Running head: ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

Analysis of Code Blue Debriefing Tools

Debra Bevens
Celestinna Davidson
Joan Gapuz
Dani Woodley
Western Washington University

Abstract
Purpose: The purpose of this literature review was to analyze a variety of post-resuscitation
debriefing techniques and/or tools, and to provide evidence for implementing the most effective
resource for improving overall code blue team performance.
Background: For years, the United States (U.S.) military has been using debriefing strategies to
deal with psychological stress related to major emotional trauma. The healthcare field has taken
this practice and adapted the process to debrief healthcare professionals in post-resuscitation
scenarios.

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

Methods: A literature review was conducted comparing and contrasting different debriefing
tools and analyzed for the strategy that will provide the code team with optimal results. The
following are elements that were focused on: communication amongst the code team, confidence
in code execution, role clarity during a code, improvement in times to defibrillation and/or
intubation, emotional decompression, and overall code team performance.
Results: There were consistent findings that linked post-resuscitation debriefing to subjective
improvements in clinician confidence, leadership skills, and overall code team performance.
There was a lot of controversy over which method was the most effective route to take; however,
it was agreed that some type of debriefing should always occur. Further high-quality research
must be done in the future to determine which technique(s) will be linked to optimal
performance. Research findings are beginning to indicate that a combination of several tools is
the most effective route, but which combination is yet to be determined.
Implications: Healthcare professionals, who are involved in code blue situations, must have an
effective tool to evaluate the code teams overall post-resuscitation performance. Being able to
reflect on the efficiency of the code will help the code team better understand areas where they
are successful versus areas where improvement is needed. Performing in a code blue team can
be emotionally difficult, and debriefing provides a healthy opportunity for the code blue team to
de-stress and reflect.
Keywords: code blue, resuscitation, debriefing, simulations, debriefing structures,
nursing

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

Analysis of Code Blue Debriefing Tools

Code Blue! The overhead, whole system page that makes a healthcare provider stop,
and get that little knot in his/her stomach. The panic that can set in when a person in your care
experiences a cardiac and/or respiratory arrest, that will require cardiopulmonary resuscitation, is
a feeling that nobody will ever get used to. Post-resuscitation, after the dust has settled, and the
frenzy is over, what happens then? How do the healthcare providers, involved in the code,
decompress after the stress of, hopefully, saving somebodys life or sadly not being able to
resuscitate the patient? PeaceHealth St. Joseph Medical Center has been attempting to solve the
question as to which code blue debriefing approach will be the most effective for their facility.
The aim of this paper is to analyze several different code blue debriefing structures to provide
evidence of the most effective tool. Understanding implementation of the most effective code
blue debriefing structure will optimize the overall code team performance in an acute care
setting.
Debriefing after a code blue is a common practice that can enable healthcare workers,
involved in the code blue, examine all elements of a successful or unsuccessful code. The
debriefing process offers a chance to highlight emotional stressors and develop strategies to
deal with them, while also presenting an opportunity for further training (Shore, 2014, p. 117).

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

Sandhu et al. (2014) helps establish key phases of the debriefing process as reactions,
description, analysis, and summary or application of the resuscitation attempt. Also,
incorporating an informal initial diffusing in the minutes or hours following a resuscitation
attempt, then providing a thorough team performance debriefing at a later point in time is
thought to be beneficial (Sandhu et al., 2014).
There is great debate over which debriefing approach is the most beneficial for overall
team performance. Debriefing is classified into two main types of timing, as it pertains to postresuscitation debriefing; hot debriefing and cold debriefing. Couper and Perkins (2013) describe
hot debriefing as an immediate debrief that focuses on team members reactions to the code;
whereas, cold debriefing happens several days or weeks after the code, allowing team members
time to process the event, analyze their actions, and reflect on the resuscitation attempt.
Examination of different debriefing structures will demonstrate how it can improve team
communication, effectiveness of code blue resuscitation attempts, improve team confidence in
their particular roles, and ultimately improve the overall code team response.
Literature Review
After thorough analysis of the literature, several themes emerged among the data
including timing of the debriefing process, structure of the debriefing, and common debriefing
tools.
Hot Debriefings
The Chillicothe code debriefing tool, the Debriefing In Situ Conversation after Emergent
Resuscitation Now (DISCERN), and the Team Strategies and Tools to Enhance Performance and
Patient Safety (TeamSTEPPS) are just a few hot debriefing themes found in the literature review.
The origins of debriefing, in the healthcare setting, stem from a U.S. military background. The
U.S. military has used debriefing techniques to help soldiers deal with psychological stress after
a major trauma (Couper & Perkins, 2013). The Department of Veterans Affairs (VA) medical
team has improved their cardiopulmonary resuscitation code process by using a debriefing

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

questionnaire called the Chillicothe code debriefing tool. This tool guides postcode discussion,
and helps the team collect information on the code event (Percarpio et al., 2010). This particular
type of debriefing tool is a hot debriefing questionnaire that is best suited to be executed
immediately after a code. Percarpio et al. (2010) describes that the questionnaire focuses on
guiding questions that cover the progression of the code, patient condition, availability of
necessary equipment and/or medications, highlighting any problems that arose,
recommendations for improvement, and satisfaction ratings of the code based on a 5-point Likert
scale. Overall, the implementation of the Chillicothe debriefing tool has found to have achieved
a more consistent code process with a more timely code response, fewer equipment issues, and
more successful first attempt intubations (Percarpio et al., 2010).
There are many different approaches and challenges in utilizing a debriefing tool. One of
the biggest challenges, or barriers, to debriefing, identified by a pediatric emergency department
multidisciplinary team in Texas, was the lack of a standardized protocol. The multidisciplinary
team created a standardized checklist form, in order to facilitate qualitative debriefings and
collect data on healthcare teams performance, called the Debriefing In Situ Conversation after
Emergent Resuscitation Now (DISCERN) (Mullan, Wuestner, Kerr, Christopher, & Patel, 2012).
This tool was created by following debriefing best practice guidelines according to Salas, Klein,
King, et al. (2008) and to have a debriefing tool or form that would be readily available, quick
to complete, useful for quality improvement (QI)... and simple to use for leaders with varied
debriefing experience (Mullan et al., 2012, p. 947). The DISCERN tool includes a basic script
or advice for running a team debriefing and its structure provides a section for addressing
positive and negative components that happened during a resuscitation. Some questions that are
included in the tool are: what went well during our care for the patient, what could have gone
better during our care for the patient (add potential solutions if able), and was anyone confused

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

at any time during the resuscitation about who was the patient team leader (PTL)? After
evaluating the implementation of this novel tool, several significant themes emerged such as
cooperation, coordination, communication, situational awareness, leadership, and teamwork
among the healthcare team. Overall, the implementation of the DISCERN tool could potentially
be disseminated in other clinical areas or settings to facilitate and improve the performance of
the code team after resuscitations (Mullan et al., 2012).
The Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS) model is an evidence-based model comprised of four teachable-learnable skills:
leadership, mutual support, situation monitoring, and communication (Agency for Healthcare
Research and Quality (AHRQ), 2013, p. 4). The Patient Care Team interacts between the four
skills and the desired outcomes of the team (Performance, Knowledge, and Attitudes). The
TeamSTEPPS model is targeted at optimizing performance among teams of healthcare
professionalsenabling them to respond quickly and effectively to whatever situations arise
(AHRQ, 2015, p. 1). Within the TeamSTEPPS model, the debriefing format consists of four
phases: engagement, focus, reflection and critique, and application to everyday practice
(Gururaja, Yang, Paige, & Chauvin, 2008). In the engagement phase, the facilitator uses openended questions to employ the code team to reflect on their individual and team performance.
The focus phase is where the facilitator presents short definitions of teamwork competencies and
engages the team to correspond their actions and behaviors with the competencies. The third
phase, reflection and critique, the code team is encouraged to reflect on competencies of
teamwork and how these skills can improve their overall teams effectiveness. In the final phase,
application to everyday practice, the facilitator recommends that the code team chooses one or
two teamwork competencies they would like to improve upon and apply those competencies to
their practice. (Gururaja et al., 2008).

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

These hot debriefing tools are just a few examples out of many structures in the current
literature. As you can see, there are various differences and similarities among the debriefing
tools discussed above. Overall, hot debriefing tools are used immediately after a code blue and
tend to yield stronger results.
Cold Debriefings
Cold debriefings give the code team additional time and an opportunity to evaluate the
code blue. The cold debriefings discussed in this article are video-taped simulation based team
training and debriefing and the 3D Model of Debriefing: Defusing, Discovering, and Deepening.
One debriefing tool, the 3D Model of Debriefing, can actually be used for both types of
debriefing times.
Video-taped simulation based team training and debriefing implements made-up
scenarios that allow the team to practice and learn in a safe environment that does not put any
patients lives at risk. The scenarios are video-taped and shown to the participants so they can
debrief about their performance and learn from it (Severson, Maxson, Wrobleski, & Dozois,
2014). A systematic review analyzed the benefits of video-playback and found that there were
inconsistent results with this debriefing method. One study discovered that a combination of
video and verbal feedback improved behaviors, but another study noticed that there was no
difference in performance if the video was shown (Scherer, Chang, Meredith et al., 2003;
Salvodelli, Naik, Hamstra et al. 2005). Fanning and Gaba (2007) found that one advantage to
video-playback is that it may be useful for adding perspective to a simulation, to allow
participants to see how they performed rather than how they thought they performed, and to help
reduce hindsight bias in assessment of the scenario (pg. 122). In this specific study, scenarios
were video-taped and immediately shown to the participants. Authors found that the video
vignettes assisted in discussion during the reflection and critique phase. Participants were able to

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

enhance their performance and became proficient in their skills. It also allowed for more time
during the discussions (AHRQ, 2015).
A final debriefing structure, that was analyzed, was the 3D Model of Debriefing:
Defusing, Discovering, and Deepening. This debriefing model focuses on the adult learners
emotional reactions, behaviors and opinions, which deepens the learning experience. The 3D
Model of Debriefing was modeled after David Kolb, PhD of Social Psychologys theory of
Experiential Learning (Zigmont, Kappus, & Sudikoff, 2011). Kolbs theory is defined as
enhanced learning through an integrated process of four stages that are mutually supportive of
and serving the next stage. The first phase of the 3D Model, defusing, immediately follows the
simulation or actual code blue. Its purpose is to allow the releasing of emotions to reduce stress
and anxiety, facilitate meaningful discussions, and to permit the facilitator to observe and assess
key themes for the debriefing. The releasing of emotions will set the stage for the analysis of the
code blue during the second phase, discovering. In the discovering phase, the facilitator assists
in the reflection, usually through objective perspective (Zignont et al., 2011, p. 56) and uses
detailed open-ended questions to permit the code team to articulate their decision making process
(mental model). After the team has expressed their mental model, the facilitator will identify
gaps or opportunities for learning (Zignont et al., 2011, p. 57) and compare the teams model to
expected or target mental model (ie, newer evidence) (Zignont et al., 2011, p. 57). The final
phase, deepening, is the synthesizing of the new information and knowledge acquired from the
discovering phase by the code team and applying it to future code blues. Ultimately, the goal of
defusing, discovering, and deepening is to facilitate learning and to improve daily practice and
patient outcomes (Zignont et al., 2011, p. 56).

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

The code debriefing tools discussed above are only a few examples of cold debriefing
methods. This type of debriefing allows time for the code team to examine, organize, and
communicate their emotions about the event and provide effective outcomes.
Synthesis of Literature
While all the debriefing tools have definite pros and cons, there are common trends
amongst them all. To execute the most effective debriefing session for both hot and cold
debriefing models, having a facilitator present to lead the process has been most successful. The
facilitator can ensure that all members of the code team are included in the debriefing, and able
to decompress emotionally, as well as, provide key information about the execution of the code.
Many of the techniques have written scripts and/or advice outlined so the facilitator has a guide
to follow for effective debriefing. All of these debriefing methods allow time after a code to
provide the team an opportunity to reflect on what happened during the code blue, where
improvements can be made, strengths seen, and if communication amongst the code team was
effective. There were consistent findings of improved overall code team performance with all
the above defined methods, with the exception of the video-taped method. This method showed
inconsistent findings, and/or no significant improvements in the resuscitation process to note.
There were several conflicting findings amongst the articles which made comparing them
difficult at times. A variety of the debriefing methods were cold debriefings whereas the others
were hot debriefings. There is no strong research available, to date, as to when is the best time to
carry out an effective debriefing. The majority of research tends to focus mainly on hot
debriefing sessions. While some of the debriefing methods take place immediately following the
code, at the point of care, for example, Chillicothe, DISCERN tool, and TeamSTEPPS method,
the others were completed off the floor, away from the environment of the code. Along these
same lines, some of the tools were in questionnaire form, some were video-taped, and the rest
were verbal situations which made the process difficult to compare. Also, there appears to be a

