Today I responded to the most pitiful code ever. Keep in mind that I work at a LTCF. Here's a list of what went wrong during the code.....
1. The crash cart was not stocked, yet the night nurses have been initialing that it has been fully stocked for the past two weeks. I attempted to hook up the suction machine before discovering that there was no tubing or yankauers in the drawer.
2. 'Code Blue' was not announced over the external paging system. I wouldn't have known about it if I didn't spot a couple of people running to a particular patient's room.
3. A bunch of people were standing around in the patient's room with their hands in their pockets, doing absolutely nothing. At least they could have offered to take over the task of the chest compressions, since our hands and arms tend to become exhausted.
4. The patient coded during the lunch hour when the majority of the nurse managers and other employees had left the building to dine at restaurants.
Any questions, comments, or opinions on this matter? Do you think I'm being overly critical? By the way, the code was unsuccessful (of course).
Wow, this brings back memories! Over a year ago, when I had just started this job (it was actually my second day here) I had the most inept code happen...
First of all, my office is on the exact opposite side of the facility from where the code was. I was on the phone trying to find someone to cover a callout, when there was a knock on my door and a CNA told me they thought "Mrs. Smith" had passed. I said "IS SHE A CODE?" The CNA did not know. Now, mind you, they could have paged me overhead, but didn't because it was nighttime. (Needless to say, I made sure they all knew the definition of "emergency" and when it is okay to page overhead after that!) So I run over to that side of the facility, the LPN is sitting behind the nurse station, calmly. I said "Is Ms. Smith a code?" She looked at me blankly and said "I don't know, I assume she's DNR." I grabbed her chart, flipped it open- she was a full code. I hollered at the CNA to call 911 while I ran into the resident's room, pulled the pillows out from behind her head and tilted her head back. No breathing/pulse. Now the crash cart is here, and the backboard is missing. Great. So I had the LPN help me yank the headboard off her bed and put it under her, I start compressions while the LPN reaches for the Ambu bag. Guess what? It's missing. I throw my supply room keys at the CNA and she runs to get one, the LPN puts it together and tries to hook it up to the O2 tank. Tank's empty. I send another CNA after a new O2 tank, while the LPN tries to force room air into her lungs with the Ambu. There was mucus blocking her airway. I grab for the suction, and the tubing was missing. By now I was ready to cry. I'm still doing compressions, and wondering where EMS is, when someone says "Noone went to let them in." WHAT?!?!?!? So someone goes to let them in (the facility can only be opened by an ID badge at night) and fails to let the remaining two members of the EMS team in. The ones with the intubation kit.
Needless to say, the first thing I did after that was to completely revamp the facility's code policy, with daily crash cart checks and monthly drills. I'll never forget that nightmare. And no, the resident did not survive...
I don't think you're being overly critical. It's always a good idea after a code to review the process and see what needs to be improved. As long as it doesn't turn into a punitive finger pointing game of "you should have done...." which is answered by "well you should have......".
Make it a learning experience. Have some inservices, come up with a plan, have some mock codes so it goes better the next time.
I sure haven't read anything good about LTCF's on here. I guess that's one field I'll try and stay away from!
Just to show that these things don't always happen in LTC. I was a new RN of only 9 months and working in a very small community hospital. Our hospital was 22 beds counting the 3 in our SCU. We had a nursing home on the first floor and one on the third floor, while we were sandwiched in between.
We had a 3 bed SCU that was being covered by a nurse with a fresh carotid endardectomy, a nurse in ER with the only doctor in house and me with 10 patients and an aide. One of our patients was 3 days post endardectomy and had been transferred to the floor that day. She was a frequent visitor to us and well-known to all the staff there that night. She rang for assistance to the BSC and as she was an AKA about a year out from that surgery I went in to help the aide transfer her over. I asked the aide if she would stay with her and call for help. She said OK. Now, as I said we knew this patient very well, she asked the aide if it was OK for her to sit there for a bit as it was going to take her a while, the aide made certain that she knew to call for help and the patient assured her that she would. After about, 10 minutes, I suddenly hear the nurse in our SCU scream out to check on her. As I ran down the hall, I hear this dull thud and run into the room to find her face down on the floor in a pool of blood. The SCU nurse calls a code, but the only one able to respond was a nursing home nurse. I sent her for the crash cart, while rolling this patient after determining the blood wasn't from an open surgery site and starting CPR. The doctor finally arrived from ER 2 floors down and after quickly instructing the nursing home nurse on how to bag the patient, I got the patches on her for a quick look. While trying to do compressions, give meds to correct her arrhythmia (not a shockable one according to the doctor), and talking the NH nurse through the bagging, the doctor looked up at me and asked if anyone present was ACLS certified. I couldn't help but laugh hystericlly and say, Nope not a one. We finally got the CRNA in from home 10 miles away to intubate and was able to get the patient back into the SCU.
The rhythm was torsades and after bolusing her with magnesium and stabilizing her. The doctor came to me and said that all things considered we did a good job, but she was writing the incident up for administration to see that we needed more training. After that it was require that all nurses working there, including the nursing home nurses, be ACLS certified within a year of hire date.
