APPENDIX 20
Memorandum by the Royal College of Pathologists
(GP25)
"Out of Hours" reporting of markedly
abnormal laboratory test results to primary care: whose responsibility
and what to do?
1. DEFINITIONS
Out of Hours: That period of the working
week when the Primary Care Centre is unmanned and/or responsibility
for patient care has been passed from the normal General Practitioner
(GP) to a deputising service.
Markedly Abnormal Laboratory Test Result:
A markedly abnormal result that may signify a pathophysiological
state that may be life threatening or of immediate clinical significance
and which requires urgent action. A list of such markedly abnormal
laboratory test results requires to be agreed between stakeholders.
Please see Annex listing suggested triggers for contacting primary
care services Out of Hours.
2. INTRODUCTION
The Royal College of Pathologists (RCPath) has
recently become aware of several serious untoward incidents, relating
to the inability of laboratory staff to find an appropriate primary
care physician to act on a life-threatening or markedly abnormal
test result. The Regional Councils of the RCPath provided examples
of such incidents or near misses and these have been collated
to identify important themes and to form the basis of these guidelines.
The problems in reporting and acting on markedly
abnormal laboratory test results fall into three main areas.
— Laboratory staff knowing whom to
contact when a GP surgery is closed and knowing how to make that
contact.
— Staff at the GP deputising service
appreciating the importance of the abnormal result and being willing
to accept responsibility for a result that was generated through
a request made by the GP or other appropriate primary care staff
within normal working hours.
— Staff at the GP deputising service
being able to contact the patient and access patient records as
part of the corrective action.
Examples:
"The telephone receptionist who answered
the phone and took the results had no idea how abnormal the results
were and was relying on my judgement to call a doctor, which she
seemed reluctant to do."
"Some years ago we established that it
is the responsibility of the General Practitioner Deputising Service
(GPDS) to follow up abnormal results out of hours. The problem
that we now face is that the request form often does not include
the patient's address (the return address is given as the GP's
surgery, which is closed out of hours). Therefore when we contact
the GPDS with grossly abnormal results, they cannot act on them
in a high proportion of cases. The GPDS then returns to the laboratory
asking for further contact information which may not be available!"
3. GENERAL PRINCIPLE
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 GP
deputising service. It is the responsibility of the clinical team
to act upon that abnormal result in the interests of the patient
(or the community in the event of an infectious disease).
4. IDENTIFYING
AN ABNORMAL
LABORATORY TEST
RESULT
Agreement is required between all stakeholders
on what constitutes a markedly abnormal laboratory test result.
A failsafe method is required within the laboratory to help biomedical
scientist staff (BMS) to identify results that fall within the
agreed abnormal category. Junior BMS staff should be able to contact
senior members of the department (medical staff or clinical scientists)
out of hours and pass to them the responsibility for communicating
a markedly abnormal result to the relevant primary care physician.
5. COMMUNICATING
AN ABNORMAL
LABORATORY TEST
RESULT
Primary Care Centres should inform the laboratory
of specific arrangements for making telephone contact with a GP
out of hours. Laboratories should collate this information into
a formal document and display it in a prominent place. Senior
members of the laboratory department should be able to access
this information at all times.
When reporting a markedly abnormal result out
of hours, laboratory staff are required to give the following
information:
— the name and date of birth of the
patient together with any unique patient identifier;
— the abnormal test result (and reference
range if requested);
— the date and time of the request;
— the name of the requesting physician
and/or the practice number;
— as much clinical history as is available;
and
— contact details for the patient,
including address and telephone number.
Where appropriate they may also advise on a
recommended course of action.
Laboratories should maintain records of all
abnormal results communicated out of hours. The record should
include the information specified above together with the name
of the person to whom the result was communicated and the date
and time of the communication, and any advice given.
6. PROVIDING
ADEQUATE PATIENT
INFORMATION WITH
THE REQUEST
General Practitioners who fill in request forms
for the laboratory should always consider the possibility that
the request may generate an abnormal result that may have to be
communicated out of hours to another doctor. Therefore, GP request
forms should be designed to accommodate the information specified
in the above section and GPs should provide all the necessary
details in a legible fashion.
7. TAKING ACTION
ON AN
ABNORMAL LABORATORY
RESULT
The doctor receiving the markedly abnormal laboratory
test result must decide how to act in the best interests of the
patient (or the community in the event of an infectious disease).
Each case should be treated according to it's individual circumstances.
Action may include the following:
— contact with the GP who made the
request;
— direct contact with the patient;
— generation of a follow-up request;
and
— liaison with Health Protection staff.
8. STAKEHOLDERS
The following are stakeholders in facilitating
the effective communication of markedly abnormal laboratory test
results out of hours:
— Laboratory staff (BMS, medical staff
and clinical scientists).
— General Practitioners and Community
Midwives.
— Primary Care Trusts (PCT) or Operating
Divisions (Scotland).
— GP deputising services, including
NHS Direct, and NHS24 (Scotland).
— Health Protection Teams.
— Professional bodies (RCPath, RCGP).
— