Running head: DEBRIEFING FOLLOWING A CODE BLUE

Implementation of Debriefing Program Following Code Blue

Camille Clarke, Melanie Davis, Lilia Murashov, and Kate Schuette
Western Washington University

DEBRIEFING FOLLOWING A CODE BLUE

Implementation of Debriefing Program Following Code Blue

Purpose/Aim: To assess if the implementation of a debriefing program following a Code Blue
or a simulated Code Blue improves nursing response in initiating cardiopulmonary resuscitation
and the understanding of their role as well as performance in a code blue.
Rationale: When a patient in a hospital setting goes into cardiac arrest it puts into motion a
procedure called a code blue. A code blue is fast paced and intense, it can also be used to show
gaps in education, lack of experience, and be emotionally difficult for individual providers.
Debriefing following such an event can improve patient outcomes, identify training needs, and
improve staff morale.
Methods: Using CINAHL, Google Scholar, and Proquest databases, (12) research articles were
reviewed related to the effectiveness of debriefing following Code Blues. A complication of
qualitative and quantitative studies previously published including some grey literature to find
rationale and gain understanding in why implementing a debriefing program is important and
pertinent to medical education and teamwork.
Results: The literature review proved five main themes among endorsing debriefings; improving
patient care, enhanced communication among the health team, facilitating teamwork, and the two
main types of debriefing, those that are more technical (depth of chest compression) and
behavioral, non-technical issues, related to the emotional trauma nurses deal with following
participation in a Code Blue. In a debriefing session, an individual has the opportunity to discu ss
what worked well, what interventions were used, and how the team performance can be
improved. It facilitates teamwork as well as healthcare workers coming together to discuss
events and to share their thoughts. Making the time to talk about how they can move forward
together, especially if they have faced a traumatic code the was more difficult. Debriefing
enhances communication, the open forum of being able to discuss what was effective and
brainstorm ways to improve teamwork and work more effectively together. It also provides the
unique capacity for individuals to decompress after stressful codes on many levels. Medical
professionals are expected to focus and work through tense and difficult situations, but team
members are also human, and resuscitations can be emotionally exhausting. Having the
opportunity to discuss intense feelings and the emotional component of a code can be helpful in
preventing burnout.
Implications: Debriefing has shown to be a beneficial aspect of team building and performance
of the nurses providing care. Debriefing should be implemented into practice following a code
blue to insure learning and communication among the responding team. Further research and
studies should be completed to explore patient outcomes and the impact debriefing has on the
mental health of nurses.

DEBRIEFING FOLLOWING A CODE BLUE

IMPLEMENTATION OF DEBRIEFING AFTER A CODE BLUE

When the human heart stops beating there is a short window of time when a healthcare
worker has the opportunity to start cardiopulmonary resuscitation (CPR), the mechanical act of
breathing and pumping blood throughout the body. The process must begin immediately and
include defibrillation if there is hope of the patient having a heart rhythm. There are various
technical aspects of performing CPR, including the depth and recoil of each compression and
how many compressions should be included in a minutes time. However, the most important part
is the initiation of CPR, the mobilization of a rapid response team, and defibrillation. When an
individual has cardiac arrest in the hospital setting a code blue is called and a procedure begins
that has been created to provide a patient with the life-giving lub-dub of the heart once again.
Although all nurses are certified to perform CPR, for many it is not a routine aspect of
their daily work. When they have a patient who doesnt have a heartbeat, they have the
responsibility of calling a code blue and starting the process of cardiopulmonary resuscitation. In
many in-hospital settings, when cardiac arrest occurs, the quality of care delivered during code
blue situations is below the standards of care. The problem is ineffective resuscitation, despite
code trials, CPR training, and distinct CPR guidelines. (Sutton, R., Nadkarni, V., Abella, B.,
2012).
The rapid response team includes a highly specialized team of skilled healthcare
providers who are trained to take over for the patients registered nurse or the person who called
the code blue to administer the more invasive procedures and aspects of CPR. For example, at
PeaceHealth St. Josephs Hospital in Bellingham Washington, their rapid response team consists
of the patients registered nurse, the Emergency room physician, the nurse team lead, security, an
echocardiogram technician, a pharmacist, and a respiratory therapist. While the most common

DEBRIEFING FOLLOWING A CODE BLUE

departments that cardiac arrest occurs in is the intensive care unit, operating room, and
emergency room, they can happen anytime and anywhere. Therefore, it is important that all staff
members, who will initiate a code blue call or start CPR process, feel comfortable and confident
in the process they are putting into motion.
Debriefing occurs after a code blue response giving the opportunity for those involved to
question their experience and to review that experience upon completion. Debriefing after
traumatic events, like a cardiac arrest, has been recommended for the mental health and
confidence building of those involved in the account. It has been described as the guided
reflective discussion that attempts to bridge the gap between experiencing an event and making
sense of it (Fey & Jenkins, 2015, pg. 361). It is a conversation between a group of two or more
people created to discuss and review an experienced event, real or simulated and to analyze and
reflect on what happened during said event. As Sutton et al. (2012) noted, structured debriefing
has been implemented after infrequent, stressful events dating back to World War II. Post- event
debriefs were emotionally uplifting and were found to decrease the amount of stress and/or
potential psychological trauma related to the life altering events. Although the hospital is not
the same as the battlefield, the premise of a debriefing is the same after a code (ACLS, 2014).
Medical personnel in the hospital setting are not always aware of the quality of their own
CPR administration and overall performance during a code blue. There is an expectation to
improve their CPR administration and other implementations during a code, but without selfreflection and feedback from others involved, it would be unrealistic to expect a positive change.
The implementation of a debriefing program, whether scripted or not scripted, immediately
following a code or done at a later time, has proven to have positive effects on the dynamics of
how a team works together and the understanding of roles during an event. Debriefing has also

DEBRIEFING FOLLOWING A CODE BLUE

been shown to improve the quality of care provided during resuscitation, increase clinical patient
outcomes, and increase the timeliness of CPR initiation. A debriefing program following a code
blue or mock code blue should be implemented in the hospital setting to improve the nursing
response initiating CPR and their role within the team responding to a code blue call.
Synthesis of Literature
We completed a literature review of 12 articles, both qualitative and quantitative,
exploring the uses of debriefing in code blue situations. Many studies were done following
simulations of code blues or in an educational setting. One of the main problems faced in the
writing and research pertaining to code blues and post event debriefing was the limited amount
of research done. Although there were numerous studies done on the improvement of technical
issues seen during the code blue process, like depth of chest compression, there was limited
information specifically about debriefing on its own as an improvement tool.
Improving Patient Care
There are numerous factors that play into the survival of a patient who has suffered from
cardiac arrest; one of those factors should not include the delay in initiation and performance of
CPR. An immediate debriefing, also known as hot debriefing, following a cardiac event
requiring CPR, allows for a momentary structured debrief with the team involved and helps to
solve some of those technical issues that can occur. With such low survival rates from cardiac
arrests occurring in the hospital settings, trained medical personnel must increase the
administrations of new approaches to patients and increase the quality of care given. It is
important for the survival outcome of the patient and needs to be considered.
Performing adequate and effective CPR to provide a patient with the oxygen and blood
perfusion needed to maintain the bodys supply to vital organs like the brain, require the

DEBRIEFING FOLLOWING A CODE BLUE

technical skills to do it well. According to Sutton et al. (2012), a study was conducted on adults
who had suffered from cardiac arrests in an inpatient hospital setting. They found that the rate of
survival of an adult in-hospital cardiac event had an average of 19%; and during a hospital
cardiac arrest study of pediatric patients, documentation of survival rates slightly exceeded 25%.
Sutton et al. (2012) noted from a recent study showing literature that provided objective data on
CPR performance of hospital personnel, that 23% of chest compressions were given at an
incorrect rate, and 36% of the compressions were too shallow. Low survival rates from cardiac
arrests inform healthcare providers and those administering CPR that new approaches need to be
implemented to increase the effectiveness of care given and the survival rates of patients. A hot
debriefing following such an event, where inadequate chest compressions were given, allows
staff to discuss improvements that need to be made and to put them into action in their practice.
In the literature review performed by Sutton et al, they explored all aspects of
cardiopulmonary care including the gaps between initial training of Basic Life Support, actual
execution in a clinical setting and the improvement of efficiency in performing CPR through real
time audiovisual feedback. The review also discussed debriefing following cardiac events - they
found structured debriefing to be a valuable tool in improving the compliance of care providers
and their effectiveness during simulation codes. Although debriefing alone is not an effective
tool in changing performance of the individual, it provides feedback that helps achieve best
practice.
Facilitating Teamwork
Tannenbaum and Christopher (2013) performed a quantitative meta-analysis study in
which they state debriefing proves to be effective because it promotes passive and active
learning. They encouraged self-discovery, reflection, increased quality and improvement of

