RAPID RESPONSE TEAM

and
CARDIAC ARREST/RESUSCITATION TEAM
OUTLINE
I. RAPID RESPONSE TEAM
a. Definition and Goal
b. Team Composition
c. Team Roles
d. Rapid Response Process

II. CARDIAC ARREST / RESUSCITATION TEAM

a. Definition and Goal
b. Team Composition
c. Team Roles
d. Resuscitation Process

III. EQUIPMENT AND SUPPLIES NEEDED

IV. RECOMMENDATIONS

RAPID RESPONSE TEAM

Definition: Clinical staff trained to respond rapidly to urgent calls for help when it is
suspected or apparent that a patient is experiencing serious clinical deterioration. 1

Goal: early recognition and response to change in a patient’s condition, and to prevent
further deterioration and to decide if enhanced levels of care are appropriate (for
example, in the intensive care units). 1

CURRENT STATUS at CGHMC: Non-existent

In Australian hospitals, there are three main rapid response systems1:

Medical Response team

specially trained medical practitioners and specialist nurses, which possesses the
required skills and equipment to provide a patient with immediate on-site
stabilization and management, and to start discussions on appropriate limitations
to medical intervention if indicated (for example, implementation of a 'Do not
attempt to resuscitate' or 'Not for resuscitation' order) 1

Critical Care Outreach

May involve external clinicians and resources. 1

Intensive Care Liason Nurses

Trained nurses in providing specialized support services to ward staff caring for
acutely ill patients. The aim of intensive care liaison nurses is to improve patient
outcomes through providing specialized interventions and other support services to
 acutely ill patients in hospital wards, usually but not always patients who have been
discharged from an Intensive Care Unit (ICU). 1

* The following discussion mainly focuses on the Medical Response Team. The CGHMC has
relatively substantial medical personnel composed of different subspecialties that basically offset
the need for critical care outreach team (i.e. outsourcing EXTERNAL clinicians/resources). Although
there are some critical cases that need special equipment/machine (e.g. LVAD) that is not available
in our setting, transfer to trained institution is therefore recommended. For the Intensive Care
Liaison Nurses, need to coordinate with the Nursing Service Office if this is feasible for them.

TEAM COMPOSITION:
1. SENIOR RESIDENT ON DUTY
2. JUNIOR RESIDENT ON DUTY
3. POST-GRADUATE INTERN/S
4. SENIOR NURSE ON DUTY
5. NURSE -IN-CHARGE or NURSE on duty (to the patient)

MINIMUM QUALIFICATION AND ROLES OF EACH MEMBERS OF THE RRT

PERSONNEL MINIMUM ROLE REMARKS

QUALIFICATION
SENIOR 3RD YR MEDICAL TEAM LEADER Once the subspecialty
RESIDENT on (PEDIATRIC) -verifies and confirms initial fellow/ consultant
duty RESIDENT findings comes in, he will then
take over as the team
BLS AND ACLS - prevents further deterioration leader if the main
TRAINED by providing necessary measures reason for
deterioration is
-intubates / puts in advance regarding his
airway; decides if there is a need subspecialty (i.e.
for referral to anesthesiology on Endocrinology if DKA,
duty Pulmonology if ARDS,
etc)
- ensures that the all AP’s and
fellows concerned are informed

- oversees the need for transfer

to ICU or other special units

- initiates discussion regarding

appropriate limitations to medical
interventions if indicated (DNR,
prognosis)

- decides/signals activation for the

cardiac arrest/resuscitation team if
indicated

-ensures the accuracy and

completion of orders written in
the chart
Junior 1ST YR AND/OR TEAM MEMBER
RESIDENT on 2ND YR MEDICAL
duty
 (PEDIATRIC) - early recognition, gives initial
RESIDENT measures/interventions if
deemed appropriate
BLS AND ACLS
TRAINED - activates the RRT

