Critical Results, Critical Tests - Veterans Affairs



VA HEALTH CARE SYSTEMSIOUX FALLS, SOUTH DAKOTACENTER CIRCULAR NO. 11-91March 2014REPORTING OF CRITICAL AND EMERGENT TEST RESULTSPURPOSEThe purpose of this circular is to expedite the communication of critical and emergent results to the appropriate care giver and patient.POLICYThe Sioux Falls VA Health Care System (SFVAHCS) is committed to the accurate and timely communication of critical/emergent test results to the healthcare provider responsible for responding to those results.SFVAHCS Diagnostic Services including Pathology and Laboratory Medicine, Diagnostic Imaging (Radiology and Nuclear Medicine), and Cardiovascular Services/EKG will maintain a list of critical results that will be communicated by the diagnostic service to the responsible licensed care giver within 1 hour of result verification. SFVAHCS Diagnostic Services including Pathology and Laboratory Medicine, Diagnostic Imaging (Radiology and Nuclear Medicine), and Cardiovascular Services/EKG will maintain a list of emergent results that will be communicated by the diagnostic service to the responsible licensed care giver within 15 minutes of result verification.The Medical Executive Committee will annually review the critical and emergent test result lists and revise as necessary per recommendations by individual Diagnostic Services, Patient Safety Manager or provider input. DEFINITIONSCritical Results (CR): results defined as those values or interpretations that, if left untreated, could be life threatening or place the patient at serious risk. Critical values or results are those results from laboratory, cardiology, radiology departments and other diagnostic areas that upon analysis are determined to be critical regardless of the ordering priority. Emergent Test Results (ETR): A diagnostic finding that is associated with a high likelihood of short-term poor outcome and requires either immediate therapeutic intervention or close monitoring.Responsible Licensed Care Giver (RLCG): A licensed professional who by virtue of their medical license or as directed by written order has the authority to respond to the critical test result and is responsible for the care of the patient. (i.e. MD, DO, Nurse Practioner, Physician Assistant)Surrogate Practioner: Preceptors, on call practitioners, supervisors, and service chiefs contacted in the event the ordering provider is not available. RESPONSIBILITYMedical staff, in cooperation with Clinical Chief of Pathology and Laboratory Medicine Service and the laboratory section supervisors, will be responsible for developing and updating criteria for CR/ETR for the Pathology Laboratory Medicine Service.Medical staff, in cooperation with Medical Director of Imaging Service (Radiology and Nuclear Medicine) and the Administrative Officer, Imaging Service will be responsible for developing and updating criteria for CR/ETR for the Imaging (Radiology and Nuclear Medicine) Service.Medical staff, in cooperation with Medical Director of Primary Care (PC) and Specialty Medicine Service Line, Cardiology Consultant MD and the Specialty Medicine Nurse Manager will be responsible for developing and updating criteria for CR/ETR for the Cardiovascular Diagnostic Service.Medical Executive Committee is responsible for the annual review and the approval of CR/ETR.The Medical Center Director is responsible for defining the acceptable length of time between the ordering of tests or collection of specimens and the availability of results or critical values. See attachment F.All clinical staff involved in the receipt or communication of CR/ETR are responsible for complying with the procedure outlined in Section V. Procedure.All CR/ETR will have a quarterly monitor performed by the diagnostic service for compliance and analysis of data that is reported to Quality, Safety, and Value Council. PROCEDUREEach diagnostic service or section supervisor will develop a CR/ETR list for their area. The Diagnostic Service Technologist /Technician or RN (point of care glucose) is responsible for:1. Assuring the accuracy of all CR/ETR, repeating result where indicated.2. Laboratory diagnostic staff and RNs communicate with the ordering practitioner or surrogate during that episode of care. All other technician/technologists communicate test completion to the interpreting diagnostic physician (i.e. radiologist) who is responsible for communication with the appropriate provider.3. Immediately calling the CR/ETR to the ordering provider or surrogate. See Appendix E, Table 1Assuring that the provider/surrogate receiving the CR/ETR