Code Blue, Code Blue!!!! What’s a nurse to do? Unit V How many of you have seen a Code Blue yet? Did any of you participate in the code? What do you do first in a Code Blue situation? Stay calm. Take a deep breathe and let your nursing skills take over. To an outsider, codes make look chaotic and disorganized. But to the educated eye, a code blue progresses through and orderly series of events, and each team member has their distinct role. Most hospitals require their nurses to be ACLS certified – special training through AHA

Objectives Discuss cardiac emergency to include the use of the crash cart and the importance of BLS Identify Rapid Response Team and Code Blue Team

Patient Emergency 50 % patients who code exhibit warning signs up to 6 hrs prior to arrest RRT consists of ICU nurse, RT, sometimes MD, and bedside nurse RRT at bedside within minutes to assess patient When do you call for a code? – Studies have shown almost ½ of all patients who code show warning signs up to 6 hrs prior to coding: HR <45 or >125, RR <10 or > 30, CP, AMS Well lets look first at some warning signs: This is why your assessment skills are so necessary when evaluating what’s going on with your patient. Most hospitals have a Rapid Response Team. The goal = get the patient the help he needs in order to prevent a code blue. A rapid response team aims to recognize warning signs sooner and prevent patients from arresting. Rapid-response teams enable nurses, other patient-care staff patients, or their visitor to notify a team of experts who will respond to a patient whose condition appears to be worsening. The signs of decline can be as subtle as a nurse sensing that a patient just doesn’t ‘‘look right.’’ TJC mandates patient access RRT = ICU nurse, RT, sometimes MD, bedside nurse – respond within few minutes

Criteria for calling RRT Change in heart rate (<40 or >130) Change in Systolic BP (<90 or >200) Change in resp. rate (<8 or >24) or threatened airway or change in SaO2 Change in mental status New, repeated, or prolonged seizures UO <50mL/4 hours Failure to respond to treatment to an acute problem/symptom Nurse, patient, or family member is concerned Changes can be acute or gradual! Recognizing vital signs trends and changes is CRUCIAL! , AMS, UO It takes a more perceptive nurse to anticipate and prevent a code, than to run a code well. The criteria for calling RRT facility specific can be any of the following: Change in heart rate (<40 or >130) Change in SBP (<90 or >200) 20% change in HR or rhythm change Change in resp. rate (<8 or >24) or threatened airway Change in SaO2 (< 90), or failure to respond to treatment Significant bleed Change in mental status – (new onset confusion, slurred speech) New, repeated, or prolonged seizures Failure to respond to treatment to an acute problem/symptom Staff member concerned or worried about patient

What to Do I Do If I Think My Patient is in trouble? Tell nurse responsible for patient’s care (also clinical instructor) immediately of changes in patient’s condition Rapid Response Team (RRT) team – can be called as soon as the nurse identifies changes in the patient’s condition Reassess the patient frequently

Calling Code Blue Determine unresponsiveness Call out for help Push Code Blue button at the head of bed or Pick up the phone and dial______ Identify the emergency – Code Blue Identify the location and the room # Note time using the clock in patient’s room If you are the one to find the patient, your first responsibility is to assess LOC to determine unresponsiveness. Call out loudly, “I need help in room 202”, as soon as you have established unresponsiveness. When someone answers tell them to call a code or push the Code blue button. Make sure you know what the number is at your hospital for a code blue. At Mercy the number is 7777 for all emergencies. Make sure you note the time using the clock in the patient’s room. Remember that the patient’s primary nurse must remain in the room with the patient until the end of the code.

Prior to the Code Team Arriving Start CPR Circulation Airway Breathing Defibrillation (AED only) Obtain the Crash Cart/AED Remove extra furniture from the room Unit Secretary will: Page Chaplain for Family support Call attending MD Chart to Room After establishing unresponsiveness: Start chest compressions per new BLS guide lines. Then what? Place your finger on the carotid artery and check for a pulse. And look if chest rises Second responder will bring in emergency equipment to be brought to the room. Where do we find the emergency equipment? On the crash cart. The second responder then begins two person CPR with the first responder. The code blue team should arrive within 2-3 minutes of calling the code or sooner. If the coding patient is in a room with another patient move that patient to another room. The code team will need the chart so it must be with the patient.

