APP-059-V4-Code Blue

Ministry of Health
King Saud Medical City

Total Quality Management
Riyadh, Kingdom of Saudi Arabia
ADMINISTRATIVE POLICY AND PROCEDURE(APP)

POLICY OWNER: CPR Committee
POLICY TITLE/DESCRIPTION: POLICY NUMBER AND VERSION:
Code Blue APP-KSMC-059-(V4)
EFFECTIVE DATE: 23 May 2016 REPLACES NUMBER AND VERSION:
APP-KSMC-059-(V3)
REVISION DUE: 22 May 2019 NUMBER OF PAGES: 16
APPLIES TO: All Medical & Nursing Staff of King Saud Medical City, Riyadh.
1. STATEMENT OF PURPOSE:
1.1 To ensure efficient and effective code blue by a designated code blue team.
1.2 To ensure that there are agreed mechanisms to coordinate inter-departmental
personnel in a code blue situation; in order that all resuscitative measures are taken
in a professional and appropriate manner, providing the optimum of care to bring
about (where possible) successful resuscitation.
1.3 Provide advisory and education to all KSMC departments & healthcare providers
for proactive preventive measures to decrease the CPR rate through the implementation
of the guidelines of the Saudi Heart Association in collaboration with the American Heart
Association.
1.4 Monitor appropriate KSMC staff medical emergency training by conducting education
MOCK CODE Drills in the different areas of KSMC.
2. DEFINITION(S):
2.1 “Code Blue”- is the name given to an alert call for immediate assistance in
Cardiac Arrest or Respiratory Arrest.
2.1.1 Adult Code Blue -applies to all (over the age of 14 years) anywhere in
the hospital.
2.1.2 Pediatric Code Blue - applies to all children (1 day- (14) years) anywhere
in the hospital except NICU, PICU, ER.
2.1.3 Neonatal Code Blue – applies to all neonates (0-28 Days) anywhere in the
hospital.
2.2 Code Blue Team:
Is a multidisciplinary team which responds to Code Blue Calls and to ensure that
the patient receives optimum emergency resuscitative intervention. The members
of the Code Blue team will be acquired with pagers and over head announcement
that are programmed for the Code Blue Alerts and should respond to ALL alerts.
“ SEE APPENDIX A. PROTOCOL FOR CODE BLUE PAGING SYSTEM”
2.2.1 Team Members Include:

A. Anesthetist on Call
Anesthetist response to Code blue calls will be as follows:
Regular Working days (Sunday – Thursday):
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07:30 – 03:30 hours - Anesthetist on Duty

03:30 -- 07:30 hours - Anesthetic Registrar/Resident on Call
“Public Holidays & Weekends (Friday & Saturday)-Anesthetic
Registrar/Resident on Call
The attending Anesthetist (as detailed above) will respond to any
Code alert and assume responsibility for the management until the
Internal Medicine Physician or Pediatrician arrives. Thereafter
participate as required to stabilize the patient’s Cardio-Pulmonary
status.
B. Internal Medicine Physician on call /ACLS Certified: who should
respond to all Adult Code Blue alerts and assumes responsibility for the
overall Management of the Code and termination of the code and as a
Team Leader.
C. Medical Resident on Call: who shall respond to all adult Code Blue
alerts and participate according to the needs of the situation under the
direction of the Internal Medicine Physician or Anesthetist (according to
who is present and directing the procedures).
D. Pediatrician On call PALS certified :who shall respond to all
Pediatric Code Blue calls and assumes responsibility for the overall
management of the Code.
E. Pediatric Resident on Call: who shall respond to all Pediatric Code
Blue alerts and participate according to the needs of the situation under
the direction of the Pediatrician or Anesthetist (according to who is
present and directing the procedures).
F. Respiratory Therapist on Duty: who shall assume the Responsibility
for respiratory support until the Anesthetist on the scene, thereafter shall
assist the Anesthetist.
G. Nursing Manager on Duty:

1. Designates the member of nursing staff who should record
the events; time of code; length of code; medications
dosage and times; defibrillation voltage used etc.
2. Administratively control the number of non-medical personnel and
visitors in the code area. The personnel should be limited to those
essential for the management of the code.
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3. Call for support personnel if and when needed.

