Runninghead:DEBRIEFING FOLLOWINGACODEBLUE

ImplementationofDebriefingProgramFollowingCodeBlue
CamilleClarke,MelanieDavis,LiliaMurashov,andKateSchuette
WesternWashingtonUniversity

DEBRIEFING FOLLOWINGACODEBLUE

ImplementationofDebriefingProgramFollowingCodeBlue
Purpose/Aim:
ToassessiftheimplementationofadebriefingprogramfollowingaCodeBlue
orasimulatedCodeBlueimprovesnursingresponseininitiatingcardiopulmonaryresuscitation
andtheunderstandingoftheirroleaswellasperformanceinacodeblue.
Rationale:
Whenapatientinahospitalsettinggoesintocardiacarrestitputsintomotiona
procedurecalledacodeblue.Acodeblueisfastpacedandintense,itcanalsobeusedtoshow
gapsineducation,lackofexperience,andbeemotionallydifficultforindividualproviders.
Debriefingfollowingsuchaneventcanimprovepatientoutcomes,identifytrainingneeds,and
improvestaffmorale.
Methods:
UsingCINAHL,GoogleScholar,andProquestdatabases,(
12)
researcharticleswere
reviewedrelatedtotheeffectivenessofdebriefingfollowingCodeBlues.Acomplicationof
qualitativeandquantitativestudiespreviouslypublishedincludingsomegreyliteraturetofind
rationaleandgainunderstandinginwhyimplementingadebriefingprogramisimportantand
pertinenttomedicaleducationandteamwork.
Results:
Theliteraturereviewprovedfivemainthemesamongendorsingdebriefingsimproving
patientcare,enhancedcommunicationamongthehealthteam,facilitatingteamwork,andthetwo
maintypesofdebriefing,thosethataremoretechnical(depthofchestcompression)and
behavioral,nontechnicalissues,relatedtotheemotionaltraumanursesdealwithfollowing
participationinaCodeBlue.Inadebriefingsession,anindividualhastheopportunitytodiscuss
whatworkedwell,whatinterventionswereused,andhowtheteamperformancecanbe
improved.Itfacilitatesteamworkaswellashealthcareworkerscomingtogethertodiscuss
eventsandtosharetheirthoughts.Makingthetimetotalkabouthowtheycanmoveforward
together,especiallyiftheyhavefacedatraumaticcodethewasmoredifficult.Debriefing
enhancescommunication,theopenforumofbeingabletodiscusswhatwaseffectiveand
brainstormwaystoimproveteamworkandworkmoreeffectivelytogether.Italsoprovidesthe
uniquecapacityforindividualstodecompressafterstressfulcodesonmanylevels.Medical
professionalsareexpectedtofocusandworkthroughtenseanddifficultsituations,butteam
membersarealsohuman,andresuscitationscanbeemotionallyexhausting.Havingthe
opportunitytodiscussintensefeelingsandtheemotionalcomponentofacodecanbehelpfulin
preventingburnout.
Implications:
Debriefinghasshowntobeabeneficialaspectofteambuildingandperformance
ofthenursesprovidingcare.Debriefingshouldbeimplementedintopracticefollowingacode
bluetoinsurelearningandcommunicationamongtherespondingteam.Furtherresearchand
studiesshouldbecompletedtoexplorepatientoutcomesandtheimpactdebriefinghasonthe
mentalhealthofnurses.

DEBRIEFING FOLLOWINGACODEBLUE

IMPLEMENTATIONOFDEBRIEFINGAFTERACODEBLUE
Whenthehumanheartstopsbeatingthereisashortwindowoftimewhenahealthcare
workerhastheopportunitytostartcardiopulmonaryresuscitation(CPR),themechanicalactof
breathingandpumpingbloodthroughoutthebody.Theprocessmustbeginimmediatelyand
includedefibrillationifthereishopeofthepatienthavingaheartrhythm.Therearevarious
technicalaspectsofperformingCPR,includingthedepthandrecoilofeachcompressionand
howmanycompressionsshouldbeperformedinaminutestime.However,themostimportant
partistheinitiationofCPR,themobilizationofarapidresponseteam,anddefibrillation.When
anindividualhascardiacarrestinthehospitalsettingacodeblueiscalledandaprocedure
beginsthathasbeencreatedtoprovideapatientwiththelifegivinglubduboftheheartonce
again.
AlthoughallnursesarecertifiedtoperformCPR,formanyitisnotaroutineaspectof
theirdailywork.Whentheyhaveapatientwhodoesnthaveaheartbeat,theyhavethe
responsibilityofcallingacodeblueandstartingtheprocessofcardiopulmonaryresuscitation.In
manyinhospitalsettings,whencardiacarrestoccurs,thequalityofcaredeliveredduringcode
bluesituationsisbelowthestandardsofcare.Theproblemisineffectiveresuscitation,despite
codetrials,CPRtraining,anddistinctCPRguidelines.(Sutton,R.,Nadkarni,V.,Abella,B.,
2012).
Therapidresponseteamincludesahighlyspecializedteamofskilledhealthcare
providerswhoaretrainedtotakeoverforthepatientsregisterednurseorthepersonwhocalled
thecodebluetoadministerthemoreinvasiveproceduresandaspectsofCPR.Forexample,at
PeaceHealthSt.JosephsHospitalinBellinghamWashington,theirrapidresponseteamconsists

DEBRIEFING FOLLOWINGACODEBLUE

ofthepatientsregisterednurse,theEmergencyroomphysician,thenurseteamlead,security,an
echocardiogramtechnician,apharmacist,andarespiratorytherapist.Whilethemostcommon
departmentsthatcardiacarrestoccursinistheintensivecareunit,operatingroom,and
emergencyroom,theycanhappenanytimeandanywhere.T
herefore,itisimportantthatallstaff
members,whowillinitiateacodebluecallorstartCPRprocess,feelcomfortableandconfident
intheprocesstheyareputtingintomotion.
Debriefingoccurs
afteracodeblueresponsegivingtheopportunityforthoseinvolvedto
questiontheirexperienceandtoreviewthatexperienceuponcompletion.
Debriefingafter
traumaticevents,likeacardiacarrest,hasbeenrecommendedforthementalhealthand
confidencebuildingofthoseinvolvedintheaccount.Ithasbeendescribedastheguided
reflectivediscussionthatattemptstobridgethegapbetweenexperiencinganeventandmaking
senseofit(Fey&Jenkins,2015,pg.361).Itisaconversationbetweenagroupoftwoormore
peoplecreatedtodiscussandreviewanexperiencedevent,realorsimulatedandtoanalyzeand
reflectonwhathappenedduringsaidevent.AsSuttonetal.(2012)noted,structureddebriefing
hasbeenimplementedafterinfrequent,stressfuleventsdatingbacktoWorldWarII.Postevent
debriefswereemotionallyupliftingandwerefoundtodecreasetheamountofstressand/or
potentialpsychologicaltraumarelatedtothelifealteringevents.Althoughthehospitalisnot
thesameasthebattlefield,thepremiseofadebriefingisthesameafteracode(ACLS,2014).
Medicalpersonnelinthehospitalsettingarenotalwaysawareofthequalityoftheirown
CPRadministrationandoverallperformanceduringacodeblue.Thereisanexpectationto
improvetheirCPRadministrationandotherimplementationsduringacode,butwithout
selfreflectionandfeedbackfromothersinvolved,itwouldbeunrealistictoexpectapositive

DEBRIEFING FOLLOWINGACODEBLUE

change.Theimplementationofadebriefingprogram,whetherscriptedornotscripted,
immediatelyfollowingacodeordoneatalatertime,hasproventohavepositiveeffectsonthe
dynamicsofhowateamworkstogetherandtheunderstandingofrolesduringanevent.
Debriefinghasalsobeenshowntoimprovethequalityofcareprovidedduringresuscitation,
increaseclinicalpatientoutcomes,andincreasethetimelinessofCPRinitiation.Adebriefing
programfollowingacodeblueormockcodeblueshouldbeimplementedinthehospitalsetting
toimprovethenursingresponseinitiatingCPRandtheirrolewithintheteamrespondingtoa
codebluecall.
SynthesisofLiterature
Wecompletedaliteraturereviewof12articles,bothqualitativeandquantitative,
exploringtheusesofdebriefingincodebluesituations.Manystudiesweredonefollowing
simulationsofcodebluesorinaneducationalsetting.Oneofthemainproblemsfacedinthe
writingandresearchpertainingtocodebluesandposteventdebriefingwasthelimitedamount
ofresearchdone.Althoughtherewerenumerousstudiesdoneontheimprovementoftechnical
issuesseenduringthecodeblueprocess,likedepthofchestcompression,therewaslimited
informationspecificallyaboutdebriefingonitsownasanimprovementtool.
ImprovingPatientCare
Therearenumerousfactorsthatplayintothesurvivalofapatientwhohassufferedfrom
cardiacarrest,oneofthosefactorsshouldnotincludethedelayininitiationandperformanceof
CPR.Animmediatedebriefing,alsoknownashotdebriefing,followingacardiacevent
requiringCPR,allowsforamomentarystructureddebriefwiththeteaminvolvedandhelpsto
solvesomeofthosetechnicalissuesthatcanoccur.Withsuchlowsurvivalratesfromcardiac

DEBRIEFING FOLLOWINGACODEBLUE

arrestsoccurringinthehospitalsettings,trainedmedicalpersonnelmustincreasethe
administrationsofnewapproachestopatientsandincreasethequalityofcaregiven.Itis
importantforthesurvivaloutcomeofthepatientandneedstobeconsidered.
PerformingadequateandeffectiveCPRtoprovideapatientwiththeoxygenandblood
perfusionneededtomaintainthebodyssupplytovitalorganslikethebrain,requirethe
technicalskillstodoitwell.AccordingtoSuttonetal.(2012),astudywasconductedonadults
whohadsufferedfromcardiacarrestsinaninpatienthospitalsetting.Theyfoundthattherateof
survivalofanadultinhospitalcardiaceventhadanaverageof19%andduringahospital
cardiacarreststudyofpediatricpatients,documentationofsurvivalratesslightlyexceeded25%.
Suttonetal.(2012)notedfromarecentstudyshowingliteraturethatprovidedobjectivedataon
CPRperformanceofhospitalpersonnel,that23%ofchestcompressionsweregivenatan
incorrectrate,and36%ofthecompressionsweretooshallow.Lowsurvivalratesfromcardiac
arrestsinformhealthcareprovidersandthoseadministeringCPRthatnewapproachesneedtobe
implementedtoincreasetheeffectivenessofcaregivenandthesurvivalratesofpatients.Ahot
debriefingfollowingsuchanevent,whereinadequatechestcompressionsweregiven,allows
stafftodiscussimprovementsthatneedtobemadeandtoputthemintoactionintheirpractice.
IntheliteraturereviewperformedbySuttonetal,theyexploredallaspectsof
cardiopulmonarycareincludingthegapsbetweeninitialtrainingofBasicLifeSupport,actual
executioninaclinicalsettingandtheimprovementofefficiencyinperformingCPRthroughreal
timeaudiovisualfeedback.Thereviewalsodiscusseddebriefingfollowingcardiaceventsthey
foundstructureddebriefingtobeavaluabletoolinimprovingthecomplianceofcareproviders
andtheireffectivenessduringsimulationcodes.Althoughdebriefingaloneisnotaneffective

DEBRIEFING FOLLOWINGACODEBLUE

toolinchangingperformanceoftheindividual,itprovidesfeedbackthathelpsachievebest
practice.
FacilitatingTeamwork
TannenbaumandChristopher(2013)performedaquantitativemetaanalysisstudyin
whichtheystatedebriefingprovestobeeffectivebecauseitpromotespassiveandactive
learning.Theyencouragedselfdiscovery,reflection,increasedqualityandimprovementof
experientiallearning,aswellassituationalunderstandingthroughdiscussionwithothers.Our
metaanalysisindicatesthatonaverage,debriefsimproveperformancebyapproximately25%
(Tannenbaum&Christopherpg.240).Thisisaneffectiveandstraightforwardwaytoincrease
theperformanceofournursesandotherhealthcareprofessionals.Debriefingisanimportant
componentthatshouldbeusedfollowinganycodebluesituationbecauseitworksnotjustfor
theindividual,butalsofortheteam.Implementingpostincidentdebriefingwillhelpteam
membersreflectandevaluatetheirperformancewithoutbeingworriedaboutpunitiveaction.
EnhancingCommunication
Topromoteinterprofessionalcommunication,aswellastoimprovethequalityofhealth
carepatientsreceive,simulationswithdebriefingsshouldbeperformed.Theimportanceof
debriefingaftersucheventsisessentialtothesuccessofthesetechniques.AccordingtoKing,
ConradandAhmed(2013)Manystudentsreportedthattheyhadmoreconfidencein
communicatingandspeakingupwhen[they]thoughtsomethingshouldbedoneandwerenot
afraidtoquestionthedoctorsordersasaresultofthissimulation.Thusteammemberswho
recognizethispatternandarewillingtospeakupcanpreventthistypeofpreventableerrorfrom
occurring(pg.271).Simulationswithdebriefingsfacilitatecommunicationbetweenteam
membersthatmayhavenotpreviouslybeencomfortablespeakingup.

