|Year : 2015 | Volume
| Issue : 2 | Page : 53-60
Dropped calls, Turnaround time and Document Retention Time: Crucial parameters to monitor the effective implementation of laboratory Critical alert policy for critically ill patients
Manminder Singh1, Vibha Gupta2, Piyali M Mathavan1, Harish Chandra3, Dushyant Singh Gaur3, Muthuvenkkataraman Muthu Mathavan4
1 Department of Management Studies, Himalayan Institute of Management Studies, Dehradun, Uttarakhand, India
2 Department of Pathology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
3 Department of Pathology, Himalayan Institute of Management Studies, Dehradun, Uttarakhand, India
4 Administrative and Financial Department, Himalayan Institute Hospital Trust, Dehradun, Uttarakhand, India
|Date of Web Publication||19-Jan-2016|
Dr. Vibha Gupta
Department of Pathology, Himalayan Institute of Medical Sciences, Dehradun, Uttrakhand
Source of Support: None, Conflict of Interest: None
Context: Critical alert policy adopted under laboratory accreditation guidelines  and under the National Patient Safety Goals (NPSGs) has prioritized safe and timely communication of critical alert  so that immediate treatment can be done as soon as the sample showing critical value is communicated by the laboratory. Laboratories are burdened with the analysis of samples not only from emergency and intensive care units but also from outdoor and wards; require to frame a policy, which meets the need of the critical patients. Most of the studies conducted to analyze the effective implementation of the critical alert policy look at the tip of iceberg as the percentage of critical alerts reported by laboratory and the turn- around time.
Aim: The present study was conducted to analyze the various components of critical alert policy framed by the laboratory under study.
Setting and Design: Study was conducted at a tertiary care hospital in a NABL accreditation of laboratory running since 3 years. We assessed not only the policy and procedure documented and followed by the laboratory under study as laid down under the guidelines , but also certain issue (Dropped calls), which are encountered during implementation of the critical alert policy and procedure.
Statistical Analysis: Study was a retrospective, cross-sectional.
Results: The outcome of the study highlighted the hidden component of the iceberg causing obstacle in implementation of the critical alert policy as increased dropped calls, the turnaround time of which till the writing of the manuscript was infinite. Moreover, short storage time of the document maintained by a laboratory as evidence of communication of critical alert to the caretaker by the hospital-based laboratory leaves the hospital with no evidence if required later on.
Conclusions: Detecting and correcting hidden components of critical alert policy can lead to immediate attention and treatment of critical patients and prevent mortality and mortality on one hand and on the other hand the hospital that implements this system can be prevented from the burden of medico legal cases to an extent.
Keywords: Critical alert, dropped calls, turnaround time
Key message: Dropped calls, turn- around time can be a Quality indicators to assess the effective implementation of Critical alert policy. Document of communication of critical alerts can be a useful asset for the hospital and laboratory to protect against medico legal sue.
|How to cite this article:|
Singh M, Gupta V, Mathavan PM, Chandra H, Gaur DS, Mathavan MM. Dropped calls, Turnaround time and Document Retention Time: Crucial parameters to monitor the effective implementation of laboratory Critical alert policy for critically ill patients. J Nat Accred Board Hosp Healthcare Providers 2015;2:53-60
|How to cite this URL:|
Singh M, Gupta V, Mathavan PM, Chandra H, Gaur DS, Mathavan MM. Dropped calls, Turnaround time and Document Retention Time: Crucial parameters to monitor the effective implementation of laboratory Critical alert policy for critically ill patients. J Nat Accred Board Hosp Healthcare Providers [serial online] 2015 [cited 2019 Jul 15];2:53-60. Available from: http://www.nabh.ind.in/text.asp?2015/2/2/53/174350
| Introduction|| |
The laboratory and hospital both are integral parts of a health care system and aim at providing timely, correct diagnosis, treatment, and care to patients. Hospital emergency departments and intensive care units are areas receiving and catering to mostly critical patients and are kept under special care by providing immediate medical aid, suitable infrastructure, equipment, and staff services. The laboratory, on the other hand, routinely receives samples from these critical areas, wards, and outpatient departments. To take special care of critical patients reporting to the hospital, under the National Patient Safety Goals (NPSGs), the Joint Commission has prioritized safe and timely communication of critical alert results under the subclause NPSG.02.03.01 as one of the goals. It states to "report critical results of tests and diagnostic procedures on a timely basis." 
