UPMC PRESBYTERIAN SHADYSIDE POLICY AND PROCEDURE MANUAL

Transcription

1 UPMC PRESBYTERIAN SHADYSIDE POLICY AND PROCEDURE MANUAL POLICY: INDEX TITLE: CP-12 Care of Patients SUBJECT: Rapid Response System DATE: February 28, 2013 I. POLICY CORRESPONDING PROCEDURES: CP-12-PRO Rapid Response System PUH Procedure Rapid Response System SHY Procedure It is the policy of UPMC Presbyterian Shadyside (UPMCPS) to have in place a Rapid Response System (RRS) to address the needs of patients, visitors and employees that are experiencing a crisis. The RRS is composed of the quality improvement committee known as Medical Emergency Response Improvement Team (MERIT). MERIT is responsible for oversight of all condition response activities, changes in practice and policies. The members of the MERIT Committee, the responders to the conditions, staff at the bedside that have been trained on conditions are all part of the Rapid Response System. The individual MERIT Committees of each campus will meet on a periodic basis to review emergency events and outcomes and make recommendations for improvement. MERIT reports to Patient Safety and Total Quality Council Meeting twice a year. Staff that respond to patients in crisis are known as the Medical Emergency Team (MET), or Rapid Response Team (RRT) in specific areas of the hospital. At WPIC, staff that respond to patients in crisis are known as the Medical Emergency Response Team (MERT). The MET, RRT or MERT responds to and institutes crisis management or resuscitation interventions for all patients, employees or visitors who desire and/or require these measures. Patients, employees or visitors who have received crisis management or resuscitation interventions will be triaged and transported to an appropriate patient care unit. All members of the various Rapid Response Teams should maintain current certification or equivalent training as appropriate for the situations to which they respond.

2 POLICY CP-12 PAGE 2 All emergency carts and equipment used by the RRTs are maintained as in accordance with CP-12-PRO-PUH Rapid Response System Procedure (PUH) or CP-12-PRO-SHY Rapid Response System Procedure (SHY). Employees are to initiate crisis intervention calls as appropriate for the crisis event. CRISIS EVENT DEFINITIONS: Condition C for a medical crisis (e.g. respiratory or other emergent events). Condition C should be called whenever an unstable patient needs rapid evaluation and treatment. This includes any potentially life-threatening condition other than cardiopulmonary arrest and is not limited to acute respiratory distress or hemodynamic instability for example, trauma. In the event that the patient needs to be transferred to a monitored bed or ICU, the Condition C Team will be responsible for transporting the patient. The crucial aspect of a Condition C is early request for assistance. Condition A should be initiated for any pulseless patient or a patient who is not breathing unless there is an order in the medical records indicating that the patient is not to undergo CPR, endotracheal intubation, or is in a status of comfort measures only. Condition H (Help) For situations that require attention that may not be medical in nature, patients/families are encouraged to call Presbyterian, Shadyside or WPIC for help and activating this emergency intervention. Is a method that provides patients/families the ability to initiate a Rapid Response Team for any of the following: A change in the patient s condition when they have tried to express it to the health care team and felt they did not get the proper attention for the situation. A situation where they have spoken with hospital staff from the healthcare team (physician, nurses) and still have serious concerns regarding how care is being given, managed or planned.

3 POLICY CP-12 PAGE 3 Emergency situation when they are unable to get attention from hospital personnel. Members of the Condition H team differ from the Condition C or A Team and are further detailed in the procedure. Condition L Is activated for a non-medical emergency that involves an at risk patient that has left the unit without authorization. Condition L is activated to locate the patient and return them to a safe patient environment. Condition M Is activated for a non-medical emergency that involves patients or family members that require behavioral interventions. Members of the Condition M Team differ from the Condition C or A Team and are further detailed in the procedure. Stroke Team (UPMC Presbyterian & UPMC Shadyside_ and Stroke Assessment Team (SAT) (UPMC Shadyside) Are activated when a patient presents with symptoms of a stroke. These teams report to the individual hospital Stroke Committee with reports back to MERIT. Emergencies outside the campus buildings Individuals suffering a medical emergency outside the campus buildings as identified in the hospital specific are also covered by this policy.

4 POLICY CP-12 PAGE 4 SIGNED: Holly Lorenz Vice President, Patient Care Services Sandra Rader Vice President, Patient Care Services Camellia Herisko Interim Vice President, Inpatient and Emergency Services ORIGINAL: August 7, 2002 APPROVALS: Policy Review Committee: February 6, 2013 Medical Executive Committee: Shadyside Campus: February 19, 2013 Presbyterian & WPIC Campus: February 28, 2013 PRECEDE: January 26, 2012 SPONSOR: Chair, CPR Q.I. Committee Attachments Appendix A Criteria for Initiating a Condition C or A Team Response

5 POLICY CP-12 PAGE 5 Appendix A Criteria for Initiating a Condition C or A Team Response UPMC Presbyterian Emergency Line: UPMC Shadyside Emergency Line: UPMC WPIC Emergency Line General Guidelines Any person may initiate a Condition C Team Response any time a rapid response of critical care professionals is desired. A Condition C Team Response should be used to prevent a crisis, or to prevent a crisis from escalating. The following practice guidelines are intended to assist clinicians in decision making by describing criteria for situations where it is reasonable to initiate a condition C team response. These criteria attempt to meet the needs of most patients in most circumstances. The ultimate judgment for initiating a condition C must be made by the bedside clinicians in light of the circumstances specific to that situation.

6 UPMC Condition C Calling Criteria GENERAL Any concern for a deteriorating clinical condition RESPIRATORY Difficulty in breathing Increased work of breathing/use of accessory muscles Sustained respiratory rate >30 or < 10 Escalating oxygen requirements Hemoptysis or bleeding in the upper airway Dislodged Artificial Airway (tracheotomy, etc ) CARDIOVASCULAR Chest pain Hypotension: Sustained SBP < 90 mmhg Hypertension: Sustained SBP > 200 mmhg or DBP > 120 Tachycardia: New onset sustained HR > 120 Bradycardia: New onset sustained HR < 50 Cyanosis, mottling of the extremities or pallor NEUROLOGICAL Seizures Sudden change in responsiveness, consciousness or speech New onset unexplained weakness or paralysis Sudden onset blindness Delirium requiring intravenous Ativan age > 65 years OTHER Hematemesis (vomiting fresh blood), Bleeding Hematochezia (fresh blood per rectum), Unexpected surgical site bleeding High Fever Temperature > 104F or > 40 C Heavy vaginal bleeding (> 100 cc), urge to push, sudden gush of fluid from vagina, severe Pregnancy abdominal or back pain, crowning of the fetus, or fetal distress on continuous monitoring Revised 1/2013

7 UPMC PRESBYTERIAN SHADYSIDE PROCEDURE SHADYSIDE CAMPUS PROCEDURE PROCEDURE: INDEX TITLE: CP-12-PRO-SHY Care of Patients SUBJECT: Rapid Response System DATE: March 19, 2013 CORRESPONDING POLICY: CP-12 Rapid Response System UPMC Shadyside has developed processes and procedures in order to support the Rapid Response System policy. TABLE OF CONTENTS I. Policy Application Related to Physical Location II. Procedures for Rapid Response Team Activations A. Condition A (Cardiopulmonary Arrest) & Condition C (Medical Crisis) Medical Emergency Team (MET) B. Activation of all Rapid Response Teams 1. Stroke Assessment Team (SAT) and activation of the Acute Stroke Team 2. Sepsis Team 3. Condition H (Help) 4. Condition M 5. Condition L Elopement C. Communication Duties III. Crisis Management A. Condition A and C, Medical Emergency Team B. Stroke Assessment C. Sepsis IV. Other Rapid Response Team Management A. Condition H (Help) B. Condition M C. Condition L (Elopement)

8 PAGE 2 V. Emergency Equipment, Emergency Cart Location, Usage and Maintenance VI. Procedure for Rapid Response Team calls and management to Hillman Building, Medical Center Building, Cancer Pavilion Building and North Tower (School of Nursing Building) VII. Procedure for Rapid Response Team calls, Condition A or C, occurring on outside perimeter of UPMC Shadyside, parking garages and Preservation Hall. VIII. Pediatric Emergency Event Protocol IX. Special Circumstances A. Heliport B. Roof Emergency Events C. Simultaneous Emergency Events D. Death Appendices for UPMC Shadyside Procedure Appendix A: Appendix B: Appendix C: Appendix D: Appendix E: Appendix F: Appendix G: Appendix H: Appendix I: Appendix J: Appendix K: Appendix L Appendix M: Appendix N: Appendix O: Appendix P: Guidelines for Initiation of Rapid Response Team Initiation of Response Inpatient Stroke Activation Algorithm Team Roles and Responsibilities Intensivist Bag Supply List Location of Emergency Crash Carts and AEDs Emergency Crash Cart Medication and Supply List ICU Nurse Responder Zones & Responsibilities Respiratory Therapy Zones & Responsibilities Emergency Event Elevator Operation Pharmacy Bag List Daily Crash Cart Check List Airway Roll Campus Map and outsider perimeter responder zone Pediatric Emergency Cart Locations, Medication and Supply List Multiple Defibrillator Checklist

9 PAGE 3 I. POLICY APPLICATION RELATED TO PHYSICAL LOCATION This procedure applies to the UPMC Shadyside Campus including the UPMC Shadyside Hospital, North Tower (School of Nursing Building), Medical Center Building, Cancer Pavilion Building, Preservation Hall, Hillman Cancer Center Building, connecting hallways, parking garages and outside perimeter. Campus areas excluded from this policy include: 1. Family Health Center 2. Aiken Professional Building 3. Shadyside Place 4. Hillman Cancer Center Research Side All emergency events occurring at off-campus sites requiring crisis management or resuscitative measures will be called in to Emergency Medical Services (notify Pittsburgh EMS by calling ) for provision of resuscitation and patient transport(appendix B). II. PROCEDURES FOR RAPID RESPONSE TEAM ACTIVATION A. Condition A (Cardiopulmonary Arrest) OR Condition C (Medical Crisis) Medical Emergency Team (MET) Refer to Appendix A Guidelines for Initiation of Rapid Response Team Refer to Appendix B Initiation of Response 1. In the event of a Condition C or A initiate the Rapid Response Team by calling The Medical Emergency Team will respond to: a. UPMC Shadyside Hospital b. Hillman Cancer Center, outpatient side c. Medical Center Building d. Cancer Pavilion Building, Herberman Conference Center e. North Tower (School of Nursing Building) f. Parking garages g. Preservation Hall h. Outside perimeter of the hospital

