Case Study – Recognising and Responding to the Deteriorating Patient

Introduction

Serious adverse events on Australian general wards are often preceded by hours of abnormal vital signs recorded but not acted upon. National Safety and Quality Health Service (NSQHS) Standard 8, Recognising and Responding to Acute Deterioration, mandates defined physiological triggers, an escalation protocol available to every clinician, and a rapid response capability at all hours (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2021). Sepsis is the syndrome in which the gap proves most costly, with an estimated 55,000 Australians treated and 8,700 deaths annually (Australian Sepsis Network, 2022).

This case study analyses the deterioration of a hypothetical 72-year-old post-operative patient on a metropolitan surgical ward in Victoria. It presents serial observations across four time points, works through the aggregate escalation score at each, and applies the Clinical Reasoning Cycle (Levett-Jones, 2018). An ISBAR handover, an escalation pathway diagram, an intervention plan, an analysis of sepsis timing and a reflection on failure to rescue follow. All details are fictional and no prescribing guidance is offered.

Case Presentation and History

Mr Alan Bishop (pseudonym) is a 72-year-old man admitted with generalised abdominal pain, guarding and imaging consistent with perforated sigmoid diverticulitis. He weighs 78 kg and underwent an emergency laparotomy and Hartmann’s procedure on the evening of admission, transferring to a general surgical ward the next morning. His history includes type 2 diabetes mellitus of 14 years, essential hypertension, and a 30 pack-year smoking history ceased eight years ago. On day 2 he has an indwelling catheter, a midline wound with a colostomy, patient-controlled analgesia and maintenance intravenous fluids.

Three features elevate his risk. Advanced age and diabetes blunt the febrile and inflammatory response, so infection may declare itself late. Emergency surgery for a perforated viscus carries a documented risk of intra-abdominal collection and anastomotic sepsis in the first post-operative week. The ward also runs at one nurse to four patients, constraining observation frequency and the continuity of the clinician interpreting them. Considine and Currey (2015) argue that assessment quality reflects workload and role clarity as much as individual knowledge.

Serial Observations and Escalation Scoring

The ward uses an aggregate weighted track-and-trigger chart endorsed under NSQHS Standard 8: each vital sign attracts 0 to 3 points, supplemental oxygen adds 2, any ACVPU value other than Alert scores 3, and the sum determines the required response (ACSQHC, 2021). Table 1 sets out the observations and scores.

Worked calculations

• T2 (1000): 2 (RR) + 1 (SpO2) + 0 (oxygen) + 1 (HR) + 0 (SBP) + 1 (temperature) + 0 (ACVPU) = 5. A score of 4-5 crosses the yellow-zone threshold, requiring clinical review within 30 minutes.
• T3 (1400): 3 + 2 + 2 + 2 + 1 + 1 + 0 = 11. A score of 8 or above, or any parameter scoring 3, triggers an immediate rapid response call; both conditions are met, since respiratory rate alone scores 3.
• T4 (1600): 3 + 2 + 2 + 2 + 2 + 1 + 3 = 15, with two parameters scoring 3.
• Mean arterial pressure = (systolic + 2 x diastolic) / 3. At T4: (86 + 96) / 3 = 182 / 3 = 60.7 mmHg, below the 65 mmHg marker of inadequate organ perfusion (Evans et al., 2021).
• Shock index = heart rate / systolic pressure, rising from 88 / 128 = 0.69 at T1 to 126 / 86 = 1.47 at T4, well above the 0.9 value associated with occult hypoperfusion.
• Urine output = 65 mL / (78 kg x 4 hours) = 0.21 mL/kg/hour, less than half the 0.5 mL/kg/hour oliguria threshold.

Against the quick Sequential Organ Failure Assessment criteria of respiratory rate 22 or more, altered mentation and systolic pressure of 100 mmHg or less (Singer et al., 2016), the patient scores 1 at T2, 2 at T3 and 3 at T4, confirming deterioration that crossed a threshold six hours before the rapid response call.

Applying the Clinical Reasoning Cycle

The Clinical Reasoning Cycle offers an eight-phase structure for converting observation into defensible action (Levett-Jones, 2018) and maps onto the assessment, planning and evaluation domains of the Registered Nurse Standards for Practice (Nursing and Midwifery Board of Australia [NMBA], 2016).

