COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

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1 BY ORDER OF THE COMMANDER 59TH MEDICAL WING 59TH MEDICAL WING INSTRUCTION OCTOBER 2017 Medical Operations CRITICAL TEST AND CRITICAL VALUE MANAGEMENT COMPLIANCE WITH THIS PUBLICATION IS MANDATORY ACCESSIBILITY: Publications and forms are available on the e-publishing website at for downloading or ordering. RELEASABILITY: There are no releasability restrictions on this publication. OPR: 59 MDTS/SGVLL Supersedes: 59 MDWI , 24 June 2016 Certified by: 59 MDTS/CC (Colonel Mitzi D. Thomas-Lawson) Pages: 7 This instruction implements Air Force Policy Directive 44-1, Medical Operation. This instruction defines policy and procedures to ensure the timeliness of reporting and receipt of laboratory and radiology critical values from the point of origin to the responsible Licensed Independent Provider to enable the provision of timely and appropriate treatment of the patient. This instruction applies to test results, values, and interpretations from the laboratory. This instruction applies to all personnel assigned to, employed by, or contracted to the 59th Medical Support Group, 59th Medical Operations Group, 359th Medical Group, 559th Medical Group, and 59th Dental Group. This instruction does not apply to the Air National Guard or Air Force Reserve. Refer recommended changes and questions about this publication to the Office of Primary Responsibility using the AF Form 847, Recommendation for Change of Publication. Ensure that all records created as a result of processes prescribed in this publication are maintained in accordance with (IAW) Air Force Manual , Management of Records, and disposed of IAW Air Force Records Information Management System Records Disposition Schedule. SUMMARY OF CHANGES This publication has been revised. This rewrite of 59 MDWI includes added Radiology procedures and consolidation of Laboratory procedures throughout 59th Medical Wing (MDW). 1. Responsibilities Senior Leadership will:

2 2 59MDWI OCTOBER Promote a culture that emphasizes timely reporting of laboratory or radiology critical values (results/findings) and the results of critical tests to the responsible Licensed Independent Provider Ensure all relevant personnel are educated on the policies and procedures delineated in this instruction Ensure adherence to this instruction Department Chairperson will ensure the accuracy of pager numbers on the call rosters and other contact information for reporting critical test results or critical values Ordering providers will ensure their clinic contact information and pager number are current on the call roster Ordering providers from civilian facilities will ensure their contact information is available for all requested studies All staff will follow the guidelines and procedures for submitting laboratory specimens as noted in the 59th Medical Support Group Laboratory Guide to Services. 2. Definitions A critical value is a result or finding that is abnormal to a degree that it may indicate a life threatening situation A complete listing of critical laboratory values is located within the laboratory guide. Critical values for each individual test are also available in Composite Health Care System (via the Laboratory Test Information LTI command) A listing of critical radiology values is located within Attachment 2 of this instruction A critical test always requires rapid communication to the requesting provider in order to adequately diagnose and treat the patient. The 59th Medical Wing does not currently define any test as a critical test. 3. Reporting Critical Radiology Results/Findings Ordering providers or their surrogate will be notified of critical results/findings verbally. The result must be identified as a critical finding To verify accurate transfer of verbal information, staff reporting a critical finding will first confirm the provider/patient assignment, and then ask the receiver to read back the patient s critical finding Listing and phone numbers for providers for each clinic can be found on the 59 MDW SharePoint Clinical Tab under Call Roster (AMION; each section has its own password to access the call rosters on AMION). If no response or surrogate is not available, notify the clinic registered nurse (RN) of the results and the need for provider contact If unable to contact the provider, surrogate, or a clinic registered nurse, contact the clinic s on-call provider.

3 59MDWI OCTOBER If unable to contact an on-call provider within 10 minutes of initial attempt to do so, contact the appropriate group SGH for further guidance Reporting Values/Results to off-base Civilian Facilities. Contact ordering provider or have their answering service request the provider return the call as soon as possible. At no time may findings be left with an answering service or on an answering machine. If no contact is made with the provider within 10 minutes attempt to contact the patient directly and direct them to go call 911 or go to the nearest Emergency Room depending on the criticality of the finding. 4. Reporting Critical Laboratory Values & Tests Results Critical lab values and results for all critical tests are to be called to the ordering provider (licensed independent provider) or their surrogate as soon as possible following identification of the critical result. The result must be identified as a critical test result To verify accurate transfer of verbal information, staff reporting a critical finding will first confirm the provider/patient assessment, and then ask the receiver to write down and read back the patient s name, date of birth, and test result. The reporting staff will use the following script: I have a critical (finding/test/result) to report. You will need to write down and read the information back to me to verify accuracy The receiver will write down and read back for verification before taking action on the critical value(s) or results of a critical test(s) Listing and phone numbers for on-call providers for each clinic can be found on the 59 MDW SharePoint Clinical Tab under Call Roster (AMION; each section has its own password to access the call rosters on AMION). Note: 359th Medical Group on-call listing is also provided electronically monthly If the responsible provider or other certified/privileged individual is unable to take the call, a RN may take the critical test result. Under no circumstances should results be given to unlicensed personnel (e.g. secretary, student, unit clerk) If unable to contact the provider, surrogate, or a clinic registered nurse, contact the clinic s on-call provider If unable to contact an on-call provider within 10 minutes of initial attempt to do so, contact a member of laboratory management who will contact the appropriate group SGH for further guidance Reporting Critical Values (critical results/critical tests) to off-base Civilian Facilities. Contact ordering provider or have their answering service request the provider return the call as soon as possible. At no time may results be left with an answering service or on an answering machine. If no contact is made with the provider within 10 minutes contact a member of laboratory management for guidance. 5. Documentation Requirements Radiology Personnel: Critical result notification will be documented using the Veriphy system for tracking purposes.

