VHRHC Critical Results and Reporting
Patti Tickle
Created on August 11, 2022
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Transcript
Critical Results and Critical Test Reporting
Next
VHRHC
At the end of this module, the learner will:
- Describe the timeframe for reporting critical results
- Summarize the communication process for critical results
- Describe the steps taken if unable to report critical results to the responsible licensed caregiver
- Understand information to include when documenting the receipt and communciation of critical results
Objectives
Start
Critical Results and Critical Test Reporting
Purpose
Communication of Lab Results
Point-of-Care Testing (POCT)
Respiratory Care Results
Diagnostic Results
Documentation
Click each topic for more information
Purpose
To provide safe and timely communication of critical test results to the responsible caregiver within an established timeframe so that the patient can be promptly treated.
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Policy
- Critical results are reported to the qualified responsible individual and documented within established timeframes.
- The qualified individual or responsible licensed caregiver documents receipt in the Electronic Medical Record (EMR).
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Definitions
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Responsible Licensed Caregiver
Qualified Individual
Critical Results
Those results that fall significantly out of the normal range, and which, if left untreated, could be life-threatening or place the patient at serious risk.The list of tests, defined by a multispecialty disciplinary group of physicians and approved by Vanderbilt Health Regional Hospitals and Clinics (VHRHC) facility's Medical Executive Committee (MEC) includes:
- Laboratory tests
- Imaging studies
- Electrocardiograms
- and other diagnostic tests
Licensed staff in clinical areas who receive critical values and report to the responsible licensed caregiver.
A person who acts on the test results being reported. This is primarily the attending physician or designee. This may also include an RN who is authorized to modify treatment based on a protocol.
Communication of Lab Results
Critical laboratory results may be communicated to the licensed caregiver via a call from the lab staff
-OR- in the Emergency Department (ED) Trackboard critical alerts column.If the ED provider does not confirm results in the ED Trackboard within 10 minutes, lab staff call the critical result to the ED.
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Communication of Lab Results
Critical laboratory results may be communicated to the licensed caregiver responsible for the patient as soon as possible (within one hour).
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Communication Process
Critical laboratory results are communicated as soon as possible.This may be via a direct call from the laboratory staff.The information communicated is verified in the EMR.Notification and read-back are documented in the Alerts Monitor system
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02
03
Communicating the Result
to the provider
Unable to reach
the responsible licensed caregiver
If an ED patient
has been discharged
The qualified individual receiving the critical result communicates to:
- Outpatients - the Ordering provider
- Inpatients - the Primary team
- Critical Care patients - the Critical Care team
- Emergency Department (ED) patients - the Primary provider
If the qualified individual receiving the critical result is unable to reach the responsible licensed caregiver: the information escalates to the House Supervisor The qualified individual receiving the critical result documents notification to the House Supervisor in the EMR. If lab staff are unable to contact a qualified individual or the responsible caregiver in a timely manner, the information escalates to the House Supervisor - Inpatients On-Call Provider - Outpatients The House Supervisor continues notification attempts until the responsible licensed caregiver is notified.
If a critical result is resulted on an ED patient that has been discharged or transferred to another facility, the critical result is called to the ED attending on duty.
Point-of-Care Testing (POCT)
When a provider who can act on critical results is present,POCT critical values are communicated at that time to the provider.
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Respiratory Care Lab Results
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3
Respiratory Care personnel
Immediately notify the responsible licensed caregiver.Requests a read back of the results.
Respiratory Care personnel
Documents their notification process according to departmental policy.
Documentation
The responsible licensed caregiver or qualified individual documents the notification process in the EMR.
Critical Diagnostic Results
The Interpreting Provider...
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Immediately notifies responsible licensed caregiver upon the identification of any critical result.
Includes in the critical diagnostic report, “notified and discussed with” (responsible licensed caregiver name).
Does NOT leave results on a recording device. Follows the Chain of Command for Medical Management if unable to reach responsible licensed caregiver.
Documentation
If a call is made to the unit or clinic area, the qualified individual receiving the critical result documents this in the EMR or on the appropriate downtime forms.Include in the documentation
- Date and time of notification from lab
- Description of critical result
- Name and time of the responsible licensed caregiver notified
- Reason provider not notified
Go toKnowledge Check
Question 1/8
Critical results are...
Results that fall significantly out of normal range and could be life threatening if left untreated.
Results that are reported after normal working hours, making it challenging to report them to the ordering provider.
Knowledge Check
Question 2/8
Critical laboratory results should be communicated to the licensed caregiver responsible for the patient as soon as possible. The established timeframe for this communication is...
10 minutes
1 hour
By the end of the day
Knowledge Check
Question 3/8
Ms. Jones is a patient in the Critical Care Unit. Her morning labs have resulted and the lab staff contacts the nurse to report a critical potassium of 7.2. This is confirmed in the EMR and read back to the lab staff. The nurse will then communicate this to...
The ED Provider on call
The House Supervisor
The Critical Care team
Knowledge Check
Question 4/8
The following roles are able to receive critical results except:
Licensed staff on the clinical unit
House Supervisor
Medical Receptionist on the clinical unit
Medical Provider
Knowledge Check
Question 5/8
A patient in the ED has a critical INR. The Lab has documented this on the ED Trackboard. After 10 minutes, the ED Provider has not confirmed this result. What is the next step?
Report this to the House Supervisor
Lab staff will call the ED with the critical result.
Follow the Chain of Command for Medical Management
Knowledge Check
INR 6.5
Question 6/8
Knowledge Check
Phone call to the licensed caregiver; texting the House Supervisor; the ED Trackboard.
Phone call to the licensed caregiver; phone call to a qualified individual; the ED Trackboard.
Phone call to the clinical unit; leaving a voicemail for the licensed caregiver; the ED Trackboard.
Critical laboratory results may be communicated to the licensed caregiver responsible for the patient as soon as possible (within one hour) via which of the following methods:
Mr. Walker is a patient on the Med-Surg unit. The nurse receives a phone call from the lab with a critical hematocrit level. The nurse attempts to contact the licensed provider but is unsuccessful. The next step in communication would be to contact:
Question 7/8
One of the other providers on the unit.
The House Supervisor who will continue notification attempts.
The nurse who took care of the patient last night.
The on-call provider.
Knowledge Check
Question 8/8
When a qualified individual documents the receipt of a critical result in the EMR or downtime form, which of the following is not necessary to include?
Knowledge Check
All previous results of the same test for comparison.
Reason the provider was not notified, if needed.
Date and time of notification
A description of the critical result
Name and time the responsible licensed caregiver is notified
The End!
You may close this module.
Critical Results and Critical Test Reporting policy
Resource
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