Rapid Response Team

Rapid Response Team

Intervention Form

Date of call: ______ / Person requesting Team: ______ / Location of call: ______
Time Team called: ______ / Team arrival time: ______ / Time Team left unit: ______
Reason for call as defined by the staff person or family member: (check all that apply)
Cardiovascular / Respiratory / Neurological / Other
HR > 160 with or without symptoms
HR > 140 with symptoms / Respiratory rate < 8 with or without symptoms
Respiratory rate > 36 with or without symptoms
New onset of respiratory difficulty
New pulse oximeter reading of < 85% for
> 5 minutes
Not applicable / Acute change in level of consciousness / Physician unavailable or not responding to calls and/or pages
HR < 40 with symptoms
Systolic BP < 80 with symptoms
Systolic BP > 200 with symptoms
Diastolic BP > 110 with symptoms
Chest pain unresponsive to NTG
Color change of patient or extremity (blue, pale, dusky, or gray)
Not applicable / New lethargy
Narcan® used
with no response
Seizure(s)
Sudden loss of movement or weakness of leg, arm, or face.
Not applicable / Uncontrolled bleeding
Family requests intervention
Unusual agitation > 10 min
Suicide attempt
Nurse is concerned/worried
Treating physician or nurse requires critical care assistance
Not applicable
Was the patient transferred from the ICU within 24 hours of call?
Was the patient admitted through the ED within 12 hours of call? / Yes
Yes / No
No

Situation: ______

Time / Medication Name, Dose and Route:
Time / BP / HR / RR / SpO² / T

______

______

______

______

______

Background ______

______

______

______

______

Assessment: BP______HR______T ______

RR ______SpO² ______LOC ______

______

______

______

______

______

Recommendations: See orders Interventions/ Diagnostics:

______O2 per mask/nasal cannula Bipap

______IV start ______G ______site

______Nebulizer treatment IV NS @ ______

______EKG Accu check

______Chest X-ray I-STAT

______No intervention Abdominal x-ray

______Other: ______

Outcome: Stayed in room Transferred to: ______Code II New DNR/DNI Other: ______

Names and Signatures of Responding Team members:
RN: ______/ Print Name: ______
RT: ______/ Print Name: ______
MD: ______/ Print Name: ______
RAPID RESPONSE TEAM RESPONDER FEEDBACK SUMMARY
To be completed jointly by the RN and RT at the conclusion of the call.
For any “no” answers please comment in the space provided. Your feedback is invaluable in improving the process.
1.  Did you get an adequate report from the staff that activated the team? / Yes / No
2.  Was the staff report provided in the SBAR format? / Yes / No
3.  Was your assignment/charge duties adequately covered while you were responding to the call?
RN
RT / Yes
Yes / No
No
4.  Did the person activating the team remain and assist in the assessment and treatment? / Yes / No
5.  Did you have the necessary equipment/supplies, either in the bag or on the floor, to treat the patient? / Yes / No
6.  Do you think the team was activated early enough? If no, please elaborate below. / Yes / No
7.  Do you believe you have the necessary skills/training to respond to this type of call?
RN
RT / Yes
Yes / No
No
Comments: ______

ASSESSMENT/INTERVENTION FOLLOW-UP (24 HOUR POST VISIT CLINICAL REVIEW)

To be completed within 48 – 72 hours of Rapid Response Team visit

Follow up date: ______/ Follow up by: ______
Patient outcome: / Remains on unit / Expired / Date: ______
Discharged / Date: ______/ To: Home / LTC / Other
Transferred to higher level of care / Unit: ______/ Date: ______
Notes/comments: ______
For office use only:
Thank you note to staff / Date: ______/ Entered into database / Date: ______