What triggers escalations of care based on abnormal patient observations related to complex medical conditions or inadequate medication management?

From the Guidelines

Escalations of care should be based on a comprehensive assessment of abnormal patient observations, considering both complex medical conditions and potential medication-related issues, with a focus on preventing adverse drug events and improving patient outcomes, as emphasized in the most recent study 1. When a patient's vital signs or clinical status deteriorates, healthcare providers must recognize these changes and respond appropriately by escalating the level of care. This typically involves activating rapid response teams, transferring patients to higher levels of care (such as ICU), or adjusting treatment plans. Common triggers for escalation include abnormal vital signs (tachycardia, hypotension, tachypnea, fever), decreased oxygen saturation, altered mental status, or concerning laboratory values. Medication-related issues that may necessitate escalation include:

• Adverse drug reactions
• Medication errors
• Insufficient therapeutic response For example, a patient on opioid analgesics showing signs of respiratory depression (respiratory rate <8/min) would require immediate intervention with naloxone 0.4-2mg IV/IM and possible transfer to a higher level of care, as supported by the study 1. Similarly, patients with complex conditions like sepsis require prompt recognition and escalation with early antibiotic administration and fluid resuscitation. Effective escalation systems rely on standardized early warning scores, clear communication protocols, and empowering all healthcare team members to initiate escalation when concerned about a patient's condition, regardless of hierarchy, as highlighted in the study 1. The process of deprescribing, which involves reducing the drug dose, weaning off or discontinuing the drug, or switching to a safer alternative, can also play a crucial role in preventing adverse drug events and improving patient outcomes, as discussed in the study 1. By prioritizing patient safety and well-being, healthcare providers can ensure that escalations of care are timely, effective, and tailored to the individual needs of each patient.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Escalations of Care

Escalations of care are based on abnormal patient observations which may be related to patient’s complex medical conditions or insufficient medication management 2.

Related Studies

• A study published in the Nursing standard journal in 2023 found that improvements in clinical practice are required to ensure that deteriorating patients are rapidly identified and assessed in a systematic manner 2.
• Another study published in the Journal of cardiac failure in 2024 characterized the use of medical therapies before, during and after hospitalization in patients with heart failure and diabetes 3.
• A study published in Diabetes, obesity & metabolism in 2023 discussed the clinical significance and epidemiology of the two-way association between heart failure and diabetes 4.
• A review published in The Cochrane database of systematic reviews in 2020 assessed the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness 5.
• A study published in Emergency medicine clinics of North America in 2024 discussed the management of the agitated patient, including non-coercive de-escalation strategies and pharmacologic interventions 6.

Key Findings

• Evidence suggests that improvements in clinical practice are required to ensure that deteriorating patients are rapidly identified and assessed in a systematic manner 2.
• In-hospital optimization of medical therapy in patients with heart failure and diabetes is common in participating hospitals of a large US quality improvement registry 3.
• The risk of heart failure persists even in the face of standard-of-care preventive treatments for atherosclerotic cardiovascular disease 4.
• Interactional patient-facing interventions and multi-component programmes to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses 5.
• The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary 6.

Implications for Practice

• Healthcare professionals should be aware of the importance of rapid identification and assessment of deteriorating patients 2.
• Patients with heart failure and diabetes require optimized medical therapy to prevent worsening clinical status 3.
• Patients and families should be involved in escalation of care for acute life-threatening illness to improve knowledge and preparedness 5.
• Emergency physicians should be familiar with multiple pharmaceutical options for managing the agitated patient 6.