Patient handover from OT to ICU: a distributed cognition perspective.
Tracks
Room 1
| Tuesday, December 1, 2026 |
| 10:25 AM - 10:45 AM |
| Plenary Room - Grand Central |
Overview
Dr Andrew Beck
Speaker
Dr Andrew Beck
Central Adelaide Local Health Network
Patient handover from OT to ICU: a distributed cognition perspective.
Abstract
Background
Handover of patients from the operating theatre (OT) to the intensive care unit (ICU) is a complex, high‑risk process requiring precise coordination across multiple roles. Structured tools such as SBAR strengthen communication by providing standardisation, but conceptualise handover as a linear, structured event. This overlooks the complex interactions between people, artefacts and environment. Distributed Cognition (DCog) offers a more comprehensive perspective by examining how cognitive processes are distributed across people, artefacts, and physical spaces.
Methods
Over a five‑month period at a tertiary hospital in Perth, Western Australian, four routine OT-to-ICU handovers involving intubated surgical patients were observed. Data were collected and analysed using the Distributed Cognition for Teamwork (DiCoT) framework, generating models of physical layout, information flow, and artefact use to understand how teamwork and cognition contribute to the handover process.
Results
The analysis revealed handover as a continuous, distributed process rather than a singular, structured event. Information flowed through multiple parallel channels, such as separate phone calls between medical and nursing staff, throughout the handover process including prior to patient’s arrival.
During the post patient arrival phase, artefacts, including monitors, charts, equipment, and the patient’s body, acted as external cognitive support (cognitive scaffolds) that led to specific verbal exchanges and actions.
The physical layout and staff positioning influenced what each team member can see or hear (horizon of observation), mediating access to crucial visual and auditory information.
Conclusion
Viewing handover as a standalone verbal exchange between hospital staff and the physical transfer of patients is not the perfect fit for postoperative care. DiCoT reveals handovers are complex, multi-input processes distributed across teams, physical layouts, and artefacts. Improvement to this process requires designing flexible tools that align with this distributed architecture.
Handover of patients from the operating theatre (OT) to the intensive care unit (ICU) is a complex, high‑risk process requiring precise coordination across multiple roles. Structured tools such as SBAR strengthen communication by providing standardisation, but conceptualise handover as a linear, structured event. This overlooks the complex interactions between people, artefacts and environment. Distributed Cognition (DCog) offers a more comprehensive perspective by examining how cognitive processes are distributed across people, artefacts, and physical spaces.
Methods
Over a five‑month period at a tertiary hospital in Perth, Western Australian, four routine OT-to-ICU handovers involving intubated surgical patients were observed. Data were collected and analysed using the Distributed Cognition for Teamwork (DiCoT) framework, generating models of physical layout, information flow, and artefact use to understand how teamwork and cognition contribute to the handover process.
Results
The analysis revealed handover as a continuous, distributed process rather than a singular, structured event. Information flowed through multiple parallel channels, such as separate phone calls between medical and nursing staff, throughout the handover process including prior to patient’s arrival.
During the post patient arrival phase, artefacts, including monitors, charts, equipment, and the patient’s body, acted as external cognitive support (cognitive scaffolds) that led to specific verbal exchanges and actions.
The physical layout and staff positioning influenced what each team member can see or hear (horizon of observation), mediating access to crucial visual and auditory information.
Conclusion
Viewing handover as a standalone verbal exchange between hospital staff and the physical transfer of patients is not the perfect fit for postoperative care. DiCoT reveals handovers are complex, multi-input processes distributed across teams, physical layouts, and artefacts. Improvement to this process requires designing flexible tools that align with this distributed architecture.
Biography
Dr Andrew Beck is a consultant anaesthetist at Royal Adelaide Hospital, and previous human factors fellow at Royal Perth Hospital. He holds medical and science degrees from the Universities of Edinburgh and St Andrews, and has completed specialist anaesthetic training with fellowship qualifications from the Royal College of Anaesthetists and the Australia and New Zealand College of Anaesthetists.
His work has included leadership in undergraduate education and interventional radiology anaesthesia across hospitals in Scotland and Western Australia. He has a strong interest in human factors, simulation, and anaesthetic education. He also organises the University of Glasgow undergraduate anaesthetics programme.
His academic interests include theatre efficiency, nitrous oxide decommissioning, regional anaesthesia, and peri-operative outcomes.
