Title: Nursing Chain of Command for Deterioration of Patient Condition and/or Medical Follow-up DESCRIPTION/OVERVIEW This procedure provides patient care staff guidance for ensuring effective communication and patient care when the usual chain is disrupted due to unusual circumstance. Three algorithms are discussed in this document: Chain of command: Provides nursing with the necessary direction to move up the chain as patient care warrants (Attachment A) Deterioration in Patient condition: Provides nursing with the necessary direction to escalate medical support (Attachment B) and seek immediate in-house medical back-up Activation of the Rapid Response Team (RRT): Provides nursing with the necessary direction to activate the RRT when a patient condition changes, or is suspected of changing, and the medical support is not readily available (Adult Attachment C, Pediatric Attachment D). REFERENCES Applies To: UNM Hospitals Responsible Department: Nursing Leadership, NEC Procedure Patient Age Group: ( ) N/A ( ) All Ages ( ) Newborns (X) Pediatric (X) Adult Protecting 5 Million Lives from Harm Campaign, Institute for Health Care Improvement (IHI), 2007. Rapid Response Team Decreases Code Events and Unexpected Patient Deaths Outside the ICU (IHI), retrieved April 2018 www.ihi.org AREAS OF RESPONSIBILITY Registered Nurse (RN) Primary care team Licensed Independent Practitioner (LIP) including cross cover Physician Assistant (PA) including cross cover 333 Operator Rapid Response Team (RRT) Administrative Supervisor (Admin Sup) PROCEDURE Changes in the condition of the patient are determined by assessments utilizing parameters defined in clinical practice guidelines, LIP or PA orders, the patient's previous condition, by patient safety factors, and by nursing judgment. Page 1 of 8
1. The RN notifies the responsible LIP or PA utilizing appropriate channels and chain of command. tify LIP or PA in the following order unless otherwise indicated by provider order, by routine or service, or as indicated by the patient condition (Attachment A): 1.1 Primary care team who is medically responsible for the care of the patient; 1.2 Licensed Independent Practitioners (LIPs) 1.3 Senior and/or Chief Resident and/or Fellow (if applicable); 1.4 Attending Provider 1.5 Medical Director 1.6 Service Chief/Department Chair 1.7 Executive Medical Director 1.8 Clinical Affairs On-call 1.9 Some services have additional resources (example: the on-call doctor with the medicine service, Intensivist for the ICUs) and those are considered within the procedure. 2. For ongoing concerns with provider response, the RN must notify appropriate nursing leadership for support and/or to pursue unresolved issues (Attachment A): Weekday Dayshift: RN Supervisor, Unit Director, Executive Director, and Chief Nursing Officer. Nightshift/Weekend Dayshift: RN Supervisor, Administrative Supervisor, Administrator On-call. 3. If there is no response and the situation warrants rapid intervention, call 333 to initiate the RRT for assistance and contact the Administrative Supervisor (Attachment B) 3.1. For all RRT calls initiated due to acute patient instability, the administrative supervisor is required to contact the attending and escalate the chain of command. 3.2. Patients who are actively and rapidly deteriorating may be moved to an ICU bed immediately. If no ICU bed is available on the appropriate service, the Administrative Supervisor will contact the T12 provider and then facilitate transferring the patient to T12, if room available. 4. Document in the medical record the date, time, and name of each LIP or PA notified, actions taken, and/or patient's response to treatment. 5. When the ICU team responds, the team will contact their fellow or attending for any situation in which they believe the patient does not need a higher level of care. In situations where the required level of nursing care will exceed the unit resources, the Administrative Supervisor will use the chain of command to resolve the situation. 6. The RN will perform an initial admission assessment that should be documented and serve as the baseline from which subsequent assessments should be compared in order to determine significant changes that warrant nursing intervention including notification of the LIP or PA. 7. The RN is responsible for communicating patient status, changes and/or any condition that may warrant additional treatment to the LIP or PA. 8. The RN should use the unit standards of care, LIP or PA orders for patient parameters, or RRT triggers for guidance as needed. 9. Condition changes that warrant notification of a LIP or PA may include, (but are not limited to): 9.1. Deterioration in level of consciousness 9.2. Alteration in temperature 9.3. Deterioration of vital signs 9.4. Alteration in urine output 9.5. Critical lab results Page 2 of 8
9.6. Evidence of bleeding or infection 9.7. Changes in cardiac rhythm 9.8. Chest pain/shortness of breath 9.9. Increased complaints of pain, despite medication 9.10 Continued deterioration in patient condition despite interventions 10. The RN should notify the LIP or PA if initial received orders and subsequent interventions do not resolve the patient condition. 11. The LIP or PA is responsible for responding in a timely fashion and giving clear direction. 12. If the RN has concerns with regard to the therapeutic interventions, these concerns should be shared with the LIP or PA, and then the next level of the medical team and nursing chain of command. The attending will be notified by the resident of there is a level of care transfer. 13. Documentation essentials; 13.1 Significant changes in patient status are documented in the electronic medical record (EMR) using status change notification: including the who, what, where and when of pertinent communications and outcomes. 13.2 Rapid Response Team members also complete a Rapid Response Log. 13.3 A Cardiopulmonary Arrest Record is completed for patients in cardiac arrest. te: If you feel that the LIP or PA interventions are insufficient to meet the needs of the patient continue to use the Nursing and Provider Chains to ensure the care provided is appropriate or if additional interventions are warranted. BEHAVIORAL HEALTH INPATIENT AREAS Activate a RRT by calling 333 and contact the Administrative Supervisors to respond to deterioration in a patient s medical condition. Significant changes in patient status are documented in the EMR and the medical emergency response form. Such documentation includes the who, what, where and when of pertinent communications. The RRT and LIP or PA will determine if 911 needs to be called for assistance and ambulance transfer to an emergency room DEFINITIONS 333: UNM Hospitals Internal Emergency Management phone number Chain of Command (COC): the progressive escalation in seniority rank of personnel on the medical and nursing leadership teams. Rapid Response Team (RRT): the multidisciplinary team that responds to a staff call for assistance for a patient s whose condition has deteriorated. T12: Resuscitation bed in TSICU Room 12 SUMMARY OF CHANGES Administrative Supervisor on-duty changed to Administrative Supervisor Hospital emergency phone numbers changed to 333 Medical response team changed to rapid response team T12 critical care bed resource added RESOURCES/TRAINING Page 3 of 8
Resource/Dept Clinical Education BATCAVE UNMH Policy, Procedure & Guidelines Contact Information http://hyper.unm.edu/unmh_intranet/education/ce_page/ce_staff.cfm Course Offerings: ILS, ACLS, PALS, etc. ICU Crash Bed (TSI12) UNMH Policy April 10, 2017 DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Nursing Division Consultant(s) Nursing Executive Council, Nursing Management Council, Nursing Staff Council Inpatient Leadership Team, Critical Care Committee Committee(s) UNMH PPG Committee Y Nursing Officer Sheena Ferguson, Chief Nursing Officer Y Medical Director/Officer David Pitcher, MD, Executive Physician UNM Health System Y Official Approver Sheena Ferguson, MSN, CNS, CCRNr, CNO Y Official Signature On SharePoint Date: 08/01/2018 Effective Date 08/01/2018 ATTACHMENTS Attachment A; RN Chain of Command for Day and Night Shifts Attachment B; Algorithm for Deterioration of Patient Condition Attachment C; Algorithm for Activation of the Rapid Response Team Attachment D; Algorithm for Activation of the Pediatric Rapid Response Team vs. Pediatric Code team Page 4 of 8
