Key Strategies for Code Blue Response in the OR

More than half of patients who experience cardiac arrest in the operating room don’t survive. This high mortality rate raises a crucial question: When a Code Blue is called during surgery, how well does your team respond?

A group of resuscitation and perioperative experts set out to improve Code Blue response in the OR through a collaborative approach that emphasized resuscitation, clinical practice, and quality improvement.

At Children’s Hospital of Orange County (CHOC), part of Rady Children’s Health in Orange, CA, a nurse-led team launched a focused initiative to improve intraoperative Code Blue response. The effort brought together experts in resuscitation, perioperative practice, and quality improvement to create a dual-response model tailored to the OR environment.

How Can You Improve Code Blue Outcomes in the OR?

The team partnered with OR staff to conduct a gap analysis of intraoperative Code Blue events—of which the hospital averages about six annually. They reviewed several years of cardiac arrest cases and uncovered significant opportunities to strengthen the response process. For example:

• Only 6% of cases used CPR feedback devices that give real time feedback on the rate and depth of compressions, despite this being an organizational standard.
• Just 47% of events had code documentation, limiting the ability to review and learn from events.
• Code teams often lacked crowd control and clearly defined roles during resuscitation efforts.

To address these challenges and improve overall efficiency, the team turned to research supporting a dual Code Blue response—an approach where OR-based and hospital-wide cardiac arrest teams train and respond together.

This work is based on a multidisciplinary model for patient cardiac arrest response that is applied frequently in emergency and resuscitation care. “We wanted to ensure clear communication, reduce chaos, and keep the surgical workflow as undisturbed as possible,” said Marissa Tierney, RN, MSN, PCNS-BC, CCRN, Resuscitation, Quality & Research RN at CHOC, who helped design the dual-response approach.

What’s the Difference Between Code Blue and Rapid Response in Surgery?

Not all clinical emergencies in the OR call for the same type of response. Understanding the difference between a Code Blue and a Rapid Response is essential for nurses working in the operating room.

• Code Blue in Surgery: A Code Blue is typically called when a patient experiences cardiac or respiratory arrest. In the OR, this requires immediate resuscitative efforts.
• Rapid Response: A rapid response is initiated when a patient shows signs of clinical deterioration but is not yet in full arrest. The goal is early intervention to prevent escalation.

How Does a Dual Code Blue Response Work in the OR?

Step 1: Within perioperative services, a coordinated internal response is initiated immediately, with predesignated staff members assuming critical roles such as initiating CPR, documentation, preparing and administering medications, and supporting ongoing surgical needs.

Step 2: These initial responders manage the early phase of the event until the hospital-wide Code Blue team arrives. This team includes a critical care physician, pharmacist, respiratory therapist, documentarian, additional compressors, and nursing support. Each member assumes a specific role to take over resuscitation efforts, allowing the OR team to focus on the surgical needs of the patient.

This dual-response model was implemented and refined through targeted quality improvement initiatives, simulation-based training, and staff education. Since introducing the new process at CHOC, the average response time of the organization-wide code team to perioperative Code Blue events decreased from 13 minutes to 5 minutes. CPR feedback device use rose from six to 85.7 percent, and code documentation rates improved from 47 to 80 percent.

Staff feedback has highlighted significant improvements in communication, role clarity, and leadership identification during Code Blue events. According to McKinleigh Mills, MSN, RN, CPN, CNL, CNS(c), Perioperative Clinical Practice Specialist at CHOC, these changes are making a visible difference in how teams respond under pressure.

“What was once a disorganized and fragmented process has evolved into a streamlined, collaborative effort that is uniting teams to better address the complex needs of surgical patients,” Mills said.

What Are Strategies for Setting Up a Dual Code Blue Response in the OR?

To integrate their multidisciplinary resuscitation team model for a dual Code Blue response, the nurse-led team made four major changes:

1. Improve CPR Quality
   The resuscitation and simulation teams trained OR responders on how to use CPR feedback devices and interpret real-time data on compression depth and rate. After each event, this data is reviewed to evaluate performance and guide future improvements in compression quality.
2. Implemented Code Blue Simulation Training
   Simulation training in the OR brought together both perioperative and hospital-wide Code Blue responders to help the multidisciplinary team refine each step in the dual-response process. According to Jennifer Hayes, MSN, RN, CCRN-K, Resuscitation Supervisor at CHOC, this training focused on replicating real-world conditions as closely as possible. “Another was creating scenarios in which they mirror real-life events,” Hayes said. “This includes limiting the room to only essential personnel for the case, equipment placed in the room during a surgery and placing all mock emergency equipment in their typical places.”
3. Assign Internal Code Roles by Shift
   Perioperative team members are assigned specific Code Blue roles at the start of each shift. If an emergency occurs, they receive push notifications on their work phones, prompting a rapid, coordinated internal response. This approach ensures clear role assignments and helps maintain crowd control before the hospital-wide team arrives.
4. Use a Gatekeeper Checklist for Seamless Transitions
   When the organization-wide Code Blue team enters the OR, they step into predefined roles and work in sync with the surgical team. A gatekeeper checklist ensures only essential personnel enter the operative space and includes:

• Intensivist – partners with anesthesia to run AHA algorithm
• ICU RN – connects with anesthesia to take over medications or CPR coach if anesthesia wants to give meds
• CVICU RN – takes over documentation
• ED RN – takes over code cart and supplies, as well as MTP and Rapid Infuser if needed
• Respiratory Therapist – handles airway management and runs blood gases
• Pharmacy – assist with drawing up medications
• ED Techs – compressors

Train for Intraoperative Emergencies

• Emergencies can happen at any time and perioperative teams must be prepared to take action. Is your team confident and ready to help manage a patient’s airway in an emergency? What about how to identify a cardiac arrest and know the roles responsible in a resuscitation? Refer your team to evidence-based quick guides to best practices on 10 different emergencies including airway management and cardiopulmonary resuscitation within eGuidelines+. Sign up for a free facility trial of eGuidelines+ today. 
• AORN CineMed Video Library:  Support real-world readiness with over 40 on-demand clinical videos focused on perioperative safety. Courses like Perioperative Patient Assessment and Malignant Hyperthermia help both new and experienced nurses sharpen their critical thinking and rapid-response skills.
• Periop 101: A Core Curriculum™ Cesarean Section: Prepare new and returning labor and delivery nurses for cesarean sections with this 23-module perioperative nurse training program. The course includes a learning module on obstetrical emergencies and features scenario-based elements that support practical application of didactic online learning and promotes critical thinking. Learn more about the Periop 101 Program Package and how it benefits both novice and experienced RNs on your team.
• ASC Academy: A Guide to Emergency Drills: Arm outpatient surgery leaders with the knowledge and skills to plan, conduct, and evaluate the effectiveness of emergency drills. This guide includes turnkey tools to prepare your team for: cardiac arrest, fire, local anesthetic systemic toxicity, active shooter, hospital transfer, and malignant hyperthermia.

More Code Blue & OR Safety Insights

• 5 Tips on How to Avoid Mistakes During a Code Blue in the OR
• Enhancing Team Response to Intraoperative Emergencies
• Navigating an Airway Emergency as an RN Circulator