SWAT RNs serve as expert consultants and mentors to nurses working as bedside leaders in various clinical settings. With clinical practice experience of five or more years in the areas of critical care, emergency nursing, and flight nursing, these nurses enjoy the adrenaline rush that comes with quickly assessing patients at risk for condition deterioration.

SWAT RN Role

The role of the Specialized Workforce for Acute Transport Registered Nurse (SWAT RN) has evolved in national healthcare organizations. Early detection of patients experiencing physical decline is the hallmark of the SWAT RN role. Having identified an early condition decline, bedside nurse leaders working in various clinical settings collaboratively work with SWAT RNs to promptly stabilize and prevent patient injury and death. 

Susan Dresser, Cynthia Teel, and Jill Peltzer, in their 2023 article entitled, Frontline Nurses’ Clinical Judgment in Recognizing, Understanding, and Responding to Patient Deterioration: A Qualitative Study, noted that nurses who work at the bedside are essential in the recognition of patients’ decline and initiating contact with the SWAT RN. Hence, the SWAT RN is a nursing role that is instrumental in the promotion of the nursing process and the National Council of State Boards of Nursing’s 2019 Clinical Judgment Measurement Model within the acute care setting, as they work collaboratively with bedside nurse leaders to facilitate positive patient outcomes.

A Hypothetical Case Study

The following hypothetical case study provides an opportunity to explore the SWAT RN role and examine how this role collaborates with bedside leaders to improve patient outcomes.

Case Presentation

Bernard Salzo is a 38-year-old male employed as a carpenter and painter. Unable to sleep and experiencing restlessness accompanied by shortness of breath for the last two days, Mr. Salzo presents to the emergency department (ED) at 3:00 a.m. with difficulty breathing. The triage nurse obtains his vital signs: blood pressure 134/82 mm Hg, respirations 30 breaths per minute, heart rate 102 bpm, temperature 99.8 F, and oxygen saturation on room air, 94%. The patient appears anxious and restless, requiring redirection as the triage nurse processes him. The patient states, “I have not been sleeping that well. I kind of feel discombobulated.”

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History and Assessment 

Mr. Salzo’s medical history is significant for childhood asthma and hypertension. His hypertension is managed with an ACE Inhibitor, Lisinopril 15 mg PO daily, and diuretic Furosemide 10 mg PO daily. Prescribed Montelukast sodium 10 mg PO once daily and a Proventil HFA inhaler twice daily and as needed for asthmatic symptoms. Mr. Salzo’s asthma has been stable for the past ten years. Mr. Salzo is a nonsmoker and abstains from alcohol.

Mr. Salzo is triaged, assessed by an ED nurse, examined by an ED provider, and admitted to a Medical-Surgical Unit. The nurse in the Medical-Surgical Unit suspects worsening respiratory distress, noticing that Mr. Salzo has become increasingly anxious and is moving about restlessly in bed during the admission assessment. Oxygen therapy via nasal cannula 2 L O2 is placed on the patient, and the nurse contacts the SWAT RN, who arrives in less than 5 minutes.

The SWAT RN provides a rapid assessment of the patient and reports their findings to the patient’s healthcare provider and bedside nurse leader.

  • Alert and anxious, use of accessory muscles of respiration, respiratory distress
  • RR- 32 breaths per minute and labored, BP- 143/88 mm Hg, T- 100.3 F (temporal), oxygen saturation- 90% on room air (sitting)
  • Peak flow- 185

HEENT, Skin, Neck

  • No bruits, nor thyromegaly or adenopathy
  • Bilateral tearing of the eyes noted with conjunctivae that are edematous and inflamed
  • Pharynx with clear postnasal drainage; nasal mucosa edematous with clear discharge
  • Fundi without lesions
  • Skin is supple, diaphoretic, pink, and flushed

Lungs

  • No egophony or fine crackles (rales); scattered coarse crackles present
  • Expiratory phase is prolonged with wheezes auscultated bilaterally
  • Diaphragm percusses low in the posterior chest with 2 cm; chest expansion is limited
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Cardiac

  • No clicks or gallops
  • Tachycardia, regular
  • Notable slight systolic ejection murmur (SEM) at the left lower sternal border (LLSB) without radiation

Abdomen, Extremities, Neurologic

  • Capillary refill at 3 seconds, no clubbing, no edema; extremities clammy
  • Bowel sounds present, no hyperactivity; abdomen non distended
  • Liver percusses 2.5 cm below the right costal margin, but overall size 8 cm, no tenderness or masses
  • Cranial nerves intact; DTR 2 + and symmetric; sensory intact; strength 5/5 throughout