- informs AP/fellows and

coordinate referrals properly

- writes orders in the chart

MEDICAL BLS AND ACLS TEAM MEMBER

INTERN/S TRAINED -may activate the RRT if
undoubtedly necessary

-assists in giving/facilitating
interventions as instructed by the
resident/team leader (i.e. IV
insertion, BP monitoring,
ambubagging, ECG in the
absence of technician)
SENIOR BLS AND ACLS TEAM MEMBER
NURSE ON TRAINED
DUTY -may activate the RRT if
undoubtedly necessary

-wheels in the emergency or

crash cart/ suction machine

-assists in giving/facilitating
interventions as instructed by the
resident/team leader (i.e. IV
insertion, IV medication, BP
monitoring, ambubagging)

- coordinates with other links:

ECG technician, Respiratory
technician, nurse aide, ICU if
need for transfer

NURSE -IN- BLS trained TEAM MEMBER

CHARGE or -may activate the RRT if
NURSE on undoubtedly necessary
duty (to the
patient) -wheels in the emergency or
crash cart/ suction machine

-assists in giving/facilitating
interventions as instructed by the
resident/ team leader (i.e. IV
insertion, IV medication, BP
monitoring, ambubagging)

-endorses patient to nurses of

ICU/CCU/Tele if need for transfer
RAPID RESPONSE PROCESS

SURVEILLANCE/RECOGNITION
NOD / nurse in charge/ medical intern -> quick
basic assessment then refers to the resident on
duty (ROD); may activate RRT directly if
undoubtedly necessary
ROD -> quick clinical assessment; activates RRT

*ACTIVATION OF RRT
via PAGING SYSTEM (advantage: saves time with one call;
the matter of seconds cannot be overempahsized in such
setting)
E-cart/Crash Cart at bedside
Suction machine may be needed

TREATMENT/INTERVENTION
Team leader and members should coordinate with each
other accordingly as defined by their roles
** if patient progressively deteriorates and eventually
arrests, activate cardiac arrest team

POST-TREATMENT/ INTERVENTION
transfer to special care units (ICU, CCU, telemetry,
neuro ICU) if necessary
discussion regarding appropriate limitations to medical
interventions if indicated (DNR, prognosis)

* In other hospitals they page “CODE PURPLE please proceed to ___” as indication of clinical
deterioration and need for early intervention.
** Page “CODE BLUE please proceed to ___” if patient is in cardiac arrest, hence need for
resuscitation. Previously, in our institution, they page, “Paging CGH, please proceed to ___”
CARDIAC ARREST/ RESUSCITATION TEAM
Definition: A team, led by trained medical officers, designated to respond to calls for
assistance following the cardiac arrest of a hospital patient. 1

Goal: provide a rapid effective response to a patient's cardiac arrest. This usually involves
the 4 steps of basic life support as a first response, selection and dosage of the first drug
administered, sequence and dose of subsequent administered drugs, and finally use of
defibrillation, synchronized cardioversion, and/or pacing at the correct strength or rate. 1

TEAM COMPOSITION
1. CARDIOLOGY FELLOW ON DUTY
2. SENIOR RESIDENT ON DUTY
3. JUNIOR RESIDENT ON DUTY
4. POST-GRADUATE INTERN/S
5. ICU/CCU NURSE ON DUTY
6. SENIOR NURSE ON DUTY
7. NURSE -IN-CHARGE or NURSE on duty (to the patient)

MINIMUM QUALIFICATION AND ROLES OF EACH MEMBERS OF THE CARDIAC

ARREST/RESUSCITATION TEAM

PERSONNEL MINIMUM ROLE REMARKS

QUALIFICATION
CARDIOLOGY Graduate of IM TEAM LEADER If there is no HI
FELLOW ON residency -leads the ACLS mega-code; cardiology consultant
DUTY guides the senior resident if there on board, the main
(CFOD’s); BLS AND ACLS is no Heart Institute (HI) attending decides the
senior CFOD TRAINED cardiology consultant management for the
as the Lead patient. However,
-CPR and early defibrillation if the senior resident
other members are not yet will be the one who
around will directly refer to
the main AP.
-intubates / puts in advance
airway if senior resident was
unable to di so; decides if there is
a need for referral to
anesthesiology on duty

-identifies need for other

advanced interventions (central
line insertion, pacing, PCI) and
refers directly to the HI
cardiology consultant if
applicable.