10 PAGE 4 3. For the parking garages, Preservation Hall, outside perimeter of the Hospital, North Tower (School of Nursing Building), Medical Center and Cancer Pavilion, Emergency Medical Services may also need to be notified for assistance. The dual activation may occur when placing the initial call or if later after the MET assess the situation. 4. In all instances, the Condition A or C location, including building, wing, room number, the person calling and the name of the person the Condition was called for should be given. In the event that the person needing assistance is not a patient, the caller should identify the person as a visitor or employee. The caller should not hang up until the ISD Voice Communications operator has verified all information. a. Cardiopulmonary arrests and medical or emergency event situations are overhead announced as Condition A or C, followed by the location, given three times. b. If the patient s condition warrants a Condition C page and the patient s condition deteriorates to meet the Condition A criteria before the Medical Emergency Team arrives, a second call may be placed to the emergency operator. The call should tell the operator that the patient is now a Condition A and request the emergency event be upgraded and announced. The same Medical Emergency Team responds to both events. c. In areas such as the Emergency Department, Cardiac Cath Labs or ICU where emergency events can be managed by personnel present, Stat pages for individual assistance of anesthesia or respiratory personnel may be called when appropriate. Condition A or C may also be called when necessary. d. Family members and patients may trigger an emergency call for patients, visitors or others in obvious cardiac or respiratory distress.

11 PAGE 5 B. ACTIVATION FOR ALL OTHER RAPID RESPONSE TEAMS 1. Stroke Assessment Team and activation of Acute Stroke Team 2. Sepsis Team 3. Condition H (Help) 4. Condition M 5. Condition L (Elopement) All other rapid response team activations are through the same emergency number In all instances the location, including building, wing, room number, the person calling and the name of the person that the RRT activation is being called should be given. The caller should not hang up until the ISD Voice Communications operator has verified all information. C. COMMUNICATION DUTIES 1. The ISD Voice Communications operator activates the appropriate Rapid Response Team, Condition A or C Medical Emergency Team or others as initiated by: a. Alerting specific pagers as designated in this procedure b. Audible paging in the UPMC Shadyside Building in all cases as follows: Condition A or C Building Floor Wing Room Number. Condition M or L Building Floor Wing Room Number. Condition H, Stroke Assessment Team and Sepsis Team are pager activated events, there is no audible paging. 2. ISD Voice Communication operators are also responsible for obtaining patient name and medical record number to assist with Quality Improvement process.

12 PAGE 6 3. If the ISD Voice Communications operator receives a call that should have been directed to 911, the ISD Voice Communications operator will connect the person through to ISD Voice Communications operator will perform two daily tests of the emergency event pagers. All pager-carrying members of the teams are to be alert that the test pages are sent in the morning (9:00am) and evening (8:30pm). If the test page does not come across the pager, it is the responsibility of the person carrying the pager to contact the ISD Communications Operator on the UPMC Shadyside campus to replace the pager. In the event a pager is non-functioning on an evening or weekend, the UPMC Shadyside Administrator on Duty can replace the pager. All members of the team will carry an emergency event pager. III. CRISIS MANAGEMENT A. Condition A & C, Medical Emergency Team Adult Condition A or C Medical Emergency Team Composition and Responsibilities Ideally there are 9 identified team members. More staff may respond as part of their education process to learn the roles and responsibilities of being a member of the Medical Emergency Team. See Appendix C Team Roles and Responsibilities. 1. Physician Members & Duties (Treatment Leader Role 5) a. The treatment leader should identify self as such upon arriving at the crisis event. The treatment leader will give orders, delegate responsibilities and over see interventions by other members of the team. b. The attending physician will be notified during the condition by staff on the patient care unit. The treatment leader or delegate is responsible for discussing the patient's condition with the attending physician.

13 PAGE 7 c. The treatment leader will be recognized in the following order: Attending Physician Intensivist or Fellow Senior Internal Medicine or Senior Family Practice Resident responsible for that patient d. Additional responsibilities of the treatment leader include: 1) Assessing the situation and determining if appropriate to ramp down or ramp up the responders to meet the patient s care needs. 2) Continually assessing patient s total condition and coordinating CPR efforts. 3) Ordering emergency care utilizing ACLS guidelines. 4) Manage airway and intubate if needed (Appendix E - Intensivist Bag Supply List). 5) Interpreting cardiac rhythm and 12 lead EKG. 6) Determining when to transfer the patient to the ICU or terminate the arrest efforts. 7) Signing the Emergency Event Form 8) Writing an emergency event note in the patient s record. 9) Communicating with the family/significant others. 10) Accompanying the patient on transfer 11) In the event of a second Condition A or C, the treatment leader will delegate the members of the team to respond. 2. Assisting Resident/Intern Physicians/Mid-Level NP or PA (Procedure MD Role 7 and/or Circulation Role 6) a. The resident should identify self and inform team if she/he has any knowledge of the patient.

14 PAGE 8 b. Additional responsibilities include, but are not limited to: 1) Assist with patient assessment through data collection, by reviewing patient chart for lab values, radiology reports, medications administered and status of limited therapy orders. 2) Inserting central lines/assisting with IV insertion PRN. 3) Drawing arterial blood gases and blood specimens. 4) Communicating with the attending physicians at the request of the treatment leader. 3. Nursing Members (Bedside Assistant Role 3) a. The bedside assistant is usually the nurse assigned to care for the patient. In nonpatient care units the bedside assistant may be any of the nurses that respond to the event. b. Bedside Assistant responsibilities include but are not limited to: 1) Begin CPR if necessary, transport crash cart to the patient, place on monitor immediately and assess for ventricular arrhythmias, defibrillate if necessary, set up bag-valve mask device, set up suction, place on back board, obtain vital signs including blood pressure, respiratory rate, heart rate and SpO2, obtain IV access and prepare normal saline IV infusion, administer medications in accordance with policy Arrhythmia, Emergent or Life Threatening (Infonet Merged Manual of UPMC Presbyterian Shadyside Nursing Section, Emergency). Appendix F Location of Emergency Crash Carts) 2) Remain in room to offer information on the patient and use SBAR format to communicate with all responders.

15 PAGE 9 S-Situation: use 3 5 sentences to give a brief overview and express the urgency of the situation. B Background: include pertinent history, reason for admission, other treatments the patient has received to address current situation. A Current Assessment: vital signs and changes in recent vital signs, relevant labs or radiology reports include. R Recommendations or Request. 3) Emergency Event Documentation. a) Emergency Event Form - This form must include patient identification and have a copy inserted into the patient s chart. Signature of the treatment leader is obtained. b) Electronic documentation - Change of Status Event is completed on all patients. Event details may also be entered where available. 4) Staff member either bedside nurse or ICU nurse that is completing documentation of the crisis event will also assess and manage the number of responders to the crisis event. The Emergency Event form is in duplicate. The Green copy must be included in the patient record, the Yellow copy will be sent to Pharmacy for QA and review by the MERIT Committee. 4. Nurse Anesthetist or Anesthesiologist (Airway Manager Role 1) a. Responsibilities include: 1) Assessing patient s airway and respiratory status and intubate as indicated. 2) Verifying bilateral breath sounds.

16 PAGE 10 3) Documenting in the patient record. 5. ICU Nurses - 2 responders (Crash Cart Manager Role 4 and Data Manager Role 8 or assist the bedside nurse with medication administration or procedures) a) Responsibilities include, but are not limited to: 1) Managing crash cart, deploying equipment and preparing medications (Appendix F Emergency Crash Cart Medication and Supply List). 2) Indicating or assisting in insertion of peripheral IV lines. 3) Connecting patient to monitor/ defibrillator (if not already done so) 4) Defibrillating or pacing patient as needed. 5) Administering medications. 6) Assisting, if needed, with obtaining vital signs. 7) Accompanying patient on transport to the ICU. 8) Assisting with emergency event documentation if needed. 9) Staff member, either bedside nurse or ICU nurse, that is completing documentation of the crisis event will also assess and manage the number of responders to the crisis event. 10) Arranging for appropriate ICU bed and communicate information to staff nurse. b) ICU Nurse members of the team will be from CCU/MICU, CT-ICU, NS-ICU, SICU and MS-ICU. These nurses will be assigned to respond at the beginning of each shift and respond to emergency events according to a specific geographic area. They will have successfully completed Basic Life Support, Critical Care Course, Basic Arrhythmia, ACLS and Crisis Team Training (Simulation Training at WISER).

17 PAGE 11 Appendix H addresses the ICU Nurse Responder Zones and Responsibilities. Appendix J Emergency Event Elevator Operation 6. Advanced Practice Nurse, Unit Director or Administrative Nursing Coordinator a. Responsibilities include, but are not limited to: 1) Function as a Bedside Assistant or ICU Nurse as needed. 2) Keeping the number of responding personnel in attendance to an appropriate number. 3) Arranging for appropriate ICU bed and communicate information to staff nurse. 7. Respiratory Therapy Members 3 responders (Airway Manager Role 1 or Airway Assistant Role 2) a. Respiratory Therapist responsibilities include: 1) Maintaining patient s airway. 2) Administering oxygen or respiratory treatments as ordered. 3) Performing CPR and/or assess correct performance of CPR. 4) Assisting in obtaining of arterial blood gases (ABGs). 5) Managing analysis of ABGs and returning results to Team. 6) Documenting interventions during crisis per departmental procedure. 7) Providing pulse oximeter if previously not available. 8) Assisting with intubation if necessary. 9) Assisting with transport to ICU or other designated triage area. b. Respiratory members of the team will be from assigned to respond at the beginning of each shift and respond to emergency events

18 PAGE 12 according to a specific geographic area. They will have successfully completed Basic Life Support, ACLS and Crisis Team Training. The following individuals are considered part of the medical emergency response team, but do not need to be located directly around the patient in crisis. 8. Pharmacist a. Responsibilities include: 1) Obtaining medications/iv solutions not available on crash cart. 2) Responding with the pharmacy drug bag (Appendix K - Pharmacy Drug Bag List) 3) Providing drug information concerning dosing, incompatibilities of drugs. 4) Assisting with crash cart and mixing of medications as needed. 9. Unit Secretary, HUC or Nursing Assistant a. The Unit Secretary or designee will remain available to: 1) Deliver a computer on wheels to the patient bedside. 2) Print off a copy of the Emergency Event Orders. 3) Enter orders for stat request once Emergency Event Order sheet has been completed. 4) Place calls and pages as directed. 5) Immediately print out a nurse hand off report and deliver to the treatment leader. 6) Receive, deliver and notes laboratory results to room immediately. 7) Deliver glucose monitoring device to the bedside.

