CCOT Assessing Patient for Discharge

I: You are the CCOT nurse(s)/outreach registrar today and have come to ITU to review a patient that you have been told is ready for step-down to a medical bed. ITU is under pressure to step down patients, because there are patients in the Emergency department awaiting ITU beds.

S: There is no bedside nurse available immediately, because the unit is so busy. The consultant and the SHO are in a family discussion. The SpR is somewhere in the unit.

B: 60M patient, recently admitted with septic shock secondary to UTI, has recovered. Lines removed today for step down. Last day gentamycin today. PMHx HTN, T2DM, STEMI 2014 with 2 stents.

A: Looks unwell from the end of the bed

R: He is for stepdown, needs an assessment

• Initially A own, B SpO₂ 92% on room air, tachypnoeic, RR 27, C HR102bpm SR, BP 91/43, D Awake, alert, feels a bit unwell
• Looks generally unwell
• Examination reveals that he is probably not ready for step down
• When escalated to the SpR- recommends to just “give some fluids” and step down
• As the situation escalates, the SpR will keep pushing to step down because of the bed pressures

• Initial settings: same setting stay throughout A own, B SpO₂ 92% on room air, tachypnoeic, RR 27, C HR102bpm SR, BP 91/43, D Awake, alert, feels a bit unwell                     

Registrar:

1. You are aware of the bed pressures in the hospital
2. You have patients waiting in the emergency department to be accepted to the unit
3. You keep insisting that the patient needs to go and if they are a bit hypotensive, they just need a bolus of fluid before they go