Was in a similar situation over the weekend. They wanted to recover a AAA repair in the regular PACU on the weekend with no unit clerk, tech etc. The man came out w/ a pressure of 206/106 and was given labetelol per surgeon and anesthesia. Pt bottomed out w/ a pressure in the 70's and nobody thought he could possibly be bleeding. Anesthesia wathched this guy w/this pressure for at least an hour w/pt in trendelenberg. Finally called for some blood about 2 hours later. Would not heed nurses suggestions. They were convinced it wasn't a bleed. Then he starts barking orders for drips etc, which are not in PACU (how dumb is that) Drips sent to tube w/no drip chart as they don't have dose mode on Plumb pumps. Both surgeon and Anesthesia never thought to ask for additional help from colleagues. By about 2230, w/ a belly full of blood, pt dies in PACU. I called for a meeting w/nurses involved and nurse managers. They seemed supportive at the time, but in a community hospital I just feel like it will be brushed under mat. Took onus on my part as to what could have done better. Anesthesia has bad habit of cavalier attitude toward nursing, thus rendering situation difficult at best.I feel like the pt could have been saved if he hadn't put such a huge wall around himself.
I'm so sorry that this Code went so horribly wrong. As far as doing compressions, anyone in the room is fair game for relief in our hospital. If they don't know how, they don't belong in there.
Our facility generally has successful Codes.
Everyone knows BLS, it's a requirement for the job. I think even ancillary staff like housekeepers and transporters need to have CPR, but I'm not sure.
The Code Carts really ARE checked daily. Central Supply restocks them for us, so when one Code Cart is opened--you can tell because all the drawers and equipment are "locked on" with tags--it's then sent down for restock and we get a new one.
Everyone has a role in a Code. Someone will record, a couple will take turns bagging and doing compressions till the Respiratory staffer can intubate, someone will do crowd control, the ICU nurses usually initiate the ACLS stuff until the doc gets there, and they generally work as a team.
We also have a SWAT nurse, but we usually have things pretty much under control by the time they get there.
I really feel for those in LTC who have to try to Code someone under conditions that are sometimes worse than you'd find in a public restaurant!
I always ask the staff I'm working with if they are a full code or not, sometimes I am but if it's a really bad day I tell them I'm a DNR!:chuckle But seriously, I hear ya, worked in ltc, I was the only RN for the night shift, 105 bed facility, there was an LPN on the back wing (she was the ONLY staff back there) and I had to code a resident, crash cart was the same way, the supplies were either not even there or opened/expired, no defib, suction wouldn't work even if there had been tubing, oxygen tanks were brought and the fourth one they opened had some oxygen left in it, one cna did call 911, it took them 15 minutes to get there (even though they are only 5 miles away and this was around 2 a.m.). I thought management might share my distress at the way things happened, silly me!!!!
At the ECF where Mama is, their social worker was in the Ladies Room. Another worker went in and found her just inside the door to the handicapped stall cold clammy and apneic. This lady weighed in the 300's.
The DON was just across the hall and responded. The EMTs were returning a patient from dialysis, the RN on the hall was moonlighting from her ICU job at the medical college hospital.
This gal was coded...apparently perfectly... and is back working part-time and scheduled to have bariatric surgery.
I just want to say sometimes things work out at LTC.
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LoriAlabamaRN
955 Posts
Wow, this brings back memories! Over a year ago, when I had just started this job (it was actually my second day here) I had the most inept code happen...
First of all, my office is on the exact opposite side of the facility from where the code was. I was on the phone trying to find someone to cover a callout, when there was a knock on my door and a CNA told me they thought "Mrs. Smith" had passed. I said "IS SHE A CODE?" The CNA did not know. Now, mind you, they could have paged me overhead, but didn't because it was nighttime. (Needless to say, I made sure they all knew the definition of "emergency" and when it is okay to page overhead after that!) So I run over to that side of the facility, the LPN is sitting behind the nurse station, calmly. I said "Is Ms. Smith a code?" She looked at me blankly and said "I don't know, I assume she's DNR." I grabbed her chart, flipped it open- she was a full code. I hollered at the CNA to call 911 while I ran into the resident's room, pulled the pillows out from behind her head and tilted her head back. No breathing/pulse. Now the crash cart is here, and the backboard is missing. Great. So I had the LPN help me yank the headboard off her bed and put it under her, I start compressions while the LPN reaches for the Ambu bag. Guess what? It's missing. I throw my supply room keys at the CNA and she runs to get one, the LPN puts it together and tries to hook it up to the O2 tank. Tank's empty. I send another CNA after a new O2 tank, while the LPN tries to force room air into her lungs with the Ambu. There was mucus blocking her airway. I grab for the suction, and the tubing was missing. By now I was ready to cry. I'm still doing compressions, and wondering where EMS is, when someone says "Noone went to let them in." WHAT?!?!?!? So someone goes to let them in (the facility can only be opened by an ID badge at night) and fails to let the remaining two members of the EMS team in. The ones with the intubation kit.
Needless to say, the first thing I did after that was to completely revamp the facility's code policy, with daily crash cart checks and monthly drills. I'll never forget that nightmare. And no, the resident did not survive...