Escalation must follow the patient's orders and agency policy; the following are representative thresholds.
🚩 Red flags — escalate
Fever with tachycardia, tachypnea, and new altered mental status — possible sepsis: urgent evaluation, and activate emergency response (911) for hemodynamic deterioration. (Interpret the cluster with Vital Signs.)
An acute change in mental status or new unresponsiveness — activate emergency response (911).
A rapid decline in overall condition or function — urgent provider notification per severity.
Significant unintentional weight loss or an ill or toxic appearance — provider notification for evaluation.
Signs of severe dehydration or an inability to take in fluids — urgent evaluation. (Detail in Hydration.)
New profound weakness limiting safe function — escalate per severity and orders.
