INADEQUATE handover of clinical information carries significant risks for both clinicians and their patients. As a biochemistry registrar in a large tertiary hospital I regularly encounter clinical risk as we try to effectively communicate critical results out-of-hours.
I work in a laboratory that processes all core samples, including urea and electrolytes, liver function tests and thyroid function tests, continuously on a 24/7 basis. This improves throughput and efficiency, therefore providing better patient care. Or so you would think!
Samples arriving in the lab from any GP or outpatient clinic after 5pm are analysed as and when they arrive. So how can there be a problem if results are generated more efficiently? Results are only useful if they are interpreted appropriately, communicated effectively and acted upon. Samples arriving late in the afternoon may generate critical results after the health centres are closed or the last outpatient has left the clinic. Thus, patient care can be compromised.
The Royal College of Pathologists have stated that “the responsibility of the laboratory staff is to communicate the markedly abnormal test result to the clinical team – either to the GP who made the request or to the out-of-hours provider. It is the responsibility of the requesting clinical team to review results of tests that they have requested and have proper handover arrangements in place to review and act on abnormal results after hours, in the best interests of the patient.” Our laboratory protocol, based on this advice, has been negotiated with both the primary care physicians and out-of-hours providers at a local level. Although fairly robust, problems still arise when a patient’s contact and clinical details are not available and sampling times are not clearly stated.
In my experience, a common reason for calling the out-of-hours service is a critically high potassium result. If renal function is normal this may be due to delayed receipt of the sample into the laboratory. However, this is impossible to confirm if sampling times are not clearly stated.
If this result is acted upon, the patient may have a late evening jaunt to A&E only to be told their repeat result is normal. If on the other hand the patient is on potassium supplements and an ACE inhibitor, the high potassium places them at risk of a cardiac arrhythmia or arrest and requires admission for cardiac monitoring and an insulin and glucose infusion. Thus, relevant drug information, which unfortunately is often missing, is critical to patient safety.
Traditionally, a clinician who orders a test is responsible for receiving and acting upon the results once available. However, more and more frequently it is other members of the healthcare team who order tests. Until an explicit code of practice is agreed, the lead clinician for the service should assume that they are responsible for receiving and acting upon results. In particular, clear processes are required to establish responsibility for taking action on outpatient blood results out-of-hours.
Recently, we have liaised with our cardiology department after a “near miss” on a Friday afternoon. In brief, grossly deranged urea and electrolytes from a patient attending a heart failure clinic were not reported until after the clinic had finished. There was no named physician or nurse on the request form. Several attempts to convey the abnormal results failed and finally a cryptic message (to protect patient confidentiality) was left on an answering machine at the aforementioned clinic. Fortunately, the message was picked up later that evening by a specialist nurse and the patient was admitted. However, this resulted in a formal system being put in place for abnormal results to be conveyed to CCU out-of-hours. Effective communication, both verbal and written, lies at the centre of good patient care. The General Medical Council recognises this and makes clear the expectation that doctors will “keep colleagues well informed when sharing the care of patients”.
In terms of laboratory test results, clinical risk may be reduced if suitable processes are in place for the communication of critical results and healthcare professionals provide adequate patient information with the request. Indeed, all physicians who use the laboratory service should, when completing request forms, bear in mind that the request may generate an abnormal result that may have to be communicated out-of-hours to another doctor.
Dr Caroline Millar, FRCPath, is a specialty registrar in chemical pathology and metabolic medicine