Communication in a Crisis


  • Communication is a key non-technical skill for effective crisis resource management (CRM)
  • Communication may fail in a crisis for many reasons
  • Physicians often fail to communicate what they are doing, and why, in a crisis — and when they do they often only do so with other physicians
  • With nurses there is often a delay between identifying problem and communicating it to the rest of the team
  • Closed loop communication is a simple and effective way of avoiding communication failure, but there are many other useful strategies
  • Team members must feel empowered to question and/or correct the decisions of the team leader and other team members if it in the patient’s interest
  • Safety tools such are checklists are only effective if people speak up when they identify concerns
  • Nurses have to have license to say “I’m am worried, please see this patient now.” and expect doctors to do so, rather than demand objective reasons (being able to label a concern doesn’t make it more or less valid!)


  • In 2004 The Joint Health Care Commission found that in 70% of 2455 sentinel events the primary root cause was communication failure — and in 75% of these the patient died.


“Keep everyone on the same page and ensure there are no surprises”

  • Maintain situational awreness
  • Establish a shared mental model (so that everyone knows what is happening and can contribute)
  • Establish a safe envirnoment so that others can speak up
  • coordinating tasks
  • centralizing the flow of information
  • stabilizing emotions


  • Physical constraints, e.g. noise
  • Linguistic differences
  • Differing communication styles
    • nurses tend to be trained ‘not to diagnose’ and broad and narrative in descriptions (“paint the big picture”)
    • critical care physicians tend to want focussed information and get to the question
  • Authority gradient/ hierarchy/ power distance
  • Use of jargon
  • Cognitive biases and emotional disturbance leading to misinterpretation
  • Cognitive load/ focus on other tasks


  • cite names
  • clear instruction
  • close the loop


  • Avoid mitigating language – “let’s intubate now” not “perhaps we should think about intubating”
  • Call out – team members state their actions, observations and concerns out loud
  • Fly by voice – verbalise thoughts and observations
  • Graded assertiveness
  • Focus on advocacy
  • Closed loop communication
  • SBAR
  • Below 10
  • Step back method – “let’s stop and reassess”
  • Repeat back method


  • Sender communicates a message
  • Receiver interprets the message, then acknowledges it’s receipt and communicates it back to the sender
  • Sender confirms that the intended message is received.
  • Receiver reports back when the message has been acted upon.

For example:

  • Sender: “John, give 1mg adrenaline IV followed by a 20 mL normal saline push”
  • Receiver: “OK Mike, I am going to give 1mg adrenaline IV followed by a 20 mL normal saline push”
  • Sender: “That’s correct John”
  • Receiver: “ Mike, 1mg adrenaline IV with a 20 mL normal saline fluch has been given”


Six basic command types:

  • Hint – “should things look like this”
  • Preference – “I think it would be wise”
  • Query – “what do you think we should do”
  • Shared suggestion –“ you and I should do the following”
  • Statement – “I think we need to do the following”
  • Command – “do this now”


e.g. PACE approach

  • Probe – “do you know that…?”
  • Alert – “Can we re-assess the situation…?”
  • Challenge – “Please stop what you are doing while..”
  • Emergency – “STOP what you are doing!”

Graded assertiveness is described in more detail in Speaking Up


  • Attention getter – “Excuse me, Doctor”
  • State your concern – “The patient is hypotensive”
  • State the problem as you see it – “I think we need to get help now”
  • State a solution – “I’ll phone ICU to arrange transfer”
  • Obtain an agreement – “does that sound good to you?”


  • Situation – what is going on with the patient?
  • Background – what is the clinical background, or context?
  • Assessment – what do I think the problem is?
  • Recommendation – what would I do to correct it?


  • aka below 10,000 feet communication
  • means the ‘sterile cockpit rule’ is in effect, ie. no unnecessary communication during a critical procedure
  • others should ask “I want your opinion on X, can we talk now or later?”
  • proceduralist states: “later”

References and Links

Journal articles

  • Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care. 2011 Apr;26(2):155-9. doi: 10.1016/j.jcrc.2011.03.004. PubMed PMID: 21482347.
  • Brindley PG. Patient safety and acute care medicine: lessons for the future, insights from the past. Crit Care. 2010;14(2):217. doi: 10.1186/cc8858. Epub 2010 Mar 9. Review. PubMed PMID: 20236461; PubMed Central PMCID: PMC2887110.
  • Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85-90. PubMed PMID: 15465961; PubMed Central PMCID: PMC1765783.

FOAM and web resources

  • The Nurse Path — Graded assertiveness (2013)
  • American Association of Critical-Care Nurses. The silent treatment: why safety tools and checklists aren’t enough to save lives. Aliso Viejo (CA): The Association. Available from :http://www.silenttreatmentstudy.com
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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