Improving critical value reporting has been in the quality spotlight in recent years, particularly since 2004, when it was included as one of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) National Patient Safety Goal. Under this JCAHO standard, health care organizations must track and improve not just the timeliness of reporting, but also the receipt of test results. But these values often get delayed—if the laboratorian can’t locate a physician, for example—or even incorrectly reported. Recently, an analysis of over 37,000 consecutive reportings of critical values was published and in this issue of Strategies, two of the lead study authors share what they identified as factors behind delays and their advice for improving the accuracy and efficiency of critical value reporting.
Over the past three years, representatives from Massachusetts General Hospital’s (MGH) nursing, administration, and laboratory departments, as well as physicians, have been reviewing their critical value reporting to “sew up some of the process’s loose ends,” according to Kent Lewandrowski, MD, one author of the study, which was published in a recent issue of the American Journal of Clinical Pathology [2006; 125(5):758:764]. This review included defining critical values, determining how the ranges are set, and how the values are then documented and communicated to the caregiver.
Looking at the appropriateness of critical value ranges was one of the first steps, explained Lewandrowski. Although there are unofficial national standards for critical values, he added that it was helpful to examine national data on these ranges, including the mean, median, and standard deviation for a number of different hospitals. This information can be found in the recent edition of The Tietz Textbook of Clinical Chemistry and Molecular Diagnosis (www.aaccdirect.org/ProductCatalog/Product.aspx?ID=3603). One example of this variance is the different glucose values that hospitals use to determine “critical” hypoglycemia. “Glucose values to determine critical hypoglycemia can vary from less than 60 to less than 40 mg/dL,” said Lewandrowski, who is the Associate Chief of Pathology at MGH. “If you start to look at the glucose values coming out of your lab, there are an awful lot of values between forty and sixty. So we wanted to ask ourselves how to define these ranges to avoid making frivolous and unnecessary calls while ensuring that the truly important ones get called every time.”
After refining critical value ranges, the MGH team analyzed how the lab communicated the values to the physicians. This proved to be challenging, particularly for outpatients.
“Inpatients are straightforward, they are in a fixed location, so there is always a person to take the phone call of results,” said Lewandrowski. “The biggest cause of delays is in the outpatient arena. That’s because practices located away from the hospital tend to send in specimens that arrive in the evening. By the time they are analyzed, practices are closed. The more outpatient settings we served, the more complex the set of permutations to track the physician down.” MGH is extensive, with 898 beds and primary and secondary outpatient practices from throughout the Boston area. With over 2,000 physicians in the MGH system, it can be hard for laboratorians to even determine the appropriate physician to contact. The team soon realized they needed to clarify the protocol for locating doctors to avoid situations, for example, when a laboratorian gets a critical potassium value but can’t determine the attending physician or practice.
One possible solution was to use technology and LIS applications to locate doctors and communicate critical values. All necessary data is in the system, such as the identity of the patient and what values are critical, explained Anand S. Dighe, MD, PhD, one of the study’s authors from MGH’s Department of Pathology. But this simple task breaks down quickly in real life. Once again, if it’s unclear who the ordering physician is or where he is located, any software application will be useless. In addition, JCAHO requires that the lab get an acknowledgement from the physician that he has received and understood the result.
“Once you page the physician, you are absolutely obligated to make sure that they got that page, make sure they understood that page, and understood that information,” said Dighe, adding that one solution might be a two-way paging system. This would save laboratorians a lot of time, particularly since the lab makes about 37,000 critical value phone calls a year.
“But right now, the phone offers us the best safety net that we have,” Dighe explained. “We want to investigate if can we do both, such as getting the physician the alert through an automated page and then having the lab follow up with a phone call. Until we have a foolproof system, at least getting the information to the clinician quickly is valuable. But until we have an airtight list of responding clinicians, and an airtight way of getting the acknowledgment back to the lab, we’re still going to be stuck on the phone.”
Keys to Success
As a result of this analysis, MGH’s lab currently reports a majority of its critical values within 30 minutes with successful communication to the caregiver. The team also set up documentation procedures and a monitoring process that looks for outliers, as well as strategies to eliminate outliers.
In addition to the turnaround guidelines, the hospital implemented a policy to address situations when a doctor—or even an outpatient—cannot be found. Now, laboratorians have a clear protocol on how long to try contacting the physician, and when to get additional help, which at the extreme may include having the medical director call the local police to locate patients and transport them to the emergency room for evaluation.
These types of emergency situations are why it is important to get support from top hospital management, even before undertaking this type of critical value reporting analysis, explained Lewandrowski. Extending the reach of the lab to the outpatient arena, as well as other hospital departments, is vital, so all providers should be represented in the effort. “The other key was getting nursing involved, since the nursing staff has the same concerns that we do about critical values and patient care,” said Lewandrowski. “Forming an interdisciplinary team was really a key to our success.”
For more information:
JCAHO’s Joint Commission Resources recently published a book on critical value reporting. Getting Results: Reliably Communicating and Acting on Critical Test Results offers ideas and lessons on meeting JCAHO’s National Patient Safety Goal related to timely communication of critical values. Visit www.jcrinc.com for more information.
Julie McDowell is the Editor of Strategies. She can be reached by email.