Responding in a Code Situation

Responding in a Code Situation

Advance directives/DNR (do not resuscitate) orders: Under normal circumstances, all Pts should have advance directives in their medical record that indicate whether or not they wish to be resuscitated (and to what extent resuscitative efforts should be carried out) in the event of respiratory or cardiac arrest. Note: If there is any doubt as to the interpretation (or whereabouts) of a Pt’s advance directives, then a code must be called and resuscitative efforts initiated.

Clinical Presentation

■ Unresponsive Pt with no detectiable respirations or pulse. ■ Pt in respiratory arrest with no obvious cause and is not immediately reversible (e.g., opioid intoxication, which can be reversed with an opioid antagonist such as naloxone). ■ Pt who has become critically unstable hemodynamically (e.g., HR <20, BP <70 mm Hg, unresponsive, etc.)

Immediate Interventions (Before Arrival of Code Team)

■ Stay calm! If clinical situation cannot be immediately corrected (e.g., reconnecting Pt to the ventilator, suctioning thick secretions, administering an opioid antagonist, etc.), prepare to call an overhead code (e.g., “I need STAT help in room 4; someone call an overhead code!”). Note: Always include floor, unit, and room number when calling a code. ■ Stay with the Pt and begin resuscitation measures while waiting for the code team to arrive. ■ Position the Pt flat in the supine position (do not attempt this if you are by yourself). ■ Clear the immediate Pt area of any obstacles (e.g., bedside tables, chairs) and instruct visitors to wait outside the room. ■ Administer 100% oxygen using a bag-valve mask (BVM) device. ■ Insert an oral or nasal airway if available at bedside. ■ Assess pulse and begin chest compressions if undetectable.

Ongoing Interventions (After the Code Team Has Arrived)

Depending on the hospital and the location of the code, the number of code team members will vary from five to seven or more staff members. A code team consists of one–two nurses from critical care (ICU/CCU), respiratory therapy (RT), IV therapy, a pharmacist, resident/intern physicians (at teaching facilities), attendings/hospitalists (physicians on duty), and a chaplain. ■ Inform the code team of the minimum pertinent information: ■ Pt’s admitting diagnosis and current treatments. ■ Events before calling the code. ■ Pertinent medical/surgical history. ■ Medications and allergies. ■ Status of advance directives if known. ■ Obtain the Pt’s chart and notify: ■ Surgeon on-call if a surgical Pt. ■ Attending on-call (service who admitted Pt) if a medical Pt. ■ Notify physician of type of event (e.g., cardiac arrest, unresponsive, etc.), interventions (e.g., code called, CPR in progress, intubated, defibrillated, etc.), and if Pt is responding to the resuscitative efforts being implemented. ■ Assist the code team in the resuscitation effort as requested: ■ Notify Pt’s family and/or other medical personnel. ■ Perform chest compressions. ■ Administer ventilations and assist with intubation. ■ Operate code cart and administer defibrillations. ■ Administer resuscitation drugs. ■ Record all interventions and times on the code record. ■ Record ECG strips with each rhythm change, defibrillation attempt, and medication administration. Clinical tip: Record time and other pertinent information (e.g., drugs and dosages) directly onto the ECG strips for easier recall when you are documenting after the code. ■ Carry out code team requests (e.g., order labs, 12-lead ECG, portable chest x-ray, arrange transfer to critical care, etc.). ■ Request chaplain or appropriate staff to notify and/or communicate with Pt’s family.

Documentation

■ All code team members who participated in the code must sign code record including RNs, physicians, and support staff. ■ Ensure that all times and interventions are recorded. ■ Attach ECG strips to code record in chronologic order. ■ Document a brief summary with outcome in Pt’s chart. ■ Attach code record to Pt’s chart after completed.