Escalating When You Are Worried and Nobody Else Is

Reviews of serious incidents repeatedly find someone junior who was worried and did not press the point. Not because they did not care, but because they were unsure whether their concern was legitimate, or because they raised it and were reassured and did not know it was acceptable to ask again.

At a glance

Your worry is data

Interns discount their own impression because they cannot yet explain it. But “this patient looks worse than an hour ago” is a comparison only you can make, because you are the one who saw them an hour ago. A registrar reading numbers from a screen has less information than you do, not more.

You do not need a diagnosis to escalate. “I do not know what is wrong, but something is” is a complete and legitimate reason to call.

Say it in one sentence

Ambiguity is what gets dismissed. Compress it: “I am worried about the patient in bed nine because their breathing has changed and their observations are trending the wrong way. Please can you come and see them.”

Concern, reason, request. If the request is missing, the conversation ends without a plan, and if the urgency is implied by tone rather than words, it does not survive a phone call.

Graded assertiveness

If your concern is not acted on, escalate the language rather than the volume. Each step is more explicit than the last.

1. Observation. “Their respiratory rate has gone up since this morning.”
2. Concern. “I am concerned about how they look.”
3. Question. “Can you help me understand why we are not doing anything further?”
4. Statement. “I need you to come and see this patient now.”
5. Stop. “I am not comfortable with this plan and I am going to escalate.”

Most conversations resolve at the first two steps. The value of knowing all five is that you have words ready for the situation where they do not, instead of falling silent because you cannot think how to say it.

If you are reassured but still worried

Being reassured is not the same as being satisfied. If you have raised it, been told it is fine, and still think it is not, go further up. That is what an escalation policy is for and it is not disloyalty to the person who reassured you.

Every hospital has a route for this — a critical care outreach team, a rapid response call, or an explicit chain in the escalation policy. Find out what yours is on your first day, not on the night you need it. Nurses on the ward usually know it better than the doctors do.

Making it easy for the person you call

Have the observations and their trend in front of you. Have the drug chart. Know what has changed and when. State plainly how sick you think they are. A caller who is organised gets taken seriously; a caller who is hunting for numbers mid-sentence does not, however right they are.

Documenting it

Record that you escalated, to whom, at what time, what you said, and what was advised. This is not defensive box-ticking. It creates the timeline that lets someone reconstruct what happened, and if a concern was raised and not acted on, that record is the only evidence the system has that its own safety net did not work.

What not to do

• Do not wait for the next set of observations to prove you right if you are worried now.
• Do not soften it to be polite. “Sorry to bother you, it is probably nothing, but…” tells the receiver it is nothing.
• Do not escalate by message alone for an unwell patient. Speak to a person.
• Do not stop at one attempt because you were made to feel foolish.

Last-minute checklist

• Your impression counts — you saw the patient
• Concern, reason, request, in one sentence
• State urgency in words, not tone
• Have observations, trend and drug chart to hand
• Graded assertiveness if not acted on
• Still worried after reassurance means escalate again
• Know your hospital’s escalation route before you need it
• Document who, when, and what was advised

References

• Your hospital’s escalation and deteriorating patient policy
• Local rapid response or critical care outreach criteria