DEBRIEFING FOLLOWINGACODEBLUE

Intheabovestudy,34studentswereplacedintoasimulationwithtwodebriefings
followingtheevents.Theywerethensurveyedusingaqualitativeapproachandalmosthalf
(44%)relatedtotheimportanceofcommunicationortheneedtoimprovecommunication.Other
themesthatemergedincludesharedunderstandingofgoals,teamcoordination,understandingof
distinctroles,increasedknowledgeofotherprofessions,confidenceinworkingwithother
professions,andreducedfearinspeakinguptootherprofessions(King,Conrad&Ahmed,
2013,pg.270).
EnhancingEmotionalSupport
Preandpostsurveysweregiventotraumateammembersinaqualitativestudydoneby
Berg,Hervey,BashamSaif,Parsons,Acuna,andLippoldt(2014)theyshowedanoverall
improvementinteammembersperceptionsoftheirpersonalroleontheteam,senseof
psychologicalsafety,aswellaspatientsafety(pg.205).Sjoberg,Schonningand
SalzmannErikson(2015)statethattheinformantsdescribedhowdebriefinghelpedtheirability
todevelopasapersonandasagroup:Itisniceanywaytolikereceiveconfirmationthatone
hasdone,thatwehavedoneourbest,thatcouldnothaveactedinanyotherway(pg.2526).
Inadebriefingmeetingfollowinganevent,afacilitatorwhoknowshowtodrawoutthe
informationandexperiencesofthoseinvolved,makesforthebestlearningenvironmentandway
toreceivefeedback.Bergetal.(2014)emphasizethatthedebriefingprocesswouldbevery
beneficialwhentheleaderiscommittedtogrouplearningbecauseeveryeventisalearning
opportunity.Thegroupleadershouldalsoacknowledgetheeffortofthosewhoattend.Shore
(2014)addsthatdebriefsshouldbeheldinaprivateplace,whereparticipantswouldfeelsafeto
speakopenlyandhonestly.Shealsosuggestsinvolvingapsychologistforadditionalsupportfor

DEBRIEFING FOLLOWINGACODEBLUE

staff.Sjobergetal.(2015)observedintheirstudyaleaderinastressfulsituationisvitalfor
bringingaboutorderandforavoidingunpleasantsituationsthatareotherwiseexperiencedas
chaotic(pg.2526).
IncreasesTechnicalPerformance
AkeyfindingofmetaanalysisdonebyCouper,Salman,Soar,Finn,andPerkins(2013)
indicatedimprovementofCPRprocessandtechnique,knowledgeandskillacquisition,aswell
astheimplementation.Italsoimprovesshorttermpatientoutcomes.Inadditiontothe
quantitativeassessmentofCPR,suchaschestcompressiondepthmeasurement,usingan
automatedfeedbackdefibrillatordevice,orothertechniquesintendedtoincreasepatientCPR
survival,ahighlystructuredposteventdebriefisessentialtoanalyzeoverallcodeperformance
ofthefrontlinecareprovidersinvolved.
Croweetal.(2015)createdastudywiththeaimtoevaluatethequalityofCPRinan
urbanEmergencyRoomusingbothaudiovisualfeedbackwithposteventdebriefingfollowing.
Theywantedtoassessthechestcompressionsratesrelatedtodepthandfrequencyofthe
compressionsgiven.TheCPRmetricofchestcompressiondepthhasbeenlinkedtocoronary
andcerebralperfusion,andsurvivalfromcardiacarrest(pg.11).Usingamonitordefibrillator
approvedbytheFoodandDrugAdministrationitmeasuredvariousaspectsofCPRincludingthe
rate,releasevelocity,fraction,andpreshockpause.HighqualityCPRsobjectiveistogenerate
forwardbloodflowtomaintainadequatecerebralandcoronaryperfusionuntilresuscitationcan
beachieved.Theyfoundthatthedebriefingsessionsfollowingcodeeventsallowedthemto
discussthedata,providedthemtheopportunitytolearntheirdeficiencies,and
gavethemtimeto
performatrainingrefresher.

