SummaryVanderbilt University Medical Center created a new system, known as ALERTS, for reporting critical laboratory test results to physicians. Instead of providing the data to a nurse or physician over the telephone, laboratory technologists enter all test results into the laboratory information system. The ALERTS system searches the laboratory information system for critical values, which are automatically sent via pager to the appropriate physician. The doctor can acknowledge receipt by making a phone call and entering an alert-specific code, or by making a note in the patient's electronic medical record or the computer physician order entry system. If the physician fails to respond to 2 pages within 10 minutes, a hospital telephone operator calls the physician or the patient's nurse to convey the information and document the alert acknowledgment in the system. The program has been successful in getting 95 percent of critical test results acknowledged by physicians, most within 3 minutes, and has eliminated the need for approximately 9,000 phone calls a year by laboratory technologists.Moderate: The evidence consists of pre- and post-implementation comparisons of the number of calls made by laboratory technologists to report critical laboratory test results, along with post-implementation data from a 6-month study on the percentage of physicians acknowledging critical results and median response times.
Developing OrganizationsVanderbilt University Medical Center
Date First Implemented2008
Problem AddressedSome laboratory test results indicate that a patient's condition may be life threatening if appropriate treatment is not instituted immediately. These results, known as "critical values," generally are communicated via telephone-based reporting systems that have several inherent flaws—they can be time consuming for laboratory technologists, nurses, and doctors, they often lack a mechanism to verify that the physician received the result, and they create the potential for communication delays that can be dangerous to the patient.
- Time-consuming phone calls: Telephone-based systems require laboratory technologists to phone the hospital unit housing the patient to communicate critical values. Typically, a clerk answers the phone and the technologist requests to be transferred to a nurse or physician familiar with the patient. Once the laboratory technologist reaches the care provider, the recipient writes down and reads back the critical value information to avoid errors. If the recipient is a nurse, the nurse reports the critical value to the patient's physician with a second read-back and records the reporting in the nurse's notes or another component of the medical record. In hospitals that treat many critically ill patients, the amount of time spent by laboratory technologists reporting critical values—and by nurses and doctors receiving the information—can be quite significant. For example, before implementation of this program at Vanderbilt, laboratory technologists made more than 9,000 calls each year to relay critical values.
- No verification mechanism: Unless a laboratory technologist speaks directly to the physician, telephone-based systems provide no way for the technologist to know whether the physician received the information. In fact, according to hospital audits, receipt of critical values is documented in only about two-thirds of cases, due either to the information not being communicated to the physician or to lack of documentation. One study found that slightly more than 5 percent of critical alerts never get reported to the physician responsible for acting on the information.1
- Communication delays: Depending on the circumstances, telephone-based systems can lead to delays in transmitting critical values to the physician. One study found that it took 7 minutes on average (median) to notify a physician about critical inpatient test results—4 minutes to notify a nurse and an additional 3 minutes to notify a physician.2 Lengthier delays frequently occur when the physician cannot be located or if ambiguity exists as to which physician should be notified. These notification delays can adversely affect patient outcomes.
Description of the Innovative ActivityVanderbilt University Medical Center created a new system for reporting critical values to physicians known as ALERTS. Instead of providing the data to a nurse or physician over the telephone, laboratory technologists enter all test results into the laboratory information system. The ALERTS system searches the laboratory information system for critical values, which are automatically sent via pager to the appropriate physician. The doctor can acknowledge receipt by making a phone call and entering an alert-specific code, or by making a note in the patient's electronic medical record (EMR) or the computer physician order entry system. If the physician fails to respond to the initial page and a subsequent one within 10 minutes, a hospital telephone operator calls the physician or the patient's nurse to convey the information and document the alert acknowledgment in the system. Key components of the program are described below:
- Data input and automatic paging: Laboratory technologists enter all clinical chemistry, coagulation, and hematology test results into the computerized laboratory information system. The ALERTS system continuously searches the laboratory information system for critical values, and when one occurs, the system automatically sends notification via the text pager system. (The system integrates the pager number for the appropriate physician during the creation of admitting orders or the patient transfer process.) Using a dashboard display function, the text message shows the result with the reference range, along with the patient's name, medical record number, and time the specimen was collected.
- Physician or nurse acknowledgment: Once the page is sent, four possible scenarios exist, each of which concludes with the physician or nurse acknowledging receipt of the critical value.
- Prompt reply: In the most common scenario, the physician acknowledges the page within minutes by calling the ALERTS phone response system using the phone extension and acknowledgment code provided in the message; the physician's identity is confirmed as part of the phone interaction. The physician can also acknowledge the alert receipt electronically in the hospital EMR or computer physician order entry system.
