How to give and receive a safe shift handover (I-PASS) and how to escalate a sick patient to a senior by phone (ISBAR) — with scripts a junior can use at 3 am.
At the bedside
Timed steps- 1
Prepare
BeforeUpdate the written/electronic handover list before the meeting: diagnosis, key events, current support (ventilator, vasopressors, RRT), pending results, and an explicit to-do list with times. Protect handover time and place; minimise interruptions.
- 2
Use I-PASS for each patient
Shift handoverIllness severity (stable / watcher / unstable); Patient summary (diagnosis, events, plan); Action list (who, what, by when); Situation awareness and contingency ('if MAP <65 despite noradrenaline 0.3, then…'); Synthesis by receiver (the receiver summarises back and asks questions).
- 3
Sickest first, at the bedside if possible
Shift handoverHand over unstable and 'watcher' patients first and, ideally, at the bedside so lines, drains, ventilator and the patient are seen together; confirm allergies, resuscitation status and family communication.
- 4
Phone a senior with ISBAR
EscalationIdentify yourself, your role, the patient and location; Situation — what is happening now and why you are worried; Background — diagnosis, key history, current treatment; Assessment — vital signs, your interpretation (e.g. 'I think this is septic shock'); Recommendation/request — what you need ('Please come and review within 15 minutes', 'Can I start noradrenaline?').
- 5
Close the loop
EscalationRead back the instructions received, write them down with the time, and agree when you will call back or when the senior will arrive. If you remain worried, escalate again — or higher.
- 6
Document
AfterRecord the handover/escalation, the plan and contingency in the notes; update the handover list.
I-PASS mnemonic
| Letter | Element | Example |
|---|---|---|
| I | Illness severity | 'Unstable — rising noradrenaline' |
| P | Patient summary | '54-year-old, scrub typhus with ARDS, day 3 ventilation, PEEP 12, FiO₂ 0.6' |
| A | Action list | 'Repeat ABG at 2 am; chase blood culture; family update at 9 am' |
| S | Situation awareness & contingency | 'If P/F <100 despite PEEP 14, prone and call me' |
| S | Synthesis by receiver | Receiver summarises: 'So, unstable, ABG at 2, prone if P/F <100 — call you' |
ISBAR phone script (example)
| Step | Script |
|---|---|
| Identify | 'Dr Rao, ICU night resident. I'm calling about Mr S, bed 7.' |
| Situation | 'His BP has fallen to 78/40 over 30 minutes and he is more drowsy. I'm worried.' |
| Background | 'Day 2 after laparotomy for perforation, on meropenem, noradrenaline 0.1 mcg/kg/min.' |
| Assessment | 'HR 128, lactate 4.6 from 2.1, drain output increased. I think he may be bleeding or have worsening sepsis.' |
| Recommendation | 'I'd like you to see him now. Meanwhile I've sent Hb and cross-match and given 500 mL. Should I call the surgeon?' |
Calculators for this topic
References
- 1
- 2
- 3
Escalating a deteriorating patient
Step 1 of ~3
Using ISBAR to get the right help in time.
Decision: Peri-arrest or airway/breathing threat?
Based on Institute for Healthcare Improvement; Starmer AJ, Spector ND, Srivastava R, et al. Educational use; follow local protocol.
Pathophysiology
Human working memory is limited; under fatigue and time pressure, unstructured verbal communication loses information. Hierarchy ('steep authority gradient') makes juniors hesitant to state concern or request action clearly; structured tools give permission and a script.
Evidence
- I-PASS (Starmer, NEJM 2014): handoff programme (mnemonic, training, faculty development, verbal and written handoff tool) across 9 US paediatric residency programmes. Medical errors fell by 23% (24.5 → 18.8 per 100 admissions) and preventable adverse events by 30% (4.7 → 3.3 per 100 admissions), with no increase in handoff duration.
- SBAR/ISBAR originated in naval/aviation communication and was adapted to healthcare (Kaiser Permanente; promoted by IHI) to standardise escalation calls.
- WHO Global Patient Safety Action Plan 2021–2030 lists safe communication and transitions of care as core strategies.
Controversies
- Bedside vs meeting-room handover (patient confidentiality, time, noise).
- Electronic vs paper handover tools — benefit depends on design and training more than medium.
🇮🇳 India notes
- Indian ICUs often have high patient-to-doctor ratios and long shifts; a short, structured written handover sheet per bed works better than long verbal accounts.
- Mixed-language teams: keep key terms (drug names, doses, targets) in English and read back numbers.
- NABH accreditation standards expect documented handover processes in ICUs.
References
- 1
- 2
- 3
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.