Is this all my fault??

[excessively_diverted]

So I floated to a different floor the other day at work and had a 15 year old who had chron's but was admitted for a ruptured appy and was a few days post-op. He had a normal assessment in the morning and all of his vitals all day were in the normal range except for his HR which was elevated (150). I had noticed his previous HRs were a little high 120s but it was charted that the charge nurse and physician were notified. I didn't notify charge when the the HR was 150 because he was in the same PEWS category and all his other VS were normal. He was discharged from the hospital later in the day on my shift with everything being the same as it had been all morning. He seemed fine except for his elevated HR and the doctor had rounded on him before they wrote d/c orders.

Well I got an email from the patient safety person today saying the kid had been re-admitted within 24hrs for sepsis and pneumonia and she asked why I didn't report his VS to the physician and wasn't I concerned with his HR. I wrote back that all of his other vs were normal, he was afebrile, he said he felt good and was ready to go home and he and his parents didn't have any concerns. So I didn't really think it was super critical. But now I'm wondering if I really messed up and should have said something even though everything else looked fine. I feel horrible and feel like this is all my fault. Was this something I really should have been super concerned with? Would you have said something? And do you think this is something I could get in trouble for? I'm just so sick to my stomach right now.

[NurseStorm, BSN, RN]

150 is excessively high for a 15 year old, and quite a huge jump from 120. I definitely would've ran that by the doctor to make sure they were aware before discharge. I don't know what PEWS category is (I'm Canadian), so I don't know how that factors into the decision. [if they had just been running, crying hysterically, etc may be more expected but I would wait 30-45 min and recheck. A calm 15 year old should not have a heart rate of 150]

By you floating to another floor, does that mean you typically don't deal with peds? If that is the case I think it is more a systems issue by floating people to areas they aren't familiar with and therefore potentially putting patients at risk due to unfamiliarity with regular VS for the different ages of pediatric patients.

So while yes I would've definitely reported that, if you truly don't work with pediatric patients I think that is the main problem here- that they floated you there without proper orientation or training. I don't know if you would get in trouble over that, or if it's just seen as an issue re: needing more education.

But I wish you the best

[NotReady4PrimeTime, RN]

Yes, a HR of 150 in a 15 year old should set off alarm bells all over the place, both literally and figuratively. Given the patient's history of Crohn's - likely on some form of immunosupressant therapy and therefore less likely to mount a febrile response - and a ruptured appy, I'd be very suspicious of sepsis and make sure I brought it to someone's attention - even if it's been documented as being communicated and even if the overall PEWS score hadn't changed. (I'm Canadian too, and our hospital has been using B-PEWS for probably 5 years.) I might preface my reporting of it with, "I'm perhaps way off in left field, but I'm concerned that this boy's HR was already high at 120 yesterday, and today it's persisting in the 150 range, with no other obvious changes. Is there something I'm missing?" Sometimes they're a little dry and some fluid brings it down. But in retrospect this boy was looking a bit shocky and there should have been more of an assessment done by all involved, not just you, the float nurse. Many people don't realize that what signals impending shock in adults isn't present in children until the very last minute. They maintain their cardiac output by driving up their HR - BP doesn't fall until very late in the process. Most 15 year-olds behave more like adults, but there are always those outliers.

As far as his discharge, deterioration and subsequent readmission being all your fault, it's not. There are other people in the chain of survival besides the nurse. Physicians are responsible for their own assessments; that isn't something they can legally delegate and if this boy was not assessed by a physician prior to discharge, that needs to be addressed. No peds physician worth the title would ignore that HR. The fact that you were floated out of your own area of expertise is also a system factor that can't be ignored. Yes, this situation gives the hospital a black eye, but it's a shared black eye so don't be so anxious to claim it! Learn from this and move on.

[JadedCPN, BSN, RN]

Like the comments above me said, 150 for a teenager is extremely high. I understand your thought that his trend had been in the 120s, but even that is high so I would have notified of the increase to 150. And if the charge nurse and physician would have been okay with it, I would have wanted them to explain their reasoning for why they think his HR was 150 if everything else was okay.

I have been using the PEWS system for almost my entire 10 year career and while I think it is a great guideline to use, it definitely isn't a black and white thing. I could have a PEWS of 1 but if I think something is wrong or off then I will absolutely escalate my concern as needed.

Another thing to consider is you stated you noticed his HR had been 120s but saw that it was charted that the MD and Charge nurse were notified - I would never base my decisions off of what was charted by previous nurses. I say that because you should always CYA, your license, and your patient - I can't tell you how many times I've looked at the previous nurse's charting and they've essentially copy & pasted assessments, have charted things that weren't there, or have missed huge things. So just because the charting says the MD and charge nurse were notified does not mean that they were notified.

[GE90]

Em, I would have asked the previous RN whether the docs have made a plan or have they put in any modification regarding his vs.