Before i forget: How clinicians cope with uncertainty through ICU sign-outs

Christopher P. Nemeth, Julie Kowalsky, Marian Brandwijk, Madelyn Kahana, P. Allan Klock, Richard I. Cook

Research output: Chapter in Book/Report/Conference proceedingConference contribution

9 Scopus citations


Transitions between shifts in the intensive care unit (ICU) create potential gaps in the continuity of care, and practitioners necessarily rely on distributed cognition to prevent the formation of gaps during work-cycle shift changes. The complexity and uncertainty of each ICU patient's condition require efficient communication between practitioners during transfers between departments or when cycling work through shifts. This study observed twelve unit-level exchanges among six clinicians handing off a 33-bed PICU and step-down unit, then examined them using conversation analysis. Our research shows that pediatric ICU fellow sign-outs demonstrate high context sensitivity, compact reference, gestures, and stylized expressions. We find that sign outs account for both what is known and what is not known about a patient's condition, and to assess expectations for the oncoming shift. Uncertainty about patient condition influences handoff content and form. Clinicians change the amount time that they allocate to handoffs based on other aspects of work load, such as rounds or procedures. Clinicians apportion time to discuss individual patients according to the perceived severity and stability of each patient's condition. Expertise in hand-off communications depends on the ability to prioritize relevant information and to transfer insights effectively. Relevant, efficient hand-offs significantly affect the ability of clinicians to provide care at the unit level, within and between departments, and across specialties such as intensivists, nurse anesthetists, and anesthesia technicians. Even though they affect patient care quality and continuity, sign outs are not taught but are instead learned on the job. Formal study of, and training in, the conduct of sign outs may benefit both care providers and patients alike.

Original languageEnglish (US)
Title of host publicationProceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, HFES 2006
PublisherHuman Factors an Ergonomics Society Inc.
Number of pages5
ISBN (Print)9780945289296
StatePublished - 2006
Externally publishedYes
Event50th Annual Meeting of the Human Factors and Ergonomics Society, HFES 2006 - San Francisco, CA, United States
Duration: Oct 16 2006Oct 20 2006

Publication series

NameProceedings of the Human Factors and Ergonomics Society
ISSN (Print)1071-1813


Other50th Annual Meeting of the Human Factors and Ergonomics Society, HFES 2006
Country/TerritoryUnited States
CitySan Francisco, CA

ASJC Scopus subject areas

  • Human Factors and Ergonomics


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