A (night) in the life... of a Patient At Risk (PAR) nurse

1 May 2012

Night duty on the PAR team sees Sarah Imray wake to the sound of her children back from school and return home to wave them off to school.  In between she is called out across Wellington Hospital to patients recently discharged from ICU to patients with alarmingly high EWS (early warning scores).

NAME: Sarah Imray

JOB TITLE: Registered nurse for PAR (Patient at Risk)* Team

LOCATION: Wellington Regional Hospital

4:00PM: WAKE

Three different types of music blasting from three different rooms, which means my children are home. Dinner organised, chores and homework organised, and now time for me to get organised. Head off to work to arrive at 7pm.

7:00 PM: START WORK

My colleague gives me a verbal handover and a printed sheet with the patient’s details. Tonight, I am given six patients and one referral from the duty nurse manager (DNM). There is a patient in PACU (post anaesthesia care unit) who is due to go to 6 North (ortho and neuro). The patient has a complex medical /surgical history and the duty nurse manager requests we offer support to the ward staff overnight. Of the six patients, four of them are ICU discharges. The PAR service routinely visits all ICU discharges within four to six hours. By providing this service, we reduce the number of patients who bounce back to ICU within 24 hours. Before leaving the office, I check my phone is charged, my bleep is cleared of any messages, and the PAR bag is fully stocked. Then I head off to see these patients first.

9:00 PM ASSESSMENTS

I go to assess the patient in PACU and obtain a full history before she leaves for the ward. The patient is extremely anxious and pain is a major issue. The PACU nurse is currently providing one-on-one nursing. Unfortunately, the ward will not be able to provide this high level of nursing. I speak at length to the anaesthetist, the acting charge nurse manager (ACNM) at 6N, and the DNM. After much discussion, I suggest that maybe this patient be nursed in ICU overnight as a surgical high dependency bed (HDB). After liaising with ICU ANCM and doctor, the patient was later transferred to ICU.

10:30 PM: NIGHT TEAM HANDOVER

Medical handover in MAPU (medical assessment planning unit). This is a great opportunity to meet the night team. From the handover, patients are identified who may deteriorate overnight. It is a busy meeting with several doctors talking at once.

11:00 PM: CUP OF TEA?

Back to the office to write my notes up on the patients that I have seen, admit the patient on the PAR database, check work emails, and have a cup of tea.

11:15 PM: NOT QUITE…

The phone rings – 5 South (medical) have a patient with an EWS (early warning score) of six. Could I please go and assess? My cup of tea will have to wait.

11:30 PM: ASSESSMENT

I arrive to assess patient, and after briefly introducing myself, I proceed to do a full head-to-toe assessment. I love this part of my job. It is great to spend time talking and doing a full comprehensive assessment and trying to find out what is wrong with the patient. During this assessment, I do a manual blood pressure. It is really low ­­­– SBP 55. This warrants a 777 medical emergency team (MET) call. After the 777 call is made, a resuscitation team arrives. I now liaise between nursing and medical staff. I assist the nursing staff in administering medications and fluids, inserting IDC, recording ECGs, or anything else that is required. I assist the medical staff in helping to continually monitor the patient, canulate, and venepuncture. This team now works together to stabilise this patient, which we do. Once stabilised, I leave the ward but will return later to check the patient’s progress.

01:00 AM

I visit the other two patients on my list. Both patients were assessed by my colleague during the day and a good plan of care was established. Both are stable and the nursing staff are happy with the plan of care.

02:00 AM: CUP OF TEA

Cup of tea and writing notes.

2:45 AM: EMERGENCY

Pager goes bleep, bleep, bleep! “MEDICAL EMERGENCY, RIDDIFORD HOUSE” (a residential hostel on the hospital site). Where? Ok, let’s go. When I arrive, there is only an orderly and no equipment or medical staff. The patient is complaining of central chest pain. I can do little at this stage but call for an ambulance and provide reassurance to the patient. Thankfully, the paramedics arrive with lots of equipment and the patient is safely transferred to ED.

04:00 AM

I go and check on the patient in 5S. The patient remains stable. I discuss the plan of care with the primary nurse. There is also a student nurse working and she is keen to know why I put the MET call out. This gives me a great opportunity to do some teaching, another great part of this job.

05:00 AM: LUNCH

Back in the office for lunch and note writing.

06:00 AM

I revisit the four ICU discharges from yesterday and discharge them from our service.

6:30 AM

The phone rings with another referral. I am told the patient is becoming agitated. On further questioning of the nurse, it may be that the patient is in some pain. I suggest that they give the patient analgesia and I will hand it over to my colleague.

07:00 AM: HANDOVER

Handover the patients, phone, pager, and bag. As the handover finishes, bleep bleep bleep! “MEDICAL EMERGENCY 7N”. I handed over just in time.

08:00 AM: ARRIVE HOME

I arrive home. I have seen my children at the bus stop and waved at their happy faces. I feed the dog and go to bed. Good night.

The patient at risk* (PAR) service’s home base is in the Wellington Regional Hospital’s intensive care service. Their primary role is to support and educate ward staff in looking after acutely unwell adult patients in different ward settings.