TITLE: PROTOCOLS FOR USE BY THE RAPID RESPONSE TEAM REGISTERED
NURSE
Performed By: RN who has successfully completed Core PICU nursing competencies.
Purpose: To provide protocols for use by the Rapid Response Team (RRT) Registered Nurse
Policy Statements:
1. The protocols listed in this policy may be initiated by the RRT RN prior to physician
notification as the patient condition warrants. The RRT Intensivist is to be notified as soon
as possible after initiating a protocol. These Protocols DO NOT APPLY TO EMERGENCY
DEPARTMENT, SPECIAL CARE NURSERY, PICU, ICC, AND NEONATAL INTENSIVE
CARE UNITS.
2. Each time a protocol that requires a medical order is initiated, an order MUST be written on
the physician’s order sheet (Example: Stat ABG for severe respiratory distress per Nursing
Protocol/J. Doe RN)
3. The RN may delegate specific tasks to staff within their scope of practice.
4. An RN who has completed the PICU core competencies may initiate the RRT RN protocols.
General Information:
1. If the RRT Intensivist is unavailable or not accessible, the patient’s attending physician or
partner, the Emergency Department physician, or House physician (where available) is
notified and consulted.
2. The RRT RN position is intended to support clinical decision-making in the non-critical care
areas.
3. The RRT RN may initiate the protocols in a non-critical care area.
4. The RRT RN may transfer a patient to a monitored area when performing a consultation.
5. Additional information pertaining to specific procedures may be obtained from procedure
policies.
Procedure:
1. Based on assessment, the RRT RN identifies a situation/patient condition that warrants
initiation of a protocol.
2. An order for each protocol initiated is written on the physician’s order sheet. Example: Stat
ABG for severe respiratory distress per Nursing Protocol/J. Doe RN
3. The supervising RRT Intensivist is informed that the protocol was initiated and the patient
status.
4. Patient is monitored based on the protocol initiated, response to protocol, and physician
orders.
5. Initiate a “Dr Blue” when a team response stat is indicated.
Documentation Guidelines: On form(s) appropriate to area, (may be in progress note) document
1. RRT RN assessment of patient including concern by floor staff
2. Outline protocols initiated
3. Written order on physician order sheet.
4. Patient response to intervention
5. Physician notification/attempts to contact physician
Rapid Response Team Protocols
RESPIRATORY Nursing Protocols
1. O2 to keep saturations > 90%.
CARDIOVASCULAR Nursing Protocols
1. Peripheral IV and/or keep open an
existing IV with normal saline.
2. Monitoring as indicated
2. STAT chest x-ray with reading.



Oximetry
Cardio respiratory
Apnea
3. Suction as needed.
4. For a patient in respiratory distress

Call Respiratory Therapy for
Respiratory Care Assessment and
give any previously ordered
treatment STAT x1.

Respiratory treatment X1 of
Albuterol 2.5 mg (0.5 mls) in 2.5
mls of NS nebulized using 8 – 10 L
of O2 flow

ABG or VBG testing one time.

STAT chest x-ray with reading.
5. May return to last stable ventilator
setting if patient fails ventilator weaning
as evidenced by:
Respiratory rate
O2 saturation 90%
Level of consciousness
Anxiety
Contact Respiratory Care for
Respiratory Care Assessment and to
Return patient to last stable ventilator
Setting.
6. Transfer to higher level of care if
indicated.
3. For Chest pain:
 Obtain STAT 12 lead EKG and
report results to supervising
physician.
 Cardiac monitoring (e.g.: Lead II)
 O2 to keep saturation 90%.
 B/P-Pulse-Resp. every 5 minutes
and document.
4. For symptomatic hypotension (40mm
Hg drop in systolic baseline), call
supervising Intensivist STAT and:
 Utilize MODIFIED Trendelenburg
position by elevating legs and
leaving head flat. DO NOT use
Trendelenberg position as it may
increase respiratory distress and
cause refractory bradycardia or
hypotension.
 Bolus with 10 mls/kg NS IV.
 Monitor B/P-Pulse-Resp. every 5
minutes and document until patient
is no longer symptomatic, returns to
baseline, or is transferred to a
monitored bed.
 Use non-invasive automatic cuff or
doppler stethoscope to monitor B/P.
 Remove topicals that may cause
hypotension such as Nitroglycerin
patch/paste, Duragesic, or Catapres
patch.
 Hold oral antihypertensive until
physician is consulted.
5. For suspected/active bleeding order
and draw:
 STAT CBC and send to lab
 Type and screen and hold pending
CBC results.
 If Hgb 8, send type and screen to
lab and set up 2 units packed cells
6. Transfer to higher level of care if
indicated.