Who

Physicians from Anesthesia Medicine (on call MICU and cardiology teams) Surgery Nursing House supervisor ACLS trained nurse from CCU/CTICU ED nurse for specific areas
All neuroscience floors except 6NSH All diagnostic areas (Radiology, labs, Clinics) All non-patient care areas

Pharmacy Respiratory therapy Pastoral care Patient transportation (responds if in a non-patient care area)

 Where

All codes within UNC Hospitals Within the following external boundaries: Base of Cardinal, Dogwood and Neurosciences parking deck ramps ED parking area visible from doorway of ED

Once you get there:

Physician team leader must identify self ACLS trained nurse from CCU/CTICU provides nursing support ICU nurse must remain with the patient until the patient is transferred to the appropriate level of care Primary nurse remains present for the duration of the code Pharmacist assists with medication preparation Respiratory therapy provides respiratory support Nursing supervisor Provides assistance with crowd control Facilitates patient transfer to appropriate level of care

All team members should identify themselves and their roles upon arrival

 A resuscitation

record must be kept by a documentation nurse The physician team leader signs the record and completes a summary section

 Background

80% of codes are preceded by a prolonged period of

physiologic instability Introduced at UNC in 2006 Purpose:

To quickly and appropriately respond to inpatients with early signs of physiologic deterioration, and thus: Decrease the number of Code Blues Ideally improve survival to hospital discharge

Code Rate versus RRT Call Volume Rate

20.0 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0

17.6

11.9 5.4 4.7 11.1 4.8 3.9 4.0 4.5

FY06

FY07

FY08

FY09

FY10

Codes Outside ICU & ED/1000 Discharges

RRT Calls/1000 Discharges

Service - Adult RRT and Code Blue Survival Percentages

99.4%
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

83.3% 73.8% 37.2%

83.3%

70.0% 31.7%

80.1%

69.8% 32.7%

82.8%

73.6% 32.3%

71.0% 33.1%

FY06

FY07

FY08

FY09

FY10

Survival at Discharge after ARRT (no codes)

Survival Immed. After Code

Survival at Discharge after Code(s)

 Staff

or family have concerns Acute change in HR Acute change in systolic BP Acute change in respiratory rate Acute change in oxygen saturation Acute change in urine output Acute mental status change New or prolonged seizure Patient with difficult to control pain or agitation

 Activation

of RRT by calling 6-4111 Page primary resident

 Who depends on Medicine floors:

location

3W/HD, 3BT (CRU), MPCU, 4 ADU, 6BT, 6W, 7BT, 8BT, 3,4,5 Neuro; 4 BM and 4 ONC, 5 And South (Jail) NOT cafeteria, radiology, GI suite Call a code

MICU nurse MICU fellow (when in-house) Hospitalist on call (after 7 pm) MICU resident (recommended)

 Cardiology floors: CCU nurse Cardiology team (Resident) Surgery floors: SICU team and nurse Primary team physician (or cross-cover) must

show up as well

 Physician

team leader identifies self and coordinates assessment and care with the primary physician RRT nurse from ICU provides nursing support and coordinate with primary nurse Respiratory therapy assists with maintenance of airway and ventilation

 Documentation

of Adult Rapid Response Activation must be completed by the responding care providers Debriefing following the event with the RRT and primary care team (including nurse!) should take place

 Introduced Purpose:

March 2010

To provide inpatients with acute stroke the same

care they would obtain if they presented to the ED:

Rapid head imaging Rapid evaluation by neurology Early administration of fibrinolytic therapy if indicated

 Composition

Neurology resident Neurology/neurosurgery ICU nurse Patient transport

 If

rapid response team or code blue team is worried about a primary CNS event, the team calls the hospital operator to activate the brain attack team

Adult Codes Outside of ICU & ED/1000 Discharges

(By month)

10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0

Adult Codes Outside of ICU & ED/1000 Discharges

UCL

Mean

LCL

 Med

E Resident on call is first responder to all codes/RRT in the Cancer Hospital

This includes clinics!

In

the aftermath, have a lower threshold to move patient to stepdown level of care Med E patient (and Solid Med H?) in MPCU managed by MICU team
Do not let this dissuade you from moving patient

to stepdown level of care!!!

3 West RRT/1000 discharges 24.8

6 BT 35

4 Onc 40.9

Code Blue/1000 discharges

2.8

3.6

9.1

 Its

a land far, far away It gets lonely out there

Med E resident in ED, covering patients

elsewhere Only on floor 30-40 percent of the time at night

Ryan, fix this please
Teams

are reluctant to transfer patients to stepdown

 This

is based primarily on nursing competency, not resident competency If the floor nurses say they cannot manage the patient, then they must go to stepdown If the floor nurses say they cannot manage the patient, then they must go to stepdown Nursing competencies vary by floor

 Blocking

and Belittling the referring physician or nurse There are no ICU beds
RRT nurse stays to help manage the patient You work with House Supervisor to find or make a

bed Call in the MICU fellow to lend a hand if your team is overrun
Call Dr. Carson if you get any push-back