ABC HOSPITAL CENTER



ABC HOSPITAL

POLICY NUMBER 100-9 MARCH 2013

REPORTING OF CRITICAL RESULTS

PURPOSE: Critical results of tests and diagnostic procedures that fall significantly outside the normal range and may indicate a life-threatening situation. The objective of this policy and procedure is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated. This policy is aimed at improving the effectiveness of communication among caregivers by providing guidelines on the process of timely notification of critical results to the physician/physician designee responsible for the patient.

POLICY: It is the policy of ABC Hospital that:

A critical result is to be reported to the physician/physician designee within one (1) hour of the test result being produced. The critical result is to be written down immediately by the individual receiving the result and read-back to the reporting individual.

SCOPE: Applies to inpatient and outpatient services of the following departments:

➢ Laboratory

➢ Pathology

➢ Medical Imaging (Radiology, Ultrasound, CT Scan, MRI and Nuclear Medicine)

➢ Cardiology

➢ Vascular Laboratory

➢ EEG Laboratory

➢ Respiratory Therapy/Pulmonary Function

➢ OB Ultrasound

DEFINITIONS:

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.

PROCEDURE

A list of critical 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 or as needed. The list is to be readily available in each department, on all patient care units and as an addendum to this policy. (See Addendum A) New 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

Laboratory: Laboratory personnel are responsible for notifying the nurse responsible for the patient or a Charge Nurse via telephone of all critical results.

Anatomical Pathology: The pathologist is responsible to notify the physician/physician designee of a critical result.

Medical Imaging (Radiology, Ultrasound, CT Scan, MRI and Nuclear Medicine): The radiologist is responsible to notify the physician/physician designee of all critical results.

Cardiology Services: The interpreting physician is responsible to notify the physician/physician designee of a critical result.

EKG Performed by Patient Care Unit Staff: The nurse is responsible for notifying the physician/physician designee of a critical EKG result.

EEG Laboratory: The EEG technician/Neurologist is responsible for notifying the physician/physician designee of a critical result.

Pulmonary Function/Respirator Therapy: The pulmonary technologist/respiratory therapist is responsible for notifying the physician/physician designee of a critical result.

Vascular Laboratory: The vascular technologist is responsible for notifying the physician/physician designee with the result of a critical result.

OB Ultrasound: The Maternal Fetal Medicine physician is responsible for notifying the physician/physician designee of a critical result.

Outpatients: The reporting department is responsible for notifying the physician/physician designee of a critical result. Under no circumstances is 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 a critical result, the physician/physician designee is to be notified of the critical result.

RESPONSIBILITIES

Reporting Department: As soon as a critical result is available, the reporting department is responsible to:

• Notify the appropriate individual per the department’s standard. (See 7. Department Notification Procedure)

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

• Report the critical result and request read-back to verify it was correctly understood and recorded.

• Document the 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.

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

• Document the critical result immediately on the Critical Result Form, 3-887. If this form is not utilized, the 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 result

• Read-back the result of a critical result to the reporting individual to verify it was correctly understood.

• The nurse is responsible to notify the physician/physician designee immediately of a critical result of an EKG and/or 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 result.

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

In the event that the physician/physician designee does not respond after two (2) attempts for a maximum of thirty (30) minutes, follow the Chain of Command Policy, Policy 100-16. The result of a critical test and/or critical result may not be left on an answering machine.

APPROVED: Medical Executive Committee

DISTRIBUTION: Hospital Policy Manual

Directors/Department Managers

Medical Staff Office

Critical Result Notification 100-9 (Originated: 4/14/05. Revised: 3/27/08, 3/27/10)

ATTACHMENT

1. Addendum A: Critical Tests and Results/Values by Department

2. Addendum B: Critical Test and Critical Result Form, 3-887

Addendum A: Critical Results/Values by Department

|LABORATORY - 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 | |

|Magnesium |Less than 1.0 mg/dL |Greater than 4.0 mg/dL |L & D |

| |Less than 3.1 mg/dL |Greater than 8.0 mg/dL | |

|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 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 |

|G.I. Bleed |

|MRI - Critical Results/Values |

|Cord Compression |

|Hemorrhage |

|Aortic Dissection |

|NUCLEAR MEDICINE - Critical Results/Values |

|G.I. Bleed |

|Pulmonary Embolism |

|CARDIOLOGY - Echocardiogram Critical Results/Values |

|Aortic Dissection |

|Large Pericardial Effusion with tamponade |

|Large vegetation with impending embolism |

|Mobile thrombus or tumor |

|Large Pericardial Effusion >300cc |

|Significant valve obstruction |

|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

Arterial Blood Gas Critical Value Ranges

| |

|Status Epilepticus |

|Clinical Brain Death |

| |

|VASCULAR LABORATORY - Critical Result/Value |

|DVT |

|OB Ultrasound – Critical Results |

|Biophysical profile score of 0 - 4 |

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