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RN Escalation Tip Sheets

Provider Communication SBAR

Tap a scenario to expand the quick reference and SBAR script.

🧠
Stroke
Recognition & Escalation · Activate Stroke Team immediately
›
Any BE FAST Sign
Activate Stroke Team NOW · Dial 33-911
Inpatient
Sudden onset within 24 hrs or wake-up stroke
ED
Within 6 hrs LKW · or 6–24 hrs + NYU ED Stroke Scale >2
BE FAST — Stroke Recognition
LetterSign / Symptom
BBalance — Sudden trouble walking or dizziness
EEyes — Sudden trouble seeing one or both eyes
FFace — One side droops or is numb
AArm — One arm weak or numb
SSpeech — Slurred, hard to understand, or absent
TTime — ANY symptom → Activate NOW · Dial 33-911
Time targets: door-to-doc <10 min · door-to-CT <25 min · door-to-TNK <60 min
S
Situation
"I'm calling about [patient], Room [#]. I believe they are having a stroke and I've activated the Stroke Team."
  • Symptoms: face droop / arm weak / speech / vision / balance
  • Last known well (LKW): _______________
  • Vitals: BP ___ HR ___ O2 ___
B
Background
  • Baseline neuro status: _______________
  • History of stroke / TIA: Yes / No
  • Anticoagulation: Yes / No — agent: ______
  • Blood glucose: ___ mg/dL
  • IV access in place: Yes / No
A
Assessment
"Symptoms are new from baseline and not explained by hypoglycemia. I am concerned this is an acute stroke."
  • New from baseline: Yes / No
  • Within 4.5 hr TNK window: Yes / No / Unknown
  • NIHSS score: ______
R
Request
"I need:"
  • Stroke Team to bedside now
  • STAT CT scan order
  • STAT labs: BMP, CBC, PT/INR, PTT, troponin
  • STAT EKG
  • Tenecteplase eligibility review
  • NPO — dysphagia screen pending
Policy: Stroke Program: Joint Commission Survey Talking Points · Stroke Response Team Protocol · NYU Langone Hospitals · Last Reviewed 03/2024
🫀
Hypotension
Recognition & Escalation · Recheck · Assess · Call provider
›
SBP < 90
Recheck manually. Place supine. Notify MD/NP/PA with full vitals.
MAP < 65
Notify MD/NP/PA STAT. Large-bore IV. Anticipate fluid bolus + vasopressors. Consider RRT.
SBP Drop > 20
Orthostatic. Return supine. Notify MD/NP/PA. Fall precautions. Review meds.
S
Situation
"I'm calling about [patient], Room [#]. Their blood pressure is [value] and I am concerned about hemodynamic instability."
  • BP: ___ / ___   MAP: ___
  • HR ___   RR ___   O2 ___   Temp ___
  • Symptomatic: lightheaded / dizzy / AMS / chest pain / diaphoresis
B
Background
  • Baseline BP: _______________
  • Antihypertensives / vasodilators: Yes / No
  • Recent fluid loss / bleeding: Yes / No
  • Recent surgery / procedure: Yes / No
  • Sepsis risk (fever, infection): Yes / No
A
Assessment
"I am concerned this patient is hemodynamically unstable. I suspect [hypovolemia / medication / sepsis / cardiac cause]."
  • Skin: warm / cool / clammy / mottled
  • Mental status: alert / confused / unresponsive
  • UO last hr: ___ mL  (goal ≥ 0.5 mL/kg/hr)
  • BP trend: worsening / stable / improving
R
Request
"I need:"
  • Bedside evaluation / orders
  • IV fluid bolus
  • STAT labs: BMP, CBC, lactate ± cultures
  • Hold antihypertensive medications
  • Telemetry / 12-lead EKG
  • Vasopressor orders if MAP < 65
Cause-Directed Actions
⚡ Hypovolemia — Dehydration · vomiting · bleeding · poor PO · fever
IV bolus · hold diuretics · check surgical site if post-op · supine position
💊 Medication-Induced — Antihypertensives · diuretics · opioids · post-sedation
Hold offending agent per MD order · report recent med timing to provider
🦠 Sepsis / Distributive — Fever · tachycardia · warm/flushed skin · infection source
Blood cultures x2 · IV bolus · STAT lactate · notify MD STAT · consider sepsis protocol
⚠ Activate RRT If Any
  • MAP < 65 not responding to interventions
  • AMS + hypotension
  • Mottled / clammy skin
  • UO < 0.5 mL/kg/hr
  • Lactate > 2 mmol/L
