Quality Gaps in Communicating Laboratory Results
An Interview with Dana Grzybicki, MD
Dana Grzybicki, MD, is an Associate Professor of Pathology at the University of Colorado. A practicing pathologist with a wide-ranging interest in patient safety, she has written extensively on quality issues in anatomic pathology and laboratory medicine and has published seminal work on improving screening for cervical cancer. She currently receives funding from the CDC to perform a multi-institutional study on laboratory quality. Here, she talks about some of her early findings on how laboratories communicate test results.
Devery Howerton, MD, and Michael Astion, MD, PhD, conducted this interview.
Q: Based on your analysis of data from the labs in your study, what are the largest quality gaps in communicating test results?
A: There are several significant quality gaps: poor laboratory documentation related to success in communicating test results to care providers; failure to use data about result communication to drive continuous quality improvement (QI); poor communication with clinicians regarding what information they want to receive; and lack of data on the success of communicating critical lab values on outpatients to care providers.
Q: Can you give an example of poor documentation involving communication of critical test results?
A: In the institutions we studied, lab staff frequently did not record the name of the care provider who received the result. In addition, staff did not document how many phone calls had to be made to successfully communicate one critical result. Also, most labs did not monitor the time interval between the appearance of the critical result and the receipt of the critical result by a care provider who could act on it.
Q: Does the failure to use data to drive QI mean that labs frequently fail to use the data they collect?
A: Yes. For example, almost all the labs collect data regarding the percentage of critical values that were successfully communicated to a care provider, but many of the laboratories just warehouse these data and do not use it as part of a QI project.
Q: Can you give an example of poor communication with clinicians?
A: For example, most nephrologists do not want to be called about hypercalcemia values on patients with chronic renal disease unless a patient-unique threshold is reached. A large amount of time appears to be wasted by lab professionals making calls about lab values that fall within a predetermined critical range and yet have no impact on management or patient outcomes. In fact, these events often serve to negatively impact clinician-laboratorian relationships.
Q: Why do you specifically point out communication of test results on outpatients?
A: The outpatient setting is distinct from the hospital setting because for outpatients, there might be a single care provider responsible for receiving and acting on the critical result, and the patient may be at home, decompensating and not visible to the care provider. In the hospital setting, there are multiple care providers accessing the patient and the medical record; the patient is visible and is often being observed for signs of distress. Even if the critical value is missed, there are other clinical data being collected and analyzed on the hospitalized patient.
Q: Are reporting practices for lab critical values highly variable among the organizations you have studied? If so, what are some of the common variations?
A: Most of the labs have a reporting protocol for a set of “critical values” commonly recommended by accrediting organizations and professional societies, and most of these values are communicated through phone calls to a healthcare professional associated with the patient. However, there is great lab-to-lab variability regarding what specific values of a particular analyte are considered critical; which personnel are authorized to call critical values; which personnel are authorized to receive critical values; how receipt of the critical values is documented; and how the clinical actions taken as a result of the critical value are documented.
Q: Is there a specific problem regarding oral communication of test results that you find troubling?
A: A major problem is the lack of surety at the lab end that the correct provider got the information that was reported from the lab. Many times, a technician or technologist phones a result to a hospital ward and gives the result to whoever answers the phone or to another designated non-physician provider. The laboratorian has no idea if the information is going to be dropped or used in patient care. Even though a relationship of trust often exists between lab and clinical staff, the continued lack of a closed loop on results communication is problematic because it keeps the lab disconnected from patient care. Connection to the patient helps lab learn about patient care and helps give urgency to lab quality improvement.
Q: What types of solutions exist for these communication problems?
A: A number of lab informatics tools have been developed to address some of these problems. For example, a closed system has been developed whereby clinicians are automatically notified by pager when a desired lab result is available in the hospital information system. In some cases, the result is paged directly to a wide-screen pager. These systems are mostly experimental. They have rarely been used clinically, because their success requires care providers to accurately log in and out of the system to identify when they are on and off service. Errors regarding which care providers are actually working are common and cause the computer system to page the wrong person.
A more successful method, now in common clinical use, is e-mail notification to physicians. In simple systems, the e-mail may be used to automatically notify clinicians when results are ready for the physician to retrieve. In more advanced systems that use electronic medical records, results can be e-mailed to the physician's electronic inbox. This is especially useful for pushing abnormal results to the physician. One potential advantage of e-mail notification is that the lab may also request a return e-mail from the clinician, requesting notification of receipt of the lab result. This closes the loop on the result.
Q: Do you have any information on how often critical values resulted in changes in patient management?
A: We have nearly completed a study involving critical potassium values. In this study, more than 50% of the patients who had a critical potassium value underwent some change in their management—for example, a change in medication—as a consequence of the lab communicating the critical value. Clearly, a critical value was critical to patient care.
More on This Topic
Grzybicki DM, Raab SS. Measuring health care performance: identification and standardization of laboratory quality indicators. Am J Clin Pathol 2006;126 (S1):S48–S52.
Grzybicki DM, Turcsanyi B, Becich MJ, Gupta D, Gilbertson JR, Raab SS. Database construction for improving patient safety by examining pathology errors. Am J Clin Pathol 2005;124:500–9.
Grzybicki DM. Barriers to the implementation of patient safety initiatives. Clin Lab Med 2004;24:901–11.
Raab SS, Grzybicki DM, Zarbo RJ, Jensen C, Geyer SJ, Janosky JE, Meier FA, Vrbin CM, Carter G, Geisinger KR. Frequency and outcome of cervical cancer prevention failures in the United States. Am J Clin Pathol 2007;128:817–24.
Raab SS, Grzybicki DM. Anatomic pathology workload and error. Am J Clin Pathol 2006;125:809–12.
Poon EG, Kuperman GJ, Fiskio J, Bates DW. Real-time notification of laboratory data requested by users through alphanumeric pagers. J Am Med Inform Assoc 2002;9:217–22.
Matheny ME, Gandhi TK, Orav EJ, Ladak-Merchant Z, Bates DW, Kuperman GJ, Poon EG. Impact of an automated test results management system on patients’ satisfaction about test result communication. Arch Intern Med 2007;167:2233–9.