Rapid Response Teams and transport of the critically ill Flashcards
Exam 2
Rapid Response Team Concept:
Identification of clinical deterioration that triggers early notification of a specific team of responders’ rapid intervention by the response team that includes both personnel and equipment that is brought to the patient
Rapid Response Team Concept:
What kind of evaluation occurs?
Ongoing evaluation through data collection and analysis to improve prevention and response.
Purpose of Repaid Response Team (RRT):
To reduce mortality
Provide early treatment of hemodynamic instability
Improve patient outcomes
Team Members included in RRT:
Leader is usually MD skilled in ACLS
Nurses (usually ICU or ER)
Anesthesiologist/anesthetist intubation
Respiratory therapist manages airway, sometimes intubates
Pharmacist prepares medications in some settings
Chaplain
ECG technician
Other personnel to run errands
Team Members included in RRT:
Nurses (usually ICU or ER): Who are the nurses involved?
Primary nurse
Second nurse
Another nurse
Nursing supervisor
Team Members included in RRT:
Nurses (usually ICU or ER):
Primary Nurse:
Primary nurse knows patient
Team Members included in RRT:
Nurses (usually ICU or ER):
Secondary Nurse:
Second nurse gives medications and gets equipment from crash cart
Team Members included in RRT:
Nurses (usually ICU or ER):
Another Nurse:
Another nurse records events
Team Members included in RRT:
Nurses (usually ICU or ER):
Nursing supervisor
Nursing supervisor provides traffic control and secures ICU bed (if needed)
Equipment for RRT:
Crash cart
Backboard
Monitor/ defibrillator/pacemaker
Bag-valve-mask device
Airway supplies/suction
Medications
IV supplies
Nasogastric tube
BP cuff
Equipment for RRT:
Monitor/ defibrillator/pacemaker
What is included?
AED
Transcutaneous pacemaker
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
How is mental status?
Altered Mental Status
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
How is HR?
Heart rate greater than 140bpm or less than 40bpm
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
How is RR?
Respiratory rate greater than 22breath/min or less than 8breath/min
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
How is SBP?
SBP greater than 180 mmHg or less than 90 mmHg,
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
How is O2?
O2 sat lower than 90%,
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
How is urinary output?
Urinary output of less than 50ml over 4 hours
Criteria for calling RRTs:
Call any time a staff member is concerned about changes in a patient’s condition, including:
What else could occur?
Chest Pain, loss of airway, seizure, uncontrolled pain
Criteria for calling RRTs:
What are code names?
Call- Code blue, Code 99, Dr. Heart
Criteria for calling RRTs:
What do some institutions empower family members to do?
Some institutions empower family members to activate the RRT
Interfacility transport:
What should you consider?
Consider both the method of transport and the people involved in the process.
Interfacility transport:
Why might a transfer occur?
Complex diagnostic procedures or sophisticated medical and nursing expertise exceeds what can be provided at a facility
Interfacility transport:
What are other reasons why a might transfer occur?
Family requests
Third party payer may require patients to be transported to a facility that is a member of their network
Interfacility transport:
How must a patient be before transport?
Patient must be stable before transporting.
Physician Responsibility:
What does the sending physician do in patient transfers?
The sending physician performs the patient assessment and determines the appropriate level of care during transfer.
Physician Responsibility:
What does the receiving physician do in patient transfers?
The receiving physician ensures that his or her facility is capable of providing necessary patient services to care for the patient.
Physician Responsibility:
What does the medical director of the critical care transportation agency do:
What do they provide?
Provides medical direction during transport
Physician Responsibility:
What does the medical director of the critical care transportation agency do:
What do they provide oversight for?
Medical oversight of the transportation operation includes determining minimal team composition and equipment requirements, education and practice.
Modes of Interfacility Transport:
Ground transport
Air transport
Modes of Interfacility Transport:
What should you consider?
Distance
The safety of the transport environment
Patient’s “out of hospital” time
The patient’s condition and the potential for complications
The patient’s need for critical or time-sensitive intervention
Traffic conditions
Weather conditions
Transfer Guidelines and Legal Implications:
What law exists
COBRA act of 1985; “antidumping” law
Transfer Guidelines and Legal Implications:
Provisions: What must hospitals provide?
Hospitals must provide screening examinations for every person who comes to the emergency department and requests care
Transfer Guidelines and Legal Implications:
Provisions:
If the patient has an emergency medical condition, what must the hospital provide? What must the provider do?
If the patient has an emergency medical condition, the hospital must provide stabilizing treatment or transfer the patient to another medical facility.
The physician must document that the medical benefits outweigh the risks of the transfer
Transfer Guidelines and Legal Implications:
Provisions:
Who is the transfer conducted by?
The transfer is conducted by qualified personnel, and appropriate equipment needed to provide care during the transfer is available.
Transfer Guidelines and Legal Implications:
Situations in which a patient is not stabilized, yet conditions are appropriate for transfer occur when:
- Risks of remaining at the initial facility are outweighed by the benefits of transfer
- The patient or family requests the transfer
- A physician is not present at the initial facility, but a qualified medical person certifies that the benefits outweigh the risks
- The transfer occurs with appropriate equipment and qualified personnel.
Phases of Interfacility Transport:
How many phases are there?
Five phases of transport have been identified.
Phases of Interfacility Transport:
Five phases of transport have been identified.
- Notification and acceptance by the receiving facility
- Preparation of the patient by the transport team
- The actual transport
- Turnover of the patient to the receiving hospital
- Continuous quality improvement monitoring after transport
Interfacility Transport
What must occur? Who is involved?
Benefits of the transport outweigh the risks
Specially trained transport team
Interfacility Transport
The SCCM guidelines: Who is involved?
Competent critical care nurse and at least one other person (respiratory therapist, RN, or critical care technician) accompany the patient.
Physician with training in airway management, advanced cardiac life support, and critical care or equivalent accompanies any unstable
Intrafacility Transport:
What is it also known as?
Also called intrahospital transport
Intrafacility Transport:
What does it include?
Includes the movement of patients out of the ICU to diagnostic procedure areas
Intrafacility Transport:
What does it not include?
Does not include transporting patients from the OR to an ICU or from the ICU to a step-down patient care area.
Intrafacility Transport:
What are patients vulnerable to?
Patients are vulnerable to acute changes in their clinical condition, and transport may further exacerbate their deterioration.
Intrafacility Transport:
What can reduce adverse event risk?
Use of a well-developed pretransport checklist can help reduce adverse event risk.
Intrafacility Transport:
What must we need to make sure about this kind transfer?
In this situation, we need to make sure a qualified nursing personnel follows the patient.
Logical Flow of Events
BLS
ACLS/AED
Ongoing assessment
Crowd control
Notification of family and communication
Family presence in code
If successful code, transfer to ICU
Logical Flow of Events:
What is included in ongoing assessment?
Pulse oximetry
ETCO2
Pulse checks
ABGs
Lab work
ACLS Summary
Treat patient, not monitor
CPR throughout
Early defibrillation essential
Use ETT as needed for medication administration
Provide treatment according to algorithms
ACLS Summary
What is important to do early?
Early defibrillation essential
ACLS Summary
What is done throughout?
CPR throughout
ACLS Summary
What is used for med administration?
Use ETT as needed for medication administration
Defibrillation: What does it do?
Completely depolarize the heart
Defibrillation: What does it allow for?
Allow for the resumption of rhythm
Defibrillation: What important when doing this?
Safety is essential
Defibrillation: What are complications of it?
Skin burns
Damage to heart muscle
Defibrillation: what is it called?
Automatic implantable cardioverter-defibrillator (AICD)
Defibrillation:
Automatic implantable cardioverter-defibrillator (AICD): What does it recognize?
Recognizes ectopy
Defibrillation:
Automatic implantable cardioverter-defibrillator (AICD): What does it deliver?
Delivers countershock
Defibrillation:
Automatic implantable cardioverter-defibrillator (AICD): What does it prevent?
Prevents episodes of sudden death
Defibrillation:
Automatic implantable cardioverter-defibrillator (AICD):
What should be avoided?
Placement of the paddles near the ICD is to be avoided
Do not touch patient while analyzing because it could pick up your own rhythm.
Procedure for Defibrillation:
Paddle or defibrillation pad placement
Good contact with skin (protect from burns)
Charge defibrillator to desired setting
“I’m clear, you’re clear, everyone clear, oxygen clear”
Adequate pressure with paddles
Shock
Continue CPR 2 minutes, then assess rhythm
Automated External Defibrillation (AED):
What does it do?
External defibrillator with rhythm analysis capabilities
For cardiac arrest
Automated External Defibrillation (AED):
Procedure:
Place two adhesive pads
Analysis by AED
Shock advisory
Cardioversion:
What is it?
Electrical current
Cardioversion:
How much power is used?
Lower joules (e.g., 50) compared to defibrillator
Cardioversion:
What occurs?
