Implementation of a Closed-Loop Reporting System for Critical Values and Clinical Communication in Compliance with Goals of The Joint Commission

Materials and Methods

Results

The multidisciplinary team designed a flowchart for the reporting of critical values and their acknowledgment (Fig. 1⇓ ). The flowchart starts with the medical technologist entering a test result into the laboratory information system (GE Healthcare Triple G). The ALERTS system captures the outgoing HL-7 result and, if the result fulfills the critical value criteria defined in Table 1⇑ , sends a critical value alert via the text pager system. The pager number of a covering physician for the patient has been assigned during the creation of admitting orders or the patient transfer process. The text message lists the result with reference range in addition to patient name, medical record number, and specimen collection timestamp. In the most common scenario, the physician acknowledges the page by calling the ALERTS touchtone phone response system using the phone extension listed in the message and dialing the acknowledgment code provided in the message. The physician’s identity is confirmed as part of the touchtone phone interaction. If his identity is not known by the system, he can use a unique code to identify himself. Alternatively, the physician can acknowledge the alert receipt electronically in the hospital electronic medical record (EMR) or computer physician order entry (CPOE) systems.

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Figure 1.

Flowchart of critical value reporting and acknowledgment.

A different pathway is initiated if the clinician does not respond to the critical value alert within 10 min (Fig. 1⇑ ). The page is automatically escalated to the telephone operator who monitors the status of every alert in real time via the ALERTS Status Web Application. The operator contacts the responsible physician or the patient’s nurse by phone and communicates the critical value information, receives a read-back, and documents the alert acknowledgment in the ALERTS system.

A third scenario arises when the paged clinician does not know the patient and “rejects” the page (Fig. 1⇑ ). In this case, the page is also escalated to Telephone Operator Services. The operator identifies an alternate physician using the up-to-date schedules of all clinical services and relates the message in a phone call with read-back by the physician. In the small number of cases where the operator has to relate critical value information for escalated alerts to the patient’s nurse owing to the unavailability of the patient’s physician, the nurse is then responsible for contacting the physician and informing him or her about the critical value and documenting the physician notification in the electronic nursing charting system. In all 3 pathways, the process ends with the physician acknowledging the receipt of the critical value, allowing him or her to take action and avert a negative clinical outcome. In case a sample with a critical value also has an interfering substance, a monitor informs the technologist of this situation. The technologist handles these cases manually, using the same logic as before the implementation of the ALERTS system.

Table 2⇓ summarizes the ALERTS data recorded and calculated electronically for the most recent 9 months of system use. Because the response times are skewed, we list the mean values as well as the median and 90% percentiles. In the following, we concentrate on the median because it is the parameter most commonly reported in the literature. After implementation of the ALERTS system, the median clinician response occurred in about 1.5 min. During the first 3 months, however, the responsible physicians acknowledged the pages using the automated options in only 70% of cases. To increase the physician acknowledgment rate, a “7-min reminder” page was implemented. Each time a physician fails to acknowledge an alert within 7 min of being paged, the system sends a reminder page with a warning that failure to acknowledge the alert receipt in the next 3 min will result in the alert being escalated to the telephone operator. After the implementation of the 7-min reminder page, the physician acknowledgment rate increased to near 90%. The number of alerts escalated to telephone operators correspondingly decreased from 30% to 11% (Table 2⇓ ). In 70% of these cases, the operators succeeded in closing escalated alerts by either contacting the original physician or identifying an alternate physician from the available on-call schedules. In a small fraction of cases where no physician was available (approximately 5% of the total alerts), the operators contacted the patient’s nurse to acknowledge the critical value page. The nurse was then responsible for contacting the physician and informing him or her about the critical value and documenting the physician notification in the electronic nursing charting system. The ALERTS system currently does not track documentation of these critical values, as this occurs between the nursing documentation system and the EMR. Excluding the escalation time of 10 min, the median response time achieved by the operators was 5.3 min or less. Overall, documentation of physician acknowledgment of receipt in the electronic medical record increased to 95% of critical values over 9 months, while the median time decreased to <3 min.

Before implementing the ALERTS system, nurses were responsible for notifying the clinician about critical laboratory results, which they received via phone calls from the laboratory. After introducing the system, this notification duty was removed from the nursing personnel, alleviating their workload. Because nurses play a vital role in monitoring the patient condition, however, it was important to keep nursing personnel in the critical value information flow. Thus, a “for your information” (FYI) charge nurse paging functionality on the unit where the patient is located was added to the ALERTS system, sent at the same time a physician is alerted about a critical value. The FYI charge nurse pager message includes information about the critical value result and contact information of the physician notified by the system. The charge nurse FYI paging feature provides an additional patient safety mechanism by keeping nursing personnel in the information flow, allowing nurses to intervene in patient care when immediate attention is required.

