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Critical lab value reporting more challenging in ED
Your process must be consistent
Failing to document that a critical lab value was read back, if your ED's policy requires this. Failing to realize that there are long delays in reporting urgent test results to ED physicians.
These are both common violations of The Joint Commission's requirements for reporting critical lab values that involve emergency nurses.
Because the ED receives a much higher volume of lab values that are considered "critical" compared with other hospital units, it's particularly important that your process is consistent, says Megan Sawchuk, MT (ASCP), The Joint Commission's associate director of standards interpretation. "EDs are obviously more likely to have critical values that require taking immediate action," she says.
To comply with The Joint Commission's requirements, ED nurses must verify critical test results given to them by reading back the results and then confirming the results with the person giving the information. Here are problems surveyors have identified at some EDs:
• Confusion over the definition of a critical result. "Understanding the difference between the two is something that people still struggle with," says Sawchuk.
Critical results are any test results that require immediate attention, including imaging studies, lab tests, electrocardiograms, or other diagnostic tests. A critical test is any test that is needed for the immediate care of the patient requiring rapid communication of results, even if the result is not life-threatening, so EDs usually will consider all "stats" as critical tests, Sawchuk explains.
• Failure to measure the time interval from when the nurse became aware of the result to the physician being informed. "Most often when there is a reporting problem in an ED, it's a failure in communication after the result is reported to the nurse," says Sawchuk. "Without measuring the interval between the nurse and physician, you won't know if you have a delay in that reporting process."
It's acceptable to perform a random audit of a percentage of charts, rather than auditing 100% of charts, she adds.
• Failure to follow documentation requirements. Although The Joint Commission doesn't have a specific requirement for documentation of critical values, many EDs fail to follow their own policies consistently, says Sawchuk.
"On the nursing side, documentation tends to be inconsistent," she says. The ED's policy might use "RB" as a code to indicate the read-back was done, but nurses don't always write that next to the critical value even though they might have done it, she explains.
Below are the steps taken by ED nurses at Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY, says Ann Heywood, RN, BSN, SANE, the ED's clinical practice coordinator:
— Nurses assess all results received. Critical values received by phone are read-back to the person reporting the results.
— Nursing reviews the medical record for pertinent information related to the critical result, such as previous lab results or medications. The patient is assessed immediately for complications.
— The ED nurse notifies the ED physician immediately of all critical values called into the department. Nurses document the date and time the physician was notified.
Process at one hospital
At Borgess Medical Center in Kalamazoo, MI, the lab gives the critical value to the ED charge nurse. "That value, and the name of the individual who received the call, is sent to the ED," says Ken Lanphear, RN, BSN, an ED nurse. The charge nurse notifies the ED attending physician, as well as the assigned nurse, Lanphear says. "The system works well for our department," he says.
If the patient already was discharged, the charge nurse fills out a form documenting the notification and action taken, he says. "Otherwise, there aren't any firm timelines for notifying the ED physician," says Lanphear. "The name of the person who took the call from the lab is on the lab printout, as well as the time of the call."
At Edward Hospital in Naperville, IL, ED nurses were taken out of the process entirely. "The lab calls the ED and usually speaks to the unit clerk, who in turn forwards the call to the ED physician," says Lisa DiMarco, RN, BSN, MBA, CEN, administrative director for emergency services. The physician then documents the result in their dictation, DiMarco says.
In the past, the lab would contact the ED, and a nurse would take the result and inform the physician. To improve the notification process, a hospitalwide decision was made to document the finding in the electronic medical record, says DiMarco. "So in the ED, we decided not to involve nursing, but instead, to have the lab contact the ED physician who then enters the information into their dictation. It saves a step or two," she says.
For more information on reporting critical lab values in the ED, contact: