D.21 NMVAHCS Memorandum 11-64(1) Critical Test Results.docx

CRITICAL TEST RESULTS

1. Policy: Results of diagnostic tests where the results are sufficiently abnormal so as to be life threatening to the patient (critical results or values) will be expeditiously communicated to a responsible provider for appropriate action. A critical result is only recognized after the test is performed. The important timeframe to monitor for assessing adequacy of reporting is from the identification of the critical result to the receipt by the licensed caregiver.

a. In conjunction with the medical staff, each diagnostic testing service will define critical results for their service.

b. Critical results may be modified by diagnostic services based upon clinical guidelines and medical staff recommendations.

2. Responsibility: The Chiefs of Medicine, Radiology, Surgery, and Pathology Services, and the Associate Director of Patient Care Services are responsible for implementing this policy.

3. Procedure:

a. Critical Results by Diagnostic Service:

(1) Non-Invasive Cardiology:

(a) Echo: Evidence of moderate or high suspicion of tamponade.

(b) Stress Echo: Strongly positive stress test, cardiac arrest or ischemia due to coronary disease.

(c) Nuclear Cardiology: Dangerous arrhythmia during stress testing, prolonged episode of chest pain which does not resolve when exercise is stopped and loss of consciousness during exercise, sinus tachycardia, (ST) elevations during exercise and a large effusion on imaging.

(d) Electrocardiogram (EKG): Evidence of an acute myocardial ischemia or infarction, pacemaker malfunction, arrhythmia or other abnormality which places patient at high risk for syncope or death.

(2) Radiology:

(a) New subarachnoid, subdural, epidural hemorrhage or intra-parenchymal cranial hemorrhage.

(b) Acute midline shift of the brain.

(c) New spinal cord compression.

(d) New pulmonary embolism.

(e) New pneumothorax.

(f) New unstable cervical fracture.

(g) Tension pneumothorax.

(h) Misplaced Endotracheal tube.

(i) New neoplasm.

(j) New bowel obstruction or suspected intussusception.

(k) Unsuspected pneumoperitoneum or abnormal gas collection suggestive of abscess or infarction.

(l) Suspected aortic tear.

(m) Clinically unsuspected abdominal aneurysm greater than 6 cm in diameter.

Memorandum 11-64 (1) Subj: Critical Test Results March 3, 2020 3.

(n) New ruptured or perforated viscus.

(o) Any unsuspected other finding the radiologist feels need to be called to the ordering physician.

(3) Clinical Laboratory:

Acetaminophen

>200 µg/ml

Acid-fast culture and/or smears

All positives

Blood culture

All positives

CSF cell counts

Bacteria and/or >20 WBC/mm3

CSF gram stains and/or cultures

All positives

Gentamicin

12.0 µg/ml

Joint fluid gram stains and/or cultures

All positives

Lactic Acid

≥3.5 mmol/L

Normally sterile body fluid or tissue gram stain and/or culture

All positives

TSH

>60 µIU/ml

Memorandum 11-64 (1) Subj: Critical Test Results March 3, 2020 3.

*Vancomycin (trough)

>30 µg/ml

* Proper interpretation of therapeutic drug concentrations requires that specimens be drawn at appropriate times in relation to drug administration.

(4) Vascular Laboratory:

(a) Acute deep vein thrombosis (DVT) findings on duplex evaluation.

(b) Near-total occlusion of the common or internal carotid artery (new finding).

(c) Acute occlusion of the common or internal carotid artery following intervention.

(d) Acute occlusion of arterial bypass graft (new finding).

(e) Abdominal aortic aneurysm >5.5 cm (new finding).

(f) Other significant acute vascular findings recognized by the registered vascular technologist (RVT) performing the procedure.

b. Reporting Procedure. (See Attachment A.)

c. Laboratory/Diagnostic Testing:

(1) Upon determining that a test result is “critical,” the diagnostic service will immediately report the critical result directly to the ordering provider or surrogate, responsible provider, or On-Call provider. Responsible or On-Call providers may be found on the Veterans Affairs (VA) On-Call webpage. Pagers and Primary Care Provider’s (PCP) Patient Aligned Care Team (PACT) can be identified by clicking on the 4th box on the upper banner in theComputerized Patient Record System CPRS to view the PCP and PACT team assignments. Medicine teams/hospitalists can be located at Amion.com using “unmim” as the password. For teaching services, the admitting color of the team is identified in the admission History and Physical (H&P) and Amion.com will identify the medicine color team pager. If the diagnostic service is unable to reach a provider, the following steps to report the critical results will be taken.

