INSTITUTIONAL POLICY & PROCEDURE
Index Code: INST: 09/316
Date of Original P&P: 10-01-86
Effective Date: 4/23/2014
Revision Number: 12
TITLE:
CARDIOPULMONARY RESUSCITATION & EMERGENCY MEDICAL
RESPONSE
ORIGINATOR:
Vice President & Chief Nursing Officer
APPROVAL:
____________________________________________
President, Mercy Health Saint Mary's
____________________________________________
President and CMO, Mercy Health Physician Partners
POLICY STATEMENT: Cardiopulmonary resuscitation (CPR) and life support shall be provided for all persons
who sustain an acute and sudden cessation of effective circulation and/or respiration while they are at Mercy
Health Saint Mary's or Mercy Health Physician Partners (MHSM/MHPP) except when a specific known "Do Not
Resuscitate" order has been entered in a patient's chart in accordance with Hospital guidelines or when the
physician determines CPR to be medically futile.
Cardiopulmonary life support measures shall be maintained until the patient recovers sufficiently, a physician
director or advanced life support services arrive, the patient's attending physician determines that life support
efforts should be stopped, or the physician directing the cardiac arrest team determines that all reasonable
measures have been exhausted without success.
The Cardiopulmonary Resuscitation Committee endorses that the current Basic Life Support (BLS) and Advanced
Cardiac Life Support (ACLS) guidelines by the American Heart Association will be followed for the performance
of cardiopulmonary resuscitation at MHSM/MHPP.
In keeping with the faith-based ministry of MHSM/MHPP, all personnel responding to a Cardio-pulmonary
Resuscitation shall maintain a respectful and dignified caring attitude at all times during this situation. Adequate
numbers of personnel needed to care for the patient will remain in the room and conduct themselves accordingly.
Personnel not needed in the immediate care of the patient should leave the room to better allow the care team to
communicate, collaborate, and document the events that are occurring. In the event that excess personnel do not
automatically leave the room, the nurse designated as RN #1 or any nursing or medical leadership colleague may
request that this be done.
Family members will be offered the option to be present in the patient room during resuscitation
procedures. Family members are those individuals who are relatives or significant others with whom the
patient share an established relationship.
The decision to have family present is based on the following components:
1. The agreement of the CPR director.
2. The patient’s desire to have family there.
3. The family’s desire to be present.
MHSM/MHPP will designate a family facilitator who MUST remain with the family during the CPR event. A
hospital colleague who acts as the family facilitator MUST stay with the family during the entire CPR event. Any
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MHSM/MHPP colleague can act as a family facilitator including but not limited to one of the following staff
colleagues: Nurse, Physician, social worker, chaplain, office staff or any leadership staff. Family members that are
experiencing uncontrolled emotional outbursts or violent behavior will be restricted from the room.
The role of the family facilitator includes:
1. Determine appropriate time to bring family into the room, in collaboration with the care provider.
2. Assess family member’s level of coping.
3. Prepare the family for what they may see and hear.
4. Provide clear information as to the status of the patient.
5. Position the family so the care team has sufficient room to provide care.
6. Should the patient expire, give the family member a moment then move to a bereavement room until the
patient is cleaned up.
7. Upon completion of the resuscitation, assess the need for critical incident stress debriefing.
CARDIAC ARREST TEAM
Mercy Health Saint Mary's Cardiac Arrest Team shall provide cardiac arrest services for all locations in the
Hospital including adjacent buildings and offices such as: Medical Office Building, Wege Building North and
South, Lacks Cancer Center, and by contract, for Mary Free Bed main hospital building and Great Lakes
Specialty Hospital on the 5th floor of the main hospital building. Mercy Health Saint Mary's Cardiac Arrest Team
will also assist persons who have collapsed immediately outside the Hospital and near the Hospital main entrance,
subject to the availability of qualified personnel. Emergency care of persons already in the Hospital building,
including the Emergency Department and adjacent outpatient offices/clinics, will be provided before Cardiac
Arrest Team members can respond to an arrest outside the building. If a person collapses in any of the Hospital
parking areas, available Cardiac Arrest Team members will be sent to assist. The Hospital operator will call an
ambulance service to assist in transport if directed by response team.
Emergency Department: personnel from the Emergency Department and Respiratory Therapy
therapists/technicians (where applicable) will cover Arrests that occur in the Emergency Department.
Other members of the arrest team may be requested individually as needed. The arrest team may be requested by
overhead page and the beeper system.
Newborn Nursery and Neonatal Intensive Care Unit (NICU): In Newborn Nursery and in the NICU, instead
of the specified Arrest Team Members, supervised cardiopulmonary resuscitation will be provided by nursing and
respiratory therapy personnel working in those areas and by a neonatologist, pediatrician, Neonatal Nurse
Practitioner, or senior OB/GYN resident who is in-house.
Pediatrics: In the event of a pediatric arrest, the operator will overhead page “Peds code 333”, will beeper
page “Peds Code 333” with location, and page the neonatal nurse practitioner. The following providers will
respond; Intensivist, emergency department physician and an anesthesiologist. In addition, an ENPC/ACLS
certified RN from the ED will respond. In the event of a pediatric arrest in Mary Free Bed, a PALS certified RN
from Mary Free Bed will respond. The ACLS\ENPC RN will function in a supportive role to the PALS RN at
these codes. In addition, a Neonatal Nurse Practitioner or a Neonatologist will also respond as available to any
pediatric arrest.
Patients who arrest in any of the physician office suites contingent to Mercy Health Saint Mary's may be directly
admitted to Critical Care (H2) at the discretion of the patient's physician and/or the Intensivist.
Cardiopulmonary resuscitation will be initiated by any trained personnel at the scene of the arrest and continued
by the cardiac arrest team as they arrive. In the event of multiple arrests, the team will respond to the first and
second arrest; any additional arrests will require assistance from any ACLS trained physicians hearing an
overhead code 333 and qualified respiratory and nursing personnel.
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Designated ACLS RNs from the Emergency Department (ED) and the Critical Care Unit (H2) will answer arrests
in the areas specified in the Addendum III "Areas of Arrest."
Team Members:
See Addendum III “Arrest Team Member Qualifications: Education and Competency Validation Process.”
1. Intensivist.
2. Medicine Resident House Office G-2, G-3 or G-4.
3. Designated G-1 or G-2 on the medical service.
4. Designated G-1 or G-2 on the family practice service.
5. Respiratory Therapy - 2 Therapist/Technicians.
Note: EKG technician will respond to all codes from 6:00 am to 5:30 pm.
6. Pharmacist responds from 7:00 am until 11:00 pm.
7. Nurse Manager / Clinical Resource Coordinator.
8. ACLS RN from H2 or the Emergency Department.
9. Bedside Registered Nurse (RN) from affected area.
10. Neonatal Nurse Practitioner (pediatric arrests, only).
11. Additional staff (Security, Patient Care Assistant, Mission Effectiveness, Surgical Residents) as needed.
Definitions:
BLS – Basic Life Support
ACLS – Advanced Cardiac Life Support
PALS – Pediatric Life Support
ENPC – Emergency Nurse Pediatric Certification
AED – Automated External Defibrillation
Rapid Response Nurse (RRN)
Rapid Response Team (RRT)
Policy Outline:
A. Paging a Code
B. Beepers
C. Resuscitation Responsibilities Prior to Cardiac Arrest Team Members Arrival
D. Performance of Chest Compressions
E. Cardiac Arrest Team Members – Adult
F. Cardiac Arrest Team Members – Pediatric
G. Mercy Health Physician Partners and Mercy Health Saint Mary's Offices/Clinics
H. Southwest Campus
I. Evaluation Process
Addendum I: Areas of Arrest
Addendum II: Arrest Team Members Qualifications
Addendum III: Location of Crash Carts and Equipment on Cart
Addendum IV: Medical Injury and Emergency Report Form
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PROCEDURE:
Responsibility
Department Manager/Director
Or Designee
Action
1.
Arranges for crash cart availability in his/her designated patient
care area(s).
First Person on Scene (CPR
TRAINED OR NOT) Unit
Secretary or Any Available
Hospital Personnel
1.
