# HAD Digital - Escalation Protocol

Version: 1.0.0 Date: 5 September 2026 Clinical Owner: Dr Kais Aldabbagh, Polyclinique St Come - Medical Oncology

Overview

This document defines the default escalation protocol for HAD Digital. The protocol determines how toxicity grades map to alert tiers and who receives notifications. The protocol can be customized by the prescribing oncologist per patient.

Alert Tiers

Tier 1: Routine

Trigger: Grade 1 toxicity (any symptom) Action: Log on timeline only; no immediate notification Response Time: Review at next scheduled visit or within 48 hours Responsible: HAD coordinating nurse (review), Community nurse (observation)

Example:

• Patient reports mild nausea (Grade 1)

• Logged on timeline

• Reviewed by HAD nurse at next home visit

Tier 2: Urgent

Trigger: Grade 2 toxicity (any symptom) Action: Immediate notification to HAD coordinating nurse and community nurse Response Time: Within 30 minutes during care hours; within 2 hours outside care hours Responsible: HAD coordinating nurse (primary), Community nurse (backup)

Escalation Path:

1. Alert sent to HAD coordinating nurse

1. If not acknowledged within 30 minutes → Alert sent to community nurse

1. If not acknowledged within 60 minutes → Alert escalated to on-call oncologist

Example:

• Patient reports moderate nausea with vomiting (Grade 2)

• HAD nurse receives push notification

• Nurse calls patient within 30 minutes

• Nurse assesses situation and may contact oncologist if needed

Tier 3: Emergency

Trigger: Grade 3+ toxicity (any symptom), OR Grade 2+ for specific high-risk symptoms Action: Immediate notification to on-call oncologist Response Time: Immediate (within 5 minutes) Responsible: On-call oncologist (primary), HAD coordinating nurse (backup)

High-Risk Symptoms (Grade 2+ triggers Emergency):

• Fever > 38.5°C with neutropenia risk

• Bleeding with thrombocytopenia risk

• Severe dehydration

• Altered consciousness

• Chest pain or dyspnea

• Severe allergic reaction

Escalation Path:

1. Alert sent to on-call oncologist immediately

1. Oncologist calls patient within 5 minutes

1. If oncologist unavailable → Alert sent to backup oncologist

1. If no response within 10 minutes → Emergency services contacted

Example:

• Patient reports Grade 3 fatigue with fever

• Oncologist receives immediate notification

• Oncologist calls patient

• Decision: Emergency department referral or home visit

Notification Matrix

Notification Channels

Note: SMS and phone call channels are not implemented in the MVP. These require integration with external services (Twilio, etc.) and will be added in Phase 2.

Customization

The prescribing oncologist can customize the escalation protocol per patient:

1. Override Alert Tiers: Change which grades trigger which tiers

1. Custom Recipients: Assign specific clinicians to specific patients

1. Custom Response Times: Adjust response time requirements

1. High-Risk Symptoms: Add or remove symptoms that trigger emergency escalation

Configuration: Stored in patient's treatment plan (not implemented in MVP).

Clinical Responsibility

Important: The escalation protocol is a decision-support tool, not an autonomous diagnostic system. Final clinical judgment remains with the treating physician and care team at all times.

1. Automated grades are provisional: All automated grades are flagged as provisional until reviewed by a qualified clinician for Grade ≥ 2.

1. Clinical override: Clinicians can override automated grades and escalate/de-escalate alerts based on clinical judgment.

1. Audit trail: All escalations, acknowledgments, and overrides are logged in the audit trail.

1. Liability: The platform facilitates communication; it does not replace clinical decision-making.

Implementation Notes

MVP Implementation

The MVP implements the basic escalation logic:

1. Grade 1: Logged on timeline (routine)

1. Grade 2: Alert created (urgent)

1. Grade 3+: Alert created (emergency)

Future Enhancements

1. Configurable protocols: Per-patient protocol customization

1. Time-based escalation: Automatic escalation if not acknowledged within response time

1. Multi-channel notifications: SMS, phone calls, push notifications

1. On-call rotation: Automatic on-call schedule management

1. Escalation history: Track escalation chains and response times

Testing

Test the escalation protocol with the following scenarios:

1. Grade 1 nausea: Should log on timeline, no alert

1. Grade 2 nausea: Should create urgent alert

1. Grade 3 fatigue: Should create emergency alert

1. Grade 2 fever with neutropenia: Should create emergency alert (high-risk)

1. Multiple symptoms: Highest grade determines tier

References

• CTCAE v5.0 (Common Terminology Criteria for Adverse Events)

• French National Authority for Health (HAS) guidelines for HAD

• AFSSAPS recommendations for chemotherapy toxicity management