DUCS and RATS
INTEGRIS Health
How Did We Get Here?
• 70% arrests with evidence of
respiratory/neurological deterioration
within 8 hours
(Schein, Chest 1990; 98: 1388-92)
• 66% had abnormal signs and symptoms
within 6 hours of arrest and MD notified
in 25% of cases. (Franklin, Crit Care Med;1994; 22: 224-247)
DUCS Criteria
 Acute change in heart rate to <50 or >120
 Acute change in SBP <90mmHg
 Acute change in respiratory rate <10 or > 30
 Acute change in Oxygen saturation <90% in
despite oxygen therapy
 Acute change in LOC
 Acute change in urine output to <50ml in 4 hrs
 “Gut feeling” something is wrong
What do you do if you have
a DUC?
If your patient exhibits any of the previous signs
and symptoms contact:
Day shift:
 The patient nurse or your Team Manager/Clinical
Director
Evenings, Nights, or Weekends:
 The patient’s nurse or Team Manager/Administrative
supervisor
RATS
• Rapid Assessment Team (RAT) - developed to
prevent deaths in patients who are
progressively failing outside the ICU
• INTEGRIS believes healthcare providers
should share their knowledge across
departments to assist each other in meeting
patient needs and improving outcomes.
What Difference Can a Rat
Make?
 Literature Review: Other hospitals that have
implemented such teams have reported:
 50% reduction in non-ICU arrests
 12-30% reduction in hospital mortality
 44% Reduction in post-op emergency ICU transfers
 Improved staff satisfaction and recruitment with the
presence of a support team
 Improved patient satisfaction
(Buist, BMJ 02)
Goals of the Rapid
Assessment team
Be a resource for support of staff nurses
Improved time to treatment
Improved communication between all of
the patient’s care providers
Reduction of Code Blues and hospital
mortality
Enhanced learning opportunities
Who’s On the RAT Team?
 At IBMC:
House Officer
Critical Care Registered Nurse-Code
Blue Designated back-up RN
Registered Respiratory therapist
At ISMC
House Officer or an Advanced Practice
Nurse – CNS or ARNP
Critical Care Registered Nurse
ICU Team Leader
Registered Respiratory therapist
RAT Response
The advanced practice RN and the
critical care RN will respond to assist the
patient’s primary nurse in assessing the
situation, determining nursing diagnosis,
initiating appropriate protocols, and
communicating with the physician.
The primary nurse in the lead nurse.
RAT Duties
 Obtain report from the patient’s primary nurse
(including code status).
 Evaluate patient.
 Determine if situation is one of rapid decline or
a stable problem.
 Identify clinical problem – circulatory,
respiratory, neurological.
 Treat or transfer as indicated.
 Implement RAT order sets.
SMURFS
( If All Else Fails)
 Code Blue VS. “Dr. A”
A code blue will be called to summon
adequate personnel and equipment for
resuscitative efforts in all hospital areas.
A “DR. A” will be called to summon all
members of the code blue team with the
exception of the ACLS critical care
nurses.
Code Blue Team Members
House Physician
2 Respiratory Therapists
ACLS Critical care RNs
Primary nurse of the Patient
Administrative supervisor
Pharmacist
Chaplain
Prior to the Code Team
Arrival
 Determine Unresponsiveness
 Start BLS
 Call for help *911
 Get Crash cart
 Place backboard under patient
 Connect BVM to 100% oxygen and ventilate
 Apply hands-free defib pads
 Remove furniture from the room
Prior to Code Team Arrival
 If coding patient is in a semi-private room.
Relocate the other patient to another room or
stay with the other patient during the code.
 Monitor for adequate pulse with compressions.
 Move family to another area.
 Analyze rhythm if AED available. Deliver shock
if advised by AED.
 Set up suction
 Perform chest compressions
Roles and Responsibilities
 House Physician will assume charge
 Primary nurse of the patient remains
 Unit personnel will be relieved by code team to
assume care of the other patients on the unit.
 Clinical Director or Administrative Supervisor
will arrange for critical care bed
 Chaplain remains with the family to provide
support.
Roles and Responsibilities
Respiratory Therapists assume
ventilations and assists physician with
intubation.
Pharmacist pulls and assembles
emergency medications, IV fluids, and
other supplies as needed from crash cart
The Moral of the Story
 DUCS and RATS
Keep away Smurfs