Why Handover and Escalation Are Tested in OSCEs
Communication failures during clinical handover cause more patient harm in hospitals than almost any other single factor. The National Patient Safety Agency has identified poor handover as a contributing factor in thousands of serious incidents in the NHS. OSCE setters know this — and they test it precisely because it is the skill that separates a safe junior doctor from an unsafe one.
You will face two distinct scenarios in OSCEs:
- 1Escalation call: You are an F1 on the ward. A patient has deteriorated. You must call the registrar or SHO and hand over clearly enough for them to understand the urgency and come to review.
- 2End-of-shift handover: You are handing over your patients to the night team. You must communicate who needs reviewing, what tasks are outstanding, and what action to take if things change.
Both use the SBAR (or ISBAR) framework.
The SBAR Framework
SBAR stands for Situation, Background, Assessment, Recommendation. It is the internationally recognised structured communication tool used across healthcare.
| Component | What to cover |
|---|---|
| S — Situation | Who you are, who the patient is, why you are calling, how urgently you need help |
| B — Background | Why the patient is in hospital, their relevant medical history, medications |
| A — Assessment | Your clinical findings: observations (NEWS2 score), what you think is happening |
| R — Recommendation | What you want: a decision, a prescription, them to come and review |
Some training programmes use ISBAR, which adds I — Identification at the start (your name, grade, location) to ensure the listener knows immediately who is calling.
🧠 Mnemonic
SBAR = "Somebody Bad, Act Right"
- Somebody = Situation (who, what, how urgent)
- Bad = Background (why they're here, PMH)
- Act = Assessment (what you've found, what you think)
- Right = Recommendation (what you want done)
Escalation Call: Step-by-Step
Before You Call
Do NOT call before you have assessed the patient and have information ready. The registrar will ask you questions — if you cannot answer them, you waste time and lose credibility. Before picking up the phone:
- 1Perform an A-E assessment and document your findings
- 2Pull up the observation chart — know the latest set of obs, the trend, and the NEWS2 score
- 3Know the drug chart — what is the patient on? Could this be a drug reaction or interaction?
- 4Know the relevant blood results and when they were last checked
- 5Have the patient's notes and drug chart in front of you
- 6Know what you want from the call — a review? A prescription? An urgent investigation?
💡 Tip
The SBAR call is not the time to think. Prepare your notes before dialling. Write the SBAR points down on paper if needed. A confident, structured call gets faster help than a rambling one.
The Call Itself
Identification:
"Hi, this is [name], the F1 on [ward name]. I'm calling about one of my patients and I'm quite concerned — do you have a moment?"
Situation:
"I'm calling about Mrs Patel, she's 68 years old, in bed 4 on Nightingale Ward. She was admitted yesterday with a community-acquired pneumonia. Over the last two hours she's become increasingly unwell and I'm concerned she may be developing sepsis."
Background:
"She has a background of type 2 diabetes and COPD. She's on co-amoxiclav and clarithromycin per our protocol, started this morning. Her last blood results at 2 PM showed a CRP of 180, white cell count 18, and her creatinine was up at 135 — slightly raised from her baseline of 90."
Assessment:
"Her observations right now are: temperature 38.9°C, heart rate 118, blood pressure 92/60, respiratory rate 24, and oxygen saturations 91% on 4 litres via nasal cannula. Her GCS is 15 but she's quite drowsy — her NEWS2 score is 9. On examination she has coarse crackles at the right base, her abdomen is soft, and there's no rash. I think she's developing septic shock — possibly not responding to oral antibiotics."
Recommendation:
"I've already started the Sepsis Six — I've taken blood cultures, given IV fluids, and increased her oxygen. I'd like you to come and review her urgently please, and I think she'll need IV antibiotics and possibly ICU review. Is there anything you'd like me to do in the meantime?"
💎 Clinical Pearl
End with a question: "Is there anything you'd like me to do in the meantime?" This demonstrates collaborative working and gives the registrar the chance to direct immediate actions while they are on their way.
End-of-Shift Handover
The end-of-shift handover protects patients overnight. Use SBAR for individual patients, but the overall handover also needs structure.
