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ST PETER'S HOSPITAL
POST-OPERATIVE CARE
Tag No.: A0957
Based on record review and interview, patient care staff failed to activate the Rapid Response Team (RRT) immediately when the patients's post operative blood pressure decreased to 80 millimeters systolic. The finding was noted in 1 of 5 cardiac services patients (patient #1) reviewed during the survey. Findings:
-Review of the patient's medical record on 12/8/2021 shows that the patient's pre procedure vital signs were 98.1-132-121/82, O2 sat 100% at 0727. At approximately 1140, the patient arrived at 4 McCauley post procedure where his first set of vital signs were documented and blood pressure was recorded as 108/70.
-At 1147 the patient's blood pressure was recorded to be 75/35. Blood pressure measurements continue as follows:
1200 81/61
1220 93/56
1230 77/36
1240 80/48
1250 49/36
-By 1230, a consistent trend of low blood pressure readings had developed. Rapid Response Team was not called until 1250.
-The Clinical policy entitled "Rapid Response, Including ED Go To" was reviewed by Department of Health survey staff on 1/7/2022. This policy delineates activation criteria for "Rapid Response" including acute change in systolic blood pressure to less than 80 millimeters systolic.
-The patient was diagnosed with a puncture of the right femoral artery and right femoral vein necessitating surgical repair.