As part of your rotation on the inpatient wards here at the DC VA Medical Center, you will be the team leader of the Rapid Response Team.
The members of the rapid response team include:
The On-Call Internal Medicine Wards Resident: When you are on call you act as the RRT team leader. This means there are two team leaders that respond to every RRT (both call team residents). The first resident that gets to bedside after the call will be the primary leader with the second resident supporting.
ICU Resident: the ICU resident responds to RRTs to screen for code stroke, code blue, code heart, and any obvious ICU needs and helps facilitate transfers to the ICU.
The On-Call Internal Medicine Wards Intern: who's primary responsibility is to helps place orders, double-check the patient's code status, and help uncover other pertinent details about the patient for the resident running the RRT. A major responsibility of the intern is to bring the team's rounding laptop to the RRT.
Critical care nurse: supports the floor nurse in obtaining accurate vital signs, IV access, and supporting the leader
Respiratory therapist: provides oxygen delivery systems if necessary
Floor nurse: assigned to the patient
Other people that will respond include the critical care attending during daytime hours, the primary team (either the medical resident, surgical resident, psychiatry resident, etc.) to help explain the patient’s pertinent medical history and reason for admission.
How are rrt's called?
An RRT should only be called on an inpatient that is in their assigned bed. If the patient is not admitted or not in their assigned room, the call should be corrected to a code blue. This brings transport to the patient, to either get the patient back to their assigned area or more likely to the ED where they can be better triaged.
An RRT can be called by dialing 55000 on any hospital phone and asking the operator to call a RAPID RESPONSE to YOUR LOCATION. An RRT can be called by a nurse, physician, or even a family member. The team is alerted through both Vocera and On-call pagers -- it is important the on-call team carries both of these.
Reasons for RRT Call's
SYSTOLIC BLOOD PRESSURE (SBP): >200 or <80 mmHg
HEART RATE (HR): >140 or <40 bpm with symptoms OR rate >160 bpm without symptoms.
RESPIRATORY RATE (RR): >26/min or <8/min OR respiratory distress.
PULSE OXIMETRY: <90% while on supplemental O2.
URINE OUTPUT: <50 ml / 4 hours in a non-HD patient.
SUDDEN CHANGE IN CONSCIOUS STATE: new onset seizure, agitation, delirium, or somnolence.
SUDDEN ONSET (<24 HOURS) OF ANY OF THE FOLLOWING:
· severe headache
· unilateral weakness or numbness of the face, arm or leg
· trouble seeing
8. SUSPECTED INFECTION with 2 or more of the following:
· Respiratory rate >20
· HR > 90
· Temperature >38 or <36
· WBC <4K or >12K
· Altered mental status ·
· SBP < 90 or <100 mmHg and drop >20mmHg from baseline
9. ANY MARKED CONCERN
Please remember to carry your N-95 and eye-protection throughout your call day as these are required for all code-blues and rapid responses for your protection. The Code-Carts have spare N-95s for emergencies as well.
Your responsibility is to rapidly assess and stabilize the patient while managing the team’s response to evidence of clinical decompensation.
Be prompt. If an RRT is called, you must be at bedside within 5 minutes.
Keep the people in the room at a minimum. Fewer people will keep the situation more calm. No one gets in the room without an N-95.
Place all orders in CPRS. If the patient needs a chest x-ray, then it will not be completed until you order it. Your on-call intern should be coming with your team's laptop to ensure orders are placed promptly. If you think the patient is septic and needs stat antibiotics and fluids, you must place the order or it will NOT be done. Placing the order is key!
Hand-off to the primary team or the ICU if the patient is stepping up. Always make sure to have verbal hand-off to the physician who is taking primary care of the patient and confirm who is following up what. If you are ordering labs – a stat lactate and stat CBC – either you need to follow them up or make certain that someone is following them up, otherwise there can be a significant delay in the patients care.
Re-evaluating the patient. Make sure someone will check in with the patient in 1-2 hours to confirm their stability and that nothing else has changed or worsened.
Write an RRT Physician Note – this is important for documentation purposes but also to alert the rest of the staff, consulting services, nursing staff overnight and that this decompensation was present. This should be sent to your attending to be co-signed within 1 hour of the RRT.
Ask for help! If you don’t know what is going on with the patient or what the next step should be, there are always people around and available to help. Discuss with responding critical care attending, with your attending or the on-call hospitalist, or the MICU resident. Also discuss with the ICU nurses and floor nurses too. Medicine is a team sport, and this is all for the benefit of the patient!
After hours: the on-call hospitalist is in-house overnight from 6pm-12am – they can help support you in person at a rapid response during those hours. After 12am, you can call over the phone the on-call hospitalist. In-house support from 12am-6am includes the MICU resident and the ED attending.
Labs: can be drawn by the ICU nurse who should respond with you. Make sure to place orders for the labs under “Ward Collect” and “Stat” so that they are printed immediately to the floor.
Bedside X-ray: if you order a stat chest x-ray then vocera (or dial 58899) and ask for “X-ray tech” to alert them to come to bedside now.
ABGs: the respiratory therapist will be able to draw an ABG should you require one. Please note an order needs to be placed in order for them to run the sample. These have a very fast turn around of about 15 minutes once drawn as they are run in the pulmonary lab.
Oxygen carrying capacity: Certain floors can only manage certain levels of supplemental O2. 2D and 3E cannot have more than 6L nasal canula, 4C and the PCU can support up to 10L on reinforced nasal canula (aka fake high-flow or cold high-flow). The PCU can support home BIPAP but any NEW BIPAP must go to the ICU. Any higher amounts of oxygen such as “real high-flow” or “warm high-flow” must go to the ICU.
Heads up on meds: meds need to be approved by pharmacy in order to be pulled. Call the inpatient pharmacist at x57386 or x57385 to get approval fast.
Pushing meds, like metoprolol or diltiazem, must be done by an ICU nurse. This is out of the scope of practice of the floor nurses.
If someone needs a drip, they need the ICU. Pretty much only heparin drips can be on the floor. If a patient needs diltiazem, amiodarone, insulin, or the like, they need to go to the unit.