Atch 2 - MCM 544-11-13 Ordering and Reporting of Test Results.docx

Atch 2

COLUMBIA VA HEALTH CARE SYSTEM DEPARTMENT OF VETERANS AFFAIRS COLUMBIA, SOUTH CAROLINA

Medical Center Memorandum No. 544-11-13 March 14, 2019

ORDERING AND REPORTING OF TEST RESULTS AND CRITICAL VALUES

1. PURPOSE: The purpose of this policy is to establish a Medical Center policy for ordering and reporting test results and critical values by care lines performing diagnostic tests and/or procedures. The ordering provider (i.e., the physician, physician assistant, or nurse practitioner who ordered the test) or in certain cases, the registered nurse or clinical pharmacist who is responsible for the care of the patient will be notified in a timely manner when specified diagnostic test results show critical results or when they are defined as "critical tests". In turn the patient will be notified of the results in the time frame outlined within.

2. SCOPE: This policy applies to the Wm. Jennings Bryan Dorn Department of Veterans Affairs Medical Center (VAMC), Columbia, South Carolina, and its community based outpatient clinics (CBOCs.)

3. POLICY: Outpatient notification of test results are broken down into actionable results and nonactionable results. Actionable results are further delineated as critical or noncritical. All test results will be communicated in the appropriate time frame based on these definitions.

4. DEFINITIONS:

a. Nonactionable results: The ordering practitioner will notify the patient no later than 14 calendar days from the date on which the result(s) are available.

b. Actionable results. The ordering practitioner will notify the patient no later than 7 calendar days from the date the result(s) are available.

c. Critical test results: The ordering practitioner will assess and document if immediate patient notification is needed.

d. Order Urgency:

(1) Emergency/STAT: Will be initiated and completed, as technically available, within one hour.

(2) ASAP: Will be initiated and completed, as technically available, within 4 hours as able to do within the lab.

(3) Routine: Will be initiated and completed, as technically available, within 24 hours. Advance orders will be considered routine.

e. Read Back: The process of an individual receiving the results of a critical or significantly abnormal result, or critical test by writing down and reading back the information to the individual providing this information.

f. Diagnostic Areas: Pathology and Laboratory Medicine, Imaging, Cardiology and other diagnostic areas as defined by the organization.

g. Program Areas (as surveyed by Joint Commission):

(1) Ambulatory Care

(2) Hospital, including CBOCs

(3) Home Care

(4) Intermediate Care

(5) Long Term Care

(6) Behavioral Health Care

5. PROCEDURES:

a. Ordering practitioners are responsible for:

(1) Placing the initial order containing accurate contact information for themselves;

(2) Assigning a surrogate to receive critical results/values and critical test results at times of anticipated unavailability;

(3) Initiating appropriate clinical action and follow-up on abnormal results of any tests ordered by them even if they are not the patient's PCP;

(4) Documenting treatment actions in the medical record in response to critical results/values, critical test results and significantly abnormal tests;

(5) Taking appropriate therapeutic actions;

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Memorandum

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544-11-13

(6) Communication of noncritical but actionable test results will be communicated to the veteran within 7 calendar days from the date on which the result(s) are available.

(7) Communication of nonactionable test results within 14 calendar days from the date on which the result(s) are available.

(8) Discussing test results with patients and/or authorized next-of-kin or legal guardian, as appropriate and documenting these discussions in the Computerized Patient Record System (CPRS).

b. Critical test results during Regular Business Hours (M-F 8:00 am - 4:00 pm):

(1) Critical test results and values will be reported to the ordering provider or other clinical personnel responsible for the patient's care (Nurse). If the ordering provider cannot be contacted, lab will contact the following personnel in descending order until contact is made:

(a) Clinical Section Chief

(b) Clinical Service Chief

(c) Chief of Staff

(2) The ordering or receiving provider will determine the best course of action and annotate in CPRS.

(a) Critical test results during odd tours, weekends, and holidays:

ill Critical test results and values ordered from the ICU or Emergency Department will be reported to the ordering provider or other clinical personnel responsible for the patient's care (nurse).

.(g}_ In all other instances, Critical test results and values will be reported to the Medical Officer of the Day (MOD). If MOD cannot be contacted, lab will contact the Chief of Staff.

.{fil The MOD will check CPRS to determine the urgency of contacting the patient. If the MOD determines that the patient must be contacted, the MOD will contact the AOD. The MOD will document in the medical record the required action.

ill The AOD will contact the patient and connect the patient with the MOD. The MOD will communicate the results to the patient.

