Rapid Response Team

Question 1

Medical Emergency Team (MET)

Answer 1

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

Question 2

Rapid Response Team (RRT)

Answer 2

Denotes and RN/RRT lead

Question 3

Critical Care Outreach Team (CCOT)

Answer 3

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

Question 4

What type of rapid response team format does Calgary have

Answer 4

Currently Calgary falls under the RRT format with a modified CCOT function

Question 5

What do outreach teams do

Answer 5

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

Question 6

Why were outreach team created

Answer 6

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

Question 7

Potential Benefits of Outreach Teams

Answer 7

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

Question 8

Outreach Team Definition

Answer 8

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.

Question 9

Most Responsible Health Practitioner

Answer 9

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.

Question 10

Code 66

Answer 10

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.

Question 11

Code 66 Calling Criteria

Airway

Answer 11

Threatened airway – e.g. Stridor, gasping for air

Question 12

Code 66 Calling Criteria

Breathing

Answer 12

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)

Question 13

Code 66 Calling Criteria

Circulation

Answer 13

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

Question 14

Code 66 Calling Criteria

Neurological

Answer 14

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

Question 15

Code 66 Criteria

Other

Answer 15

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

Question 16

Family Calling a Code 66

Answer 16

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

Question 17

Categorization of Calls

Answer 17

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.

Question 18

Categorization of Calls

Level 1 Call

Answer 18

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

Question 19

Categorization of Calls

Level 2 and 3 Call

Answer 19

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.

Question 20

Categorization of Calls

Level 3 Call

Answer 20

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.

Question 21

Direction of Care Definition

Answer 21

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.

Question 22

Direction of Care Can Include

Answer 22

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

Question 23

Outreach Team Responsibilities

Answer 23

–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

Question 24

What is the Role of the Outreach Team As soon as the Reach the location

Answer 24

–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

Question 25

What are the Initial Steps when the Call is Categorized as a Code 1

Answer 25

–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

Question 26

Expectations of the Unit Staff

Answer 26

–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

Question 27

Expectations of the Unit Staff

Before Outreach Arrival

Answer 27

–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.

Question 28

–During the Code 66

Answer 28

• –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

Question 29

During Code 66 Transporting the Patient

Answer 29

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.

Question 30

–Most Responsible Health Practitioner (MRHP)

Expectations

Answer 30

–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)

Question 31

MRHP Expectations According to Category of the Call

Answer 31

–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.

Question 32

When to escalate a call to the Unit Attending Physician

Answer 32

–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

Question 33

Intensivist/delegate Involvement

Answer 33

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.

Question 34

–The Outreach Team should consider notifying the Intensivist/delegate when:

Answer 34

–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

Question 35

GCS-Motor Response

Answer 35

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

Question 36

GCS-Verbal Response

Answer 36

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)

Question 37

GCS-Eye Opening Response

Answer 37

Score of 4-Spontaneously

Score of 3-To Speech

Score of 2-To Pain

Score of 1-None