Calls for help by dialing 6333 and states area and location of arrest.
(Example: 6-North, Room 618)
CPR Trained Person
2.
Begins procedures as defined under Basic Life Support (BLS) provider
card.
Registered Nurse
CPR Trained Staff
3.
Sends someone to get crash cart\AED.
A. Paging a Code
Note: ED staff delivers the crash cart to affected areas without their
own crash cart on Mercy Health Saint Mary's Campus.
Hospital Operator
4.
Overhead pages 3 times CODE 333, stating the floor or area AND
specific room number. Beeper page code 333 with floor\area and room
number.
Note: In the event of multiple arrests the ACLS RN will be provided
from ED and Critical Care on an alternating basis.
5.
Follows Policy 10/132 should an event occur outside the hospital
building, but on the property.
6. May call EMS if directed and applicable (for assistance with
Transport, extrication, etc.
B. Beepers
Operator
1.
Beeper ALL-CALL System: Types Code 333 plus specific room
number. Presses F7 for code ALL-CALL. If system down, dials
397-8289.
Cardiac Arrest Team Members
(Except ACLS Nurses from ED)
2.
Carries a beeper at all times capable of receiving the all-call.
3.
Designates a qualified substitute, if unavailable, and gives that person
the appropriate beeper.
4.
Ensures that the beeper is functioning properly at all times.
Respiratory Therapy
5.
Passes beepers on from shift to shift ensuring that the beeper is
functioning properly at all times.
ED / RR
6.
Designates an ACLS RN to respond to overhead pages of codes.
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Institutional Policy & Procedure
Physicians:
ACLS Certified Medicine G-2,
G-3 or G-4/Family Practice
Pharmacist
09/316
7.
Obtain their beepers from Medical Staff Office.
8.
Carries beeper and passes it on to next physician on call.
9.
Carries a beeper during the hours 7:00 am and 11:00 pm. Responsible
for acquisition of sedatives for areas that do not have them.
C. Resuscitation Responsibilities Prior to Cardiac Arrest Team Members Arrival
CPR Trained Person/
Registered Nurse
1.
Begins procedures as defined by Basic Life Support (BLS) provider
card.
2.
Sends someone to get crash cart.
Note: Emergency Department staff delivers the crash cart to affected
areas without their own crash cart.
3.
Attaches Automated External Defibrillator (AED) electrodes to patient
and follows steps as prompted by AED, if available in the area..
D. Performance of Chest Compressions
Any BLS Provider
1.
Gives chest compression relief if provider becomes fatigues or if RN#1
or Intensivist is concerned with the quality of compressions.
E. Cardiac Arrest Team Members – Roles for Adult Codes
Operator
Intensivist
1.
Overhead pages 3 times CODE 333, stating the floor or area AND
specific room number.
2.
Beeper pages CPR All-Call, stating Code 333 plus floor or area AND
specific room number.
3.
Performs as CPR director and delegates/supervises management of the
arrest to residents as appropriate to skill level.
4.
Assures quality arrest management is maintained by serving as
educator and advisor to house staff and intervening appropriately as
deemed necessary.
5.
Assesses personnel needs of the arrest situation and excuses all
unnecessary personnel as soon as reasonable.
6.
Follows ACLS algorithm appropriate for each arrest unless situation
dictates otherwise.
7.
Orders administration of all medication.
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Institutional Policy & Procedure
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8.
Orders administration of all defibrillation performed only by ACLS
certified RN or MD. Person who is performing the defibrilla-tion
ensures all personnel are clear of bed prior to defibrillation.
9.
Determines when patient stable to transfer to Critical Care (H2) or
when to discontinue CPR.
10.
Supervises medical management during transfer to Critical Care (H2).
11.
Completes progress notes.
12.
Ensures notification of the patient's family and attending physician
when arrest is finished or delegates to appropriate house staff.
13.
In the event of a second cardiac arrest situation, determines which
physician and personnel will respond.
Medicine Resident or G1/G2/
Surgical Resident or G1/G2/
Family Practice Resident
and Other House Staff
14.
Assumes responsibility as delegated by the Medical Intensivist for the
management of an arrest patient within their scope of practice or skill
level.
