36C24419R0074-012.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 115-06 June 15, 2015

CRITICAL TESTS AND CRITICAL RESULTS FOR NON-LABORATORY TESTS

I. PURPOSE: This Medical Center Memorandum defines the policy for identifying, reporting and flagging critical imaging exam results from the Program Chief to the ordering/treating practitioners and the staff Radiologist/Reading Physicians at this facility. Additionally, it defines the requirement for ordering a STAT non-laboratory diagnostic test and the time elements involved for reporting these results.

II. POLICY: It is this Medical Center’s policy that imaging exam results of a “critical” nature, in the Radiologist/Reading Physicians judgment, be communicated to the ordering and treating practitioners within a timeframe that allows prompt attention and appropriate action(s).

Test results shall be considered “critical” when those results indicate that the patient could be in imminent danger or serious consequences could occur unless Physician awareness is initiated immediately (hereafter this will be referred to as Critical Outcome Value).

III. RESPONSIBILITY:

A. Radiology Supervisor is responsible for: Instructing all Radiologists/Reading Physicians regarding the following policies and procedures for recognition and communication of “Critical Outcome Value” test results:

1. The Radiologist/Reading Physician will initially attempt to notify the requesting provider, attending physician, surrogate or “authorized agent” by telephone/pager.

2. In the event the Radiologist/Reading Physician cannot appropriately contact any of the former, the report will be called to the office of the Chief of Service for that specific Specialty, if no success; the Chief of Staff will act as a secondary default contact. If the patient’s ordering physician is an Urgent Care Center (UCC) doctor, then call the physician working in the UCC.

3. Ensuring that verified test result reports are available in the electronic medical record in a timely manner and the appropriate information is annotated in the electronic report.

Attachment J

MCM 115-06, Critical Tests and Critical Results for Non-Laboratory Tests

4. Understanding the concept behind the policy as well as which “Critical

Outcome Values” trigger mandatory alerts.

B. Ordering Practitioners are responsible for:

1. Placing the initial order with appropriate contact information for themselves, surrogate or preceptor if applicable. Information should include viable contact measures (i.e. telephone number/extension, pager, cell, etc.).

2. Taking responsibility for results of any orders that have been communicated to them.

Assigning a surrogate to receive “critical” test result notifications when they are not available to receive results in a timely manner as indicated in the procedure below.

3. Notify radiology if any discrepancy is noted within the completed radiology report (i.e. Left vs Right, incorrect anatomy reported, etc.). The radiology department will complete a Radiology Discrepancy Notification form which will be used to inform the Radiologist of any questionable discrepancies noted within any completed report. If applicable, the Radiologist will dictate an addendum to the report.

C. Radiologist/Reading Physicians are responsible for:

1. Notifying the requesting provider, attending physician or surrogate by telephone/pager of a “critical outcome value” report.

2. Understanding the sequence involved in case the requesting provider cannot be contacted within the appropriate time frame.

3. When possible, the contact’s name and time of contact will be added to the electronic report prior to verification.

4. Ensure that the critical outcome value and/or STAT test report is “read back” accurately by the person contacted.

5. Knowing which “Critical Outcome Values” trigger mandatory alerts.

D. Registered Nurse receiving critical/abnormal results is responsible for: Reporting results to appropriate provider or Medical Officer of Day (MOD) within 30 minutes of receiving call from contracted service and documenting notification of provider and receipt of fax.

IV. PROCEDURES:

A. All non-laboratory exams to be performed at this facility will be ordered electronically. Orders will not be accepted unless they indicate the need for the study, clinical history, and contact information (phone number and/or a pager number). Radiographic studies will not be performed without first having received this electronic order requesting the study. A verbal request for a radiographic study is considered unacceptable.

B. The results of all imaging studies performed at this facility will be entered and verified in the electronic medical record within the Hospital Information System/Radiology Information System (HIS/RIS).

C. Valid examination ordering options consist of “Routine” and “STAT”. Ordering options of “urgent” and “ASAP” should be avoided since they are ambiguous and not easily defined. A routine order reflects no time sensitive immediacy (although, if a specific date/time frame is warranted, that information should be stated within the order and that request will be accommodated when possible).

