Initiatives

Refining or Creating the List

• Have representatives from the sending (diagnostic testing centers) and receiving (ordering providers) perspective create/review the list; include both resident and attending physicians in this process; initiating dialogue between ordering provider and diagnostic center helps identify differences in how people define “critical”; dialogue helps get everyone on the same page
• Adopt a common language and operational definitions that are clear and make sense to all stakeholders (including patients) in your facility
• Limit the “red” list to:
• those values that all would agree are evidence of a life-threatening situation
• where by definition a clinical decision (action) is needed
• Strong recommendation to limit physician preference when shortening the list; biology should dictate what tests are included and the notification process, not preference; identify and stick to system-wide identified lists
• Other considerations:
• having a short list reduces “nuisance” calls to providers and alerts them to those that are truly critical and evidence of a life-threatening situation
• goal is to limit the number of nuisance calls
• aim to reduce the calling burden for the labs
• “red” category should be a rare event
• Focus on the process of communication of critical findings:
• don’t get bogged down in debating the list, do this off line with a task force
• don’t get bogged down trying to create the “perfect” list; the list will change over time
• take a gradual approach to refining the list; approach task gradually and keep open the idea of “constant” revisions; make changes gradually to ensure safety and build confidence in process; review the list every 6 months or more often as necessary
• Gather some baseline descriptive data about your existing critical value list and calling processes:
• how many critical values does your lab call each day?
• what units generate the most critical values?
• what critical values occur most frequently in your institution?
• Then, start your process by identifying a target test and a target area. 
• Pare down your list of critical values by using descriptive data to illustrate the number of extra calls that would be made by calling at a different level
• Start your implementation with the test values/interpretations that are considered in the “red” category that all agree require a prompt response (clinical emergency); pick one or two tests to start with to learn about your communication process
• once you improve your performance with a few tests you can expand your success to other communication processes;
• For specialty areas or special population groups
• use off line discussion groups to identify what the critical value limits should be for those special populations
• integrate the different values for the special populations after you have refined your processes for most patients served by your institution
• have specialty groups discuss critical value lists off-line; approach one specialty group at a time, then bring others on board
• When you expand your process to include outpatient areas, discuss if cutoff values, time targets, and processes should be same for both settings
• Engage the MSEC group that reviews and revises the lists as early as possible in this project
• Identify a physician champion for project
• Build regular review of critical value list into ongoing organizational processes
• Set clear time parameters (targets) for notification; “immediately” is not a time
• Consider revisions to list as a teaching exercise with the residents; vet recommendations with attendings

• Some implementation strategies teams have found helpful for laboratory tests:
• Make changes to the list incrementally, if there are concerns about patient safety and to build confidence in the process
• Some institutions have divided red zone into two tiers, one for MD&RN notification; another for RN only for discrete set of values when the RN has clearly defined protocols to follow (i.e. RN can take clinical action)
• Focus on “first instance of” a critical test value; work with the laboratory to improve their capacity to identify only first instance of before calling provider

• Some implementation strategies teams have found helpful for cardiology tests:
• Build buy-in with cardiologists by keeping focus on test interpretations all would agree require direct communication; identify and communicate all “high value” tests, and aim to reduce unnecessary calls
• Informally monitor cardiologist and end-user satisfaction
• Identify when immediate direct reporting to the responsible provider is necessary (call required); examples include:
• When a final interpretation is significantly different than the preliminary interpretation
• Indisputable conditions
• Recent ST segment studies
• Patient location such as critical care areas

• Some implementation strategies teams have found helpful for radiology findings:
• If specialists are reluctant to draft a list, start small, build buy-in, say list…”just for testing…”
• Build policies with language that makes sense to all stakeholders
• List includes, but is not limited to…
• New diagnosis of…
• Significant changes between a final report and a preliminary report
• Consider categories of “emergency” (1 hour) , “urgent” (within the shift), and “clinically significant or differing from initial read” (within 3 days) to identify time targets for reporting

Paula Griswold at pgriswold@macoalition.org or (781) 272-8000 x152.