D.11 36C26126R0014 PS-11-51 - Ordering and Reporting Test Results.doc

VA Northern California Health Care System Policy Statement 11-51

October 26, 2015 16.

VA Northern California Health Care System Policy Statement 11-51

October 26, 2015

ORDERING AND REPORTING PATIENT TEST RESULTS

1. PURPOSE:

To establish VA Northern California Health Care System’s (VANCHCS) policy for communicating patient test results to providers and patients.

2. SCOPE:

This policy statement applies to all VANCHCS facilities.

3. DEFINITIONS:

a. Ordering Practitioner: An ordering practitioner is a provider authorized to enter and sign orders for diagnostic tests.

b. Surrogate: A clinical team member authorized by the Ordering Practitioner in a manner consistent with VA medical facility policies to receive information from the diagnostic provider (in the absence of the ordering provider) and/or notify patients of test results in a timely manner and discusses results with the patients.

c. Doctor of the Day: A licensed practitioner who is responsible for general patient welfare when the Ordering Practitioner is away from the facility where the patient in question receives care.

d. Preceptor: A licensed independent practitioner who supervises the ordering of tests by residents or by other practitioners acting under a scope of clinical practice.

e. Diagnostic Practitioner: A diagnostic practitioner is a provider who performs or supervises the performance and interpretation of diagnostic tests either through privileges or by acting under a scope of practice.

f. Test Results: Test results include the results of laboratory and pathology testing, diagnostic imaging, and diagnostic procedures. Test results are categorized as abnormal or normal as determined by a clinical provider and are further defined as follows:

(1) Abnormal Test Results. Abnormal test results are results that fall outside a specified normal reference range, are unexpected, or could indicate the presence of a disease. An abnormal test may or may not require action and therapeutic intervention, depending on the clinical context. There are three types of abnormal test results that require action or therapeutic intervention:

a. Critical Life Threatening. Any diagnostic finding which must be acted upon by the ordering provider or their designee immediately or within a short window of time and could result in severe morbidity or mortality if left untreated.

b. Urgent Non Life Threatening. Any diagnostic finding which must be acted upon by the ordering provider or their designee within a relatively urgent timeframe (as clinically indicated to ensure timely, appropriate and effective therapeutic action).

c. Clinically Significant. A diagnostic finding that requires action by the ordering provider, or their designee, but not necessarily in an immediate or urgent time-frame.

(2) Normal Test Results. A diagnostic finding that falls within the normal reference range for the test and may or may not require immediate action or change in treatment depending on clinical circumstances.

g. Direct Communication: Transmission of test results by direct, non-electronic dialogue between the diagnostic and the ordering practitioner or surrogate by telephone or face-to-face conversation, or hand-carried report.

h. Electronic Communication: Transmission of test results by electronic means (e.g. alerts, e-mail, FAX etc.)

i. Personal Representative: A personal representative is a person who under applicable law has authority to act on behalf of the individual. This may include power of attorney, legal guardianship of an individual, the executor of the estate of a deceased individual, or someone under Federal, state, local or tribal law with such authority (e.g., parent of a minor).

4. POLICY:

Test results will be communicated to the ordering practitioner within a timeframe that allows prompt attention and appropriate action. The ordering provider further communicates test results to patients/ personal representative so that they may participate in decisions about their health care. Required timeframes are for critical, emergent, abnormal, and normal test results are listed below.

5. RESPONSIBILITY:

j. Medical Center Director is responsible for ensuring that:

(1) Appropriate process is followed in all cases when the ordering practitioner and surrogate practitioner are unavailable. A process must be in place for the communication of emergent results to another practitioner who can take action, such as the medical officer of the day, the senior medical resident, or the leader of the facility’s rapid response team.

(2) Critical tests and critical results and values are defined.

(3) The acceptable length of time between the ordering of tests or collection of specimens and the availability of results or critical values is defined.

(4) The acceptable length of time between the availability of critical tests, values, or results and receipt by the responsible provider is defined.

(a) The organization collects data on the timeliness of reporting critical tests and critical values or results.

(b) The facility assesses the data collected and determines whether there is a need for improvement, and takes appropriate action to improve and measures the effectiveness of those actions.

(c) Communication of test results to practitioners and patients is periodically monitored. Results are communicated to patients no later than 7 calendar days from the date on which the results are available, for test results that require action, and 14 calendar days from the date on which the results are available, for test results requiring no action.

k. Chief of Staff (COS) is responsible for ensuring that the all service chiefs establish a chain of responsibility for their individual service for receipt of test results.

l. Service Chiefs are responsible for establishing a chain of responsibility for their service/department for receipt of test results and communication of results to patients.

m. The Diagnostic Practitioner or designee is responsible for:

(5) Ensuring that verified test result reports are available in the medical record in a timely manner.

(6) Identifying and communicating, or ensuring that critical test results are communicated in less than one hour and urgent test and abnormal results are communicated per department policy to the ordering practitioner, the practitioner’s surrogate or the preceptor/supervisor, as appropriate. The receiving provider should write down and read back the information to the diagnostic provider to confirm communication.

(7) Documenting in the medical record the time and means of such communication and the name of the provider contacted.

n. The Ordering Practitioner is responsible for:

(8) Placing the initial order along with the appropriate contact information for themselves and their surrogate or preceptor, when applicable.

(9) Ensuring information contained in the phone directory pertaining to them is accurate.

(10) Processing electronic view alerts promptly.

(11) Initiating appropriate clinical action and follow-up on the results of any orders which they have placed.

(12) Assigning a surrogate to receive critical, urgent and/or abnormal test result notification when Ordering Practitioner is unavailable to receive and review it in a timely manner.

(13) Documenting (in the medical record) treatment actions taken in response to critical, urgent and/ or abnormal test results.

(14) Discussing test results with patients and/or authorized personal representative, as appropriate; and documenting those discussions in the medical record. Communication of results to patients should occur within 7 days for test results requiring action or 14 days for test results not requiring action, or sooner as called for in the case of urgent/ critical results.

(15) When test results indicate that an action or therapeutic intervention is needed, the ordering provider is expected to discuss potential actions or therapeutic intervention options with the patient and initiate action.

(16) Documenting in the medical record if attempts were made to contact the patient and the patient was unavailable. At a minimum, a certified letter should be sent for all test results requiring action.

(17) 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 their surrogate.

(18) Communicating test results to patients via letter, phone call or in person no later than 7 calendar days from the date on which the results are available, for results requiring action, or 14 calendar days from the date on which the results are available for results not requiring action. Secure messaging through MyHealtheVet is acceptable but no patient identifier is communicated in unsecured email. A copy of the secure message should be saved in CPRS. For abnormalities that require immediate attention, the communication should occur in the timeframe that minimizes risk to the patient. CPRS audits will track compliance of the 7-day and 14-day requirements. In the event the provider is absent for an extended period of time, they will designate a surrogate in CPRS:

(d) If the patient lacks decision-making capacity, results will be communicated to the personal representative of the patient as defined in this policy.

(e) For communications where it is important for the patient to quickly take some kind of action, such as a change in medication or a return to the medical center for further evaluation, it shall be documented that the communication was received and understood.

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.

(19) Communication of test results to patients outside of the setting of an outpatient visit is documented in the medical record.

(20) The ordering practitioner may delegate the task of communicating the test results to a licensed or certified healthcare staff if clinically appropriate.

(21) For tests ordered by residents, the preceptor has the responsibility for ensuring that the required communication and documentation occurs.

6. PROCEDURES:

o. Results neither urgent or abnormal: If the test results are neither urgent nor abnormal they may be communicated to the ordering provider or surrogate by ensuring the results are placed in the patient’s electronic medical record in a timely manner. The ordering provider will contact the patient within 14 calendar days to inform them of a normal test result. Communication may occur in person, by letter, by telephone, or by secure messaging.

p. Urgent and critical test results: If a Diagnostic Practitioner and/or lab personnel interpret/determine the test results are urgent/critical, the ordering provider, surrogate or preceptor will be contacted by direct communication. See Attachment A for laboratory critical tests, Attachment B for cardiology critical tests, and Attachment C for radiology critical tests. If the ordering practitioner is not available after hours or during weekends and holidays, the process specified in Attachment D should be followed: See Attachment D for the current call pathway for reporting critical values when the ordering practitioner is not available.

q. Abnormal test results: If the Diagnostic Practitioner interprets the test results to be abnormal those results can be transmitted by direct or electronic communications within 7 calendar days.

r. Exceptions In exceptional circumstances, it may be necessary to delay communication of test results beyond the timeframes identified above. 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.

s. Quality and Performance Monitoring Procedures: Regular monitoring of compliance shall be performed by designated staff from each of the diagnostic services to analyze their process for reporting and timeliness of the critical test result. The information should include.

· Patient ID (Full Name/Full SSN)

· Date of Test/Exam

· Location of Ward/Clinic (origin of request)

· Time Test Completed (analysis completed)

· Time Test Result Reported (read-back process)

· Name and Title of Person Receiving Results

· Name and Title of Person Giving Result

· Confirmation of “Read-Back” documentation (yes or no)

· Total Time Interval of Process (from time result known to time result given to provider)

7.

