Rapid Response Team Flashcards
Medical Emergency Team (MET)
Denotes a physician lead team
First MET developed in 1990 in Australia
Positive effects on hospital were reported in 1995 which led to the adoption of METs around the globe
Rapid Response Team (RRT)
Denotes and RN/RRT lead
Critical Care Outreach Team (CCOT)
Can be either format with a physician lead or RN/RRT lead team, but includes in its mandate the follow-up of patient recently discharged from ICU, as well as other forms of non-urgent hospital patient surveillance
What type of rapid response team format does Calgary have
Currently Calgary falls under the RRT format with a modified CCOT function
What do outreach teams do
Outreach teams are used to help in the management of inpatient and non-inpatient who have been deemed as physiologically unstable.
They do this by supporting the primary care team with the assessment and stabilization of the patient
Why were outreach team created
Studies showed that adverse events occured in 7-5% of hospital admittance and 21% of these resulted in death
It was also showed that 37% were preventable and had there tended to be many hours of physiological deterioration before the adverse event occured
so outreach teams and code 66 were created to interve before there is a adverse event when there starts to be signs of deterioration
Potential Benefits of Outreach Teams
Reduction of cardiac arrests
Reduction in ICU admission and re-admission rates
Reduction in ICU or hospital length-of-stay
Reduction in ICU or hospital mortality
Outreach Team Definition
Outreach Team means an ICU Outreach Registered Nurse (ORN), Outreach Registered Respiratory Therapist (ORRT).
The Intensivist/delegate will attend Code 66 calls based on patient acuity and patient care needs.
Most Responsible Health Practitioner
Most Responsible Health Practitioner means the health practitioner who has responsibility and accountability for the specific treatment/procedure(s) provided to a patient who is authorized by Alberta Health Services to perform the duties required to fulfill the delivery of such a treatment/procedure(s) within the scope of his/her practice.
The MRHP can be the patient’s attending physician, on-call physicians, residents, Nurse Practitioners, clinical associates or Bedside Physicians. The MRHP at the time shall respond to all Code 66 calls on their patients and will direct care in collaboration with the Outreach Team.
Code 66
Code 66 means a call to the Outreach Team for a patient that has physiological compromise with the presence of one or more Code 66 calling criterion. The ICU Outreach Team responds to a Code 66 call within 15 minutes to assist the primary care team with the assessment and stabilization of the patient.
Code 66 Calling Criteria
Airway
Threatened airway – e.g. Stridor, gasping for air
Code 66 Calling Criteria
Breathing
Acute change in respiratory rate less than eight (8), or greater than 30 breaths per minute
Acute change in oxygen saturation (SpO2) to less than 90%, despite O2 delivery greater than five (5) litres per minute (L/min)
Code 66 Calling Criteria
Circulation
Pulse rate less than 40 or greater than 140 beats per minute (bpm)
Systolic blood pressure less than 90 mmHg, greater than 200 mmHg, or an acute change in systolic BP
Code 66 Calling Criteria
Neurological
Sudden decrease in Level Of Consciousness (LOC) or decrease in Glasgow Coma Scale score (GCS) of two (2) or more points
Prolonged or repeated seizures
Code 66 Criteria
Other
Concern about an acute change in urinary output to less than 50 millilitres (mL) in four (4) hours and worried about patient
Anytime a caregiver or family member is seriously worried about a patient with or without the above criteria present
Family Calling a Code 66
We do not have a process in place to support family’s calling a Code 66, however, if they are extremely anxious about their family members and they relay that to the bedside RN, and that is the reason they decide to call the Code 66, the working group wanted to legitimize this avenue for staff members on the ward that this is completely appropriate
Categorization of Calls
Categorization of Calls means all Code 66 patients are categorized by the Outreach Team within the first 10 minutes of arrival.
Depending on physician involvement (MRHP and/or Intensivist/delegate) and resources required, patients are categorized into one of three (3) Levels.
Categorization may change over the duration of the call. The categorization process is meant to determine resources required to appropriately manage patient care.
Categorization of Calls
Level 1 Call
Level 1 calls require an immediate call/page to the Intensivist/delegate to direct care.
The team does not need permission from the MRHP to categorize the call this way, this is their decision.
Requires immediate MRHP direction of care and handover to the intensivist/delegate when necessary
Requires immediate intensivist/delegate awareness/attendance at the call
Categorization of Calls
Level 2 and 3 Call
For Level 2 and Level 3 calls, if the entire call is handled by the MRHP and the team has signed off the call, there is no avenue to then make the Intensivist/delegate aware of the patient if the team has concerns.
If the team has concerns, they need to get the Intensivist/delegate involved in the call, during the call.
If the team feels the Intensivist/delegate needs to be involved in the call, they DO NOT need permission from the MRHP for this, this is at their discretion.
Categorization of Calls
Level 3 Call
Note with a Level 3 call, even if it’s a simple problem solved (O2 not hooked up, etc.) the MRHP still needs to be notified prior to the call that a code 66 was called on their patient and if the MRHP has not responded to the primary care team, you will need to make that page/call. We also need to ensure we have notified the MRHP that we have attended to their patient, solved the problem and have signed off the call. The reason for this is in the case of “silent decompensation”, the patient is the MRHPs responsibility and they should be assessing their patient.
Direction of Care Definition
Direction of caremeans being actively aware of a patient’s current situation, deciding and taking responsibility for the course of action and following up on that course of action.
The MRHP and/or Intensivist/delegate is expected to direct care in person whenever possible. Alternatively, direction of care may be performed over the phone.
Direction of Care Can Include
Directing, specifying and clarifying orders
Ordering and reviewing the appropriate investigations
Providing a plan of care
Obtaining consultations as appropriate
Coordinating care
Determining patient disposition
Providing report/handover when appropriate
Outreach Team Responsibilities
The ORN/ORRT will provide therapy for the patient while functioning within their scope of practice
The ORN/ORRT will perform roles, functions and responsibilities in which they are educated, competent, and have the authority to perform
The ORN/ORRT may not administer medications, order tests/procedures, or perform invasive tasks without a direct or verbal order from a physician or Nurse Practitioner
Respond to the Code 66 within 15 mins
What is the Role of the Outreach Team As soon as the Reach the location
Obtain a brief SBAR from the primary care provider upon arrival
- Situation:Name, age, admitting diagnosis & GOC
- Background:Pertinent past medical history
- Assessment/Response:Reason why you are calling the Code 66 (Calling criteria), any interventions/response, and/or communication with the MRHP.
Perform a primary assessment and categorize the patient into Level 1, 2 or 3 within 10 minutes of arrival
What are the Initial Steps when the Call is Categorized as a Code 1
If you initially Categorize a patient as Level 1
Immediately contact the Intensivist/delegate
If direct contact cannot be made within 5 minutes of this categorization, a Code Blue may be called
Direct communication with the Intensivist/delegate (either in person or via telephone) is best for efficient and accurate communication
Expectations of the Unit Staff
The unit staff can include Primary Nurse/Care Provider (e.g. Physiotherapist, Occupational Therapist, Respiratory Therapist etc.)
Initial Communication
- Contact MRHP to determine the need for a Code 66
- This step is a requirement
- Activate the Code 66
- If the MRHP has not responded, attempt contact again
- If activator is not the primary nurse, contact the primary nurse to inform of Code 66
Expectations of the Unit Staff
Before Outreach Arrival
Where applicable, ensure patient chart, workstation-on-wheels (WOW) are in theroom, suction is set up, oxygen is applied, clear any excess equipment or supplies and assist other patients away from the area
We have also asked that where possible, it would be extremely useful for the Outreach Team to have a portable phone available with the WOW so they may communicate with the MRHP and/or Intensivist/delegate without having to leave the patient’s bedside.
During the Code 66
- The primary nurse/delegate and/or care provider shall remain in the patient room or location of the Code 66
- Collaborate with the Outreach Team on the care the patient requires. Examples include (but are not limited to):
- IV initiation and assembling IV lines
- Gathering and preparing other supplies
- Administering medications and blood products
- Assisting with diagnostic procedures,
- Contacting other services as directed
- Documenting vital signs and/or care interventions as directed by the Outreach Team
Accompany the patient on transport (e.g. CT scan, ICU, other unit/area)
- Provide a report to receiving area if patient requires transfer
- Inform and update patient’s family
- Complete and submit the Outreach Code 66 Feedback form, provided by the Outreach Team.
