*Original post released on 6/17/2020
*The role titles in this article are simplified for understanding
Code situations are a bit tricky at times. I know nurses who dread them and those who live for the challenge that a code brings. Either way, as health care professionals, our goal is ALWAYS to prevent our patients from ever having to experience this. A rapid (or medical) response team activation occurs when the primary nurse of a patient, not located in the ER or ICU, has reason to suspect the patient has an underlying issue that needs to be addressed urgently. A rapid response may be called for altered HR, RR, BP, chest pain, stroke symptoms, low oxygenation/urine output, etc. The ultimate goal of a RRT or MRT is to intervene before the patient experiences injury or respiratory/cardiac arrest. This does not always happen, which is why there are code situations. Typically, when a code is called, there is specific language used to indicate what type of code situation is occurring. Doing this helps staff bring necessary equipment and activate the necessary channels in cases of emergency (Ex: cath lab for ST elevation myocardial infarction, teleneuro for stroke, etc.). The photo below depicts some of the different types of codes that can be called.
Since I work in an ICU, we’ll discuss the most severe type of code situation I tend to experience and attend – a code blue. In this situation, there are a specific set of people who are required to attend. These personnel include (but are not limited to): the primary nurse, the charge nurse/other nursing staff members, code team lead RN, the nursing supervisor, respiratory therapist (RT), the ER/Critical Care physician, phlebotomist, x-ray technician, and a security guard. The phlebotomist and x-ray tech typically wait until the code is done to perform diagnostic tests and security is present mainly for crowd control.
When the code team personnel arrive, the primary nurse is responsible for recalling the history of events leading up to the arrest/code, disclosing the patient’s code status as well as placement of all lines and drains currently in place. Typically they also assist with placing the defibrillation pads and backboard for compressions. After this, the primary nurse can assist with calling different departments for necessary items (Ex: pharmacy for vasopressors or blood bank if transfusion of blood products are anticipated). The charge nurse and other nursing staff can assist with grabbing any supplies not present in the room or crash cart. Additionally, this nurse or their charge nurse may call the family to notify them of the event. This is done for many reasons, however it is mainly done to have family come to the hospital (if not already present) and to revisit code status when applicable. Following the code, the primary nurse is also responsible for the documentation of the code and major events that occurred during the code.
Other assigned roles for the members of the code team include: leader, “medication preparer”, “medication pusher”, “compressor(s)”, and “recorder”. I like the graphic to the left to help with visualization of a code layout. The leader directs others who are present into these roles, relays pertinent information to key personnel, updates healthcare providers as they arrive. The medication preparer controls the crash cart contents and its medications. This person listens to the physician order meds to be given during the code and confirms these orders verbally prior to medication administration. If the physician is not present, the leader directs meds to be given per ACLS or PALS protocol but the preparer still verbally confirms all orders prior to administration of any medication.
The medication pusher takes all medications directly from the preparer and is the ONLY person to be administering medications. This is done to promote timely delivery of medications, prevent duplicate administration, and eliminate confusion. Once a med has been pushed, this person should verbalize the name of the drug given and the dose (Ex: “Epi 1mg in.”). After the med has been pushed, it should always be flushed either with a pre-packaged flush syringe, with NS already running (if ordered), or both…flushed then allow fluids to run until next med is due to be given.
The compression team should consist of at least 2 people (don’t necessarily have to nurses) but ideally contains 3 to 4 members. Once compressions are indicated, the first person begins compressing and doesn’t stop until pulse check, which occurs two minutes after initiation. At pulse check, this person feels for a pulse and the next person prepares to take over. If there is no pulse and compressions are still indicated, the next person resumes for two additional minutes. This pattern continues until the code is called or the patient has return of spontaneous circulation (ROSC). This trade off sequence is done to prevent or limit compressor fatigue as much as possible.
The recorder is responsible keeping track of the timing of events associated with the code situation. Typically this is performed by the nursing supervisor as there is also usually a metrics tool involved; however, if the supervisor is delayed or not present, the leader of the code team will likely assume this role. Events recorded can include: time code was called, times that key personnel arrived, initiation of CPR, administration times for different medications, times of line/drain placement, time of intubation, calls and the times the calls were made, timing of diagnostic tests, end of code/ROSC/time of death, etc.
Last, but certainly not least, are the roles of the respiratory therapist(s) and physician. The RT maintains control of the patient’s airway and cervical spine until the physician arrives in addition to providing ambu-bag ventilation as needed. They also suction the patient as needed, assist with intubation if needed, and set up the ventilator with the settings ordered by the physician. After intubation and as ordered, they also perform arterial sticks to assess the patient’s blood gases. Many times, there are respiratory supplies in the crash cart. So it is likely that the medication preparer will access and share the cart supplies along side one designated RT. The physician’s role is to give verbal orders for meds/fluids/defibrillation/pacing/etc. They also take control over the patient’s airway and c-spine in the event of intubation. After intubation, they provide the RT with orders for vent settings. In addition to these actions, the physician also inserts lines for access as needed (IV/IO) as well as drains (chest tubes) for enhanced patient management. If the patient does not make it through the code situation, the physician is the person in charge of determining when to call the situation to a close and establish time of death.
Code situations are a bit tricky at times, but when you really think about the many different roles and actions all occurring to save another human’s life, it truly becomes a beautiful symphony of synchronous and emotionless effort. I say that because we cannot allow our emotions to interfere in the process; they are reserved for post-code after de-escalation of the situation. And don’t ever feel like your emotions are not valid. You may feel sad, angry, happy, confused, frustrated, etc. or any combination of those emotions after a code situation. That’s perfectly valid. All you can do in a code situation is perform your assigned role to the best of your ability and perform that role cohesively with the other involved. Let me know if you’ve been in a code situation and how it turned out! If you have any questions, feel free to leave them in the comments below.