Pharmacist Role on Rapid Response/Code Team?

[NYCGuy86]

Hey everyone. So today at work (I work part time as a PCA/tech) we had a rapid response. In my hospital, the rapid response team is composed of various resident physicians, nursing supervisor, and a respiratory therapist. They are called for emergent situations, including those that could evolve into a code. Today, apparently the patient had a seizure and was unresponsive for a period of time (I wasn't involved at the beginning, so this is what I hear). They called the rapid response, and after awhile, the nurses were attempting to start the patient on fosphenytoin, but they spent a good deal of time trying to figure out the dose, how to prepare it, etc. For this and one or two other medications (I believe versed was another), they were looking up drug charts, discussing/arguing amongst each other how to calculate the dosage. The whole time, I was standing there thinking "if only there was a pharmacist on the rapid response team!". Interestingly, there is a satellite pharmacist around the corner from our unit, but for some reason they didn't think to run over to the pharmacist for help with the fosphenytoin instead of spending about 20 minutes discussing it and looking things up.

So, my question ultimately is, what role do pharmacists play on the rapid response/code teams in your experience? Should all hospitals have a pharmacist on these teams, or are the nursing staff competent enough to deal with the drug issues in these situations (not trying to put down nurses, but I also think, in my limited experience, that having a pharmacist there would also allow them to focus on other important issues).

Thanks!

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[Its Z]

Provide code drugs

 

[rxlea]

A pharmacist goes to every code here. I'm surprised they had fosphenytoin on the floor...what does your institution have in the code cart? No diazepam?

But yes, pharmacists play a vital role on the team.

 

[hsb1104]

I think it depends on the hospital... I've worked at a couple who had pharmacists on the team but my current one does not. But they only have access to drugs in the crash cart... if they needed something like a Cerebyx drip they'd have to phone down a verbal to us.

 

[PharmDstudent]

I think it depends on the hospital... I've worked at a couple who had pharmacists on the team but my current one does not. But they only have access to drugs in the crash cart... if they needed something like a Cerebyx drip they'd have to phone down a verbal to us.

Same here. If they want other drugs, pharmacy has to dispense them.

I'd rather not go to codes. I went to a code once and stood by the door and watched a patient die. No fun.

 

[njac]

Rapid Response is a mixed bag - the vast majority of them don't require pharmacist interventions. When they need a pharmacist they usually call.

Code team - the drug drawer is MINE. touch drugs I didn't hand you and I'll bite you. I keep track of timing of meds and how fast to infuse them (Amio pulseless vs pulse, ditto for Mag), I discuss Hs and Ts with the physician and come up with potential causes.

 

[WVUPharm2007]

I did this for a while. You are basically the drug chucker. I had the bicarb syringe screw-together down to mere seconds. Little yellow and blue plastic doohickeys flying everywhere. Occasionally, they might ask you **** like, "can I push this magnesium?!?!" upon which you'd say, "Yes, but do it slowly..." Or whatever. It wasn't that bad.

Honestly, whenever the hospitalists weren't around and some random family doctor was running it, I felt like a situation where I was in over my head might arise, but they always seemed to do okay.

Now should pharmacists be on these teams...I dunno, its cool if they are there, but its not a necessity.

 

[psychoandy]

So, my question ultimately is, what role do pharmacists play on the rapid response/code teams in your experience? Should all hospitals have a pharmacist on these teams, or are the nursing staff competent enough to deal with the drug issues in these situations (not trying to put down nurses, but I also think, in my limited experience, that having a pharmacist there would also allow them to focus on other important issues).

baseline: i work in a teaching hospital. clinical staff are part of the code team, and if it's your floor where someone's coding, you go as well. we do not respond to rapid response unless specifically requested.

1.) rapid response - unclear role. if someone is desatting and having pulmonary edema, i don't need to be up there getting lasix from the med room, total waste of my time. but if someone was seizing on the floor i can override fosphenytoin from the pyxis or grab some IV keppra before the interns even think about it.

code response - should be providing ACLS meds from the cart, facilitating delivery of meds that aren't, running pt's med list/MAR, etc.

