Let me start off by saying I'm a new grad, just started working in a Progressive Care Unit (step-down ICU) almost 2 months now. My unit is connected to the ICU (we have the same managers covering both units and nurses often get floated between the two). I frequently hear codes and rapid response calls on the overhead and I have a few questions..
My preceptor was telling me how sometimes if a patient is in severe pain and the RN cannot get in touch with their attending to get pain meds ordered, you can call a rapid and get that physician/resident/whoever shows up to administer a one-time dose of pain meds. I was under the impression that you'd only call rapid response for things like: concerning changes in BP/HR/R/O2 sat, changes in mental status, new chest pain, etc. So now my first question is - What are appropriate times to call a rapid response? Or is it just different per hospital policy?
My second inquiry - I understand the rapid team is usually made up of respiratory therapists, PAs, residents, intensivists, critical care nurses, etc. Am I expected to respond to rapid calls if I am free? I'm ACLS/PALS certified and have been encouraged by my preceptors and managers to answer code blues if I can. I'm also just curious because I hear overhead announcements of rapid response and code teams needed on other floors. Are critical care nurses expected to leave their patients and run to these calls throughout the hospital?
Sorry if these are dumb questions.. I'm just a newbie to all this. Thanks!
Last edit by LUCBSN on Mar 12, '17
Mar 12, '17
Our charge nurse usually goes to all of our rapids/codes, or another senior staff member. Being a new grad and new to the unit you would probably not be able to respond to these by yourself. That being said if i am free and a code is called i always ask my charge if i can tag along with her.
Mar 12, '17
A lot will be facility specific. A rapid response at my hospital brings the supervisor & an ICU nurse who is specifically assigned RR & codes for the shift. That's it, no MD; if you're having a respiratory issue, you make a 2nd page for RT (although they often respond anyway).
Our guidelines state a RR is appropriate for chest pain, new onset SOB, sats <90 that don't respond to O2, HR >130, RR >30, SBP>180 & any situation that the RN or family feels that something isn't right (I'm prob missing a couple other parameters but these are most common). Severe pain & MD isn't responding to pages? Not really, because all that would happen there is that the ICU RN responding to RR would page the MD again. In that situation when a page is not returned, we notify the supervisor who takes it up the medical's chain of command & the CMO would give an order if necessary. An ER doc & nurse, along with RT & phlebotomy will respond to codes at my hospital in addition to the ICU nurse & supervisor.
The expectation for you to respond to any RR or codes should be outlined for you by your manager. At my facility, a newer nurse doesn't do this until after an orientation specifically for that while teamed up with an experienced RN, usually after being on the job for several months. Each shift, one RN is assigned the RR/code box & usually has no pt load.
Mar 12, '17
We have a designated nurse assigned to do advanced assessments and US IV access. They have advanced protocols written out of what they can do without an order. As far as I know, pain control is not something they do. We don't have a designated "code team". For us, 2 nurses go (one from MICU and another from SICU). On night shift, the code is paged out over the intercom and the ED doc is paged or the on-call hospitalist. RT responds with 2 of their own. I go to these as often as I can and typically lead the team until the MD gets there. I started in the ICU with ACLS and had a solid background in leading codes so my unit had no problem letting me go as soon as I was off orientation.
Mar 12, '17
As far as when to call a RRT check with your facilities policy. They should have a policy outlining what qualifies, who attends, paperwork to complete, etc..
The part about not getting pain meds usually there is a process in place to address providers not returning calls. Check with your chain to see what that involves. I have had issues in the past as an RN where we had to get the manager involved and sometimes drag in the medical director for non-responsive providers.
In the Icus I worked the Code/RRT pager was usually carried by a nurse with one patient. When the code went off and he/she would take that patient the pager is them passed on to another nurse with one patient. Different facilities handle this responsibility differently.
As a new nurse it is always good to see the process in action or the clusterF at work. However, many codes get way too many lookie-loos and they can congest the areas.
Overall codes are not scary and as long as you know your role it can be a pretty cool example of teamwork.
Mar 12, '17
The correct answer to when to call a Rapid Response Team (RRT, Met Team, or even a CODE BLUE) is ......anytime that you feel that the situation warrants one. Simply put, you are allowed to trust your gut. However, if you call an RRT for pain meds, then that patient better have some other issues as well or else you will likely receive remediation.
Mar 12, '17
The point of calling RRT to a patient's bedside is to prevent further deterioration of the patient's condition when the patient is not responding to whatever measures you are allowed to do by your local protocols. It's basically to prevent having to call a Code, and would ideally be called for as soon as you realize that the patient needs immediate intervention to prevent said imminent code.
Another reason to call the RRT (if physician led) is to provide a second look at a patient whose condition is not improving or even deteriorating under the care of the patient's current attending physician. This kind of RRT call would be more for getting that second opinion and you'd better be able to articulate why you called for this one. While I personally wouldn't call an RRT for inadequate pain control, I wouldn't fault family for doing so.
Many of the facilities I'm familiar with have a system that's separate from RRT that allows for another provider to evaluate the patient because of inadequate pain control or other similar non-RRT/non-Code issue and when they do have that program in place, it's often made a part of the orientation of a patient and family to the room.
Mar 13, '17
Our hospital has policies to designate when to call a rapid response. Those are guidelines. You call a rapid response when a patient's condition changes or warrants more interaction that you can give. New chest pain is a mandatory rapid response at our hospital (regardless of what I think it is). If I am unsure and I am not afraid the patient is currently dying or crashing, I would ask my charge for her second opinion. If it is not critical, then we are to attempt to contact the attending (or assigned resident) first. If we have not received a call back in a reasonable amount of time or the doctor directs us to, we then call a rapid. We can call a rapid for uncontrolled pain (again, after attempting to contact the physician). I called several rapid responses my first year. I also took time to be taught when they arrived...(some are more patient than others) if I should have tried any other interventions before I called. However, our policy is to call if we feel intervention is needed .... and that has reduced our actual codes called to a minimum.
Know that they will expect that new vital signs will be waiting for them...and if they are that critical, you better be standing with the patient or close by when they arrive.
I totally pissed a doctor off by calling a rapid for low urine output on a patient...but when I sat down to do her I&Os, I realized that she had less than 50 ml (via foley) for almost 24 hours (so not just my shift). I knew this lovely elderly lady had walked in to the hospital and was not admitted for a renal issue. It was her 84th birthday and I was not going to have her kidneys failing as a birthday present. The doctor didn't respond in over an hour in spite of 2 pages. The rapid team was able to order the fluid bolus she needed and add continuous fluids to her meds. Her output was acceptable by the end of my shift (she was severely dehydrated). The doctor was pissed when he called 2 hours after my first page but I don't care. I did what was best for the patient. She walked out of the hospital with her other issue resolved and her kidneys functioning normally.
I also caught an active brain bleed on an otherwise non-symptomatic patient....ungodly high blood pressure and she had just arrived from the emergency department with no blood pressure meds ordered.
I have rapid responded a delirium patient to get meds to calm her down and keep her safe....another for hallucinations that made her paranoid (she needed to be declared temporarily incompetent so I could give her meds against her will). I have also called for a patient whose pain was obviously out of control and the covering doctor was too afraid to prescribe sufficient opioids to a patient he didn't know.
I have even had the shift from hell where I had two rapids going on at the same time....got to know that PA and the respiratory therapist very well that night. Luckily, I haven't needed to call so many...partially because I have less critical patients and partly because I have the experience to intercede better and sooner.
I'd rather explain why I called a rapid response than why I didn't and patient was injured. Your ACLS training is for codes...not for rapid responses. You don't have the knowledge as a new nurse to be part of the rapid team usually.
Mar 13, '17
I would call my nursing supervisor i.e go up the chain of command. Maybe she will have better luck getting in touch with someone. Write an incident report about the doctor not responding to your calls. You do not want to be blamed for a "delay in treatment." Does your hospital have a pain management team, a PA or an NP who can be called in such a situation? Ask the nursing supervisor whether or not you should call the RRT. Even if others think that calling an RRT is unwarranted, if you cannot get in touch with someone to give you an order for pain medication, then I would call the RRT. We are patient advocates. I could never leave a patient screaming in severe pain. Your duty is to your patient first and foremost. Severe pain is a change in the patient's condition, so yes if no-one responds, call the RRT.
Mar 13, '17
Our facility has a dedicated Rapid Response team. I am one of the night shift rapid nurses. Our triggers are HR <50 (if symptomatic and not normally that low) or HR >130, SBP <90 (Unless they run in the 80's as base) or SBP >180, RR <10 or >30, respiratory distress, Change in mental status, hypoglycemia, falls, possible sepsis, a nurses that has a concern for any reason does not need to meet paramaters, IV access (difficult) or difficult lab draws.
Our ICU charge responds if we can't or are not working (we are not fully staffed in our department).
Mar 13, '17
I personally would never call a rapid response over pain management, unless the pain was so extremely bad and the patient's vital signs were out of whack and the physician wasn't answering. At my facility we call rapid responses when you feel like you need to. For example, new onset seizures, low sats that won't come back up, severe fluid overload, family member faints, etc. I had a patient who was having multiple mini seizures but it was not new onset, I called the doc and got an order for STAT Ativan. If I was not able to get in touch with the hospitalist I would have called a rapid. When we do call a rapid response there is a dedicated team of ICU nurses, respiratory therapists, phlebotomy, EKG, and the nursing supervisors come. It's tricky at first deciphering when to call a rapid but it gets easier in time. Good luck!!
Mar 13, '17
Yeah, I agree with most of you about the pain management - I had never heard of calling RR for that issue either which was why I was a bit confused.
I'll definitely look into my own hospital's policies regarding this. Thank you all for your input and examples!!
Mar 13, '17
Does anyone else work on a unit where you don't call rapids? I work on a cardiac telemetry/universal bed and we receive both tele and ICU patients, though only ICU trained nurses take those patients. Anyway, we don't call rapids, possibly because we already have ICU nurses at the ready. We call a code if things get real bad, but no rapids. Anyone else in this situation?
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