D.7 MCP 658-11-34 Reporting Critical Results.docx

Salem VA Medical Center Salem, VA 24153

REPORTING CRITICAL RESULTS

MCP 658-11-34

Rescinded Document:

Signatory Authority:

Rebecca J. Stackhouse, CTRS, FACHE Medical Center Director

Responsible Owner:

Francis Cannizzo, MBA, MD, PhD Chief of Staff

1. POLICY

MCM 658-11-34, Reporting Critical Results, dated January 20, 2017

Effective Date:

September 8, 2020

Recertification Date:

September 8, 2025

It is the policy of this Medical Center that critical tests and critical diagnostic test results will be accurately and expeditiously communicated to the ordering practitioner or surrogate for his/her immediate knowledge. It is also the policy of this Medical Center that a write-down/read-back verification and confirmation procedure be used for the communication of the test results.

2. JUSTIFICATION

To establish policy and procedures for the identification and communication of critical diagnostic results in order to facilitate timely clinical intervention. This policy applies to all inpatients and outpatients inclusive of the Community Living Center, Home Based Primary Care and Salem Veterans Affairs Clinics.

3. RESPONSIBILITIES

a. The Medical Executive Council (MEC) is responsible for the approval of the critical test and critical result lists for diagnostic tests performed at the Medical Center.

b. The Chief of Staff is responsible for ensuring that the designated tests are performed and critical results are communicated so that appropriate and timely treatment is provided to Medical Center patients.

c. The Chiefs of Diagnostic Testing Services are responsible for ensuring that staff follows procedures to identify and report critical results within time frames outlined by this Medical Center Policy. Chiefs are to establish monitors to ensure compliance with this Medical Center Policy.

d. The Chiefs of Clinical Services are responsible for ensuring that practitioners follow procedures to evaluate, document, and act on critical results in a timely manner.

4. OTHER PARAGRAPHS

a. Communication of Critical Results

(1) Upon detecting a critical result for inpatients, outpatients (inclusive of the Community Living Center (CLC), Salem Clinics and Home Based Primary Care) and reference lab identified (called to the lab), Pathology and Laboratory Medicine personnel will telephone results immediately to the requesting practitioner or surrogate. Communication should occur within 30 minutes of awareness. Critical results notification is to be documented as test comments in the Veterans Health Information Systems and Technology Architecture (VISTA) system (name of physician notified and read back, Date/Time, Lab Employee initials). In the event that the ordering practitioner or surrogate cannot be reached, the technologists are to go up the chain of command promptly (Attending, Service Chief, Chief of Staff) to reach a provider who can make an immediate treatment decision for the care of the patient. For outpatient critical results that are identified after hours, the Administrator on Duty (AOD) is to be notified who will ensure appropriate emergency management through the Emergency Department.

(2) Imaging personnel, upon determination of critical results, will communicate the results by phone or in person with the ordering practitioner. If the ordering practitioner cannot be contacted, the report will be given to the practitioner’s surrogate and the contact documented in the radiologist’s report. In the event that the ordering practitioner or surrogate is not available, the results will be directly communicated to the Chief of the Service.

(3) The non- invasive Attending Cardiologist, or immediately available Cardiologist, or Nurse Practitioner, will be notified upon determination of EKG critical test results within 10 minutes. The Cardiologist or Nurse Practitioner will make a decision regarding the EKG reading and the necessity for transport to the Emergency Department or Primary Care Team referral.

(4) The Cardiology Echocardiography (ECHO) technologist, who identifies a critical result/value, will alert the non-invasive Attending Cardiologist within 15 minutes of image acquisition. The non-invasive Attending Cardiologist will make a decision regarding admission and inform the referring physician within 15 minutes of his/her notification.

(5) A “read back” procedure is to be used whenever critical results are verbally communicated. The practitioner receiving a verbal report is to write down, read back, and confirm the information so that accuracy can be assured.

(6) The critical result timeliness of reporting data will be collected, trended, analyzed and reported to the Medical Executive Council (MEC). The results of the data will be utilized to improve performance.

September

8, MCP

658-11-34

5. DEFINITIONS

a. Critical Test. A diagnostic test or exam that always requires rapid communication of results whether normal or abnormal. No critical tests have been identified by the medical staff for this Medical Center and its outreach efforts.

b. Critical Result. Critical results are any diagnostic test result where a delay in reporting may result in adverse outcomes for the patient. These are the type of results that have to be reported to the ordering practitioner or surrogate within a specified predetermined period of time so that immediate action can be taken to address the abnormality. The time interval of concern is from the time the result is available until received and acknowledged by the clinician who can act on the result.

c. Pathology and Laboratory Medicine Critical Results. Pathology and Laboratory Medicine Service recognizes a number of critical results as listed in Appendix A. Once a critical value is detected, communication to the provider should occur within 30 minutes of awareness and validation.

d. Imaging Service Critical Results. Imaging Service recognizes a number of critical results as listed in Appendix B. These results must be reported within 60 minutes of detection.

e. Cardiology Service Critical Results. Cardiology Service has defined critical results to be Electrocardiograms (EKG’s) performed in Cardiology Service and recognizes a number of critical results as listed in Appendix B. The non-invasive Attending Cardiologist, or immediately available Cardiologist or Nurse Practitioner will be notified upon determination of EKG critical results within 10 minutes. The Cardiology Echocardiogram technologist who identifies a critical result/value will alert the non- invasive Attending Cardiologist within 15 minutes of image acquisition. The non-invasive Attending Cardiologist will make a decision regarding admission and inform the referring physician within 15 minutes of his/her notification.

6. REFERENCES

a. The Joint Commission Hospital Accreditation Standards, current edition.

b. VA Laboratory Accreditation News Vol. 9, Issue 2, September 2008.

c. College of American Pathologists General Checklist, current edition.

7. RESCISSION

Medical Center Memorandum 658-11-34, Reporting Crritical Results, dated January 20, 2017.

8. REVIEW

This MCP requires review, 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 September 2025. 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

Rebecca J.

Digitally signed by Rebecca J. Stackhouse 156979

Stackhouse 156979 Date: 2020.09.08 12:58:40 -04'00' Rebecca J. Stackhouse, CTRS, FACHE Medical Center Director

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

DISTRIBUTION: Emailed to the Top Management and AFGE Distribution List on May 18, 2020. MCPs are available at: https://dvagov.sharepoint.com/sites/salem/Salem%20Medical%20Center%20Policies%20 MCPs/Forms/AllItems.aspx

Attachments

Attachment A

Arterial Blood Gas

Coagulation

>5.0

mmol/L Hematology

25.0/k/cmm

Chemistry

Microbiology

mmol/L

mmol/L

Peak > 10.0 ug/mL

Peak > 50 ug/mL

Kinetic >30 ug/mL

Peak >30 ug/mL

Kinetic >10 ug/mL

Peak >10 ug/mL

Attachment B