Code Carnivals: Resuscitating Code Blue

Training With Accelerated Learning

Vicky A. Keys, MSN, RN-BC, Peggy Malone, RN, MN, CCRN, Carla Brim, MN, PHCNS-BC,
CEN, Heather Schoonover, MN, PHNCS-BC, Cindy Nordstrom, BS, RN, and
Melissa Selzler, BSN, RN

abstract
Nurses in the hospital setting must be knowledgeable
about resuscitation procedures and proficient in the delivery of care during an emergency. They must be ready to
implement their knowledge and skills at a moments notice.
A common dilemma for many nurses is that cardiopulmonary emergencies (Code Blues) are infrequent occurrences.
Therefore, how do nurses remain competent and confident
in their implementation of emergency skills while having
limited exposure to the equipment and minimal experience
in emergency situations? A team of nurse educators at a
regional medical center in Washington State applied adult
learning theory and accelerated learning techniques to develop and present a series of learning activities to enhance
the staffs familiarity with emergency equipment and procedures. The series began with a carnival venue that provided
hands-on practice and review of emergency skills and was
reinforced with subsequent random unannounced code drills
led by both educators and charge nurses.
J Contin Educ Nurs 2009;40(12):560-564.

urrently, all nurses at a 169-bed regional medical

center located in Washington State must renew
their Basic Life Support card every 2 years, according
to American Heart Association standards (American
Heart Association, 2008). To receive a completion card,
each participant must demonstrate skill in providing
cardiopulmonary resuscitation, defibrillation, and rescue breathing, and providing assistance to a choking
victim. Basic Life Support training is meant to prepare
individuals to respond to a cardiopulmonary emergency.
Although nurses acquire these skills, those who work
on certain inpatient units may not have the opportunity
560

to use their Code Blue skills with any regularity. The

implementation of a facility-wide Rapid Response Team
further decreased the frequency of Code Blue situations.
The RRT provides early and rapid intervention in response to an acute change in a patients condition. When
the rare Code Blue does occur, the bedside nurses are at
best anxious and at worst incompetent in the delivery of
emergency care.
The nursing staff communicated through their annual educational needs assessment survey that they both
needed and desired to have practice with Code Blue situations. The critical care unit and the emergency department participated in a needs assessment as well, but did
not identify the need for Code Blue drills. In general, the
staff on the medical-surgical, telemetry, pediatrics, obstetrical, and behavioral health units felt ill prepared for
emergencies because of their infrequent occurrence. In
addition, the Joint Commission on the Accreditation of
Healthcare Organizations makes the recommendation
to train appropriate staff to recognize the need for and
use of designated equipment and techniques in resuscitation efforts (The Joint Commission, 2008).
To meet the needs of the staff and maintain accreditation compliance, the nurse educators developed and preMs. Keys is Nurse Educator, Ms. Malone is Clinical Nurse Specialist,
Ms. Brim is Clinical Nurse Specialist, Ms. Schoonover is Regional Director, Learning and Development, Ms. Nordstrom is Nurse Educator, and
Ms. Selzler is Education Coordinator, PeaceHealth St. John Medical
Center, Longview, Washington.
The authors thank Mike Cullom for assistance with editing.
Presented at the Pacific Institute of Nursing Conference, Honolulu,
Hawaii, March 18-20, 2009; and the Indiana Wesleyan University
Midwest Scholars Conference, Indianapolis, Indiana, March 6, 2009.
Address correspondence to Vicky A. Keys, MSN, RN-BC, PeaceHealth St. John Medical Center, 1615 Delaware Avenue, Longview,
WA 98632.
doi:10.3928/00220124-20091119-03