RN #1 (ACLS Certified RN from
from ED or RRT)
15.
Assesses personnel needs of the arrest situation and excuses all
unnecessary personnel as soon as reasonable.
16.
Initiates ACLS protocols until the Physician Leader arrives.
17.
Assesses situation. Assures that crash cart is present.
18.
Establishes airway (via oral airway and ambu bag) and begins
ventilations.
19.
Gives direction to continue chest compressions\AED interventions and
begins ACLS protocols.
20.
Connects to monitor and interprets cardiac rhythms if not already done.
Ensures appropriate strips are recorded, marked, and placed in chart.
21.
Defibrillates as appropriate per ACLS guidelines.
22.
Evaluates current IV access. Starts peripheral IV as necessary, unless
physician leader plans central line.
23.
Begins algorithm per ACLS protocol for drug therapy, including
Eprinephrine 1:10,000 1 mg IVP or Atropine up to 1mg IVP.
24.
Reports to Physician leader arriving on scene what has been
accomplished up to that point.
25.
Supervises nursing roles throughout the code. Provides supervision
and direction for non-medical staff, including respiratory therapy.
26.
Supervises preparation and maintenance of all medications.
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Institutional Policy & Procedure
RN #2 (RN Caring for Patient)
RN #3 (Recording Nurse From Affected Area)
Nursing Leadership Personnel
(CRC, Clinical Lead, CNS,
Educator, Nurse Manager)
Respiratory Therapists/
Technicians
09/316
27.
Assists with placement and operation of external pacemaker and
internal transvenous pacemaker.
28.
When patient appropriate for transfer, accompanies physician and
patient to Critical Care (H2).
29.
Reviews CPR record for completeness and accuracy related to arrest
with recording RN.
30.
Remains in the room; actively participates and assigns a recorder.
Administers medications upon instruction of CPR Director or ACLS
RN. Clearly announces when medications are given so that all team
members can hear and that the arrest record is complete.
31.
Sets up suction equipment or delegates.
32.
Provides information about patient to code team.
33.
If requested by RN #1, accompanies patient to Critical Care (H2).
34.
Contacts Respiratory Therapy for crash cart exchange or restocks crash
cart immediately following the arrest. Ensures that cart is completely
restocked.
35.
Completes documentation as appropriate including CPR note, transfer
note or expiration note.
36.
Maintains accurate CPR record.
37.
Reminds CPR Director and Crash Cart Manager of time intervals
between medications.
38.
Reviews record with RN #1 and CPR Director and/or Intensivist to
verify accuracy and completeness of information.
39.
Maintains normal unit operations (care of all patients on the unit).
Allows CPR team to function independently unless assistance is
requested.
40.
Additional tasks that may be helpful to the team may include support
of the family and to facilitate notification of pastoral care or attending
physician.
41.
When directly admitted to Critical Care (H2), facilitates getting patient
admitted electronically by Admitting so that stat orders can be
processed.
42.
Assign one therapist as airway manager and one therapist or technician
as assistant.
43.
Manages airway, according to BCLS standards by providing
ventilation via resuscitation bag with oxygen source as available.
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Institutional Policy & Procedure
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44.
Sets up suction equipment if not already done and suctions airway as
necessary.
45.
Sets up appropriate oxygen source for transport.
46.
Provides materials necessary for arterial blood gasses and draws radial
or brachial ABGs if requested.
47.
Performs ABGs and provides verbal results to the code team STAT.
48.
Assists with intubation and secures tube post intubation.
49.
Accompanies patient during transfer to Critical Care (H2). Manages
airway and ventilation during transfer. Assures ventilator ready upon
patient arrival to the Critical Care (H2).
50.
Restocks respiratory equipment on the arrest cart immediately
following the arrest and\or replaces crash cart to exchange areas.
Note: See Institutional policy 12\413, Crash Cart Maintenance.
Pharmacist (7 am – 11 pm)
51.
Anticipates medication needs at arrest.
52.
Assists RN#1 in mixing I.V. medications and in drawing up other
meds.
53.
Assists CPR Director in calculating dosages of medications.
54.
Determines compatibility of I.V. mixtures and bolus medications.
F. Cardiac Arrest Team Members – Roles for Pediatric Codes
Operator
1.
Overhead pages 3 times PEDS CODE 333, stating the floor or area
AND a specific room number. Also Beeper pages the CPR all-call
PEDS Code 333 + floor or area AND a specific room number. In
addition, pages the Neonatal Nurse Practitioner at 397-3792 with Code
333 + floor or area AND a specific room number.
Physician Director
(Family Practice Resident,
NNP, Intensivist)
2.
Performs as CPR director and delegates/supervises management of the
arrest to residents as appropriate to skill level.
3.
Assures quality arrest management is maintained by serving as
educator and advisor to house staff and intervening appropriately as
deemed necessary.
4.
Assesses personnel needs of the arrest situation and excuses all
unnecessary personnel as soon as reasonable.
5.
Follows PALS algorithm appropriate for each arrest unless situation
dictates otherwise.
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6.
Orders administration of all medication.
7.
Orders administration of all defibrillation performed only by PALS
certified RN or MD.
8.
Determines when patient stable to transfer to DeVos Children’s
Hospital if needed.
9.
Completes progress notes.
10.
Ensures notification of the patient's family and attending physician
when arrest is finished or delegates to appropriate house staff.
Intensivist
11.
In the event of a second cardiac arrest situation occurring elsewhere is
the hospital, determines which physician and personnel will respond.
RN #1 (ACLS\ENPC Certified
RN from ED\PALS Certified RN)
12.
Assesses personnel needs of the arrest situation and excuses all
unnecessary personnel as soon as reasonable.
13.
Initiates PALS\ENPC protocols until the Physician Leader arrives.
14.
Assesses situation. Assures that Pediatric Broselow crash
cart\traveling pediatric resuscitation bag is present.
15.
Establishes airway (via oral airway and ambu bag) and begins
ventilations.
16.
Gives direction to continue chest compressions\AED interventions and
begins PALS\ENPC protocols.
17.
Connects to monitor and interprets cardiac rhythms if not already done.
Ensures appropriate strips are recorded, marked, and placed in chart.
18.
Defibrillates as appropriate per PALS\ENPC guidelines.
19.
Evaluates current IV access. Starts peripheral IV/IO as necessary,
unless physician leader plans central line.
20.
Begins algorithm per PALS\ENPC protocol for drug therapy, including
Eprinephrine 1:10,000 0.1 mg\kg IVP or per Braselow tape or per
patient specific emergency sheet.
21.
Reports to Physician leader arriving on scene what has been
accomplished up to that point.
22.
Supervises nursing roles throughout the code. Provides supervision
and direction for non-medical staff, including respiratory therapy.
23.
Supervises preparation and maintenance of all medications.
24.
Assists with placement and operation of external pacemaker.
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Institutional Policy & Procedure
RN #2 (RN Caring for Patient)
RN #3 (Recording Nurse From Affected Area)
Nursing Leadership Personnel
(CRC, Clinical Lead, CNS,
Educator, Nurse Manager)
Respiratory Therapists/
Technicians
09/316
25.
When patient appropriate for transfer, accompanies physician and
patient as needed.
26.
Reviews CPR record for completeness and accuracy related to arrest
with recording RN.
27.
Remains in the room; actively participates and assigns a recorder.
Administers medications upon instruction of CPR Director or RN #1.
Clearly announces when medications are given so that all team
members can hear and that the arrest record is complete.
28.
Sets up suction equipment or delegates.
29.
Provides information about patient to code team.
30.
If requested by RN #1, accompanies patient to ICU.
31.
Contacts Respiratory Therapy for crash cart exchange or restocks crash
cart immediately following the arrest. Ensures that cart is completely
restocked.
32.
Completes documentation as appropriate including CPR note, transfer
note or expiration note.
33.
Maintains accurate CPR record.
34.
Reminds CPR Director and Crash Cart Manager of time intervals
between drugs.
35.
Reviews record with RN #1 and CPR Director and/or Intensivist to
verify accuracy and completeness of information.
36.
