I've been a member of this board for a long long time. Some background on me: 6.5 years of nursing, started as a CNA, worked as an LPN and now I'm an RN on a Med/Surg floor for the past 1.5 years.
Last week, I had a patient who was on remote tele and was an older gal with various co-morbidities including obesity, diabetes, CAD and recent CVA with minimal residuals. I had this lady for a total of 5 days and my doctor assigned to her was a internal medicine resident who doesn't have the best reputation.
The first day I get this patient, her pulse is in the 30 to 40 range, the tele is picking up 3 to 5 second bouts of asystole and her BP is 200ish/90 ish. The patient is lethargic and gray, and is very difficult to wake up.
I immediately page the doctor. No response for about 15 minutes. Meanwhile I have my CNA and myself in the room doing vitals, trying to wake up the patient, ect. I page the MD again and calls me, says he's aware of the situation and plans to make rounds on her in about 30 minutes or so. I tell him I feel he needs to be here sooner than that, he blows me off and says he will come when he's doing rounds. I page my charge nurse, tell her the situation, and she tells me to call the CAT. Which is Cricical Assessment Team Nurse, or the charge nurse up in ICU. The CAT nurse comes down, assesses my patient and agrees that the patient should be up in ICU on a drip. He pages the doctor. He gets no response.
2 HOURS LATER the doctor finally shows up, declares the patient to be fine, her BP is now around 160/80 and she is much more awake and looks to be in better color. He orders an oral BP medication and consults with cardiology, and the patient ends up getting a pacemaker. Meanwhile he and his attending physician scold me on the floor, and insinuate I don't know how to properly take vital signs. Apparently my charge nurse or the ICU nurse don't know how to take a blood pressure either.
Yesterday I get a call from my Clinical Coordinator that I need to have a meeting with her and the Unit Manager, and that its "Going to take too long to pull me off the floor so we need you to come in on your day off."
Nurses, did I do something wrong here? Did I rush things, or am I justified in initiating a CAT response? Thanks for the replies, this has been eating me up.
No need to be on eggshells. Discussion and debate are not argumentative, they're simply all of us sharing our views and opinions based on our judgments and experiences.
The patient was clearly in a dangerous situation and in need of immediate intervention... in my world, that's a rapid response. A code is for an asystolic patient on whom we're initiating the appropriate ACLS algorithm.
Keep in mind that I have no experience working the floor; my only experience is in the ED and the ICU.
My thinking is that the patient was in a severe symptomatic bradyarrhythmia, with 3-5 second periods of asystole. ACLS provides an algorithm for symptomatic bradycardia, which includes heart blocks. That's why I said I think a code would have been appropriate.
My thinking is that the patient was in a severe symptomatic bradyarrhythmia, with 3-5 second periods of asystole. ACLS provides an algorithm for symptomatic bradycardia, which includes heart blocks. That's why I said I think a code would have been appropriate.
Understood.
For me, a code means CPR. Everything else is aimed at not having to call a code and includes everything up to and including intubation, cardiac drips, and an emergent transvenous pacer at the bedside.
I'm curious: For the people working on the wards, what's the difference between a code blue and a rapid response?
Sounds like you work in a community, rather than an academic teaching hospital. In a city hospital RNs, PCTs, unit secretaries, hell, housekeepers are encouraged to call a rapid response if the resources to deal with a change in condition are not RIGHT THERE.
One of the few positive things I have to say about my previous unit director was the he emphasized at EVERY staff meeting, EVERY review: No one will EVER be reprimanded for calling a RRT. EVER. It is always better to call and realized you didn't need the extra support than to hem and haw, second guessing yourself until it becomes a full blown code.
At the community hospitals I've worked at, it's been the same way. When it doubt, you call! I've never seen anyone punished or talked down to for calling a rapid response or code- not matter what the circumstances turned out to be.
I'm sure I'm repeating what was said before me, but find a new job. Any place that says you overreacted when you called a rapid/MET/CAT on a lethargic patient with a pulse in the 30-40's is a place that's jeopardizing your license and career.
Next time a patient is in distress gather a committee together to discuss what to do; then get a second and third opinion before you intervene, call the doctor, call a code, etc. It appears that is what management wants you to do!
For me, a code means CPR. Everything else is aimed at not having to call a code and includes everything up to and including intubation, cardiac drips, and an emergent transvenous pacer at the bedside.
I'd like to first say that many facilities do not differentiate between cardiac or respiratory arrests - both are treated as "code" situations. It is possible that bag-mask ventilating a patient will be the only real intervention needed immediately for a patient whose arrest was respiratory in nature (though often they also get narcan and transferred to a higher level of care too). This can occur especially in patients with a history of or at risk for seizures. It is why my old unit manager defied administration's ruling that ambu bags would not be allowed to be kept in any space outside of a crash cart (ironically the powers that be allowed us to have a box in our pyxis of ACLS drugs to take with tele patients on transport, especially if they were being transported post-rapid response or on stat imaging orders). Patient who seize (whether or not you have to medicate them to stop the seizure) are at risk of losing their airway. Also - transporting a neuro patient for a stat CT scan who you're afraid has re-bled post burr holes or hemicrani? Not the time to not have ACLS drugs, the defibrillator and an ambu bag.