The ACCEPTED Handover Framework
| Letter | Component |
|---|---|
| A | Administrative (bed numbers, names, diagnoses) |
| C | Clinical summary (what's happened today, what's planned) |
| C | Concerns (patients you're worried about) |
| E | Expected events (procedures, results due) |
| P | Pending tasks (bloods, imaging, referrals not yet completed) |
| T | To-do list for the night team |
| E | Escalation triggers (specifically: "If X happens, do Y") |
| D | DNR/ceiling of care status — CRITICAL |
⚠️ Red Flag
Always communicate DNACPR and ceiling of care status at handover. A night SHO who is unaware that a patient is for comfort measures only may initiate inappropriate resuscitation. Handing over "she is for DNACPR and comfort care only — if she deteriorates please call the family but do not call the crash team" is a patient safety imperative.
Structuring Individual Patient Handover
For each patient requiring overnight attention, use a one-minute SBAR summary:
"Bed 7, Mr Chen, 74, admitted with decompensated heart failure. He's been diuresed today and his creatinine has ticked up to 145 from a baseline of 110 — worth monitoring. His NEWS2 is 2, he's stable. I need you to check a repeat U&E at 6 AM and chase the echo result — it should be available by midnight. If his creatinine goes above 180 or he becomes oliguric, call the renal team. He's full resus."
Each handover entry should answer: who, why here, current status, pending tasks, escalation trigger, ceiling of care.
Common OSCE Scenarios
Scenario 1: Unresponsive Patient
Student finds a patient unconscious on the ward. They must call 2222 (arrest call) and simultaneously begin an A-E assessment, delegate tasks to nursing staff (get the crash trolley, start CPR if no pulse), and communicate clearly under pressure.
Scenario 2: Deteriorating Chest Pain
New onset chest pain post-operatively. Student must do an A-E, start oxygen, take an ECG, and make an SBAR call to the cardiology registrar.
Scenario 3: Overnight Handover
Given a list of 8 patients and 10 minutes to hand over to the night team. Student must prioritise who needs flagging (high NEWS2, pending procedures, ceiling of care issues) and structure each handover clearly.
What Examiners Penalise
| Mistake | Why it matters |
|---|---|
| Calling without doing an A-E first | Gives incomplete information; unsafe |
| Not knowing the NEWS2 score | Shows you haven't assessed the patient systematically |
| Vague recommendations ("I think someone should see her") | The registrar can't act on this — be specific |
| Forgetting to ask "is there anything you want me to do?" | Misses collaborative safety net |
| Not documenting the call | If it's not written down, it didn't happen |
| Handing over without ceiling of care status | Puts patients at risk of inappropriate resuscitation |
💡 Tip
Document every escalation call: Time, who you spoke to, what you reported, what was agreed. Use this exact phrase: "Discussed with [name, grade] at [time] — plan as above." This protects you and creates an auditable record.
Common Examiner Follow-Up Questions
"The registrar you call is dismissive and tells you not to worry. What do you do?"
"Patient safety comes first. I would be clear and explicit: 'I understand, but I am genuinely concerned about this patient — her NEWS2 is 9 and she's requiring increasing oxygen. I need you to come and review her.' If they still decline, I would escalate to the next level — the consultant on call or the hospital at night team. Most hospitals have an escalation policy for exactly this situation. I would document the entire conversation — who I spoke to, what I said, what they said, and what I did next. Accepting a dismissal when you genuinely believe a patient is in danger is never the right answer."
"What is a NEWS2 score and why is it used in escalation?"
"NEWS2 — the National Early Warning Score 2 — is a standardised scoring system used across NHS England to identify patients at risk of deterioration. It scores six physiological parameters: respiratory rate, oxygen saturations, use of supplemental oxygen, temperature, systolic blood pressure, heart rate, and level of consciousness. A total score of 5–6 triggers an urgent review; 7 or above triggers an emergency response. NEWS2 provides a common language for escalation — when I say 'NEWS2 of 9' every clinician in the hospital knows the level of urgency without needing further explanation, which reduces communication ambiguity during handover."
"What is a DNACPR order and what does it cover?"
"A Do Not Attempt Cardiopulmonary Resuscitation order is a clinical decision, ideally made in discussion with the patient and/or their family, that CPR should not be attempted in the event of cardiac or respiratory arrest. It is not a 'do not treat' or 'do not escalate' order — a patient with a DNACPR order should still receive full active treatment for reversible conditions, antibiotics for infections, IV fluids for dehydration, and good symptom control. It applies only to the specific decision not to attempt CPR. It must be clearly documented, signed by a senior doctor, and communicated at every handover. It should be reviewed at each change in the patient's condition."