August 11, 2005

In This Issue . . .

Test Results Delivered after Hospital Discharge are Cause for Patient Safety Concern
Julie L McDowell

Typically, patients look forward to being discharged from a hospital, but what they don’t know is that all of their lab results may not have reached their attending physician, according to a recent study conducted in two Boston academic tertiary care hospitals. Attending physicians may never find out about these potentially actionable results that could influence diagnosis and treatment, which could be addressed in follow-up visits or communicated to the physician’s primary care physician (PCP). These findings highlight the lack of communication among health care providers—one of the many weaknesses stoking patient safety concerns in hospital settings. This month, Strategies examines how medical test results can fall through the cracks and the increased pressure on laboratorians to identify—and communicate—critical values.

Every day, hospital laboratorians conduct tests on thousands of patients’samples, the results of which are intended to be viewed and acted upon by physicians. However, Boston researchers recently found that after following 2,644 consecutive hospital patients discharged from February to June 2004, 41% had test results return after they left the hospital, out of which 9% were potentially actionable, according to a study published in the July 19th issue of Annals of Internal Medicine (2005;143:121-128). In addition, follow-up surveys with the patients’ attending physician and PCPs found that not only did the physicians not know of the actionable results, they often weren’t aware that the test had been ordered.

How can this happen? “Most of the physicians we surveyed were attending physicians on academic medical services, so the team that they work with includes residents and interns, with the attending physicians generally in a teaching and supervisory role,” explained lead researcher Christopher L. Roy, MD, an internal medicine physician at Brigham and Women’s Hospital (Boston, Mass). “While the attending physician is taking care of the patient and needs to be fully aware of all of the patient’s details, he or she doesn’t do the order writing—it’s the intern that writes the test order. So there is the potential for the attending physician to not know about a lab result that was ordered.” One example would be if the intern noticed that a patient had anemia and ordered some blood tests to look at iron levels. The attending physician wouldn’t necessarily know that these tests had been ordered, so he wouldn’t know to notify the patient’s PCP if these results were pending at discharge.

According to Roy this situation is not uncommon when a patient is discharged, but he notes that this is the first study to quantify the volume and percentage of patients being discharged with pending test results, along with the clinical importance of those results that might cause attending or primary care physicians to alter treatment or care decisions. “Unfortunately, we found that with the results that were clinically actionable, even though there were only a small number, physician awareness was rather low,” he said. “This is a situation where you have a large volume of results and a lot of opportunities for missed communication or lack of communication among physicians. This means that better systems need to be in place to ensure that the physicians caring for these patients are informed of any results or any change in results after a patient goes home.”

The role of the clinical lab lies in each facility’s protocols for reporting critical values and then communicating these to the physician. But based on the results of Roy’s study, these values could be going unnoticed—either because they are not getting to the physician or the physician is so inundated with data that these critical values are overlooked.

Since this is the first close look at pending test results, it’s difficult to propose specific revisions. However, an electronic medical record (EMR) system would be one step to improvement. For example, since implementing an EMR system in 1996, Geisinger Health System in Pennsylvania is now electronically linked to its 55 clinical practice sites and two hospitals spread out over 38 rural counties. When patients are discharged, their pending test results are stored in their EMR, explained Conrad Schuerch, MD, Director of the Division of Laboratory Medicine, Geisinger Medical Laboratories in Danville, Pa., who added that it is the responsibility of the attending physician to communicate these results to the PCPs. All PCPs in the Geisinger network will have electronic access to all inpatient lab records, as do a subset of non-Geisinger physicians who have limited access to these EMRs. But for most non-Geisinger primary care physicians the in-hospital laboratory information must be communicated from the hospital physician, a process which would be hard to monitor, according to Schuerch.

Roy believes the resolution lies in distilling important from irrelevant test results and then setting up a “smart alerting system” to communicate with physicians. But discerning what is important requires some clinical knowledge of the patient’s medical history, meaning this would have to be a multidisciplinary approach rather than just an alerting system coming out of the lab’s IT infrastructure. “We found in our study that many of these test results were irrelevant, even though they were abnormal,” said Roy. “You don’t want to [irritate] physicians with frequent alerting, but coming up with a smarter system that only transmits legitimate alerts is a real challenge.”

Reader Follow-up:

Do you have any possible solutions? If so, please send them in an email to Julie McDowell, the Editor of Strategies.

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