ATTACHMENT A: RN Chain of Command (DAYS) Patient s RN RN Supervisor House Officer Unit Director Executive Director CNO..................... Administrative Supervisor (if appropriate) Licensed Independent Practitioner (LIP) Senior and/or Chief Resident and/or Fellow Attending Provider and/or Medical Director Service Chief / Department Chair *Unable to reach primary MD 1) Call operator for intern covering for team. 2) Call resident on call (night float after 8pm) 3) Call attending on call (Use PALS) Executive Medical Director Clinical Affairs On-Call RN Chain of Command (Nights/Weekends) Patient s RN RN Supervisor House Officer Administrative Supervisor Administrator On-Call...... Unit Director On-Call (if appropriate)............... Licensed Independent Practitioner (LIP) Senior and/or Chief Resident and/or Fellow Attending Provider and/or Medical Director Service Chief / Department Chair Executive Medical Director Clinical Affairs On-Call Page 5 of 8
ATTACHMENT B: Algorithm for Deterioration of Patient Condition Does patient have indication to initiate ACLS? Declining Cardiac, Respiratory or Mental Status Call 333 RN Supervisor will facilitate the notification of the following: Rapid Response @ 333 (Deteriorating Patient) and the Administrative Supervisor and the primary care team (see below). Administrative Supervisor will escalate the chain of command if primary care team has not responded within a reasonable amount of time. Neurosurgical/Neurology Call Primary Team & use chain of command Surgical including Orthopedics Call Primary Team & use chain of command Medicine and FP Call Primary Team & use chain of command Unable to reach On-Call Team & Patient Deteriorates Unable to reach On-Call Team & Patient Deteriorates Unable to reach On-Call Team & Patient Deteriorates Day Night Day Night Day Night 1.Call NSI Resident 2.Call NSI Attending 1.Call Critical Care Intensivist 1.Call TSI Resident 2. Call TSI Attending 1. Call Critical Care Intensivist 1.Call MICU Resident 2. Call MICU Attending 1.Call Critical Care Intensivist Page 6 of 8
ATTACHMENT C: ALGORITHM FOR ACTIVATION OF THE ADULT RAPID RESPONSE TEAM (Outside of ICU) RN notified of patient change Rapid Response to arrive as soon as possible from activation unless otherwise established RN Assesses patient for Early Signs of Clinical Decline RRT communicates with RN, Admin Sup. and MD to intervene on patient s behalf: Facilitates Chain of Command see algorithm B Provides ongoing assessment and monitoring of patient Collaborates with patient care team: MD, ACNP,RN, RCP/RT Initiates ordered treatments Implement ALS protocols as needed Does patient have Early Signs of Clinical Decline? RN calls: 1. 333 Rapid response 2. Admin. Supervisors 3. Patient s Primary Medical Team Continue with plan of care Assess if higher level of care needed RRT remains to assist with patient as needed RRT assists with 1:1 care if needed and facilitates transfer to higher level of care with Admin Supervisor. (see algorithm B for contacting MD) Attending must be notified! RRT documents event per RRT Response Log ATTACHMENT D: ALGORITHM FOR ACTIVATION OF THE PEDIATRIC RAPID RESPONSE TEAM (RRT) VS. PEDIATRIC CODE TEAM Page 7 of 8
RN notified or identifies patient change Does patient have indication to initiate PALS? Does patient have early signs of clinical decline? Start Pre- Rapid Response Form RN calls patient s Primary Medical Service If delayed response from patient s Primary Medical Service or patient continues to show signs of clinical decline, call 333 and indicates the need for a Pediatric Rapid Response Team Call 333 and indicates the need for Pediatric Code Team with unit location and room number. Document event on Pediatric Cardiopulmonary Resuscitation Record Continue with plan of care Rapid Response to arrive as soon as possible from activation unless otherwise established RRT communicates with RN and MD to intervene on patient s behalf: Facilitates Chain of Command see algorithm A Provides ongoing assessment and monitoring of the patient Collaborates with patient care team: MD, PNP, RN, RCP/RT Initiates ordered treatments tifies Admin Sup Assess if higher level of care needed RRT remains to assist with patient as needed RRT assists with 1:1 care if needed and facilitates transfer to higher level of care. Attending must be notified! RRT documents event per RRT Response Log Page 8 of 8