36C26318R0288-016.docx

COMMUNICATION OF TEST RESULTS

1. PURPOSE:

Timely communication of test results to patients and practitioners is important to the provision of quality care. Test results include laboratory testing, diagnostic imaging and diagnostic procedures and may be identified as routine, abnormal, emergent, or critical. Critical, emergent, and immediate action values or results will be defined by each department. Test results will be communicated appropriately, and the process for communication will be monitored, and if appropriate, action taken to improve the timeliness of reporting and the timeliness of receipt by the patient or responsible licensed caregiver.

2. POLICY:

It is the policy of VA Black Hills Health Care System that test results must be communicated to the ordering practitioner, or surrogate practitioner, within a timeframe allowing prompt attention and appropriate clinical action to be taken, and that the ordering practitioner further communicates such test results to patients, so that they may participate in health care decisions. This policy defines the emergent, critical and immediate action result values and describes the reporting process for values and interpretations. The policy also includes the identification of surrogate practitioners in the event that the ordering practitioner is not available.

3. DEFINITIONS:

A. Ordering Practitioner. An ordering practitioner is a licensed independent practitioner (LIP) authorized to enter and sign orders for diagnostic tests by privileges or acting under a scope of clinical practice.

B. Surrogate: A licensed independent provider (LIP) with the same or equivalent credentials or privileges of the ordering practitioner who can respond to a critical value in the absence of the ordering provider by taking action if needed for direct patient care.

C. Test Result: Test results include the results of laboratory testing, diagnostic imaging and diagnostic procedures.

D. Critical Value or Result: A critical test result is defined as those values or interpretations that, if left untreated, could be life threatening or place the patient at serious risk. Critical values or results are those results from laboratory, cardiology, radiology departments and other diagnostic areas that upon analysis are determined to be “critical” regardless of the ordering priority. All emergent test results and some abnormal test results constitute critical values or results.

E. Emergent Test Result. An emergent test result is a diagnostic finding associated with a high likelihood of short-term poor outcome and requires either immediate therapeutic intervention or close monitoring.

F. Immediate Action Result. A diagnostic finding which requires attention by the inpatient/CLC nurse to protect other veterans and staff. Usually an isolation risk.

G. Abnormal Test Result. An abnormal test result is a diagnostic finding that requires attention by the ordering practitioner, but not necessarily in an immediate time frame.

H. Personal representative. A personal representative is a person who has authority to act on behalf of the patient if the patient lacks decision making capacity. This may include power of attorney and/or legal guardian.

4. PROCEDURES:

A. For communication of Emergent and Critical Results from Diagnostic Practitioner to the Ordering Practitioner:

(1) For emergent and critical results identified in cardio-pulmonary procedures, clinical laboratory, radiology and anatomic pathology, the results will be directly communicated (either face to face or telephonic) from the diagnostic practitioner to the ordering provider within the timeframes outlined in the attachments. Voice mail or e-mail notification is not acceptable.

(2) The ordering provider will be paged or contacted by his/her office phone. The primary care or specialty team units can be contacted for assistance in locating the ordering provider.

(3) The ordering provider will assign a qualified surrogate practitioner to receive critical, emergent, or abnormal test result notifications when he/she is unavailable. These assignments will be made clearly known to the provider’s surrogate and service line leadership.

(4) If the surrogate provider is unknown or unavailable, the result will be reported directly to the service line physician manager for action or assignment. If the service line manager is unavailable, the report will be called to the Chief of Staff for action or assignment.

(5) During Weekend, Holiday, Evening and Night (WHEN) hours, the emergent and critical results will be called directly to a provider in the Emergency Department (Fort Meade) or the Urgent Care clinic (Hot Springs) unless otherwise specified on the order.

(6) The diagnostic practitioner will note the date, time and name of the provider or surrogate receiving the result in the body of the report, as an addendum, or as a note in the Computerized Patient Record System (CPRS).

(7) The provider receiving the emergent or critical result will write down, read back and verify the results with the caller.

B. For the communication of Immediate Action results from the diagnostic practitioner to the nurse (inpatient or CLC).

(1) For immediate action results identified in the clinical laboratory, the results will be directly communicated (either face to face or telephonic) from the diagnostic practitioner to the nurse in charge of the inpatient or CLC veteran within the timeframes outlined in the Attachments. Voice mail or e-mail notification is not acceptable.

C. For communication of Results from the Ordering Practitioner or Surrogate to the Patient:

(1) It is the responsibility of the ordering practitioner to communicate test results to the patient whether normal or abnormal, critical or non-critical. Results are communicated to patients no later than 7 calendar days from the date on which the results are available for test results requiring action, and 14 days for all other results. For abnormalities that require immediate attention, the 7-day limit is irrelevant, as the communication should occur in the timeframe that minimizes risk to the patient.

(2) Communication of test results to patients will be completed in writing, by phone, or in personal conversation. Notification of test results will be documented in the CPRS patient record.

(3) Tests ordered while the patient is an inpatient, but results reported after discharge, are treated as outpatient tests. These tests are communicated by the ordering inpatient provider or his/her surrogate.

(4) If the patient lacks decision making capacity, results will be communicated to the personal representative of the patient.

