Escalation must follow the patient's orders and agency policy; the following are representative thresholds.
🚩 Red flags — escalate
Blood pressure above 180/120 mmHg with symptoms (headache, visual change, chest pain, dyspnea, focal weakness) — possible hypertensive emergency: activate emergency response (911). (See Hypertension overlay.)
SpO2 below 90% on usual settings with distress — urgent or emergency evaluation. (See Respiratory.)
Heart rate above 120 sustained or below 50 with symptoms, or a new symptomatic irregular rhythm — urgent provider notification per parameters.
Temperature above 100.5 °F with tachycardia, tachypnea, and altered mental status — possible sepsis: urgent evaluation. (See General / Constitutional.)
Symptomatic hypotension or syncope — immediate safety intervention and provider escalation.
A rapid adverse change in any parameter from the patient's baseline — escalate per severity and orders.
