Canadian Medical Education Journal 2012, 3(1)

Canadian Medical Education Journal

Major Contribution/Research Article

Code Blue Emergencies: A Team Task Analysis and

Educational Initiative.
James W. Price,1,2 Oliver Applegarth,1,2 Mark Vu,1,2 and John R. Price2
1
Department of Anesthesiology, Pharmacology & Therapeutics, Vancouver General Hospital
2
University of British Columbia, Vancouver, British Columbia, Canada
Published: 31 March, 2012
CMEJ 2012, 3(1):e4-e20 Available at http://www.cmej.ca
© 2012 JW Price, Applegarth, Vu, and JR Price; licensee Synergies Partners

This is an Open Journal Systems article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0) which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Abstract
Introduction: The objective of this study was to identify factors that have a positive or negative influence on
resuscitation team performance during emergencies in the operating room (OR) and post-operative recovery unit
(PAR) at a major Canadian teaching hospital. This information was then used to implement a team training
program for code blue emergencies.
Methods: In 2009/10, all OR and PAR nurses and 19 anesthesiologists at Vancouver General Hospital (VGH) were
invited to complete an anonymous, 10 minute written questionnaire regarding their code blue experience. Survey
questions were devised by 10 recovery room and operation room nurses as well as 5 anesthesiologists
representing 4 different hospitals in British Columbia. Three iterations of the survey were reviewed by a pilot
group of nurses and anesthesiologists and their feedback was integrated into the final version of the survey.
Results: Both nursing staff (n = 49) and anesthesiologists (n = 19) supported code blue training and believed that
team training would improve patient outcome. Nurses noted that it was often difficult to identify the leader of the
resuscitation team. Both nursing staff and anesthesiologists strongly agreed that too many people attending the
code blue with no assigned role hindered team performance.
Conclusion: Identifiable leadership and clear communication of roles were identified as keys to resuscitation team
functioning. Decreasing the number of people attending code blue emergencies with no specific role, increased
access to mock code blue training, and debriefing after crises were all identified as areas requiring improvement.
Initial team training exercises have been well received by staff.

Correspondence: James W. Price, MD, MMEd., FRCPC, Department of Anesthesiology, Pharmacology &
Therapeutics, Vancouver General Hospital, University of British Columbia, Room 3200, 910 West 10th
Avenue, Vancouver, British Columbia, Canada, V5Z 4E3; Tel: (604) 875-5855; Fax: (604) 875-5344. E-mail:
[email protected]

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Canadian Medical Education Journal 2012, 3(1)