For most "floor" and some stepdown units, the resources are drastically different than those in an ICU (as I'm assuming your environment might be based on your post). Where I worked the floor (hybrid stepdown and floor) and the floor/stepdown units where I work now, patients are not intubated outside of code/rapid response situations (though my old unit was the only non-ICU area in the hospital that took trachs - so we had an airway), and we were unable to utilize transvenous pacing (didn't have this resource on our unit). Our defibrillator could pace someone if needed (but if we were using the defibrillator we'd progressed to a "code" situation), and usually only paced post-resuscitation and prior to transport to the OR, EP lab or ICU. We occasionally had super chronic and stable vents (the kind of patient who will always be vent dependent), and sometimes vents were set up to be used for CPAP or BiPAP (if we didn't have enough other devices for CPAP or BiPAP in the hospital).
The type of rescue equipment available on most units (floor and stepdown) would include ambu bags, oral airways, the defibrillator, and the crash cart (stocked per facility - meds, supplies (maybe intubation equipment, maybe arterial or central line kits), etc).
I'm curious: For the people working on the wards, what's the difference between a code blue and a rapid response?
In all four of the hospital I've worked at, the rapid response (or equivalent with a different name) was meant for patients who had major status changes (decrease in neuro status, LOC or GCS, etc), beside blood glucose of outside of specific parameters (something like less than 40 or greater than 200), blood pressure or heart rate significantly too high or too low (or outside of a specific parameter for patients with parameters), etc. This was meant for patients who had declined and had the potential to decline further. It was/is meant to get more eyes and experience in the room, to formulate a new plan (transfer to higher level of care, new medications/fluids, more scans, etc) and prevent patients from declining to the point of coding. Families, patients, etc were encouraged to call if "something seemed off especially if nursing or medical staff were not attentive to their concerns".
Code (in all of the places I've worked) is used to refer to respiratory and/or cardiac arrest. Technically, all of the facilities I worked in included patients whose HR was less than 30 or more than 160 (sustained, in a non-pediatric patient we had different parameters for peds or neonatal patients). The rationale being that for a rate that low inadequate perfusion is occurring (as mentioned before there is an ACLS algorithm for this), and a rate that high there is a risk of conversion from sinus tachycardia into a lethal rhythm such as ventricular tachycardia. Obviously lethal rhythms - ventricular tachycardia, ventricular fibrillation, asystole, PEA, were all code calls.
I now work in an area that does not always hear the housewide rapid response or code calls. It depends on the day how many we have. Depends on acuity of patients... Though I personally think that there is something to the theory of there being more during full moons or on Friday the 13th. The last Friday the 13th I worked was bad house-wide.
I've called rapid response for a lot less. Don't doubt yourself or your career choice. If that was my family member or friend, I would be thankful that he/she had a nurse who gave a damn enough to get them the medical attention that they required.
I agree w/others who have posted here re: finding another job. Keep your job for now, but start putting your resume out there. Or maybe look for a transfer to another unit at your facility, since the nature of different units can vary widely depending on the hospital you work at. There's nurse managers out there who would be proud to have you as a part of their team. This isn't one of them.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
Next time a patient is in distress gather a committee together to discuss what to do; then get a second and third opinion before you intervene, call the doctor, call a code, etc. It appears that is what management wants you to do!
But you can't make a decision without a quorum. So you have to make sure to meet on a day when everyone can be there.
I agree, it sounds like you were on top of things and the resident was very slow to respond. I hope the resident gets a chewing-out by his attending!!
Although I agree you did nothing wrong, if you have a union, I hope you had a union rep with you. Clearly the clinical coordinator was NOT on your side! Unbelievable! Sounds like you need to move on from that unit, whether to another unit in the hospital or another hospital altogether! Good luck!
I feel you were totally justified in your actions.
We all (most of us) hate change and looking for new jobs, starting all over....sucks. But this place sounds unsafe, I'd be worried each & everytime you have similar happen.
I too would suggest you start looking for maybe a teaching hospital. Good Luck !
Code vs. RR ? At my place (a teaching hospital) they call it a "code white", the nurse can call code white, they'll send the ICU nurse, Respiratory - House Officer soon after if deemed necessary. We are allowed to call code white even if we just have a gut feeling about our patient, no specific criteria. Our codes usually are for the patient who has stopped breathing for the most part.
I wish you the best - sounds like you are a good nurse and you need to work somewhere that actually appreciates your worth. Take Care !
Susie2310
2,121 Posts
My thinking is that the patient was in a severe symptomatic bradyarrhythmia, with 3-5 second periods of asystole. ACLS provides an algorithm for symptomatic bradycardia, which includes heart blocks. That's why I said I think a code would have been appropriate.