SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY

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Roderick Brown
6 years ago
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1 TITLE: SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY REPORTING OF CRITICAL RESULTS AND DIAGNOSTIC PROCEDURES POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 02/20/06 3/30/18 Clinical 1 of 7 Job Title of Responsible Owner: Director of Critical Care, Trauma Services, and Hemodialysis S1013 Non-Clinical PURPOSE: POLICY STATEMENT: To identify the process for reporting critical results of tests and diagnostic procedures on a timely basis to the responsible licensed caregiver so the patient can be promptly treated. Each department performing tests should define, the timeframe for reporting, and who will report, to a licensed caregiver EXCEPTIONS: A physician may elect not to be called in the event a critical result is expected and has provided orders to address the result. PROCEDURE: 1. The ancillary personnel or MD/DO of the testing department will notify the ordering/designated physician or the licensed nurse caring for the patient. At the time the result is provided and the result is in the electronic medical record (EMR), there will be a verbal read back from the person receiving the result to the person reporting the result. If the critical result is not in the EMR, the person receiving the result will write down and read back the written information to the reporting person to ensure accuracy of the communication. 2. If the testing department does not notify the ordering physician, the values will be called to a licensed nurse, a verbal read back will be completed and the nurse will within one hour of the resulted test: a. inform the physician or his designee of the result, including a verbal read back, or b. implement any previously received orders regarding test results, or c. implement an approved protocol. 3. The qualified personnel shall document any physician(s) or designee notified of the results. a. In SCM, in any and/or other electronic system, physician notification, under the assessment/reassessment flow sheet; b. Other designated area in paper chart.

2 2 of 9 4. Unavailability of responsible licensed caregiver when the responsible licensed caregiver is not available, follow policy 01.ADM.00 Chain of Command. 5. Any critical tests results will be communicated by the interpreting physician or technologist to the ordering/covering physician or to the licensed nurse caring for the patient if the physician is not available. 6. Critical results obtained after the patient is discharged will be called to the ordering physician or designee per protocol. RESPONSIBILITY: It is the responsibility of the department directors to see that the staff is aware of, and adhere to, this policy. It will be the physician's responsibility to notify the patient of the results. REFERENCES: The JC Comprehensive Accreditation Manual for Hospitals (CAMH) Joint Commission, NPSG Lab Policy , Lab, Result Notification Values Critical Results SMH Policy Chain of Command (01.ADM.00). SMH: Author. AUTHOR(S): ATTACHMENT(S): Dana Rickard, Laboratory Mark Pellman, Director, Respiratory Care Services Sue Olsen, Director of Critical Care, Trauma, Hemodialysis Mary Geary, Executive Director, Quality Reporting of Results by Department APPROVALS:

3 3 of 9 Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: Date Quality Improvement/Patient Safety Committee Mary Geary, PhD, RN 3/27/2018 Director/Responsible Owner: Vice President/Executive Director: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Sue Olsen, MSN, RN, CCRN, CNML Director of Critical Care 3/14/2018 Connie Andersen, RN, CNO 3/15/2018 Dr. James Fiorica, MD, CMO 3/21/2018 Medical Executive Committee: (if clinical and review requested by CMO and COS) Chief Executive Officer (Interim): David Verinder, CEO 3/23/2018

4 4 of 9 Department Description of Test Reported Reporting Flow Critical Results per Department Respiratory Care Laboratory Blood Gas High and Low Critical Results, policy BLG.001 *unless excluded by physician order High or low critical lab results as notified by lab. See attached addendum. Respiratory Therapist to licensed nurse or physician Medical Technologist or Technician to attending nurse or covering physician PaO2 less than 60 or greater than 125 PaCO2 less than 25 or greater than 50 ph less than 7.30 or greater than 7.55 Exceptions: 1. Patients on O2 therapy that are being taken off for room air ABG s only. 2. Patients with chronic PaC02 >50 with a ph of Patients with chronic Pa02 < 60 with Sa02> 92%. Patients with Pa02 > 125 with order or a 02 protocol.

5 5 of 9 PHYSICIAN NOTIFICATION CRITICAL RESULT LIST TEST NAME UNITS PANIC RESULT LOWER UPPER Acetaminophen ug/ml >150 Acid Fast Culture Acid Fast, Smear Alcohol, Ethyl gm/dl >.350 Amikacin ug/ml Trough: >10.0 Peak: >35.0 Aminophylline ug/ml >20 Ammonia Adult umol/l >75 Child <10y umol/l >39 Bilirubin, Neonatal 0-2 Months mg/dl >15 Bilirubin, Total 0-6 Days mg/dl >15 Blood Count-parts thereof Path review ordered for 1 st occurrence inpatient Body Fluid-sterile site for clin. sig. pathogenic bacteria Blood Culture Bordetella pertussis * Calcium mg/dl <6.0 >14.0 Campylobacter * Carbon Dioxide (CO2) meq/l <12 >40 Chloride, Serum meq/l <70 >130 Clostridium Perfringens from wound Any isolated * Clostridium Difficile (OP notified in a.m. Cryptococcal Antigen Test CSF Culture CSF Gram Stain CSF Lactic Acid meq/l >3.2 CSF Smear CSF WBC /mm3 >9 Dialysis Water >200 CFU * Digoxin ug/ml >3.0 Dilantin ug/ml >30 Toxic: >40 Diphtheria on initial culture Diphtheria (not initial culture) * Direct Viral Stains E.Coli 0157:H7 (screen) * TEST NAME UNITS PANIC RESULT LOWER UPPER Fibrinogen mg/dl <100 Fibrinogen Degradation ug/ml >160 Products

6 6 of 9 FTA Fungus (systemic isolate) * Gentamicin ug/ml >2.5 trough >9.9 Peak Glucose Adult mg/dl <50 >400 Newborn 0-2M mg/dl <40 >300 Gram Stain, Blood Hematocrit Adult % <18 >60 Newborn 0-6D % <24 >70 CAN % <18 >60 Hemoglobin Adult gm/dl <6.0 >20.0 Newborn 0-6D gm/dl <8.0 >25.0 CAN gm/dl <6.0 >20.0 Heparin, Anti-Xa IU/ml >1.8 Hepatitis A IgM * Hepatitis B (Surface Antigen and Core IgM) HIV Influenza A&B Antigen Influenza A&B Antigen < 5 y * Iron, Total ug/dl >499 Kleihauers-Betke (fetal HGB stain) Lactic Acid, Blood meq/l >3.2 Legionella Urine Antigen *Lithium meq/l >2.0 Listeria monocytogenes * Malaria Smear Presumptive Magnesium mg/dl <1.1 >7.0 Methotrexate mcm/l > hrs past last dose N. meningitides * Partial Thromboplastin (APTT) sec. >125 >150 Pertussis * Phenobarbital ug/ml >60 Platelet /mm3 <50,000 >1,000,000 CAN /mm3 <10,000 >1,000,000 Potassium Adult meq/l <2.5 >6.2 Newborn 0-2M meq/l <2.7 >7.0 Prothrombin sec >44 (sec.may change with reagent sensitivity) INR >4.0 Salicylate mg/dl >30 Lethal: >60 Salmonella * Shigella *

7 7 of 9 Sodium meq/l <120 >155 Staphylococcus (VISA, VRSA) * Tegretol ug/ml >20 Tobramycin ug/ml Trough: >2.5 Peak: >10 Troponin >0.05 CT Urinalysis Newborn Ketone Trace or > Newborn Glucose Trace or > Vancomycin ug/ml Trough >20 Peak: >55 Vibrio * Viral Culture: 0-6 months of age Volatiles Acetone >250 mg/dl Methanol >40 mg/dl Isopropanol >150 mg/dl WBC Adult /mm3 <2,000 >30,000 Newborn /mm3 <2,500 >40,000 CAN /mm3 <2,000 >30,000 Western Blot Confirmed or indeterminant *denotes tests that lab reports immediately to infection control. Infection control contact information: Mon-Fri 6a.m. to 3p.m. Ext Afterhours and weekends the lab will call The County Health Dept

POLICY STATEMENT: Critical values as defined below, shall be communicated in accordance with the following guidelines.

POLICY STATEMENT: Critical values as defined below, shall be communicated in accordance with the following guidelines. IDENT Type of Document Applicability Type Title of Owner Title of Approving Official Date Effective 10/26/2016 Date of Next Review 10/26/2018 TITLE: Critical Values PURPOSE: To promote patient safety by