Introduction terms 'nursing', 'code blue', 'crisis resource

management', 'operating room', 'anesthesiologists'
The operating room nurses at Vancouver General and permutations thereof. Search terms were
Hospital have recently implemented a program of selected through discussion with nurses,
nursing education days. The purpose of this initiative anesthesiologists, and librarians with considerable
was for nurses to identify areas of their practice medical education and simulation teaching
which require further training. Prior to this, an experience, therefore suggesting that these terms
informal survey of operating room (OR) and post- would capture inclusive results. Hand searching
anesthesia recovery room (PAR) nursing staff at references from papers collected and internet
Vancouver General Hospital identified code blue searching were also employed. To our surprise, no
situations as the most stressful situations that nurses studies were identified which addressed code blue
face in their daily practice. Therefore, this survey training or management in the operation room and
also identified an area of our anesthesiology practice post-anesthesia recovery room from nurses’ or
that required improvement. In discussions with the anesthesiologists’ perspectives.
department of nursing and anesthesiology, we
decided to create a questionnaire to gather Two separate surveys were developed for nursing
information on the current state of code blue staff and anesthesiologists regarding their
management in the OR and PAR from the experience with code blue emergencies. Both
perspective of both groups of health professionals. questionnaires were rigorously designed and
evaluated prior to administration. Ten recovery
Our questionnaire was developed after a thorough room and operating room nurses as well as five
literature search revealed little background anesthesiologists who had an interest in medical
information with respect to interdisciplinary code education were contacted by the authors prior to
blue management in the OR and PAR. Although survey creation. These professionals represented
there is substantive evidence suggesting better four different hospitals in British Columbia (years of
performance by medical trainees (medical students experience ranging from 5-30 years), and each
and residents) during simulated code blue scenarios contributed questions for the survey. Questions
and other complex procedural tasks after high- were compiled and three iterations of the survey
fidelity simulation training sessions, no previous were reviewed by this pilot group of nurses and
studies have asked resuscitation team members in anesthesiologists and their feedback was integrated
the operating room and post-anesthesia recovery into the final version of the survey. To compensate
rooms (nursing staff and anesthesiologists) what survey participants for their time and to increase
they believe are the essential components of survey response rate, two gift certificate prizes were
effective team performance during a code blue available for those who completed the survey (total
1,2
resuscitation. value $200).
The purpose of this study was to identify both The survey used likert-scale multiple-choice
positive and negative factors affecting code blue responses combined with open-ended questions. A
management in the OR and PAR at a major Canadian scaled rating methodology was selected, as this was
teaching hospital and then to address these deficits similar to previous studies that assessed medical
with an ongoing educational initiative aimed at 3,4
education environments. Respondents were asked
improving code blue team performance in our OR to indicate their agreement with each statement
and PAR units. ranging from strongly disagree to strongly agree.
Methods Responses included: strongly disagree (1), disagree
(2), neutral (3), agree (4), and strongly agree (5). The
Survey Development questionnaires can be found in Appendix 1 and 2.
The literature search was limited to human and Participants were then invited to complete the 10-
English-language articles. MEDLINE and CINAHL minute, anonymous survey (41 questions for nursing
(1966 to September 2010) were searched with the staff, 35 questions for anesthesiologists, which were

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Canadian Medical Education Journal 2012, 3(1)

made available for 8 weeks. Two sets of reminder e- Table 1. Demographic data, code blue experience
mails were sent to both nurses and anesthesiologists and ideal number of practice sessions per year of
at 3-week intervals. All data were stored within a OR/PAR nurses and anesthesiologists.
locked cabinet on-site at Vancouver General Hospital Question OR PAR
and were subsequently transcribed onto a password- Nurses Nurses Anesthesiologists
protected departmental computer for analysis. (n = 22) (n = 25) (n = 19)
Gender 20 female, 23 female, 2 female,
Data Analysis
2 male 2 male 17 male
SPSS 8 (SPSS Inc., Chicago, IL, USA) was used for Age 44.7 (14.0) 41.7 (11.1) 49.1 (10.4)
statistical analysis. Multiple choice questions are Years
11.6 (8.77) 11.1 (10.2) 16.4 (10.1)
presented as median (interquartile range). For open- experience
ended questions, themes were discovered through No. of
codes
data analysis and inter-rater reliability testing was 20.7 (25.4) 10.8 (19.9) 34.5 (38.0)
involved
performed to ensure at least 80% agreement with
between the three separate individuals, who Ideal
categorized the data and identified themes. The number of
code blue 1.64 (1.10) 1.75 (0.91) 1.10 (0.83)
‘Top 3’ responses and the number of times they
practice
appeared in the data were reported where sessions/yr
applicable. Numerical data, such as the participants’
age, number of years worked and the number of All nursing staff strongly supported mandatory code
code blues they participated in are presented as blue training and believed that it would improve
means. both patient outcome and their own comfort in
managing code blue situations (Table 2). Very few
Results
nurses had previously participated in code blue
Demographics training, had completed advanced cardiac life
A total of 49 nurses (OR and PAR combined) and 19 support (ACLS) training, or had used a patient
anesthesiologists responded to our survey which simulator for learning (Table 3). Nursing staff felt
represents a response rate of 37.7% and 37.2% anxious about participating in code blue training
respectively (of a total of 70 full time OR nurses, 60 with their colleagues watching, but more
full time PAR nurses, and 51 anesthesiologists). This comfortable if their colleagues would participate
was in keeping with the response rate of previous alongside them in code blue training exercises.
surveys of resident doctors in Canada at 27.4% and a Nursing staff strongly supported using a debriefing
review of 199 online surveys from a variety of process following code blue emergencies, but noted
disciplines indicating a comparable average response that this rarely happens in their daily practice. With
3,4
rate of 32.5%. The demographic data are shown in respect to roles during code blue emergencies,
Table 1. nursing staff were most comfortable acting as the
events recorder, followed by acting as the drug
administration nurse. Nursing staff were least
comfortable controlling the defibrillator.

