Episode #297 From OR To ICU: How Checklists And Clean Hands Save Lives

Hospitals are busy places and patients often need to be transported between operating rooms, procedural areas, and ICUs. So, even if you are not practicing critical care, this is a important for all anesthesia professionals. Here are some key takeaways that you can use this week whether you are working in the ICU or transporting patients in the hospital.

• Recommendations for preventing the spread of pathogens include the use of alcohol-based hand sanitizer at least 4 times per hour while caring for patients in the ICU and at least 8 times per hour while providing anesthesia care in the operating room.
• You can use the UCLA OR to ICU Handover tool that starts with communication of ICU needs by the OR team, followed by an ICU bed request by the OR nurse, then a nursing verbal report to the ICU charge nurse and physician verbal report to the ICU physician about 1-2 hours before the end of the case, a phone call with updates 15 minutes before transport to the ICU, and finally transport to the ICU with patient monitors and equipment transferred and patient stabilized before bedside handoff report using the checklist and involving the surgeon, anesthesia professional, ICU nurse, and ICU physician.

Hello and welcome back to the Anesthesia Patient Safety Podcast. I’m your host, Alli Bechtel. When I’m not podcasting about patient safety, I provide patient care as an anaesthesiologist. Here’s what we will be talking about today: Transmission of information during handoffs and prevention of transmission of pathogens.

Before we dive further into the episode today, we’d like to recognize Solventum, a major corporate supporter of APSF. Solventum has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Solventum – we wouldn’t be able to do all that we do without you!”

Our featured article is from the October 2025 APSF Newsletter. It is “ICU Patient Safety Frontiers: Reducing Harm Through Better Handoffs and Infection Prevention” by Jonathan Charnin and Randy Loftus. To follow along with us, head over to APSF.org and click on the Newsletter Heading. The fourth one down is Newsletter archives. Then, click on October 2025 and scroll down until you get to our featured article today. I will include a link in the show notes as well.

Today, we are focusing on two important parts of keeping patients safe in the ICU: Structured handoffs to improve communication and perioperative infection control bundles. Did you know that the first intensive care units were created in the 1950’s to help treat patients with respiratory failure? The idea was to bring together specialized knowledge and resources for these critically ill patients. Now, you can find intensive care units in hospitals all around the world and in many of these you will also find anesthesia professionals who have additional training in critical care. Even if you are not a crucial care anesthesia professional, you may still find yourself in the ICU for patient transport to and from the operating room or providing anesthesia care for ICU patients who require surgery.

Let’s take a closer look at the intersection between critical care and anesthesia care. Adult respiratory distress syndrome or ARDS is a common cause of respiratory failure in the ICU that has a high mortality. In 2000, the Acute Respiratory Management in ARDS or ARMA trial was published which changed the management for patients with ARDS with an emphasis on the protective effects of low tidal volume ventilation. Since then, a key component of managing patients with ARDS or at risk for ARDS includes low tidal volume ventilation and this has led to decreases in the incidence and mortality of ARDS. This ventilation strategy calculates the tidal volume dose based on the patient’s ideal body weight, about 6mls per kilogram, leading to less ventilator-induced lung injury. Higher tidal volumes were found to increase inflammation even in uninjured lung. Low tidal volume ventilation started in the ICU, but most anesthesia professionals are now familiar with this strategy since it made its way to the operating room as well. Lung injury from large tidal volume ventilation is preventable and anesthesia professionals can embrace this practice change moving from high volume ventilation 10-12mls per kilogram ideal body weight to low tidal volume ventilation, about 6ml per kilogram to help reduce preventable harm.

Now, that we have seen safety improvements moving from the ICU to the OR, we need to go back to the ICU and talk about patient safety for ICU patients related to information sharing during handoffs of care and preventing transmission of pathogens.

There are regular handoffs in the ICU between ICU professionals during change of shift as well as additional handoffs between team members outside of the ICU when patients leave the ICU to undergo surgery, procedures, or diagnostic tests and upon their return to the ICU. There is a lot of information that needs to be shared from hemodynamic to imaging results, pharmacologically relevant genetic testing, medication administration and timing for the next dose to patient wishes and requests, and more. There is a threat to patient safety here from failing to transmit all of the required information. Communication gaps can lead to errors. Let’s look at the 2020 New England Journal of Medicine article, “Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts.” This was a multicentre, cluster-randomized, crossover trial that compared the impact of extended duration duty shifts of 24 hours or more with shift work, 16 hours or less, for trainees in the ICU. There were more medical errors in the shorter duration duty periods and more errors in the ICU unit as a whole. The increased number of handoffs as a result of the shorter duration shifts may have been a contributing factor. As a quick aside, there are some important discussion points from this study. The intervention schedule with 16hr or less shifts had the benefits of improved residents’ sleep and neurobehavioral performance with the consequence of increased workload. The National Academy of Medicine recommended that resident physician work-hour reduction should only occur alongside an investment of resources to support appropriate staffing and infrastructure. This study highlights multiple threats to patient safety in the ICU: excessive work hours, excessive workloads, and poor handoffs. Check out the citation in the show notes.

