Patrick Lewis, a fictional 71-year-old inpatient receiving treatment for pneumonia, is quieter and more confused than two hours ago. His daughter, Ruth, says his breathing looks different. A healthcare assistant reports that he needed help to sit up and has passed little urine. His most recent documented NEWS2 was 3, but it predates these changes. You are the ward doctor. When you arrive, Patrick is drowsy but rousable, respiratory rate 29/min, oxygen saturation 91% on 2 litres/min, pulse 112/min, blood pressure 92/58 mmHg and temperature 38.4°C.
No real patient or identifiable patient information is used.- Recognise concern about change as a clinical trigger and begin an immediate structured reassessment rather than debate the previous score.
- Identify and treat immediate threats, repeat complete observations, interpret the trajectory and establish an explicit monitoring and review plan.
- Escalate with a concise problem representation, urgency, specific request and agreed response time, then escalate again if the response is delayed or dismissive.
- Explain actions and uncertainty to the patient and relative, use local independent rapid-review routes appropriately and document ownership and loop closure.
See the purpose behind each line
Ruth, thank you for speaking up. You know what is usual for your father. Tell me exactly what has changed, when you first noticed it and whether it is continuing to worsen.
A relative's longitudinal knowledge may identify deterioration before a threshold is reached; the response validates the signal without substituting it for assessment.He was talking normally after lunch. Now he keeps drifting off, his breathing is faster and he has hardly passed urine. This is not him.
I am concerned too. I am going to assess his airway, breathing, circulation and neurological state now, repeat a complete set of observations and start immediate treatment for any threats. Please stay nearby; I will update you after the first assessment.
The candidate states concern, moves to ABCDE and gives a near-term communication commitment rather than offering reassurance.Patrick, I am Dr Shah. You seem more unwell, so I am checking your breathing and circulation and calling for urgent help. I will explain each step as we go.
Even when cognition is impaired, address the patient, communicate simply and preserve dignity while urgent care proceeds.The earlier NEWS2 was only 3. The registrar says they are tied up and suggests another set of observations in an hour.
That score predates new confusion, hypoxaemia, tachypnoea and hypotension. My concern and the current physiology require an urgent response now. Please activate the local emergency deterioration pathway and ask the registrar and critical-care or outreach clinician to attend. I will stay with Patrick, begin treatment within my competence and call the consultant if the response is not immediate.
A precise, graded escalation request makes urgency, requested expertise and the fallback route explicit; hierarchy does not close the concern.My SBAR is: Patrick Lewis, 71, admitted with pneumonia, has deteriorated over two hours. He is newly confused, respiratory rate 29, saturation 91% on 2 litres, pulse 112 and blood pressure 92/58. I am treating immediate threats and need senior and critical-care assessment now for suspected acute deterioration, with a decision on level of care. Please confirm who is coming and the expected arrival time.
The escalation contains identification, trajectory, discriminating findings, actions already taken and a specific ask with closed-loop confirmation.What if nobody comes? We tried to raise concerns earlier.
I will not wait passively. I am escalating through the emergency pathway and will remain responsible until help arrives. If you feel your concern is still not being addressed, this hospital may also have a separate rapid-review route such as Martha's Rule; I will show you the local process. It complements, but does not replace, the emergency response already under way.
The clinician owns escalation and explains the independent route accurately without shifting responsibility onto the family.Ruth, the team is attending now. We are treating Patrick while we investigate the cause and decide the safest level of care. I will update you again in 20 minutes, or sooner if the plan changes. I will record what you noticed, the observations, who was called, when they responded and who owns the next review.
The close provides truthful uncertainty, a timed update, named ownership and documentation of the entire safety loop.The central skill is not reciting NEWS2 or naming Martha's Rule; it is converting concern into reliable action. Start with the patient: call for help when needed, use ABCDE, repeat a complete and reliable observation set, compare with baseline and trajectory, and treat immediate threats within competence. A low or old aggregate score never vetoes clinical concern. Escalation should carry a brief problem representation, the change over time, important physiology, actions already taken, the level of urgency and a definite request. Ask who will attend and by when. If a senior response is dismissive or delayed, restate the risk, use the emergency or critical-care pathway and escalate further rather than documenting that somebody was informed. A ceiling-of-treatment or DNACPR decision does not mean no assessment or no treatment: clarify the agreed limits, treat reversible problems within them and seek an appropriate senior decision. Keep Patrick and Ruth informed without promising an outcome. Martha's Rule is a locally implemented independent rapid-review route in England for unresolved concerns about deterioration; it is not a single national telephone number, a general complaint route, a guaranteed intensive-care transfer or a substitute for ordinary emergency escalation. Close the loop by documenting the concern, assessment, response, treatment, decision-maker, monitoring frequency, review time, escalation ceiling and communication with the patient or family.