4. Arrange with ICU for the patient’s transfer after successful
resuscitation.
5. Liaise with family members utilizing the nurse translator/patient
relation's officer, social worker, security as appropriate to the
situation.
H. Assigned Nurse / Compressor (RN) on Duty
1. Assist in the resuscitation, assuming duties as the following:
1.1 He/she will announce for the arrest to the nearby nurse, who will
inform charge nurse and activate the whole team.
1.2 He/she will press timer on monitor.
1.3 He /She will commence chest compressions; The Compression
Nurse (he/she) will provide chest compression till CPR team arrives.
1.4 Once the team leader is available, he/she will give brief note
about diagnosis and circumstances before arrest.
I. Medication Nurse (RN)

1) He/she will be responsible for IV line patency, and give
medications as per team leader orders, using a close loop
communication.
2) He/she has to take venous blood gases (VBG) and random blood
sugar immediately at time of CPR and upon team leader request if
needed.
3) If she/he encounters a problem in IV line, she has to inform the team
leader to take action.
J. Monitoring Nurse (RN)

1. To bring the Crash Cart near the bed side, attach the ECG leads to the
patient and connect to Defibrillator / Cardiac Monitor.
2. Monitoring the Rhythm and Vital Signs during the Code Blue.
3. To prepare for the intubation if needed.
K. Timer / Recorder (RN)

1) She will fill the CPR form acting as a mentor and document the
following:
1.1 Type of arrest (respiratory and/or cardiac) as determined by team
leader.
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1.2 Rhythm at time of arrest and subsequent rhythms during the

process of CPR.
1.3. Time of start of first chest compression.
1.4. Time of arrival of each life support member.
1.5. DC shock availability and function.
1. 6. Use of DC shock or not, if used the dose, time and type.
1.7. Medications given as ordered by team leader.
1.8. Time of CPR termination.
1.9. Outcome after CPR termination.
1.10 If patient revived post-resuscitation care plan.
L. Security Guard:
1. Control the scene for any violence and prevent crowding.
1.1 Take responsibility for preventing any visitors that
are not required, as directed by the team leader.
3. EQUIPMENT/MATERIAL/FORM(S):
3.1 Crash cart (Ready with Monitor)
3.2 Cardiopulmonary Resuscitation Record
3.3 Telephone / Pager
4. POLICY STATEMENT(S):
4.1 King Saud Medical City shall have a well-rehearsed life threatening emergency
response plan that works anytime, anywhere in the facility that will generate
an emergency response from the appropriate response team ( Code Blue)
to all patients in Cardiac or Respiratory arrest.
4.1.1 All patients found to be in a state of cardiac or pulmonary arrest will
have a Code blue alert except for those being documented as not to be
resuscitated (DNR) i.e., known terminal cases as defined by the
admitting physician.(Refer to APP-KSMC-060-Allow Natural Death).
4.2. It is the policy of KSMC that all healthcare providers (medical and nursing
staff) will be trained and updated in CPR procedures (BCLS-Basic Cardiac
Life Support and Advanced Life Support based on their specialty).
4.3 As per KSMC policy, it is required that code blue alert will be initiated by the
discoverer, who will initiate the cardio-pulmonary resuscitation and verbally call
for assistance. The assistant will ensure:

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APP-KSMC-059-(V3)
4.3.1"Code Blue Alert" is called by; 1970 (General Hospital)/555(Pediatric &

