OCONEE REGIONAL HEALTH SYSTEMS, INC.
POLICY AND PROCEDURE
OCONEE REGIONAL MEDICAL CENTER
SUBJECT: Reporting of Critical Test Results
POLICY: ADM-PC-060
and Alert Values
Applies To: All Clinical Departments
Approved By: Chief Operating Officer
Revision Date: May, 2008
Department: Administration
=====================================================================
PURPOSE:
To identify and establish the responsibilities of personnel reporting and receiving critical test
results; to define critical tests and alert values; to list the critical tests and values for particular
departments; to define the acceptable time for reporting these results to the responsible licensed
caregiver; and to describe the process of reporting the Critical Tests/Values and identifying to
whom they are to report.
DEFINITIONS:
Critical Test: means a test ordered for a patient with potentially life threatening symptoms
which can narrow down a differential diagnosis and assist the physician in determining the
appropriate course of action. They are reported even if within normal limits. These tests are
usually ordered STAT.
Alert Value: means a value 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.
Responsible Licensed Caregiver: means within the scope of their practice and in accordance
with organizational policy, practice protocols or guidelines the following may receive and act on
a critical result; a Nurse Practitioner (NP), Physician’s Assistant (PA), Registered Nurse (RN),
Pharmacist or Licensed Respiratory Care Practitioner (RCP).
POLICY:
It is always preferable for the results of Critical Tests and Alert Values to be reported directly to the
ordering physician.
The performance of critical tests/procedures as defined by this policy is given priority over
routine tests. They may or may not be designated as STAT.
Critical test results (normal or abnormal), as defined by this policy, must be communicated to
the responsible licensed caregiver ASAP but not more than 1 hour of being ordered.
Alert Values must be communicated as soon as possible from the time they are recognized or
with in 1 hour to the responsible licensed caregiver.
SUBJECT: Reporting Critical Values / Results
POLICY: ADM-PC-060
PROCEDURE:
I.
Include ordering physician’s name on every order.
II.
Follow department protocol to expedite the performance of the test.
III.
Prior to the performance of any diagnostic test, validate the correct patient by using two
identifiers.
IV.
If the hard copy of the test result/value is not available for the responsible licensed
caregiver to view, they will write down the results and read it back to the technologist or
technician.
V.
The technician will document the notification including the time, date, and who
communicated and received the critical value/result in the medical record.**
** Exception - Physician to physician communication. A record of this communication
will be done via dictation.
VI.
CARDIOPULMONARY CRITICAL TESTs (as defined by this policy)
A.
B.
C.
D.
VII.
ABG’S
EKG’s
ECHO
Ultrasound
CARDIOPULMONARY ALERT VALUES
A. ABGs
CRITICAL ABG
INDICATORS
UNITS
LOW
LIMIT
HIGH
LIMIT
PaCO2
mmHg
21
66
Ph
-
7.21
7.59
PaO2
mmHg
45
-
B. EKGs
1.
2.
3.
4.
5.
PVCs >3 in a row
Blocks
Tachycardia >120bpm
Bradycardia <40bpm
Supraventricular Tachycardia
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SUBJECT: Reporting Critical Values / Results
POLICY: ADM-PC-060
6. Ventricular Tachycardia
7. Acute changes ST elevation or automated interpretation of EKG as Acute MI
C. PULMONARY FUNCTION ALERT VALUES
1. FeV1 < 1.0L
2. Bronchial Provocation: ≥20% decrease in FeV1
D. CARDIAC ULTRASOUND ALERT VALUES
1.
2.
3.
4.
Pericardial effusion with associated RV collapse
Ejection fraction (EF) <20% or change in EF
Acute Valvular Insufficiency
Severe Aortic Stenosis or Mitral Stenosis
PROCEDURE:
A. Communicate results to the physician, primary nurse, or respiratory therapist.
B. Abnormal EKGs or ABG results must be communicated within 15 minutes
after results are known.
** Note: Dr. Wesley King requests all ABG’s ordered by him be called
directly to him, even if results are within normal limits.
C. Attach a comment in the LIS (Laboratory Information System) or progress
notes that indicates to whom the critical limit results were communicated,
noting “R&V” after having the party repeat and verify the results.
VIII. RADIOLOGY
A.
CRITICAL TESTS (as defined by this policy)
1.
2.
3.
4.
5.
B.
Chest X-ray
Ultrasound (abdomen/pelvis or testicular)
Head CT
Chest CT
CT (abdomen and/or pelvis)
CRITICAL ALERTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
Aortic Dissection
Bowel Perforation with Free Air
Esophageal or Bronchial Obstruction
CVA, Brain or Spinal Cord Mass or Bleed
Ectopic Pregnancy
Leaking Aortic Aneurysm
Life Threatening Misplaced Tube or Line
Ovarian/Testicular Torsion
Pulmonary Embolism
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SUBJECT: Reporting Critical Values / Results
POLICY: ADM-PC-060
10. Significant Solid Organ Laceration
11. Spinal Cord Compression or Injury
12. Tension Pneumothorax
13. Cardiac tamponade
14. Pericardial effusion with or without cardiac tamponade
15. Acute congestive heart failure
16. Myocardial rupture
IX.
LABORATORY ALERT VALUES
A.
HEMATOLOGY
1.
2.
3.
4.
5.
6.
7.
8.