2.) most hospitals should have a pharmacist on code teams. it's not that RNs can't do it, but pharmacists are more effective at it and there are better things RNs should be doing (getting O2, finding the always-missing pulseox, getting access, CPR, documenting, etc). on ASHP messageboard a lot of institutions support "all or nothing"; as in, if you don't have enough staff to respond on evenings/nights/weekends, pharmacists shouldn't respond because you don't want to give the wrong expectation. personally i think that's *****ic.

Code team - the drug drawer is MINE. touch drugs I didn't hand you and I'll bite you.

personally I get pissed when a.) there's medical junk on the code cart when i arrive, like dusty clipboards and stehoscopes and stuff or if b.) anesthesia or someone tries to put dirty laryngoscope blades or bloody catheters and crap all over the top where i would mix meds.

 

[Pharmacyjoedotcom]

Here is what I consider the role of a pharmacist on a rapid response team:

Pharmacist's Role

1. Obtain needed medications
2. Look for medication related causes of the patient's deterioration
3. Assist the team as needed
   • Often by reading aloud recent labs and meds administered
4. Anticipate and prepare in advance for the patient's pharmacotherapy needs

I discuss this in more detail on my podcast at http://www.pharmacyjoe.com/pharmacists-as-members-of-the-rapid-response-team/

 

[pulmoblast]

Our code RRT teams can do all of that without a pharmacist. The last thing required in a critical situation is another wise guy "trying to help."

Stay out of codes/RRT. If you wanna play doctor, go to med school.

 

[gwarm01]

Our code RRT teams can do all of that without a pharmacist. The last thing required in a critical situation is another wise guy "trying to help."

Stay out of codes/RRT. If you wanna play doctor, go to med school.

Yeah, okay buddy.

In codes/rapid response I just act as a facilitator for code drugs. Get whatever they need from the pyxis, communicate with the pharmacy/IV room to get stat drugs made and to the patient ASAP. Periodically I will make bedside epi drips or whatever is needed. I'm not "trying to help" or playing doctor, I am getting my team what they need, when they need it.

I don't know if your a med student or actually a doctor

I would hope they are a student, but maybe a doctor that has had to deal with one of those pharmacists that think they are god's gift to medicine. You know the type, can't see the forest for the trees. Delays critical therapy over insignificant issues. Pages doctors to ask questions you would be embarrassed to even bring up, then goes to lunch leaving it to fall on you.

Excuse me, sorry for that. It's new graduate/resident season and we haven't quite beat the nonsense from academia out of them yet.

 

[pulmoblast]

I am a pulm/crit fellow and a Resus committee member who overseas and reviews all codes in the hospital. We have a code kit which has all drips and meds we need. If you running to the Pyxis to get your code meds then that's slow and sad.

I respect ICU pharmacists a lot in the ICU when they help us dose and review meds...but...I am sorry my opinion on codes is as above

Btw do you want to be a code team member at 3am in the morning on call or only between the hours of 9 to 5 Monday through Friday ?

 

[sakigt]

Interesting. I work evenings and the times Ive gone up to codes in the ICU and the team says they can handle it I hang around anyway and something I cant do needs to be done and they step away from the meds. Doc calls for the meds, RN thinks they arent ready, turn around and see Ive dun dosed and drawn it up for them. Oh, and heres the flush you need too. I hung around after a code in the GI lab as well when they said Pharmacy could go, just to hear them freaking out about how to give Levophed. Took the vials (did they think they were going to push it or something??), made the bag, dosed the patient.

