1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 14: Rapid Response Teams and Transport of the Critically Ill Patient

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Rapid Response Team (RRT) Calling Criteria

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Example of a Rapid Response Team Protocol See Figure 14-1.

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Gaining Administrative Buy-in When Developing a RRT Institute for Health Care Improvement findings support RRT as a way to decrease length of stay and save costs. Chart audits of in-hospital arrests and events leading to arrests support the need for RRT. Need support from administration so ICU nurses on RRT are freed up to make calls as needed

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Team Structure of RRT Members: experienced ICU nurse and others (respiratory therapist, nurse practitioner, hospitalist or intensivist, physician assistant) Members must be ready to go to the emergency immediately. Members must be onsite. The critical care nurse must be willing to respond and educate.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Communication Tools and Protocols Used By RRT Protocol provides guidelines to ensure each member understands and performs assigned duties. Communication tools provide rapid report and ability to audit for continuous improvement. –SBAR (situation, background, assessment, recommendation)

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Training for RRT Policies and protocols for RRT ACLS training and training in triage Roles and responsibilities of each team member and the staff nurse Use of communications tools, such as SBAR Chain of command When palliative care is appropriate

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Training for Staff About Using RRT Policy and procedure for using RRT Staff nurse responsibilities Reminders on what to do when an emergency occurs (badge reminders, pocket cards, etc.)

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Calling Criteria and the Mechanism to Activate the RRT System Make sure calling criteria are readily available to all staff (badge reminders, pocket cards, posters, sticker on every medical record or Kardex). Make sure the activation number is also available on all of the information above.

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Feedback Mechanisms For Continuous Improvement of RRT Establish tracking mechanism to determine RRT effectiveness –Patient outcomes (chart audits) –Satisfaction surveys from staff using RRT

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation of RRT Effectiveness Codes per 1,000 discharges Codes outside the ICU Number of times the RRT system was used and the number of admissions to ICU, number of hospital days

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins SBAR Communication Tool See Box 14-3.

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Interfacility Transfer Algorithm See Figure 14-2.

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Advantages and Disadvantages of Ground Versus Air Transport AdvantagesDisadvantages Ground transportCarry more equipment and staff No weight restrictions Longer estimated time of arrival (ETA) Hard to provide interventions on bumpy road Air transportShorter ETA Crew has specialized training Weight limitations Less staff and equipment Weather and altitude restrictions

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The critical care nurse is preparing for the arrival of a patient via ground critical care transport. Which of the following should the nurse consider first when setting up for the transfer? A. The time the patient is not in the hospital B. Travel time needs to be considered as top priority C. Equipment and supplies the patient will need D. Arrival time of the family

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Equipment and supplies the patient will need Rationale: The transport team will take back their equipment, and the equipment may be different from the facility’s, so the nurse needs to be prepared for the switchover. This is a top priority in the choices provided. The other statements are important for determining issues such as how much time the nurse has to prepare for the patient, and making sure to include the patient’s family on their arrival after settling in the patient. The patient is in a mobile critical care unit, so out-of- hospital time is less of an issue.

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Emergency Medical Transfer Active Labor Act Flowchart See Figure 14-3.

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Factors of an Effective Interfacility Transfer Determine benefits versus risks of the transfer Determine appropriateness of accepting facility Provide interfacility transfer report Evaluate transfer process for continuous quality improvement

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study 1 A 44-year-old man needs to be flown to a level I trauma center to undergo surgery and further stabilization. Phase 1: What role should the ED physician and RN provide in terms of notifying and gaining acceptance from the receiving facility and completing the institution’s transfer list? Phase 2: What items from the chart and tests should the RN get ready? What should the RN include in the transfer report to the transport team and the RN at the receiving facility?

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study 1 (cont.) Phase 3: What should the transport RN and team do during this phase? What role should the RN at the receiving facility play to prepare for the patient? Phase 4: What steps should the transport team take during the turnover process at the receiving facility? What steps should the RN at the receiving facility take during this phase? Phase 5: What continuous quality indicators should be considered during this phase for the transport team, the receiving facility, and the facility that sent the patient?

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Guidelines for Accompanying Personnel for Interfacility Transfer

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Equipment Necessary for Interfacility Transport Airway and ventilation/resuscitation equipment ACLS medications Monitor/defibrillator/external pacemaker IV pumps and tubing Equipment for stabilization of neck and spine Equipment to monitor vital signs Communication equipment

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study 2 A 64-year-old patient in the cardiac care unit develops sustained ventricular tachycardia with a weak thready pulse and hypotension. The dysrhythmia is not responding to medications and only temporarily responds to cardioversion. The electrophysiologist wants to perform electrophysiology studies in the cardiac cath lab, which is seven floors down, and the patient may need a implantable defibrillator. 1.What are the indications for intrafacility transport? 2.What process should be used during the transport?

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The nurse is preparing a patient for air transport to another facility. The client is diagnosed with an inferior wall MI and has a history of vertigo. The nurse should: A. Provide a transdermal scopolamine patch B. Remove the nasogastric tube C. Position the patient supine and raise the legs on a pillow to take pressure off the abdomen D. Provide oxygen by a tight-fitting mask

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Provide a transdermal scopolamine patch Rationale: The transdermal scopolamine patch will lower the risk for motion sickness. The patient needs to be side-lying and the head of the bed needs to be elevated. The oxygen needs to be provided in a less confining manner, such as a nasal cannula, so if the patient vomits, there is less risk of aspiration. The patient has a nasogastric tube in place to decompress the stomach and lessen the risk for aspiration, so the tube needs to stay in place during the transport.

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following trauma patients is not a candidate for high-altitude air transport to the level I trauma center? A. A patient requiring neurosurgical intervention B. A patient who was deep sea diving, hit a reef, and was buddy breathing and has decompression sickness C. A patient with an open pelvic fracture who received 7 units of packed red blood cells to stabilize BP D. A patient bitten by a rattlesnake; ground travel time is 60 minutes

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. A patient who was deep sea diving, hit a reef, and was buddy breathing and has decompression sickness Rationale: High-altitude flying will worsen the decompression sickness. In decompression sickness, nitrogen bubbles are trapped in the bloodstream and could lead to an air embolus. The patient would need either ground transport or low-altitude transport (<1,000 feet) to a trauma center with a hyperbaric chamber for treatment. The other three patients could benefit from the speed of air transport.