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Rapid Response / Code Blue Training

We all know that CPR saves lives, but to perform effective CPR, it requires a

highly organized team with clear roles and responsibilities. As we watch this

video filmed at the Ochsner Simulation Center, pay attention to how the roles

shift as the patient's condition transitions from a Rapid Response into a

Code Blue.

Clinical deterioration can happen at any time.

Early intervention starts with the

Bedside Nurse who assesses the patient and calls for support from the Charge Nurse

if she feels something is just not right.

Hi Mr. Jones. This is your nurse, Kiara,

I came in to take you vital signs. How are you feeling today?

[groans]

I'm gonna go ahead and get your blood pressure.

Your blood pressure's a little low. I'm gonna go ahead and call my Charge Nurse for some support.

I feel like I could die.

Hi Raenell. This is Kiara. I'm in room 926 with Mr. Jones.

He doesn't look too good...

The Bedside Nurse provides a quick report to convey

any urgency or signs of clinical deterioration.

The Charge Nurse immediately responds to support the Bedside Nurse

and provide a secondary assessment of the situation.

Hey. What's going on?

Hey, this is Mr. Jones. He came in last night.

This morning he was feeling fine. I just took his blood pressure. His systolic was in the low 80's.

He said he feels like he's about to die and he said he's feeling a little...

short of breath right now.

I'm not liking the way he's looking. I'm gonna go ahead and call a Rapid.

And I'll go ahead and call the Primary Team.

Hey I'm in 26. I have a Rapid.

Hi this is Kiara. I'm calling about the patient in room 926, Mr. Jones.

Hey I have a Rapid. Can I get some help in here? Bring the monitor.

Can someone come in here and take a look at him? We're calling the Rapid Response right now.

Thank you.

They both use a standardized SBAR format:

Situation, Background, Assessment, and Request to communicate their concerns of clinical deterioration.

The Bedside Nurse calls the Primary Team while the Charge Nurse activates a Rapid.

The Charge Nurse also calls for help and a monitor.

As personnel respond, she will designate roles and responsibilities.

He's already on telemetry.

Alright.

Let's get his pulse...

The Rapid Response Nurse and Respiratory Therapist arrive within minutes to conduct a primary survey

while receiving an updated SBAR report.

Hi I'm Brittany, the Rapid Response Nurse. This is Jamie, the Respiratory Therapist.

Can you tell me what's going on?

Yes, this is Mr. Jones. He came in last night with COPD exacerbation.

I came in just this morning and checked him. His systolic was in low 80s which is a

significant change from this morning and his sats have now dropped to the 80s.

I'm gonna take a listen to him.

Mr. Jones, can you take a deep breath for me?

Mr. Jones?

Mr. Jones?

It doesn't look like he's responding.

His pulse is actually pretty thready.

Mr. Jones? Hey bud.

Mr. Jones.

Let's go ahead activate CPR.

You calling a code? Calling a code.

The patient's condition deteriorates and the Code Team is activated.

I have a Code Blue in 26.

CPR should be initiated within one minute of the patient becoming unresponsive

Remember your priorities: compressions come first, then airway, and breathing.

Compressions should not be halted for more than 10 seconds at any point during resuscitation,

such as when pads are placed in the anterior-posterior position.

Alright, on the count of three, we're gonna turn him towards you.

One, two, three.

Okay, lay him flat and resume compressions.

End-tidal CO2 monitoring is added to the ambu bag...

Alright, let's go ahead and add the end-tidal CO2.

...to allow for goal-directed resuscitation.

End-tidal CO2 and see-through CPR can be used to avoid pulse check interruptions.

Let's analyze the rhythm.

Rate, depth, and recoil with compressions can be assessed

using enhanced defibrillator feedback technology.

Hold compressions.

Analyzing.

The Rapid Response Nurse uses the analyze function...

Shock advised.

Stand clear.

...to determine if a shock is needed until the Code Physician arrives.

Shock delivered. Resume CPR.

Defibrillation needs to occur within two minutes of identification of a shockable rhythm.

Now that the Rapid has shifted to a Code, roles and responsibilities for those in the room also shift.

The Rapid Response Nurse leads the Code and coordinates the critical care personnel by name,

which include Anesthesia, Critical Care Physicians, and Critical Care Nurses.

The Charge Nurse coordinates local responders by name, which include the Recorder,

who uses a computer or portable device for documentation, Security for crowd control,

Runners for additional supplies, and the Chaplain, who is there for the family.

Bed management occurs outside the room by the ICU Charge Nurse, Patient Flow Coordinator,

and House Supervisor.

When the Code Team arrives, the Rapid Response Nurse gives a SBAR report to the Code Physician

and the Code is run according to the patient's clinical condition.

Hey Dr. Kahn. I'm the Code RN. We just shocked him at 150 for a V-Fib arrest.

He looks to still be in V-Fib. The last shock was delivered a minute and a half ago.

Thank you, Brittany.

Have we given any meds yet?

No meds yet. We do have IV access.

Let's give Epi.

Notice the closed-loop communication, which is critical during a Code.

Good compressions.

One milligram of Epi in.

Good. Looks like we have a good airway and you're ventilating.

At pulse check, we're gonna switch compressors.

Looks like it's V-Fib. Let's go ahead and shock.

Charging at 200 joules.

Everybody stand clear.

Shocking.

Shock delivered.

Resume CPR.

Resume compressions.

10 seconds till pulse check.

Pulse check.

He has a pulse with compressions.

Hold compressions.

We have a pulse.

Good job guys. Let's secure the airway and let's call the ICU.

If there were a code on your floor today, would you know what to do?

Work with your team until everyone on your unit knows their roles and responsibilities so that we can

change and save more lives.