Cardinal Signs of Failure

1
Cardinal Signs of Failure
2
Failure to Rescue Early Intervention

• Failure to identify early cardinal signs of
  change in a patient to prevent an arrest or
  sudden physiological collapse.
• Failure to obtain resources and interventions for
  a patient with cardinal signs of collapsing
  physiological system(s)

3
DATA

• Failure to recognize early subtle cardinal signs
  and symptoms of deterioration
• Failure of system thus staff not able to obtain
  resources or level of care for patient with
  cardinal signs of change

4
Contributing Factors

• Failure in planning (includes assessments,
  treatments goals)
• Failure in communication (pt to staff, staff to
  staff, staff to LIP
• Failure to recognize deteriorating patient
  condition

5
Clinical Instability Prior to Arrest

• 70 show evidence of respiratory deterioration
  within 8hrs of arrest
• 66 show abnormal signs and symptoms within 6hrs
  of arrest and MD notified only 25 of cases

6

• Respiratory
• Cardiovascular
• Neurological
• Surgical bleeding or occlusion

7
Respiratory

• Work of Breathing (ventilation)
• Respiratory rate gt30 or lt8 breaths/min
• Use of accessory/abdominal muscles
• Difficulty completing sentences
• Airway/Lung Status
• Upper airway obstruction (wheezing vs. stridor)
• Ineffective cough with inability to mobilize
  secretions
• Aspiration (coughing with any oral intake of
  liquids/solids)
• Oxygenation Issues
• SaO2 lt 95 on supplemental oxygen (COPD lt90)
• O2 sat decreases lt90 with any movement/activity
  (COPD lt88)
• Crackles, peripheral edema (pneumonia vs. CHF)
• ABG (ph lt7.3 or gt7.5, PCO2 lt30 or gt60, PO2 lt60 on
  RA)

8
Cardiovascular

• Dysrhythmia/Rate Issues
• Change from baseline ECG rhythm (afib, aflutter,
  heart block, ST elevation or depression)
• Increase in PVCS, PACS
• Heart rate gt120 or lt50 (or /- 20 from baseline)
  with symptoms
• Heart rate lt30 even if not symptomatic
• Pump Issue
• Systolic BP lt90 or gt180 (/- 20 from baseline)
• Systolic lt80 even if not symptomatic
• Chest pain unrelieved with oxygen and Nitro
• Acute change in or increasing crackles (CHF)
• Perfusion Issue
• Cool, clammy skin with poor pulses
• Urine output lt200ml over 8hr time frame
• Decreased level of consciousness
• Temp gt39 or lt35

9
Neurological

• Decreased LOC
• Seizures
• New facial droop or extremity weakness on one
  side of body
• New onset of agitation or delirium

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Role of Assessment

• Admit Screening
• Shift Assessment
• Care Plan
• Shift Report
• Transfer Note

11
Intervention

• Continued assessment
• Notify and involve team
• Know and access resources
• Role of USL or charge Nurse
• Initiate RRT
• Code 99

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Ward RN responsibilities PRIOR to initiating RRT

• As patients condition has changed and cardinal
  signs of failure have developed it is an
  expectation that the following will occur
• Page ward team resident intern or covering team
  via text message sent to the resident via the
  page operator (or web link). Request that the
  following message be displayed need immediately
  to unit ____ room bed number and then
  extension
• notify charge nurse of patient condition
• once ward team arrives collaborate to determine
  need for RRT
• If transfer to ICU is indicated but do not need
  RRT call ICU USL to determine bed availability
• NOTE ACTIVATE RRT if no bed available for
  stabilization and resource allocation OR if no
  ward team response and patients condition
  warrants immediate intervention
• If need help immediately and cannot wait 10
  minutes for the arrival of the RRT then call a
  Code 99.

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Role of Rapid Response TeamRRT

• Assess
• Stabilize
• Assist with communication
• Education support
• Assist with transfer, if necessary

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RRT Members

• RN Unit Shift Leader (USL) ICU
• Respiratory Therapist (RT)
• Senior MICU Resident
• Facilitator

15
Key Elements

• Team available to respond immediately
• Onsite and accessible 24/7
• Critical care skills

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Benefits of RRT

• Early intervention and stabilization
• Prevention of arrest situations
• Decrease in FTR events
• Decrease in codes occurring out of ICU

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Ward RN role during RRT

• Dial 47 and activate RRT, state ward location,
  room and bed number
• If attending for ward team not present ask
  secretary to notify ward attending via paging
• Stay with patient and provide RRT information
  regarding patient status and synopsis of Cardinal
  sign presentation, using SBAR format (Situation
  Background Assessment Recommendations). Have flo
  cart available in room to facilitate process and
  order entry.
• In conjunction with ICU RRT member provide
  treatment interventions.
• If patient to be transferred completed transfer
  note and provide report to ICU RN accepting
  patient.
• Complete RRT initiation note in CPRS
• Complete RRT feedback form and fax to QM

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Primary team/covering teamrole during RRT

