[ConfusedRN]

I work in a large, very busy Family Practice office. We have mostly CMA's, a couple of LPN's and 3 RN's. I'm looking for some sort of protocol for running a code in the office setting. Like who is in charge of what, who records, etc. I was unsure how this would work say if there were no RN's in the office when a code occurs. I am sure that most of the work would be taken on by one the providers, but the ancillary staff is going to have some responsibility. Just wonder if anyone out there had something like this implemented in their office.

Thanks!!

[Nurse Ratched]

A few questions: what's the extent of the equipment you have available (full crash cart including drugs, defibrillator?) Do you have an outpatient endo clinic and things like that to contend with, or are we strictly talking about Ethel keeling over in the waiting room before she's seen? What's your response time from EMS?

[ConfusedRN]

We have a crash cart (more like a case really) has all the regular stuff, drugs, defibrillator, etc. We are just a free standing, on it's own office- just regular patients coming in for care. We have had a couple of patients walk in in distress and had to whip out the crash cart, but definately not a true Code Blue. Response time for EMS, about 5-10 mins for emergency, 10-15 for non-emergency.

[Nurse Ratched]

Just brainstorming with you . We have a defib but some time back dispensed with the drugs. We have a similar EMS response time. We have no one ACLS certified. Your office might consider that, which would leave you with the basics of life support in which I am assuming all your staff are trained. I know it's hard contemplating not having the drugs, but really ask yourself if you would ever be in a position of actually pushing cardiac drugs, and how comfortable would your providers be in calling the shots (you know them - they may be world class former ER docs, or know emergency medicine like the back of their hand, but if they don't then having the meds available may be more of a liability.)

So for your particular office, someone needs to be in charge of:

Calling 911
Getting the crash case
Starting the whole BLS process leading up to defibrillation if necessary - pass the recording to whomever looks least up to handling anything else
Herding other patients to another area if it happens in a more public area of the clinic

The RN or LPN in her absence should be in charge of initiating this process. The doc will presumably be immediately involved and can assess the pt, determine need for CPR/defib, etc. What am I missing? - it's early lol.

[sirI]

And, to add to the above excellent ideas:

Be certain all in your clinic are BLS certified. Many state health agencies require this of all physician clinics. Even the ancillary personnel. Check with the laws of your health entities.

The idea of ACLS certification for all licensed personnel is a great idea. This will carry the initial BLS a step further. If you have no plans of utilizing the drugs in the ACLS protocol, I agree with Nurse Ratched, it will be more of a liability to have them and not utilize them if indicated. So, be certain your physicians plan to actually use these drugs and if not, get rid of them.

You need to have the ACLS protocols attached or inside the crash case. Never should the individual be required to recall the procedure/s and/or drugs and their dosages required, in an emergency.

If you plan to conduct an emergency using the ACLS protocols including drugs, your crash case must include (you can refer to an ACLS text for additional information):

Protocols (laminated for water/body fluid protection)

Drugs per each protocol

Oxygen

Oxygen tubing and delivery unit

Intubation supplies (ped and adult) including appropriate sized ambu bags/masks/ET tubes

Stethoscope

B/P cuff (ped and adult)

IV fluids

IV start kit

Pocket mask (these also should be placed at each HCP area for immediate use, including the front office), various syringes w/wo various sized needles, IV tubings, prep pads, razor, tape, extra defib pads, gloves ..........

Be certain you also assign someone to check the defibrillator daily. And, keep a log of said daily check. This same person should check the crash case daily as well (document on the crash case log) to ensure it is readily available and contains all the necessary items. One should not have to open this case and sift through all the items in order to verify all is there. You can obtain the "break-away keys" from the Pharmacy at the hospital. Use one to "lock" the case. When checking the case daily, one need only verify the case is "locked" and ready for use. The remainder of these "keys" should be locked in the controlled substances case/cabinet to ensure security.

Develop an intraoffice protocol that outlines how and when the appropriate personnel are kept updated. (ACLS is re-cert every two years and the office personnel must have updates/practice codes more often).

And, write a policy/procedure for all of the above. Have the physician/s approve and keep in your records. Update as needed.

[ashour]

respectectedc sir: i need details of code blue procedure and policy please if possiple.
thanks

[rjflyn]

Actually the best money spent is going to be on purchasing an AED and training your staff in its use. As ACLS is one of those skill that if you dont use it frequently you are going to lose it. For example a code or two a year isnt worth it. If your running that a month I would wonder if your office is in the wrong location ie does it need to be attached to a hospital so the hospitals code team can run them.

RJ

[suzanne4]

I agree with RJ. Your physicians have no business even attempting to intubate unless they do it regularly. Any patient that needs intubation, can be successfully bagged with 100% O2 until the paramedics arrive.

And unless you do it routinely, having one or even a handful of code situations per year, is not going to keep you comfortable with it. What happens is you do not have a physician in the office at that time?

Best suggestion, make sure that you have functional O2 and an AED. By the time that you get thru with getting an IV started, you are going to have a team there. That patient can have compressions done and bagged, and you will still have the same outcome. The key is to get them defibrillated as soon as possible.

I definitely would not start with the full cart. Your office is not equipped for it. Safer for everyone if the paramedics are there in just a few minutes.

[ConfusedRN]

We do have an AED, I believe it is required now for outpatient facilities. We are all trained on the use, I mean it really isn't rocket science. The patients at our office will come right to our office, no matter what their condition- even if we tell them until we are blue in the face to go to the ED. At least 4-5 times per week, we have an active chest pain come in, among other things that really have NO BUSINESS coming to our office. We have 3 doc's recently out of residency that are comfortable with codes, intubation, etc. We just have no actual "policy" that outlines who gets what, yadda yadda yadda. I guess we have survived this long without one.

[suzanne4]

And what happens if you have polciy in place, and no doctor on site then?

And to add to that, most family practice physicians do not intubate routinely, even if they just finished a residency; or even run a code.
At least not in any of the training programs that I have ssen thru the years.

A couple months of ER medicine or a month in the ICU...............you lose skills and quite rapidly.