1. Paul Clarke, RN BSN Rapid Resuscitation Action Plan: How One Unit Tries To Beat The Odds

2. Disclosure Statement  I do not have any relevant financial relationships with any commercial interests to disclose.

3. Objectives  Discuss Goals for Rapid Resuscitation Action Plans  Review Inclusion Criteria  Current Methodology  Preliminary Outcomes

4. Problem  Current Pediatric CVICU Code Outcomes  Nursing Turnover  Jr. Physicians

5. Solution  Unit Specific Code Review Committee  Examined Past Codes  RAP, ASAP

6. Goals  To prevent code events in the CVICU at Children’s of Alabama by identifying patients at high risk for cardiac or respiratory arrest  To reduce severity of remaining code events by identifying best choice interventions based on most likely route of deterioration

7. Goals  Improve efficiency of code events by pre- identifying healthcare provider roles to speed time to first interventions  Decreased code events and reduction in severity will improve patient outcomes

8. Inclusion Criteria  Single Ventricle physiology pre or post Stage I palliation  Neonates with restrictive atrial septum (d-TGA or single ventricle)  Neonates POD 0 and POD 1  Open Sternum

9. Inclusion Criteria  High inotropic/vasopressor support including  Three or more infusions (milrinone only included if 1 mcg/kg/min or greater)  Epinephrine > 0.05 mcg/kg/min  Vasopressin > 0.04 units/kg/hr  History of prior arrest during current hospitalization

10. Inclusion Criteria  New onset cardiomyopathy/myocarditis on epinephrine and/or dopamine infusion  Known difficult airway/upper airway obstruction  ECMO patients up to 48 hours post- decannulation

11. Inclusion Criteria  Known pulmonary hypertension  Severe lung disease requiring:  PEEP > 10  100% FiO2 and iNO

12. Process  Multidisciplinary “RAP” team  RAP rounds twice daily, once per shift

13. RAP Sheet

14. Process  RAP sheet to include  Reason(s) patient is high risk  Warning signs and notification parameters for RN/RT  Potential prevention measures for arrest  Necessary equipment and medication to have readily available at bedside  Patient specific first steps in event of arrest

15. Process  RAP sheet reviewed and updated each round  Bedside Nurse responsible for keeping needed medications in locked bedside cart

16. Process  RAP sheet reviewed for all nursing handoffs  Code Roles preassigned to minimize role duplication and extraneous personnel

17. Interventions Beyond RAP  Three Person Suction  Pre-sedate with noxious stimuli/Minimal Stimuli  Prostaglandin Checks  20/10’s Rule

18. Current Progress  Initiated August 2014  Better multidisciplinary awareness and communication  MD, NP, RT and RN acceptance