Maternity Hospital) and stating clearly and calmly, Name; Adult
or Pediatric Code Blue Ward and Room Number. E.g. dial 1970/555.
Ex. This is Staff Nurse Maha Adult Code Blue. 300 –B
Female Surgical Ward Room 2A
4.3.2 That the ‘Crash Cart’ and laryngoscope are delivered to the bedside,
and that it is connected to the electrical points.
4.3.3 Ensure oxygen and suction is available and operable.
4.4 Adult CPR team as per their responsibility shall follow the ACLS (Advance Life
Support) guidelines and algorithms based on the updated American Health
Association (AHA) algorithms (2010).
4.5 Pediatric CPR team shall follow the updated PALS (Pediatric Advance Life
Support) guidelines and algorithms of the American Health Association (2010)
4.6 NICU team shall be responsible to follow the updated NRP (Neonatal
Resuscitation Program) guidelines and Algorithms (2010).
4.7 Maternity Code Blue Team shall follow the updated AOLS (Advanced Obstetric
Life Support) guidelines and algorithms.
4.8 Any trauma cases need to be resuscitated shall follow the updated ATLS
(Advanced Trauma Life Support) guidelines and algorithms (2010)
4.9 Health care professionals should not perform mouth to mouth breathing. The use
of a barrier device is highly recommended, Example: face shield, pocket mask or
bag-valve mask.
4.8 Effective Chest Compression shall be performed on all victims to be able to
improve the chances of survival by following the critical characteristics of
high-quality CPR as follows:
4.8.1 Start compression within 10 seconds of recognition of cardiac arrest.
4.8.2 Push hard and push fast: Compress at a rate of at least 100 per minute
with a depth of at least 5cm (cinches for adults, approximately 5 cm
(2 inches) for children, and approximately 4 cm (1 ½ inches) for infants
with the universal chest compression –ventilations 30 : 2 ratio.
4.8.3 Allow complete chest recoil after each compression.
4.8.4 Minimize interruptions in compressions (try to limit interruptions to
≤ 10 seconds)
4.8.5 Give effective breaths that make the chest rise.
4.8.6 Avoid excessive ventilation.
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4.9 Code Blue Team members should carry out their assigned tasks, ensuring that
there is only one clear leader of the team as per the delegation of authority
process.
4.10 Designated primary responders, of the Code Blue team, will not be permitted
to leave the hospital building during their defined shift time, unless he/she has
delegated his/her responsibility to an appropriate member of staff i.e., a member
of staff of same grade and experience.(Delegation process)
4.11 Only the Team Leader, directing the code blue may terminate the code
blue procedure. His/her decision will be the determining factor. (Based on
cardiac unresponsiveness to adequately perform Advanced Life Support
measures).
4.12 On receipt of the Code Blue Call the switchboard will:
4.12.1 Call through the overhead pager ‘CODE BLUE’ indicating the location
and type. Example:
ATTENTION; ATTENTION… ADULT CODE BLUE 300- G MALE
SURGICAL WARD ROOM 3D
4.12.2 The call will be made clearly and calmly and be repeated approximately
15 seconds after the first alert.
4.12.2 Automatic code blue pagers shall be initiated, ensuring clear details are
transmitted.
4.13 For any pediatric code blue in the General hospital, the Adult Code blue team
will respond till the pediatric specialist arrives.
Note: For any Code Blue that will be activated in the Dental Center, the Adult
Code Blue Team of General Hospital will respond to the code.
5. PROCEDURE(S):
5.1 The staff member discovering the patient in a state of cardiac or
respiratory arrest should:
5.1.1 Step 1: Assessment and Scene Safety:
The first rescuer who arrives at the side of the patient quickly
ensures that the scene is safe. The rescuer should then check the
patient for a response:

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APP-KSMC-059-(V3)
A. Make sure the scene is safe for you and the patient. (You do not
want to become a patient yourself.
B. Tap the patient’s shoulder and shout, “Are you alright?”
Determine the patient for a response and look for
normal or abnormal breathing. If no response and no
breathing( i.e., only gasping shout for help).
(Assessment of Unresponsiveness)
C. Check if the patient is breathing, If patient is not breathing or
not breathing normally (i.e., you must activate the emergency
response system).
c1. If cardio-pulmonary arrest is established, call verbally
“Code Blue” to gain assistance.
c2. Initiate CPR procedure having established that the
patient is in a state of cardiac/respiratory arrest;
c2.1 Lay the patient flat, if possible on a firm surface (in
emergency or with undiagnosed trauma cases, ensure
adequate care is taken to protect the cervical spinal cord).
(Positioning the Victim)
c2.2 Ensure good clear airway, (tilt the head/lift
the chin); if there is no evidence of head trauma. If neck
injury is suspected, open the airway by the jaw thrust
maneuver only if trained to do so.
Steps to perform head tilt-chin lift:
1) Place one hand on the victim’s forehead
and push with your palm to tilt the head back.
2) Place the fingers of the other hand under
the bony part of the lower jaw near the chin.
3) Lift the jaw to bring the chin forward.
(AIRWAY)
5.1.2 Step 2: Activate the Emergency Response System and get AED (or
Defibrillator) if available, and then return to the victim to check
a pulse and begin CPR( (C-A-B-SEQUENCE)
5.1.3 Step 3: Pulse Check:

Healthcare providers should take no more than 10 seconds to check
for a pulse.
Locating the Carotid Artery Pulse: To perform a pulse check in the
adult, palpate the carotid pulse, if you do not definitely feel a pulse
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within 10 seconds, start chest compression:

A. Locate the trachea, using 2 or 3 fingers.
B. Slide these 2 or 3 fingers into the groove between the trachea and
the muscles at the side of the neck, where you can feel the carotid
pulse.
C. Feel for a pulse for at least 5 but no more than 10 seconds. If you
do not definitely feel a pulse, begin CPR, starting with chest
compressions(C-A-B sequence).
5.1.4 Step 4: Begin Cycles of 30 chest compressions and 2 Breaths (CPR):

Chess compression in adult.
A. Position yourself at the victim’s side.
B. Make sure the patient is lying face up on affirm, flat surface.
If the patient is lying face down, carefully roll him face up.
If you suspect the patient has a head or neck injury, try to
keep the head, neck and torso in a line when rolling the
patient to a face up position.
C. Put the heel of one hand on the center of the patient’s
chest on the lower half of the breastbone.
D. Put the heal of your other hand on top of the first hand.
E. Straighten your arms and position your shoulders directly
over your hands.
F. Push hard and fast.
f1. Press down at least 5cm (2 inches) with each compression
(this requires hard work). For each chest compression, make
sure you push straight down on the patient’s breastbone.
f2. Deliver compression in a smooth fashion at a rate of at least
100/min.
G. At the end of each compression, make sure you allow the chest to
recoil (re-expand) completely. Chest recoil allows blood to flow
into the heart and is necessary for chest compression to create
blood flow. Incomplete chest recoil is harmful because it reduces
the blood flow created by chest compressions. Chest compression
and chest recoil/relaxation times should be approximately equal.
H. Minimize interruptions.
5.2 Utilize the Performance guidelines for one-man and two –man CPR for
further information on the depth of compression.

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APP-KSMC-059-(V3)
PERFORMANCE GUIDELINES IN ONE-MAN AND TWO-MAN CPR

ADULT CHILD INFANT NEONATAL
0-28 Days
Age Over 14 1yr. to 14 1 month -1 yr.
( 0-1 month )
30:2 (1rescuer) 30:2 (1rescuer) 3:1
( 90 compression: 30
30:2 (1&2
Ratio 15:2 15:2 (2 ventilations- 120
rescuer)
(2 rescuer) rescuer) events/min)-
2 Rescuer
1/3rd of the Anterior
Chest
1 ½-2 inches 1/3 to ½ the depth of the chest Posterior Diameter of the
Compression
Chest
Ventilation 1 second 1 second 1 second 1 second
Neonatal Self Inflating
Volume 600-800 ml 500ml puff Bag/
T-Piece Resuscitation
Hand/ 2 Thumb Preferred /
2 hands 1 or 2 hands 1 fingers
Technique 2 Fingers
Lower Third of the
Lower half Below nipple Sternum
Nipple line (which lies between the
Position sternum line
xiphiod and a line drawn
between nipple lines)
Approx. Approx. Approx.
Rate 100/min. 100/min. 100/min. 40-60 Breaths per minute
5.3 When the Code Blue Team arrives, they will take over their defined roles.
Team Leader assigns the roles and responsibility for the Code Blue Team.
e.g., attaching and monitoring the ECG, Compression, preparation of ET tube,
suction and medications.
5.4 The ‘Code Blue Team’ works under the leadership of the Team Leader
(Anesthetist or Internal Medicine Consultant On-Call / Pediatrician on Call.)
5.5 Medication Nurse and Charge Nurse assumes the overall responsibility for the
medications, ensuring that the ampoules are retained.
5.5.1 The name, dose and concentration of the drug should clearly be stated.
Labels each drug that is drawn up as per Team Leader’s Order / Physician
Order (ready label for adrenaline, Sodium, Calcium, Cordarone should be
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APP-KSMC-059-(V3)
available)
(Note: labeling of drugs should be performed if the drugs are drawn up in
anticipation of need i.e., before being asked for).
5.5.2 Where possible, the Medication Nurse (RN) controls the medications,
drawing up and labeling resuscitative drugs that may be required. This
saves time and allows for more efficient and effective cardio-pulmonary
resuscitation measures.
5.6 Timer / Recorder (RN) takes overall responsibility for documenting the events.
5.6.1 Time of arrest.
5.6.2. Medications given, time dosage and response.
5.6.3 DC shocks given, time, voltage and response.
5.6.4 Patient vital signs if present-cardiac status e.g., asystole, ventricular
fibrillation etc.
5.7 One defined Team Leader (Anesthetist or Consultant Internal Medicine/Pediatrician)
takes overall control and directs all proceedings, ensuring that clear instructions
are given to the attending Code Blue Team and that there is total cooperation between
nurses and doctors.
5.8 Nurses and physicians not actively participating in the code blue absents themselves
and attend to other patients/relatives needs, and to general control of the ward/clinic
area.
5.9 Transfers the patient to ICU if the resuscitation is successful and ROSC (Return of
Spontaneous Circulation) for close observation and monitoring. Prior to transfer;
5.9.1 Contacts ICU by phone and informs that the patient shall be transferred.
The information should include;
A. Current cardio-pulmonary status.
B. Patient’s name and age.
C. Current diagnosis (if known). If not, then the primary admission diagnosis.
D. IV fluid in progress.
5.10 Transfers all documentation with the patient including the following:
5.10.1 The patient’s complete medical records (medical chart)
5.10.2 Nursing observation sheets and CPR Record.
5.10.3 Record of resuscitation completed by the Physician/Team Leader; the data
will include:
A. Time of the arrest.
B. Sequence of events including the number and voltage of DC shock,
C. Medications administer during the Code.
D. Outcome of resuscitation i.e., Sinus Rhythm of self ventilating, etc.