DEBRIEFING FOLLOWING A CODE BLUE

experiential learning, as well as situational understanding through discussion with others. Our
meta-analysis indicates that on average, debriefs improve performance by approximately 25%
(Tannenbaum & Christopher pg. 240). This is an effective and straightforward way to increase
the performance of our nurses and other healthcare professionals. Debriefing is an important
component that should be used following any code blue situation because it works not just for
the individual, but also for the team. Implementing post-incident debriefing will help team
members reflect and evaluate their performance without being worried about punitive action.
Enhancing Communication
To promote interprofessional communication, as well as to improve the quality of health
care patients receive, simulations with debriefings should be performed. The importance of
debriefing after such events is essential to the success of these techniques. According to King,
Conrad and Ahmed (2013) Many students reported that they had more confidence in
communicating and speaking up when [they] thought something should be done and were not
afraid to question the doctors orders as a result of this simulation. Thus team members who
recognize this pattern and are willing to speak up can prevent this type of preventable error from
occurring (pg. 271). Simulations with debriefings facilitate communication between team
members that may have not previously been comfortable speaking up.
In the above study, 34 students were placed into a simulation with two debriefings
following the events. They were then surveyed using a qualitative approach and almost half
(44%) related to the importance of communication or the need to improve communication. Other
themes that emerged include shared understanding of goals, team coordination, understanding of
distinct roles, increased knowledge of other professions, confidence in working with other

DEBRIEFING FOLLOWING A CODE BLUE

professions, and reduced fear in speaking up to other professions (King, Conrad & Ahmed,
2013, pg. 270).
Enhancing Emotional Support
Pre and post surveys were given to trauma team members in a qualitative study done by
Berg, Hervey, Basham-Saif, Parsons, Acuna, and Lippoldt (2014) they showed an overall
improvement in team members perceptions of their personal role on the team, sense of
psychological safety, as well as patient safety (pg. 205). Sjoberg , Schonning and SalzmannErikson (2015) state that the informants described how debriefing helped their ability to develop
as a person and as a group: It is nice anyway to like receive confirmation that one has done, that
we have done our best, that could not have acted in any other way (pg. 2526).
In a debriefing meeting following an event, a facilitator who knows how to draw out the
information and experiences of those involved, makes for the best learning environment and way
to receive feedback. Berg et al. (2014) emphasize that the debriefing process would be very
beneficial when the leader is committed to group learning because every event is a learning
opportunity. The group leader should also acknowledge the effort of those who attend. Shore
(2014) adds that debriefs should be held in a private place, where participants would feel safe to
speak openly and honestly. She also suggests involving a psychologist for additional support for
staff. Sjoberg et al. (2015) observed in their study a leader in a stressful situation is vital for
bringing about order and for avoiding unpleasant situations that are otherwise experienced as
chaotic (pg. 2526).
Increases Technical Performance
A key finding of meta-analysis done by Couper, Salman, Soar, Finn, and Perkins (2013)
indicated improvement of CPR process and technique, knowledge and skill acquisition, as well

DEBRIEFING FOLLOWING A CODE BLUE

as the implementation. It also improves short-term patient outcomes. In addition to the

quantitative assessment of CPR, such as chest compression depth measurement, using an
automated feedback defibrillator device, or other techniques intended to increase patient CPR
survival, a highly structured post event debrief is essential to analyze overall code performance
of the front line care providers involved.
Crowe et al. (2015) created a study with the aim to evaluate the quality of CPR in an
urban Emergency Room using both audiovisual feedback with post-event debriefing following.
They wanted to assess the chest compressions rates related to depth and frequency of the
compressions given. The CPR metric of chest compression depth has been linked to coronary
and cerebral perfusion, and survival from cardiac arrest (pg. 11). Using a monitor-defibrillator
approved by the Food and Drug Administration it measured various aspects of CPR including the
rate, release velocity, fraction, and pre-shock pause. High quality CPRs objective is to generate
forward blood flow to maintain adequate cerebral and coronary perfusion until resuscitation can
be achieved. They found that the debriefing sessions following code events allowed them to
discuss the data, provided them the opportunity to learn their deficiencies, and gave them time to
perform a training refresher.
Improves Behavioral-Non-Technical Performance
Couper et al. (2013) found evidence of small to moderate improvements in medical
provider performance as well as patient outcomes. As Sutton et al. (2012) noted, structured
debriefing has been implemented after infrequent, stressful events dating back to World War II.
Post-event debriefs were emotionally uplifting and decreased the amount of stress and/or
potential psychological trauma related to the life altering events. Today, post event debriefing is
utilized to focus on improving care during a code blue response.

