UPMC Presbyterian Shadyside policy: Rapid Response System ... · SUBJECT: Rapid Response System DATE: February 28, 2013 CORRESPONDING PROCEDURES: CP-12-PRO Rapid Response System PUH

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UPMC PRESBYTERIAN SHADYSIDE

POLICY AND PROCEDURE MANUAL

POLICY: CP-12

INDEX TITLE: Care of Patients

SUBJECT: Rapid Response System

DATE: February 28, 2013

CORRESPONDING PROCEDURES: CP-12-PRO

Rapid Response System PUH Procedure

Rapid Response System SHY Procedure

I. POLICY

It is the policy of UPMC Presbyterian Shadyside (UPMCPS) to

have in place a Rapid Response System (RRS) to address the

needs of patients, visitors and employees that are

experiencing a crisis. The RRS is composed of the quality

improvement committee known as Medical Emergency Response

Improvement Team (MERIT). MERIT is responsible for

oversight of all condition response activities, changes in

practice and policies. The members of the MERIT Committee,

the responders to the conditions, staff at the bedside that

have been trained on conditions are all part of the Rapid

Response System. The individual MERIT Committees of each

campus will meet on a periodic basis to review emergency

events and outcomes and make recommendations for

improvement. MERIT reports to Patient Safety and Total

Quality Council Meeting twice a year.

Staff that respond to patients in crisis are known as the

Medical Emergency Team (MET), or Rapid Response Team (RRT)

in specific areas of the hospital. At WPIC, staff that

respond to patients in crisis are known as the Medical

Emergency Response Team (MERT). The MET, RRT or MERT

responds to and institutes crisis management or

resuscitation interventions for all patients, employees or

visitors who desire and/or require these measures.

Patients, employees or visitors who have received crisis

management or resuscitation interventions will be triaged

and transported to an appropriate patient care unit.

All members of the various Rapid Response Teams should

maintain current certification or equivalent training as

appropriate for the situations to which they respond.

http://infonet2.upmc.com/Policies/PRSH/Documents/CP12%20PRO%20PUH.pdf

http://infonet2.upmc.com/Policies/PRSH/Documents/CP12%20PRO%20SHY.pdf

POLICY CP-12

PAGE 2


All emergency carts and equipment used by the RRTs are

maintained as in accordance with CP-12-PRO-PUH Rapid

Response System Procedure (PUH) or CP-12-PRO-SHY Rapid

Response System Procedure (SHY).

Employees are to initiate crisis intervention calls as

appropriate for the crisis event.

CRISIS EVENT DEFINITIONS:

Condition C for a medical crisis (e.g. respiratory or other

emergent events). Condition C should be called whenever an

unstable patient needs rapid evaluation and treatment. This

includes any potentially life-threatening condition other

than cardiopulmonary arrest and is not limited to acute

respiratory distress or hemodynamic instability for

example, trauma. In the event that the patient needs to be

transferred to a monitored bed or ICU, the Condition C Team

will be responsible for transporting the patient. The

crucial aspect of a Condition C is early request for

assistance.

Condition A should be initiated for any pulseless patient

or a patient who is not breathing unless there is an order

in the medical records indicating that the patient is not

to undergo CPR, endotracheal intubation, or is in a status

of comfort measures only.

Condition H (Help) For situations that require attention

that may not be medical in nature, patients/families are

encouraged to call 7-3131 Presbyterian, 3-3131 Shadyside or

586-9742 WPIC for help and activating this emergency

intervention.

Is a method that provides patients/families the ability to

initiate a Rapid Response Team for any of the following:

A change in the patient’s condition when they have tried to

express it to the health care team and felt they did not

get the proper attention for the situation.

A situation where they have spoken with hospital staff from

the healthcare team (physician, nurses) and still have

serious concerns regarding how care is being given, managed

or planned.

POLICY CP-12

PAGE 3


Emergency situation when they are unable to get attention

from hospital personnel.

Members of the Condition H team differ from the Condition C

or A Team and are further detailed in the procedure.

Condition L

Is activated for a non-medical emergency that involves an

at risk patient that has left the unit without

authorization. Condition L is activated to locate the

patient and return them to a safe patient environment.

Condition M

Is activated for a non-medical emergency that involves

patients or family members that require behavioral

interventions. Members of the Condition M Team differ from

the Condition C or A Team and are further detailed in the

procedure.

Stroke Team (UPMC Presbyterian & UPMC Shadyside_ and Stroke

Assessment Team (SAT) (UPMC Shadyside)

Are activated when a patient presents with symptoms of a

stroke. These teams report to the individual hospital

Stroke Committee with reports back to MERIT.

Emergencies outside the campus buildings

Individuals suffering a medical emergency outside the

campus buildings as identified in the hospital specific are

also covered by this policy.

POLICY CP-12

PAGE 4


SIGNED: Holly Lorenz

Vice President, Patient Care Services

Sandra Rader


Camellia Herisko

Interim Vice President, Inpatient and Emergency

Services

ORIGINAL: August 7, 2002

APPROVALS:

Policy Review Committee: February 6, 2013

Medical Executive Committee:

Shadyside Campus: February 19, 2013

Presbyterian & WPIC Campus: February 28, 2013

PRECEDE: January 26, 2012

SPONSOR: Chair, CPR Q.I. Committee

Attachments

Appendix A – Criteria for Initiating a Condition C or A Team

Response

POLICY CP-12

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Appendix A –

Criteria for Initiating a Condition C or A Team Response

UPMC Presbyterian Emergency Line: 7-3131

UPMC Shadyside Emergency Line: 3-3131

UPMC WPIC Emergency Line 6-5555

General Guidelines

Any person may initiate a Condition C Team Response any time a

rapid response of critical care professionals is desired. A

Condition C Team Response should be used to prevent a crisis, or

to prevent a crisis from escalating.

The following practice guidelines are intended to assist

clinicians in decision making by describing criteria for

situations where it is reasonable to initiate a condition C team

response. These criteria attempt to meet the needs of most

patients in most circumstances. The ultimate judgment for

initiating a condition C must be made by the bedside clinicians

in light of the circumstances specific to that situation.


UPMC Condition C Calling Criteria

GENERAL

Any concern for a deteriorating clinical condition

RESPIRATORY

Difficulty in breathing

Increased work of breathing/use of accessory muscles

Sustained respiratory rate >30 or < 10

Escalating oxygen requirements

Hemoptysis or bleeding in the upper airway

Dislodged Artificial Airway (tracheotomy, etc…)

CARDIOVASCULAR

Chest pain

Hypotension: Sustained SBP < 90 mmHg

Hypertension: Sustained SBP > 200 mmHg or DBP > 120

Tachycardia: New onset sustained HR > 120

Bradycardia: New onset sustained HR < 50

Cyanosis, mottling of the extremities or pallor

NEUROLOGICAL

Seizures

Sudden change in responsiveness, consciousness or speech

New onset unexplained weakness or paralysis

Sudden onset blindness

Delirium requiring intravenous Ativan age > 65 years

OTHER

Bleeding Hematemesis (vomiting fresh blood), Hematochezia (fresh blood per rectum), Unexpected surgical site bleeding

High Fever Temperature > 104F or > 40 C

Pregnancy

Heavy vaginal bleeding (> 100 cc), urge to push, sudden gush of fluid from vagina, severe abdominal or back pain, crowning of the fetus, or fetal distress on continuous monitoring

Revised 1/2013


UPMC PRESBYTERIAN SHADYSIDE

PROCEDURE

SHADYSIDE CAMPUS PROCEDURE

PROCEDURE: CP-12-PRO-SHY

INDEX TITLE: Care of Patients

SUBJECT: Rapid Response System

DATE: March 19, 2013

CORRESPONDING POLICY:

CP-12 Rapid Response System

UPMC Shadyside has developed processes and procedures in order

to support the Rapid Response System policy.

TABLE OF CONTENTS

I. Policy Application Related to Physical Location

II. Procedures for Rapid Response Team Activations

A. Condition A (Cardiopulmonary Arrest) & Condition C

(Medical Crisis) Medical Emergency Team (MET)

B. Activation of all Rapid Response Teams

1. Stroke Assessment Team (SAT) and activation of the

Acute Stroke Team

2. Sepsis Team

3. Condition H (Help)

4. Condition M

5. Condition L – Elopement

C. Communication Duties

III. Crisis Management

A. Condition A and C, Medical Emergency Team

B. Stroke Assessment

C. Sepsis

IV. Other Rapid Response Team Management

A. Condition H (Help)

B. Condition M

C. Condition L (Elopement)

http://infonet2.upmc.com/Policies/PRSH/Documents/CP12.pdf

SHADYSIDE CAMPUS

PROCEDURE CP-12-PRO-SHY

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V. Emergency Equipment, Emergency Cart Location, Usage and

Maintenance

VI. Procedure for Rapid Response Team calls and management to

Hillman Building, Medical Center Building, Cancer Pavilion

Building and North Tower (School of Nursing Building)

VII. Procedure for Rapid Response Team calls, Condition A or C,

occurring on outside perimeter of UPMC Shadyside, parking

garages and Preservation Hall.

VIII. Pediatric Emergency Event Protocol

IX. Special Circumstances

A. Heliport

B. Roof Emergency Events

C. Simultaneous Emergency Events

D. Death

Appendices for UPMC Shadyside Procedure

Appendix A: Guidelines for Initiation of Rapid Response Team

Appendix B: Initiation of Response

Appendix C: Inpatient Stroke Activation Algorithm

Appendix D: Team Roles and Responsibilities

Appendix E: Intensivist Bag Supply List

Appendix F: Location of Emergency Crash Carts and AEDs

Appendix G: Emergency Crash Cart Medication and Supply List

Appendix H: ICU Nurse Responder Zones & Responsibilities

Appendix I: Respiratory Therapy Zones & Responsibilities

Appendix J: Emergency Event Elevator Operation

Appendix K: Pharmacy Bag List

Appendix L Daily Crash Cart Check List

Appendix M: Airway Roll

Appendix N: Campus Map and outsider perimeter responder zone

Appendix O: Pediatric Emergency Cart Locations, Medication and

Supply List

Appendix P: Multiple Defibrillator Checklist

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I. POLICY APPLICATION RELATED TO PHYSICAL LOCATION

This procedure applies to the UPMC Shadyside Campus

including the UPMC Shadyside Hospital, North Tower (School

of Nursing Building), Medical Center Building, Cancer

Pavilion Building, Preservation Hall, Hillman Cancer Center

Building, connecting hallways, parking garages and outside

perimeter.

Campus areas excluded from this policy include:

1. Family Health Center

2. Aiken Professional Building

3. Shadyside Place

4. Hillman Cancer Center – Research Side

All emergency events occurring at off-campus sites

requiring crisis management or resuscitative measures will

be called in to Emergency Medical Services (notify

Pittsburgh EMS by calling “9-911”) for provision of

resuscitation and patient transport(Appendix B).

II. PROCEDURES FOR RAPID RESPONSE TEAM ACTIVATION

A. Condition A (Cardiopulmonary Arrest) OR Condition C

(Medical Crisis) Medical Emergency Team (MET)

Refer to Appendix A – Guidelines for Initiation of

Rapid Response Team

Refer to Appendix B – Initiation of Response

1. In the event of a Condition C or A initiate the

Rapid Response Team by calling 3-3131.

2. The Medical Emergency Team will respond to:

a. UPMC Shadyside Hospital

b. Hillman Cancer Center, outpatient side

c. Medical Center Building

d. Cancer Pavilion Building, Herberman

Conference Center

e. North Tower (School of Nursing Building)

f. Parking garages

g. Preservation Hall

h. Outside perimeter of the hospital

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3. For the parking garages, Preservation Hall,

outside perimeter of the Hospital, North Tower

(School of Nursing Building), Medical Center and

Cancer Pavilion, Emergency Medical Services may

also need to be notified for assistance. The

dual activation may occur when placing the

initial call or if later after the MET assess the

situation.