- Document events preceding the Code 66 up until the time the Outreach Team arrives
- Once the team arrives, the charting then begins on the Code 66 Summary Form
During Code 66 Transporting the Patient
Please note the team should not be accompanying patients on transfer without the primary care provider.
The Outreach team should not be primarily responsible for the patient, the patients care provider needs to accompany the patient as well.
Most Responsible Health Practitioner (MRHP)
Expectations
Notified prior to the activation of a Code 66
The MRHP is responsible for responding to a Code 66 call within 15 minutes of the call being made. In the event that the MRHP is unable to physically attend the Code 66 call, the expectation is as follows:
The MRHP calls the unit/area where the patient is located and speaks with the Outreach Team regarding patient status and directs care over the phone
If the MRHP is unable to call the unit (e.g. they are performing surgery at the time) they will assign a delegate in their place who will immediately respond to the Code 66 (either in person or over the phone)
MRHP Expectations According to Category of the Call
Level 1 – Provide immediate direction of care for the patient in collaboration with the Outreach Team and provide handover to the Intensivist/delegate if/when necessary.
Level 2 - Provide immediate direction of care for the patient in collaboration with the Outreach Team
Level 3 – May/may not involve direction of care, however, will be notified of the call.
When to escalate a call to the Unit Attending Physician
When to escalate a call the Unit Attending Physician (note: the MRHP may not be the attending physician):
When the MRHP at the time of the Code 66 is not the patient’s attending physician, the attending physician will be notified by the Outreach Team and/or by the MRHP in the following instances:
The MRHP is unavailable or unable to provide appropriate medical direction for the care of the patient
The patient requires admission to the Intensive Care Unit or transfer to a unit/area requiring more advanced monitoring and/or treatment
Goals of care need to be addressed and/or family discussion or conference is necessary and the MRHP is unavailable or unable to provide appropriate care
Intensivist/delegate Involvement
Level 1 – Requires immediate Intensivist/delegate awareness/attendance and direction of care for the patient.
Level 2 – No involvement in patient care and will not be made aware of call
Level 3 – No involvement in patient care and will not be made aware of call.
For Level 2 and 3 calls, the exception to the rule is any time the ORN/ORRT is worried or unsure and would like the support of the Intensivist/delegate
Determine the need for a followup visit(s) for Level 1 patients.
If a Code 66 escalates to a Code Blue, the Intensivist/delegate directing care for the Code 66 will provide handover to the Code Blue Intensivist/delegate lead, if appropriate/applicable.
The Outreach Team should consider notifying the Intensivist/delegate when:
Admission to ICU may be required
A higher level of intervention is required
The team is unsure of what direction should be taken
The patient is not responding as expected to therapies
Difficulty communicating with attending service
There is discrepancy over the medical direction for the patient
Non-invasive ventilation (NIV) is required
Cardiac or respiratory crisis is imminent
A call has lasted more than 1 hour with no apparent resolution
3 or more calls for the same patient
Any time the ORN/ORRT is worried or unsure and would like the support of the Intensivist/delegate
GCS-Motor Response
Score of 6-Obey Commands
Score of 5-Localized Pain: Will use other appendage to stop the painful stimulus and is higher level response as opposed to withdrawal
Score of 4-Withdrawal: Attempt to pull away from painful stimuli
Score of 3-Abnormal Flexion: Arms come up and curl and toes will curl over tends to be bilateral
Score of 2-Abnormal Extension: Arms extend and tends to be a bilateral extension
Score of 1-Flaccid: No response completely limp
GCS-Verbal Response
Score of 5-Oriented
Score of 4-Confused
Score of 3-Inappropriate Words
Score of 2-Inappropriate Sounds
Score of 1-No Response
Poorly suited for patients with impaired verbal response (e.g., aphasia, hearing loss, tracheal intubation)
If intubated put a “T” after the level (e.g. 5 T) because it will affect their score as they cant score higher than 1)
GCS-Eye Opening Response
Score of 4-Spontaneously
Score of 3-To Speech
Score of 2-To Pain
Score of 1-None
