What to do in a code situation

GingerSue · Apr 13, 2007

I would think that times and actions would be need to be documented.

Do you have policy?

Cattitude · Apr 13, 2007

I have a huge question. We had a code in our office earlier in the week. Several things went wrong, but I have a question as to who is to chart what. First, should I call the nursing board in my state to find a definitive answer? here's my situation:
Code happens and no one is charting except for a small paper towel as to when drugs were given, times, etc. (THIS WAS NOT AN IDEAL CODE). The lead nurse was in the code before it even started happening. She never charted on word except that 911 called and pt. transported. The doctor did his own documentation and she states that is all we need. I am NOT comfortable with this at all. I think she should document everything from point a to point b with times included and all who were present. She keeps refusing and I told my administrator that I was not comfortable with that. What should I do and what is the correct thing to be done? Should the doctor document and the end, or should she document?
P.S. We are in the process of ratifying our code process, but I need the answer to this question yesterday.

The lead nurse needs to chart on the code. there needs to be a detailed record of what meds were given and what happened. It doesn't have to be lengthy just include the facts.

For goodness sake do we as nurses let the docs do our charting in any other situation? Heck no so why would a code be any different?

That nurse is crazy to not document.

anne74 · Apr 13, 2007

Did any of the nurses do anything for the patient? Then yes - nursing needs to chart.

In our hospital, it doesn't have to be the lead nurse, but one of the nurses just takes on the role as the recorder. Then that's all they do during the code - other nurses shout out what drugs they're giving, etc, and the person charting times everything and documents everything done. On our code cart we have a sheet that already has what info is needed - then we just write it in as it's happening. I'm surprised you don't have something like that already - just a paper towel?

kmoonshine, RN · Apr 13, 2007

When we run a code, it is ideal to have one nurse assigned to documentation. They stand by the door/curtain, document who is present as well as who comes in/goes out. Everything is documented. We continuously chart "CPR in progress" as well as what time we check the monitor and what our interventions are according to ACLS protocol (ie "CPR held - asystole; CPR resumed"). The person who is documenting states which clock in the room everyone is to use. The nurses pretty much run the codes where I work; the doctor is coming in and out, but the nurses are the ones pushing meds, documenting, assessing and intervening as appropriate, etc.

It is my opinion that the nurse should have been continuously documenting. If this were to go to court, all you have is what the doctor documented. It will make it appear as if the nurses did nothing, or just called 911. Documenting shows whether or not you acted appropriately in the given circumstances by doing things such as checking the heart rhythm, pushing appropriate meds, assessing to rule out causes of the code (ie hypothermia, hypoglycemia, etc). It also shows that you acted within your scope of practice. Lack of documentation supports "failure to rescue".

Patients can crash so quickly, and I've seen nurses grab a paper towel to start charting. But, they also yell for help and scream "get the chart". We also have code documentation forms on the code carts.

Check your hospital/facility P&P. If you're in a hospital, pop into the ED or ICU and ask the staff what the RN's role in documentation is. If there is no P&P, advocate for having one in place.

Obviously, doctors and nurses are not the same thing. So why should the doctor be the only one to document? Nurses should be charting and including the patient's response to the doctor's treatment. We are the patient's advocate after all.

No code is perfect. Learn from this code and examine what went right, what went wrong. During a code situation, you need to have a strong nurse documenting - they usually are the one telling the other nurses what to do (saying things like "we need a temp", "what's the urine output", or "draw blood cultures"). Document and cover your butt.

huskersfan · Apr 13, 2007

Absolutely everything needs to be documented from times to meds to patient response/no response to meds etc. I would document all I did in the code if the lead nurse isn't doing it. We have scribbled notes on paper towels, or arms where ever at times when a quick code happens, but you have it for your documentation.