  • Rapid deterioration in any vital parameter
Policy: Rapid Response & Patient Deterioration Protocols · NYU Langone Hospitals · Refer to Ellucid: nyumc.ellucid.com
🩸
Hypoglycemia
Treat first · Call provider · Use SBAR as your script
›
≥ 70 mg/dL
Normal — no action. Notify MD if BG >400.
< 70 mg/dL
Recheck immediately. Notify MD/NP/PA AND treat. Recheck 15 min. (<60 if pregnant)
Unresponsive
Airway. Stay. Activate RRT. Notify MD. D50 IV if access; Glucagon 1 mg SQ if no IV.
S
Situation
"I'm calling about [patient], Room [#]. Their blood glucose is [value] and I am notifying you and discussing treatment."
  • BG on recheck: ___ mg/dL at ___ (time)
  • Responsive: Yes / No  ·  Able to take PO: Yes / No
  • Symptoms: shakiness / diaphoresis / confusion / pallor
B
Background
  • Diabetic: Yes / No — Type: ______
  • Insulin given: Yes / No — type / dose / time: ______
  • NPO / tube fed: Yes / No
  • Bariatric surgery hx: Yes / No
  • Pregnant: Yes / No  ·  Beta-blocker use: Yes / No
A
Assessment
"I treated with [treatment]. BG after treatment is [value]. Patient is [responding / not responding]."
  • Treatment given: 15g oral / D50 / D10W / Glucagon
  • BG after treatment: ___ mg/dL
  • BG trending: Up / Down / Stable
R
Request
"I need:"
  • New orders — BG not ≥ 70 after 2 doses
  • IV access / D50 or D10W order
  • Glucagon order (no IV access)
  • Insulin order review / adjustment
  • RRT activation (unresponsive)
Treatment Pathways
✅ Able to take PO — Give 15g glucose (Omnicell) orally. Recheck in 15 min. BG ≥70 → meal/snack within 30 min, recheck at 60 min. Still <70 → 2nd dose 15g, recheck 15 min → call MD.
Post-op Bariatric: IV Dextrose only — no oral glucose.
🚫 NPO / Unable to swallow — D50 50 mL IV push over 5 min (preferred) OR D10W 250 mL over 16 min. Recheck BG 15 min after dextrose. Still <70 → repeat dose → call MD for new orders.
🚨 Unresponsive — Activate RRT — Airway first. Stay. Call RRT. Notify MD. IV → D50 or D10W. No IV → Glucagon 1 mg SQ, turn on side, D5W 75 mL/hr. Recheck BG 15 min after Glucagon.
Policy: Hypoglycemia, Management of the Adult Patient · NYU Langone Hospitals Departments of Nursing · Reissue Date: 06/2026
🧪
CIWA / Alcohol & Benzo Withdrawal
Call provider when score hits threshold
›
CIWA ≤ 7 — Mild
Monitor. CIWA-Ar + vitals Q4h. No call unless clinical change.
CIWA 8–14 — Moderate
Notify MD/NP/PA STAT. Meds as ordered. Reassess 30 min after IV / 60 min after PO.
CIWA ≥ 15 — Severe
Activate RRT. Notify MD/NP/PA STAT. Meds as ordered. Reassess 30 min after IV benzo.
S
Situation
"I'm calling about [patient], Room [#]. I have a concern about alcohol/benzo withdrawal."
  • Current CIWA-Ar score: _______
  • Vital signs: BP ___ HR ___ RR ___
  • Main symptoms: tremor / diaphoresis / agitation / n/v / hallucinations
B
Background
  • TAPS: Alcohol __ /4   Benzo __ /3
  • Hx of seizures or DTs: Yes / No
  • Last drink / benzo dose: _______________
  • Meds already given: _______________
  • Social Work / Addictions consult: Yes / No
A
Assessment
"I am concerned this patient is in active withdrawal. CIWA is [score] and trending [up/down/stable]."
  • CIWA ≥ 8 after 3 doses in < 3 hrs: Yes / No
  • Diazepam ≥ 40 mg/hr or ≥ 200 mg total: Yes / No
  • Intubated / using RASS instead: Yes / No
R
Request
"I need you to:"
  • Medication orders for withdrawal
  • Psychiatry / Addictions consult
  • Labs & urine specimen orders
  • Falls / airway / seizure precautions
  • Confirm: stop CIWA if <8 × 48 hrs
⚠ Activate RRT If Any
  • CIWA ≥ 15
  • CIWA remains ≥ 8 after 3 medication doses in < 3 hours
  • Diazepam ≥ 40 mg/hr or ≥ 200 mg total
  • Sudden increase in agitation / anxiety / restlessness → repeat CIWA + vitals immediately
*ED/ICU: notify Attending Physician — they determine if RRT is indicated
Policy: Substance Use & Withdrawal (TAPS) · NYU Langone Ellucid · Reviewed 02/2025
🚨
BERT / Behavioral Emergency Response Team
Activate first if imminent violence · Dial 33-911
›
🔴 Activate BERT + Call LIP Now
Imminent violence or harm to self, staff, or others · Patient making threats · Combative behavior with active safety risk
🟡 Call LIP First, Then Activate BERT
Escalating agitation not responding to de-escalation · Suicidal/homicidal ideation · Acute psychiatric decompensation without immediate violence
Always Rule Out First: Hypoglycemia · Hypoxia · Pain · Delirium · Medication effect — check glucose, O2 sat, vitals before or during BERT activation
S
Situation
"I'm calling about [patient], Room [#]. I'm activating BERT for a behavioral emergency."
  • Behavior: agitation / threats / combativeness / self-harm
  • Imminent violence: Yes / No
  • Vitals: BP ___ HR ___ O2 ___ Glucose ___
B
Background
  • Admission diagnosis: _______________
  • Psychiatric history: _______________
  • Current psych meds: _______________
  • Prior BERTs this admission: Yes / No
  • Recent mental status change: Yes / No
A
Assessment
"I am concerned this patient poses a safety risk. Medical causes [have/have not] been ruled out."
  • Medical cause ruled out: Yes / No / Pending
  • Other patients/staff at risk: Yes / No
  • De-escalation attempted: Yes / No — outcome: ______
  • Patient in restraints: Yes / No
R
Request
"I need:"
  • STAT meds for agitation / sedation
  • Restraint order (verbal acceptable)
  • Psychiatry consult
  • Increased observation / 1:1 sitter
  • You at bedside
Phase Responsibilities
① Safety Huddle — Before Entering
RN presents: events, recent mental status, sleep disruption, relevant history. Team Leader (Psych RN) leads. Abbreviate if imminent violence.
② During Crisis — Your Role
Stay at bedside. Administer STAT meds as ordered. Apply restraints only when ordered. Complete tasks directed by BERT Team Leader.
③ After — Required Before You Leave
File occurrence report. Complete EMR documentation. Participate in debrief. If patient restrained → notify Psychiatry on-call.
Policy: Behavioral Emergency Response Team (BERT) · NYU Langone Hospitals Departments of Nursing · Reissue Date: 04/2026
🛡️
Falls
Post-Fall Response & Escalation · Assess for injury · Apply ABCS
›
ABCS — Injury Risk Factors
LetterRisk Factor
AAge / Frailty — Age >85 or clinical frailty
BBones — Fracture risk or history · Osteoporosis
CCoagulation — Anticoagulants · Platelet or bleeding disorder
SSurgery — This admission: lower extremity, thoracic, or abdominal
Head Strike / ABCS Factor
Post-Fall Order Set. Notify MD/NP/PA + Nursing Leadership now.
No Head Strike / No ABCS
Routine vitals + orthostatic VS ×1. Notify MD + Leadership. Monitor for delayed symptoms.
Escalate to RRT If
New neuro change · Unresponsive · Suspected neck/spine injury → immobilize, do not move.
S
Situation
"I'm calling about [patient], Room [#]. They have fallen and I am notifying you for evaluation."
  • Time of fall: _______________  ·  Witnessed: Yes / No
  • Head strike: Yes / No / Unknown
  • Responsive: Yes / No
  • Visible injury: _______________
B
Background
  • Morse Falls Score: ___
  • ABCS factors: A / B / C / S / None
  • Anticoagulation: Yes / No — agent: ______
  • Prior falls this admission: Yes / No
  • Baseline neuro status: _______________
A
Assessment
"I am concerned about [injury / neuro change]. This patient has [ABCS / head strike / unwitnessed fall] and requires evaluation."
  • Vitals: BP ___ HR ___ O2 ___
  • Neuro change from baseline: Yes / No — describe: ______
  • Neck or head pain: Yes / No
R
Request
"I need:"
  • Bedside evaluation
  • Post-Fall Order Set
  • Imaging orders (head CT / X-ray)
  • Consult orders as appropriate
  • Increased observation / VCO
Required documentation — every fall: Electronic Incident Report · Falls Debrief Form · Post-Fall Huddle · EMR documentation with updated care plan · MD/NP/PA notification (name + time)

Policy: Falls/Falls with Injury Prevention & Safety Program · NYU Langone Hospitals Departments of Nursing · Reissue Date: 09/2025
⬇ Combined Reference
📋
All SBAR Tip Sheets
All 6 scenarios in one expanded view
›
🧠

Stroke

Activate Stroke Team · Dial 33-911
Any BE FAST Sign
Activate NOW · Inpatient: within 24 hrs · ED: within 6 hrs LKW
S
Situation
"Calling about [patient], Room [#]. I believe they are having a stroke and I've activated the Stroke Team."
  • Symptoms · LKW · Vitals: BP / HR / O2
B
Background
  • Baseline neuro · Stroke/TIA hx · Anticoagulation · BG · IV access
A
Assessment
"New from baseline, not explained by hypoglycemia. Concerned this is an acute stroke."
  • New from baseline · TNK window · NIHSS score
R
Request
  • Stroke Team now · STAT CT · STAT labs · EKG · TNK review · NPO
🫀

Hypotension

Recheck · Assess · Call provider
SBP <90
Recheck manually. Supine. Notify MD/NP/PA.
MAP <65
Notify STAT. Large-bore IV. Fluid bolus. Consider RRT.
S
Situation
"Calling about [patient], Room [#]. BP is [value] and I'm concerned about hemodynamic instability."
  • BP / MAP · HR · RR · O2 · Temp · Symptomatic: lightheaded / AMS / diaphoresis
B
Background
  • Baseline BP · Antihypertensives · Fluid loss/bleeding · Surgery · Sepsis risk
A
Assessment
"I suspect [hypovolemia / medication / sepsis / cardiac cause]."
  • Skin · Mental status · UO last hr (goal ≥0.5 mL/kg/hr) · BP trend
R
Request
  • Bedside eval · IVF bolus · STAT labs + lactate · Hold antihypertensives · EKG · Vasopressors if MAP <65
🩸

Hypoglycemia

Treat first · Then call
<70 mg/dL
Recheck. Notify MD AND treat. Recheck 15 min.
Unresponsive
Airway. Stay. RRT. D50 IV or Glucagon 1mg SQ.
S
Situation
"Calling about [patient], Room [#]. BG is [value], notifying you and discussing treatment."
  • BG on recheck · Responsive · PO able · Symptoms
B
Background
  • DM type · Insulin given · NPO/tube fed · Bariatric · Pregnant · Beta-blocker
A
Assessment
"I treated with [treatment]. BG is now [value]. Patient is [responding / not responding]."
R
Request
  • New orders if BG still <70 after 2 doses · IV access/D50 · Glucagon · Insulin review · RRT if unresponsive
🧪

CIWA / Withdrawal

Alcohol & Benzo · Call at threshold
CIWA ≤7
Monitor Q4h. No call unless change.
CIWA 8–14
Notify MD STAT. Meds. Reassess.
CIWA ≥15
RRT + MD STAT. Meds. Reassess 30 min.
S
Situation
"Calling about [patient], Room [#]. I have a concern about alcohol/benzo withdrawal."
  • CIWA score · Vitals · Symptoms: tremor / diaphoresis / agitation / hallucinations
B
Background
  • TAPS scores · Seizure/DT hx · Last drink/benzo · Meds given · SW consult
A
Assessment
"Active withdrawal. CIWA is [score] and trending [up/down/stable]."
  • ≥8 after 3 doses in <3 hrs · Diazepam threshold · RASS if intubated
R
Request
  • Withdrawal meds · Psych/Addictions consult · Labs · Precautions · Stop CIWA order if <8 ×48 hrs
🚨

BERT

Behavioral Emergency · Dial 33-911
🔴 Activate BERT + Call LIP Now — imminent violence
🟡 Call LIP First, Then BERT — escalating agitation without violence
S
Situation
"Calling about [patient], Room [#]. I'm activating BERT for a behavioral emergency."
  • Behavior · Imminent violence · Vitals + glucose
B
Background
  • Admission dx · Psych hx · Current psych meds · Prior BERTs · Recent MS change
A
Assessment
"Patient poses safety risk. Medical causes [have/have not] been ruled out."
  • Medical cause ruled out · Others at risk · De-escalation outcome · Restraints
R
Request
  • STAT meds · Restraint order · Psych consult · 1:1 sitter · Bedside presence
🛡️

Falls

Assess for injury · Apply ABCS
Head Strike / ABCS Factor
Post-Fall Order Set. Notify MD + Leadership now.
No Head Strike / No ABCS
Routine vitals + orthostatic VS. Notify MD + Leadership.
S
Situation
"Calling about [patient], Room [#]. They have fallen and I am notifying you for evaluation."
  • Time · Witnessed · Head strike · Responsive · Visible injury
B
Background
  • Morse score · ABCS factors · Anticoagulation · Prior falls · Baseline neuro
A
Assessment
"Concerned about [injury/neuro change]. Patient has [ABCS/head strike/unwitnessed fall]."
  • Vitals · Neuro change · Neck/head pain
R
Request
  • Bedside eval · Post-Fall Order Set · Imaging · Consults · VCO

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