36C25818Q0069-006.pdf

Southern Arizona VA Health Care System

Radiology Service Line

Tucson, Arizona

Radiology Service Standard Operating Procedure (SOP) No. 55

SOP 114-17-55

April 24, 2017

CRITICAL RESULTS AND TESTS POLICY AND LISTING

1. PURPOSE: To describe a standardized procedure for the timely notification ofresponsible licensed caregivers of the results of radiology examinations that may have an immediate impact on patient management ( critical examinations/values) and a process to monitor the effectiveness of this procedure.

2. POLICY: Radiologists responsible for interpreting and reporting imaging examinations will utilize a standardized process for the immediate notification and documentation of notification of responsible ordering providers about critical tests or critical results/values. Critical results are communicated as soon as possible to an appropriate licensed provider with a goal of completing notification within 30 minutes from the time the abnormal finding is recognized.

3. DEFINITIONS:

a. Critical Result on Imaging Examination: The result of an imaging examination that may have immediate clinical significance to the patient requiring immediate attention by a practitioner. See Critical Results/Findings List (Attachment A).

b. Critical Test: An imaging examination that is performed for a specific indication in which immediate notification of results is required in all cases and therefore, for reporting purposes, any result is considered a critical finding for that examination.

c. Read Back: A method used to ensure understanding of information being communicated, often used between members of the caregiving team. The process involves the receiver of a verbal or telephone order, test result, or entering it into a computer, and then reading it back and receiving confirmation from the individual who gave the order or test result.

4. RESPONSIBILITIES:

a. The Medical Executive Committee approves critical values criteria and notification procedures upon the recommendation of the Chief, Radiology.

b. The Chief, Radiology is responsible for the overall coordination and execution of the process for timely reporting of critical imaging examinations and critical imaging results.

ATTACHMENT 5

SOP 114-17-55

c. The Chief, Radiology in conjunction with the Diagnostics Quality Assurance (QA) coordinator is responsible for monitoring critical value reporting times and developing improvement processes as needed.

d. Responsible ordering practitioners are responsible for receiving critical results/values and are responsible for verifying the accuracy of reporting by reading back the communicated results.

e. Radiology technologist are responsible for notifying the radiologist when a critical test has been performed.

5. PROCEDURES:

a. Reporting of radiologic interpretations is performed whenever possible using voice recognition (PowerScribe) and Veterans Integrated Systems Technology Architecture (VISTA) imaging systems.

b. An alert system utilizing diagnostic codes when reporting results is used for providing electronic notification. The following codes generate an electronic alert to the requesting physician.

(1) Code 4: An abnormality that may indicate a significant problem, but which does not require immediate clinical intervention. An example is a solitary lung nodule.

(2) Code 5: An abnormality that indicates a significant problem which may require immediate or urgent intervention to prevent poor patient outcome. These findings require immediate notification of the clinician. Examples include unknown free air or unknown intracranial hemorrhage.

(3) Code 9: An abnormality that includes malignancy as a diagnostic possibility.

c. The responsible ordering practitioner is notified immediately after a critical examination or critical result is verified.

d. A verbal read-back of test results process is always used for reporting critical values/results of critical examinations. Responsible practitioners who receive critical test results/values by telephone are instructed and expected to first write the results down and then communicate them back to the caller.

e. The radiologist assigns all reports from critical tests or with critical results as Code 5. In addition, the time from initial recognition to practitioner notification is documented in the final report.

f. Residents and attending physicians are paged. For inpatients when contact information about requesting primary responsible caregiver is missing or erroneous, refer to the list of

Medicine, Surgery, etc., teams found on TucNet to identify the appropriate provider based on the attending assigned to the patient.

g. For outpatients, the ordering provider is contacted by paging or telephone during regular working hours.

h. For after-hour reads involving the contract teleradiology service, the Administrative

Officer of the Day is notified.

i. In the event that contact is made with a provider who is not the patient's responsible caregiver, this individual will, if possible, assist in identifying the appropriate contact.

j. Critical results are called to appropriate providers as delineated below. In the event contact is not made within 10 minutes or less, proceed to the next responsible caregiver on the priority list.

k. Critical results which have been previously documented with appropriate notification do not require repeat notification unless there has been a change which is felt critical to the patient's care. Examples not requiring repeat notification would include follow-up deep vein thrombosis

(DVT) or follow-up intracranial hemorrhage where the findings are stable or improving.

6. REFERENCES:

a. Joint Commission Hospital National Patient Safety Goals, NPSG.02.03.01.

Improve Staff Communication, dated 2013.

b. Veterans Health Administration Directive 1088. Ordering and Reporting Test Results.

c. Veterans Health Administration Directive 1103. Prevention of Retained Surgical Items.

d. American College of Radiology (ACR) Practice Parameters for Communication of Diagnostic Imaging Findings, dated 2014.

7. RESCISSION: None.

orgen

Chief Radiologic Technologist

Robert B. Good, MD

Acting Chief, Radiology Service

Attachment:

A: Critical Results/Findings List

Location Business hours

Inpatient 1. Ordering provider

2. Resident

3. Attending

4. Chief of Care Line

Outpatient 1. Ordering provider

2. Primary Care provider

3. Chief of Care Line

Emergency Responsible ED physician

Department

(ED)

Rehabilitation 1. Ordering provider and 2. Attending

Transitional 3. Clinical Director, RTCL

Care Line

(RTCL)

CRITICAL RESULTS/FINDINGS LIST

• Ectopic Pregnancy

• Testicular or Ovarian Torsion

• Pneumoperitoneum

• Acute Intracranial Hemorrhage

• Cervical Spine Fracture

After hours

1. On-call resident

2. On-call attending

3. Hospitalist

SOP 114-17-55

Attachment A

Page 1 of2

4. House Officer of the Day

(ED physician)

House Officer of the Day

(ED physician)

Responsible ED physician

1. On-call attending

2. Hospitalist

• Thoracic or Lumbar Spine Fracture with spinal cord compression

• Aortic Dissection

• Mediastinal or Retroperitoneal Hematoma

• Intracranial mass with new herniation

• Pulmonary embolism or Deep Vein Thrombosis (DVT)

• Hemoperitoneum

• Acute liver, spleen or renal laceration

• Airway compromise

• Appendicitis

• Abscess

• Pneumatosis of the bowel wall

• Portal venous gas

• Acute arterial embolism or occlusion

• Tension pneumothorax

• Any other finding which is critical to the patient's care

Attachment A

Page 2 of2

CRITICAL TESTS (Positive or negative finding must be called to responsible caregiver)

• Intra-operative radiograph(s) sent immediately (STAT) for emergent intra-operative decision making ( e.g., retained surgical instrument).

• Non-Contrast head Computed Tomography (CT) ordered as ST AT as part of Acute Ischemic Stroke (AIS) protocol.

MONITORING TIMELINESS OF NOTIFICATION OF CRITICAL VALUES AND RESULTS

OF CRITICAL TESTS

a. The timeliness of critical result reporting is monitored as the interval between the time that an abnormal result is first recognized by the radiologist to the time when the responsible licensed care giver is notified of the critical result. This information is collected by review of Code 5 reports. These data are summarized, reviewed by the Clinical Director, Imaging Service, and reported to the Medical Executive Board at least annually. The goal for critical values verification to notifications is 80 percent(%) in less than(<) 30 minutes, 90% in < 60 minutes, and 100% overall.

b. The timeliness of notification of results of critical tests is monitored as the interval between the time the exam is ordered to the time when the responsible licensed care giver is notified. The goal for critical results order to notification time is at least 90% in < 3 hours for radiology and

< 6 hours for nuclear medicine studies, and 100% overall.