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Trillium Health Partners’ training boosts staff confidence for code blue emergencies
Sep 13, 2021, By: Heather Ead
nurses responding to a code blue test
A needs assessment of nurses and other health-care providers revealed that it can be challenging to access and maintain basic life support recertification.

Supporting a code blue emergency — cardiopulmonary arrest — is a stressful event, particularly for novice staff. Staff have reported feelings of anxiety, confusion, and even the inability to act during a code blue situation (Ryzner & Kujath, 2018).

Studies reinforce the value of providing code blue training to improve perceived comfort and anxiety levels of staff (Sanseau et al., 2020). Regular training and review around basic life support (BLS) also helps increase confidence, particularly for nurses who work in areas where a code blue occurs infrequently (Ryzner & Kujath, 2018).

Use of hands-on simulation with a video briefing has been demonstrated to improve response times for staff commencing cardiopulmonary resuscitation (CPR) (Ryzner & Kujath, 2018). This is an important strategy to apply in BLS training, as a rapid response is always desired to optimize patient outcomes.

Survival rates and neurological outcomes following in-hospital cardiac arrest have greatly improved over the past decade (Girotra et al., 2012). The risk-adjusted rate for survival following a code blue was 22.3% in 2009 (Girotra et al., 2012). Survival rates alone range from 11% to 35% following in-hospital cardiac arrest (Menon et al., 2018). Unfortunately, these rates continue to plateau (American Heart Association, 2020).

A needs assessment regarding ongoing education at our organization revealed a common theme among nurses and other health-care providers, such as physiotherapists, occupational therapists, dietitians, and patient care assistants. We identified that it can be challenging to access and maintain BLS recertification. Access to courses can be limited and is often costly; another common barrier was related to time commitments (e.g., arranging a day away from work to attend an educational session).

This article examines how we identified an opportunity to improve access to BLS recertification. In recognition of the value of annual recertification, our goal was to create on-site recertification sessions to provide staff with improved knowledge and comfort to support emergency situations. Additionally, we aimed to fulfil this goal at minimal or no cost to health-care providers.

BLS training

Studies reinforce the value of providing code blue training to improve perceived comfort and anxiety levels of staff.

The process to become a BLS instructor requires several steps. Generally, this includes attending a two-day course, purchasing training manuals and supplies, remaining current with BLS guideline updates, and providing three or more sessions annually.

During completion of these requirements, I learned that BLS is not a legislated or accredited process. This partly explains the wide variance in cost, length of course, and methodology of teaching of different BLS providers.

Further, governing bodies such as the College of Nurses of Ontario (CNO) do not provide direction around BLS requirements for nurses. In contacting the practice quality department of the CNO, I was informed that the CNO does not require nurses to obtain BLS training or provide recommendations on the frequency of renewal. BLS requirements are at the discretion of the employer. This adds to the variance among health-care organizations regarding ongoing requirements for BLS competency.

As a nurse educator, I felt that staff should not be expected to pay for mandatory training. I was motivated to create a pay-it-forward approach, where review sessions would be cost free, but have an optional, suggested $10 donation to a selected charity each month. Some of the charities we have supported through our recertification sessions are noted below.

Improving access

By improving access to BLS classes and removing the barrier of cost, I was eager to support this initiative. After completing the two-day instructor course in 2018, my first BLS session was with a small group of nurses at the orthopaedic patient care unit at Trillium Health Partners.

I was soon asked to provide larger sessions for staff from multiple departments. We have several large clinical training rooms with audiovisual and CPR manikins of various ages for practice (adult, child, and infant).

At the BLS sessions I reviewed the current guidelines of the International Liaison Committee on Resuscitation (ILCOR) and the Heart and Stroke Foundation (HSF) of Canada. After successful demonstration of BLS skills, staff complete a multiple-choice test. Upon completion of the session, staff are provided a BLS card that can be renewed after one year.

After 17 months of providing these monthly sessions to staff at Trillium Health Partners, this initiative received a quality award in the “Sustainable Innovation” category at our annual quality awards event.