Considering the situation and collecting cues

Cues extend well beyond Table 1. Handover recorded that Mr Bishop had not passed flatus, that stoma output was minimal and that he had been unusually quiet. Focused assessment would add capillary refill, peripheral temperature, wound and stoma inspection, abdominal palpation, blood glucose and the fluid balance trend. Massey et al. (2017) found that nurses often detect deterioration through intuitive cues preceding measurable vital sign change.

Processing information and identifying the problem

Processing requires clustering rather than listing. Tachypnoea, widening pulse pressure, tachycardia, fever and oliguria form a distributive shock pattern, not five unrelated abnormalities. Competing explanations must be discriminated: pulmonary embolism would account for the tachypnoea and desaturation but not the fever and falling pressure, while third-space hypovolaemia would account for the tachycardia and oliguria but not the rising oxygen requirement. Sepsis from an intra-abdominal source explains the whole cluster and fits the surgical history, meeting the Sepsis-3 definition of organ dysfunction caused by a dysregulated host response to infection (Singer et al., 2016).

Establishing goals, taking action and evaluating outcomes

Goals must be measurable and time-bound: escalate immediately, restore mean arterial pressure above 65 mmHg, achieve urine output above 0.5 mL/kg/hour, maintain SpO2 at 94 per cent or above, and secure a documented senior plan within 30 minutes. Actions and evaluation appear in Table 2. The cycle insists that evaluation feeds back into cue collection; the 1600 observations exist only because the 1400 plan specified fifteen-minute reassessment.

The Recognise and Respond Pathway

Figure 1 illustrates the escalation pathway applied to this case, including the reassessment loop that converts escalation into continuing surveillance.

Clinical Handover Using ISBAR

Structured handover reduces the ambiguity that allows concern to be discounted. The ISBAR below represents the rapid response call placed at 1600.

• Identify: “This is Priya Raman, registered nurse on ward 5 South, calling about Mr Alan Bishop, 72, bed 12.”
• Situation: “I am making a rapid response call. His aggregate score is 15, he is newly confused, and his blood pressure is 86 over 48.”
• Background: “He is day 2 following emergency laparotomy and Hartmann’s procedure for perforated diverticulitis. He has type 2 diabetes and hypertension, and has been febrile since 1000.”
• Assessment: “Respiratory rate 30, saturations 90 per cent on 6 litres, heart rate 126, mean arterial pressure 61, urine output 0.21 mL per kilogram per hour. His abdomen is distended and tender, peripheries cool with capillary refill of four seconds. I believe he is septic from an intra-abdominal source.”
• Recommendation: “I need urgent bedside review now, the sepsis pathway commenced with blood cultures and venous lactate, and a decision about critical care escalation.”

The handover shows three features associated with effective escalation: it names the concern rather than reporting numbers alone, states a specific recommendation, and asserts a timeframe. Massey et al. (2017) identify the missing recommendation as a common reason escalation fails to produce timely attendance.

Nursing Interventions, Rationales and Evaluation

Sepsis Pathway and the Significance of Timing

The Sepsis Clinical Care Standard places time at the centre of quality, requiring that suspected sepsis prompts assessment, investigation and treatment without delay (ACSQHC, 2022). Seymour et al. (2017), analysing more than 49,000 patients under a mandated protocol, found each additional hour to bundle completion associated with higher risk-adjusted mortality. Table 3 compares recommended and documented timing.

Table 3 makes the analytic point plain. Once sepsis was recognised, every subsequent step complied with the standard; the decisive failure occurred earlier, in the six hours between the yellow-zone trigger at 1000 and recognition at 1600. Compliance measured from recognition therefore flatters performance, because the clock starts only once the diagnosis has been entertained. Any audit that ignores time from first physiological trigger will under-detect this failure mode.