-identifies post-arrest care

accordingly (transfer to special
units, facilitation of diagnostic
procedures) and refers to the HI
Cardiology Consultant if
applicable
 - Ensures and oversees that the
roles of each members are being
done

SENIOR 3RD YR MEDICAL TEAM MEMBER

RESIDENT on (PEDIATRIC) -steps up and acts as the team
duty RESIDENT leader (with defined roles written
above) while the CFOD is not yet
BLS AND ACLS around
TRAINED
-CPR

-early defibrillation

-intubates / puts in advance

airway

-in the absence of HI cardiology

consultant on board, refers
directly to the main AP and
coordinates with the CFOD
accordingly

- ensures that the all AP’s and

fellows concerned are informed

- ensures the accuracy and

completion of orders written in
the chart

Junior 1ST YR AND/OR TEAM MEMBER

RESIDENT on 2ND YR MEDICAL
duty (PEDIATRIC) -CPR
RESIDENT
-early defibrillation
BLS AND ACLS
TRAINED - informs AP/fellows and
coordinate referrals properly

- writes orders in the chart

MEDICAL BLS AND ACLS TEAM MEMBER

INTERN TRAINED -CPR
-early defibrillation
-assists in giving/facilitating
interventions as instructed by the
resident/team leader (i.e. IV
insertion, BP monitoring,
ambubagging, ECG in the
absence of technician)
ICU/CCU BLS AND ACLS
Nurse TRAINED -wheels in the emergency or
crash cart/ suction machine

-CPR
 -early defibrillation

-administration of emergency
medications

SENIOR BLS AND ACLS TEAM MEMBER

NURSE TRAINED -wheels in the emergency or
crash cart/ suction machine
-CPR
-early defibrillation
-administration of emergency
medications

- coordinates with other links:

ECG technician, Respiratory
technician, nurse aide, ICU if
need for transfer

-assists in giving/facilitating
interventions as instructed by the
resident/team leader (i.e. IV
insertion, IV medication, BP
monitoring, ambubagging)

NURSE -IN- BLS trained TEAM MEMBER

CHARGE or -CPR
NURSE on -assists in giving/facilitating
duty (to the interventions as instructed by the
patient) resident/ team leader (i.e. IV
insertion, IV medication, BP
monitoring, ambubagging)

-endorses patient to nurses of

ICU/CCU/Tele if need for transfer
RESUSCITATION PROCESS

The process of resuscitation is in accordance with the updated guidelines American Heart
Association/International Liaison Commission on Resuscitation Guidelines for Cardiopulmonary
Resuscitation and emergency Cardiovascular Care published in 2015. The chain of survival of in-
hospital cardiac arrest (IHCA) should be applied in our setting.

CHAIN OF SURVIVAL OF IN-HOSPITAL CARDIAC ARREST2

 RESUSCITATION PROCESS in accordance with the Chain of Survival of IHCA

SURVEILLANCE AND PREVENTION

this is actually the application rapid response process as discussed in
the previous section

*ACTIVATION OF THE CARDIAC ARREST/RESUSCITATION TEAM

via PAGING SYSTEM (advantage: saves time with one call; the matter of
seconds cannot be overempahsized in such setting)
E-cart/Crash Cart at bedside
Suction machine may be needed

IMMEDIATE HIGH QUALITY CPR

Team leader and members should coordinate with each other accordingly as
defined by their roles

RAPID DEFIBRILLATION AND ADVANCED LIFE SUPPORT

Identify shockable rhythms and give approprite intervention. Facilitates
procedures such as temporary pacing/central line insertion if needed.
Advanced Airway
Activation of cathlab if indicated

