The deteriorating patient you have already escalated
You are the RN caring for Mr Petrov, 72, on a surgical ward at 14:00. He had a laparotomy 36 hours ago. At 13:00 his NEWS2 was 5 (RR 24, SpO2 92% on 2 L, HR 104, BP 102/58, T 38.1°C, new confusion). You escalated to the registrar, who said 'I'll come when I can' and did not attend. At 14:00 his observations are RR 28, SpO2 89% on 4 L, HR 122, BP 88/50, T 38.6°C, GCS 13, urine output 15 mL in the last hour. The registrar is in theatre.
1. Apply the escalation framework. What do you do now, and why is 'waiting for the registrar' not acceptable?
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This is a time-critical deterioration consistent with sepsis and possible hypovolaemia or anastomotic leak. The trend is worsening despite oxygen and time. Waiting is not acceptable because:
- Deterioration is documented and progressive - NEWS2 has risen, blood pressure is falling, urine output is falling, and consciousness is reducing.
- Escalation is a graded process - when the first responder is unavailable, I must escalate to the next level: the nurse in charge, the on-call surgical registrar, the ICU outreach or rapid response team, and if necessary the duty manager or consultant.
- The patient's safety overrides hierarchy. I would not accept 'when I can' as a plan; I would ask for a time and a named clinician.
Actions now:
- Call the rapid response/outreach team and state the observations and trend.
- Stay with the patient, call for a colleague, sit him up, apply high-flow oxygen as ordered, and prepare for fluid resuscitation.
- Repeat observations every 5–15 minutes and document.
- Check blood glucose, ECG, and cannula patency; take bloods if ordered (lactate, cultures, FBC, U&E).
- Prepare for possible transfer to a higher-acuity area.
- Inform the nurse in charge and document the escalation timeline, including who was called and when.
2. Write the ISBAR handover you would give the rapid response team, and explain what you would document afterwards.
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ISBAR:
- I - Mr Petrov, 72, bed 8, day 2 post-laparotomy.
- S - I am calling because he is deteriorating: RR 28, SpO2 89% on 4 L, HR 122, BP 88/50, T 38.6°C, GCS 13, urine 15 mL/hour.
- B - Admitted 36 hours ago, open laparotomy, no known allergies, IV cannula in situ, NEWS2 was 5 at 13:00 and the surgical registrar was informed but is in theatre.
- A - I think this is sepsis with possible hypovolaemia or an intra-abdominal complication. He is not responding to oxygen and his blood pressure is falling.
- R - I need urgent review and a management plan, and I am asking whether he should be transferred to a higher-acuity area. I have bloods ready and the resuscitation trolley is at the bedside.
Documentation afterwards: the observations and times; the NEWS2 scores; who I escalated to at 13:00 and 14:00, and their response; the rapid response call time and arrival; interventions given; the patient's response; the plan agreed; and that the family were informed if appropriate. Documentation must be contemporaneous and factual, because it is both a clinical record and evidence of appropriate escalation.