Fact-checked by Grok 2 weeks ago

Code Blue

Code Blue is a hospital emergency code used to indicate a medical emergency, most commonly cardiac arrest or respiratory arrest in adult patients. It signals the need for immediate resuscitation by a multidisciplinary team. Although there is no universal national standard, Code Blue is widely recognized in the United States, Canada, Australia, and New Zealand.^[1]^[2]^[3] The term originated in the early 1960s, developed by Dr. Hughes Day as part of efforts to improve emergency responses in coronary care units.^[4] It allows for discreet announcements to assemble trained personnel without alarming others. Variations exist across institutions and regions; for example, some facilities use Code Blue specifically for adult emergencies, with Code White or Code Pink for pediatric cases.^[5]^[6] Rapid response is critical, as survival rates in cardiac arrest depend on quick intervention, including CPR and defibrillation. Training in Code Blue protocols, often using simulations, is required for hospital staff and has been a key part of safety standards since widespread adoption in the 1990s.^[3]^[7]^[6]

Definition and Purpose

Meaning of Code Blue

Code Blue is a standardized hospital emergency code that signals a life-threatening medical crisis, most commonly cardiac arrest, respiratory arrest, or other critical conditions necessitating immediate resuscitation efforts.^[1]^[8] This alert activates a hospital-wide response team to provide urgent interventions such as cardiopulmonary resuscitation (CPR) directly at the patient's location.^[2] The designation of "Code Blue" specifically indicates that the affected individual—whether a patient, visitor, or staff member—experiences a sudden and severe deterioration that prevents safe transport to another area, requiring on-site stabilization to prevent death.^[1] It underscores the need for rapid, coordinated action in situations where vital functions like heartbeat or breathing cease abruptly.^[3] The use of color-coded emergency systems in hospitals originated in the mid-20th century to communicate crises discreetly and minimize panic among non-essential personnel. The term "Code Blue" itself was coined in 1960 by cardiologist Dr. Hughes Day at the University of Kansas Medical Center, inspired by the cyanosis (bluish skin discoloration) observed in patients suffering severe arrhythmias before cardiac arrest.^[4]^[9] Examples of events triggering a Code Blue include a sudden loss of pulse in a patient with known heart disease, cessation of breathing due to airway obstruction, or an unexpected collapse from ventricular fibrillation leading to no detectable heartbeat.^[1]^[3] These scenarios demand immediate intervention to restore circulation and oxygenation, often determining survival outcomes.^[8]

When It Is Called

A Code Blue is primarily activated in response to an unexpected cardiac arrest, characterized by the absence of a detectable pulse in an adult patient.^[1] This trigger indicates a life-threatening cessation of effective cardiac output, often requiring immediate cardiopulmonary resuscitation.^[8] Similarly, respiratory arrest, defined as the complete absence of spontaneous breathing, prompts a Code Blue declaration to address acute hypoxia and potential secondary cardiac compromise.^[1] Combined cardiopulmonary failure, where both cardiac and respiratory functions fail simultaneously, also necessitates this activation as a unified emergency response.^[8] Secondary scenarios that may lead to a Code Blue include severe hypotension that remains unresponsive to initial fluid resuscitation or vasopressor therapy, escalating to imminent arrest.^[10] Witnessed patient collapse in non-intensive care areas, particularly if accompanied by unresponsiveness, further justifies the call to mobilize resuscitation resources promptly.^[11] Acute airway obstruction, such as from foreign body aspiration or anaphylaxis, triggers Code Blue when it results in respiratory failure and hypoxia despite basic maneuvers like the Heimlich or jaw thrust. Code Blue activations are distinguished from non-arrest emergencies managed by rapid response teams, which address early vital sign instability—such as systolic blood pressure below 90 mmHg without arrest, tachycardia exceeding 140 beats per minute, or tachypnea over 28 breaths per minute—before progression to full cardiopulmonary collapse.^[10] This differentiation ensures that Code Blue is reserved for confirmed or highly suspected arrests, optimizing resource allocation in hospital settings.^[12] Factors influencing the timing of a Code Blue call include the patient's location, with inpatient wards and procedural areas prompting faster activation due to proximity to monitoring equipment, compared to outpatient clinics where external emergency services may be involved initially.^[1] Observed symptoms like agonal breathing—ineffective, gasping respirations signaling impending cardiac arrest—prompt immediate pulse checks and Code Blue initiation if no pulse is found, emphasizing the need for rapid clinical assessment.^[12]

Activation Process

How the Code Is Announced

In hospitals, a Code Blue is typically announced using overhead paging systems operated by the hospital's central operator or communication center, where staff dial a designated emergency line—such as 2222 or 6-1234—to report the event and trigger the alert.^[13]^[14] The announcement often includes a warning tone followed by a verbal message specifying the code and precise location, for example, "Code Blue, third floor, Room 123," to enable rapid and targeted response from the code team.^[1] Any hospital staff member who witnesses or suspects a cardiac or respiratory arrest in an adult patient can initiate the Code Blue call, emphasizing immediate action without delay for non-specialized personnel.^[1] To minimize false alarms, which can account for up to 91% of activations in some settings due to factors like staff anxiety, protocols generally require the caller to briefly verify the emergency by assessing the patient's responsiveness, pulse, or breathing before notifying the operator, though the emphasis remains on speed to preserve life.^[8] Many facilities supplement traditional overhead paging with electronic alerts delivered via secure smartphone apps, text messaging systems, or wearable devices integrated with bedside code buttons, allowing for simultaneous notifications to on-call team members and potentially reducing response times by mapping alerts directly to the incident location.^[15] In cases of technical failures, such as paging system outages, backup protocols include manual methods like sending a staff runner to alert nearby personnel or using phone chains to contact key responders directly.^[16] These dissemination strategies ensure efficient team mobilization while the discovering staff begins basic stabilization efforts, such as initiating chest compressions if trained.^[17]

