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 Table of Contents  
Year : 2021  |  Volume : 65  |  Issue : 3  |  Page : 315-317  

Nonverbal closed loop communication during COVID-19 pandemic – Proposal of four tick technique

1 Consultant, Department of Anesthesiology and Critical Care, Meenakshi Hospital, Thanjavur, Tamil Nadu, India
2 Consultant Pediatric Cardiac Anesthesiologist, Department of Pediatric Cardiac Care, MIOT Hospital, Chennai, Tamil Nadu, India
3 Senior Consultant and Head, Department of Anesthesiology and Critical Care, Meenakshi Hospital, Thanjavur, Tamil Nadu, India
4 Consultant Psychiatrist, Manam Behavioural Medicine Clinic, Coimbatore, Tamil Nadu, India

Date of Submission06-Feb-2021
Date of Decision07-Jul-2021
Date of Acceptance12-Aug-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Vinodhadevi Vijayakumar
Department of Anesthesiology and Critical Care, Meenakshi Hospital, 244/2, Trichy Main Road, Near New Bus Stand, Thanjavur - 613 005, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_106_21

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This COVID-19 pandemic has posed difficulty in verbal communication among health-care workers with usage of respirators and personal protective equipments. We propose a four tick technique for the nonverbal closed loop communication in health-care settings with limited resources such as low and middle-income countries. It is simple, easy to learn, train, effective, ensuring patient safety and can be extended to nonhealth-care settings and in electronic form.

Keywords: COVID-19 pandemic, four tick technique, nonverbal closed loop communication, sign language in health care

How to cite this article:
Vijayakumar V, Srinivasan O, Ganesamoorthi A, Vijayakumar N. Nonverbal closed loop communication during COVID-19 pandemic – Proposal of four tick technique. Indian J Public Health 2021;65:315-7

How to cite this URL:
Vijayakumar V, Srinivasan O, Ganesamoorthi A, Vijayakumar N. Nonverbal closed loop communication during COVID-19 pandemic – Proposal of four tick technique. Indian J Public Health [serial online] 2021 [cited 2023 Feb 7];65:315-7. Available from:

   Introduction Top

Closed-loop communication (CLC), including a call-out (CO), is based upon the use of standardized terminology and procedures to ensure safe communication.[1] A CO is a primary verbalization used to make the team aware of a meaningful change or observation in regards to patient care.[1]

   Components of Closed Loop Communication Top

CLC is a communication model originating from military radio transmissions based on verbal feedback to ensure proper team understanding of a meaningful message.[2] CLC is a three-step process, where

  1. The transmitter communicates a message to the intended receiver
  2. The receiver accepts the message with acknowledgment of receipt through verbal confirmation, seeking clarification if required and
  3. The original transmitter verifies that the message has been received and correctly interpreted, thereby closing the loop.[2]

   Closed Loop Communication and Team Work Top

The patient safety and avoidance of medical errors are based on the prevention of system-based error as opposed to sole reliance on a health-care provider's vigilance.[3] CLC is not only efficacious in high-intensity fields such as aviation, the military, and the nuclear industry but is also applicable in emergency medicine, obstetrics, and anesthesia.[4] These concepts are used in courses such as advanced trauma life support, advanced cardiac life support, and TeamSTEPPS training.[5] Medical errors and failure to rescue are commonly attributed to ineffective communication during operative care in “low frequency, high acuity” events, including trauma resuscitation and cardiac arrest situations.[6] American Heart Association specifies the closed loop communication as an essential competency for a provider and mentions it as an important and first assessment in the debriefing tool, while assessing team dynamics.[7] It includes (1) orders acknowledged and confirmed when given and (2) orders announced when executed.

   Alternatives to Verbal Communication Top

Verbal communication has multiple limitations during a pandemic. Apart from being a common means of contagion spread, it is also difficult to verbally communicate due to respirators and other personal protective equipments. There has been proposal for usage of sign language for the same.[8]

   Disadvantages of Sign Language in Health-Care System Top

There are multiple different sign languages with the background of five different language families, but they are difficult for nonsigners to learn and nonspecific for drug quantification and administration. For example, if sign “A” is described for “Adrenaline,”[8] it can be easily misinterpreted for “Atropine.” The dosage of the drugs cannot be correctly mentioned only by the sign language. This signed mode of spoken language in a health-care system might lead to compromise in patient safety. Closed loop communication is difficult. Both the transmitter and receiver have to be in direct line of vision and they should stop what they are doing and be observant about when the other person will be showing signs. The process further complicates when multiple communications are happening simultaneously. Applying sign language for critical areas such as operation theater and intensive care might result in disaster.

   Proposal of Four Tick Technique Top

Our quest for a simple, easy to learn and train, effective strategy of closed loop communication for the execution of a specific message to ensure patient safety, amidst the difficulty posed by this COVID-19 pandemic for verbal closed loop communication lead us to the innovation of the four tick technique.

