TITLE: MOCK CODE BLUE

PURPOSE
1.1. To strengthen every student their code response and to improve the mock code blue
outcome
1.2. To teach, reinforce and evaluate the student’s management during mock code and
ensure the efficient and effective mock code scenarios
1.3. To provide realistic and interactive learning arena for participants to practice the key
principles of the BLS “chain of survival” before the code blue team arrive.
1.4. This guideline is to improve confidence, comfort level, resuscitation skills and knowledge
of every student by increasing the exposure to resuscitation procedures, equipment, and
documentation techniques equal to their level of training and responsibility controlled, non-
threatening environment.
OPERATIONAL DEFINITIONS:
2.1. MOCK CODE BLUE – is a simulation of a real code, providing an inter professional learning
environment that is interactive, closely resembles real clinical simulations, and allows
opportunity for formative assessment of the participants.
2.2. SIMULATION – defined as a “technique” to replace or amplify real experiences with
guided/planned immersive experiences to evoke or replicate substantial aspects of the real
world in an interactive fashion.
2.3. FACILATATOR – Conducting the mock code; lead the debriefing session.
2.4. OBSERVER – to observe or document the finding in the mock code blue evaluation form
during the enactment. also attend the debriefing session.
EQUIPMENT/MATERIAL FORM/s:
1. Mannequins
2. Competency guidelines (See appendix A)
3. Crash Cart (See appendix B)
4. Pen and Paper
GUIDELINES:
1. The mock code blue team will not replace the code blue team in the hospital but shall
test the current system to find problems that may not be apparent without mock codes
2. All those involves I having exposure in the hospital especially emergency department
should be included in the mock code training as this provides opportunities to improve
team dynamics and communication to enhance the ability to work as a team in times
of real emergencies.
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 3. Duration of mock code shall be brief as providers are more likely to get the most out of
training exercises when they are short, frequent, and intense lessons with instructions and
practice.
a. Twenty (20 minutes’ session (10 for debriefing 10 for code)
4. Facilitator and observer must have ACLS, PALS or NRP
5. The facilitator must do the following conduct mock code and lead debriefing session
where:
a. The Mock code blue alert will be initiated by the facilitator, who will initiate the
Mock CPR and call (verbal) for assistance
b. Promote the progression of mock code scenario
c. Ensure the scenario is presented in a consistent and orderly fashion to allow the
team members the opportunity to demonstrate their knowledge and skills in a
realistic setting.
d. Responsible for maintaining the reality of scenario and allow the scenario to
progress in the direction that the team is leading even if the flow of scenario
deviates from the original scenario (e.g. if the team members do not put the
oxygen on a hypoxic patient, the facilitator should indicate the saturation has
dropped)
e. During the mock code, the facilitator shall provide clinical updates and patient
response to the team’s actions and procedures
f. The facilitator during the debriefing should involve all the team members to
enhance this valuable learning experience.
g. The team will determine the areas of appropriate patient management and
areas needing improvement in technical and critical thinking
h. The facilitator will provide positive feedback to ensure the mock code is a positive
learning experience
REFERENCES:
Pediatric Mock Code tool kit, 2nd edition March 2012; Illinois Emergency Medical Services for
Children, Illinois Department of Public Health and Loyola University Health Syst
Joint Commission International Hospital Standards Manual 5th edition; Care of patient Chapter
standard 3.2
Mock Code Committee Handbook, 2008; Lucile Packard Children's Hospital Stanford

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APPENDIX A

STANDARD OF CARE:

Nurses, often the first responders in a hospital cardiac arrest, need to improve their resuscitation
skills in order to recognize the emergency and institute the use of crash cart & AED, and other
life saving measures.

COMPETENCY STATEMENT:

To keep the nurses periodically updated in their skills regarding intervening with emergency
resuscitation measures with current emphasis on “High-quality CPR”.
To immediately recognize the sudden cardiac arrest or respiratory arrest, nurses are schedules
to complete the competencies.

REFERENCE:

1. Mock code blue guidelines

2. Cardio Pulmonary Resuscitation (CPR) guidelines, American Heart Association.

Performance Criteria MET NOT REMARKS/

MET COMMENTS
1. Understands the criteria for the initiation of CPR that is normally
a combination of unresponsiveness and lack of breathing.
2. Recognizes and identifies the risk of deterioration in patient’s
vital signs and conscious status.
Establishes unresponsiveness

3. Ensures and determines the safety of herself/ himself, patient

and the scene itself before initiating the resuscitation.
4. Approaches the patient and---
• Shakes the victim gently & shouts twice “Are you OK”
• Also to elicit a response, if appropriate pinches the ear
lobe-
• If appropriate, rubs on the sternum using the knuckles of
the fingers.

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5. Calls for the help of other nurses, if patient is not responding
and does not appear to be breathing normally (Call First – Call
Fast approach)

6. Once the second nurse is available, request to get the crash

cart and call for CODE BLUE as per guidelines mentioned
above

7. Positions the patient on supine and places the cardiac board,

if appropriate and suspected no neck injury-
8. Turns or rolls the patient as a unit, supporting the head & neck,
if patient is lying face down.

9. Initiates CPR with C-A-B (CIRCILULATING, AIRWAY,

BREATHING) sequence

10. Exercise the knowledge of “High- Quality conventional

manual chest compression with rescue breaths-
“High-quality CPR”
• Push- hard and push fast technique
• Adequate number of compressions: >100/minute,
• Adequate depth of compressions: 2” or 5 cm
• Minimal interruptions for ventilation
• Allow complete recoil of chest,
• Do not over ventilate,

Chest Compressions:
11.“Looks for signs of circulation, “by-
• Looking for movement ∙
• Checks for the pulse
For adults; Locates the carotid artery & checks for pulse by ---
Feels for Adam’s apple (thyroid cartilage or windpipe) with 2
fingers and slides the fingers to the depression (groove) between
the trachea and neck muscles and applies slight downward
pressure for several seconds,

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12.12. If no pulse, locates for the placement of hands for chest
compressions-
• Runs the index and middle fingers along the lower
margin of the rib cage and locates the sternal notch
with middle finger-
• Places the index finger next to the middle finger and
places the heel of one hand above the middle
finger and the other hand on top of the first-

13. Interlocks the finger of both hands and keeps the fingers off
the chest to ensure that pressure is not applied over the
victim’s ribs.
• Ensures not to apply any pressure over the upper
abdomen or bottom tip of the sternum.

14. Locks the elbow into position, straightens the arms, position s
her/ himself vertically above the patient’s sternum-

15. Starts chest compressions as per insistence of “High-

quality CPR” mentioned above-
16. Keeps the heel of the hand lightly in contact with the chest
during relaxation phases allowing complete re-coil of the
chest-

Establishes the airway- (5 – 10 sec)

17. Ensures that there is no suspected neck injury-
18. If there is neck injury, performs jaw thrusts maneuver, if trained
to perform-

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19. Open the airway by head tilt & chin lift maneuver, when there is
no suspected neck injury-
• Places the palm of the hand (near to patient’s head) on
the forehead of the patient,
• Places the index and middle finger of other hand on the
bony part of the chin
• Simultaneously performs head tilt and chin lift

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20. Assess the breathing

21. Places the ear just one inch above the mouth and nose of
the patient and-
• Keeps the airway open by head tilt and chin lift, looks for
the chest movement (rise & fall)
• Listens at the victim’s mouth for breath sounds (air
escaping sounds during exhalation)
• Feels for the flow of the air against his/ her cheek

22. If breathing is absent or inadequate, give 2 rescue breaths

using the bag valve mask with reservoir connected to oxygen
source (3-5 sec)

23. Ensures that

• The right size face mask is chosen for the patient size,
• Place the curve of the mask on the bridge of the nose,
• Holds the mask by using “C & E” technique, ensuring it is
covering the mouth and nose.

24. Places the other hand on the forehead of the patient-

25. Opens the airway by head tilt and chin lift,
26. Provides 2 rescue breathings by watching for chest rise (1
breath for I second) 3 seconds

27. Once second nurse arrives with crash cart, ensures the use of
AED (Automated External Defibrillator) by-
• Ensuring to switch ‘ON’ the machine,
• Placing the apex and sternal pads as per the
directions on the leaf of the pad cover
• Allow the machine to analyzes the rhythm and ensures
that no one touches the bed

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28. If shock is advised, again ensures that no one is touching the
bed with vocal alerts and visual inspection and presses the
shock button and continues with chest compressions-
Vocal alerts: ‘ I am clear, you are clear and every one clear’
Visual inspection: Look around the bed to ensure no one is
touching the bed

29. If shock is not advised, continues CPR with chest

compressions -
30. Continues CPR with chest compression / breaths at the rate
of 30:2 ratio cycle, until the CODE team arrives-

31. Ensures that the treating physician or MRP (most responsible

person) or ON- call concerned physician was notified about
the CODE

32. Once CODE BLUE team arrives, ensures that the team was
properly assisted and coordinated in the resuscitative process
under the supervision of the CODE team leader-

Performance criteria:
33. If there is no pulse & breathing, continues 5 cycles of CPR
(approximately 2 minutes) before checking for carotid pulse-
30:2 compression / rescue breaths using ‘ High-quality CPR’
(Depth 4-5cm or 1/3 of the depth of the chest)

34. If there is pulse & no breathing, continues with support

ventilations/breathing every 5-6 seconds, ( 10-12 breaths per
minute

35. If there is pulse & breathing, places the patient in recovery

position If appropriate and keeps the airway open for patient
to breathe -

36. Monitors for breathing and pulse-

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37. Recovery position --- If there is ‘NO’ suspected neck injury
and if allowed:
• Places the patient’s arm nearest to her/ him at a right
angle to patient’s body, so it is bent at the elbow with the
palm pointing upwards,
• Takes the other arm gently and places it across the
patient’s chest so the back of the hand is against the
opposite check, and holds it there to guide and support
the patient’s head while she rolls the patient,
• With her/ his other hand, lifts the patient’s furthest knee
and pulls it up until the patient’s foot is flat on the bed.
• Rolls the patient’s towards her into the patient’s side by
carefully pulling on the bent knee.
• Ensures that the top arm is supporting the head and the
bent leg is on the bed to stop the patient from rolling
backward.
• Gently tilts the head back slightly and raises the chin
forward and make sure that the airway will stay open
and clear
• Ensures that the patient is breathing and any blood or
vomit from the mouth can drain away.
• Stays with the patient monitoring pulse & respirations until
the treating physician has arrived and further decision
was taken
SPECIAL FOCUS FOR CHILDREN / INFANT PATIENTS
ADULTS (over CHILD (12 INFANT (up to 12
8 years of months to 8 months)
age) years)
Checks for By shaking on By shaking on By patting gently
responsiveness the shoulders the shoulders on the sole of
or pinching or pinching the feet or on
the ear lobe the ear lobe the chest
or using the or using the
knuckles to knuckles to
rub on the rub on the
sternum sternum
Pulse location Carotid Carotid Brachial artery
artery (neck) artery (neck) (arm)

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Circulation 2 hands, 2 1 hand, 1 2 fingers, ½ chest
inches; 30 inch: 30 depth or thumbs
compressions compressions encircling the
chest; 30
compressions

Airway Head tilt and Head tilt and Slightly tilt the
Opening chin lift chin lift head into
“sniffers position”

1. Ensures not to over extend the neck

2. Monitors for breathing and pulse-
• Places the infant flat on his/her back on firm & flat surface-

3. Measures one finger width below the imaginary inter

mammary line for assessing the landmark of chest
compressions-
4. If there is no pulse & breathing, continues 5 cycles of CPR
(Approximately 2 minutes)
• 30:2 compression s/ rescue breaths at the rate of 100
compressions per minute with minimal interruptions (Depth
1/3 to ½ of the depth of the chest)
• 15:2 compressions/ rescue breaths if two resuscitation

5. If there is pulse & no breathing, continues with support

ventilations/breathing every 3-5 seconds, (12-20 breaths per
minute)

6. Documents the performance in the nurses’ notes-

7. Endorses the interventions, if patient revived and transferred to

critical care unit-

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APPENDIX B
CRASH CART DRUGS
1. Amiodarone 50 mg/ml (3ml Ampoule) IV Injection 5
2. Atropine Sulfate 0.1 mg/ml 5
3. Calcium Chloride 10% (10 ml) Prefilled 2
4. Dextrose 50 % (50 ml) IV Vial 2
5. DOButamine HCL 500mg/250ml D5w premixed Bag or Vial 1
6. DOPamine 800mg/250ml D5w premixed Bag or Vial 1
7. Epinephrine 1:10,000 (0.1mg/ml) 10 ml Prefilled Syringe 10
8. Nor epinephrine 1 mg/ml (4ml/amp) IV Ampoule 2
9. Procainamide HCL 100 mg/1ml (10 ml/vial) IM/IV Injection 2
10. Sodium Bicarbonate 8.4% (50 ml) IV Vial 2
11. Magnesium Sulfate 10 % (2 g /20 ml) Vial 2
12. Vasopressin 20 units/ml Vial 2
13. Lidocaine 2% (20mg/ml) 100 mg/5ml Prefilled Syringe 2
14. Lidocaine infusion 2g/500ml D5w premixed Bag or Vial 2
15. Distilled water for injection 10 ml 5
1ST DRAWER(IV ESSENTIAL EQUIPMENTS)
1. Syringes 1, 2, 5, 10, 20 ml 5 each
2. IV cannula (16,18,20,22, 24) 2 each
3. Intraosseous infusion needles (Adult & Pediatric 1 each
4. Three way stop cock 3 pieces
5. Opsite dressing 10x14 cm 1 piece
6. Central venous catheter (Adult & Pediatric) 1 each
7. CVP monitoring set 1 piece
8. Suture (Silk 2 pieces
9. Aspirating needle 2 pieces
10. Alcohol swab 1 box
11. Burette/Solu-set 1 piece
12. IV set 3 pieces
13. Scalpel /Surgical blades 2 pieces
14. Clipper 1 piece
15. Adhesive tape roll (size 2″) 1 piece
16. Tourniquet 1 piece
2ND DRAWER (AIRWAY MANAGEMENT EQUIPMENT)
1. Tracheostomy tube ( all sizes) 1 each
2. Sterile Gloves (S.M,L) 2 each
3. Sterile Gauze 4x4 1 pack
4. Drainage Bag 2 pieces

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 5. Non rebreathing O2 mask 1 piece
6. Syringe 50cc 2 pieces
7. Nasogastric tubes (6,8,10,12,14,16,18) 2 each
8. Suction Catheter (all size) 2 each
9. Yankuer (Adult and Pediatrics) 1 each
3RD DRAWER (AIRWAY MANAGEMENT EQUIPMENT)
1. Airway (0-5) 2 each
2. ET tubes uncuffed (for pediatrics: 2.5,3,3.5,4,4.5,5,5.5 2 each
3. ET tubes cuffed ( for Adults: 6,6.5,7,7.5,8,8.5) 2 each
4. Laryngoscope set with different blades nad sizes (in functional order) 1 piece
5. Magils Forceps (Adult and Pediatrics) 1 each
6. Intubation Stylet (Adult and Pediatrics) 1 each
7. E.T tie/roll gauze 1 piece
8. Lidocaine gel 1 piece
9. Bandage Scissors 1 piece
10. Penlight 1 piece
11. Spare batteries 1 piece
BOTTOM PART OF THE CRASH CART
1. Dextrose 5% NaCl 0.225% 500ml 1 piece
2. Dextrose 5% 500ml 2 pieces
3. Dextrose 10% 500ml 1 piece
4. Ringer Lactate 500ml 1 piece
5. NaCl 0.9% 500ml 2 pieces
6. Plasma Protein fraction 500ml 1 piece
7. Mannitol 500ml 1 piece
8. Hydroxy Ethyl Starsh (HES) 500ml 1 piece
LEFT PART OF THE CRASH CART
1. Stethoscope 1 piece
2. BP Apparatus (aneroid type) 1 piece
3. Spare ECG recording paper 1 piece
4. ECG Electrodes (Adult and Pediatrics) 1 piece
5. Defibrillator conductive gel 1 piece
6. Chlorhexidine swab stick /Povidone 10% bottle 1 piece

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