ICU · Ethics
Acute severe community-acquired pneumonia: ICU handover and communication
Also known as ICU handover · Communication in ICU · SBAR handover · Clinical handover
Clinical handover is the transfer of professional responsibility and accountability for patient care from one clinician/team to another. Poor handover is a leading cause of preventable patient harm — the Joint Commission attributed the majority of sentinel events to communication breakdown, and the ANZICS CORE and ICNARC datasets repeatedly identify failed handover as a root-cause contributor to ICU morbidity. ICU handover contexts: shift change (nursing + medical), ICU-to-ward transfer, ED-to-ICU referral/upgrade, inter-hospital retrieval, weekend/holiday/long-weekend handover, and emergency/event handover (cardiac arrest, rapid response, deterioration). Structured tools: ISBAR (Identify, Situation, Background, Assessment, Recommendation — the ANZ standard with explicit identification step), SBAR (Situation, Background, Assessment, Recommendation — the original Kaiser Permanente model), I-PASS (Illness severity, Patient summary, Action list, Situation awareness with contingencies, Synthesis by receiver — most evidence-based, reduced medical errors 23% and preventable adverse events 30% in the NEJM 2014 trial), and ISOBAR (Identify, Situation, Observations, Background, Agreed plan, Read-back — Australian Commission on Safety and Quality in Health Care variant). Handover failure modes: missed information, wrong/duplicated/omitted medication, delayed investigation or treatment, loss of contingency plans, and absent situational awareness of the deteriorating patient. Critical-event communication techniques: closed-loop communication (sender → receiver reads back → sender confirms), read-back/verify-back of verbal orders and drug doses, and crew resource management (CRM) principles adapted from aviation. Principles of every handover: structured, concise, accurate, timely, documented in the medical record, with an explicit opportunity for questions and a synthesis/read-back step.
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Target exams
Red flags
Exam practice
SAQ — ISBAR handover for an ICU-to-ward transfer
10 minutes · 10 marks
A 72-year-old man was admitted to ICU 6 days ago with severe community-acquired pneumonia and septic shock, intubated for 4 days. He has now been extubated for 48 hours, on nasal high-flow oxygen at 30 L/min FiO2 0.35, off vasopressors for 72 hours, GCS 15, and has passed a swallow assessment. The ward bed manager calls to say a respiratory ward bed is available for transfer in 2 hours. The night registrar asks you to perform the handover.
SAQ — Communication failures contributing to an ICU adverse event
10 minutes · 10 marks
During a busy night shift a 58-year-old woman on your ICU deteriorates: HR 130, BP 80/45, lactate rising from 2.1 to 4.8 mmol/L over 3 hours. At 03:00 the night registrar telephones the on-call consultant and says ‘she’s not looking great, I think we should do something’. The consultant, woken from sleep, replies ‘ok, keep an eye on her, call me if worried’. At 06:30 the patient has a PEA arrest and dies. A root-cause analysis is convened.
Clinical pearls
Red flags
ISBAR framework — the deconstructed handover
ISBAR (Identify, Situation, Background, Assessment, Recommendation) is the ANZ-standard structured handover and escalation tool. It is SBAR with an explicit Identify step prepended — a deliberate forcing function that prevents the single most common handover error: talking about the wrong patient, or speaking to a clinician who does not know who is calling. ISBAR is mandated by the Australian Commission on Safety and Quality in Health Care (ACSQHC) NSQHS Standards (Communicating for Safety Standard) and is the default tool taught in ANZ ICU training and the CICM/FCICM curriculum.[2]
I — Identify
Who and to whom
- State YOUR identity, role, and team: "This is Dr Lee, ICU registrar on for Bay 4-6."
- State the PATIENT identity: full name, date of birth, bed/bay number, and one unique identifier (UR number).
- Confirm you are speaking to the RIGHT person (on phone): "Am I speaking to the night consultant on call?"
- Pitfall: omitting identity on a ward-to-ICU phone call — the receiving consultant cannot judge acuity, and the call may be misattributed.
S — Situation
Why now?
- One or two sentences capturing the CURRENT problem and why you are communicating NOW.
- "Mr X, day 3 ICU, ventilated for ARDS, is calling about a new desaturation to 82% on FiO2 0.6."
- Includes the headline: stable / deteriorating / crashing. For I-PASS users this maps to illness severity (stable / watcher / unstable).
- Pitfall: burying the lead in background before stating why the call is happening — the receiver cannot triage attention.
B — Background
Relevant history
- Pertinent past only — admission diagnosis, key comorbidities, course so far, lines/drains/ventilation status, allergies, code status.
- "Admitted with H1N1 pneumonitis, intubated 72h, Pronovost line day 2, no allergies, not for CPR per family meeting."
- Filter ruthlessly — the receiver does not need the full admission clerking. Tailor depth to the listener (ward nurse vs new ICU consultant).
- Pitfall: reciting the entire admission note — causes listener fatigue and obscures the actionable content.
A — Assessment
Your analysis
- Your synthesis of the current state — vital trends, examination, key investigations, and your working diagnosis/interpretation.
- "Assessment: new unilateral wheeze and rising peak airway pressure with falling SpO2 — consistent with right main-stem migration or mucus plugging until proven otherwise."
- State your level of certainty and your concern: "I am worried this is tube migration."
- Pitfall: presenting raw data (vital signs, labs) without interpretation — the receiver must re-derive the problem and may reach a different conclusion.
R — Recommendation
The ask
- The specific request or action: review now, give drug X, arrange scan, change ventilation, escalate to consultant.
- "I will auscultate and pull the tube back 2 cm, recheck ABG in 30 min, and call you if SpO2 stays <90%. Please come now if it does not improve."
- Always close with contingency and a timeframe ("call me back in 20 min regardless"). For verbal drug orders: state drug, dose, route, and request read-back.
- Pitfall: no recommendation — leaving the receiver to guess what is wanted. The "R" is the most frequently omitted element and the one with the strongest evidence for changing outcome.
Structured handover tools compared
Several mnemonics compete in the ICU space. They share a common logic — situation first, then context, then plan — but differ in structure, evidence base, and the contexts in which they perform best. The exam-relevant skill is knowing WHICH tool fits WHICH transition, and being able to argue the choice.[1][2]
SBAR
Situation–Background–Assessment–Recommendation
- Origin: US Navy nuclear submarine programme, adapted for healthcare by Kaiser Permanente (Haig 2006). The original and most widely taught healthcare handover tool.
- Strengths: short, memorable, four letters, easy to teach. Builds a shared mental model and flattens hierarchy between nurse and doctor.
- Best use: nurse-to-doctor escalation of the deteriorating patient; brief phone handovers; rapid response calls.
- Weakness: no explicit identification step, no read-back/synthesis step, and no structured contingency planning. Less suited to a full shift handover of many complex patients.
ISBAR
Identify + SBAR
- Origin: WHO Patient Safety Alliance and adopted as the ANZ standard by ACSQHC. SBAR with an explicit Identify step.
- Strengths: forces identification of sender, patient, and intended receiver on EVERY contact — closes the wrong-patient/wrong-recipient gap that SBAR leaves open.
- Best use: the default ANZ handover and escalation tool; telephone referrals; ward-to-ICU and ICU-to-ward communication.
- Weakness: still lacks a mandatory synthesis/read-back step and a structured contingency section; depth of Background is operator-dependent.
I-PASS
Illness severity–Patient summary–Action list–Situation awareness–Synthesis
- Origin: Starmer/Spector Boston Children's Hospital; validated in the 2014 NEJM multisite trial (9 paediatric residency programmes).
- Strengths: MOST EVIDENCE-BASED — reduced medical errors by 23% and preventable adverse events by 30%; built-in Action list (to-dos), Situation awareness (contingencies: "if X then Y"), and Synthesis (receiver reads back).
- Best use: shift-change handover of multiple complex patients; ICU-to-ward transfer; any setting where the receiving team assumes ongoing care overnight.
- Weakness: longer to deliver; needs training (a 2-hour workshop plus faculty observation and feedback) and institutional buy-in to sustain. The Synthesis step fails if the receiver is too junior to challenge.
ISOBAR
Identify–Situation–Observations–Background–Agreed plan–Read-back
- Origin: Australian variant promoted by ACSQHC and the WA/NSW health systems; SBAR-style with explicit Observations and a Read-back element.
- Strengths: builds observations (vital signs) and read-back into the mnemonic — both are weak points in plain SBAR. Common in Australian ED-to-ICU and MET-call contexts.
- Best use: Australian MET calls, ED-to-ICU referrals, nurse-to-medical emergency escalation.
- Weakness: less international recognition than SBAR/I-PASS; the "O" can encourage data-dumping without the synthesis that I-PASS Assessment/Synthesis forces.
Why ICU handovers fail — failure modes and consequences
ICU patients accumulate an enormous volume of pending tasks, titrated therapies, and contingency plans; the handover is the moment all of this is transferred to a fresh, often more junior, and frequently busier team. The Joint Commission's sentinel-event analysis repeatedly identifies communication failure as the leading root cause of unintended harm, ahead of clinical knowledge gaps. The failure modes below are the recurring patterns.[2]
Missed / lost information
Omission
- Mechanism: information exists in the sender's head but is never verbalised or documented — pending cultures, an outstanding family-meeting decision, a "do-not-reintubate" agreement, an allergy, a planned tracheostomy.
- Consequence: delayed investigation, wrong antibiotic, unwanted escalation, repeat of a decision already made. The receiver "didn't know what they didn't know".
- Mitigation: structured tool (I-PASS Action list forces enumeration of tasks); bedside handover (the chart and the patient are in view); written handover document that survives the shift.
Wrong / duplicated / omitted medication
Drug error
- Mechanism: ICU patients average 10-20 medications with frequent changes (vasopressor titration, antibiotic de-escalation, anticoagulation holds for procedures). The handover is the breakpoint where doses are double-counted, missed, or continued after they should stop.
- Consequence: duplicated anticoagulation and bleeding; omitted antibiotics and sepsis relapse; continued sedatives delaying wean. ICU-to-ward transition is the highest-risk period — up to half of patients have at least one medication discrepancy.
- Mitigation: formal medication reconciliation (Best Possible Medication History) at EVERY transition, especially ICU-to-ward; document STOP dates for antibiotics and sedatives; read-back verbal orders.
Delayed investigation or treatment
Time-critical loss
- Mechanism: a pending CT, blood culture, or family-meeting decision is mentioned in passing but not assigned to a named person with a timeframe. The receiver assumes someone else owns it.
- Consequence: a subdural haematoma scanned a day late; a positive blood culture not acted on; a goals-of-care conversation that never happens before an arrest.
- Mitigation: I-PASS Action list convention — each task names ONE responsible person, a deadline, and a check-back ("Dr Patel to ring radiology re CT head before 09:00 and document the outcome").
Lost contingency plan
No "if-then"
- Mechanism: the day team held a mental "if the lactate rises again, start noradrenaline" plan that was never handed over; overnight the patient deteriorates and the night registrar re-derives a plan from scratch, late.
- Consequence: delayed escalation, avoidable MET call or arrest, and decision-making fatigue in a junior at 03:00.
- Mitigation: I-PASS Situation Awareness ("if-then" contingencies) and an explicit overnight threshold to call the consultant: "If MAP <65 despite 30 mL/kg, start noradrenaline 5-20 mcg/min AND call me — I would rather be woken than not."
Absent situational awareness
No synthesis
- Mechanism: data is handed over without interpretation; the receiver nods but has not formed a shared mental model of how sick the patient is and what to watch for.
- Consequence: the receiver does not recognise deterioration because they never knew the baseline trajectory; the "watcher" patient is treated as routine.
- Mitigation: I-PASS Illness severity (label each patient stable / watcher / unstable) AND Synthesis by receiver (the receiver summarises back, forcing an active mental model).
Hierarchical / cultural failure
Not speaking up
- Mechanism: a nurse or junior doctor senses a problem but does not escalate because of hierarchy, fatigue, or a previous dismissive response. The handover is one-way.
- Consequence: preventable arrests — the warning signs were present but never reached a decision-maker.
- Mitigation: SBAR/ISBAR as a shared mental model that explicitly flattens hierarchy; psychological safety ("if you are worried, call — I will not be cross"); structured response to escalation (MET call without fear of criticism).
Interruption / cognitive overload
Environment
- Mechanism: handover delivered in a noisy bay, interrupted by alarms, phone calls, and other staff; the receiver is task-switching and cannot encode the information.
- Consequence: shallow encoding → rapid forgetting → missed task overnight.
- Mitigation: protected handover time (the unit stops taking referrals for 20-30 min); quiet space for the consultant-to-consultant handover; bedside handover with a pause for the nurse-led portion.
The shift change — a step-by-step protocol
The medical and nursing shift handover is the highest-frequency handover in the ICU and the one over which the unit has the most control. A disciplined, repeatable protocol converts a chaotic changing-of-the-guard into a reliable transfer of responsibility.[2]
The ICU shift handover — from pre-read to synthesis
1. Prepare before the handover (10-15 min)
The outgoing team updates the electronic handover document for every patient: working diagnosis and day of admission, current status (ventilation, vasopressors, renal replacement therapy, lines/drains), the day's significant events, pending results, the Action list (named tasks with timeframes), and explicit contingencies ("if...then...and call me"). A pre-populated document means the verbal handover reinforces rather than transcribes.
2. Agree the format and timing
Adopt ONE structured tool unit-wide — I-PASS for the medical handover of multiple complex patients, ISBAR for individual escalations. Hold a protected handover window (the unit stops accepting new admissions/referrals unless emergent) so the incoming team is not interrupted. Run medical and nursing handovers in parallel where staffing allows.
3. Lead with illness severity (the "I" of I-PASS)
For EACH patient the outgoing registrar first states illness severity: STABLE (no active titration, routine), WATCHER (at risk of deterioration — low threshold to review), or UNSTABLE (actively deteriorating, on escalating support). This single label orients the incoming team's attention and triages who to round on first.
4. Deliver a structured patient summary (S-P)
Concise narrative: admission diagnosis, hospital/ICU course, current physiological state, key active problems, and the plan. Avoid reciting the chart — interpret. Highlight anything that changed in the last shift (new vasopressor, failed SBT, new organ failure). Keep each patient to 2-3 minutes.
5. Hand over the Action list explicitly (A)
Read out every pending task, naming ONE responsible person and a deadline for each: "Dr Khan to chase the sputum culture and document by 12:00; bedside nurse to re-site the femoral line before theatre." Mark each task as done/undone on the shared document. Unfinished tasks are explicitly re-assigned, not assumed.
6. State the contingencies — Situation Awareness (S)
For each "watcher/unstable" patient, give a specific if-then plan: "If lactate rises >4 or MAP <65 despite fluids, start noradrenaline and call me." Agree the overnight threshold to call the consultant. This is the step that prevents the 03:00 re-derivation of a plan from scratch.
7. Move to the bedside for the nursing-led portion
Where possible, complete the handover AT THE BEDSIDE so the patient, monitors, lines, drains, infusions, and drug chart are all in view. The incoming nurse checks infusions (drug, concentration, rate, line), lines (site, dressing, insertion date), alarms and ventilator settings, and confirms drug chart and observation chart are current.
8. Synthesis / read-back by the receiver (the second S of I-PASS)
The incoming registrar restates the key issues, the action items, and the contingencies for each unstable patient. This forces active encoding and surfaces any misunderstanding immediately: "So for Mr X, your worry is the rising lactate — if it hits 4 I start noradrenaline and call you. For Ms Y, the tracheostomy is booked for tomorrow and she is for ceiling of care of intubation. Correct?"
9. Document the handover in the medical record
The handover is a clinical event — record date, time, the clinicians involved, and the plan in the progress note (an SBAR/I-PASS template). Verbal handovers that are not documented effectively did not happen, from a medico-legal standpoint, and will not be acted on by the next shift.<Cite id="1" />
10. Open the floor for questions and confirm the safety net
End with an explicit invitation: "What have I missed? What are you most worried about overnight?" and restate the overnight consultant contact pathway. A handover that ends without questions has almost certainly failed to surface a concern.
Patient transfer handover: ICU to ward
The ICU-to-ward transfer is the single highest-risk transition in the patient journey. The patient moves from a 1:1 or 1:2 nursing ratio, continuous monitoring, and immediate physician access to a 1:4+ ratio, intermittent observations, and a team that did not manage the acute illness. Readmission to ICU within 48-72h (the standard readmission metric) is the quality signal that the transfer was premature or the handover inadequate; a rate >5-10% warrants investigation.[2]
ICU-to-ward transfer — from readiness check to ward handover
1. Confirm ward readiness, not just ICU bed pressure
Decide on physiological readiness, NOT on bed availability. The patient should be off vasopressors and continuous renal replacement therapy, have a stable and treatable respiratory status, controlled pain/agitation, and no pending time-critical result that would force a return. Use a structured discharge checklist. Premature discharge for bed pressure is a documented predictor of readmission and death.<Cite id="2" />
2. Complete and reconcile the medication chart
Perform a formal Best Possible Medication History and reconcile against the pre-admission list. Explicitly STOP ICU-only drugs (sedatives, muscle relaxants, prophylactic stress-ulcer cover if no longer indicated, IV PPIs stepped down to oral) and restart appropriate ward medications (antihypertensives, oral hypoglycaemics, anticoagulants at the correct post-procedural timing). Document antibiotic STOP/REVIEW dates. Up to half of ICU discharges have at least one medication discrepancy.<Cite id="2" />
3. Write a structured discharge summary that a ward team can act on
Include: admission diagnosis and key interventions, current clinical status and ceiling of care / goals-of-care decision, active problems and the plan for each, pending investigations with who will action them, follow-up arrangements (microbiology review, outpatient clinic, rehabilitation), and an explicit "if...then..." deterioration plan with thresholds to re-escalate. A discharge summary written days later is a handover failure.
4. Hand over verbally to the receiving team (ISBAR or I-PASS)
A phone or face-to-face ISBAR with the receiving ward doctor and nurse: identify patient, state the situation (transferring today, stable/watcher), background (ICU course), assessment (current state and main risks), and recommendation (what to watch for, what to do if deteriorating, who to call). Do NOT rely on the discharge summary alone.
5. Brief the patient and family
Explain the move, the change in monitoring, what to expect, and the plan. Confirm goals-of-care status is understood and documented. Family briefing at transfer reduces anxiety-driven readmission calls and aligns expectations.
6. Manage the technology transition
Convert ICU monitoring to ward-appropriate observations (frequency set by track-and-trigger score). Remove arterial/CVC lines if no longer needed (and document). Ensure oxygen, inhalers, nebulisers, and any non-invasive ventilation are available on the ward. Confirm tracheostomy (if present) has a ward-safe plan, speaking valve, inner cannula, and trained staff.
7. Agree the follow-up and the safety-net
ICU outreach / follow-up within 24-48h for high-risk patients; clear escalation pathway back to ICU or MET if the ward team is concerned; a named ICU contact for 24h. State explicitly: "If observations breach the MET criteria, call a MET — do not wait."<Cite id="2" />
Patient transfer handover: ED to ICU, and inter-hospital transfer
The direction of transfer changes the handover dynamic. ED-to-ICU is an upgrade — the receiving ICU needs a complete clinical picture to assume care. Inter-hospital retrieval adds geography, transport physiology, and a third team (the retrieval service) in the loop.[2]
ED to ICU (upgrade)
Receivers take over high-acuity care
- Dynamic: the ED team has resuscitated and stabilised; the ICU team assumes definitive care. The handover is a full clinical transfer, not an update.
- Tool: ISBAR or ISOBAR — ED-to-ICU referrals are the canonical ISBAR use case in ANZ. Lead with the diagnosis and physiological state ("intubated, ventilated, MAP 70 on noradrenaline 15").
- Must include: airway status (intubated? tube size/depth), ventilation settings and latest ABG, haemodynamics and vasopressors, fluids and blood products given, drugs given (especially sedatives, paralysers, antibiotics, time of first antibiotic), key investigations (CT, lactate trend), resuscitation goals met/unmet, and family awareness.
- Common failure: the ED team focuses on the resuscitation narrative and omits the granular detail ICU needs (exact vasopressor rate, last potassium, allergies, code status). Use a checklist (e.g. the ISOBAR or a structured admission template) to force completeness.
Ward to ICU (deterioration / MET)
Escalation
- Dynamic: the ward team has called for help; the ICU team decides admit vs advise. The ward owns the patient until ICU formally accepts.
- Tool: ISBAR from the ward team to ICU; the ICU responder documents acceptance and the ceiling of care.
- Must include: why the MET/escalation was called (the trigger and the trend), the working diagnosis, what has been done, the patient's baseline and wishes, and the explicit question ("please review for ICU admission").
- Common failure: the ward nurse/doctor gives a long background without stating the ask; the ICU team cannot tell whether this is an advice call or an admission request. The ISBAR "Recommendation" forces the ask.
Inter-hospital retrieval
Three-team handover
- Dynamic: referring hospital → retrieval team → receiving ICU. Each interface is a handover; information degrades at every step ("Chinese whispers").
- Tool: structured written transfer document PLUS verbal ISBAR at each interface. The retrieval service (e.g. Adult Retrieval Victoria, NSW Aeromedical, RFDS) usually mandates a standardised handover template.
- Must include: full clinical summary, interventions and timing, drugs and infusions running (with concentrations), ventilation settings, lines and drains, investigations, imaging on a disc/USB, and the goals-of-care / consent status confirmed with the family BEFORE transfer.
- Common failure: incomplete handover at the referring-hospital-to-retrieval interface because the referring team is task-saturated; the receiving ICU then inherits an information gap. A retrieval doctor who re-derives and documents a full ISBAR before transport closes the gap.
Hospital to hospital (step-down / repatriation)
Return to local hospital
- Dynamic: a tertiary ICU patient repatriates to a lower-acuity hospital closer to home once stabilised. The receiving hospital may have less ICU capability.
- Tool: full written summary (treated like an ICU-to-ward discharge but to another ICU) plus verbal ISBAR to the receiving ICU consultant.
- Must include: ceiling of care agreed between the two units (will the receiving hospital reintubate? escalate again?), tracheostomy/long-term ventilation plan if relevant, rehabilitation needs, and the family understanding of the move.
- Common failure: repatriating a patient whose needs exceed the receiving hospital's capability (e.g. a fresh tracheostomy to a hospital with no tracheostomy cover), precipitating a second retrieval. Match capability before transport.
Closed-loop communication during critical events
During a cardiac arrest, rapid sequence intubation, massive transfusion, or any high-acuity time-critical event, ordinary conversational communication fails: noise, stress, and cognitive load degrade accuracy. Closed-loop communication (also called check-back or read-back) is the aviation/CRM-derived technique that restores reliability. The principle is that information is not "sent" until it has been received, understood, and confirmed.[1]
The closed loop — every verbal order and drug dose
1. Sender issues the message, naming the receiver
Direct the instruction to a named individual, by role or name, to avoid the "diffusion of responsibility" where everyone assumes someone else will act: "Sarah, please draw up 100 mcg of adrenaline — that is one millilitre of the 1:10,000 concentration." Avoid generic "someone give adrenaline."
2. Receiver reads back the message verbatim
The receiver repeats the drug, dose, route, and rate back to the sender: "100 micrograms of adrenaline, one millilitre of 1:10,000, IV push, drawing up now." This is NOT parroting — it is independent confirmation that the message was encoded correctly. The read-back catches sound-alike errors (adrenaline vs noradrenaline, hydrocortisone vs hydroxyzine, TEN-fold dosing errors).
