Critical Values - January 2009 - (Page 35) Volume 2 • Issue 1 • January 2009 “I would suggest periodically sampling a few records for the required reporting interval, focusing on high-volume or problematic tests first,” adds Peck. “If you have some evidence of occasional monitoring of this interval and action taken when a problem is identified, that will be satisfactory for compliance.” Defining Turnaround Time “Many people fall into the trap of thinking in the lab silo,” Dr. Garon says. Karin Olson “The lab may handle the specimen only for a portion of the time, so laboratories consider the TAT only what happens in the lab. But the larger institution, namely, the hospital, has responsibility for the entire TAT. “For critical tests, if an institution is measuring only the time in the lab, then it is not measuring the whole TAT,” says Dr. Garon. “The clock starts when the test is ordered and ends when the results are in the hands of a licensed caregiver. The lab might not be responsible for all aspects of TAT, but the larger hospital is responsible for the whole TAT. “In my institution, tests in the emergency room are drawn by nursing, so delays in the pre-analytical phase are unlikely to be caused by the lab. Those delays are still part of the turnaround time, and the institution needs to measure and improve it. The institution should look at the different phases of TAT—pre-analytic, analytic, and post-analytic—separately, because that’s a good way to identify problems. The lab might contribute data on only two or three of these phases, but often Anthony Kurec all the data are captured by the laboratory information system.” doctor several times a day to report these values when it isn’t necessary.” The Joint Commission allows for this as long as an organization has a policy stating when critical values in chronic patients need to be called back. One way to overcome this is to raise the threshold of critical results. “Studies show that by changing thresholds, such as in the dialysis clinic, hospitals can decrease unnecessary phone calls to doctors and costs,” says Kurec. Another approach would be to customize critical values based on which department orders the test. “Lots of doctors would like critical values to be more customized for their patient populations,” says Karin Olson, MT(ASCP), program associate for quality, University of Iowa Hospitals and Clinics, Iowa City. But that’s not so easy for nurses. “From the nursing perspective, the more a hospital can standardize the process of reporting results from department to department and test to test, the more success they will have,” says King. “Nurses work in more than one department. The process should be the same regardless of the department.” Once the laboratory staff reports a critical value to the licensed caregiver, the hospital must have a mechanism for evaluating when the physician actually received the information and when treatment or action was taken, says Olson. “Once the licensed caregiver has the critical value report, it is sometimes difficult to identify in the patient’s chart the action taken as the result of a critical value report. The appropriate action can vary depending on the patient circumstances or condition.” Olson’s laboratory tries to avoid multiple exceptions to the critical values calling policy. “Introducing multiple exceptions into a process creates more opportunities for staff to forget or confuse the exceptions,” she says. Ideally, a laboratory information system would have the ability to have multiple critical value lists based on location or service unit, Olson says. “Having a computer system that can flag critical values based on different sets of parameters or rules is more reliable than having humans trying to remember all the different rules.” Other Challenges Challenges Posed by Chronic Conditions Hospitals are challenged by patients with chronic conditions who have abnormal values as defined by the hospital but are within the “normal” range for that patient, says Denise King, RN, MSN, CEN, president of the Emergency Nurses Association. For example, if a patient is admitted with diabetic ketoacidosis, 400 mg/dL or higher may be a critical value on a blood glucose test. There is going to be a period of time when the patient’s sugar is higher than that critical value. “The hospital must be able to articulate a policy that anything higher than that value is not going to be a critical value for that particular patient,” King says. “If a blood sugar is done every 30 minutes, you don’t want to call the Ms. Stat is a freelance health writer based in Northbrook, IL. 35
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