- Seven-minute warning: If the physician fails to acknowledge an alert within 7 minutes of being paged, the system sends a reminder page with a warning that failure to acknowledge the alert receipt in the next 3 minutes will result in the alert being escalated to the telephone operator. Again, the doctor can respond by phone or electronically as described above.
- Escalation to operator phone call: If the clinician does not acknowledge the pages within 10 minutes, a telephone operator receives an alert and attempts to reach the assigned physician by phone to communicate the critical value. If the patient's physician is not available, the operator identifies an alternate physician using the up-to-date schedules of all clinical services or relays the critical value to the patient's nurse, who is responsible for informing the physician about the critical value and documenting this notification in the electronic nursing charting system. Once reached, the operator has the physician or nurse read back the value, and documents the alert acknowledgment in the ALERTS system.
- Rejected pages: If the paged clinician is not caring for the patient, he or she can reject the page, which also escalates the page to a telephone operator. The operator identifies an alternate physician and relays the message to that physician or the patient's nurse in a phone call with read-back, as described above.
- Simultaneous communication to unit nurses: At the same time a page goes out to a doctor, the system sends a page to the charge nurse on the patient's unit that contains the critical value and contact information for the notified physician. These "for your information" (FYI) pages provide an additional mechanism for ensuring patient safety by keeping nursing personnel in the information loop, thus allowing them to intervene if a patient requires immediate attention and a physician cannot be reached.
- Real-time monitoring to stimulate quality improvement: The ALERTS system displays the reporting status of all critical values in real time, and also produces monthly data by individual physician and physician group, thus allowing trends to be identified and problems to be quickly uncovered and corrected. When individual physicians have low rates of responding to pages within 7 minutes, a senior laboratory or hospital official contacts the physician to review the importance of a prompt response.
References/Related ArticlesParl FF, O'Leary MF, Kaiser AB, et al. Implementation of a closed-loop reporting system for critical values and clinical communication in compliance with goals of the Joint Commission. Clin Chem. 2010;56(3):417-23. Epub 2009 Dec 29. [PubMed]
A transcript of a podcast from Clinical Chemistry with the hospital's Director of Technology Integration is available at: http://www.aacc.org/events/podcast/Documents/201003_Shultz.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .)
Contact the InnovatorFritz F. Parl, MD, PhD
Director, Clinical Chemistry Laboratory
Professor of Pathology
Vanderbilt University Medical Center
Nashville, TN 37232
Phone: (615) 343-9117
Innovator DisclosuresDr. Parl has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe program has been successful in getting 95 percent of critical test results acknowledged by physicians, most within 3 minutes, and has eliminated the need for approximately 9,000 phone calls a year by laboratory technologists.
Moderate: The evidence consists of pre- and post-implementation comparisons of the number of calls made by laboratory technologists to report critical laboratory test results, along with post-implementation data from a 6-month study on the percentage of physicians acknowledging critical results and median response times.
- High physician acknowledgment rate: A 6-month study (from January to June of 2009) found that 90 percent of critical results had been acknowledged by the physician via return page within 10 minutes, and an additional 5 percent had been acknowledged after the telephone operator contacted the responsible physician. In the remaining 5 percent of cases, the physician could not be reached and the telephone operator gave the result to a nurse who then took responsibility for contacting the physician and documenting this notification.
- Rapid response: In the 90 percent of cases where physicians responded to the page, response time averaged 3 minutes (as measured by the median). In cases escalated to telephone operators, response time averaged 15 minutes (i.e., an additional 5 minutes beyond the 10 minutes that elapsed from the initial page until the operator received an alert and placed the call).
- Virtual elimination of technologist calls: The ALERTS system virtually eliminated the need for calls from laboratory technologists to report critical values. Before the system's introduction, technologists made approximately 9,000 calls per year, with the time required to reach the appropriate nurse or physician ranging from 1 to 10 minutes or more. Assuming an average of 7 minutes per call, the new system resulted in time savings of 1,050 hours of technologists' time, or about one-half of a full-time equivalent technologist.
- Likely reduction in errors: Although no hard data are available, the elimination of these 9,000 phone calls likely reduced the rate of clerical errors and the need to correct reports due to interruptions.
Context of the InnovationVanderbilt University Medical Center is a tertiary-care, 1,000-bed academic medical center in Nashville, TN. More than 1,200 physicians practice at the hospital, supervising the training of about 850 residents and fellows. Each month, the medical center relays roughly 800 critical laboratory values to physicians. Hospital leaders decided to develop the ALERTS system after realizing that the existing telephone-based system did not allow the hospital to follow The Joint Commission's recommendation that laboratories deliver critical values to physicians in a timely fashion and verify their receipt.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Forming committee, setting program goal: In 2007, the hospital formed a committee that included senior hospital officials, laboratory staff, information technology (IT) staff, and physicians. The committee met weekly to develop a system to improve and measure timeliness of delivery and receipt of critical values.
- Decision to involve telephone operators: Early in the development process, the committee decided to use telephone operators to call clinicians in cases where they do not respond within 10 minutes. The committee felt that operators were well suited for this task because they have access to up-to-date call schedules for all clinical residents, fellows, and faculty, and have minimal difficulty tracking a physician. The number of alerts escalated to operators (approximately 100 per month, or 3 to 4 per day) represents only a small addition to their workload, and hence has had no adverse impact on their ability to perform other duties.
- Training: In late 2007, IT staff conducted separate training sessions for all laboratory technologists and telephone operators in advance of the ALERTS system rollout. The training occurred on different shifts and lasted approximately 15 to 30 minutes. Training operators became especially critical because their involvement represented a new responsibility; during these sessions, they learned to use the ALERTS system to monitor acknowledgment of critical value alerts and to close escalated pages. They also learned to read and pronounce the names of critical laboratory tests. A representative from the hospital's Clinical Diagnostic Laboratories periodically audits the operator's performance.
- Notifying physicians: Physicians did not require targeted training on the new system because they were already familiar with operating a pager as part of their regular clinical duties. They were notified via e-mail about the ALERTS system and the new process for acknowledging critical values.
- Gradual rolling out of program: In 2008, the hospital gradually implemented the ALERTS system, beginning with a few tests and floors, and expanding over time to the entire hospital and full regimen of tests.
- Improving system over time: Following the initial rollout, developers made two key changes to enhance the system:
- Seven-minute reminder page: Physicians initially had 10 minutes to respond to a page before a telephone operator became involved. However, during the first 3 months, the responsible physician acknowledged the page using the automated options in only 70 percent of cases. To increase this rate, program leaders instituted a followup reminder page after 7 minutes, which raised the physician's response rate to the pages to 90 percent.
- Communication loop function for nurses: Although the ALERTS system reduces nurse workload by eliminating the need to answer phone calls, some nurses felt that the new system took them out of the information loop. To correct this problem, developers added the aforementioned FYI function to ensure nurses receive critical values via page simultaneously with physicians.
Resources Used and Skills Needed
- Staffing: The ALERTS system did not require the hiring of additional personnel. Hospital IT staff developed the software as part of their regular jobs and laboratory technologists, physicians, and operators incorporate the system into their daily work routine.
- Costs: Program costs are minimal. Because physicians already used pagers, the hospital did not need to purchase additional equipment.
Getting Started with This Innovation
- Take a multidisciplinary approach: Although communicating a critical value to a clinician may seem relatively straightforward, many variables must be considered. To ensure the system functions as smoothly as possible, "step outside the laboratory" and consider all stakeholders' points of view. Consult physicians, nurses, and telephone operators upfront, and make sure that IT staff who develop the system software have a strong understanding of the real-world implications of various system features.
- Emphasize benefits to physicians: Of all participants, physicians remain most likely to be skeptical of the merits of a new pager-based reporting system, because it forces them to change their routine and take a more active role (by requiring them to make a return phone call instead of just receiving the information by phone). At Vanderbilt, most clinicians quickly accepted the new responsibility once they understood that the return call did not require a lot of time and that the new system offered many positive features, including quicker communication, built-in documentation, and the potential to improve quality of care. However, physician leadership may need to directly contact those physicians—usually few in number—who adapt to the system slowly.
Sustaining This Innovation
- Stay on top of staff training: An ongoing training system ensures employees receive prompt and thorough training on their role. For example, each July, new residents are familiarized with the ALERTS system as part of their orientation. Additionally, telephone operators who become responsible for communicating critical values must receive training to be proficient in reading and pronouncing the names of the critical laboratory tests.
Use By Other OrganizationsA number of other hospitals have contacted Vanderbilt officials to learn how to implement similar pager-based reporting systems.
Howanitz PJ. Laboratory critical values policies and procedures: a college of American Pathologists Q-Probes Study in 623 institutions. Arch Pathol Lab Med. 2002;126(6):663-9. [PubMed]
Valenstein, P. Notification of critical results: a College of American Pathologists Q-Probes study of 121 institutions. Arch Pathol Lab Med. 2008;132(12):1862-7. [PubMed]
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Service Delivery Innovation Profile
Original publication: September 29, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 01, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 20, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.