D.35- COMMUNICATION OF CRITICAL LABORATORY RESULTS AND IOC 22-11.pdf

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Department of Memorandum Veterans Affairs

Date: June 13, 2022 LABORATORY PROTOCOL

22-11

From: Chief Pathologist, P&LMS

Subj: COMMUNICATION OF CRITICAL LABORATORY RESULTS FOR THE CLINICAL

LABORATORY AND INTRAOPERATIVE CONSULTS

To: P&LMS Staff

PURPOSE:

1. The purpose of this policy is to define the required notification and documentation system for communicating laboratory results defined as critical by departmental policy.

2. The purpose of this policy is to meet or exceed the intent of all regulatory agencies.

POLICY:

• The Laboratory at Syracuse VA Medical Center defines Intra-Operative Consults (Frozen

Section) as critical tests. Critical tests require notification of an authorized provider regardless of the result of the test.

• In addition, specific clinical test results are defined as critical. Critical results require immediate notification of an authorized provider or staff member to facilitate prompt patient intervention.

• It is the responsibility of the authorized ordering provider to give and document appropriate patient care in response to the receipt of a critical laboratory result.

PROTOCOL:

A. Critical Clinical Laboratory Results:

1. Critical laboratory results will be defined and posted in each laboratory section, as well as in the laboratory manual. The document will be dated to indicate the last revision or review.

2. The technologist will attempt to contact the ordering physician and communicate the

"critical result” by telephone or electronic messaging via Microsoft Teams immediately after the result is confirmed. If there is no response within 10 minutes, please to try to communicate the results via a different method and/or a different authorized surrogate.

Attachment D.35 36C24224R0049

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3. All critical results given by telephone, must be read back to the laboratory technologist to ensure accuracy of communication. All critical results given by electronic messaging must be confirmed that the authorized person received the communication.

4. Documentation in the computer will include at least the following:

a. Technologist making the notification.

b. Test/analyte exceeding critical limits.

c. Authorized person receiving and reading back the result via telephone, their credentials, and their location, (as appropriate) or authorized person acknowledging and confirming receipt of critical via electronic messaging, their credentials, and their location, (as appropriate)

d. Date and time communication completed.

e. Method of communication (see examples below):

- for telephone use comment CVCR (critical value called -read back)

- for electronic messaging use comment CVEM (confirmed receipt of critical value via electronic messaging)

“Troponin Critical value called – reach back by Dr. Smith on 5/17/22 at 07:02/MST”

“Joe Smith, PA Confirmed receipt of critical value via electronic messaging of WBC on

5/17/22 at 07:02/MST”

5. When "No Significant Change" applies, as defined in sectional critical value protocols/policies, computer documentation still needs to include the “NSC” comment, the test/analyte exceeding critical limits, the date, and the initials of the responsible technologist (verifying technologist). The date on which the value was previously called may also be included.

6. In addition to calling the physician, all ICU critical values must be called to an ICU

Registered Nurse (RN).

7. When the ordering physician is not available, the following will apply:

a. EMERGENCY DEPARTMENT

i. The lab staff will call the ED and ask to speak to the ordering provider (MD, PA, or NP).

ii. If the ordering provider is unable to come to the phone, then the critical value will be reported to an available Registered Nurse (RN).

b. OPERATING ROOM

(Surgeons will be instructed to leave their pagers with the circulating nurse when they are in the operating room)

i. The lab staff will page the ordering physician when there is a critical value

ii. If the ordering physician is unable to come to the phone, the circulating

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c. INTENSIVE CARE UNITS i The lab staff will call the ICU to give the critical value to an ICU Registered

Nurse (RN) only.

ii. At that time the nurse will tell the lab staff which physician should be called or paged.

iii. The lab staff will then page the physician so that the lab staff can report the critical value directly to the physician.

d. IN-HOUSE WARDS

i. The lab staff will call other providers on the patient’s Medicine Team, found on AMION and/or the current Medicine Team List, which is found on amion.com (login: vasyr).

ii. If the providers on the same team are unavailable, the lab staff will call the ward to ask which physician should be called or paged.

iii. The lab staff will then page the physician so that the lab staff can report the critical value directly to the physician.

**NOTE: Monday through Friday between 12:00 – 13:00 only, critical values for Medicine Team patients, Teams 1, 2, 3 and 4, must be called to the Medicine Team Attending and not to a

Resident or an Intern.**

e. IN-HOUSE PRIMARY CARE CLINICS

(Team Red, Team Blue, the Women’s Health Clinic, and the Specialty Clinics.)

i. The lab staff will attempt to contact the ordering primary care provider via electronic messaging, extension/pager or by calling:

x-56515 for Team Red and Team Blue x-54652 for WHC x-Please see phone list for all other clinics

ii. If the ordering provider is unavailable, the lab staff will ask the MSA who answers the phone, to be forwarded to the RN Case Manager that works with the ordering provider.

f. COUMADIN CLINIC

i. The lab staff will page the Coumadin Clinic pager 315-241-1035 for any of

Coumadin Clinic staff

ii. If there is not a response from the Coumadin Clinic pager, the lab staff will contact MSA who answers the phone at x-52615 and the call will be forwarded to an available provider. Electronic messaging may be used when there is no response from the Coumadin Clinic pager.

g. CBOCs (Rome, Auburn, Binghamton, Potsdam, Tompkins/Cortland, Oswego, and Watertown)

i. The lab staff will attempt to contact the ordering provider

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ii. If the ordering provider is unable to come to the phone or unavailable by electronic secure messaging then the lab staff will give the critical result to a

Registered Nurse (RN) only.

8. The lab staff will document ALL attempts that were made in contacting the ordering provider and/or the designated surrogate(s) in the computer.

9. In the rare event that an authorized person cannot be identified or reached on the phone, the ED Attending/ Night Float is authorized to take the result off-hours. During the day shift the result should be forwarded to the Quality Assurance Coordinator to continue the effort to contact an authorized provider.

B. Heparin Level: Anti-Xa (Heparin- Unfractionated) Critical Results:

1. UFH (Unfractionated Heparin) critical results will NOT be called to the ordering MD, PA, NP, or PharmD, as with other critical clinical laboratory results.

2. UFH critical results will be called to the Current Registered Nurse (RN) or the

Charge Nurse (RN), who are authorized ordering providers for this test.

3. The lab staff will document ALL attempts that were made in contacting the Current

Registered Nurse or the Charge Nurse.

4. In the rare event that the Current Registered Nurse or the Charge Nurse cannot be identified or reached on the phone, the Nursing Supervisor will be paged.

This will occur on both off-hours and the dayshift.

5. When the Current Registered Nurse and the Charge Nurse are both unavailable and the critical result(s) must be given to the Nursing Supervisor then a statement will be entered in the computer stating that the “Current RN and the Charge Nurse were both unavailable”. This documentation will show that due to circumstances out of the control of the laboratory a critical result had to be given to another RN, other than the authorized above stated (section B-2) personnel.

C. Positive Blood Cultures

1. If the patient is hospitalized at the time of the positive blood culture detection, refer to the protocol outlined in section A of this policy. The gram stain results for positive blood cultures should be called within one hour of detection during the dayshift hours and within two hours of detection during the off-hour shifts.

2. Refer to Laboratory Protocol 22-12 “Communication of Positive Blood Culture Results on Discharged Patients for the Clinical Laboratory” regarding the specific policy on the communication of positive blood cultures on discharged patients.

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QUALITY ASSURANCE:

With the approval of the Medical Executive Council a target of 30 minutes was established as the normal period within which communication of a critical test result should occur. It is understood that on occasion there will be difficulties contacting an authorized provider. For these instances the result will be reported and released, and the documentation of the final call will be added to the comment section of the result field later when the call is complete.

Efforts to communicate a critical test result that exceed 30 minutes from the time the result becomes available will be flagged in the comment section and monitored for improvement purposes. The time(s) the provider(s) was paged will be noted in the comment section of the result. The time the call or electronic method is actually complete, and the result read-back or confirmed receipt via electronic messaging will be documented in a separate comment. These accessions will be flagged for improvement purposes by using the expandable comment “NCV” which expands to “Notification of critical result exceeded established timeframe”. See the example below:

“Dr. Smith paged on 6/26/07 at 11:34 with PLT result by MST”

“PLT result called and read back by Dr. Smith at 12:45 on 6/26/07, MST”

NCV = “Notification of critical result exceeded time limit”

The QA Coordinator will be responsible for ensuring that all new employees are educated in the laboratory policy for the reporting and notification of critical results.

The list of critical values is maintained in the Laboratory Test Definitions File.

Other significantly abnormal clinical laboratory results (not defined as critical)

1. The notification of positive Hepatitis results are provided to the Infection Control Nurse and the established Hepatitis email groups at each VISN 2 site by E-Mail. The E-mail is printed and maintained for documentation. A View Alert is also sent via CPRS to the ordering provider.

2. Positive results for the Mono test are communicated via View Alert to the ordering provider.

3. Positive results for the Treponema Antibody are communicated (via View Alert) to the ordering provider and provided to the Infection Control Nurse or surrogate through E-mail.

4. An effort to alert the provider for significantly abnormal send-out test will be documented in the computer.

5. Positive results for Occult Blood/FIT are communicated to the floor/service and a View Alert is sent via CPRS. Positives for inpatients are called to the floor/service.

6. See Attachment 22-11: Microbiology Notification of Critical Tests and Significant Findings for Microbiology testing notification policy.

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Communication of Intraoperative Consult diagnosis:

1. Intra-operative consults will be defined as a critical anatomic test that requires rapid verbal diagnosis.

2. For IOC’s, the diagnosis will be repeated back by the receiving staff via telephone.

3. The pathologist / resident making the call will document their name as the person placing the call, who was called, and the date and time the call was complete on the final report.

4. When physicians/providers are notified of a new malignancy P-code 11301 will be used. The confirmation of new malignancy by second pathologist will be used and P-code 11300 will be used.

REFERENCE:.

SOP 119-001: Heparin Dosing via Weight Based Heparin Dosing Nomogram, August 2021

RESCISSION/S: 05-09, 06-04, 07-02, 09-01, 12-01, 15-01, 16-11, 19-11

RESPONSIBILITY: Overall responsibility resides with the Chief Pathologist, P&LMS

REVIEW & REVISION SCHEDULE:

• Annual review by Chief Pathologist (date and initials below)

• Revision every 3 years: Due 2025

Seena Kumar, MD

Chief Pathologist, Pathology and Laboratory Medicine 113

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22-11: Communication of Critical Laboratory Results for the Clinical Laboratory and

Intraoperative Consults

Date Annual Review Complete: Initials of Reviewer (Lead Pathologist)

Review Due 2023

Review Due 2024

REVISION DUE 2025