War-game an ICU stepdown hand-off by proving each grade lane has a named owner, a measured age-out, and a reverse path before draft clocks start governing every stepdown transfer.
ICU stepdown hand-offs fail when "cleared for stepdown" means a status without a decision artifact, when teams dual-count a draft grade as both aspirational and live, and when high-acuity transfer families still pin to one thin bed desk because the lane inventory is incomplete. The review needs one written inventory of stepdown lanes, one owner who can deny a risky shortcut, and a documented consequence when a failed grade ages past the deadline.
Name the transfer packet in writing
State which stepdown classes the hand-off covers, the effective date, which grade lanes change, how versions are stored, and what happens to patients already in flight. Name the units that feel it first and the safety promises that depend on coherent stepdown handling. If the memo mixes an ICU stepdown hand-off with a ventilator wean protocol and a same-day discharge rule, split them.
Write the decision you will make if the war game finds nothing new. Also write the reverse criteria: the missed lane, acuity gap, or patient deadline that would force an ICU stepdown hand-off rollback within a stated window.
Hand-off failures to force early
- A high-acuity stepdown class stays soft while the aggregate ICU dashboard stays green.
- Two teams claim the same lane ownership and neither can force a freeze at week end.
- A restore has already left a case without a trusted grade state.
- The primary stepdown export lags beyond the planned observation window.
- An operator skips a grade gate because a bed transfer cutoff is near.
- Receiving-unit readiness claims lack a stored exhibit at hand-off time.
For each failure, require detection time, unit impact, containment, and the authority to force an ICU stepdown hand-off rollback. Commands and export links belong in the runbook.
Seat the ICU and receiving chairs
Feed Pingpong the hand-off memo, the lane exhibits, and seating briefs for ICU ops, stepdown nursing, bed management, and quality. First pass steelmans the hand-off. Later passes attack from those seats. Final pass turns surviving objections into phased lane rules, mitigations, or a changed recommendation. Agreement across passes is not proof. Keep the objections that still have evidence gaps.
Pair with a ventilator wean protocol, the LTACH ops lead seat, a same-day discharge rule, and a step-down criteria rewrite. More operating decisions live in the war-game decisions hub.
Ship the hand-off only when approved and blocked grade labels can be reproduced from stored stepdown exports without a verbal override.