TITLE: PROTOCOLS FOR USE BY THE RAPID RESPONSE TEAM ...



TITLE: PROTOCOLS FOR USE BY THE RAPID RESPONSE TEAM REGISTERED NURSE

Performed By: RN who has successfully completed Core PICU nursing competencies.

Purpose: To provide protocols for use by the Rapid Response Team (RRT) Registered Nurse

Policy Statements:

1. The protocols listed in this policy may be initiated by the RRT RN prior to physician notification as the patient condition warrants. The RRT Intensivist is to be notified as soon as possible after initiating a protocol. These Protocols DO NOT APPLY TO EMERGENCY DEPARTMENT, SPECIAL CARE NURSERY, PICU, ICC, AND NEONATAL INTENSIVE CARE UNITS.

2. Each time a protocol that requires a medical order is initiated, an order MUST be written on the physician’s order sheet (Example: Stat ABG for severe respiratory distress per Nursing Protocol/J. Doe RN)

3. The RN may delegate specific tasks to staff within their scope of practice.

4. An RN who has completed the PICU core competencies may initiate the RRT RN protocols.

General Information:

1. If the RRT Intensivist is unavailable or not accessible, the patient’s attending physician or partner, the Emergency Department physician, or House physician (where available) is notified and consulted.

2. The RRT RN position is intended to support clinical decision-making in the non-critical care areas.

3. The RRT RN may initiate the protocols in a non-critical care area.

4. The RRT RN may transfer a patient to a monitored area when performing a consultation.

5. Additional information pertaining to specific procedures may be obtained from procedure policies.

Procedure:

1. Based on assessment, the RRT RN identifies a situation/patient condition that warrants initiation of a protocol.

2. An order for each protocol initiated is written on the physician’s order sheet. Example: Stat ABG for severe respiratory distress per Nursing Protocol/J. Doe RN

3. The supervising RRT Intensivist is informed that the protocol was initiated and the patient status.

4. Patient is monitored based on the protocol initiated, response to protocol, and physician orders.

5. Initiate a “Dr Blue” when a team response stat is indicated.

Documentation Guidelines: On form(s) appropriate to area, (may be in progress note) document

1. RRT RN assessment of patient including concern by floor staff

2. Outline protocols initiated

3. Written order on physician order sheet.

4. Patient response to intervention

5. Physician notification/attempts to contact physician

Rapid Response Team Protocols

|RESPIRATORY Nursing Protocols |CARDIOVASCULAR Nursing Protocols |

|O2 to keep saturations > 90%. |Peripheral IV and/or keep open an existing IV with normal |

| |saline. |

|Monitoring as indicated | |

| |STAT chest x-ray with reading. |

|Oximetry | |

|Cardio respiratory |For Chest pain: |

|Apnea |Obtain STAT 12 lead EKG and report results to supervising |

| |physician. |

|Suction as needed. |Cardiac monitoring (e.g.: Lead II) |

| |O2 to keep saturation (90%. |

|For a patient in respiratory distress |B/P-Pulse-Resp. every 5 minutes and document. |

| | |

|Call Respiratory Therapy for Respiratory Care Assessment and|For symptomatic hypotension ((40mm Hg drop in systolic |

|give any previously ordered treatment STAT x1. |baseline), call supervising Intensivist STAT and: |

| |Utilize MODIFIED Trendelenburg position by elevating legs |

|Respiratory treatment X1 of Albuterol 2.5 mg (0.5 mls) in |and leaving head flat. DO NOT use Trendelenberg position |

|2.5 mls of NS nebulized using 8 – 10 L of O2 flow |as it may increase respiratory distress and cause |

| |refractory bradycardia or hypotension. |

|ABG or VBG testing one time. |Bolus with 10 mls/kg NS IV. |

| |Monitor B/P-Pulse-Resp. every 5 minutes and document until|

|STAT chest x-ray with reading. |patient is no longer symptomatic, returns to baseline, or |

| |is transferred to a monitored bed. |

|May return to last stable ventilator setting if patient |Use non-invasive automatic cuff or doppler stethoscope to |

|fails ventilator weaning as evidenced by: |monitor B/P. |

|(Respiratory rate |Remove topicals that may cause hypotension such as |

|O2 saturation (90% |Nitroglycerin patch/paste, Duragesic, or Catapres patch. |

|(Level of consciousness |Hold oral antihypertensive until physician is consulted. |

|(Anxiety | |

|Contact Respiratory Care for |For suspected/active bleeding order and draw: |

|Respiratory Care Assessment and to |STAT CBC and send to lab |

|Return patient to last stable ventilator | |

|Setting. |Type and screen and hold pending CBC results. |

| |If Hgb (8, send type and screen to lab and set up 2 units |

|Transfer to higher level of care if indicated. |packed cells |

| | |

| |Transfer to higher level of care if indicated. |

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