/ CHHS16/117

Canberra Hospital and Health Services

ClinicalProcedure

BHRC Code Blue – Medical Emergency Response for Brian Hennessy Rehabilitation Centre

Contents

Canberra Hospital and Health Services

Contents

Purpose

Scope

Section 1 – Code Blue Activation

Section 2 – Code Blue Response

Section 3 – Post Code Blue

Implementation

Related Policies, Procedures, Guidelines and Legislation

Search Terms

Attachments

Attachment 1 – Code Blue Criteria

Attachment 2 – basic Life Support Process

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.

Back to Table of Contents

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.

Back to Table of Contents

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 hospitalthen 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 ReportingProcedure, 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.

Back to Table of Contents

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.

Back to Table of Contents

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

Back to Table of Contents

Search Terms

Code Blue

Brian Hennessey Rehabilitation Centre (BHRC)

Mental Health, Justice Health & Alcohol and Drug Services (MHJHADS)

Medical Emergency

Back to Table of Contents

Attachments

Attachment 1 – Code Blue Criteria

Attachment 2 – basic Life Support Process

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> 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

Back to Table of Contents

Back to Table of Contents

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