Handover and communication in critical care

Contents

Overview

Communication failures are implicated in a majority of serious adverse events in critical care. The ICU environment — complex, fast-paced, with frequent handovers, multiple teams, and a high cognitive load — creates particular vulnerability. Structured handover tools and standardised processes reduce error at these high-risk transitions.

Handover Types in the ICU

Shift handover: Nurse-to-nurse and doctor-to-doctor handovers at shift change are the highest-frequency handover events. They transfer responsibility for ongoing monitoring, treatment decisions, and anticipated events.

Perioperative handover: The anaesthetic team handing over to the ICU team following surgery is a critical transition. The patient is newly arrived in an unfamiliar state, with recent surgical, anaesthetic, and haemodynamic history to communicate.

Inter-team handover: Between specialist teams (cardiology, surgery, nephrology) and the ICU team during the patient's admission.

Discharge handover: From ICU to a ward or HDU on step-down.

Inter-hospital transfer: Transfer of a critically ill patient between hospitals, either for specialist care or repatriation.

Structured Handover Frameworks

SBAR (Situation, Background, Assessment, Recommendation):

  • Situation: Who is the patient, what is happening now, and why am I handing over?
  • Background: Relevant history, reason for admission, past medical history, medications
  • Assessment: Current clinical status, active problems, trends
  • Recommendation: What needs to happen next, any outstanding tasks, anticipated events

SBAR reduces ambiguity and structures the communication so both parties understand the situation and the plan. It is widely adopted in UK critical care.

ISBAR adds an Identity step at the start — the caller identifies themselves and confirms the recipient's identity before proceeding.

Read-back: The receiver repeats back critical information (drug doses, investigation results, escalation plans) to confirm accurate receipt.

Closed-loop communication: The sender gives an instruction, the receiver confirms receipt and completion of the action. Common in resuscitation teams and aviation.

Elements of Effective ICU Handover

A comprehensive ICU medical handover includes:

  1. Patient identity, age, and reason for ICU admission
  2. Admission diagnosis and key events during the admission
  3. Current organ support: ventilator settings, vasopressor doses, renal replacement mode and settings
  4. Active problems and their status — what is being treated, what is improving, what is not
  5. Pending investigations — what has been sent, when results are expected, what decision depends on them
  6. Overnight or next-shift anticipated events — planned procedures, expected deteriorations, family discussions
  7. Ceiling of care and resuscitation status — this must be explicitly communicated, not assumed
  8. Family: what they have been told, the status of any ongoing conversations

Written documentation (nursing notes, medical notes, electronic records) supplements verbal handover but does not replace it.

Failure Modes

Common handover failures in the ICU include:

  • Interruptions during handover (bedside procedures, alarms, bleep calls)
  • Cognitive overload reducing the quality of information transmitted
  • Omission of critical safety information — particularly ceiling of care
  • Failure to communicate the patient's baseline and what they were like before this admission
  • Poor synthesis — the handing-over clinician lists facts rather than constructing a coherent narrative
  • Lack of documentation — no written record of what was handed over

Physical environment matters: a designated, quiet handover space with the clinical record available reduces interruptions and information loss.

Transfer of Critically Ill Patients

Inter-hospital transfer of critically ill patients is high-risk. The Intensive Care Society (ICS) Guidance on the Transfer of the Critically Ill Adult (2019) sets the minimum standards.

Pre-transfer

  • Clinical stabilisation: optimise oxygenation (target FiO2 <0.6 if possible), ensure haemodynamic stability, secure all vascular access, verify ETT position, drain pneumothorax
  • Equipment check: transport ventilator, portable monitor, defibrillator, oxygen sufficient for the journey plus 30-minute reserve, suction, emergency drugs, IV infusions
  • Documentation: referral letter including admitting diagnosis, relevant results, medications, allergies, current observations, and ventilator settings
  • Communication: receiving unit must accept and be prepared for the patient's arrival; relatives informed

The Transfer Team

A minimum of two trained staff: a doctor with competency in managing deterioration en route, and a nurse or paramedic. The team should be familiar with the transport equipment.

During Transfer

Continuous monitoring of SpO2, ECG, blood pressure, ETCO2. A portable infusion system maintains drug infusions without interruption. Any deterioration during transfer should be managed by stopping and stabilising before continuing.

Documentation

A structured transfer record should accompany the patient and include the receiving team's name and contact, the route, the clinical status at departure, and any events during transfer.

ICU Discharge

Step-down from ICU to a general ward or HDU is a transition with documented associated risk of deterioration. ICU discharge planning should include:

  • Clear documentation of the reason for ICU admission and the clinical course
  • Current active problems and ongoing treatment plans
  • Drug chart review and reconciliation (many ICU-specific medications should be discontinued)
  • Monitoring requirements and escalation criteria — including which changes should trigger ICU review or readmission
  • Ceiling of care and resuscitation status, confirmed and documented
  • Outstanding investigations and who is responsible for reviewing them
  • Communication with the patient and family — what has been explained, ongoing information needs
  • Referrals in place (physiotherapy, nutrition, psychology, ICU follow-up)

Premature discharge and out-of-hours discharge are associated with higher ICU readmission rates and mortality. Discharge decisions should consider the receiving ward's monitoring capability.

Viva Questions

What elements should be included in a structured ICU medical handover?

A structured ICU handover should communicate patient identity and reason for admission, the admitting diagnosis, and any significant events during the admission. Current organ support — ventilator settings, vasopressor doses, renal replacement therapy parameters — must be explicitly transferred, not assumed to be read from the chart. Active clinical problems should be summarised with a clear assessment of their trajectory. Outstanding investigations and the decisions that depend on their results should be identified. Anticipated events in the coming shift — expected deteriorations, planned procedures, results due — allow the incoming team to prepare. The ceiling of care and resuscitation status must be stated explicitly. The status of family communication and any ongoing sensitive conversations should be handed over. The handover should be structured (SBAR is a widely used framework) and delivered without interruption, with read-back of critical information.

What are the principles of safe inter-hospital transfer of a critically ill patient?

Safe transfer requires a pre-transfer phase, the transfer itself, and a formal handover at the receiving unit. Pre-transfer, the patient should be clinically stabilised to the extent possible: oxygenation optimised, haemodynamics controlled, vascular access secured, and ETT position confirmed with capnography. All infusions should be on a battery-operated syringe driver system. Equipment must include a transport ventilator, portable monitor with ECG, SpO2, blood pressure and capnography capability, a defibrillator, adequate oxygen, suction, and emergency drugs. The transfer team must have at least a doctor competent to manage in-transit deterioration. Documentation travels with the patient. The receiving unit must be contacted and confirmed as ready before departure. Monitoring is continuous throughout the transfer; if the patient deteriorates significantly, the vehicle should stop and the clinical situation addressed before continuing.

A patient is being stepped down from ICU. What key information must be communicated to the ward team?

The ward team needs to understand why the patient was in the ICU and what the clinical course has been, so they can recognise relevant complications or deterioration. Active problems should be clearly listed with their current management plans and expected trajectory. The drug chart should be reviewed and rationalised — ICU-specific infusions, monitoring, and interventions should be either continued explicitly or discontinued with a documented reason. Escalation criteria must be defined: what change in observations, consciousness, or clinical status should prompt the ward team to contact ICU or call the outreach team. Resuscitation status and ceiling of care should be confirmed and documented — this should not be left for the ward team to determine. Any outstanding investigations should have a named clinician responsible for reviewing and acting on the results. Family communication should be summarised: what the family understands about the patient's condition and whether further discussions are planned.