Stephanie, RN: Hello, my name is Stephanie. I'm going to be your nurse this evening.
How are you feeling? Sara: I'm so tired.
I can barely keep my eyes open.
Stephanie, RN: Do you have a history of any urinary tract or kidney problems such surgery, infections, kidney stones,
cancer, sensitive bladder? Have you had a pregnancy, sexually transmitted disease?
Have you been taking any antibiotics, muscle relaxants, medicines for neurologic or stomach problems?
Have you been experiencing any urinary retention, urgency, frequency at night, burning during urination,
nausea, vomiting, or chills? Sara: I take Tylenol and Yaz birth control pills.
[Sara's roommate:] She has been really run down the past few days.
I'm really worried about her. She's been in bed with the covers over her head,
not going to class and complaining her back has been hurting.
Actually she has had a heating pad on it. Stephanie, RN: Yeah, the life of a college student.
Oh she's probably just tired from studying and staying up late.
She just needs some IV antibiotics and IV fluids. She'll be much better tomorrow.
Night Nurse: She still has a temperature of about 102
and her heart rate is up to 120. I've given her Tylenol twice during my shift,
which seems to help for a little while. She also has IV fluids running at 100ml/hr.
Stephanie, RN: Why is she still so febrile? Something else is going on.
Could she be septic? She has a new documented infection.
Her temperature is greater than 100.4, and her heart rate is greater than 90, despite IV hydration.
She may have to go to the ICU if she continues to decompensate.
Sara, it's Stephanie.
Can you wake up for me? Sara: I think I feel a little bit better today.
Stephanie, RN: According to our hospital guidelines, she meets several criteria for activation
of the Rapid Response Team: 1. I'm worried about her BP dropping; 2.
Her heart rate is 116 and her respiratory rate is 28. I'm going to call.
I'm not sure if this is entirely necessary. I hope I'm making the right decision.
Yes, operator, could you please page the Rapid Response Team. I need them to go to room 221.
Right, patient's blood pressure is dropping. Thank you.
Marie, NP: Okay, we're here. Why did you call us?
What seems to be the situation? Stephanie, RN: This is Sara and she goes
to the Edward Winter University and came into the ER with pyelonephritis.
She was admitted yesterday afternoon. She has no remarkable medical history.
She has a temperature is 102.8. I'm worried that she might be septic.
Marie: What would you expect? She has a UTI.
She probably just needs a little more fluid. So did you really need to call us?
You know college kids. She was probably out late each night this week.
Roommate: Hey, what's going on here? Is she okay?
She hasn't been feeling well for awhile and hasn't been out at all.
Marie: Anyway, we'll take it from here. She still is febrile and tachy.
When did she get her last bolus of fluids? Dr. Michele McCormick, MD: I received your page
and heard the Rapid Response called overhead. What's going on with my patient?
[Pager goes off.] Can you handle this for me?
It is just a complicated UTI. I've got another patient consult in the ED.
I'll be right back. Night Nurse: I'm here now, Stephanie, for a report
when you get a chance. Marie: Let's give her a fluid bolus of a liter.
When was her last acetaminophen?
Why are you hanging Lactated Ringers?
She needs normal saline. Please pay attention when I ask for a medication.
And why did you give her acetaminophen? She had it 2 hours ago.
Please change the fluids to normal saline at 1000ml over 20 minutes.
Re-check her blood pressure after the fluids, and draw a lactate and blood cultures.
Night Nurse: I just took her temperature. It's 102, heart rate of 100, respiratory rate
of 24, and a BP 86/40. Stephanie: Wait, Marie?
Can I talk to you for a second? So, are you going to move her to the ICU
and initiate the severe sepsis protocol? I think I should notify Dr. McCormick first.
I want to know what she thinks about this. Marie: She needs to be moved.
You can check with Dr. McCormick, but the Rapid Response Team is responsible for her treatment.
We need to move her to an area where she will be monitored. Stephanie: Yes, she needs to be moved,
but the Rapid Response Team doesn't realize how sick she is. I'm concerned about her BP dropping too quickly.
She's not responding to treatment, and she won't be monitored closely enough in the step down;
I wish they would move her to ICU. I still think I should notify Dr. McCormick,
but I am not going disagree with Marie. There's not enough time for that.
So let's review the plan. I will facilitate her getting a bed in step down. Dr. McCormick, please put in the transfer orders and be sure
to include the sepsis protocol. Dr. McCormick Please call me if her pressure drops below 85.
Stephanie: And will you come back to see her? Marie: Dr. McCormick and I will be back to see her
after she is admitted to step down. If you have any concerns about her,
or if she gets worse before then, please call us.