Our work is inspired by the application WhatsApp, which uses two ticks and a color coding for communication between the transmitter and receiver for any message. We propose four ticks without color coding for commands (messages) which requires execution of an action. Although the classical description of closed loop communication does not include the execution of the command (message),[2] we propose to include the execution and accomplishment of the command (message) as a component [Table 1].
Table 1: Components of nonverbal closed loop communication and the four tick technique

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  • First tick: The transmitter can write a message (command) and tick it with time only when he wants the command to be executed. The transmitter can choose the needed command from available multiple precise short text commands if using an electronic medium. It can be written on a paper or displayed on an electronic screen
  • Second tick: The receiver acknowledges reading of the message (command) with a tick. The receiver should have access to mark tick on the paper or the digital screen. If any doubts the receiver should raise it now. In an electronic medium, multiple precise short text doubts can be available, if the observer choose to raise
  • Third tick: Once the action for the message (command) is accomplished, the receiver marks the third tick
  • Fourth tick: The transmitter marks the fourth tick acknowledging the execution of action and the communication loop is closed.

   Advantages of the Four Tick Technique Top

The advantages of four tick technique are it is easy to learn and practice. Effective nonverbal closed loop communication is possible even in resource-limited settings of low and middle-income countries as it would require only a writing medium (a paper) and a device (pen or pencil) to write the message and mark the tick. Can be extended to any form of definitive closed loop communication for any purpose in any language. Unlike sign language the training required is very minimal, as it needs only understanding of a simple concept rather than learning signs for many words and actions in multiple languages.

   Extended Usage of Four-Tick Technique Top

As we prepared mainly for the effective closed loop communication between anesthesiologist and their assistant (anesthesia technician), its use can be extended outside the operation theater [Table 2], outside hospital, at home, at work place, anywhere in the world for definitive and effective communication between individuals and teams in a common language.
Table 2: Examples of Non-verbal closed loop communication for execution of a command a) between an Anesthesiologist and the assistant Anesthesia Technician, b) between a physician and the assistant nurse

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Limitations of closed loop communication

If more than one team member initiates CO and CLC simultaneously, communication overload can result. CLC utilizing effective and clear communication does not always come naturally for team members. The factors including time pressure, excessive workload, and organizational hierarchies, and interpersonal factors can negatively impact the use of CLC.[3]

Although communication overload is alarming, appropriate and timely vocalization of concerns on behalf of the patient safety is integral to a successful interprofessional team.[3]

Repetitive simulation training with CLC, will allow the formal integration of this mode of communication into everyday practice for health professionals.[3]

   Conclusion Top

Our proposal of this communication strategy of four tick technique for nonverbal closed loop communication during this COVID-19 pandemic, will help in effective communication of specific message in the health-care system improving the patient safety with minimal resources and training of the interdisciplinary team members. It can be extended to any form of definitive closed loop communication between two individuals for any purpose, in any language in the world.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Salas E, Wilson KA, Murphy CE, King H, Salisbury M. Communicating, coordinating, and cooperating when lives depend on it: Tips for teamwork. Jt Comm J Qual Patient Saf 2008;34:333-41.  Back to cited text no. 1
Burke CS, Salas E, Wilson-Donnelly K, Priest H. How to turn a team of experts into an expert medical team: Guidance from the aviation and military communities. Qual Saf Health Care 2004;13 Suppl 1:i96-104.  Back to cited text no. 2
Salik I, Ashurst JV. Closed Loop Communication Training in Medical Simulation. StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.  Back to cited text no. 3
Siassakos D, Bristowe K, Draycott TJ, Angouri J, Hambly H, Winter C, et al. Clinical efficiency in a simulated emergency and relationship to team behaviours: A multisite cross-sectional study. BJOG 2011;118:596-607.  Back to cited text no. 4
Chen AS, Yau B, Revere L, Swails J. Implementation, evaluation, and outcome of TeamSTEPPS in interprofessional education: A scoping review. J Interprof Care 2019;33:795-804.  Back to cited text no. 5
Ghaferi AA, Dimick JB. Importance of teamwork, communication and culture on failure-to-rescue in the elderly. Br J Surg 2016;103:e47-51.  Back to cited text no. 6
American Heart Association Forms. Texas: The Association. Team Dynamic Debriefing Tool. Available from: [Last accessed on 2021 Feb 03].  Back to cited text no. 7
Singh MR, Kundra S, Singh S, Grewal A, Singh T. Sign language in anesthesiology in times of novel corona virus pandemic. J Anaesthesiol Clin Pharmacol 2020;36:S81-2.  Back to cited text no. 8


  [Table 1], [Table 2]


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