POST - ARREST CARE

transfer to ICU/CCU
identify reversible causes of cardiac arrest and treat
Medical limitations if indicated (DNR/DNI)

*Page “CODE BLUE please proceed to ___” if patient is in cardiac arrest, hence need for
resuscitation. Previously, in our institution, they page, “Paging CGH, please proceed to ___”
EQUIPMENTS AND SUPPLIES NEEDED
1. Emergency/ Crash Carts
2. Defibrillators with Pacing Capability
3. Portable Suction Machines

Based on the Emergency Carts and Defibrillators requested to the Medical Director:

AREA EQUIPMENT REMARKS

Critical Care Unit
Intensive Care Unit
Cardiovascular Telemetry
Medical Arts Building
(8th Floor)
Emergency Room
Delivery room Pay
2 units of emergency carts
1 defibrillator (biphasic)
1 defibrillator (biphasic) with
pacing capability
2 units of emergency carts
1 defibrillator (biphasic)
1 defibrillator (biphasic) with
pacing capability
1 unit of emergency cart
1 defibrillator (biphasic) with
pacing capability
1 unit of AED
3 units of emergency cart
1 unit of emergency cart
existing units will be turned
over to N6 and MS5
Existing units will be turned
over to 4A and 5A
Existing unit will be turned
over to Service Pavillon
For clinic’s emergency use
To be placed at the Pediatric,
OB, Surgery
Replacement for the old units

4B 1 unit of emergency cart Replacement for the old units

5B 1 unit of emergency cart Replacement for the old units

The existing E-carts will be turned over to the following areas:

1. N6
2. MS5
3. 4A
4. 5A
5. Charity OB/Pedia
6. Charity DR/NSU Complex
7. Charity MMS
8. Charity FMS

MINIMUM E-CART SUPPLIES AND MEDICINES

DEFIBRILLATOR EPINEPHRINE 1MG/1ML
ECG VASOPRESSIN
ADULT ELECTRODE DOTS NOREPINE-
PHRINE
2MG/2ML
4MG/4ML
SUCTION CATHETERS DOPAMINE
200MCG/AMP
AMBU BAG DOBUTAMINE
250MCG/AMP
AMBU BAG FACE MASK SODIUM BICARBONATE
50MEQS/50ML
ENDOTRACHEAL TUBE FUROSEMIDE
20MG/2ML
ET TUBE STYLET ADENOSINE
 LARYNGOSCOPE HANDLE VERAPAMIL
LARYNGOSCOPE BLADE LABETALOL

IV CATHETER ESMOLOL

IV TUBING AMIODARONE
(MICROSET MACROSET) 150MG/AMP
PLR LIDOCAINE
50ML/AMP
PNSS MAGNESIUM
2500/10ML
D5W ATROPINE
1MG/1ML
D5 NM DIGOXIN
0.5MG/2ML
D5 IMB NITROGLYCERINE or IV ISOSORBIDE DINITRATE

SYRINGE MIDAZOLAM/ DIAZEPAM

HYDROCORTISONE
DEXTROSE 50G 50ML (D5050)
CALCIUM GLUCONATE
POTASSIUM CITRATE
MORPHINE

RECOMMENDATIONS
1. Functional paging system. Make sure that almost if not all areas especially call rooms or
doctors’ lounge, ICU, CCU, CV telemetry are reached by the paging system.
2. Actual simulation of the RRT
3. Senior Nurses at the wards should be ACLS certified. Currently, they are only required to
have BLS certificate
4. Each E-cart should be audited at least once EVERYDAY for the completeness of supplies
5. Each defibrillators should be regularly checked by maintenance.

REFERENCES:

1. Australian Commission on Safety and Quality in Health Care/Australian Institute of Health

and Welfare

2. 2015 American Heart Association/International Liaison Commission on Resuscitation

Guidelines for Cardiopulmonary Resuscitation and emergency Cardiovascular Care