HD-EM-001 · Cardiac Arrest & Code Blue (UPDATED)

Cardiac Arrest and Code Blue Response in Hemodialysis Unit

Policy HD-EM-001 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To establish standardized, rapid response to cardiac arrest in dialysis patients that accounts for blood circuit, anticoagulation, electrolyte shifts, and vascular access, per AHA 2020, MOH-Jordan Code Blue Policy 2023, and JCI IPSG.6.

2 Scope

Applies to all RNs, physicians, dialysis technicians, and code team members. Covers arrests during HD, pre-HD, and post-HD in unit.

3 Definitions

Code Blue Cardiac arrest – unresponsive, no pulse, no breathing Code Aqua Water system failure (different from Code Blue) ROSC Return of Spontaneous Circulation Disconnect Priority Air embolism > blood loss > machine damage – patient off in <60 sec

4 Policy Statement UPDATED

Update 1.1 <60 second disconnect & ACLS modifications

<60 second disconnect. No CPR while on machine. ACLS modified for HD. Defibrillate first if witnessed VF. RN initiates Code Blue.

Enhanced: • <60 Second Disconnect: Patient must be off HD machine before CPR starts. CPR on HD chair with blood lines connected is ineffective. • No CPR While on Machine: Chest compressions cause blood pump stop + venous pressure alarms. Must disconnect first. • ACLS Modified for HD: Consider hyperkalemia, air embolism, dialysate error in all arrests. • Defibrillate First: If VF/VT witnessed in unit, defibrillate before disconnect if defib pads already on. Otherwise disconnect first. • Never Delay for MD: RN initiates Code Blue and disconnects. No MD order needed.

Rationale: JCI runs mock codes during surveys. <60 second disconnect is a JCI standard. CPR on a connected HD machine is ineffective.

5 Procedure: Code Blue Response – HD Patient On Machine UPDATED

Phase 1: Recognition & Activation – 0-10 Seconds

Step	Action	Key Point
1. Assess	Check response + pulse + breathing ≤10 sec	Agonal gasps = no breathing
2. Call Code	Shout "Code Blue Room ___" + press code button + call overhead	"Code Blue, Dialysis Station 5"
3. Start Timer	Code recorder starts timer at T=0	Document all times

Phase 2: Disconnect from HD Machine – 10-60 Seconds – 2 Staff UPDATED

🎯 Target: Patient off machine + flat + pads on = <60 seconds

RN #1 – Blood Return:

Press STOP on machine. Silence alarms.
Clamp arterial line (red clamp) closest to patient.
Clamp venous line (blue clamp) closest to patient.
Disconnect arterial from patient access. Connect to saline rinse-back port OR cap.
Open saline 300mL. Return blood at 150-200 mL/min. Do NOT use machine rinse-back if dialysate error suspected.
When blood returned: Clamp venous. Disconnect from patient. Apply pressure dressing to access.
Shout "OFF" when patient disconnected.

RN #2 – Prep for CPR:

Lower chair to flat. Remove pillow.
Backboard under patient if not hard surface.
Crash cart to bedside. Attach defib pads.
Time keeper starts timer.

If CVC: Clamp both lumens. Disconnect. Do NOT attempt to aspirate. Cover with sterile dressing.

If AVF/AVG: Hold site 10-15 min after needle out. Heparinized patient = prolonged bleeding.

Phase 3: ACLS – Starts Minute 1 UPDATED

Time	Action	HD-Specific Modifications
0-1 min	CPR 30:2. 100-120/min. Attach defib	Do not shock while on machine. Disconnect first unless pads on + witnessed VF
1-2 min	Rhythm check. Shock if VF/VT. Resume CPR 2 min	If hyperkalemia suspected: CaCl 1g IV push BEFORE epi
2-4 min	IV/IO access. Epi 1mg q3-5min	Use CVC if present. If no IV, use IO. Avoid AVF/AVG for drugs
4-6 min	Consider H's & T's	HD H's: Hyperkalemia, Air embolism, Hypotension, Hypoxia, Dialysate error, Tamponade
6+ min	Amiodarone if refractory VF	CaCl + Bicarb if K >6.5 or peaked T waves

HD-Specific Causes to Treat Immediately:

Hyperkalemia K >6.5: CaCl 1g IV push over 2-5 min = stabilizes heart · Bicarb 50mEq IV if acidotic · Insulin 10 units + D50W 25g IV · Resume HD STAT once ROSC for K removal
Air Embolism: Left lateral Trendelenburg position · 100% O₂ non-rebreather · Clamp venous line immediately during arrest
Dialysate Error: If conductivity/pH abnormal before arrest: Do NOT return blood · Labs: K, Ca, pH stat · Treat based on error
Hypotension/UFR Too High: 500mL NS bolus · Consider if UFR >13 mL/kg/hr caused hypovolemia

Phase 4: Post-ROSC Care – First 30 Minutes

DO NOT RESTART HD until cleared by MD. Risk of re-arrest.

Labs STAT: K, Ca, Mg, pH, Hgb, lactate, cardiac enzymes.

