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Matt Morgan: Hand over your invisible patients

BMJ 2023; 380 doi: (Published 21 February 2023) Cite this as: BMJ 2023;380:p390
  1. Matt Morgan, consultant in intensive care medicine
  1. Western Australia
  1. mmorgan{at}
    Follow Matt on Twitter: @dr_mattmorgan

My colleague in intensive care looked tired. Numerous patient stickers were stuck at skewed angles on the computer screen. Paperwork covered the desk like patchwork, including death certificates and transfer letters. Yet the intensive care unit (ICU) behind them was serene.

“Not much to hand over tonight,” my colleague summarised. And that was true: there was an unusual number of empty beds, no outstanding procedures to do, no expected admissions, and only stable patients—but still plenty of admin work left to do. The handover was done in record time. This was strange.

What some handovers can conceal is the tremendous amount of challenging work that happens before the clocks signal the end of a shift. In this instance this included some difficult conversations that allowed a frail patient with pneumonia to be cared for with dignity on the ward rather than having a prolonged death in intensive care; the air traffic control level logistics to transfer someone with severe heart failure to a specialist centre; the countless units of blood pumped into a young patient after a serious car crash; and then the family support and governance after they sadly died.

In many medical specialties, the better and harder you work, the less you have to show for it. Striving for zero emails in your inbox—being efficient, skilled, and hard working—will often lead to more work. Although the aim of every ICU admission is an ICU discharge, more patients leaving means more admin work. And this is fine. Healthcare isn’t about what you have to show, it’s about patient outcomes.

Yet there’s something missing in handover on those hectic days when apologies are offered for the small tasks left undone:

“Sorry, I didn’t get a chance to update that family.”

“Sorry, I forgot to fill out that form.”

“Sorry, I haven’t replaced that nasogastric tube.”

As in life, context is everything. Yet the forward looking, brief nature of handover can ignore the full history. Important details can be lost. I wonder whether we should hand over the patients who aren’t there, or the procedures that are no longer needed? Would starting a handover with history perhaps help explain the present? Some people agree with me—because my colleague did exactly that.

“Not much to handover tonight,” they started. “It’s been a crazy day, with one complex transfer, a sad death, five referrals that are not being admitted, and a team who have worked super hard. Thank you all.”

I think the medical handover should recognise the past and the work that may go unseen. If we include this, then the small things—any omissions or neglected tasks during the previous shift—can be explained by the bigger picture. This fuller handover allows us to see what really matters: the patients who aren’t there, for better or for worse.


Thanks to Sebastian Knudsen for leaving me little to do, and to Steve Webb for his insight that the aim of every ICU admission is an ICU discharge.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

  • Provenance and peer review: commissioned; not externally peer reviewed.

  • Matt Morgan is an adjunct clinical professor at Curtin University, Australia, honorary senior research fellow at Cardiff University, UK, a consultant in intensive care medicine at the Royal Perth Hospital in Australia, and an editor of BMJ OnExamination.