European Journal of Cardiovascular Medicine

Approximately 350,000 cardiac arrests are detected in the USA, and 209,000 occur inside hospitals [21]. Even with breakthroughs in resuscitation science, about 25% of patients survive a cardiac arrest while hospitalized [21]. For individuals experiencing cardiac arrest, the American Heart Association has issued recommendations that the first attempt at defibrillation should be made within two minutes of a cardiac arrest caused by shockable rhythm i.e., ventricular tachycardia or ventricular fibrillation. The first assisted ventilation should begin within one minute [4] by implementing an early detection of a cardiac arrest episode, prompt action, and the activation of a “code blue” team. The hospital offers the code blue simulation program to assist the person in resolving this problem, particularly regarding unfamiliarity with the equipment, difficulty locating supplies, and the synergy of the code blue team. The personnel in this unit are cautious when dealing with code-blue situations. It causes a glitch when handling this crisis. The researcher chose the nurses because the nurses are always the first people who encounter coded patients who will act as first responders. Simulation-based training improves clinical skills and judgment while fostering self-confidence and teaching participants the importance of teamwork and communication in a clinical context [14]. With simulation training programs, nurses can acquire and practice the clinical skills necessary for emergency scenarios efficiently and safely. Strong evidence has been shown  that nurse leaders and educators can utilize simulation to give novice nurses the experience of recognizing clinical deterioration and the knowledge and comfort to act [17]. The simulation of the code blue situation is highly advised and necessary in educating the nurses on how to handle this actual code blue to avoid ambiguity in this process. Although the nurses have experience handling code blue, if the organization implements better guidelines and training, it will reduce the hiccup during the code blue event and improve the patient outcomes and staff’s confidence level. Providing the guidelines and code blue simulation training for the nurses, will increase the staff's confidence and competence in handling code blue events. This action will reduce the unnecessary complication i.e., brain or tissue hypoxia and increase the good outcome among the code blue patient.

Minister of Health, Brunei, Dato Seri Setia Dr Haji Mohd Isham bin Haji Jaafar has declared that cardiovascular disease (CVDs) accounted for 26% of all deaths in Brunei Darussalam in the year 2021 and this statistic bring the CVDs as no 1 killer of Bruneian,[16]. The age-standardized premature CVD mortality rate in the Sultanate was about 135 per 100,000 population in 2021. This rate is comparable to many Western countries and is like the reported age-standardized CVD mortality rate in the United States (US) at 130 per 100,000 population in 2019,” statement by the Minister of Health in the Borneo Bulletin [16]. In the patients with STEMI, left main coronary artery disease (CAD) was associated with a higher rate of incidence, 32.56% of sudden cardiac arrest (SCA) versus 10.72% [11]. This statement is important for the hospital to fully equip the staff with code blue management because the incidence of SCA is more than 30% among coronary artery disease (CAD).

2023 CVL Procedure at Gleneagles JPMC: 1958

1. Coronary Angiogram:1187
2. PCI:621
3. Graft Study:54
4. LV/RV Gram/Aortogram:28
5. Rotablator:20
6. IVL:48

From the number of procedures at GJPMC,  per month about 150 to 163 procedures were conducted at GJPMC Cardiac laboratory. In the patients with STEMI, left main coronary artery disease (CAD) was associated with a higher rate of incidence, 32.56% of sudden cardiac arrest (SCA) versus 10.72% [11]. Preparedness and readiness for disasters are needed in this situation. The staff needs to be well equipped with the code blue management that can happen at any time and location from the minute a patient steps into the hospital.

Code Blue Readiness Survey

Table1. Code Blue Readiness Survey Result

This survey is conducted to see the staff perception on the code blue event readiness , whether they’re ready and confident in managing the code blue event. The questionnaires were distributed to 100 staff but only 45 voluntarily answered it. 53% who participated came from the critical care unit, medical and surgical units representing 8.8%, outpatient clinics gave 13.3% and others units came out with 24.4%. The result also shows that most of the staff are ready to have a code blue at any time and we need to reflect back on the majority of participants that came from the critical care unit. We can appreciate the survey by understanding that the staff have less confidence in handling the defibrillator, using SBAR and scribing during the code blue event. Total of 68.8% i.e almost all of the participants answered by participating the code blue drill  on “my code blue readiness could be further improved’. Attending the code blue will improve their competency and confidence in managing the code blue event especially in the unit that really had the event. 

Figure 1: Code Blue Root Cause Analysis

Benefits of the CBS Program

Simulation learning and scenario-based training are designed to mimic the real situation. This helps them to raise the levels of both their proficiency and self-confidence, which will enhance productivity, performance, and even job satisfaction. [23]. The training is conducted within a safe environment because it does not involve the real patient and situation. The CBS program will improve the staff response time in the code blue management. Increase job satisfaction and reduce unnecessary stress in incompetent performing procedures and equipment handling. reduce complications e.g., Brain or tissue hypoxia for postcode patients. Simulation programs require the learner to practice i.e., the simulation process. That will facilitate the nurses to remember the training and have a higher long-term retention rate. It has also been shown by research that learners are more motivated when training is contextually relevant and the effect of learning by doing. Repetition over time, especially with simulation learning, enables information in short-term memory to be processed into long-term memory, [23]. Adult learners appreciate long-term memory more, and this learning method is suitable for adults in training them with knowledge and skills. This method will change their attitude toward code blue management.

Simulation learning and scenario-based learning are both powerful tools to help nurses to understand the actions taken and the consequences of their choices. This will facilitate building critical thinking, reasoning, and reflection in the actions taken [17]. Simulated learning allows learners to practice and even fail in a safe environment, and even the patient’s lives will not be at risk [23]. Nurses can challenge the given scenario, try out alternatives, and experience different outcomes, which can widen their learning and experience e.g., in the post-CABG patient that had Cardiac Tamponade, the code blue drill can incorporate the requirement of emergency chest reopening in ICU. There's no cost for mistakes because it's a simulated environment. Simulated scenarios will build understanding, and the nurses can reflect it during a real emergency. Nurses will appreciate this learning method in building their understanding and skill toward code blue management, [23] has mentioned that nurses can develop problem-solving skills and learn from feedback without putting anyone or anything at risk. They can reflect on the choices they made, and the outcomes achieved and develop improved judgment and better problem-solving skills in code blue management. The debriefing process will have two-way communication the nurses and facilitator are giving and providing feedback in getting or providing the best action during the event. As we know nurses are abode with high acuity patients and nursing shortage, this CBS program will cater the job training, that will target the objectives of the training directly and cost-effectively for the organization because it can be done by facilitators that train in handling code blue management, that can be conducted and observe the outcome by having the code blue drill in its own institution or hospital.

Benefits of the CBS Program

Figure 2: Code Blue Simulation Benefit

Code Blue Simulation (CBS) Program

It is a program of training that involves the participants in the theory session and also clinical session i.e. practice with the procedures involved in code blue management. Meanwhile, simulation training involves code blue drill practice where the participants will form the code blue team and participate in the CB drill that mimics the real CB event. The participant will be assessed by the assessor using the code blue observation checklist and the appropriate response throughout the created scenario. The benefits of a code-blue simulation include the ability to evaluate and verify employee competency in code blue management. For individuals experiencing a cardiac arrest, the American Heart Association has issued recommendations that the first attempt at defibrillation should be made within two minutes of a cardiac arrest caused by shockable rhythm i.e., ventricular tachycardia or ventricular fibrillation, and the first assisted ventilation should begin within one minute [4]. Early detection of a cardiac arrest episode, prompt action, and the activation of a “code blue” team. The hospital offers the code blue simulation program to assist the person in resolving this problem, particularly regarding unfamiliarity with the equipment, difficulty locating supplies, and the synergy of the code blue team.

Delphi Techniques

Table 2: Delphi techniques survey result

Reliability Statistics for the Delphi techniques with the Cronbach’s Alpha .915, so we know that the reliability coefficient is very good, and the questionnaires are valid to use as a research instrument. 

