Volume 4, Number 2, February 2023 e-ISSN: 2797-6068 and p-ISSN: 2777-0915
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KEYWORDS Hospitals; code blue; cardiac |
ABSTRACT Cardiac Arrest is a form of emergency due to
malfunction of electrical waves in the heart that cause arrhythmias, so that
the heart cannot pump blood to the brain, lungs, and other organs that can
occur to anyone and at any time so that it needs proper and immediate
treatment to be able to save the patient's life. In the case of hospitals, an
activation code system to respond to cardiac arrest, called Code blue, was
established to provide an appropriate, fast, and systematic Basic Life
Support. The Code blue system was formed by the local hospital by
establishing a code blue system, including code blue teams, BLS equipment and
equipment, code blue activation��
through communication systems in hospitals, and regular education and
training to ensure quality control. Cardiac Arrest treatment is the ability to be
able to detect and react quickly and correctly to restore the heart rate to a
normal condition as soon as possible to prevent brain death and permanent
death, The patient's chances of survival are reduced by 7 to 10 percent every
minute that runs without cardiopulmonary resuscitation and defibrillation |
INTRODUCTION
������� Based on
data by the American Heart Association (AHA), in America there are morethan 200,000 cases of in-hospital cardiac arrest (IHCA)
per year, with survival rates varying from hospital to 0 to 36.2%. The
prevalence of cardiac arrest according to the Indonesian Association of
Cardiovascular Specialists (PERKI) ranges from 10 out of 100,000 normal people
under the age of 35 years and annually reaches around 300,000 -350,000 events.
Cardiac arrest is a form of emergency that must receive appropriate and immediate
treatment from a trained medical or general public (Dame, Kumaat, & Laihad, 2018).
Cardiac arrest can be restored if treated promptly with cardiopulmonary
resuscitation or Cardiopulmonary Resuscitation (CPR/RJP) and defibrillation to
restore normal heart rate. The patient's chances of survival are reduced by
about 10 percent at every minute that runs without RJP and defibrillation (Aminuddin, 2013).
Code blue is a code activation
system in patients who experience cardiac arrest, respiratory arrest, or
emergency situations that require resuscitation. Several major hospitals inIndonesia have implemented a code blue activation system by
using a telephone network to a certain number agreed upon by each hospital.
When a patient is found who is experiencing a condition of respiratory arrest
and cardiac arrest, the health worker who finds the patient will activate the
blue sign / code. The central operator will disseminate information to the
captain of the code blue team in the form of the location of the incident.
After the captain of the code blue team receives the notification, the captain
of the code blue team goes directly to the scene with the duration of time
required between receiving the message "code blue" (code blue
activation) and the arrival of the code blue team at the scene is 5 to 10 minutes
(Monangi, Setlur, Ramanathan, Bhasin,
& Dhar, 2018).
The establishment of the code
blue system aims to reduce mortality and increase the rate of spontaneous
return of circulation. Delayed cardiac arrest treatment is associated with a
reduced life expectancy of cardiac arrest patients. To achieve the goal of
implementing the code blue system requires an early introduction of cardiac
arrest cases, in this case knowledge of the code blue system and basic life
support. Based on this, the activation of the ideal code blue system should be
able to facilitate resuscitation in patients with medical emergencies and
cardiac arrest conditions with an adequate response (Kilgannon et al., 2017).
Bibliography Review
Definition
Code Blue is the stabilization
of a medical emergency that occurs within the hospital area. This medical
emergency condition requires immediate attention. A code blue should start
immediately whenever a person is found in a cardiac or respiratory arrest
condition (unresponsive, not palpable pulse, or breathing) e.g.
a patient in need of resuscitation.
A code blue team is a team of
doctors and paramedics designated as a "code-team", who quickly go to
patients to perform rescue measures. The team used crash carts,
wheelchairs/stretchers, essential tools such as defibrillators, intubation
equipment, suction, oxygen, ambubags, resuscitation
drugs (adrenaline, atropine, lignocaine) and IV sets to stabilize patients with
Basic Life Support (Vindigni, Lessing, & Carlbom, 2017).
Basic Life Support (BLS) is
the beginning of an emergency response. BLS can be performed by medical
personnel, paramedics or laypeople who see the victim for the first time.
Skills must be mastered by paramedics and medical personnel, and ordinary
people should also master them, because often victims are found first not by
medics.� The basic life support principle
is to provide external assistance to circulation and ventilation in cardiac
arrest or respiratory arrest patients through RJP/ CPR.� BLS is a way of providing life support das ar which includes airway free (airway/A), adequate
breathing (B), adequate circulation (circulation/C).
�Code Blue
Objectives
a)
To provide rapid
resuscitation and stabilization for victims who experience emergency cardio
respiratory arrest conditions within the hospital area.
b)
To form a
well-trained team with emergency medical paralatans
that can be used quickly.
c)
To begin BLS
skills training and the use of automated external defibrillators (AEDs), for
all hospital teams both clinical and non-clinical based.
d)
Placement of BLS
equipment in various strategic locations within the hospital area to facilitate
rapid response to medical emergencies.
e)
There is a common
mindset / perception of the emergency management system in the hospital in an
integrated manner.
f)
Similarity of
action patterns is obtained in the handling of emergency cases within the
hospital.
g)
Speed up the
response of the emergency team at the hospital to avoid deaths and disabilities
that should not have occurred (FAUZIAH, 2019).
Code Blue Team Organization
The Code blue team is a team
that is always ready at any time / at all times. The primary response code blue
team consists of a crew that has mastered Basic Life Support (BLS). The Code
blue team consists of 3 to 4 members, namely (Bhoi, Sharma, Singh, Sardana, &
Chauhan, 2015):
��� 1 team
coordinator
��� 1 medic
��� 1 assistant
medic and 1 or 2 nurses (implementing nurse and resuscitation team)
��� 1 support
group (if necessary)
Job description:
1.� Team
coordinator
-�� Held by a
NICU/ICU doctor
-�� In charge of coordinating
all team members. Working with training makes emergency training needed by the
team.
2.� Medical
person in charge
-�� Doctor on
duty / room doctor
-�� Identifying
the initial / triage of the patient
-�� Lead patient
response in the event of an emergency
-�� Lead the team
during RJP implementation
-�� Determining
the next attitude
3.� Implementing
nurse
-�� Together with
the medical doctor to triage the patient
-�� Helping
doctors in medical charge handle emergency and emergency patients
4.� Resuscitation
team
-�� Trained
nurses and room doctors/doctors on duty
-�� Providing
basic life support to emergency or emergency patients
-�� Performing
cardiopulmonary resuscitation to emergency or emergency patients
-�� Team Code
blue's roster is the responsibility of the Coordinator
each month in the MECC.
Each team member will have
designated responsibilities such as team leader, airway manager, chest
compressions, IV line, drug preparation and defibrillation. Each designated
team member must bring a mobile phone.
�Code Blue
System Management
1. Code Blue Phase
a.� Alert System
There should be a good, coordinated system in place
that is used to activate the alert of a medical emergency within the scope of
the hospital to the members of the code blue team. The existing phone system
will be used.
In the event of a medical emergency, hospital
personnel anywhere within the scope of the hospital can activate a response
from code blue by phone for assistance and activation:
I.�� Local Alert
-�� Announcement
via PA system
-�� Display the
names of primary blue code teams in strategic locations in their zones
-�� After code
blue activation occurs, the Primary Team must leave their work and take the
code blue bag and rush to the location and start CPR/BLS
II. Hospital
Alert
-�� Priority 1:
To enable secondary team code blue from ETD
-�� Priority 2:
To check (as a second safety net) the activation of the team code blue primer.
Members of the primary code
blue response team that have been determined around the place where the medical
emergency occurred will respond to the code blue situation as soon as possible.
The team members will mobilize their resuscitation devices and rush to the
medical emergency site. The code blue ETD team will also respond to code blue
situations.
2.� Central Responsibility
/ Hospital Operator Towards Blue Line Code in Hospitals
-�� Assume every
call in the code blue line is the actual case code blue (until it can be
proven).
-�� Code blue
calls must be answered as soon as possible (< 3x ringing)
-�� Vital
information is:
1) Name and name
of person/paramedic team/doctor team code blue
2) Exact location
3) Trauma or
medical cases
4) Adult or child
3.� Immediate
Intervention at the Scene
The team at the scene of a medical emergency found the
patient unconscious or in cardiac and Respiratory Arrest responsible for
requesting further assistance, initiating resuscitation using Basic Life
Support (BLS) guidelines and ALS skills as well as sufficient equipment,
trained and complete HR (Garg et al., 2017).
4.� Guidelines
for implementing the Code Blue Team in the field
Initial management before the arrival of the Code Blue team
-�� The
hospital's blue code team mobile number is placed throughout the rooms in the
hospital including offices, elevator lobbies, corridors, canteens, parks,
parking lots, and other locations within the hospital
-�� Hospital
personnel who find victims must be able to activate local notifications to the
primary blue code team or someone to each team's cellphone or to the telephone
number and forward the information spread to the center / hospital operator
-�� Instructing
the team to move towards the scene, they should also ask for further assistance
from the nearest team if available
-�� At the same
time, the activation of the hospital notification must be done by calling the
designated hospital code blue number
-�� The party in
charge of a particular area (from another space) should also be notified to
come to the location immediately
-�� While waiting
for the arrival of the main code blue team (Primary), if a team trained for BLS
is available, it is informed the team must start the BLS (airway position,
breathing assistance, chest compressions etc.)
-�� If there is
no BLS-trained team, the team on the scene must wait for experienced help and
guard the location from crowds
-�� If a cardiac
monitor, manual defibrillator or automated external defibrillator (AED) is
available, this equipment should be attached to the patient to determine
defibrillation needs, this phase is performed by an experienced team or a team
trained in Alert Cardiac Life Support (ACLS)
-�� The team from
each room will be responsible for the maintenance of their resuscitation kits
that are already available
-�� All code blue
case data must be sent to the team coordinator, for further evaluation of the
implementation of the code blue team in the field / scene, including the
response time of receiving messages and the response time of the� code blue team's arrival� at the scene.
Figure 1 Initial management before the arrival of the Code Blue team
5.� The Arrival of the Code Blue
Team
-�� After the code blue team
members received code blue activation, they had to stop their current duties,
take their basic resuscitation kits (equipment bags) and rush to the medical
emergency site on foot.
-�� The code blue team had to
quickly respond moving towards the location using the shortest route available
and arrived within < 5 minutes.
-�� Response time (standard
service) code blue call / activation of the arrival of the code blue team at
the scene must be stored data (for MONEV).
-�� The code blue� team arrives at the ready location with the
basic resuscitation kit equipment, what if the victim is still in cardiac or
respiratory arrest,� the team will take
over the task of resuscitation (the team coordinator directs for further
action).
-�� What when needing a heart
monitor, manual defibrillator or automatic external defibrillator (AED), this
equipment should be attached to the patient to determine the need for
defibrillation, this phase is performed by an experienced team or a team
trained in Alert Cardiac Life Support (ACLS)
-�� Patient management is then
handed over to the code blue team coordinator
-�� If resuscitation is
unsuccessful (the victim died at the scene of the crime/ DOA patient, the
victim is transferred to the forensic department, not to the emergency room
(for further documentation or confirmation of death, as well as administration
completed in the forensic section).
Figure 2 Help when the code blue� team comes (Olasveengen et
al., 2021)
�
6.� Equipment Needed by the Code
Blue Team
All levels of the hospital team must be moderately
trained at least in BLS and AED use. AED and resuscitation kit bases should be
placed in different areas within the hospital grounds and easily accessible for
medical personnel and Code blue teams to use
Semi-Automated Defibrillators (SAED) must be present near the Emergency
Trolley. A package of SAED x 2 electrodes and a disposable razor must be stored
in the SAED package box. The electrode package should not be opened until
before discharging (Quan et al., 2015).
Resuscitation equipment is placed in an area that often needs resuscitation
assistance so that when code blue appears the team designated as code blue The
team will immediately be able to access the equipment. If code blue is called
in an area without crash-cart, the team designated code blue will carry a
crash-cart or resuscitation kit.
Figure
3 BLS10 Equipment
�7. Code Blue Activation Criteria
Patients who have the following criteria can be activated code blue,
namely:
-�� Adult Medical emergency
criteria
-�� Pediatric Medical emergency
criteria
Figure 4 Adult and pediatric medical emergency criteria (Marsum,
Windari, Subinarto, & Candra, 2018)
8. Adult and children's cardiac arrest algorithm
About 1.2% of adult individuals admitted to United States Hospitals,
suffer cardiac arrest in hospitals, and more than 20,000 infants and children
experience cardiac arrest each year. This condition is one of the factors that
makes changes to the guidelines related to cardiac arrest management in adults
and children. Here are recommendations for basic life support and advanced
cardiovascular life support in the� 2020
AHA� guidelines.
Figure
5 Adult Cardiac Arrest Algorithm (Cheng et al., 2020)
Figure
6 Adult Cardiac Post-Arrest Care Algorithm
Figure
7 Cardiac Arrest Algorithm in Children
RESEARCH METHOD
The research method used is a review of publications with an extensive systematic literature search related
to the implementation of Code Blue in
hospitals.� through electronic database
searches, namely Google Schoolar,
NCBI, and Guideline.
This journal search was conducted by researchers using keywords: Code Blue Team Management in Hospitals,
CPR, Defibrillation in Cardiac Arrest which is limited from 2013 to 2022. It
also includes a review of the National and International CPR Guidelines.
The journals and articles obtained are then filtered based on the title and
abstrak chosen by the researcher based on the desired
criteria, namely, the Implementation of Code
Blue in Hospitals. Meanwhile, journals that are not relevant to the
research topic are issued. After sorting according to these criteria, a
systematic review is carried out. The inclusion criteria used in the systematic
review are journals published from 2013 to 2022 on the Code Blue System in Hospitals, CPR, and Cardiac Arrest
Management.
Of the 10,349 articles found in searches that match the keywords needed by
researchers, restrictions were made based on publication time from 2013 to
2022, then 5,042 articles were obtained, then restrictions were made based on
the ease of access to fulltext available 103 articles with conformity
to the criteria, targets and goals of obtaining 9 articles for systematic
review.
Identification Fulltext ease of access Initial search on data base (n = 10,349 Restrictions based on publication time (n = 5,042) Articles that are easy to access fulltext
(n=103) Articles for systematic review (n=9) According to the criteria Restrictions
Figure 8 Article Review Selection
Process Scheme
Code blue system is an emergency system� consisting of a code blue team� consisting of doctors and paramedics
designated as a "code-team", who quickly go to patients to carry out
rescue measures on all patients with emergencies during respiratory arrest and
or cardiac arrest� .� The application of the� code blue system aims to reduce mortality and
increase the return of spontaneous circulation (ROSC) or the return of
spontaneous circuses.�
Patients who experience cardiac arrest are given
assistance in the form of Basic Life Support (BHD), where the p rinsi is to
provide external assistance to circulation and ventilation in patients with
cardiac arrest or respiratory arrest through RJP / CPR. 4 CPR of� good quality,�
with early defibrillation, early correction of underlying etiology and
effective post-resuscitation treatment are essential to improve neurological
recovery after a heart attack.
In implementing Code Blue in hospitals, it is
necessary to pay attention to important things, such as (Rahmawati, Emaliyawati, & Kosasih,
2019) :
1.
In some studies, it is said that patients
with Code Blue are not always patients with cases of cardiopulmonary arrest, so
it is necessary to verify the patient's condition before activating Code
Blue.�
2.
Many studies have shown that the existence
of the Code Blue� team is effective in
preventing deaths. This can be seen from the indicators of spontaneous
circulation returning to normal from the patient or commonly known as ROSC
(Return of Spontaneous Circulation). One of the studies� from Thomas & Shafi (2017) in the study
"Survival After In Hospital Cardiac Arrest and Code blue Initiation"
found that 130 patients could be saved or obtained patient circulation back to
normal (ROSC) from 442 code blue calls (Desrochers, 2021).
3.
The process of providing basic life
support assistance in the Code Blue�
system refers in principle to the chain of survival in accordance with
the 2015 AHA guidelines. These include: immediate detection of the victim's
condition and asking for help (early access), immediate
cardiopulmonary resuscitation (early cardiopulmonary resuscitation), early
defibrillation, early advanced cardiovascular life support and post
cardiac-arrest care.
The implementation of Code Blue assistance in� accordance with the AHA (American Heart
Association) protocol� will provide
better results, which can be seen� in
Code Blue help� in the number of patients
who have been helped well, with indicators of ROSC incidence.
CONCLUSION
Code blue is a code activation
system in patients who experience cardiac arrest, respiratory arrest, or
emergency situations that require resuscitation. Several major hospitals in
Indonesia have implemented a Code Blue activation system by using a telephone
network to a certain number agreed upon by each house.
The establishment of the code
blue system aims to reduce mortality and increase the rate of spontaneous
return of circulation. Cardiac arrest can be restored if treated immediately
with cardiopulmonary resuscitation or cardiopulmonary resuscitation (CPR/RJP)
and defibrillation.
With the Code Blue team, it is
effective in preventing death cases. One of the indicators of seeing the
success of the Code Blue Team Service is the occurrence of ROSC (Return of
Spontaneous Circulation) in patients with heart-lung arrest.
The management of
cardiac-pulmonary arrest through the services of the Code Blue Team carried out
in accordance with the protocols of the international guidelines compiled by
the AHA is carried out correctly and effectively will provide better results.
So that it can improve the life rate of patients with previous cases of Cardiacpulmonary Arrest by looking at the ROSC indicator as
a success in cardiacpulmonary arrest management
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