University of Kentucky / UK HealthCare Policy and Procedure Policy # A08-075

Title/Description: Communication of Critical Values, Critical Results, and/or Significant Findings

Purpose: To communicate critical values, critical results, and/or significant findings to the appropriate caregiver in a timely manner.

Policy Definitions

Critical value Critical result Significant finding

Procedure Clinical Laboratories

List of critical values, critical results, and significant findings Laboratory personnel notification and escalation Laboratory personnel documentation of provision of a critical value or critical result Read back confirmation Evaluation of timeliness of reporting and audits

Department of Radiology List of critical results and significant findings Notification and Escalation Radiology physician documentation of provision of a critical result or significant finding Read back confirmation Evaluation of timeliness of reporting and audits

For all other Acute Care and Ambulatory Care Areas Notification and Escalation Nursing documentation of receipt of a critical value or critical result Evaluation of timeliness of nursing reporting and audits

Critical results from Point of Care testing Documentation of critical results from point of care testing Evaluation of timeliness of Point of Care reporting and audits

Exclusions to this policy References Persons and Sites Affected Policies Replaced Effective Date Review/Revision Dates

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 1

Policy Critical values, critical results, and/or significant findings are reported to the responsible licensed caregiver in a timely manner as set forth in this policy. If the responsible licensed caregiver is unavailable, appropriate escalation procedures are followed.

Definitions Critical value

1. An analytic result that suggests a clinical condition that might be life-threatening or one that might require immediate clinical intervention; or

2. A qualitative result or pathological interpretation that might affect patient care and might require timely clinical intervention.

Critical result 1. A laboratory test whose result is identified as always requiring notification of the clinical

caregiver, whatever the result;

2. An imaging examination whose interpretation suggests a clinical condition that might be life-threatening or one that might require immediate clinical intervention.

Significant finding An imaging examination whose interpretation is of sufficient significance that it warrants timely notification of the clinical caregiver.

Procedure Clinical Laboratories List of critical values, critical results, and significant findings A list of critical values, critical results, and significant findings may be found in LAB 704.

Laboratory personnel notification and escalation Laboratory staff who discover a critical value, critical result, or significant finding shall notify the responsible licensed caregiver in a timely manner, as specified in LAB 703.

Laboratory personnel documentation of provision of a critical value or critical result When the critical value communication to a clinical provider has been completed, the contact information, contact’s role, and time of communication with confirmation that read back was performed shall be entered into the laboratory information system. This information shall be automatically entered into the patient’s Electronic Medical Record (EMR).

Read back confirmation When a person receives a critical value or critical result from the laboratory, he or she shall listen to and write down the results, and then repeat them back to the laboratory personnel to verify accuracy of communication.

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 2

Evaluation of timeliness of reporting and audits Automated reports with regard to timeliness of laboratory communication are generated on a monthly basis. Outliers are identified and reported to the Nursing Quality and Safety Council.

Department of Radiology List of critical results and significant findings A list of critical results and significant findings applicable to Radiology is outlined in DR01-06, Communication of Radiology Critical Results and Significant Findings.

Notification and Escalation Radiology physicians who discover a critical result or significant finding shall notify the responsible licensed caregiver either immediately or in a timely manner, as specified in DR01-06, Communication of Radiology Critical Results and Significant Findings.

Radiology physician documentation of provision of a critical result or significant finding When the critical result or significant finding communication to a clinical provider has been completed, the contact information, contact’s role, and time of communication with confirmation that read back was performed shall be entered into the radiology physician’s report which is found in the radiology information system (RIS). This information shall be automatically conveyed in the radiology physician’s report into the patient’s Electronic Medical Record (EMR).

Read back confirmation When a person receives a critical result or significant finding from radiology, he or she shall listen to and write down the results, and then repeat them back to the radiology physician to verify accuracy of communication.

Evaluation of timeliness of reporting and audits

1. A sampling of data is sent from UK∙MDs to the Department of Radiology for auditing compliance of critical results or significant findings communication delivery times.

2. UK∙MDs shall query the initial time of contact, escalation notes, and time of communication of critical results and/or significant findings. This data is sent to the Department of Radiology Quality, Safety & Compliance Medical Director for compliance auditing.