(a) For outpatients during regular hours, if the primary care provider or surrogate cannot be reached, the critical value may be communicated to the Registered Nurse (RN) on the PACT and the RN will communicate the critical result to the responsible provider and document this communication in the Nursing Critical Value Notification note within the CPRS.

(b) For outpatients during off hours and weekends, the Emergency Department (ED) Physician will be contacted and given the critical value. The ED Physician will then make a determination of an appropriate treatment plan and will attempt to contact the patient if the lab result requires immediate intervention.

(c) For inpatients, the critical result may be reported to a RN on the ward. The nurse receiving the critical results will contact the responsible provider within 30 minutes and communicate the information. The nurse will document the communication in the Nursing Critical Result Notification note within CPRS.

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(2) Diagnostic service testing personnel are responsible for identifying critical values as defined in this Medical Center Memorandum (MCM). Once a critical result is recognized, every effort will be made to communicate the critical result to a responsible provider within 30 minutes. If the time taken to notify the provider exceeds 30 minutes, the reason for the delay will be documented in CPRS.

d. Point of Care Testing:

(1) The employee performing the Point of Care test is responsible for identifying critical results as defined in this MCM.

(2) Capillary Blood Glucose (CBG):

(a) Critical CBG results less than 50 mg/dl always require repeat testing.

(b) Critical CBG results greater than 500 mg/dL always require repeat testing except when the immediately preceding result (finger stick or serum) was also critically high. Repeat testing should always be performed immediately on the same meter and before the patient is treated. Repeat tests are performed to verify the accuracy of the original test.

(c) In cases where a patient is symptomatic, treatment should be prepared while performing repeat test. In cases where the patient’s symptoms require urgent treatment (e.g., patient is unresponsive), the need for immediate intervention supersedes required repeat testing.

(d) Repeat tests should agree within ± 15 mg/dL for critical low (less than 50) and ± 80 mg/dL for critical high (greater than 500) results.

1 If agreement is not acceptable, a 3rd finger stick test should be performed. Two of the three results should agree within the stated range. If no agreement follows, a venous sample should be sent to the Laboratory for testing.

2 Repeat tests within the stated range will receive appropriate interventions from the nurse and if necessary in consultation with the lab and/or provider.

(e) Notification to the responsible provider of critical CBG results (<50 or >500) should be completed within 30 minutes. The RN or designee will document in the Nursing Critical Result Notification note in CPRS which provider was notified, the results communicated, read back, date/time provider was notified, and the name of the nurse notifying the responsible provider.

(f) NOTE: Documented notification is not required if a patient has current written Insulin Protocol Orders, however the employee performing the test must enter the meter comment “INSULIN PROTOCOL” at the time of testing.

(3) Arterial Blood Gases (ABG) and Hematocrit Testing at the Point of Care: The critical result will be conveyed to a responsible provider within 30 minutes. The RN or designee will document in the Nursing Critical Result Notification note in CPRS. This includes but is not limited to which provider was notified, the results communicated, read back, date/time provider was notified, and the name of the nurse notifying the responsible provider.

e. Monitoring: Data will be collected on turnaround times by each service to ensure compliance with this policy and as required by the Joint Commission’s Patient Safety Goal. Turnaround times will be monitored from the time the critical result is obtained to the time the responsible caregiver was notified.

(1) Each service involved in the communication of critical results to providers will monitor their turnaround times and assess the need for improvement.

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(2) Each service, in collaboration with Patient Safety Manager will decide the mechanism for monitoring and determine the frequency with which monitoring is to occur and how the assessment of adequacy is communicated to the respective diagnostic service chief or nursing supervisor. If corrected action is required, the service chief or responsible nursing supervisor will decide on the appropriate action and report corrective measures to the Patient Safety Committee.

4. References: Joint Commission Hospital Accreditation Standards (current edition), National Patient Safety Goal 2.

5. Rescission: Medical Center Memorandum 11-64, Critical Tests and Critical Test Results dated July 30, 2014.

6. Expiration Date: December 7, 2020

Signed MCM in D/FMO File Andrew M. Welch, MHA, FACHE Director

Attachment

Distribution: “M”

Algorithm for Critical Result Reporting Process image1.emf