D.23 - NMVAHCS - MCP 11-64(1) - Critical Test Results.pdf

CRITICAL TEST RESULTS

New Mexico VA Health Care System

Albuquerque, NM

MCP 11-64 (1)

Signatory Authority

Director NMVAHCS

Rescinded Document

MCP 11-64 Critical Test Results dated

May 26, 2022

Service Line

Chief of Staff

Effective Date

May 2022

Responsible for Updates

Chief of Staff

Recertification Date

May 31, 2027

1. POLICY

This medical center policy (MCP) establishes requirements regarding the communication of critical test values and diagnostic procedures. Expeditious communication of diagnostic test results where the result is abnormal to be life-threatening to the patient (critical results or values) to the responsible provider for appropriate action is imperative. Recognition of critical results occurs after the test completion. The important timeframe to monitor for assessing the adequacy of reporting is from identifying the critical result to the receipt by the licensed provider.

2. JUSTIFICATION

This policy fulfills the local policy mandate in VHA Directive 1088 (1) Communicating

Test Results to Providers and Patients dated October 7, 2015, and Joint

Commission NPSG.02.03.01.

3. SUMMARY OF CHANGES

Updated procedures.

4. DEFINITIONS

a. Critical Result or Critical Value. A diagnostic test or study that has an immediate and possible life-threatening impact on a patient requires treatment or management decisions to avoid adverse patient outcomes.

https://ba.va.gov/s/va-policy-search

September 2023 MCP 11-64 (1)

b. Diagnostic Service. Any service that performs diagnostic testing or studies that evaluate or examine disease-related conditions' presence or absence.

c. Licensed Independent Provider. A physician, dentist, or other recognized specialist with prescriptive authority and medical privileges granted through the

Medical Staff by the Board of Trustees. This may include advanced practice registered nurses (APRN), physician assistants, and podiatrists.

d. Ordering Provider. A licensed independent practitioner who places a request for a diagnostic study.

e. Responsible Provider. A licensed independent practitioner is assigned responsibility for managing the care and treatment of a patient.

f. SOP. Standard Operating Procedure.

g. Surrogate. A licensed independent practitioner is designated to act on behalf of another provider to provide patient care treatment and management.

5. RESPONSIBILITIES

a. Clinical Service Chiefs. The Clinical Service Chiefs are responsible for:

Ensuring the implementation of this SOP within their service.

b. All NMVAHCS Staff Involved in Diagnostic Testing. All staff involved in diagnostic testing and communicating critical test results to responsible providers are responsible for compliance with this policy.

6. OTHER PARAGRAPHS

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 chest pain episode which does not resolve when exercise stops, loss of consciousness during exercise, sinus tachycardia, (ST) elevations during exercise and a large effusion on imaging.

(d) Electrocardiogram (EKG): Evidence of acute myocardial ischemia or infarction, pacemaker malfunction, arrhythmia or other abnormality which places the 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.

(n) New ruptured or perforated viscus.

(o) Any unsuspected other finding the radiologist feels needs to be called to the ordering provider.

(3) Critical Laboratory. NOTE: Proper interpretation of Critical Test Results requires the drawing of specimens at appropriate drug administration times.

(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 an intervention.

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

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

https://dvagov.sharepoint.com/sites/VHAABQDCS/External%20Library/Critical%20Test%20Results.docx

(f) Other significant acute vascular findings, the registered vascular technologist (RVT) performing the procedure recognizes.

b. Reporting Requirements. See the Algorithm for the Critical Result Reporting

Process flow chart.

(1) Laboratory/Diagnostic Testing:

(a) Upon determining that a test result is "critical," the diagnostic service will immediately report the critical test result directly to the ordering provider, surrogate, or On-Call provider. This notification will be verbal with two-way interaction. At no time will the notification be made via texting, instant messaging, or phone message "left in the care of." On-Call providers are found on the Veterans Affairs (VA) On-Call webpage. Patient Aligned Care

Team (PACT) information is in the Electronic Health Record (EHR).

Medicine teams/hospitalists can be located at Amion.com using "unmim" as the password. The admitting team's color is identified by a nursing text order in the EHR. Amion.com will identify the medicine color team pager. If the diagnostic service is unable to reach the ordering provider/surrogate, reporting the critical test results requires the following:

1. For outpatients during regular business hours, the critical test result may be communicated to the Registered Nurse (RN) on the PACT, and the RN will communicate the critical test result to the responsible provider and document this communication in the Nursing Critical

Results Notification in the EHR.