Ordering option of “Today” should be used for tests that need to be performed the same day for inpatients and outpatients that must travel a distance for care. The STAT orders option is to be utilized ONLY when a patient’s condition is deemed to be life-threatening or a critical medical decision is pending the resulting outcome of the study.

D. The STAT requests are to be completed and have results reported to the responsible clinician within two hours from the time the study is ordered with the following exceptions: Certain imaging studies require a patient to prep properly prior to initiating the requested study (i.e. oral prep for a CT ABD/Pelvis, bowel cleansing for IVP, holter monitor, stress test, or bladder filling for pelvic sonogram). These and other similar types of studies will routinely fall outside the established two hour window from ordering to interpretation of the study and is considered acceptable practice.

E. Studies that are ordered as Routine or STAT, but upon a Radiologist’s/Reading

Physician interpretation, demonstrate a “Critical Outcome Value” result, will have those results reported to the responsible clinician within 30 minutes from recognition of the Critical Outcome Value. Additionally, the radiology studies will be electronically flagged as “Critical” within the HIS/RIS. A Critical Outcome Value result requires direct communication consisting of a phone report with a read back of “OK” following an accurate, verbal read back of the report by the responsible clinician. When possible, the electronic report will contain the time, means of communication (telephone/in person), and the name of the person contacted by the interpreting Physician.

F. Critical/Abnormal results from tests performed by contracted services in the

Community will be called to the Patient Care Facilitator (PCF) at 814-868-8661.

When the operator picks up, ask to be connected to the PCF. If the PCF does not answer, call back to the same number and request the PCF be paged. The exception to this policy is Critical / Abnormal results of cardiac studies during regular business hours being called to the Cardiac Lab.

G. If a responsible clinician associated with the case cannot be contacted, the results will be reported to the clinician’s surrogate, “authorized agent” or supervisor, as appropriate. In the event the Radiologist/Reading Physician cannot appropriately contact any of the former, the report will be called to the office of the Chief of Service for that specific Specialty Medicine as primary default contact and, if no success, the Chief of Staff will act as a secondary default contact. .In the event that the requesting provider or a physician specifically involved in the case in question is physically present with the Radiologist/Reading Physician; during or directly following the interpretation of the study, the phone call is not necessary.

H. “Critical Outcome Values” findings that require direct communication and urgent attention include, but are not limited to:

1. Imaging Results

a. Pneumothorax or Subcutaneous Emphysema

b. Leaking or ruptured abdominal aortic aneurysm

c. Brain Hemorrhage

d. Acute subdural/epidural hematoma

e. Unstable spinal fracture

f. Spinal Cord Compression

g. Unsuspected Pneumoperitoneum (not post op)

h. Significant misplacement of tubes or catheters

i. Pulmonary embolism

j. Critical Carotid Stenosis

k. GI Obstruction

l. Appendicitis

m. Abscess

n. Unexpected Malignancy

o. Ectopic Pregnancy

p. Testicular Torsion

q. Deep Vein Thrombosis (DVT)

r. In the setting of trauma, pleural effusion, widened mediastinum or free fluid

s. Acute Stroke

2. Echocardiograms:

a. Significant Pericardial Effusion

b. Tamponade

c. Dissection

d. LV Clot

3. Pharmacological/Nuclear Stresses:

a. Left Main

b. LV Cavity Dilitation

c. Ischemia suggestive of Multi-vessel Disease

4. Holters:

a. 3rd degree AV Block

b. Sinus pause >3.0 seconds

c. Syncope with non-sustained V-tach >15 seconds

V. REFERENCE: The Joint Commission Comprehensive Accreditation Manual for

Hospitals, Nursing Care Centers, Home Care, Behavioral Health, and Laboratory & Point-of-Care Testing, (current editions)

VI. FOLLOW UP RESPONSIBILITY: Chief, Clinical Services and Supervisor, Radiology

VII. REPORTING REQUIREMENTS: Performance Improvement Monitoring Reports for the timeliness of reporting critical tests and critical outcome values.

VIII. RESCISSION: MCM 111-09, Critical Tests and Critical Results for Non-Laboratory

Tests, dated July 18, 2012.

(Original Signed 6/15/15) David P. Cord Medical Center Director