4 4 59MDWI OCTOBER Laboratory Personnel: Critical results, full name of provider/rn notified, date & time of the notification, responsible laboratory staff member, and read back of the result must be documented as part of laboratory documentation Referral laboratories may report critical results directly to clinical personnel, or to the referring laboratory Registered Nurses Receiving Critical Laboratory and Radiology critical values (results/findings) or results of critical tests The RN receiving the critical value or results from a critical will immediately notify the patient s provider and document a telephone consult in Armed Forces Health Longitudinal Technology Application (AHLTA) to include the following details: Date and time of read back followed by read back ( RB ) The lab or radiology critical value (result/finding) or result of a critical test The name of the person reporting the information Date and time that the provider or surrogate was notified and read back was performed followed by RB Responsible Licensed Independent Provider The provider must document the information within one of the following: An AHLTA note or outpatient telephone consult An entry into Essentris (Same day surgery/ambulatory Procedures Unit patient) An entry on the SF 509, Progress Notes. 6. Timeliness of Critical Finding/Result Reporting If the time from result discovery/generation to provider notification exceeds 60 minutes, the reporting department will generate a Patient Safety Report The investigation and development of necessary corrective action(s) will involve coordination between the particular Ancillary Service and the receiving Clinic. 7. Data Monitoring, Collection, and Analysis Monitoring and evaluation of the critical lab test and value reporting process will be performed monthly by the Laboratory. This data will be evaluated for trends regarding organizational compliance Audits must look at a minimum of the following components: For Critical Tests, the key metric for the audit is 100% compliance for notification (within 60 minutes) from the time the test was ordered to the time the provider was notified For Critical Values, the key metric for the audit is 100% compliance for notification (within 60 minutes) from the time the result/report was determined to be critical to the time the provider was notified.

5 59MDWI OCTOBER The Patient Safety Office will review and analyze selected data and report findings to the Executive Committee of the Medical Staff, the Performance Improvement Committee, and the Board of Directors on a quarterly basis. JOSEPH R. RICHARDS, Colonel, USAF, MC Chief of the Medical Staff

6 6 59MDWI OCTOBER 2017 References Attachment 1 GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION AFPD 44-1, Medical Operations, 9 June 2016 Accreditation Association for Ambulatory Health Care (AAAHC), 2012 Accreditation Handbook for Ambulatory Health Care, Quality of Care, Chapter 4 59 MDWI , Patient Safety, 10 January MDWI , Laboratory Program, 29 April 2014 SG NOTAM , Ordering and Communicating Test Results, March 2012 WHASC Lab Guide, 1 October 2014 Adopted Forms AF Form 847, Recommendation for Change of Publication SF 509, Medical Record - Progress Notes Abbreviations and Acronyms AHLTA Armed Forces Health Longitudinal Technology Application IAW In Accordance With MDW Medical Wing RB Read Back RN Registered Nurse Terms Critical Results/Values Test results that are abnormal to a degree that it may indicate a life threatening situation. Critical Test A test or exam that always requires rapid communication of results, whether those results are normal or abnormal. Read Back The process of confirming the Responsible Licensed Caregiver s understanding of the notifying party s communication of the Critical Value by asking the Responsible Licensed Independent Provider, Surrogate, or Registered Nurse to document the communicated information and then reading it back to the notifying party.

7 59MDWI OCTOBER Attachment 2 59 RSQ RADIOLOGY CRITICAL RESULTS/FINDINGS LIST A2.1. This is not an all-inclusive list and professional judgment is key in determining the criticality of imaging findings. New diagnosis of, or unsuspected acute: A Aortic aneurysm rupture. A Aortic dissection. A Bowel perforation with free air. A Bronchial foreign body. A Ectopic pregnancy. A Intracranial hemorrhage or hydrocephalus. A Leaking aneurysm (cerebral, thoracic, or abdominal). A Life-threatening misplaced tube or line. A Molar pregnancy. A Placental abruption. A Significant solid organ injury. A Tension pneumothorax. A Torsion (ovarian or testicular).