RIDGEVIEW MEDICAL CENTER AND CLINICS

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1 RIDGEVIEW MEDICAL CENTER AND CLINICS #5575 SUBJECT: REPORTING OF CRITICAL TEST RESULTS AND CRITICAL VALUES ORIGINATING DEPT: Laboratory DISTRIBUTION DEPTS: 7650, 8000, 7575, 7240, 7505, 7600 ACCREDITATION/REGULATORY STANDARDS: Original Date: 5/05 (Nursing Admin) Revision Dates: 7/06, 8/07, 4/09, 8/11, 10/12, 1/15, 7/15, 3/16 Reviewed Dates: APPROVAL: Administration: Lab Director: PURPOSE: To identify and establish the responsibilities of personnel reporting and receiving critical test results. To define critical tests and values. To list the critical tests and values for individual services. To define the acceptable time for reporting these results to the responsible licensed caregiver. To describe the process of reporting critical results/values. DEFINITIONS: Critical Test: A test ordered for a patient with potentially life threatening symptoms which can assist the physician with differential diagnosis and determining appropriate course of action. All critical tests are reported immediately (STAT), even if the results are considered to be normal. Critical Value/Result: A value/result at such variance with normal as to represent a pathophysiologic state that is life-threatening unless some action is taken in a short period of time. Licensed Caregiver: The individual currently responsible for the patient s immediate care needs: Attending/admitting physician ED physician PA (Not applicable to Home Health) Consulting physician Physician covering for the attending. CNM Authorized agent: A non-physician/pa licensed professional who is designated to receive critical test results/values RN, Pharmacist, or Respiratory Therapist. POLICY - CLINICS: Notification by lab personnel, to the ordering clinician (or if the ordering clinician is not available, report will be given to another clinician within that same clinic) of a lab value that falls outside the normal value for that test and falls within the critical value range or that represent a life threatening pathophysiologic state for the patient, will occur within 15 minutes of lab personnel receiving that abnormal result. Authorized RMC Lab personnel will call the clinic laboratory where the test was ordered and report the critical value using Verbal Read Back process. Clinic lab personnel will document the critical value/result on the Critical Value Phone report and deliver it to the ordering clinician. If the ordering clinician is not available, the Critical Value Phone report will be given to another clinician within the clinic for review, action and signature. Only the clinician will notify the patient by phone, of the critical lab value. The Critical Value Phone report will be scanned into the patient s EMR. A task is entered in Allscripts for the ordering clinician by the Clinic Lab personnel. Document valid only on date printed: 7/7/2016 Page 1 of 5

2 PROCEDURE: The performance of a critical test, as defined by this policy, is given priority over routine tests. Critical test results/critical values must be communicated to an authorized agent with 10 minutes of the availability of a critical result/value. Authorized agents are required to notify the licensed caregiver of critical results/values within 30 minutes of reception. Examples A: Critical Tests and Critical Values by Service Please note these are examples of tests, this is not an all inclusive list. Some of these tests may be ordered routinely. Cardiopulmonary: Critical Tests 1. ABGs 2. EKG 3. Echocardiogram/Cardiac Ultrasound Cardiopulmonary: Critical Results/Values 1. ABG: PCO2 - > 60 Ph - < 7.20 or > 7.6 PO2 - < 40 Carbon Monoxide - >15% 2. EKG: PVCs > 3 in a row Supraventricular Tachycardia 2 nd or 3 rd degree block Ventricular Tachycardia Bradycardia < 40bpm Acute ST changes 3. ECHO/Ultrasound: Pericardial effusion Cardiac tamponade Ejection fraction < 20% Ruptured papillary muscle Thrombus 76-99% carotid vessel occlusion Imaging: Critical Tests 1. Chest X-ray 2. Ultrasound (abdomen/pelvis or testicular) 3. Head CT 4. Chest CT 5. Abdominal/Pelvic CT 6. MRI Imaging: Critical Results 1. Aortic dissection 2. Bowel perforation with free air 3. CVA, brain or spinal cord mass or bleed 4. Ectopic pregnancy 5. Leaking aortic aneurysm 6. Ovarian/testicular torsion 7. Pulmonary embolism 8. Significant solid organ laceration 9. Spinal cord compression/injury 10. Tension pneumothorax 11. Pericardial effusion with or without cardiac tamponade 12. Acute congestive heart failure Document valid only on date printed: 7/7/2016 Page 2 of 5

3 Laboratory: Critical Tests / Values (This policy does not apply to recurring critical values unless current patient condition warrants further intervention or critical value is significantly changed from previous values) Laboratory testing is considered a critical test only if ordered STAT. Routine lab testing can result in critical values at which time this policy would be in effect. When a specimen is sent to a reference lab for processing, critical values are called to the licensed caregiver or authorized agent by the reference lab. All lab tests drawn by Home Health personnel are considered to be routine. In the event that a routine lab test results in a critical value, this policy would be in effect with respect to notification of an authorized agent and the licensed caregiver. Exception: Hospice patients are exempt from this unless MD requests immediate notification of the critical results. Does not apply to results addressed through RMC routine protocols, i.e. Heparin PTT, Insulin Sliding Scale or other physician orders relating to the test. See Policy # Medication Administration and Monitoring for Verbal Read Back procedure. Test Chemistry Albumin BUN Calcium Creatinine Glucose Potassium Magnesium Phosphorus Sodium Uric Acid Bili (newborn) Lactic Acid Hematology/Coagulation Hemoglobin (> 4 weeks) Platelets Critical Value < 2.0 gm/dl > 80 mg/dl < 7.0 or > 13.0 mg/dl > 5.0 mg/dl < 50 or > 400 mg/dl Adults:< 3.0 or > 5.8 mmol/l Neonates: >8.0 mmol/l < 1.0 or > 5.0 mg/dl < 1.2 mg/dl Peds: 0-1 yr: <2.0 mg/dl or >10.0 mg/dl < 125 or > 152 mmol/l >14.0 mg/dl > 15.0 mg/dl >12.0 mg/dl Newborn >4.00 mmol/l < 7.0 or > 20 g/dl < 20,000 or > 1 million WBC < 2,000 or > 30,000 Fibrinogen < 100 mg/dl INR > 5.0 PTT Therapeutic Drugs Acetaminophen > 120 seconds hours post ingestion hours post ingestion Document valid only on date printed: 7/7/2016 Page 3 of 5

4 Therapeutic Drugs continued Digoxin Dilantin Gentamicin Salicylate Lithium Vancomycin Depakene Microbiology Blood culture CSF/Body Fluid culture Sterile Fluids (CSF, Joint, etc Stool Cultures Vaginal/Rectal Swab OB Smear or Culture Bone Marrow > 2.4 mg/ml 14 mcg/ml (0-2 months of age) 30 mcg/ml ( 3 months of age) > 12(random and trough) >12 (peak) mcg/ml > 30 mg/ml > 1.6 mmol/l > 60 mcg/ml > 150 mcg/ml Positive cultures - (Includes Acid-Fast Bacillus Positive Gram stain Positive Cultures Positive for Salmonella, Shigella, Campylobacter, E. coli 0157 Group B Beta Strep Positive Acid-Fast Bacillus Positive for bacteria or yeast Document valid only on date printed: 7/7/2016 Page 4 of 5

5 Ridgeview Clinics Critical Value Phone Report Chanhassen Chaska Delano Excelsior Howard Lake Westonka Winsted Patient Name DOB: Date Drawn/Sent Physician/Provider Test Requested RESULTS Normal Range Person Calling Person Taking Call Date of Call Time Physician/Provider Signature Action to be Taken: Date: Time: Please scan into EMR under Outside Lab Results when complete ; , Critical Value Phone Report Document valid only on date printed: 7/7/2016 Page 5 of 5