D.38 Critical Result Reporting 02.pdf

VA SALT LAKE CITY HEALTH CARE SYSTEM

VETERANS HEALTH ADMINISTRATION

DEPARTMENT OF VETERANS AFFAIRS

MEMORANDUM 113.07

REPORTING OF CRITICAL LABORATORY RESULTS

1. PURPOSE: To establish a process for reporting critical and urgent laboratory results to responsible providers, to facilitate timely clinical interventions for patient care, and to aid patients participating in health care decisions.

2. POLICY: All critical laboratory values as defined by Pathology & Laboratory Medicine

Service (P&LMS), in consultation with clinical services as appropriate, will be called and electronically reported into VISTA/CPRS within 60 minutes of result verification to a provider responsible for that patient’s care. The process for notification of Critical Values from contracted referral laboratory services is the same as Salt Lake City VA (SLC VA)

Laboratory.

3. DEFINITIONS:

a. CRITICAL VALUE: “Critical values” are those findings, even if from routine test orders, which require rapid verbal communication of those results to a responsible provider.

If the test ordered results in a critical value, the test result will be called to the responsible provider as per the detailed procedures in paragraph 5. The contact information and appropriate comment(s) will be entered into the patient’s chart after the result has been communicated to the responsible provider. The list of critical values is available upon request from the laboratory and available on the P&LMS SharePoint site.

b. CRITICAL TEST: “Critical tests” are those tests which will always require rapid communication of results within an established turnaround time, even if normal. SLC has only one critical test- Frozen Section.

All OR specimens for frozen section will be communicated to the provider directly within a target time of 20 minutes. This data is tracked on a monthly basis. All OR specimens for frozen section will be communicated directly to the provider within a target time of twenty minutes. Audits of compliance will be performed and reported to the HCIC Committee.

c. STAT TEST: Tests that are designated as critical by the provider (i.e. ordered as STAT).

STAT Test requests will be reported electronically and available in CPRS within 1 hour of receipt in the Laboratory.

d. Responsible Provider: Individual involved with the care of a patient who can affect the handling and treatment of a patient based on a critical result. The paged provider has the responsibility to contact the Laboratory in a timely manner.

D.38 REPORTING OF CRITICAL LABORATORY RESULTS

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MEMORANDUM 2

e. On Call Directory: There are three lists On-Call Day and On-Call Night (M-f Nights only) and another On-Call Night (Weekend/Holiday Only). The on call directory is located on the Laboratory SharePoint and on the intranet directory (under the tab

“Directory then to the “On Call Directory”.)

f. Midlevel/Nurse Practitioner (PA)/Physician Assistant (PA): Medical Staff in SICU providing coverage who can take critical values.

g. Cross Cover: Medical staff who provide the Medicine Service coverage on nights, weekends and holidays.

4. RESPONSIBILITY:

a. P&LMS staff will recognize critical laboratory values and call the responsible provider within 60 minutes of verification of a critical value.

b. The responsible provider contacted is responsible for accepting the critical result and taking whatever clinical action is indicated.

c. A verification or “read back” is required from the responsible provider taking the critical lab results to confirm the information was understood correctly.

d. Each clinical service is responsible for maintaining accurate contact information for providers, on-call lists and computer based paging systems (i.e. smart web).

5. PROCEDURES:

a. VERIFY RESULT: Upon discovery of a critical value, the technologist will determine the validity of the test by comparing the obtained value to the relative value of other tests results and insure that internal quality control limits have been met. If required by the procedure, confirmatory testing will be performed.

b. NOTIFICATION

1) Inpatient Wards

a) 0700 to 1900 (7am to 7 pm)

(1) Page the ordering provider, if no response after 10 minutes, page the same provider again.

(2) If no response, page the ATTENDING provider. This number is found in

CPRS at the top of the Cover sheet.

(3) If no response after 10 minutes call the Chief of Service. Consult the On-Call

Day Directory. Each service is listed next to the ward name.

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MEMORANDUM 3

(4) If the Chief of Service fails to call back in 10 minutes, please page again.

(5) If there is no response, call the Chief of Staff at extension 1249 or 801-618-

6785.

b) 1900 to 0700 (7 pm to 7 am) & Weekends or Holidays:

(1) MICU, 3A/IPU (Inpatient Psychiatry) or Rehab: Use the On-Call directory and page the listed provider up to two times. If no response, steps iii-v in item

b) above.

(2) Dialysis: Use the On-Call directory for Renal. If no response follow steps 2c-e from above.

(3) 3W, OR, Telemetry or 2E: Call the ward and ask what SERVICE the patient is on.

(a) MEDICINE:

I. Page the Cross Cover INTERN at ID# 10000954, if no response, page again in 10 minutes.

II. If still no response, call the Chief of Service. Consult the On-Call

III. If the Chief of Service fails to call back in 10 minutes, please page again

IV. If there is no response, call the Chief of Staff at extension 1249 or

801-618-6785.

(b) SURGERY:

I. Using the On Call Directory page the specific service in Surgery that the patient is being seen by (i.e. Thoracic, Vascular, Ortho, etc.), if no response, page again in 10 minutes.

II. If still no response, call the Chief of Service. Consult the On-Call

III. If the Chief of Service fails to call back in 10 minutes, please page again

IV. If there is no response, call the Chief of Staff at extension 1249 801-

618-6785.

(c) PTT Heparin Protocol: If the test is a PTT/Heparin Protocol critical, call the results to the RN on the unit.

MEMORANDUM 4

2) Community Based Outpatient Clinics (CBOC) EXCEPT WEST VALLEY

a) BEFORE 430 pm - Use the following list to call critical values to the CBOC:

When the extension is called, tell the person answering the phone (who should be a provider) that you have a critical value.

Elko 775-738-0188

Ely 775-289-3612 x131

Idaho Falls 208-522-2922

Nephi 435-725-1050

Ogden 801-479-4105

Orem 801-235-0953

Pocatello 208-232-6214

Price 435-613-0342

Roosevelt 435-725-1050

St. George 435-634-7608

b) AFTER 430 pm - Call the Emergency Department x1405 and give directly to a responsible provider. If no provider is available, call back in 10 minutes. After three attempts, notify the Chief of Staff at extension 1249 or 801-618-6785.

3) West Valley NON-Coumadin location

a) BEFORE 430 pm

(1) Page the ordering provider, if no response after 10 minutes, page the same

(2) If still no response, page the West Valley Doc of the Day. This is found on the Laboratory SharePoint page or intranet directory.

(3) If still no response after 10 minutes, call the Chief of Ambulatory Care at801-

755-2465.

(4) If still no response, page the Chief of Ambulatory Care again.

(5) If still no response, call the Chief of Staff at extension 1249 801-618-6785.

responsible provider. If ED is not available, call back in 10 minutes. After three attempts, notify the Chief of Staff at 801-618-6785.

4) West Valley Coumadin Location (WSLCoum)

(1) Call Extension 6503 and give results to RN.

MEMORANDUM 5

(2) If no response, page the ordering provider (RN), if no response after 10 minutes, page the same provider again.

(3) If still no response, page the West Valley Doc of the Day. This is found on the Laboratory SharePoint page or intranet directory.

(4) If still no response after 10 minutes, call the Chief of Ambulatory Care at801-

755-2465.

(5) If still no response, page the Chief of Ambulatory Care again.

(6) If still no response, call the Chief of Staff at extension 1249 or 801-618-6785.

responsible provider. If ED is not available, call back in 10 minutes. After three attempts, notify the Chief of Staff at 801-618-6785.

5) Outpatient Hospital Based Clinics

a) Before 5 pm

(1) If the patient is a Coumadin (BluCoum) ordering location, call to 2170. If no response or the patient is a Primary Care (PrimCar) or Women’s Clinic ordering location, proceed to step (2).

(2) Page the ordering provider, if no response after 10 minutes, page the same provider again. If no response, proceed to step (3).

(3) If no response and the patient is a Primary Care (PRIMCAR) or

OB/Gyn/Women’s Clinic ordering location, go to the DAY On-Call directory and page the “Doc of the Day”.

(4) For all other ordering locations, call the Chief of Service. Consult the On-Call

(5) If the Chief of Service fails to call back in 10 minutes, please page again.

(6) If there is no response, call the Chief of Staff at extension 1249 or 801-618-

6785.

b) AFTER 5 pm and Weekends or Holidays

(1) If the patient is a Coumadin or OB/Gyn Women’s Clinic ordering location, call results directly to the ED x1405 and give directly to a responsible provider.

MEMORANDUM 6

(2) If the patient is a PrimCar ordering location, page the ordering provider, if no response after 10 minutes, page the provider again. If no response call the

ED x1405 and give directly to a responsible provider.

(3) Outpatient Hospital Based Clinic other than Coumadin or

PrimCar,Women’s Clinic/OB/Gyn:

(a) Utilize the Night, Weekend & Holiday On-Call List for the ordering location posted as appropriate.

(b) If no response after 10 minutes, page the same provider again.

(c) If still no response, call the Chief of Service.

(d) If still no response after 10 minutes, page the Chief of Service again.

(e) If still no response after 10 minutes, call the Chief of Staff at 801-618-6785.

6) Home Based Primary Care

(1) Contact the ordering provider using contact information in CPRS and/or

Outlook, if no response after 10 minutes contact the same provider again using the same method.

(2) If still no response, call the Emergency Department x 1405 and provide result to a responsible provider. If ED is not available, call back in 10 minutes.

(3) If still no response after 10 minutes, call the Chief of Staff at extension 1249 or 801-618-6785.

b) AFTER 4:30 pm and Weekends or Holidays

(1) Call the Emergency Department x 1405 and provide result to a responsible provider. If ED is not available, call back in 10 minutes.

(2) If still no response after 10 minutes, call the Chief of Staff at 801-618-6785.

PLEASE NOTE: HBPC provider contact information is not accessible using computer based paging systems (i.e. SmartWeb).

7) Emergency Room

a) Call x1405 and ask to speak to a responsible provider to notify of a critical value.

b) If the provider is not available, call back in 10 minutes.

c) After three attempts, notify the Chief of Staff at extension 1249 or 801-618-6785.

8) Holistic Health/Pain Clinic: Call ED x1405 after hours

MEMORANDUM 7

9) Locations not on the List:

a) Page the ordering provider, if no response after 10 minutes, page the same

b) If no response after 10 minutes, call the Chief of Staff at extension 1249 or 801-

618-6785.

c. WRITE DOWN/READ BACK

1) The technologist will request the provider/nurse receiving the critical value to

"WRITE DOWN" the following information:

a) Patient's Full Name

b) Patient's Full Social Security Number

c) Test Name and Critical Value

2) Example Script:

This is ________________from the VA SLC Laboratory, I have a critical

Name of Tech value, please write down the following information:

Patient's Full Name Full Social Security Number

The Critical Value is a ______________ at _____________

Test Name Value

Can you please read back that information to me?

d. DOCUMENTATION

Laboratory personnel will document under "test comments” all of the contact information. Documentation must include the full name and title of the provider who received the critical result. Date & time called and initials of the tech that called the results and verified the "Read Back". If several steps were taken in the process to relay the critical value, each of those contact persons should be listed along with the time paged and the time the call was returned.

There are two "canned" comments available for insertion into the contact comments:

1) "CRB" = Critical results called to and verbally confirmed by:

2) "NCRB" = Critical read back process not completed

MEMORANDUM 8

e. QUALITY ASSURANCE

The Laboratory Quality Assurance Coordinator will monitor and report compliance with this policy on a monthly basis to the Medical Director P&LMS and the Process

Improvement Committee (PIC).

6. REFERENCES:

• College of American Pathologists Laboratory Accreditation Program, General Inspection

Checklist, 2010.

• 2011 Comprehensive Accreditation Manual, Joint Commission on Accreditation of

Healthcare Organizations.

• VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, Department of Veterans Affairs, October 8, 2008.

• Include stat vs. routine

• Critical value list

7. RESCISSION: None

8. RECERTIFICATION DATE: Memorandum 113.07 is due for recertification on or before the last day of August 2021.

9. FOLLOW-UP RESONSIBILITY: Chief, Pathology & Laboratory Service (113).

Shella Stovall, MNA, RN

Director