reads the result back.Obtaining the full name of the provider/surrogate receiving the result and documenting in the computer under the test report the name of the receiving clinical staff person and the date/time the result was received and read back. Point of care glucose calls are documented on the CPRS Critical Result Report Template.If unable to contact the appropriate provider for a CR/ETR, the diagnostic personnel must notify the appropriate Service Line Chief or if unsuccessful, the Chief of Staff. For Emergent test results the diagnostic personnel must notify a rapid response team or emergency room provider if the ordering provider/surrogate is unavailable. See appendix E, Table 2Diagnostic Practitioners must utilize clinical judgment to determine if a result is a CR/ETR finding/value. Therefore, the list of CR/ETR attached delineates most, but not all results deemed critical at the medical center.Timeliness – CR must be reported within 1 hour of verifying the results. ETR must be reported within 15 minutes of verifying the results (Excluding “Specific Women Veteran Result Reporting)..Medical/Surgical/Mental Health Providers, Medical Residents on Call (MROC), and Emergency Department physicians are responsible for:Calling a rapid response team when appropriate.Appropriately utilizing the write down read back process when receiving critical results. The receiver of the information must:write down the complete critical value or result or enters it into the medical record systemread back the critical value or resultreceive verbal confirmation from the individual who gave the critical value or resultObtaining a surrogate for view alert notifications if absent from assigned tour of duty.Specific Women Veterans Result Reporting: An abnormal cervical pathology or mammography is not considered a critical result. Please refer to Center Circular 11-100 Ordering And Reporting Outpatient Diagnostic Test Results for further guidance. Cervical results are required as follows: The cervical pathology report of Normal (NEM-No Evidence of Malignancy) results must be communicated to the patient in terms easily understood by a layperson within 14 days from the date of the pathology report becoming available. Documentation of a letter and/or verbal communication with the patient must be entered into CPRS. If using the United States (U.S.) Postal Service, confirmation of the receipt of these results is not required. For any abnormal cervical pathology report, the results must be communicated within 5 business days of the report being issued.Breast results are required as follows: When the mammography report assessment is “Suspicious” or, “Highly Suggestive of Malignancy,” the lay summary results and recommended course of action should be communicated to the patient as soon as possible but no later than 5 business days after the mammogram. One way to achieve this is through documented direct verbal communication. However, prompt verbal communication does not obviate the need to also provide written communication to the patient within 30 calendar days of the date of the mammogram.OTHERNoneREFERENCESVHA Directive 1106 and VHA Handbook 1106.1 “Pathology & Laboratory Medicine Service Procedures”.The Joint Commission Manual Hospitals, current editionCollege of American Pathologists Accrediting Manual, current editionCenter Circular 113-15, Point-Of-Care Testing for Whole Blood GlucoseCenter Circular 11-23, Transcription and Implementation of Medical Staff OrdersOrdering and Reporting Test Results, VHA directive 2009-019, March 24, 2009RESCISSIONCenter Circular 11-91, dated October 2012 FOLLOW-UP RESPONSIBILITYChief of StaffReview Date: January 2017 March 2015This center circular will remain in effect until rescinded.DARWIN G. GOODSPEED, FACHE DirectorATTACHMENTS:Emergent and Critical Laboratory ResultsB. Radiology Critical ResultsC. EKG/Echocardiogram Critical ResultsD. Critical Result Report TemplateE. Call Tree for Critical Test/Emergent Test Results F. Designated Time from Order to Result AvailabilityINFORMATION:Reporting of Critical Test Results, ORIGINATOR:Chief of StaffREQUIRED CONCURRENCE: Pathology Laboratory Medicine Chief (113) Diagnostic Imaging Chief (115)Primary and Specialty Medicine Service Line (111)Surgical/Specialty Care Service Line (112)Mental Health Patient Service Line (116A)Associate Director Patient Care Service (001NE)Chief of Staff (11)Director (00)EC&R Service Line Director (114)QuadKEY WORDS:Critical ResultsCritical TestsEmergent Test ResultsRESCISSIONS:Center Circular 11-91, dated October 2012REVIEW DATE: March 2017 March 2015 (since II D states the list will be reviewed annually)Attachment AEMERGENT TEST RESULTSCarbamazepineAbove 13 mcg/mlCarbon MonoxideGreater than 10%Calcium</=6 mg/dl; >/=13 mg/dlCO2Below 15 mEq/LDigoxinAbove 3.0 ng/mlDilantinAbove 25 mcg/mlGlucoseBelow 45 mg/dlAbove 500 mg/dlpCO2 (Arterial Blood)Below 20 mmHgAbove 60 mmHgpH (Arterial Blood)Below 7.2Above 7.6PO2 (Arterial Blood)Below 50 mm HgPotassiumBelow 3.0 mEq/LAbove 6.5 mEq/LSodiumBelow 118 mEq/LAbove 155 mEq/LValproic acidAbove 150 mcg/mlHematologyHemoglobin-Below 8 gm/dlHematocrit-Below 24 %WBC-Below 1.5 k/cmmPeritoneal fluid WBC-Above 250 k/uLPlatelets-Below 30 k/cmm-Above >1,000,000 k/cmmProthrombin time/INR-INR > 4.5Partial thromboplastin time-Above 125 secondsCRITICAL LABORATORY RESULTSChemistryGentamicinTrough level: Above 2.5 mcg/mlPeak level: Above 12 mcg/mlLidocaineAbove 5.0 mcg/mlLithiumAbove 2.5 meq/LNAPAAbove 35 mcg/mlPhenobarbitalAbove 45 mcg/mlProcainamideAbove 12 mcg/mlQuinidineAbove 5.0 mcg/mlTheophyllineAbove 25 mcg/mlTobramycinTrough level: -Above 2.5 mcg/mlPeak level: -Above 12 mcg/mlTroponin >/=0.12 ng/mlVancomycinTrough level:-Above 20 mcg/mlChemistryTroponin>/= 0.12 ng/mlBlood bankEmergency released uncrossmatched blood units on a patient with a clinically significant antibody.Any transfusion reaction investigation that is indicative of a hemolytic transfusion reaction.MicrobiologyBlood culturesPositive gram stain, ID and susceptibilityClostridium difficilePositive PCRBody fluids Positive gram stain, ID and susceptibilityBone marrowPositive gram stain or growthCSFPositive antigen test, growth or gram stainEnteric pathogenAll bacterial or viral pathogensIV tips>15 coloniesSputum, bronch, BALDiagnostic gram stains or heavy growthMRSA, VISA, VRSA, VREAll sites except surveillanceStrep pneumoPenicillan resistant, fluoroquinolone resistant and on this antibioticResistant gram negative rodsESBL, Amp C or multiple resistance to all aminoglycoside and 3rd & 4th cephalosporinsClostridium perfringens Suspected gram stain or heavy growthGC or Chlamydia PCRPositive results LegionellaPositive urine EIA, positive DFA or growthMycobacteriumPositive smear or growthPneumocystis carniiPositive resultsFungal culturesHistoplasma, Coccidioides, Blastomyces, Cryptococcus or growth from sterile siteParasitologyAll stool and blood pathogenic parasitesSerology Positive IgM for Mycoplasma, EBV, CMV or other agentsViral culture or DFAPositive results for respiratory viruses from inpatients onlyDialysis culture or LALCultures or LAL with unacceptable levelsHIVWestern blot positiveIndia InkPositive resultsInfluenzaPositive resultsPertusisPositive resultsStreptococcus pneumoniaPositive urine EIAAnatomic PathologyIf the evaluation of any anatomic pathology specimen concludes there is an unexpected diagnosis of clinical significance, the patient’s provider must be personally notified by verbal communication as soon as possible (ideally, within 1 working day of the time that diagnosis was made). Such diagnoses may include, but are not limited to, change of a frozen section diagnosis after review of the permanent section if clinically significant and/or unexpected mycobacterial, fungal or other significant infectious organisms identified on special stains.All frozen sections called with routine single frozen section specimens within 20 minutes of receipt in lab.Attachment BIMAGING SERVICE The following pathophysiologic categories that are new findings and require immediate clinical attention are will be considered critical results and the Radiologist is responsible for provider contact. RADIOLOGY CRITICAL RESULTSAcute aortic dissectionAcute appendicitis or abscessAcute intracranial hemorrhage or significantly worsened known intracranial hemorrhageAcute or significantly worsened DVTAcute or significantly worsened PEAcute skeletal trauma - fracture requiring treatmentAcute skeletal trauma-fracture requiring treatmentAcute testicular or ovarian torsionAll Pulmonary Emboli Anatomic obstruction- bowel, genitourinaryBowel obstruction Ectopic pregnancyLeaking AAANew perforated viscousNew soft tissue mass-traumatic,inflammatory,tumor,etcNew Ultrasound Deep Vein ThrombosisRetained surgical itemsSignificant displacement or misplaced tubes or cathetersUnexpected pneumoperitoneumUnexpected pneumothorax Unexpected soft tissue airUnstable spine fractureUnsuspected pneumothorax or pneumoperitoneum/free intraabdominal air or air outside anatomic boundariesVascular abnormalities-acute embolic,acute occlusion, acute bleedNUCLEAR MEDICINE CRITICAL RESULTSV/Q scans = intermediate or 50% or higher probability pulmonary