RAPID RESPONSE TEAM EVENT RECORD (RRTER)

SECTION- A

Date ____________________ Event Location ___________________________ Time RRT Called ___________________________

Time first RRT member arrived ____________________________ Time last RRT member departed ________________________
Diagnosis ____________ _________________________________ ____________________________________________________
____________ __________________________________________ ____________________________________________________
____________ __________________________________________ ____________________________________________________

Vital signs taken within 4 hours PRIOR to RRT call (if none enter, last documented vital signs prior to activation):
Date Time HR BP RR SpO2 Temp
/
/
Vital signs at time of RRT call: Blood Glucose:
Time HR BP RR SpO2 Temp GCS
/ E V M =
/ E V M =
Illness Category:  Medical Cardiac  Medical Non-Cardiac  Surgical  Trauma  Other ______________
Previously in:  ICU  AKU  CCU Date of transfer out: _____________ Sedation/Anesthesia/ED within 24 hrs:  Yes  No

SECTION- B
RRT Triggers: ( all that apply in first box) RRT Assessment: ( all that apply in second box)
  Staff member concerned about the patient   Acute change in urinary output to <0.5ml/kg/hr in 4 hours
  Acute change in heart rate <50   Acute change in level of consciousness
  Acute change in heart rate >130 bpm   Significant bleeding
  Acute change in systolic BP <90mmHg   Seizures
  Acute change in RR <10 breaths per min   Acute agitation or delirium
  Acute change in RR >30 breaths per min   dysrythmia
  Acute change in oxygen sat <90% despite O2   other

SECTION- C

RRT Interventions: Check all done or ordered during event:  None

Medications: Respiratory Interventions: Cardiac Interventions: Diagnostic Interventions:
 Establish IV access NS at KVO  Continuous Pulse Oximetry  Continuous Cardiac  12 lead ECG
 Supplemental O2 Monitoring  Labs:  B. Glucose by prick x __
 Fluid Bolus
 NC Mask NRB _______lpm/ FiO2  External Cardiac Pacer
500mL NS IV x _____ doses  CBC  Elect  Mg  Phos
 Suctioning
 Nitroglycerin  CK, CKMB & Troponins
 Tracheostomy Care/Replacement Neuro Interventions:
0.4 mg SL x _____ doses  Seizure Precautions  Type & Screen
 Bag-Valve-Mask Ventilation
 ICP Precautions  PT, PTT, INR
 Diazepam 5mg IV X ______ doses  Oral/Nasal Airway Insertion
 Recovery Position  AED Level ______________
 D50 50mL IVP  Salbutamol Nebulizer
Tx 5mg x _____ doses  Chest Xray

 Arterial Blood Gases  Acute Abdominal Series  KUB
 CT scan
 Others _____________

_____________

Rapid Response Team Event Record RCH-357-1434

SECTION- D

Additional physician orders during event:

__________________________________________________ ______________________________________________________
__________________________________________________ ______________________________________________________
__________________________________________________ ______________________________________________________
__________________________________________________ ______________________________________________________

RRT Outcome:
 No therapy necessary
 Progressed to cardiac or respiratory arrest
 Stat transfer to operating room (OR)
 Status changed to DNR after RRT evaluation
 Responded to therapy, remained on current unit
 Transfer to step-down unit (AKU) required
 Transfer to Cardiac Cath Lab
 Transfer to ICU required
 Transfer to another hospital
 Died during RRT event

Comments: ________________________________________________________________________________________________
__________________________________________________________________________________________________________

Unit RN Signature ___________________ Print Name/ Stamp ________________________ Date/Time ______________________

RRT RN Signature ___________________ Print Name/ Stamp ________________________ Date/Time ______________________

RRT RT Signature ___________________ Print Name/ Stamp ________________________ Date/Time ______________________

RRT Physician Signature ___________________ Print Name/ Stamp _____________________ Date/Time ___________________

Rapid Response Team Event Record RCH-357-1434