Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11217 The implementation of code blue by nurses as first responders in outpatient and inpatient rooms at Malang Indonesia Hospital Tony Suharsono,¹ Sunarmi,1,2 Nur Ida,1,2 Bella Nove Khirria,1,2 Nazla Asrin,1,2 Ikhda Ulya1 1Nursing Department, Faculty of Health Sciences, Universitas Brawijaya, Indonesia; 2Bachelor Nursing Program, Faculty of Health Sciences, Universitas of Brawijaya, Indonesia Abstract Introduction: In-Hospital Cardiac Arrest (IHCA) is a frequent occurrence that necessitates prompt and appropriate assistance to improve survival rates. Nurses in public care rooms and outpa- tients are expected to be first responders to IHCA until an activat- ed hospital code blue team arrives. Therefore, this study aims to analyze the implementation of code blue response by nurses in outpatient and hospital inpatient rooms in Malang. Design and Methods: This is a quantitative study that uses observational methods with a cross-sectional approach compris- ing of 109 inpatient and outpatient care room nurses from 9 hos- pitals in Malang. The implementation of code blue was measured by a simulated case of adult cardiac arrest in a hospital inpatient room. Results: The nurses involved were 67.0% female, where the majority have a D3 education qualification (57.7%), with more than ten years working experience (45%). Furthermore, 83.5% of nurses work in regular care rooms and 16.5% come from outpa- tient rooms. The results showed that the implementation of code blue by nurses in regular care and inpatient rooms was 66.7% and 65.9%, respectively in the insufficient categories. In addition, the Mann-Whitney U test obtained a p-value of 0.929. Conclusions: In conclusion, there was no significant differ- ence in the implementation of code blue that occurred in the inpa- tient and outpatient rooms. Further studies were recommended to observe code blue events directly and take samples with balanced proportions. Introduction Cardiac arrest is a case that often occurs in the intensive care unit, the general ward, or the outpatient room.1 t is a sudden ces- sation of heart function in a person characterized by the absence of pulse and other signs of circulation.2 The survival rate follow- ing in-hospital cardiac arrests has been reported to be 7–26.7%. According to a study, CPR had survival rates of 14.7%, 16%, and 12% in the U.S., the U.K., and Turkey, respectively. Furthermore, reported that this rate after CPR varies in different countries and is generally low.3,4 Cardiopulmonary resuscitation (CPR) is one of the most stressful events for nurses that require immediate action with a survival rate as low as 20% and their speed and performance affect survival after CPR.5,6 The study reported that the survival rate data for outpatients is 4.3% while inpatients have a much bet- ter survival, which is 14.88%.7 Some of the factors that affect the survival of these patients include age, duration of CPR, delay in starting CPR, and speed of the team arriving at the scene.8 Due to its critical life-saving role, the current study on CPR and ED nurs- es focused on improving performance for patient outcomes.9 Lack of CPR skills of nurses and physicians contributes to the poor out- come of cardiac arrest victims,10-11 therefore, it is their profession- al responsibility to remain competent through regular updates.12,13 Cardiac arrest is a leading cause of death in hospitals, there- fore, special attention is required in its handling. Some of the strategies developed by hospitals to prevent cardiac arrest deaths include implementing early warning systems, forming rapid response teams, and building a code blue system that provides a follow-up response.8,14 The code blue team aims to provide help quickly and appropriately to improve the survival rate of cardiac arrest victims in the hospital, through continued assistance and defibrillation.15 The nurses are responsible for initiating the CPR and performing basic life support until the team arrives; therefore, they need to be informed of and follow the CPR rules.16 Design and Methods This quantitative study uses observational methods with a cross-sectional approach and was conducted between 17-21 December 2020 on nurses working at certain hospitals in the Malang region. The inclusion criteria of respondents in this study were nurses who worked in the general ward and nurses who worked in hospitals that had implemented the code blue system. The respondents comprises 109 inpatient and 91 outpatient nurses working in the general ward, outpatient care unit of 9 hospitals in Malang Region and were not part of a code blue team (Table 1). The instrument used in this study was a questionnaire contain- ing data on the characteristics of respondents and an overview of the implementation of code blue include the initial response of nurses in the treatment room and identification of the quality of CPR actions performed by nurses who responded early using the code blue implementation guide developed by American Heart Article Significance for public health In-Hospital Cardiac Arrest (IHCA) is a frequent occurrence that necessitates prompt and appropriate assistance to improve survival rates. Nurses in public care rooms and outpatients are expected to be first responders to IHCA until an activated hospital code blue team arrives. The application of the code blue response by nurses in outpatient and hospital inpatient rooms in Malang is documented in this study. [Healthcare in Low-resource Settings 2023; 11(s1):11217] [page 169] No n- co mm er cia l u se on ly Association by measuring a simulated case of adult cardiac arrest in the hospital by asking when and how to call the code blue team, and what to do while waiting for their arrival. Data were collected using a google form requiring the respondents’ ID card that shows where they work and also fill out a statement indicating that they are not a member of the code blue team. The completely and valid- ly filled data were presented and univariate analysis was conduct- ed. The bivariate test was conducted using the Mann-Whitney U test because the data obtained is not normally distributed. The level of confidence used is 5%. Furthermore, ethical clearance was obtained from the Faculty of Medicine, Universitas Brawijaya with No. 212/EC/KEPK/12/2020. Result and Discussion The majority of respondents in the study were female and were in their early adult age range. Also, nearly half of the patients are nurses with over 10s years of working experience and 98% of the respondents had participated in socialization and code blue simu- lations in their workplace hospital. About 93% of nurses did not consider advanced cardiac arrest and code blue system. The results showed that there was no significant difference in the implementation of code blue in inpatient and outpatient rooms (Table 2 and 3). The majority of respondents had participated in socialization and code blue simulations organized by their work- place hospitals in the past year. This condition shows good under- standing and acceptance by nurses when receiving materials and following simulations, ensuring that its implementation throughout the rooms in the hospital is relatively the same. The results are con- sistent with the reports of the study that code blue simulation can improve ability and confidence.17-20 Furthermore, high-fidelity simulation has the potential to help HCPs retain the necessary knowledge to perform CPR successfully.21 The nurses involved in this study have also participated in basic life support training, which includes basic relief in cardiac arrest patients. They were taught periodically how to recognize cardiac arrest conditions, activate code blue, perform pulmonary resuscitation, and use AED while waiting for further helpers. Furthermore, there was a significant improvement in nurses’ knowledge and abilities after a brief training in BLS, and some information and skills were retained after six months.22-24 They were also able to recognize cardiac arrest conditions and perform well-conscious examinations. Meanwhile, the method of calling the team code blue in this study is to reach a call a specific number using a telephone. Some hospitals use phones with special lines to activate code blue by calling the team through the emergency installation telephone number and then calling certain units to for- ward the information to all units. This is consistent with the reports of the study that some of the ways to activate the team include tele- phone calls and pressing the code blue button, however, no hospi- tal has used GPS to detect the location of the incident.25 The part of nurses’ role as the first helper of cardiac arrest that requires improvement is the effort to locate and use the AED that has been placed by the hospital to minimize delays in defibrillation of cardiac arrest patients. Additionally, most nurses have per- formed well in their function of chest compression while waiting for the team’s arrival. Based on the results, the factors that affect the outcome of CPR include delayed attendance of the team, inad- equate skill, and deficient CPR equipment.26 Three types of barri- ers were identified, namely procedural barrier, which is the time lost due to language and communication issues as well as tele- phone problems. The second and third barriers include CPR knowledge (skill deficits, perceived benefit), and personal fac- tors.27 The study’s limitations include an imbalanced number of respondents and the lack of measurement of code blue application during the simulation procedure. Furthermore, the number of inpa- tient and outpatient nurse respondents should be equal to compare and measure the implementation of code blue using direct simula- tion rather than surveys. Conclusions The majority of code blue implementation by nurses as the first helper on cardiac arrest in the hospital is sufficient. Furthermore, there is no significant difference between the implementation in Article [page 170] [Healthcare in Low-resource Settings 2023; 11(s1):11217] Table 1. Respondent characteristics. Variable Category N (%) Sex Male 36 33 Female 73 67 Total 109 100 LoW* <5 years 26 23.9 5-10 years 34 31.2 >10 years 49 45 Total 109 100 Work place Walking clinic 18 16.5 General ward 91 83.5 Total 109 100 *LoW: length of work . Table 2. Implementation of code blue by nurses in outpatient and inpatient rooms. Variable Category N (%) Implementation of code blue Less 36 33 Fair 72 66.1 Good 1 0.9 Total 109 100 Table 3. Difference in implementation of code blue by nurses in the inpatient and outpatient room. Implementation of code blue Room Less Fair Good p n % n % n % OPR* 6 33.3% 12 66.7% 0 0% 0.929 IPR* 30 33.0% 60 65.9% 1 1.1% 36 33.0% 72 66.1% 1 0.9% *OPR; outpatient room; IPR: inpatient room. No n- co mm er cia l u se on ly the outpatient and inpatient room. 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Efficacy and retention of Basic Life Support education including Automated External Defibrillator usage during a physical education peri- Article [Healthcare in Low-resource Settings 2023; 11(s1):11217] [page 171] Correspondence: Ikhda Ulya, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java Indonesia 65151, Tel.: +62 341 5080686, Fax: +62 341 5080686, E-mail: ikhda.fk@ub.ac.id Key words: Code blue, nurses, outpatient, inpatient. Acknowledgment: The authors are grateful to the Research Development and Community Service Agency of the Medical Faculty of Brawijaya University for funding this study Contributions: All authors contributed equally to this article. IU, S, NI, NA conducted this study & TS served as chief of research project and reviewed the final article. Conflict of interests: The author declares no conflict of interest. Funding: This study was financially supported by the Research Development and Community Services Agency of the Medical Faculty of Brawijaya University. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Informed consent: Written informed consent was obtained from a legal- ly authorized representative(s) for anonymized patient information to be published in this article. Clinical trials: This study has been approved by health research ethics committee of Faculty of Medicine, University of Brawijaya Malang. Conference presentation: Part of this paper was presented at the 2nd International Nursing and Health Sciences Symposium that took place at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. Received for publication: 6 December 2021. Accepted for publication: 15 May 2022. 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