University of Tennessee Health Science Center

Discussion Questions Submitted by Kathy Meinbresse, BSN Student, University of Tennessee Health Science Center, Memphis, Tennessee, USA

1. What parts of this scenario really caught your attention?

2. Describe an emergency code you have witnessed. What went smoothly and what needed improvement? 8 o Is there a code/medical response team where you work? o What are the steps to activating the code team? o What emergency equipment is available to you?

3. Brainstorm ways to educate hospital staff about how to activate code teams.

4. You are selected for an improvement team in response to this event. What recommendations would you make? Consider: o Standardization of equipment o BLS/CPR for the First Responder training o Assessing the environment and all equipment upon entering the scene 5. Where is communication likely to break down at the code site? o Who should be notified in the event of a patient code? o How can you make Do Not Resuscitate orders available and effective?

5. The commentary mentions improving the “chain of survival.” Consider your own clinical environment. What changes would you suggest to shorten the time before access to emergency services, CPR and possible defibrillation?


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 called.
The inpatient psychiatry facility is adjacent to a major academic medical center. Thus, the “code
team” (comprising 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
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 floor).
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
Bruce D. Adams, MD, COL, MC, US Army, Chief, Department of Clinical Investigation, William
Beaumont Army Medical Center
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 conditions.

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 site.”(4)
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 offcampus 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 campus.(6)
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 situations.(9,10)

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
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 CMS.
A rapid and robust response requires prior planning, training, and equipping of these
outlying areas.
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
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
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.

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; 2004.

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 2005;35:33.
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

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