sans POOR cle OU takes Asap ie asta Reporting Critical Results of Diagnostic Test Policy 02, Policy title: Policy number sop-012, 1, Purpose/ Objective a. To reach effective communication of critical results; timely, accurate, complete, un- ambiguous, and understood by the recipient. b. To provide guidelines for reporting critical results of diagnostic tests. To develop a system enabling hospital to monitor timeliness of critical results report- ing. 2. Policy 1. The hospital has defined critical values for each type of diagnostic test, where each department that performs diagnostic tests has developed a list of the test results con- sidered to be critical (Attachments A, B and C). b. Critical results shall be communicated by the one doing the diagnostic test (radiolo- ist, laboratory doctoritechnician, nurse...) to the patient's physician within 10 minutes ¢. The complete test result is documented and read back by the receiver and confirmed by the individual giving the result, (Verbal & Telephone orders policy) 3. Definitions/ abbreviations a. Critical results of diagnostic tests: (also referred to as panic values) any values! in- terpretations for which delays in reporting can result in serious adverse outcomes for patients, must be reported immediately to healthcare practitioners and require appro- priate and timely intervention. b. Bed-Side Testing or Point of Care Testing (POCT): itis a medical testing at or near the site of patient care. ¢. OPD: Outpatient Department. 4. Procedure a. For Inpatients 1. Process of Reporting of Lab critical results: Once the critical result is confirmed Laboratory doctor /technician/ shall: = Track the patient on the hospital information system by location to iden fy the patient position (ICU , surgery , oncology) at the same day. = Call the nurse in ward telling that there is a critical result. ~The nurse shall call the patient's physician who is responsible for patient's care to tell him/her the critical result. = Ifpatient's physician not available, the nurse, will inform nursing supervi sor and he will reach physician, If patient's physician can not be reached to be recorded in the critical log. II. Radiology Critical Results once confirmed (after radiology consultant approv- al) Radiology doctor shall reports the critical result to the responsible physi- cian by phone. IIL, Documentation of lab and radiology critical results: ‘* Nurse / physician who receives the critical result, will: Follow the same methodology of verbal/ telephone order ie. WRITE DOWN, READ BACK and CONFIRM. 1BRR AA aS olor OU tate Cau sg ast Policy title: _[ Reporting Critical Results of Diagnostic Test Policy Policy number sop-012 [ Version Number @ ‘© Lab doctor/lab technician/ Radiology doctor! physician who receives the radiology critical will record in Panic Value Log for lab and radi- ology (Attachment D). © Nurses Document lab critical results in nursing notes and Panic value log form( attachment H) and doctor will sign in 12 hrs. b. For Outpatient 1. Once the critical result is confirmed: During working hours Laboratory doctor /echnician / radiologist shall: + For lab (stat and urgent results): = position of the patient identified by the location on the request or buy pa~ tient is tracking on the HIS = The technician o lab doctor will Call the nurse telling that there is a La- boratory critical result. = The nurse will inform the patient's treating physician, + For lab (routine results) = Track the patient on the hospital information system by location to identi fy the patient position (ICU, surgery , oncology, radiology and radiother- apy ) at the same day. = Call the nurse to inform him/her that there is a Laboratory critical result, = The nurse will inform the patient's treating physician. © For Radiology (stat and urgent Critical Results): = position of the patient identified by the location on the request or by pa~ tient tracking on the HIS. - Once confirmed (after radiology consultant approval) Radiology doctor shall reports the critical result to requesting physician, ‘+ For Radiology (routine Critical Results): = once confirmed (after radiology consultant approval) Radiology doctor shall report the critical result to ER physician (as there is no clinic ap- pointment for the patient at the same day) IL After working hours or patient not in the hospital: Laboratory doctor / technician / radiologist shall: * For laboratory: Call the ER nurse telling that there is a Laboratory criti- cal result, then the nurse will inform the ER physician who will contact patient by call center. * Radiology Critical Results once confirmed (for radiology consultants that write reports as TELE) , the consultant contact the radiodiagnosis, specialist to record the critical result and Radiology doctor shall reports, the critical result to the ER physician. IV. Documentation of lab and radiology critical results: ‘© Laboratory doctor! physician who receives the radiology critical will record in Panic Value Log for lab and radiology (Attachment D). «nurse and doctor who receives the critical result, will: Follow the same methodology of verbal / telephone order ie. WRITE DOWN, READ BACK and CONFIRM. then Document in Panic value log form (at- tachment H and D). Reporting critical Results for radiology Department: 2[Poticy vine: | Reporting Critical Results of Diagnostic Test Policy [Poticy number Teop-012 Version Number 02 + If the Patient's is inside the hospital (outpatient) the radiology spe- cialist (after radiology consultant approval) reports the critical result to the requesting physician. ~ If the Patient's outside the hospital the radiology speciall the critical result to the Emergency physician and the E: physician will contact the patient through the call center. - The radiology Physician will record the result in Panic Value Log for lab and radiology (Attachment D) = The requesting physician who receives the result Follow the same methodology of verbal / telephone order i.e., WRITE DOWN, READ BACK and CONFIRM, Then document in Panic value log form (attachment D) c. For point of care testing: 1. Reporting and documentation: * Once the critical result is confirmed, the nurse shall tell the result to Pa- tients Physician at once. «If Patient's physician not available, nurse will inform nursing supervisor who will contact physician. © Documentation: in Panic Value Log. 4. For ECHO Critical Value: 1. ECHO Critical Results once confirmed the ECHO clinic physician shall re- ports the critical result to the requesting physician according to department by phone and document it panic value log for lab and radiology. ‘Measures to be taken in case of critical results 1. The doctor deals with the patient according to the evidence of clinical guide- lines in cases of critical results. Il. The physician shall take the corrective action as soon as possible and as clinically indicated 5, References GAHAR standards. 6. Related forms/ attachments: Attachment A: List of Radiology Critical Results. ‘Attachment B: List of Laboratory Critical Results. Attachment C: List of Critical Results of Diagnostic Bedside Tests. Attachment D: Panic value log for lab & radiology. Attachment E: ECHO critical test results. Attachment G: List of telephone number to report critical value. ATTACHMENT H: Panic value log. reports ergencyPoly title: Reporiing Critical Results of Diagnostic Test Policy. Coley number Topaz [Version Number Jo ~ This list approved by medic List of Radiolo; ical d. Abdomen © Free air In abdomen (No recent surgery) # Ischemic bowel 2 Appendicitis # Acute testicular torsion © Portal venous air © Volvutus ‘+ ‘Traumatic visceral injury + Retroperitoneal hemorrhage * Bowel obstruction ‘+ Contrast leak visceral injury * Progressive collection (post- operative) ce. General + Significant line / tube misplace~ ment © Acute DVT © Arlerial occlusion(acute) * Appendicular fracture. ‘© retained surgical foreign body critical finding of gamma camera Any bony fracture medivat center, U.S. MRI, X ray and itrasound ors: © Cerebral hemorrhage / hematoma © Brain tumor herniation syndrome © Acute stroke + Intracranial infection / empyema Complex skull fracture Unstable spine fracture # Spinal cord compression Neck © Airway compromise (e.g. epiglot- fitis) + Carotid artery dissection * Critical carotid s Chest © Tension pneumothorax © Eimpyema * Cardiac tamponade * New arterial dissection © Aortic dissection + Pulmonary embolism + Rupture aneurysm or impending ‘upture ‘* Mediastinal emphysema © Covid-19 (Co-rads 4 and 5) Depariment of medical image. poliey and procedures and protocol, (critical fiud) university of 1 committee (No. 2) in 15/2/2022Policy title: Reporting Critical Results of Diagnostic Test Policy Policy number sop-012 ~ [version Number 02 Attachment B List of laboratory critical results Tainan [ender [Lower tiie [Upper [wa] coo —— — went wae io nae ‘mpl Heavies wes 1656) sae Tae a Saya aes Sees aa ree = ea ee ee = ae fate [anes = Faken HL suka = hay ise PE Tr Taine = “Tonia Fes aunt — Wie = (mamta Ut ad srg ine bra age an Poe wT ue eee oti Bee Boos Pr cigs ET Tay de (cea ed J Hale Wd penal Po prior | ance rc ow Tae napa TT acon ees ae =| aie | —— | a eee es — oo rele oan ae —, ee eae == Ts {Conner eswnoloy stain forndveee veh (CECAE ) Vion 8.0, Nvenber 27.200, ite Fobookel Ciel Cena ond Noles Dancer 62017 “inert Lacon 20162 Lslection west aad anpustin of iil spss an arcSees RORNER, Scloy OU teats Cada Sig esa Policy title: _[ Reporting Critical Results of Diagnostic Test Policy _ Policy number sop-012 Version Number [oz Attachment C List of Critical Results Bedside Tes ‘a, Blood Glucose (Bedside Test) (Age greater than 1 Month <40 mg/dL_and > 450 mg/dLPolicy title: | Reporting Critical Results of Diagnostic Test Policy Policy number [sop-012 [version Number [o2 1 Attachment D Panic value log for lub & radiology Panic value log for lab and radiology Date [Time] Patient Name MMRN investigation] Ree:It Sender | ID) Receiver | 1D ab — ; 8 « b _| is 6 a pp ® # a[Policy title: | Results of Diagnostic Test Policy Policy number [sop-012 ‘Version Number o Attachment E ECHO critical test results ‘A positive finding of a new thrombus/ new mass in the heat ford during a routine echo. A large pericardial effusion or evidence of cardiac tamponade. Severely enlarged right ventricle. Severe, aortic stenosisPolicy title: ic Test Policy Policy number 0-012 Version Number 2 Attachment G List of telephone number to report exi OPD ONC __ OPD PEDIATRIC ENDOSCOPY _ | oe: aeReporting Critical Results c* Dir nostic Test Policy Teep-012 Version Number To2 a CHMENT TH: Panie value log Panic value log ect | vite 10ing Critical Results of Diagnostic Test Policy Rep [sop-012 [Version Number 2 Job title Name Signature Prepared by: Quatity specialist Alaa Ahmed Kamel Department. Reviewed by: fant CHO for nursing Quality & Patient Safety ager | Head iCu Department Head of Quality & Patient Safety j Head ef Radiology department | Miss Asmaa Mubarak Dep Man. | Bilal Ahmed | Dr. Abdelhay Elsayed | | Dr. Mohamed Kaffas T | Dr/ Ahmed Safwat Prof. Dr. Medhat Youssef Prof. Dr. Fayek Ghalet sion " floctive Date of Us ¥: 1/6/2022 16.2022, J