When a “code blue” is called for immediate patient resuscitation, healthcare personnel rush to the bedside to instigate life-saving measures that may be physically demanding and go on for a prolonged time. How often are healthcare workers injured when performing a code, and what are the primary risks?
Those were the questions asked by Stephen M. Vindigni, MD, MPH, a gastroentologist at the University of Washington School of Medicine in Seattle. Having observed occupational code-related injuries and heard anecdotal reports, Vindigni undertook a comprehensive review of the literature.1 Vindigni and colleagues found such reports were few and far between in the medical literature, though he thinks the injuries go widely unreported for a variety of reasons. Code activities include performing chest compressions, assessing and restoring cardiac rhythm, and stabilizing the airway, he says.
“A lot of us, particularly in internal medicine, pulmonary, critical care are involved in codes quite frequently,” Vindigni says. “The focus is always on the patients, but little has been written for the individuals who perform the codes. We have heard anecdotal stories where providers have been injured during code situations.”
One of the co-authors of the paper incurred severe and prolonged neck pain after performing a code that included repeated CPR and other emergency measures.
“That case was an overnight code, when probably fewer hospital staff were available than usual,” Vindigni says. “It was sort of a routine code, but it was lengthy. There were fewer providers to [assist with] chest compressions and the co-author suffered a subdural hematoma. Basically, a severe neck strain that went on for a couple of weeks without much improvement. It was managed conservatively and in the end was OK, but it was the result of the vigorous chest compressions with multiple rounds of CPR.”
Vindigni is aware of another case where a provider was running to answer a code, but tripped and fell and suffered knee ligament damage serious enough to require surgery.
“These things happen,” he says. “Those kinds of stories prompted us to review the literature to see if there was anything out there on what the risks are to healthcare providers who are running codes. We were kind of surprised, actually, to find that there really was nothing.”
Though they found few published case reports of code-related injuries, the researchers did manage to quantify a variety of occupational risks during these procedures that include infectious, electrical, musculoskeletal, chemical, irradiative, and psychological harms.
“Infections are much lower than they used to be now that we are not really doing that much mouth-to-mouth resuscitation,” Vindigni says. “We are also using the newer needle [safety] devices. I think the electrical and chemical risks are pretty low. Musculoskeletal is probably the most common and one of the least reported because you might just go with it and take some aspirin or acetaminophen and move on. Those are probably minor musculoskeletal things like [pain in the] back, shoulder, and neck strain.”
Injured workers may take a day off, but typically will rebound from these injuries and not necessarily report them. Of 6,266 articles reviewed in the meta-analysis, 73 relevant studies shed some light on the risks healthcare workers face when performing codes. The review does quantify risks that are rare but real, but the common misperception to overcome from the outset may be that there is no risk associated with codes and resuscitation. It seems likely that such injuries are frequently underreported or not reported at all in many cases, he notes.
“I think that is very likely,” he says. “We probably hear a little bit more about things like needlestick injuries because the providers may go and seek post-exposure prophylaxis. But you hear very little about the psychological effects of being involved in codes. There is a little bit of stigma, especially if you are in training. If you are an intern or a resident, you don’t want to be the person that goes and complains or is the one with the injury. It’s just part of the process. You’re involved in a code, you’re slugging through your internship or your residency, and self-care sort of falls by the wayside.”
Role for Employee Health
Employee health professionals can help by encouraging reporting of any code-related injuries and reducing some of the mental health stigma. Codes are likely to increase as the patient population becomes older and more acutely ill. Increased reporting and discussion could lead to some prevention measures for injuries during emergency resuscitation, he says.
“There are definitely things that can be done to help limit the effects or the risks to the people involved in those codes,” he says. “Even little things like making sure that the height of the bed is appropriate for the person providing the chest compressions. Just basic things that we probably don’t reflect on very well after a code.”
In that regard, a routine debriefing after a code may be beneficial in processing the psychological effect, he says.
“Talking right afterward could be very helpful because it is very hard to reassemble the entire group of people who were involved in a code at a later date,” he says. “Codes are multidisciplinary. It’s not just the doctors. You have nurses there, you often have clergy, students, radiology, and techs. It can be a very diverse group with a very different level of experience.”
Code discussions and feedback could lead to some practice changes or valuable insights. Many medical centers have code leaders or someone similar to best facilitate these conversations, he says.
“A lot of times, myself included, we do talk a little about the code afterward, but it sort of stops there,” he says. “Having a person to follow up on those areas where we could have done a little better, areas for improvement [could be beneficial]. There may be some additional research or some type of quality control to actually implement some of the things that are discussed during the code.”
There is the potential for healthcare workers to be somewhat traumatized by the event, particularly if the patient dies — but again, workers may be reluctant to volunteer information about their mental state or report any injuries.
“It is a stressful situation, and when people die it can be really stressful,” Vindigni says.
That said, he does not recommend a team leader ask if anyone was injured during the immediate aftermath of a code.
“There would still be underreporting because no one wants to be the center of attention,” he says. “Sometimes injuries — particularly musculoskeletal — are delayed. You may not feel that muscle strain until hours later, or the next day after the adrenaline calms down.”
The best alternative is a confidential reporting system for healthcare injuries or post-code mental anguish. “There needs to be a way for people to report and communicate injuries in a way that feels comfortable,” he says.
1. Vindigni SM, Lessing JN, Carlborn. Hospital resuscitation teams: A review of the risks to the healthcare worker. Journal of Intensive Care 2017;5:59: https://doi.org/10.1186/s40560-017-0253-9.