I know when Im not wanted, and I dont take offense. No need to be so harsh :thumbsup:

 

[Dred Pirate]

I attend probably on average of 5-10 or more codes/code "ish" situations a week. I work in the ED and ICU.
Things I do in a code:
1. obviously pull meds from crash cart - but usually the RN's do this - we have a specified RN who stands by the cart and puts together abbojects.
2. Facilitate meds from pyxis (think intubation meds, mix drips, etc)
3. Do chest compressions - as a pharmacist I rarely do this, but on occasion on long codes when the techs are wearing out.
4. Think through the H&T's and make recommendations.
5. Know the doses front and backwards so the RN doesn't guess when the MD gives a vague order, or saves the MD from looking silly when they don't know
as a side note I was in a code with a cardiologist in the cath lab and he didn't know how to give amio in a code. He was telling the RN to give 150mg over 15 minutes. I stepped in professionally and told them it is a 300mg push.
6. Calling the pharmacy for odds and ends things, or if the code cart is running low.
7. Compatibility info - usually have limited lines
8. Know your formulary - especially when asked - what paralytic do we have?
9. Be an extra set of hands, grabbing central lines, IO's, other random supplies - a tech can do this, but you look smart when you can help out.
10. Consult with MD on post-ROSC care - espectially when titrating drips (ED RN's do a bad job at this), recommend proper sedation.
11. Run the defibrillator and actually shock patients

as to @pulmoblast - he is acting like a tool - and thinks he knows it all - I have one doc that won't do an intubation until I am at bedside - seems silly, but hey. The MD's love having us, I probably attend more codes than anybody in the hospital except for the night shift RPh's since they cover the entire house. Think about it - at any given time in the ED there is 1 Rph, 7 MD,s 20 Rn's - when there is a code - that Rph responds to all, yet there is only 1-2 MD's and 3 RN's/

 

[pulmoblast]

I attend probably on average of 5-10 or more codes/code "ish" situations a week. I work in the ED and ICU.
Things I do in a code:
1. obviously pull meds from crash cart - but usually the RN's do this - we have a specified RN who stands by the cart and puts together abbojects.
2. Facilitate meds from pyxis (think intubation meds, mix drips, etc)
3. Do chest compressions - as a pharmacist I rarely do this, but on occasion on long codes when the techs are wearing out.
4. Think through the H&T's and make recommendations.
5. Know the doses front and backwards so the RN doesn't guess when the MD gives a vague order, or saves the MD from looking silly when they don't know
as a side note I was in a code with a cardiologist in the cath lab and he didn't know how to give amio in a code. He was telling the RN to give 150mg over 15 minutes. I stepped in professionally and told them it is a 300mg push.
6. Calling the pharmacy for odds and ends things, or if the code cart is running low.
7. Compatibility info - usually have limited lines
8. Know your formulary - especially when asked - what paralytic do we have?
9. Be an extra set of hands, grabbing central lines, IO's, other random supplies - a tech can do this, but you look smart when you can help out.
10. Consult with MD on post-ROSC care - espectially when titrating drips (ED RN's do a bad job at this), recommend proper sedation.
11. Run the defibrillator and actually shock patients

as to @pulmoblast - he is acting like a tool - and thinks he knows it all - I have one doc that won't do an intubation until I am at bedside - seems silly, but hey. The MD's love having us, I probably attend more codes than anybody in the hospital except for the night shift RPh's since they cover the entire house. Think about it - at any given time in the ED there is 1 Rph, 7 MD,s 20 Rn's - when there is a code - that Rph responds to all, yet there is only 1-2 MD's and 3 RN's/

"I have one doc that won't do an intubation until I am at bedside - seems silly, but hey. The MD's love having us, I probably attend more codes than anybody in the hospital except for the night shift "

You're the man my friend !

 

[Dred Pirate]

View attachment 195044

"I have one doc that won't do an intubation until I am at bedside - seems silly, but hey. The MD's love having us, I probably attend more codes than anybody in the hospital except for the night shift "

You're the man my friend !

yup - your a tool

I don't know why I keep feeding the trolls.

You my friend are the exception to the rule

 

[pulmoblast]

Yup I am the troll and your the man
Don't let me take too much of your time...there are probably patients needing intubation out there who are just waiting for their friendly neighborhood pharmacist to come by...

 

[Dred Pirate]

Yup I am the troll and your the man
Don't let me take too much of your time...there are probably patients needing intubation out there who are just waiting for their friendly neighborhood pharmacist to come by...

your 29 - you have a lot to learn in life buddy - like as professionals we all have our expertise - you can learn a lot from others - respect the abilities of others, if you bicker - the only ones that loose are the patients.

 

[confettiflyer]

We're not on the code response team as the pulm/crit guy described...and I'm glad. I usually show up and provide background assistance to the rest of the crash team and anticipate unusual medication usage not within the realm of standard crash cart administration (like factor products or TXA or something).

Those usually aren't your run of the mill situations, and level of response is directly related to each pharmacist's ability, so yes, it'll be a 9-5 thing (or really ass o'clock til 4pm or so when I leave)...I wouldn't expect our evening or night staff to do the same.

Most codes are run just fine without pharmacy...except maybe when new nurses are manning the cart and panic. It becomes a "tie up one pharmacist, ignore 50 other patients" scenario without added benefit.

So stop knocking on the pulm guy's nuts everyone, he has a point.

 

[GoldfishPharmD]

I HATE codes with a passion. To those pharms that are doing them and are appreciated by your team, keep doing you. Don't let someone on the internet undermine your work and stop bothering trying to prove yourself online. It's not worth it. Everyone's goal should be to care for their patients, not to belittle colleagues, especially if they have enough free time to come harass people on the pharmacy forums...

 

[pulmoblast]

Exactly...we all have our expertise and we should learn to stick to it

I don't argue with pharmacists about MICs and AUCs and kinetics etc and I don't pretend to help you when we need approval for restricted drugs etc

On our ICU rounds, the input of everyone on the team is sought and valued ...including pharmacy nurses and social work

This is neither practical not desirable in a crashing/code situation where too many people create chaos and ultimately harm the patient

Why do you feel to participate in things that you are neither trained nor licensed for ?

Patients will be better off we stick to our jobs and try not to be heroes who do everything like our superhero pharmacist here who codes and intubates and supervises cardiologists in the lab...

PS.I would like to see you try this with a surgeon or an anesthesiologist in the OR or SICU

 

[pulmoblast]

PS I posted here because this topic was brought up last week in our resus committee meeting as one particular pharmacist requested a duplicate code pager and be part of the code team so that he could "help" with codes/RRT between the hours of 9-5 Mondays through Fridays excluding all public holidays

Our committee declined that request but made him in charge of stocking and checking our code kit everyday and orienting new nurses and fellows with it (which everyone appreciates)

He however still shows up at some codes and makes it a point to shout his recommendations to everyone around

 

[BidingMyTime]

I have never been on a code team. I find the thought of being on one pretty scary (although I suppose if I were going to be on one, I'd have some preparation and training, and be less scared.) Pharmacists are not on them at my hospital (we are too small, as was brought up, it would quickly tie up one pharmacist with 1 patient, at the expense of all the other patients.) Any standard emergency med is available in the crash cart, and the crash team is well prepared to dose and administer them. Any ASAP med would have either be 1) approved & mixed by pharmacy or 2) approved by pharmacy for removal from the Pyxis/Omnicell.
Now, if there is a large teaching hospital, with lots of pharmacists, and lots of non-standard emergency drugs in their crash cart, then it would make sense to have a pharmacist on the code team.

 

[confettiflyer]

He however still shows up at some codes and makes it a point to shout his recommendations to everyone around

That's freaking annoying. Oh I replied to you above but didn't quote you, but yeah, I'm with you on this.... I show up and hang around and wait for "weird ****" requests.

 

[Dred Pirate]

We're not on the code response team as the pulm/crit guy described...and I'm glad. I usually show up and provide background assistance to the rest of the crash team and anticipate unusual medication usage not within the realm of standard crash cart administration (like factor products or TXA or something).

