On-call escalation rules decide who gets woken, how quickly and by what route when something goes wrong out of hours. Written well, they let a night coordinator, an answering service or an automated voice send the right call to the right person without guessing. Written badly, or not written at all, they leave a tired person to decide at 2am. This guide gives you a template for Irish home care and hospice teams.
A note on scope. Escalation rules route calls. They do not give clinical advice, and nobody who applies them should interpret a symptom. The decision about what to do clinically always belongs to your nurse or senior clinician.
Why on-call escalation rules matter
Older people are the group most likely to ring about a fall, a change or a worry. A 2026 TILDA study in BMJ Open found that 1 in 8 people aged 70 and over needed medical attention for a fall in a 12-month period, and 1 in 16 attended an emergency department. The HSE's Urgent and Emergency Care Operational Plan 2024 says one third of adults aged 75 and over live with frailty in Ireland, and that up to 70% of older adults who present to the emergency department live with frailty. Your clients are in that population. Many of them have little margin when something changes.
There is also a staffing reason. The Department of Health's Strategic Workforce Advisory Group lists unsociable hours, working alone and burnout among retention problems in care. Clear rules reduce the number of unnecessary wake-ups and the stress of uncertainty. They work as a retention tool.
A good rule removes the decision from the worst hour of the night and puts it into the calmest hour of the week.
The four levels
Four levels are enough for most agencies. More than that and people stop remembering them. Hettie uses the same four, and you can use them whatever system you run.
| Level | Meaning | Who is told | How |
|---|---|---|---|
| 1. Information | Nothing to do now. Goes into the morning summary. | Coordinator | Summary, dashboard |
| 2. Attention | Someone from the agency needs to call back by the next working day or the branch deadline. | Coordinator | Dashboard, email, text if you choose |
| 3. Urgent | Someone from the agency needs to speak to the person now. | On-call nurse or manager | Live transfer, then alert call and text, then the chain |
| 4. Emergency | Immediate risk reported. | Caller is told to ring 112 or 999. On-call is alerted at the same time. | Alert call and text, chain until acknowledged |
What goes at each level
Below are example triggers. Treat them as a starting point and adapt them with your nurse lead. You can raise any trigger to a higher level. Do not lower the emergency and urgent ones.
Level 4: Emergency
- Cannot breathe, or is gasping.
- Chest pain, or pain going down the arm.
- Person will not wake, is unresponsive or has collapsed.
- Face drooping, slurred speech or an arm that will not lift.
- Heavy bleeding that will not stop.
- On the floor and unable to get up, or has hit their head.
- Says they want to end their life.
- Violence or danger in the house, or smoke.
Script for the caller: "Please hang up and call 999 or 112 now." If someone says they cannot call, the call handler stays on the line and the on-call person is alerted at once. For anyone at risk of self-harm, add Samaritans on 116 123.
Level 3: Urgent
- A fall with no injury reported, but the person is alone.
- A missed visit where the client is alone and dependent.
- A medicine has run out, or a double dose is reported.
- New confusion reported by a family member.
- Severe or new pain reported.
- A concern about abuse or neglect.
- A family carer who says they cannot cope tonight.
- A carer who cannot make a visit in the next few hours.
- In hospice, distress or agitation reported by the family. See our guide to hospice out of hours calls.
Level 2: Attention
- A recent hospital or emergency department visit.
- A complaint, such as lateness.
- A request to change or cancel a visit.
- Low mood or repeated loneliness.
- A request for a call back.
Level 1: Information
- Thanks, praise or a satisfied reply.
- A confirmation, such as "see you tomorrow".
- An enquiry about starting new care.
Combination rules that catch what single triggers miss
- Two level 2 triggers in one call move up to level 3 if one of them is a fall, pain or medicine.
- A caller who says "this is urgent" or "it can't wait" is treated as level 3 at least.
- If a call could fit two levels, always choose the higher one.
Who gets told, how fast and what if they do not answer
Every level 3 or 4 rule needs four answers written down.
- Who is first. A named role, not a name that will be out of date.
- How they are reached. A live transfer, a call, a text, or all three.
- How long before the next person. Choose a short interval you can defend, shorter for a live transfer and a little longer for an alert chain. Set your own numbers and test them.
