CLN - Feature
Timely communication of test results that fall significantly outside the expected range and pose potential life-threatening risks is crucial for effective patient care. However, as healthcare systems offer new methods of electronic communication, clinical laboratories must navigate not only regulatory requirements but also the increasingly noisy information environment providers experience.
The Joint Commission (TJC) defines a critical value as one requiring immediate communication of results. Regulations from agencies and accreditors such as the Centers for Medicaid and Medicare Services, TJC (National Patient Safety Goal NPSG.02.03.01), and the College of American Pathologists (CAP) Checklist statement (GEN.20316, COM.30000, COM.30100) mandate that laboratories develop and implement an alert system for critical values (CAP- critical values reporting QT10).
Although the regulatory considerations for implementing a critical value reporting system from these different agencies have a lot of commonalities, there are some notable differences. CAP COM 3000 and CAP COM.30100 indicate critical results can be communicated by phone or electronically, whereas TJC requires that the communication be via telephone or verbal. Notably, both agencies accept electronic transmission of results. In addition, CAP requires that the recipient confirm receiving the information but does not specifically require that a “readback” of the result be electronically transmitted. TJC requires that a readback be done while communicating the critical result.
Historically in our hospital system, like most others, this has been done through a telephone call to the “responsible licensed provider/licensed independent practitioner.” The laboratory technician resulting the test is responsible for calling the ordering licensed independent practitioner (LIP) within 30 minutes. If the provider cannot be reached, communication is escalated according to a predefined algorithm indicated in our standard operating procedure. This current system has been in place for many years and has stayed the same through the electronic revolution in medical records in the past decade.
We conducted a survey to understand the perception of the providers who receive these critical results with the aim of understanding their readiness to utilize the newer options available for critical result notification. One such method we assessed was provider awareness of EPIC Haiku notification. Secure messaging has also become available at our hospital system since the completion of the survey. The results of the survey could guide healthcare systems in identifying potential areas of improvement. They also might inspire innovative solutions that will enhance the use of technologists’ time and increase the efficiency of timely delivery of these results to the right provider, while minimizing unwanted distractions.
The survey was sent to all providers at the University of Texas Medical Branch across all campuses (one main campus on the island of Galveston and four smaller hospitals in the suburbs) via a broadcast email. It consisted of 10 questions, with some questions providing the option for a free-text input, some with required categorical responses, and others with multiple choice options. The survey was open to participants for a period of 4 weeks, with two reminder emails sent out at regular intervals. A total of 544 providers opened the survey, with 191 of them completing it (35.1%). Among the respondents, 84% were physicians (n=161), including faculty members, residents, and fellows. Fifteen percent (15%) of the respondents identified as advanced practitioners.
In the era electronic medical records (EMRs), multiple modalities exist through which physicians can track laboratory results of their patients. We attempted to analyze the most used methods with a multiple-choice question in which providers could check all that apply. The options were periodic check of EMR, phone call from the laboratory, checking before seeing the patient again, and using the patient list in the EMR and the flag feature to identify critical results.
The survey showed that 54.4% of our respondents use two or more methods, and around 21% responded that they only rely on periodic checks of the EMR (Figure 1).
Only 6.8% of providers indicated that they depend only on phone calls from the lab, while around 2% responded that they check these results only before seeing the patient again, or only as needed. Only two providers reported using Haiku for checking critical results.
When asked to rate the perceived frequency of critical result notifications from the laboratory, 27% felt that they are called only rarely by the lab and 39% indicated that they were called “sometimes” (Figure 2). 
Twenty-two percent of the respondents reported that they were “often” called by the laboratory, with 6% specifying that they received these calls often even when they are not on call. The remaining 6% did not provide specific response about the frequency of phone notifications.
More than a third (35%) of the respondents felt that the critical result calls distract them from patient care (Figure 3). Fifty five percent indicated that the calls did not distract (disagree/strongly disagree) from patient care. One provider wrote that it distracts them from their sleep which in turn takes away from patient care due to fatigue.
Most still find the calls useful: 58% reported they find them useful, with 14% indicating that they were indispensable to patient care. However, 38% of the providers felt that these calls are not useful, and 5% of those believed the disadvantages of the call outweighed the advantages.
Some went on to explain that sometimes these results are either expected or not a surprise because they are already being tracked and do not warrant immediate intervention. A few raised concerns about the current system of calling the ordering provider instead of the on-call provider, and a few others disagreed with the critical nature of some test results.
Forty percent of the respondents reported that they appreciate the calls about electrolyte levels the most, with potassium being the most frequently mentioned component. Approximately 25% of the respondents felt that hemoglobin results are very helpful as well. Approximately 20% of the respondents mentioned that receiving calls about positive cultures was of vital importance, with suggestions made to add all positive cultures in neonates to the critical value list, not just blood and CSF.
Blood glucose levels, specifically hyperglycemia, also were highlighted as an important call to receive by 15% of the providers. Approximately 10% of respondents mentioned the importance of specialized tests relevant to their specific specialties. Most of the providers from the pediatrics department indicated that they appreciate the calls about bilirubin levels and reported that blood cultures in neonatal intensive care unit also were of vital importance.
Which results do providers believe have the least utility? Many of the respondents felt that none of the currently reported critical values should be excluded from the list. However, among those who responded, activated partial thromboplastin time was cited as the least useful laboratory results that is called in to physicians; most of the providers said that these can be reported to the nurses on the floor, as they manage the heparin drip.
Although the protocol in our laboratory is not to call a critical result if the same one has already been reported in the past 72 hours, some providers mentioned receiving phone calls for repeat critical values (perhaps outside the 72-hour window) and said it was not useful. Some suggested that low glucose levels, specifically those for outpatients, could be excluded from the list since several hours would have passed, and there would be nothing actionable resulting from the call.
Our hospital system utilizes the EPIC EMR system, with Haiku available as an application for smart phones and other electronic devices. The Haiku app is protected by a duo security system for multifactor authentication. It allows users to place orders on-the-go, as well as check the results as soon as they have been uploaded, by selecting the “notify me” option while ordering the test.
When asked if they were familiar with this option of choosing EPIC Haiku notifications for critical results, only 33% responded affirmatively. However, when asked how likely they would be to adopt a different system for the delivery of critical result notification from the laboratory, an overwhelming majority of providers (around 82%) said they would very likely/likely consider adopting a new system. Some providers went on to suggest secure text messaging systems, Microsoft teams, and EMR alerts as alternatives. A minority specified that they were uncomfortable or unable to get Haiku to work on their phones, pointing to a potential area of intervention.
Our conclusions from the survey are that most respondents do find the critical result notifications from the laboratory useful, but the current system could be improved to remove redundant laboratory tests and adopt secure smart systems to better communicate these results. An increase in providers’ awareness of newly available modalities of notification seems to be the need of the hour, as they offer a tailored menu from which the clinician can choose to be notified about specific results for a specific patient.
Boosting provider awareness of these new systems seems to offer a good chance of success, as almost 82% of providers indicated that they would be willing to consider adopting a new system for critical result notifications.
It is also notable that more than a third of the providers indicated that the phone calls distract them from patient care. We believe this adds urgency to the need to work on alternative ways to communicate critical results.
Sri Bharathi Kavuri, MD, is a resident physician in the department of pathology at University of Texas Medical Branch at Galveston in Galveston, Texas. Email: [email protected]
Carlos Clark, DO, is an assistant professor and chief medical information officer at University of Texas Medical Branch at Galveston in Galveston, Texas. Email: [email protected]
Odutayo Olalekan, MSc, MBA, is a project manager, hospital administration at University of Texas Medical Branch in Galveston, Texas. Email: [email protected]
Anthony O. Okorodudu, PhD, MBA, is a professor in the department of pathology and director of the clinical chemistry division and sample management client services at University of Texas Medical Branch in Galveston in Galveston, Texas: Email: [email protected]