Computerized Laboratory Alerting

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Computerized Laboratory Alerting

• Satellite Meeting 8
• Focus on Information Technology for Laboratory
  Medicine
• Bologna, Italy
• REED M. GARDNER, Ph.D.LDS Hospital University
  of Utah
• Reed.Gardner_at_hsc.utah.edu
• Saturday 5 June 1999 1130 to 1200

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Transcribed Dictation
ICU/SURGERY
Nurse Care Plans
Pulse Oximeters
Infectious Disease
Nursing Procedure Charting
Ventilators
KNOWLEDGE DATABASE
Pharmacy
Mixed Venous Saturations
IV Pumps
ECG Lab
DECISION MAKING PROCESSOR, DATA AND TIME DRIVER
MIB Data
Bedside Monitors
INTEGRATED CLINICAL DATA BASE
Surgery Anesthesia Charting
Physiologic Data
X-Ray
Laboratory
Blood Gas Lab
Data Review Alerts Computations Interpretations Pr
otocols
Pathology
Surgery Schedule
Blood Bank
Admitting
Catherization
Medical Records
Respiratory Therapy
OUTPUT
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Definition Critical Value

• A critical laboratory value represents a
  pathophysiological state at such variance with
  normal as to be life-threatening unless something
  is done promptly and for which some corrective
  action could be taken.
• Lundberg GD Med Lab Observ 1972

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Editorial Panic Value Notification

• Since failures of communication of important
  pieces of information between people.are so
  frequent, responsibility of the laboratory
  person who first recognizes the vital information
  to make certain the information is properly
  communicated..
• Lundberg GD JAMA 1990

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Critical Values ACAP Practice Parameter

• Appropriate use of critical values improves
  patient outcome by ensuring the physicians are
  promptly notified of immediate life-threatening
  conditions. The best way to report
  critical values are by telephone or by
  alphanumeric pager.
• Am J Clin Pathol 1997108247-253

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Clinical Laboratory Improvement Act (CLIA) 1988
USA

• The laboratory must develop and follow written
  procedures for reporting imminent
  life-threatening laboratory results or panic
  values. In addition, the laboratory must
  immediately alert the individual or entity
  requesting the test or the individual responsible
  for utilizing the test results when any test
  result indicates an imminent life-threatening
  condition.

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Current Weaknesses in the Critical Value
Reporting Process

• 1. Values are not always reported
• 2. Data are NOT usually reported to
  primary clinicians
• 3. Alert documentation is incomplete
• Laboratory
• Clinicians

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Study of Critical ValueReporting at LDS
HospitalNov. 1992 - Feb. 1993
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Men more frequently need to be reminded than
informed.

• Samuel Johnson
• 1770

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Clinical Decision Making

• It is simply unrealistic to think that
  individuals can synthesize in their heads scores
  of pieces of evidence, accurately estimate the
  outcomes of different options, and accurately
  judge the desirability of those outcomes for
  patients.
• David M. Eddy, MD, PhD
• JAMA 1990 2631265-1275

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Clinical Decision Making

• ...All confirm what would be expected from common
  sense The complexity of modern medicine exceeds
  the inherent limitations of the unaided human
  mind.
• David M. Eddy, MD, PhD
• JAMA 1990 2631265-1275

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Expert Systems

• We dont need EXPERT systems!
• We need MEDIOCRE systems to prevent us from
  making stupid mistakes.
• Dean F. Sittig, PhD
• November 1990

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How alerts usually works at LDS Hospital

• Laboratory test results are --
• Entered into laboratory computer
• Verified by lab personnel
• Transmitted to Clinical Computer System
• Stored in patient database
• Reviewed on bedside terminals

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Then Critical Values Are

• Telephoned to floor
• Documented
• Time of call
• Person receiving call
• Stored in patient database

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Critical Value Criteria(Patient-Specific)
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Data on effectiveness of Nurse Pager computerized
critical value reporting(Oct. 23, 1993 to Jan
21, 1994)
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Distribution of Acknowledgment Times(Oct. 23,
1993 to Jan. 21 1994)
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Data on effectiveness of CLAS IIs Computerized
critical value reporting(Oct. 23, 1993 to Jan
21, 1994)
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Data on effectiveness of CLAS IIs Computerized
critical value reporting(Oct. 23, 1993 to Jan
21, 1994)
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Patient - Specific Criteria

• 92 (308/335) Judged valid (nurses)
• Verbal feedback positive
• No pattern for invalid alerts
• Encourages rapid acknowledgment

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Comparison of Nurse Pager with other critical
value reporting systems
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Alert Acknowledgment

• Ensures alert reception
• Allows documentation
• Uses computer terminal
• Can review lab data
• Can review other alerts

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Advantages of a Computerized Critical Value
Reporting System

• All critical values reported
• Reported directly to primary nurse/physician
• Reported as soon as results are available
• Documentation is improved
• Can re-transmit alerts if necessary
• Integration with computerized care methods

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Effective User Interface

• Feedback to clinicians
• Acknowledgment by clinicians
• Human factors

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Other Design Issues

• Multiple critical values per lab test
• Patient discharges/transfers
• Successive lab tests-one patient
• Same results transmitted multiple times
• What if NO pager working

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Conclusions

• CLAS II effective in reporting Critical Values
• Compares favorably to other systems
• Nurses not required to be at terminals
• Every critical value reported
• 76 of Critical Values to primary nurse
• Automatic documentation

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