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

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 location• Medicine floors:

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 March 2010 Purpose:

• 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

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 6 BT 4 Onc

RRT/1000 discharges

24.8 35 40.9

Code Blue/1000 discharges

2.8 3.6 9.1

It’s 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