Okay, back to handoffs which is an emerging research area looking for the optimal way to synthesise relevant information to effectively support a transition of care. Structured handoffs between anesthesia professionals and the ICU team requires time and attention to detail. There are electronic tools that may be used to help with the information transfer.  The I-PASS tool is a structured handoff approach that has been suggested by the Agency for Healthcare Research and Quality that may be helpful. We have talked about the Multicentre Handoff Collaborative  before on the podcast. This is  special interest group that is supported by the APSF to research, educate, and promote safe handoffs. There are so many resources for the implementation of perioperative handoff initiatives. Click on the Handoff Education checklist. There is an ICU to OR pocket card handoff resource that you can start using immediately. Then, when you are going back to the ICU after the surgery, you can use the OR to ICU handoff checklist and timeline. Check out the show notes for a link to this resource. Going forward, keeping patients safe during handoffs in the ICU will require that clinicians recognize the importance of excellent communication and use the appropriate tools to make sure that a successful transition of care occurs.

Next up, let’s talk about preventing pathogen transmission in the ICU. This is a critical consideration for keeping patients safe. The ICU is an area where critically ill patients can receive care from specialized teams, but the environment in the ICU is also conducive for potential pathogen transmission leading to nosocomial infections that can become life-threatening. And most of these nosocomial infections are preventable. There is a call to action for all professionals providing patient care for critically ill patients to understand the serious risks for ICU patients and the tools that are available to prevent nosocomial infections.

Here are some important considerations for pathogen transmission in the ICU:

There are similar challenges in the ICU and in the OR.

Multi-drug resistant pathogens are a particular concern in the ICU. Bacteria with antibiotic resistance may develop a biofilm which allows prolonged survival on environmental surfaces.

Contamination of 100 colony forming units of any bacteria recovered from highly contacted surfaces in the ICU environment has been associated with the detection of major bacterial pathogens on that surface.

Once this bacterial reservoir has been established, like on the bed rail or the adjustable pressure-limiting valve in the OR, the bacteria continues to spread to clinicians and patients until effective decontamination.

The authors remind us that many of the same interventions that generate life-saving care in the ICU also produce opportunities for pathogens to create new infections. Vascular access catheters, urinary drainage catheters, endotracheal tubes, and surgical or traumatic wounds may be susceptible to nosocomial infections. We all know that the hands of healthcare professionals are often the cause of pathogen transmission. There is research using bacterial genome analysis of bacterial populations in anesthesia work environments and anesthesia professionals hands showing that pathogen transmission does occur in the operating room. Similar research in the ICU has revealed that poor hand hygiene is related to pathogen transmission and health-care associated infections.

So, what can we go? Well, the methods for preventing pathogen transmission are clear in the medical literature. Let’s review them now:

Frequent utilization of alcohol-based hand sanitizers. The APSF Patient Safety Priorities Advisory Group for Infectious Diseases recommends the use of alcohol-based hand sanitizer at least 4 times per hour while caring for patients in the ICU and at least 8 times per hour while providing care in the operating room.

And attention to isolation requirements.

We have come along way with providing intensive care for critically ill patients especially when it comes to treatment for respiratory failure and shock. Going forward, there is an urgent need for improvements in handoffs and transitions of care as well as preventing transmission of nosocomial pathogens. When healthcare professionals are provided the necessary information during handoff, they can make the best decisions leading to improved outcomes. When nosocomial infections are prevented, patient outcomes will improve as well. Keeping patients safe in the ICU requires that we transmit optimal information during handoffs and not transmit pathogens during patient care.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

We talked about the Perioperative Multi-Center Handoff Collaborative on the show today. Have you checked out any of the other APSF Patient Safety Resources? Head over to ASPF.org and click on the Patient Safety Resources heading. Here you will find the APSF initiatives, the Anesthesia Patient Safety Podcast, video library, collaborations, the APSF Technology Education Initiative, In the Literature, News and Updates, collaborations, the Patient guide to anesthesia and surgery, International resources, and Helpful Links.

So many great resources to help improve anesthesia patient safety.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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