KulRN · Apr 13, 2007

***This is my first code experience**Yesterday, I was the lead nurse in our team, one of our patients coded. It happened at 0855, I have not physically seen and assesed this patient. I had 8 patients that day with 1 LVN and 1 Tech. I was in the middle of getting my other (next door) patient ready for a procedure (transport in the room to p/u the patient)....this patient was not supposed to have the procedure done until 1300 that day but OR decided to push it earlier, so I was busy in the room getting her all ready (paperworks....night shift did not complete) when I came out of this patient's room I saw my Charge Nurse pushing the crash cart and asked " Did you know that one of your patient's coding?" I dropped everything down and headed towards this patient that's coding...Pt is a 70 year old male with diagnoses of Renal Failure (not on dialysis), upon entering the room, there were at least 3 other people in the room including another RN ,CN and respiratory tech. He had aspirated and was hyperventilating. The monitor tech had notified my CN (not me) that prior to coding he was running SB in the low 30's. Luckily there was a cardiologist at the nurses desk when it happened so he was able to assess and looked at the patient, within 3 minutes Rapid Response came, cardiologist giving orders, CPR in progress, and my role was giving report to the RRT and MD ( I couldn't get to my patient since everyone's around him), another RN was assigned to chart on the board during ACLS drugs administration and Defib, RT was bagging the patient RRT doing compression and pushing drugs, ER Doctor came and took over...House supervisor, the unit Director, and chaplian (on the phone with the family) were present as well guiding me....34 minutes later the ER Doctor called it off and patient was pronounced dead. And I was basically left alone with the body after that and the CN and unit Director told me to have my LVN and Tech to do postmortem care because I have paperworks to complete. The code sheet was completed by the RRT and was signed by the Cardiologist and ER Doctor and I had to complete another form. I also had to do my nursing notes (1 1/2 pages of it) and I feel like I did not really cover the whole thing, during the code I was in the state of shock and panic (remember this is my first), I wasn't sure what to do and how to start (my critical thinking run away from me that even the simpliest task I was not able to do...thank God there were people helping me)...I was also worried about my other patients whom out of the 8 I had that day I was only able to assess 3 when the code happened. My note was something like this:

0855:"Prompted by CN about patient on code status, upon entering and initial assesment, pt was found in respratory distress, breathing shallow at 14, pulses palpable, and had coughed up thick brownish secretion, O2 sat at 2 liters 88%. Airway maintained, RRT on the way, crash cart in the room, cardiologist present and giving orders.

0857: CPR started, RN (me) giving report to MD. Cardilogist giving order.

0858:RRT arrived, CPR still in progress. RN gave report. (pulses, breathing and responsiveness were no longer viable)

0905: ER MD arrived, pt converted to VFib, order for Defib given, ACLS drugs started. RN (me) stayed in the room during code. CPR still in progress. Chaplain on the phone with patients family. RN placed call to Primary MD. CPR still in progress.

0937: ER MD called it off and pronounced patient dead.

0945: Family called spoke with the Charge nurse. Postmortem care started.

I know that there are more things that I should've added and documented. I'm just hoping that this will not haunt me later. I had no clue that this patient was in bad shape, the night RN did not mention anything to me and I found out later on her documentaion that at 2100 pt had wet/rhales lung sounds and had coughed up brownish sputum as well and O2 sat was 87%. 2230 Primary MD came but no mentioned about 2100 assesment, only patient was complaining of groin pain and MD ordered for CT pelvis that morning. Had I known, I could've assesed him first. I'm really beating myself for what had happened. I started my shift at 0730 and it happened at 0855.

TazziRN, RN · Apr 13, 2007

One person documents, that is her job in the code. Documentation includes the time the code started, time of meds given and what meds given and via what route, time 911 was called, defib attempts if any, and the name of each staff person involved in the code. Nursing documentation is in addition to the MD's documentation. If, heaven forbid, this pt or the family sued and the lead nurse was called into court, without her own documentation she would not have a leg to stand on.

tridil2000, MSN, RN · Apr 13, 2007

0855:"Prompted by CN about patient on code status, upon entering and initial assesment, pt was found in respratory distress, breathing shallow at 14, pulses palpable, and had coughed up thick brownish secretion, O2 sat at 2 liters 88%. Airway maintained, RRT on the way, crash cart in the room, cardiologist present and giving orders.
0857: CPR started, RN (me) giving report to MD. Cardilogist giving order.
0858:RRT arrived, CPR still in progress. RN gave report.
0905: ER MD arrived, pt converted to AFib, order for Defib given, ACLS drugs started. RN (me) stayed in the room during code. CPR still in progress. Chaplain on the phone with patients family. RN placed call to Primary MD. CPR still in progress.
0937: ER MD called it off and pronounced patient dead.
0945: Family called spoke with the Charge nurse. Postmortem care started.

i think you meant v-fib instead of a-fib.

Mommy TeleRN, RN · Apr 13, 2007

Call me dumb cuz I just learned how to handle codes - but why was CPR initiated if the pulses were palpable and the pt was still breathing?

KulRN · Apr 13, 2007

i think you meant v-fib instead of a-fib.

I meant VFib not Afib...

KulRN · Apr 13, 2007

Call me dumb cuz I just learned how to handle codes - but why was CPR initiated if the pulses were palpable and the pt was still breathing?

at 0857 when CPR was started, patient was no longer responsive and pulses and breathing were no longer viable.