The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

RESPIRATORY CARE PRACTIONER: CODE BLUE PROCESS COORDINATOR FOR AN ACADEMIC UNIVERSITY MEDICAL CENTER

K. J. Thompson-Lumen1, A. Alipoon1, L. Scott1, M. Lum1

Background: In September 1998, responsibility to correct the Joint Commission supplemental recommendations for the medical center’s emergency response equipment was given to the hospital’s Office of Staff Development. A registered nurse was assigned the task and a quality improvement program encompassing all aspects of the Code Blue process was initiated. As resuscitation technology and regulatory requirements for the Code Blue process continued to grow in complexity, it became mandatory that the Code Blue process be managed by a full-time staff member. In June 2003, the Chair of the Code Blue Committee requested the Department of Respiratory Care assume oversight and complete responsibility for the Code Blue process. A new respiratory care practitioner (RCP) position to oversee the Code Blue process and ensure regulatory compliance was approved by the hospital administrator.

Method: The Code Blue Process Coordinator (CBPC) manages: 119 code blue carts, 148 airway kits, 140 defibrillators, 38 automatic external defibrillators (AED) and the training of caregivers on documentation compliance and equipment function.
Break down of time spent:
• Inspection 25%
     – Equipment, including 119 code blue carts
     – Documentation
• Education 45%
     – In-services
     – Mock Code Blues
     – Equipment
     – Competencies
• Quality Improvement 20%
     – Auditing all Code Blues events(approximately 490/year)
     – Auditing Transitional Care events(approximately 1653/year)
     – Auditing Rapid Response Team events(approximately 81/year)
     – Reporting to Quality Improvement Committees
• Policy Review 15%
     – Reviewing, revising and developing policies, procedures, techniques and documentation

Conclusion: The RCP as a Code Blue Process Coordinator is an effective option. Hospital staff compliance with Code Blue documentation requirements improved with each successive audit and the incidence of expired equipment/medication found in the code carts decreased. Our CBPC has been well received with both the nursing and physician staff having expressed their appreciation for the excellent job our Code Blue Process Coordinator has done.

Results:
Year/Month Documentation Compliance Item or Medication expired in code cart
2004 May 58% 14%
2004 December 74% 1%
2005 May 80% 4%



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