Critical values, as defined by Lundberg,  are life-threatening results that require immediate notification to the patient's health care provider. He developed a system in which clinical laboratory personnel reported these values immediately to appropriate health care providers so that suitable treatment could be given quickly. This can be life-saving or morbidity-preventable action on the one hand and on the other hand, failure of communication can lead to medical errors, adverse events, and big liability claims. ,,,,
Soon after Lundberg's classic observations in 1972, many laboratories and accreditation agencies such as National Accreditation Board for Testing and Calibration Laboratories (NABL) have adopted it as regulatory requirements under the International Organization for Standardization (ISO) Geneva, Switzerland under the subclause 5.9.  It states that it remains the responsibility of the laboratory to establish critical parameters and values of the same, the policy and procedures for communication of these results to the patient's health care provider in a timely manner, and appropriate documentation of the critical value reporting.
Hence, the laboratory is asked to develop and implement a critical value reporting system.
Considering the impact of this policy on the health outcome of critical patients, laboratories all around the world have adopted it as one of the quality indicators. 
The present study aimed at analysis of the critical alert policy and its outcome as a policy, which is written precisely and clearly helps each individual involved in the system to work for better implementation of that policy and an excellent outcome.
| Materials and Methods|| |
The present study was a retrospective, cross-sectional conducted at a tertiary care hospital in a NABL accreditation of laboratory running since 3 years. The study was conducted in the hematology and biochemistry sections of the laboratory as these sections were having higher sample load and with more number of critical parameters [Table 1].
|Table 1: Critical alert parameters along with the reference limits adopted by the laboratory|
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To look for the effective implementation of critical alert policy, in our study we assessed not only the policy and procedure documented and followed by the laboratory under study as laid down under the guidelines , but also certain issues, which are encountered during implementation of the critical alert policy and procedure. Thus, the laboratory was assessed on two aspects. One aspect was according to the guidelines (ISO; 15189 and the NPSGs , ) laid down to implement critical alert policy in a laboratory. The other aspect included certain issues that are encountered when implementing the guidelines of critical alert policy as shown in [Table 2].
|Table 2: Issues about the critical alert policy as per the reference literature and those encountered during the practical implementation in the laboratory under study|
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All the tests conducted in both these sections during the study period were considered eligible for sampling in this study. Only those results that were in the critical range were included in this study and the results that were outside the critical range were excluded.
The laboratory had the policy to communicate the critical alerts generated under the documented policy of using the telephone to locate the patient as early as possible. All those calls, which were not received at the receiver's side or unavailability of the patient at the location as mentioned in the request form caused the missing entries in the controlled document (TECH/FR/03).
To look for the implementation of this policy, we scrutinized the documented evidence of communication of these critical alert values to the health care professionals.(TECH/FR/03), The total number of critical alerts that were generated by the laboratory but not documented was collected and were labeled as "dropped calls."
| Results|| |
We studied various aspects of critical alert policy implementation and Segregated the findings as shown in [Table 3]. Out of the total tests performed in both the sections during the study period (12,502), 224 tests (1.72%) were critical alert values. When compared with the documentation system of the laboratory, out of 224 critical results generated, 74 were those which were not reported as other critical alerts and were released as routine test results. This means that out of 224, only 150 test results were informed immediately and would have helped the treating physicians to take immediate action. Thus, 74 of the critical alerts were not informed immediately due to multiple reasons, e.g., the phone was busy in the ward, the patient has shifted to some other ward and could not be traced. Considering that every uninformed critical alert value could lead a critical patient into the risk of increased mortality and morbidity, this number is important. Hence, we studied the policy and procedure of the laboratory related to the reporting of critical alerts and found certain aspects, which still need to be looked upon by the policymakers.
