Helen’s statement continues to haunt me, “Louis was in the one place he could not get the help he needed.” This was very true, had he been at home and gone to the ER I believe things would have been very different. It is beyond frustrating and very disappointing that in a facility that is staffed with numerous people who are trained to evaluate and treat a multitude of conditions and who have so many tools and diagnostics at their disposal that something like this can occur. It begs the question, at what point could we have changed things? It appears as though the nurse may have been out of her element with a postsurgical patient which may have contributed. Perhaps nursing should be able to request a floater from a surgical floor? Also, should there be a protocol for nurses to activate if they feel a patient needs evaluation by a fresh set of eyes? Had a rapid response been called a different team may have evaluated him and done further workup to catch the progression earlier. Potentially criteria other than a nurse feeling a patient is declining (i.e rapid change in symptoms/vitals, persistent pain, no change in management despite evaluation by primary team) would trigger this response. We have nurse driven responses with specially trained response teams for stroke and chest pain, why not creating a reassessment team?