• Stay at bedside and evaluate patient with RRT
• Communicate patients goals of care or
  limitations of treatments requested by patient
• If ICU transfer ensues, write transfer orders and
  note
• If patient remains on floor
• Re-evaluate patient in ½ hour
• Document in CPRS progress note format the event
• Notify patients family of transfer to ICU or
  significant change in clinical status
• Notify attending of transfer to ICU or
  significant change in clinical status

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Team Roles- ICU RN USL

• Respond to RRT page and arrive at the bedside
  within 10 minutes
• Assure patients primary team has been called
• Assess patient with bedside RN who initiated the
  RRT call using SBAR format (Situation Background
  Assessment Recommendations)
• Assist / support bedside RN in providing ordered
  treatments
• Generate orders in CPRS and chart in BCMA any
  administered medications/fluids
• Assist in transfer of patient to higher level of
  care if necessary
• Document in CPRS using RRT template (may need to
  use generic progress note and/or paper flow sheet
  until template completed)

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Team Role- RT

• Give priority to all RRT calls and arrive at the
  bedside within 10 minutes.
• Assessment of patient including the following
• Color
• Level of consciousness
• Level of activity
• Respiratory rate pattern
• Breath sounds
• Cough/sputum production
• Work of breathing
• VS HR,BP,Sp02
• Oxygen delivery system amount of delivered
  oxygen
• Diagnosis History including recent treatments.
• Inform RN, Team and USL of assessment results and
  recommendations
• Help transport patient to ICU if necessary
• Document in CPRS Respiratory Progress note and
  RRT Log

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Team Role- MICU Resident

• Respond to RRT page and arrive at patients
  bedside within 10 minutes
• Perform patient assessment with RRT team, primary
  team and ward nurse
• Initiate therapies as needed
• Assist with triage decisions
• Communicate with primary team
• Assist with transport, if needed
• If patient to be transferred include in admission
  note details of the RRT response
• If patient to remain on ward, write a brief note
  regarding RRT assessment, interventions,
  treatments and recommendations

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FacilitatorMed Surg CNS

• Observes, completes RRT process evaluation form,
  looks for opportunities for improvement and
  education.
• Reviews charts of all RRT responses and FTR cases
• Problem solves road blocks in the system

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Documentation

• Who?
• Why?
• What?
• When?

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Notes

• ICU RN USL will place a RRT Note in CPRS
• Ward RN will complete Cardinal Signs Note
• Primary team/covering team will include pertinent
  information in their transfer note
• If pt not tx, then at the 30 min re-evaluation of
  patient a brief note related to event and
  reassessment findings

25
Feedback

• To RRT- the ICU USL will give the initiator a
  feedback form that will be faxed to QM
• From RRT- document on worksheet any specific
  feedback or suggestions for improvement
• Facilitator present notes opportunities for
  improvement reviews all charts
• RRT workgroup will be looking at data, trends,
  system issues, documentation, etc

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Case Scenario

• JC is 75 y/o male admitted from ECU with resp.
  distress. HX COPD, HTN, CAD, 50pk yr smoker.
  Initial O2 sats 70 on RA. His O2 sats increased
  to 88 on 3 l/NC. Admitted with dx pneumonia,
  exacerbation of COPD.
• Upon arrival to ward A,A,A x4, HR 105, BP 150/88,
  RR32, T 38C, Sat 90 3L/NC. Using accessory
  muscles upper chest. BS diminished throughout and
  crackle right base.
• What concerns you?
• What will you be monitoring and how frequently?
• What actions will you take?

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Case Scenario continued

• Two hours after arrival. You get a call reporting
  that patient complaining of increased SOB, HR
  110, RR 36, Sat 86 on 3L/NC, crackles right
  base, insp. wheezes anterior chest
• What is your next step?
• What resources do you need?

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RRT arrives

• Nebulizer treatment
• Oxygen via venti mask 40
• ABG
• pH7.27, CO2 70, O2 55, HCO3 22, sat 87

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Case Scenario

• Mr. H 58 yr old admitted from ECU chief complaint
  of fatigue, intermittent jaw pain and new onset
  Afib. Hx DM, HTN, 1pk day smoker x 40 yrs.
  Father died age 60 MI, 2 uncles had strokes in
  their 50s.
• Admit assessment AAAx4, HR 120-98, BP 160/98 T
  98.6, RR20, crackles posterior bilateral,
  complains of jaw aching, intermittent nausea,
  cool.
• What concerns you?
• What will you be monitoring and how frequently?
• What actions will you take?

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Case scenario (cont)

• What orders do you anticipate?
• What are you assessing for to tell you if the
  patient is deteriorating?
• What is he at risk for?

31
Case Scenario

• Mr. R 63 yr old admitted from ECU with CHF. Hx
  DM, HTN, MI in 2001 with CABG.
• Assessment AAA x4 but difficulty completing
  sentences due to SOB, HR 120, RR 36, BP 160/80,
  accessory muscle usage, crackles 2 up posterior,
  bounding pulses, 2pitting toes to calfs, S3,
  JVD, distended abd with slight R upper quad pain,
  cool, clammy, weeping sore on R ankle
• What concerns you?
• What will you be monitoring and how frequently?
• What actions will you take?

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Case scenario (cont)

• What orders do you anticipate?
• What are you assessing for to tell you if the
  patient is deteriorating?
• What is he at risk for?