rapid response team

[murse1015]

I had a pt that was admitted for intractable back pain, imaging was negative, Neurosurgery workup was negative. pt. seen by pain management MD who ordered a boat load of new narcotics and sedatives (Scheduled oxycontin, PRN roxicodone, flexerill, baclofen, and neurontin and ativan) gave the patient his 8am scheduled meds, then at 9:30 upon reassessment pt. c/o 8/10 pain. pt requested his PRN roxicodone and ativan, which I gave at 10 am. At 11:00 am, pt a+ox3 speaking in full sentences, still c/o "excruciating pain". VSS. I went in around 12n to give him insulin, he was hunched over in the chair lethargic, but arousable. Assisted him back to bed VSS. At 12:30 went in to get another pt. OOB. glanced over and his RR was 10, more lethargic. called attending MD for narcan order, who told me to call pain service. paged pain service-no response. paged anesthesia attending who supervises pain service- who said they didnt want to step on pain service's toes. I'm at the pt's bedside and his RR is now 7 and he is only responsive to sternal rub. I called a rapid response, the hospitalist arrived gave me the narcan order, pushed the narcan and pt. awake and alert...c/o pain.

it seems like the attending and pain services gave me an attitude for calling a rapid response. just wondering if maybe I shouldnt have given all those meds (I didn't question them because this was day two on this regimen) or if it was the right thing to do by calling a rapid??should I have called it sooner?

[elizabell]

We have standing narcan orders for pretty much anyone who has narcotics ordered so, I can't really see this happening to me... but, if it had --

If I was seriously concerned that the patient was oversedated and I wasn't getting an MD response, I would have had my charge nurse lay eyes on patient to get her in the loop and get her opinion. I probably would have given the narcan on override and fyi paged the team and asked for an order. If the narcan wasn't effective, THEN I would have called an RRT. Because, I know the first thing the RRT team would have asked is "Have you tried Narcan?" and I cannot imagine a nurse at my facility getting in trouble for overriding narcan.

To avoid this whole situation, when I'm not getting a prompt response from MDs over something urgent like this, I often find it helpful to put in a text page to the primary team "trying to avoid an RRT" or "my charge nurse wants me to call an RRT." Just mentioning RRT normally gets the resident to jump on it because if I call an RRT because the resident wasn't being responsive, he has to answer to his attending.

[kayern]

Too bad they were angry. You were advocating for your patient. I've been in many RRTs where a member of the RRT team questions the M/S nurse calling the RRT. Continue to go with your gut..........its usually right. Isn't it better to err on the side of patient safety than not. Keep up the good work