Initial Response by Staff

Upon recognizing signs of cardiac or respiratory arrest in a hospital setting, on-site personnel initiate the immediate response by first verifying scene safety to protect themselves and others from hazards, as emphasized in the American Heart Association's (AHA) guidelines for basic life support (BLS).^[18] This step ensures rescuers can approach without risk, allowing safe assessment of the patient.^[19] Next, staff check the patient's responsiveness by tapping the shoulders and shouting for a response while simultaneously calling for nearby help if not already done.^[18] If unresponsive, they activate the emergency response system—such as dialing the hospital's Code Blue line or using an overhead page—and request an automated external defibrillator (AED) and emergency equipment, or delegate someone to retrieve them.^[19] This rapid activation mobilizes resources while the initial assessor proceeds to BLS.^[18] Basic life support begins with assessing airway, breathing, and circulation (the ABCs). Staff open the airway using the head-tilt/chin-lift maneuver, avoiding the jaw-thrust if a cervical spine injury is not suspected.^[18] They then check for breathing; if absent or only gasping (agonal breaths) is observed, and no pulse is detected within 10 seconds via carotid palpation, CPR is initiated immediately.^[19] For breathing assessment in trained personnel, rescue breaths are provided if a bag-mask device is available, aiming for visible chest rise with one breath every 6 seconds (10 breaths per minute).^[18] Circulation support follows with high-quality chest compressions if no pulse is present, performed at a rate of 100 to 120 compressions per minute and a depth of at least 5 cm (2 inches) in adults, allowing full chest recoil between compressions.^[18] The compression-to-ventilation ratio is 30:2 for single rescuers or two-rescuer teams without advanced airway management, continuing in cycles until an AED arrives or the code team takes over.^[19] Compressions should be delivered with the patient's torso at the level of the rescuer's knees to optimize force and minimize fatigue.^[18] If an AED is available nearby, it is applied as soon as possible after starting CPR, with the patient's chest exposed and pads placed in an anterolateral position: one pad on the right upper chest below the clavicle and the other on the left mid-axillary line at the level of the fifth intercostal space.^[18] The AED analyzes the rhythm, and if a shockable rhythm is detected, a shock is delivered per device prompts, followed by immediate resumption of CPR for 2 minutes.^[19] These initial BLS measures by on-site staff bridge the gap until the full code team arrives for advanced resuscitation.^[18]

Code Blue Procedure

Resuscitation Steps

The resuscitation steps during a Code Blue follow the standardized adult cardiac arrest algorithm outlined in the 2025 American Heart Association (AHA) guidelines, emphasizing high-quality cardiopulmonary resuscitation (CPR) integrated with advanced life support interventions to restore spontaneous circulation.^[20] These steps prioritize the CAB sequence—Circulation (chest compressions), Airway management, and Breathing (ventilations)—to address the immediate needs of a patient in cardiac arrest, with the goal of minimizing interruptions in CPR and rapidly identifying treatable rhythms.^[21] Upon confirmation of cardiac arrest, the team initiates high-quality CPR immediately, starting with chest compressions at a rate of 100–120 per minute and a depth of at least 5 cm (2 inches) on the lower half of the sternum, allowing full chest recoil between compressions and limiting interruptions to less than 10 seconds.^[21] Compressions continue in uninterrupted 2-minute cycles, during which the patient's rhythm is assessed using a defibrillator or monitor.^[20] If a shockable rhythm such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) is identified, defibrillation is performed promptly with a biphasic energy dose of 120-200 J (or manufacturer-recommended), followed by immediate resumption of CPR for another 2-minute cycle without pausing to check the pulse; subsequent shocks may escalate energy if needed.^[21] For non-shockable rhythms like asystole or pulseless electrical activity (PEA), CPR continues with rhythm reassessment every 2 minutes, and epinephrine is administered intravenously or intraosseously every 3–5 minutes to support circulation, starting as soon as possible after initiation.^[21] Throughout efforts, reversible causes (H's and T's: hypovolemia, hypoxia, hydrogen ion/acidosis, hypo-/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis) should be identified and treated.^[20] Airway management begins with bag-valve-mask (BVM) ventilation to provide oxygen, using a compression-to-ventilation ratio of 30:2 during initial cycles, ensuring visible chest rise without excessive volume that could cause gastric insufflation.^[21] As expertise allows and without compromising CPR quality, the team progresses to advanced airway techniques, such as supraglottic airway insertion or endotracheal intubation, transitioning to asynchronous ventilations (one breath every 6 seconds) once secured to maintain continuous compressions; waveform capnography is recommended to confirm placement and monitor CPR quality via end-tidal CO2 (ETCO2).^[21] Throughout, the team briefly coordinates roles to assign compressor, ventilator, and monitor duties, ensuring seamless execution.^[21] Resuscitation efforts are terminated upon achievement of return of spontaneous circulation (ROSC), indicated by a palpable pulse and adequate perfusion, or in the presence of a valid do-not-resuscitate (DNR) order.^[20] If ROSC is not achieved after prolonged, high-quality efforts—typically 20–30 minutes without reversible causes identified—termination may be considered based on clinical judgment and institutional protocols, though decisions prioritize potential for recovery.^[21]

Equipment and Medications

In Code Blue responses, essential equipment is rapidly mobilized from crash carts or dedicated resuscitation stations to support immediate life-saving interventions. Core items include manual defibrillators or automated external defibrillators (AEDs), which deliver electrical shocks to treat shockable rhythms like ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), with biphasic devices preferred at initial energies of 120-200 J (or manufacturer-recommended) escalating as needed for subsequent doses.^[21] Monitoring devices such as electrocardiogram (ECG) monitors for rhythm assessment and pulse oximeters for oxygen saturation tracking are integral, often integrated into multi-parameter units that also display end-tidal CO2 (ETCO2) to gauge CPR quality and confirm airway placement.^[21] Crash carts typically contain intravenous (IV) access supplies like catheters, tubing, and intraosseous (IO) needles for rapid vascular access when peripheral IVs fail; suction devices to clear airway secretions; and oxygen delivery systems including masks, nasal cannulas, and bag-valve masks for ventilation support.^[22] Airway management tools are critical for securing ventilation in patients with compromised airways during arrest. These include endotracheal tubes in various sizes for intubation, laryngoscopes with Macintosh or Miller blades for visualization, and bougies or stylets to facilitate tube placement in difficult airways, often supplemented by supraglottic devices like laryngeal mask airways as interim options.^[21] Such equipment enables advanced airway techniques when basic maneuvers prove insufficient, with waveform capnography recommended to verify tube position and monitor ventilation efficacy.^[21] Pharmacological agents form the backbone of drug therapy in Code Blue protocols, administered via IV or IO routes to address arrhythmias and support circulation. Epinephrine, at a dose of 1 mg every 3-5 minutes, is indicated for all cardiac arrest rhythms to improve coronary and cerebral perfusion during CPR, particularly enhancing outcomes in non-shockable rhythms like asystole or pulseless electrical activity (PEA).^[21] For refractory VF or pVT after defibrillation attempts, amiodarone is given as 300 mg IV/IO initially, with an optional repeat dose of 150 mg, to stabilize membranes and suppress ventricular arrhythmias; lidocaine (1-1.5 mg/kg initial, 0.5-0.75 mg/kg repeat) is an alternative antiarrhythmic.^[21] Atropine, dosed at 0.5 mg IV/IO every 3-5 minutes (maximum 3 mg total), is used for symptomatic bradycardia in peri-arrest scenarios, such as unstable bradycardic rhythms preceding full arrest, to increase heart rate by blocking vagal effects.^[21] Following return of spontaneous circulation (ROSC), post-resuscitation care incorporates targeted temperature management (TTM) tools to mitigate neurological injury in comatose survivors. These include surface cooling devices like blankets or pads, intravascular catheters for internal cooling, or evaporative methods, aiming to maintain core temperature between 32-37.7°C for at least 36 hours before gradual rewarming and fever prevention.^[23] This intervention, evolved from therapeutic hypothermia, is supported by evidence showing improved neurologic outcomes when initiated promptly after ROSC.^[23]

Code Team Composition

Roles and Responsibilities

The Code Blue team is a multidisciplinary group assembled rapidly in response to a cardiac or respiratory arrest, with each member assigned specific roles to ensure efficient resuscitation efforts. This structure optimizes task delegation, minimizing delays and enhancing patient outcomes during high-stress emergencies. Responsibilities are delineated to promote clear communication and adherence to evidence-based protocols, such as those outlined in Advanced Cardiovascular Life Support (ACLS) guidelines. The team leader, often a physician such as an intensivist or emergency medicine specialist, or in some cases a senior nurse with advanced training, oversees the entire response. This individual coordinates team actions, makes critical decisions on interventions like defibrillation or termination of efforts, and assumes responsibility for declaring the time of death if resuscitation proves unsuccessful. The leader ensures compliance with institutional protocols and facilitates post-event debriefing to improve future responses. The compressor focuses on delivering high-quality chest compressions to maintain circulation. Typically performed by nurses, respiratory therapists, or other trained personnel, this role involves uninterrupted compressions at a rate of 100-120 per minute and a depth of at least 5 cm in adults, with rotations every 2 minutes to prevent compressor fatigue and sustain compression quality. Proper technique is vital, as suboptimal compressions can reduce survival rates by up to 50%. The airway manager, usually an anesthesiologist, respiratory therapist, or experienced nurse, manages airway patency and ventilation. This includes securing the airway via bag-mask ventilation or endotracheal intubation, monitoring end-tidal CO2 and oxygen saturation, and adjusting ventilatory support to avoid hyperventilation, which can compromise coronary perfusion. Effective airway management is crucial, as delays in intubation have been associated with lower return of spontaneous circulation rates. The medication administrator, often a pharmacist or nurse, prepares, administers, and documents resuscitative drugs such as epinephrine or amiodarone according to timed intervals specified in ACLS algorithms. This role ensures accurate dosing— for instance, epinephrine every 3-5 minutes during arrest—and tracks medication history to prevent errors, which can occur in up to 20% of codes without clear documentation. The recorder meticulously logs all events, including timestamps for compressions, defibrillations, medications, and rhythm checks, to support quality assurance reviews and legal documentation. In smaller teams, this duty may fall to a nurse or designated staff member using electronic or paper tools. Additionally, a runner retrieves essential supplies like crash cart items or blood products from nearby areas, ensuring seamless access without interrupting core resuscitation tasks. Training for these roles, including simulations, is essential to role proficiency but is covered in dedicated certification programs.