4. In all instances, the Condition A or C location,

including building, wing, room number, the person

calling and the name of the person the Condition

was called for should be given. In the event that

the person needing assistance is not a patient,

the caller should identify the person as a

visitor or employee. The caller should not hang

up until the ISD Voice Communications operator

has verified all information.

a. Cardiopulmonary arrests and medical or emergency event situations are overhead

announced as “Condition A or C”, followed by

the location, given three times.

b. If the patient’s condition warrants a Condition C page and the patient’s condition deteriorates

to meet the Condition A criteria before the

Medical Emergency Team arrives, a second call

may be placed to the emergency operator. The

call should tell the operator that the patient

is now a Condition A and request the emergency

event be upgraded and announced. The same

Medical Emergency Team responds to both events.

c. In areas such as the Emergency Department, Cardiac Cath Labs or ICU where emergency events

can be managed by personnel present, “Stat”

pages for individual assistance of anesthesia

or respiratory personnel may be called when

appropriate. Condition A or C may also be

called when necessary.

d. Family members and patients may trigger an emergency call for patients, visitors or others

in obvious cardiac or respiratory distress.

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B. ACTIVATION FOR ALL OTHER RAPID RESPONSE TEAMS

1. Stroke Assessment Team and activation of Acute

Stroke Team

2. Sepsis Team

3. Condition H (Help)

4. Condition M

5. Condition L (Elopement)

All other rapid response team activations are through

the same emergency number 3-3131. In all instances

the location, including building, wing, room number,

the person calling and the name of the person that the

RRT activation is being called should be given. The

caller should not hang up until the ISD Voice

Communications operator has verified all information.

C. COMMUNICATION DUTIES

1. The ISD Voice Communications operator activates

the appropriate Rapid Response Team, Condition A

or C Medical Emergency Team or others as

initiated by:

a. Alerting specific pagers as designated in this

procedure

b. Audible paging in the UPMC Shadyside Building

in all cases as follows:

Condition A or C – Building – Floor – Wing – Room

Number.

Condition M or L – Building – Floor – Wing – Room

Number.

Condition H, Stroke Assessment Team and Sepsis

Team are pager activated events, there is no

audible paging.

2. ISD Voice Communication operators are also

responsible for obtaining patient name and

medical record number to assist with Quality

Improvement process.

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3. If the ISD Voice Communications operator receives

a call that should have been directed to 911, the

ISD Voice Communications operator will connect

the person through to 911.

4. ISD Voice Communications operator will perform

two daily tests of the emergency event pagers.

All pager-carrying members of the teams are to be

alert that the test pages are sent in the morning

(9:00am) and evening (8:30pm). If the test page

does not come across the pager, it is the

responsibility of the person carrying the pager

to contact the ISD Communications Operator on the

UPMC Shadyside campus to replace the pager. In

the event a pager is non-functioning on an

evening or weekend, the UPMC Shadyside

Administrator on Duty can replace the pager. All

members of the team will carry an emergency event

pager.

III. CRISIS MANAGEMENT

A. Condition A & C, Medical Emergency Team

Adult “Condition A or C” Medical Emergency Team

Composition and Responsibilities

Ideally there are 9 identified team members. More

staff may respond as part of their education process

to learn the roles and responsibilities of being a

member of the Medical Emergency Team. See Appendix C

– Team Roles and Responsibilities.

1. Physician Members & Duties

(Treatment Leader – Role 5)

a. The treatment leader should identify self as

such upon arriving at the crisis event.

The treatment leader will give orders,

delegate responsibilities and over see

interventions by other members of the team.

b. The attending physician will be notified

during the condition by staff on the patient

care unit. The treatment leader or delegate

is responsible for discussing the patient's

condition with the attending physician.

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c. The treatment leader will be recognized in

the following order:

Attending Physician

Intensivist or Fellow

Senior Internal Medicine or Senior Family

Practice Resident responsible for that

patient

d. Additional responsibilities of the treatment

leader include:

1) Assessing the situation and determining

if appropriate to ramp down or ramp up

the responders to meet the patient’s

care needs.

2) Continually assessing patient’s total

condition and coordinating CPR efforts.

3) Ordering emergency care utilizing ACLS

guidelines.

4) Manage airway and intubate if needed

(Appendix E - Intensivist Bag Supply

List).

5) Interpreting cardiac rhythm and 12 lead

EKG.

6) Determining when to transfer the

patient to the ICU or terminate the

arrest efforts.

7) Signing the Emergency Event Form

8) Writing an emergency event note in the

patient’s record.

9) Communicating with the

family/significant others.

10) Accompanying the patient on transfer

11) In the event of a second Condition A or

C, the treatment leader will delegate

the members of the team to respond.

2. Assisting Resident/Intern Physicians/Mid-Level NP

or PA

(Procedure MD – Role 7 and/or Circulation–Role 6)

a. The resident should identify self and inform team if she/he has any knowledge of the

patient.

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b. Additional responsibilities include, but are not limited to:

1) Assist with patient assessment through data

collection, by reviewing patient chart for

lab values, radiology reports, medications

administered and status of limited therapy

orders.

2) Inserting central lines/assisting with IV

insertion PRN.

3) Drawing arterial blood gases and blood

specimens.

4) Communicating with the attending physicians

at the request of the treatment leader.

3. Nursing Members

(Bedside Assistant – Role 3)

a. The bedside assistant is usually the nurse assigned to care for the patient. In non-

patient care units the bedside assistant may be

any of the nurses that respond to the event.

b. Bedside Assistant responsibilities include but are not limited to:

1) Begin CPR if necessary, transport crash

cart to the patient, place on monitor

immediately and assess for ventricular

arrhythmias, defibrillate if necessary,

set up bag-valve mask device, set up

suction, place on back board, obtain vital

signs including blood pressure,

respiratory rate, heart rate and SpO2,

obtain IV access and prepare normal saline

IV infusion, administer medications in

accordance with policy “Arrhythmia,

Emergent or Life Threatening (Infonet

Merged Manual of UPMC Presbyterian

Shadyside – Nursing Section, Emergency).

Appendix F – Location of Emergency Crash

Carts)

2) Remain in room to offer information on the

patient and use SBAR format to communicate

with all responders.

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S-Situation: use 3 – 5 sentences to give

a brief overview and express the urgency

of the situation.

B–Background: include pertinent history,

reason for admission, other treatments the

patient has received to address current

situation.

A–Current Assessment: vital signs and

changes in recent vital signs, relevant

labs or radiology reports include.

R–Recommendations or Request.

3) Emergency Event Documentation.

a) Emergency Event Form - This form must include patient identification and have

a copy inserted into the patient’s

chart. Signature of the treatment

leader is obtained.

b) Electronic documentation - Change of Status Event” is completed on all

patients. Event details may also be

entered where available.

4) Staff member either bedside nurse or ICU nurse that is completing documentation of

the crisis event will also assess and

manage the number of responders to the

crisis event. The Emergency Event form is

in duplicate. The Green copy must be

included in the patient record, the Yellow

copy will be sent to Pharmacy for QA and

review by the MERIT Committee.

4. Nurse Anesthetist or Anesthesiologist

(Airway Manager – Role 1)

a. Responsibilities include:

1) Assessing patient’s airway and

respiratory status and intubate as

indicated.

2) Verifying bilateral breath sounds.

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3) Documenting in the patient record.

5. ICU Nurses - 2 responders

(Crash Cart Manager – Role 4 and Data Manager –

Role 8 or assist the bedside nurse with

medication administration or procedures)

a) Responsibilities include, but are not limited

to:

1) Managing crash cart, deploying

equipment and preparing medications

(Appendix F – Emergency Crash Cart

Medication and Supply List).

2) Indicating or assisting in insertion of

peripheral IV lines.

3) Connecting patient to monitor/

defibrillator (if not already done so)

4) Defibrillating or pacing patient as

needed.

5) Administering medications.

6) Assisting, if needed, with obtaining

vital signs.

7) Accompanying patient on transport to

the ICU.

8) Assisting with emergency event

documentation if needed.

9) Staff member, either bedside nurse or

ICU nurse, that is completing

documentation of the crisis event will

also assess and manage the number of

responders to the crisis event.

10) Arranging for appropriate ICU bed and

communicate information to staff nurse.

b) ICU Nurse members of the team will be from

CCU/MICU, CT-ICU, NS-ICU, SICU and MS-ICU.

These nurses will be assigned to respond at

the beginning of each shift and respond to

emergency events according to a specific

geographic area. They will have

successfully completed Basic Life Support,

Critical Care Course, Basic Arrhythmia, ACLS

and Crisis Team Training (Simulation

Training at WISER).

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Appendix H addresses the ICU Nurse Responder

Zones and Responsibilities.

Appendix J – Emergency Event Elevator Operation

6. Advanced Practice Nurse, Unit Director or

Administrative Nursing Coordinator

a. Responsibilities include, but are not limited

to:

1) Function as a Bedside Assistant or ICU

Nurse as needed.

2) Keeping the number of responding

personnel in attendance to an

appropriate number.

3) Arranging for appropriate ICU bed and

communicate information to staff nurse.

7. Respiratory Therapy Members – 3 responders

(Airway Manager – Role 1 or Airway Assistant –

Role 2)

a. Respiratory Therapist responsibilities

include:

1) Maintaining patient’s airway.

2) Administering oxygen or respiratory

treatments as ordered.

3) Performing CPR and/or assess correct

performance of CPR.

4) Assisting in obtaining of arterial

blood gases (ABGs).

5) Managing analysis of ABGs and returning

results to Team.

6) Documenting interventions during crisis

per departmental procedure.

7) Providing pulse oximeter if previously

not available.

8) Assisting with intubation if necessary.

9) Assisting with transport to ICU or

other designated triage area.

b. Respiratory members of the team will be from

assigned to respond at the beginning of each

shift and respond to emergency events

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according to a specific geographic area.

They will have successfully completed Basic

Life Support, ACLS and Crisis Team Training.

The following individuals are considered part of

the medical emergency response team, but do not

need to be located directly around the patient in

crisis.

8. Pharmacist


1) Obtaining medications/IV solutions not

available on crash cart.

2) Responding with the pharmacy drug bag

(Appendix K - Pharmacy Drug Bag List)

3) Providing drug information concerning

dosing, incompatibilities of drugs.

4) Assisting with crash cart and mixing of

medications as needed.

9. Unit Secretary, HUC or Nursing Assistant

a. The Unit Secretary or designee will remain

available to:

1) Deliver a computer on wheels to the

patient bedside.

2) Print off a copy of the Emergency Event

Orders.

3) Enter orders for stat request once

Emergency Event Order sheet has been

completed.

4) Place calls and pages as directed.

5) Immediately print out a “nurse hand off

report” and deliver to the treatment

leader.

6) Receive, deliver and notes laboratory

results to room immediately.

7) Deliver glucose monitoring device to the

bedside.

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10. Chaplain as needed:


1) Remaining with family and/or significant

others

2) Staying with patient’s roommate when

applicable

11. Transport

For emergency event located in non-patient care

areas, such as lobbies or cafeteria, Medical

Center Building, Cancer Pavilion, Hillman Cancer

Center, the School of Nursing and JROC, Transport

Services will respond with an EMS style transport

cart and back board to assist with transporting

patients.

12. Security

For emergency event located in non-patient care

areas, such as lobbies or cafeteria, Medical

Center Building, Cancer Pavilion the School of

Nursing and the Hillman Building, Security

Services will respond to assist with crowd

management and facilitate rapid transport of

patients.

After 5:00pm and on weekends Security will

respond to MRI and Cardiac Cath Labs to ensure

that MET Responders have access into these areas.