2. For outpatients during off-hours and weekends, the Emergency

Department (ED) Physician will be contacted and given the critical test result. The ED Physician will then determine the appropriate treatment plan and contact the patient if the lab result requires immediate intervention.

3. For patients transferred from the ED or inpatient setting to a higher level of care facility, the critical test result will be communicated to the on-call physician representing the service that the patient was on at the time of transfer. The on-call physician will then make a determination of the clinical significance of the critical test result. This communication https://dvagov.sharepoint.com/sites/VHAABQDCS/External%20Library/Algorithm%20for%20Critical%20Results%20Reporting%20Process%20Flow%20Chart%20A%20%20B.pdf https://dvagov.sharepoint.com/sites/VHAABQDCS/External%20Library/Algorithm%20for%20Critical%20Results%20Reporting%20Process%20Flow%20Chart%20A%20%20B.pdf of the critical test result will be documented in an addendum to the

Interfacility Transfer Note. The Discharge Instructions under the Notes tab in the EHR will indicate if the patient was transferred to another facility as "Discharged to Facility/Facility Admission Orders." Discharge

Instructions that state "Discharge Instructions to Patient" indicates that the patient was discharged to home (outpatient).

4. For inpatients, report the critical result to an RN in the ward. The nurse receiving the critical test result 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 the EHR.

(2) Diagnostic service testing personnel are responsible for identifying critical values defined in this MCP. Once a critical result is recognized, make every effort to communicate the critical result to a responsible provider within 30 minutes. If the time taken to notify the provider exceeds 30 minutes, document the reason for the delay in the EHR.

c. Point of Care Testing.

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

(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. Always perform repeat testing immediately on the same meter before treating the patient. Performing repeat tests verifies the accuracy of the original test.

(c) In cases where a patient is symptomatic, prepare treatment while performing the repeat test. In cases where the patient's symptoms require urgent treatment (e.g., the 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 the agreement is not acceptable, perform a 3rd finger stick test. Two of the three results should agree within the stated range. If no agreement follows, send a venous sample to the Laboratory for testing.

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

(e) Notify the responsible provider of the critical CBG results (<50 or >500) within 30 minutes. The RN or designee will document in the Nursing

Critical Result Notification note in the EHR, including which provider was notified, the results communicated, read back, the date/time provider was notified. The nurse's name notifying the responsible provider.

NOTE: If a patient has current written Insulin Protocol Orders, documented notification is not required. 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:

Convey the critical results to a responsible provider within 30 minutes. The

RN or designee will document in the Nursing Critical Result Notification note in the EHR. This includes but is not limited to which provider was notified, the results communicated, read back, date/time of provider notification and the nurse's name notifying the responsible provider.

d. Quality Assurance 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.

Monitor the turnaround times from the time the critical result is obtained to the responsible caregiver's notification time.

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

(2) In collaboration with Patient Safety Manager, each service will decide the mechanism for monitoring and determine the frequency with which monitoring communication occurs and how the assessment of adequacy 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.

7. RECORD RETENTION AND STORAGE

a. Federal Records related to this policy, regardless of medium, shall be created, maintained, and dispositioned in accordance with the VHA Records Control

Schedule (RCS) 10-1, General Records Schedule (GRS) or other NARA-approved records schedule, if applicable.

b. Federal Records shall be stored per the National Archives & Records

Administration (NARA) Facility Standards for Records Storage, as described in

36 Code of Federal Regulations (CFR) 1234.

8. REFERENCES

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

Dated October 7, 2015.

b. VHA Handbook 1106.01 Pathology and Laboratory Medicine Service dated

January 29, 2016.

c. VHA Directive 6300 (1), Records Management October 22, 2018.

d. VA Directive 6300, Records and Information Management, September 21, 2018.

e. Joint Commission Hospital Accreditation Standards.

9. REVIEW

This MCP will be reviewed 120 days before recertification or sooner if changes to governing documents are cited in the references above.

10. RECERTIFICATION

This MCP is scheduled for recertification on the last working day of July 2028. This

MCP will continue to serve as a local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

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SIGNATORY AUTHORITY

Robert McKenrick

Executive Director

NOTE: Signature remains valid until rescinded by appropriate administrative action.