Training Requirements

All healthcare staff in hospitals are required to maintain Basic Life Support (BLS) certification, which covers fundamental skills in cardiopulmonary resuscitation (CPR), use of automated external defibrillators (AEDs), and relief of foreign-body airway obstruction, to ensure immediate initiation of resuscitation during a Code Blue event.^[24] This certification is mandated by standards from accrediting bodies like The Joint Commission, emphasizing evidence-based training programs for resuscitation readiness.^[25] BLS certification must be renewed every two years through American Heart Association (AHA)-approved courses to keep skills current.^[26] Members of the Code Blue team, including physicians, nurses, and other advanced responders, must hold Advanced Cardiac Life Support (ACLS) certification, which builds on BLS by incorporating advanced airway management, rhythm recognition, intravenous access, and pharmacologic interventions during cardiac arrest.^[27] ACLS training is essential for effective team-based resuscitation and is also renewed biennially per AHA guidelines.^[26] These certifications ensure that core team members can adhere to standardized algorithms, improving survival outcomes in in-hospital cardiac arrests.^[28] The 2025 AHA Guidelines recommend that in-hospital code teams comprise members with ACLS training and utilize designated or dedicated teams with clearly defined roles to optimize resuscitation efforts.^[29] Simulation training plays a critical role in preparing staff for Code Blue scenarios, utilizing high-fidelity mannequins that replicate physiological responses to practice realistic cardiac arrest situations.^[30] These sessions focus on enhancing team dynamics, such as role clarity and closed-loop communication, while reducing errors in high-stress environments through deliberate practice and feedback.^[31] High-fidelity simulations have been shown to improve resuscitation performance by simulating the chaos of actual events without risking patient safety. Hospital-specific drills, known as mock Code Blues, are conducted quarterly to maintain proficiency and identify system-level gaps in response protocols. These unannounced or scheduled exercises involve real-time activation of the overhead announcement and response by on-duty staff, followed by structured debriefings to analyze performance and address deficiencies like equipment access or role confusion.^[32] Regular mock codes align with AHA recommendations for ongoing in-situ training to sustain high-quality resuscitation efforts.^[30] Training for Code Blue responses emphasizes interdisciplinary collaboration, bringing together nurses, physicians, respiratory therapists, and security personnel in joint sessions to foster coordinated actions.^[33] Respiratory therapists, for instance, practice airway management alongside physicians handling defibrillation, while security supports crowd control during simulations.^[34] This approach ensures seamless integration of diverse expertise, as evidenced in hospital programs that report improved team cohesion and response times through such integrated training.^[35]

History and Standardization

Origins

The emergence of Code Blue in the 1960s and 1970s coincided with heightened awareness of cardiac arrest, spurred by the American Heart Association's promotion of cardiopulmonary resuscitation (CPR) techniques in 1960, which combined chest compressions and mouth-to-mouth breathing for the first time.^[36] This advancement emphasized the need for rapid, organized responses to sudden cardiac events in hospitals, prompting innovations in emergency alerting systems. In 1962, cardiologist Hughes W. Day, M.D., pioneered the world's first acute coronary care unit at Bethany Medical Center in Kansas City, Missouri, where he introduced the term "Code Blue" to denote a cardiac arrest requiring immediate resuscitation, alongside the development of the mobile cardiac crash cart equipped with essential medications and defibrillators.^[4] Code Blue was part of a broader shift in U.S. hospitals toward color-coded emergency alerts, adopted in the mid-20th century to replace numeric codes and reduce miscommunication during crises, allowing discreet paging over public address systems without alarming patients or visitors.^[37] These systems gained initial traction in major urban medical centers, where the volume of emergencies necessitated efficient coordination among staff. The approach drew inspiration from military and aviation communication protocols, which prioritized concise, unambiguous signals for high-stakes situations to ensure swift team mobilization.^[6] Early implementation faced significant challenges due to the absence of national standardization, leading to inconsistent interpretations of Code Blue and similar alerts across facilities—for instance, some hospitals assigned varying meanings to the same color codes, potentially delaying responses in inter-hospital transfers or shared care scenarios.^[37] This variability highlighted the need for eventual regulatory efforts to unify protocols, though such formalization occurred later in the field's evolution.

