D.7 Communicating Test Results Policy.pdf

COMMUNICATING TEST RESULTS TO PROVIDERS AND PATIENTS

MCP 11-14

VA North Texas Health Care System Dallas, TX 75216

Rescinded Document:

See paragraph 7.

Signatory Authority:

Jason Cave, JD, SES Executive Director

Effective Date:

July 11, 2024

Responsible Owner:

Jeffrey L. Hastings, MD, MS Chief of Staff

Recertification Date:

July 31, 2029

1. POLICY

This medical center policy (MCP) establishes the process at VA North Texas Health Care System (VANTHCS) to communicate test results to ordering providers and patients within a timeframe that allows for prompt attention and appropriate action to be taken.

2. JUSTIFICATION

This MCP exists to meet the local policy mandate in Veterans Health Administration (VHA) Directive 1088, Communicating Test Results to Providers and Patients, dated July 11, 2023.

3. RESPONSIBILITIES

a. VA Medical Facility Executive Director. The VA medical facility Executive Director is responsible for ensuring overall medical facility compliance with VHA Directive 1088 and this MCP.

b. VA Medical Facility Chief of Staff. The VA medical facility Chief of Staff is responsible for ensuring test results are communicated to ordering providers and patients within a timeframe that allows for prompt attention and appropriate action to be taken, in compliance with VHA Directive 1088 and this MCP.

c. VA Medical Facility Chief of Health Administration Service. The VA medical facility Chief of Health Administration Service is responsible for ensuring that VA medical facility front-line staff responsible for or involved in the entry of administrative data adhere to VHA Directive 1604, Data Entry Requirements for Administrative Data, dated December 18, 2023, so that updated contact information for all patients is maintained in the electronic health record (EHR) and is available to all staff involved in the test results notification process.

Sherman CBOC - RFP 36C25726R0018

July 11, 2024 MCP 11-14

d. VA Medical Facility Service-Level Leadership. VA medical facility service-level leadership are responsible for:

(1) Developing written service-level workflows addressing the receipt and communication of test results, in compliance with VHA Directive 1088 and this MCP.

(2) Ensuring that all staff in any unit of service (e.g., section, clinic) within their responsibility are aware of and follow said workflows.

(3) Maintaining up-to-date rosters of units of service within their responsibility and corresponding personnel, along with current and accurate contact information, so that they are readily available on the VANTHCS intranet (W:\CallRosters) to diagnostic services and other staff.

(4) Ensuring that ordering providers within their responsibility have assigned surrogates to receive EHR-based notifications and test results during planned or unplanned absences longer than three (3) business days.

(5) Encouraging ordering providers within their responsibility to implement the Recommended Practices for VA Clinical Staff described in A Checklist to Improve CPRS “View Alert” Notifications, to better manage EHR-based notifications related to test results.

4. OTHER PARAGRAPHS

a. Test results should be communicated by diagnostic services to ordering providers within a timeframe that allows for prompt attention and appropriate action to be taken. Specifically, critical test results must be communicated by diagnostic services to ordering providers or designees within 60 minutes after the results become available.

Notification by the diagnostic services may occur through any synchronous communication modality that allows for real-time verbal verification or “read-back” of the critical test results by the ordering providers or designees. For every critical test result, diagnostic services are responsible for documenting in the EHR the name of the provider notified, that accurate verbal verification or “read-back” was obtained, and the time and method of communication.

b. Upon identification of a critical test result, the diagnostic service will follow the relevant communication cascade below. Providers will be contacted in the specified order using the information in the intranet call rosters, moving to the next level in the cascade if any contact is unable to be reached within 15 minutes.

(1) Outpatient Cascade.

(a) Monday through Friday (except Federal holidays) from 8:00 a.m. to 4:30 p.m.

