Department of Pediatric Newborn Medicine
Clinical Practice Policy: NEWBORN RAPID RESPONSE AND INFANT CODES
Effective Date: 03/12/2020
Policy Number:
Contact Person(s)
Approved by: Clinical Practice Council 03/12/2020 Revision 12.17.20
Personnel Approved for:
Location Approved for: Obstetrics/Newborns
Keywords: Rapid Response, Infant/Newborn Code, Emergent Transfer of Infant, Code Blue
Newborn, Code Blue OB
I. Purpose: To provide guidelines for Newborn Rapid Response and Infant Codes including
emergent care and transfer from non NICU areas to the NICU.
II. Presumes Knowledge of:
• WNH Standard Policy Statements
• WHN I.1 Infant Identification (CPGS)WNH R.1 Resuscitation of an Infant
• WNH T.1 Infant Thermoregulation
• WNH T.4 Infant Transport
• 1.2.1 Cardiopulmonary Resuscitation Response Teams (Code Teams)
• 1.2.3 Rapid Response Policy
III. Guidelines/Information: Newborn Code Team and Rapid Response Team Information
1. The Code Blue Newborn Team consists of a NICU based intra-disciplinary team that responds to
all neonatal emergencies in the hospital.
2. Coverage is 24/7.
3. The appropriate team is activated by the NICU Stat Line Nurse for events within CWN or via
calling 2-6555 (Hospital STAT line) for pager and overhead paging for events outside of the
inpatient floors Center for Women and Newborns Building.
o The appropriate team is activated by the Code Blue Newborn or OB via group pages for
events outside CWN, such as those occurring in the MRI suites (Lee Bell, L1,or the
Building for Transformative Medicine), ED, Tower and Shapiro buildings. In the event of
Department of Pediatric Newborn Medicine
a paging downtime or power failure, overhead pages will be used for calling and
activating RRS and code teams as well as the STAT line NICU nurse utilizing voalte
to communicate to the emergency team members.
4. Code Blue Newborn Team includes: Neonatal Attending, neonatal fellow, pediatric resident,
LIP, NICU Triage RN, NICU NIC, and registered respiratory therapist (RRT).
5. Rapid Response Team 1 includes: NICU Triage RN, delivery room resident #1 (DR 1), RRT.
6. Rapid Response Team 2 includes: NICU NIC, neonatal fellow, delivery room resident #2 (DR
2), RRT.
7. In the event of simultaneous emergencies, team 1 will be paged and dispatched first, and then
Team 2 will be paged and dispatched.
8. In the event an infant is the subject of two (2) Rapid Response calls, strong consideration should
be given to the following:
• Transfer to NICU Triage for monitoring and evaluation by the attending
neonatologist, if this has not yet occurred.
• Low threshold for NICU admission if infant is being evaluated in NICU triage for
the second time. If the decision is to NOT admit the infant, there should be a
discussion regarding the plan between the NICU attending neonatologist and the
baby’s attending pediatrician.
9. All code equipment is to be brought to the infant requiring resuscitation outside of CWN 5,
6, 9, 10. For infants born precipitously on 8 south or births that occur in other areas of the hospital,
the NICU team will transport the required equipment to the infant.
IV. Suggested Roles and Responsibilities: Newborn Code and Newborn RRS:
1. CODE: The neonatal attending physician will assume the role of code team leader. If needed, any
additional Neonatal Resuscitation Program (NRP) credentialed clinician may assume the role of code
team leader to organize the resuscitative efforts of the newborn.
2. RRS: The responding neonatal LIP will assume the role of RRS team leader and will assign
individual roles for responding clinicians.
3. All clinicians are responsible for documenting assessment and interventions in the Newborn Code/
Rapid Response Narrators (nursing) or by documenting a Significant Event/RRS or Code Note (LIP/
Respiratory Therapy) in the electronic health record.
V. Criteria for Infant Code Team or RRS Activation:
1. Infant Code
• Any need to start NRP
• Apnea-Persistent requiring PPV
Department of Pediatric Newborn Medicine
• Bradycardia (HR Persistently < 80 bpm)
• Central cyanosis
• Cyanosis (Circumoral, unresponsive to BBO2)
• Floppy Baby (Absent tone/lack of resp effort = stunned infant requiring resuscitation)
• Persistent oxygen saturation less than 85% (>10 mins of life)
• Seizure like activity
2. Newborn Rapid Response
• Respiratory:
• RR >70
• O2 Sat 85-89% (>10 mins of life and requiring Oxygen)
• Grunting/Flaring/Retracting
• Neurologic:
• Acute Change/Lethargy
• Decreased/abnormal tone
• Cardiovascular:
• HR persistently >210
• Other:
• Any Fall/Drop Event
• Initial Presentation after home birth
• Uncontrolled bleeding
• Unexplained pain
• Unresolved parental concern
• Any Staff member concern
VI. How to Activate an Infant Code or Newborn RRS in WBN/PP/CLB/Antenatal(see Addendum I)
1. Newborn Nursery (CWN 9 & 10):
a. For a Rapid Response: Please press the “staff assist” button in the nursery to initiate a
local response from colleagues on your floor. Once an additional staff member arrives,
please use the NICU STAT Red phone located in each Nursery (direct line to the
NICU) to relay to the Stat RN the rapid response information using the G.I.R.L
acronym.
b. For a Code Blue Newborn: Please press the Code Blue NB button in the nursery. This
will send an automatic page to the newborn code team and does not require an
additional phone call to the STAT RN. A local team member should be ready to
inform the newborn code team upon arrival of the details pertaining to the code.
2. Center for Labor and Birth (CLB) dial x31164 (direct line to the NICU).
3. Antenatal dial x31164(direct to the NICU stat line) for precipitous birth situations.
Department of Pediatric Newborn Medicine
a. All infant resuscitation equipment is to be brought and set up outside of the
mothers room by the NICU team. The warmer set up with a neopuff and gases is
the most important, followed by the code cart if needed.
4. Any staff member calling the NICU stat line must use the G.I.R.L acronym to state the following:
a. Gestational Age of the Infant
b. Indication for Call (Reason for impending birth or Rapid Response/Code)
c. Relevant Information for NICU team (if any)
d. Location
VII. How to Activate an Infant Code for an admitted patient outside of CWN (see Addendum
II)
1. Call 2-6555
2. Ask for a Code Blue Newborn
3. Any staff member calling a Code Blue Newborn must state the following:
a. Request Code Blue Newborn (inpatient newborn)
Provide detailed location – building, floor, dept/pod, room
Communication with Parents: NICU Code/Rapid Response team will update parents concerning the events
for their infant
VIII. Code Blue Elevator Pass Information
1. NICU Triage RN, Attending Triage MD, RRT and NICU UC’s front desk have Code Blue Elevator
Passes for use in responding to code situations.
2. To use the Code Blue Elevator Pass:
a. Swipe Code Blue Elevator Pass in card reader or scan Code Blue Elevator Pass at
elevator and push up or down button.
b. Once elevator arrives, ask any visitors or other hospital staff to vacate.
c. Once inside the elevator, swipe Code Blue Elevator Pass in card reader or scan Code
Blue Elevator Pass.
d. Press and hold “Door close” button and floor number button until elevator door
shuts.
e. Use same directions for returning to NICU with an infant.
3. Equipment: Code Blue Elevator Pass
IX. Procedure:
1. WBN/CLB:
Department of Pediatric Newborn Medicine
Call for help by using NICU stat line x31164 or use red phone (WBN only) for code or rapid response
situation. Well newborn nurseries can press their Code Blue NB button to elicit an automatic page to the
code team and does not require a phone call.
• In the event of a power failure, call x2-6555 to have code or RRS overhead paged o All
procedural actions occur simultaneously as appropriate NICU personnel become available.
o The CLB/PP nurse is the first responder in these situations. The NICU team responds
immediately for codes and within 10 minutes for rapid response calls.
2. WBN: Bring infant to nursery (if not already in nursery).
3. MRI Suites:
• The MRI technician will stop the scan and be responsible for calling for help using the
hospital code line (2-6555) and requesting a Code Blue Newborn.
• The nurse that accompanied the infant from the NICU will be responsible for moving the baby
to the designated resuscitation area outside the magnet.
• The MRI staff will be responsible for the NICU resuscitation team gaining access to the
resuscitation area.
• NOTE THE MRI MAGNET IS ALWAYS ON. For patient and staff safety no
resuscitation will occur in the magnet. The resuscitation team will NOT enter the
magnet. The MRI technician will monitor for MRI safety.
4. All areas:
• Place infant on warming table when available.
• Apply O2 saturation probe.
5. At the same time, first responder nurse (or designee): delegate another nurse to communicate with
and update family.
6. Assess infant’s status using NRP guidelines:
• If infant is not breathing: clear airway as needed and give positive pressure ventilation
(PPV) and consider supplemental oxygen to achieve target saturation limits.
• If infant is breathing but remains dusky in color: provide blow by O2, which requires an
increase on the wall blender to ensure oxygen is being provided not just room air. o
Tactile stimulation may be tried two times.
▪ WBN uses self-inflating bags with flow inflating bags available for
NICU responding clinicians.
▪ CLB uses flow inflating bags
▪ MRI suites use flow inflating bags.
▪ Flow inflating bags can be found in all Neonatal code carts.
7. Evaluate HR and start compressions if HR<60 after 30 seconds of effective PPV with 100% O2.
• Effective PPV is defined by bilateral breath sounds and rise in chest movement.
8. Give report to NICU team responding to call.
9. Transfer to NICU.
10. NICU/PP: Notify private pediatrician about situation and transfer to NICU.
Document assessment and interventions in the Newborn Code/ Rapid Response Narrators in the
electronic health record. LIP/ Respiratory Therapists should write a detailed Significant Event
Department of Pediatric Newborn Medicine note or Code/RRS progress note. The time/date
stamp on the note should ideally be adjusted to fall between the Code/RRS start and end times
as indicated in the Code /RRS Narrator.
REFERENCES:
1. American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2012).
Guidelines for Perinatal Care (7th ed.). Ch 8, Care of the Newborn, pp 266-276, 280-284. Washington,
DC: Author.
2. American Heart Association and American Academy of Pediatrics. Handbook for Neonatal
Resuscitation Textbook, 7th ed. 2016. Lessons 1-6. Washington, DC: AHA/AAP.
3. Donn, S. M. & Sinha, S. K. Manual of Neonatal Respiratory Care 2012. 3rd ed. Ch 13 Neonatal
Resuscitation, pp. 121-127. New York: Springer.
4. Gardner, S.L, Carter, B.S., Enzman-Hines, M., & Hernandez, J.A. (Eds.). 8th ed., 2016,
Merenstein & Gardner’s Handbook of Neonatal Intensive Care. Niemeyer, S. et al, Ch 4, Delivery
room Care, pp. 47-70; Hernandez, J. A. Ch. 5, Initial Nursery Care, pp. 71-104. Elsevier: St.
Louis.
Addendum I:
Communication to Primary Pediatrics team after Newborn Code Blue or Rapid Response:
•
RRS or Code Team documents findings in Newborn’s chart, including plan and disposition of newborn.
•
NICU team communicates plan to private pediatrician as well as CLB/WBN/PP staff.
Addendum II:
*This also applies to any MRI performed at the Building for Transformative Medicine (BTM)
Addendum III:
