May 2010

Editor:
Fredrick L. Kiechle, MD, PhD

Q. We have a recurring problem with critical values from clinics after hours (and a similar problem with travelers who are eligible for care at our facility). The problem is, we are unable to contact the patient’s physician because the clinic is closed and no on-call physician is available. Do you have recommendations?

A. Like other medical centers, we experienced difficulties in notifying responsible care-givers who were caring for outpatients. Though we could reliably identify responsible caregivers nearly 100 percent of the time for inpatients, we had more difficulty reaching the ordering caregiver in the outpatient arena because of the following challenges:

• Not all tests were ordered by physicians; some were ordered by nurse practitioners, who were not on an on-call list.
• Not all services were covered 365 days per year/24 hours per day, such as rehabilitation centers.
• We did not always have contact information for the patients, such as a cell phone number, in case the lab could not contact a responsible provider and we wanted the patients to report to our emergency department.
• Ordering providers were not always aware they were responsible for receiving and reading back critical values/results.

After identifying these gaps in our system, we took the issue to our Clinical Practice Committee, which consists of physicians representing all of our clinical practices. The mandate was “If you order it, you own it.” Working with our Clinical Practice Committee, we implemented a call-back system to identify all clinical services, including all outpatient services, and required that all services designate a responsible caregiver on call who could receive the critical values/results and read them back. In some cases, the responsible care-giver was not the ordering physician. For example, in some cases the internal medicine resident was responsible for taking action, even if he or she had never seen the patient. The on-call database is kept up to date. Senior physicians and administrators notify the chair of the responsible department or division if there are miscommunications or difficulties in reach-ing a provider. We have been successful in improving our rate of reaching clinicians who can take responsibility for acting on critical values for outpatients nearly 100 percent of the time, and all services are covered 365 days per year/24 hours per day. We also improved our documentation of how patients could be contacted.

Before we implemented these changes, critical values were given to our on-call clinical chemistry fellows or pathology residents, but they could not take action on behalf of the patients and were not in a position to be the designated responsible caregivers.

Our emergency department acts as our safety net for patients if we cannot contact a responsible caregiver because of technical difficulties like a malfunctioning pager. This occurs rarely.

Our having implemented this system has resulted in safer care for the patients in our institution, and other centers can set up a similar system. The following key elements are required:

• Buy-in by the institution’s senior medical leadership that less than 100 percent success in reaching a responsible caregiver is unacceptable for optimal patient care.
• Acceptance by all of the clinicians that if a test is ordered, they or the clinical service of which they are a member must cover the service 365 days per year/24 hours per day for inpatients and outpatients and take responsibility for receiving critical values/results.
• Development of a database that shows where your vulnerabilities lie.
• A spirit of continuous quality improvement and collaboration between the laboratory and all of the clinical practices to improve the system of calling critical values.
• Root-cause analysis when failures occur.

Ultimately, a focus on building a patient-centric system requires strong pathologist leadership to ensure a safe and reliable system. Though meeting regulatory and compliance guidelines is absolutely necessary, that does not always motivate physicians, including pathologists, to become involved. Patient care does.

References

James S. Hernandez, MD, MS
Assistant Professor of
Laboratory Medicine and Pathology
Mayo Clinic College of Medicine
Medical Director of Laboratories
Chair, Division of Laboratory Medicine
Mayo Clinic in Arizona

Q. I work in the microbiology department of a community hospital. One of our pulmonologists has been submitting bronchial wash, bronchoalveolar lavage, and bronchial brush specimens together from his patients for routine, acid-fast bacilli, and fungal cultures, as well as cultures for Legionella and direct fluorescence antibody, C. trachomatis/psittaci, Mycoplasma, C. pneumoniae, and general viral. He orders these cultures on all three sources. Is it necessary to test all three sources or is one adequate?

A. For the routine microbiology workup of the orders you mention, normally one of those specimen types should be adequate. Be aware that certain pathogens may have a prevalence for the upper or lower respiratory tracts, where sputum may be preferred over a bronchoalveolar lavage or vice versa. There is also the disease presen-tation of the patient where this helps to dictate which respiratory specimen to collect. Of course, there must be enough specimen volume to accommodate all the microbiology testing requested. Additionally, if some of these tests are sent to a reference laboratory, sample(s) must obviously be split among the in-house and reference lab testing.

Does the clinician also order cytology or any other additional tests on these specimens, or are these specimens solely for microbiology? Your pulmonologist, not knowing fully the specimen requirements of your histology/cytology department, may be confused about the different specimen types for the different tests. We have seen this at our institution.

I would start a dialogue with your pulmonologist to understand his or her reasoning for collecting these three bronchial specimens. Is there literature to support this practice? Is it only this pulmonologist within that group? It would be desirable to have some standardization with regard to how the pulmonologists are collecting samples from all of their patients. Perhaps one of your pathologists can talk with that pulmonologist. Sometimes a physician-to-physician conversation is all that is needed. Opening lines of communication with your clinicians helps establish a collegial working relationship—with the patient ultimately benefiting.

Rodney C. Arcenas, PhD, D(ABMM)
Clinical Scientist—
Microbiology/Molecular
Pathology Consultants of South Broward
Memorial Healthcare System
Hollywood, Fla.