Critical tests vs. critical results
Q. What exactly is meant by the term “critical results?” And what are the time frames that we should be measuring?
A. “Critical result” refers to both the results of a critical test and results with critical values. Organizations will need to make a distinction between "critical tests” and "critical results”. “Critical tests” are those tests which will always require rapid communication of the results, even if normal. The time interval to be measured should be from ordering the test to reporting the result to a clinician that can act on the result. "Critical results," also known as “critical values,” are test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests (e.g., “panic values” or “red-line values”). Measurement would be the time interval from the identification of the critical result to the receipt by the responsible licensed care giver.
Agents of the caregiver
Q. Do critical results have to be reported “directly” to the responsible licensed caregiver?
The ultimate objective is to report to the responsible licensed caregiver. Reporting critical results to an authorized “agent” of the responsible licensed caregiver will meet the requirement if the organization can demonstrate that there will be no significant additional delays in getting the test result to the responsible licensed caregiver so that the patient can be promptly treated. This last part is particularly important since the objective of these requirements is to avoid any unnecessary delays in treatment. It is the responsibility of the organization to demonstrate through data collection and analysis that this routing of the critical test report will not delay treatment.
Interpretive components of test results
Q. It is fairly easy to define “critical test results” such as laboratory values, but how should we define those test results that have an interpretive component?
For "critical results" that involve an interpretive component, it may be useful to develop a list of the more common findings that warrant rapid communication (e.g., “panic values” or “red-line values”) and add "other results that are determined by the laboratorian, radiologist, or other diagnostician to be critical to the patient's subsequent treatment decisions." If a subset of “critical test results” is not defined by the organization, surveyors will consider all verbal or telephone reports of diagnostic tests to be “critical.”
Non-laboratory testing
Q. Is the term “critical results” limited to laboratory tests?
No. The goal applies to all diagnostic tests including imaging studies, electrocardiograms, laboratory tests and other diagnostic tests defined by the organization as “critical”.
Chronically critical values
Q. When the patient has a chronic condition and the lab values are “critical” by our hospital’s definition but are actually within the “normal” range for that particular patient, the lab and nursing staff find themselves calling the same physician several times a day to report these values when it really isn’t necessary. Can we develop a policy for patients with certain chronic conditions that will allow the physician to define the “critical” levels of the lab values that should be reported for a specific patient?
A. Each health care organization may define for itself what the “critical values” are. Provisions may be made for certain patient-specific situations in which values that would be “critical” for most patients are not critical for a particular patient or for patients with a particular diagnosis. The parameters must be objectively defined and are known to all staff who are involved in the process of reporting values.
Repeatedly critical values
Q. When a repeat test value is still critical but is showing improvement, does it still need to be considered a “critical result” and reported in that time frame?
A. This is a matter of definition and each organization can define for itself the circumstances under which a test result is considered “critical.” It is permissible to define “critical results” differently for repeat tests. For example, this may be represented as different “panic value” limits for repeat tests or may be based on the direction of change in the subsequent test results. The default, however, should be to treat the repeat result as a critical result.
Stat testing
Q. Please clarify for me how the Joint Commission would like to address the word "stat" in relation critical results or panic values.
A. The term “stat” is not used in Joint Commission requirements. However, National Patient Safety Goal 02.03.01, which requires measurement, assessment, and improvement of the timeliness of reporting critical test results, applies to critical results (for example, “panic values”) as well as critical tests, often referred to as “stat” tests or those tests that must be conducted and reported quickly. Whatever term you choose to identify critical tests, Your turnaround time must be established by policy. Then, as part of your activities related to NPSG.02.03.01, you should include measurement of the timeliness of reporting the results of critical tests. The measurement in this situation is from the time the test is ordered to the time the result is reported.
Perfusionists
Q. Our perfusionists are nationally certified professionals in cardiovascular surgery. Although they are not "licensed", they are highly trained and certified to use laboratory results to make treatment decisions on the heart/lung pump. They perform point-of-care blood gas, chemistry and coagulation tests in the cardiovascular OR. National Patient Safety Goal 02.03.01 states that critical test results must be reported to a licensed caregiver. Is there any reason that critical results cannot be called from the laboratory to a certified perfusionist?
A. The intent here is that the critical results get to the person who will be able to respond to the results to provide the needed care to the patient in a timely manner. Usually that will be a physician or, perhaps, a nurse working under an approved protocol. However, if the perfusionist is the one who will be responding to the results and that person is legally authorized and also permitted by the hospital to do so, then that will be acceptable under this requirement. The fact that the perfusionist is "certified" rather than "licensed" is not a problem. The purpose of the term "licensed" is that the individual must be legally authorized to respond to the critical test result.
Sample size and randomization
Q. Are we expected to measure, assess, and improve the timeliness of reporting all critical tests and all critical results at all times?
A. As with other PI activities, you don’t need to be measuring everything (all critical tests and all critical results) at all times. You can select certain tests and certain categories of critical results; measure, assess, and improve those; then move on to other “critical tests” and “critical results.”
Responsible licensed caregiver
Q. Who is considered a responsible licensed caregiver?
A. The "responsible licensed caregiver" is the person who will act on the test results being reported. That will usually be the attending physician but may be another licensed independent practitioner or, in certain situations, a registered nurse who is authorized to modify treatment based on a protocol. Reporting of a critical test result to an authorized "agent" of the responsible licensed caregiver will meet this requirement if the organization can provide assurance that there will be no significant additional delay in communicating the test result to the responsible licensed caregiver so that the patient can be promptly treated.