Section D.13 - Memorandum 011-025 Critical Result Notification Protocol.pdf

Department of Veterans Affairs (VA) Memorandum 011-025 Central Texas Veterans Health Care System (CTVHCS) December 18, 2018 Austin-Temple-Waco Community-Based Outpatient Clinics (CBOCs)

CRITICAL RESULT NOTIFICATION PROTOCOL

1. CHANGES: Added Imaging Critical Results Notification Information

2. RESCISSION: Memorandum 113-002 dated February 4, 2016, and Memorandum 114-002, dated March 21, 2018.

3. NEXT REVIEW DATE: December 2021.

4. AFFECTED SERVICES: All clinical services.

5. POLICY: CTVHCS is committed to reporting critical laboratory and imaging test results to the ordering provider or designated surrogate in a manner that supports prompt attention and appropriate and effective patient treatment. Critical result values will be identified for CTVHCS patient population and procedures for practitioner notification will be outlined and approved by the Clinical Executive Council. For Critical Test Results see Attachments A and B.

6. DEFINITIONS:

a. Lab Test Results: A critical laboratory test result which may require immediate intervention by a practitioner. See Attachment A.

b. Imaging Test Results: Critical imaging test results/findings are those that require direct communication and urgent attention. These include but are not limited to:

(1) any finding that has the potential to be life-threatening or that could cause serious harm and requires an urgent intervention or change in patient management. Specific conditions/findings that meet this requirement are listed in Attachment B; and

(2) any finding that would result in the cancellation of ongoing or imminent treatment.

7. RESPONSIBILITY:

a. Service Chiefs of Diagnostic Services are responsible for:

(1) instructing staff regarding policies and procedures for communication of critical exam/test results;

(2) ensuring that potentially life-threatening findings, or findings requiring urgent intervention, have been directly communicated and documented in the diagnostic report;

(3) ensuring that an audit is performed each month, and taking action when the audit shows an unsafe reporting practice.

CTVHCS Memorandum 113-002 December 18, 2018

b. Lab Test Results: Laboratory Technicians and Technologists are responsible for:

(1) the notification of practitioner within 60 minutes of result completion

(2) documenting critical result notifications in a timely manner in VISTA/CPRS to include the following information:

(a) patient's name and social security number.

(b) critical test and result.

(c) name of practitioner receiving result.

(d) Date and time of result notification.

(e) Technician/Technologist's initials documenting phone call.

c. Imaging Test Results: Imaging Service Physicians (radiologists and Nuclear Medicine physicians) are responsible for:

(1) ensuring that verified test result reports are available in the medical record in a timely manner;

(2) providing documentation in the examination report that verifies appropriate communication of critical results to a provider, to include:

(a) name of the provider contacted

(b) means of communication of results

(c) date of time of the communication

(d) documentation of provider “read back” of the critical result(s)

(3) using Radiology Diagnostic Result Code 20 for all critical results.

8. PROCEDURE:

a. Lab Test Results: When critical results are identified, excluding those denoted “VIEW ALERT ONLY”, proper notification must be completed within 60 minutes. If no response to notification within five minutes, repeat notification. If no response within five minutes of repeated notification, go to the next step in notification cascade and continue at five-minute intervals through each step of the cascade until results are successfully conveyed to a practitioner.

CTVHCS Memorandum 113-002 December 18, 2018

(1) Critical Result

(a) Inpatients: the order of notification is as follows:

1. Monday through Friday, 8:00 a.m. - 5:00 p.m.

a. Ordering practitioner (call to RN, only in OR)

b. Section Chief

c. Service Chief

d. Chief of Staff

2. After hours (weekdays between 5:00 p.m. – 8:00 a.m., Saturday, Sunday, and holidays):

a. Temple:

(1) Follow Inpatient Ward On Call Schedule

(2) Hospitalist On Call (call operator or AOD 40890 for information)

(3) Chief of Medicine or Chief of Surgery

(4) Chief of Staff

b. Waco:

(1) MOD, extension 53779

(2) Administrator on Duty (AOD), extension 53405 or 53073 for additional contacts or information.

(b) Outpatients: the order of notification is as follows: (Temple/Waco/Austin)

1. Monday through Friday, 8:00 a.m. – 5:00 p.m.

a. Ordering provider

b. Primary Care Provider

c. Primary Care Supervisor

d. Chief Medical Officer/Deputy Chief of Staff

e. Chief of Staff

CTVHCS Memorandum 113-002 December 18, 2018

2. After hours (weekdays between 5:00 p.m. – 8:00 a.m., Saturday, Sunday, and holidays):

a. Temple, CBOC, OPC

(1) Emergency Department Physician

(2) Emergency Department Chief

(3) Chief of Service

(4) Chief of Staff

b. Waco

(1) MOD, (254) 598-8873

(2) Administrator on Duty (AOD), extension 53405 or 53073 for additional contacts or information.

(c) Coagulation Results--Outpatient: Coumadin Clinic

1. Monday – Friday 0800 to 1630:

a. Anticoagulation Clinic Pharmacist – ext. 40005, 42943, 40561, 40272

b. Anticoagulation Clinic pager – 356

c. Associate Chief of Pharmacy Services, Clinical Services – 40703\

d. Chief of Pharmacy Service – 40539

2. After hours (weekdays between 4:30 p.m.-8:00 a.m., Saturday, Sunday, and holidays):

a. Temple, CBOC, AOPC

(1) Emergency Department Physician

(2) Emergency Department Chief

(3) Chief of Service

(4) Chief of Staff

CTVHCS Memorandum 113-002 December 18, 2018

(d) For verbal telephone reporting of critical test results, verify the test result by requesting the practitioner "read back" the test result. Document the "read back" by entering the abbreviation: CRB in the comment section of the final report. CRB expands to: Obtained "read back" on critical result notification.

If results are hand-carried, enter CRP in the report comment section which expands to:

Critical results, hard copy handed to provider. Enter name of practitioner (or RN only in OR) receiving hand-carried results, initials of person delivering the results, and time of delivery.

(2) Ancillary Testing:

(a) Point-of-Care Glucose Testing: All critical result notification comments will be documented in VISTA upon downloading the glucose meter.

1. While the test is displayed, the operator will select a preprogrammed or custom notification comment that will appear with the results on the patient chart.

2. Notify the practitioner.

3. Notify the unit charge nurse or nurse manager.

(b) Pulmonary Medicine: When critical test results are identified, provider notification must be completed within 30 minutes. All critical result notifications will be documented in VISTA with the following information.

1. If results are called: name of practitioner (or RN only in OR) receiving results, time results called, and initials of person documenting the phone call. Document the “read back” by entering the abbreviation CRB in the comment section of the report.

2. If results are hand-carried: name of practitioner (or RN only in OR) receiving hand-carried results, initials of person delivering the results, and time of delivery.

3. If there is no need to call results: document the reason there is no need for critical result notification, i.e., home oxygen renewal.

(3) Anatomic Pathology:

(a) New malignancies (except for Skin Basal Cell Carcinoma and Skin Squamous Cell Carcinoma) are verbally communicated to the ordering provider. If ordering provider cannot be reached within one working day, the following notification cascade will follow:

1. Section Chief

2. Service Chief

3. Chief of Staff

CTVHCS Memorandum 113-002 December 18, 2018

(c) If the provider cannot be reached and escalation to Section Chief/ Service Chief/ Chief of Staff is required, a CPRS (electronic medical record) “new diagnosis of malignancy pathology” progress noted may be entered into the patient’s record for the new diagnosis of malignancy by the diagnosing pathologist as per VHA Directive 1106.01 p.64.

In addition, the pathologist must designate the provider as an additional signer (co-signer) to the progress note. This provides a mechanism to validate that the message has been received and read by the patient’s provider. The progress note cannot be “completed” until the co-signer (provider) signs the note. The time the co-signer signs the note is automatically recorded (verification/validation) and should be entered into the surgical pathology report as well.

(d) Notification of new malignancy diagnosis by the pathologist is also documented in the surgical pathology report. Documentation must include the date of notification and the person notified.

(e) Reference Laboratory: The practitioner is notified of critical test values as results are received from reference laboratories. In addition to anatomic pathology findings, this would include cancers or malignancies identified in definitive testing in clinical hematology or molecular pathology and documented as such in a corresponding anatomic pathology report.

(f) Critical Result Exceptions: Some non-critical test results will be flagged as "critical" by VISTA in order to notify the practitioner with an electronic View Alert. This is critical flagging for electronic notification ONLY and need not be called to the practitioner. These tests include occult blood, hepatitis C antibodies and C RNA by PCR, PSA, H. pylori and others.

b. Imaging Test Results:

(1) Critical Result:

(a) During normal duty hours, all imaging critical test results must be directly communicated to the ordering provider or designated surrogate provider (i.e., either telephonically or in person) within sixty (60) minutes of discovery. If the ordering provider (or his/her surrogate) cannot be contacted, the appropriate Service Chief should be notified.

(b) Imaging findings for outpatient examinations that are interpreted during non-duty hours (after normal duty hours, on weekends, and on Federal holidays) should be directly communicated to an on-duty Emergency Department physician within sixty (60) minutes of discovery.

(c) Critical imaging findings for inpatient examinations that are interpreted during non-duty hours should be directly communicated to the ordering provider (if in-house), a CTVHCS hospitalist, or the appropriate Medicine or Surgery physician on-call.

CTVHCS Memorandum 113-002 December 18, 2018

(2) Critical Tests:

(a) A critical imaging test is defined as an imaging examination that is ordered by a provider with an urgency designation of ‘STAT’ and is telephonically called in to the Imaging Service and declared to be a medical emergency. Results of a true ‘STAT’ exam will be treated as a medical emergency for diagnostic purposes with results transmitted to the ordering provider in the same manner as a critical imaging test result.

(b) The formal interpretations of all ‘STAT’ imaging tests that are telephonically called in to the Imaging Service and declared a medical emergency are required to be verified/completed in VistA/CPRS within 110 minutes from the date/time that the patient has arrived in the Imaging Service and been registered for the ‘STAT’ examination in VistA.

1. To support the unique nature of Emergency Department (ED) operations, all imaging exams ordered from the ED with an assigned urgency status of URGENT or STAT will be processed as medical emergencies and interpreted within 110 minutes from the time the patient has arrived in the Imaging Service and been registered in VistA (for non-ambulatory patients that require a portable x-ray exam (see #2 immediately below).

2. For ‘STAT’ portable x-ray exams requested from any location, the imaging test interpretations should be completed within VistA within 110 minutes from the date/time the call for the ‘STAT’ exam was received by the Imaging service and the exam subsequently registered in VistA.

3. Every attempt will be made to interpret exams ordered as ‘STAT’ (but have not been telephonically called into the Imaging Service and declared a medical emergency) within 110 minutes after the patient has been registered in VistA.

9. QUALITY MONITORING: To ensure compliance with Joint Commission standards, a compliance audit of notification and documentation requirements will be submitted monthly for review by the CTVHCS Patient Safety Committee.

10. REFERENCES: College of American Pathologists (CAP) standard GEN.41320 and GEN.41330; Advance for Administrators of the Laboratory, December 1999, pg. 62;

Medical Laboratory Observer Supplement: Clinical Lab Reference 2000-2001, pg. 38-39;

Clinical Hematology: Principles, Procedures, Correlations, Second Edition 1998, pg. 107, 638-640; and current Joint Commission National Patient Safety Goals. VHA Directive 1106.01, pg.36; CAP standards COM.30000 and COM.30100. VHA Directive 2009-019 Ordering and Reporting Test Results, March 24, 2009.

/s/ Christopher R. Sandles, MBA, FACHE Director

CTVHCS Memorandum 113-002 December 18, 2018

CEC Approved: 9/4/2018

Attachment A: Critical Laboratory Results Attachment B: Emergent/Critical Results for Diagnostic Imaging

CTVHCS Memorandum 113-002 December 18, 2018

ATTACHMENT A

CRITICAL LABORATORY RESULTS

Critical result is a laboratory value which may require immediate intervention by a practitioner. CTVHCS identified critical results are:

a. Chemistry:

ANALYTE LESS THAN GREATER THAN

Bilirubin, Total 15 mg/dL(View Alert Only) Blood Urea Nitrogen 104 mg/dL Calcium 7.0 13.0 mg/dL Chloride 75 126 mmol/L CO2 11 40 mmol/L Creatinine 7.4 mg/dL CSF Glucose 37 438 mg/dL Glucose 51 400 mg/dL Magnesium 1.0 4.9 mg/dL Phosphorus 1.2 8.9 mg/dL Potassium 2.8 6.0 mmol/L Osmolality 250 326 mmol/kg Sodium 120 158 mmol/L Troponin I (Temple) 0.49 ng/mL Troponin I (Austin/Waco) 0.7 ng/mL

b. Drugs (Therapeutic or Toxic):

Acetaminophen 70 ug/mL (View Alert Only) Carbamazepine 12 ug/mL Digoxin 2.2 ng/mL Ethanol 300 mg/dL Gentamicin trough: 2.0 ug/mL peak: 10 ug/mL random: 7.5 ug/mL Lithium 1.5 mmol/L Phenytoin 22 ug/mL Salicylate 50 mg/dL(VIEW ALERT

ONLY)

Tobramycin trough: 2.0 ug/mL peak: 10.0 ug/mL random: 7.5 ug/mL

Valproic Acid 125 ug/mL

CTVHCS Memorandum 113-002 December 18, 2018

Vancomycin trough: 20ug/mL peak: 40 ug/mL random: 40 ug/mL

c. Hematology/Coagulation:

TEST LESS THAN GREATER THAN

Hemoglobin 7 19 gm/dl White Blood Cell Count 2,000 30,000/mm Platelet Count 30,000 1.0 million/mm

INR 5.0

PTT 120 seconds Fibrinogen 80 mg/dL Blast Cell Given to pathologist for review on first time patients only.

Technologist will notify practitioner.

d. Microbiology:

Positive Blood Culture (60-minute notification) (The provider will always be notified on the first positive culture and will be offered the option not to be contacted for further positive cultures with identical gram stain morphology and/or identification for the same patient.)

Positive Wound Culture (surgery only) (VIEW ALERT ONLY) Positive CSF Culture Positive CSF Gram Stain

e. Ancillary Testing:

(1) Arterial Blood Gas:

TEST LESS THAN GREATER THAN

pH 7.30 7.50 pC02 30 50 mm/Hg p02 60 100 mm/Hg HC03 11 40 mmol/L

Note: There is no need to call critical results when patient is tested post-exercise, tested to renew/qualify patient for home oxygen, or when HBCO is elevated.

(2) Point-of-Care:

TEST LESS THAN GREATER THAN

Whole Blood Glucose 51 400 mg/dL

Whole Blood Creatinine 7.4 mg/dL

CTVHCS Memorandum 113-002 December 18, 2018

Note: Individual diabetic control criteria and critical levels may be determined for each patient by the patient's practitioner. However, all test results exceeding established laboratory critical values for blood glucose level of less than 51 mg/dL or greater than 400 mg/dL will be reported immediately to the practitioner. Test results greater than 400 md/dL should be confirmed by repeat test. Confirmation by laboratory method is at the discretion of the practitioner. Test results greater than 400 mg/dL obtained upon follow up to a previously confirmed critical result need not be repeated.

CTVHCS Memorandum 113-002 December 18, 2018

ATTACHMENT B

Emergent/Critical Results for Diagnostic Imaging

Brain & Acute Infarct Spinal Cord Acute Cord Compression

Depressed Skull Fracture Hemorrhage (newly diagnosed) Impending Herniation of Brain

Chest Aspirated foreign body Mediastinal Emphysema (non post-operative)

Pericardial Effusion (in patient with signs or symptoms of cardiac tamponade) Pneumothorax (new or enlarging) Tuberculosis (new finding) Discitis

Abdomen & Acute Appendicitis Pelvis Acute Bowel Obstruction

Acute Cholecystitis / Emphysematous Cholecystitis Anastomotic Leak Diverticulitis (acute and newly diagnosed) Ectopic Pregnancy Free Intraperitoneal Air (non post-operative) GI Bleeding Site (positive localization by Nuclear Medicine test) Necrotic Bowel / Portal Venous Air Obstructing Urolithiasis in the setting of possible sepsis Ovarian Torsion Renal Emphysema Ruptured Hollow Viscus Subcapsular hemorrhage

Vascular Acute DVT System Dissection (acute or newly diagnosed)

Moderate to severe reversible perfusion defect on radionuclide cardiac studies Leaking Aneurysm Pulmonary Thromboembolism

CTVHCS Memorandum 113-002 December 18, 2018

Musculoskeletal Acute Dislocation (newly diagnosed) System Acute, Significant Fracture (newly diagnosed or unknown to the clinician as found in CPRS)

Miscellaneous Abscess (newly diagnosed) Misplaced Catheter, Tube or Line

Testicular Torsion

Ectopic Pregnancy