1. Initial Response
Equipment Readiness
- Crash cart location: _________________
- Defibrillator check frequency: Daily □ Weekly □
- Emergency medication inventory: _________________
Staff Roles
- Team Leader: _________________
- Primary Response RN: _________________
- Secondary Response RN: _________________
- Documentation Staff: _________________
2. Code Blue Protocol
Activation Procedure
- Code announcement method: _________________
- Backup communication system: _________________
Response Timeline
- First responder arrives: ____ seconds
- Crash cart arrives: ____ seconds
- Code team assembles: ____ minutes
3. Specific Emergency Procedures
Acute MI Protocol
- Primary PCI response time: _________________
- Cath lab notification process: _________________
- Transfer protocol (if applicable): _________________
Cardiac Arrest Management
- CPR initiation criteria: _________________
- Defibrillation protocol: _________________
- Post-ROSC care pathway: _________________
4. Documentation Requirements
During Emergency
- Vital signs frequency: _________________
- Medication administration log: □
- Intervention timeline: □
Post-Event
- Debrief meeting required: Yes □ No □
- Quality review timeline: _________________
- Incident report completion: _________________
5. Contact Information
Emergency Response Team
- Cardiology on call: _________________
- Cath lab supervisor: _________________
- Emergency department: _________________
6. Quality Metrics
Performance Indicators
- Door-to-balloon time target: _________________
- CPR quality metrics: _________________
- Documentation compliance: _________________
Template Version: [Date]
Next Review Date: [Date]