More on Sepsis

7 Dec

Here is one awful situation that will surely make your hair stand up.

Patient comes in I think from the nursing home, foley is inserted in the ED, out comes chunky soup into the foley bag. Blood pressures in the 80s, change of mental status. Diagnosis is urosepsis. ED does blood cultures, gives one dose of antibiotics, hangs up some normal saline and gives report to night shift tele RN. ED RN tells tele RN: pt on room air, NSS infusing at 100ml hour,NSR, pt given Tylenol for rectal temp of 102F, blood cultures sent, SBP  now in the 90s, WBC count elevated. The tele RN stops and says, “This patient sounds to be septic, did you get a lactate level according to sepsis screening?” The ED RN flips out becomes verbally defensive and tells the tele RN: “Not every patient needs a lactate level drawn.” Well, after that the teleRN calls the nursing supervisor and voices her concerns, she is shut down by the nursing supervisor who verbalized, “I have worked with that ED RN, she is a good nurse, do not worry about it.”

Patient gets to the tele floor, tele RN assesses: NSS bone dry to the line (not a drop left, and wonders for how long? certainly not for the quick transport), pt is tachypnic >30 resps per minute on 5 liters of oxygen (she said room air), pt is febrile rectal temp 101, pt SBP via doppler is 70 (she said in the 90s), pt is sinus tachycardia 130s (she said NSR), peripheral pulses NOT palpable, pulse ox: unattainable.

Wow. what a big change in condition from the ED holding room to the telemetry floor in less than ten minutes, this patient appears to be crashing. I am not saying it is NOT possible, but the attitude delivered from the ED RN when questioned about sepsis screening put the tele RN on edge to start with.

Immediate interventions by telemetry RN: Fluid resuscitation with NSS started, ABG obtained now, lactate now, rapid response called now.

The outcome: Pt was found to be hypoxic and in severe metabolic acidosis followed by a lactate level >5. The patient was immediately transferred from telemetry to ICU, where the patient then arrested cardio-pulmonary style and died exactly one hour from leaving the emergency department.

I am not writing this post about the ED nurse not screening for sepsis, I know that acute care patients are not stable, hell if we only wanted to deal with stable we would be working in doctors offices or something like that. The point is that sepsis screening was missed, the patient sat in the ED holding tank for 8 hours post triage and admit orders and interventions were missed, delayed by exactly that much time. If the patient were to have been screened prior to crashing upon arrival to telemetry the patient would of been admitted to critical care and would of received aggressive antibiotics and fluid resusc and hemodynamic monitoring as per severe sepsis standards.

The response: “She is a good nurse, do not worry.” is a highly inappropriate response from the supervisor. It is not about being a good nurse or a bad nurse (we are not label givers), it is about following the hospital policy and providing standards of care. The attitude of the ED nurse just made the whole situation less tolerable.

We are all in this together and that is for the patient, our job would be so much easier if we would all just work together. And on that note: my next blog post is going to be rant about myself and how awful I have been lately. Coming soon.


2 Responses to “More on Sepsis”

  1. Cherie December 16, 2009 at 02:39 #

    Hello, I’m searching for nursing related blogs like mine and I stumbled your site, nice blog!. I hope you could also include me in your blogroll.

    By the way, you have a very good writing skills here. Keep up the good work.

  2. keepbreathing December 20, 2009 at 03:52 #

    “She is a good RN, don’t worry about it.”

    Unfortunately in healthcare, rules are often enforced based on WHO you are or WHO you know, rather than what you do or how you act. Sigh…

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