| Discussion|| |
Considering the recommendations under the subclause 5.8.8 of ISO 15189; 2012,  the critical alerts should represent a shared policy between the laboratory and medical care providers; in our case study, it was found that though the list of critical test parameters was available with the laboratory, the reference of which was taken from the documented literature and although regular feedback from the clinicians regarding their satisfaction on critical alert services was taken by the laboratory, no amendments in the list of critical alert parameters were made since 3 years of providing this service. Thus, evidence of clinician involvement was not seen, which was similar to most of the surveys done where the laboratory consultants are the stakeholders in determining which test parameters and what values of the same should be in the list of critical alert [Table 4]. ,,, The value was as low as 13% in one of the Chinese surveys.  Hence, we concluded that in most of the studies the contribution taken from the actual user (clinicians) for critical parameters and their value is minimal contrary to the recommendations. The impact of this recommendations can be seen in a survey study conducted by Don-Wauchope and Chetty where 115 physicians were asked to assess the appropriateness of 11 critical alert thresholds in use by the laboratory and it was found that 7 out of 11 thresholds values of critical parameters did not meet the level of acceptance and thus required review.  Taking the detailed feedback from clinicians on the one hand will improve the communication between the laboratory and treating physician and on the other hand, this will help the laboratory to filter a few of the calls, which are clinically not critical but are increasing the number of calls and diluting the sense of urgency.  A continuous process of revision of the parameters and critical cutoff should be undertaken to optimize the sensitivity and practicality of the criteria.
|Table 4: References taken to frame the list of critical alert across various country-based surveys|
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According to Singh and Vij,  the policy and the procedure about the critical alert services should clearly answer the question as to whom the results should be conveyed. In our study, the expected answer was the concerned treating units/clinician in charge (as per the policy of laboratory). This means that the critical alert values can be received by any person posted at the location where the patient was admitted. In the present study, most of the times it was the nursing staff posted at the patient's location who received the phone calls. Thus, the nursing staff in our study were most frequently receiving the critical values. The survey summary by Campbell et al. found that most of the laboratories deliver the critical alerts to nurses ranging from 91%  in the US survey to 29% in Italy  except Spain and China where the nursing staff involved was much less (3% and 0%, respectively). ,
Including nurses in the loop for communication of critical alert values improves transmission of the critical results in a timely manner by the laboratory due to their availability most of the time at patient's location but it increases the turnaround time of critical alert information to reach the person who has to take the appropriate action; as the nursing staff is not entitled to take decision it further takes time to locate the treating physician, ultimately delaying the required treatment of the patient. Some of the survey studies conducted in the United States  and Italy  showed that the main obstacle for communicating the critical alert was the communication break with the physicians. The recommendations mainly aim to direct the laboratory to convey the critical values to caretakers  but this is only half the work done as no monitoring system has been stressed upon to see how much time is taken from receiving the critical results from the laboratory to the actual action taken by the caretakers. There need is to develop systems of direct communication to the treating physician for timely action for critical alert patients.
Regarding the mode of communication, it was found that by most of the national surveys done in various countries ,,,, traditional telephonic communication for conveying the critical alerts from the laboratory was used. However, at present there is an increasing interest in using automated systems as short message service (SMS) , and call centers in delivering critical results.  These modes have been helpful in decreasing not only the dropped calls but also in decreasing the turnaround time by directly conveying the information about critical values to the decision-maker. ,
The study showed that the turnaround time for reporting the critical alerts services in the laboratory under study was an average of 18 min against the policy of the laboratory, which stated that it reported them as early as possible. In the Italian study,  the turnaround time of critical alerts should be predefined, such as 60 min, so that failures to report in the defined time can be taken as one of the areas needing improvement. In the present study, since the turnaround time was quantitative, it was not possible to look into areas of improvement.