(5) Communication with patients can occur in person, by telephone, through My HealthE Vet, or in writing using the “Results Letter” in CPRS. No patient identifiable information is to be communicated to patients by regular email. The communication of test results must be in a format with explanation as needed in order that it can be understood by the lay-person/patient. Note: copying a laboratory or radiology report verbatim is NOT generally considered understandable by the non-medical layperson.

(6) The results are communicated by licensed or certified health care staff. It is not required that the ordering practitioner personally communicates every result, but this task may be delegated to other licensed health care staff when clinically appropriate.

(7) When, despite best efforts, it is not possible to contact the patient (e.g., the patient has moved and left no contact information), all attempts to communicate with the patient are documented in the medical record. NOTE: Inpatient, emergency or urgent care often involves extensive, repetitive testing with rapidly changing clinical conditions. Therefore, for patients in the inpatient, emergency, or urgent care setting, it is not required or expected that each individual test result is communicated to the patient. The ordering practitioner or the care team the patient is part of should strive to effectively communicate relevant information to the patient about the patient’s medical condition. Results of specific tests may be included in this communication as appropriate.

5. RESPONSIBILITIES:

A. Ordering Provider: Responsible for communicating test results to the patient or authorized patient representative within 7 days of receiving the result if action is required, or 14 days for all other test results. The provider is required to document notification, and to initiate an appropriate plan of care or follow up as clinically indicated.

B. LIPs as Surrogates: Responsible for accepting critical values from clinical staff, recording and reading back the results and taking action if needed for direct patient care.

C. Clinical service line managers or chief of staff: Responsible for acting as the surrogate when needed as described above and ensuring the compliance with this policy.

6. REFERENCES:

A. VHA Directive 2009-019 Ordering and Reporting Test Results.

7. RECISSIONS:

A. DIAG-09 Lab-Critical Laboratory Values

B. DIAG-11 Respiratory Therapy-Arterial Blood Gas (ABG) Value Reporting

C. DIAG-10 Imaging- Abnormal Test Results

8. REISSUANCE: October 2018

9. RESPONSIBILITY: Chief of Staff

Sandra L. Horsman, MBM Director

ATTACHMENT A: IMAGING TEST RESULTS

A. All imaging studies to be performed at the VABHHCS will be ordered through VistA/CPRS and include the reason for the study, the name of the ordering practitioner, and the practitioner’s contact information including a pager number. A patient safety assessment form will be required for IV contrast and MRI examinations.

B. Critical results as defined below are coded in the Powerscribe system with Code 1002: “Critical Abnormality” and will be directly communicated to the ordering practitioner within 60 minutes from the time of detection through the process identified in this policy. Results may be determined critical regardless of the ordering priority (i.e. STAT, urgent, routine, etc).

C. Radiology studies that are ordered STAT are to have results recorded in CPRS within two hours from the time the study is completed. Note: Certain imaging studies require a patient to prep properly prior to initiating the requested study.

CRITICAL RESULTS TO PROVIDER

ATTACHMENT B: CARDIO-PULMONARY TEST RESULTS

A. Non-invasive cardiology procedures with critical results as defined below will be directly communicated to the ordering practitioner as soon as recognized and no later than 30 minutes through the process identified in this policy. Results may be determined critical regardless of the ordering priority (i.e. STAT, Urgent, Routine, etc).

CRITICAL RESULTS

ATTACHMENTS C: Clinical Laboratory/Blood Gas/POC Glucose:

A. Critical results as defined below will be reported as soon as recognized and no later than 30 minutes by the process outlined in this policy. Results may be determined critical regardless of the ordering priority (i.e. STAT, urgent, routing, etc).

B. Laboratory Studies that are ordered STAT are to have results entered into VISTA within 60 minutes from the time the order was accessioned in the laboratory.

C. Point of Care (POC) glucose results that are critical will be reported to the patient’s provider by the nurse and documented in the template progress note within CPRS.

D. Repeat critical values that are known or expected due to treatment or recognized medical conditions do not have to be repeatedly reference the initial notification and the reason for not repeating the notification.

CRITICAL RESULTS TO PROVIDER

Acetaminophen regardless of result.

Hemoglobin <7.0 or > 20.0 000mm3 Gentamycin Trough >2.5 ug/ml Blood Culture + with confirmed gram stain

WBC

<2000 mm3 >20000 mm3

Hematocrit < 20% > 58%

Platelet <60000 mm3 >soo 000 mm3

INR

>4.0 Phenytoin >20mg/dl (Dilantin) +MRSA Culture results + Methicillin Resist Staph Au

PTT

>100 sec

Vancomycine Resist Entero.

Magnesium 1.0 or > 4.0 mg/dl

Carbapenem Resist Enterobacteriacea

>500 ng/mL

Troponin 1> 0.12 ng/mL

POC Fingerstick Glucose <40 or >400

IMMEDIATE ACTION TO NURSING

MRSA admission surveillance positive- NEWLY identified

MRSA SURV NARES DNA

MRSA SURV NARES AGAR

CRITICAL VALUE REPORTING – ANATOMIC PATHOLOGY

To define the standard operating procedure for reporting of critical anatomic test results by the laboratory contractor.

A. All new diagnoses of malignancy, with the exception of squamous cell cancer of the skin and basal cell cancer, must be reported by the pathologist verbally to the provider who performed the procedure or surrogate.