Synchronized delivery on R wave (prevents “shock on T”)
Cardioversion:
What does it disrupt?
Disrupts ectopic foci
Ectopic foci- the release of electrolyte stimuli in other places where it should be released.
Overviewof Medications used in a Rapid Response?
Oxygen
Epinephrine
Vasopressin
Atropine
Amiodarone
Lidocaine
Adenosine
Magnesium
Sodium Bicarbonate
Dopamine
Oxygen: What does it treat?
Treat hypoxemia
Oxygen: What does it improve?
Improve tissue oxygenation
Oxygen: How is it delivered?
Delivered via mouth to mask or bag-valve device (BVD) to mask or ETT
Oxygen: During a cardiopulmonary arrest how much is oxygen is used?
During a cardiopulmonary arrest 100% oxygen (15 L/min via BVD)
Epinephrine: What is it?
Potent vasoconstrictor
Epinephrine: What kind of effect does it have?
Alpha- and beta-adrenergic effects
Epinephrine: What kind of heart rhythms is it given for?
Ventricular fibrillation (VF),
pulseless ventricular tachycardia (VT),
and asystole
Epinephrine:
How is it given?
1 mg (10 mL of a 1:10,000 solution) IV push every 3 to 5 minutes
Can also be given via ETT
Epinephrine:
How is it given via ETT?
(through the ETT the dilution is 2 to 2.5 mg
diluted in 19 mL of NS or sterile water).
Epinephrine:
How is it infused?
Continuous infusion begins at 1 mcg/min (1 mL in 250 or 500 mL of D5W or NS); infuse at 2-10 mcg/min and titrate as needed.
Vasopressin: What is it?
Nonadrenergic vasopressor/alternative to epinephrine
Vasopressin: What does it cause?
Intense vasoconstriction at high doses
Vasopressin: How effective is it?
May be as effective as epinephrine
Vasopressin: What is the dosing?
Onetime dose of 40 units IV for VF/pulseless VT
Vasopressin: What is another way it can be given?
Can be given via ETT (dilute in 10 mL of NS)
Atropine: What does it do?
Decreases vagal tone
Atropine: What is it used to treat?
Symptomatic bradycardia
Atropine:
Symptomatic bradycardia: What is the dosing?
0.5 mg every 3 to 5 min IV push
Maximum of 3 mg
Atropine:
How else can this medication be given?
Can be given via ETT (2-3 mg diluted in 10 mL of NS or sterile water
Amiodarone (Cordarone): What does it do?
Reduces membrane excitability
Prolongs the action potential and retards the refractory period;
Amiodarone (Cordarone):
It prolongs the action potential and retards the refractory period; what does this lead to?
Prolongs the action potential and retards the refractory period; thus facilitates the termination of VT and VF
Amiodarone (Cordarone):
What other properties does this drug have?
Alpha-adrenergic and beta-adrenergic blocking properties
Amiodarone (Cordarone):
What is the dosing during a cardiac arrest?
During cardiac arrest 300 mg IV loading bolus
Lidocaine: What is it?
Antidysrhythmic
Lidocaine: What does it do?
Suppresses ventricular ectopy
Lidocaine: What is the dosing?
Bolus 1 to 1.5 mg/kg; additional bolus 0.5 to 0.75 mg/kg every 5 to 10 minutes up to 3 mg/kg
Lidocaine:
Bolus 1 to 1.5 mg/kg; additional bolus 0.5 to 0.75 mg/kg every 5 to 10 minutes up to 3 mg/kg
What should you follow with?
Follow with infusion at 2 to 4 mg/min (1 g in 250 mL 5% dextrose in water)
Lidocaine:
Bolus 1 to 1.5 mg/kg; additional bolus 0.5 to 0.75 mg/kg every 5 to 10 minutes up to 3 mg/kg
Follow with infusion at 2 to 4 mg/min (1 g in 250 mL 5% dextrose in water)
What is the concentration?
Concentration: 1 mg/min = 15 mL/hr
Lidocaine:
What should you always assess for?
Assess for lidocaine toxicity
Lidocaine:
How else can it be administered? What is the dosing of this?
Can be administered via ETT tube (2-4 mg/kg diluted in 10 mL of NS or sterile water)
Adenosine:
What does it do?
Slows conduction through AV node
Adenosine:
What is the primary use of this drug?
Primary use for paroxysmal supraventricular tachycardia
Adenosine:
How is it given?
Rapid IV push through port nearest insertion site of IV followed by rapid flush of 20 mL NS
Adenosine:
What is the dosing?
