University of Kentucky / UK HealthCare

Policy and Procedure

Policy # A08-075

Title/Description: Communication of Critical Values, Critical Results, and/or Significant

Findings
Purpose: To communicate critical values, critical results, and/or significant findings to the

appropriate caregiver in a timely manner.

Policy
Definitions
Critical value
Critical result
Significant finding
Procedure
Clinical Laboratories
List of critical values, critical results, and significant findings
Laboratory personnel notification and escalation
Laboratory personnel documentation of provision of a critical value or critical result
Read back confirmation
Evaluation of timeliness of reporting and audits
Department of Radiology
List of critical results and significant findings
Notification and Escalation
Radiology physician documentation of provision of a critical result or significant finding
Read back confirmation
Evaluation of timeliness of reporting and audits
For all other Acute Care and Ambulatory Care Areas
Notification and Escalation
Nursing documentation of receipt of a critical value or critical result
Evaluation of timeliness of nursing reporting and audits
Critical results from Point of Care testing
Documentation of critical results from point of care testing
Evaluation of timeliness of Point of Care reporting and audits
Exclusions to this policy
References
Persons and Sites Affected
Policies Replaced
Effective Date
Review/Revision Dates

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 1

Policy
Critical values, critical results, and/or significant findings are reported to the responsible licensed
caregiver in a timely manner as set forth in this policy. If the responsible licensed caregiver is
unavailable, appropriate escalation procedures are followed.
Definitions
Critical value
1. An analytic result that suggests a clinical condition that might be life-threatening or one
that might require immediate clinical intervention; or
2. A qualitative result or pathological interpretation that might affect patient care and might
require timely clinical intervention.
Critical result
1. A laboratory test whose result is identified as always requiring notification of the clinical
caregiver, whatever the result;
2. An imaging examination whose interpretation suggests a clinical condition that might be
life-threatening or one that might require immediate clinical intervention.
Significant finding
An imaging examination whose interpretation is of sufficient significance that it warrants timely
notification of the clinical caregiver.
Procedure
Clinical Laboratories
List of critical values, critical results, and significant findings
A list of critical values, critical results, and significant findings may be found in LAB 704.
Laboratory personnel notification and escalation
Laboratory staff who discover a critical value, critical result, or significant finding shall notify
the responsible licensed caregiver in a timely manner, as specified in LAB 703.
Laboratory personnel documentation of provision of a critical value or critical result
When the critical value communication to a clinical provider has been completed, the contact
information, contacts role, and time of communication with confirmation that read back was
performed shall be entered into the laboratory information system. This information shall be
automatically entered into the patients Electronic Medical Record (EMR).
Read back confirmation
When a person receives a critical value or critical result from the laboratory, he or she shall listen
to and write down the results, and then repeat them back to the laboratory personnel to verify
accuracy of communication.

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 2

Evaluation of timeliness of reporting and audits

Automated reports with regard to timeliness of laboratory communication are generated on a
monthly basis. Outliers are identified and reported to the Nursing Quality and Safety Council.
Department of Radiology
List of critical results and significant findings
A list of critical results and significant findings applicable to Radiology is outlined in DR01-06,
Communication of Radiology Critical Results and Significant Findings.
Notification and Escalation
Radiology physicians who discover a critical result or significant finding shall notify the
responsible licensed caregiver either immediately or in a timely manner, as specified in DR0106, Communication of Radiology Critical Results and Significant Findings.
Radiology physician documentation of provision of a critical result or significant finding
When the critical result or significant finding communication to a clinical provider has been
completed, the contact information, contacts role, and time of communication with confirmation
that read back was performed shall be entered into the radiology physicians report which is
found in the radiology information system (RIS). This information shall be automatically
conveyed in the radiology physicians report into the patients Electronic Medical Record
(EMR).
Read back confirmation
When a person receives a critical result or significant finding from radiology, he or she shall
listen to and write down the results, and then repeat them back to the radiology physician to
verify accuracy of communication.
Evaluation of timeliness of reporting and audits
1. A sampling of data is sent from UKMDs to the Department of Radiology for auditing
compliance of critical results or significant findings communication delivery times.
2. UKMDs shall query the initial time of contact, escalation notes, and time of
communication of critical results and/or significant findings. This data is sent to the
Department of Radiology Quality, Safety & Compliance Medical Director for
compliance auditing.
For all other Acute Care and Ambulatory Care Areas
Notification and Escalation
All other staff, including but not limited to Echocardiography laboratory, Electroencephalogram
laboratory, Neurological Testing, Birthing Center (OB), Pathology laboratory, Vascular
laboratory, and Nursing staff, who discover a critical value, critical result, or significant finding
shall notify the responsible licensed caregiver within 30 minutes.
If the responsible licensed independent provider is unavailable or does not respond to the
notification in a timely manner:

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 3

1. In the acute care environment the nurse shall follow the NU01-05 Nursing
Responsibilities and Relationships with Medical Staff for Escalation and further action.
2. In the ambulatory care setting, the clinic nurse, certified medical assistant, or other
support personnel shall follow the Escalation process outlined in LAB 703.
Nursing documentation of receipt of a critical value or critical result
In the acute care environment, nursing communications and documentation of critical values and
related physicians or designated licensed providers orders are recorded in the patients
EMR. The nurse who received notification of the critical value, critical result, or significant
finding shall perform read back confirmation and document receipt of the notification as follows:
1. Upon receipt of a Critical Value, the nurse or other authorized licensed care provider
shall enter the test or critical value in the status box by clicking and adjusting to the time
the value was communicated.
2. Elements of required documentation to be completed are:
(a) Critical value;
(b) Provider notification (including name of provider); and
(c) Response or action taken.
In the ambulatory care environment, it is the responsibility of the trained staff who received the
critical lab value to report it immediately to the licensed independent provider or their designee
and document the results properly in the medical record along with the name of the caregiver
notified and any response/action taken.
Evaluation of timeliness of nursing reporting and audits
EMR audits are performed to verify utilization of the EMR recording tools to track effective
communication and patient management.
Critical results from Point of Care testing
Documentation of critical results from point of care testing
Critical results from Point of Care Testing performed by staff in both acute care and ambulatory
care environments are documented in the medical record by staff performing the testing as
specified in POC002, Point of Care Critical Results Reporting Policy.
Evaluation of timeliness of Point of Care reporting and audits
Point of Care (POC) audits are completed to measure compliance with documentation
requirements for POC critical values and reported to the Point of Care Steering Committee.
Exclusions to this policy
When approved by the Medical Staff Executive Committee, specific critical results may be
exempted from this policy:
1. If a critical value or critical result is consistent with three (3) prior values or critical
results that have been performed within a seven day period and while the patient is
assigned to the same service and attending physician;

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 4

2. If the critical value or critical result is consistent with the previously reported outpatient
result; or
3. Any critical value with an approved specific protocol in place. The use of the protocol
represents the communication and documentation to the physician or licensed care
provider i.e., Insulin, Heparin, etc.
4. An order placed in the medical record by the physician or licensed care provider for
treatment of the critical lab value serves as the communication and documentation of
appropriate notification.
References
A08-030, Hand-off Communications
A08-060, Development of Clinical Guidelines and Pathways;
A08-290, Patient Care Orders;
NU01-05, Nursing Responsibilities and Relationships with Medical Staff.
NU01-06, Communication Guidelines for Nursing Personnel;
NU08-06, Medical Orders;
The Joint Commissions National Patient Safety Goal 02.03.01: Critical Tests, Results, and
Values

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 5

Persons and Sites Affected

Enterprise

Chandler

Good Samaritan

Kentucky Childrens

Ambulatory

Department

Policies Replaced
Chandler HP
Ambulatory KC

Good Samaritan
Other

Effective Date: 4/15/2015

Kentucky Childrens CH

Review/Revision Dates: 3/2012; 4/15/2015

Approval by and date:

Signature
Date _______________
Name
Patty Hughes, Nursing Director, Oncology Services, Review Team Leader
Signature
Name
Barbara Bush, Administrative Manager, Clinical Laboratories

Date _______________

Signature
Name
M. Denise Quandt, Administrator, Department of Radiology

Date _______________

Signature
Name
C. Darrell Jennings, MD, Chair, Department of Pathology

Date _______________

Signature
Name
M. Elizabeth Oates, MD, Chair, Department of Radiology

Date _______________

Signature
Name
Marcus Randall, MD, Chief, Ambulatory Services

Date _______________

Signature
Name
Colleen Swartz, Chief Nurse Executive

Date _______________

Signature
Name
Bernard Boulanger, MD, Chief Medical Officer

Date _______________

Signature
Name
Anna L. Smith, Chief Administrative Officer

Date _______________

Signature
Name
Michael Karpf, MD, Executive Vice President for Health Affairs

Date

Policy # A08-075 Communication of Critical Values, Critical Results, and/or Significant Findings 6