19 10. Chaplain as needed: SHADYSIDE CAMPUS PAGE Transport a. Responsibilities include: 1) Remaining with family and/or significant others 2) Staying with patient s roommate when applicable For emergency event located in non-patient care areas, such as lobbies or cafeteria, Medical Center Building, Cancer Pavilion, Hillman Cancer Center, the School of Nursing and JROC, Transport Services will respond with an EMS style transport cart and back board to assist with transporting patients. 12. Security For emergency event located in non-patient care areas, such as lobbies or cafeteria, Medical Center Building, Cancer Pavilion the School of Nursing and the Hillman Building, Security Services will respond to assist with crowd management and facilitate rapid transport of patients. After 5:00pm and on weekends Security will respond to MRI and Cardiac Cath Labs to ensure that MET Responders have access into these areas. 13. Patient Disposition a. The treatment leader will decide the disposition of the patient. Out-patients, employees or visitors may be directly admitted to a critical care unit or be transported to the emergency department for further assessment and treatment before admission. This will include outpatients or clinic patients from the Hillman Cancer Center, radiology or other diagnostic test areas and employees or visitors.

20 PAGE 14 In- patients who have received crisis management or resuscitative intervention will be triaged and transported to an appropriate patient care unit. b. Any patient, employee or visitor that is intubated, on vasopressor therapy or considered critically unstable may be directly admitted to an intensive care unit. When an ICU bed is not immediately available an ICU Nurse and when necessary a Respiratory Therapist will remain with the patient until transfer. c. Patients from the Hillman Cancer Center that are ill and require on-going care and admission to a medical unit, may directly be admitted to an oncology bed. d. Patients, employees or visitors that are stable and require on-going care and questionable admission will be transported to the Emergency Department for further evaluation. e. When a patient has been identified as needing to be directly admitted, a phone call is made to the DAC at f. The patient s name, age, birth date and social security number are needed and will allow the patient to be entered into Medipac so that orders can be written on admission. g. An admitting physician and diagnosis are required. The intensivist can serve as the admitting physician. h. If a bed is not available, the patient will go to the Emergency Department. B. Crisis Management - Stroke The Acute Stroke Team is based out of UPMC Presbyterian and is available for management of cerebrovascular event. The Stroke Assessment Team (SAT) or attending physician may notify the Acute

21 PAGE 15 Stroke Team through MedCall. When the patient meets Condition C criteria the Condition C Rapid Response Team must be activated as part of the Stroke Assessment Team (SAT). This allows for physician to physician discussion of treatment. The Stroke Assessment Team is comprised of a Neuro ICU Nurse and Intensivist. The Stroke Assessment Team will evaluate the patient and pending assessment will activate the Acute Stroke Team and/or the Condition C Rapid Response Team. When a patient presents with stroke symptoms in the Emergency Department, ICU or Cardiac Cath Lab and an attending physician is available for phone consult with the Acute Stroke Team, a Condition C does not need to be activated (Appendix C). C. SEPSIS TEAM Sepsis Team is comprised of ICU nurses from the MICU. Two nurses will respond to Sepsis Team Activation page to assess the patient and contact the intensivist for further care orders. IV. OTHER RAPID RESPONSE TEAM MANAGEMENT A. CONDITION H: CONDITION HELP Condition H may be activated by patients or family members by dialing A Condition H is to be used when: 1. A breakdown in how care is being managed or there is confusion about the plan of care and the healthcare team is not responding to their questions/concerns. 2. A noticeable clinical change in the patient and the healthcare team is not responding to their concerns. 3. Telecommunications Department will request the location and the nature of the situation and activates Condition H pagers. Telecommunications Department calls main phone number of floor where Condition H called to alert staff.

22 4. Team Membership: SHADYSIDE CAMPUS PAGE 16 B. CONDITION M a. Physician from Internal Medicine Non-Teaching Service 1) Assesses the situation and makes recommendations as to how to remedy the problem. 2) Documents in the patient record and as needed communicates to other members of the Health Care Team. b. Administrative Nursing Coordinator 1) Assists with any needed transfer to a higher level of care. 2) Reports details of the Condition H to Director of Inpatient Nursing, Vice President of Patient Care Services and Director of Patient Care Services Business Operations. c. Patient Relations Coordinator 1) Provides support as needed in psychosocial events or situations of patient dissatisfaction as directed by physician. 2) Conducts post-condition H patient/family interview to evaluate issues contributing to the need to call a Condition H and documents information on the Condition H (HELP) Follow-up Questionnaire. d. Unit Nurse Caring for the Patient 1) Responds to provide background information on the patient and meets immediate clinical need. 2) Documents in the nurses note regarding Condition H. Condition M is a behavioral code that is called for a patient or visitor who is experiencing a crisis that could pose a potential threat to themselves, patients, staff or visitors. A trained team consisting of Administrative Nursing Coordinator, Security Staff, and other specially trained personnel will respond. To activate code dial Ext

23 PAGE 17 C. CONDITION L - ELOPEMENT Staff may activate Condition L by calling A non-medical crisis that involves a patient, usually disoriented or confused, that has left the unit without authorization. Condition L is activated to located the patient and return them to a safe patient environment. Upon locating the patient other teams may be activated pending the specific patient needs. V. EMERGENCY EQUIPMENT, CPR CART LOCATION, USAGE AND MAINTENANCE A. ISOLATION AND INFECTION CONTROL PRACTICES DURING CONDITIONS 1. All staff entering the room must dress in the appropriate isolation garb. PST/NA should assist with the distribution of isolation garb. 2. Limit the number of staff that have direct contact with the patient to: a. Treatment Leader b. Airway Management Team c. Bedside Nurse 3. Defibrillator must go into the room and be attached to the patient vial monitoring/multifunction pads. 4. Whenever possible, leave the crash cart outside the patient room. Station and ICU Nurse or MS Nurse at the cart to pass necessary equipment into the room. At no time should patient safety be compromised, when necessary, bring the crash cart into the patient room. 5. When the cart goes into the room of an isolation patient one nurse should be designated to manage the crash cart. The nurse should not come in contact with the patient s environment or the patient. No others should enter the drawers of the crash cart. 6. After the event the cart, defibrillator and any other external equipment must be wiped with bleach wipes before sending to pharmacy. If the cart is contaminated, supplies may remain with

24 PAGE 18 the patient and pharmacy is too notified if the drugs are to discarded. 7. All other isolation practices are to be followed. B. CRASH/CODE CARTS LOCATION, USAGE & MAINTENANCE 1. Emergency medications and equipment will be consistently available, controlled, and secured in the pharmacy, hospital departments, ambulatory care areas or satellites, inpatient and outpatient care area. Emergency medication and equipment will be consistently available to nonpatient care areas. It is the responsibility of the Department of Pharmacy and Therapeutics, Nursing, Respiratory Care, Central Services, Hospital Departments, and physician office/satellite staff to conduct and document that regular inspection of emergency medications and supplies occur. 2. Red plastic seals (to protect the integrity of the contents) are only available from the Department of Pharmacy and Therapeutics. 3. A list with the location of drugs according to drawers, special equipment, and respiratory equipment supplied on the carts is available on top of the cart. 4. The integrity of the carts, expiration dates of the first medications and supplies to expire, and the red seal number is checked daily by designated personnel using the Emergency Cart checklist. The seal number is recorded on the checklist, as well as the expiration date. The daily checklists are maintained for one year by the department head or designee of the area where the emergency cart is located. Appendix F. 5. The Pharmacy Department is responsible for supervising, auditing and appropriately restocking the code cart with emergency medications, including replacing outdated medication. After a crash cart is used the unit staff will place the cart in a locked room or keep it at the unit station under close observation to keep it secure until it is exchanged by Pharmacy. Unit staff will contact the Pharmacy via telephone to inform them that the crash cart has been used and that a new cart is needed.

25 PAGE The cart is checked and replaced after each use according to established procedures. Each cart is sealed by the pharmacy with a red seal to protect the integrity of its contents. If a cart s red seal is broken, the entire cart is exchanged. The crash cart and Emergency Cart checklists are checked each month as a part of the monthly inspection by the pharmacy. 7. Emergency carts with defibrillator, resuscitation equipment and medications are available on every patient care unit and diagnostic area throughout the hospital. (Appendix G Emergency Crash Cart Medication and Supplies list, Appendix F Locations of Emergency Crash Carts). 8. If an arrest occurs in the Medical Center Building UPMC Cancer Pavilion, or Bridge to Hillman Cancer Center, a crash cart is located in the lobby of the Medical Center Building (near the elevators). When an arrest occurs in these areas, pharmacist will retrieve the cart and take it to the site of the arrest. 9. Nursing personnel may obtain a training crash cart from Nursing Education and may open the cart for review of equipment and drugs. C. DEFIBRILLATORS AND AEDS 1. Defibrillators are available on every crash cart. Defibrillators function as Shock Advisory or AEDs. They are programmed to manufacturers and American Heart Recommendations. Daily or weekly check is documented on the Daily Emergency Crash Cart Checklist (Appendix L). In specific areas (Emergency Department, OR, Cardiac Cath Lab and CT-ICU) there are additional defibrillators that require daily defibrillator check. A multiple defibrillator check list may be used. (Appendix P Multiple Defibrillator Check list) 2. AEDs are available on the Shadyside campus and are placed in areas that make them available for rapid deployment and use by Health Care Professionals and the lay public (See Appendix F - Location of AED's).

26 PAGE Areas that are closed over the weekend, holidays or time of low census will document on the Daily Emergency Crash Cart Checklist that the area was closed. 4. Daily, weekly and monthly equipment check are performed by a member of the staff in any department where there is a crash cart, defibrillator or AED. 5. A designee of the MERIT Committee will perform the daily, weekly and monthly checks of the West Hallway equipment. Documentation of the checks are maintained on the Daily Emergency Crash Cart Checklist or AED Check List. D. Intensivist Bag & Airway Rolls 1. Intensivist will maintain a bag with emergency supplies to assist in managing airways (Appendix E.) 2. Respiratory will maintain the Airway Rolls located in the ICUs, Hillman Cancer Center and the Cath Lab (Appendix M). Respiratory Therapy will transport an Airway Roll to all emergency events. E. BACKBOARDS 1. Backboards with securing straps are available for use when a patient, visitor or employee has fallen and back or cervical injury is a potential. Backboards are located in the West Wing Closet, Hillman Cancer Center second floor, Emergency Department and NS-ICU 4 West. F. STAIR CHAIR 1. Located on 6 Pavilion is a Stair Chair that can utilize when transporting a patient down steps is required. 2. Additional Stair Chairs and Carts may be located throughout the hospital per Disaster Management.

27 PAGE 21 VI. PROCEDURE FOR CONDITION A OR C AT HILLMAN, MEDICAL CENTER, CANCER PAVILLION AND North Tower (School of Nursing) Hillman Cancer Center Hillman Cancer Center will have an in-house First Response Team Monday through Friday between 8:00am and 4:30pm, excluding recognized holidays, to respond to patient and staff emergencies. Shadyside Campus Emergency Event Team will respond to between 7:00am and 7:30pm. The Hillman First Response Team will respond to Condition A or Cs with the patient care side of the Hillman Cancer. Condition A or Cs in the covered driveway and garage will be assessed by the treatment leader and if needed will be a dual response from the City of Pittsburgh EMS. Emergency events in the research side of the Hillman Building will be handled by City of Pittsburgh EMS, by dialing A. First Response Team Composition 1. Treatment Leader Senior nurse, PA or NP. a. Current in AHA ACLS training. b. Attended Crisis Team Training at WISER. c. Complete annual competency and review standing orders 2. Nursing personnel from the first, second and third floors of the patient care areas of Hillman Cancer Center. a. Current in BLS Certification. b. Preferred current in AHA ACLS training. c. Attended Crisis Team Training d. Complete annual competency and review standing orders 3. Security personnel stationed within Hillman Cancer Center. 4. Pharmacy personnel B. Emergency Equipment i. Emergency Crash Carts will be maintained on the ground, first, second, third and fourth floors with an additional Emergency Crash Cart is

28 PAGE 22 located in the pharmacy on the second floor (Appendix F Location of Emergency Crash Carts). A Broselow Pediatric Crash Cart is maintained on the second floor in the treatment area. It is the responsibility of the staff on their respective floors to bring the Crash Cart to the location of the event. In the event of a Condition C or A on the fourth floor or garage level, the treatment leader will respond with a crash cart. ii. iii. Airway bag and emergency drugs will be kept in the Pharmacy on the second floor and delivered to emergency events. (Appendix K Adjunct Pharmacy Bag). Defibrillators with AED/Shock Advisors will be maintained on each Emergency Crash Cart. C. Procedure 1. When an adult emergency event occurs, the ISD Voice Communications operator is notified by dialing extension on any available telephone. Immediately, the ISD Voice Communications operator will activate the Hillman First Response Team alpha pagers and the Shadyside Emergency Event Team. When the hospital team is activate the emergency event and location will go out on the overhead calling system, followed by activation of the Emergency Event pagers assigned to specific members of the emergency event team. 2. Staff witnessing the event should begin the delivery of emergency care. a) Begin CPR if necessary, transport crash cart to the patient, place on monitor immediately and access for ventricular arrhythmias, defibrillate if necessary, set up bag-valve mask device, set up suction, place on back board, obtain vital signs including blood pressure, respiratory rate, heart rate and SpO2, obtain IV access and prepare normal saline IV infusion.

29 PAGE 23 b) Remaining in room to offer information on the patient, use SBAR format to communicate with all responders. S-Situation: use 3 5 sentences to give a brief overview and express the urgency of the situation. B Background: include pertinent history, reason for admission, other treatments the patient has received to address current situation. A Current Assessment: vital signs and changes in recent vital signs, relevant labs or radiology reports include. R Recommendations or Request. c) Completing Emergency Event Form 3. The Treatment Leader will assess and manage unless the hospital team is requested and the intensivist will assume the treatment leader role. 1. Responsibilities include: a. Respond with Emergency Bag (Appendix K- Hillman First Responder Bag Medication and Supply List) Identify self as the treatment leader, delegate responsibilities and over see interventions by other members of the team. b. Assessing the situation and determining if appropriate to ramp down or ramp up the responders to meet the patient s care needs. a) Continually assessing patient s total condition and coordinating CPR efforts b) Ordering emergency care utilizing ACLS guidelines and the approved protocols. c) Determining when to transfer the patient to the emergency department or patient care unit. d) Signing the Emergency Event Form

30 PAGE 24 e) Writing an emergency event note in the patient s record f) Communicating with the family/significant others g) Accompanying the patient on transfer h) In the event of a second Condition A or C, the treatment leader will delegate the members of the team to respond and ensure the activation of the hospital team. D. Protocols In specific situations, approved protocols may be initiated. As part of the initiation of a Protocol: 1. BLS, ACLS and PALS algorithms will be instituted. 2. Appropriate patient positioning and monitoring will be instituted. 3. Secure airway and administration of oxygen in the appropriate manner for the patient condition after establishing and maintaining a patent airway. 4. Establish and IV of normal saline. Hypotensive Protocol Patient with BP < 90 mm Hg systolic and clinical signs of inadequate tissue perfusion or altered level of consciousness. Vital signs every 5-10 minutes Start IV (20 gauge or greater) 250 cc bolus NSS IV Chest Pain Protocol Capped {what do you mean by capped } Nitroglycerine tab 0.4 mg SL if BP > 90 mm Hg systolic (establish patient is not on sildenafil (Viagra) or vardenafil (Levetra) within 24 hours or tadalafil (Cialis) within 48 hours.) Respiratory Distress Access patient for shortness of breath, wheeze, poor airway exchange.

31 PAGE 25 Identify need for a breathing treatment Prepare and administer Breathing Treatment Alupent Nebulizer (0.3ml in 2.5 ml NSS) unless contraindicated Patient allergy Patient condition Or identify the need for diuresis Reassess Patient Administer furosemide 40 mg IV. Adverse Drug Reaction Protocol For patients demonstrating hives, rash or difficulty breathing from a medication: Benadryl 50 mg IV (IM if no IV access) Solu Medrol 125 mg IV (IM if no IV access) If patient develops Shortness of Breath associated with anaphylaxis: Epinephrine 1:1000 concentration 0.3 to 0.5 mg subcutaneous Albuteral 5mg/6ccNSS nebulizer for wheezing or strider If patient demonstrates Rigors: Demerol mg IV Medical Center, Cancer Pavilion, and North Tower (School of Nursing Building) A. When an adult emergency event occurs, the ISD Voice Communications operator is notified by dialing extension on any available telephone. B. When the Emergency Event Team responds along with Security and Transport, a decision should be made by the physician in charge regarding appropriate transportation to the Shadyside campus. If the patient is critically ill and unstable, City EMS, 911 may be called for transport.

32 PAGE 26 VII. PROCEDURE FOR CONDITION A OR C OCCURRING ON OUTSIDE PERIMETER OF UPMC SHADYSIDE, PARKING GARAGES AND PRESERVATION HALL In-patients, out-patients, visitors and employees that experience a medical crisis outside of the buildings identified in this procedure but within the perimeter of the hospital will be responded to by activating a Condition C for the Medical Emergency Team and upon assessment a call to 911 for City EMS support. Patients that are stable and can be safely transported by wheelchair may be transported without calling City EMS. Response team for the outside perimeter will be the Administrative Nursing Coordinator, Emergency Department Nurse, Emergency Department APCT or PCT, Respiratory Therapy and Security. The defined area that the team will respond to is: Aiken Avenue Visitor Parking Garage Centre Avenue Visitor Parking Garage Aiken Avenue Employee Parking Garage Driveway from Aiken Avenue back through the loading docks of the Shadyside Hospital. Driveway to the street at the main entrance on Centre Avenue. Alley between the Aiken Avenue Visitor Parking Garage and the hospital building. Driveway to the street at the Medical Building entrance. Appendix N Campus Map and Outside Perimeter Responder Zones. Responders from the emergency department will respond with a wheelchair, defibrillator with pulse oximeter and noninvasive blood pressure equipment, oxygen tank and administration supplies. The hospital response team will remain with the individual and assist or administer CPR or other lifesaving techniques, as appropriate, within their scope of practice until the Emergency Medical System (EMS)Team arrives or until the patient is taken to the Emergency Department. Upon arrival at the scene, the hospital response team leader will either:1) make the determination to cancel the city EMS call if they are not

33 PAGE 27 required for evaluation, management or transport to the hospital and have not yet arrived on scene; or 2)transfer care to the EMS squad for ongoing management and or transport to the Emergency Department and assign team members to brief the EMS team leader on the situation. If care is transferred to the If the patient requires a stretcher for transport city EMS must be notified. All events that occur outside the hospital are to be entered into Risk Master. VIII.PEDIATRIC EMERGENCY EVENT PROTOCOL Pediatric event is defined as a person under 13 years of age. When the age of the child is unknown, a pediatric event may be activated. UPMC Shadyside is an adult acute care institution but has specialty areas that deliver care to pediatric patients. Two areas have been identified as pediatric care areas: Department of Radiation Oncology and the Hillman Cancer Center. It is also recognized that other areas may provide services to pediatric patients and that there are pediatric visitors on the premise that may require emergency care. A. Criteria for activation of pediatric condition Any change in condition or concern regarding the condition of a pediatric patient by the nurse, physician, respiratory therapist or parent. B. Procedure 1. When a pediatric patient is known to be in the hospital the ISD Voice Communications operator will be notified by the patient care area (Radiation Oncology or Hillman). The ISD operator will send out a pediatric patient alert via alpha numeric pager to the pediatric emergency event team and administrative personnel. The purpose of this page is informative that responders may review procedures. 2. When a pediatric emergency event occurs, the ISD Voice Communications operator is notified by dialing extension on any available