What changes the plan?
- The repeated NEWS2 remains low, but Patrick is newly confused and Ruth says he is markedly different: Escalate on clinical concern. Check the completeness and reliability of measurements, assess the trajectory and investigate the new cognitive change; do not use the aggregate score as a rule-out test.
- Patrick develops severe respiratory distress, peri-arrest physiology or an immediately threatened airway: Bypass routine graded escalation, activate the emergency response, begin ABCDE treatment within competence and summon clinicians with advanced airway and resuscitation skills.
- The first senior contacted advises waiting without reviewing the current findings: State the objective changes and risk, make the requested response explicit, use the local critical-care or emergency pathway and escalate to the next accountable senior while continuing care.
- Patrick has a DNACPR decision and an agreed ward-based ceiling of treatment: Do not interpret this as 'do not treat'. Confirm the scope and currency of the plan, treat reversible deterioration within the agreed ceiling, seek senior review and explain the plan to Patrick or the appropriate representative.
- Patrick cannot participate because of acute confusion and Ruth raises concerns: Continue urgent care in his best interests, address him respectfully, use Ruth's observations as evidence, identify any health and welfare proxy or advance decision and revisit involvement as capacity improves.
- A clinician gives telephone advice but Patrick continues to worsen: Request bedside review and a time-bound response; worsening physiology or concern requires renewed escalation, not repeated reliance on remote advice.
- Ruth asks for Martha's Rule or a second opinion: Explain and facilitate the hospital's local independent rapid-review route where available while maintaining immediate clinical escalation. Clarify that Martha's Rule addresses unresolved deterioration concern and is distinct from a routine second opinion.
- The response team is delayed because of competing emergencies: Stay with Patrick or ensure competent continuous attendance, continue treatment and monitoring, reactivate the emergency chain, escalate capacity risk and document who has accepted responsibility and the revised response time.
“Thank you for speaking up. What is different from usual, when did it change and is it getting worse?”
“The earlier score predates this change; I am reassessing now and escalating on the current physiology and clinical concern.”
“My immediate priorities are these threats; these treatments are under way, and I need this level of review now.”
“Please confirm who is attending and by what time. If that response does not happen, I will escalate again.”
“A treatment ceiling guides the appropriate level of intervention; it does not mean that reversible deterioration is ignored.”
“I will update you at this time, and this named clinician will own the next review.”
“His NEWS2 is only 3, so he is safe.”
NEWS2 supplements clinical judgement; an old or low score cannot exclude deterioration and clinical concern itself can trigger a response.“The registrar knows, so my job is done.”
Sending a message is not closed-loop escalation. The clinician must confirm the response and escalate again if it is inadequate.“You are understandably anxious.”
Used as the main response, it reframes clinically useful concern as emotion and risks diagnostic dismissal.“He is DNACPR, so there is nothing more to do.”
DNACPR concerns cardiopulmonary resuscitation; assessment and proportionate treatment must follow the person's goals and agreed ceiling.“Call Martha's Rule if you are unhappy.”
This transfers responsibility to the family and misrepresents a rapid-review pathway as a complaint service.“Someone will review him soon.”
There is no named responder, urgency, expected arrival time or fallback if review does not occur.- Debating or recalculating an earlier score before assessing a newly unwell patient.
- Failing to call for help, use ABCDE or treat an immediate threat while arranging senior review.
- Accepting incomplete, implausible or stale observations without repeating and checking them.
- Escalating without stating the trajectory, important findings, urgency, actions taken and a specific request.
- Treating a message sent or telephone advice received as completion of the escalation loop.
- Allowing hierarchy, workload or a dismissive first response to delay rescue.
- Equating DNACPR or a treatment ceiling with no active assessment or treatment.
- Using Martha's Rule as a substitute for immediate clinical escalation or giving a generic number without checking local implementation.
- Failing to document observations, response times, treatment, ownership, monitoring frequency, escalation limits and family communication.
Test the communication decision
Could I do this reliably?
Practise a 45-second escalation from Patrick's bedside: what has changed, what you have found, what you are doing, exactly who you need and by when. Which sentence will you use if the first response is dismissive?
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