Escalation and Communication Between Support Workers and Nurses

This is something that is present in most serious incident reviews, where a community care worker has noticed the change two days before.

The information existed. The worker was aware of the decreased appetite, the new confusion, the wound that looked different, and that observation died in transit between noticing and clinical response, because the worker wasn't sure it mattered, or wasn't sure who to tell, or told somebody who was the wrong somebody, or wrote it in notes nobody clinical would have read for a week. It is hardly ever the attention of the worker that fails. It's the lack of a planned route from what workers see to what nurses want to know.

Nurses cannot be everywhere, and that's why the observation capacity of the support worker is important, and why it's wasted if the escalation pathway is left to improvisation. A working protocol is not a policy document. It's a brief set of answers that any worker who works with your patients can say.

The four questions a working protocol answers

What should be reported for this patient? Generic instructions generate generic noise. The helpful one is patient-specific and short: for this person, these three or four, expressed in plain observational language, are the changes that are relevant, falls or near falls, eating or drinking noticeably less, new or worsening confusion, changes to this wound, breathlessness at rest. The right authors are the nurses, because you're familiar with the changes that indicate this clinical picture, and the plain language is the point, workers report what they see, not what they conclude.

Who is told, and how fast? Each report must have a destination name and a speed. The effective structure is two lanes: urgent-today items, where there is a phone number to answer and an agreed response time; and routine observations, with an agreed place where clinical staff read them and an agreed rhythm when they read them. The most frequent protocol failure is a "report concerns" instruction that has no name attached: concerns that are reported to the air remain in the air.

What does the worker do while waiting? For the urgent lane, workers need the holding instructions: stay with the patient, what to do, what not to do, and when the answer is simply an ambulance. It is one paragraph, and it is the paragraph that counts at the worst possible time.

What happens after? Reports that go nowhere teach workers not to report. Even one line of recognition of what the report resulted in is what keeps the surveillance system alive. The sooner workers learn what their observations led to, the sooner they start to move the next one up. Workers who learn nothing stop escalating.

Set the culture as deliberately as the protocol

The protocol takes place in a cultural context in which nurses have a high degree of control: the treatment of over-reporting. The system is merely recalibrated for silence if the worker who makes the call experiences even the slightest bit of irritation when it turns out to be harmless, and the two-days-earlier sentences come from silence. The stated rule and the practised one is, if a call ends up being empty, that's the system working. The observation-judgement boundary safeguards this for everyone: workers are never asked to make a judgement on whether a change is clinically significant or not, but simply report the changes on their list, so that no report is ever wrong.

How this plays out in practice

Imagine a community caseload that develops a protocol for every care plan: a "watch list" on every care sheet, one phone number for the "urgent" lane, one "routine" lane on the care sheet that a nurse reviews daily, and one "thank you" at the end of each call, no matter the outcome.

A few months later, a worker calls about a minor issue: one of the usually chatty clients has been speaking in monosyllables since yesterday. The nurse visits that afternoon and discovers the client is developing a urinary tract infection, the kind that progressed to delirium and hospitalisation last year. Treatment starts that same day. Under the old way, the worker would have waited to mention it. The protocol didn't make the worker observant. It gave the observation somewhere to go.

Next steps

This week, choose five patients and jot down each one's watch list: three or four changes, one urgent number, one routine channel, and one closing-the-loop habit. Then say the sentence that's the answer to everything: a call about nothing is the system working.