According to the ISO 15189; 2012 accreditation standards, subclause 5.8.10, the records of the difficulties in critical alert delivery need to be maintained.  Studies conducted by Singh et al.,  Wager et al.,  and Hanna et al.  state that the laboratory can keep the documentation of failed attempts to verbally communicate critical values. In our study, we found that laboratory was keeping the record of the same as "dropped calls." These calls were about 33% of the total critical alerts; thus 33 out of 100 critical alerts were never informed immediately and attended against the policy of reporting the critical alerts "as early as possible." Thus, 33 out of every 100 critical patients because of the failure to inform critical values might have landed in increased chances of morbidity and mortality. Thus, to assess the effective implementation of critical alert policy, the dropped calls percentage provides useful information for auditors and thus, provides the scope of improvement of the laboratories.
Among the few suggestions as given by Singh and Vij,  one was that the laboratory should prepare an escalation procedure so that the laboratory staff knows whom to call when the primary care physician is not available due to any reason. The other aspect of the escalation procedure is that it increases number of call attempts to trace the patient's location, which demands the motivation of the technician who himself is burdened with a heavy load of analysis of the samples received not only from critical areas but also from noncritical and outpatient departments. Moreover, tracing the patients delays the analysis of the other samples as the technician is involved in telephonic tracing. This can delay some of the pending critical alert values of the samples, the analysis of which is awaited.
In the present study, it was found that most of the technicians traced the location of the patients making two calls. Thus, the laboratories should consider this important practical problem faced by the technicians in reporting the critical alerts. We recommend that either the automation (SMS or software system) or a dedicated clerk should be made responsible for receiving critical alerts from the laboratory and conveying the same at the corresponding location of the patient/concerned clinician. These services cause a nominal economic burden on the hospital against the huge amount to be paid for medicolegal claims. This will hopefully reduce the number of the dropped calls as well as the turnaround time of critical alert reporting.
In the accreditation guidelines NABL-112, subclause 4.13  states that the retention time of the quality and technical records, should be decided according to national, regional, and local regulations except for few of the quality records as specified  to ensure quality patient care. The laboratory under our study was maintaining the critical alert records for a period of 6 months. If we are required to look at the previous records about the implementation of critical alert services, this document is the only record available within the hospital (no regulatory agency stresses the documentation of the exchange of information in the hospital records/patient's file), which can prove to be helpful not only to monitor the laboratory's role toward the care of critical patients but also can be a legal evidence to save the hospital against the medicolegal cases. None of the previous studies had looked into this important aspect regarding the retention time of critical alert records. The authors believe that retention time of this record should be included in the category of the existing directions given by NABL.  Thus, either the retention time of this records should be increased or it should be the part of the laboratory accreditation system to direct the hospital for which these services are provided to document the same in the patient's file.
Last but not the least, the awareness about critical alert service of the laboratory among the caretakers (trainee doctors, nursing staff, ordering physicians, and the technical staff in the laboratory) is another factor on which depends the effective implementation of critical alert services. According to Hanna et al.,  against the recommendation for safe practice for communicating critical test results, there should be orientation and continuing education about how to communicate, how to respond, and team work for clinical emergencies; we the authors believe that when the hospital staff is educated about the critical alert system and its significance on the one hand and on the other hand, if reward/punishment awarded is related to implementation of the policy, the motivation, which is required for continuous efforts remains high. Thus, the outcome of the joint efforts will ultimately help to reduce the mortality and morbidity of critical patients and reduce the medicolegal burden on the health care institute.
| Conclusion|| |
Critical alert policy is one of the strong pillars of the health care system involving the laboratory and the caretakers who deal with critically ill patients. It helps as critical patients are diagnosed and treated on a priority level to prevent mortality and morbidity, which may have been caused due to failure/absence of the system. The need of the hour is to modify certain regulations so that the laboratory and hospital implementing this critical alert reporting system have 0% dropped calls with the shortest turnaround time, prolongs storage time of the document providing the evidence of implementation of the system, prevents patient mortality and morbidity, and protects the hospital from medicolegal sues to an extent.
We are thankful to all the technical staff working in the hematology and biochemistry sections for actively helping us in facilitating the process of data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]