Pediatric Codes in your ED?

Altra, BSN, RN · Aug 13, 2007

Peds codes require the same dance as adult codes. As you said, someone needs to chart, 1-2 people need to be giving meds and you probably need a minimum of 3 other people to keep compressions going, run for stuff as needed and just generally be a pair of hands. You're also likely to have respiratory, maybe a social worker, etc.

As long as things are progressing, I dunno, I might not be so quick to throw people out. It is a great learning opportunity, the people doing compressions get tired (or maybe there's a medical or nursing student lurking who has never done compressions on an actual person), a new nurse or resident can get an IO if there isn't good IV access, etc.

I understand what you're asking but we don't utilize protocols as narrowly defined as what you're looking for.

bill4745, RN · Aug 14, 2007

Ditto, similar to adult codes, but 1-2 extra people for 3 reasons: 1; learning experience for them, since we don't have many peds codes. 2; an extra brain or two helps when dosing meds. 3; We often need someone with the parents, and yes, we allow parents in the room. Has rarely been a problem. and it lets them see that everything possible is being done, and lets them be with their child if we are not successful.

One thing different in peds codes-if we have enough notice and a weight or length from the medics, we draw up epi and atropine before arrival.

vamedic4, EMT-P · Aug 14, 2007

At my facility (peds level I) there are several people in the room during a code, the code pager activates and the necessary individuals respond, including: (by the way, this is a teaching hospital)

ER attending

ER senior resident

ER fellow

ER intern

Charge RN

Document RN

Patient's RN

Med RN

Pediatric Tech (paramedic)

Resp. Supervisor and Therapist

ER pharmacist

Social Work

Chaplain

The Charge RN is responsible for seeing things run smoothly and helping out wherever a need is identified or delegating roles to RNs and assistive staff.

The Documentation RN is responsible for documentation of the code: when meds were given, what meds, what treatments were ordered, the response of the patient to the therapy.

The Patient's RN is responsible for providing history to the docs and care already rendered (what they had done prior to the code occurring) as well as participating in the code in whatever capacity she feels comfortable.

Med RN is just that- she stands by to administer meds ordered by the docs.

Tech- provides assistance with BLS, bagging, IV/IO starts, labs, and serves as a runner.

Respiratory - Ensures airway patency after intubation, performs all resp. treatments, operates ventilator.

Pharmacist: Ensures correct dosages of meds, draws meds up, mixes any drips.

Social Work is there to provide assistance to the family in whatever way they can..getting the family something to eat, somewhere to temporarily sleep or a ride to/from home.

Chaplain - They're called to help with the family's spiritual needs, to pray with them and help to calm them down.

Many times there are "extra" people standing in doorways, and it can be a nightmare crowd control problem. These people need to be told to go on about the business of the unit and they'll be called if needed.

vamedic4

Kidrn911 · Aug 16, 2007

I work in a 50 bed Level I, which recently expanded to include a "pediatric ED" having 10 dedicated peds bed in a separate locked unit. It is a truly beautiful area, and the management has put a lot of time into making it nice and doing extra training with nurses. I can honestly say we have grown a lot in the last few years, and our pediatric care has improved greatly.
BUT we have been getting a lot of peds arrests/codes lately and it seems that we don't have a specific "dance" like when we have adult codes (I work both adult and peds). For adults, everyone knows we have a med RN, a charting RN, a floating RN, and a CPR RN/tech (if enough people are available). It seems like with peds codes we have a lot of people in the room, but not enough direction for everyone. We had one last week that I ended up throwing people out of the room because they were just standing there.
What is your typical pediatric code protocol? Where does your med nurse stand, and your doc? My understanding is that most dedicated children's hospitals have a very specific plan and jobs for people when it comes to codes. I think it is time to put that into motion.
Any help is appreciated!!

I work in a level 1 trauma Pediatric ER.

Peds actually only require the same as an adult code. The difference I see that is happening with confusion is that many more people are willing to respond to peds, because no one can bare the thouht of a child coding. That is great, but it can cause confusion and actually make the code harder to run. Policy should be unless you have a specfic job, stand to the side, until you are asked to do something

We are successful in having 1 RN and Paramedic at bedside. 1 Doing meds, 1 charting. If we get RT or a pharmacist at bedside that is great, but really rare for us. We also have a chaplain or SW dealing with family, and often a Spanish interpreter.

stayseerrn · Aug 17, 2007

Worked at an inner city peds er which saw approximately 80,000 kids a year, and saw, unfortunately, way too many codes. As everyone has said, you do the same type of dance you would do with adults. Because our unit was so busy, we couldn't have everyone down in the code room because the rest of the unit can't come to a stand still. What worked best was to designate a team in the er whose job it was to respond to codes in the er. Here is the breakdown of the people used:

RN to document (usually the primary RN)

Medication RN

Procedure RN (IV, foley, NGT, etc)

Paramedic or EMT for compressions and retrieval of things

ER Doc or Docs (1 must be an attending)

RT (responsible for maintaing airway & bagging after intubation)

All of these roles are pretty straightforward as to what each does. The procedure RN and the paramedic would rotate on things like compressions and grabbing different supplies. The RN documenting also has to work with the ER attending at being the coach of the team. The documenting RN is to keep track of who is doing what, where we are in the code process, calling in extra help if needed, and throwing out extra bodies that are in the way. So it is important that the documenting RN be experienced and up to speed on their PALS, as they will help the ER attending and be their eyes & ears.

As you can see, you can accomplish much of the same amount of work as you do with adults without having a room full of people. One thing you can do is to have your ER attendings run mock codes during downtimes. This is one thing we used to do quite frequently, and it really helped to to get our dance down.

Have faith and trust in the knowledge that you already have.

Trauma Columnist · Aug 17, 2007

I think where the confusion is with the education provided to the staff as well as the number of peds codes versus adult codes. I worked at a level 1 for 10 years and of course the adult codes far outnumbered the peds codes. We all felt very comfortable with the adult codes but the pedi codes could get hectic as we all tried to stay on top of things.

Maybe more education? Have some mock codes? Ensure staff feel comfortable with pedi meds, pedi care. For me, the family involvement was always hard. I could memorize the drugs, know exactly what to do but when the grieving parents were there it was very hard.

I do fully support family presence during resuscitation though and that does add another dimension of stress to the situation. I worked nights and we would have:

One attending and one resident,

One resp therapist

Two RNs

One tech

One chaplain and that was it.

stayseerrn · Aug 17, 2007

I completely agree with you when it comes to the family members of pediatric code pateint. It is so hard to know how to deal with the grieving family members. Also, like you, I feel it is extremely important for families to be present during a resuscitation. While it does put a great deal of stress on the healthcare providers, I feel that it does help the family come to terms with what may be a negative outcome much faster than if they were not in the room. It also gives them a sense that the healtcare providers really did care for the family member and really did try to do all they could.