Evolution and Regulations

The evolution of Code Blue protocols has been marked by significant standardization efforts beginning in the late 20th century. In 1986, the American Heart Association (AHA) updated its Advanced Cardiovascular Life Support (ACLS) algorithms as part of its Emergency Cardiac Care (ECC) and CPR guidelines, providing a structured framework for resuscitation responses that emphasized sequential interventions for cardiac arrest rhythms, building on the initial ACLS foundations established in 1975.^[38]^[39] Subsequent updates, such as those in 2010, further refined these protocols by prioritizing high-quality chest compressions with minimal interruptions to improve circulation during resuscitation.^[40] The AHA continued updating these guidelines, with the 2025 release emphasizing distinctions between breaths and ventilations, simplified training, and enhanced recommendations for shockable rhythms in adult cardiac arrest.^[21] Technological advancements have transformed Code Blue activation and monitoring from manual processes to integrated digital systems. By the 2010s, hospitals began transitioning from overhead paging to automated alerts via electronic health records (EHRs) and mobile devices, enabling faster team mobilization.^[41] In the 2020s, artificial intelligence (AI)-driven early warning systems (EWS) integrated with EHRs have emerged to predict patient deterioration, reducing the incidence of Code Blue events by alerting staff to vital sign abnormalities before arrest occurs.^[42] Internet of Things (IoT) devices, such as real-time location systems for equipment and staff, have further enhanced response efficiency by locating crash carts and directing teams precisely.^[43] Regulatory oversight in the United States has reinforced these developments through accreditation and participation requirements. The Joint Commission, in its 2022 resuscitation standards (effective January 1, 2022), mandates hospitals to implement processes for timely emergency responses, including regular competency assessments via simulations like mock codes to ensure staff preparedness.^[44] While the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation do not specify exact Code Blue response times, they require hospitals to maintain emergency preparedness plans that support rapid intervention, aligning with AHA recommendations for defibrillation within minutes of arrest to meet quality metrics.^[45] These regulations emphasize measurable performance, such as team assembly and intervention timelines, to sustain accreditation and reimbursement eligibility. Evidence-based updates have contributed to measurable improvements in outcomes. Nationwide data from the AHA's Get With The Guidelines-Resuscitation registry show in-hospital cardiac arrest survival rates rising from 13.7% in 2000 to 22.3% by 2009, with further gains to 31.1% by 2014, attributed in part to post-2010 emphases on high-quality CPR and rapid defibrillation.^[46]^[47] These advancements, driven by iterative guideline revisions and technological aids, have reduced mortality while enhancing neurologic recovery among survivors.^[48]

Variations and International Use

Institutional Differences

Institutional differences in Code Blue implementation reflect adaptations to local resources, patient populations, and operational constraints across hospitals, particularly in the United States. While core objectives remain consistent—rapid response to cardiopulmonary arrest—variations emerge in protocol design, team structure, and performance metrics to align with institutional capabilities. Protocol customizations allow hospitals to tailor alerts to specific needs. For instance, some facilities use "Code 99" interchangeably with Code Blue to denote medical emergencies requiring immediate resuscitation, particularly in settings emphasizing broad emergency signaling.^[49] Others limit Code Blue to adult cardiac or respiratory arrests, employing separate designations like Code White for pediatric cases to ensure age-appropriate responses.^[5] In contrast, certain institutions extend the Code Blue protocol to encompass pediatric arrests, integrating specialized pediatric equipment and personnel from the outset.^[50] Team size and availability differ markedly by hospital type and location. Small rural or low-complexity hospitals often assemble smaller Code Blue teams, primarily led by hospitalists and supported by general nurses and respiratory therapists, with frequent reliance on external emergency medical services (EMS) for advanced interventions due to limited on-site specialists.^[51] Large urban or academic centers, however, deploy larger, multidisciplinary teams including in-house ICU physicians, anesthesiologists, and pharmacists, enabling more comprehensive immediate care without external dependencies.^[51] Response times and metrics are adjusted based on institutional resources and geography. Urban facilities typically target team arrival within 1 to 3 minutes to maximize survival rates, achieving mean response times around 2.8 minutes in evaluated cases.^[52] Resource-constrained settings, such as rural hospitals, may set more flexible goals up to 5 minutes, accounting for greater distances and fewer staff, which can extend actual arrival times. Integration with other codes enhances efficiency in some systems. Code Blue protocols often overlap with rapid response teams, enabling early intervention for patient deterioration to avert full arrests; for example, nurse-led emergency response units have reduced Code Blue activations by up to 58% by stabilizing pre-arrest cases before escalation.^[53]

Global Perspectives

In countries such as Canada, Australia, and New Zealand, the "Code Blue" designation is widely adopted for signaling in-hospital cardiac or respiratory arrest, mirroring practices in the United States and closely aligned with the International Liaison Committee on Resuscitation (ILCOR) guidelines that emphasize standardized resuscitation protocols.^[54]^[55]^[56]^[57] These nations participate actively in ILCOR's consensus development, ensuring that Code Blue activations trigger rapid multidisciplinary responses focused on high-quality chest compressions, defibrillation, and airway management as per the latest evidence-based recommendations (as of 2025, including updates to post-cardiac arrest care).^[58] In Europe, hospital emergency signaling for cardiac arrest often relies on numeric codes rather than color-based terms like "Code Blue," with a push toward standardization through the adoption of "2222" as the internal telephone number for activating resuscitation teams across institutions.^[59]^[60] This approach, endorsed by the European Resuscitation Council (ERC), aims to reduce confusion in multilingual and multicultural environments, particularly as only about 10% of European hospitals previously used a uniform number before broader implementation efforts.^[61] Additionally, European protocols place strong emphasis on do-not-attempt-resuscitation (DNAR) compliance, guided by ERC statements and EU patient rights frameworks that prioritize advance directives and ethical decision-making to avoid futile interventions.^[62]^[63] In developing countries, formal Code Blue systems are less common due to resource constraints, with many facilities relying on verbal alerts or simplified announcements to initiate basic cardiopulmonary resuscitation (CPR) without dedicated overhead paging infrastructure.^[64] The World Health Organization (WHO) addresses these gaps through programs like Basic Emergency Care (BEC) and basic life support (BLS) training initiatives, which promote low-cost, scalable education for frontline health workers to improve early recognition and response to cardiac arrest in low-resource settings.^[65] These efforts focus on community-level BLS dissemination to enhance bystander intervention, as formal hospital teams may be delayed or unavailable.^[66]^[64] In low- and middle-income countries, these factors result in lower survival rates post-cardiac arrest, underscoring the need for tailored adaptations to ILCOR and WHO frameworks to bridge disparities in emergency care delivery.^[67]^[68]

References

[1]
Hospital Code Blue: What It Means & Why It's Called - Cleveland Clinic
Jul 25, 2022 · A code blue hospital announcement means that an adult is having a medical emergency, usually cardiac or respiratory arrest.
[2]
What Is a Code Blue? - WebMD
Apr 27, 2025 · Hospital staff may call a code blue if a patient goes into cardiac arrest, has respiratory issues, or experiences any other medical emergency.
[3]
Code blue: A guide to hospital codes and what they mean
Nov 7, 2024 · Code blue usually means that someone is experiencing a life threatening medical emergency. It often means cardiac arrest, when the heart stops, or respiratory ...
[4]
Hospital Emergency Codes - HASC
History of the Emergency Codes · RED for fire · BLUE for adult medical emergency · WHITE for pediatric medical emergency · PINK for infant abduction · PURPLE for ...
[5]
Code Blue Protocol: How Hospitals Handle Critical Situations
May 12, 2025 · These codes, which vary slightly by region or institution, originated in the 1960s to keep emergency announcements clear and concise. Code Blue ...
[6]
What Do the Different Hospital Emergency Codes Mean? - IntelyCare
Terms like code blue gained popularity in hospitals in the 1990s, with the prevailing belief that such terms could allow trained staff to respond to significant ...
[7]
Code blue training saves lives - VA News
Jul 15, 2025 · Code blue—a hospital emergency code indicating that a patient needs resuscitation—requires trained personnel to ensure the best possible outcome ...Missing: definition | Show results with:definition
[8]
Blue code: Is it a real emergency? - PMC - PubMed Central
A “blue code” was defined as any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital alert.
[9]
[PDF] Hospital Emergency Codes: Standardization and Plain Language
There has been a trend to standardize overhead emergency codes, with an increased focus on the adoption of plain language announcements.
[10]
1960-1969 - University of Kansas Medical Center
Dr. Day and his colleagues also develop the cardiac "crash cart" and the term "code blue." The unit's success depended on the use of a highly trained ...
[11]
A proposed system for standardization of colour-coding stages ... - NIH
The coining of this term is attributed to pioneering Kansas cardiologist Hughes Day, who was inspired by the observation that most patients with severe ...
[12]
Rapid Response Systems | PSNet - Patient Safety Network - AHRQ
In contrast to standard cardiac arrest or "code blue" teams, which are summoned only after cardiopulmonary arrest occurs, rapid response teams are designed ...
[13]
Code Blue (Protected) | Department of Anesthesiology and Pain ...
2) scenario # 2 Code Blue called due to respiratory failure or airway obstruction;. 3) scenario # 3 Code Blue called due to a non cardio-respiratory event e.g., ...
[14]
https://radiology.ucsf.edu/patient-care/patient-safety/mri/code-blue
[15]
[PDF] EMERGENCY RESPONSE CODES - Augusta University
CODE BLUE - CARDIAC ARREST. In case of Cardiac Arrest, follow this procedure: 1. Contact paging operator at 1-2222. Give location and as much information as ...<|control11|><|separator|>
[16]
MRI Code Blue Protocol - Radiology | UCSF
Call a Code Blue Dial 6-1234. Announce to the Code Blue operator the following: "Code Blue MRI, Room #______. Instruct a staff member to go out in the hallway ...
[17]
Smartphone alerts may lead to faster response to in-hospital cardiac ...
Oct 31, 2022 · They electronically mapped code blue buttons present behind each patient bed to a secure smartphone texting system that also connected with the ...Missing: apps | Show results with:apps
[18]
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001369
[19]
01. Code Blue | Hospital Handbook
During Code Blue, stay calm, check your pulse, identify the code leader, check code status, and appoint specific people to tasks like chest compressions and IV ...
[20]
Part 7: Adult Basic Life Support: 2025 American Heart Association ...
Oct 22, 2025 · In adult cardiac arrest, rescuers should perform chest compressions with the patient's torso at approximately the level of the rescuer's knees.
[21]
[PDF] Adult Basic Life Support Algorithm for Healthcare Providers
Monitor until emergency responders arrive. Verify scene safety. • Check for responsiveness. • Shout for nearby help. • Activate emergency response.
[22]
2025 Algorithms | American Heart Association CPR & First Aid
Adult* Basic Life Support for Health Care Professionals Algorithm. *If signs of puberty, treat as adult. AED indicates automated external defibrillator; ALS, ...
[23]
Part 9: Adult Advanced Life Support: 2025 American Heart ...
Oct 22, 2025 · The 2025 guidelines provide guidance for the treatment of cardiac arrest, including ventricular fibrillation, pulseless ventricular tachycardia, ...
[24]
Crash Cart Management in Emergency Situations
What is in a crash cart? · ECG electrodes · Sterile gloves of various sizes · Sutures of various sizes and materials · Suction supplies · Salem pump ...
[25]
Part 11: Post–Cardiac Arrest Care: 2025 American Heart ...
Oct 22, 2025 · It is reasonable that temperature control be maintained for at least 36 hours in adult patients who remain unresponsive to verbal commands after ...
[26]
Basic Life Support (BLS) Course Options
Learn more about Basic Life Support (BLS) CPR and AED course options from the AHA ... BLS Renewal Course takes approximately 4 hours ...Missing: frequency | Show results with:frequency
[27]
None
Nothing is retrieved...<|control11|><|separator|>
[28]
FAQs about AHA Training | American Heart Association CPR & First ...
Q: When do I need to renew my course completion card? A: Course completion cards are valid for two years through the end of the month during which the course ...
[29]
Advanced Cardiovascular Life Support (ACLS)
The American Heart Association's ACLS course builds on the foundation of lifesaving BLS skills, emphasizing the importance of high-performance teams.Missing: Blue | Show results with:Blue
[30]
Part 6: Resuscitation Education Science: 2020 American Heart ...
Oct 21, 2020 · These guidelines contain recommendations for the design and delivery of resuscitation training for lay rescuers and healthcare providers.Missing: drills | Show results with:drills
[31]
Best Practices for Education and Training of Resuscitation Teams for ...
Nov 15, 2021 · Mock codes have continued to be a cornerstone of resuscitation training, however we found that not all training is equal. Studies have shown ...
[32]
The Effect of Mock Code Blue Simulations and Dedicated Advanced ...
Nov 25, 2020 · Currently, the majority of resident physicians have minimal exposure to ACLS or code blue training outside of BLS/ACLS certification courses.Missing: frequency | Show results with:frequency
[33]
[PDF] Code Blue: Do You Know What To Do? Increasing Nurse ...
May 21, 2021 · A code blue is a patient with unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital alert.
[34]
Mock Code Blue Simulations: Which Type Is Best For Your Hospital?
Aug 6, 2023 · Code Blues require high levels of coordination between interdisciplinary staff members (physicians, nurses, respiratory therapists, pharmacists, ...
[35]
Calming the chaos: Simulated code interdisciplinary team training
Sep 21, 2014 · At Oregon Health & Science University (OHSU), a Magnet® hospital, the code blue team may consist of staff who've never worked together before.
