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Communication of Critical Results and Critical Tests/Procedures (3.3.6)

Communication of Critical Results and Critical Tests/Procedures (3.3.6) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Communication

3.3.6


UW HEALTH CLINICAL POLICY 1
Policy Title: Communication of Critical Results and Critical Tests/Procedures
Policy Number: 3.3.6
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: November 15, 2016

I. PURPOSE

The purpose of this policy is to ensure that there is an effective communication of a patient's critical results
and critical tests / procedures between diagnostic service and clinicians caring for the patient within a
reasonable time for safe and effective patient care. This policy is to ensure that the appropriate
referring/requesting clinician is identified and able to be contacted with these results.

II. DEFINITIONS

A. Critical tests (includes critical diagnostic procedures): tests and procedures whose results warrant rapid
communication regardless of whether the results are normal or not. UW Health does not require all critical
tests to be reported verbally. The Laboratory's routine reporting process is sufficient for compliance.
B. Critical results: test and procedure results that fall outside a predetermined range so that rapid
communication to a responsible provider is necessary.
C. Providers: individual who can take action on the result
i. GME trainees: Physician with status of resident or fellow.
ii. Medical Staff: Attending physician or faculty.
iii. Advanced Practice Provider (APP)
D. First Instance Rule: For inpatients, the laboratory will call critical results the first time the limit is exceeded. A
new call is made every 7 days if the value for the test continues to be critical. Whenever a value falls outside
the critical range and then becomes critical again, a new call is made. Every call for a critical value starts a
new 7 day period. See UW Health Clinical Laboratories Critical Results and Tests for tests in which this rule
applies.
III. POLICY ELEMENTS

A. Critical results and critical tests/procedures and the appropriate reporting timeliness will be defined by the
performing departments per Appendix B. Critical results are reported to the ordering provider or licensed
staff member who can act on them generally within 60 minutes of when the result is available, unless
otherwise defined. The time frame and type of communication in which critical tests/procedures will be
performed and reported are unique for each test because of the variability in how these tests are ordered
and performed. The timeliness for reporting critical tests/procedures ordered for a future time will be
monitored from the time the test/procedure is performed. Critical tests/ procedures are not synonymous with
"stat" tests.
B. If the caregiver performing and/or interpreting the test or procedure is the provider who is also acting on the
results, they are exempt from this policy.
C. It is the expectation that every patient has an identified medical staff member and may have a designated
provider available for discussion of a test/procedure or result every minute of the day. The patient's bed,
unit, medical staff and provider will be assigned by virtue of their current clinical service. Outpatient areas
should have providers or residents on-call to handle results 24 hours a day seven days a week.
D. The institution has an electronic system that tracks all patients by patient service. This system will be
updated immediately whenever changes (patient service or service physician) occur. This updating should
be performed by a single appropriate service within the Institution.
E. The paging service is the desired method to locate the assigned and on-call provider for all services, and will
be best able to facilitate rapid communication between clinicians when test/procedure results need to be
provided to, or discussed with, the responsible clinician.
F. The expectation is that wherever possible all tests/procedures requested for a patient should be requested
via the Hospital electronic system and will identify the patient's clinical service at the time of the request.
While clinicians not serving on the patient's clinical service team may request tests/procedures for the
inpatient's clinical service, the responsibility for the result lies with the patient's clinical service physicians.
For example, if a test/procedure is ordered on a patient for whom you are the assigned service provider, the
result of that test/procedure is your responsibility. In outpatient areas the contact service for the results is
identified by the ordering service.
G. The request should list in addition to the responsible medical staff, the name of the clinician who places the



UW HEALTH CLINICAL POLICY 2
Policy Title: Communication of Critical Results and Critical Tests/Procedures
Policy Number: 3.3.6

order for the test regardless of whether that clinician is a member of the patient's clinical service team, a
clinician seeing the patient while on-call, or a clinician seeing the patient in consultation. This will allow the
responsible service staff to discuss the patient plan of care with the clinician who ordered the test and who
may have the unique clinical information relevant to the ordered test/procedure.
H. If the assigned clinical service provider is contacted by Paging and refuses to accept a patient's critical result
or critical tests/ procedures result, Paging will contact that clinician's (physician or otherwise) immediate
superior using Paging's existing developed hierarchical system. This hierarchy rises to Clinical Department
Chair and Vice President for Medical Affairs and assures that every critical or unexpected clinical
result/report will get to the appropriate clinician at any time of the day.

IV. PROCEDURE

A. General Procedure:
ξ The person calling with the critical test/procedure or critical result should identify the receiver,
preferably by employee position and ID number.
ξ If the caller deems the receiver is suitable to accept the information, the caller will document the
information provided as outlined in the caller's operating procedures.
ξ Staff receiving critical test/procedure or critical results must write them down, read them back, and
receive confirmation of the accuracy from the individual who communicated the information.
B. The acceptable time frame for communicating critical test results from the time the result is available to the
time it is communicated to an individual who can act upon that information, such as a responsible physician,
is within 60 minutes unless otherwise defined (see Appendix B).
C. Inpatients including observation patients: Results that are appropriate for Health Unit Coordinators (HUCs)
to communicate, such as critical laboratory results, will be transmitted directly to HUCs. The HUC will
communicate the results to the patient's nurse who then contacts the provider as appropriate and
documents in Health Link. Nurse clinicians will be the first line of communication on the unit in the absence
of a HUC. In situations where direct clinician contact is preferred or required at the caller's discretion (e.g.,
an unexpected important radiology finding) the calling party will request Paging to place him/her in contact
with the appropriate level of clinician. This will follow the procedures outlined by the paging service, including
the default times and hierarchical escalation of seniority when the call is not responded to or the clinician
refuses to accept the result/report. For inpatients where the first instance rule is followed, communication
and documentation of results is expected only for critical results called by the laboratory. Under certain
circumstances, the critical result may be an expected result by the patient care team and existing orders are
in place to treat the result. It is not expected that the results are communicated to the provider within 60
minutes in this circumstance.
D. Operating Room: All critical results coming from the OR will be called back to the OR. If the patient is no
longer in the OR, notify the ordering physician.
E. Emergency Department: Critical tests/procedures or critical results that originated in the ED will be called to
the ED. The call will be transferred to the physician caring for the patient. If the patient has been transferred
elsewhere in the hospital, the ED clinician will inform the caller of the patient transfer and new clinical
service. The caller will contact the appropriate service individual: HUC for urgent laboratory results and
provider for information requiring provider-to-provider transfer of information. When the clinical service is not
known or the patient is in transit, the ED personnel will be responsible for determining the appropriate
clinical service clinician and will contact that clinician with the test/procedure result to ensure that the
appropriate indication and result are provided to the clinician taking over the patient's care.
F. Discharged Inpatients: When the test/procedure request is made while the patient is an inpatient yet the
results become available after the patient is discharged, then the patient's discharging service medical staff
will receive the result, interpret it, and initiate the appropriate action. During regular service hours the caller
will contact Paging with the name of the attending physician or patient clinical service that ordered the
test/procedure. The Paging staff will page the service medical staff physician of record when the
test/procedure order was generated and if that physician is not available (away from the institution) then the
current discharging service medical staff will be contacted. If the result becomes available after hours, then
the discharge service's on-call medical staff will be paged for contact with the caller.
G. UW Health Outpatients: The caller may either contact the ordering clinician's identified service or clinic
directly (if known) with the results or contact Paging with the ordering physician’s identified service or clinic
to be put into contact with the clinic's listed professional staff that is designated to receive results. In
circumstances where physician-to-physician contact is appropriate, the caller may contact the ordering
physician directly, or contact Paging to be put into contact with the physician. After hours the clinic's on call



UW HEALTH CLINICAL POLICY 3
Policy Title: Communication of Critical Results and Critical Tests/Procedures
Policy Number: 3.3.6

physician will be paged.
H. Non-UW Health Clinics: The results will be called to the referral source contact number using data internally
arranged e.g., laboratory service.
I. UW Health Home Health: Follow Home Health policy 4.26 Waived Testing Staff Performance of Tests and
Equipment Calibration and 4.27 Communication of Lab and Test Results.

V. MONITORING OF TIMELINESS OF REPORTING CRITICAL TEST / PROCEDURES AND CRITICAL
RESULTS

Clinical areas involved in critical results and critical tests will do monthly sample audits. On a quarterly basis,
the timeliness of reporting critical results and critical tests will be reviewed by the Accreditation and
Regulatory Readiness Committee. Actions to improve the timeliness of reporting will be pursued if
appropriate.

VI. COORDINATION

Author: Director, Nursing Quality and Safety
Senior Management Sponsor: SVP, Patient Care Services and CNE
Reviewers: Administrative Director, Clinical Labs, Surgical Services Directors
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: September 19, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

Appendix A - Reporting Critical Lab Results Flowchart
Appendix B - Critical Result and Critical Test Table

IX. REVIEW DETAILS

Version: Revision
Next Revision Due: November 2019
Formerly Known as: Hospital Administrative policy #8.07