34 PAGE 28 telephone. The ISD Voice Communications operator will answer and say Emergency Line What is your emergency? The person making the call should identify that it is a Pediatric Condition and the location: Pediatric Condition Radiation Oncology. The caller should not hang up until ISD Voice Communications operator has verified all information including that it is a "pediatric condition". Immediately, the ISD Voice Communications operator will call the emergency event and location on the overhead calling system. This will be followed by activation of the Condition A/C pagers. 3. The following personnel will respond to all pediatric arrests: C. Equipment a. Emergency Department physician - Treatment Leader b. Nurse Anesthetist/Anesthesiologist - Airway Manager c. Emergency Department Nurses - Crash Cart Manager, Bedside Assistant or Procedures d. Pharmacist - Crash Cart Manager e. Respiratory Therapist - Airway Assistant & Circulation f. Administrative Nursing Coordinator - Data Collection & Documentation g. Nurse responsible for the patient - Bedside Assistant h. Family Practice Resident i. In the Hillman Building the Hillman First Response Team will respond to the Hillman pediatric emergency events j. Radiology Tech portable x-ray k. Chaplain and Social Work Services are available by beeper if needed. 1. A Pediatric Crash Cart containing defibrillator with appropriate pediatric equipment, IV equipment, emergency medications, and other emergency equipment will be maintained in the Emergency Department, Hillman Cancer Center and Radiation Oncology when a pediatric patient is present.

35 PAGE 29 Appendix O Pediatric Crash Cart Locations, Medication and Supply List. 2. Upon hearing the Pediatric Condition alert, the Emergency Department nurse assigned to the Pediatric Team will bring the Pediatric Crash Cart to the area designated by the alert if other than Radiation Oncology or the Hillman Cancer Center. D. Responsibilities of each Pediatric Team Members are as follows: 1. Emergency Department Physician Responds to the Pediatric Emergency Event and takes charge of the medical management of the patient. 2. Emergency Department Nurse Brings pediatric arrest cart and assists with medications and procedures 3. Pharmacist Assists with medications and pediatric drug calculations. 4. Administrative Nursing Coordinator Assists with documentation of event. Keeps the number of responding personnel in attendance to an appropriate amount. Coordinate transportation if necessary. 5. Nurse Responsible for the Patient Provides chart information to include historical background on the patient. Assist with procedures and documentation of event. 6. Nurse Anesthetist/Anesthesiologist Responsible for airway and/or intubation. 7. Respiratory Therapists Maintain airway and CPR. Manages analysis of blood gases and return results to the Cardiac Arrest Team. 8. Family Practice Resident Assist Emergency Department Physician. 9. Hillman First Response Team (Hillman Events) responds with pediatric cart, assist with CPR if needed, IV access until pediatric team arrives. E. Disposition of Pediatric Patient A. The appropriate physician at CHP will be notified as soon as possible. After the patient has been stabilized, transfer to the Emergency Department for further medical screen and treatment by the

36 PAGE 30 Emergency Department physician. Patient may be discharged or transferred to Children s Hospital of Pittsburgh. Patients that are in Radiation Oncology with ambulance back up, if stable may be transported to Children s Hospital. Patients that are in Hillman Cancer Center may be triaged to the ED or via ambulance to Children s Hospital. Patients will be transferred to Children s Hospital as soon as possible. B. All Emergency Department members of the pediatric emergency event team will be encouraged to attend the PALS course. C. Nursing personnel may open the pediatric cart for review of equipment and drugs. However, prior to opening the cart, notify Pharmacy that the cart will be opened for review. After the review, Pharmacy must be notified immediately to check and re-lock the cart. (Appendix O Pediatric Emergency Cart Locations, Medication and Supply List). IX. SPECIAL CIRCUMSTANCES A. Helicopter Transport Patient Cardio-pulmonary Arrest 1. Helicopter Transport personnel will inform the receiving unit or security that the patient is arresting. The receiving unit or security will notify the ISD telecommunications operator of the request Condition A or C at the Heli Pad. The overhead page will be activated and the message to meet at the second floor elevator at a time 5 minutes before arrival of the helicopter announced. The pager system will go out with the estimated time to arrival and will be used to inform the team to arrive at the second floor elevator 5 minutes before the arrival of the helicopter. The Helicopter Transport personnel are responsible for initiating arrest procedures. Patients are under their control until the patient is transferred from the carrier to the patient s hospital bed. The patient should be resuscitated and stabilized by the Helicopter Transport personnel in the elevator room at the Heliport.

37 PAGE 31 If additional support is needed, a medical emergency team consisting of 1 CT-ICU Nurse, 1 respiratory therapist, 1 CRNA or Anesthesiology and an intensivist will respond to the second floor elevator that assessing the roof. Security will coordinate and escort the team to the heliport elevator. Staff will remain inside the building and assist from that point. Only requested equipment needs transported to the helipad. 2. Once the patient is transferred to the receiving unit bed, any further emergent procedures (e.g., inserting arterial lines, etc.) will be done by physicians and nurses of the hospital. B. Emergency Event on the Roof 1. When a medical emergency (e.g. injury or cardiac arrest) occurs on the roof one of the hospital buildings, the Emergency Event Team should be notified via the ISD Voice Communications operator stating Condition A or C on the roof of ( and state building ) report to Floor. The ISD Voice Communications operator will also notify city EMS. 2. Nurses from the ICUs that cover emergency events of their building assignments will respond to roof emergencies. The nurses should take a defibrillator with pulse oximeter and noninvasive blood pressure monitoring equipment immediately to the top floor of the respective building. Respiratory Therapy will respond with oxygen tank and oxygen administration equipment. Security will also respond to the emergencies and will direct the Team on how to access the roof. 3. The Emergency Event Team will implement appropriate arrest or emergency procedures for the affected patient. The Pharmacy will bring an emergency drug box to the site. The top floor s crash cart will be brought by the unit to the stairwell leading to the roof.

38 PAGE As soon as it is medically feasible, the patient should be transferred to the appropriate area (e.g. Emergency Department or Cath Lab.) C. Simultaneous Emergency Events In the event of a second Condition A or C, the charge physician will delegate the members of the team to respond. D. Death All hospital policies and procedures that pertain to the death of a patient are followed when the patient expires.

39 Appendix A Criteria for Initiating a Rapid Response Team Call Any person at any time may initiate a call for a Rapid Response Team by calling the emergency number Teams available for calling are: 1. Condition C 2. Condition A 3. Stroke Assessment Team (SAT) 4. Sepsis Team 5. Pediatric Condition 6. Condition H - Help 7. Condition M 8. Condition L - Elopement Criteria for Initiating Condition C (Crisis) Any person may initiate a Condition C or A call at any time a rapid response of critical care professionals is desired. A Condition C Team response should be used to prevent a crisis or to prevent a crisis from escalating. The following practice guidelines are intended to assist clinicians in decision-making by describing criteria for situations where it is reasonable to initiate a Condition C Team response. These criteria attempt to meet the needs of most patients in most circumstances. The ultimate judgment for initiating a Condition C must be made by the bedside clinician in light of circumstances specific to that situation. General Guideline: Any concern for a deteriorating clinical condition. Respiratory: Difficulty in breathing Increased Work of breathing and/or use of accessory muscles New pulse oximeter readings < 85% for more than 5 minutes and/or new requirements for more than 50% oxygen to keep saturations > 85% Sustained respiratory rate <10 or > 30. Excalating oxygen requirements

40 SHADYSIDE CAMPUS PAGE 34 Hemoptysis or bleeding in the upper airway Dislodged artificial airway Cardiovascular: New onset Chest Pain or recurrent chest pain unrelieved by medication. Hypotension sustained SBP < 90 mmhg Hypertension sustained SBP > 200 mmhg or DBP > 120 mmhg Tachycardia new onset sustained HR > 120 Bradycardia new onset sustained HR < 50 Cyanosis, mottling or pallor of an extremity SIRS/Sepsis The Sepsis Team will be activated when the patient presents with two or more of the SIRS Criteria. The Condition C may also activated when the patient is unstable: HR > 90 RR > 20 or PaCO2 < 32 mmhg WBC > 12,000/mm 3 or < 4,000/mm 3 Temp >38 C or < 36 C PLUS one of the following: SBP >90 mmhg Lactate > 2 Suspected or confirmed infection Acute Neurologic Change: Stroke Assessment Teams (SAT) will be activated for suspected stroke patients. Condition C Treatment Leader may also activate the SAT. At UPMC Shadyside the Stroke Assessment Team is activate for a patient that is stable presenting with stroke symptoms. Seizures (outside of seizure monitoring unit) Sudden change in responsiveness, consciousness, confusion, speech or understanding New onset unexplained weakness, paralysis loss of balance or coordination

41 PAGE 35 Sudden onset blindness or visual disturbances in one or both eyes Severe onset headache Delirium requiring intravenous medication administration in > 65 year olds or unexplained agitation. Other: More than 1 STAT page required to assemble team needed to respond to a crisis Narcan use without immediate response Bleeding: hematemesis, hematochezia or surgical site hemorrhage Pregnancy heavy vaginal bleeding (>100cc), urge to push, sudden gush of fluid from vagina, severe abdominal or back pain, crowning of fetus or fetal distress noted on continuous monitoring Condition A Criteria any patient without respiration or circulation. Stroke Assessment Team (SAT) Stroke Assessment Team (SAT) is available for assessment and acute management of suspected cerebrovascular events. When a patient is unstable the SAT and Condition C Team may be activated simultaneously. When a patient presents with stroke symptoms in the Emergency Department, ICU or Cardiac Cath Lab and an attending physician is available for phone consult with the Acute Stroke Team through MedCall. Pediatric Condition Any change in condition or concern regarding the condition of a pediatric patient by the nurse, physician, respiratory therapist or parent. Condition H Condition H may be activated by patients or family members. A Condition H is to be used when: A breakdown in how care is being managed or there is confusion about the plan of care and the healthcare team is not responding to their questions/concerns. A noticeable clinical change in the patient and the healthcare team is not responding to their concerns.

42 PAGE 36 Condition M Condition M is a behavioral code that is called for a patient or visitor who is experiencing a crisis that could pose a potential threat to themselves, patients, staff or visitors. Condition L A non-medical crisis that involves a patient, usually disoriented or confused, that has left the unit without authorization. Condition L is activated to located the patient and return them to a safe patient environment. Upon locating the patient other teams may be activated pending the specific patient needs.

43 Initiation of Response SHADYSIDE CAMPUS PAGE 37 APPENDIX B Location Number to Call Response Team Aiken Professional Building Family Health Center Hillman Building Research Side Hillman Building Clinical Side Hospital Garages & Outside Perimeter (When emergency transport is required Pittsburgh Emergency Medical Services Pittsburgh Emergency Medical Services Pittsburgh Emergency Medical Services Hillman First Response Team Shadyside Rapid Response Team Pittsburgh Emergency Medical Services after hours Shadyside Rapid Response Team Emergency Department Team Pittsburgh Emergency Medical Services Medical Center Offices Hillman Cancer Pavilion Offices (When emergency transport is required) (When emergency transport is required) Shadyside Rapid Response Team Pittsburgh Emergency Medical Services Shadyside Rapid Response Team Pittsburgh Emergency Medical Services Preservation Hall (When emergency transport is required Shadyside Place Emergency Department Team Pittsburgh Emergency Medical Services Pittsburgh Emergency Medical Services North Tower (School of Nursing) (When emergency transport is required) Shadyside Emergency Event Team Pittsburgh Emergency Medical Services UPMC Shadyside Shadyside Emergency Event Team UPMC Shadyside Roof Area (When emergency transport is required Shadyside Rapid Response Team Pittsburgh Emergency Medical Services

44 Appendix C UPMC Shadyside Rapid Response Team Inpatient Stroke Activation Algorithm SAT Team Responsibilities: Initiate oxygen therapy to keep Sa02>92% HOB 30 unless contraindicated Continuous cardiac monitoring Complete NIHSS Note Last Known Normal Enter CT Order in Cerner Non contrast CT within 20 minutes Activate PUH ACUTE STROKE TEAM VIA MED CALL Consider CTA of head and neck Keep NPO until Bedside Swallowing Screen (BSD) Document: Assessment/Treatment/Plan of Care/Conversation with PUH Neurology Bedside RN Responsibilities Apply cardiac monitor/obtain vital signs/blood glucose Note Last Known Normal Provide Patient History/Nurse Handoff Report to Team CT no hemorrhage probable ischemic stroke Patient with sudden onset stroke symptoms Facial Droop/Arm Weakness/Speech Changes/Time is Brain (FAST) Apply cardiac monitor, obtain vital signs and finger stick glucose. Treat hypoglycemia. NOTE LAST KNOWN NORMAL Dial the Emergency Number: and request the appropriate RRT. HEMODYNAMICALLY STABLE Activate Stroke Assessment Team (SAT) NSICU RN and CCM Resident NOT HEMODYNAMICALLY STABLE Activate Condition C Return from CT reevaluation by CCM or neurologist Complete history (focused for rtpa exclusion criteria) Physical/neuro exam Lab Work if not already completed (CBC, CMP, Coags) Maintain normothermia and normoglycemia CONDITION C TEAM WILL TREAT AS APPROPRIATE CCM/ Physician may directly contact the PUH Acute Stroke Team for treatment guidelines Abbreviated Criteria for Initiating a Condition C: Respiratory: SaO2 <85% for more than 5 minutes or 50% or more oxygen demand to keep >85%; Rate of <10 or >30; Hemoptysis Cardiovascular: SBP <90 or >200; DBP>120; HR <50 or >120; SIRS/Sepsis Acute Neurological Changes: Unstable suspected stroke; seizures; severe new onset headache; sudden change in responsiveness; consciousness If team suspects a stroke event has occurred, follow same guidelines as SAT Team. If stroke confirmed follow Ischemic and Hemorrhagic guidelines below. Blood on CT hemorrhagic stroke Possible IV rtpa Candidate Symptom onset to administration of rtpa 180 minute max (earlier better) Transfer to NSICU Refer to rtpa Order Set / Screening Rule out contraindications Start 2 nd IV if not done Manage BP if > 185/110 Consider need for foley, OG/NGT and insert before infusion MD to explain risk/benefits Nursing care per rtpa order set If rtpa given: NIHSS/BP q 15 min during admin & then for 2 hrs q 30 min for 6 hrs q 1hr for 16 hrs Not a rtpa Candidate MD to document reason not given Notify attending MD Obtain Neurology Consult Manage BP if SBP>220 and/or DBP>120 Continue cardiac monitor Perform BSD Give ASA PO/PR if CT neg for bleed Initiate Ischemic Stroke Order Set Transfer to appropriate unit (NSICU, 6W, 3E or 5M) 2011 Stroke Protocol NPO until BSD Screen with speech evaluation VTE Prophylaxis (SCDs) Rehabilitation Evaluation (PT/OT/SLP) NIHSS per unit routine Stroke Education TIA/Ischemic add: Antithrombotic Fasting Lipid Panel/Statin Intracerebral Hemorrhage (ICH)/Subarachnoid Hemorrhage (SAH) Transfer to NSICU Obtain Neuro Surgery Consult Assess need for airway Seizure precautions Manage BP keep SBP<160 and/or DBP<90 HOB 30 unless contraindicated Perform BSD Consider need for Foley, OG/NGT Treat elevated coags Be prepared for possible OR References: Rapid Response System SHY Campus, 2010 American Stroke Association Protocols for Ischemic Stroke, 2009; Intracerebral Hemorrhage, 2007; Aneurysmal Subarachnoid Hemorrhage, 2009 (bmm 6/11) Suspected Stroke Requires Immediate Evaluation and Treatment: TIME IS BRAIN!

45 Appendix D Roles 1. Airway Manager 2. Airway Assistant 3. Bedside Assistant (Usually Floor RN and ICU Nurse Support) 4. Crash Cart Mgr (ICU RN & Pharmacist) 5. Treatment Leader 6. Circulation 7. Procedure MD (NP/ PA) 8. Data Manager (Floor Nurse or ICU RN) Aide Responsibilities Assess, count respiratory rate, assist ventilation, intubate, check pupils Assist airway manager, oxygen and suction setup, suction as needed, monitor pulse oximetry Report to team SBAR. Check pulse, obtain vital signs, pulse oximeter placement, assess patent IV s, push meds, capillary blood sugar Deploy equipment, bag-valve-mask, backboard, pads, suction, paper record, prepare meds, run defibrillator Assess team responsibilities, data, direct treatment, set priorities, triage patient. (Could be ICU RN until the MD arrives) Check pulse, place defib pads, perform chest compressions Perform procedures, IVs, chest tubes, ABGs Role tags, AMPLE, lab results, chart, record interventions Bring capillary blood sugar machine, patient chart and other requested equipment DeVita, 2005 Ancillary Nursing Coordinator support and bed acquisition Transport - stretcher Security crowd control and transport assistance

46 Appendix E UPMC Shadyside Intensivist Bag Supply List Quantity Supply 2 #7.0 cuffed ETT with stylettes 3 #7.5 cuffed ETT with stylettes 3 #8.0 cuffed ETT with stylettes 2 #8.5 cuffed ETT with stylettes 4 end-tidal CO2 detectors 4 sets of headgear 10 10cc syringes 10 packets of Surgilube 2 Yankuer Nasopharyngeal Airways (Sized 7, 7.5, 3 and 8) 10 Sterile tongue blades 1 #6 Shiley cuffed trach 1 #4 Shiley cuffed trach 1 Cudet tipped disposable Bougie 2 #15 Blade scalpels 2 Spare trach ties Melkor Cricothyrotomy Kit with a cuffed 1 cric tube 2 MacIntosh #3 blades 2 MacIntosh #4 blades 2 Miller #3 blades 1 Miller #4 blade 2 Laryngoscope handles 1 Bottle of Benzocaine Spray 1 Tub of 5% Lidocaine Ointment 1 Pair of Magills forceps Etomidate and Succinylcholine in ICU 1 intubation pack 6 Small biohazard bags Checked by: Date:

47 APPENDIX F Locations of Emergency Crash Carts with Defibrillators & AEDs Location Floor Area/Cart Location Floor Area/Cart Pavilion 1 MRI South 2 Med Surg ICU Pavilion 1 Nuc Med #1 South 2 Ortho Pavilion 1 Per Vasc Lab South 3 Dialysis Main 1 Radiology Film Room South 4 Cardiology Main 1 Radiology Rm A-1 South 5 Cath Lab #1 Main 1 Radiology Rm A-2 South 5 Cath Lab #2 East 1 GI Lab #1 South 5 Cath Lab #3 East 1 GI Lab #2 West 1 Non-Invasive Cardiology East 2 ASC West 2 PACU East 3 Family Practice Teaching West 3 Medical ICU #1 East 4 Medical Cardiology #1 West 3 Medical ICU #2 East 4 Medical Cardiology #2 West 3 Medical ICU #3 East 5 Short Stay West 4 Neurosurgical ICU #1 West 4 Neurosurgical ICU #2 Main 1 ED MAC West 4 SICU Cart #1 Main 1 ED Main Cart #1 West 4 SICU Cart #2 Main 1 ED Main Cart #2 West 5 Orthopedics Main 2 Cardiothoracic ICU #1 West 6 Neuro/Surgical Main 2 Cardiothoracic ICU #2 West 7 ABMT #1 Main 2 Cardiothoracic ICU #3 West 7 ABMT #2 Main 2 DAS Cart #1 Main 2 PRE-OP HOLDING AREA Main 1 Broselow Pediatric Cart ED Broselow Pediatric Cart Main 3 Cardiothoracic Surgery #1 Main G Backup Main 3 Cardiothoracic Surgery #2 Main 4 Surgical Oncology Main 5 Oncology AED Locations Main 6 Pulmonary Medicine 1 West Wing, Garage Elevator Area Main 6 Pulmonary Medicine 1 Aiken Building Main 7 Oncology #1 1 School of Nursing Main G JROC Hillman Cancer Center Pavilion 2 Ortho Floor Area/Cart Pavilion 3 Medical Cardiology G Security Desk

48 PAGE 42 1 Beckwith 1 Radiology Control Room Pavilion 4 Invasive Cardiology #1 2 Treatment Area Pavilion 4 Invasive Cardiology #2 3 Treatment Area Pavilion 5 Invasive Cardiology 4 Treatment Area Urologic Comprehensive Care 4 Pavilion 6 Pavilion 7 Program Urologic Comprehensive Care Program Med. Ctr. 1 Professional Office Building Med. Ctr. 5 Cardiopulmonary Rehab 2 2 Treatment Area Pharmacy Broselow Pediatric Cart Treatment Area

49 Crash Cart Contents List (Revised 2012) Drawer 1 APPENDIX G 3 Adenosine 6mg/2ml vial 2 Furosemide 100mg/10 ml 1 Nitroglycerin SL tab 1/150 6 Amiodarone 150mg/3 ml 2 Haloperidol 5mg/ml 4 Norepinephrine 4mg/4ml 4 Aspirin 81mg (chewable) tablet 2 Hydralazine 20mg/ml Phenylephrine 100mg/10 ml 1 MDV 1 Clopidogrel 300mg tablet 2 Hydrocortisone 250mg/2ml 4 Phenytoin 250mg/5ml 1 Diphenhydramine 50 mg/ml 2 Magnesium Sulfate 1 gm/2 ml 7 Vasopressin 20 units/1 ml 1 Epinephrine 1mg/ml 30 ml MDV 2 Metoprolol 5 mg/5 ml Emergency Cart Information 1 Booklet 2 Flumazenil 0.5 mg/5 ml 2 Naloxone 0.4 mg/ml Emergency Event Flowsheet 2 Sodium Chloride 0.9% 10 ml 2 (Form#06-040) Drawer 2 3 Atropine 1mg/10 ml 1 Dopamine 400mg/250ml D5W Premix 1 Lidocaine 2gm/250ml Premix 2 Calcium Chloride 1gm/10ml 8 Epinephrine 1:10,000 10ml 1 Magnesium Sulfate 4gm Premix 1 Dextrose 50% 50ml 2 Labetalol 20mg/4ml 6 Sodium Bicarbonate 50meq/50ml Dobutamine 1000 mg/250ml 1 Premix 5 Lidocaine 100mg/5ml Drawer 3 20 Alcohol Wipes 2 Instrument set w/suture 2 Stopcock (Single) 1 Angiocath 14G x 2" 3 IV Start Kit 3 Syringe 3 ml 2 Angiocath 16G x 3 1/4" 10 Medication Added Label 12 Syringe 10ml 1 Angiocath 18G x 1 1/4" 10 Needle (Filter) 19G 2 Syringe 20ml 1 Angiocath 20G X 1" 5 Needle 18G x 1 1/2" 1 Syringe 60ml 1 Quad-Lumen Central Line 1 Needle 20G x 3 1/2" Spinal 1 Tape 1" Cloth 1 Betadine Solution 1 Push Button Blood Collection Set 1 Tape 1 Transpore 2 Biohazard Specimen Bags 12 Normal Saline 10 ml Flush 2 Tourniquet (Latex-Free) 2 Blood Transfer Device 2 Polyskin Dressing 5cmx7cm 2 Vacutainer Needle 22G 6 Blue Cap (M20018) 4 SmartSite Port (2000E) 4 Vacutainer Holder (Clear) 2 Central Line Dressing Kit 2 SmartSite Extension Set ( ) 2 Vacutainer Holder (Luer Lock) 2 Chloraprep 1 Sorbaview Dressing 10 Vial Access Pin (2201) 2 Frepp 2 4x4 Gauze Sterile Boat Drawer 4 1 D5W 100 ml Bag 1 INFU-STAT Pressure Infuser 4 Secondary Set (72007N) 1 D5W 250 ml Bottle/Non-DEHP Bag 2 Normal Saline 100 ml Bag 4 SmartSite Infusion Set ( ) 1 D5W 1000 ml Bag 4 Normal Saline 250 ml Bag 2 Smartsite Extension Set (20028E) 1 Hextend 500ml 3 Normal Saline 1000 ml Bag Drawer 5 2 Barrier Kit 1 16 FR Salem w/reflux RESPIRATORY BOX 1 Connector, 5-in-1 1 Suction Cannister 5 Arterial Blood Gas Sampling Kits 1 Flashlight w/batteries 1 Suction Regulator 1 End Tidal CO2 Detector BX Gloves, Nitrile Latex-Free MEDIUM 1 Suction Tubing 6 1 Head Gear - Intubation 3 Gloves, Sterile MEDIUM 3 Surgilube Packets 2 Suction Catheter Kit 14FR 3 Gloves, Sterile LARGE 1 Yankauer Suction Tip 1 Nasal Trumpet 26 FR 1 Hazardous Waste Bag 6 N95 Mask 1 Nebulizer w/tubing

50 PAGE 44 Outside of Cart Respiratory Bag (Hang on Cart) 1 Backboard 1 Emergency Cart Booklet 1 Ambu Bag 1 Cart Contents List (Attached to side shelf) 1 Razor 3 Airways 80mm, 90mm, 100mm 1 Oxygen Tank (Must be above 1000 PSI) 9 Blood Tubes 1 Oyxgen Flowmeter 2 Zoll Defib Multi Purpose Pads 1 Sharps Container 1 Mask, Oxygen non-rebreather 5 Emergency Event Flowsheet (Form # ) 1 Peep Valve (Adjustable)

51 APPENDIX H Responder Zones NS-ICU & SICU (1 Nurse from each unit) 4M 6M 5W 6W West Wing Concourse Library WW Conference Rooms West Wing Testing Medical Building North Tower (School of Nursing) West Wing Courtyard Back up to any area when there are simultaneous second events. MICU/CCU (2 Nurses) 7M 7W 5M Cafeteria Gift Shop 1 West Respiratory Therapy 1 Main, Information Desk Non-Interventional Cardiology Posner Courtyard & Lobby (1 Main Entrance Area) Roof Main & West Towers Hillman Cancer Center Cancer Pavilion (Herberman Conference Center) Responsibilities NS-ICU - Backboard as needed to Posner, Main and West Wing areas. SICU / NS-ICU - Backboard is stored in the West Wing Closet with emergency cart. Obtain when needed for the West Wing areas. Pharmacy will bring emergency cart from the West Wing closet to non-patient care areas. West Wing Closet also houses small patient carrier. MICU/CCU - Backboard is stored in the West Wing Closet with emergency cart. Obtain when needed for Main and Posner areas. Request backboard from NS-ICU for 7M or 7W events. Hillman has backboard equipment. Pharmacy will bring emergency cart from the West Wing closet to non-patient care areas. With CT-ICU (1 Nurse) 3 Main CT-ICU & MS-ICU (1 Nurse from each unit) Basement (includes JROC) 1P 1E 1S 2P 2E 2S 2M 3P 3E 3S (Dialysis) 4P 4E 4S 5P 5E Cath Lab 6P/7P Emergency Department Pavilion & East Wing Roof Radiology, MRI, Ultrasound GI lab East Entrance Information Desk Back board when requested to basement, all East, Pavilion and Posner and Main lobby areas. Request from ED. Pharmacy will bring crash cart to basement areas. CT-ICU Invasive Cart when requested to any event CT-ICU with MICU/CCU (1 Nurse) 3M CT-ICU, 1 nurse only to PACU, helipad and ED Staff only, equipment only on request.

52 Emergency Department Pediatric Crisis any area Outside Perimeter, Parking Garages 1 Main, Information Desk Main Driveway Posner Courtyard & Lobby Radiology, MRI, Ultrasound GI lab East Entrance Information Desk SHADYSIDE CAMPUS PAGE 46 High risk areas for pediatric patients: JROC & Hillman Cancer Center. Bring Pediatric Crash Cart to JROC Back board when requested to basement, all East, Pavilion, and Main lobby areas. Rev. Feb/2013

53 Appendix I Respiratory Therapy Responder Zones DISTRIBUTION OF RESPIRATORY RAPID RESPONSE TEAM PAGERS 1. The shift supervisor will respond and delegate at all emergent events (Condition A/C). Beeper # The Surgical therapist will respond to all Condition A and C s in the following areas: West Wing, Posner Tower, PCI (Hillman), and Physician Office Building. Beeper # The Medical/CCU therapist will respond to all Condition A and C s in the following areas: West Wing, Posner Tower, and Physician Office Building. Beeper # The Cardio-Thoracic therapist will respond to all Condition A and C s in the following areas: Pav, South, East, Emergency Room. Beeper # The ABG therapist will report to the ABG Lab and then if needed will respond to all Condition A and C s in the following areas: Pav, South, East, Emergency Room. Beeper # The Pav/South therapist respond to all Condition A and C s in the following areas: Pav, South, East, Emergency Room. Beeper # The 6 Main therapist will respond to all Condition A and C s in the following areas: West Wing, Posner Tower, and Physician Office Building. Beeper # The Calls Person will respond to all STAT calls to the Emergency Room

54 General Overview: Emergency Event Elevator Operation APPENDIX J Emergency Elevator keys {Are we going to be using card access now?} are carried by Respiratory Therapy, ICU Nurse Responders and Anesthesia. Same key activates all Emergency Elevators. The key switch calls all elevators tied to that switch and calls them to floor that activates the switch. Both elevators will respond. Emergency Elevators: West Wing Elevators (#17, #18 and #19) There are 2 separate Emergency Elevator Key Switches. There is a key switch between elevators 17 (Patient Use Only Elevator) and 18 that calls these 2 elevators and a second switch between elevator 18 and 19 that calls these 2 elevators. This elevator has activation switches on all floors. Key switches are identified by only a blue ring around the keyhole. Most frequently used elevator. Access to West and Posner wings. Responders from CCU, MS-ICU, NS-ICU and Anesthesia will use this elevator. Patient will most frequently be transported by this elevator. Operation: Key switch will activate two elevators, operator choice to activate entire bank by using both key switches. Once the elevator responds, the key needs to be used on the inside key switch. Insert the key, turn to on, press the selected floor button, press the door close button and hold until the door completely closes. The door will then open on the selected floor and stay open as long as the key activation switch is in the on position. Operator must turn the elevator off and remove the key to release the elevator. Key can be removed in the on position and lock the elevator to that floor with the door open.

55 PAGE 49 Posner (Main) Elevators (#10 and #11) This elevator only has an activation switch on the second floor. This elevator would be accessed by second floor staff responding to events. This key switch has a button that illuminates when the key switch has been activated to inform the caller the system has responded to the call. Operation: Key switch will activate both elevators. Once the elevator responds, the key needs to be used on the inside key switch. Insert the key, turn to on, press the selected floor, the door will close automatically. There is no door close button on this set of elevators. There is an internal elevator button that illuminates over the key switch to inform users that emergency event elevator system has been activated. Main Tower, Heliport Elevator #28 This elevator has activation switches on all floors. This elevator has access to the heliport and the roof. Operation: Once the elevator responds, the key needs to be used on the inside key switch. Insert the key, turn to on, press the selected floor button, press the door close button and hold until the door completely closes. The door will then open on the selected floor and stay open as long as the key activation switch is in the on position. Operator must turn the elevator off and remove the key to release the elevator. Key can be removed in the on position and lock the elevator to that floor with the door open. Pavilion (#1 and #2) This elevator has activation on 2 only. This elevator is a secure elevator.{we no longer have Labor and Delivery.} Operation: Once the elevator responds, the key needs to be used on the inside key switch. Insert the key, turn to on press the selected floor button, press the door close button and hold until the door completely closes. The door will then open on the selected floor

56 SHADYSIDE CAMPUS PAGE 50 and stay open as long as the key activation switch is in the on position. Operator must turn the elevator off and remove the key to release the elevator. Key can be removed in the on position and lock the elevator to that floor with the door open. Holding the selected floor button in, will also close the doors on this elevator, the button must be held until the door closes completely. This elevator is also activated internally with a swipe card. East JROC These 2 elevators have switches on all floors. Operation: Key switch will activate both elevators. Once the elevator responds, the key needs to be used on the inside key switch. Insert the key, turn to on, press the selected floor and hold the selected floor button until the door closes completely. There is no door close button on this set of elevators. This is an elevator that travels between 2 floors. There is no key activation for this elevator. JROC can be reached by the West elevators or the Main elevator #28. Medical Center Offices (#21 and #22) When approaching Medical Center Building from the hospital, the elevators on the right are the key switch activated elevators. Operation: Key switch will activate both elevators. Once the elevator responds, the key DOES NOT need to be used on the inside key switch. Press the selected floor and hold the selected floor button until the door closes completely.

57 PAGE 51 NOTE: For Emergency Events in Medical Center Building 1 and Medical Center Building 2, the crash cart is stored in a locked closed next to the Hopwood Library and has a swipe mechanism for unlocking. It is recommended the ICU staff that will respond to these areas will have a swipe card attached to the elevator key. NOTE: To access Medical Center Building 2 and Hillman Building after hours, a swipe card is needed. The Emergency Response plan does not require staff to respond after 5:00 p.m., before 7:00 a.m. or on weekends and holidays. The same swipe card that will unlock the closed with the crash cart will activate the door switch. Hillman Cancer Pavilion Offices There is no emergency event key access to this set of elevators. The far left elevator has a card swipe that will call the elevator. This can be the same card that is issued to unlock the closet door for the crash cart. Operation: Use the swipe card to activate the emergency call, enter the elevator and use the swipe card on the internal card swipe, press the floor button and close door button until the door closes completely. Key Distribution: Anesthesia Respiratory Intensivist CT-ICU MS-ICU NS-ICU CCU SICU ED

58 Appendix K PHARMACY ADJUNCT CODE BOX CONTENTS 2 Albuterol Neb 0.083%- 3ml 2 Methylprednisolone 125mg/2ml 6 Alcohol wipes 2 Calcium Gluconate 10% -10ml 5 Midazolam 2mg/2ml 2 Code Box Charge Sheet 2 Diazepam 10mg/2ml 2 Morphine 5mg/1ml 4 Blank IV labels 1 Diltiazem 25mg/5ml 2 Phenobarbital 130mg/ml 1 Carpuject 2 Etomidate 40mg/20ml 3 Procainamide 1000mg/2ml 4 18G safety needles 2 Fentanyl 100mcg/2ml 1 Propofol 10mg/ml -50ml 2 10ml Syringe 1 Glucagon 1mg kit 2 Racemic Epinephrine neb 2.25% 0.5ml 2 5ml Syringe 1 Glucose Gel 2 Sterile Water for inj 10ml 4 3ml Syringe 1 Insulin Regular 100 units/1ml 1 Succinylcholine 200mg/10ml 2 Insulin Syringe 2 Lorazepam 2mg/1ml 2 Vecuronium 10mg vial 2 Filter Straw

59 UPMC Shadyside EMERGENCY CART DAILY CHECK LIST SHADYSIDE CAMPUS PAGE 53 Appendix L Appendix L 90 & 100 mm oral airway Emergency Event Forms and RRS Emergency Cart Information Unit/Area Month Year Booklet Blood Tubes: 2 Red tops, 2 Gold, 2 Purple, 1Blue, 1 Seal number and drug expiration date must be recorded daily. Gray, 1 If Green a cart is used and replaced or checked by pharmacy, document on reverse side date when a cart or lock is changed. Place an * in the date box if there are comments written on the reverse side. If unit is closed, Replace write outdated closed blood for tubes that and day. MFPs If crash cart needs a new lock, there are expired drugs or supplies please notify pharmacy at This form is to remain on the unit for 1 year. Date Seal number Crash Cart Maintenance Log (Yellow Form on top of cart) Expiration Date: Blood Tubes Within Expirati on Date: Emergency Equipment Locked Emergency Cart with full oxygen tank, back board and needle box Defibrillator with cable attached to multifunction pads (MFPs), second set of MFPs, pulse oximeter cable and probe, NIBP tubing and cuff, ECG electrodes, razor Respiratory Bag with bag-valve-mask, PEEP valve, nonrebreather face mask, oxygen flow meter with nipple, 80, Emergency Equipment (Listed Above) Checkmark Defibrillator Check Performed Completing the below information is verification the Defibrillator Check was performed (Procedure on back of this form). Defibrillator First MFP Control Number Expiration Date Example /17/2012 3/ /5/13 NCM Initial s Form Rev: 2/1/12 Page 1 of 2

60 PAGE 54 UPMC Shadyside EMERGENCY CART DAILY CHECK LIST Date Note Name Example: 2/1/12 Seal broken, cart used. Pharmacy notified and new cart supplied, seal #12456 placed on cart. Cherry Ames, RN ZOLL M SERIES DEFIBRILLATOR MONITOR DAILY CHECK Daily Visual Inspection 1. Verify that the instrument is connected to AC power and the Charger On light is illuminated. 2. Check that the unit is clean and nothing is stored on the unit. 3. Inspect the unit, accessories, all cables, cords and connectors for damage, cuts in the insulation, or bent and broken connector pins. Verify ECG cable, pulse oximeter cable, NIBP cuff and tubing are attached. 4. Verify that two sets of multi-function electrodes (MFPs) are available. One set must be connected to the multifunction cable connector and a second set is on top of the crash cart. 5. Verify that all needed disposable supplies are available, in proper condition, and not expired - ECG electrodes, recorder paper, razor. Defibrillator Check: 1. Unplug defibrillator from wall outlet to test battery operation. 2. Turn the main selector switch to Monitor, 4- beep tone heard. 3. Monitor message on display. ECG size x 1, Pads as lead selected. 4. Remove the cable from the disposable pads connector and connect the cable to the black test connector. 5. Turn the main selector switch to Defib and set energy level to 30 joules. 6. Press record and press the CHARGE button, at the tone, press SHOCK button. 7. Verify TEST OK message on screen. 8. Remove the cable from the black test connector and re-connect the cable to the disposable MFPs connector. 9. Plug the unit back into AC power. Pacer Functionality Test: 1. When testing pacing function, remove multifunction cable from MFPs. 2. Turn to PACER, set pacer rate to 150 ppm, press Recorder button. 3. Check the rhythm strip for pace pulses that should occur every 2 large squares (10 small squares). 4. Press 4:1 button, pace pulses should occur every 8 large squares. Press the Recorder button to stop strip. 5. Verify that PACER OUTPUT defaults at 0mA and that there is no CHECK PADS message. 6. Turn PACER OUTPUT to 16mA, verify CHECK PADS message appears on display and pace alarm sounds. 7. Turn PACER OUTPUT back to 0mA and press Clear Pace Alarm. 8. Turn defibrillator off. Reconnect MFPs to the multifunction cable with the red end. Form Rev: 2/8/12 Page 2 of 2

61 PAGE 55 Appendix M EACH ROLL CONTAINS 1 3 MAC blade/handle 1 3 Miller blade/handle 1 4 MAC blade/handle 1 4 Miller blade/handle 2 - CO2 detectors 1 head gear 1 PEEP valve ET tube ET tube ET tube ET tube ET tube ET tube 2 stylets 1 Bougie 1 Yankauer sx 1 sx catheter 2 oral airways (90mm, 100mm) 4 nasal airways (6.5, 7.0, 7.5, 8.0) 2 10cc syringes 2 surgilubes SECURED WITH 1 RED PULL-TITE PLASTIC LOCK

62 Campus Map SHADYSIDE CAMPUS PAGE 56 Appendix N The defined area that the team will respond to is: Aiken Avenue Visitor Parking Garage Centre Avenue Visitor Parking Garage Aiken Avenue Employee Parking Garage Driveway from Aiken Avenue back through the loading docks of the Shadyside Hospital. Driveway to the street at the main entrance on Centre Avenue. Alley between the Aiken Avenue Visitor Parking Garage and the hospital building. Driveway to the street at the Medical Building entrance.