CODE BLUE EVALUATION

(Life Threatening Medical Emergency)

REFER TO SPP 15-02 MEDICAL EMERGENCY POLICY

 Drill  Actual Incident 911 CALLED:  YES NO

DATE: _________________________________ SITE/LOCATION: _______________________
TIME CALLED: _________________________ ANNOUNCEMENT STOPPED: ____________
TIME NURSE RESPONDED: _____________ TIME STAFF RESPONDED: ______________
TOTAL ELAPSED TIME FOR STAFF TO RESPOND: _____________minutes.

NAME OF INDIVIDUAL (if known): _____________________________________________________

TYPE OF MEDICAL EMERGENCY:

 Seizure  Choking/Blocked airway  Unresponsive
 Fall  Stroke/Heart Attack  Other ________________________
Comments: ____________________________________________________________________

CHART SENT FOR AND ARRIVED/AVAILABLE:  YES  NO

Comments: ____________________________________________________________________

EMERGENCY EQUIPMENT:
Arrived at scene of emergency within 2 minutes  YES  NO
Blood Pressure cuff/Stethoscope available  YES  NO
Oxygen functioning and on  YES  NO
EMERGENCY CARE:
Vital Signs: B/P: __________ Pulse: ____________ Resp: ____________
Medications given: ____________________________________________________________

AUTOMATIC EXTERNAL DEFIBRILLATOR (AED) USED:  YES  NO

CARDIOPULMONARY RESUSCITATION:
CPR certified staff at scene  YES  NO
CPR initiated  YES  NO
Comments: __________________________________________________________________

CAREGIVERS NOTIFIED BY: ________________________________________________________

EVALUATION:
 Appropriate response/no issues encountered
 Appropriate response/issues encountered (document below)
 Inappropriate response (document below)

DESCRIBE THE MEDICAL EMERGENCY AND OUTCOME (Use reverse side if necessary):
______________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________

___________________________________ ______________________
Form completed by: Date:
• REPORT IS TO BE COMPLETED AND RETURNED TO THE SAFETY OFFICER AT 92ND STREET WITHIN 24 HOURS.
• BOLDED ITEMS ARE APPLICABLE WHERE CCN NURSING STAFF ARE LOCATED (92nd ST., Waukesha)

Reviewed by Medical Director:

CODE BLUE _______________________________ Date: _________
08/14
 EVALUATION OF CODE BLUE

1. A code blue drill will be performed at least annually at each CCN location. Code blue drills are
coordinated by the Safety Officer and with the appropriate CCN site/program
supervisor/manager.

2. Evaluation of an actual medical emergency occurring at a CCN location will meet the
requirement of a drill.

3. The site/program supervisor/manager will complete the appropriate sections of the code blue
evaluation form for all medical emergencies. At sites/programs that have CCN nursing staff, the
CCN nurse will complete all sections of the code blue evaluation form.

4. An Incident/Accident/Matter of Record Form (CCN 048) or Workers Compensation Injury

Report (CCN 275) should be completed and forwarded to the appropriate SLT member.

5. All medical emergencies need to include a description of the incident, diagnosis made,
treatment provided, medications administered and recommendations for follow-up care.

6. If a medical emergency requires the use of the Automatic External Defibrillator (AED) the
Safety & Compliance Coordinator or the Safety Officer must be contacted to assess the
unit and replenish used items.

7. All reports are to be reviewed and signed by the supervisor/manager of the site/program where
the medical emergency or drill occurred.

8. Staff at community based sites must call the Safety Officer at 92nd street (479-9296) to report the
medical emergency immediately following the incident and proceed with the written report.

9. The Executive Officer and the Division Senior Leadership Team member must be informed of
all medical emergencies immediately following the incident.

10. All medical emergency or Code Blue evaluation forms must be forwarded to the Safety Officer
at 92nd Street.

11. Site Supervisor/Manager is responsible for insuring that the drills are conducted and steps are
taken to rectify any deficiencies identified during the drill/incident.

12. Reports are summarized and recommendations for improvement are reported to the CCN
Administration through the Environment of Care Committee and the Staff Quality Committee.

Continued from the front of form:

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CODE BLUE
08/14