S02 - Attachment D7 - 11-52-23 REPORTING TEST RESULTS.pdf

VA NORTHERN INDIANA HEALTH CARE SYSTEM (VANIHCS)

June 2023 POLICY NO. 11-52-23

REPORTING TEST RESULTS

1. PURPOSE: To establish a process for effective timely communication of patient test results to practitioners and to patients.

2. POLICY: The policy of the VA Northern Indiana Health Care System (VANIHCS) is that test results be communicated to the ordering practitioner, or surrogate practitioner, within a timeframe allowing prompt attention and appropriate clinical action to be taken.

3. DEFINITIONS: These definitions are provided for implementation of this policy at VANIHCS and do not necessarily coincide with any other common use of these terms.

a. Ordering Practitioner: An ordering practitioner is a practitioner authorized to enter and sign orders for diagnostic tests by privileges or acting under a scope of clinical practice.

b. Preceptor: A preceptor is a licensed independent practitioner who supervises the ordering of tests by residents, or by other practitioners authorized to order tests under a scope of clinical practice.

c. Surrogate Practitioner: A surrogate practitioner is a designated alternative, preceptor, on-call practitioner, supervisor, or service chief who provides coverage in the event that the ordering practitioner is not available.

d. Diagnostic Practitioner: A diagnostic practitioner is a practitioner who performs or supervises the performance and interpretation of diagnostic tests by privileges or acting under a scope of practice.

e. Test Result: Test results include the results of laboratory testing, diagnostic imaging, and diagnostic procedures.

f. Critical Value or Result: A critical value or result is defined as those values or interpretations that, if left untreated, could be life threatening or place the patient at serious risk. Critical values or results are those results from laboratory, cardiology, radiology departments and other diagnostic areas that upon analysis are determined to be “critical” regardless of the ordering priority. All emergent test results and some abnormal test results constitute critical values or results. The critical test list results are defined as those tests that require rapid communication of results even if the results are normal.

g. Emergent Test Result: An emergent test result is a diagnostic finding that is associated with a high likelihood of short-term, poor outcome and requires either

POLICY NO. 11-52-23

immediate therapeutic intervention or close monitoring.

h. Abnormal Test Result: An abnormal test result is a diagnostic finding that requires attention by the ordering practitioner, but not necessarily in an immediate time frame.

i. Direct Communication: Direct communication is the transmission of test results by direct, non-electronic dialogue between the diagnostic practitioner and the ordering practitioner, or surrogate practitioner, by telephone or face-to-face conversation, or hand-carried report.

j. Electronic Communication: Electronic Communication is the transmission of test results by electronic means (e.g., view alerts, e-mail, FAX, etc.).

k. Personal Representative: A personal representative is a person who, under applicable law, has authority to act on behalf of the individual. This may include power of attorney, legal guardianship of an individual, the executor of the estate of a deceased individual, or someone under Federal, state, local or tribal law with such authority (e.g., parent of a minor). Personal representative is further defined in VHA Handbook 1605.1 “Privacy and Release of Information.”

4. PROCEDURES:

a. For the tests requiring physician interpretation, the staff member performing the diagnostic testing, including radiology, pathology, and cardiopulmonary technologists, will expedite the process of interpretation by the physician of stat tests and the tests identified by the automated reading systems as critical or abnormal. The physician interpreting the test will communicate the results to the ordering practitioner.

b. For tests such as laboratory test results where a physician interpretation is not involved in identifying the critical nature of the result, the technologist performing the test will directly communicate the results.

c. The staff from the testing department will page the practitioner responsible for receiving the results by placing a “stat page”. The page will be identified as stat by adding “911” after the extension number.

d. The person to be contacted with critical and vital test results is the ordering provider. When the ordering provider is not available, an alternative practitioner will be designated. If neither the ordering practitioner nor the alternate is available during administrative hours, the service chief will be notified.

e. When the ordering physician is a consultant or Medical Officer of the Day (MOD) and is not available at VANIHCS when the critical / emergent test needs to be communicated, the primary care provider for outpatients and the attending provider for inpatients will be contacted.

f. On weekends, holidays, and during non-administrative hours, the critical and emergent test results will be reported to the inpatient attending physician, the emergency room physician, or the Marion campus MOD.

5. RESPONSIBILITIES:

a. Chief of Staff:

(1) Ensuring a process is in place for communication of results from diagnostic practitioner to ordering practitioner all values and interpretations that are immediately life threatening, as well as those that otherwise require prompt clinical attention.

(2) Establishing a system of surrogate practitioners in the event that the ordering practitioner is not available.

b. Clinical Executive Board:

(1) Defining critical tests and critical results and values are defined.

(2) Defining acceptable length of time between the ordering of tests or collection of specimens and the availability of results or critical values.

(3) Defining acceptable length of time between the availability of critical tests, values, or results and receipt by the responsible provider.

(4) Defining acceptable length of time between the availability of critical tests, values, or results and notification of the patient or appropriate representative.

c. Clinical Testing Areas (e.g. Pathology and Laboratory Medicine Service, Radiology, and Cardiopulmonary):

(1) Recommending, in conjunction with medical staff, critical decision levels for tests performed by their respective services.

(2) Expediting the process of the confirmation process of any critical test results reporting to the practitioners.

d. Clinical Service Chiefs:

(1) Ensuring that the health care providers:

(a) Are knowledgeable of critical decision levels for diagnostic tests.

(b) Accept the critical decision levels that are communicated to them and read back the results to the reporting person.

(c) Take timely therapeutic action upon receiving the critical tests results.

(d) Make timely medical record documentation of the actions taken in response to the test results.

(e) Assign an alternate to receive the results when the ordering practitioner is not available.

(f) Define the acceptable length of time between the availability of critical tests, values, or results and receipt by the responsible provider.

(2) Collecting data on the timeliness of reporting critical tests and critical values or results and reported to Medical Executive Board (MEB) on a quarterly basis.

(3) Assessing the data collected, determining whether there is a need for improvement, and taking appropriate action to improve and measure the effectiveness of those actions. The synopsis of the above actions will be reported to the CEB on a quarterly basis.

(4) Ensuring that the communication of results to practitioners and patients is periodically monitored to document adherence to VHA and local policies.

(5) Reviewing monitors of test result communication.

(6) Ensuring a chain of responsibility is established within their department for receipt of test results and communication of results to patients.

(7) Ensuring that the diagnostic practitioner or designee:

(a) Identifies and communicates expediently all critical, emergent, or abnormal test values or results to the ordering practitioner, the practitioner’s surrogate, or the supervisor, as appropriate.

(b) Ensures that verified test results reports are available in the patient’s electronic medical record in a timely manner.

(c) Documents the time and means of such communication and the name of the practitioner contacted in the medical record. This documentation is not required for abnormal tests that are not critical or emergent.

(8) Ensuring that the ordering practitioner:

(a) Places the initial order, includes the appropriate contact information, and identifies the surrogate practitioner, when applicable.

(b) Initiates appropriate clinical action and follows up the results of any orders which they have placed.

(c) Assigns a qualified surrogate practitioner to receive critical, emergent, or abnormal test result notifications when they themselves are unavailable to review results in a timely manner to prevent avoidable delays in treatment or response.

(d) Documents treatment actions in response to critical, emergent, or abnormal test results in the patient’s electronic medical record.

e. Diagnostic Practitioner:

(1) Identify and communicate expediently all critical, emergent, or abnormal test values or results to the ordering practitioner, the practitioner’s surrogate, or the supervisor, as appropriate.

(2) Ensure that verified test results reports are available in the patient’s electronic medical record in a timely manner.

(3) Document the time and means of such communication and the name of the practitioner contacted in the medical record. This documentation is not required for abnormal tests that are not critical or emergent.

f. Ordering Practitioner:

(1) Place the initial order, include the appropriate contact information, and identify the surrogate practitioner, when applicable.

(2) Initiate appropriate clinical action and follow up the results of any orders which they have placed.

(3) Assign a qualified surrogate practitioner to receive critical, emergent, or abnormal test result notifications when they themselves are unavailable to review results in a timely manner to prevent avoidable delays in treatment or response.

(4) Document treatment actions in response to critical, emergent, or abnormal test results in the patient’s electronic medical record.

(5) Follow patient notification procedures and timelines as outlined in the Attachment.

6. REFERENCES:

a. Joint Commission Comprehensive Accreditation Manual for Hospitals

b. Joint Commission National Patient Safety Goals. Available at:

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

c. VHA Directive 1088, Communicating Test Results to Providers and Patients, dated January 24, 2022

d. VHA Manual M-2, Part VI, Chapter 4, Clinical Programs, Part VI, Pathology and Laboratory Medicine

e. VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, dated January 29, 2016

7. RESCISSIONS: Medical Center Policy 11-52-21, Reporting Test Results, dated February 2021 will be formally rescinded with the publication of this revised version.

8. REVIEW DATE: February 2028

9. FOLLOW-UP RESPONSIBILITY: Chief of Staff

10. SIGNATORY AUTHORITY

Anthony L. Colón, FACHE Interim Medical Center Director

Link to Attachment

Attachment

COMMUNICATING TEST RESULTS

1. To Ordering Practitioner:

a. Critical values or results

(1) Critical values or results must be transmitted immediately by direct communication from the diagnostic practitioner, or surrogate, to the ordering practitioner or surrogate practitioner, and this communication must be documented in the Veterans Health Information Systems and Technology Architecture (VistA).

(2) For telephonic reporting of critical values or results, the complete test result must be verified by having the person receiving the information record “read back” the complete test values or results. It is expected that:

(a) The receiver of the information writes down the complete critical values or results or enters it into the medical record system.

(b) The receiver of the information reads backs the critical values or results.

(c) The receiver of the information receives confirmation from the individual who gave the critical values or results.

(3) The critical and vital test results that require a stat call to the practitioners are as follows:

(a) Laboratory: Values that require immediate notification to the provider are listed in Pathology and Laboratory Medicine Service Standard Operating Procedure PALMS 001, titled Critical Values, and have been approved by the Medical Staff to include:

VANIHCS Pathology Laboratory Service

Critical Values February 13, 2023

CHEMISTRY:

Sodium <120 >160 mmol/L

Potassium <2.8 >6.0 mmol/L Glucose <40 >500 mg/dL Calcium <6.0 >14.0 mmol/L

CO2 <13 >40 mmol/L Phosphorous <1.0 mg/dL Magnesium <1.0 mg/dL

Attachment 2

Ethanol >0.35 g/dL Troponin >0.06 ng/mL

Lactic Acid >4.0 mmol/L

DRUGS - THERAPEUTIC:

Acetaminophen >150 ug/mL - 4 hrs post ingestion

>50 ug/mL - 12 hours post ingestion Carbamazepine >12 ug/mL

Digoxin >2.5 ng/mL Dilantin (Phenytoin) >40 ug/mL

Lithium >1.5 mmol/L Phenobarbitol >40 ug/mL

Primidone >24 ug/mL Quinidine >10 ug/mL

Procainamide & NAPA Procainamide: >12 ug/mL

NAPA: >12 ug/mL Salicylate >30 mg/dL

Theophylline >25 ug/mL Valproic Acid >200 ug/mL

DRUGS - ANTIBIOTICS:

Gentamycin >2.0 g/mL (Trough) > 12 ug/mL (Peak or Random) Tobramycin >2.0 g/mL (Trough) > 12 ug/mL (Peak) Vancomycin >20 g/mL (Trough) > 45 ug/mL (Peak)

HEMATOLOGY/COAGULATION:

APTT >70 seconds

Hemoglobin <7.0 >20 mg/dL

INR >5.0

Platelets <20,000 >1,000,000 /cmm WBC <2,000 >30,000 /cmm

MICROBIOLOGY:

Positive Blood Culture Positive VRE, CRE Indication of Clostridium perfringes in a wound culture Positive Inda Ink, CSF Positive CSF or Sterile Body Fluid Gram Stain or Culture excluding Urine

Multidrug resistant Acinetobacter baumanli, Klebsiella spp and Pseudomonas spp.

Positive MRSA (Not consistent with Previous Result) Positive ACUTE Occult Blood Positive Direct AFB Smear and/or Culture Positive culture for Mycobacterium tuberculosis

BLOOD BANK:

Transfusion Reaction Workup - Positive transfusion reaction workup (Also called to the Chief, PALMS)

Attachment 3

1 Critical values will immediately be entered into the computer and the practitioner or designee will be notified within 30 minutes of completion of the test.

a APTT-P is part of the Heparin Protocol orders for inpatients receiving IV heparin. For these tests, critical results will be called to the RN taking care of the patient at the time the critical result is identified.

b The result will be documented and read-back by the receiving provider, RN (APTT-P results only), or designee to verify the result was accurately received; the read-back will be documented by lab staff in the laboratory computer system as a comment with the result.

2 If a value is consistent with a previously-called result, the physician can be notified by the computer “View Alert”, with the exception of critical potassium results. All critical potassium values will be called regardless of the previous value.

3 A report of all critical values called will be documented under the comment area of the test result with the person notified, time, and initials of the person reporting the value.

(b) Radiology: When the radiologist identifies the following conditions, the ordering practitioner or the designee will be directly contacted by the radiologist within 60 minutes of interpretation. The results will be communicated verbally and the verification of such information sharing will be documented in the medical record within the body of the report.

1 Pneumothorax, (new finding) 2 Leaking or ruptured abdominal aortic aneurysm 3 Ischemic small bowel on CT 4 Acute extra-axial collection, including acute subdural hematoma and epidural hematoma 5 Unstable spinal fracture 6 Pneumoperitoneum (not post op) 7 Misplacement of tubes or catheters 8 Fractures 9 New finding suggestive of malignancy

(c) Cardiopulmonary:

1 Electrocardiograms (ECG / EKG) a The technologist performing the electrocardiogram will review the automated reading immediately after performing the test. If an alert is noted, the tracing will be immediately brought to the attention of the ordering practitioner.

Attachment 4 b Since in most cases the ECG will have already been read, with appropriate action already taken by the provider, the physician interpreting the test will first check the chart in CPRS to determine if it is necessary to notify the ordering provider.

c The findings that require immediate notification are:

i. Acute ST-segment elevation MI

ii. High grade atrioventricular block

iii. Sustained supraventricular tachycardia

iv. New Atrial fibrillation/flutter

v. Sustained ventricular tachycardia and torsades de pointes

vi. Severe bradycardia rhythms

2 Echocardiogram a Cardiac Tamponade b Acute ventricular septal defect-post MI c Aortic dissection d Obstructive (clotted) prosthetic heart valve e Pseudoaneurysm f Papillary muscle rupture-post MI g Cardiac tumors h Left ventricular clots i Severe aortic stenosis j Moderate/Large pericardial effusion k Acute mitral or aortic regurgitation l Valvular vegetations

b. CRITICAL TEST LIST: Critical Tests List results are defined as those tests that require rapid communication of the results even if the results are normal.

(1) Anatomic Pathology: Frozen Sections – the determination of turnaround time should start at the time the specimen is received in the anatomic pathology laboratory and is 20 minutes for each frozen section. Some specimens may require multiple frozen sections to properly assess the margins and or submitted structures.

(2) Laboratory Medicine: Suspected Transfusion Reaction (preliminary results)

– within 4 hours of provider’s order.

(3) Laboratory Medicine / Cardiopulmonary: Blood Gases for Inpatients/Outpatients – within 60 minutes of provider’s order.

(4) Imaging Service: Stat CT of the Head – within 60 minutes from the time the radiologist views the image.

Attachment 5

c. EMERGENT TEST RESULTS:

(1) Emergent Test Results must be transmitted by direct communication from the diagnostic practitioner, or surrogate, to the ordering practitioner, or surrogate, and this communication must be documented in VistA.

(2) If the ordering practitioner is not available, communication needs to be made to the surrogate practitioner. The ordering practitioner, or surrogate, must document receipt of this information, as well as any changes to the care plan. In all cases, when the ordering practitioner and surrogate practitioner are unavailable, a process must be in place for the communication of emergent test results to another practitioner who can take action, such as the medical officer of the day, the senior medical resident, or the leader of the facility’s “rapid response team,” or equivalent.

d. ABNORMAL TEST RESULTS: Abnormal test results may be transmitted from the diagnostic practitioner, or surrogate, to the ordering practitioner, or surrogate, by direct or electronic communication. The ordering practitioner, or surrogate, needs to document any change in care plan.

e. TEST RESULTS THAT ARE NEITHER EMERGENT NOR ABNORMAL: Test results that are neither emergent nor abnormal may be communicated to the ordering practitioner, or surrogate.

2. To Patient or Appropriate Representative

a. Emergent/critical test results

(1) The ordering practitioner will notify the patient, or appropriate representative of the patient, of the critical test results including frozen section pathology results within 24 hours or sooner if immediate action is required, where delaying could place the patient at serious risk if untreated.

(2) Communication of critical results with patients can occur in person, by telephone only. The ordering provider will document in CPRS the communication of the result and the patient or appropriate representative’s understanding of the results and the plan of care.

(3) For patients in the inpatient, emergency, or urgent care setting, it is not required or expected that each individual test result is communicated to the patient. The ordering practitioner or the care team the patient is part of should strive to effectively communicate relevant information to the patient about the patient's medical condition.

Results of specific tests may be included in this communication as appropriate.

b. Abnormal (not emergent /critical) and normal test results

Attachment 6

(1) The ordering provider/surrogate communicates outpatient test results and actions to patients, or an appropriate representative, no later than 14 calendar days from the date on which the results were available to the ordering practitioner.

(2) Significant abnormalities may require review and communication in a shorter timeframe and does not apply to abnormalities that require immediate attention.

(3) Communication of results with patients can occur in person, by telephone, or in writing. Secure messaging through My HealtheVet is an acceptable method of communication. This communication must be documented in CPRS.

(4) Test results ordered while the patient is an inpatient but reported after discharge are treated as outpatient test results and are communicated by the inpatient ordering provider/surrogate.

(5) The results must be communicated by licensed or certified health care staff.

It is not required that the ordering practitioner personally communicates every result, but this task may be delegated to other licensed health care staff when clinically appropriate.

The ordering provider must document and define what is to be communicated to the patient in CPRS and add the licensed or certified staff member as an additional signer.

(6) When, despite best efforts, it is not possible to contact the patient (e.g., the patient has moved and left no contact information), all attempts to communicate with the patient are documented in the medical record.