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10

In a study performed at the Veterans Affairs (VA) Hospital in Ann Arbor Michigan, they
examined the trends of the code team after implementing a CPR code-debriefing tool. The tool
they use at the Chillicothe VA Hospital is a two-paged survey that was designed to be a quick,
postcode discussion allowing team members to express areas of success and improvement. After
extended use of the retrospective posttest only design, the team members expressed improvement
in multiple areas. According to Parcarpio (2010), the results of their study showed increased
code team response, positive improvement in team cohesiveness as well as deeper
communication. They also had less issues with equipment and an increase in successful
intubations (pg. 429).
Perspective and Gaps
There were not many conflicting findings in doing the research and literature review for
the implementation of debriefing following code blues or other traumatic experiences for
healthcare workers. It was difficult to find studies that were specific to the qualitative data
collection of emotions, confidence, and if debriefing provides the inter-personal communication
to decompress for nurses following a high stress situation. Due to the limited number of available
studies, it was difficult to assess the amount of conflicting information. There were few articles
in the literature that described the relationship between debriefing and patient outcomes, because
many of them were done in a simulation setting.
Evaluation Plan
It is difficult to measure how debriefing works or its effectiveness outside of nontechnical aspects. There are many parts to CPR implementation -- teamwork, preparedness,
confidence in initiating the procedure, being comfortable communicating with the doctor and
how an individual can cope with the situation they have experienced. Increased teamwork,

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11

knowledge of specific role in code blue participation, better patient outcomes/survival rate, and
decreased technical errors are ways to determine effectiveness of practice change.
Implications of Change
Nurses debrief whether it is in a structured setting or not. The need for debriefing is
important and when it is not practiced, people find alternative ways for expressing their feelings.
In a study that used semi-structured interviews of nurses, one acknowledged: I seek out
someone to talk to, or call and talk to a friend or someone else who works in health care
(Sjoberg et al., 2015, p. 2526). Since debriefing helps reduce stress levels, it could decrease sick
leave and increase staff morale. In her article Shore (2014) suggested that debriefing allows staff
to express their emotions and enables them to ask questions following the incident.
Suggestions for Change in Clinical Practice
A debriefing should begin as a diagnostic tool for the individual or a response team,
exploring the strengths and weaknesses of performance and developing a supportive space for
improvement. Implementing a program also allows the training and introduction of new leaders,
empowers individuals to guide their teams through a debriefing session, or talk with those who
are struggling on an individual level using their experience or performance. There is an overall
goal to create a shared mental model where a team or healthcare workers are unified in their
thinking and their process in responding to a code blue. Mental models are based on explaining
or anticipating particular events. The definition of a mental model is of a situation, psychological
representations of real, hypothetical or imaginary. They help to explain reasoning and
expectations of an individual. (Mental models, n.d.)
A Code Blue does not happen very often in medical offices, which could be why many
nurses are not familiar with debriefing. I work in a cardiology office in the nuclear department,

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where I perform myocardial perfusion tests. When one of my patients had a myocardial
infarction during an exercise stress test, I called a Code Blue. About ten medical personnel
showed up, and as soon as they saw the patients ECG on the monitor, they panicked. Since the
patients heart rate was dropping, we injected atropine and within a minute his heart rate began
to rise back to normal, not needing to use a defibrillator. After our patient was taken to the
catheterization laboratory, I found one set of defibrillator pads on the countertop and one set in
the garbage can. For the next few days, I replayed the whole event in my brain over and over
again. I was very thankful that my patient did not need to be defibrillated because the
defibrillator pads were not on the crash cart with the defibrillator.
I wish we could have had a post debrief at my workplace. We could have reviewed and
resolved this chaotic and disorganized event, and learned what areas needed improvement.
During the debriefing we could have discussed what duties needed to be assigned, how many
people should have stayed in the room, and who was responsible for the crash cart and calling
the ambulance. At the moment we, as a medical office, are not ready for an emergency situation,
but I feel with continued mock trials and immediate post debriefings, these technical difficulties
and miscommunications could be resolved.
Our proposed clinical practice change is to implement a post-event debriefing that would
include a structured immediate debrief, recognizing the difficulty of the situation just
experienced. This would be a time to address any major technical issues faced by the team.
Immediate response is needed because it is likely the only time when the personnel involved in
the code, will have a momentary opportunity to be together and discuss what happened. There
are various tools and structures that exist to facilitate debriefing; create an informative learning

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environment guiding conversation and encouraging the discussion for better performance to
provide best practice for patients.
In a large hospital, like St. Josephs Hospital PeaceHealth, where they are serving a
specific and close-knit community, it is important to implement debriefing into the Code Blue
procedure to create a team with better communication, teamwork, and understanding as to what
their role is within that team. This especially applies for the primary care nurse, who is not a part
of the rapid response team and doesnt feel needed or necessary upon their arrival. Having the
time and opportunity to express emotions and discuss aspects of care that could have been better
provided is what an immediate debriefing can provide. Being able to learn from nurses who
routinely respond to Code Blue calls creates understanding and confidence for the nurse may
find a Code Blue to be an unusual occurrence in their day-to-day practice.

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