BHRC Code Blue – Medical Emergency Response for Brian Hennessy
Rehabilitation Centre
CHHS16/117
Canberra Hospital and Health Services
Clinical Procedure
BHRC Code Blue – Medical Emergency Response for Brian Hennessy
Rehabilitation Centre
Contents
Canberra Hospital and Health Services1
Contents1
Purpose2
Scope2
Section 1 – Code Blue Activation2
Section 2 – Code Blue Response3
Section 3 – Post Code Blue4
Implementation5
Related Policies, Procedures, Guidelines and Legislation5
Search Terms5
Attachments6
Attachment 1 – Code Blue Criteria6
Attachment 2 – basic Life Support Process6
Purpose
To provide guidelines for the notification, staff response and
escalation process in the event of a medical emergency of a person
with mental disorder or mental illness, visitor or staff. To
mobilise resources, providing a timely, coordinated response,
including:
· A rapid and appropriate response;
· Clearly understood command, control and communication
structures;
· Clearly defined roles for all staff; and
· Transition back to normal business with minimal
disruption.
Scope
This Clinical Procedure applies to all staff employed at Brian
Hennessy Rehabilitation Centre (BHRC).
Section 1 – Code Blue Activation
Code Blue relates to a medical condition that has the potential
to be life threatening and/or cannot be managed with the available
resources at hand.
A Code Blue is activated by staff for all persons on the Brian
Hennessy campus.
On all occasions of a code blue, nursing staff MUST attend the
scene and assess the situation.
Activating a Code Blue
A duress alarm is used to indicate Code Blue and may be
activated at any time if a staff member has any concerns with a
person’s medical status. (Attachment 1)
A staff member will depress the duress alarm and indicate that
there is a Code Blue and the location of the person.
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Section 2 – Code Blue Response
Code Blue Response Process
All available Staff will respond to the location of the Code
Blue.
The nurse in charge (NIC) will coordinate the response to the
Code Blue and allocate roles to the staff.
Staff not allocated a role will resume normal duties.
Basic Life Support Process (Attachment 2)
· Danger: Quickly assess the situation for danger.
· Responsiveness: Check for the person’s response and note the
time.
· Send for help:
· Notify staff at BHRC using the duress alarm system.
· NIC or delegated staff member are to contact ACT Ambulance
Service (ACTAS)
· Dialling 0_000 from government phones state clearly the exact
location, extent and type of emergency.
· A staff member is to be allocated to meet the ambulance crew
at the front entrance to ensure access and direction.
· A staff member will retrieve the Automated External
Defibrillator (AED) from the administration block next to the
photocopier.
· Airway: maintain a clear airway.
· Breathing: watch for normal breathing.
· Circulation:
· if no breathing OR abnormal breathing, commence
cardiopulmonary resuscitation (CPR)
Defibrillation:
· Attach the AED to the person. Continue CPR until AED is
attached, power is switched on and the machine delivers the command
“Don’t Touch the Patient”.
· Follow subsequent instructions until ACTAS responders
arrive.
BHRC staff will initiate immediate Basic Life Support (BLS)
procedures and ensure that the person is safe and life maintaining
treatment is provided until ACTAS arrive.
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Section 3 – Post Code Blue
Following Code Blue
If the person remains at BHRC a management plan is completed
with clear instructions for staff to follow.
If the person is transferred to hospital then a management plan
will become the responsibility of that facility.
In the absence of the BHRC Team Leader and Clinical Nurse
Consultant (CNC), the NIC is responsible for ensuring that staff
are debriefed.
All Code Blue – Medical Emergencies fall under the Significant
Incidents Reporting Procedure, the associated procedure must be
followed. This includes providing a thorough handover to the
Director on Call (outside of business hours), and Team Leader and
Operational Director of the program (within business hours).
In the event that a death has been medically pronounced, follow
specific requirements as outlined in the Management of the When
death Occurs Procedure.
Documentation requirements
The NIC will also complete necessary documentation, including an
entry into the person’s Electronic Clinical Record and a RISKMAN
before leaving the Centre.
If a Code Blue was called for a visitor to the BHRC a Riskman
needs only to be completed.
Code Blue Drills and Equipment Checks
· Regular Code Blue drills are held every 3 months and
co-ordinated by the CNC and a record of these drills is
maintained.
· Emergency equipment i.e. oxygen and suction is located in each
Villa and Extended Care Unit (ECU).
· Emergency equipment is checked and tested daily.
· AED is checked daily.
Basic Life Support Training (BLS) Requirement
All medical, nursing, allied health and HSO staff are to receive
BLS training within 4 weeks of commencement of duty with a
refresher due annually.
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Implementation
All BHRC staff will be provided with access to this procedure
upon commencement with the team in addition to file path to access
on the Policy Register.
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Related Policies, Procedures, Guidelines and Legislation
Policies/Procedures/Plans
· Code Blue – Medical Emergency Plan
· When Death Occurs Policy
· When Death Occurs SOP
· MHJHADS - Significant Incidents Reporting SOP
· Code Blue Response Procedure- Adults, Paediatrics,
Neonates
· Vital Signs and Early Warning Scores Clinical Procedure
Guidelines
· The Australian Resuscitation Council - Resuscitation
Guidelines
Legislation
· Mental Health Act 2015
· Health Records (Privacy and Access) Act 1997
· Human Rights Act 2004
· Public Sector Management Act 1994
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Search Terms
Code Blue
Brian Hennessey Rehabilitation Centre (BHRC)
Mental Health, Justice Health & Alcohol and Drug Services
(MHJHADS)
Medical Emergency
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Attachments
Attachment 1 – Code Blue CriteriaAttachment 2 – basic Life
Support Process
Disclaimer: This document has been developed by ACT Health,
specifically for its own use. Use of this document and any reliance
on the information contained therein by any third party is at his
or her own risk and Health Directorate assumes no responsibility
whatsoever.
Date Amended
Section Amended
Approved By
E.g.: 17 August 2014
Section 1
ED/CHHSPC Chair
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Doc Number
Version
Issued
Review Date
Area Responsible
Page
CHHS16/117
1
01/08/2016
01/08/2019
MHJADS
1 of 9
Do not refer to a paper based copy of this policy document. The
most current version can be found on the ACT Health Policy
Register