.(fil The MOD will annotate in the chart that the results were provided to the patient.

ifil If after speaking with the patient, the MOD determines that the patient needs immediate evaluation, the MOD will advise the patient to go to the nearest Emergency Department.

ill The MOD will ask the patient which Emergency Department (ED) he/she will use and the approximate time of arrival to that ED. MOD will also consult his/her list of South Carolina hospitals (http://www.scha.om{hospitals) to match the hospital with Emergency Department.

ifil Once the MOD knows which hospital Emergency Department the patient will go to and receives permission from that patient to contact that ED, MOD will contact the AOD and request that he/she put the local hospital ED physician in contact with the MOD.

illl MOD will execute a warm hand-off with the local hospital ED.

ilQl MOD will document in CPRS the disposition of the patient and ensure that the ordering provider receives a view alert of the activity. Additionally, the next business day, the Lab staff will inform the ordering provider or provider covering for that provider of the critical lab reported the previous night/weekend.

c. Critical Test results and/or critical values received verbally or by telephone by the receiving provider or MOD must be written down first, followed by a read-back and verification of the values/test results to the person providing that information.

d. Exceptions:

In exceptional circumstances, it may be necessary to delay communication of test results beyond the timeframes identified above. For example, communicating a diagnosis of terminal cancer or Human Immunodeficiency Virus (HIV) in a sensitive, empathic manner may require a face-to-face visit at a time convenient to the patient, which could extend beyond the 7 day time frame. Due to the sensitive nature of certain test results, the determination of how to report these results are best made on a case by-case basis. Review and discussion of test results need to be provided to the patient, or patient's personal representative, with an opportunity for questions and discussion.

e. Communicating test in the acute care setting (inpatient, emergency or urgent care):

(1) Communicating test results to patients after discharge. When results of tests ordered and performed while the patient is inpatient become available after discharge, they are communicated to the patient by the ordering inpatient provider, or their designee, unless responsibility is transferred to an outpatient provider, or their designee, and the transfer is documented in CPRS. The transfer of responsibility to the outpatient provider may occur via synchronous or asynchronous communication. The requirements for transfer of responsibility, such as acknowledgment or acceptance by the outpatient provider, should be determined by the local facility .

(2) Settings of acute care often involve 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 provider or the patient's care team should strive to effectively communicate relevant information to the patient about the patient's medical condition, as needed, to ensure the patient is able to engage effectively in the treatment plan. Results of specific tests may be included in this communication, as appropriate.

f. If the patient lacks decision making capacity, communicate results to the personal representative of the patient as identified.

g. If, despite best efforts, it is not possible to communicate test results to the patient (e.g., the patient has moved and left no contact information), all attempts to contact the patient are documented in CPRS. At a minimum, a certified letter should be sent for all test results requiring action.

6. RESPONSIBILITIES:

a. Providers and/or nursing are responsible for accepting critical test results by telephone in accordance with this memorandum.

b. Surrogates are responsible for acting as the ordering provider would.

c. Clinical Service Chiefs are responsible for educating providers and ensuring their staff follows the policy and procedures for verbal/telephone reporting of critical test results as outlined in this memorandum. Charts will also be audited for documentation of adherence to the policy during the chart reviews for FPPE and OPPE's

d. Nursing is responsible for communicating the critical results to the provider(s) and following protocols as outlined.

e. Radiology is responsible for providing communication for abnormal test results and a warm handoff for critical results per the Radiology SOP 114-71 and 114-73.

f. The Medical Record Committee will evaluate compliance on a quarterly basis.

g. Each Laboratory Technologist will know what constitutes a critical test &/or critical test result as per the Dorn Laboratory SOP and Manual.

7. REFERENCES:

a. CAMH, current edition.

b. Medical Center Memorandum No. 554-11-81, Medical Staff Bylaws.

c. Department of Veterans Affairs, Veterans Health Administration Handbook 1106.1;

d. Commission on Laboratory Accreditation Laboratory Accreditation Program Laboratory General Checklist, Question GEN.41 320;

e. The Joint Commission 2011 Laboratory Services National Patient Safety Goals;

f. Pathology and Laboratory Medicine Department, User's Manual, Section 3-1;

g. Pathology and Laboratory Medicine Department, Comprehensive Quality Assurance Manual, p. 32;

h. Medical Laboratory Observer, Clinical Laboratory Reference, Table of Critical limits;

i. VHA Directive 1088/2015 Communicating Test Results to Providers and Patients

j. VA Handbook 5005/53, Medical Support Assistant (MSA) GS-0679 Qualification Standard.

k. VHA Handbook 1400.01, Resident Supervision.

I. VHA Handbook 1400.04, Supervision of Associated Health Trainees.

m. VHA Handbook 1605.1, Privacy and Release of Information.

n. Radiology SOP 114-71, Policy for reporting Critical Values

o. Radiology SOP 114-73, Policy for reporting Abnormal tests

8. RESCISSION: MCM 544-11-13, dated February 24, 2016.

9. FOLLOW-UP RESPONSIBILITY: The Office of the Chief of Staff. This memorandum will be updated as program requirements change, but no later than 3 years from the date of issue.

David L. Omura, DPT, MHA, MS Director/CEO image1.png