D.8 - Attachment G “Guideline for Communication of Significant Imaging Results”.pdf

CRITICAL RESULTS AND TESTS

MCP 637-11-66

Charles George VA Medical Center Rescinded Document:

Asheville, NC 28805 637-11-66, Critical Test Results Dated June 25, 2020

Signatory Authority: Effective Date:

Charles George VA Medical Center Executive Director January 2022

Responsible Owner: Recertification Date:

Chief, Imaging Service January 2027

1. POLICY

Critical results shall be conveyed by synchronous communication between the reporting and receiving staff. Communication shall occur within time frames set by this policy (Attachment 1). The recipient of critical results is responsible for initiating appropriate clinical action, and for documenting actions in the Computerized Patient Record System (CPRS).

Results of critical tests shall be communicated to the ordering practitioner/surrogate within the time frames set by this policy (Attachment 1).

2. JUSTIFICATION

This policy defines critical results and critical tests and set standards for the turnaround time and communication of results in the Western North Carolina VA Health Care System (WNCVAHCS).

3. RESPONSIBILITIES

a. Medical Center Director Responsibilities: Ensure that a local policy directing communication of critical results is established.

b. Chief of Staff Responsibilities:

(1) Ensure that the Medical Executive Council (MEC) reviews and approves annually the list of critical results.

(2) Establish communication standards to include, official modes of communication, defined sites of contact information and measures of compliance.

(3) Establish effective processes for communicating critical results including a

Chain of Responsibility.

January 2022 MCP 637-11-66

(4) Establish monitors of the effectiveness of results communication and compliance with VHA and local policy.

(5) Ensure a performance improvement process to identify and correct process deficiencies.

c. Clinical Service Chief Responsibilities:

(1) Ensure that providers comply with established communication standards.

(2) Ensure that a current Chain of Responsibility is posted in the electronic folder, Asheville On Call.

(3) Ensure that current principal contact information is posted in Asheville On Call and other sites designated by communication standards.

d. Ordering Provider/Surrogate responsibilities:

(1) Ensure timely availability by posted contact information during duty hours.

(2) Accept critical result(s), initiate appropriate clinical action and document critical result(s), assessment, and actions in CPRS.

(3) Comply with “Write Down/Read Back” requirement when receiving critical results.

e. Reporting Clinical Staff Responsibilities:

(1) Communicate critical results to the ordering provider/surrogate by synchronous communication within the time frames specified in Attachment 1, or document in CPRS that the critical result(s) was recognized, acknowledged and/or treated.

(2) Document in CPRS the date, time, method of communication, and name of the provider/surrogate contacted.

f. Diagnostic Service Responsibilities:

(1) Establish a list of critical results for the diagnostic services provided.

(Attachment 1)

(2) Establish turnaround time (TAT) for communication of critical results.

4. DEFINITIONS

a. Definition 1. Critical Result: A test result that requires timely and specific treatment, where delay or lapse in care may result in significant morbidity, poorer outcome or death. The critical nature is an index of clinical impact, regardless of ordering priority. The time sensitivity is determined by the clinical course of an unaddressed result. Critical results are subclassified as Critical Life Threatening or Urgent Not Immediately Life Threatening:

(1) Critical Life Threatening: A test result that requires immediate treatment or action in a time frame of minutes to an hour.

(2) Urgent Not Immediately Life Threatening: A test result that has a significant impact on clinical outcome that requires initiation of treatment in hours to days to be considered effective care.

b. Definition 2. Critical Test: A test for which timely results communication is the standard for both normal and abnormal results.

c. Definition 3. Chain of Responsibility: A contingency plan for results notification that identifies a cascade of alternate contacts from the ordering provider to designated surrogates to receive critical results and initiate appropriate care when the ordering provider is not available.

d. Definition 4. Synchronous Communication: Real-time communication such as, in person, telephone conversation, IM or Clinical Video Telehealth (CVT).

Synchronous communication denotes immediate, bidirectional communication that confirms delivery and receipt of results.

e. Definition 5. Turnaround Time (TAT): The time from results known to the time communicated to provider/surrogate.

5. REFERENCES

a. VHA Directive 1088: Communicating Test Results to Providers and Patients.

b. The Joint Commission (2015f) NPSG 02.03.01.

c. CGVAMC Medicine Service Policy Memo, Cardiology Procedures and

Reporting Results, 637-111-03.

d. VHA Communication of Test Results Toolkit.

6. FOLLOW-UP RESPONSIBILITY: Chief, Imaging Service is responsible for the contents of this MCP.

7. RECISSION

MCM 637-11-66 Critical Test Results, dated June 25, 2020 is rescinded.

8. REVIEW

MCPs are reviewed annually, recertified five (5) years from the date of issue or previous recertification, and updated as needed when new guidelines (VHA handbooks, directives, accreditation standards, regulatory agency standards, etc.)

are received.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of January 2027. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATURE AUTHORITY

__/s/_______________________________________

STEPHANIE YOUNG

Charles George VA Medical Center Executive Director Date Approved: January 26, 2022_______________

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MCPs are available at:

Asheville Medical Center Policies - All Documents (sharepoint.com) This is an internal VA Web site that is not available to the public.

Attachment: Benchmark Turnaround Times (TAT) by Service https://dvagov.sharepoint.com/sites/v6office/v6mcp/ashmcm/Forms/AllItems.aspx

Attachment

Benchmark Turnaround Times (TAT) by Service

Pathology and Laboratory Medicine Service (P & LMS)

Critical, life-threatening results are communicated to the ordering provider/designee within 20 minutes of the results becoming available.