Preliminary Laboratory Results

  • pH- 7.48; PaO2- 70; PaCO2- 33 mm Hg
  • HCT- 33.0% and HgB- 7.2 g/dL
  • WBC- 7,680
  • PLTS- 246,000

Bedside Nurse Leader and SWAT RN Collaboration

The SWAT RN maintains closed-loop communication with the bedside nurse leader assigned as the primary care nurse for Mr. Salzo. The bedside nurse leader and SWAT RN discuss the patient’s time of initial decline, treatment approaches that were effective, and next steps. The SWAT nurse respectfully acknowledges the bedside nurse’s prior knowledge about the patient’s health history and recent health status change while modeling clinical judgment in managing the clinical case scenario.

General Outcome

Mr. Salzo complains of chest tightness. Intravenous access via Mr. Salzo’s right arm in the cephalic vein was secured. The bedside nurse leader inquires about potential allergen exposure and the use of methylprednisolone (Solu-Medrol) intravenously. The SWAT RN and team decided to assess the patient’s response to a bronchodilator. The SWAT RN administers Albuterol nebulizer treatments. An electrocardiogram (ECG) reveals sinus tachycardia (Figure 2.). The elevated white blood cell count (WBC) is suggestive of infection. A chest x-ray shows a large area of opacity in the right lung. A sputum sample is obtained and sent for culture and sensitivity. Blood cultures were obtained as well.

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Admitted to the Medical-Surgical Unit with the primary diagnosis of asthma exacerbation and pneumonia, Mr. Salzo starts the intravenous (IV) antibiotic ceftriaxone (Rocephin) 1 gm twice daily. On day 2 of antibiotic therapy, a repeat chest x-ray reveals the presence of a mass in the right lung. Further diagnostic tests reveal that the mass is a malignant neoplasm. Mr. Salzo was diagnosed with lung cancer adenocarcinoma.

Education

The unknown or atypical presentations are the driving factors in bedside nurse leaders utilizing clinical judgment in the decision-making process to ramp patient assessment to the level of consultation before rapid patient deterioration occurs. Mr. Salzo’s diagnostic presentation appeared typical for asthma. However, his elevated WBCs suggested infection was present. The resolving pneumonia treated with IV antibiotic therapy revealed a malignant tumor mass, adenocarcinoma.

Adenocarcinomas typically proliferate within the cells that line the alveoli. According to the Centers for Disease Control and Prevention (CDC), in 2022, 50% to 60% of lung cancers were diagnosed in patients with no smoking history. The CDC noted in 2022 that 10% to 20% of nonsmoker cancers are squamous cell carcinomas and 6% to 8% small cell lung cancers. The CDC also noted that risk factors associated with lung cancer include family history, pipe smoking, cigarette and cigar smoking, beta-carotene supplements in heavy smokers, human immunodeficiency virus (HIV), and environmental risk factors. Mr. Salzo’s dual occupation as a carpenter and painter, both environmental risk factors, likely placed him at risk for the development of lung cancer. Wood dust can be inhaled and enter the airway and lung tissues, causing scarring and irritation. The paint contains benzene solvents that, inhaled, can lead to oral and lung cancers.

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The National Council of State Boards of Nursing Clinical Judgment Measurement Model provides the nursing profession with a roadmap for enhancing critical thinking, clinical decision-making, and clinical judgment within the clinical setting. SWAT RNs, because of their advanced clinical practice experience and knowledge, effectively role model closed-loop communication and evidenced-based practice clinical interventions and provide clinical expertise “in live-time” to bedside nurse leaders during emergent patient cases.

Conclusion

Mr. Salzo, transferred to an oncology unit, begins cancer treatment. The bedside nurse leader provides him with education about his new diagnosis. His clinical presentation to the ED for an asthmatic exacerbation and the combined efforts of all healthcare team members have contributed to Mr. Salzo’s diagnosis and current implementation of treatment for lung cancer. The early involvement of SWAT RNs is instrumental in supporting bedside nurse leaders (and nurses in other settings) with the provision of rapid assessments and necessary diagnostics in ensuring the consistent delivery of evidence-based practice care for patients entering healthcare systems. In the 2020 article, Using Benner’s Model of Clinical Competency to Promote Leadership, Barry Quinn discusses the novice to expert level nurse in clinical practice. Because the SWAT RN is an expert level nurse, their role is essential in developing leadership and competency of bedside nurse leaders in recognizing patients with rapidly declining physiological problems. Hence, SWAT RNs’ roles are beneficial in promoting clinical judgment in bedside leaders at all practice levels (e.g., novice to expert).

Bridgeport SWAT Nurse Team
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