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lack of research regarding the effectiveness of these methods. The DISCERN method was
studied only in a Texas Childrens Hospital in a single pediatric ED; TeamSTEPPS was used in
an operating room at Louisiana State University Health Sciences Center; and the Chillicothe
method was used primarily in the Chillicothe VA medical center. However, over 120 VA medical
centers providers have been trained in the debriefing process, so optimistically more research in
this area will be forthcoming (Percarpio et al., 2010).
Some barriers to the debriefing techniques utilized were the ability for all code team
members involved, to gather and complete a debriefing. Post-code, healthcare workers seem to
vanish, back to the work they were doing before the code blue was called. Many times, the nurse
caring for the patient was left alone to pick up the pieces, and keep the patient stable. The
research shows that it is essential for all team members to at least be able to defuse emotionally
post-resuscitation (Zignont et al., 2011). The only model that focuses thoroughly on the
emotional aspect of the individual and team is the 3D Model of Debriefing. The weakness with
this model revolves around there being no actual studies that used the 3D Model of Debriefing,
therefore, its effectiveness is in question (Zignont et al., 2011). Other major weaknesses with
these models were that none of the researchers discussed the financial burden
(training/overtime/video equipment/supplies) of debriefings, the time needed away from direct
patient care, and the coordination of the efforts of facilitators and the code team. These are all
factors that a facility would have to undergo to implement these specific tools.
Suggestions for Change
The research suggests that a combination of debriefing models is best. The models that
authors suggest for PeaceHealth St. Joseph Medical Center are the 3D Model of Debriefing:
Defusing, Discovering, and Deepening and the Chillicothe code debriefing tool. The 3D Model
of Debriefing focuses on the emotional aspect of a post-resuscitation debriefing and the

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Chillicothe code debriefing tool focuses on the procedural aspect, which both aspects are central
to the debriefing process. PeaceHealth St. Joseph Medical Center can implement these tools in
post-resuscitation debriefing by first utilizing the Chillicothe code debriefing tool to assess the
code process by focusing on the code teams skills and patient outcomes. Following the
Chillicothe code debriefing tool, the code team can transition into the 3D Model of Debriefing
where they can release emotions, reflect on the event, receive feedback and support from other
code team members, and grow from the experience.
Although there are several types of debriefing models, there is not one specific tool that
fits the mold for all situations or facilities. What works for one unit, may not work for another.
We suggest that the facility appraise the type of situations that may occur on the units and choose
the best model that fits their needs.
Overall, all forms of debriefing were effective and results indicated improvement of
performance scores and individuals self perception of competence. Significant
improvement was noted in individuals who participated in any one of the debriefing
activities compared to groups who did not participate in any debriefing (Dufrene &
Young, 2014, p. 375).
Therefore, it is better to have some sort of debriefing, than no debriefing at all. Some units may
even choose a combination of a few different debriefing methods like the combination chosen for
PeaceHealth St. Joseph Medical Center. After appraising the different types of debriefing
methods mentioned in this article, facilities can do further research about implementation of the
method.
Evaluation Plan
One way to measure and evaluate the effectiveness of implementing a debriefing tool,
after a code blue resuscitation, is by conducting pre and post surveys. The survey questions can
be tailored using the Agency for Healthcare Research and Quality (AHRQ) hospital patient
safety questionnaire and administered to the code blue team that participated in the event. The

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pre and post survey questionnaire can be divided into four themes: role on team, personal
psychological safety, patient safety, and team communication (Berg, et al., 2014). The survey
can address statements to evaluate if participants felt that they understood their role during
resuscitation, if they felt comfortable reporting problems that occurred during resuscitation, if
they believed the process was effective in delivering care to patients, and if staff felt free to
question the decisions of those with more authority (Berg et al., 2014). Another component may
be added to the post survey to specifically address the participants acceptability and perceptions
of the chosen debriefing tool. This component of the survey can include statements to evaluate if
using the chosen debriefing tool was worthwhile and if it should be continued in the future (Berg
et al., 2014). Overall, it is important to formulate an evaluation plan in order for facilities to
measure the effectiveness of the chosen debriefing structure and make changes and
improvements accordingly.
Conclusion
It is clear that debriefing after a code blue is essential for the code team, however, the
actual structure of the debriefing is still something that needs further exploration. Advantages of
hot debriefing are the ability of defusing emotions appropriately, being able to immediately
reflect on the access to equipment and medications, and on the overall code teams performance.
Hot debriefing also presents an opportunity for the team members to discuss areas of
improvement immediately (Zignont et al., 2011). Implementing the debriefing soon after the
resuscitation provides easier recall of events and the potential of having more team members
participate before their shifts end versus trying to gather all participants in a later debriefing
session. When the debriefing is off-site and scheduled at a later point in time (cold debriefing),
emotions may not be defused properly and the code environment may be lost. On the other

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hand, cold debriefing does allow the code team additional time to examine and evaluate the code
blue and determine what the team can take away from the code.
There are many different structures of debriefing after a code blue that are available for
use, however, most have only been tested on a limited basis, if at all. More research and testing
are recommended, since each clinical setting is unique with its own environment and code team.
A combination of the 3D Model of Debriefing and the Chillicothe code debriefing tool will be
the best option for PeaceHealth St. Joseph Medical Center. Improving the code teams
collaboration, skills, communication, and ultimately the outcomes of the code blue are the goals
of an effective debriefing structure. In order to accomplish these goals, it is recommended that
PeaceHealth St. Joseph Medical Center continue to develop, assess, evaluate, and improve upon
an appropriate debriefing structure.

References
Agency for Healthcare Research and Quality (AHRQ). (2013). TeamSTEPPS 2.0: Team
strategies & tools to enhance performance and patient safety. Retrieved from
http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculumtools/teamstepps/instructor/essentials/pocketguide.pdf
Agency for Healthcare Research and Quality (AHRQ). (2015). TeamSTEPPS 2.0: Core
curriculum. Retrieved from http://www.ahrq.gov/professionals/education/curriculumtools/teamstepps/instructor/index.html
Berg, G. M., Hervey, A. M., Basham-Saif, A., Parsons, D., Acuna, D. L., & Lippoldt, D. (2014).
Acceptability and implementation of debriefings after trauma resuscitation. Journal of
Trauma Nursing, 21(5), 201-208. doi:10.1097/JTN.0000000000000066
Couper, K., & Perkins, G. D. (2013). Debriefing after resuscitation. Current Opinion In Critical
Care, 19(3), 188-194.

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

14

Dufrene, C., Young, A. (2014). Successful debriefing - best methods to achieve positive learning
outcomes: a literature review. Nurse Education Today, 34, 372-376. doi:
10.1016/j.nedt.2013.06.026
Fanning, R. M., & Gaba D. M. (2007). The role in debriefing in simulation-based learning.
Society for Simulation in Healthcare, 2(2), 115-125. doi:
10.1097/SIH.0b013e3180315539.
Gururaja R.P., Yang T., Paige, J.T., & Chauvin, S.W. (2008). Examining the effectiveness of
debriefing at the point of care in simulation-based operating room team training.
Advances in Patient Safety: New Directions and Alternative Approaches. Rockville
(MD): Agency for Healthcare Research and Quality (US). Retrieved from:
http://www.ncbi.nlm.nih.gov/books/NBK43676/
McLeod, S. A. (2013). Kolb - Learning Styles. Retrieved from:
http://www.simplypsychology.org/learning-kolb.html
Mullan, P. C., Wuestner, E., Kerr, T. D., Christopher, D. P., & Patel, B. (2013). Implementation of
an in situ qualitative debriefing tool for resuscitations. Resuscitation, 84(7), 946-951.
doi:10.1016/j.resuscitation.2012.12.005
Percarpio, K., Harris, F., Hatfield, B., Dunlap, B., Diekroger, W., Nichols, P., & ... Neily, J.
(2010). Code debriefing from the Department of Veterans Affairs (VA) Medical Team
Training program improves the cardiopulmonary resuscitation code process. Joint
Commission Journal On Quality & Patient Safety, 36(9), 424-429.
Salvodelli, G. L., Naik, V. N., Hamstra, S. J., Morgan, P. J. (2005). Barriers to the use of
simulation-based education. Canadian Journal of Anesthesia, 52(9), 944-950.
Sandhu, N., Eppich, W., Mikrogianakis, A., Grant, V., Robinson, T., & Cheng, A. (2014).
Postresuscitation debriefing in the pediatric emergency department: a national needs
assessment. CJEM: Canadian Journal Of Emergency Medicine, 16(5), 383-392.
Scherer, L. A., Chang, M. C., Meredith, J. W., Battistella, F. W. (2003). Videotape review leads to
rapid and sustained learning. The American Journal of Surgery, 185(6), 516-520.

ANALYSIS OF CODE BLUE DEBRIEFING TOOLS

15

Severson, M. A., Maxson, P. M., Wrobleski, D. S., Dozois, E. J. (2014). Simulation-Based team
training and debriefing to enhance nursing and physician collaboration. The Journal of
Continuing Education in Nursing, 45(7). 297-303. doi: 10.3928/00220124-20140620-03
Shore, H. (2014). After compression, time for decompression: debriefing after significant clinical
events. Infant, 10(4), 117-119.
Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). The 3D model of debriefing: defusing,
discovering, and deepening. Seminars in Perinatology, 35(2), 52-58.
doi:10.1053/j.semperi.2011.01.003