The initial dose is a 6 mg IV push over 1 to 3 seconds, followed by a 20-mL rapid saline flush. Expect short pause in rhythm after administration
A second and third dose of 12 mg may be given 1 to 2 minutes later
Magnesium: What is it given for?
Refractory VF, torsades de pointes (type of VT)
Known deficiency of magnesium
Magnesium
What is the dosing given for VF/pulseless VT cardiac arrest?
When VF/pulseless VT cardiac arrest is associated with torsades de pointes, 1 to 2 g of magnesium sulfate diluted in 10 mL of D5W is given IV/IO over 5 to 20 minutes.
Magnesium
What is the dosing given nonarrest situations?
In nonarrest situations, a loading dose of 1 to 2 g mixed in 50 to 100 mL of D5W is given over 5 to 60 minutes.
IV bolus followed by infusion titrated by magnesium levels
Sodium Bicarbonate:
When is this given?
According to ABGs
Sodium Bicarbonate:
What is this used to treat?
Treatment of metabolic acidosis
Sodium Bicarbonate:
What is important to remember about this medication?
Do not mix with other medications (precipitate)
Sodium Bicarbonate:
How often is this given? Why?
Rarely given; limited data available to support administration during arrest.
Sodium Bicarbonate:
What is the dosing?
Initial dosage of sodium bicarbonate is 1 mEq/kg by IV push.
If Sodium Bicarbonate is mixed with Mg, what happens?
Sb reduces effect of mg if mixed together.
Dopamine:
What is it used to treat?
Symptomatic hypotension
Dopamine:
What does it do?
Vasoactive (vasoconstrictor) to increase BP
Dopamine:
How is it administered?
Continuous drip
Dopamine:
Continuous drip
2 to 5 mcg/kg/min (learn calculations)
Dopamine:
What is the dose dependent on?
Dose is dependent on blood pressure control
Dopamine:
In doses greater than 20 mcg/kg/min, what happens?
In doses greater than 20 mcg/kg/min, marked vasoconstriction occurs
Dopamine:
Why do effects occur?
Effects dose related
Dopamine:
What do moderate doses do?
Moderate doses = cardiac doses
Dopamine:
What do higher doses do?
Higher doses = vasopressor doses
Dopamine:
What should you consider before giving dopamine?
Consider need for fluids versus dopamine
Lifestyle Considerations:
What should older adults have?
Advance directives for the older patient
Lifestyle Considerations:
What so older adults have an increased incidence of?
Older adults have an increased incidence of complications during an arrest (rib fractures)
Lifestyle Considerations:
What occurs with people with renal or hepatic disease?
Higher drug concentrations with renal and or hepatic disease
Lifestyle Considerations:
What kind of responses differ?
Differing responses to beta-adrenergics
Lifestyle Considerations:
What is important to remember about some meds?
Narrow therapeutic range of some medications
Lifestyle Considerations:
What is less effective in older adults?
CPR is less effective with older adults with comorbidities.
Documentation of Events
What should someone be assigned to do during a code?
Assign someone to document events during the code and record rhythm strips
Documentation of Events
Assign someone to document events during the code and record rhythm strips:
What is included?
Time started
Actions taken and patient’s response
Intubation and airway management
Vital signs
Team members present
Documentation of Events
Assign someone to document events during the code and record rhythm strips:
Actions taken and patient’s response can include?
Defibrillation
Medications
Procedures
Pacemakers
Postresuscitation:
What are the goals?
Optimize cardiopulmonary function
Transport to critical care unit
Determine cause of arrest to prevent
Postresuscitation:
What is there management of?
Management of patient care continues
Post-CPR Interventions:
What is included?
12-lead ECG
Arterial line
Pulmonary artery catheter
Indwelling urinary catheter for hourly output
NG tube if bowel sounds are absent or if patient is mechanically ventilated
Serial neurological exams
Post-CPR Interventions:
Why is an indwelling urinary catheter put in?
Indwelling urinary catheter for hourly output
Post-CPR Interventions:
Why is an NG tube put in?
NG tube if bowel sounds are absent or if patient is mechanically ventilated
Post-CPR Care:
What is included?
Palliative comfort care
Head CT scan and EEG if comatose
Blood glucose levels (may be hyperglycemic)
Post-CPR Care:
Palliative comfort care: What is included?
Pain management
Sedation
Anxiety management
Supporting the Family:
Should they be present during a code?
Providing information
Active communication
Visitation after a code
Support from chaplain and nursing staff
