DUCS and RATSDUCS and RATS

INTEGRIS HealthINTEGRIS Health

How Did We Get Here?How Did We Get Here?

• 70% arrests with evidence of 70% arrests with evidence of respiratory/neurological deterioration respiratory/neurological deterioration within 8 hours within 8 hours (Schein, Chest 1990; 98: 1388-92)(Schein, Chest 1990; 98: 1388-92)

• 66% had abnormal signs and symptoms 66% had abnormal signs and symptoms within 6 hours of arrest and MD notified within 6 hours of arrest and MD notified in 25% of cases. in 25% of cases. (Franklin, Crit Care Med;1994; 22: 224-247)(Franklin, Crit Care Med;1994; 22: 224-247)

DUCS CriteriaDUCS Criteria

Acute change in heart rate to <50 or >120Acute change in heart rate to <50 or >120 Acute change in SBP <90mmHgAcute change in SBP <90mmHg Acute change in respiratory rate <10 or > 30Acute change in respiratory rate <10 or > 30 Acute change in Oxygen saturation <90% in Acute change in Oxygen saturation <90% in

despite oxygen therapydespite oxygen therapy Acute change in LOCAcute change in LOC Acute change in urine output to <50ml in 4 hrsAcute change in urine output to <50ml in 4 hrs ““Gut feeling” something is wrongGut feeling” something is wrong

What do you do if you What do you do if you have a DUC?have a DUC?

If your patient exhibits any of the previous signs If your patient exhibits any of the previous signs and symptoms contact:and symptoms contact:

Day shift: Day shift: The patient nurse or your Team Manager/Clinical The patient nurse or your Team Manager/Clinical

DirectorDirector

Evenings, Nights, or Weekends:Evenings, Nights, or Weekends: The patient’s nurse or Team The patient’s nurse or Team

Manager/Administrative supervisorManager/Administrative supervisor

RATSRATS

• Rapid Assessment Team (RAT) - developed to Rapid Assessment Team (RAT) - developed to prevent deaths in patients who are prevent deaths in patients who are progressively failing outside the ICUprogressively failing outside the ICU

• INTEGRIS believes healthcare providers INTEGRIS believes healthcare providers should share their knowledge across should share their knowledge across departments to assist each other in meeting departments to assist each other in meeting patient needs and improving outcomes.patient needs and improving outcomes.

What Difference Can a What Difference Can a Rat Make?Rat Make?

Literature Review: Other hospitals that have Literature Review: Other hospitals that have implemented such teams have reported:implemented such teams have reported:

50% reduction in non-ICU arrests 50% reduction in non-ICU arrests (Buist, BMJ 02)(Buist, BMJ 02)

12-30% reduction in hospital mortality12-30% reduction in hospital mortality 44% Reduction in post-op emergency ICU transfers44% Reduction in post-op emergency ICU transfers Improved staff satisfaction and recruitment with the Improved staff satisfaction and recruitment with the

presence of a support teampresence of a support team Improved patient satisfactionImproved patient satisfaction

Goals of the Rapid Goals of the Rapid Assessment teamAssessment team

Be a resource for support of staff nursesBe a resource for support of staff nursesImproved time to treatmentImproved time to treatmentImproved communication between all of Improved communication between all of

the patient’s care providersthe patient’s care providersReduction of Code Blues and hospital Reduction of Code Blues and hospital

mortalitymortalityEnhanced learning opportunitiesEnhanced learning opportunities

Who’s On the RAT Team?Who’s On the RAT Team?

At IBMC:At IBMC:House OfficerHouse OfficerCritical Care Registered Nurse-Code Critical Care Registered Nurse-Code

Blue Designated back-up RNBlue Designated back-up RNRegistered Respiratory therapistRegistered Respiratory therapist

At ISMCAt ISMC

House Officer or an Advanced Practice House Officer or an Advanced Practice Nurse – CNS or ARNPNurse – CNS or ARNP

Critical Care Registered Nurse Critical Care Registered Nurse

ICU Team LeaderICU Team LeaderRegistered Respiratory therapistRegistered Respiratory therapist

RAT ResponseRAT Response

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

The primary nurse in the lead nurse.The primary nurse in the lead nurse.

RAT DutiesRAT Duties

Obtain report from the patient’s primary nurse Obtain report from the patient’s primary nurse (including code status).(including code status).

Evaluate patient.Evaluate patient. Determine if situation is one of rapid decline or a Determine if situation is one of rapid decline or a

stable problem.stable problem. Identify clinical problem – circulatory, Identify clinical problem – circulatory,

respiratory, neurological.respiratory, neurological. Treat or transfer as indicated.Treat or transfer as indicated. Implement RAT order sets.Implement RAT order sets.

SMURFSSMURFS( If All Else Fails)( If All Else Fails)

Code Blue VS. “Dr. A”Code Blue VS. “Dr. A”A code blue will be called to summon A code blue will be called to summon

adequate personnel and equipment for adequate personnel and equipment for resuscitative efforts in all hospital areas.resuscitative efforts in all hospital areas.

A “DR. A” will be called to summon all A “DR. A” will be called to summon all members of the code blue team with the members of the code blue team with the exception of the ACLS critical care exception of the ACLS critical care nurses.nurses.

Code Blue Team MembersCode Blue Team Members

House PhysicianHouse Physician2 Respiratory Therapists2 Respiratory TherapistsACLS Critical care RNsACLS Critical care RNsPrimary nurse of the PatientPrimary nurse of the PatientAdministrative supervisorAdministrative supervisorPharmacistPharmacistChaplainChaplain

Prior to the Code Team Prior to the Code Team ArrivalArrival

Determine UnresponsivenessDetermine Unresponsiveness Start BLSStart BLS Call for help Call for help *911*911 Get Crash cartGet Crash cart Place backboard under patientPlace backboard under patient Connect BVM to 100% oxygen and ventilateConnect BVM to 100% oxygen and ventilate Apply hands-free defib padsApply hands-free defib pads Remove furniture from the roomRemove furniture from the room

Prior to Code Team Prior to Code Team ArrivalArrival

If coding patient is in a semi-private room. If coding patient is in a semi-private room. Relocate the other patient to another room or Relocate the other patient to another room or stay with the other patient during the code.stay with the other patient during the code.

Monitor for adequate pulse with compressions.Monitor for adequate pulse with compressions. Move family to another area.Move family to another area. Analyze rhythm if AED available. Deliver shock Analyze rhythm if AED available. Deliver shock

if advised by AED.if advised by AED. Set up suctionSet up suction Perform chest compressionsPerform chest compressions

Roles and Roles and ResponsibilitiesResponsibilities

House Physician will assume chargeHouse Physician will assume charge Primary nurse of the patient remainsPrimary nurse of the patient remains Unit personnel will be relieved by code team to Unit personnel will be relieved by code team to

assume care of the other patients on the unit.assume care of the other patients on the unit. Clinical Director or Administrative Supervisor Clinical Director or Administrative Supervisor

will arrange for critical care bedwill arrange for critical care bed Chaplain remains with the family to provide Chaplain remains with the family to provide

support.support.

Roles and Roles and ResponsibilitiesResponsibilities

Respiratory Therapists assume Respiratory Therapists assume ventilations and assists physician with ventilations and assists physician with intubation.intubation.

Pharmacist pulls and assembles Pharmacist pulls and assembles emergency medications, IV fluids, and emergency medications, IV fluids, and other supplies as needed from crash cartother supplies as needed from crash cart

The Moral of the StoryThe Moral of the Story

DUCS and RATSDUCS and RATS

Keep away SmurfsKeep away Smurfs