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Learn how to stay compliant with the new requirement for reporting critical test results and lab values

Accreditation Connection, September 10, 2004

Now that the new goals are finally out, we asked accreditation and patient safety experts to share their compliance tips for the new goals. Here's what that they had to say.

Goal #2c: This new requirement for reporting critical test results and lab values calls for organizations to measure, assess, and take action to improve the timeliness of reporting these results to the appropriate licensed caregiver.

You should already have a hospitalwide definition of critical test results. If you don't, you'll struggle with compliance for this goal, predicts Brenda Gail Summers, MBA/MHA, MSN, RN, CNAA, senior consultant with The Greeley Company, a division of HCPro in Marblehead, MA.

Once you have a definition, put a two-step process in place:

1. Acceptable measurements include total turnaround time or the time the test is completed to the time the result is called to the nursing unit/practitioner. Define an acceptable turnaround time frame for reporting, says Summers. Consider whether total turnaround time means from the moment someone writes the order until the result is back, or from the time an individual collects the specimen until he or she receives the result, or from the time an individual sends the specimen to the lab until he or she receives the result.

Example: If your hospital defines the expected turnaround time for a stat lab test as 20 minutes from the time the order is written until the result is back, but, in practice, this process exceeds 20 minutes, you're in trouble. To improve the process, break it down into the following five increments, monitor the time it takes to accomplish each, and then take action where necessary:

?  Order written to order received by the phlebotomist
?  Order received by the phlebotomist to specimen collected
?  Specimen collected to arrival in lab
?  Arrival in lab to test completion
?  Test completion to result called

2. Define your total turnaround time from when your lab receives the test results to when the provider who acts on the results receives the information, says Summers. Define whether this means the time the lab calls the nurse or from the time the nurse calls the physician. If the turnaround time exceeds your defined time period, break the process down into increments like you did in step one to figure out where you can make up the time.

Realize that critical test results apply to all diagnostic testing, including electrocardiograms, imaging studies, lab tests, arterial blood gases performed by respiratory therapy staff, and other diagnostic studies, says Sue Dill, RN, MSN, JD, vice president of legal services at Memorial Hospital of Union County in Marysville, OH. Part of this goal applies only to the lab-that all values defined as critical by the lab are reported directly to the responsible caregiver. This time frame must be established by the lab in cooperation with nursing and medical staff. If a licensed caregiver is not available to receive the results, your hospital needs a mechanism for reporting findings to an alternative caregiver.

Don't come up with a separate set of activities just because this is a safety goal, warns Glenn D. Krasker, MHSA, president of Critical Management Solutions, a consulting firm that specializes in medical error risk reduction in Wilmington, DE. Instead, follow the same processes your lab and radiology department have most likely used for years to improve your turnaround time.

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