1 Ordering provider or designee.

2 On-call provider or critical result pager for section, if applicable.

https://dvagov.sharepoint.com/sites/VHAOPCOps/Policy/CTR/CTR%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FVHAOPCOps%2FPolicy%2FCTR%2FCTR%20Documents%2FView%20alerts%20checklist%2Epdf&parent=%2Fsites%2FVHAOPCOps%2FPolicy%2FCTR%2FCTR%20Documents https://dvagov.sharepoint.com/sites/VHAOPCOps/Policy/CTR/CTR%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FVHAOPCOps%2FPolicy%2FCTR%2FCTR%20Documents%2FView%20alerts%20checklist%2Epdf&parent=%2Fsites%2FVHAOPCOps%2FPolicy%2FCTR%2FCTR%20Documents

3 Section Chief, if applicable.

4 Service Chief.

5 Chief of Staff.

(b) Monday through Friday afterhours (4:30 p.m. to 8:00 a.m.), weekends (Saturday and Sunday), and Federal holidays.

1 Ordering provider or designee.

2 Emergency Department (ED). The ED must not serve as the default location for off-tour reporting and should only be notified of critical test results if the ordering provider or designee cannot be reached. In that case, an ED provider will decide if the critical test result warrants immediate evaluation and/or treatment. If immediate care is needed, the ED provider will contact the patient by telephone, recommend that he/she goes to an ED, and document this communication in the EHR with the ordering provider included as an additional signer to the note. Otherwise, if immediate care is not needed or the patient cannot be contacted, the ED provider will document the circumstances in the EHR with the ordering provider included as an additional signer to the note.

(2) Non-Intensive Care Unit Inpatient Cascade.

(a) Monday through Friday (except Federal holidays) from 8:00 a.m. to 4:30 p.m.

1 Registered Nurse (RN) assigned to the patient (applicable only if the critical result is a PTT-Heparin for a patient who is on a heparin drip protocol).

2 Ordering provider or designee.

3 Attending for ordering provider’s team, if applicable.

4 Section Chief, if applicable.

5 Service Chief.

6 Chief of Staff.

(b) Monday through Friday afterhours (4:30 p.m. to 8:00 a.m.), weekends (Saturday and Sunday), and Federal holidays.

1 RN assigned to the patient (applicable only if the critical result is a PTT-Heparin for a patient who is on a heparin drip protocol).

2 Ordering provider or designee.

3 Cross-cover provider.

4 Attending for cross-cover team, if applicable.

5 Service Chief.

6 Chief of Staff.

(3) ED and Intensive Care Units Cascade. At all times, critical test results may be communicated to any available physician or advanced practice provider in the ED or intensive care units. In addition, critical results of tests ordered under structured infusion protocols (e.g., PTT-Heparin for a patient on a heparin drip protocol, blood glucose value for a patient on an insulin drip protocol) may be directly communicated to the RN who is taking care of the patient.

c. All test results requiring action must be communicated by the ordering provider or designee to patients within 7 calendar days from the date on which the results are available to the ordering provider or designee. Test results that do not require action must be communicated by the ordering provider or designee to patients within 14 calendar days from the date on which the results are available to the ordering provider or designee. The timing, content, method, and documentation of the communication must follow VHA Directive 1088, summarized below for easy reference.

Aspects of Communication

Test Results Requiring Action

Test Results Not Requiring Action

Timing Within 7 calendar days from the date on which the results are available

Within 14 calendar days from the date on which the results are available

Content Must include a discussion of potential actions or therapeutic intervention options

Sufficiently detailed to allow the patient to be informed and engaged in their health care

Method Synchronous or asynchronous, but not by automated test result release via MyHealtheVet.

At the provider discretion, a certified letter may be sent to the patient if other communication methods have been unsuccessful

Synchronous or asynchronous, including by automated test result release via MyHealtheVet

Documentation All attempts must be documented in the EHR

Documentation in the EHR is encouraged but not required

d. Unless otherwise prohibited by a relevant controlling body (e.g., licensing board) or document (e.g., VHA directive, scope of practice, functional statement), the following members of the health care team, including Clinical Contact Centers, may notify patients of test results on behalf of and, when applicable, under the direction of the ordering provider. If delegating the communication of test results requiring action, the provider will ensure that the appropriate health care team member can effectively discuss potential actions or therapeutic intervention options with the patient and that action is initiated accordingly in a timely manner. In any instance, the ordering provider maintains responsibility for all test results he/she orders, unless there are pre-existing, mutually agreeable, and clearly documented arrangements made with a designee.

Health Care Team Members

Test Results Allowed to Communicate

Communication Methods

Practitioners (e.g., physicians, dentists, podiatrists, nurse practitioners, certified registered nurse anesthetists, physician assistants, clinical pharmacists)

Normal and abnormal (all) Synchronous or asynchronous

Registered Nurses* Normal, urgent abnormal, and clinically significant abnormal†

Synchronous or asynchronous

Licensed Vocational Nurses*

Normal Synchronous or asynchronous

Advanced Medical Support Assistants*

Normal Synchronous or asynchronous

*Under provider direction.

†Only practitioners will communicate critical test results to patients.

e. For patients in inpatient or equivalent residential care settings (e.g., Community

Living Center), it is not required or expected that each individual test result is communicated to the patient. Instead, the patient’s care team must effectively communicate relevant test results to the patient, as needed, to ensure the patient is able to engage effectively in his/her treatment plan. When test results become available after discharge, they are communicated and acted upon by the inpatient ordering provider or designee, unless that responsibility has been transferred to an outpatient provider or designee and said transfer is clearly documented in the EHR.

f. If potentially life-changing test results are being provided to a Veteran with a High Risk for Suicide – Patient Record Flag, communication must occur within the timeframes specified in this MCP and preferably through a synchronous modality.

g. When the ordering provider is a health professions trainee who is unavailable to receive, communicate, or act upon test results within the timeframes specified in this MCP, the supervising practitioner or the practitioner responsible for the patient’s care is the designee and has the responsibility for ensuring that the required communication, action, and documentation occurs per VHA Directive 1088 and this MCP.

h. Monitoring of the effectiveness and compliance with the test results notification process described in VHA Directive 1088 and this MCP will be done through the External Peer Review Program (EPRP). EPRP scores are tracked and addressed by the Performance Measures Committee, which informs the Executive Governance Board through the Strategic Analytics for Improvement and Learning (SAIL) Council.

i. Breast and cervical cancer screening test results must be communicated and documented per VHA Directive 1105.03, Mammography Program Procedures and Standards, dated May 21, 2018, and VHA Directive 1330.01(7), Health Care Services for Women Veterans, amended May 14, 2023.

5. DEFINITIONS

a. Abnormal Test Results. Abnormal test results are test results that fall outside a specified normal reference range, are unexpected, or could indicate the presence of disease. An abnormal test may or may not require action and therapeutic intervention, depending on the clinical context. There are three types of abnormal test results that require action or therapeutic intervention:

(1) Critical. A critical test result is any new abnormal test result which is emergent and imminently life-threatening, must be acted upon by the ordering provider or designee immediately or within a short window of time, and could result in severe morbidity or mortality if not addressed. Test results recognized as critical at VANTHCS are listed in the appendices to this MCP.

(2) Urgent. An urgent test result is any new abnormal test result which is not imminently life-threatening but must be acted upon by the ordering provider or designee within a relatively urgent timeframe, as clinically indicated to ensure timely, appropriate, and effective therapeutic action.

(3) Clinically Significant. A clinically significant test result is any new abnormal test result that requires action by the ordering provider or designee, but not necessarily in an immediate or urgent time frame.

b. Asynchronous Communication. Asynchronous communication is communication that occurs when parties involved are not present at the same time, such as through electronic notifications in the EHR, non-instant secure messaging (e.g., secure email), automated messaging, fax, or letter. For the purposes of this MCP, secure instant messaging is considered asynchronous communication if not all parties involved are engaging at the same time.

c. Diagnostic Services. Diagnostic services are all units within the VA medical facility in charge of performing and/or interpreting diagnostic tests (e.g., laboratory, radiology tests, asynchronous telehealth interpretation). For the purposes of this MCP, “diagnostic service” refers to any employee within those units who is responsible for or involved in communicating test results.

d. Normal Test Results. Normal test results are test results that fall within the reference range for that test.

e. Synchronous Communication. Synchronous communication is communication that occurs when parties involved are all present at the same time, such as in person, telephone, video teleconference, or secure instant messaging if all parties involved are engaging at the same time.

6. REFERENCES

a. VHA Directive 1088, Communicating Test Results to Providers and Patients, Jason Cave, JD, SES VA North Texas Health Care System Executive Director Date Approved: July 11, 2024 dated July 11, 2023, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10366.

b. VHA Directive 1105.03, Mammography Program Procedures and Standards, dated May 21, 2018, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=6423.

c. VHA Directive 1330.01(7), Health Care Services for Women Veterans, amended May 14, 2023, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5332.

d. VHA Directive 1604, Data Entry Requirements for Administrative Data, dated December 18, 2023, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=11628.

7. RESCISSION

VANTHCS MCP 11-14, Communicating Test Results to Providers and Patients, dated April 23, 2021, is rescinded.

8. REVIEW

This MCP must be reviewed at minimum at recertification and including when there are changes to the governing document.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of July 2029.

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

10. SIGNATORY AUTHORITY

JASON CAVE Digitally signed by JASON CAVE Date: 2024.07.11 13:30:55 -05'00'

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MCPs are available at:

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APPENDIX A

A-1

PATHOLOGY & LABORATORY MEDICINE SERVICE

1. CRITICAL CHEMISTRY RESULTS

Serum Analyte Less Than Greater Than

Calcium (total) 6.9 mg/dL 13.0 mg/dL

Bicarbonate 10 mmol/L 40 mmol/L

Glucose 50 mg/dL 500 mg/dL

Magnesium 1.2 mg/dL 4.0 mg/dL

Potassium 2.7 mmol/L 6.2 mmol/L

Sodium 120 mmol/L 160 mmol/L

Ionized Calcium 0.80 mmol/L 1.40 mmol/L

Hs Troponin I 50.0 pg/mL (only initial for episode of care)

Therapeutic Drugs Greater Than

Acetaminophen 35 µg/mL

Amikacin (Peak or Routine) 35 µg/mL

Amikacin (Trough) 10 µg/mL

Carbamazepine 20 µg/mL

Digoxin 2.5 ng/mL

Free Phenytoin 3 µg/mL

Gentamicin (Peak or Routine) 12 µg/mL

Gentamicin (Trough) 2.5 µg/mL

Lithium 1.5 mEq/L

Phenobarbital 60 µg/mL

Phenytoin (Dilantin) 30 µg/mL

Salicylate 300 mg/L

Tacrolimus 20.0 ng/mL

Theophylline 25 µg/mL

Tobramycin (Peak or Routine) 12 µg/mL

Tobramycin (Trough) 2.5 µg/mL

Valproic Acid 170 µg/mL

Vancomycin (Trough) 30 µg/mL

2. CRITICAL HEMATOLOGY RESULTS

Blood Analyte Less Than Greater Than

Absolute neutrophils 0.2 K/µL (Inpatient)

0.5 K/µL (Outpatient)

Hematocrit 21%

Hemoglobin 7.0 g/dL

Platelets 30 K/µL

PT/INR (International Normalized Ratio)

INR >4.5

A-2

Blood Analyte Less Than Greater Than

PTT & PTT-Heparin ≥100 seconds (Inpatient) >50 seconds (Outpatient)

Blood smear for malaria or other parasites

Critical if positive, especially P. falciparum

3. CRITICAL IMMUNOLOGY RESULTS

Test Critical Result

Cryptococcal antigen (CSF) Positive (Sample titered)

4. CRITICAL MICROBIOLOGY RESULTS

Test Critical Result

Mycobacterium tuberculosis (PCR) Positive

Any culture Presence of highly unusual antimicrobial resistance detected (e.g., Enterococcus

sp. and Staphylococcus sp. resistant to vancomycin) *Except vancomycin-resistant Enterococcus (VRE) cultured from specimen types other than blood

Highly significant or unusual microorganisms (e.g., Nocardia, Listeria, Legionella, or Brucella)

Gram stain suggesting gas gangrene or another systemic toxemia

Blood culture Positive

CSF and other Sterile Body Fluid (Pleural, Peritoneal, and Synovial) Culture, Gram Stain, or preps

Positive

Surgical wound culture Positive for Streptococcus pyogenes (Group A)

Stool Clostridioides difficile Positive for toxin test (antigen/toxin assay)

Eye Culture and Gram Stain Smear Organism seen with gram stain description

5. CRITICAL ARTERIAL BLOOD GASES RESULTS

Test Less Than Greater Than pH 7.200 7.600 pCO2 10 mm Hg 65 mm Hg pO2 40 mm Hg sO2 70%

A-3

Test Less Than Greater Than

HCO3 10 mmol/L 40 mmol/L

O2Hb % 70%

CoHb % 15%

Lactate >4.0 mmol/L

MetHb >30%

APPENDIX B

B-1

DIAGNOSTIC IMAGING SERVICE

1. CRITICAL RADIOLOGY RESULTS

a. Any finding that has the potential to be life threatening or could cause serious harm and that requires an urgent intervention or change in patient management (e.g., pulmonary embolism, deep venous thrombosis).

b. Any finding that might result in prolongation of patient pain or discomfort (e.g., acute fracture).

c. Any finding that would result in the cancelation of significant on-going or imminent treatment.

d. Specific conditions (not exhaustive list):

(1) Acute hemorrhage

(2) Aortic dissection

(3) Bowel obstruction

(4) Deep venous thrombosis

(5) Ectopic pregnancy

(6) Foreign object (e.g., post-surgical), depending on location and nature of the object

(7) Free air peritoneum

(8) Hemothorax

(9) Incorrect location of venous access, catheter, or tube (e.g., endotracheal tube)

(10) Intracranial hemorrhage

(11) Leaking aortic aneurysm

(12) Life-threatening cardiovascular/respiratory problem (e.g., pulmonary embolism)

(13) Life-threatening neurological problem

(14) Occlusive intracranial stroke

(15) Perforated viscus

(16) Pneumothorax

(17) Possible tuberculosis

APPENDIX B

B-2

(18) Ruptured aneurysm

(19) Significant musculoskeletal/vascular injuries

(20) Spinal cord compression

(21) Testicular torsion

(22) Unstable vertebral fracture

(23) Any other condition determined by the radiologist as requiring immediate intervention for treatment

APPENDIX C

C-1

NUCLEAR MEDICINE SERVICE

1. CRITICAL NUCLEAR MEDICINE RESULTS

a. Bone Scan – unexpected significant result (e.g., metastasis with possible orthopedic jeopardy)

b. Gastrointestinal Bleeding Scan – positive for active bleeding

c. Hepatobiliary (HIDA) Scan – positive for acute cholecystitis

d. Lung Scan – high probability of acute pulmonary embolism

e. Myocardial Perfusion Scan (Cardiac Stress Test) – high risk abnormal

f. PET Scan/Hybrid Imaging – any new finding with high probability for significant increase in morbidity and/or mortality that requires urgent attention

g. Any other study result that, in the professional opinion of the interpreting Nuclear Medicine physician, may significantly impact patient management and/or clinical outcome