THE QUALITY - CO$T CONNECTION

Don't fail to communicate critical test results

Compliance continuing to be problematic

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

It could be a routine preoperative check X-ray that shows a suspicious-looking lesion or a STAT blood test suggesting a potentially virulent infection. The test results must be communicated to the ordering physician. When critical test results are not received by the physician in a timely manner there can be tragic results. In 2005 The Joint Commission added a National Patient Safety Goal requiring improvements in the communication of critical tests and test results. This is essentially a performance improvement goal. Hospitals must measure, assess, and improve (if appropriate) the reporting of results. Recent data from Joint Commission surveys show that compliance with these requirements continues to be problematic.

To comply with this patient safety goal, each diagnostic area must identify critical tests and critical results. Be sure to include input from attending physicians in this process to ensure everyone is in agreement as to the definition of "critical." Some hospitals use the following definition: any test or test result that would immediately change the course of care. For instance, a head CT scan of a trauma patient or an oxyhemoglobin in the case of suspected carbon monoxide poisoning — these would be critical tests given the clinical situation. Critical results are different. It is the results, not the test itself that is critical. For example, an electrocardiogram might not be considered a critical test; however, the results are critical if the study reveals a potentially dangerous arrhythmia that requires immediate intervention.

It is not necessary for each diagnostic area to have an extensive list of critical tests or test results. Hospitalwide there may be as few as five to six tests or results that are considered critical. Don't get bogged down in creating a comprehensive list. It is better to take a gradual approach and over time refine the list. It should be considered a "work in progress" in keeping with the intent of ongoing performance improvement.

Critical tests are probably the most difficult to identify because the patient's clinical condition must be taken into consideration and not just the test. For instance, a head CT head for a patient with a possible concussion may not be as critical as the same test done for a patient who has obvious head trauma. Rather than identify specific tests, some hospitals use the following definition: A critical test is defined as a STAT test with critical values/results or other results that are determined by the diagnostician to be critical to the patient's subsequent treatment decisions. Other hospitals have selected specific tests and designated them as critical. Examples include:

  • CT head scan to rule out subdural hematoma or as part of a stroke protocol;
  • chest X-ray after central line placement to rule out unexpected pneumothorax;
  • chest X-ray to evaluate endotracheal tube position;
  • CT spine scan ordered to rule out fracture in trauma cases.
  • arterial blood gas showing the following results: pH <7.20 & >7.50, PaCO2 <20mmHg & > 55mmHg, or PaO2 <55mmHg;
  • cerebrospinal fluid gram stain;
  • pathology frozen section.

In addition, some hospitals allow the physician to designate any test as critical at the time of ordering. It is also important to acknowledge that the diagnostician should immediately initiate physician contact for any condition that appears to need prompt treatment.

Once you've identified tests and values that are considered critical, establish turn-around targets for each. Start by gathering some baseline data about current practices. What you want to know for critical tests: average time from order of the test to time of report. What you want to know for critical values: average time from identification of critical value to time of report. Then ask the reporting department and receiving physicians to agree on the definition of a "prompt" turn-around for each test or value. If you begin with just a list of the most critical tests and results, it is easier to establish expected turn-around times. If your initial list includes some tests or results that are considered by some to be less critical, turn-around targets may be harder to agree on.

For critical tests, an acceptable turn-around (from order to report) must be defined. This includes identifying how quickly critical tests must be completed by the diagnostic service and how quickly the results must be reported. Depending on the test, the reporting of results might be anywhere from a few minutes to an hour. For example, the ordering physician should be immediately told if a patient's radiology exam shows any of the following: endotracheal tube in bronchus, tension pneumothorax, ruptured aneurysm, saddle emboli, significant intracranial bleed, cervical spine fracture, or unexpected free intraperitoneal air. In less urgent situations, such as a hemoglobin of less than 6g/dl for an adult patient, it may be sufficient to notify nursing personnel or the ordering physician within 30 minutes.

Periodically revisit your list of critical tests and test results and make incremental changes either based on patient safety concerns, when new tests become available, or when technological advances allow for even faster reporting.

Educate all stakeholders in the turn-around expectations and then regularly gather and analyze information to determine how often targets are being met. It is important that all steps in the reporting process are defined and the steps are documented so that timeliness data can be gathered. For example, make it clear who is responsible for calling the nurse with critical laboratory results and what the nurse is responsible for documenting in the patient's record. Often hospitals require the date and time the results were communicated and the name and title of the person who called the nurse with the results. Also define how quickly the nurse is to communicate the results to the ordering physician and how this communication is documented and what to do if the ordering physician cannot be contacted within the required timeframe.

Tests performed in services such as radiology require interpretation by a physician with subsequent reporting of the results. In these circumstances, you'll need to document the time the test was completed, the time when it was read by the radiologist, and the time the results were reported to the ordering physician. If the process is not entirely electronic, each time increment will need to be manually entered into a log or on the report itself.

Joint Commission surveyors assess compliance with this safety goal and related standards by reviewing patient care records and determining the degree of adherence to the recommendations. Surveyors will want to see your list of critical tests and critical results/values, the target turn-around time for the tests and value, and your measurement strategies. Because this patient safety goal has been in place since 2005, Joint Commission surveyors will expect to see you've got at least 12 months of timeliness data and the data are being used to make turn-around improvements.

Resource

Communicating Critical Test Results Toolkit. Massachusetts Coalition for the Prevention of Medical Errors. Available at: www.macoalition.org.