D.20 - JDD VAMC Critical Test Results 11LAB-58.pdf

JOHN D. DINGELL VA MEDICAL CENTER 11LAB-58

DETROIT, MI 48201 February 14, 2018

Policies and procedures cannot possibly address all situations. Please make sure that you exercise good judgment and common sense. Remember that patient needs always come first.

The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

CRITICAL TEST RESULTS

1. PURPOSE

To provide guidelines for reporting critical test results including but not limited to laboratory and diagnostic radiology tests.

2. POLICY

It is the policy of this medical center to establish and adhere to criteria for the immediate notification of the responsible provider when critical limits of specified test results are exceeded.

3. DEFINITIONS

a. Critical Test Result-A test result that is beyond the normal variation with a high probability of a significant increase in morbidity and/or mortality in the near future. (Appendix A)

b. Read-Back Process- The read-back process is a process of verifying critical test results verbally via the telephone. The individual who is receiving the result will write it down, read back what they have been told and receive confirmation that it is correct.

c. Responsible Provider – The provider may be a Physician, Physicians’ Assistant, Nurse

Practitioner, Registered Pharmacist, or Emergency Department Nurse.

d. Established Notification Time – Critical results should be called to the responsible provider within 30 minutes of verifying the result.

4. RESPONSIBILITIES

a. The Chief of Staff is responsible for ensuring that all qualified providers comply with the policy relating to critical test results.

b. Each clinical service chief is responsible for reviewing service policies to assure that providers conform to medical center policy.

c. The provider or the individual receiving the critical test result will use the read-back process.

2.

Medical Center Numbered Memorandum 11LAB-58

d. It is the responsibility of the individual receiving the critical test result to determine if the patient requires immediate follow-up. During non-administrative hours for outpatients this responsibility is that of the Medical Officer of the Day (MOD).

5. PROCEDURE

a. During administrative hours (Monday through Friday 0800-1630) the following procedures should be followed:

(1) The testing service will identify and notify the patient’s provider. If the patient is located in the Emergency Department, the ED physician or the ED nurse can be notified of critical results. (See PALMS policy – (Appendix B); Radiology policy – (Appendix C).

(2) If unable to contact the patient’s provider, the Chief of the respective service or designee will be contacted and given the patient’s name, social security number, provider name and the critical test result.

(3) If notified, the Chief of the service will have ultimate responsibility to provide appropriate follow-up.

(4) The following information will be provided to the ordering individual or Chief of service; patient name, test ordered, and critical result. The receiving individual will read back what they have heard. The individual initiating the call will document the following: the full name of the person you spoke with, the initial time the provider was paged, the date and time the provider was notified, the critical test result and that the information was verified by read back.

b. During non-administrative hours (after 1630, weekends, and holidays) the following procedures should be followed:

(1) Inpatient- The testing service will contact the primary physician or on-call physician (as indicated by the on-call schedule) and provide them with the patient’s name, test ordered, and critical result.

(2) Outpatient or CBOC patient- The testing service will contact the Medical Officer of the Day (MOD) and inform him/her of the patient’s name, test ordered, and critical result. The receiving individual will repeat back what they have heard. The individual initiating the call will document the following: the full name of the person you spoke with, the initial time the provider was paged, the date and time the provider was notified, the critical test result and that the information was verified by read back.

(3) Emergency Department – The testing service will contact either the Emergency

Department physician or ED nurse to relay critical results. The technologist will inform him/her of the patient’s name, test ordered, and critical result. The receiving individual will repeat back what they have heard. The individual initiating the call will document the following: the full name of the person you spoke with, the initial time the provider was paged, the date and time the provider was notified, the critical test result and that the information was verified by read back.

https://dvagov.sharepoint.com/sites/VHADetroit/Policies/11LAB-58%20Appendix%20B.docx https://dvagov.sharepoint.com/sites/VHADetroit/Policies/11LAB-58%20Appendix%20C.docx

3.

Medical Center Numbered Memorandum 11LAB-58

(4) It is up to the provider receiving the critical test result (Inpatient = primary physician or physician on-call; Outpatient = MOD; or Emergency Department = ED physician or ED Nurse) to determine the urgency of treatment and follow-up. If deemed necessary, the MAA will attempt to contact the patient via telephone, night letter, local police, etc. and inform the patient of the critical test result and request that he/she report to the VAMC Emergency Department as soon as possible for medical evaluation or admission if necessary or advise the patient to seek immediate treatment at the closest community emergency room if the situation warrants.

6. REFERENCES

The Joint Commission, updated edition.

Diagnostic Radiology Service Policy: Reporting Critical Imaging Diagnosis, dated September 2012.

Pathology and Laboratory Medicine Policy and Procedures, “Critical/Panic Value Reporting”, GEN002, dated December 26, 2017 Emergency Department Nursing Advanced Triage Protocol, dated November 2012

7. FOLLOW-UP RESPONSIBILITY

Pathology and Laboratory Medicine Service (PALMS) is responsible for the contents of this Medical Center memorandum. Questions may be referred to the ACOS for PALMS.

8. RECISSION

MCNM 11LAB-58, Critical Lab Results, dated January 15. 2016

9. EXPIRATION DATE

February 14, 2023 //s// Pamela Reeves, M.D.

Medical Center Director

Distribution: Facility Wide

VA MEDICAL CENTER Appendix A DETROIT, MI May 20, 2021

A-1

LABORATORY CRITICAL/PANIC VALUES

I. CHEMISTRY

TEST LOW HIGH

Glucose 50 mg/dL 400 mg/dL Sodium 120 mmol/L 158 mmol/L Potassium 2.9 mmol/L 5.5 mmol/L Chloride 75 mmol/L 126 mmol/L* Carbon Dioxide (CO₂) 11 mmol/L 40 mmol/L Calcium 6.6 mg/dL 12.9 mg/dL Ionized Calcium 0.82 mmol/L 1.55 mmol/L Phosphorus 1.2 mg/dL 8.9 mg/dL* Urea Nitrogen N/A 104 mg/dL* Creatinine N/A 7.4 mg/dL* Creatinine Kinase N/A >600 UL Amylase >500 U/L* Arterial PO₂ 40 mm Hg None Arterial PCO₂ 20 mm Hg 70 mm Hg Arterial pH 7.2 units 7.6 units Ethyl Alcohol >300 mg/dL Troponin-T Female ≥15 ng/L Troponin-T Male ≥23 ng/L Troponin-T Delta Value ≥6 ng/L Free T4 0.7 ng/dL ˃2.4 ng/dL* AFP ˃20 ng/dL* Lactic Acid ˃3 mmol/L Lithium ≥1.5 mmol/L

* Low or high values for chloride, urea nitrogen, amylase, bicarbonate, creatinine, phosphorus, and AFP and FreeT4 will not be called to the provider immediately as these results are not deemed “critical” but serve more as a “panic” value indicating a condition that the provider should be alerted to. These results are readily available in the computer.

II. THERAPEUTIC DRUG LEVELS

TEST CRITICAL/PANIC VALUE

Carbamazepine >20 mcg/mL Digoxin > 2.0 mcg/mL Phenytoin (Dilantin) > 20 mcg/mL Valproic Acid > 125 mcg/mL Vancomycin Trough > 20 mcg/mL

A-2

III. HEMATOLOGY

TEST LOW HIGH

Hemoglobin < 7.0 grams > 18 grams Hematocrit < 15.0% > 60.0% WBC < 1,000/cu.mm. >30,000 cu.mm.

Platelets < 50,000/cu.mm. > 800,000/cu.mm.

Blasts present Absolute Neutrophil Count <500

INR >4.4

PTT >75.0 seconds Fibrinogen < 100 mg/dL Fibrin Split Products >40 High Sensitivity D-Dimer > 7650 ng/mL Cryptococcal Antigen Positive

IV. MICROBIOLOGY

Positive Blood Cultures Positive Gram Stain (Sterile Fluids) Positive Acid- Fast Bacilli Smears and Cultures

A-3

RADIOLOGY CRITICAL IMAGING DIAGNOSES

• Cerebral hemorrrhage / hematoma

• Brain tumor with mass effect

• Depressed skull fracture

• Spinal cord compression

• Mediastinal emphysema

• Carotid artery dissection

• Discitis

• Pneumothorax

• Aortic dissection if not chronic

• Pulmonary embolism

• Ruptured aneurysm

• Impending aneurysm rupture

• Free air in abdomen (if no recent surgery, feeding tube other drain)

• Appendicitis

• Portal venous air

• Volvulus (if definite, not can’t r/o)

• Acute traumatic visceral injury

• Retroperitoneal hemorrhage

• Stress induced ischemia

• Ectopic pregnancy

• Testicular torsion

• Ovarian torsion

• DVT (acute, not chronic)

• Significant line/or tube misplacement