On volume, guideline literature describes an initial crystalloid target of 30 mL/kg for sepsis-induced hypoperfusion, which for this patient equates to 78 x 30 = 2,340 mL (Evans et al., 2021). The figure warrants critical rather than mechanical application, since fixed weight-based volumes carry risk in older patients with cardiac or renal comorbidity. The Australian and New Zealand PLUS trial found no mortality difference between balanced multielectrolyte solution and saline, suggesting that timing and titration matter more than the fluid chosen (Finfer et al., 2022). Antimicrobial urgency rests on limiting microbial proliferation, yet indiscriminate broad-spectrum use conflicts with stewardship obligations under NSQHS Standard 3. The nursing contribution is not to select agents or volumes, which are prescribing decisions, but to ensure samples precede therapy and that the physiological response is measured and reported.

Reflection: Human Factors and Failure to Rescue

Failure to rescue describes death following a recoverable complication, and is now understood as a property of systems rather than individual competence (Ghaferi & Dimick, 2016). Reflecting on this case, I am struck that no single act of negligence explains the six-hour delay. The observations were taken, charted and scored correctly. What did not occur was the interpretive step that converts a score into a call.

Several human factors plausibly contribute. Normalisation of deviance is the most powerful: mild tachycardia and low-grade fever are so ordinary on day 2 after laparotomy that they are attributed to inflammatory response or pain, and each unremarkable reading dulls sensitivity to the trend. Task saturation is the second, since comparing four patients’ trends competes with dressings, analgesia and discharge planning. Third, hierarchy and anticipated dismissal deter escalation, particularly where an earlier call met irritation. Read through the SEIPS framework, which situates performance within a work system of tasks, tools, environment and organisation (Carayon et al., 2020), the delay reflects chart design, staffing and escalation culture rather than knowledge deficit.

Two implications follow for my practice. The first is to treat the score as an instruction rather than information: NSQHS Standard 8 exists so that escalation does not depend on individual confidence, and a nurse who calls on a documented trigger acts within scope. The second is to escalate on trend and on concern before the threshold is reached, since the standard preserves the right of any clinician, and of a family member, to activate the response system. Had a sepsis screen been applied at the 1000 trigger, the therapeutic window would have opened six hours earlier.

Conclusion

This case study has traced a recoverable post-operative deterioration to septic shock, showing through worked calculation how the aggregate score moved from 0 to 5, then to 11 and 15, crossing the clinical review threshold at 1000 and the rapid response threshold at 1400. The Clinical Reasoning Cycle showed that the decisive skill lay in clustering cues into a discriminating problem statement rather than in gathering more data, and ISBAR converted that judgement into a time-bound request. Timing analysis revealed compliant care after recognition but a six-hour delay that no post-recognition audit would detect. Recognising and responding to deterioration is a system capability governed by NSQHS Standard 8, and its weakest link remains the step between a charted abnormality and a voiced concern.

References

Australian Commission on Safety and Quality in Health Care. (2021). National safety and quality health service standards (2nd ed.). ACSQHC.

Australian Commission on Safety and Quality in Health Care. (2022). Sepsis clinical care standard. ACSQHC.

Australian Sepsis Network. (2022). Australian sepsis report. The George Institute for Global Health.

Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M. (2020). SEIPS 3.0: Human-centred design of the patient journey for patient safety. Applied Ergonomics, 84, 103033.

Considine, J., & Currey, J. (2015). Ensuring a proactive, evidence-based, patient safety approach to patient assessment. Journal of Clinical Nursing, 24(1-2), 300-307.

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., & French, C. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), 1974-1982.

Finfer, S., Micallef, S., Hammond, N., Bellomo, R., Delaney, A., & Myburgh, J. (2022). Balanced multielectrolyte solution versus saline in critically ill adults. New England Journal of Medicine, 386(9), 815-826.

Ghaferi, A. A., & Dimick, J. B. (2016). Importance of teamwork, communication and culture on failure-to-rescue in the elderly. British Journal of Surgery, 103(2), e47-e51.

Levett-Jones, T. (Ed.). (2018). Clinical reasoning: Learning to think like a nurse (2nd ed.). Pearson Australia.

Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open, 4(1), 6-23.

Nursing and Midwifery Board of Australia. (2016). Registered nurse standards for practice. NMBA.

Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., & Phillips, G. S. (2017). Time to treatment and mortality during mandated emergency care for sepsis. New England Journal of Medicine, 376(23), 2235-2244.

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., & Bauer, M. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801-810.