The Journal of Continuing Education in Nursing December 2009 Vol 40, No 12

sented a three-part series of learning activities designed

around cardiopulmonary emergencies in the inpatient
setting. Adult learning theory teaches that adults are interested in learning that is problem-centered and has immediate relevance to their work (Kearsley, 2008). From
this theoretical beginning, the nurse educators embraced
the principles of accelerated learning, which include
providing a positive environment of contextual learning
with a variety of learning options that promote learner
involvement (Center for Accelerated Learning, 2008).
These concepts provided the framework used by the
nurse educators for structuring the learning activities.
The first event in the series was a Code Carnival.
This event was followed by random unannounced
Code Blue drills on each unit. The third and final activity is ongoing unannounced Code Blue drills provided by the unit charge nurses. Each activity provided
the opportunity for staff to practice basic emergency
skills, to have hands-on experience with resuscitation
equipment, and to identify and clarify the role of code
responders.
Code Carnivals
To set the tone for the Code Carnival, a hospital conference room was decorated in a circus theme, which
included balloons, hats, and a big top. The dcor reflected the accelerated learning principle of providing a
positive environment that is stimulating and free from
stress (Center for Accelerated Learning, 2008). Different stations were set up in the conference room. Each
station replicated a familiar game and corresponded to
a different component of a Code Blue. The stations included resuscitation equipment and techniques for both
the adult and pediatric populations. A sign was posted
at each station giving brief instructions on how to play
the game. Details are provided for each of the following games: Whats My Role?, Pin the Defibrillator Pads
on Annie, Inflate the Clowns Lungs, Beat the Clock to
Restock the Code Drawer, Where Is It?, and Spin the
Medication Wheel.
The carnivals were widely advertised at staff meetings
as a preparation for future drills. Posters were placed on
each of the inpatient units and in the hospital elevators.
Announcements were published in the hospitals daily
and monthly newsletters. Ten Code Carnivals were
scheduled over a period of 6 months. Each carnival was
open for drop-in participation from 7:30 a.m. until 4:00
p.m. These hours accommodated all shifts and allowed
for spontaneous attendance. Although each station was
designed for the registered nurse (RN), each also had a
variation for certified nursing assistants and technicians,
thereby providing every member of the health care team

an opportunity for involvement as it related to their

scope of practice. It took approximately 30 to 45 minutes
for an RN and 15 to 20 minutes for technicians and certified nursing assistants to complete all of the games. The
carnivals were attended by a total of 318 staff, including
223 RNs and 72 certified nursing assistants. The remaining 23 participants were technicians and technologists.
Ideally, the stations were to be completed in order,
with each game building on the previous content. The
stations progressed from the basic to the more complex
components of a Code Blue; however, participants were
able to visit a station and play a game out of sequence
with no disruption of the learning process. Individuals
could repeat stations as desired to enhance their learning.
The Whats My Role? game was designed to familiarize participants with the roles of Code Blue responders. By policy, the responders are identified to be a unit
charge nurse, an emergency department physician, an
advanced cardiac life support or pediatric advanced life
support nurse, the house supervisor, a pharmacist, a respiratory therapist, a laboratory technician, an electrocardiogram technician, a security officer, and a chaplain.
For the game, cardboard cutouts of popular celebrities
were placed on a table. Each celebrity represented one
of the code responders. For example, John Wayne represented security! Laminated cards were placed on the
same table. The front of the card identified the responder
by title and the back defined that responders role in a
Code Blue. The object of the game was to match the
description card to the corresponding cutout. A nurse
educator was available to answer questions and provide
feedback and confirmation. In addition to reflecting the
accelerated learning principle of learner involvement
(Accelerated Learning Center, 2008), this station provided a humorous look at the code responders and set
the tone for the remaining games.
The objective of the Pin the Defibrillator Pads on Annie game was the correct application and use of an automated external defibrillator (AED). Adult and pediatric
mannequins and trainer AEDs were provided. At this
station, participants functioned as first responders to an
accident. Their responsibility was to assess the patient
and apply the AED pads to the mannequin. In keeping
with the carnival theme, the station was manned by a
nurse educator who was wearing clown apparel and the
mannequins were wearing big red bow ties and red rubber noses. The nurse educator was available to provide
feedback and direction as necessary. Participants could
practice with both the adult and pediatric AED pads and
explore the differences in size and application.
Inflate the Clowns Lungs was the next station. One

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561

adult intubation head and one infant intubation head

were placed on a table. The lungs on each mannequin
were visible. Disposable mouthpieces and bag valve
masks were provided. Each participant was required to
open the airway and provide adequate rescue breathing.
Visualization of the lungs inflating provided immediate
feedback as to whether breaths were adequate. Again,
participants could practice on both the adult and infant
mannequin intubation heads. Recurrent comments by
staff showed their amazement at the size of an infants
lungs. For added fun, brightly colored clown wigs were
placed on the mannequins. Both the Pin the Defibrillator Pads on Annie and the Inflate the Clowns Lungs
games demonstrated the accelerated learning principle
of contextual learning (Center for Accelerated Learning,
2008).
The learning objective of the Beat the Clock to Restock the Code Drawer game was to familiarize the
player with the contents of the airway and intravenous
access drawers on the code cart. A second fully stocked
code cart was used, but only the first and second drawers were unlocked. The organizational template used
by central supply to stock the carts uniformly was
laminated and posted above the code cart to serve as a
map. A nurse educator would remove the contents of
both drawers. The participants were asked to refer to
the map and restock the drawer exactly as shown on the
laminated template. This could be done individually or
in teams. Initially, this task was to be completed against
the clock; however, before the first carnival, the nurse
educators decided not to add the pressure of a time
limit. A Broselow pediatric cart was set up on specified
carnival days to accommodate the pediatric unit staff.
This approach reflected the principles of learner collaboration and contextual learning (Center for Accelerated Learning, 2008).
For the station Where Is It?, the training Code Blue
cart was set up. The cart was fully stocked except for
medications. Access to the medication drawer was provided at another station. On top of the training cart was
placed a basket of laminated cards. Each card listed one
item from inside the Code Blue cart. The participant
selected a minimum of three cards and then located the
items in the cart. At this station, participants could pick
up and handle any or all of the items in the code cart.
Many of the nurses commented that they had never seen
inside the locked drawers. Informal feedback indicated
that this station was very important and useful for the
nurses, many of whom returned to play the game again.
The nurse educators were close at hand to answer questions or to help locate equipment.
The nurse educator at this station also provided a
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brief explanation of the basic A, B, C, D, E configuration of the Code Blue carts at the regional medical center.
The first drawer, A/B, contains all airway/breathingrelated equipment. The second drawer, C, contains the
intravenous or circulation equipment. The third drawer,
D, holds the drugs, and the bottom, larger drawer,
E, holds everything else, such as an extra suction canister and glass intravenous bottles.
The final game, Spin the Medication Wheel, was designed to provide an opportunity for staff to become
familiar with emergency medications. The most commonly used resuscitation medications were identified
and their names were written and placed on the wheel.
Medication drawers were obtained from the pharmacy
department and placed on a table next to the wheel. By
spinning the wheel, each participant was provided a brief
patient scenario in which a specific drug was needed.
Participants were then responsible for locating the identified medication in the drawer. The participating RNs
were not advanced cardiac life support providers and
therefore were not required to independently identify
what medication might be needed. However, because
they are often called on to pull the medications from the
code cart and prepare them for administration, familiarity with the location and appearance of the medications
is essential. Use of the scenarios provided a basis for
discussion of the medications and their application. A
pediatric medication drawer was also set up on specific
carnival days to accommodate the pediatric staff. The
process of identifying and handling the medications was
of enormous benefit to the nursing staff. Participants
had many questions about concentrations, speed of administration, and contraindications. The nurse educators were surprised by the number of staff who shared
that they were afraid of the medication drawer and
had never seen the contents!
Random Code Drills
After the final Code Carnival, the nurse educators
implemented random unannounced code drills on every
unit and every shift. The nurse educators held a total of
17 unannounced code drills. Although the drills were
designed primarily to help the nursing staff, all responding departments were notified of the expectation to respond according to their scope of practice. This added
credibility to the exercises and tested the integrity of the
entire response process. Immediately before the drill, the
emergency department physician, the hospital operator,
and the house supervisor were notified by telephone.
The emergency department physician was not required
to respond. The house supervisor selected an empty bed
on the designated unit. This heightened the element of

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surprise because the nurse educators did not have to

search for an empty room, potentially signaling to staff
the impending drill.
To initiate the Code Blue drill, the nurse educators
would place a mannequin torso in a bed and activate the
call light. The person who answered the call light was told
that he or she was the first responder and asked what he
or she would do next. If the first responder was an RN,
a patient scenario was given and emergency procedures
were to be implemented. If the first responder was not
an RN, the individual was coached to call for assistance
and initiate Basic Life Support procedures until more
help arrived. The staff had to be encouraged to push the
Code Blue button or call the hospital operator, and participants were coached to ensure that they included the
word drill when giving the information and location
to the operator. The code drill was stopped shortly after
the advanced cardiac life support nurse arrived.
There was a sign-in sheet for all responders. A debriefing was held after the drills at which time the staff
were asked how they felt the drill went and whether
they would have done anything differently or if they
were unsure of the role of a responder. Without exception, the drills prompted positive discussion. Often,
process and equipment problems were identified. Aside
from the nervousness associated with anticipating the
unannounced drill, the staff appreciated the opportunity to practice. All hospital departments participated
with a positive attitude. In some instances, physicians
who were completing rounds on their patients also participated in the drill. It took two nurse educators approximately 20 to 30 minutes for each drill from set-up
through debriefing.
Unit-Specific Drills
The third event in the series is the transition of the
Code Blue drills to the unit charge nurses. The expectation for the unit charge nurses to perform routine quarterly code drills on their respective units was established
by the managers. During a meeting, unit charge nurses
were offered the opportunity to practice the mechanics of the drills. They were also shown and provided the
Code Blue drill manual developed by the nurse educators, which includes instructions for implementing the
drills, a list of equipment needed, patient scenarios, and
attendance rosters. Taking ownership of the Code Blue
drills is consistent with adult learning theory that states
that adults need to be involved in both the planning and
the evaluation of their instruction (Kearsley, 2008). The
nurse educators have now shifted their role to that of
mentor and resource person. Herein lies the ultimate
success of the project. The unit charge nurses gained the

