Below is an example of one hospital’s guide for new grad nurses on when to call the Rapid Response Team (RRT).  Check with your facility’s guidelines as they may differ but take a look at this one as it will give you some pretty good general guidelines.  It’s always better to lean on the side of caution and call the RRT if you are unsure of your situation.


 

Inevitably, emergent care is needed on occasion. If you are uncomfortable with a patient’s condition, it is your responsibility to alert the MD, your charge nurse or another experienced nurse and to use the resources available to you to bring additional attention to the patient.

 

There are several resources available to you. These include the medical team, your charge nurse (or other experienced nurse on the floor), Respiratory Therapy, the Rapid Response Team and the Code teams.

 

Your unit based educators and managers are also a resource. It is important to realize that you are never alone and that asking for help is appropriate, important and expected.

Calling a Rapid Response

The Rapid Response Team (RRT) is available to assist with patients who are experiencing an acute deterioration in their physical condition or mental status. The goal of calling an RRT is to bring the appropriate resources to the bedside to stabilize a patient. The motto of the RRT team is “Let’s Rescue rather than Resuscitate.”

 

Research has shown that the early intervention prevents further deterioration in the patient’s status and reduces the likelihood that the patient will become unresponsive and need to be coded.

 

2 To Call an RRT, dial (your code extension) and ask for the Rapid Response Team. Give the Unit and the room number.

 

The Rapid Response Team includes one or more doctors, a respiratory therapist and an experienced ICU nurse.

 

Basic Parameters for calling rapid response:

  • Heart rate <50 or >130
  • Respiratory rate <8 or >25
  • Blood Pressure (systolic) <90 or >200
  • Oxygen saturation <90%
  • Change in mental status
  • Worried about patient’s condition

To prepare for emergency personnel’s arrival:

  • Obtain adequate venous access
  • Take vital signs
  • Set up suction
  • Set up oxygen
  • Have emergency equipment at bedside such as code cart and life-pack

 

Calling a Code Blue

A Code Blue (adult code) is called when a patient is unresponsive.

 

When calling a code, you dial 155 and state that you are calling a code 5/Code Blue (adult medical emergency), you give the 3 specific location including building, floor and room number and a main phone number in case the operator needs more information.

 

The first nurse on the scene has these responsibilities:

  1.  Assessment
  2.  Initiate CPR
    To initiate CPR

    • Circulation, airway, breathing, (CAB)
    • Start compressions if necessary, 30 compressions
    • Head Tilt/Chin Lift, then 2 ventilations
  3.  Place CPR board under patient when it arrives
  4. Ambu, chest compressions per CPR guidelines (30 compressions to 2 ventilations)
  5. Delegation
  6. Make eye contact and specify who does what: “John, get the AED, Sally get the defibrillator, Jan get the code cart”
  7. Obtain and verify IV access if necessary
  8. Stay with Patient to answer questions

 

Tasks to delegate include:

  • Get AED (Automated External Defibrillator)
  • Get complete monitoring defibulator
  • Call 155 (include location, type of code, your name)
  • Get Code Cart which includes:
    1. Ambu bag, O2 and suction
    2. CPR board 4
    3. Intubation Equipment
    4. IV access equipment
  • Set up above Equipment
  • Get patient chart and flowsheet
  • Get Glucometer
  • Care of rest of patient assignment to fellow RNs

Important: The primary nurse must stay with the patient ready to answer when appropriate in SBAR format (Situation/Background/Assessment/Plan) these questions:

  • What happened?
  • Prior Medical History
  • Critical Labs

The Second Nurse (who is usually a critical care nurse from the code team) on the scene is expected to:

  • Turn AED on
  • Attach pads
  • Wait for instructions from AED
  • Place board under patient prior to analyzing rhythm

 

A third nurse (critical care nurse #2 if available) is expected to:

  • Stay at code cart drawing up medications
  • Facilitate team management

 

Fourth nurse if available: documents.

When the MD arrives, the pads from the AED may be attached to the monitoring defibrillator at the MD’s request.

 

Other items/equipment that may be needed during a code:

Central line kit, Facemask, Hats, Gowns, Gloves, Manual BP cuff, Doppler, Extra flushes, IV fluids, Medications

 

Important Note: Codes usually involve a large team of experienced clinicians but being prepared to take the appropriate actions in the first several minutes can make a huge difference in outcomes. If you have the opportunity to observe codes as a new nurse, take advantage of those opportunities to watch and learn. After the code or RRT is over, review what happened with your educator and ask any questions you may have.
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