In this episode, I’ll discuss how to predict the pharmacotherapy needs of your patient and team during an inpatient medical emergency.
I consider there to be 3 skill levels that pharmacists progress through as they learn how to respond to inpatient medical emergencies such as code blue and rapid response calls:
Level 1 I call “just being a pharmacist.” This is when you do regular pharmacist things like drawing up and labeling medications, and calculating doses. This work is valuable because it frees a nurse up to be hands-on with a patient.
Level 2 is helping to identify and reverse the cause of the patient’s deterioration. This includes listening to the bedside nurses description of what happened prior to the emergency, and reviewing a patients medications, labs, and other clinical data to pinpoint the cause of deterioration.
Level 3 is predicting and preparing for the pharmacotherapy needs of the patient in advance, prior to the physician ordering medications for those needs. Preparing for these needs in advance greatly reduces the usual lag time between a physician’s medication order and the implementation of that order to benefit the patient.
So how can a pharmacist develop the skill to predict pharmacotherapy needs and prepare for them in advance? By assessing each emergency scenario through the lens of your knowledge and experience to answer the question “What is the worst thing that could go wrong right now?” Then, bring the medications and supplies to the bedside that would be needed for that worst-case scenario.
Here are some examples:
1. You are on a rapid response call for a septic patient and observe that the patient is drowsy, receiving supplemental oxygen, and nurses are asking for a manual blood pressure cuff because the electronic one isn’t giving a reading.
The worst-case scenario involves this patient needing rapid sequence intubation (because they are drowsy and requiring oxygen) and fluid boluses and vasopressors (because their blood pressure can’t be easily read). By bringing the necessary medications to the bedside when you notice this, you can have them ready to go before the physician orders them.
2. You are on a rapid response call for a GI bleed patient and you observe the nurses to be discarding a bedpan with fresh, bright red blood.
This is a condition called hematochezia, and it suggests that the patient is having a very large upper GI bleed for there to be fresh blood in the stool. Knowing that this means the patient may become critically ill very quickly due to large blood loss, a pharmacist can obtain crystalloid IV fluids and vasopressors while the rest of the rapid response team attends to the patient. This will allow for immediate supportive care until an endoscopy can be performed.
3. You are in the room during a rapid sequence intubation and notice the provider is having difficultly placing the tube on the first attempt. The patient’s oxygen saturation and heart rate begin to decrease below their pre-intubation baseline.
Most of the time this scenario turns out fine, the airway is secured on the second attempt and the patient’s vital signs return to normal. However, this could also signal a worst-case scenario of impending intubation-related cardiac arrest. At this point, as I have typically finished preparing and handing to the nurse all medications needed for rapid sequence intubation, and the rest of the staff is directly attending to the patient, I will obtain the code cart, bringing it just outside the room so that it is available should it be needed. The reason I leave the cart outside the room is that the last thing a physician or respiratory therapist wants to see out of the corner of their eye during a challenging intubation, is the code cart being rolled into the room.
In each of these scenarios, the medications brought to the bedside will not always be needed, and I do not open vials or spike IV bags ahead of time to avoid waste. But in the event the worst-case scenario does occur, your team and ultimately the patient will benefit from having the correct medications immediately available at the bedside instead of down the hall in the automated dispensing cabinet.
No matter what skill level of code blue and rapid response you are at, from having never attended a code to being an experienced member of the medical emergency team, my Hospital Pharmacy Academy has in-depth, practical trainings to help you bring your emergency response skills to the next level. This is in addition to many other resources to help you in your practice.
No matter what skill level of code blue and rapid response you are at, the Hospital Pharmacy Academy has specific trainings to help you bring your emergency response skills to the next level. To learn more, go pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.