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Intensivist Educators will provide the initial and ongoing education and ongoing continuous quality improvement of these medical directives as directed by the section - Critical Care. PURPOSE: 1. To define the diagnostics and interventions that may be performed by the responders of the RRS for any patient seen by the team. 2. All calls to a physician responsible to the RRS, by a RRS responder are deemed a medical consult from the patients Most Responsible Physician (MRP) / Nurse Practitioner (NP). 3. To comply with the professional standards and guidelines of the College of Physicians and Surgeons of Ontario, the College of Respiratory Therapists of Ontario and the College of Nurses of Ontario. 4. Documentation of the use of the Medical Directive will be made with a notation in the space provided on the Physician orders. SBAR communication will be used to report all interventions. Inclusion Criteria: 1. Any adult in-patient that is referred to the RRS. Exclusion Criteria: 1. Any out-patient 2. Any pediatric patient. Early Recognition: Traditional vital signs have been used to assess at-risk patients. In most circumstances, physiologic abnormalities in the vital signs occur well before a cardiac arrest takes place. These activation criteria are used to mobilize the Rapid Response System. This is the “Lakeridge Health - Medical Early Warning System (MEWS)” which will be used as activation criteria. This will apply to the 2013 Rapid Response System (RRS) Directives listed: Respiratory Distress MEDICAL DIRECTIVE Rapid Response System (RRS) – Respiratory Distress Approved by/Date: February 26, 2013 (For LHB Pilot Only) Lakeridge Health Page 3 of 9 RESPIRATORY DISTRESS MEDICAL DIRECTIVE Authorized to whom: Appropriately educated RRS responders (RRTs and RNs) working within Lakeridge Health may initiate the following therapies for in- patients, who present with symptoms of airway compromise, tachypnea, dyspnea, orthopnea, cyanosis, shortness of breath, accessory muscle use, stridor, crackles, wheezes and /or cyanosis. Medical Directive Description: · Manage airway including support of oxygenation and ventilation (intubation if necessary) · Oxygen therapy as required to maintain oxygen saturation above or equal to 92%; patients who have COPD 88-92% · Initiate monitoring including cardiac, blood pressure and pulse oximetry. · Vital signs including temperature Q 5-30 minutes and prn · Review patient history and diagnosis · Perform an assessment and follow the standardized bronchodilator treatment guidelines below. · Stat ABG (pH, pO2 and pCO2) · STAT Portable Chest X-ray – upright if possible · Stat Blood Work (CBC, electrolytes, glucose, urea, creatinine, Magnesium, Phosphorus, Corrected calcium) – See Appendix · Insert a large (16 if possible) gauge IV of 0.9% sodium chloride at 30mL/hr. · Intraosseous access may be attained when it is a very unstable, life threatening situation and when IV access has not been successful after 2 attempts or 90 seconds of searching for a suitable vein. · If on auscultation CRACKLES - Position patient in Semi to high Fowlers · Continuous Positive Airway Pressure (CPAP)/Bi-level Positive Airway Pressure (Bipap) initiation: - NOTE: patients who require ongoing CPAP/Bipap must be transferred to a Critical Care Unit - If severe respiratory distress (respiratory rate greater than 30) and/or oxygen saturation less than 90% on 100% oxygen by nonrebreather or high-flow/Optiflow - Contraindications: systolic pressure less than 90 mmHg systolic, suspected pneumothorax, decreased level of consciousness leading to compromise of airway patency, inability to sit upright, unable to cooperate with CPAP, abdominal surgery within 7 days - Start at 5 cm H20 and increased by 5 cm H20 to maximum 15 cm H20 as required to relieve symptoms/hypoxia and as tolerated by patient MEDICAL DIRECTIVE Rapid Response System (RRS) – Respiratory Distress Approved by/Date: February 26, 2013 (For LHB Pilot Only) Lakeridge Health Page 4 of 9 - May initiate Bipap if ongoing respiratory distress despite CPAP or evidence of hypercapnea (PaCO2 greater than 50 and pH less than 7.3 OR EtCO2 greater