COVID-19 concerns

While a code blue emergency is always stressful, staff have voiced that they now feel better prepared when these situations arise.

In light of COVID-19, having on-site sessions also prevents staff from entering an external facility and potentially being in contact with outside personnel. During the first wave of the COVID-19 pandemic, all sessions were temporarily put on hold. In compliance with social distancing, hand sanitization, and use of personal protective equipment, the delivery of the sessions was modified, and offerings resumed in the fall of 2020.

The number of attendees at each session has been reduced to ensure that staff can remain two metres apart. The sessions are also no longer offered in a central location for staff from all units to join. Instead, these classes are provided directly at the staff’s department in their classroom or conference room. This ensures consistency of staff that work and learn together, helping to prevent exposure to anyone who is an asymptomatic carrier of the COVID-19 virus.


To evaluate the outcomes of this initiative, attendees were provided a brief Likert scale questionnaire following their attendance at the BLS session. This survey evaluated their knowledge and comfort in responding to a code blue before and after the session. On average, 92% of staff surveyed felt more confident and knowledgeable following BLS recertification. See questionnaire responses below.

While a code blue emergency is always stressful, staff have voiced that they now feel better prepared when these situations arise. Having on-site sessions also allows the instructor to review organization-specific policies, such as use of personal protective equipment when treating patients with standard- and heightened-risk status. For example, a level 2 isolation gown is worn to support a code blue with a standard-risk patient, while a level 3 gown (or higher) is used with patients who have a heightened-risk status (i.e., are currently positive for the COVID-19 virus).

In future, I will continue to partner with ILCOR and HSF to ensure that the recertification sessions and materials are aligned to current guidelines. Some staff have shown an interest in having an on-site advanced cardiac life support (ACLS) course. This is an opportunity for educators working in critical care to consider.

A key lesson learned from this initiative is to be on the alert for gaps and challenges that health-care providers consistently face. With a team approach, these gaps can be transformed into a sustainable improvement initiative for the organization, and possibly a pay-it-forward opportunity for our community partners and charities.

List of charities supported by code blue review sessions

BLS session questionnaire (average of Likert scale responses (5 = strongly agree, 1 = strongly disagree)

I find it difficult to attend a BLS session:

  • Before Trillium Health Partners (THP) session: 4
  • After THP session: 1

I feel prepared for a code blue event:

  • Before THP session: 2
  • After THP session: 4

I feel knowledgeable about child and infant guidelines:

  • Before THP session: 2
  • After THP session: 4

I feel knowledgeable about adult guidelines:

  • Before THP session: 3
  • After THP session: 4

I have anxiety about responding to a code blue event:

  • Before THP session: 4
  • After THP session: 3


American Heart Association. (2020). Highlights of the 2020 American Heart Association guidelines for CPR and ECC. Heart and Stroke Foundation of Canada. Retrieved from

Girotra, S., Nallamothu, B. K., Spertus, J. A., Li, Y., Krumholz, H. M., & Chan, P. S. (2012). Trends in survival after in-hospital cardiac arrest. New England Journal of Medicine, 367, 1912–1920. doi:10.1056/NEJMoa1109148

Menon, V., Prasanna, P., Edathadathil, F., Balachandran, S., Moni, M., Sathyapalan, D., Pai, R., & Singh, S. (2018). A quality improvement initiative to reduce ‘out-of-ICU’ cardiopulmonary arrests in a tertiary care hospital. Quality Management in Health Care, 27(1), 39-49.

Ryzner, D. M & Kujath, A.S. (2018). Low-fidelity code blue simulation on the orthopaedic unit. Orthopaedic Nursing, 37(4), 230–234. doi:10.1097/NOR.0000000000000475

Sanseau, E., Thomas, A., Jacob-Files, E, Calhoun, A., Romero, S, & Kant, S. (2020). Feasibility of low-fidelity pediatric simulation-based continuing education curriculum in rural Alaska. Cureus, 12(5), 1-17.

Heather Ead, RN, MHS is a clinical educator at Trillium Health Partners in Mississauga, Ont. She can be reached by email at: