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Who You’ll Hear
Kati Kleber, MSN RN CCRN-K – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, speaker
Melissa Stafford, BSN RN CCRN SCRN – Highly experienced and currently practicing nationally certified neurocritical care nurse
Elizabeth Mills, BSN RN CCRN – Highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center
What You’ll Learn
- Code Teams
- Rapid Response Teams
- What is a code?
- Code Blue Tips
- Post-code debriefings
- Mock Codes
Code Team
A team of people who respond immediately to a patient who is unresponsive, not breathing, or does not have a pulse.
- Lippencott: Code blue, do you know what to do?
- 2016 American Heart Association Advanced Cardiac Life Support Guidelines
Rapid Response Team (RRT)
A team of people with critical care expertise who can be at the bedside quickly. They can be summoned before a respiratory or cardiac arrest occurs.
- May include nurses from critical care, respiratory therapy, critical care physicians or hospitalists, and/or advanced practice providers (like NP’s, PA’s)
- Policies and procedures differ between facilities; various hospitals may have different triggers (increasing heart rate, increasing oxygen requirements, change in level of consciousness).
- You want to notify the patient’s physician in these instances, however RRT’s are necessary when you need another set of eyes on the patient immediately and cannot wait for a physician to return their pages
- Rapid Response Teams in Hospitals Increase Patient Safety
- Institute for Healthcare Improvement: Rapid Response Teams
What’s a code?
A code is when a patient is unresponsive, stopped breathing, or does not have a pulse.
Roles of people in the room
- Chest compressions: can be anyone with BLS training (yes, CNA’s!) and typically a few people are needed for this role to switch in/out during pulse checks because it’s exhausting
- Airway manager: typically providing oxygen via bag-valve mask (BVM) until respiratory therapy arrives and/or an advanced airway is placed
- Mixing/drawing meds: someone at the code cart, pulling meds as they are needed
- Giving meds: someone at the point where the IV access is (and if no access is available, they’re working on it)
- Shocker: this person is managing the defibrillator (placing pads, charging, pressing shock, viewing rhythm)
- Recorder: someone writing down everything when it happens at the precise time (each second counts)
- Leader: typically taken by the advanced practice provider or physician, this person is calling the shots… they’re interpreting the rhythm, following ACLS protocol, and telling the team what to do when
Code Blue Tips
- Be prepared before it happens
- Know where the code cart is
- Know how to activate a code (how to call it overhead, where the buttons are)
- Always have suction set up and an ambu bag in all of your patient’s rooms
- (Follow your institution’s policies, however most have ambu bags and suction being set up as part of a normal room set-up)
- You may freeze the first few times when you see this scenario – it will get better with time as you get used to the situation
- Always assess first – do they have a pulse?
- If they don’t have a pulse – compressions is the MOST important immediate intervention
- Simultaneously call for help and allow others to come in and fill in the above roles
- When the code team arrives
- Be prepared to answer questions – do not leave
- Team will ask what happened before code, history, and many other questions
- Be a relief CPR person, be a runner, but do not leave
- Make sure someone has contacted family/support system if they are not present
- If patient survives code and needs to be transferred to a higher level of care, you as the patient’s primary nurse, must go with the code team to the patient’s new room in critical care and give a hand-off to the receiving nurse and ensure next of kin has been notified
- Be prepared to answer questions – do not leave
Post-code debriefings/huddles are so important
Have mock-codes on your unit
- How to Run a Mock Code
- YouTube video of a mock code
- NYMed clip of a code (go to 5:15) – highly recommend watching this entire show for great examples
I’d like to put in a plug for what’s called “closed-loop communication.”
In closed-loop communication:
1. A request is made (“Draw up RSI meds plz”)
2. Clarification is requested if nec (“What would you like?” “150mg Sux, 30mg Etomidate plz.”
3. The request is repeated back “150mg Sux, 30mg Etomidate”
4. Person performing affirms completion “150mg Sux, 30mg Etomidate drawn up and ready.”
This is really important. Like, not dancing-master ACLS important, but actually very important. I ran a code on the floor last week and the communication was awful. Make a request — silence. Is it happening? Is someone working on it? Did they have to go to the pharmacy for the meds? Is someone working on a second line? Calling the surgeon? Getting ready to take over compressions?
It’s ESPECIALLY useful when an order can’t be carried out! “Call their surgeon, please.” “We can’t reach them; HUC is trying to find the on-call.” Resources are limited in a code, stuff goes wrong, supplies are missing, personnel are limited, but if you don’t tell me there’s a problem with what I asked for, I DON’T KNOW. And it’s not good practice at all for the thing to just not happen until I have bandwidth to ask why it isn’t happening.
Whew. Sorry to rant. As an ER doc who runs codes, this is my plea: Talk to me! A code is no time for the silent treatment.
Robert I LOVE THIS. Can I turn this into a blog post? Or would you consider guest-blogging or being interviewed on this? Man, I’m wishing we added this into the episode, but making a follow up blog post and link to it on this post would help nail this point home.