emboliMyocardial Perfusion Studies (Cardiolite Stress, Cardiolite, Regadenoson, Cardiolite Dobutamine) if the area of ischemia is greater than 25% of left ventricular volume. Attachment CCARDIOLOGY SERVICEFor all Cardiology Critical Results the Technician will:?Notify Physician or send to urgent care if Veteran does not have an appt that day.? Technician will escort patient to destination.?Put note in chart that physician notified.? Critical EKGsThe technician/nurse will give the EKG printout with the computer interpretation immediately to the ordering physician or to the nurse responsible for the patient if the ordering physician is not immediately available. If the computer interpretation indicates a critical result a physician must be notified immediately.The interpreting Cardiologist will review all EKG’s and notify the ordering provider of any critical results not previously identified by the computer. ST elevation Severe tachycardia arrhythmias (Heart rates > 150 per minute)Ventricular TachycardiaBradycardia (<40 BPM) Critical EchocardiogramsIdentification of any of the following on echocardiogram is considered a critical result:Large pericardial effusionSignificant valve obstructionUnusual echo density, vegetation or tumorRuptured Chordae Critical Vascular ResultsIdentification of any of the following vascular results are considered a critical result:Cold extremityABI index below .5Graft Imaging- Occlusive clot/thrombus with ultrasound imagingAttachment DCRITICAL RESULT REPORT TEMPLATE For all point of care glucose Critical Results the RN will enter the Critical Result Report Template in CPRS. Attachment ECall Tree for Critical Results/Emergent Test ResultsCall triageOrdering providerBackup contact will be a surrogate that consists of another provider or the Service Line Chief (after hours call the AOD at ext. 6355 to connect the diagnostic personnel to the Service Line Leader.)If a surrogate cannot be reached contact the Chief of Staff at extension 6729 or by paging their Administrative Officer at 251 during business hours. After hours the Chief of Staff can be contacted by calling the AOD at ext. 6355. Patient Location1st Contact number Backup (surrogate)Contact informationExtensionPagerCardiologyOrdering ProviderSpecialty Medicine Service Chief5989231CBOC – Routine ToursOrdering Provider at the CBOCPOD member at CBOC followed by CBOC Service Line Chief8-874-2231Aberdeen: 8-831-2221 or (605) 229-3500Sioux City: 8-874-2221 or (712) 258-4700 Spirit Lake: 8-870-2223 or 712-336-6400 Wagner: 8-836-2221 or 605-384-2340Watertown: 8-837-2221 or 605-884-2420CBOC – Off Tours ED doctorExt: 6952ED doctorExt: 6947CLC - Routine ToursOrdering providerExtended Care and Rehabilitation Service Chief5313139CLC – Off ToursED doctorExt: 6952ED doctorExt: 6947Emergency Department (ED)Extension: 6952 ED doctor Extension: 6947 ED doctorENTOrdering ProviderSpecialty Medicine Service Chief5989231HBPCOrdering Provider Extended Care and Rehabilitation5313139Inpatient – hospital medicalOrdering ProviderMedical OD (on call)442Inpatient – hospital surgicalOrdering ProviderSurgical PA (on call)variesInfectious Disease SpecialistOrdering ProviderSpecialty Medicine Service Chief5989231NephrologyOrdering ProviderSpecialty Medicine Service Chief5989231Mental HealthOrdering ProviderMental Health Service Chief6659230Outpatient CR/ETR during off-tours (M-F 1700-0730, weekends and holidays)ED doctorExt: 6952ED doctorExt: 69477814203PodiatryOrdering ProviderSurgical Specialty Medicine Chief6178548Primary CareOrdering ProviderPOD member PulmonologistOrdering ProviderSpecialty Medicine Service Line Chief5989231Resident ClinicOrdering ProviderPrimary Care Service Line Chief7814203Respiratory Therapy or Overnight Oximetry/Pulmonary ClinicOrdering ProviderRT Pager 383 or Primary Care Service Line Chief7814203PodiatryOrdering ProviderSurgical Specialty Medicine Service Chief6178548Rapid Response TeamED doctorDial 10 and overhead page367Specialty Clinics – 4th floorOrdering Provider Extension: 6088 or 6221 UrologyOrdering ProviderSurgical Specialty Medicine Service Line Chief6178548Attachment FDesignated Time from Order to Result AvailabilityServiceUrgencyOrder to Result Pathology and Laboratory MedicineSTAT1 hourASAP2 hoursAcute Stroke Protocol (Basic metabolic panel, PT/INR, PTT, troponin, CBC/platelet)45 minutesRadiologySTAT1 hourASAP3 hoursNPO studies will require 4-8 additional hoursNuclear MedicineSTAT24 hoursASAP48 hoursEKGsER chest pain10 minutesSTAT20 minutesEchocardiogramsSTAT1 hourVascular resultsSTAT1 hour ................
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