Those usually aren't your run of the mill situations, and level of response is directly related to each pharmacist's ability, so yes, it'll be a 9-5 thing (or really ass o'clock til 4pm or so when I leave)...I wouldn't expect our evening or night staff to do the same.

Most codes are run just fine without pharmacy...except maybe when new nurses are manning the cart and panic. It becomes a "tie up one pharmacist, ignore 50 other patients" scenario without added benefit.

So stop knocking on the pulm guy's nuts everyone, he has a point.

I disagree - we respond to codes 24/7 - myself and another pharmacist train all of those that will respond. We ensure that they are comfortable in the situation and know what a pharmacist's role is. That is dealing with the "out of crash cart requests" and mainly post ROSC care - as honestly that is where most of the questions come from, especially out side of the controlled ICU/OR environment. I NEVER said that we step in a "shout our recommendations to everyone around" as @pulmoblast stated. Like I said, I was in the cath lab for a code and the attending had to pull out his phone because he didn't know the algorithm, is this the norm? of course not, but he appreciated me stepping in and PROFESSIONALLY giving advice. I have never never once had a MD complain that we were overstepping out bounds. I cannot count the number of times the RN's have gone out of their way to thank us for our help. You are a young dude pulmo and took everything I said out of context. We all know our roles, I have a role in those situations. The OP's questions was what is a pharmacists role in a code situation and I answered what I do.

Look at these threads - not all dealing with codes, but you can see what other specialties take are - maybe you can learn a lesson from your older more experienced colleagues.


http://forums.studentdoctor.net/threads/what-role-do-you-see-for-a-pharmacist-in-the-ed.1128562/

http://forums.studentdoctor.net/threads/what-role-do-you-see-for-a-pharmacist-in-the-ed.1128562/

 

[GoldfishPharmD]

PS I posted here because this topic was brought up last week in our resus committee meeting as one particular pharmacist requested a duplicate code pager and be part of the code team so that he could "help" with codes/RRT between the hours of 9-5 Mondays through Fridays excluding all public holidays

Our committee declined that request but made him in charge of stocking and checking our code kit everyday and orienting new nurses and fellows with it (which everyone appreciates)

He however still shows up at some codes and makes it a point to shout his recommendations to everyone around

Sounds like you're having issues with this particular pharmacist. You are of course entitled to your opinion and if you don't feel the need to have a pharmacist around, you don't have to like you stated your team rejected the pharmacist's request. However, I don't see the need to come in here and be downright rude to other people just trying to look out for patients. Of course when you stated that pharmacists are just an annoyance, people are going to get defensive. For their particular hospital/team they are needed and appreciated. Don't understand why it can't be left at that. I didn't see anyone act like they're the "man" because they help out on codes, boss physicians around, or imply they were the most important person on the team. Can't we all just get along.

 

[Pharmacyjoedotcom]

Our code RRT teams can do all of that without a pharmacist. The last thing required in a critical situation is another wise guy "trying to help."

Stay out of codes/RRT. If you wanna play doctor, go to med school.

PS I posted here because this topic was brought up last week in our resus committee meeting as one particular pharmacist requested a duplicate code pager and be part of the code team so that he could "help" with codes/RRT between the hours of 9-5 Mondays through Fridays excluding all public holidays

Our committee declined that request but made him in charge of stocking and checking our code kit everyday and orienting new nurses and fellows with it (which everyone appreciates)

He however still shows up at some codes and makes it a point to shout his recommendations to everyone around

The truth trickles out!

Pharmacist participation on the cardiopulmonary resuscitation team reduces mortality (12,880 reduced deaths, p=0.009).

 

[KidPharmD]

PS.I would like to see you try this with a surgeon or an anesthesiologist in the OR or SICU

Not a superhero pharmacist, but I want to share my expierence. I also come from a place where the drug tray/bag is the pharmacist's responsibility during a code (a pharmacist responds to every code 24/7) I will say that my experience is similar to those above. It is mostly about being there to provide drugs faster. Of course, in a pediatric hospital drug provision is more than assembling premade syringes.
I don't know about others but I am trained (BLS/PALS/ACLS certified, Pharmacy participating with resident code training, Mock code attendance, etc) and licensed for all the activities I participate in during a code.

Also as for the quoted statement, we don't participate in the OR because the OR takes care of their own (mostly for sterile area issues). However we do go to the PACU and work very well with the anesthesiologists and heavily participate in both Code and RR in the Cardiac Surgery ICU (and you have never met a diva doctor till you work with pediatric heart surgeons).

The truth trickles out!

Pharmacist participation on the cardiopulmonary resuscitation team reduces mortality (12,880 reduced deaths, p=0.009).

Love this.

 

[Dred Pirate]

I will agree with pulmo dude on one thing - you gotta do it 24/7 - you can't have your cake and eat it too. If you want to be taken seriously you have to either be there for everything or not. If you only show up during bankers hours, you provide a disservice to the off hour codes.

@KidPharmD Do you find PALS beneficial? I took it and thought it really didn't help me. Basically - fluids and epi is all it taught me (this is coming from me as an ACLS instructor)

 

[confettiflyer]

I disagree - we respond to codes 24/7 - myself and another pharmacist train all of those that will respond. We ensure that they are comfortable in the situation and know what a pharmacist's role is. That is dealing with the "out of crash cart requests" and mainly post ROSC care - as honestly that is where most of the questions come from, especially out side of the controlled ICU/OR environment. I NEVER said that we step in a "shout our recommendations to everyone around" as @pulmoblast stated. Like I said, I was in the cath lab for a code and the attending had to pull out his phone because he didn't know the algorithm, is this the norm? of course not, but he appreciated me stepping in and PROFESSIONALLY giving advice. I have never never once had a MD complain that we were overstepping out bounds. I cannot count the number of times the RN's have gone out of their way to thank us for our help. You are a young dude pulmo and took everything I said out of context. We all know our roles, I have a role in those situations. The OP's questions was what is a pharmacists role in a code situation and I answered what I do.

Look at these threads - not all dealing with codes, but you can see what other specialties take are - maybe you can learn a lesson from your older more experienced colleagues.


http://forums.studentdoctor.net/threads/what-role-do-you-see-for-a-pharmacist-in-the-ed.1128562/

http://forums.studentdoctor.net/threads/what-role-do-you-see-for-a-pharmacist-in-the-ed.1128562/

I think half this was directed at pulmo, but I'll add that a lot of the experience will depend on the internal machinations of your institution. A robust training and code response program in place may obviate the need for clinical pharmacist intervention/assistance, whereas another institution may have a vacuum and need clinical pharmacy assistance during the event and post care.

More power to you if you're in the latter, but at least in our case, it became a scarcity issue where literally dozens of patients would be ignored if pharmacy were formal parts of the code team. Personally, my attendance is usually proximity based....I can't help it if I'm standing at the nurses station in the unit and someone codes in the room across from me, I'm not going to hide.

But know my professional limits is also key, sounds like pulmo guy had a goose of a pharmacist barking away inappropriately. That's distracting.

 

[KARM12]

We provide code coverage 24/7. We run the med tray. It is more of a med safety guard than anything...making sure things are drawn up/mixed appropriately. You would be amazed of the all administration errors that are prevented. None of the pharmacist sit there and shout out what to do unless asked. We are all PALS/ACLS trained (on top of our own annual department competency. I personally do not find any excitement or enjoyment when I am the one who is covering the code pager.

Agree that if you do it, you should be able to provider 24/7 coverage. That way you can define the specific responsibilities of each team member. Sounds like the mentioned pharmacist is not the most tactful, but to say all of us are useless and untrained is kind of ridiculous.