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ImprovesBehavioralNonTechnicalPerformance
Couperetal.(2013)foundevidenceofsmalltomoderateimprovementsinmedical
providerperformanceaswellaspatientoutcomes.AsSuttonetal.(2012)noted,structured
debriefinghasbeenimplementedafterinfrequent,stressfuleventsdatingbacktoWorldWarII.
Posteventdebriefswereemotionallyupliftinganddecreasedtheamountofstressand/or
potentialpsychologicaltraumarelatedtothelifealteringevents.Today,posteventdebriefingis
utilizedtofocusonimprovingcareduringacodeblueresponse.
InastudyperformedattheVeteransAffairs(VA)HospitalinAnnArborMichigan,they
examinedthetrendsofthecodeteamafterimplementingaCPRcodedebriefingtool.Thetool
theyuseattheChillicotheVAHospitalisatwopagedsurveythatwasdesignedtobeaquick,
postcodediscussionallowingteammemberstoexpressareasofsuccessandimprovement.After
extendeduseoftheretrospectiveposttestonlydesign,theteammembersexpressedimprovement
inmultipleareas.AccordingtoParcarpio(2010),theresultsoftheirstudyshowedincreased
codeteamresponse,positiveimprovementinteamcohesivenessaswellasdeeper
communication.Theyalsohadlessissueswithequipmentandanincreaseinsuccessful
intubations(pg.429).
PerspectiveandGaps
Therewerenotmanyconflictingfindingsindoingtheresearchandliteraturereviewfor
theimplementationofdebriefingfollowingcodebluesorothertraumaticexperiencesfor
healthcareworkers.Itwasdifficulttofindstudiesthatwerespecifictothequalitativedata
collectionofemotions,confidence,andifdebriefingprovidestheinterpersonalcommunication
todecompressfornursesfollowingahighstresssituation.Duetothelimitednumberofavailable

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studies,itwasdifficulttoassesstheamountofconflictinginformation.Therewerefewarticles
intheliteraturethatdescribedtherelationshipbetweendebriefingandpatientoutcomes,because
manyofthemweredoneinasimulationsetting.
EvaluationPlan
Itisdifficulttomeasurehowdebriefingworksoritseffectivenessoutsideof
nontechnicalaspects.TherearemanypartstoCPRimplementationteamwork,preparedness,
confidenceininitiatingtheprocedure,beingcomfortablecommunicatingwiththedoctorand
howanindividualcancopewiththesituationtheyhaveexperienced.Increasedteamwork,
knowledgeofspecificroleincodeblueparticipation,betterpatientoutcomes/survivalrate,and
decreasedtechnicalerrorsarewaystodetermineeffectivenessofpracticechange.
ImplicationsofChange
Nursesdebriefwhetheritisinastructuredsettingornot.Theneedfordebriefingis
importantandwhenitisnotpracticed,peoplefindalternativewaysforexpressingtheirfeelings.
Inastudythatusedsemistructuredinterviewsofnurses,oneacknowledged:Iseekout
someonetotalkto,orcallandtalktoafriendorsomeoneelsewhoworksinhealthcare
(Sjobergetal.,2015,p.2526).Sincedebriefinghelpsreducestresslevels,itcoulddecreasesick
leaveandincreasestaffmorale.InherarticleShore(2014)suggestedthatdebriefingallowsstaff
toexpresstheiremotionsandenablesthemtoaskquestionsfollowingtheincident.
SuggestionsforChangeinClinicalPractice
Adebriefingshouldbeginasadiagnostictoolfortheindividualoraresponseteam,
exploringthestrengthsandweaknessesofperformanceanddevelopingasupportivespacefor
improvement.Implementingaprogramalsoallowsthetrainingandintroductionofnewleaders,