WBC
<1,000/mm3
Platelets
<30,000/mm3
Hemoglobin
<6 mg/dl
Hematocrit
<15
INR
Partial Thromboplastin (PTT)
Heparin PTT
< 66
Manual Diff
instance only
9. Malaria smear
B.
>35,000/mm3, First instance only
>1000,000/mm3, First instance only
>20 mg/dl
>60
>4.1
>95
>120
Blasts or Malignant cells, first
Positive
CHEMISTRY AND DRUG LEVELS:
1. Glucose
2. Sodium
3. Potassium
4. CO2
5. Calcium
6. Magnesium
7. Phosphorus
8. Ammonia
9. Bilirubin
10. TSH
11. CKMB
12. Troponin
13. SGOT
14. SGPT
15. BUN
16. Creatinine
17. Acetaminophen
18. Digoxin
19. Ethanol
20. Gentamicin
21. Phenobarbital
<40 mg/dl
<120 mEq/L
<2.5 mEq/L
>400 mg/dl
>160 mEq/L
>6.5 mEq/L
<15 mEq/L
<7.0 mg/dl
>13.0 mg/dl
<1.0 mg/dl
>5.0 mg/dl
<1.0 mg/dl
>9.0 mg/dl
>100 First instance only
> 15
>50 First instance only
Elevated, First instance only
Elevated, First instance only
>500 First instance only
>500 First instance only
>100 First instance only
>5 First instance only
>50 First instance only or higher than previous
>2.5 ng/ml
>400 First instance only
P>10.0 mcg/ml- CALL TO PHARMACY
T>2.5mcg/ml - CALL TO PHARMACY
>40 mcg/ml
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SUBJECT: Reporting Critical Values / Results
22. Phenytoin
23. Procainamide & NAPA
24. Quinidine
25. Salicylate
26. Tegretol (Carbamazepin)
27. Theophylline
28. Valproic Acid
29. Vancomycin
30. HIV-1 antibody screen
C.
RPR
Rotavirus
RSV
AFB culture and smear
5. Blood cultures
6. C. Diff
7. Cryptococcus antigen
8. CSF & Body
Fluid Smear & Stains
9. Hemophilus influenza
antigen
10. Neisseria Meningitidis
Antigen
11. Stool Cultures
12. OR Gram stains
13. Surveillance swabs
14. Wound Cultures
Reactive
Positive
Positive
Positive, First instance only, complete notification
when ID is received from reference lab.
Positive, first instance only unless subsequent stains
are different from original*
Positive, First instance only
Positive
Malignant cells or Blasts, Positive gram stains or
fungus, positive India Ink preparations
Positive
Positive
Positive for Salmonella, Shigella, Yersenia,
Campylobacter, Vibrio, E Coli 0157**
Positive
Positive for VRE, MRSA, VRSA
Positive for clostridium
BLOOD BANK
1. Cross match
2. Antibody Screens
3. Antibody screen
during pregnancy
E.
>30 mcg/ml
>30 mcg/ml
>5 mcg/ml
>30 mg/L
>15 mg/dl
>20 mcg/ml
>100mcg/ml
P >26 mcg/ml- CALL TO PHARMACY
T>10 mcg/ml- CALL TO PHARMACY
Reactive
MICROBIOLOGY
1.
2.
3.
4.
D.
POLICY: ADM-PC-060
No match, Incompatible prior to surgery or
significant delay in testing
Reactive
Positive (one causing HDN)
PROCEDURE: ALERT VALUES will be called directly to the responsible
licensed caregiver within 1 hour. For more specific instructions: see Laboratory
Policy LAB-GEN-1007: Alert Values.
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SUBJECT: Reporting Critical Values / Results
POLICY: ADM-PC-060
F.
DOCUMENTATION: Documentation of when, to whom and “read back and
verified” must be entered into the medical record. The information may be
entered via the Laboratory computer system or noted in the Progress Notes or
Nurse’s notes as applicable.
G.
PERFORMANCE MONITORING:
1. A review of 50% of all critical tests WITH CRITICAL RESULTS will be
done by the Patient Safety Committee or their designee. The threshold is 97%
of critical tests were completed and the results reported to the responsible
licensed caregiver with in 1 hour.
2. A review of 100% of all laboratory alert value turn around times will be done
by Lab. The threshold is 97% of alert values are reported with in 1 hour to the
responsible licensed caregiver.
REVIEW RESPONSIBILITIES:
Patient Safety Committee
FORMS:
None
REFERENCES:
JCAHO 2005 National Patient Safety Goal 2b
LAB-GEN-1007: Alert Values
LAB-GEN-1012: Reporting of Amended Results
* LAB-MC-462: Positive Blood Culture Physician Notification
** LAB-MC-490: Rapid Identification of E. Coli
ORMC Cardiopulmonary policy # 01-23-03
ORMC Radiology policy # RAD 8 b “Reporting Critical Results”
Reporting of Amended Results - Consult LAB policy LAB-GEN-1012: Reporting of Amended
Results.
Medical Laboratory Observer Clinical Laboratory Reference, Table of Critical Limits
APPROVAL SIGNATURES:
_____________________________________
___________________________________
Chair - Patient Safety Committee
Chief Operating Officer
_____________________________________
___________________________________
Chief of Staff
Policy and Procedure Committee
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SUBJECT: Reporting Critical Values / Results
Date of Origin: December 2003
Revision Date: May 9, 2008
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POLICY: ADM-PC-060