13. Patient Disposition

a. The treatment leader will decide the

disposition of the patient. Out-patients,

employees or visitors may be directly

admitted to a critical care unit or be

transported to the emergency department for

further assessment and treatment before

admission. This will include outpatients or

clinic patients from the Hillman Cancer

Center, radiology or other diagnostic test

areas and employees or visitors.

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In- patients who have received crisis

management or resuscitative intervention

will be triaged and transported to an

appropriate patient care unit.

b. Any patient, employee or visitor that is

intubated, on vasopressor therapy or

considered critically unstable may be

directly admitted to an intensive care unit.

When an ICU bed is not immediately available

an ICU Nurse and when necessary a

Respiratory Therapist will remain with the

patient until transfer.

c. Patients from the Hillman Cancer Center that

are ill and require on-going care and

admission to a medical unit, may directly be

admitted to an oncology bed.

d. Patients, employees or visitors that are

stable and require on-going care and

questionable admission will be transported

to the Emergency Department for further

evaluation.

e. When a patient has been identified as

needing to be directly admitted, a phone

call is made to the DAC at 3-2404.

f. The patient’s name, age, birth date and

social security number are needed and will

allow the patient to be entered into Medipac

so that orders can be written on admission.

g. An admitting physician and diagnosis are

required. The intensivist can serve as the

admitting physician.

h. If a bed is not available, the patient will

go to the Emergency Department.

B. Crisis Management - Stroke

The Acute Stroke Team is based out of UPMC

Presbyterian and is available for management of

cerebrovascular event. The Stroke Assessment Team

(SAT) or attending physician may notify the Acute

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Stroke Team through MedCall. When the patient meets

Condition C criteria the Condition C Rapid Response

Team must be activated as part of the Stroke

Assessment Team (SAT). This allows for physician to

physician discussion of treatment. The Stroke

Assessment Team is comprised of a Neuro ICU Nurse and

Intensivist. The Stroke Assessment Team will evaluate

the patient and pending assessment will activate the

Acute Stroke Team and/or the Condition C Rapid

Response Team. When a patient presents with stroke

symptoms in the Emergency Department, ICU or Cardiac

Cath Lab and an attending physician is available for

phone consult with the Acute Stroke Team, a Condition

C does not need to be activated (Appendix C).

C. SEPSIS TEAM

Sepsis Team is comprised of ICU nurses from the MICU.

Two nurses will respond to Sepsis Team Activation page

to assess the patient and contact the intensivist for

further care orders.

IV. OTHER RAPID RESPONSE TEAM MANAGEMENT

A. CONDITION H: CONDITION HELP

Condition H may be activated by patients or family

members by dialing 3-3131. A Condition H is to be used

when:

1. A breakdown in how care is being managed or there

is confusion about the plan of care and the

healthcare team is not responding to their

questions/concerns.

2. A noticeable clinical change in the patient and

the healthcare team is not responding to their

concerns.

3. Telecommunications Department will request the

location and the nature of the situation and

activates Condition H pagers. Telecommunications

Department calls main phone number of floor where

Condition H called to alert staff.

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4. Team Membership:

a. Physician from Internal Medicine Non-Teaching Service

1) Assesses the situation and makes recommendations as to how to remedy the

problem.

2) Documents in the patient record and as needed communicates to other members of

the Health Care Team.

b. Administrative Nursing Coordinator

1) Assists with any needed transfer to a

higher level of care.

2) Reports details of the Condition H to

Director of Inpatient Nursing, Vice

President of Patient Care Services and

Director of Patient Care Services

Business Operations.

c. Patient Relations Coordinator

1) Provides support as needed in

psychosocial events or situations of

patient dissatisfaction as directed by

physician.

2) Conducts post-Condition H patient/family

interview to evaluate issues contributing

to the need to call a Condition H and

documents information on the Condition H

(HELP) Follow-up Questionnaire.

d. Unit Nurse Caring for the Patient

1) Responds to provide background

information on the patient and meets

immediate clinical need.

2) Documents in the nurses note regarding

Condition H.

B. CONDITION M

Condition M is a behavioral code that is called for a

patient or visitor who is experiencing a crisis that

could pose a potential threat to themselves, patients,

staff or visitors. A trained team consisting of

Administrative Nursing Coordinator, Security Staff,

and other specially trained personnel will respond. To

activate code dial Ext. 3-3131.

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C. CONDITION L - ELOPEMENT

Staff may activate Condition L by calling 7-3131. A

non-medical crisis that involves a patient, usually

disoriented or confused, that has left the unit

without authorization. Condition L is activated to

located the patient and return them to a safe patient

environment. Upon locating the patient other teams

may be activated pending the specific patient needs.

V. EMERGENCY EQUIPMENT, CPR CART LOCATION, USAGE AND

MAINTENANCE

A. ISOLATION AND INFECTION CONTROL PRACTICES DURING

CONDITIONS

1. All staff entering the room must dress in the

appropriate isolation garb. PST/NA should assist

with the distribution of isolation garb.

2. Limit the number of staff that have direct

contact with the patient to:

a. Treatment Leader b. Airway Management Team c. Bedside Nurse

3. Defibrillator must go into the room and be

attached to the patient vial

monitoring/multifunction pads.

4. Whenever possible, leave the crash cart outside

the patient room. Station and ICU Nurse or MS

Nurse at the cart to pass necessary equipment

into the room. At no time should patient safety

be compromised, when necessary, bring the crash

cart into the patient room.

5. When the cart goes into the room of an isolation

patient one nurse should be designated to manage

the crash cart. The nurse should not come in

contact with the patient’s environment or the

patient. No others should enter the drawers of

the crash cart.

6. After the event the cart, defibrillator and any

other external equipment must be wiped with

bleach wipes before sending to pharmacy. If the

cart is contaminated, supplies may remain with

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the patient and pharmacy is too notified if the

drugs are to discarded.

7. All other isolation practices are to be followed.

B. CRASH/CODE CARTS LOCATION, USAGE & MAINTENANCE

1. Emergency medications and equipment will be

consistently available, controlled, and secured

in the pharmacy, hospital departments, ambulatory

care areas or satellites, inpatient and

outpatient care area. Emergency medication and

equipment will be consistently available to non-

patient care areas. It is the responsibility of

the Department of Pharmacy and Therapeutics,

Nursing, Respiratory Care, Central Services,

Hospital Departments, and physician

office/satellite staff to conduct and document

that regular inspection of emergency medications

and supplies occur.

2. Red plastic seals (to protect the integrity of

the contents) are only available from the

Department of Pharmacy and Therapeutics.

3. A list with the location of drugs according to

drawers, special equipment, and respiratory

equipment supplied on the carts is available on

top of the cart.

4. The integrity of the carts, expiration dates of

the first medications and supplies to expire, and

the red seal number is checked daily by

designated personnel using the Emergency Cart

checklist. The seal number is recorded on the

checklist, as well as the expiration date. The

daily checklists are maintained for one year by

the department head or designee of the area where

the emergency cart is located. Appendix F.

5. The Pharmacy Department is responsible for

supervising, auditing and appropriately

restocking the code cart with emergency

medications, including replacing outdated

medication. After a crash cart is used the unit

staff will place the cart in a locked room or

keep it at the unit station under close

observation to keep it secure until it is

exchanged by Pharmacy. Unit staff will contact

the Pharmacy via telephone to inform them that

the crash cart has been used and that a new cart

is needed.

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6. The cart is checked and replaced after each use

according to established procedures. Each cart is

sealed by the pharmacy with a red seal to protect

the integrity of its contents. If a cart’s red

seal is broken, the entire cart is exchanged. The

crash cart and Emergency Cart checklists are

checked each month as a part of the monthly

inspection by the pharmacy.

7. Emergency carts with defibrillator, resuscitation

equipment and medications are available on every

patient care unit and diagnostic area throughout

the hospital. (Appendix G – Emergency Crash Cart

Medication and Supplies list, Appendix F –

Locations of Emergency Crash Carts).

8. If an arrest occurs in the Medical Center

Building UPMC Cancer Pavilion, or Bridge to

Hillman Cancer Center, a crash cart is located in

the lobby of the Medical Center Building (near

the elevators). When an arrest occurs in these

areas, pharmacist will retrieve the cart and take

it to the site of the arrest.

9. Nursing personnel may obtain a “training crash

cart” from Nursing Education and may open the

cart for review of equipment and drugs.

C. DEFIBRILLATORS AND AEDS

1. Defibrillators are available on every crash cart.

Defibrillators function as Shock Advisory or

AEDs. They are programmed to manufacturers and

American Heart Recommendations. Daily or weekly

check is documented on the Daily Emergency Crash

Cart Checklist (Appendix L). In specific areas

(Emergency Department, OR, Cardiac Cath Lab and

CT-ICU) there are additional defibrillators that

require daily defibrillator check. A multiple

defibrillator check list may be used. (Appendix

P – Multiple Defibrillator Check list)

2. AEDs are available on the Shadyside campus and

are placed in areas that make them available for

rapid deployment and use by Health Care

Professionals and the lay public (See Appendix F

- Location of AED's).

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3. Areas that are closed over the weekend, holidays

or time of low census will document on the Daily

Emergency Crash Cart Checklist that the area was

closed.

4. Daily, weekly and monthly equipment check are

performed by a member of the staff in any

department where there is a crash cart,

defibrillator or AED.

5. A designee of the MERIT Committee will perform

the daily, weekly and monthly checks of the West

Hallway equipment. Documentation of the checks

are maintained on the Daily Emergency Crash Cart

Checklist or AED Check List.

D. Intensivist Bag & Airway Rolls

1. Intensivist will maintain a bag with emergency

supplies to assist in managing airways (Appendix

E.)

2. Respiratory will maintain the Airway Rolls

located in the ICUs, Hillman Cancer Center and

the Cath Lab (Appendix M). Respiratory Therapy

will transport an Airway Roll to all emergency

events.

E. BACKBOARDS

1. Backboards with securing straps are available for

use when a patient, visitor or employee has

fallen and back or cervical injury is a

potential. Backboards are located in the West

Wing Closet, Hillman Cancer Center – second

floor, Emergency Department and NS-ICU – 4 West.

F. STAIR CHAIR

1. Located on 6 Pavilion is a Stair Chair that can

utilize when transporting a patient down steps is

required.

2. Additional Stair Chairs and Carts may be located

throughout the hospital per Disaster Management.

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VI. PROCEDURE FOR CONDITION A OR C AT HILLMAN, MEDICAL CENTER,

CANCER PAVILLION AND North Tower (School of Nursing)

Hillman Cancer Center

Hillman Cancer Center will have an in-house First Response

Team Monday through Friday between 8:00am and 4:30pm,

excluding recognized holidays, to respond to patient and

staff emergencies. Shadyside Campus Emergency Event Team

will respond to between 7:00am and 7:30pm. The Hillman

First Response Team will respond to Condition A or Cs with

the patient care side of the Hillman Cancer. Condition A

or Cs in the covered driveway and garage will be assessed

by the treatment leader and if needed will be a dual

response from the City of Pittsburgh EMS. Emergency events

in the research side of the Hillman Building will be

handled by City of Pittsburgh EMS, by dialing 9-911.

A. First Response Team Composition

1. Treatment Leader – Senior nurse, PA or NP.

a. Current in AHA ACLS training.

b. Attended Crisis Team Training at WISER.

c. Complete annual competency and review standing

orders

2. Nursing personnel from the first, second and

third floors of the patient care areas of Hillman

Cancer Center.

a. Current in BLS Certification.

b. Preferred current in AHA ACLS training.

c. Attended Crisis Team Training

d. Complete annual competency and review standing

orders

3. Security personnel stationed within Hillman

Cancer Center.

4. Pharmacy personnel

B. Emergency Equipment

i. Emergency Crash Carts will be maintained on the

ground, first, second, third and fourth floors

with an additional Emergency Crash Cart is

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located in the pharmacy on the second floor

(Appendix F – Location of Emergency Crash Carts).