DEBRIEFING FOLLOWINGACODEBLUE

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empowersindividualstoguidetheirteamsthroughadebriefingsession,ortalkwiththosewho
arestrugglingonanindividuallevelusingtheirexperienceorperformance.Thereisanoverall
goaltocreateasharedmentalmodelwhereateamorhealthcareworkersareunifiedintheir
thinkingandtheirprocessinrespondingtoacodeblue.Mentalmodelsarebasedonexplaining
oranticipatingparticularevents.Thedefinitionofamentalmodelisofasituation,psychological
representationsofreal,hypotheticalorimaginary.Theyhelptoexplainreasoningand
expectationsofanindividual.(Mentalmodels,n.d.)
ACodeBluedoesnothappenveryofteninmedicaloffices,whichcouldbewhymany
nursesarenotfamiliarwithdebriefing.Iworkinacardiologyofficeinthenucleardepartment,
whereIperformmyocardialperfusiontests.Whenoneofmypatientshadamyocardial
infarctionduringanexercisestresstest,IcalledaCodeBlue.Abouttenmedicalpersonnel
showedup,andassoonastheysawthepatientsECGonthemonitor,theypanicked.Sincethe
patientsheartratewasdropping,weinjectedatropineandwithinaminutehisheartratebegan
torisebacktonormal,notneedingtouseadefibrillator.

Afterourpatientwastakentothe
catheterizationlaboratory,Ifoundonesetofdefibrillatorpadsonthecountertopandonesetin
thegarbagecan.Forthenextfewdays,Ireplayedthewholeeventinmybrainoverandover
again.Iwasverythankfulthatmypatientdidnotneedtobedefibrillatedbecausethe
defibrillatorpadswerenotonthecrashcartwiththedefibrillator.
Iwishwecouldhavehadapostdebriefatmyworkplace.Wecouldhavereviewedand
resolvedthischaoticanddisorganizedevent,andlearnedwhatareasneededimprovement.
Duringthedebriefingwecouldhavediscussedwhatdutiesneededtobeassigned,howmany
peopleshouldhavestayedintheroom,andwhowasresponsibleforthecrashcartandcalling

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theambulance.Atthemomentwe,asamedicaloffice,arenotreadyforanemergencysituation,
butIfeelwithcontinuedmocktrialsandimmediatepostdebriefings,thesetechnicaldifficulties
andmiscommunicationscouldberesolved.
Ourproposedclinicalpracticechangeistoimplementaposteventdebriefingthatwould
includeastructuredimmediatedebrief,recognizingthedifficultyofthesituationjust
experienced.Thiswouldbeatimetoaddressanymajortechnicalissuesfacedbytheteam.
Immediateresponseisneededbecauseitislikelytheonlytimewhenthepersonnelinvolvedin
thecode,willhaveamomentaryopportunitytobetogetheranddiscusswhathappened.There
arevarioustoolsandstructuresthatexisttofacilitatedebriefingcreateaninformativelearning
environmentguidingconversationandencouragingthediscussionforbetterperformanceto
providebestpracticeforpatients.
Inalargehospital,likeSt.JosephsHospitalPeaceHealth,wheretheyareservinga
specificandcloseknitcommunity,itisimportanttoimplementdebriefingintotheCodeBlue
proceduretocreateateamwithbettercommunication,teamwork,andunderstandingastowhat
theirroleiswithinthatteam.Thisespeciallyappliesfortheprimarycarenurse,whoisnotapart
oftherapidresponseteamanddoesntfeelneededornecessaryupontheirarrival.Havingthe
timeandopportunitytoexpressemotionsanddiscussaspectsofcarethatcouldhavebeenbetter
providediswhatanimmediatedebriefingcanprovide.Beingabletolearnfromnurseswho
routinelyrespondtoCodeBluecallscreatesunderstandingandconfidenceforthenursemay
findaCodeBluetobeanunusualoccurrenceintheirdaytodaypractice.

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