[36]
Simulated Code Interdisciplinary Team Training Simulation - OHSU
The Code team at OHSU is an interprofessional team that includes a Critical Care Fellow, Anesthesiologist, Respiratory Therapist, Pharmacist and three ICU RNs.
[37]
CPR through history | American Heart Association
Jun 1, 2018 · 1960 - CARDIOPULMONARY RESUSCITATION Combination of chest compressions and mouth-to-mouth resuscitation. Training required to perform ...
[38]
Variability of emergency color codes for critical events between ...
Thirty-four different codes were used across hospitals. The codes used most variably were yellow (10 meanings), orange, black, green (7 meanings each), and gray ...
[39]
Part 6: Advanced Cardiovascular Life Support | Circulation
The first ACLS “algorithms” appeared in the 1986 ECC and CPR Guidelines. These outlines of the 4 algorithms presented the interventions for the 4 arrest rhythms ...
[40]
History of CPR | American Heart Association CPR & First Aid
CPR evolved from early methods like mouth-to-mouth, to chest compressions, and finally, the combination of breathing and chest compressions in 1960.Missing: Blue | Show results with:Blue
[41]
Improving cardiac resuscitation outcomes both inside and outside ...
Jun 25, 2013 · There are 5 critical components of high-quality CPR: minimize interruptions in chest compressions, provide compressions of adequate rate and ...
[42]
Faster Code Blue Response | Infographic - TigerConnect
How Hospitals Can Speed Code Blue Response Time by 2.5 Minutes. See how hospitals can speed code blue response with mobile alerts routed to assigned code ...<|separator|>
[43]
Deep Learning–Based Early Warning Systems in Hospitalized ...
Aug 22, 2025 · Therefore, the primary objective of this study was to evaluate the effectiveness of applying an AI-EWS on clinical outcomes, including Code Blue ...
[44]
IoT Improves Hospital Color Codes for Safer Response - AiRISTA Flow
Jan 28, 2025 · Code Blue: IoT devices trigger immediate alerts to nearby medical teams. RTLS systems help locate crash carts and necessary equipment, reducing ...
[45]
R3 Report Issue 29: Resuscitation Standards for Hospitals
Jun 15, 2021 · Effective January 1, 2022, new and revised requirements related to resuscitation care will be applicable to Joint Commission-accredited hospitals and critical ...
[46]
42 CFR Part 482 -- Conditions of Participation for Hospitals - eCFR
Documentation of the updated examination must be placed in the patient's medical record within 24 hours after admission or registration, but prior to surgery or ...Title 42 · CFR 482.24 · Patient's rights. · Subpart A —General Provisions
[47]
Trends in Survival after In-Hospital Cardiac Arrest
Nov 15, 2012 · Both survival and neurologic outcomes after in-hospital cardiac arrest have improved during the past decade at hospitals participating in a large national ...
[48]
Nationwide survival after inhospital cardiac arrest before and after ...
Dec 15, 2017 · There was a significant improvement in survival after inhospital CPR from 24.1% in 2007 to 31.1% in 2014 (Ptrend < 0.001). However, we did not ...
[49]
Improving Temporal Trends in Survival and Neurological Outcomes ...
Jan 9, 2018 · These improvements in CPR quality could be attributed to monitoring and feedback (both intra-arrest and during debriefing), quality improvement ...
[50]
Atlanta team addresses Code 99 in the era of COVID-19 - SimLEARN
Aug 5, 2020 · Code 99 is a medical emergency requiring resuscitation. Creating a protocol for code 99 is not the first thing that comes to mind when we imagine a pandemic.
[51]
Pediatric Code Blues: 4 Unique Considerations - Nuvara
Oct 3, 2022 · How are pediatric Code Blues different from adult codes, and what can hospitals do to optimize care for infants and children?
[52]
Variations in Code Team Composition During Different Times of Day ...
Low-complexity hospitals, which are generally rural, had team compositions and responsibilities that were visibly different from higher-complexity hospitals.
[53]
Evaluation of Code Blue Notifications and Their Results - NIH
Code blue is one of the important practices for preventing mortality and morbidity and increasing the quality of care in hospitals.
[54]
Guidelines for appropriate in-hospital emergency team time ...
Setting time guidelines for Advanced Cardiac Life Support (ACLS) improved initiation of CPR, emergency team arrival, first defibrillation, and first medication ...Missing: 1986 | Show results with:1986
[55]
Nurse-led medical emergency response reduces code blue team ...
Acute deterioration of patients in the inpatient setting is covered by a code blue team (members of the Critical Care team) and a Rapid Response Nurse Team ( ...
[56]
Emergency Codes - William Osler Health System
Code Blue – adult (age 18 or older) cardiac arrest/medical emergency · Remain calm, listen for overhead announcements and follow instructions from Osler staff.
[57]
What Is a Code Blue? A New Nurse's Guide to Hospital Emergency ...
Sep 27, 2022 · “Code blue” means that a patient is undergoing a medical emergency in the form of cardiac arrest or respiratory arrest, whereas “code red” signifies that a ...
[58]
Code Blue (Paediatric Rapid Response Team Call) - Starship Hospital
Aug 7, 2025 · A Paediatric Code Blue Call should be initiated for all children with a cardiac or respiratory arrest, medical emergency requiring immediate ...
[59]
2024 International Consensus on Cardiopulmonary Resuscitation ...
Nov 14, 2024 · This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force ...
[60]
[PDF] Greif – 1 CONFIDENTIAL ILCOR Summary Statement 1 2024 ...
Apr 3, 2024 · (ILCOR) International Consensus on Cardiopulmonary Resuscitation and ... ROC Australian and New Zealand out-of-hospital cardiac arrest Epistry.
[61]
2222 Cardiac Arrest Call - ESAIC
The 2222 cardiac arrest call is a standardised internal telephone number used in European hospitals to summon help when a patient experiences a cardiac arrest.
[62]
[PDF] Final_2022_cardiac number 2222
Sep 18, 2022 · Standardization of the emergency cardiac arrest number is important to ensure early arrival of the cardiac arrest team, and standardization ...
[63]
Usage of do-not-attempt-to-resuscitate orders in a Swedish ...
Aug 1, 2020 · Usage of do-not-attempt-to-resuscitate orders in a Swedish community hospital – patient involvement, documentation and compliance. Emilie ...
[64]
Basic Emergency Care - World Health Organization (WHO)
The Basic Emergency Care Course (BEC) is a joint WHO/ICRC/IFEM learning programme for first contact health workers who care for patients with acute illness ...
[65]
Tracking differences between Language-Barrier and Non ... - PubMed
Oct 27, 2021 · International studies have found emergency calls with language barriers (LB) result in longer delays to out-of-hospital cardiac arrest (OHCA) recognition.Missing: challenges response countries infrastructure
[66]
A Scoping Review Across Low, Middle, and High-Income Countries
Background: Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited ...
[67]
The global survival rate among adult out-of-hospital cardiac arrest ...
Feb 22, 2020 · Out-of-hospital cardiac arrest (OHCA) is a major public health challenge, with an average global incidence among adults of 55 OHCAs per 100,000 ...