- Who is next. A second on-call, then the coordinator, then the director of operations.
The chain should keep going until a human confirms they have the call. In Hettie, for instance, an urgent alert stays open and keeps alerting until someone takes it, and it never closes itself. Whatever you use, adopt that principle. An alert that closes because nobody answered is a hidden failure.
What the caller hears
Callers need to know what is happening. Write short sentences for each case.
- Live transfer: "I am putting you through to the on-call nurse now. Please stay on the line."
- No answer: "I could not reach the on-call team just now. I have marked this as urgent and they will ring you back. If it gets worse, or you think it is an emergency, ring 999 or 112."
- Clinical question: "That is a question for your nurse. I will pass it on now."
Never let a handler say that something is "probably nothing", that the caller does not need to go to hospital or that they should wait until morning. Those are clinical judgements.
A worked example: a fall at 11pm
A client's son rings at 11pm. He says his mother fell in the bathroom but is back in her chair and says she is fine. She lives alone.
- The call handler records the caller, the client, the callback number and one line in the son's own words: "Mum fell in the bathroom, she's back in her chair."
- The rule for a fall without a reported injury, with a person alone, is level 3, urgent.
- The call is put through to the on-call nurse, who hears a one-line summary before the line connects.
- The nurse decides what to do. That might be a call to the client, a visit or advice to ring 999 or 112 if the picture changes.
- If the nurse does not answer, the chain moves to the second on-call, then the coordinator, until someone confirms.
- The next morning, the summary shows who took the call, when and what was decided, and the coordinator rings the son back.
If the son had said his mother could not get up, or had hit her head, the rule would have been level 4. The caller would be told to ring 112 or 999 at once, and the on-call person would be alerted in parallel.
Put it on one page
A rule card should fit on a single sheet that anyone answering the phone can use. Include the four levels, the example triggers, the chain with names or roles, the caller wording and a line at the bottom that says what nobody on the line may ever do: give clinical advice. Put the date and the name of the person who approved it at the top.
Protecting the people on call
Rules that wake people for everything will drive them out. Review three things monthly.
- Volume. How many level 3 and 4 alerts per person per week? Is it fair?
- Quality. Of the alerts that woke someone, how many were rightly level 3 or 4? Adjust triggers that raise too many false alarms, but never loosen the emergency ones.
- Rest. Check how the Organisation of Working Time Act 1997 applies to your on-call roster, and take advice from an employment law adviser.
A first layer that answers every call and sorts by your rules can reduce wake-ups without hiding anything. Our article on after-hours phone cover compares the options, and the guide to counting missed calls shows how to measure the effect.
Testing and reviewing
Rules on paper are not rules in practice. Once a quarter, run a drill. Make test calls for a fall, a missed visit, a medicine problem and a distressed family. Time the response, check the record and look at who was told. Ask the on-call team what felt wrong. Change one thing, then test again.
Keep a short change log with a date and the name of whoever approved each edit. It shows that the rules are living, and it is the kind of record an inspector will value once registration begins. If a supplier or system applies your rules for you, see our guide to AI voice and GDPR for the data protection questions to settle first. Our Care Centre page shows how rules like these are set up in practice.
Sources
- TILDA / Trinity College Dublin: One in eight older people in Ireland require medical attention for a fall each year (BMJ Open, 11 February 2026)
- HSE: Urgent and Emergency Care Operational Plan 2024
- Department of Health: Report of the Strategic Workforce Advisory Group on Home Carers and Nursing Home Healthcare Assistants (September 2022)
Frequently asked questions
How many escalation levels should we have?
Four is usually enough: information, attention, urgent and emergency. Each level should have a clear owner, a route and a response time you can test. More levels make rules harder to remember.
Should escalation rules decide whether a client goes to hospital?
No. Rules route a call to the right person. Whether a client needs a nurse visit, a GP or an ambulance is a clinical decision for your nurse or for the emergency services. If a caller describes an emergency, they should be told to ring 112 or 999.
How often should we review our rules?
Review monthly for volume and fairness, and run a test drill each quarter. Also review whenever you have a serious incident, a change in your on-call team or a change in regulation.