A Broselow Pediatric Crash Cart is maintained on

the second floor in the treatment area. It is

the responsibility of the staff on their

respective floors to bring the Crash Cart to the

location of the event. In the event of a

Condition C or A on the fourth floor or garage

level, the treatment leader will respond with a

crash cart.

ii. Airway bag and emergency drugs will be kept in

the Pharmacy on the second floor and delivered to

emergency events. (Appendix K – Adjunct Pharmacy

Bag).

iii. Defibrillators with AED/Shock Advisors will be

maintained on each Emergency Crash Cart.

C. Procedure

1. When an adult emergency event occurs, the ISD

Voice Communications operator is notified by

dialing extension “3-3131 on any available

telephone. Immediately, the ISD Voice

Communications operator will activate the Hillman

First Response Team alpha pagers and the

Shadyside Emergency Event Team. When the

hospital team is activate the emergency event and

location will go out on the overhead calling

system, followed by activation of the Emergency

Event pagers assigned to specific members of the

emergency event team.

2. Staff witnessing the event should begin the

delivery of emergency care.

a) Begin CPR if necessary, transport crash cart

to the patient, place on monitor immediately

and access for ventricular arrhythmias,

defibrillate if necessary, set up bag-valve

mask device, set up suction, place on back

board, obtain vital signs including blood

pressure, respiratory rate, heart rate and

SpO2, obtain IV access and prepare normal

saline IV infusion.

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b) Remaining in room to offer information on the

patient, use SBAR format to communicate with

all responders.

S-Situation: use 3 – 5 sentences to give a

brief overview and express the urgency of the

situation.

B–Background: include pertinent history,

reason for admission, other treatments the

patient has received to address current

situation.

A–Current Assessment: vital signs and changes

in recent vital signs, relevant labs or

radiology reports include.

R–Recommendations or Request.

c) Completing Emergency Event Form

3. The Treatment Leader will assess and manage

unless the hospital team is requested and the

intensivist will assume the treatment leader

role.

1. Responsibilities include:

a. Respond with Emergency Bag (Appendix K- Hillman First Responder Bag Medication and

Supply List) Identify self as the treatment

leader, delegate responsibilities and over

see interventions by other members of the

team.

b. Assessing the situation and determining if appropriate to ramp down or ramp up the

responders to meet the patient’s care needs.

a) Continually assessing patient’s total

condition and coordinating CPR efforts

b) Ordering emergency care utilizing ACLS

guidelines and the approved protocols.

c) Determining when to transfer the patient

to the emergency department or patient

care unit.

d) Signing the Emergency Event Form

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e) Writing an emergency event note in the

patient’s record

f) Communicating with the family/significant

others

g) Accompanying the patient on transfer

h) In the event of a second Condition A or

C, the treatment leader will delegate the

members of the team to respond and ensure

the activation of the hospital team.

D. Protocols

In specific situations, approved protocols may be

initiated.

As part of the initiation of a Protocol:

1. BLS, ACLS and PALS algorithms will be instituted.

2. Appropriate patient positioning and monitoring will

be instituted.

3. Secure airway and administration of oxygen in the

appropriate manner for the patient condition after

establishing and maintaining a patent airway.

4. Establish and IV of normal saline.

Hypotensive Protocol

Patient with BP < 90 mm Hg systolic and clinical signs of

inadequate tissue perfusion or altered level of

consciousness.

Vital signs every 5-10 minutes

Start IV (20 gauge or greater)

250 cc bolus NSS IV

Chest Pain Protocol

Capped {what do you mean by “capped”} Nitroglycerine tab

0.4 mg SL if BP > 90 mm Hg systolic (establish patient is

not on sildenafil (Viagra) or vardenafil (Levetra) within

24 hours or tadalafil (Cialis) within 48 hours.)

Respiratory Distress

Access patient for shortness of breath, wheeze, poor airway

exchange.

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Identify need for a breathing treatment

Prepare and administer Breathing Treatment Alupent

Nebulizer (0.3ml in 2.5 ml NSS) unless contraindicated

Patient allergy

Patient condition

Or identify the need for diuresis

Administer furosemide 40 mg IV.

Reassess Patient

Adverse Drug Reaction Protocol

For patients demonstrating hives, rash or difficulty

breathing from a medication:

Benadryl 50 mg IV (IM if no IV access)

Solu Medrol 125 mg IV (IM if no IV access)

If patient develops Shortness of Breath associated with

anaphylaxis:

Epinephrine 1:1000 concentration 0.3 to 0.5 mg

subcutaneous

Albuteral 5mg/6ccNSS nebulizer for wheezing or strider

If patient demonstrates Rigors:

Demerol 25 – 50 mg IV

Medical Center, Cancer Pavilion, and North Tower (School of

Nursing Building)

A. When an adult emergency event occurs, the ISD Voice

Communications operator is notified by dialing

extension 3-3131 on any available telephone.

B. When the Emergency Event Team responds along with

Security and Transport, a decision should be made by

the physician in charge regarding appropriate

transportation to the Shadyside campus. If the

patient is critically ill and unstable, City EMS, 911

may be called for transport.

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VII. PROCEDURE FOR CONDITION A OR C OCCURRING ON OUTSIDE

PERIMETER OF UPMC SHADYSIDE, PARKING GARAGES AND

PRESERVATION HALL

In-patients, out-patients, visitors and employees that

experience a medical crisis outside of the buildings

identified in this procedure but within the perimeter of

the hospital will be responded to by activating a Condition

C for the Medical Emergency Team and upon assessment a call

to 911 for City EMS support. Patients that are stable and

can be safely transported by wheelchair may be transported

without calling City EMS.

Response team for the outside perimeter will be the

Administrative Nursing Coordinator, Emergency Department

Nurse, Emergency Department APCT or PCT, Respiratory

Therapy and Security.

The defined area that the team will respond to is:

Aiken Avenue Visitor Parking Garage

Centre Avenue Visitor Parking Garage

Aiken Avenue Employee Parking Garage

Driveway from Aiken Avenue back through the loading

docks of the Shadyside Hospital.

Driveway to the street at the main entrance on Centre

Avenue.

Alley between the Aiken Avenue Visitor Parking Garage

and the hospital building.

Driveway to the street at the Medical Building

entrance.

Appendix N – Campus Map and Outside Perimeter Responder

Zones.

Responders from the emergency department will respond with

a wheelchair, defibrillator with pulse oximeter and non-

invasive blood pressure equipment, oxygen tank and

administration supplies. The hospital response team will

remain with the individual and assist or administer CPR or

other lifesaving techniques, as appropriate, within their

scope of practice until the Emergency Medical System

(EMS)Team arrives or until the patient is taken to the

Emergency Department. Upon arrival at the scene, the

hospital response team leader will either:1) make the

determination to cancel the city EMS call if they are not

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required for evaluation, management or transport to the

hospital and have not yet arrived on scene; or 2)transfer

care to the EMS squad for ongoing management and or

transport to the Emergency Department and assign team

members to brief the EMS team leader on the situation. If

care is transferred to the If the patient requires a

stretcher for transport city EMS must be notified.

All events that occur outside the hospital are to be

entered into Risk Master.

VIII.PEDIATRIC EMERGENCY EVENT PROTOCOL

Pediatric event is defined as a person under 13 years of

age. When the age of the child is unknown, a pediatric

event may be activated.

UPMC Shadyside is an adult acute care institution but has

specialty areas that deliver care to pediatric patients.

Two areas have been identified as pediatric care areas:

Department of Radiation Oncology and the Hillman Cancer

Center. It is also recognized that other areas may provide

services to pediatric patients and that there are pediatric

visitors on the premise that may require emergency care.

A. Criteria for activation of pediatric condition

Any change in condition or concern regarding the

condition of a pediatric patient by the nurse,

physician, respiratory therapist or parent.

B. Procedure

1. When a pediatric patient is known to be in the

hospital the ISD Voice Communications operator

will be notified by the patient care area

(Radiation Oncology or Hillman). The ISD

operator will send out a pediatric patient alert

via alpha numeric pager to the pediatric

emergency event team and administrative

personnel. The purpose of this page is

informative that responders may review

procedures.

2. When a pediatric emergency event occurs, the ISD

Voice Communications operator is notified by

dialing extension “3-3131” on any available

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telephone. The ISD Voice Communications operator

will answer and say “Emergency Line… What is your

emergency?” The person making the call should

identify that it is a “Pediatric Condition” and

the location: “Pediatric Condition – Radiation

Oncology.” The caller should not hang up until

ISD Voice Communications operator has verified

all information including that it is a "pediatric

condition". Immediately, the ISD Voice

Communications operator will call the emergency

event and location on the overhead calling

system. This will be followed by activation of

the Condition A/C pagers.

3. The following personnel will respond to all

pediatric arrests:

a. Emergency Department physician - Treatment Leader

b. Nurse Anesthetist/Anesthesiologist - Airway Manager

c. Emergency Department Nurses - Crash Cart Manager, Bedside Assistant or Procedures

d. Pharmacist - Crash Cart Manager e. Respiratory Therapist - Airway Assistant &

Circulation

f. Administrative Nursing Coordinator - Data Collection & Documentation

g. Nurse responsible for the patient - Bedside Assistant

h. Family Practice Resident i. In the Hillman Building the Hillman First

Response Team will respond to the Hillman

pediatric emergency events

j. Radiology Tech – portable x-ray k. Chaplain and Social Work Services are available

by beeper if needed.

C. Equipment

1. A Pediatric Crash Cart containing defibrillator

with appropriate pediatric equipment, IV equipment,

emergency medications, and other emergency

equipment will be maintained in the Emergency

Department, Hillman Cancer Center and Radiation

Oncology when a pediatric patient is present.

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Appendix O – Pediatric Crash Cart Locations,

Medication and Supply List.

2. Upon hearing the Pediatric Condition alert, the

Emergency Department nurse assigned to the

Pediatric Team will bring the Pediatric Crash Cart

to the area designated by the alert if other than

Radiation Oncology or the Hillman Cancer Center.

D. Responsibilities of each Pediatric Team

Members are as follows:

1. Emergency Department Physician – Responds to the Pediatric Emergency Event and takes charge of the

medical management of the patient.

2. Emergency Department Nurse – Brings pediatric arrest cart and assists with medications and

procedures

3. Pharmacist – Assists with medications and pediatric drug calculations.

4. Administrative Nursing Coordinator – Assists with documentation of event. Keeps the number of

responding personnel in attendance to an

appropriate amount. Coordinate transportation if

necessary.

5. Nurse Responsible for the Patient – Provides chart information to include historical

background on the patient. Assist with

procedures and documentation of event.

6. Nurse Anesthetist/Anesthesiologist – Responsible for airway and/or intubation.

7. Respiratory Therapists – Maintain airway and CPR. Manages analysis of blood gases and return

results to the Cardiac Arrest Team.

8. Family Practice Resident – Assist Emergency Department Physician.

9. Hillman First Response Team (Hillman Events) – responds with pediatric cart, assist with CPR if

needed, IV access until pediatric team arrives.

E. Disposition of Pediatric Patient

A. The appropriate physician at CHP will be notified

as soon as possible. After the patient has been

stabilized, transfer to the Emergency Department

for further medical screen and treatment by the

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Emergency Department physician. Patient may be

discharged or transferred to Children’s Hospital

of Pittsburgh. Patients that are in Radiation

Oncology with ambulance back up, if stable may be

transported to Children’s Hospital. Patients

that are in Hillman Cancer Center may be triaged

to the ED or via ambulance to Children’s

Hospital. Patients will be transferred to

Children’s Hospital as soon as possible.

B. All Emergency Department members of the pediatric

emergency event team will be encouraged to attend

the PALS course.

C. Nursing personnel may open the pediatric cart for

review of equipment and drugs. However, prior to

opening the cart, notify Pharmacy that the cart

will be opened for review. After the review,

Pharmacy must be notified immediately to check

and re-lock the cart. (Appendix O – Pediatric

Emergency Cart Locations, Medication and Supply

List).

IX. SPECIAL CIRCUMSTANCES

A. Helicopter Transport Patient Cardio-pulmonary Arrest

1. Helicopter Transport personnel will inform the

receiving unit or security that the patient is

arresting. The receiving unit or security will

notify the ISD telecommunications operator of the

request Condition A or C at the Heli Pad. The

overhead page will be activated and the message to

meet at the second floor elevator at a time 5

minutes before arrival of the helicopter

announced. The pager system will go out with the

estimated time to arrival and will be used to

inform the team to arrive at the second floor

elevator 5 minutes before the arrival of the

helicopter. The Helicopter Transport personnel are

responsible for initiating arrest procedures.

Patients are under their control until the patient

is transferred from the carrier to the patient’s

hospital bed. The patient should be resuscitated

and stabilized by the Helicopter Transport

personnel in the elevator room at the Heliport.

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If additional support is needed, a medical

emergency team consisting of 1 CT-ICU Nurse, 1

respiratory therapist, 1 CRNA or Anesthesiology

and an intensivist will respond to the second

floor elevator that assessing the roof. Security

will coordinate and escort the team to the

heliport elevator. Staff will remain inside the

building and assist from that point. Only

requested equipment needs transported to the

helipad.

2. Once the patient is transferred to the receiving

unit bed, any further emergent procedures (e.g.,

inserting arterial lines, etc.) will be done by

physicians and nurses of the hospital.

B. Emergency Event on the Roof

1. When a medical emergency (e.g. injury or cardiac

arrest) occurs on the roof one of the hospital

buildings, the Emergency Event Team should be

notified via the ISD Voice Communications

operator stating “Condition A or C on the roof of

(…and state building…) report to …Floor.” The ISD

Voice Communications operator will also notify

city EMS.

2. Nurses from the ICUs that cover emergency events

of their building assignments will respond to

roof emergencies. The nurses should take a

defibrillator with pulse oximeter and non-

invasive blood pressure monitoring equipment

immediately to the top floor of the respective

building. Respiratory Therapy will respond with

oxygen tank and oxygen administration equipment.

Security will also respond to the emergencies and

will direct the Team on how to access the roof.

3. The Emergency Event Team will implement

appropriate arrest or emergency procedures for

the affected patient. The Pharmacy will bring an

emergency drug box to the site. The top floor’s

crash cart will be brought by the unit to the

stairwell leading to the roof.

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4. As soon as it is medically feasible, the patient

should be transferred to the appropriate area

(e.g. Emergency Department or Cath Lab.)

C. Simultaneous Emergency Events

In the event of a second Condition A or C, the charge

physician will delegate the members of the team to

respond.

D. Death

All hospital policies and procedures that pertain to

the death of a patient are followed when the patient

expires.


Appendix A

Criteria for Initiating a Rapid Response Team Call

Any person at any time may initiate a call for a Rapid

Response Team by calling the emergency number 3-3131.

Teams available for calling are:

1. Condition C

2. Condition A

3. Stroke Assessment Team (SAT)

4. Sepsis Team

5. Pediatric Condition

6. Condition H - Help

7. Condition M

8. Condition L - Elopement

Criteria for Initiating “Condition C” (Crisis)

Any person may initiate a Condition C or A call at any time a

rapid response of critical care professionals is desired. A

Condition C Team response should be used to prevent a crisis or

to prevent a crisis from escalating.

The following practice guidelines are intended to assist

clinicians in decision-making by describing criteria for

situations where it is reasonable to initiate a Condition C Team

response. These criteria attempt to meet the needs of most

patients in most circumstances. The ultimate judgment for

initiating a Condition C must be made by the bedside clinician

in light of circumstances specific to that situation.

General Guideline:

Any concern for a deteriorating clinical condition.

Respiratory:

Difficulty in breathing

Increased Work of breathing and/or use of accessory muscles

New pulse oximeter readings < 85% for more than 5 minutes

and/or new requirements for more than 50% oxygen to keep

saturations > 85%

Sustained respiratory rate <10 or > 30.

Excalating oxygen requirements

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Hemoptysis or bleeding in the upper airway

Dislodged artificial airway

Cardiovascular:

New onset Chest Pain or recurrent chest pain unrelieved by

medication.

Hypotension – sustained SBP < 90 mmHg

Hypertension – sustained SBP > 200 mmHg or DBP > 120 mmHg

Tachycardia – new onset sustained HR > 120

Bradycardia – new onset sustained HR < 50

Cyanosis, mottling or pallor of an extremity

SIRS/Sepsis

The Sepsis Team will be activated when the patient presents with

two or more of the SIRS Criteria. The Condition C may also

activated when the patient is unstable:

HR > 90

RR > 20 or PaCO2 < 32 mmHg

WBC > 12,000/mm3 or < 4,000/mm

3

Temp >38 C or < 36 C

PLUS one of the following:

SBP >90 mmHg

Lactate > 2

Suspected or confirmed infection

Acute Neurologic Change:

Stroke Assessment Teams (SAT) will be activated for suspected

stroke patients. Condition C Treatment Leader may also activate

the SAT. At UPMC Shadyside the Stroke Assessment Team is

activate for a patient that is stable presenting with stroke

symptoms.

Seizures (outside of seizure monitoring unit)

Sudden change in responsiveness, consciousness, confusion,

speech or understanding

New onset unexplained weakness, paralysis loss of balance or

coordination

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Sudden onset blindness or visual disturbances in one or both

eyes

Severe onset headache

Delirium requiring intravenous medication administration in > 65

year olds or unexplained agitation.

Other:

More than 1 STAT page required to assemble team needed to

respond to a crisis

Narcan use without immediate response

Bleeding: hematemesis, hematochezia or surgical site

hemorrhage

Pregnancy – heavy vaginal bleeding (>100cc), urge to push,

sudden gush of fluid from vagina, severe abdominal or back

pain, crowning of fetus or fetal distress noted on continuous

monitoring

“Condition A” Criteria – any patient without respiration or

circulation.

Stroke Assessment Team (SAT)

Stroke Assessment Team (SAT) is available for assessment and

acute management of suspected cerebrovascular events. When a

patient is unstable the SAT and Condition C Team may be

activated simultaneously. When a patient presents with stroke

symptoms in the Emergency Department, ICU or Cardiac Cath Lab

and an attending physician is available for phone consult with

the Acute Stroke Team through MedCall. Pediatric Condition

Any change in condition or concern regarding the condition of a

pediatric patient by the nurse, physician, respiratory therapist

or parent.

Condition H

Condition H may be activated by patients or family members. A

Condition H is to be used when:

A breakdown in how care is being managed or there is

confusion about the plan of care and the healthcare team is

not responding to their questions/concerns.

A noticeable clinical change in the patient and the

healthcare team is not responding to their concerns.

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Condition M

Condition M is a behavioral code that is called for a patient or

visitor who is experiencing a crisis that could pose a potential

threat to themselves, patients, staff or visitors.

Condition L

A non-medical crisis that involves a patient, usually

disoriented or confused, that has left the unit without

authorization. Condition L is activated to located the patient

and return them to a safe patient environment. Upon locating

the patient other teams may be activated pending the specific

patient needs.

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APPENDIX B

Initiation of Response

Location Number to Call Response Team

Aiken Professional

Building 9-911

Pittsburgh Emergency Medical

Services

Family Health Center 9-911 Pittsburgh Emergency Medical

Services

Hillman Building –

Research Side 9-911


Services

Hillman Building –

Clinical Side

3-3131

9-911

Hillman First Response Team

Shadyside Rapid Response Team


Services after hours

Hospital Garages &

Outside Perimeter

3-3131

9-911

(When emergency

transport is

required


Emergency Department Team


Services

Medical Center Offices

3-3131

9-911

(When emergency

transport is required)



Services

Hillman Cancer Pavilion

Offices

3-3131

9-911

(When emergency




Services

Preservation Hall

3-3131

9-911

(When emergency

transport is

required

Emergency Department Team


Services

Shadyside Place 9-911 Pittsburgh Emergency Medical

Services

North Tower

(School of Nursing)

3-3131

9-911

(When emergency


Shadyside Emergency Event Team


Services

UPMC Shadyside 3-3131 Shadyside Emergency Event Team

UPMC Shadyside

Roof Area

3-3131

9-911

(When emergency

transport is

required



Services


Appendix C

UPMC Shadyside Rapid Response Team Inpatient Stroke Activation Algorithm

SAT Team Responsibilities: Initiate oxygen therapy to keep Sa02>92% HOB 30° unless contraindicated Continuous cardiac monitoring Complete NIHSS – Note Last Known Normal Enter CT Order in Cerner Non contrast CT within 20 minutes Activate PUH ACUTE STROKE TEAM VIA MED CALL

7-7000 Consider CTA of head and neck Keep NPO until Bedside Swallowing Screen (BSD) Document: Assessment/Treatment/Plan of

Care/Conversation with PUH Neurology

CONDITION C TEAM WILL TREAT AS APPROPRIATE CCM/ Physician may directly contact the PUH

Acute Stroke Team 7-7000 for treatment guidelines

Abbreviated Criteria for Initiating a Condition C: Respiratory: SaO2 <85% for more than 5 minutes or 50% or

more oxygen demand to keep >85%; Rate of <10 or >30; Hemoptysis Cardiovascular: SBP <90 or >200; DBP>120; HR <50 or

>120; SIRS/Sepsis Acute Neurological Changes: Unstable suspected stroke;

seizures; severe new onset headache; sudden change in responsiveness; consciousness

Bedside RN Responsibilities Apply cardiac monitor/obtain vital signs/blood

glucose Note Last Known Normal Provide Patient History/Nurse Handoff Report to Team

If team suspects a stroke event has occurred, follow same guidelines as SAT Team. If stroke confirmed follow Ischemic and Hemorrhagic guidelines below.

Possible IV rtPA Candidate Symptom onset to administration of rtPA 180 minute max (earlier better) Transfer to NSICU Refer to rtPA Order Set /

Screening Rule out contraindications Start 2

nd IV if not done

Manage BP if > 185/110 Consider need for foley, OG/NGT

and insert before infusion MD to explain risk/benefits Nursing care per rtPA order set If rtPA given: NIHSS/BP

q 15 min during admin & then for 2 hrs

q 30 min for 6 hrs q 1hr for 16 hrs

Blood on CT –

hemorrhagic stroke

Not a rtPA Candidate MD to document reason not given Notify attending MD Obtain Neurology Consult Manage BP if SBP>220 and/or DBP>120 Continue cardiac monitor Perform BSD Give ASA PO/PR if CT neg for bleed Initiate Ischemic Stroke Order Set Transfer to appropriate unit (NSICU,

6W, 3E or 5M)

2011 Stroke Protocol NPO until BSD Screen with speech evaluation VTE Prophylaxis (SCDs) Rehabilitation Evaluation (PT/OT/SLP) NIHSS per unit routine Stroke Education TIA/Ischemic add: Antithrombotic

Fasting Lipid Panel/Statin

Intracerebral Hemorrhage (ICH)/Subarachnoid Hemorrhage (SAH) Transfer to NSICU Obtain Neuro Surgery Consult Assess need for airway Seizure precautions Manage BP – keep SBP<160

and/or DBP<90 HOB 30° unless contraindicated

Perform BSD Consider need for Foley,

OG/NGT Treat elevated coags Be prepared for possible OR

References: Rapid Response System SHY Campus, 2010 American Stroke Association Protocols for Ischemic Stroke, 2009; Intracerebral Hemorrhage, 2007; Aneurysmal Subarachnoid Hemorrhage, 2009 (bmm 6/11)

Return from CT – reevaluation by CCM or neurologist Complete history (focused for rtPA exclusion criteria) Physical/neuro exam Lab Work if not already completed (CBC, CMP, Coags) Maintain normothermia and normoglycemia

CT no hemorrhage – probable ischemic

stroke

Patient with sudden onset stroke symptoms –

Facial Droop/Arm Weakness/Speech Changes/Time is Brain (FAST)

Apply cardiac monitor, obtain vital signs and finger stick glucose. Treat hypoglycemia. NOTE LAST KNOWN NORMAL

Dial the Emergency Number: 3-3131 and request the appropriate RRT.

HEMODYNAMICALLY STABLE – Activate Stroke Assessment Team (SAT) NSICU RN and CCM Resident NOT HEMODYNAMICALLY STABLE – Activate Condition C

Suspected Stroke Requires Immediate Evaluation and Treatment: TIME IS BRAIN!


Appendix D

DeVita, 2005

Roles Responsibilities

1. Airway Manager

Assess, count respiratory rate, assist ventilation,

intubate, check pupils

2. Airway

Assistant

Assist airway manager, oxygen and suction setup,

suction as needed, monitor pulse oximetry

3. Bedside

Assistant

(Usually Floor RN

and ICU Nurse

Support)

Report to team SBAR. Check pulse, obtain vital signs,

pulse oximeter placement, assess patent IV’s, push

meds, capillary blood sugar

4. Crash Cart Mgr

(ICU RN &

Pharmacist)

Deploy equipment, bag-valve-mask, backboard, pads,

suction, paper record, prepare meds, run defibrillator

5. Treatment

Leader

Assess team responsibilities, data, direct treatment,

set priorities, triage patient. (Could be ICU RN until

the MD arrives)

6. Circulation

Check pulse, place defib pads, perform chest

compressions

7. Procedure MD

(NP/ PA) Perform procedures, IVs, chest tubes, ABGs

8. Data Manager

(Floor Nurse or

ICU RN)

Role tags, AMPLE, lab results, chart, record

interventions

Aide Bring capillary blood sugar machine, patient chart and

other requested equipment

Ancillary

Nursing Coordinator – support and bed acquisition

Transport - stretcher

Security – crowd control and transport assistance


Appendix E

UPMC Shadyside

Intensivist Bag Supply List

Quantity Supply

2 #7.0 cuffed ETT with stylettes




4 end-tidal CO2 detectors

4 sets of headgear

10 10cc syringes

10 packets of Surgilube

2 Yankuer

3

Nasopharyngeal Airways (Sized 7, 7.5,

and 8)

10 Sterile tongue blades

1 #6 Shiley cuffed trach

1 #4 Shiley cuffed trach

1 Cudet tipped disposable Bougie

2 #15 Blade scalpels

2 Spare trach ties

1

Melkor Cricothyrotomy Kit with a cuffed

cric tube

2 MacIntosh #3 blades

2 MacIntosh #4 blades

2 Miller #3 blades

1 Miller #4 blade

2 Laryngoscope handles

1 Bottle of Benzocaine Spray

1 Tub of 5% Lidocaine Ointment

1 Pair of Magills forceps

1

Etomidate and Succinylcholine in ICU

intubation pack

6

Small biohazard bags

Checked by:

Date:


APPENDIX F

Locations of Emergency Crash Carts with Defibrillators & AEDs

Location Floor Area/Cart Location Floor Area/Cart

Pavilion 1 MRI South 2 Med Surg ICU

Pavilion 1 Nuc Med #1 South 2 Ortho

Pavilion 1 Per Vasc Lab South 3 Dialysis

Main 1 Radiology Film Room South 4 Cardiology

Main 1 Radiology Rm A-1 South 5 Cath Lab #1

Main 1 Radiology Rm A-2 South 5 Cath Lab #2

East 1 GI Lab #1 South 5 Cath Lab #3

East 1 GI Lab #2 West 1 Non-Invasive Cardiology

East 2 ASC West 2 PACU

East 3 Family Practice Teaching West 3 Medical ICU #1

East 4 Medical Cardiology #1 West 3 Medical ICU #2

East 4 Medical Cardiology #2 West 3 Medical ICU #3

East 5 Short Stay West 4 Neurosurgical ICU #1

West 4 Neurosurgical ICU #2

Main 1 ED MAC West 4 SICU Cart #1

Main 1 ED Main Cart #1 West 4 SICU Cart #2

Main 1 ED Main Cart #2 West 5 Orthopedics

Main 2 Cardiothoracic ICU #1 West 6 Neuro/Surgical

Main 2 Cardiothoracic ICU #2 West 7 ABMT #1

Main 2 Cardiothoracic ICU #3 West 7 ABMT #2

Main 2 DAS Cart #1

Main 2 PRE-OP HOLDING AREA Main 1 Broselow Pediatric Cart ED

Main 3 Cardiothoracic Surgery #1 Main G

Broselow Pediatric Cart

Backup

Main 3 Cardiothoracic Surgery #2

Main 4 Surgical Oncology

Main 5 Oncology AED Locations

Main 6 Pulmonary Medicine 1

West Wing, Garage Elevator

Area

Main 6 Pulmonary Medicine 1 Aiken Building

Main 7 Oncology #1 1 School of Nursing

Main G JROC Hillman Cancer Center

Pavilion 2 Ortho Floor Area/Cart

Pavilion 3 Medical Cardiology G Security Desk

SHADYSIDE CAMPUS


PAGE 42


1 Beckwith

1 Radiology Control Room

Pavilion 4 Invasive Cardiology #1 2 Treatment Area

Pavilion 4 Invasive Cardiology #2 3 Treatment Area

Pavilion 5 Invasive Cardiology 4 Treatment Area

Pavilion 6

Urologic Comprehensive Care

Program 4

Treatment Area

Pavilion 7

Urologic Comprehensive Care

Program 2

Pharmacy

Med. Ctr. 1 Professional Office Building 2

Broselow Pediatric Cart

Treatment Area

Med. Ctr. 5 Cardiopulmonary Rehab


APPENDIX G 1

Crash Cart Contents List (Revised 2012) 2 Drawer 1 3

3 Adenosine 6mg/2ml vial 2 Furosemide 100mg/10 ml 1 Nitroglycerin SL tab 1/150

6 Amiodarone 150mg/3 ml 2 Haloperidol 5mg/ml 4 Norepinephrine 4mg/4ml

4 Aspirin 81mg (chewable) tablet 2 Hydralazine 20mg/ml 1 Phenylephrine 100mg/10 ml MDV

1 Clopidogrel 300mg tablet 2 Hydrocortisone 250mg/2ml 4 Phenytoin 250mg/5ml

1 Diphenhydramine 50 mg/ml 2 Magnesium Sulfate 1 gm/2 ml 7 Vasopressin 20 units/1 ml

1 Epinephrine 1mg/ml 30 ml MDV 2 Metoprolol 5 mg/5 ml 1 Emergency Cart Information Booklet

2 Flumazenil 0.5 mg/5 ml 2 2

Naloxone 0.4 mg/ml Sodium Chloride 0.9% 10 ml 2

Emergency Event Flowsheet (Form#06-040)

4 Drawer 2 5

3 Atropine 1mg/10 ml 1 Dopamine 400mg/250ml D5W Premix 1 Lidocaine 2gm/250ml Premix

2 Calcium Chloride 1gm/10ml 8 Epinephrine 1:10,000 10ml 1 Magnesium Sulfate 4gm Premix

1 Dextrose 50% 50ml 2 Labetalol 20mg/4ml 6 Sodium Bicarbonate 50meq/50ml

1

Dobutamine 1000 mg/250ml Premix

5 Lidocaine 100mg/5ml 6

Drawer 3 7 20 Alcohol Wipes 2 Instrument set w/suture 2 Stopcock (Single)

1 Angiocath 14G x 2" 3 IV Start Kit 3 Syringe 3 ml

2 Angiocath 16G x 3 1/4" 10 Medication Added Label 12 Syringe 10ml

1 Angiocath 18G x 1 1/4" 10 Needle (Filter) 19G 2 Syringe 20ml

1 Angiocath 20G X 1" 5 Needle 18G x 1 1/2" 1 Syringe 60ml

1 Quad-Lumen Central Line 1 Needle 20G x 3 1/2" Spinal 1 Tape 1" Cloth

1 Betadine Solution 1 Push Button Blood Collection Set 1 Tape 1” Transpore

2 Biohazard Specimen Bags 12 Normal Saline 10 ml Flush 2 Tourniquet (Latex-Free)

2 Blood Transfer Device 2 Polyskin Dressing 5cmx7cm 2 Vacutainer Needle 22G

6 Blue Cap (M20018) 4 SmartSite ® Port (2000E) 4 Vacutainer Holder (Clear)

2 Central Line Dressing Kit 2 SmartSite® Extension Set (10011253) 2 Vacutainer Holder (Luer Lock)

2 Chloraprep 1 Sorbaview Dressing 10 Vial Access Pin (2201)

2 Frepp 2 4x4 Gauze Sterile Boat

8 Drawer 4 9

1 D5W 100 ml Bag 1 INFU-STAT Pressure Infuser 4 Secondary Set (72007N)

1 D5W 250 ml Bottle/Non-DEHP Bag 2 Normal Saline 100 ml Bag 4 SmartSite ® Infusion Set (24200007)

1 D5W 1000 ml Bag 4 Normal Saline 250 ml Bag 2 Smartsite ® Extension Set (20028E)

1 Hextend 500ml 3 Normal Saline 1000 ml Bag

10 Drawer 5 11

2 Barrier Kit 1 16 FR Salem w/Reflux RESPIRATORY BOX

1 Connector, 5-in-1 1 Suction Cannister 5 Arterial Blood Gas Sampling Kits

1 Flashlight w/Batteries 1 Suction Regulator 1 End Tidal CO2 Detector

BX Gloves, Nitrile Latex-Free MEDIUM 1 Suction Tubing 6’ 1 Head Gear - Intubation

3 Gloves, Sterile MEDIUM 3 Surgilube Packets 2 Suction Catheter Kit 14FR

3 Gloves, Sterile LARGE 1 Yankauer Suction Tip 1 Nasal Trumpet 26 FR

1 Hazardous Waste Bag 6 N95 Mask 1 Nebulizer w/Tubing

SHADYSIDE CAMPUS


PAGE 44


13 Outside of Cart Respiratory Bag (Hang on Cart)

1 Backboard 1 Emergency Cart Booklet 1 Ambu Bag

1 Cart Contents List (Attached to side shelf) 1 Razor 3 Airways – 80mm, 90mm, 100mm

1 Oxygen Tank (Must be above 1000 PSI) 9 Blood Tubes 1 Oyxgen Flowmeter

2 Zoll Defib Multi Purpose Pads 1 Sharps Container 1 Mask, Oxygen non-rebreather

5 Emergency Event Flowsheet (Form # 06-040) 1 Peep Valve (Adjustable)


APPENDIX H

Responder Zones

Responsibilities

NS-ICU & SICU

(1 Nurse from each unit)

4M 5W

6M 6W

West Wing Concourse

Library

WW Conference Rooms

West Wing Testing

Medical Building

North Tower (School of Nursing)

West Wing Courtyard

Back up to any area when there are

simultaneous second events.

NS-ICU - Backboard as needed to Posner, Main

and West Wing areas.

SICU / NS-ICU - Backboard is stored in the West

Wing Closet with emergency cart. Obtain when

needed for the West Wing areas.

Pharmacy will bring emergency cart from the

West Wing closet to non-patient care areas.

West Wing Closet also houses small patient

carrier.

MICU/CCU

(2 Nurses)

7M 7W

5M

Cafeteria Gift Shop

1 West – Respiratory Therapy

1 Main, Information Desk

Non-Interventional Cardiology

Posner Courtyard & Lobby (1 Main Entrance

Area)

Roof Main & West Towers

Hillman Cancer Center

Cancer Pavilion (Herberman Conference

Center)

With CT-ICU (1 Nurse)

3 Main

MICU/CCU - Backboard is stored in the West Wing

Closet with emergency cart. Obtain when needed

for Main and Posner areas.

Request backboard from NS-ICU for 7M or 7W

events.

Hillman has backboard equipment.

Pharmacy will bring emergency cart from the

West Wing closet to non-patient care areas.

CT-ICU & MS-ICU

(1 Nurse from each unit)

Basement (includes JROC)

1P 1E 1S

2P 2E 2S 2M

3P 3E 3S (Dialysis)

4P 4E 4S

5P 5E Cath Lab

6P/7P

Emergency Department

Pavilion & East Wing Roof

Radiology, MRI, Ultrasound

GI lab

East Entrance Information Desk

CT-ICU with MICU/CCU (1 Nurse)

3M

CT-ICU, 1 nurse only to PACU, helipad and ED

Back board when requested to basement, all

East, Pavilion and Posner and Main lobby areas.

Request from ED.

Pharmacy will bring crash cart to basement

areas.

CT-ICU – Invasive Cart when requested to any

event

Staff only, equipment only on request.

SHADYSIDE CAMPUS


PAGE 46


Emergency Department

Pediatric Crisis any area

Outside Perimeter, Parking Garages

1 Main, Information Desk

Main Driveway

Posner Courtyard & Lobby

Radiology, MRI, Ultrasound

GI lab

East Entrance Information Desk

High risk areas for pediatric patients:

JROC & Hillman Cancer Center.

Bring Pediatric Crash Cart to JROC

Back board when requested to basement, all

East, Pavilion, and Main lobby areas.

Rev. Feb/2013


Appendix I

Respiratory Therapy Responder Zones

DISTRIBUTION OF RESPIRATORY RAPID RESPONSE TEAM PAGERS

1. The shift supervisor will respond and delegate at all

emergent events (Condition A/C). Beeper # 263-9169

2. The Surgical therapist will respond to all Condition A and

C’s in the following areas: West Wing, Posner Tower, PCI

(Hillman), and Physician Office Building. Beeper # 263-

9618.

3. The Medical/CCU therapist will respond to all Condition A

and C’s in the following areas: West Wing, Posner Tower,

and Physician Office Building. Beeper # 263-9280.

4. The Cardio-Thoracic therapist will respond to all Condition

A and C’s in the following areas: Pav, South, East,

Emergency Room. Beeper # 263-9893.

5. The ABG therapist will report to the ABG Lab and then if

needed will respond to all Condition A and C’s in the

following areas: Pav, South, East, Emergency Room. Beeper

#263-9595.

6. The Pav/South therapist respond to all Condition A and C’s

in the following areas: Pav, South, East, Emergency Room.

Beeper #263-9486.

7. The 6 Main therapist will respond to all Condition A and

C’s in the following areas: West Wing, Posner Tower, and

Physician Office Building. Beeper #263-9377.

8. The Calls Person will respond to all STAT calls to the

Emergency Room


APPENDIX J

Emergency Event Elevator Operation

General Overview:

Emergency Elevator keys {Are we going to be using card

access now?} are carried by Respiratory Therapy, ICU Nurse

Responders and Anesthesia.

Same key activates all Emergency Elevators.

The key switch calls all elevators tied to that switch and

calls them to floor that activates the switch. Both

elevators will respond.

Emergency Elevators:

West Wing Elevators (#17, #18 and #19)

There are 2 separate Emergency Elevator Key Switches.

There is a key switch between elevators 17 (Patient Use

Only Elevator) and 18 that calls these 2 elevators and a

second switch between elevator 18 and 19 that calls these 2

elevators.

This elevator has activation switches on all floors.

Key switches are identified by only a blue ring around the

keyhole.

Most frequently used elevator. Access to West and Posner

wings. Responders from CCU, MS-ICU, NS-ICU and Anesthesia

will use this elevator. Patient will most frequently be

transported by this elevator.

Operation:

Key switch will activate two elevators, operator

choice to activate entire bank by using both key

switches.

Once the elevator responds, the key needs to be used

on the inside key switch. Insert the key, turn to

“on”, press the selected floor button, press the “door

close” button and hold until the door completely

closes. The door will then open on the selected floor

and stay open as long as the key activation switch is

in the “on” position. Operator must turn the elevator

off and remove the key to release the elevator. Key

can be removed in the “on” position and lock the

elevator to that floor with the door open.

SHADYSIDE CAMPUS


PAGE 49


Posner (Main) Elevators (#10 and #11)

This elevator only has an activation switch on the second

floor. This elevator would be accessed by second floor

staff responding to events.

This key switch has a button that illuminates when the key

switch has been activated to inform the caller the system

has responded to the call.

Operation:

Key switch will activate both elevators.



“on”, press the selected floor, the door will close

automatically. There is no door close button on this

set of elevators. There is an internal elevator

button that illuminates over the key switch to inform

users that emergency event elevator system has been

activated.

Main Tower, Heliport Elevator #28

This elevator has activation switches on all floors.

This elevator has access to the heliport and the roof.

Operation:



“on”, press the selected floor button, press the “door





“off” and remove the key to release the elevator. Key


elevator to that floor with the door open.

Pavilion (#1 and #2)

This elevator has activation on 2 only.

This elevator is a secure elevator.{We no longer have Labor

and Delivery.}

Operation:



“on” press the selected floor button, press the “door



SHADYSIDE CAMPUS


PAGE 50




“off” and remove the key to release the elevator. Key


elevator to that floor with the door open. Holding

the selected floor button in, will also close the

doors on this elevator, the button must be held until

the door closes completely.

This elevator is also activated internally with a

swipe card.

East

These 2 elevators have switches on all floors.

Operation:




“on”, press the selected floor and hold the selected

floor button until the door closes completely. There

is no “door close” button on this set of elevators.

JROC

This is an elevator that travels between 2 floors.

There is no key activation for this elevator.

JROC can be reached by the West elevators or the Main

elevator #28.

Medical Center Offices (#21 and #22)

When approaching Medical Center Building from the hospital,

the elevators on the right are the key switch activated

elevators.

Operation:


Once the elevator responds, the key DOES NOT need to

be used on the inside key switch.

Press the selected floor and hold the selected floor

button until the door closes completely.

SHADYSIDE CAMPUS


PAGE 51


NOTE: For Emergency Events in Medical Center Building 1

and Medical Center Building 2, the crash cart is

stored in a locked closed next to the Hopwood

Library and has a swipe mechanism for unlocking.

It is recommended the ICU staff that will respond

to these areas will have a swipe card attached to

the elevator key.

NOTE: To access Medical Center Building 2 and Hillman

Building after hours, a swipe card is needed.

The Emergency Response plan does not require

staff to respond after 5:00 p.m., before 7:00

a.m. or on weekends and holidays. The same swipe

card that will unlock the closed with the crash

cart will activate the door switch.

Hillman Cancer Pavilion Offices

There is no emergency event key access to this set of

elevators.

The far left elevator has a card swipe that will call the

elevator. This can be the same card that is issued to

unlock the closet door for the crash cart.

Operation:

Use the swipe card to activate the emergency call,

enter the elevator and use the swipe card on the

internal card swipe, press the floor button and “close

door” button until the door closes completely.

Key Distribution:

Anesthesia

Respiratory

Intensivist

CT-ICU

MS-ICU

NS-ICU

CCU

SICU

ED


Appendix K

PHARMACY ADJUNCT CODE BOX CONTENTS

2 Albuterol Neb 0.083%- 3ml 2 Methylprednisolone 125mg/2ml 6 Alcohol wipes

2 Calcium Gluconate 10% -10ml 5 Midazolam 2mg/2ml 2 Code Box Charge Sheet

2 Diazepam 10mg/2ml

2 Morphine 5mg/1ml 4 Blank IV labels

1 Diltiazem 25mg/5ml

2 Phenobarbital 130mg/ml 1 Carpuject

2 Etomidate 40mg/20ml 3 Procainamide 1000mg/2ml 4 18G safety needles

2 Fentanyl 100mcg/2ml 1 Propofol 10mg/ml -50ml 2 10ml Syringe

1 Glucagon 1mg kit

2 Racemic Epinephrine neb 2.25% 0.5ml 2 5ml Syringe

1 Glucose Gel

2 Sterile Water for inj 10ml 4 3ml Syringe

1 Insulin Regular 100 units/1ml 1 Succinylcholine 200mg/10ml

2 Insulin Syringe

2 Lorazepam 2mg/1ml 2 Vecuronium 10mg vial 2 Filter Straw

SHADYSIDE CAMPUS


PAGE 53


Appendix L

Appendix L

UPMC Shadyside

EMERGENCY CART

DAILY CHECK LIST

Unit/Area________Month_________Year_________

Seal number and drug expiration date must be recorded daily. If a cart is used and replaced or checked by

pharmacy, document on reverse side date when a cart or lock is changed. Place an “*” in the date box if there

are comments written on the reverse side. If unit is closed, write “closed” for that day. If crash cart

needs a new lock, there are expired drugs or supplies please notify pharmacy at 3-2800. This form is to remain on the unit for 1 year.

Date

Seal

number

Crash Cart

Maintenance

Log

(Yellow

Form on top

of cart)

Expiration

Date:

Blood

Tubes

Within

Expirati

on Date:

Emergency

Equipment

(Listed

Above)

Checkmark

Defibrillator Check Performed

Completing the below information

is verification the

Defibrillator Check was

performed (Procedure on back of

this form).

Defibrillator

First MFP

Control Number

Expiration Date

Initial

s

Example 12345 12/17/2012 3/12 √ 54321 5/5/13 NCM

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Form 06-1620 Rev: 2/1/12 Page 1 of 2

Emergency Equipment

Locked Emergency Cart with full oxygen tank, back board

and needle box

Defibrillator with cable attached to multifunction pads

(MFPs), second set of MFPs, pulse oximeter cable and

probe, NIBP tubing and cuff, ECG electrodes, razor

Respiratory Bag with bag-valve-mask, PEEP valve, non-

rebreather face mask, oxygen flow meter with nipple, 80,

90 & 100 mm oral airway

Emergency Event Forms and RRS Emergency Cart Information

Booklet

Blood Tubes: 2 Red tops, 2 Gold, 2 Purple, 1Blue, 1

Gray, 1 Green

Replace outdated blood tubes and MFPs

SHADYSIDE CAMPUS


PAGE 54


UPMC Shadyside EMERGENCY CART DAILY CHECK LIST

Date Note Name

Example:

2/1/12

Seal broken, cart used. Pharmacy notified and new cart

supplied, seal #12456 placed on cart.

Cherry Ames, RN

ZOLL M SERIES DEFIBRILLATOR MONITOR DAILY CHECK Daily Visual Inspection

1. Verify that the instrument is connected to AC power and the “Charger On” light is illuminated.

2. Check that the unit is clean and nothing is stored on the unit.

3. Inspect the unit, accessories, all cables, cords and connectors for damage, cuts in the

insulation, or bent and broken connector pins. Verify ECG cable, pulse oximeter cable, NIBP cuff

and tubing are attached.

4. Verify that two sets of multi-function electrodes (MFPs) are available. One set must be connected

to the multifunction cable connector and a second set is on top of the crash cart.

5. Verify that all needed disposable supplies are available, in proper condition, and not expired -

ECG electrodes, recorder paper, razor.

Defibrillator Check:

1. Unplug defibrillator from wall outlet to test battery operation.

2. Turn the main selector switch to Monitor, 4- beep tone heard.

3. “Monitor” message on display. ECG size x 1, “Pads” as lead selected.

4. Remove the cable from the disposable pads connector and connect the cable to the black test

connector.

5. Turn the main selector switch to Defib and set energy level to 30 joules.

6. Press record and press the CHARGE button, at the tone, press SHOCK button.

7. Verify “TEST OK” message on screen.

8. Remove the cable from the black test connector and re-connect the cable to the disposable MFPs

connector.

