Action 8.06

Delays in treatment can occur in the absence of clear criteria for escalating care.^1-3 Escalation protocols provide clear, objective criteria that prompt clinicians to call for help, and endorse calling for help when clinicians, patients, family members or carers are subjectively concerned about a patient acutely deteriorating.

Identify parameters for escalation

Use a graded response system within the escalation protocol. This means that the escalation protocol includes at least two levels of response to acute deterioration:

• An emergency response (for example, from a rapid response team) to criteria that indicate severe acute deterioration
• At least one other level of response (for example, from the treating or on-call team) for criteria that indicate less severe deterioration.

The two levels are recommended because early treatment of acute deterioration is better – patients who trigger medical emergency calls have high mortality rates^4,5, and delayed calls to medical emergency teams are associated with poorer outcomes.^6,7

Work with clinical groups to agree on the criteria that indicate acute deterioration in physiological and mental state. Identify the thresholds to trigger escalation of care before acute deterioration becomes severe, and thresholds to trigger a call for emergency assistance when acute deterioration is severe. Use the escalation mapping tool to match the thresholds and parameters that indicate acute physical deterioration to the appropriate response.

Mapping tools can also be used for developing a local escalation protocol for deterioration in a person’s mental state. Use the signs described in tools such as the mental health triage tool to set thresholds for escalation in response to observed or reported changes in a person’s mental state. Consider local clinical capacity and access to mental health expertise to decide whether the response can be implemented by the treating team, or referral should be made to a clinical psychiatry liaison or other available service. Engage the patient, and their carer and family in shared decision making about escalation of care. Patient pain and distress that are unable to be managed using available treatments may indicate acute deterioration that needs urgent treatment. Include pain and distress as a criterion for escalation in the protocol.

Patients may show signs of clinical deterioration other than those identified in the escalation protocol, and there is evidence that clinician worry or concern may precede deterioration in vital signs.⁸ Include clinician worry or concern as a criterion for escalation in the protocol.

Develop policies and guidance

Develop policies and provide training to guide clinicians in preventing and responding to severe aggressive behaviour and violence. When developing policies and responses to severe behavioural disturbance, provide specific guidance on appropriate responses for older patients, highlighting that:

• Behavioural disturbances are commonly associated with delirium or dementia
• Behavioural disturbances may be related to fear, communication difficulties or an unfamiliar setting (in which case, de-escalation strategies and involvement of family members can be successful)
• Sedation should be avoided, and any use should be in line with age-specific evidence; over-sedation can have serious adverse effects, such as dehydration, falls, respiratory depression, pneumonia and death⁹
• Clinicians should refer to specialist older people’s mental health services, if possible.

Refer to the ‘Minimising patient harm’ criterion in the Comprehensive Care Standard for further detail on preventing delirium and managing cognitive impairment; predicting, preventing and managing self-harm, suicide, aggression and violence; and minimising restrictive practices.

Localise escalation policies that consider the size, role, location and available resources of different services within the organisation. For example, escalation protocols in the emergency department may differ significantly from escalation protocols in the dialysis unit or the mental health unit. Different escalation protocols may be needed for different groups of patients – for example, children may need different escalation protocols from adults.

Escalation protocols can be complex, involving multiple steps and different communication pathways. Develop a flow diagram to summarise escalation processes and provide clinicians with a quick reference tool. Display posters of the escalation flow diagram near telephones in clinical areas, or provide clinicians with identification tag cards for quick reference.

Delays in treatment can occur in the absence of clear criteria for escalating care.^1,3 Escalation protocols provide clear, objective criteria that prompt clinicians to call for help, and endorse calling for help when clinicians, patients, family members or carers are subjectively concerned about a patient acutely deteriorating.

Identify parameters for escalation

Although there is low prevalence of episodes of acute deterioration in a person’s mental state in day procedure services, the health service organisation needs to ensure that, if a person does experience acute deterioration in their mental state, members of the workforce have the skills to initiate an immediate response to ensure safety, and communicate their concerns to relevant parties.

Use a graded response system within the escalation protocol. This means that the escalation protocol includes at least two levels of response to acute deterioration:

• An emergency response (for example, urgent review by a consultant anaesthetist, a call to the ambulance service) to criteria that indicate severe acute deterioration
• At least one other level of response (for example, from a senior nurse) for criteria that indicate less severe deterioration.

The two levels are recommended because early treatment of acute deterioration is better – patients who trigger medical emergency calls have high mortality rates^4,5, and delayed calls to medical emergency teams are associated with poorer outcomes.^6,7

Work with clinicians to agree on the criteria that indicate acute deterioration in physiological and mental state. Identify the thresholds to trigger escalation of care before acute deterioration becomes severe, and thresholds to trigger a call for emergency assistance when acute deterioration is severe. Consider the extra time necessary to transfer patients whose condition acutely deteriorates to a tertiary referral hospital when planning an escalation protocol. Use the escalation mapping tool available from the Commission’s website to match the thresholds and parameters that indicate acute physical deterioration to the appropriate response. The mapping tool can also be used for deterioration in mental state to determine what should trigger a response, and required actions to keep patients and the workforce safe.

Patient pain and distress that are unable to be managed using available treatments may indicate acute deterioration that needs urgent treatment. Include pain and distress as a criterion for escalation in the protocol.

