ID abnormal vital signs more quickly

A patient's condition 'can and will' decline

Hours after arrival in the ED, a patient's condition suddenly, unexpectedly, deteriorates. How do you get this patient immediate help? Here are different approaches used by ED nurses:

A "trigger" program brings immediate help to patients with abnormal vital signs.

When an ED nurse at Beth Israel Deaconess Medical Center in Boston calls a "trigger," this brings a charge nurse, senior resident, and attending physician to the patient. ED nurses use this criteria:

— heart rate less than 40 or above 130;

— respiratory rate less than 8 or over 30;

— blood pressure less than 90;

— oxygen saturation less than 90% on room air;

— marked nursing concern.

"A trigger can be called at any point during the patient's stay," says Shelley Calder, RN, CEN, MSN, clinical nurse specialist for the ED. "We have seen that patients can and will decline hours after arrival."

A "rapid response" nurse works alongside ED nurses caring for critically ill patients having an acute event.

"In these events, we need all hands on deck. These critical patients often require complex diagnostic workups, treatments, or medical procedures," says Teri Arruda, MSN, FNP-BC, CEN, an ED nurse at Mission Hospital in Mission Viejo, CA. "These resources often require multiple nurses to administer the best possible care." (See Clinical Tip, below, on improving care in these situations by using packets.)

ED nurses call a "Code Purple" if a pediatric patient is deteriorating or is found in distress, which alerts the designated ED code team to respond.

For example, if a child suddenly goes into respiratory distress, "the goal is to provide the immediate intervention before they lose their pulse or spontaneous respiration," says Rosie Rodriguez-Henderson, RN/MHL, an advanced clinician in the pediatric ED at Baptist Children's Hospital in Miami.

To call the "code purple," nurses pull buttons that sound an alarm heard in every patient room, and a light flashes outside the patient's room.

The team consists of a physician team leader, a pediatric ED technician, and three nurses. The nurses include a primary nurse, who does all documentation during the code; a medication nurse, who draws up all medications and continuous drips as needed; and a procedure nurse, who performs procedures such as intravenous line starts, setups for line placements, and cardiopulmonary resuscitation. "Depending on the individual needs of the patient, we request assistance from other areas such as respiratory therapists, child life specialists, chaplains, and radiology," says Rodriguez-Henderson.

Clinical Tip

Packets can give better critical care outcomes

Teri Arruda, MSN, FNP-BC, CEN, an ED nurse at Mission Hospital in Mission Viejo, CA, recommends developing packets to use when caring for patients who present with critical care events such as stroke, sepsis, or an ST-segment elevation myocardial infarction. Each packet includes the appropriate checklist, algorithm, order set, and guidelines.

"These packets effectively guide the patient's care," says Arruda. "The packets support critical thinking during an acute event. The novice to expert nurse can benefit from this tool. It reduces error and promotes better patient outcomes." [Editor's note: The ED's sepsis code packet is included.]


For more information on obtaining immediate help when a patient's condition changes, contact:

  • Shelley Calder, RN, CEN, MSN, Clinical Nurse Specialist, Emergency Department, Beth Israel Deaconess Medical Center, Boston. Phone: (617) 754-2310. E-mail:
  • Rosie Rodriguez-Henderson, RN/MHL, Advanced Clinician, Pediatric Emergency Room, Baptist Children's Hospital, Miami Phone: (786) 596-6966. E-mail: