Eyes wide open in the ICU: A scoping review of tools and strategies for situational awareness.

Abstract

Background: Situational awareness (SA) is a critical nontechnical skill for intensive care unit (ICU) physicians, underpinning safe decision-making and patient safety. Despite its importance, evidence regarding how SA is assessed and improved in ICU practice remains fragmented.

Objectives: To map the existing evidence on interventions and assessment methods for SA among physicians in adult ICUs, and to evaluate their reported effectiveness.

Design: Scoping review of randomised controlled trials, quasi-experimental studies, cross-sectional studies, and qualitative studies, conducted in accordance with PRISMA-Scr guidelines.

Data sources: MEDLINE, Web of Science, Scopus, and PsycINFO were searched from inception to July 2024. Reference lists and supplementary searches were performed.

Eligibility criteria: We included studies involving ICU physicians, residents and medical students working in adult ICUs that assessed or intervened on SA. Exclusions included studies limited to paediatric/neonatal ICUs, non-ICU staff, inter-unit handovers, reviews, opinion pieces and nonpeer-reviewed literature.

Results: From 991 records, 11 studies were included. Simulation-based training consistently improved SA and team co-ordination, while lecture-based training alone was largely ineffective. Crew resource management (CRM) courses increased self-reported awareness but had mixed effects on outcomes. Technological tools (e.g. dashboards, 3D visualisations) showed promise in enhancing early recognition of clinical deterioration and supporting decision-making. SA assessment was most frequently performed using the Situation Awareness Global Assessment Technique (SAGAT), though this remains impractical for real-time ICU use. Methodological quality was generally moderate, with small sample sizes and heterogeneity limiting quantitative synthesis.

Conclusions: Simulation-based interventions and novel technological tools appear most effective in enhancing SA among ICU physicians, whereas CRM and didactic methods yield mixed results. The lack of validated, ICU-specific SA assessment tools represents a critical gap. Future research should focus on scalable, team-based training models, context-appropriate assessment instruments, and integration of technological decision-support to strengthen SA and improve patient safety.