Maintains normal unit operations (care of all patients on the unit).
Allows CPR team to function independently unless assistance is
requested.
37.
Additional tasks that may be helpful to the team may include support
of the family and to facilitate notification of pastoral care or attending
physician.
38.
Assign one therapist as airway manager and one therapist or technician
as assistant.
39.
Manages airway, according to BCLS standards by providing
ventilation via resuscitation bag with oxygen source as available.
40.
Sets up suction equipment if not already done and suctions airway as
necessary.
41.
Sets up appropriate oxygen source for transport.
42.
Provides materials necessary for arterial blood gasses and draws radial
or brachial ABGs if requested.
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Institutional Policy & Procedure
Pharmacist (7 am – 11 pm)
09/316
43.
Performs ABGs and provides verbal results to the code team STAT.
44.
Assists with intubation and secures tube post intubation.
45.
Accompanies patient during transfer. Manages airway and ventilation
during transfer if needed.
46.
Restocks respiratory equipment on the arrest cart immediately
following the arrest.
47.
Anticipates medication needs at arrest.
48.
Assists RN#1 in mixing I.V. medications and in drawing up other
meds.
49.
Assists CPR Director in calculating dosages of medications.
50.
Determines compatibility of I.V. mixtures and bolus medications
G. Mercy Health Physician Partners and Mercy Health Saint Mary's Offices/Clinics-off campus
BLS Trained Staff
1.
Provides BLS to persons located in the physician office including the
waiting area.
Second Responder
2.
Calls 911.
BLS Trained Staff
3.
Performs cardiopulmonary resuscitation using Basic Life Support
guidelines until care is assumed by EMS.
4.
Documents the event on the Medical Injury and Emergency Report
Form (Addendum IV).
5.
Sends a copy of the Medical Injury and Emergency Report Form with
the EMS team.
1.
Provides BLS and\or ACLS to persons located within the southwest
campus campus building and surrounding parking lots.
2.
Transports patient to Southwest Emergency Department.
1.
Enters a report into VOICE system for each Code 333.
H. Southwest Campus
ACLS Staff
I. Evaluation Process
Registered Nurse #1/
Registered Nurse #2
Note: Emergency Department and Surgical Services evaluate through
mortality and morbidity review within the department.
Institutional Policy & Procedure
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09/316
Note: This report should include any identified opportunities for
improvement. If risk management issues are identified, Risk
Management is notified concurrently.
Note: Risk Management forwards VOICE reports to the Clinical
Service Director for Critical Care for review by a Clinical Nurse
Specialist and/or a physician (MD).
References:
American Heart Association. PALS Provider Manual. 2011.
American Heart Association. Advanced Cardiovascular Life Support, May 2011.
Concurrent Consent(s):
Vice President & Chief Nursing Officer
_____________________________
Vice President, Medical Affairs
_____________________________
Clinical Service Director
Emergency, Trauma & Critical Care
_____________________________
Chief of Emergency Medicine
______________________________
Chief of Anesthesia
______________________________
Director, Risk Management
_____________________________
Quality Improvement Committee Chair
MHSM/MHPP
_____________________________
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AREAS OF ARREST
Addendum I - Instit. P&P 09/316, Cardiovascular Resuscitation
Rapid Response Team (RRT) will respond to all codes, except off campus offices.
Location
Levels 3-9
Main Hospital Building
1st Floor Main Hospital including
Radiology, Respiratory Therapy
Cardiac Cath Lab & Cardiology
Testing
Interventional Radiology
Security - Loretto Hall
- Surgery Prep
- PACU
- SSU
- PAS
- OR
Hospital Parking Areas
Mary Free Bed Hospital
ACLS RN
Responder
RRT
Crash Cart
Location
Floor with arrest.
