Section: Hematology Subsection: Miscellaneous. Approved by: Dr. Carmen Morales Written By: Hematology Discipline Signature:

Transcription

1 Document History: Title: Hematology Critical Values Site(s) Site(s): DSM sites with Delphic LIS Document #: Version #: 07 Section: Hematology Subsection: Miscellaneous Approved by: Dr. Carmen Morales Written By: Hematology Discipline Signature: Date: 03-MAR-2014 Date: 26-FEB Annual Review: # Reviewed by: Date: Approval: Date: 1 Gail Turnbull 09-APR-2013 Dr. C. Morales 10-APR Andrew Hartel 01-NOV-2013 Dr. C. Morales 06-NOV Gail Turnbull 03-MAR-2014 Dr. C. Morales 03-MAR Summary of Revisions: # Details of Revisions: Date: Approval: Date: 1 New document 2 Revised 3 Fibrinogen <1.0 g/l added as an Alert Value 03-MAR-2008 C Morales 10-NOV-2009 Included critical CSF TNC>or equal to 10x106/L 03-JUN-2008 Included abnormal / suspect cells observed for fluids as critical. Changed alert to critical throughout document and title 04-DEC-2008 Documentation and activation of occurrence report of failure 10-NOV-2009 of notification (p 3-4) 4 Include SBH 01-MAY-2012 C. Morales 01-MAY-2012 Include WAM Critical Result Procedure for WBC, PLT and HGB 5 Sites to include all WRHA sites with WAM 09-APR-2013 C. Morales 09-APR Amend Critical values schistocytes/spherocytes/sickle cell/csf TNC (p.2) 7 Sites to include all DSM sites with Delphic LIS Policy and procedures include requirement for documentation of first and last name of person notified of critical results. 01-NOV-2013 C. Morales 06-NOV MAR-2014 Dr. C. Morales 03-MAR-2014 Page 1 of 5

2 Hematology Critical Values Purpose: This procedure provides instructions to describe the steps and actions when phoning and documenting critical values. Policy: Critical Hematology values, that may require urgent evaluation/action by the Physician, must have immediate verbal notification (phone call) to the location on the requisition. This must be documented in the report with the test name and value, the date and time of the notification, and the first and last name of the person accepting results. Refusal to provide this information will be documented in the patient report. Read back by the person taking the results is required, There must be documentation of any failure of attempts to notify the appropriate person. There must be follow up of any occurrences of failed notification attempts. Materials: Reagents Supplies Equipment n/a n/a WAM and LIS Workstation Telephone Sample: Any sample processed at DSM Hematology Laboratories with Delphic LIS. See Critical Values below. Quality Control: All critical results must be phoned, and documentation of the date/time and person who took the results recorded in the report. Procedure: Follow the activities in the table below: Notification of Step Action Critical Results 1 The following are DSM Critical Values, which will initiate a phone call of the results: WBC 2.0 or > 50 x 10 9 /L 1st time same day HGB HSC only 50 g/l 1st time same day HGB except HSC 65 g/l 1st time same day PLT - HSC only 20 x 109/L Every time PLT- Except HSC 50 x 109/L 1st time same day WBC Differen ial Suspect leukemia 1 st encounter (with statement that HP review pending) Red Cell > 10 spherocytes/hpf 1 st encounter of each admission Morphology > 10 schistocytes/hpf 1 st encounter of each admission Increased sickle cells 1 st encounter only if not previously diagnosed by hemoglobin electrophoresis Malaria Positive Every time (with statement that HP speciation pending) CSF TNC < 1 month old: >27 Every time > 1 month old: 10 CSF/Fluid morphology Abnormal/suspect cells observed Every time (with statement that HP review pending) INR 5.0 Every time APTT >150 s Every time Fibrinogen <1.0 g/l Every time Page 2 of 5

3 2 Request to speak to either the nurse unit manager or the responsible Physician. If neither is available, the ward clerk can accept the results. Request the first and last name (and position) of the person accepting the result. If there is a refusal to provide the full name, explain that is a DSM Laboratory (policy) requirement and if this information is refused, the comment the person taking the information refused to provide their last name. 3 Give the name of the test and the results (value and units). Ask the person taking the results to repeat all the information back. (This includes the patient name, hospital number and results) 4 If there is no answer at the number indicated on the request 1. For any clinical service, there should be/will be a Physician on call who can be reached through the Paging Operator. 2. For Referred In requests, there should be a designated contact for critical values. (Refer to DRENQ format and DOCTOR format in LIS) Documenting Critical values 1 LIS/Middleware Actions DSM Sites with Delphic LIS and WAM Document WBC and PLT critical value notification for WBC and P WAM as per Procedure A: Documenting Critical Results in WAM Document critical value notification for COAG, PBF morphology o body fluids in Delphic LIS as per Procedure B: Documenting Critical Results in Delphic LIS. DSM with Delphic LIS no WAM Document critical value notification for WBC, PLT, COAG, PBF morphology or body fluids in Delphic LIS as per Procedure B: Documenting Critical Results in Delphic LIS Procedure A: Documenting For critical values on WBC and PLT (as per WAM rules) Critical Results in WAM 1 DOCUMENTATION EDIT screen appears when a sample ID with Critical results is validated Patient demographic information is displayed on top header of the screen 2 Call critical values that appear at right side of screen. Note: WBC appears with two (2) decimal places; convert to one (1) decimal place to notify ward and document in Comments. 3 Give the name of the test and the results (value and units). Ask the person taking the results to repeat all the information back. (This includes the patient name, hospital number and results) 4 After calling the results, enter the information into the mandatory fields: Call To/Loc: person notified At time of call (populated with current time - can be changed hh:mm) On date of call (populated with current date - can be changed dd/mm/yy) Read back: Yes/No Comments: free text results. ** Click OK ** If the person taking the results has refused to provide their last name, include the comment the person taking the information refused to provide their last name. Page 3 of 5

4 Procedure B: Documenting Critical value results in Delphic LIS: 1 Call up the appropriate format and accession # for the following: Test Format Field Abnormal WBC Differential* CBC PCOM-CBC Comment Abnormal RBC Morphology CBC PCOM-CBC Comment INR/APTT/Fibrinogen COAG MLAC-Coag Comment Positive Malaria MAL Phoned to CSF TNC CSFH Phoned to CSF Abnormal/suspect cells CSFH Phoned to Fluids abnormal/suspect cells HFLD Comment Additional tests documented in LIS for Non WAM sites: Test Format Field WBC CBC PCOM-CBC Comment PLT CBC PCOM-CBC Comment 2 Insert &CVP (Critical value(s) phoned to): 3 Free text: First and Last name** of person accepting results, test name, results (and units if applicable), date and time. Indicate that results have been read back by adding &RB (Results have been read back).after the end of quotation marks. ** If the person taking the results has refused to provide their last name, include the comment the person taking the information refused to provide their last name. If: Abnormal differential(1 st encounter suspect leukemia), Abnormal / suspect cells (CSF & Fluids) Then: Add & HPBF (Suspect/abnormal cells noted/observed on blood film, hematopathologist on call has been notified and will issue a definitive report) on DIFF format. Add &HPSL (Suspect abnormal cells noted/observed on slide, hematopathologist on call has been notified) on appropriate format. Page 4 of 5

5 4 Document any failure of attempts to notify the appropriate person and any other subsequent actions as directed below. ie: Attempt made to contact Physician on call unsuccessful on reporting format. If: Inpatient results, Outpatient results and unable to call physician on call and unable to leave a message on the physician s answering machine (only if there is an identified), Referred specimen requests and no contact information or physician cannot be reached. Then: Initiate site specific Occurrence Report, following facility/rha procedure Contact CMO of Hospital: For HSC, call for hospital paging service Notify discipline Director or Hematopathologist on call. Initiate site specific Occurrence Report. Follow facility/rha procedure. Refer to DSM Policy, Reporting Critical Value, Contact forwarding laboratory to forward results (leave message on off hours). Contact Hematopathologist on call and notify failure of notification. Refer to DSM Policy, Reporting Critical Values, Critical Values: See Procedure Step #1. References: College of American Pathologists (CAP) Laboratory General) HEM:30000 Related Procedures: All DSM Procedures that include critical result values DSM Policy: Reporting Critical Values [ ] Page 5 of 5