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Final DRAFT
Entity Policy
Code: Entity: Fairview Ridges Hospital
Manual: Patient Care and Organizational
Category: Provision of Care, Treatment and Services
Subject:
Rapid Response Team- Combined Policies
Adult, Pediatric, OB, Newborn
Purpose: To provide early intervention and stabilization to prevent clinical
deterioration to any individual prior to the event of respiratory,
cardiac arrest or other adverse health event. To decrease the
hospitals overall mortality rate and to provide safe effective and
efficient patient centered care.
Policy: The Rapid Response Team may be summoned at any time by a
patient, patient’s visitor, staff member or hospital volunteer to assist
in the care of patient who has a dramatic change of health status
before the patient has an adverse event or a cardiac arrest.
Criteria for calling the RRT may include the following

Acute change in Heart Rate, Systolic BP, or Respiratory Rate

Acute Change in O2 Saturation

Acute change in Level of Consciousness

Dramatic onset of acute pain

Acute Chest Pain

Acute Seizure

Worry or concern over patient condition
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At FRH, there will be four different levels of Rapid Response
Team depending on criteria of the patient
Rapid Response Team - Adult – 17 years and older. Team
includes: Hospitalist or House Dr only hours (6 p – 7 a) Flying
Squad RN, ICU Charge RN and Respiratory Therapist
Rapid Response Team – Obstetric – pregnant woman. Team
includes:L and D charge nurse, ICU-RN, Flying Squad RN, MDA,
NNP, SCN charge nurse and any available OB physician. If no OB
physician available, L&D charge nurse will determine whether to
call patient’s physician or OB of the week.
Rapid Response Team – Pediatric 1 month to 16 years. Team
includes:Flying Squad RN, ED ICU, Respiratory Therapist – pt to be
transported to ED using unstable Peds pt protocols
Rapid Response Team – Newborn – corrected gestational age of
equal to or less than 44 weeks (four weeks past expected due date),
Team includes: NNP, SCN RN, Respiratory Therapist and Flying
Squad RN – pt will be transported to ED using unstable Peds PT
protocols or may be transported Special Care Nursery
All individuals will have appropriate efforts attempted when
assessed to be deteriorating unless there is a written DNR/DNI
physician's order or other limited resuscitation orders are recorded.
ACLS, PALS, and NRP guidelines will be followed for the
appropriate age groups.
Staff responding to the call will be trained and competent to
recognize the need for and use of equipment in resuscitative efforts.
Procedure: Fairview Ridges Hospital site specific procedure(s)
To activate the Rapid Response Team:
Caller

Caller determines the need for rapid response team
interventions and is responsible to assure notification of the
RRT team by calling 111 on the nearest phone. Do not press
the “Code Blue” button.
 Caller stays with the patient until the RRT arrives
Special Note:
 If patient becomes unconscious or loses pulse or
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

respirations (SHOUT FOR HELP and call code blue
DIAL 111 on nearest phone). IF possible use Code Blue
button
Initiates Basic Life Support measures in accordance with
American Heart Association Standards.
Note time patient discovered and report observations at that
time to RRT Recorder.
Operator Responsibilities
"Rapid Response Team Adult" – 17 years and older
“Rapid Response Team – Obstetric” – pregnant woman >
"Rapid Response Team Pediatric" – 1 month to age 16.
“Rapid Response Team Infant birth to 29 days

When a caller dials 111 to activate the Rapid Response
Team, the operator will ask for the location (room number
and bed number). The caller should provide if possible the
operator with the name and phone number of the nursing unit
where the event is occurring.

When the RRT system is activated by dialing 111 the
operator will page overhead “Rapid Response Team” RRT
type and location three times, and then repeat once.

Rapid Response Team will be paged to the code blue pagers
and additional providers as outlined in communication plan
and are activated for only designated team members. If a full
Code Blue is called then all designated members will be
paged
Rapid Response Team – ADULT 17 years and older
All team members will have a code blue pager and respond
immediately to the location when a RRT is called.
HOSPITALIST OR HOUSE PHYSICIAN 6pm to 7 am
 Dr will respond immediately to all Adult RRTs if 6 pm to
7am.and weekends. If during day time hours and Hospitalist
does not respond immediately page stat
 Assumes team leadership responsibilities immediately upon
arrival.
 Remains as Team Leader in charge of assessment and rescue
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


efforts
May use other responding physicians in consultation
Contacts the patient’s attending physician service if they are
not present
Documents RRT events in the patient’s medical record
FLYING SQUAD RN
 Reports to area/room where RRT is occurring
 Initiates IV insertion and fluids
 Acts as team leader until the physician arrives, calls
hospitalist stat as required
 Identifies cardiac rhythm and treats according to current
ACLS protocol
 Monitors and maintains IV lines
 Administers medications as required.
ICU RN
 Assists Flying Squad RN as required may leave if released
from response
 If no Flying Squad present the assumes team leader role until
physician arrives
 Identifies cardiac rhythm and treats according to current
ACLS protocol
 Monitors and maintains IV lines
 Administers medications as required.
RESPIRATORY THERAPY
 Respiratory assessment and maintains airway and assures
oxygenation
 Assists as necessary during RRT and the transfer of the
patient as required
PATIENTS PRIMARY RN (when hearing overhead page)
 Reports to the patient room to respond to questions regarding
the patient
 Assists with RRT as appropriate
 Functions as recorder: documents RRT events, rhythm
strips and disposition on Record
 Assists with patient transfer
 Completes documentation of RRT in the patient’s chart
 Completes the post response evaluation form
Special Note – code blue


If patient becomes unconscious or loses pulse or
respirations or requires ACLS medications
(SHOUT FOR HELP and call code blue DIAL 111 on
nearest phone) Initiates Basic Life Support measures in
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accordance with American Heart Association Standards.
Note time patient discovered and report observations at that
time to RRT Recorder.
Special Note Re STEMI
If the patient is diagnosed with a ST Elevation MI (STEMI) at time
of response – the physician will follow the STEMI transfer policies
(attachment 1) and will activate the Cath Lab as per protocol.
Fairview Southdale will be the hospital of choice unless the patient
has payer or personal choice.

Follow-up after RRT ADULT
Appropriate Follow up is required with patient and primary nurse
Flying Squad RN will
 Visit patient and nursing team at their discretion but not
greater than 4 hours after RRT called.
RAPID RESPONSE TEAM “PEDIATRIC”
Rapid Response Team Pediatric will be initiated for persons between
the ages of 1 month to 16 years of age
The Emergency Dept. Physician (PALS certified) will ONLY
respond to the patient care area in the event of a Pediatric Code Blue.
In the event of a deterioration of a pediatric patient, the pediatric life
support guidelines will be utilized and initiated by Code Blue team.
Broselow pediatric crash carts will be located in the Emergency
Department and Pediatrics Unit (2nd floor). The pediatric cart is
intended for patients up to 36 kg or approximately 80 pounds. If
Child is greater than 36 kg or 80 pounds a adult crash cart will be
brought to the bedside
PATIENTS PRIMARY RN

Completes documentation of RRT in the patient’s chart

When appropriate, assists with patient transfer to Emergency
Department if appropriate.
 Stays with child in ED until transfer to higher level of care
takes place, unless relieved by ED staff.
 Completes post RRT evaluation tool for primary nurse
FLYING SQUAD RN
 Reports to area/room where RRT is called
 Utilizes RRT Standing Orders, as appropriate.
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
Acts as team leader and speaks with the attending
pediatrician or ED physician regarding the patient’s clinical
status. Transfer to the ED after immediate stabilization, if
appropriate.
 Completion of the RRT Evaluation tool for RRT
 Assists with remaining patients on Peds, if required, when
Peds RN is in ED
ED RN
 Assists Flying Squad RN as required. May be released from
situation by other members of the team when not needed.
 If no Flying Squad present, assumes team leader role until
physician arrives or is called
 Identifies cardiac rhythm and treats according to current
ACLS protocol
 Utilizes RRT Standing Orders, as appropriate.
 Monitors and maintains IV lines
 Administers medications after pharmacy has prepared them.
RESPIRATORY THERAPY
 Respiratory assessment and maintains airway and assures
oxygenation
 Utilizes RRT Standing Orders, as appropriate.
 Assists as necessary during RRT and the transfer of the
patient to ED
Contingency plan for transferring unstable pediatric patients to
Emergency Department for stabilization prior to transfer to
higher level of care
The attending pediatrician will be contacted regarding the patient’s
clinical status. Orders for transfer to the ED for immediate
stabilization will be obtained.
The patient is transferred to the Emergency Department by RRT
Pediatric. The primary nurse from pediatrics remains with the
patient to assist the ED staff in providing care. The flying squad
returns to the pediatric floor and cares for the Peds RN’s patients
until she returns. The emergency room may choose to take over
nursing care of patient.
Emergency Department physician and staff are responsible for
immediate stabilization of the patient. Ongoing management of the
patient is the responsibility of the attending pediatrician who is
expected to be on-site. The attending physician is responsible for
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making arrangements for the patient’s transfer to another facility.
All orders will be initiated and processed on paper rather than
entered in FCIS
The length of time the patient will remain in the Emergency
Department is determined on a case-by-case basis, but is not
expected to exceed 4 hours.
Follow-up after RRT PEDS
Appropriate Follow-up is required with patient and unit nursing team
Flying Squad RN will
 Visit patient/parents and nursing team at their discretion but
not greater than 4 hours after RRT called.
 They will ensure that post RRT evaluation forms are filled
out and ensure that patient is aware and understands events
from the RRT

RAPID RESPONSE TEAM – OBSTETRIC
In the event of the deterioration of a pregnant woman, with or
without trauma - the rapid response team will be initiated. This
includes patients in the ED and other areas of the hospital.
OB PHYSICIAN or if in ED, ED PHYSICIAN until OB arrives
 Reports to area/room where RRT is called and immediately
assumes care
 Continues care until OB arrives
MDA–
 Reports to area/room where RRT is called IF ABLE
OTHERWISE:
 Stand by for emergent Cesarean delivery
LABOR AND DELIVERY CHARGE NURSE
 Reports to area/room where RRT is called
 Acts as team leader until OB arrives. If there is no in house
OB, delegates team member to call patient’s OB or OB of the
week as appropriate.
 Assesses patient per protocol
 Determines need to transfer patient to OR, ED or L&D
 Reports patient status to responding physician
 Completes RRT post evaluation tool
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NEONATAL NURSE PRACTITIONER and SCN-R.N.
 Reports to area/room where RRT is called
 Stand by for imminent delivery
Follow-up after RRT OBSTETRIC
Appropriate follow up is required with patient.
L and D Charge Nurse will:
 Visit patient and nursing team at their discretion but not
greater than 4 hours after RRT called, to assure that the
patient is aware and understands events as they occurred.
 Complete RRT post evaluation tool
 evaluation form
RAPID RESPONSE TEAM “NEWBORN”
Rapid Response Team Infant will be initiated for infants with
corrected gestational age equal to or less than 44 weeks (four
weeks from expected due date) generally less than 30 days of age.
The Emergency Dept. Physician (PALS certified) will ONLY
respond to the patient care area in the event of a Pediatric/Newborn
Code Blue.
In the event of a deterioration of a pediatric/newborn patient, the
pediatric life support guidelines will be utilized and initiated by
Code Blue team.
PATIENTS PRIMARY PEDS RN (when hearing overhead
page)
 Assists with patient stabilization and
 Completes documentation of RRT in the patient’s chart
 Stays with infant and family until transfer to higher level of
care takes place
 If infant is transferred to SCN, SCN will assume care of
infant who will be admitted to the isolation room
NEONATAL NURSE PRACTITIONER
 Reports to area/room where RRT is called
 Stabilizes infant
 Acts as team leader and speaks with the attending
pediatrician and/or neonatalogist regarding the patient’s
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
clinical status.
Determines need of transfer to another unit
 SCN for closer observation to isolation room
 Peds for continued care
FLYING SQUAD RN
 Reports to area/room where RRT is called
 Assists with remaining patients on Peds unit
SPECIAL CARE NURSERY RN
 Reports to area/room where RRT is called
 Brings infant crash cart to area/room
 Assists NNP in stabilization of infant
 Completion of the RRT Evaluation Tool
RESPIRATORY THERAPY
 Respiratory assessment and maintains airway and assures
oxygenation
 Assists as necessary during RRT and the transfer of the
patient to site of transfer
Contingency plan will be activated if NNP/SCN is unavailable
for transferring unstable pediatric patients to Emergency
Department for stabilization prior to transfer to higher level of
care
The attending pediatrician will be contacted regarding the patient’s
clinical status. Orders for transfer to the ED for immediate
stabilization will be obtained.
The patient is transferred to the Emergency Department by RRT
infant. The nurse from pediatrics remains with the patient to assist
the ED staff in providing care. The emergency room may choose to
take over nursing of patient.
Emergency Department physician and staff are responsible for
immediate stabilization of the patient. Ongoing management of the
patient is the responsibility of the attending pediatrician who is
expected to be on-site. The attending physician is responsible for
making arrangements for the patient’s transfer to another facility.
All orders will be initiated and processed on paper rather than
entered in FCIS
The length of time the patient will remain in the Emergency
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Department is determined on a case-by-case basis, but is not
expected to exceed 4 hours.
Follow-up after RRT Newborn
Appropriate Follow up is required with patient and primary nurse
SCN RN will
 Visit patient/parents and the nursing team at their discretion
but not greater than 4 hours after RRT called.
 They will ensure that post RRT evaluation forms are filled
out and ensure that patient is aware and understands events
from the RRT
Joint Commission on Accreditation of Healthcare Organizations
Care of Patients, TX.8
Patient Rights, RI 1.2.6, 1.2.7
Improving Organizational Performance, PI 3.1.1
Internal Ref: FRH “Rapid Response Teams:”
Source: RRT action team –
- Helen Strike RN Team Leader
- Peter Sandgren MD Physician Leader
Emergency Response Committee
- Diane Nelson , RN, Manager, ICU, Co-chair
- Peter Sandgren, MD, Co-chair
- Collaborative Practice Council – SCN
- Perinatal Quality Improvement Committee
- Pediatric Quality Improvement Committee
Approved by: Joint Practice and Patient Safety
Medical Executive Committee
Date Effective: 10/05
Date Reviewed:
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