Obs chart and escalation simulator: recognise, escalate, ISBAR

Tool 1 / Obs chart

Plot the obs. Read the zone.

Enter a set of adult observations. Each one lands in a zone, and the most serious zone, plus a few extra rules, tells you who needs to know and how fast.

How the example zones work

The zones. The bands follow the layout of the sample adult Rapid Detection and Response (RDR) chart that SA Health publishes (2020 revision). That chart follows the national approach: colour bands for each observation, and a set response for each colour. Normal SpO₂ is 95–100%.
Counting rule. Three or more yellow observations need a medical review. Three or more red observations need a rapid response call.
30-minute rule. If an RN review or medical review hasn't happened within 30 minutes, or you're more worried, go up a level.
Worry is a trigger. Your worry, or the patient's or family's, is a reason to escalate even when every number is in range. In SA public hospitals, patients and families can raise concerns themselves through "You're worried, we're listening".
Other charts. Some Australian charts, like the Commission's ADDS chart, give each observation a score and act on the total. The thresholds and names differ (MET, MER, rapid response, Code Blue), but the idea is the same: the further from normal, the faster the response.
Modifications. A doctor can document different calling criteria for one patient for a set time. One example is a lower SpO₂ target in some chronic lung disease. Apart from the 88–92% SpO₂ target option above, this simulator doesn't apply them, so always check the chart and the resuscitation plan or goals of care.

Tool 2 / Scenarios

What would you do now?

Six fictional patients. Each set of obs is plotted as it comes in. Decide what happens next, then see the feedback. Trends matter as much as single numbers.

Tool 3 / ISBAR phone call

Build the call before you dial.

Know what you're asking for, and by when, before you pick up the phone. Fill in the gaps, practise it out loud, and finish with a read-back so everyone leaves with the same plan.

On placement your supervising RN usually makes this call. Building the ISBAR is still the best way to hand over clearly to them, and it's good practice for when you're the RN.

Identify

Who you are name and role Where ward or unit Who you're calling The patient practice details only

Situation

Why you're calling, and what has changed

Say it plainly: "I am worried about this patient."

Background

Why they're in hospital, day of stay Relevant history Baseline usual obs, cognition, mobility Allergies, resuscitation plan or goals of care

Assessment

Obs now, and how they've changed

What you can see A to E, colour, work of breathing What you've already done

What you think is going on optional, it's fine to say you're not sure

Recommendation

What I'm asking for By when

Anything specific tests, orders, a plan for the night

Before you hang up, ask "What would you like me to do in the meantime?" "What should I call you back for?"

Read it back

Closed-loop communication: repeat the plan in your own words so any mix-up shows up now, not at 3 am.

What they said they'll do What I'll do in the meantime Call back if

Your call

Read it aloud. Aim for about a minute.

If they're not concerned

Stay polite, stay on the facts, and keep the patient at the centre.

Ask them to explain: Can you help me understand why you're not concerned? I might be missing something. They may know something you don't.
Restate the worry with the facts: Her RR has gone from 18 to 30 in two hours and she's on new oxygen. I'm still worried.
Ask for something specific: Would you be able to see her within 30 minutes? or What would make you want to come in?
Agree on what happens next, and read it back.
Document it: the time, who you spoke to, what you reported and the plan.
Still worried? Escalate up the chain: the RN in charge, then a more senior doctor. If the patient meets the criteria, or you're seriously worried, call a rapid response. You never need permission to do that.

Tool 4 / MET call handover

Thirty seconds of handover when the team walks in.

When the rapid response team arrives, they need the key facts fast. Pick the ward type, fill it in or print a blank one to keep on your clipboard.

Template adapted, with permission, from MET call handover resources by Elizabeth RN.

Ward type Medical Surgical Neuro

Medical ward MET handover · ISBAR

IIdentify	Your name and role. Patient's name and age.
SSituation	Why you called the MET. Why they're in hospital and their day of stay. The operation, post-op day and any complications. What's changed neurologically, and when.
BBackground	Relevant history, especially heart and lungs. Usual cognition. Allergies. Resuscitation plan or goals of care. Infection precautions. Lines, drains, catheters, wound, epidural or PCA. Usual neuro status (GCS, pupils, limb strength, speech). Seizure history.
AAssessment	Obs now and their usual. ECG, BGL. IV access and whether it works. Fluid balance, urine output, drain and wound loss. GCS now vs before, pupils, limb strength, neurovascular obs. What you've done: position, oxygen, medicines given and when.
RRecommendation	Treating doctor and team. Do they know? Family or substitute decision-maker, and how to reach them. What you need from the team.

Be prepared: while you wait for the team

Tool 5 / Speaking up

Say it clearly. Keep the patient at the centre.

Speaking up is easier with the words ready. Focus on the patient and the facts, not the person. Use "I" statements, and be clear about what you need.

Passive

Quiet, hesitant, hard to hear
Apologises for calling
Hints instead of asking
Closed body language, little eye contact
The concern gets lost

Assertive

Calm, clear, a volume that suits the space
Facts first, then the concern
Says exactly what's needed and by when
Open body language, eye contact, respects personal space
Respects the other person's view, and asks for it

Aggressive

Loud, fast, interrupting
Blames or accuses
Crowds personal space
Shuts down questions
People get defensive, and the message is lost

Four steps when you're not being heard

1. Concern"I'm concerned about Bed 4. Her breathing rate has doubled since this morning."
2. Question"Can we look at her obs together? Am I missing something?"
3. Request"I need a medical review within 30 minutes, please."
4. Escalate"I'm still worried, so I'm going to call the registrar, or a rapid response."