The ALERTS system was implemented in stages, starting with a few tests and inpatient floors and ending with the entire hospital and all tests listed in Table 1⇑ . The full implementation of the ALERTS system has led to the near-complete elimination of phone calls by medical technologists reporting critical values for inpatients. Before the introduction of the ALERTS system, approximately 9000 phone calls per year were logged by the Clinical Laboratories. The time to contact the appropriate nurse on the patient floor varied from 1 to >10 min. If we assume an average of 7 min per call (based on the study cited above (7)) including read-back of the result, the introduction of the ALERTS system resulted in time savings of 1050 h of technologists’ time for the Clinical Laboratories, or approximately one half of a full-time equivalent technologist. We did not measure any laboratory quality outcomes that might be affected by technologists having to call critical values; however, it is likely that the elimination of 9000 phone calls improved overall turnaround times and reduced the rate of clerical errors and/or corrected reports due to interruptions.

Discussion

A growing number of publications have addressed the reporting of critical values (4)(5)(6)(7)(9)(12)(13)(14). A recent CAP-sponsored study of 121 institutions determined that it takes a total of 7 min to relate a critical value to the responsible clinician (7). However, this determination, involving 3545 critical values, was performed manually in a labor-intensive manner. We report on 6850 critical values made over a 9-month period of time by the electronic closed-loop ALERTS system.

The essential elements for a successful electronic reporting system have been defined (15). Shabot et al.(16) described a text pager–based notification of critical values, but the system did not document receipt of the alert. A conceptually similar system to ALERTS described by Kuperman et al. (8) also employed physician pagers and operators and nurses as part of an escalation strategy. The system was evaluated in a pilot study of 4 tests (glucose, potassium, sodium, hematocrit) monitored over a 2-month period. The documented physician response rate in this limited study was 69% (8). This is nearly identical to our direct physician response rate before we instituted the 7-min reminder, which resulted in an eventual 89% rate. Their system did not include a touchtone phone method for acknowledgment, which also may have contributed to our higher response rate, although the reminder appears more likely given the timing of the change. Importantly, their study differed from ours in that it did not report an overall physician receipt rate or response time. We were unable to identify any studies with documented physician receipt rates higher than 70%.

We added the Telephone Operator Services as an integral component to increase documented direct physician contact to 95% (89% direct acknowledgment plus 6.5% via the operator). For the remaining 5%, the operators notified the nurse, allowing a 100% success rate of notification (no abandoned alerts). Although operators may not be an obvious choice, they turned out to be highly dedicated and well suited for this task. In contrast to laboratory-based medical technologists, operators have access to up-to-date call schedules for all clinical residents, fellows, and faculty and had minimal difficulty tracking a physician to redirect the text page or deliver the critical value by phone. Within a few months, adding the operators for escalation shortened the overall median time to physician documentation to <3 min (Table 2⇑ ), in contrast to the 7 min found in the CAP study (7). Although the operators had a noticeable impact on the success of the ALERTS system, it should be noted that the number of alerts escalated to them (about 100 per month or 3–4 per day) was a negligible addition to their workload and had no adverse impact on operator performance.

From the laboratory point of view, the ALERTS system has been a resounding success, with significant time saving by medical technologists. Similarly, the nursing staff has been relieved of the task of notifying the responsible clinician of critical values except in those few instances when the operator could not locate the physician. The physicians have accepted the ALERTS system and, after some initial hesitation and education, improved their acknowledgment rate. Instead of being verbally notified of a critical value by a nurse, the clinicians realize the benefit of the electronic alert and its built-in documentation. Finally, from an institutional point of view, the ALERTS system is entirely electronic and documents every time point in the reporting pathway.

The ALERTS system has been successfully implemented for inpatients, providing information 24/7. Critical values for outpatients typically account for <20% of all critical values (12)(14), and we plan to address these in the next phase of the project using the experience gained to date. Future work will also address the 5% of operator-to-nurse alerts. Currently the nurse is instructed to enter the physician notified within the nursing documentation system, which does not always occur. The plan is to automatically escalate the alert to the charge nurse if this documentation has not occurred in a reasonable amount of time. The ALERTS system captures the outgoing HL-7 results from our Laboratory Information System (LIS) but was developed as a freestanding program at VUMC without participation of the LIS vendor. Thus, the ALERTS system is amenable to use with any other LIS provided a standard HL-7 interface is accessible. The system is not commercially available at the present time.

We conclude that the ALERTS system has decreased physician notification time and increased completeness of documentation of physician receipt in comparison to our prior practice and to the published literature. It has also decreased manual notification effort while providing a standardized process of reporting of critical results in compliance with The Joint Commission goals.