key points
Emergency Skills
Keys, V. A., Malone, P., Brim, C., Schoonover, H., Nordstrom, C.,
Selzler, M. (2009). Code Carnivals: Resuscitating Code Blue
Training With Accelerated Learning. The Journal of Continuing
Education in Nursing, 40(12), 560-564.

1
2

Nurses in the hospital setting must remain competent in the

implementation of Basic Life Support skills.
There are limited opportunities to practice and apply these
skills in many inpatient settings because of the infrequency of
cardiopulmonary emergencies.

A series of activities based on adult learning theory and

accelerated learning techniques was designed to enhance
performance and increase staff confidence in the event of a
cardiopulmonary emergency (Code Blue).

knowledge and skills necessary to lead the team in a Code

Blue drill, and the entire team has gained confidence in
their ability to function in a real-life emergency.
Application
The concept of a Code Carnival can easily be adapted
to a smaller setting. It took the nurse educators approximately 30 to 35 minutes to gather the equipment and
set up the conference room for the carnival. In lieu of a
full carnival, individual stations could be set up, focusing on one component of the code drill at a time. Each
station could also be set up and used as a traveling game
to be taken to the nurses station for a quick in-service
or presented at a staff meeting. Although the training
code cart, a fully stocked code cart, and pharmacy drawers were used during the carnivals, adjustments could be
made if necessary to accommodate abbreviated versions.
For example, laminated pictures of the contents of code
drawers are still helpful in providing a simulated learning
opportunity to the staff. Obtaining one drawer at a time
from a code cart is another way to downsize the project
while still providing the learning opportunity.
Conclusion
Adult learning theory and accelerated learning provided the foundation for the development of the Code
Carnivals and Code Blue drills. This training methodology provided a variety of opportunities for staff to handle
and practice using the emergency equipment in a relaxed
environment, and when used in conjunction with Code
Blue drills, it enhanced staff readiness and confidence to

The Journal of Continuing Education in Nursing December 2009 Vol 40, No 12

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handle real-life emergency situations. Immediate informal feedback indicating that the carnival experience was
helpful to staff was consistent and frequent. The time requirement for individual participation was small, yet the
Code Carnival provided multiple learning options. Many
of the staff played the games repeatedly or returned to
subsequent carnivals for additional practice. During the
code drill phase, the educators queried staff as to whether
the learning opportunities at the Code Carnival resulted
in improved readiness for a Code Blue. Without exception, staff indicated that they felt more prepared and
much more comfortable with a Code Blue as a result of
the games played at the Code Carnival.

564

References
American Heart Association. (2008). Emergency cardiovascular
care program administration manual: Guidelines for program
administration and training. Retrieved October 8, 2008, from
www.americanheart.org/downloadable/heart/1203523321943801485%20PAM%202008%20Txt.pdf
Center for Accelerated Learning. (2008). What is accelerated learning?
Retrieved October 9, 2008, from www.alcenter.com/what_is.php
Kearsley, G. (2008). Andragogy. Retrieved October 9, 2008, from
http://tip.psychology.org/knowles.html
The Joint Commission. (2008). History tracking report: 2008 to 2009
requirements (Standard PC.9.30 EP 4). Retrieved October 8, 2008,
from www.jointcommission.org/NR/rdonlyres/4683BD3F-85FA4B69-A607-630CC2EE13A3/0/CAH_PC_08_to_09.pdf

The Journal of Continuing Education in Nursing December 2009 Vol 40, No 12

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