What Happens During a Code in the ER?

What Happens During a Code in the ER?

When a patient is described as having “coded,” this generally refers to cardiac arrest. In such a case, urgent life-saving measures are indicated. This can happen within and outside of medical facilities. The benefit of the occurrence in a professional health care setting is that policies and guidelines are in place to address this life-threatening crisis . What follows is the perspective of responding to a code from an ER nurse.

Just as every patient is different, so is every code. The causes and outcomes of every code have to do with the characteristics of the patient in question: the history of present illness and, of course, their comorbidities. Timothy Wrede, RN, is a long-time emergency and critical care nurse in the suburbs of New York City, as well as a former EMT who has seen his fair share of codes. According to Wrede, nothing matters during a code so much as the team that responds to it. “It is imperative to ensure that a good team of doctors, nurses, and ancillary staff are working together efficiently in order to achieve resuscitation of spontaneous circulation (ROSC),” says Wrede. 


According to Wrede, a veteran of level-I trauma care, when it comes to staffing a code, less is more. Studies suggest that thirteen is the maximum number of personnel participating in an effective code. Included in this number are professionals that go beyond those immediately at the bedside, such as pharmacy, lab, and spiritual services. “There’s nothing worse than 25 people crammed into a patient room trying to coordinate resuscitation,” according to Wrede. For him, the minimum is five ‘in the box’, or in direct proximity to the patient, as well as one team member ‘outside of the box’. “One doctor, three nurses, and two aides are more than sufficient to obtain or sustain an airway while maintaining a clear line of vision of the patient, the patient’s monitor, and other team members,” he says. This consists of one nurse on either side of the patient responsible for gaining peripheral IV access, administering IV medication, and obtaining blood samples for lab work. The code recorder, usually an RN, documents everything that occurs, including every medication given, timing, team actions, compressions, defibrillation, and patient response. 

Wrede’s description of the ideal code team is very similar to the American Heart Association’s recommendation for high-quality CPR teams.  It includes a “triangle” of providers doing chest compressions, defibrillating, breathing for the patient, and providing medications, in addition to a code recorder and a physician outside of the triangle.  The physician acts as a team leader by making high-quality treatment decisions, providing feedback, and overseeing team actions.

For Wrede, the most important times for a code are before and after it.  Having a competent team with pre-assigned roles, as well as the opportunity to review and debrief afterward to improve the process continuously, and allow for best patient outcomes. Many hospitals address this by establishing a code team that arrives every time a code is called, with well-established roles, and protocols. Wrede’s experiences describe codes in the ED, although codes are generally run the same regardless of where they take place. The biggest difference is the patient context.

When You Can’t Shake It: The Aftermath of a Code

When You Can’t Shake It: The Aftermath of a Code

Nursing is so many things. It is critical thinking, technical skills, proficiency and efficiency, prioritizing, strategizing, questioning—using our minds and also our hearts. Overall, we are caregivers. Regardless of where we work, we all experience rough days, tough patients, and trying codes. Sometimes, the experience stays on our minds and weighs on our hearts long after the shift ends. Some of us can compartmentalize it and can easily move on. 

There will always be patients, families, codes, and experiences you just can’t shake. You mull over every single decision you made, dream about the situation again, dissect everything you could have done differently. You get down about things you could have executed better. These aren’t productive behaviors, and over time they can increase nurse job dissatisfaction and emotional burnout. What can you do when you find yourself ruminating?

1. Debrief.

Debriefing after a resuscitation event is one of the single most important things you can do with your team. Some units are better about facilitating a debrief than others, so if your team seems reluctant to do so, push for it yourself. It can be both educational and healing to discuss the way the code progressed as a team. You can focus on what worked and what could have gone better, you can brainstorm ways to improve the system and processes, and you can talk about improving patient safety and communication. Codes are stressful, and debriefs are a way to rebuild communication, enhance teamwork, and decompress.

2. Find your friends.

After rough experiences, I often find myself texting or calling my nurse colleagues who participated in a resuscitation with me about what we went through. Sometimes it’s easier to talk it out after some time passes and you have a clearer head and mind. If you’re still thinking about a patient or a code response the day after, reach out to your work best friend and talk it out.

3. Write it down.

You may not be a writer, but you’d be surprised at how much better it can make you feel to write down your thoughts. For some people, writing them down is the best way to process feelings and put them behind you. If you don’t have a journal, you could write on a piece of paper and then throw it away, or open a blank computer document and type it out instead. It can help organize your feelings and provide a powerful release.

4. Reach out to management.

Many employers offer employee assistance programs, which can provide additional resources if you still feel troubled after a code. You could also try getting in touch with your facility’s chaplain for extra support.

5. Be kind to yourself.

Exercise. Breathe. Get together with non-work friends. Visit family. Read a book. Do something for you. Allow yourself to feel how you feel, and don’t be too hard on yourself about your performance or your experience. Part of nursing is the art and science of caring, so let yourself care. It’s why we do what we do.