Baystate Med CTR Rapid Response Team Recordwith SBAR

Patient Identification Information/Sticker
(12/4/08)
RAPID RESPONSE TEAM

RECORD
FAMILY ACTIVATED CALL:
Date:_______ Time RRT Called: _______ Time RRT Arrived: _______
CALLER TO COMPLETE
Person (Name) placing call: ________________________________
Responders:
RN
RT
IV RN
MD/Resident
Covering Physician: __________________ MD notified Yes/No: ___________ Response Yes/No: ___________ Arrival time:___________
SITUATION
Concern that something is wrong
BACKGROUND / HISTORY
Other
Failure to Respond to Treatment
Other Acute Decline in Patient
Condition
Neurological
Acute Change in Level of
Consciousness
Difficulty Speaking
Agitation, Delirium or Seizures
Early Sepsis
Infection-documented or suspected
On anti infective therapy
Increased/decreased WBCs count
( > 12,000 or < 4,000)
Respiratory
Respiratory Distress (rate <8 or >28
BPM)
Threatened Airway
Change in Respiratory Rate
SaO2 less than 90% on O2
(<90% despite supplement O2)
Cardiovascular
Change in Systolic BP (<90 mmHg)
Change in HR (<40 or >130 BPM)
Diabetes
Renal
Dialysis
CHF
Stroke
Surgery _________
Pneumonia
Other:
DNR/DNI
CMO
RRT NURSE ASSESSMENT ON ARRIVAL:

Initial vital signs: (2 or more consider early sepsis)
Temp:______ (>100.4 or <96.8)
HR:______ (>90 bpm)
LOC:________ Breath Sounds: _______________
RR:______ (>20) BP: _________ O2 Sat ________ FiO2: ________

Pain Level: ________ (0-10 Scale)
Blood Sugar: ____________
UNRESPONSIVE PATIENT:
TESTS/LABS:
Administer 50ml D50 (1 amp)

Time administered: __________
Repeat POC in 20 min: __________
AIRWAY/BREATHING:
Titrate FiO2 to maintain patients O2 saturation >92% (use any modality)

Time: ____________
Modality used: _________________
PORTABLE CXR_________
CQ: Pneumonia
(HX new/sudden onset respiratory
symptoms/distress
& no CXR obtained within last 24 hours)
CIRCULATION:
If no signs/symptoms of HF & SBP <80mm: Administer 500ml 0.9%

NS x 1
Time administered: ______________

N/A
12 lead ECG Time: ________
MEDICATIONS/ADDITIONAL INTERVENTIONS:
Check POC glucose If <60 mg/dl: If patient

awake:
administer 25ml D50 (1/2 amp)
Time administered: _____________
Repeat POC BG: ________________
ISTAT POC ABG, Lactate, & Electrolytes if not

previously done in the last 30-60
minutes
Time: _________
pH: _____________
Lactate:_____________
CO2 _____________
PO2 _____________
HCO3 ____________
ADDITIONAL VITAL SIGNS / TIME
Continue documentation of meds & vital signs on back of *WHITE FORM*
RRT NURSE FINAL ASSESSMENT:
#194 12-2008
Disposition:
No transfer
Intercare
ICU or CICU
Physician: ___________________________________________
RRT RN: _____________________________________________
Follow Up Visit: _________________________________
RRT DEPARTURE TIME:_____________
Progressed to Code
Made DNR/CMO Time of transfer: _______
RRT RT: ______________________________________________

Time of Visit: ________________________
RRT Call Debrief Conducted:

Family involved in debrief
Patient had subsequent Code Blue;
Yes
No
Yes
No
Patient expired;
Patient survived to discharge (Date) ____________________________
White Copy Send to Medical Record
Yellow Copy Return to Division of Healthcare Quality
ADDITIONAL DOCUMENTATION / TIME
Continue documentation on progress note if necessary
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
SBAR report to physician about a critical situation
S
B
A
R
Situation
I am calling about <patient name and location>
The patients code status is <code status>
The problem I am calling about is ___________________________________.
I am afraid the patient is going to arrest.
I have assessed the patient personally:
Vital Signs are:
Blood Pressure _______/_______, Pulse ________, Respiration _______ &
Temperature _________
I am concerned about the:
Blood pressure because it is less than 90 or 30 mmHg below usual.
Pulse because it is
over 130 or
less than 40.
Respiration because it is
less than 8 or
over 24.
Background
The patients mental status is:
Alert and oriented to person, place and time.
Confused and
cooperative or
non-cooperative.
Agitated or combative.
Lethargic but conversant and able to swallow.
Stuporous and not talking clearly and possible not able to swallow.
Comatose. Eyes closed. Not responding to stimulation.
The skin is:
Warm and dry
Pale
Mottled
Diaphoretic
Extremities are cold
Extremities are warm
The patient
is not or
is on oxygen:
The patient has been on _______________(l/min) or (%) oxygen for _______________ minutes
(hours)
The oximeter is reading _______________%
The oximeter does not detect a good pulse and is giving erratic readings
Assessment:
This is what I think the problem is: <say what you think is the problem>
The problem seems to be
cardiac
infection
neurologic
respiratory
______________
I am not sure what the problem is but the patient is deteriorating
The patient seems to be unstable and may get worse, we need to do something
Recommendation:
I
suggest or
request that you <say what you would like to see done>
Transfer the patient to critical care
Come to see the patient at this time
Talk to the patient or family about code status
Ask the on-call family practice resident to see the patient now
Ask for a consult to see the patient now
Are any tests needed:
Do you need any tests like
CXR,
ABG,
EKG,
CBC or
BMP?
Others:
If a change in treatment is ordered then ask:
How often do you want vital signs?
How long do you expect this problem will last?
If patient does not get better when would you want us to call again?

Baystate Med CTR Rapid Response Team Recordwith SBAR

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Baystate Med CTR Rapid Response Team Recordwith SBAR

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Patient Identification Information/Sticker

RAPID RESPONSE TEAM

Person (Name) placing call: ________________________________

RRT NURSE ASSESSMENT ON ARRIVAL:

LOC:________ Breath Sounds: _______________

RR:______ (>20) BP: _________ O2 Sat ________ FiO2: ________

Administer 50ml D50 (1 amp)

Titrate FiO2 to maintain patients O2 saturation >92% (use any modality)

If no signs/symptoms of HF & SBP <80mm: Administer 500ml 0.9%

Time administered: ______________

Check POC glucose If <60 mg/dl: If patient

ISTAT POC ABG, Lactate, & Electrolytes if not

Continue documentation of meds & vital signs on back of *WHITE FORM*

RRT NURSE FINAL ASSESSMENT:

RRT DEPARTURE TIME:_____________

Made DNR/CMO Time of transfer: _______

RRT RT: ______________________________________________

RRT Call Debrief Conducted:

White Copy Send to Medical Record

Yellow Copy Return to Division of Healthcare Quality

ADDITIONAL DOCUMENTATION / TIME

Continue documentation on progress note if necessary

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LOC: Breath Sounds: _______

RR:__ (>20) BP: _ O2 Sat FiO2: ____

Continue documentation of meds & vital signs on back of WHITE FORM