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© 2013 UPMC All Rights Reserved
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.
POLICY CP-12
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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
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© 2013 UPMC All Rights Reserved
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
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© 2013 UPMC All Rights Reserved
SIGNED: Holly Lorenz
Vice President, Patient Care Services
Sandra Rader
Vice President, Patient Care Services
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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© 2013 UPMC All Rights Reserved
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.
© 2013 UPMC All Rights Reserved
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
© 2013 UPMC All Rights Reserved
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)
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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
a. Responsibilities include:
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:
a. Responsibilities include:
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.
© 2013 UPMC All Rights Reserved
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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© 2013 UPMC All Rights Reserved
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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© 2013 UPMC All Rights Reserved
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
Pittsburgh Emergency Medical
Services
Hillman Building –
Clinical Side
3-3131
9-911
Hillman First Response Team
Shadyside Rapid Response Team
Pittsburgh Emergency Medical
Services after hours
Hospital Garages &
Outside Perimeter
3-3131
9-911
(When emergency
transport is
required
Shadyside Rapid Response Team
Emergency Department Team
Pittsburgh Emergency Medical
Services
Medical Center Offices
3-3131
9-911
(When emergency
transport is required)
Shadyside Rapid Response Team
Pittsburgh Emergency Medical
Services
Hillman Cancer Pavilion
Offices
3-3131
9-911
(When emergency
transport is required)
Shadyside Rapid Response Team
Pittsburgh Emergency Medical
Services
Preservation Hall
3-3131
9-911
(When emergency
transport is
required
Emergency Department Team
Pittsburgh Emergency Medical
Services
Shadyside Place 9-911 Pittsburgh Emergency Medical
Services
North Tower
(School of Nursing)
3-3131
9-911
(When emergency
transport is required)
Shadyside Emergency Event Team
Pittsburgh Emergency Medical
Services
UPMC Shadyside 3-3131 Shadyside Emergency Event Team
UPMC Shadyside
Roof Area
3-3131
9-911
(When emergency
transport is
required
Shadyside Rapid Response Team
Pittsburgh Emergency Medical
Services
© 2013 UPMC All Rights Reserved
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!
© 2013 UPMC All Rights Reserved
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
© 2013 UPMC All Rights Reserved
Appendix E
UPMC Shadyside
Intensivist Bag Supply List
Quantity Supply
2 #7.0 cuffed ETT with stylettes
3 #7.5 cuffed ETT with stylettes
3 #8.0 cuffed ETT with stylettes
2 #8.5 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:
© 2013 UPMC All Rights Reserved
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
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PROCEDURE CP-12-PRO-SHY
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© 2013 UPMC All Rights Reserved
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
© 2013 UPMC All Rights Reserved
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
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© 2013 UPMC All Rights Reserved
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)
© 2013 UPMC All Rights Reserved
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.
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PROCEDURE CP-12-PRO-SHY
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© 2013 UPMC All Rights Reserved
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
© 2013 UPMC All Rights Reserved
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
© 2013 UPMC All Rights Reserved
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.
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© 2013 UPMC All Rights Reserved
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.
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, 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:
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.
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:
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
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© 2013 UPMC All Rights Reserved
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. 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:
Key switch will activate both elevators.
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 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:
Key switch will activate both elevators.
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.
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PROCEDURE CP-12-PRO-SHY
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© 2013 UPMC All Rights Reserved
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
© 2013 UPMC All Rights Reserved
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
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© 2013 UPMC All Rights Reserved
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
PROCEDURE CP-12-PRO-SHY
PAGE 54
© 2013 UPMC All Rights Reserved
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
PROCEDURE CP-12-PRO-SHY
PAGE 55
© 2013 UPMC All Rights Reserved
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
PROCEDURE CP-12-PRO-SHY
PAGE 56
© 2013 UPMC All Rights Reserved
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.
© 2013 UPMC All Rights Reserved
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
PROCEDURE CP-12-PRO-SHY
PAGE 58
© 2013 UPMC All Rights Reserved
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
Tube,blood collection
purple 70075
2 EA
Tube,blood collection
red 109763
2 EA
Tube,blood collection
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
PROCEDURE CP-12-PRO-SHY
PAGE 59
© 2013 UPMC All Rights Reserved
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
© 2013 UPMC All Rights Reserved
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
Normal Saline Bag 0.9% 500mL 1
Normal Saline Bag 0.9% 100mL 4
© 2013 UPMC All Rights Reserved
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
PROCEDURE CP-12-PRO-SHY
PAGE 62
© 2013 UPMC All Rights Reserved
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.
© 2013 UPMC All Rights Reserved
SIGNED: Sandra Rader
Vice President, Patient Care Services
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