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Ask the Expert: Because physicians are so difficult to reach, how can you ensure that critical test results are communicated to them in a timely manner?

Accreditation Connection, June 6, 2005

1. Decide which results are critical and how soon they must be communicated

It's important to prioritize the lab values, "otherwise the lab will end up calling the physician too much, and the physician will end up ignoring their calls," says David Bates, MD, MSc, chief of general medicine at Boston's Brigham and Women's Hospital and medical director of clinical and quality analysis for Partners HealthCare System.

Brigham and Women's Hospital assigned test results and values to one of the following three categories:

 Red results are life-threatening emergencies that must be communicated to the physician and acted upon immediately. These include blood counts that have changed significantly, low potassium readings, or an unstable spine fracture.
 Orange results-such as low levels of cortisol, an atrial fibrillation or flutter, or cardiac tumors-require clinical action within six to eight hours.
 Yellow results require clinical action within a few days. These include a biopsy finding that suggests a malignancy, and any new bone fracture.

2. Keep your red list short

This is an extremely difficult task but a key one. The shorter the list, the more likely physicians will support your efforts to contact them.

Bates and a team of clinicians found that too many red results makes it tough to gain physician support. And although they're working to whittle it down, Bates stresses that hospitals "need to do what's best for the patient, not what's best for the physician."

3. Contact the primary physician whenever possible

Lab technicians, pathologists, and radiologists often provide critical test results to a nurse, either by telephone or fax, and assume that the nurse will convey the results to the physician as soon as possible. But this important information sometimes slips through the cracks, says Bates.

Labs must report all critical lab values directly to a responsible licensed caregiver within time frames established by the laboratory. When the patient's responsible licensed caregiver is not available within the time frames, there must be a mechanism to report the critical information to a designated back-up.

4. Develop a way to easily identify and contact the primary physician and how to contact them

Centralize and empower the hospital's communication center to serve as the repository of call schedules and notification operations.

Brigham and Women's Hospital uses an electronic sign-out system that helps hospital staff determine who is covering for any given physician. Of course, the information that staff can access is only as good as the data that physicians enter into it, but the system has improved communication. "Our challenge is to make it clear about who is taking care of a patient at any one time," Bates says.

5. Develop a fail-safe way to communicate critical results when the primary physician is not available

Implement a time-tracking system that will prompt lab staff or a nurse to identify an alternate person when the patient's primary physician can't be tracked down, suggests Bates. Then, identify someone else who can act upon a patient's critical test result, such as the chief of pathology, an intensivist, or someone on the code team.

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