DUCS and RATS INTEGRIS Health

How Did We Get Here? 70% arrests with evidence of respiratory/neurological deterioration within 8 hours (Schein, Chest 1990; 98: 1388-92) 66% had abnormal signs and symptoms within 6 hours of arrest and MD notified in 25% of cases. (Franklin, Crit Care Med;1994; 22: 224-247) Tell the story of Dr. Griggs attending the conference where he found out about DUCS

DUCS Criteria Acute change in heart rate to <50 or >120 Acute change in SBP <90mmHg Acute change in respiratory rate <10 or > 30 Acute change in Oxygen saturation <90% in despite oxygen therapy Acute change in LOC Acute change in urine output to <50ml in 4 hrs “Gut feeling” something is wrong Once we identified our DUCS criteria we piloted it on the unit that had the most codes every month. What do thing happened to the number of codes on that unit? How much do you think it decreased their codes by? 50% 60%.... Their codes dropped to zero. So we decided to pilot it on another unit and the same thing happened. So we went house wide with it on both campuses. We saw a dramatic drop in the number of codes in each hospital.

What do you do if you have a DUC? If your patient exhibits any of the previous signs and symptoms contact: Day shift: The patient nurse or your Team Manager/Clinical Director Evenings, Nights, or Weekends: The patient’s nurse or Team Manager/Administrative supervisor

RATS Rapid Assessment Team (RAT) - developed to prevent deaths in patients who are progressively failing outside the ICU INTEGRIS believes healthcare providers should share their knowledge across departments to assist each other in meeting patient needs and improving outcomes. Out of the DUCS criteria came the RAT team. This is an IHI initiative that every hospital has instituted to prevent patients from failing outside of the ICU.

What Difference Can a Rat Make? Literature Review: Other hospitals that have implemented such teams have reported: 50% reduction in non-ICU arrests (Buist, BMJ 02) 12-30% reduction in hospital mortality 44% Reduction in post-op emergency ICU transfers Improved staff satisfaction and recruitment with the presence of a support team Improved patient satisfaction

Goals of the Rapid Assessment team Be a resource for support of staff nurses Improved time to treatment Improved communication between all of the patient’s care providers Reduction of Code Blues and hospital mortality Enhanced learning opportunities

Who’s On the RAT Team? At IBMC: House Officer Critical Care Registered Nurse-Code Blue Designated back-up RN Registered Respiratory therapist

At ISMC House Officer or an Advanced Practice Nurse – CNS or ARNP Critical Care Registered Nurse ICU Team Leader Registered Respiratory therapist

RAT Response The advanced practice RN and the critical care RN will respond to assist the patient’s primary nurse in assessing the situation, determining nursing diagnosis, initiating appropriate protocols, and communicating with the physician. The primary nurse in the lead nurse.

RAT Duties Obtain report from the patient’s primary nurse (including code status). Evaluate patient. Determine if situation is one of rapid decline or a stable problem. Identify clinical problem – circulatory, respiratory, neurological. Treat or transfer as indicated. Implement RAT order sets. The order set has things like lab, medication, procedures that the RAT team can use to help evaluate, treat and stabilize the patient at the bedside. However, if the patient needs to be transferred to an higher level of care the team will do so.

SMURFS ( If All Else Fails) Code Blue VS. “Dr. A” A code blue will be called to summon adequate personnel and equipment for resuscitative efforts in all hospital areas. A “DR. A” will be called to summon all members of the code blue team with the exception of the ACLS critical care nurses.

Code Blue Team Members House Physician 2 Respiratory Therapists ACLS Critical care RNs Primary nurse of the Patient Administrative supervisor Pharmacist Chaplain

Prior to the Code Team Arrival Determine Unresponsiveness Start BLS Call for help *911 Get Crash cart Place backboard under patient Connect BVM to 100% oxygen and ventilate Apply hands-free defib pads Remove furniture from the room The person who finds the patient unresponsive will yell for help and start CPR. Above the head of the bed is an orange pouch that has a face mask that you will use during CPR until a ambu bag arrives with the crash cart. The second responder will dial *911 and tell the operator that there is a code blue in (give the patients room number). Then they start helping move furniture out of the patients room in order to make room for the crash cart and the code team.

Prior to Code Team Arrival If coding patient is in a semi-private room. Relocate the other patient to another room or stay with the other patient during the code. Monitor for adequate pulse with compressions. Move family to another area. Analyze rhythm if AED available. Deliver shock if advised by AED. Set up suction Perform chest compressions If the patient has a room mate in the room try and move them out of the room before it fills up with people. If you are unable to move the room mate some one will need to stay with that patient during the code. Can you talk about what is happening on the other side of the curtain? Yes, you can explain that there is an emergency and that they are doing everything they can to help that patient.

Roles and Responsibilities House Physician will assume charge Primary nurse of the patient remains Unit personnel will be relieved by code team to assume care of the other patients on the unit. Clinical Director or Administrative Supervisor will arrange for critical care bed Chaplain remains with the family to provide support. You may be asked to assist with chest compression. Ask what is the ratio of compression to ventilation. Explain why they need to change the person doing chest compression every two mintues.

Roles and Responsibilities Respiratory Therapists assume ventilations and assists physician with intubation. Pharmacist pulls and assembles emergency medications, IV fluids, and other supplies as needed from crash cart

The Moral of the Story DUCS and RATS Keep away Smurfs