ORIGINAL EFFECTIVE DATE: Unknown 8.

REVIEW, RESCISSION, OR REISSUE DATE:

The Chief of Staff, (11) will review this policy for rescission or reissue within five years of the date of issue.

9.

REFERENCES:

VHA Directive 1088, Communicating Test Results to Providers and Patients 10.

RESCISSION:

Policy Statement 11-51, dated, August 6, 2014 David Stockwell, MHA Director

Attachments- 4

ATTACHMENT A: CRITICAL DIAGNOSTIC TEST RESULTS

LABORATORY

7. PURPOSE:

To define an appropriate timeframe for notification of the results of critical tests to the ordering provider or surrogate.

8. POLICY:

The results of critical tests will be directly communicated to the ordering practitioner or surrogate in the timeframe specified below.

9. DEFINITIONS:

t. Critical Tests: “Critical tests” are those tests that the organization has determined should be expedited and completed within a specified time frame due to potential impact to the patient of receiving or not receiving a Critical Value or Result. Critical tests may include laboratory or non-laboratory tests.

u. Direct Communication: Direct communication is the transmission of test results by telephone, face-to-face conversation, or hand carried report between lab personnel and the ordering or on-call care provider.

10. PROCEDURES:

v. Critical Test for Pathology and Laboratory Medicine: Results of intraoperative consultation by a Pathologist, typically a frozen section diagnosis but may be the findings of gross examination or evaluation of cytologic material.

w. Timeframe for Communication of Results: Intraoperative results will be directly communicated within 20 minutes for a single part intraoperative consultation. Multipart intraoperative consultations may take an additional 15 minutes for each additional specimen, e.g. 50 minutes for 3 specimens and 95 minutes for 5 specimens. Communication of the results may take place after all the parts have been evaluated, if all are negative.

x. Documentation: The time from receipt of the specimen to time of report will be noted in the final report for each case that an intraoperative consultation is requested.

11. RESPONSIBILITIES:

y. The Chief of Pathology and Laboratory Medicine is responsible for ensuring that the timeframes for communication of the results of critical tests are met.

12. CRITICAL VALUES AND ALERTS

z. Physicians/ordering providers will be notified in less than one hour of the following critical values and alerts:

Chemistry

- Creatine Kinase (IU/L)

- Troponin (ng/ml)

0.08

Blood Gas

Hematology

- Hemoglobin (g/dl) (or decrease of 3 g/dl from previous determination)

Coagulation

- PT (not on coumadin), Prothrombin Time (sec)

- INR (for patients on coumadin)

- aPTT (not on heparin), Partial Thromboplastin Time (sec)

- aPTT on heparin

Toxicology

- Therapeutic Drugs

Level exceeding therapeutic range

- Valproic Acid (mcg/mL)

Fluids

- Spinal fluid leukocyte count (WBC/cmm)

- Positive Gram stain or culture of blood or spinal fluids, thoracentesis, paracentesis or joint fluids.

- Presence of blasts in Wright stains of blood or body fluid *

- Positive and fast stain or presumption tuberculosis culture

*Chronically elevated values for creatinine, WBC, Blasts and CO2 need not be called (see below).

Low serum calcium will be corrected for serum albumin (see correction below)

aa. Transfusion Service Critical Values

13. REPORTING PROCEDURES FOR REPEAT CRITICAL VALUES:

ab. Repeat Creatinine values greater than 3.5 mg/dl do NOT have to be called to the provider. The Technologist enters “Creatinine results consistent with previous result” into VISTA.

ac. Repeat critical low WBC do not need to be called unless the Absolute Neutrophil Count (ANC) is less than 700. The Technologist enters “White blood cell result consistent with previous result and Absolute Neutophil Count > 0.7 k/cmm” into VISTA.

ad. Repeat critical high WBC does not need to be called if previous was called within previous two weeks or the WBC’s are predominantly well differentiated lymphocytes, i.e. CLL and the count is less than 100,000. The Technologist enters “White blood cell count result consistent with previous result” into VISTA.

ae. Repeat CO2 greater than 45 do not need to be called to the provider. The Technologist enters, “CO2 result consistent with previous result” into VISTA.

af. Guidelines for calling repeat Creatine Kinase critical values

· Call first time result greater than or equal to 1000

· A repeat CK over 1000 does not need to be called unless it is greater than 3000 or the previous result was more than a week earlier

