Your Captain Speaking: The Turnover Report

Samantha, my partner, tells me we have a call listed as nonurgent. We’ve done these many times, and they often turn out much different. A call to the nursing home for a vague chief complaint: weakness. When we get there and assess the patient and get the report from the staff, we know this patient is in trouble. 

On the way to hospital Samantha builds a much better picture of what’s going on, and it’s not pretty. As we start the transfer to the ED room, the nurse walks in and is obviously not happy.

“We’re really busy. Whatcha got?”

Samantha starts to give the nurse the report but after only about three words is interrupted with, “What’s the chief complaint? That’s all I want.”

We are both quiet for a moment. We hate this kind of treatment, and we also hate it for the patient. What are we going to do?

This is actually a big deal. A bad turnover report can lead to mistakes, and mistakes can kill. A recent study from John Hopkins University revised the leading causes of death in the U.S.¹ Cardiac causes are still No. 1—no surprise—and cancer is still second. Previously No. 3, respiratory-related causes are now the fourth-leading killer. They have been surpassed by medical mistakes, which are now No. 3. Roughly a quarter million people a year die of medical mistakes in the USA.

Those aren’t just complications but actual causes of death. Lots more mistakes don’t lead to patient death. Higher infection rates, wrong medications, procedures meant for someone else, dropped patients—the list is long. Not surprisingly, turnover reports, improperly done, can lead to significant mistakes in later care. 

The Aviation Experience 

Pilots make mistakes too, but we are responsive to changes for safety-related problems. On flights over eight hours, we add a third or even fourth pilot. We figure out a work-rest plan and then switch. Back in the day the turnover was rather informal, inconsistent, and led to lots of errors. What kind have I seen? Nothing you’d have noticed as a passenger, but they were there: a fuel pump switch left off to balance the tanks but now way out of balance the other way; a position report not accomplished; a flight log not filled out correctly (think a PCR missing a drug that was actually given); destination weather that went below minimums but wasn’t mentioned. That’s all stuff that should have been discussed.

Pilots changed the way we did things. Crew Resource Management (CRM) was a good part of it. The captain is senior, tired, and a grump who gets out of his seat without saying much to his junior replacement other than, “Fly that direction and don’t crash into anything. Call me in three hours.” The relief pilot puts CRM to work, calls his colleague by name, says he’s uncomfortable and why, and provides a solution: “Captain Blanchet, I’m uncomfortable on where we are. How about a full turnover report?” 

Not only do these CRM ninja skills work like a charm, but we added two other secret weapons. On a little card attached to the back of the crew member’s ID card is a checklist with the required minimum items to be covered. And we made the use of this checklist mandatory.

Back for More

Let’s go back to our patient. Samantha wants to give a good report, but the nurse is not listening. She glances over at me, and I’m grinning because I know what’s next. 

The nurse snaps back at Samantha. Samantha just pauses a moment and repeats, “Misty, I’m uncomfortable turning over the patient with only the chief complaint. We’re required to give a good turnover report. It will only take a minute.” That’s all that’s needed—everyone in the room knows it’s the right thing to do. Samantha gives the brief and then glances at the small turnover checklist attached to her ID card to make sure she covered all the items. 

What about when we pick up a patient and it feels like we get more from dispatch than from the caregiver? “Here’s your paperwork” does not constitute a turnover report. Don’t be afraid to go back for seconds if needed! Once I got what I thought was a complete report, walked into the hospital’s patient room, and found my teenage patient in police handcuffs, which was never mentioned. Use your ninja CRM skills and go back for seconds or even thirds. 

What does some of the research say? First, there is no standardized name for the process, and the terms turnover report, handoff, transfer of care, and patient report all seem to be used interchangeably. An excellent article from the American Academy of Pediatrics had a wonderfully written paragraph that brings it home:²

“Current ToC practices have been criticized as being highly variable and unreliable. Results of a questionnaire and follow-up observation study revealed that the ToC processes were unstructured, informal, and error prone, consistent with findings from other studies. In another analysis of ToC processes, nonstandardized approaches led to adverse clinical consequences, near-misses, and ineffective or duplicative care.”

It’s a hot mess. We’re doing a terrible job at transfer of care in the medical community as a whole. While this article and others have some outstanding suggestions, such as having family members present when giving the turnover report, we know that’s not always possible. 

Disappointingly, many articles like this miss a key solution: Use a checklist! A checklist provides for a standardized, more consistent, less variable report. The use of checklists in the medical community is still in its infancy, but they can be a powerful tool.³

There will be a reckoning in the future on medical mistakes. At some point death certificates will start to list medical mistake as a cause of death. When a family receives a death certificate with that listed, there will be harsh and painful consequences. Accusations of mistakes will also start to appear on patient reports even without a fatal result. We in EMS do not want to make mistakes, but if we are where a mistake begins, we could bear the brunt of the consequences. Here’s some advice: Give good patient care. Write an accurate and complete patient report. Get, and then give to the next caregiver, a good turnover report. Use a checklist.

References

1. Makary MA, Daniel M. Medical error—the third-leading cause of death in the U.S. BMJ, 2016 May 3; 353: i2139.

2. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee. Handoffs: Transitions of Care for Children in the Emergency Department. Pediatrics, 2016; 138(5): 2,016–2,680.

3. Blanchet D, Blanchet B. Why Checklists Are Your Friend. EMS World, https://www.emsworld.com/article/219405/why-checklists-are-your-friend.

Dick Blanchet (ret.), BS, MBA, worked as a paramedic for Abbott EMS in St. Louis and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years.