Sample Hospital



Sample Hospital

|TITLE: Critical Test and Critical Result Notification |

|SCOPE: All Departments and Patient Care Personnel |

|EFFECTIVE DATE: 11/17/08 |Approved By: Administration |

|Originator: Mary Smith, RN, DON |Page 1 |

PURPOSE

To improve the effectiveness of communication among caregivers by providing guidelines on the process of timely notification of: a critical test result and/or a critical result to the physician/physician designee responsible for the patient.

POLICY

It is the policy of Sample Hospital that:

A result of a critical test is to be reported to the physician/physician designee within one (1) hour of the time the test is ordered.

A critical result is to be reported to the physician/physician designee within one (1) hour of the test result being produced.

The result of a critical test and/or a critical result is to be written down immediately by the individual receiving the critical test result and/or critical result and read-back to the reporting individual.

DEFINITIONS:

Critical test: A test which will always require rapid communication of the result, whether normal or abnormal. A critical test is commonly identified as "STAT."

Critical result: A finding (even if from a routine test), which will always require rapid communication of the result. The result is from a test with a pre-established critical or “panic” level and a test result where it is clinically evident that a delay in reporting would have the potential to cause a serious adverse outcome for patient.

Physician Designee: The licensed caregiver who has assumed responsibility for a given patient’s care in the absence of the responsible physician. In the responsible physician’s absence, the physician designee will make decisions and order the necessary treatment in response to the result of a critical test and/or a critical result so that the patient may be promptly treated.

PROCEDURE

A list of critical tests and results specific to the department will be developed and approved by the administrative and medical directors of the department. The list is to be reviewed and approved by the Medical Staff minimally every three years. The list is to be readily available in each department, on all patient care units and as a component of this policy. New critical tests and/or critical results may be added to the department’s list, as needed, at any time, with the approval of the Medical Staff.

DEPARTMENT NOTIFICATION PROCEDURE

Inpatient Care:

Laboratory: Laboratory personnel are responsible to notify the nurse responsible for the patient via telephone of the results of the department-specified critical tests and all critical values. Should the nurse responsible for the patient’s care not be immediately available to receive this telephone call, the result of the critical test or critical value is to be reported directly to the Nursing Unit’s Charge Nurse. The nurse responsible for the patient or Charge Nurse is then responsible for notifying the patient’s physician/physician designee of a result of a critical test and/or a critical result.

Medical Imaging (Radiology): The radiologist is responsible to directly notify the physician/physician designee of a result of a critical test and/or a critical result.

EKG Performed by Patient Care Unit Staff: The nurse is responsible to directly notify the physician/physician designee of a critical EKG and/or a critical EKG result.

Pulmonary Function/Respirator Therapy: The pulmonary technologist/respiratory therapist is responsible to directly notify the physician/physician designee of a critical test and/or a critical result.

Speech Language Pathology: The speech therapist is responsible to directly notify the physician/physician designee of a critical test and/or a critical result.

Outpatient Care: The reporting department is responsible to directly notify the physician/physician designee of a critical test result and/or a critical result. Under no circumstances is a critical test result and/or a critical result to be left with an answering service or secretary or sent via e-mail.

When a patient is discharged prior to the receipt of the result of a critical test and/or critical result, the physician/physician designee is to be notified of the critical test result and/or the critical result.

RESPONSIBILITIES

Reporting Department: As soon as the result of a critical test and/or a critical result is available, the reporting department is responsible to:

• Notify the appropriate individual per the department notification procedure listed above.

• Identify the patient utilizing the two (2) patient identifiers, neither of which can be the room number.

• Report the result of the critical test and/or critical result and request read-back to verify it was correctly understood.

• In the department computer system, document the result of the critical test and/or critical result, name of the individual who received the information, date and time of notification.

• In the event Laboratory personnel are not able to speak to the assigned nurse, the Charge Nurse and/or another nurse can receive the information and subsequently notify the physician/physician designee.

Nurse and/or Physician/Physician Designee: When receiving a result of a critical test and/or a critical result, the nurse and/or physician/physician designee is responsible to:

• Document the result of a critical test and/or a critical result immediately on the Critical Test and Critical Result sticker. If this sticker is not utilized, the result of a critical test and/or a critical result is to be documented immediately in a progress note that includes the following:

• Date and time of the report

• Name of the reporter

• The critical test result and/or critical result

• Read-back the result of a critical test and/or critical result to the reporting individual to verify it was correctly understood and documented.

• The nurse is responsible to notify the physician/physician designee immediately of a result of a critical test and/or critical result of an EKG and/or report from the Laboratory. The following conditions are exempted form the requirement for immediately notifying the physician/physician designee:

• A physician’s order contains an action(s) to be implemented upon receipt of a critical test result and/or a critical value

• A protocol and/or policy approved by Medical Staff outlines an action(s) to be implemented upon receipt of a critical test result and/or critical result.

• The critical result reaches the therapeutic goal directed by the physician.

• The critical result demonstrates improvement in the patient’s condition and has been addressed by the physician in the patient’s treatment plan.

• In a Code or other emergent event, a result of a critical test and/or a critical value is often given directly to the physician in charge of the Code/emergent event. Documentation of the critical test result and/or critical result as outlined above is not required.

CHAIN OF COMMAND FOR NOTIFICATION OF A CRITICAL TEST RESULT AND/OR A CRITICAL RESULT

In the event a physician/physician designee does not respond after two (2) attempts for a maximum of thirty (30) minutes:

• Notify your Department Manager.

• Initiate help soon enough to ensure notification within the one (1) hour time frame.

• If the patient’s condition/situation is deemed emergent, the Department Manager is to notify the on-call physician and/or initiate a Rapid Response (Code White) or Code Blue, as appropriate.

• All attempts to contact a physician/physician designee are to be documented in the medical record to include:

• Date and time of the attempt

• Name of the person making the attempt

The result of a critical test and/or critical result may not be left on an answering machine.

SAMPLE HOSPITAL

CRITICAL TESTS AND CRITICAL RESULTS/VALUES

LABORATORY

|Critical Tests |Normal Ranges |

|STAT CSF Gram Stains |Negative |

|STAT Serum Lactates |0.5 – 2.2 mmol/L |

|STAT CSF Cell Counts |RBC: 0 - 0 % Lymphs: 100 |

| |WBC: 0 -10 % Segs: 0 |

|Critical Values |

|TESTS |LOW |HIGH |AGE |

|Acetaminophen | |Greater than 150ug/ml | |

|Alcohol (Ethanol) | |Greater than 400 mg/dl | |

|Amikacin Peak | |Greater than 35 mcg/ml | |

|Amikacin Trough | |Greater than 8 mcg/ml | |

|Bacterial Antigen (CSF/Blood/Serum) | |Positive | |

|Bilirubin Total | |Greater than 12mg/dl |Less than 3 days |

| | |Greater than 13mg/dl |3-5 days |

| | |Greater than 15mg/dl |5-14 days |

|Blood Culture (Gram Stain/Culture) | |Positive |any organism |

|Blood Parasites | |All Positive | |

|Body Fluids, Sterile (Gram Stain/Culture) | |Positive |any organism |

|Calcium |Less than 6 mg/dl |Greater than 13 mg/dl | |

|Carbamazepine (Tegretol) | |Greater than 20 ug/mL | |

|Cerebral Spinal Fld (Gram Stain/Culture) | |Positive |any organism |

|Chloride |Less than 75 mmol/L |Greater than 125 mmol/L | |

|CO2 |Less than 10 mmol/L |Greater than 40 mmol/L | |

|DAT | |Positive |Newborn |

|Digoxin | |Greater than 2.5 ng/mL | |

|Eye (Culture/Gram Stain) | |Positive |any organism |

|Fibrinogen |Less than 100 mg/dl | | |

|Gentamicin Peak | |Greater than 12 ug/mL | |

|Glucose |Less than 30 mg/dL |Greater than 300 mg/dL |0-31 days |

| |Less than 40 mg/dL |Greater than 500 mg/dL |32 days + |

|Hematocrit |Less than 18% |Greater than 65% | |

|Hemoglobin |Less than 6.0 g/dL | | |

|India Ink | |Positive | |

|pCO² |Less than 20 mmHg |Greater than 70 mmHg | |

|pH |Less than 7.25 |Greater than 7.60 | |

|pO² |Less than 40 mmHg | | |

|HC03 |Less than 10 mmol/L |Greater than 40 mmol/L | |

|Acetone |Positive | |Newborn - 1 mo |

|Lithium | |Greater than 2.0 mmol/L | |

|Phenobarb | |Greater than 60 ug/mL | |

|Phenytoin (Dilantin) | |Greater than 40 mcg/ml | |

|Phosphorus |Less than 1.0 mg/dL | | |

|Platelet Count |Less than 50,000 ul |Greater than 1,000,000 ul | |

|Potassium |Less than 2.5 mEq/L |Greater than 6.0 mEq /L | |

|Protime | |Greater than 30 sec | |

|INR | |Greater than 5 | |

|PTT | |Greater than 100 sec | |

|Salicylate | |Greater than 30 mg/dL | |

|Sodium |Less than 125 mEq /L |Greater than 160 mEq /L | |

|Theophylline | |Greater than 25 mcg/ml | |

|Tissue (Sterile Body Site) | |Positive | |

|Tobramycin Peak | |Greater than 12 mcg/mL | |

|Tobramycin Trough | |Greater than 2 mcg/ml | |

|Troponin T | |Greater than 0.5 mg/ml | |

|Valproic Acid | |Greater than 200 mcg/ml | |

|Vancomycin Peak | |Greater than 60 mcg/ml | |

|Vancomycin Trough | |Greater than 20 mcg/ml | |

|WBC |Less than 1,500 ul |Greater than 50,000 ul | |

RADIOLOGY

Critical Tests

• Chest Single View: Indication to rule out pneumothorax

• Chest Single View: Indication for ET tube placement

• Brain CT: Indication to rule out bleed and/or hemorrhage

• Chest CT with contrast: Indication to rule out pulmonary embolism

• Pelvic Sonogram: Indication to rule out Ectopic Pregnancy

• Scrotum and Contents Sonogram: Indication to rule out Torsion

Critical Results/Values

• Pneumothorax/Pneumoperitoneum

• New/Significantly changed intracranial hemorrhage

• Positive Visceral Trauma

• Ectopic Pregnancy

• Testicular/Ovarian Torsion

• DVT

• New Aortic Dissection,

• Support Tube/Line Position/Malposition ETT/lines

• Pediatric Non-accidental Trauma

• Pulmonary Embolism

• Ischemic Bowel

• Pneumomediastinum

• Massive Pleural Effusion

• Intestinal Obstruction

• Total collapse/white out

INTERVENTIONAL RADIOLOGY

Critical Test

• Visceral Arteriogram: Indication to rule out Ischemic Bowel, G.I. Bleeding

Critical Results/Values

• Aortic Dissection

• Pulmonary Embolism

• G.I. Bleed

MRI

Critical Test

• Spine MRI: Indication to rule out Cord Compression

Critical Results/Values

• Cord Compression

• Hemorrhage

• Aortic Dissection

CARDIOLOGY

Critical Test

• STAT EKG

EKG Critical Results/Values

• ST Elevation with greater than 2mm without bundle branch block or acute myocardial infarction

• Severe tachycardia arrhythmias (heart rates >150 bpm)

• Frequent multifocal PVC’s with runs of 3 or more PVC’s

RESPIRATORY CARE/PULMONARY FUNCTION

Critical Tests - None

Arterial Blood Gas Critical Value Ranges

ADULT/PEDIATRIC - Less than 7.20 or Greater than 7.60

PaCO2 - Greater than 70 mmHg

Pa02 - Less than 40mmHg

SPEECH PATHOLOGY

Critical Test

• STAT Swallowing Evaluation

Critical Result

• Aspiration and/or choking; significant oro-pharyngeal Dysphagia

|Review Date |Revision Date |Signature |

|11/08 | | |

| | | |

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