For all other Acute Care and Ambulatory Care Areas Notification and Escalation All other staff, including but not limited to Echocardiography laboratory, Electroencephalogram laboratory, Neurological Testing, Birthing Center (OB), Pathology laboratory, Vascular laboratory, and Nursing staff, who discover a critical value, critical result, or significant finding shall notify the responsible licensed caregiver within 30 minutes.

If the responsible licensed independent provider is unavailable or does not respond to the notification in a timely manner:

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1. In the acute care environment the nurse shall follow the NU01-05 Nursing Responsibilities and Relationships with Medical Staff for Escalation and further action.

2. In the ambulatory care setting, the clinic nurse, certified medical assistant, or other support personnel shall follow the Escalation process outlined in LAB 703.

Nursing documentation of receipt of a critical value or critical result In the acute care environment, nursing communications and documentation of critical values and related physician’s or designated licensed provider’s orders are recorded in the patient’s EMR. The nurse who received notification of the critical value, critical result, or significant finding shall perform read back confirmation and document receipt of the notification as follows:

1. Upon receipt of a Critical Value, the nurse or other authorized licensed care provider shall enter the test or critical value in the status box by clicking and adjusting to the time the value was communicated.

2. Elements of required documentation to be completed are:

(a) Critical value;

(b) Provider notification (including name of provider); and

(c) Response or action taken.

In the ambulatory care environment, it is the responsibility of the trained staff who received the critical lab value to report it immediately to the licensed independent provider or their designee and document the results properly in the medical record along with the name of the caregiver notified and any response/action taken.

Evaluation of timeliness of nursing reporting and audits EMR audits are performed to verify utilization of the EMR recording tools to track effective communication and patient management.

Critical results from Point of Care testing Documentation of critical results from point of care testing Critical results from Point of Care Testing performed by staff in both acute care and ambulatory care environments are documented in the medical record by staff performing the testing as specified in POC002, Point of Care Critical Results Reporting Policy.

Evaluation of timeliness of Point of Care reporting and audits Point of Care (POC) audits are completed to measure compliance with documentation requirements for POC critical values and reported to the Point of Care Steering Committee.

Exclusions to this policy When approved by the Medical Staff Executive Committee, specific critical results may be exempted from this policy:

1. If a critical value or critical result is consistent with three (3) prior values or critical results that have been performed within a seven day period and while the patient is assigned to the same service and attending physician;

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2. If the critical value or critical result is consistent with the previously reported outpatient result; or

3. Any critical value with an approved specific protocol in place. The use of the protocol represents the communication and documentation to the physician or licensed care provider i.e., Insulin, Heparin, etc.

4. An order placed in the medical record by the physician or licensed care provider for treatment of the critical lab value serves as the communication and documentation of appropriate notification.

References A08-030, Hand-off Communications

A08-060, Development of Clinical Guidelines and Pathways;

A08-290, Patient Care Orders;

NU01-05, Nursing Responsibilities and Relationships with Medical Staff.

NU01-06, Communication Guidelines for Nursing Personnel;

NU08-06, Medical Orders;

The Joint Commission’s National Patient Safety Goal 02.03.01: Critical Tests, Results, and Values

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Persons and Sites Affected Enterprise Chandler Good Samaritan Kentucky Children’s Ambulatory Department

Policies Replaced Chandler HP Good Samaritan Kentucky Children’s CH Ambulatory KC Other

Effective Date: 4/15/2015 Review/Revision Dates: 3/2012; 4/15/2015

Approval by and date:

Signature Date _______________ Name Patty Hughes, Nursing Director, Oncology Services, Review Team Leader

Signature Date _______________ Name Barbara Bush, Administrative Manager, Clinical Laboratories

Signature Date _______________ Name M. Denise Quandt, Administrator, Department of Radiology

Signature Date _______________ Name C. Darrell Jennings, MD, Chair, Department of Pathology

Signature Date _______________ Name M. Elizabeth Oates, MD, Chair, Department of Radiology

Signature Date _______________ Name Marcus Randall, MD, Chief, Ambulatory Services

Signature Date _______________ Name Colleen Swartz, Chief Nurse Executive

Signature Date _______________ Name Bernard Boulanger, MD, Chief Medical Officer

Signature Date _______________ Name Anna L. Smith, Chief Administrative Officer

Signature Date Name Michael Karpf, MD, Executive Vice President for Health Affairs

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