9. Plug the unit back into AC power.

Pacer Functionality Test:

1. When testing pacing function, remove multifunction cable from MFPs .

2. Turn to PACER, set pacer rate to 150 ppm, press Recorder button.

3. Check the rhythm strip for pace pulses that should occur every 2 large squares (10 small

squares).

4. Press 4:1 button, pace pulses should occur every 8 large squares. Press the Recorder button to

stop strip.

5. Verify that PACER OUTPUT defaults at “0mA” and that there is no “CHECK PADS” message.

6. Turn PACER OUTPUT to 16mA, verify “CHECK PADS” message appears on display and pace alarm sounds.

7. Turn PACER OUTPUT back to 0mA and press “Clear Pace Alarm.”

8. Turn defibrillator off. Reconnect MFPs to the multifunction cable with the red end.

Form 06-1620 Rev: 2/8/12 Page 2 of 2

SHADYSIDE CAMPUS


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Appendix M

EACH ROLL CONTAINS

1 – 3 MAC blade/handle 1 – 3 Miller blade/handle

1 – 4 MAC blade/handle 1 – 4 Miller blade/handle 2 - CO2 detectors 1 – head gear

1 – PEEP valve 1 – 6.0 ET tube 1 – 6.5 ET tube 1 – 7.0 ET tube

2 – 7.5 ET tube 2 – 8.0 ET tube 1 – 8.5 ET tube 2 – stylets

1 – Bougie 1 – Yankauer sx 1 – sx catheter 2 – oral airways (90mm, 100mm)

4 – nasal airways (6.5, 7.0, 7.5, 8.0) 2 – 10cc syringes 2 – surgilubes

SECURED WITH 1 RED PULL-TITE PLASTIC LOCK

SHADYSIDE CAMPUS


PAGE 56


Appendix N

Campus Map

The defined area that the team will respond to is:

Aiken Avenue Visitor Parking Garage

Centre Avenue Visitor Parking Garage

Aiken Avenue Employee Parking Garage

Driveway from Aiken Avenue back through the loading docks of the

Shadyside Hospital.

Driveway to the street at the main entrance on Centre Avenue.

Alley between the Aiken Avenue Visitor Parking Garage and the

hospital building.

Driveway to the street at the Medical Building entrance.

http://shadyside.upmc.com/Images/Sub/ShadysideCampMap.pdf


Appendix O

Pediatric Emergency Cart Medication and Supply List

UPMC Shadyside Broselow Pediatric Emergency Event Cart Supply List

Sept 2007

QTY. DESCRIPTION P/S # QTY. DESCRIPTION P/S #

ON CART TOP OF CART

1 EA

Resuscitator

bag/Pediatric 5

Emergency Event

Flowsheet

1 Oxygen cylinder Resp/C.S. 1 Clip Board

1 Flowmeter, oxgyen C.S. 1 Portable Suction

1 Backboard C.S. 1

Box Gloves -

Medium

1 Sharps Container 100078

DRAWER #1 MEDICATIONS

DRAWER #2 PINK/RED

Pink: 6 - 7 kgs

Red: 8 - 9 kgs

DRAWER #2 Cardiac

Bin

Broselow IV Assess Pack Pink/Red BP cuff

Broselow IO Assess Pack

Yellow/White/Blue

BP cuff

Broselow Intubation Pack

Orange/Green BP

Cuff

Broselow Oxygen Delivery

Pack BP Manometer

Size 1 LMA 2 EA

Zoll Pediatric

Multifunction

Pads

Size 1-1/2 LMA 2 EA

Packages

Pediatric

Electrodes 136871

DRAWER #3 Purple DRAWER #4 Yellow

Purple: 10 - 11 kgs

Broselow IV

Assess Pack

Broselow IO

Assess Pack

Broselow IV Assess Pack

Broselow

Intubation Pack

Broselow IO Assess Pack

Broselow Oxygen

Delivery Pack

Broselow Intubation Pack Size 2 LMA

Broselow Oxygen Delivery

Pack 5 4x4s

5 2x2s

DRAWER #3 - IV Bin DRAWER #5 White

3 EA Angiocath 22ga x 1"

Broselow IV

Assess Pack

3 EA Angiocath 24ga x 5/8"

Broselow IO

Assess Pack

3 EA

Butterfly 25ga x 3/4"

w/12" tubing

Broselow

Intubation Pack

3 EA

Butterfly 23ga x 3/4"

w/12" tubing

Broselow Oxygen

Delivery Pack

SHADYSIDE CAMPUS


PAGE 58


2 EA IV Loops

Resuscitation and

Emergency

Infusions Book

3 Single Stopcocks DRAWER #6 Blue

1 Micropore Tape 2"

Broselow IV

Assess Pack

2 Tourniquets

Broselow IO

Assess Pack

2 EA

Bio-hazard bag,sm

(speci) 9613

Broselow

Intubation Pack

2

Vacutainers Blood

Collection with Blunt

Cannula

Broselow Oxygen

Delivery Pack

2 EA

Needle, vacutainer 22

ga. 100234 Size 2-1/2 LMA

2 EA

Tube,blood collection

blue 10225 DRAWER #7 Orange

2 EA


purple 70075

2 EA


red 109763

2 EA


gold 109762

Broselow IV

Assess Pack

6 EA

Interlink inject site

Baxter 8962

Broselow IO

Assess Pack

6 EA B-D lever lock cannula 8911

Broselow

Intubation Pack

6 EA

B-D blunt plastic

cannula 8359

Broselow Oxygen

Delivery Pack

6 EA Needle, 19 ga filter B-D 8994 DRAWER #8 Green

6 EA Needle, 18 ga x 1-1/2 52635

6 EA Needle, 22 ga

6 EA Syringe, 10ml 9770

Broselow IV

Assess Pack

6 EA Syringe, 5ml

Broselow IO

Assess Pack

6 EA Syringe, 3ml

Broselow

Intubation Pack

2 EA

Syringe, 1ml w/ 27ga

needle

Broselow Oxygen

Delivery Pack

2 EA

Central Line Dressing

Kits

2 Chloroprep Sticks

6 EA Yellow Medication Labels

6

Flushes, normal saline

10ml Pharmacy

DRAWER # 9 IV SOLUTIONS

& RESPIRATORY EQUIPMENT

2 IV Tubing 1

Endo Tube size

6.5 Cuffed

4 Normal saline 100ml bag 1

Endo Tube size

4.0 Uncuffed

SHADYSIDE CAMPUS


PAGE 59


1 EA Normal saline 250ml bag 6210 1

Endo Tube size

3.5 Uncuffed

1 Normal saline 500ml bag 1

Endo Tube size

3.0 Uncuffed

1 EA

Dextrose w/ water 100ml

bag 54171 1

Endo Tube size

2.5 Uncuffed

1 Tape Cloth 1"

2 EA Kits, blood gas sampling 109730 2

Laryngoscope

Handles

2 Batteries "C"

1

Pediatric Pulse Oximeter

Probe 1 EA Connector, 5 in 1 9995

1 Forehead Oximeter Probe

1 Finger Oximeter Probe 1 EA Flowmeter, oxgyen C.S.

1

End tidal CO2 Detector -

Adult 1 EA

Ambu/Resuscitator

bag Infant

2

End tidal CO2 Detector -

Ped 1 EA

Ambu/Resuscitator

bag Child

2

Magill Forceps -

Pediatric

1 EA Yankauer suction 10097


Pediatric Crash Cart Drugs Drawer # 1

Drug Quantity

Broselow Tape 1

Adenosine 6mg/2 mL 2

Amiodarone 50mg/mL 3mL 4

Atropine 0.4mg/mL 1mL 6

Calcium Chloride 100mg/mL 10mL 2

Dextrose 50% 0.5g/mL 50 mL 1

Diazepam 5mg/mL 2mL 2

Diphenhydramine 50mg/mL 1mL 1

Epinephrine 1:10,000 0.1mg/mL 10mL 4

Epinephrine 1:1000 1mg/mL 30mL 1

Flumazenil 0.1mg/mL 5mL 1

Furosemide 10mg/mL 10ml 1

Hydrocortisone 250mg/2ml 2ml 2

Lidocaine 10mg/mL 5mL 3

Mannitol 25% 0.25g/mL 50mL 2

Midazolam 1mg/mL 2mL 2

Naloxone 0.4mg/mL 1mL 3

Norepinephrine 1mg/mL 4mL 2

Normal Saline Inj 10mL 3

Normal Saline Inj 30mL MDV 2

Phenobarbital 130mg/mL 1mL 2

Phenytoin 50mg/mL 2mL 5

Sodium Bicarb 1 meq/mL 50mL 3

Sterile water 10mL 2

D5W Bag 500mL 1

Dobutamine Premix Bag 250mg/250mL 250mL 1

Dopamine Premix Bag 400mg/250mL 250mL 1

Lidocaine Premix Bag 2g/500mL (0.4% 500mL) 500mL 1

Magnesium Sulfate Premix Bag 40mg/ml 100ml 1

Normal Saline Bag 0.9% 250mL 2




Appendix P

UPMC Shadyside Emergency Department

DEFIBRILLATOR CHECK LIST

Unit/Area____________Month____________Year________________

Defibrillator/Pacing Function Check Performed & Reattached Cable to Pads

Instructions for test on Reverse Side

Defib

ID

Number

Date

Initials

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Revised 11/08

SHADYSIDE CAMPUS


PAGE 62


ZOLL M SERIES DEFIBRILLATOR MONITOR DAILY CHECK Daily Visual Inspection

1. Verify that the instrument is connected to AC power and the “Charger On” light is

illuminated.

2. Check that the unit is clean (with no fluid spills) and nothing is stored on the

unit.

3. Inspect the unit, accessories, all cables, cords, and connectors for damage, cuts

in the insulation, or bent and broken connector pins. ECG cable, pulse oximeter

cable, NIBP cuff and tubing.

4. Verify that two sets of multi-function electrodes are available. One set must be

connected to the multifunction cable connector and a second set is on top of the

crash cart.

5. Verify that all needed disposable supplies are available, in proper condition, and

not expired - ECG electrodes, recorder paper, razor.

Verify pediatric pads for defibrillation with pediatric crash cart (Located in the

ED & Hillman Cancer Center).

DC Defibrillator check:

1. Unplug defibrillator from wall outlet to test battery operation.

2. Turn the main selector switch to Monitor, 4- beep tone heard.

3. “Monitor” message on display. ECG size x 1, “Pads” as lead selected.

4. Remove the cable from the disposable pads connector and connect the cable to the

black test connector.

5. Turn the main selector switch to Defib and set energy level to 30 joules. Press

record and press the CHARGE button, at the tone, press SHOCK button.

6. Verify “TEST OK” message on screen.

7. Remove the cable from the black test connector and re-connect the cable to the

disposable MFE pads connector. Plug the unit back into AC power.

Pacer Functionality Test:

1. When testing pacing function, remove multifunction red cable from MFE pads.

2. Turn to PACER, set pacer rate to 150 ppm, press Recorder button.

3. Check the rhythm strip for pace pulses that should occur every 2 large squares (10

small squares).

4. Press 4:1 button, pace pulses should occur every 8 large squares. Press the

Recorder button to stop strip.

5. Verify that PACER OUTPUT defaults at 0mA and that there is no “CHECK PADS” message.

6. Turn PACER OUTPUT to 16mA, verify “CHECK PADS” message appears on display and pace

alarm sounds.

7. Turn PACER OUTPUT back to 0mA and press “Clear Pace Alarm.”

8. Turn defibrillator off. Reconnect MFE pads to the multifunction red cable.


SIGNED: Sandra Rader


ORIGINAL: August 7, 2002

APPROVALS:

Policy Review Committee: March 6, 2013

Medical Executive Committee:

Shadyside Campus: March 19, 2013

PRECEDE: September 20, 2011

SPONSOR: Chair, CPR Q.I. Committee