Patients may show signs of clinical deterioration other than those identified in the escalation protocol, and there is evidence that clinician worry or concern may precede deterioration in vital signs.⁸ Include clinician worry or concern as a criterion for escalation in the protocol.

Escalation protocols can be complex, involving multiple steps and different communication pathways. Develop a flow diagram to summarise escalation processes and provide clinicians with a quick reference tool. Display posters of the escalation flow diagram near telephones in clinical areas, or provide clinicians with identification tag cards for quick reference.

Refer to the ‘Minimising patient harm’ criterion in the Comprehensive Care Standard for further details on preventing delirium and managing cognitive impairment; predicting, preventing and managing self-harm, suicide, aggression and violence; and minimising restrictive practices.

Examples of evidence

Select only examples currently in use:

• Policy documents that identify agreed criteria that indicate acute deterioration in physical, mental or cognitive condition that trigger escalation of care, and the expected responses
• Policy documents that include consideration of the organisation’s size, role, location and services provided; localised escalation strategies; and tailored escalation for specialist patient groups
• Documented protocols that are available to the workforce for escalating care when acute deterioration in a patient’s condition is detected
• Documented localised escalation protocols
• Escalation flow diagrams
• Audit results of compliance with the escalation protocols
• Committee and meeting records in which clinicians agreed on the parameters that indicate acute deterioration for escalation
• Resources or tools that help clinicians to use the escalation protocols.

MPSs and small hospitals will need to:

• Work with clinical groups to agree on parameters that indicate acute deterioration and require escalation of care – delays in treatment can occur in the absence of clear criteria for escalating care ^1-3
• Develop and implement protocols for escalating care when acute deterioration in a patient’s condition is detected – escalation protocols provide clear, objective criteria that prompt clinicians to call for help, and endorse calling for help when clinicians, patients, carers or family members are subjectively concerned about a patient acutely deteriorating.

Identify parameters for escalation

Use a graded response system within the escalation protocol. This means that the escalation protocol includes at least two levels of response to acute deterioration:

• An emergency response (for example, from a rapid response team) to criteria that indicate severe acute deterioration
• At least one other level of response (for example, from the treating or on-call team) for criteria that indicate less severe deterioration.

The two levels are recommended because early treatment of acute deterioration is better – patients who trigger medical emergency calls have high mortality rates,^4,5 and delayed calls to medical emergency teams are associated with poorer outcomes.^6,7

If appropriate, base the escalation protocol on one that was developed by the Local Hospital Network, state or territory health department or nearby larger hospital. However, it will need to be adapted to reflect the organisation’s available services and resources.

Work with clinical groups to agree on the criteria that indicate acute deterioration in physiological and mental state. Identify the thresholds to trigger escalation of care before acute deterioration becomes severe, and thresholds to trigger a call for emergency assistance when acute deterioration is severe. Consider the extra time necessary to transfer patients whose condition acutely deteriorates to a tertiary referral hospital when planning an escalation protocol. Use the escalation mapping tool available to match the thresholds and parameters that indicate acute physical deterioration to the appropriate response.

Mapping tools can also be used for developing a local escalation protocol for deterioration in a person’s mental state. Use the signs described in tools such as the mental health triage tool to set thresholds for escalation in response to observed or reported changes in a person’s mental state.  Consider local clinical capacity and access to mental health expertise to decide whether the response can be implemented by the treating team, or referral should be made to a clinical psychiatry liaison or other available service. Engage the patient, and their carer and family in shared decision making about escalation of care. Patient pain and distress that are unable to be managed using available treatments may indicate acute deterioration that needs urgent treatment. Include pain and distress as a criterion for escalation in the protocol.

Patients may show signs of clinical deterioration other than those identified in the escalation protocol, and there is evidence that clinician worry or concern may precede deterioration in vital signs.⁸ Include clinician worry or concern as a criterion for escalation in the protocol.

Develop policies and guidance

Develop policies and provide training to guide clinicians in preventing and responding to severe aggressive behaviour and violence. When developing policies and responses to severe behavioural disturbance, provide specific guidance on appropriate responses for older patients, highlighting that:

• Behavioural disturbances are commonly associated with delirium or dementia
• Behavioural disturbances may be related to fear, communication difficulties or an unfamiliar environment (in which case, de-escalation strategies and involvement of family members can be successful)
• Sedation should be avoided, and any use should be in line with age-specific evidence; over-sedation can have serious adverse effects, such as dehydration, falls, respiratory depression, pneumonia and death⁹
• Clinicians should refer to specialist older people’s mental health services, if possible.

Refer to the ‘Minimising patient harm’ criterion in the Comprehensive Care Standard for further detail on preventing delirium and managing cognitive impairment; predicting, preventing and managing self-harm, suicide, aggression and violence; and minimising restrictive practices.

Localise escalation policies that consider the size, role, location and available resources of different services within the organisation. For example, escalation protocols in the emergency department may differ significantly from escalation protocols in the dialysis unit or the mental health unit. Different escalation protocols may be needed for different groups of patients – for example, children may need different escalation protocols from adults.

Escalation protocols can be complex, involving multiple steps and different communication pathways. Develop a flow diagram to summarise escalation processes and provide clinicians with a quick reference tool. Display posters of the escalation flow diagram near telephones in clinical areas, or provide clinicians with identification tag cards for quick reference.