Table 3: reliability coefficient result and category

The curriculum of Code Blue Simulation

The syllabus or curriculum for the CBS section was created by agreement using the Delphi Technique and ADDIE model. The Delphi techniques consist of selecting an expert panel with knowledge of code blue management. The researcher selected numerous occupations or fields for the panel of experts, this is to obtain a distinct viewpoint or opinion on managing the coded patient. The selected expert panel came from different backgrounds, consisting of Cardiac Surgeons, Intensivists, Respiratory Therapists, Critical Care Nurses, Critical Care Unit Managers, and Code Blue Coordinators. “ADDIE” stands for Analyze, Design, Develop, Implement, and Evaluate. The researcher developed the curriculum based on the ADDIE module and used an algorithm of adult cardiac arrest by AHA [3]. The model will categorize the training as a clinical practice, communication and competency.

Implementation of CBS Program

The CBS module consists of 4 stations, the curriculum based on American Heart Association on Adult Cardiac Arrest Algorithm,[3].

Station 1

Performing the correct cardiopulmonary techniques and depth

Station 2

Preparing and administering the emergency drugs that are used during cardiorespiratory arrest.

Station 3

Airway Management- using manual resuscitator, LMA insertion, and assisting in intubation.

Station 4

Analyze life-threatening ECG and perform the best intervention based on the scenario given and the usage of cardioversion, AED, Defibrillation, and transcutaneous pacing

Mega Code

The participants need to arrange themselves in one team that consists of 5 to 6 members.

1. Team leader
2. Medication Nurse
3. Airway management
4. CPR
5. Defibrillator (cardioversion, AED, Defib and pacing)
6. CB Recorder

The simulation of the code blue drill is based on scenarios given and the participants need to respond accordingly to the best action as per AHA Guidelines Adult Cardiac Arrest, [3], (pVT, VF Asystole, PEA).

Code Blue Drill Observation

Simulation‐based education encompasses three phases: pre-briefing, exposure to the simulation experience, and debriefing [10]. The focus of this review is on the end. Debriefing is an essential part of simulation‐based education and can be defined as a structured and guided process between people, after a simulated training session [5]. The debriefing objective is to facilitate the participants to do reflective thinking during the code blue drill taking place, this action will facilitate the learning process and retain the knowledge longer than didactic teaching. Simulation has the power to create a safe, realistic environment for nurses or participants to practice skills and scenarios [17]. The participants will understand their actions and what to improve in the future. The samples will form the code blue team that consists of 6 members (CB Team Leader, Airway, CPR, Medication, Defibrillation, and the recorder). The facilitator will record and observe the code blue drill session. The CB team needs to respond accordingly to the scenario given e.g., be able to interpret and analyze the ECG and give the correct action as per AHA 2020 guidelines. The CB facilitator will use the code blue observation form and give the score on the code blue drill exercise. The facilitator will also observe the attitude of the participants throughout the session on the code blue drill.

The code blue form will indicate the observation of the participant based on the category as below, the assessor will choose and observe the 4 labels in answering each of the questions.

4. Yes
5. Partially
6. No

1.   Not applicable

Clinical Practice

1. Recognized the medical emergency e.g. cardiac arrest, respiratory arrest
2. Determines unresponsiveness within 10 seconds
3. Anticipated the code blue -call for help/ press code blue button
4. Performed CPR < 1 mins
5. ET Trolley to the room
6. Proper hand bagging with MRB/Ambu Bag.
7. Apply backboard
8. Apply a defib pad and turn on the defibrillator.
9. Defibrillate patients with shockable rhythm (pVT/VF) < 2 mins

Communication

1. Leader comm effectively
2. Roles were assigned, and each team member could perform the task accordingly.
3. Team members collaborate well
4. clear message/using closed-loop communication.
5. Event recorded: event documentation completed.

Competency

1. MRB skill good
2. CPR skill good
3. Intubation/LMA done timely

Other/any feedback

The assessor can write feedback on any finding during the code blue drill or mock code. This is by answering a free text e.g. to improve in closed loop communication after getting the instruction for the code blue team leader.

The Code Blue Simulation program will improve the participant’s confidence,  response times, and overall performance during Code Blue emergencies. The CBS program enhances nurses’ emergency response skills by providing realistic, hands-on training, leading to more efficient and coordinated care during critical situations. Ongoing implementation of simulation-based training is recommended to boost the confidence among the participants to prevent complications and improve patient outcomes.

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