· Values greater than 3000 only need to be called once unless greater than 10000 or the previous result was more than a week earlier

· All values greater than 10000 need to be called

· CK not called, put in comment that “CK consistent with previous result” into VISTA.

ag. Serum calcium < 7.6 will be corrected for serum albumin using the formula:

Calcium (corrected) = Calcium + 0.8*(4 – Albumin)

All values are serum/plasma values. The technologist enters “Low Calcium corrected for Albumin, Corrected Calcium not critical.”

ah. Repeat Troponin critical results do not have to be called when a critical Troponin result was called within the previous 3 days. The technologist enters, “ Troponin called within past 3 days. By policy, no repeat call made.”

ATTACHMENT B: CRITICAL TEST VALUES

CARDIOLOGY

Physicians/ordering providers will be notified in less than one hour of the following cardiology diagnostic test:

Routine Electrocardiograms with the following results:

1. Acute ST-segment elevations of 1 mm or more in 2 or more contiguous leads

2. Acute ST segment depression of 2 mm or more in 2 or more contiguous leads

3. High grade atrioventricular block

4. Sustained ventricular tachycardia or torsade des pointes

Echocardiographic Studies with the following results:

1.

Tamponade

2. Acute VSD-post MI

3. Aortic dissection

4. Obstructive clotted prosthetic heart valve

5. Pseudoaneurysm

6. Papillary muscle rupture-post MI

7. New valvular vegetations

Holter Monitor

1. High Grade atrioventricular block

2. Sustained ventricular tachycardia or torsade des pointes

Results reported by Cardiology to the ordering provider in 6-8 hours Routine Electrocardiograms with the following results:

1. New atrial fibrillation or flutter with rapid ventricular response (HR > 150)

2. Sustained supraventricular tachycardia with HR >150

3. Severely bradycardic rhythms (<35 beats/min)

4. Idioventricular rhythm

Echocardiographic Studies with the following results:

1. Severe AS (valve area of <0.7 sq cm) not known to be pre-existing

2. Large pericardial effusion

3. Cardiac tumors

4. New LV clot

5. Malfunctioning prosthetic heart valve

6. Acute mitral or aortic regurgitation

ATTACHMENT D: CRITICAL TEST VALUES

AFTER HOURS CALL

If the ordering practitioner is not on-site and available to receive test results after hours, on week-ends or on holidays, the following process should be followed: Please refer to the VANCHCS intranet for names and phone numbers of physicians on-call for the sites listed below.

· East Bay (Martinez, Oakland, Mare Island, Fairfield OPC) - contact the Sub-Acute physician on call.

· Central Valley (Sacramento VAMC, McClellan OPC) - contact the Sacramento VAMC Emergency Department Physician.

· Redding/Chico contacts the Sacramento VAMC Emergency Department Physician.

ATTACHMENT C: CRITICAL TEST VALUES

RADIOLOGY

Radiology exams interpreted by the VA National Teleradiology Program (NTP) will follow NTP guidelines for determination of Critical and Emergent Test Values and notification will be according to NTP Policies and Procedures. Critical and Emergent Test Values for exams interpreted by NCHCS Radiologists are as follows:

(f) Physicians/ordering providers will be notified in less than one hour of the following radiology diagnostic test that are new, unexpected and/or life threatening:

1. Acute appendicitis/peritonitis

2. Acute brain infarction

3. Acute cholecystitis

4. Acute DVT

5. Acute epiglottitis

6. Acute PE

7. Acute Pulmonary Edema

8. Aneurysm- Leaking

9. Bowel Obstruction

10. Cord compression

11. CSF Leak

12. Ectopic pregnancy

13. Empyema of the brain

14. Foreign body in airway

15. Fracture of major weight bearing bone

16. Significant Hemorrhage/Bleed (includes brain and body)

17. Significant Hydronephrosis

18. Ischemic Bowel Disease

19. Pneumomediastinum

20. Pneumoperitoneum

21. Pneumothorax (new and /or enlarging and/or tension)

22. Significant misplacement of tubes or catheters

23. Testicular Torsion

24. Traumatic diaphragmatic herniation

ATTACHMENT D: EMERGENT TEST VALUES RADIOLOGY

Results reported by Radiology to the ordering provider within 48 hours:

1. AAA (Enlarging or greater than or equal to 5 cm); significant other aneurysm like iliacs

2. Abscess, osteomyelitis, TB or other significant infection

3. Brain Aneurysm (includes head and neck)

4. Neoplasm

5. Triple Vessel Disease

6. Unexpected Cancer