(1542) Singing the False Blues: Reducing False Code Blue Alarms With a Simple Intervention

Introduction: In-hospital cardiac arrest is a critical event with high morbidity and mortality, necessitating immediate attention from a multidisciplinary medical team. Many hospitals utilize "Code Blue" teams and hospital-wide alarm systems to mobilize physicians, nurses, respiratory therapists, and pharmacists. Frequent false alarms waste valuable time and resources. High false alarm rates desensitize Code Blue teams, delaying arrival and time to resuscitation. We identified a high rate of false Code Blue alarms and hypothesized that installing protective covers on alarm buttons could mitigate accidental activations and reduce this rate.

Methods: Before implementing the intervention, we looked at the data for false Code Blue alarms across the hospital for a rolling year of July 2023 to June 2024. Data collected included the cancellation rate, reason, the department in which the cancellation occurred, and the accidental push by role. Various solutions were considered, including implementing a 10-second alarm delay, to allow for cancellation, placing protective covers over the Code Blue buttons, and suspending the hospital-wide alarm system. Ultimately, protective covers were installed and data collection continued.

Results: Prior to intervention, the false Code Blue alarm rate fluctuated from 52% to 90%, averaging 70.5%. Accidental pushes were identified as the primary cause of false alarms, with the highest number of activations occurring in the Acute Surgical Unit. Following the installation of protective covers, the false alarm rate decreased from 70.5% to 7.14% in the post-intervention period. Each cover cost $392, resulting in a total expense of $21,264 including installation.

Conclusions: False Code Blue alarms drain valuable resources, contribute to alarm fatigue, and detract attention from patients needing critical care. Our institution faced a persistent issue with frequent false alarms. Implementing a simple, inexpensive solution—protective covers for alarm buttons—led to a significant reduction in false activations, dropping from 70.5% to 7.14% in the immediate post-intervention period. Further research is needed to determine the national prevalence of this problem and to evaluate secondary outcomes, such as cost savings and patient impact.