Evaluation of Code Blue Response Efficiency in Hospitals: A Multidisciplinary Clinical Performance Study Across Emergency, Anesthesia, Operating Room, Pharmacy, Clinical Nutrition, Health Information, and Health Security Services
Abstract
Background In hospital cardiac arrest (IHCA) remains a critical emergency associated with high mortality and significant neurological morbidity. Its incidence ranges from 1–6 per 1000 hospital admissions, emphasizing the need for rapid, coordinated intervention systems such as Code Blue teams. Tertiary hospitals face additional challenges due to high patient volume, case complexity, and resource limitations, especially in low and middle income countries.
Aim This study aimed to evaluate Code Blue activations in a tertiary teaching hospital over six years, analyzing frequency, patient characteristics, Early Warning Score (EWS), palliative burden, and clinical outcomes to identify improvement opportunities in emergency response and patient safety.
Methods A descriptive, retrospective review of Code Blue events was conducted. Data included demographic characteristics, activation timing, ROSC outcomes, EWS values, and palliative scores. Intensive care unit arrests were excluded to focus on ward based events.
Results The overall ROSC rate was 17.7%, aligning with rates reported in comparable middle income countries but influenced by patient acuity and arrest etiology. Most patients presented with high EWS at admission, indicating significant physiological instability, and many also had high palliative scores, reflecting advanced chronic disease. Sepsis emerged as a major contributor to mortality, highlighting suboptimal early recognition and inconsistent protocol adherence.
Conclusion Code Blue activations were frequently associated with acute physiological deterioration and severe chronic illness, underscoring the need for strengthened early warning systems, structured sepsis management, improved palliative integration, and multidisciplinary coordination. Targeted quality improvement interventions may reduce preventable cardiac arrests and enhance survival outcomes.
Full text article
References
Schluep M, Gravesteijn BY, Stolker RJ, Endeman H, Hoeks SE. One-year survival after in-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2018;132:90–100. doi:10.1016/j.resuscitation.2018.09.001
Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-hospital cardiac arrest: a review. JAMA. 2019;321(12):1200–1210. doi:10.1001/jama.2019.1696
Gong XY, Wang YG, Shao HY, et al. A rapid response team is associated with reduced overall hospital mortality in a Chinese tertiary hospital: a 9-year cohort study. Ann translat Med. 2020;8(6):317. doi:10.21037/atm.2020.02.147
Deb R, Alam MI, Patil AT, Razvi S, Reddy KS, Paul R. Innovating the way medical emergency teams function, can this lead to better patient outcomes? An attempt to understand this better. Intens Care Med Exp. 2015;3(S1):1–2. doi:10.1186/2197-425X-3-S1-A144
Brand RA. Standards of reporting: the CONSORT, QUORUM, and STROBE guidelines. Clin Orthop Relat Res. 2009;467(6):1393–1394. doi:10.1007/s11999-009-0786-x
Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation. 2013;84(4):465–470. doi:10.1016/j.resuscitation.2012.12.016
Giwangkancana GW, Anina HN, Sukandar H. Predicting end-of-life in a hospital setting. J Multidisciplinary Healthcare. 2024;31:619–627. doi:10.2147/JMDH.S443425
Edwards JM, Nolan JP, Soar J, et al. Impact of the COVID-19 pandemic on in-hospital cardiac arrests in the UK. Resuscitation. 2022;173:4–11. doi:10.1016/j.resuscitation.2022.02.007
Gupta K, Girotra S, Nallamothu BK, Kennedy K, Starks MA, Chan PS. Impact of the three COVID-19 surges in 2020 on in-hospital cardiac arrest survival in the United States. Resuscitation. 2022;170:134–140. doi:10.1016/j.resuscitation.2021.11.025
Alao DO, Mohammed NA, Hukan YO, et al. The epidemiology and outcomes of adult in-hospital cardiac arrest in a high-income developing country. Resusci Plus. 2022;10:100220. doi:10.1016/j.resplu.2022.100220
Ocen D, Kalungi S, Ejoku J, et al. Prevalence, outcomes and factors associated with adult in hospital cardiac arrests in a low-income country tertiary hospital: a prospective observational study. BMC Emerg Med. 2015;15(1):1–6. doi:10.1186/s12873-015-0047-0
Desai R, Parekh T, Patel U, et al. Regional trends in in-hospital cardiac arrest following sepsis-related admissions and subsequent mortality. Resuscitation. 2019;143:35–41. doi:10.1016/j.resuscitation.2019.08.007
Duazo C, Hsiung JC, Qian F, et al. In-hospital cardiac arrest in patients with sepsis: a national cohort study. Front Med. 2021;8:731266. doi:10.3389/fmed.2021.731266
Rossi S, Shields A, Gauge N, et al. Employing quality improvement methodology in sepsis: an electronic sepsis order set further improves compliance with the surviving sepsis campaign 3-hour bundle. Critical Care. 2014;18(S1):1–82. doi:10.1186/cc13553
Saran S, Gurjar M, Azim A, Maurya I. Structural risk factors for hospital-acquired infections in intensive care unit. HERD Health Env Res Des J. 2021;14(2):328–336. doi:10.1177/1937586720978825
Gerry S, Bonnici T, Birks J, et al. Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology. BMJ. 2020;369. doi:10.1136/bmj.m1501
Jang JG, Hur J, Hong KS, Lee W, Ahn JH. Prognostic accuracy of the SIRS, qSOFA, and NEWS for early detection of clinical deterioration in SARS-CoV-2 infected patients. J Korean Med Sci. 2020;35(25).
Rochmawati E, Wiechula R, Cameron K. Current status of palliative care services in Indonesia: a literature review. Int Nurs Rev. 2016;63(2):180–190. doi:10.1111/inr.12236
Arisanti N, Sasongko EP, Pandia V, Hilmanto D. Implementation of palliative care for patients with terminal diseases from the viewpoint of healthcare personnel. BMC Res Notes. 2019;12(1):1–5. doi:10.1186/s13104-019-4260-x
Aziz F, Paulo MS, Dababneh EH, Loney T. Epidemiology of in-hospital cardiac arrest in Abu Dhabi, United Arab Emirates, 2013–2015. Heart Asia. 2018;10(2):e011029. doi:10.1136/heartasia-2018-011029
Authors
Copyright (c) 2025 Raneem khalid Altuwayrish, Mohammed Mesfer Mohammed Aldawsari, Minahi Fehaid Musaibeeh Alotaibi, Turki Bader Saleh Alshammari, Fadi Awadh Hamoud Almutairi, Amnah Ahmed Saleh, Sharifah Abdulrahman Zarbatan, Talal Saud Hulayyil Alanazi, Haasan Ali Ali Mashyakhi, Abdullah Solan Mhnashi
This work is licensed under a Creative Commons Attribution 4.0 International License.