Many hospitals teach a named speaking-up program in orientation. Find out which one your placement uses and the words it teaches.

Phrase bank

Tap a phrase to copy it. They're starting points, so make them sound like you.

Hierarchy and confidence

Differences in role, age, experience, gender and culture can make speaking up feel harder. That's normal, and it's why escalation systems exist.
The patient is the shared goal. Keep coming back to them and to the facts.
It's better to escalate and have no change to the plan than to stay quiet and be wrong. Escalating a real concern is never a waste of anyone's time.
Get to know the team when you see them in person. A familiar voice on the phone is easier to listen to.
If someone responds with rudeness or belittling, that's a conduct issue. Report it to the RN in charge or your facilitator. It never stops you escalating.

Adapted, with permission, from assertive communication and phone escalation teaching resources by Elizabeth RN.

Evidence / Why it matters

Worry is data. Clear calls get action.

Worry predicts deterioration.In 3,522 surgical ward patients in the Netherlands, nurses' worry on its own was a good predictor of unplanned ICU or HDU admission or unexpected death. Adding the signs behind the worry to vital-sign scores predicted it better than vital signs alone.Douw et al., 2016

Nurses' worry is often right.In a US study across four adult wards, 77% of the deterioration events that nurses flagged were confirmed by reviewers. A raised worry score was strongly linked with ICU transfer in the next 24 hours.Romero-Brufau et al., 2019

Not every escalation starts with a score.In 151 observed escalations on UK wards, about half weren't triggered by an early warning score at all, but by things like bleeding, infection or chest pain. The most common type was the call where the person escalating already knew the outcome they wanted.Ede et al., 2025

Delays are often about culture, not knowledge.Nurses at an Australian private hospital linked delays to hierarchy and indecision, to gatekeeping and rigid protocols, and to their own confidence to escalate.Noye et al., 2023

Nurses see it coming.Surgical nurses in Melbourne described recognising deterioration before patients met rapid response criteria. Track-and-trigger charts helped them act early.Mohammmed Iddrisu et al., 2018

Being wrong about calling is OK.After an escalation course, one doctor in training reflected that it's acceptable to be wrong about needing to escalate, but not about failing to escalate.Cotter et al., 2019

Sources

Where this comes from.

Checked in October 2026. Scenarios are fictional.

Australian Commission on Safety and Quality in Health Care, Recognising and Responding to Acute Deterioration Standard (NSQHS Standard 8), including escalation for worry from staff, patients and families, and sample observation and response charts.
Australian Commission on Safety and Quality in Health Care, Adult Deterioration Detection System (ADDS) chart (2012).
SA Health, Rapid Detection and Response (RDR) observation charts: the sample adult chart and its 2020 revision fact sheet, used for the example bands, the counting rule and the 30-minute rule.
SA Health, You're worried, we're listening: consumer-initiated escalation of care.

References

Al-Hawaiti, M. R., Sharif, L., & Elsayes, H. (2025). Assertiveness in nursing: A systematic review of its role and impact in healthcare settings. Nursing Reports, 15(3), 102. https://doi.org/10.3390/nursrep15030102
Cotter, J. M., Ziniel, S., Lockwood, J., & Reese, J. (2019). Care escalation: Teaching residents how to effectively communicate patient care concerns. MedEdPORTAL, 15, 10833. https://doi.org/10.15766/mep_2374-8265.10833
Douw, G., Huisman-de Waal, G., van Zanten, A. R. H., van der Hoeven, J. G., & Schoonhoven, L. (2016). Nurses' 'worry' as predictor of deteriorating surgical ward patients: A prospective cohort study of the Dutch-Early-Nurse-Worry-Indicator-Score. International Journal of Nursing Studies, 59, 134–140. https://doi.org/10.1016/j.ijnurstu.2016.04.006
Ede, J., Kent, B., Watkinson, P., & Endacott, R. (2025). Successfully initiating an escalation of care in acute ward settings: A qualitative observational study. Journal of Advanced Nursing, 81(2), 887–896. https://doi.org/10.1111/jan.16248
Mohammmed Iddrisu, S., Hutchinson, A. F., Sungkar, Y., & Considine, J. (2018). Nurses' role in recognising and responding to clinical deterioration in surgical patients. Journal of Clinical Nursing, 27(9–10), 1920–1930. https://doi.org/10.1111/jocn.14331
Noye, S., Kumar, K., Hutchinson, A., & Willcox, J. (2023). Nurses' perspectives on delays in care escalation in an acute private hospital. Collegian, 30(5), 660–667. https://doi.org/10.1016/j.colegn.2023.07.006
Romero-Brufau, S., Gaines, K., Nicolas, C. T., Johnson, M. G., Hickman, J., & Huddleston, J. M. (2019). The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours. JAMIA Open, 2(4), 465–470. https://doi.org/10.1093/jamiaopen/ooz033

The "signs behind the worry" list paraphrases the nine indicators in the Dutch-Early-Nurse-Worry-Indicator-Score (DENWIS; Douw et al., 2016).

Acknowledgement

Parts of this page are adapted, with permission, from teaching resources by Elizabeth RN, including the MET call handover template, the phone escalation tips and the speaking-up content.