Policies and procedures are guidelines and are not a substitute for the exercise of individual judgment. If you are reading a printed copy of this policy, make sure it is the most current by checking the on-line version TITLE CLIN_189 CRITICAL RESULT NOTIFICATION APPLICABILITY Edward Hospital, Linden Oaks Hospital POLICY STATEMENT(S) Critical test results, which include both the results of critical tests and test results with critical values, will be reported in a timely manner. Actions will be taken to measure, assess and if necessary, improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver, of critical test results. DEFINITION(S) Critical Tests: any stat diagnostic test, procedure and/or study that is critical to the treatment plan and requires rapid communication of the result, whether normal or abnormal. Critical Test Values: A value that represents a pathophysiological state, at such variance with normal, as to be life threatening. This value also requires rapid communication. Timely and Reliable Fashion: Critical result notification is the time frame of 60 minutes from the time the result is first identified as a critical value to the time of responsible, licensed caregiver notification. Critical test notification times are defined by assay and referenced in the critical test table in this policy. The time span measured is from order entry to result communicated to the responsible licensed caregiver able to take action on the finding. Responsible Licensed Caregiver is the licensed caregiver able to initiate appropriate clinical action on behalf of the patient. The RN may initiate action based on a defined protocol or physician order. If neither option is available the RN will contact the physician or advanced practice nurse (APN) with the result. If the physician or APN is unavailable, then the covering physician, house physician, or department medical director shall be contacted to accept the critical result. If for any reason, a physician is unable to be reached, and no approved protocol is available for the nurse to act upon, then the clinical staff will activate the alternate notification system (see alternate notification) below. Alternate Notification - if for any reason, the ordering physician is unable to be reached in a timely fashion, then the clinical staff will follow the Chain of Command to Resolve Clinical Issues Policy: CLIN_014. The alternate notification should be activated no more than 45 minutes from the time the result was first known. PROCEDURE I. CRITICAL TEST RESULT NOTIFICATION: A. All results, both normal and abnormal, of critical tests will be called directly to the ordering physician.
II. CRITICAL RESULT NOTIFICATION: A. LABORATORY: 1. The laboratory staff member will phone the critical results to the appropriate responsible, licensed caregiver. Inpatient: this will be the nurse directly caring for the patient, who will then notify the physician as necessary. ED patient: staff will give the result directly to the ED physician and, if unavailable, to the charge nurse. Outpatient: staff will speak directly with the physician or nurse in the ordering physician s office. 2. The person receiving the results will document the results and read back the patient s name and critical result for verification. 3. The RN on the unit receiving the critical results is responsible for immediately contacting the physician or responsible, licensed caregiver, unless otherwise addressed by a standing order. 4. The lab staff member will note the following in the patient record: The time of the call. The electronic record access mnemonic of the staff member receiving the report, or the name of the physician or APN receiving the report. Documentation of the completed read back. B. PATHOLOGY: 1. The pathologist will call all critical anatomic pathology results directly to the ordering physician. 2. The time and date of such notification will be documented with an indication code at the end of the transcribed report. 3. Pathologist will document read back of critical results in the transcribed report. C. RESPIRATORY: 1. The respiratory therapist will call the physician directly with critical results. 2. The physician will read back the critical values to the therapist. 3. The therapist will document on the flow sheet the time, date of notification, and the first initial and last name of the physician to whom the results were reported. 4. The therapist will also document completion of the read back in the patient record. D. RADIOLOGY: 1. The radiologist will phone the critical results to the appropriate responsible, licensed caregiver. Inpatient: the radiologist will phone the critical result to the RN directly caring for the patient. The RN will then assume the responsibility of notifying the ordering physician. ED patient: The radiologist will phone the critical result to the ED physician and, if unavailable, to the charge nurse. The charge nurse will assume the responsibility of notifying the ordering physician.
Outpatient: The radiologist will notify the Radiology front desk to begin the paging process. The radiologist will communicate the critical value directly to the ordering physician when he/she responds to the page. 2. The Radiology front desk staff will : Initiate the page to the ordering physician. If the page is not returned within the first 15 minutes, they will re-page the physician at the 15 and 30 minute interval if necessary. If the ordering physician fails to return the page within 45 minutes, then the radiologist will contact the patient, notify them of the results, and send them to the emergency department. The front desk staff will document the times of the pages, the time the physician answered the page, and will record information in the PACs notes/log sheet. 3. The radiologist will note this communication/action at the end of the transcribed report stating: Report of the critical value First name of RN or Physician receiving the report Time and date of notification Verification that read back occurred E. CARDIOLOGY: 1. All suspected critical findings will be called by clinical leader or RN to the cardiologist on call or responsible, licensed caregiver within the defined time frame. 2. The person receiving the results will document the results and read back the patient s name and critical result for verification. 3. The cardiac diagnostics staff member will document all communications in the Cardiac Critical Value Communications Log. F. DOCUMENTATION BY THE RECIPIENT OF CRITICAL RESULTS: 1. Inpatient results will be recorded electronically, through use of the Critical Value Assessment or patient care note by the RN receiving the results. 2. Linden Oaks Hospital patient results will be recorded electronically with the use of the Critical Test Result Note. 3. Outpatient staff will record notification in the chart including item and date of notification, test name and result and staff member receiving the result. CROSS REFERENCE(S) Policy No: CLIN_189 Previous Policy No.: CLIN_004 Effective Date: 07/17/1986 Policy Creation Date: 07/17/1986 Most Recent 06/04/2012
Revision/Review Date: Initiated By: Medical Director-Laboratory and Pathology Approval: Medical Executive Committee 07/11/2007, 08/13/2008, 05/13/2009; 12/16/2009; 11/10/2010 Medical Staff Quality Committee 10/14/2008 Edward Hospital Quality Committee: 11/10/2009; 11/9/2010 Policy Committee 07/12/2007, 04/10/2007, 04/10/2008, 11/25/2008, 05/14/2009; 11/05/2009; 07/08/2010; 01/13/2011; 03/10/2011; 05/12/2011; 06/04/2012
CRITICAL TESTS Called for Both Abnormal and Normal Test Department Order to result communicated Frozen tissue section Laboratory 30 minutes ECHO to rule out: Cardiology 150 minutes Cardiac tamponade Ventricular septal defect, post MI CT of brain Code STROKE patients Radiology 45 minutes CRITICAL VALUES CARDIOLOGY CRITICAL VALUES EKG 12 Lead Automatic Printout Suggestive of: Acute Myocardial Infarction, or printout reading of Acute MI Heart rate of less than 35 bpm, or printout reading of Heart Beat less than 35 bpm Ventricular Tachycardia, or printout reading of V tach Heart rate greater than 140 bpm on outpatients only ECHO Test with These Findings: Severe aortic stenosis with a 50 mm mean gradient Large pericardial effusion Suspected ascending aortic dissection Holter & Event Monitor with These Findings: Sustained heart rates below 40 bpm. Third degree AV block. Heart rates consistently greater than 185 bpm. Seven runs or more of ventricular tachycardia. Stress Tests with These Findings: Evidence of stress induced angina with or without ECG, ECHO, or nuclear imaging evidence. Resting or exercise induced sustained arrhythmias or changes in heart rhythm that may pose potential life threatening situations.
LABORATORY AND PATHOLOGY CRITICAL VALUES Chemistry Test Neonatal (0-30 days) Pediatric (30 Days - 17 Years) Adult ( 18 Years) Units of Measure Acetaminophen >40 >40 >40 µg/ml Caffeine >50 >40 µg/ml Calcium <6 >12 <7 >12 <6 >13 mg/dl CPK (CK) >1000 >1000 >6000 IU/L Digoxin >2.5 >2.5 >2.5 ng/ml Glucose <40 >200 <50 >200 <50 >400 mg/dl to exclude patients undergoing stimulation tests. to exclude patients undergoing stimulation tests. Lithium >2 >1.5 >1.8 meq/l Magnesium <1 >6 <1 >6 <1.2 >5.9 mg/dl Neonatal total >18 mg/dl Bilirubin Phenobarbital >50 >50 >60 µg/ml Phenytoin >20 >20 >30 µg/ml Phosphorus <1 <1 >8 <1.5 NA mg/dl Potassium <3 >6.5 <3 >6 <3 >6 meq/l Salicylate >30 >30 >30 mg/dl Sodium <120 >155 <125 >150 <120 >160 meq/l Theophylline >20 >20 >20 µg/ml Troponin >0.045 >0.045 >0.045 First critical value only every 48 hours ng/ml Valproic Acid >120 >120 >150 µg/ml Triglyceride >200 N/A N/A Mg/dl Hematology Absolute Neutrophil Count 0.5 0.5 0.5 First critical value only for MedOnc patients and outpatient Cancer Center patients. 10 3 /UL Agranulocytosis Anytime Anytime Anytime APTT >80 N/A >80 >300 Seconds Fibrinogen <100 <100 <60 mg/dl
Hemoglobin <7 <7 N/A 7 >20 gm/dl Initial Observation Anytime Anytime Anytime of Blasts Test Neonatal (0-30 days) Pediatric (30 Days - 17 Adult ( 18 Years) Units of Measure Years) INR >3 >3 >4.99 INR PAT Patients >1.49 Platelets <50 >1 >1 Million Million <20 >1 Million <20 <10 for MedOnc patients only WBC <4 >30 <2 >40 <1 MedOnc patients not called 10 3 /UL >100 10 3 /UL Urine Positive pregnancy test on LOH patients All inpatient presumptive positive drug screens Microbiology First Positive Blood Culture Smears All Positive CSF smears & cultures All positive malaria smears All agents of bioterrorism Anatomic Pathology Critical Notification Adipose tissue in an endometrial biopsy, a finding that almost always represents omentum or extrauterine soft tissue and therefore indicates perforation of the uterus. All significant infectious organisms identified in tissue specimens or cytology. Absence of chorionic villi/trophoblastic tissue when clinically expected (potential ectopic pregnancy). RESPIRATORY CRITICAL VALUES ARTERIAL BLOOD Test Neonatal (30 days) Pediatric (30 Days/7 Yrs) Adult ( 18 Yrs) Units of Measure COHb >10 >10 >10 % MetHb >2 >2 >5 % O 2 Hb <85 <85 <85 % PCO 2 <20 >60 <20 >60 <20 >60 mmhg
Ph <7.2 >7.52 <7.2 >7.52 <7.2 >7.52 Units PO 2 <40 <55 <55 mmhg VENOUS Venous PO 2 N/A N/A <30 N/A mmhg Pulmonary Embolism Report CT Chest V/Q Study Pulmonary Angiogram New Intracranial Hemorrhage CT Head MRI Head New Deep Vein Thrombosis Ultrasound Venous Doppler Acute Arterial Occlusion CT Abdomen and lower extremity US- Duplex Doppler of extremities MRI- Extremities Retroperitoneal Bleed CT Abdomen pelvis without contrast US Epidural Abscess RADIOLOGY CRITICAL VALUES