Rapid Responses & Codes

Rapid Responses and Codes:

24 hours a day, each service is responsible for their patients during Rapid Responses and Codes. Once signed out, the covering provider is responsible for all Rapid Responses and Codes for those patients they are covering. During the night, Night 2 is only required to attend those rapid responses for our covering services.

While the hospitalists do not staff ALL rapid responses and codes covered by the medicine services from 7P – 7A, the residents may need assistance in running codes/rapid responses and all benefit from coaching and feedback (particularly in the beginning of the year). If you choose to attend a rapid response or code of a non-hospitalist patient:

DURING the event: Identify the resident running the code (MICU and CICU have red lanyards that they wear) If no one is running the code, pick a resident and inform them they will be running the code. Be sure the resident is positioned properly in the room in order to run the code or rapid response efficiently (e.g., foot of the bed, side of the bed etc.) Stand behind the resident and coach them as THEY run the code. Encourage them to be efficient and effective leaders: watch the clock, utilize others to gather information or labs, utilize others to place lines and perform CPR, etc. No code leader should ever be looking at a computer, placing a line, performing CPR – they should be utilizing their team and running the code.

AFTER the event: Have a quick debrief with the residents that were present. One idea is to use the “feedback sandwich.” Compliment: Thank them and detail one specific thing they did very well Coach: Detail one specific thing that they should work on in the future Encourage: Thank them again and leave them with positive reinforcement.

One of the residents or you should complete a significant event note for any rapid response or code that meets the criteria for ‘critical care;’ be sure to use the “.significanteventnote” smartphrase. If there is no attending present, these notes should be routed to the attending that was taking care of the patient during the day.

** If YOU have attending privileges, these notes should be routed to you as the attending present during the event. All procedure notes should be routed to you as well. The attending will then document critical care time at the bottom of the note in increments of 30 minutes -- these are billable. 4 criteria must be documented by the attending MD: Patient is critically ill What made the patient critically ill What your intervention was Amount of time personally spent in patient care on the floor

Rapid Response Activation criteria: Family and staff are worried about the patient and are empowered to call rapid response (A "gut feeling" is more than enough!) Acute change in heart rate (to <40 or >130 BPM) Acute change in systolic BP or decrease below 90 mmHg Acute change in respiratory rate (to <8 or >30 per min.) Acute change in O2 saturation (to <90%) Acute change in urine output (to <50 mL in 4 hours) Acute mental status change or neurological changes New or prolonged seizure Patient with difficult to control pain or agitation

Members of the Rapid Response Team: Primary RN Rapid Response RN Primary MD team Respiratory Therapist House Supervisor Patient and family members

Rapid Response Event expectations: - Time Out - Lead by Rapid Response RN when all key stakeholders are present - Primary RN, Primary MD, RT and patient/family member introduced - Brief synopsis of what activated the rapid response by primary RN - Primary MDs can provide brief history or pertinent past medical history - Establishes expectations during rapid- expect to stay around for debrief - Debrief - Summarize interventions and discuss plan of care for patient - Ensure closed loop communication between primary team, primary RN and Rapid Response RN - Discuss any suggestions for improvement or identify what went well

*Time Outs and Debriefs can be deferred based on patient condition. If it is an emergency, patient comes first!

Qualifications of a rapid response nurse: - ICU experience - Patient assessment and technical skills - Focused assessment - Aiding with implementing critical care interventions - IVs - EKG interpretation - Medication understanding - Protocol understanding - Leadership skills: liaison for primary RN and MD team to promote collegial conversations and mutual understanding - Knowledge of hospital systems and how they work (House Supervisors are also a great resource for this): criteria for stepdown vs ICU status

Additional emergency response systems that can be activated from a rapid response include: - Code Sepsis - STAT antibiotics from pharmacy - Sepsis bundle and order set, adherence to CMS guidelines for reimbursement - BAT Code - Stroke team notified- Neurology MD comes to bedside or meets primary team and patient down in CT scan - Neurology available to mobilize TPA administration or Interventional Radiology - CT scan notified- holds table - CRT (Cardiac Response Team) - Cardiology fellow and CICU RN come to bedside - Cardiology fellow can activate STEMI pager if patient meets criteria

Rapid nurses can initiate standing orders prior to arrival of the provider at bedside: - Labs - CBC - BMP - ABG or VBG - Troponin and cardiac enzymes for chest pain - 12 lead EKG - POC Glucose

Team 2 Rapid Response Event defined: - Team 2s are paged overhead when a second rapid has been called within 1 hour of another rapid response - Team 2 Responders consist of Charge RNs and LIPs from ICUs - TICU- 5AND, CTSU - CICU- ICCU - SICU- Surgical floors, Neuroscience and Women’s Hospital - MICU- Medicine floors, Oncology, Psych, Rehab - ICUs are always available for consultation if you need a critical care set of eyes! - It is a common misunderstanding the activating a Team 2 Rapid is the only way to get the ICU MDs