Code Blue Blind Spots: Mapping Nursing Exposure to Cardiac Arrests

In-hospital cardiac arrest (IHCA) requires high-performance team responses under pressure, yet its relative rarity creates challenges for maintaining individual and team competence. Nurses often serve as first responders, but little is known about how their actual exposure to IHCA varies across time and schedule patterns.

We analyzed spatial-temporal patterns of Code Blue activations at a tertiary care hospital from January 2023 through December 2024. Using switchboard data, we identified 208 IHCA events across 17 locations and modeled nursing exposure based on nine standard 28-day work schedules and 9,991 randomly generated variants (10,000 total). For each schedule, we calculated the number of Code Blue events encountered and the intervals between exposures.

Code Blues were unevenly distributed across wards, with 30% occurring in a single cardiology step-down unit. Among the nine standard schedules, nurses would experience a median of 15 Code Blues over two years, with median gaps between exposures of 36 days (IQR 34.5–47). All nine core schedules contained at least one gap exceeding 90 days. Across 10,000 modeled schedules, the median time between exposures was 38 days (IQR 31–50.5), with 98% of schedules containing at least one gap longer than 90 days.

Even in high-incidence wards, most nurses experience long, irregular intervals between cardiac arrest events—periods long enough for CPR and resuscitation skills to decay. These invisible gaps suggest an opportunity to target simulation-based or just-in-time training to individuals or units most at risk of skill erosion, thereby improving readiness and team performance during IHCA.