ECG: Look for ST changes, peaked T's, arrhythmia.

Transfer: ICU/CCU mandatory. Call ambulance if not in-house.

Machine: Quarantine. Download treatment data. Biomed checks dialysate. Do NOT reuse.

Family: Notify within 15 min per HD-AD-002.

If No ROSC After 30 Min: Medical Director or Code Team Leader may terminate code per Jordan law + MD documentation.

7 Staff Roles During Code UPDATED

1st RNRecognize arrest, call code, disconnect, start CPR

2nd RNCrash cart, defib, timer, recorder

In-Charge RNTeam leader until MD arrives. Assigns roles. Crowd control

TechCrowd control, bring O₂, run labs, compressions relief

Medical DirectorCode team leader. Drug orders. Termination decision

RecorderHD-EM-001-F2 Code Blue Record – every drug, time, rhythm

8 Special Situations UPDATED

Isolation HBV/MDROStaff in PPE continue code. Do NOT delay for gown. Use dedicated cart items

Arrest in Waiting RoomNo disconnect needed. Standard ACLS. Call 911 if no ICU

DNR PatientVerify DNR form signed. No CPR. May return blood + comfort measures

Pregnant >20 weeksLeft uterine displacement. OB team stat. Same disconnect rules

PediatricUse peds pads. Disconnect same way. Dose meds by weight

10 Training & Drills – JCI Requirement UPDATED

Update 3.1 Mock code drills & disconnect competency

Initial: ACLS for RNs, BLS for techs. Quarterly mock code drills. Annual competency.

Enhanced: • Initial: All RNs ACLS certified. BLS for techs. Return demo: disconnect in <60 sec. • Quarterly: Mock code drill. Scenario rotates: hyperkalemia, air embolism, VF. • Annual: Competency: disconnect + CPR + defib + documentation. • Fail: If cannot disconnect <60 sec or forgets to check pulse = retrain + no patient care until pass. • Documentation: HD-EM-001-F3 Mock Code Drill Log with times.

Rationale: JCI runs mock codes during surveys. Disconnect <60 sec is a JCI standard. Drill documentation must be on file.

11 Quality Monitoring – QAPI UPDATED

Update 4.1 New & refined quality metrics

Code rate <1.0, disconnect <60 sec, 1st shock <3 min, ROSC >30%, survival >10%, crash cart 100%.

Added: • % staff who pass <60 sec disconnect drill – target 100% • Time from arrest to first shock (VF/VT) – target <3 min • % codes with documented HD-specific cause considered – target 100% • Time from ROSC to ICU transfer – target <30 min.

Rationale: Expanded KPIs address JCI audit red flags: drill performance, defib speed, HD-specific documentation, and transfer timeliness.

12 References UPDATED

Update 5.1 Updated reference list

AHA. Advanced Cardiovascular Life Support Guidelines 2020. Cardiac Arrest in Dialysis.
KDOQI. Managing Cardiovascular Disease in Dialysis 2020.
MOH-Jordan. Code Blue Policy for Hospitals, 2023.
JCI. International Patient Safety Goal 6: Reduce harm from clinical alarm systems.
MOH-Jordan Code Blue Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	<60 second disconnect mandatory; no CPR while on machine; ACLS modified for HD; RN initiates Code Blue without MD order	JCI runs mock codes during surveys. <60 sec disconnect is JCI standard. CPR on connected HD machine is ineffective.
5. Phase 2	Stepwise disconnect protocol: clamp lines, disconnect, return blood with saline (not machine rinse-back if dialysate error), shout "OFF", prep CPR	Machine rinse-back can deliver contaminated dialysate if error caused arrest. Clear "OFF" signal coordinates team.
5. Phase 3	HD-specific ACLS: CaCl BEFORE epi if hyperkalemia; air embolism protocol (left lateral Trendelenburg); dialysate error protocol (do NOT return blood)	Hyperkalemia, air embolism, and dialysate errors are HD-specific causes. CaCl stabilizes the heart before epi.
5. Phase 4	Post-ROSC: DO NOT restart HD; ICU transfer mandatory; machine quarantine; family notification <15 min; 30-min termination criteria	Restarting HD post-arrest can cause re-arrest. Family notification is a JCI standard.
10. Training	Quarterly mock code drills; disconnect <60 sec competency; fail = retrain + no patient care	JCI runs mock codes during surveys. Drill documentation must be on file.
11. QAPI	New KPIs: staff pass drill (100%), time to first shock (<3 min), HD-specific cause considered (100%), ROSC to ICU transfer (<30 min)	Addresses JCI audit red flags: drill performance, defib speed, and transfer timeliness.

Policy HD‑EM‑001 · Proposed updates June 26, 2026 All changes reviewed against AHA 2020, KDOQI 2020, MOH‑Jordan 2023, JCI IPSG.6.
⚠️ This policy is audit-proof for JCI + MOH 2023. If your team can't get the patient off the machine in <60 seconds, you fail.

Cardiac Arrest Code Blue In Dialysis · Version 2026-06-27 · Hemodialysis Unit

📋 Back to All Policies · 🖨️ Print This Page

Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.