Laboratory Test Result Reporting and Inquiry Procedures

Similar documents
Therapeutic and Critical Drug Levels

If a critical result is obtained for a clinic patient after the clinic has closed, we will notify the individual on-call for the clinic.

35.0. ug/ml Trough. 8.0 Carbamazepine 15.0 ug/ml Digoxin 2.5 ng/ml Gentamicin Peak Random Trough

Test Critical Low Critical High Alerting Category

OHIOHEALTH Laboratory Services INPATIENT, ED AND OTHER HOSPITAL BASED PATIENT CRITICAL VALUE NOTIFICATION LIST

Laboratory Values, Critical. ThedaCare. Date Last Reviewed: 4/5/2018 Reviewing Body(s): Quality; Laboratory Leadership

PEACEHEALTH LABORATORIES

PENN STATE MILTON S. HERSHEY MEDICAL CENTER TABLE OF CRITICAL LAB VALUES CURRENT AS OF: 1/2015

Results that require action

CRITICAL VALUES, SIGNIFICANT FINDINGS LIST and STAT RESULTS

MidMichigan Health LABORATORY POLICY Title: Effecti ve te: Key Words: places: Category: Applicability: reference laboratory

JOB AID CRITICAL VALUES AND TESTS W/O MICRO CRITICAL TESTS. Always call results for the following test(s):

Comments / Frequency (if not each time)

CRITICAL VALUES, CRITICAL TEST RESULTS AND SIGNIFICANT FINDINGS LIST

1. HISTORY. This issue publishes a revision of this publication.

Inspector's Accreditation Unit Activity Menu

Specimen Collection Requirements

Specimen Collection Requirements

Epic Labs Orderable As STAT PRIORITY As of 06/22/2016

CLIA APPROVED PROFICIENCY TESTING PROGRAMS ACCUTEST, INC. P.O. Box 999 Westford, Massachusetts (800)

RIDGEVIEW MEDICAL CENTER AND CLINICS

ALERT VALUE PROTOCOL INITIAL EVALUATION: 1. Determine the category of the alert value by reviewing the Alert Value List.

1. Purpose 1.1. To define testing locations, schedule and order priority for each test performed in the core laboratory.

GENERAL INFORMATION CLINICAL LABORATORY PHONE DIRECTORY

GRADING CRITERIA for CMS Regulated Analytes

SPECTRA EAST, INC. Rockleigh, NJ

NORTH SHORE - LONG ISLAND JEWISH HEALTH SYSTEM LONG ISLAND JEWISH MEDICAL CENTER DEPARTMENT OF LABORATORY MEDICINE REFERENCE RANGES

ISO 15189:2012 Internationally-Recognized Accredited Laboratory. SPECTRA EAST, INC. Rockleigh, NJ

Program Analyte Unit Target Limit Absolute SD %

cobas c 501 analyzer and cobas c 311 analyzer Within Run Imprecision Guidelines

Postanalytical phase

Bassett Healthcare Clinical Laboratory

PROFICIENCY TESTING. Clinical Laboratory Improvement Amendments (CLIA) DOs and DON Ts. Brochure # 8

CERTIFICATE OF ACCREDITATION

OMCJH.CHEM.COLL.INF.1001 Therapeutic Drug Monitoring Guidelines

IP Lab Webinar 8/23/2012

M.D.IPA, M.D.IPA Preferred, Optimum Choice and Optimum Choice Preferred STAT Laboratory List Revised Jan. 5, 2017

Reference Range: Age/sex dependent; appropriate normals provided with result Analytical Time: 4 hours Day(s) Test Set Up: Daily CPT Code: 84100

Annex to the Accreditation Certificate D-EP according to DIN EN ISO/IEC 17043:2010

Controls & Calibrators Clinical Chemistry

PROGRAM General Information

Types of target values, acceptable ranges

LABORATORY NORMAL RANGES. Prepared by Date Adopted Supersedes Procedure # / Dated William T. Pope, PhD and

for therapeutic drug monitoring

NPQR 2018 Qualified Clinical Data Registry (QCDR) Measures 21_18247_LS.

SCOPE OF ACCREDITATION TO ISO 15189:2012. SPECTRA, EAST LABORATORY 8 King Road Rockleigh, NJ Stylianos Lomvardias, M.D.

New Test Announcements

Therapeutic Drug Monitoring (TDM) Guidelines in Blood for Pediatrics and Adults

Hamilton Regional Laboratory Medicine Program

Hamilton Regional Laboratory Medicine Program

Add your company slogan LOGO

Therapeutic drug monitoring. Department of Clinical Pharmacology, Wrocław Medical University

COMPLIANCE. Individual Highlights: Advance Beneficiary Notices Medical Necessity IL Requisition Reflex Test List Panel Test. September 2018.

PHA 5128 Final Exam Spring 2004 Version A. On my honor, I have neither given nor received unauthorized aid in doing this assignment.

Case Log Number(s) Veterinarian or VTS Accurately report test results, using appropriate units of measurement Quality Control/Assurance Date Mastered

A written order to request the performance of a laboratory test can be initiated by the following parties:

DEPARTMENT OF MICROBIOLOGY IMPORTANT NOTICE TO USERS Turnaround Times (TATs) for Microbiology Investigations

QUALITY CONTROL. Linearity Sets

DrugSmartCup & DrugSmartDip Accuracy Report as produced by Ameditech, Inc.

Chapter 17 Worksheet Code It

Physician Office Laboratory Tests

Proficiency Testing LABFACTS Requirements for good laboratory practice and COLA Laboratory Accreditation programs are underlined.

Notes from the Sentinel Liaison

Collection (Specimen Source Required on all tests) Sputum: >5 ml required. First morning specimen preferred.

Rapid Laboratories In House Tests

Traceability in External Quality Assessment: How Weqas ensures traceability in EQA and stresses its importance to users. David Ducroq.

Perform Gram stain only. Select Survey D5, Gram Stain

Clinical Microbiology CLS 2019 Clinical Microbiology Laboratory Scheme Application Form

PCL ALVERNO INSTALLING NEW ANALYZERS AND AUTOMATION

Hematology & Coagulation Practicum Objectives CLS - 647

MICROBIOLOGY SPECIMEN COLLECTION MANUAL

MEMORANDUM. These reference ranges are effective immediately but sample requirements remain unchanged currently.

WSLH. Calibration Verification/ Linearity Products. roficiency. esting. Products provided in partnership with:

HANDLING GENERAL INFORMATION TEST REQUESTS TYPES OF TESTS TEST REQUEST FORM

Minimum Whole Blood Volumes for Microcollection Tubes for Neonates, Pediatrics, Patients less than 45 kg (100 lb) and Difficult Collections

Epilepsy Society Therapeutic Drug Monitoring Unit (TDM Unit) Chalfont Centre for Epilepsy Chesham Lane Chalfont St Peter Buckinghamshire, SL9 ORJ

What tests should be on the Alert List?

Proficiency Testing Evaluation

lab Test Name notes on collection container type CBC AUTO HEMOGLOBIN & HEMATOCRIT

MEDICAL HISTORY. 23-Jan-2018 to 23-Jan VCA Miller-Robertson Animal Hospital 8807 Melrose Ave, Los Angeles, CA (310)

January Testing Delays and Spurious Results Caused by Improper Specimen Collection

Forensic Toxicology Scope of Testing and Detection Limits

INTOXICATION DEATHS ASSOCIATED WITH DRUGS OF ABUSE OR ALCOHOL BALTIMORE, MARYLAND QUARTERLY REPORT: FOURTH QUARTER, 2008 AND 2008 SUMMARY

Manufacturer Report for Siemens Unassayed Chemistry Lot Exp 30 Jun 2018

Dynacare Laboratories

Tables of Normal Values (As of February 2005)

Routine, Every 2 hours, Starting today, If temperature greater than 38.5 C initiate Evaluation for Possible Sepsis Physician Order #829

Reflex Test Protocols

You will receive an Advance Shipment Notice (ASN), which reminds you of upcoming shipments and test events, before

CME/SAM. An Examination of the Usefulness of Repeat Testing Practices in a Large Hospital Clinical Chemistry Laboratory

Cleveland Clinic Laboratories. Trust in us for everything you need in a reference lab.

INTOXICATION DEATHS ASSOCIATED WITH DRUGS OF ABUSE OR ALCOHOL BALTIMORE CITY

Annex to the Accreditation Certificate D-EP according to DIN EN ISO/IEC 17043:2010

Bio-Rad Laboratories EXTERNAL QUALITY ASSURANCE SERVICES EQAS. External Quality Assurance Services

HEMATOLOGY AND COAGULATION ANALYTIC PROTOCOLS

Bio-Rad Laboratories EXTERNAL QUALITY ASSURANCE SERVICES EQAS. External Quality Assurance Services

Assays for therapeutic drug monitoring

Dynacare Laboratories Test Changes

6/6/2016 pg. 1 of 24

Transcription:

Jump to: Pathology Information System Critical Value Reporting Policy Microbiology Result Reporting Procedures Antimicrobial Susceptibility Result Reporting Surgical Pathology Result Reporting Cytopathology Result Reporting Molecular Pathology Reporting Laboratory Result Reporting and Inquiry Procedures PATHOLOGY INFORMATION SYSTEM VCUHS Department of Pathology is supported by the Cerner Clinical Information System (CIS). The Pathology Information System (PIS) Group is responsible for the proper operation and maintenance of the Laboratory Information System (LIS) which functions to facilitate and support specimen accessioning, analysis, and result reporting. Most laboratory reports for inpatients and most VCUHS Clinics are reported and retrieved from the CIS System. The exceptions are some non-pathology Ancillary ing, and some referral laboratory studies. These printed final reports are sent to Medical Records and to the ordering physicians. Computer-Generated and Charted Reports (Electronic Result Reporting Fax and Remote Printers) Outreach clients Reports for outreach clients are provided by a fax printer at their site that prints either a daily report or broadcasts of the results as completed. VCUHS patients Inpatient results are not printed but are available in CIS as soon as they are completed. Ambulatory Care stat results print on CIS printers on test completion; routine results print once daily in the morning to CIS printers in the clinic areas. For some referral test results that are not available in CIS, printed reports are sent to Ambulatory Clinic areas or to Medical Records for inclusion in the paper chart. For users without access to CIS, requests for results should be made as follows: Client Services at (804) 828-7284

Hospital policy restricts the use of telephone inquiries for patient results to authorized individuals. Laboratory personnel are restricted in releasing patient information. On-Line Computer Result Retrieval Within the hospital environment, view or print laboratory reports from the CIS System. Telephone Inquiries To obtain verbal laboratory results, call the laboratory Help-Line at (804) 828-7284 or (804) 828-PATH for assistance. Outcomes and Research Reporting PIS may be authorized to provide laboratory data and specialized reports to support research projects and outcomes studies. Requests for such reports should be made in writing to Dr Richard McPherson, Chairman, Clinical Pathology, at VCUHS, Box 980258, Richmond, VA 23298-0258; email rmcpherson@mcvh-vcu.edu. CRITICAL VALUE REPORTING POLICY [Go to Top] The following protocol is used by the Pathology Laboratories for the rapid reporting of results of analytical tests which may have critical impact on patient care. A technologist will communicate the results of Critical s and Panic Values to a licensed healthcare provider caring for the patient as soon as results are available and, as appropriate, after confirming the value. Panic values and critical results should always be called within 60 minutes of obtaining the result. Providers should be prepared to document and read back all patient information communicated to them by technologists. Critical tests are tests that require rapid communication of results, whether normal or abnormal. Results of critical tests are communicated to a licensed provider who is caring for the patient within sixty minutes of obtaining the result. Critical tests defined by the VCUHS Department of Pathology: Frozen Sections Parathyroid Hormone (PTH) during parathyroid surgery HIV-1 antibody, no prenatal care L&D HIV-1 antibody, employee occupational exposure Page 2 of 11

Panic Values/Critical Results are test results that are abnormal to a degree that it may indicate a life threatening situation. These panic values or critical results are established by the Department of Pathology in consultation with VCUHS providers and outreach customers. Panic values are communicated to a licensed healthcare provider within 60 minutes of obtaining the result. All critical values (where appropriate) should be flagged ("C") in the laboratory report. Reporting Flags are noted in the table below: H value is higher than reference range. L value is lower than reference range. C value is a critical or panic result. Critical values obtained on patient samples from outside the VCUHS will be called to the physician at the telephone number indicated on the request form. Calls will be made as soon as results are completed. For any questions, contact the laboratory director or pathology resident. CHEMISTRY Calcium <7 d 6-12 mg/dl <6 mg/dl >12 mg/dl 8 d - 10 y 9.4-10.9 mg/dl <6.6 mg/dl >12 mg/dl 11 y to adult male 9.2-10.7 mg/dl <6.6 mg/dl >12 mg/dl 11 y to adult female 8.9-10.5 mg/dl <6.6 mg/dl >12 mg/dl Glucose, fasting Adult 65-100 mg/dl <50 mg/dl >500 mg/dl 1 mo-3 y 60-100 mg/dl <50 mg/dl >500 mg/dl Page 3 of 11

<30 d 40-90 mg/dl <40 mg/dl >500 mg/dl Lithium 0.5-1.5 mmol/l NA >2 mmol/l Magnesium 1.8-2.4 mg/dl <1 mg/dl >4.9 mg/dl Phosphorus 2.5-4.6 mg/dl <1.3 mg/dl NA Potassium 3.6-5.1 mmol/l <2.8 mmol/l >6.1 mmol/l <3 d 5.0-7.5 mmol/l <2.8 mmol/l >7.5 mmol/l 3 d - 3 mo 4.0-6.2 mmol/l <2.8 mmol/l >6.2 mmol/l Sodium 135-145 mmol/l <125 mmol/l >155 mmol/l Cryptococcal antigen (first time positive to ID) IMMUNOLOGY Negative Positive HIV Ab/Western blot Negative Positive RSV antigen Negative Positive Viral isolation No virus isolated Positive MICROBIOLOGY AFB cultures No growth Positive AFB smears No AFB seen Positive Blood culture No growth Positive Bordetella pertussis FA Negative Positive CSF cultures No growth Positive CSF Gram stain No organism seen Positive Cultures positive for the growth of: Brucella species, Bordetella pertussis, Clostridium botulinum, Corynebacterium diphtheriae, Francisella tularensis, Listeria species, Streptococcus Group A from sterile sites or wounds only, Yersinia pestis No growth Positive Page 4 of 11

Legionella culture or antigen No growth/negative Positive Malaria Smears Negative Positive Mycology cultures No growth Positive (from sterile sites only) Shiga Toxin antigen Negative Positive HEMATOLOGY Hemoglobin (Hgb) For age specific 7 g/dl reference ranges refer to Pathology Catalog of Laboratory Services appendices Hematocrit (Hct) For age specific 20% (only if Hgb is not reported) reference ranges refer to Pathology Catalog of Laboratory Services appendices Platelet (PLT) For age specific 40 (x 10 9 /L) reference ranges refer to Pathology Catalog of Laboratory Services appendices WBC For age specific 2 (x 10 9) reference ranges refer to Pathology Catalog of Laboratory Services appendices Peripheral Smear Findings 20.0 g/dl* (except newborn infants) 1000 (x 10 9 /L) 50 (x 10 9 /L) Presence of blasts, intra- or extra- Page 5 of 11

cellular organisms determined as clinically relevant by Pathologist Critical values are called each occurrence except on inpatients with known hematologic disturbance URINALYSIS Ketones Negative 80 mg/dl (4+) BODY FLUIDS Presence of bacteria or yeast after smear confirmation Presence of blasts or neoplastic cells after smear confirmation CSF (WBC) (0-5 cells) WBC 200 mm 3 Activated partial thromboplastin time (APTT) COAGULATION 25-38 sec >150 sec D-Dimer <0.50 μg/ml FEU >5 μg/ml FEU Fibrinogen 180-450 mg/dl <60 mg/dl Heparin induced platelet Negative Positive antibody Protime (PT) Call Laboratory for Range 56 sec, INR 5 MOLECULAR DIAGNOSTICS Herpes Simplex Virus by Negative Positive PCR TOXICOLOGY Acetaminophen 10-20 mg/ml 100 mg/ml Alcohols Page 6 of 11

Acetone Negative 1000 mg/l Ethanol Negative 4000 mg/l Isopropanol Negative 200 mg/l Methanol Negative 200 mg/l Aluminum Dialysis patient <40 μg/l >60 μg/l Amikacin Environmental exposure: 0-9 μg/l Trough 1-8 mg/l 10 mg/l Peak 25-35 mg/l 40 mg/l Anticonvulsants Carbamazepine 7-12 mg/l 15 mg/l Phenobarbital 15-40 mg/l 50 mg/l Phenytoin 10-20 mg/l 40 mg/l Primidone 5-12 mg/l 15 mg/l Barbiturate scan Amobarbital 1-5 mg/l 10 mg/l Butabarbital 1-5 mg/l 10 mg/l Butalbital 1-5 mg/l 10 mg/l Pentobarbital 1-5 mg/l 10 mg/l Secobarbital 1-2 mg/l 5 mg/l Caffeine Children 8-20 mg/l 50 mg/l Page 7 of 11

Adults 3-15 mg/l 50 mg/l Chloramphenicol Trough 5-10 mg/l 25 mg/l Peak 10-20 mg/l 25 mg/l Chlordiazepoxide 0.5-3.0 mg/l 5 mg/l Clonazepam 0.015-0.060 mg/l 0.08 mg/l Desipramine 40-160 ng/ml 400 ng/ml Digoxin 0.5-2.0 ng/ml 2.4 ng/ml Doxepin 50-100 ng/ml 400 ng/ml Ethosuximide 40-100 mg/l 150 mg/l Ethylene glycol Negative >0 Gabapentin 2-15 mg/l 20 mg/l Gentamicin Trough 0.5-2.0 mg/l 2 mg/l Peak 5.0-10.0 mg/l 12 mg/l Haloperidol 2-20 ng/ml 50 ng/ml Heavy metals None detected Any positive Ibuprofen 10-50 mg/l 200 mg/l Lidocaine 1-5 mg/l 6 mg/l Lithium Saliva 1-3 ng/dl 3.5 ng/dl Red blood cell 0.2-0.8 ng/dl 0.9 ng/dl Methotrexate Subject to MD's interpretation N-acetyl procainamide Not defined 40 mg/l Page 8 of 11

(NAPA) Norchlordiazepoxide 0.2-0.7 mg/l Nortriptyline 50-150 ng/ml 400 ng/ml Phenytoin free 1-2 mg/l 4 mg/l Procainamide 4-10 mg/l 16 mg/l Quinidine 2-5 mg/l 10 mg/l Salicylate 150-250 mg/l 500 mg/l Theophylline Newborn 8-12 mg/l 25 mg/l Children/adults 10-20 mg/l 40 mg/l Tobramycin Trough 0.5-1.5 mg/l 12 mg/l Peak 5-10 mg/l 12 mg/l Tricyclics, total 50-100 ng/ml 500 ng/ml Valproic acid 50-100 mg/l 200 mg/l Vancomycin Trough 5-10 mg/l 90 mg/l Peak 30-40 mg/l 90 mg/l Page 9 of 11

MICROBIOLOGY RESULT REPORTING PROCEDURES [Go to Top] Result Report (Routine Bacteriology) 1. One area of the report will give the Gram stain results on direct smears of clinical specimens when applicable. 2. Organisms will be listed followed by either quantitative (of colonies/ml) in the case of urine cultures or semiquantitative (rare, few, moderate, many) for other cultures, indicating the number of colonies that grew on primary culture media. Rare: The organism grew only in the broth culture but not on the agar plate media. Few: Growth only in the primary inoculum area of the agar plate (1+). Moderate: Growth occurred in primary inoculum and in second quadrant of the agar plate (2+). Many: Growth occurred in primary inoculum and in second, third, and fourth quadrants of agar plate (3+, 4+). 3. Preliminary reports on a patient's specimen are reported whenever new information of possible clinical significance becomes available. When work on a specimen is completed, a final report will be issued. ANTIMICROBIAL SUSCEPTIBILITY TEST RESULT REPORTING Routine Bacterial Susceptibility ing Routine susceptibility testing is performed by a combination of several methodologies which include the Vitek automated system and Disk Diffusion. Results are reported within an interpretive category: S I R susceptible intermediate resistant If further technical information is needed, please call the Microbiology Laboratory at 828-9077. Page 10 of 11

SURGICAL PATHOLOGY RESULT REPORTING [Go to Top] Results of Surgical Pathology examinations of small biopsies and minor cases not requiring extra fixation time, additional sections, or special stains or studies are available by phone at 828-9739 or by inquiry from the Pathology Information System (PIS) usually by the end of 3 working days from time of receipt in the Surgical Pathology Laboratory. Large and complex specimens and those requiring additional stains or special procedures will add several extra working days to this turnaround time before the final report is signed out and printed for distribution. Small biopsies for expedited processing and review (transplant biopsies and cases approved by senior attending pathologists) that arrive in the laboratory before 11 AM will be processed and reviewed the same day, with a verbal report available by 4 PM. Final printed reports can be faxed upon request to the attending physician. CYTOPATHOLOGY RESULT REPORTING [Go to Top] Gynecologic specimens are resulted using 2001 The Bethesda System (TBS) for reporting cervicovaginal cytologic diagnoses. This format includes a descriptive diagnosis and an evaluation of specimen adequacy. The Bethesda nomenclature is designed to standardize results based on the most abnormal cells present. The major categories of TBS are as follows: negative for intraepithelial lesion or malignancy benign cellular changes (includes reactive cell changes repair, and infections) epithelial cell abnormalities (includes ASCUS, AGUS, LGSIL, HGSIL) other malignant neoplasms Nongynecologic specimens are reported by a statement of cell types present and descriptive diagnoses; a statement regarding specimen inadequacy is included when necessary. MOLECULAR PATHOLOGY REPORTING [Go to Top] All Molecular Diagnostics testing results are reported in Cerner except for HIV genotyping, Prader-Willi/Angelman syndrome, hereditary pancreatitis, fragile X mutation by Southern blot and PCR, and T and B cell gene rearrangement. The previously listed exceptions are reported via fax directly from the Molecular Diagnostics Laboratory. all viral load testing is reported within two weeks of receipt of sample. Hematopathology tests are resulted within two to three weeks of receipt of sample. Page 11 of 11