Who Delivers
Crash Cart
Unit Staff
ED
ED
ED Staff
ED
Department
Department Staff
ED
ED
RRT
Department
ED
Department
Department Staff
ED Staff
Department Staff
ED
ED
ED Staff
Mary Free Bed Staff
Clinical Trial Unit -1st floor
Wege South - 3rd floor
ED
RRT
ED
ED
3 West Utility Room Mary
Free Bed
ED
Department
Cardiology Testing Center
Wege South – 4th floor
Wege North 4th Floor
ED
ED
Department
Family Medicine Office
Department Staff
Department Staff
Cardio Test Center & Cardiac
Rehab Staff
Department Staff
4200 Staff
Wege North 3rd Floor
ED
Family Medicine Office
4200 Staff
Diabetes Center, Level II Wege
Diabetes Center Staff
Diabetes Center, Level II Wege
Diabetes Center Staff
Diabetes Center, Level II Wege
Diabetes Center Staff
ED
ED Staff
Department
OR
Department Staff
OR Staff
Lacks OP Surgery
ED Lacks OP Surgery-Staff
Department
Unit
Department Staff
Department Staff
ED
ED Staff
Proc. Room
Department
ED
H1 Staff
Department Staff
ED Staff
Jefferson Building
Wege North 2nd Floor
ED
- Diabetes Education/
Endocrine Assoc.
Wege Building
ED
-Atrium
-Pharmacy
- Lab
Wege North Building
ED
-TIS - Conf. Rooms
Lacks Radiation Oncology
ED
(Lower Level)
S
ED
Lacks OP Surgery
RRT
(2nd Floor)
Lacks Breast Center
ED
(2nd Floor)
Lacks 3rd Floor
RRT
RRT
Lacks Inpatient
(4th Floor)
RRT
Lacks
(5th Floor)
Hauenstein 1
RRT
Hauenstein 2 & 3
RRT
All Other Areas Not Mentioned
ED
nrsgadmn\p&ps\instit\09-316\11-1-13
ARREST TEAM MEMBERS QUALIFICATIONS:
EDUCATION AND COMPETENCY VALIDATION PROCESS
Addendum II - Instit. P&P 09/316, Cardiovascular Resuscitation
Team Member
Initial Education
Competency Validation Process
Intensivist
ACLS Certification
Maintaining Board Certification in
Specialty or ACLS Certification
Medicine Resident House Office
G-2, G-3 or G-4
ACLS Certification
Ongoing mentoring by senior residents
after each Arrest or attending physicians
Designated G-1 or G-2 on the
medical service
ACLS Certification in G-1 year, Ongoing mentoring by senior residents
BCLS prior to starting G-1 year after each Arrest or attending physicians
House officer on surgical
service
ACLS Certification
G-1 or G-2 on the family
practice service
PALS Certification in G-1 year Ongoing mentoring by senior residents
after each arrest or attending physicians
ACLS Certification in G-1 year,
BCLS prior to starting G-1 year
Respiratory Therapy - 2
Therapist/Technicians
Role reviewed in orientation,
BCLS
BCLS every 2 years, policy or practice
changes.
Provided orally and verbally as they
arise.
Pharmacist
ACLS RN from Critical Care
Reviewed in orientation ACLS
Updates as needed
ACLS Certification and role
reviewed in orientation
ACLS Recertification
ACLS RN from the Emergency
ACLS Certification
ACLS Recertification
Department
ENPC Certification and role
Ongoing mentoring by senior residents
after each Arrest or attending physicians
Reviewed in orientation
RN from affected area
Reviewed in orientation
BCLS Recertification
PCA from affected area
Reviewed in orientation
BCLS Recertification
PALS certified RN
PALS Certification and
Reviewed in orientation
PALS recertification
Neonatal Nurse Practitioner
NRP Certification and
Reviewed in orientation
NRP recertification
Nurse Manager/Clinical
Resources Coordinator
Reviewed in orientation
Updates as needed
ENPC Trained RN
ENPC Training
Updates on Pediatrics provided
Off campus RN, staff or provider BCLS training
nrsgadmn\p&ps\instit\09-316\11-1-13
BCLS Recertification
LOCATION OF CRASH CARTS
Addendum III - Instit. P&P 09/316, Cardiovascular Resuscitation
Note: All carts have defibrillator pads appropriate to the patient population served.
Location:
Exchange
Portable Suction
Main Hospital
1st floor
Cath Lab
Cath Lab and Special Procedures Holding Area
Cat Scan
Interventional Radiology
3rd Floor
OR— internal defib spoons
PACU - Adult and Broslow Pediatric Cart
SSU/Surgery Prep
SSU – Braselow cart
5th Floor
Great Lakes specialty LTAC
6th Floor
Psych-Med Unit (PMU)
Endoscopy- room off back hall
7th Floor
7N
7S
8th Floor
Inpatient Hemodialysis
8N
8S Adult cart
Neonatal Intensive Care Unit (NICU) - Cart and Defibrillator
9th Floor
Birthing Center (Labor and Delivery)
Post Partum
Medical Office Building (MOB)
Clinical Trial Unit
Wege South
3rd Floor
Cardiac Rehab
Cardiovascular Testing Center
4th Floor
Pulmonary Office Suite 415
Wege North
2nd Floor
Diabetes & Endocrinology Center
4th Floor
Family Medicine Clinic, Suite 4200
continued on following page
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
*Not SMHC owned
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Location:
Exchange
The Lacks Cancer Center
Medicine Oncology – 1 Floor
OP Surgery– 2nd Floor
Adult Cart with internal defib spoons
Braslow Pediatric Cart
Inpatient Unit – 3rd Floor
Inpatient Unit – 4th Floor
Hauenstein Building
ED-Ground Floor
1 in each trauma room (4) ; 2 sets of internal defibrillator spoons
1 in supply corridor between station 3 & 4
Braselow cart
Traveling Pediatric Resuscitation Bag
1st floor Clinics
2nd floor-H2-3 carts
3rd floor-H3: 2 carts
Mary Free Bed Hospital
* Code Master
st
Yes
Portable Suction
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
* These institutions own and are responsible for the presence and functioning of the equipment in these
locations. (i.e. Mercy Health Saint Mary’s is not responsible for the equipment. Mercy Health Saint Mary’s
provides contractual services for staff only to respond to an arrest.)
nrsgadmn\p&ps\instit\09-316\11-1-13
MEDICAL INJURY & EMERGENCY REPORT
LOCATION _______________________________________
DATE & TIME _________________________________
NAME ________________________________ HISTORIAN ________________________ DOB ___________________
□ PATIENT
□ NON-PATIENT
PCP ____________________________________ NEXT OF KIN ________________________
NOTIFIED _____________ TIME _____________ ADVANCED DIRECTIVE _______________
CHIEF COMPLAINT _______________________________________________________________________________
□ NKDA
ALLERGIES _____________________________________________________ SMOKER
□ YES
□ NO
CURRENT MEDICATIONS __________________________________________________________________________
________________________________________________________________________________________________
HISTORY
□ DIABETES
□ CAD
□ CHF
□ ASTHMA
□ COPD
□ CANCER
□ ANTICOAG THERAPY
VITAL SIGNS
TIME
BLOOD PRESSURE
PULSE
RESPIRATIONS
PULSE OX
PAIN
BLOOD GLUCOSE
NURSING ASSESSMENT
AIRWAY
BREATHING
PULSE
MENTATION
SKIN
PAIN
□ OPEN □ CLOSED
□ SPONTANEOUS □ LABORED □ ASSISTED □ APNIC
□ PRESENT □ ABSENT
□ ALERT □ DISORIENTED □ AGITATED □ UNCONSCIOUS
□ NORMAL □ WARM □ COOL □ PALE □ CYANOTIC □ DIAPHORETIC
□RATING:
/10
LOCATION:
INJURIES
ACTIONS
□ 911 TIME EMS CALLED:
□ OXYGEN LITERS:
□ AED □ ADULT PADS
□ MEDICATIONS GIVEN:
TIME EMS ARRIVED:
□ MASK
REPORT GIVEN TO:
□ NASAL CANNULA
□ PEDIATRIC PADS
□ AMBU BAG
# OF SHOCKS:
EVENT REPORT: __________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
STAFF PRESENT _________________________________________________________________________________
RECORDER ____________________________________________________________________ DATE ____________
Addendum IV, 09/316, Cardiopulmonary Resuscitation & Emergency Medical Response
nrsgadmn\p&ps\instit\09-316
Revised 1-28-2013