CHEMISTRY

TEST LESS

THAN

GREATER

THAN

Calcium mg/dL 6.0 13 cTNl ng/ml (1st critical result per cardiac event)

0.1

Creatinine mg/dL (if > 60 days from last critical result notification)

7.4

Glucose mg/dL 50 500

Ionized Calcium mmol/L 0.82 1.55

Magnesium mg/dL 1.0 5.0

Potassium mmol/L 2.8 5.5

Sodium mmol/L 120 158

HEMATOLOGY

CSF Cell Count 10 WBC/mm 3

Hct % 18

Hgb g/dL 6.6

Platelets 20,000

WBC 2,000 50,000

ARTERIAL BLOOD GASES

ANALYTE UNIT CRITICAL

LOW

CRITICAL

HIGH

pH 7.21 7.59 pCO2 mmHg 19 67 p02 mm Hg 43

MetHb 51

Na mmol/L 120 158

K mmol/L 2.8 6.2

Ca++ mmol/L .78 1.58

Glucose mg/dL 46 484

TCO2 mmol/L 11 40

COAGULATION

PT(INR) 4.5

PTT seconds 100

THERAPEUTIC DRUG MONITORING

TDM ASSAYS UNIT GREATER

THAN

Acetaminophen ug/ml 150

Carbamazepine ug/ml 20

Digoxin ng/ml 2.5

Dilantin ug/ml 40

Lithium mEq/L 2.0

Valproic Acid ug/ml 200

Vancomycin (trough level only) ug/ml

MICROBIOLOGY

A. Critical Results Reported to Provider/Designee as required by P & LMS Critical Value Policy

Positive Blood Culture

Positive CSF culture, gram stain

Positive gram stain from OR tissue or fluid

Positive culture, gram stain from a normally sterile body fluid (excludes urine)

B. Urgent Not Immediately Life-Threatening results reported to charge nurse, clinic nurse or ID Team within 24 hours

Positive AFB smear or culture

Positive Clostridioides difficile toxin assay

Positive culture/ assay for MRSA (MethiciIlin Resistant Staphylococcus aureus) first occurrence

Positive culture for VRE (Vancomycin Resistant Enterococci)

Positive culture for multidrug resistant gram-negative bacilli (e.g. Pseudomonas aeruginosa and others). Must be resistant to aminoglycosides

Positive culture for ESBL (Extended Spectrum Beta-lactamase) producer

Positive cultures for CP-CRE (Carbapenemase Producing-Carbapenem Resistant Enterobacteriaceae)

Positive stool culture for Salmonella, Shigella, Campylobacter or other Enteric Pathogens including Shiga toxin producing E. coli.

Positive parasite assay

Positive viral screen for influenza (novel & seasonal) to Respiratory panel for influenza, RSV, Bordetella pertussis

C. Public Health Infectious Disease - Reported within 24 hours

Positive result that requires reporting to an outside agency (e.g. HIV, Hepatitis B Surface Antigen, others) will be called to the patient provider/designee.

TRANSFUSION MEDICINE

Urgent Not Immediately Life-threatening results reported to charge nurse, clinic nurse or provider/designee within 24 hours.

Positive Antibody Screen

Positive DAT

Elution Report

Extreme Blood Shortages

Surgery Patient with Antibodies

Transfusion Reaction Work-up Report

Change in Medical Record

Instrument Error

Other — Determined at time of Occurrence.

Cardiology - Medicine Service

DIAGNOSTIC

TEST

CRITICAL RESULT

RESULTS

COMMUNICATION

TAT

EKG

3rd degree AV block or complete heart block

Technician to notify an MD on duty and/or ordering provider/designee of findings within

2nd degree AV block type Il

Sustained or prolonged ventricular tachycardia

ST elevation or ST depression suggesting Acute Coronary Syndrome

10minutes of completion

Holter Monitor Sinus arrest pauses ≥ 6 seconds

Technician to notify cardiologist on duty and/or ordering provider/designee of findings within 15 minutes of completion

2nd degree AV block type Il 3rd degree AV block or complete heart block

Sustained ventricular tachycardia

Echocardiogram Large pericardial effusion or signs of cardiac tamponade

Technician to notify cardiologist on duty and/or ordering provider/designee of findings within 15 minutes of completion

Intracardiac mass or thrombus

Intracardiac vegetations

Intracardiac shunts

Stress Test Significant Decrease in systolic BP with exercise

Action as indicated within 10 minutes by supervising cardiologist, advanced practice provider, or other covering provider

Patient admitted to the medical center if further treatment required

ST elevation or ST depression likely due to ischemia during exercise or recovery

Non-sustained or sustained ventricular tachycardia

Symptomatic bradycardia

Imaging Service Results notification TAT is measured from the time the result is recognized to the time of result communication to the ordering provider/designee.

Critical Life Threatening and Urgent Not Immediately Life-Threatening results require synchronous results communication

CRITICAL LIFE-THREATENING RESULT ≤ 60 MINUTE TAT

Tension pneumothorax

Pulmonary embolism (acute, excludes incidental finding)

Bronchial or esophageal intubation

Intracranial hemorrhage (new, or progression)

Brain herniation

Spinal cord compression

Rupture or impending rupture of aortic aneurysm

Acute aortic or other major artery dissection

Pneumoperitoneum (suspected bowel perforation)

URGENT NOT IMMEDIATELY LIFE-THREATENING RESULT

RESULT TAT

New or suspected malignancy 7 calendar days

Unexpected progression or recurrence of malignancy 7 calendar days

Positive myocardial perfusion exam 72 hours

Acute appendicitis 2 hours

Acute cholecystitis 2 hours

Bowel obstruction 2 hours

CRITICAL TEST - IMAGING

EXAM TAT

STAT intraoperative radiograph for possible foreign body or retained instrument

30 minutes