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5.11 The anesthetist, the medical or pediatric resident and ward staff nurse (RN)
accompanies the patient being transferred to ICU following a successful
resuscitation.
5.12 The attending physician monitor’s the patient continuously in the Post
Resuscitation Care Unit.
5.13 The anesthetist records all actions undertaken by him/her during the resuscitation in
the multidisciplinary progress notes
5.13.1 Status of the patient on arrival.
5.13.2 Time of intubations.
6. RESPONSIBILITY:
6.1 ACLS, PALS, NRP, AOLS, ATLS Certified CPR team member is responsible
to deliver D/C Shock during the code.
6.2 It is the responsibility of all the Heads of Departments and the CPR Committee
to review, modify and monitor the implementation of this policy and procedures.
6.3 CPR TEAMS:
6.3.1 ER Code Blue Team – General Hospital
a. ER Consultant – Team Leader
b. RT- Airway
c. ER Resident/Specialist Doctor –Airway / Compressor
d EMT- Compressor
e. Nurse (RN)– Medication Nurse
f. Nurse (RN)– Timer and Recorder
g. Nurse (RN)– Monitoring Nurse
h. Nurse (RN)– Nursing Manager
6.3.2 OR Code Blue Team
a. OR Anesthesia Consultant – Team Leader
b. OR Anesthesia Specialist-Compressor
c. OR Anesthesia Specialist-Airway
d. NURSE (RN) – Medication Nurse
e. NURSE (RN) - Timer and Recorder
f. NURSE (RN) - Monitoring Nurse
6.3.3 ICU Adult Code Blue Team

a. ICU Specialist – Team Leader
b. RT-Airway
c. Nurse (RN)– Medication Nurse

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d. Nurse (RN)– Monitoring Nurse

e. Nurse (RN)–Timer and Recorder
f. Nurse (RN)– Compressor
6.3.4 Outside ICU Adult Code Blue Team (General Hospital)
a. Internal Medicine physician ACLS certified - Team Leader
b. Internal Medicine Resident-Compressor
c. Anesthesiologist on call-Monitoring Physician
d. RT-Airway
e. Nurse(RN) – Medication Nurse
f. Nurse (RN)- Timer and Recorder
g. Nurse (RN)-Monitoring Nurse
6.3.5 Pediatric Code Blue Team – Ward
a. Pediatric specialist -Team Leader
b. PICU Specialist-Team Leader
b. Pediatric Resident - Compressor
c. Pediatric Anesthesiologist-Airway
d. RT- Airway
e. PICU Nurse (RN)-Medication Nurse
f. Ward Nurse (RN)-Timer and Recorder
h. Ward Nurse (RN)-Monitoring Nurse
6.3.6 Pediatric ICU Code Blue Team
a .ICU Specialist-Team Leader
b .RT-Airway
c. Nurse (RN)– Compressor
d. Nurse(RN) – Medication Nurse
e. Nurse (RN)– Timer and Recorder
f. Nurse (RN)– Monitoring Nurse
6.3.7 Pediatric ER Code Blue Team
a. ER Consultant- Team Leader
b. ER Specialist- Airway
c. Pediatric Resident-Compressor
d. Nurse (RN) – Medication Nurse
e. Nurse (RN)-Timer and Recorder
f. Nurse(RN)- Monitoring Nurse
6.3.8 NRP Code Blue Team
a. NICU Specialist - Team Leader
b. RT-Airway

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c. Nurse (RN)– Compressor

d. Nurse (RN)– Medication Nurse
e. Nurse (RN)– Timer and Recorder
f. Nurse (RN)– Monitoring Nurse
6.3.9 Maternity Code Blue Team
a. ICU Specialist- Team Leader
b. Anesthetist on call- Airway
c. RT-Airway
d. OB/Gyne Specialist -Compressor
e. Nurse (RN)-Medication Nurse
f. Nurse (RN)-Monitoring Nurse
g. Nurse (RN)-Timer/Recorder
h. Security
6.3.10 AKU Code Blue Team

a. Medical / ACLS Certified-Team Leader
b. Anesthesiologist – Airway
c. RT-Airway
d. Nurse (RN)- Compressor
e. Nurse (RN)- Medication Nurse
f. Nurse (RN)- Timer and Recorder
g. Nurse (RN)- Monitoring Nurse
h. Security
6.3.11 OPD Code Blue Team
a. Medical / ACLS Certified- Team Leader
b. Anesthesiologist – Airway
c. Nurse (RN)-Compressor
d. Nurse (RN)-Medication Nurse
e. Nurse (RN)-Timer and Recorder
f. Nurse (RN)-Monitoring Nurse
g. Security
6.3.12 EMS Code Blue Team

a. EMT- Team Leader
b. EMT- Airway
c. EMT- Compressor
d. EMT- Circulation / Medication
e. EMT- Documentation
g. Security

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APP-KSMC-059-(V3)
7. REFERENCES:
7.1 American HEART Association, BLS for Healthcare providers, 2011
International English Edition Student Manual (Professional)
7.2 Neonatal Resuscitation Textbook, 6th Edition, 2012, American Academy of
Pediatrics and American Heart Association, Editor; John Kattwinkel MD, FAAP,
Louis P. Halamwk, MD, FAAP
7.3 BLS for Healthcare Providers Student Manual, 2010, American Heart
Association. Editor: Mary Fran Hazinski, RN, MSN, Senior Science Editor. S.
Lynn Hunter Wilson.
7.4 Heartsaver® First Aid CPR AED Student Workbook, 2010, American Heart
Association. Editor: Mary Fran Hazinski, RN, MSN, Senior Science Editor. S.
Lynn Hunter Wilson.
7.5 Advanced Cardiovascular Life Support Provider Manual, 2010,
American Heart Association. Editor: Elizabeth Sinz, MD, Associate Science
Editor, Kenneth Navaroo, content Cunsultant.
7.6 Pediatric Advanced Life Support Provider Manual (PALS), 2010,
American Heart Association. Editor: Leon Chameides, MD, Content Consultant.
Ricardo A. Samson, MD, Associate Science Editor
7.7 Advanced Life Support in Obstetrics ( ALSO®) By American Academy of Family
Physicians. Editor: Elizabeth Baxley, MD, Chair, Mark Deutchman, MD.
7.8 ATLS Student Course Manual 9th Edition PDF
7.9 National Guard Health Affairs-APP-1420-001(No Code Policy) Nov.12, 2005.
7.10 King Faisal Specialist Hospital and Research Center-IPP-MCO-MC
ADM-08-005(Use of the Crash Cart Inspection Procedure Checklist), April 2004.
7.11 King Faisal Specialist Hospital and Research Center-IPP-MCO-MC
ADM-07027(Code Blue Team Composition and Responsibilities), March 23, 2005
7.12 The New Technical Aspects of Basic Life Support Policy and Procedures of
CPR for Hospitals, Cardio-Pulmonary Resuscitation (CPR), new 2005 Guidelines.
Dr. Mohamed Abdullah Seraj, M.B., B. Ch., D.A., F. C. A. R. C.S.I.-Professor
and Consultant Anesthesiologist, Chairman of National CPR Committee, Saudi
Heart Association / Paul J. Harvey, Faculty of Saudi Heart Association.

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APP-KSMC-059-(V3)
8. APPROVALS:
NAME TITLE SIGNATURE DATE
Ms. Victoria G. Policy& Procedure

Prepared Ramirez Section Senior Nurse
by: Coordinator
Dr. Adil Hussain COP Chapter
Coordinator/Quality
Kakpuri
Specialist
Mr. Mohammed Policy &Procedure
Altaweel Section Head
Mr. Jamal Al Ghamdi Head of Emergency

Services
Dr. Munzer Kumalmaz Director of King Fahad

Kidney Center
CPR Committee
Dr. Saleh Al-Shehri
Chairman
Dr. Aziza Donques COP Chapter Leader
Reviewed
by: Dr. Khalid Ali Al Anzi Medical Director
General Hospital
Dr. Hana Ibrahim Al Medical Director
Madany Maternity Hospital
Medical Director
Dr. Abdulhadi Altalhi
Pediatric Hospital
Dr. Yousef Sharif Total Quality

Management Director
Ms. Celina Eves Chief Nursing Officer
Approved Dr. Abdulrahman

Chief Medical Officer
by: Alqahtani

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APP-KSMC-059-(V3)
9. POLICY AND PROCEDURE HISTORY:
Initial PP: Version 1 APP-KSMC-059-(V1) Dated: 15 January 2007
Replaced by: Version 2APP-KSMC-059-(V2) Dated: 26 December 2010
Replaced by: Version 3 APP-KSMC-059-(V3) Dated: 26 August 2012
Replaced by: Version 4 APP-KSMC-059-(V4) Dated: 23 May 2016
Deleted Date: ______________________________
Replaced by New PP: PP No. &Version____________ Dated: ________________

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ADMINISTRATIVE POLICY AND PROCEDURE(APP)

2.2.1 Team Members Include:

Version (4) 23 May 2016 Page 1 of 16

ADMINISTRATIVE POLICY AND PROCEDURE(APP)

07:30 – 03:30 hours - Anesthetist on Duty

G. Nursing Manager on Duty:

ADMINISTRATIVE POLICY AND PROCEDURE(APP)

3. Call for support personnel if and when needed.

I. Medication Nurse (RN)

J. Monitoring Nurse (RN)

K. Timer / Recorder (RN)

ADMINISTRATIVE POLICY AND PROCEDURE(APP)

1.2 Rhythm at time of arrest and subsequent rhythms during the

Version (4) 23 May 2016 Page 4 of 16

ADMINISTRATIVE POLICY AND PROCEDURE(APP)

4.3.1"Code Blue Alert" is called by; 1970 (General Hospital)/555(Pediatric &

ADMINISTRATIVE POLICY AND PROCEDURE(APP)

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ADMINISTRATIVE POLICY AND PROCEDURE(APP)

5.1.3 Step 3: Pulse Check:

ADMINISTRATIVE POLICY AND PROCEDURE(APP)

within 10 seconds, start chest compression:

5.1.4 Step 4: Begin Cycles of 30 chest compressions and 2 Breaths (CPR):

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ADMINISTRATIVE POLICY AND PROCEDURE(APP)

PERFORMANCE GUIDELINES IN ONE-MAN AND TWO-MAN CPR

ADMINISTRATIVE POLICY AND PROCEDURE(APP)

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6.3.3 ICU Adult Code Blue Team

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ADMINISTRATIVE POLICY AND PROCEDURE(APP)

d. Nurse (RN)– Monitoring Nurse

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ADMINISTRATIVE POLICY AND PROCEDURE(APP)

c. Nurse (RN)– Compressor

6.3.10 AKU Code Blue Team

6.3.12 EMS Code Blue Team

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ADMINISTRATIVE POLICY AND PROCEDURE(APP)

NAME TITLE SIGNATURE DATE

Ms. Victoria G. Policy& Procedure

Mr. Jamal Al Ghamdi Head of Emergency

Dr. Munzer Kumalmaz Director of King Fahad

Dr. Yousef Sharif Total Quality

Approved Dr. Abdulrahman

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ADMINISTRATIVE POLICY AND PROCEDURE(APP)

9. POLICY AND PROCEDURE HISTORY:

Initial PP: Version 1 APP-KSMC-059-(V1) Dated: 15 January 2007

Replaced by: Version 2APP-KSMC-059-(V2) Dated: 26 December 2010

Replaced by: Version 3 APP-KSMC-059-(V3) Dated: 26 August 2012

Replaced by: Version 4 APP-KSMC-059-(V4) Dated: 23 May 2016

Deleted Date: ______________________________

Replaced by New PP: PP No. &Version____________ Dated: ________________

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Replaced by New PP: PP No. &Version Dated: ____