Once the code team arrives Do not stop CPR when the first team member arrives Continue until someone is ready to take over Once the code blue team arrives advanced cardiac life support protocols are initiated. Each team member has a specific job. Go to next slide

Code Team & Their Roles Hospitalist or ER doctor– team leader – intubation, gives orders Critical Care Nurse – gives meds Supervisor / Staff nurse – documents Respiratory therapist – assists respirations, may intubate as well Lab – ABG, BMP, CBC NA –CPR, brings crash cart and chart, help with other patients Chaplain - assist with taking family to quiet location Student – CPR, observation Members of the code team: ED MD or other responding MD, ICU nurse, unit supervisor, staff nurse, RT, Lab, CNA, chaplain, security Team Leader: Usually a physician directs and coordinates the resuscitation efforts, but an ACLS certified nurse can run a code until the physician arrives. The team leader usually stands at the foot or head of the bed. She needs a clear view of the patient to make sure that procedures and assessments are performed rapidly and accurately. Defibrillator Operator: A physician or ACLS nurse actually delivers the shock. Most victims of cardiac arrest die of lethal arrhythmias. Rapid defibrillation is the key to survival. AEDs in hospitals. Intubationist: This is usually a physician or respiratory therapist. Assist with setting up of equipment and having suction available. Medication Nurse: Establishes and maintain IV lines, calculate drug dosages, prepare and administer drugs and fluids. Staff nurse: give info to MD (next slide), documentation Lab, CNA, chaplain, student

What the Code Team Needs to Know Current Diagnosis / Recent Treatments or Procedures Events Leading Up to Code Recent Meds Primary MD Code Status Other Pertinent History: Allergies, MRSA Status, Diabetic, Cardiac, respiratory history, etc. Current Diagnosis / Recent Treatments or Procedures Events Leading Up to Code Recent Meds Primary MD Code Status Other Pertinent History: Allergies, MRSA Status, Diabetic, Cardiac, respiratory history, etc.

Post – Code Responsibilities Patient’s nurse gives report to receiving nurse Family Care Code Summary printed EKG Strips charted Completed Code Sheet signed by physician in charge of the code Code Evaluation completed and sent to Risk Management Cart Exchange Documentation The final phase of the code blue is the winding down phase. Efforts are now aimed at maintaining the victim in stable condition until he can be transported to a critical care bed, or deciding to terminate the code. If patient is being transferred then the patient’s primary nurse gives report to the receiving nurse. Primary nurse should accompany her patient to the ICU.

Documentation Patient assessment ECG rhythm (strip) Notification of MD, orders received Treatments initiated & patient response, post treatment rhythm (strip) If transferred, mode of transport, transfer note, receiving unit bed number, receiving nurse All of this will need to be documented in the patient’s record.

The Crash Cart Example Top O2 tank, portable suction, ambu bag Defibrillator Intubation equipment Possibly meds O2 tank, portable suction, ambu bag Front drawers and Side drawers Meds IV equipment + fluids Resp supplies Trays Misc (gloves, sutures, flashlight, batteries) Example As soon as the crash cart arrives place the CPR board under the patient (need to break lock to open cart). On the top of the crash cart is the defibrillator, defibrillator pads, electrodes, possibly meds and respiratory drawer. Some hospitals keep the respiratory equipment in what looks like a tackle box. The front drawers contain meds, IV equipment, fluids and trays (i.e. central line), resp supplies like non-rebreather mask, suctioning equip).

Emergency Medications Oxygen Epinephrine Amiodarone Atropine Adenosine (Adenocard) Diltiazem Digoxin Lidocaine Magnesium Sulfate Dobutamine Dopamine Narcan Remind students that they will NOT be giving medications in a code situation, however, they are responsible for knowing in what situations that these medications will be used and what the expected outcomes and side effects are of the medications. The top drugs used in a code are epinephrine, amiodarone, and atropine.

Do Not Resuscitate Full code or No Code Documentation on chart of MD order MD discussion with patient / family Chart labeled MAR labeled What if family changes their mind?? What about Directed Code Status? Patient may not want CPR or intubation but does want arrhythmias treated.

Student’s Role in a Code Assessment / reassessment Notify nurse immediately of changes in the patient’s status Perform CPR Observe during the Code Help with patient’s family