Why are phone escalations so easy to get wrong?
Much urgent communication in healthcare happens by phone or bleep. The person you are calling cannot see the patient or your face, and is often in the middle of something else. Details are easily misheard or forgotten.
Hierarchy and anxiety get in the way too. Junior staff often worry about bothering a senior, especially at night, and soften their message so much that the listener does not realise the patient is unwell. A tired senior may not ask the questions that would reveal it. Serious incident reviews often describe a call that was made but in which the urgency was not conveyed or not heard.
What should you do before you pick up the phone?
Two minutes of preparation makes the call shorter and avoids a second call when the listener asks for something you do not have.
- See the patient: Assess them yourself, or make sure the person calling is the one who did. Repeat unexpected observations.
- Gather the facts: Have the observation chart and NEWS2 or other relevant score, the drug chart, recent results, notes, and the treatment escalation and resuscitation status in front of you.
- Decide what you need: A review, advice, a prescription, or someone to come now? How soon? What can you start in the meantime?
- Know the escalation route: Check your local escalation policy, so you know who comes next if you cannot reach the first person or the response is not enough.
- Jot down SBAR: Write a few words under Situation, Background, Assessment and Recommendation.
- Find somewhere quiet: Move away from noise if you can, with a pen ready to write instructions down.
How do you structure the call so it gets a response?
Check you are speaking to the right person and that they can talk. Then use SBAR, with your concern in the first sentence.
Chidi is a staff nurse on an orthopaedic ward at 01:40. Brian, 81, had a hip fracture repair yesterday. His NEWS2 has gone from 2 to 6. Heart rate 116 and irregular, BP 98 over 58, resp rate 23, sats 93% on 2 litres, temperature 37.6. He is newly muddled and has passed 50 mL of urine in four hours.
"Hi, sorry to bother you, it's Ward 12. I've got a man in bed 7, he had his hip done yesterday, his obs are a bit up and he's a bit confused. Could you see him at some point?" Doctor: "I'm stuck in ED, I'll come when I can."
"Hi, is that the orthopaedic FY1? This is Chidi, staff nurse on Ward 12. I'm calling about Brian in bed 7, and I'm worried he's deteriorating. He's 81, day one after a hip fracture repair, and he's for full escalation. His NEWS2 is 6, up from 2 at 22:00. Heart rate 116 and irregular, BP 98 over 58, resp rate 23, sats 93% on 2 litres, temperature 37.6. He's newly confused and has passed 50 mL of urine in four hours. I need you to review him within 30 minutes. While you're on your way, shall I do an ECG, bloods including a lactate, and a fluid balance review?"
The strong call lets the doctor prioritise immediately. The concern is clear, the data supports it, there is a time frame, and Chidi offers useful actions. He does not apologise for calling. Calling is his job, and responding is theirs.
Phrases that work
- "I am worried about this patient."
- "His NEWS2 is 6 and rising."
- "I need you to see him now," or "within 30 minutes".
- "What would you like me to do while you're on your way?"
- "If you can't come in that time, who should I call?"
What if the doctor won't come or doesn't seem to listen?
Sometimes the listener is busy elsewhere, underestimates how unwell the patient is, or disagrees. If you are still concerned, you must escalate further. This is not undermining a colleague. It is protecting the patient.
Graded assertiveness: PACE
Graded assertiveness means making your message stronger, step by step, until it is heard. PACE (Probe, Alert, Challenge, Emergency) is widely taught in UK healthcare.
| Level | What it sounds like |
|---|---|
| Probe | "Could the irregular heart rate and low urine output mean he's getting sicker?" |
| Alert | "I'm worried his blood pressure is dropping and he's not passing urine." |
| Challenge | "I'm very concerned. I don't think it's safe for him to wait an hour. I need you to see him now." |
| Emergency | "I believe he's at immediate risk. I'm calling the registrar and outreach now." |
Some teams use CUS: I am Concerned, I am Uncomfortable, this is a Safety issue. When a team agrees on these words in advance, everyone has permission to use them.
- Restate clearly: Repeat your concern with the data and a specific request.
- Set a time limit: "If you can't be here in 30 minutes, I'll call the registrar."
- Go to the next level: Use your escalation policy: registrar, critical care outreach, nurse in charge, site manager or consultant.
- Call for emergency help if needed: If the patient is at immediate risk, call the medical emergency team.
- Document and report: Record each call. If a delay put the patient at risk, complete an incident report so the system can learn.
How do you take results and instructions over the phone safely?
When you answer a call, give your name and role, listen to the whole message, then ask focused questions. If the caller has not said what they need, ask: "What would you like me to do?"
Lab: "Sodium for bed 11 is 118." Nurse: "OK, thanks." She writes 128 on a paper towel and mentions it to the doctor later.
Lab: "I have a critical result for Ward 5." Nurse: "Can I take the patient's full name, date of birth and hospital number?" She writes them down. "And the result?" Lab: "Sodium 118." Nurse: "So that's sodium one-one-eight for that patient, correct?" Lab: "Correct." She records the result, the time and the caller's name, then calls the doctor straight away using SBAR.
- Confirm identity with at least two identifiers. Two patients on one ward can share a surname.
- Write critical information down at once and read it back.
- Follow your medicines policy on verbal or telephone orders. Many organisations restrict them. Where allowed, read back, record, and make sure the prescriber completes the prescription promptly.
- Doctors prescribing remotely should follow GMC guidance on prescribing, including having enough knowledge of the patient.
How can you make yourself easier to understand on the phone?
