The Night Shift Handover
A regional hospital runs a 12-hour night shift with one resident covering two wards: a 24-bed general medical ward and a 6-bed high-dependency unit (HDU). At 02:40 the resident is called to the HDU for a patient whose systolic blood pressure has fallen from 118 to 84 mmHg over 40 minutes, heart rate 112, respiratory rate 26, temperature 38.4 °C. Simultaneously, a nurse on the general ward reports a 79-year-old patient who has become acutely confused and is trying to climb out of bed. The resident has no senior support on site; the consultant is reachable by phone and lives 35 minutes away. Hospital policy requires that any patient with a NEWS2 score of 7 or above be reviewed by a doctor within 30 minutes, and that falls-risk patients be nursed with one-to-one supervision where staffing allows. Tonight the general ward is staffed at 4 nurses for 24 patients, which is one below the minimum ratio in policy.
1. Identify the immediate priorities for the resident and justify the order in which they should be addressed.
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The resident must first recognise that the HDU patient meets the escalation threshold: a systolic of 84 with tachycardia, tachypnoea and fever is consistent with a NEWS2 score well above 7, triggering the 30-minute review rule. The confused elderly patient is also urgent but, on the information given, has no documented physiological deterioration - the risk is of a fall, not of imminent cardiovascular collapse.
The defensible order is therefore:
- Attend the HDU patient now. Begin basic resuscitation (oxygen if hypoxic, IV access, fluid bolus per protocol) and simultaneously call the consultant. The 35-minute travel time means the phone call must happen immediately, not after assessment.
- Escalate staffing. Ask the nurse-in-charge to provide one-to-one supervision for the confused patient, or move that patient to a visible bay near the nurses' station.
- Return to the general ward once the HDU patient is stabilised or the consultant is en route.
The reasoning is triage by time-criticality, not by age or sympathy. A patient who may be in septic shock can deteriorate within minutes; a confused patient under observation has a slower risk trajectory. The resident should also document why the second patient was briefly deferred, because that decision will be scrutinised later.
2. The resident decides to phone the consultant before examining the HDU patient. A colleague argues this wastes time and the resident should assess first. Evaluate this disagreement.
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Both positions contain a valid instinct, and the judgement lies in what the phone call is for.
If the call is a request for permission or a lengthy narrative, the colleague is right: the resident is delaying hands-on care for a patient who may be peri-arrest. If the call is a brief activation - stating the observations, the working diagnosis and the request that the consultant start travelling - it costs perhaps 60 seconds and buys a 35-minute head start on the only senior help available.
The stronger answer is that the resident should make a short activation call while a nurse begins basic monitoring and oxygen, then examine. This is not indecision; it is parallel processing. The colleague's objection assumes the call and the assessment compete for the same minutes, but they need not.
The resident should also be honest about the limits of their competence. If they are uncertain how to manage a likely septic patient, the call is not optional. The real error to avoid is a long, reassuring-sounding phone call that delays both the examination and the consultant's departure from home.