3. Sender confirms accuracy ("That is correct")
The sender explicitly confirms the read-back is accurate before the drug is given. If incorrect, the sender corrects: "No — one hundred MICROGRAMS, not milligrams." The loop is only closed when the sender confirms; silence is not confirmation.
4. Receiver executes and announces completion
After administration, the receiver reports back the outcome: "100 micrograms adrenaline given IV at 14:32." This closes the second loop — the sender knows the action was completed and can update the team. Document the time and dose in the arrest record.
Read-back / verify-back
Verbal orders
- Every verbal or telephone order (drug, dose, ventilator change, ceiling-of-care decision) is read back by the receiver and confirmed by the sender. Mandated by Joint Commission and ACSQHC NSQHS as a National Patient Safety Standard.
- Highest yield for sound-alike drugs (adrenaline/noradrenaline, hydromorphone/morphine), high-alert drugs (insulin, heparin, potassium, neuromuscular blockers), and paediatric weight-based doses.
- The sender must not be satisfied with a nod — wait for the read-back and confirm "correct".
Crew resource management (CRM)
Team behaviours
- Borrowed from aviation (Crew Resource Management / TeamSTEPPS). Core behaviours: brief and debrief; use names and roles; one leader at the head of the bed; flat hierarchy so any team member can voice a concern ("I am concerned about..."); situational awareness shared aloud.
- Specific tools: SBAR for escalation, "call-outs" to announce critical events ("pulse is back, 14:32"), "check-backs" (closed loop), "huddles" for a quick team sync, and "STEP" (Status of patient, Team members, Environment, Progress toward goal) for situational awareness.
- Reduces ambiguity, distributes workload, and empowers the most junior person to stop an unsafe act — the human-factors defence that catches errors the protocol cannot.
SBAR during the arrest
Structured updates
- Use SBAR for the periodic situation report during a prolonged arrest: Situation ("4 min in, VF arrest"), Background ("post-MI, 20 min since arrest"), Assessment ("third shock, amiodarone given, no output"), Recommendation ("prepare for eCPR consideration / call consultant").
- Prevents the team drifting without a shared mental model; gives the leader a forced pause to re-plan every 2-4 minutes (aligned with the ALS algorithm).
Critical language / graded assertiveness
Speaking up
- A shared vocabulary for escalation that bypasses politeness without causing offence. Two common models: CUS ("I am Concerned, I am Uncomfortable, this is a Safety issue") and the two-challenge rule (if a concern is voiced twice and ignored, escalate up the chain).
- Designed for the nurse who sees the surgeon about to cut the wrong side, or the registrar who hears the consultant call for the wrong drug. Gives permission to interrupt.
- Mandate as a unit behaviour; rehearse in simulation. A team that has never practised graded assertiveness will not use it in a real crisis.
Worked example — ISBAR for an ICU-to-ICU consultant escalation
A night registrar calls the on-call ICU consultant about a deteriorating patient. This is the verbal script — note the explicit Identify, the lead-with-acuity Situation, the filtered Background, the interpretive Assessment, and the specific Recommendation with a contingency.[3]
A complete ISBAR escalation call — annotated
I — Identify
"Good evening, this is Dr Nguyen, the night ICU registrar at Royal X ICU. I am calling about Mr John Citizen, UR 12345678, in Bay 3. Am I speaking with the on-call consultant, Dr Patel?" — Identifies sender, patient (with two identifiers), and confirms the recipient.
S — Situation
"The situation is that Mr Citizen is deteriorating — he was admitted 48 hours ago with H1N1 pneumonitis and ARDS, and over the last two hours his PaO2/FiO2 has fallen from 180 to 95 on volume-control ventilation despite increasing PEEP to 14 and FiO2 to 0.9. I am worried we are losing the airway–oxygenation battle and I would like you to come in." — Leads with acuity and a time-stamped trajectory; states the ask early.