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Table 2. Survey Responses.*

Question OR Nurses PAR Nurses Anesthesiologists
(n = 22) (n = 25) (n = 19)
1. I have a clear understanding of my role during a code blue 4 (1) 4 (1) 4 (2)
2. I feel comfortable announcing my role and communicating with 4 (1) 4 (1) 4 (1)
the resuscitation team during a crisis
3. The team can easily identify that the anesthesiologist is in charge 3 (2) 3 (2) 4 (1)
during code blues
4. The anesthesiologist should be in charge of running the code blue 5 (1) 5 (1) N/A
5. The effectiveness of chest compressions is clearly being assessed 3 (1) 4 (1) 4 (1)
in most cardiac arrest situations
6. I believe one nursing role during code blues should be crowd 3 (2) 4 (1) 4 (1)
control
7. I believe one nursing role during code blues should be assessing 3 (1) 3 (1) 2 (1)
the effectiveness of chest compressions during cardiac arrest
8. I feel comfortable drawing up resuscitation drugs during a code 4 (1) 3 (2) N/A
blue
9. I feel comfortable acting as the events recorder during a code 4 (0) 3 (1) N/A
blue
10. I feel comfortable operating the defibrillator during a code blue 3 (2) 4 (2) 4 (1)
11. While taking part in a code blue, I feel comfortable asking for help 4 (1) 4 (0) 5 (1)
12. During a code blue I am most concerned about making a mistake 3 (2) 3 (2) 2 (1)
13. The code leader / I clearly announce the drugs I administer during 2 (2) 2 (1) 4 (1)
a code blue
14. Crowd control is an issue at code blues in the OR/PAR 4 (1) 4 (1) 4 (1)
15. The use of patient simulators could play an important role in my 4 (1) 5 (1) 4 (0)
critical incident training
16. Code blue training should be multi-disciplinary, including nursing, 4 (1) 5 (1) 4 (1)
anesthesiology, and surgery
17. Practicing multi-disciplinary, team-based code blue scenarios at 4 (1) 5 (1) 4 (0)
my institution would make me more comfortable in code blue
situations
18. Practicing multi-disciplinary, team-based code blue scenarios at 4 (1) 4 (1) 3 (1)
my institution would improve patient outcomes
19. Code blue and crisis management training should be a mandatory 5 (1) 5 (0) 4 (0)
part of my continuing education
20. I feel anxious about participation in mock code blue scenarios 3 (2) 3 (1) 2 (1)
21. I would feel comfortable participating in a code blue scenario 4 (1) 4 (2) 3 (1)
with my colleagues observing me
22. I would feel comfortable participating in a code blue scenario 4 (0) 4 (1) 4 (1)
with my colleagues also participating alongside me
23. After a code blue, the team involved undergoes a debriefing 1 (1) 2 (2) 2 (1)
process recapping the events and allowing all team members to
voice concerns
24. I believe that team debriefing after code blues is important 4 (1) 5 (1) 4 (0)
25. I believe that code blues in the OR/PAR at VGH are effectively run 4 (1) 3 (1) 4 (1)
* Reported as median (interquartile range) according to 5 point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral,
4 = agree, 5 = strongly agree). N/A = question not asked.

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Table 3. Crowd control, previous code blue training, and the use of simulation for education.
Statement OR Nurses PAR Nurses Anesthesiologists
n = 22 n = 25 (n = 19
In my experience there are 95.5% 80% 84.2%
too many people in the
room during code blues
I have completed previous 45.5% 92% 36.8%
code blue training
I have previously used a 13.6% 72% 42.1%
patient simulator for code
blue training

*Responses dichotomized and reported as percentage of responses indicating "agree" and "strongly agree"
with the respective statements.

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Table 4. Open-ended Responses.

(Top 3 responses reported with number of responses in brackets)

Question OR Nurses PAR Nurses Anesthesiologists

The reason for poorly run 1. Poor communication ("MD’s 1. No leader identified (17) 1. Too many people in the
codes at my hospital are: assumed we knew what room/Patient factors
was going on") (10) /Unclear leader (12)
2. Poorly defined roles for 2. Too many people in the 2. Poor communication (4)
team members (5) room (15)
3. Too many people in the 3. No role designation (2) 3. Fixation errors/poor role
room (5) delegation (3)
My anxiety during a code 1. Lack of training, not 1. Lack of training, not 1. Patient’s outcome (7)
blue comes from: knowing what to do (10) knowing what to do (11)
2. Not knowing who to listen 2. Performance anxiety (6) 2. Concern over reason for
to (7) code being a personal error
(3)
3. Performance Anxiety/too 3. Too many people in
room/angry doctor
shouting orders (5)
How to improve code 1. More training sessions (22) 1. More training 1. More training
blue team performance at sessions/mock codes (21) sessions/mock codes (7)
my hospital:
2. Improving communication 2. Improve leadership from 2. Decreased number of
skills among team anesthesiologist (8) people in the room (6)
members/ better
leadership from
anesthesiologist (7)
3.Crowd control/more 3.Crowd control/more 3. Better leadership/
debriefing (6) debriefing (6) communication/role
identification (3)
The best modality of the 1. Simulation (20) 1. Simulation (20) 1. Simulation (8)
code blue team to
practice and learn is:
2. Case-based learning (8) 2. Case-based learning (10) 2. Case-based learning (8)

Hurdles to my 1. Time constraints (19) 1. Time constraints (15) 1. Time constraints (9)
participation in code blue
training sessions are:
2. Training is not available (4) 2. Performance anxiety/ 2. Performance anxiety (2)
Monetary compensation (5)
3. Monetary compensation (4)

Nurses could help team N/A N/A 1. Improved communication of

performance during code their roles to team leader
blues by: (12)
2. Improved documentation
(5)
3. More training mock codes
(2)

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Nurses strongly agreed that the the anesthesiologist Leadership and Communication
should be the leader of the code blue. However,
An effective leader is of paramount importance in
nurses in both the operating room and recovery
the functioning of the code blue team.
room noted that in many of their experiences it was
often difficult to identify the leader of the code . A recent study noted that a 10-minute period of
Nursing staff noted that anesthesiologists needed to instruction in leadership skills improved resuscitation
improve on announcing the drugs being skills of medical students in a simulated code blue
2
administered during crisis situations so that the environment. These instructions not only improved
recording nurse could document them accurately. resuscitation skills but also led to more rapid and
Interestingly, most anesthesiologists felt that they sustained CPR performance – a factor which has
clearly announced the drugs given during the code been stressed as one of the most important changes
blue to the recording nurse. in the revised ACLS guidelines. Leadership instruction
included: deciding what to do, telling your colleagues
Anesthesiologists
what they should do, making short, clear statements,
In contrast to what was noted by nurses, and ensuring adherence to the ACLS algorithm.
anethesiologists said that they clearly announced
One suggestion to help improve leadership and
their role and were easy to identify as the leader of
communication from the anesthesiologist during
code blue situations in the OR and PAR.
crises may come from the ‘SBAR’ pneumonic, which
Anesthesiologists believed that debriefing following
is used on hospital wards for patient handover and
a code blue took place more often than nursing staff
communicating critical patient information between
reported and fully supported the use of debriefing 7,8
healthcare professionals. The letters 'SBAR' stand
after a crisis situation. Few anesthesiologists had
for: Situation, Background, Assessment, and
attended code blue training sessions or had used
Recommendations, and is well known in the medical
patient simulators for learning. Anesthesiologists
education literature. In contrast to previous models
also suggested that nurses needed to improve the
using ‘SBAR’ for handing over care for patients, we
communication of their role to the team leader
would suggest that anesthesiologists could use this
during a crisis.
technique in an emergency situation as follows:
Both nursing staff and anesthesiologists strongly
After inducing a patient in the operating room and
agreed that too many people attending the code
noting profound hypotension and lack of a pulse the
blue with no assigned role was a real issue that
anesthesiologist announces to the operating room:
needed to be addressed in both the operating room
and post-operative recovery unit. Both groups Situation: “I need everyone’s attention, we have a life
agreed that "code blues are effectively run at our threatening emergency here, Patrick (nurse) please
hospital". call a code blue immediately."

Discussion Background: "We have a 53 year old man who

presented with a perforated viscous in the
The results of this questionnaire provide insight into emergency department who is now in a pulses
factors influencing the most critical, life-threatening electrical activity arrest post-induction."
situations in the OR and PAR: code blue
resuscitations. Areas that were singled out as critical Assessment: "I think this is likely due to the patient’s
for optimal performance in a code blue scenario overwhelming sepsis and a result of a relative
were: effective leadership with clear communication anesthetic overdose with induction."
between team members, coordinated team Recommendation: "Dr. Keegan (staff surgeon) and
functioning, and crowd control. Post-resuscitation Dr. Coppin (resident surgeon) please start CPR
debriefing was also identified as an area requiring immediately while I administer a fluid bolus and
improvement. draw up epinephrine to support his blood
pressure…."

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Canadian Medical Education Journal 2012, 3(1)

This approach has the three-fold effect of increasing Nurse Training

situational awareness among team members:
A comprehensive review of the literature was
establishing a chain of command, clearly identifying
performed to assess nurses' knowledge and skill
the anesthesiologist as the resuscitation leader, and
retention following cardiopulmonary resuscitation
outlining a plan with identified team members 11
training. Twenty-four studies met inclusion criteria
performing specifically delegated tasks. As noted in
and were included in the final results. The results
our survey, operating room nurses believed that
indicate that nurses benefited from practicing
poor communication resulted from anesthesiologists
commonly seen arrest scenarios using simulation.
assuming that nurses know what was the cause and
treatment of the arrest, where this was often not the Current evidence supports the need for ACLS
case. The regular use of ‘SBAR’ throughout the training for all critical care nurses. Previous studies
resuscitation would ensure that nursing staff not also have demonstrated that skill and knowledge
only understand their role in resuscitation but also degradation is common and to keep skills effective
the code leader’s assessment and intended plan of and patients safe, an ongoing training program for
12
action – all identified in our survey as being keys to resuscitation teams is essential among nurses. It
successful team performance during resuscitation. has been suggested that the use of 'surprise' mock
codes are key to improving team performance
With respect to educational modality, nurses
during actual emergency situations both at a
strongly supported simulation as the preferred 14
departmental and hospital level.
modality to practice code blue training, whereas
anesthesiologists noted both case-based learning How to Get Started with Team Training: Team Task
and simulation equally as the preferred learning tool. Analysis
Previous studies have suggested that “anxiety about Team task analysis is a procedure for determining
performing in front of peers is the largest hurdle for the operational skills needed for the smooth
anesthesiologists participating in simulation-based 14
coordination of a team. After identification of
9
training exercises”. these components, the team can then practice and
Coordinated Team Function and Team Training learn the requisite knowledge, skills and behaviours
necessary to improve performance (Figure 1).
Training is defined as the acquisition of knowledge,
skills and behaviours that lead to an improvement in Figure 1. Educational Initiative Flow Chart.
performance in a particular domain. Salas et al.
completed an extensive, cross-disciplinary meta- Initiative
analysis examining whether team training translates for change
into improved team performance. Using rigorous
inclusion criteria, 45 primary studies were included
in the analysis, which included a total of 2650 teams Team task analysis
from such diverse backgrounds as the military, (e.g.: survey,
10 feedback
aviation, and the business sector. Eighty of the
teams included in the review were from the field of
medicine. The findings of the analysis suggest that Skills, behaviour or
team training accounted for approximately 12% to knowledge requiring
19% of the variance in examined outcomes. Salas et improvement
al. suggest that this was likely an underestimate of
the benefit of team training on subsequent
performance. Salas et al. go on to note that: "given Educational initiative to
the heightened interest in team training in health improve performance
care, change agents in health care institutions should
utilize this information to bolster their argument for
implementing such training."

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Canadian Medical Education Journal 2012, 3(1)

Our questionnaire can be thought of as a team task Suggestions to help with crowd control in our
analysis for OR and PAR nurses and anesthesiologists questionnaires included restricting the number of
with respect to team training and code blue people allowed to enter the operating room,
management at our hospital. The training that creating a daily code blue team, and self-awareness
follows this initial fact-finding survey should education whereby people attending code blues who
incorporate guidelines for effective team training are not directly involved in the resuscitation effort
which include: pre-practice tools, emphasis on could help to reduce the number of people who are
teamwork components identified in the team task acting as a distraction to the resuscitation team by
analysis, ensure that training facilitates adaptive removing themselves and others from the area.
behaviours, promotes a safe learning climate where
Debriefing
team members can voice their opinion freely,
ensures team members apply closed loops of The use of debriefing as a learning tool was seen to
communication. and is followed by a post-training show dramatic improvements in team performance
14
evaluation of the training intervention. of an operating room team learning a new method
16
of minimally invasive cardiac surgery. Given all the
As noted in our survey findings, most nurses and
educational, emotional, and team building benefits
doctors cite 'time pressure' as the biggest hurdle to
of effective debriefing, it was surprising to find that
their participation in code blue training sessions.
both nursing staff and anesthesiologists rarely
Therefore, to improve delivery of team training to
participated in debriefing sessions after code blue
nurses and anesthesiologists, sessions should be
emergencies (Table 2). Both groups would like to see
built into nurses' and doctors' continuing education
debriefing sessions occur more regularly. Collecting
and mandatory rounds time. This has been
all team members together and organizing a team
accomplished at the authors' institution by
debriefing session should be the responsibility of the
scheduling mock codes in the OR and PAR during
team leader and this is something that we have
weekly anesthesiology and nursing rounds.
started to employ at our institution. As with all
Anesthesiologists volunteer to lead mock codes in
feedback, feedback during debriefing sessions
the company of an anesthesiologist moderator and
should be courteous, relevant for the learner, given
an experienced OR or PAR nurse. Sessions are built
in manageable amounts, and solicited from all team
upon a safe, no-fault learning environment and the
members.
use of repetitive practice of commonly encountered
emergencies and procedures in each unit. Each Future Directions
session is learner-centred with sufficient time to At our institution, we have used the results of this
complete a debriefing process to help plan future survey to plan monthly, multidisciplinary mock code
mock code blue training sessions. blue training sessions for our anesthesiologists, OR
Crowd Control and PAR nurses that are relevant to our daily
practice and educational needs. We invite
Having too many responders in the OR and PAR
respiratory therapists, surgeons and residents to
during code blue resuscitation was identified by both
participate when they are available. Using the
nurses and anesthesiologists as hindering team
feedback we have received in our survey, our
performance. In a previous study of 30 hospital ward
scenarios and mock code blue sessions aim to
nurses, too many individuals present at
improve the anesthesiologist’s announcement of
resuscitations was identified as a significant barrier
15 taking the leadership role during the resuscitation,
to effective team functioning. There is currently
the support of this leadership role by other
little data in the literature on how large crowds of
anesthesiologists attending the resuscitation, the
onlookers with no assigned role at code blue
use of the ‘SBAR’ technique at the beginning, middle,
resuscitations may affect team performance and
and end of the emergency, improving
ultimately patient outcome.
communication between code blue team members,
and having strategies to ensure the ideal number of

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Canadian Medical Education Journal 2012, 3(1)

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15. Hemming TR, Hudson MF, Durham C, Riches K.

Effective resuscitation by nurses: perceived barriers
and needs. J Nurses in Staff Dev. 2003;19(5):254-259.

16. Edmondson W, Bohmer R, Pisano G: Speeding up

team learning. Harvard Bus Rev. 2001 Oct:125-132.

17. Joint Commission on Accreditation of Healthcare

Organizations. Sentinel event statistics, June 29, 2004.
Available at:
www.jcaho.org/accredited+organizations/ambulatory
+care/sentinel+events/sentinel+events+statstics.htm.

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APPENDIX 1
VGH OR/PAR Nursing Code Blue Questionnaire
Please help us assess the experience of VGH OR & PAR nurses with respect to code blues
All responses will be kept confidential and you may withdraw your participation at anytime

Background Information
1. I work in the: OR PAR (Please circle)
2. How long have you been nursing in the OR/PAR at VGH? _________
3. Approximately how many code blues have you observed, or participated in, at VGH? _________
Roles During Code Blues

Strongly Disagree Neutral Agree Strongly

Disagree Agree
4. During a code blue I have a clear understanding of my role in the
OR/PAR.
5. I feel comfortable announcing my role and communicating with the
team during a code blue.
6. It is easy to identify who is in charge during a code blue situation in the
OR/PAR
7. The anesthesiologist should most often be the code blue leader in the
OR/PAR.
8. The effectiveness of chest compressions is clearly being assessed in most
cardiac arrest situations.
9. I believe a nursing role during code blues should be assessing the
effectiveness of chest compressions during cardiac arrest.
10. Crowd control is an issue at code blues in the OR/PAR.

11. I believe a nursing role during code blues should be crowd control.

12. I feel comfortable drawing up resuscitation drugs in a code blue.

13. I feel comfortable acting as the events recorder during a code blue.

14. I feel comfortable using the defibrillator during a code blue.

15. During a code blue I am most concerned about making a mistake.

16. While part of a code blue in the operating room, I feel comfortable
asking for help.
17. The anesthesiologist clearly announces the drugs they administer during
a code blue to the nursing events recorder.
18. I believe that code blues in the OR/PAR at VGH are effectively run.

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Canadian Medical Education Journal 2012, 3(1)

Code Blue Training

Strongly Disagree Neutral Agree Strongly

Disagree Agree
19. Code blue training should be a mandatory part of my continuing
education.
20. Patient simulators should play an important role in critical incident
training for operating room and PAR nurses.
21. Crisis Resource Management training (communication, teamwork,
designation of roles during emergency situations etc) should be a
mandatory part of my continuing education.
22. Code blue training should be multi-disciplinary, including nursing,
anesthesiology, and surgery.
23. Having the opportunity to practice multi-disciplinary, team-based code
blue scenarios at my institution may improve patient outcomes.
24. Having the opportunity to practice multi-disciplinary, team-based code
blue scenarios at my institution would make me more comfortable in a
code blue situation.

25. I feel anxious about participation in mock code blue scenarios in the
OR/PAR.

26. I would feel comfortable participating in a code blue scenario with my

nursing colleagues observing me.
27. I would feel comfortable participating in a code blue scenario with my
colleagues also participating alongside me.
28. I believe that team debriefing after code blues is important.

29. At previous codes that have gone poorly, I would suggest that a major factor for this was: (please list)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
30. My anxiety during code blues comes mostly from: (please list)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
31. I have previously used a patient simulator for code blue training
Yes No

32. I have previously completed ACLS training

Yes No

33. I have previously participated in code blue training

Yes No

34. Ideally, how many code blue training sessions should OR nurses participate in per year? ______ /yr

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Canadian Medical Education Journal 2012, 3(1)

35. The biggest hurdle for my participation in code blue training is:
Time constraints Monetary compensation Performance anxiety Not Useful Other (please list)

36. What is the best modality to teach code blue training?

Lecture Self Directed Case Based Discussion Simulation Other (Please specify)

37. After a code blue in the OR/PAR, the code team involved undergoes a debriefing process recapping the events
and allowing all team members to express concerns:
Never Rarely Sometimes Often Always

38. My age is: __________

39. My gender is: Male Female

40. Please provide three suggestions on how operating room code blues at VGH can be improved:
1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

3. _________________________________________________________________________________________

41. Please offer any other feedback pertaining to code blue CME training that you think may be beneficial:

Thank you for participating in our survey!

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 Canadian Medical Education Journal 2012, 3(1)

APPENDIX 2

VGH Anesthesiologist Code Blue Questionnaire

Please help us assess the experience of VGH Anesthesiologists with respect to code blues
All responses will be kept confidential and you may withdraw your participation at anytime

Background Information:
1. How long have you been an anesthesiologist at VGH? _________
2. Approximately how many OR code blues have you observed or participated in at VGH? _________

Roles During Code Blues

Strongly Disagree Neutral Agree Strongly

Disagree Agree
3. During a code blue I have a clear understanding of my role in the
operating room/PAR.
4. I feel comfortable announcing my role and communicating with the
team during a code blue.
5. I believe the OR team can easily identify that the anesthesiologist is in
charge during an OR code blue.
6. While part of a code blue in the operating room, I feel comfortable
asking colleagues for help.
7. I believe a nursing role during code blues should be assessing the
effectiveness of chest compressions during cardiac arrest.
8. Crowd control is an issue at code blues in the OR/PAR.

9. I believe a nursing role during code blues should be crowd control.

10. I feel comfortable having nurses draw up resuscitation drugs during a

code blue.
11. I announce the drugs I administer during a code blue to the nursing
events recorder.
12. I feel comfortable operating the defibrillator during a code blue.

13. During a code blue I am most concerned about making a mistake.

14. When I call a code, I feel comfortable with the amount of help I receive
from my colleagues.
15. I believe that code blues in the OR/PAR at VGH are effectively run.

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 Canadian Medical Education Journal 2012, 3(1)

Code Blue Training

Strongly Disagree Neutral Agree Strongly

Disagree Agree
16. Code blue training should be a mandatory part of my continuing
education.
17. The use of patient simulators could play an important role in my critical
incident training as an anesthesiologist.
18. Crisis Resource Management training (communication, teamwork,
designation of roles during emergency situations etc) should be a
mandatory part of my continuing education.
19. Code blue training should be multi-disciplinary, including nursing,
anesthesiology, and surgery.
20. Having the opportunity to practice multi-disciplinary, team-based code
blue scenarios at my institution would make me more comfortable in a
code blue situation.
21. Having the opportunity to practice multi-disciplinary, team-based code
blue scenarios at my institution may improve patient outcomes.
22. I feel anxious about participation in mock code blue scenarios in the
OR/PAR.
23. I would feel comfortable participating in a code blue scenario with my
anesthesia colleagues observing me.
24. I would feel comfortable participating in a code blue scenario with my
anesthesia colleagues also participating alongside me.
25. I believe that team debriefing after code blues is important.

26. At previous codes that have gone poorly, I would suggest that a major factor for this was: (please list)

27. My anxiety during code blues comes mostly from: (please list)

28. I have previously used a patient simulator for code blue training
Yes No

29. I have previously participated in code blue training

Yes No

30. Ideally, how many code blue training sessions should anesthesiologists participate in per year? ______ /yr

31. The biggest hurdle for my participation in code blue training is:
Time constraints Monetary compensation Performance anxiety Not Useful Other (please list)

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Canadian Medical Education Journal 2012, 3(1)

32. What is the best modality to teach code blue training?

Lecture Self Directed Case Based Discussion Simulation Other (Please specify)

33. In my experience, the number of people in the OR during code blues is:
Far too few Too few About Right Too Many Far too many

34. After a code blue in the OR/PAR, the code team involved undergoes a debriefing process recapping the events
and allowing all team members to express concerns:
Never Rarely Sometimes Often Always

35. My age is: __________

36. My gender is: Male Female

37. Please provide three suggestions on how operating room code blues at VGH can be improved.
1. ____________________________________________________________________________________________
2. ____________________________________________________________________________________________
3. ____________________________________________________________________________________________

38. Please provide three suggestions on how nursing staff in the operating room during code blues at VGH can be
more helpful.
1. ____________________________________________________________________________________________
2. ____________________________________________________________________________________________
3. ____________________________________________________________________________________________

Thank you for participating in our survey!

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