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Hospital creates policy to make critical test results stick


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Virtually every facility has its own way of managing the reporting of critical test results (CTR).

With the 2008 National Patient Safety Goals (NPSG) now including requirement 2C, which addresses improved CTR communication, hospitals are looking for practical and effective ways to secure proper CTR reporting.

Geri Pyle, RN, MS, a healthcare consultant in Palm Springs, CA, and a member of the BOJ advisory board, says there is a direct link between the related delay in treatment associated with sentinel events and CTR.

"There are a million horror stories when this information isn't immediately transmitted to a physician [who] can then order the medication, which can affect the survival of the patient," says Pyle.

An issue of documentation

Often, hospitals have a policy of reporting CTRs but do not have a paper trail to document that communication.

Such was the case for New Hanover Regional Medical Center in Wilmington, NC, before it implemented a CTR sticker program.

"Before we had the policy, we didn't have critical tests defined," says Susan Ramsey, RN, MSN, PCCN, New Hanover's patient safety manager.

CTR reporting was sporadic; sometimes reporting was documented on a Post-it note, and the nurse would forget to put it in the chart, says Ramsey.

"It was a well-laid-out policy, but in practice, it was pretty broken," she adds.

Hospitals must create a system that works for them, Pyle says, adding that "every hospital is different in recordkeeping [practices]--some are electronic, others are not."

Hospitals can tailor their CTR policies to meet the needs of their documentation and recordkeeping methods. Finding a policy that fits is left to the hospitals' discretion.

For New Hanover, using stickers was the best option for communicating and documenting results appropriately. Currently, New Hanover uses a yellow sticker with the CTR value identified in red (for a sample sticker, click here.

The sticker has a progression of steps the nurse must complete and check off, including:

  • Recording the date and time
  • Identifying where the call was from
  • Verifying that the order was received
  • Confirming that the order was read back to the physician
  • Signing off on the order

The nurse then puts the sticker on the physician's progress note.

"The stickers are very clear. We're communicating results appropriately and documenting them," says Ramsey.

Applying stickers, stamps, a certain color paper, or simply saying that it's a CTR are all valuable ways to report results, says Pyle.

"These techniques are good for tracking," she adds. "Let's prevent the delay in treatment and find what makes people go on alert."

Linda Kissik, RN, CPHQ, risk manager and director of improving organizational performance at Landmark Medical Center in Woonsocket, RI, has also successfully made use of a sticker system for reporting CTRs.

"We have a bold orange sticker with a checklist that has to be put on the physician sheet," says Kissik. "The biggest change in implementing this was educating staff."

A focus on education

Educating staff members about becoming alert to CTRs is equally important, says Ramsey. "Our staff responded well to the policy. They like the sticker and it reminds them what they need to document," she says.

New Hanover has been pleased with the results since it implemented its policy. The biggest challenge has been convincing separate entities (e.g., the radiology and laboratory departments) of the need to define CTRs.

"Once we were over this hurdle, everything else was in place," says Ramsey.

She recommends finding a policy that works by speaking with other hospitals about their policies and then exploring your hospital's needs.

"Don't make it more difficult than it has to be," says Ramsey. "There's so much information. Stick with intent, take a step back, take your time, and look at what applies to your organization, what works for you."

Kissik says Landmark Medical Center educated staff members by demonstrating the standardized way of documenting CTRs. The nurse educator played a major role in the education effort and worked individually with staff members who were not consistent with using the new documentation process.

Humor was also interjected into the education process. "I walked around with a sticker on my forehead one day," said Kissik.

Kissik found that listening to what staff members had to say was beneficial to initiating and improving the program. We listen to staff members regarding trends and glitches in the system, she says.

Sticking to what works from hospital to hospital is the best way to report, says Pyle. "There isn't a best system. Find what works for your hospital," she says.

In the future, Ramsey says she would like to see development and growth with interventional CTRs and identification in critical tests.

"It's important to not bite off more than you can chew in the beginning. Don't get too into the detail, and make sure to communicate hospitalwide," says Ramsey.