Rapid Response and Code Blue

Rapid Response and Code Blue

What is a Rapid Response?

  • Activation Triggers: A Rapid Response should be activated if a patient exhibits:

    • Anaphylaxis suspected

    • Acute changes in:

      • Blood pressure

      • Heart rate

      • Mental status

      • Respiratory status

      • Oxygen status

    • Caregiver concerns about the patient

Who Answers a Rapid Response Request?

  • Rapid Response Team:

    • Critical care RN

    • Respiratory Therapist

    • Critical care resident/provider

  • Team Responsibilities:

    • Assist caregiver in assessing and stabilizing the patient

    • Organize information for communication to the patient’s resident/provider

    • Provide education and support to staff, patient, and family

Nursing Interventions While Awaiting Arrival of Rapid Response Team

  • Initial Actions:

    • Obtain a full set of vital signs (if not already done)

    • Check blood glucose

    • Conduct a focused assessment

    • Communicate with the patient:

      • Example: "Mr. Smith, I’m concerned about your blood pressure..."

  • Key Questions:


    Is the patient experiencing chest pain?

    • Determine if it is cardiac-related


    • Actions:

      • Obtain a 12-lead EKG (based on unit policy)

      • Conduct a thorough assessment:

        • Deep breath, palpation, location/length/character of pain, other complaints



    Is the patient hypoxic or do they have an increased RR?

    • Oxygen saturation less than 90% or increased respiratory distress


  • Actions

    • Look at the patient

    • Auscultate breath sounds

    • Place the patient on an appropriate oxygen delivery system that will provide more oxygen than they are currently receiving (depends on current oxygen sat)

    • Monitor continuous oxygen saturation


Is the patient hypotensive?

  • Systolic blood pressure less than 100 or 30 points lower than baseline


  • Actions:

    • Look at patient

    • Check skin and pulses

    • Monitor temperature, heart rate, respiratory rate, and blood pressure


Does the pt have a change in LOC or neurological status?

  • Possible over-sedation if on narcotics/opioids


  • Signs of Stroke:

    • Facial droop, hemiparesis, slurred speech, confusion

  • Assessment Techniques:

    • Ask the patient to smile- is it uneven?

    • Ask the patient to raise both arms - does one arm drift downward?

    • is the patients speech slurred?

    • does the patient have a headache or trouble seeing?


Did the patient fall?

  • Key Considerations:

    • Determine mechanism of injury

    • Was the fall witnessed or unwitnessed?

    • Check for head injury- did they hit their head?

  • Actions:

    • Assess LOC and movement of extremities

    • Look for numbness, weakness, or tingling in any extremity

What is a Code Blue?

  • The patient has gone into cardiac or respiratory arrest

    • The pt is not breathing and/or the pt has no pulse

  • Immediate Action:

    • Initiate CPR as the patient is clinically dead.