests will
occur to visitors or staff either within its non-core clinical
areas (clinics, psychiatric units, rehabilitation facilities, etc.)
or within the building's public areas such as gift shops, lobbies,
or food courts.(7)
Unfortunately, the code blue team typically arrives to these
locations well past the recommended Tdefib benchmark of
3 minutes.(1)
This translates into lost lives. Ironically, casinos or airports,
with their robust public access defibrillator systems, may be safer
for visitors than most hospitals!(7,8)
The causes and solutions of delays are multifactorial:

  • Automated External Defibrillators (AEDs)
    vs. Crash-Carts.
    Traditionally, code teams must roll
    cumbersome defibrillation equipment from distant clinical areas and
    locate and then assess the victim—all before defibrillation.
    Pre-positioning lightweight public access AEDs throughout a
    hospital's public areas and then utilizing available bystanders as
    first responders significantly shortens Tdefib for these
  • Team Personnel. Code blue team
    members should be familiar with the geographic layout of their
    areas of responsibility as well as clinical staff that they may
    encounter. A map will help clarify these responsibilities and speed
    response times. Mock codes will help reveal these deficiencies
    while improving code team leadership skills.(11) Large hospitals may need more than one cardiac arrest
    response team. For example, in our hospital, the ED staff
    explicitly cover the first two floors and the parking lot while
    medical residents cover all else.
  • Equipment. Simple things like
    oxygen connectors or defibrillator pads can prove to be most
    uncooperative under stress, but standardized and ergonomically
    designed resuscitation equipment saves valuable time.(12)
    Hospitals must institute measures to ensure daily inspection of
    crash-carts, including those in areas that rarely have cardiac
    arrests. "We are just a psychiatry unit" is no excuse, especially
    given the risks of physical and chemical restraints often used in
    inpatient psychiatry units. A free video is available (entitled "Shock,
    Shock, Shock: Are You Ready for a Cardiac Arrest?" [requires
    registration to view]) that demonstrates how to "check the checker"
    and ensure that defibrillators are actually inspected.(13)
  • Activation. Continually train all
    hospital employees and volunteers how to "activate the emergency
    response system."(2) The
    activation system should be both simple and redundant (e.g.,
    simultaneous activation with both digital pager and overhead public
    address systems).
  • Response Systems. The Table shows several potential models for responding to
    these public areas. While "best" strategy depends ultimately on the
    hospital's resources, we think the best solution is properly
    resourced code blue teams throughout the hospital campus. Large
    facilities may require more than one team to cover the entire area.
    The hospital CPR committee should be responsible for assigning team
    members and conducting at least semiannual practice mock codes. The
    hospital leadership through its CPR committee must also establish
    standards for BLS (for all hospital employees) and ACLS (for
    professional clinical staff) training.

Take-Home Points

  • Hospitals have a moral and legal
    obligation to respond appropriately to cardiac arrests throughout
    the hospital campus.
  • According to Joint Commission and
    federal EMTALA regulations, the hospital campus can be
    defined as any type of medical facility located within 250 yards of
    the main hospital building plus any other area as determined by
  • A rapid and robust response requires
    prior planning, training, and equipping of these outlying
  • CPR training should be performed on a
    regular basis for even these low-risk areas.
  • Standardize equipment throughout the
    hospital to prevent ergonomic issues as seen in this case.

Bruce D. Adams, MD
COL, MC, US Army
Chief, Department of Clinical Investigation
William Beaumont Army Medical Center


1. American Heart Association and the
International Liaison Committee on Resuscitation. Guidelines 2000
for cardiopulmonary resuscitation and emergency cardiovascular
care, IX: the automated external defibrillator: key link in the
chain of survival. Circulation. 2000;102(suppl 8):I60-I76. [go to PubMed]

2. American Heart Association and the
International Liaison Committee on Resuscitation. Guidelines 2000
for cardiopulmonary resuscitation and emergency cardiovascular
care, XII: from science to survival: strengthening the chain of
survival in every community. Circulation. 2000;102(suppl
8):I358-I370. [go to PubMed]

3. Joint Commission of Accreditation of
Healthcare Organizations: accreditation manual for hospitals.
Oakbrook Terrace, IL: Joint Commission Resources; 2006:155-216.

4. US Department of Health and Human Services,
Centers for Medicare and Medicaid Services. Clarifying policies
related to the responsibilities of Medicare participating hospitals
in treating individuals with emergency medical conditions. Federal
Register. 2003;68:53248-53250. Available at:
. Accessed
September 27, 2007.

5. Stiller JA. A first look at the 2003 EMTALA
regulations. Health Lawyers Wkly. September 5, 2003.

6. US Department of Health and Human Services,
Centers for Medicare and Medicaid Services. CMS Manual System: Pub.
100-02 Medicare Benefit Policy. Washington, DC: US Dept of Health
and Human Services, Centers for Medicare and Medicaid Services;

7. Adams BD. Cardiac arrest of nonpatients within
hospital public areas. Am J Cardiol. 2005;95:1370-1371. [go to PubMed]

8. Faster care in a casino? Nursing. September

9. Adams BD, Anderson PI, Stuffel E. "Code Blue"
in the hospital lobby: cardiac arrest teams vs. public access
defibrillation. Int J Cardiol. 2006;110:401-402. [go to PubMed]

10. Warwick JP, Mackie K, Spencer I. Towards
early defibrillation--a nurse training programme in the use of
automated external defibrillators. Resuscitation. 1995;30:231-235.
[go to PubMed]

11. Kaye W, Mancini ME. Use of the Mega Code to
evaluate team leader performance during advanced cardiac life
support. Critical Care Medicine. 1986;14:99-104. [go to PubMed]

12. Adams BD, Easty DM, Stuffel E, et al.
Decreasing the time to defibrillation: a comparative study of
defibrillator electrode designs. Resuscitation. 2005;66:171-174.
[go to PubMed]

13. Adams BD. Shock, Shock, Shock: Are You Ready
for a Cardiac Arrest [videotape]? Asheville, NC: Quality America;
2007. Available at:
Accessed September 27, 2007. (Requires registration to view).


Table. Potential Models for Responding to
Cardiac Arrests in Public Areas.

Approach Features Advantages Disadvantages
Ad hoc Example is this case None Confusion and delays
Immediate transport to ED
by clinic staff
"Scoop and run" without
Relatively fast transport
to ED
Delayed defibrillation;
need transport equipment
AED emplacement Bystanders begin
Very easy to use. Follow
American Heart Association (AHA) Public Access Defibrillation (PAD)
program policies
Expensive to outfit entire
Use of community EMS
Call 911 EMS teams familiar with
"field response"
Delays. May not relieve
EMTALA obligation
Code Blue Team Standard hospital "crash
Experienced highly skilled
Unfamiliar surroundings =
delayed arrival