Escalations

An escalation is the step you take when an alert needs more than a phone call: when a clinician with prescribing authority must look at the chart, when the patient may need to be seen, or when the standing care plan does not cover what the readings show. Escalations live at Monitoring -> Escalations and follow a defined lifecycle that the portal enforces.

When to escalate

Escalate any time you would otherwise feel uncomfortable closing the alert yourself. Concrete triggers:

A Critical alert with a value that won't resolve after one patient contact.
Two consecutive Critical readings in the same vital from the same patient inside 60 minutes.
A patient reporting symptoms (chest pain, shortness of breath, syncope, confusion) regardless of the reading.
A medication-related concern: non-compliance, suspected adverse reaction, or a new prescription colliding with the RPM data.
A trend approaching threshold that, in your clinical judgment, needs proactive intervention before it hits Critical.

Priority levels

The portal supports three priority levels, mapped to clinical urgency:

STAT (Stat (Immediate)). Patient may be in physiologic distress. Page the on-call provider within 60 seconds and stay on the phone with the patient until the provider responds. Examples: SpO2 < 88%, systolic > 200 mmHg with symptoms, glucose < 50 mg/dL with altered mental status.
Urgent: needs provider attention today, ideally within 4 hours. Examples: persistent BP > 180 systolic, fasting glucose consistently > 300 mg/dL across three days, 5-lb weight gain in a CHF patient over 48 hours.
Routine: needs provider review but is safe to wait until the next business-day clinic block. Examples: trending BP creep over two weeks, medication reconciliation request, lab order needed.

A STAT escalation pages the on-call provider within 60 seconds. If you have not received an acknowledgement (provider opened the escalation in the portal) within 5 minutes, call the on-call cell phone directly. Do not assume the page went through.

Creating an escalation

Open the patient's chart at Patients -> select patient -> Alerts or stay in Monitoring -> Patient Monitoring with the patient expanded.

Click Escalate. The escalation modal opens prefilled with the patient name and the alerts you'd selected.

Pick a Priority (STAT, Urgent, or Routine) and a Reason category:

Critical Vital Sign. Any single reading in the danger zone.
Abnormal Trending, pattern over days/weeks.
Multiple Consecutive Alerts, same vital, multiple readings.
Patient Reported Symptoms. Patient is telling you something the device can't.
Non-Compliance Concern. Missed readings, medication issues.
Medication Concern. Suspected reaction or interaction.
Clinical Judgment, anything not covered above.
Other. Last resort; explain in the details.

Fill Reason details with a concise summary the provider can read in 10 seconds. Include the latest reading, the trend, what the patient said, and what you've already tried.

Example: "BP 192/108 at 09:14, repeat 188/106 at 09:32. Patient reports headache, denies chest pain or vision changes. Confirmed morning lisinopril taken on time. Last clinic visit 4 weeks ago, target 130/80."

Add a Recommended action if you have one ("Same-day telehealth visit, consider amlodipine increase") and submit.

The escalation lands in the queue with status Pending Review, the priority badge you selected (STAT in red, Urgent in orange, Routine in gray), and a counter that starts ticking from the moment you clicked Submit. Average response time across the queue is shown in the Avg Response KPI on the dashboard.

Contacting the patient

For STAT and most Urgent escalations, call the patient before or immediately after submitting. Stay on the line for STAT calls if the patient consents. Your voice is the safety net.

What to ask, every time:

Are you having chest pain, shortness of breath, dizziness, or confusion right now? Yes to any → 911 plus STAT escalation, regardless of vital values.
When did you take your last dose of [medication]?
Have you eaten in the last hour? Caffeine? Stress?
Where are you measuring: sitting at the kitchen table, lying down, just got up from bed?
Take one more reading right now while we're on the phone.

Document the answers in the escalation Reason details before submitting. This saves the provider 5 minutes of asking the same questions when they call back.

Paging the on-call provider

The portal sends a notification to the assigned provider the moment you submit, but practices vary in how aggressively that hits the provider's pager or phone. Confirm your clinic's pathway with your medical director, then standardize:

STAT: submit escalation, then immediately call the on-call pager number. Do not rely on the in-app notification alone.
Urgent: submit, then send a chat or SMS heads-up if your practice uses one. Most providers want a nudge for urgent items.
Routine: submit only. Providers triage routine escalations during their next clinical session, typically same-day or next-business-day.

If the assigned provider doesn't acknowledge a STAT inside 5 minutes, escalate to the backup on-call. Document who you called and when in the escalation's notes.

Escalation lifecycle states

The portal moves an escalation through six states:

State	Meaning
Pending	Submitted, not yet seen by a provider.
Acknowledged	Provider has opened it but not started action.
In Progress	Provider is actively working on it.
Pending Billing	Clinical action complete, waiting on time/CPT documentation.
Completed	Closed with a clinical note and (when applicable) billing entries.
Cancelled	Closed without action: duplicate, mistaken submission, or patient declined intervention.

You'll see these as colored pills in the Status column. The Active filter at the top of the page shows everything that isn't Completed or Cancelled, that's your worklist.

Marking high-acuity and documenting the action

When the provider closes an escalation, three things must happen for the record to be complete:

Status moves to Completed (or Cancelled with a reason).
Action taken is documented, what the provider decided. New prescription, dose change, ED referral, watchful waiting with 24-hour follow-up, etc.
Time is logged for billing. The provider clicks Mark Complete and the BillingResolveModal prompts for minutes spent and whether the encounter was interactive (phone or video contact with the patient).

If you're closing an escalation without billing (for example, a duplicate submission or a soft-call you handled in 90 seconds) use Close Without Billing from the action menu. Do not invent time to fill the field. Audit-friendly documentation matters more than capturing every minute.

See Documenting for billing for exactly what counts as billable time and how the 99457/99458 codes attach to escalation resolutions.

What to do if you disagree with the resolution

You'll occasionally see a STAT escalation closed quickly with a note that doesn't match the severity. Your clinical manager owns the quality review here. Flag it in your weekly Monday huddle, not by re-opening the escalation. The audit trail is your friend: every state change, note, and billing entry is timestamped and attributed in the Activity tab on the escalation record.

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