Sepsis Recognition on a Busy Medical-Surgical Unit
A 74-year-old man admitted two days ago for a urinary tract infection is now on the medical-surgical floor. At 14:00 the nurse reports new confusion, HR 118, BP 92/54 (baseline 140/80), RR 26, temp 38.9 C, and SpO2 91% on room air. He has a peripheral IV, an indwelling urinary catheter placed on admission, and a history of heart failure with ejection fraction 35%. The unit has one rapid response team covering the whole hospital, and the nearest ICU bed is currently occupied but expected to open within two hours. The covering resident is in the operating room and unreachable by pager for the next 30 minutes.
1. What should the bedside nurse and charge nurse do in the first 15 minutes?
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Treat this as suspected sepsis with hypoperfusion. First, call the rapid response team now rather than waiting for the resident; the RRT exists for exactly this gap in coverage. Simultaneously initiate the sepsis bundle elements that nursing can start under standing orders or protocol: obtain full vitals including repeat BP, apply continuous pulse oximetry and cardiac monitoring, draw blood cultures before antibiotics if not delayed, draw lactate, and establish a second large-bore IV. Give supplemental oxygen to keep SpO2 in a reasonable range, recognizing that his heart failure makes overly aggressive fluids risky. Begin a cautious crystalloid bolus (for example 250-500 mL) with reassessment rather than a full 30 mL/kg dump, because of the EF of 35%. Notify the attending of record and document the RRT activation time. Prepare antibiotics per the unit's sepsis protocol. Do not delay antibiotics while awaiting the resident.
2. How should the team weigh fluid resuscitation against his heart failure, and what monitoring is needed?
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The standard sepsis recommendation of 30 mL/kg crystalloid is a starting point, not a mandate; in a patient with an EF of 35% and possible volume overload, give smaller boluses (250-500 mL) and reassess after each: BP, HR, mentation, capillary refill, urine output, and lung exam. Watch for crackles, increased work of breathing, or falling SpO2, which suggest he is intolerant. If he remains hypotensive after modest fluids, start a vasopressor early rather than continuing to pour in volume; norepinephrine is first-line and should not be delayed for a central line if peripheral access is available under protocol. Monitor lactate trend, urine output via the catheter, and mental status. Because his confusion could be sepsis, hypoxia, or a medication effect, document the baseline and reassess after interventions. The catheter is also a potential source; note insertion date and consider whether it should be removed once cultures are obtained.
3. What should happen if the ICU bed is not available when he needs it?
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Escalate. The charge nurse should notify the house supervisor and the attending of record, and the RRT should document that the patient meets ICU criteria but no bed is available. Continue full resuscitation and monitoring at the current level; if the unit cannot provide continuous cardiac monitoring or vasopressor administration, that is a patient safety event requiring a bed or transfer. Consider whether another monitored bed or step-down unit exists. If the patient deteriorates and cannot be safely managed on the floor, the RRT leader should request an emergency bed assignment or transfer to another facility, following the hospital's capacity escalation policy. Document times of each request, who was contacted, and the responses. Do not let the patient wait unmonitored because the resident is unreachable; the attending on call for the service should be paged. After the event, file an incident report and raise the coverage gap at the quality committee.