B — Background
"Background: 58-year-old, previously well, BMI 32, intubated day 1 for type 1 respiratory failure, proned once on day 1, currently on volume-control TV 6 mL/kg ideal body weight, PEEP 14, FiO2 0.9, driving pressure 18. On noradrenaline 12 mcg/min for MAP 68. Paralysed with cisatracurium infusion. Latest chest X-ray shows bilateral consolidation, slightly worse on the right. No pneumothorax on lung ultrasound. Last ABG 20 min ago: pH 7.28, PaCO2 52, PaO2 58, HCO3 24, lactate 2.1." — Filtered to the variables that bear on the oxygenation problem; interprets the imaging.
A — Assessment
"My assessment is that he has severe, worsening ARDS with a P/F of 95 despite lung-protective ventilation, prone positioning, and paralysis. The PaCO2 is rising with a permissive-hypercapnia strategy but pH is now <7.30. I cannot exclude a right main-stem migration or a new mucus plug, though lung ultrasound did not show a pleural sync. I think he may need a second prone session, recruitment manoeuvre consideration, and escalation of ventilatory strategy — and I want your eyes on him." — An interpretation, not a data dump; states certainty and the working differential.
R — Recommendation
"My recommendation is that you come in now to review. While you are en route, I will re-check tube position with bronchoscopy, repeat the ABG, and prepare for a second prone turn. If his SpO2 drops below 85% or he becomes haemodynamically unstable, I will call you immediately on the mobile. Does that plan sound right, and is there anything else you would like me to do before you arrive?" — A specific ask, the steps already in train, an explicit contingency with a threshold to recall, and an invitation for the read-back/confirmation.
Landmark trials and guidelines
Starmer 2014 (NEJM) — the I-PASS Handoff Bundle (PMID 33529977)
Haig 2006 — SBAR as a shared mental model (PMID 16617948)
De Meester 2013 — SBAR reduces unexpected death (PMID 23537699)
Joint Commission Sentinel Event Data — communication as root cause
Abraham 2021 — ICU handover systematic review (PMID 34402722)
Additional clinical pearls
Red flags — when handover failure is imminent
Exam revision summary
Definitions
Core concepts
- Handover = transfer of professional responsibility and accountability between clinicians/teams.
- Closed-loop communication = sender → named receiver reads back → sender confirms → receiver executes and announces.
- Contingency = an explicit if-then plan with a threshold to escalate ("if MAP <65 despite fluids, start noradrenaline and call me").
Tools
Four mnemonics
- ISBAR (Identify, Situation, Background, Assessment, Recommendation) — ANZ standard, ACSQHC NSQHS.
- SBAR (Situation, Background, Assessment, Recommendation) — US/Kaiser original, shared mental model.
- I-PASS (Illness severity, Patient summary, Action list, Situation awareness, Synthesis) — most evidence-based, NEJM 2014.
- ISOBAR — Australian variant with explicit Observations and Read-back.
Evidence
Numbers to quote
- I-PASS (Starmer 2014, NEJM): medical errors -23%, preventable adverse events -30%, no change in handover duration.
- De Meester 2013 (Resuscitation): SBAR reduced unexpected death from 0.99 to 0.34 per 1,000 admissions.
- Joint Commission: communication = leading root cause of sentinel events, ahead of knowledge gaps.
High-risk moments
Where to focus
- ICU-to-ward transfer (highest-error transition; reconcile medications, write summary, hand over verbally).
- Night/weekend handover (reduced senior cover, fatigue — extra structure and contingencies).
- Verbal orders in arrests (read-back mandatory; sound-alike and ten-fold errors).
- Inter-hospital retrieval (three-team handover; information degrades at each interface).
References
- [1]Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
- [2]Desmedt M, Ulenaers D, Grosemans J, et al. Clinical handover and handoff in healthcare: a systematic review of systematic reviews. International journal for quality in health care : journal of the International Society for Quality in Health Care, 2021.PMID 33325520
- [3]Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 2006.PMID 16617948
- [4]De Meester K, Vermoere M, Vermeulen L, et al. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Resuscitation, 2013.PMID 23537699