Rapid Response

What it is actually for

People on medical floors do not usually arrest out of nowhere. They deteriorate first. The tachycardia starts in the afternoon, the respiratory rate creeps into the high twenties by evening, the pressure sags overnight, and somebody codes at four in the morning. Go back through the chart afterwards and the numbers were abnormal for hours with nobody escalating. That is the pattern rapid response systems exist to interrupt.

So a rapid response is not a small code. It is the intervention that happens early enough that a code never occurs. A call that ends with "they were fine, we adjusted the oxygen" is a success, not a waste of your time, and you should say so out loud to the nurse who called. Every time you make somebody feel foolish for calling, you buy yourself an arrest three weeks from now.

Activation criteria

Most institutions use something close to this. Learn yours, because the numbers differ.

That last one is the most important criterion on the list and the one people are embarrassed to use. It outperforms the numeric triggers for a simple reason: the numbers are single measurements crossing arbitrary lines, while an experienced nurse comparing this patient to the same patient four hours ago is integrating skin color, work of breathing, speech, posture, restlessness and a dozen things nobody charts. A respiratory rate of 26 in someone who was 14 all week is more alarming than a rate of 30 in someone who has been 30 since admission, and only the person at the bedside knows the difference.

So when the nurse says "I do not like how he looks," go. That is a complete sentence and it does not need a number attached.

The first two minutes

Walk in and do these things before you form an opinion.

1. Look at the patient from the doorway. Are they sitting up, tripoding, sweaty, gray, silent? A patient who cannot finish a sentence is a different problem from one who is annoyed at the fuss.
2. Get your own vitals. A manual pressure in both arms if the automated one is odd, a real respiratory rate counted over 30 seconds, a saturation with a good waveform. The respiratory rate on the flowsheet is the most fabricated number in the hospital.
3. Check a glucose. Every time, on everyone, no exceptions. It takes seconds and it is the one cause you can reverse standing there.
4. Put them on the monitor and get an EKG rhythm strip, plus a 12 lead if there is any chest pain, dyspnea or arrhythmia.
5. Confirm IV access works. Flush it. Half the wasted minutes in a deterioration go on discovering the line is infiltrated.
6. Ask the nurse one question: "What is different from four hours ago?" They already know the answer and it is usually the diagnosis.

A worked ABCDE

Do this in order, out loud, and fix what you find before moving on. It is boring and it is why you will not miss anything.

The eight usual causes

On a general medical floor, the overwhelming majority of rapid responses are one of these.

• Sepsis. Fever or hypothermia, tachycardia, wide pulse pressure, rising lactate, mottling. Cultures, broad antibiotics within the hour, fluids.
• Pulmonary edema. Wet lungs, orthopnea, distended neck veins, hypertension. Furosemide, nitroglycerin, sit them up, BiPAP.
• Arrhythmia. New atrial fibrillation with rapid ventricular response, or a wide complex tachycardia. Rate control if stable, electricity if not.
• Pulmonary embolism. Sudden dyspnea and tachycardia, clear lungs, hypoxia that does not fit the film. Get a CT angiogram.
• Opiate oversedation. Sleepy, respiratory rate of 6, pinpoint pupils, a hydromorphone dose an hour ago. Naloxone titrated, and hold the standing order.
• Hypoglycemia. Insulin plus a missed tray. One amp of D50 and then find out why the meal never arrived.
• Bleeding. Tachycardic and hypotensive before the hemoglobin has had time to fall. Type and screen, transfuse, find the source. A soft abdomen does not exclude it.
• Mucus plugging. An abrupt saturation drop with unilateral absent breath sounds, often postoperative or in a weak cougher. Suction, chest physiotherapy, bronchoscopy if it does not clear.

Where does this patient go

You have three options and should pick within about fifteen minutes: stay on the floor with a plan, move to telemetry or step-down, or go to the unit.

Move them if they need anything the floor cannot deliver: a vasopressor, a titratable drip, high flow oxygen or non-invasive ventilation, frequent neurologic checks, hourly labs, or an airway unlikely to hold for eight hours. Move them if you fixed the problem but do not trust it to stay fixed. And move them if you find yourself planning to come back and check in an hour, because that is you telling yourself the floor is the wrong place.

Numbers, trajectory, what you have done, what you expect to need next, and the ask. If the answer is no, write down who said no and why, escalate to your attending, and keep the patient in front of you until somebody senior to both of you decides otherwise.

Escalation versus goals of care

Here is the part nobody teaches. A large share of rapid response calls are on patients with advanced cancer, end stage heart failure or advanced dementia, for whom the honest question is not "which pressor" but "does this person want any of this."

Check the code status before you do anything irreversible, and check whether it was ever discussed with the patient or simply copied forward. "Full code" documented by an intern at 2 a.m. six months ago is not a goals of care conversation.

If the trajectory is clearly downward and nobody has had the conversation, you are allowed to start it, at three in the morning, in a hallway, with a daughter on speakerphone. Something like: "Your father is much sicker tonight than he was this morning. I can move him to intensive care and put him on a breathing machine. I want to be honest that I do not think that will get him back to how he was. Can you help me understand what he would say about that?"

Then document it properly, because a conversation that is not written down did not happen. See documenting difficult conversations.

Documenting it

Write it before you leave the floor. It should show what you found, what you did, how they responded, and what happens next.

Note the times, the vitals recorded as taken by you, the explicit response to treatment, and the named people you spoke to. That last detail matters most when somebody reads this a year from now.

Handing back

The rapid response ends when somebody owns the patient again, and that transfer is where the gains get lost. Do not walk away having only written a note. Speak to a human being.

If the patient stays on the floor, tell the covering physician and the nurse three things: what you think happened, what specifically would make you want to be called again, and by when you expect a reassessment. "Call me back if the respiratory rate goes above 28 again or the saturation drops below 92, and get a repeat gas at 02:00" is a usable instruction. "Monitor closely" is not.

If they transfer, give a verbal handoff to the receiving team as well as the written one, and make sure the primary attending hears about it tonight rather than reading it on rounds. For the structure of that conversation, see handoff and signout. For the calls that come in before anyone thinks to call a rapid response, see common night calls.