You are bleeped at 03:00 about a ward patient whose NEWS2 has risen from 3 to 9 over four hours. How do you approach this?

Question

A 67-year-old, day 5 after admission with cellulitis, now has RR 28, SpO2 90% on 2 litres, HR 122, BP 96/58, temperature 38.4, new confusion. The foundation doctor who called you has already seen her and is worried.

Accepted Answer

While I am on the phone I would give holding instructions so that treatment starts before I arrive: oxygen titrated to a target of 94 to 98 unless she is at risk of hypercapnic failure, a full set of repeat observations, large-bore IV access, bloods including a venous gas with lactate, cultures, an ECG, and I would ask them to stay with her. Then I would go, because a NEWS2 rising from 3 to 9 over four hours is a trajectory and needs to be seen. I would also say to the foundation doctor that I am glad they called, and I would treat their worry as data — clinical concern from the person who has been watching the patient is an independent predictor of deterioration and I would say so. On arrival I would do an A-E assessment with simultaneous treatment, and I would look at the observation chart, the fluid balance and the drug chart myself rather than relying on a summary. The important discipline here is not to anchor on the cellulitis. Day-5 deterioration in a hospitalised patient has a broad differential: worsening or uncontrolled infection including a collection or necrotising infection, a hospital-acquired pneumonia, a second source such as a line or urinary sepsis, pulmonary embolism given five days of immobility, myocardial infarction, pulmonary oedema from over-resuscitation, AKI, and a drug reaction. I would examine the affected limb specifically for signs of a deep or necrotising infection. I would start the Sepsis Six if sepsis is likely and take a targeted approach to imaging. Crucially, I would check her ceiling of care and resuscitation status now rather than at the point of arrest, and if nothing is documented I would make a decision with the consultant. I would then escalate to the consultant on call and critical care outreach using SBAR with a specific ask, document clearly, and update the family.

The Deteriorating Ward Patient at Night

Framework checklists