On the phone, your voice carries the whole message. Clear speech is a professional skill. It is not about losing your accent.
- Speak a little slower than face to face and pause between SBAR sections.
- Say numbers digit by digit where they could be confused: one-five for 15, five-zero for 50.
- Spell names and medicines that might be misheard, using the phonetic alphabet if it helps.
- Avoid local abbreviations, especially when calling another hospital or service.
- Say units in full: milligrams, micrograms, units, millilitres per hour.
- If the line is poor, say so and call back from somewhere quieter.
When receiving, it is safer to say you did not catch something than to guess. Many internationally educated staff find phone calls the hardest part of starting in the UK, because of accents, speed and local terms. Practising SBAR calls with a colleague, writing a short script and asking for local abbreviations to be explained are normal and sensible.
What about calling a consultant at night or another hospital?
Most consultants would rather be called about a sick patient than find out in the morning. Your organisation may say when a consultant must be told, for example before an emergency operation, on admission to critical care or after an unexpected death. Prepare as usual, lead with your concern and your question, and be clear whether you need advice, a decision or for them to come in.
When calling a team in another hospital, give your name, role, hospital, ward and a call-back number at the start, in case you are cut off. Have key results and imaging reports ready, and agree who will document the advice and whether it will be confirmed in writing.
When speaking to patients' relatives by phone, confirm who you are speaking to and check the patient has agreed to information being shared, in line with your confidentiality duties and local policy. Do not leave clinical details on voicemail.
How should you document an escalation call?
Record the time, the name and role of the person you spoke to, what you told them, the advice or plan, any read-back, and when you will review or escalate again.
Professional standards for doctors, nurses, midwives and allied health professionals all require clear communication with colleagues and prompt action when a patient's safety is at risk. Escalating a genuine concern is good practice, even if the patient turns out to be well.
Building confidence with escalation calls
Confidence on the phone grows with rehearsal. Practise a few SBAR calls with a colleague or educator, keep a short card of phrases, and ask for feedback after real calls. Review calls that did not go well without blaming yourself: what was missing, and what will you say next time?
Our course Telephone Communication and Escalation covers preparing for calls, SBAR, receiving results and advice, graded assertiveness, speaking clearly and documentation, with worked dialogue and reflective prompts. Our separate guide to SBAR handover gives more examples across different settings.
Frequently asked questions
How do I escalate a deteriorating patient as a nurse?
See the patient, gather the observations, NEWS2, charts and escalation status, and decide what you need. Call the right person under your escalation policy, state your concern first, give the data using SBAR, and ask for a review within a set time. Read back instructions, document the call and escalate further if needed.
What should I do if the doctor won't come to see my patient?
Restate your concern with the data and a specific request, and set a time limit. If the response still does not match the risk, go to the next level under your escalation policy, such as the registrar, outreach team or nurse in charge. Call the emergency team if the patient is at immediate risk, and document each call.
What is PACE in nursing communication?
PACE stands for Probe, Alert, Challenge, Emergency. It is a graded assertiveness approach that helps you strengthen your message step by step, from asking a question to stating clearly that the patient is at immediate risk and that you are escalating.
Should I apologise when calling a doctor at night?
There is no need to apologise for raising a genuine concern. Introduce yourself, check they can talk, and state your concern in the first sentence. Apologising can make the call sound less urgent than it is. Calling is your job, and responding is theirs.
How do I take a critical result over the phone?
Take the patient's full name and at least one other identifier, write the result down immediately, and read it back to the caller for confirmation. Record the result, the time and the caller's name, then inform the responsible clinician without delay using SBAR.
What should I write in the notes after an escalation call?
Record the time, who you spoke to and their role, the information you gave, the advice or plan agreed, whether instructions were read back, and when you will review or escalate again. Write it as soon as possible after the call.
What is Martha's Rule?
Martha's Rule is an NHS England patient safety initiative that gives patients, families and carers a route to request an urgent review if they are worried someone is getting worse. It also includes daily check-ins and staff escalation rights. It is being rolled out across hospital services in phases, so check how it works locally.
Related courses
Telephone Communication and Escalation
This course teaches you how to make and receive urgent clinical telephone calls clearly and safely. It covers preparing before you call, structuring…
Breaking Bad News Training (SPIKES)
This course teaches a structured, compassionate approach to breaking bad news using the six-step SPIKES framework. Each step is explained with worked…
Difficult Conversations with Patients and Families
This course gives you practical, published approaches for conversations that involve anger, disagreement, complaints or expectations that cannot be…
Sources and further reading
- National Early Warning Score (NEWS) 2. Royal College of Physicians.
- SBAR implementation and training guide. NHS England (NHS Institute for Innovation and Improvement).
- Martha's Rule programme. NHS England.
- Good Medical Practice (2024). General Medical Council.
- Good practice in prescribing and managing medicines and devices. General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Standards of conduct, performance and ethics. Health and Care Professions Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
More guides
The SPIKES Protocol for Breaking Bad News, With Example Conversations
The SPIKES protocol for breaking bad news explained step by step, with example conversations, useful phrases, common mistakes and what to do afterwards.
How to Handle Difficult Conversations With Patients and Families
How to handle difficult conversations with patients and families: calming anger, the NURSE approach, apologising, complaints, disagreement and safe boundaries.
SBAR Handover: Examples and Template for Nurses and Doctors
SBAR handover explained with a simple template and worked examples for nurses, doctors, physiotherapists, paramedics and community staff, plus read-back tips.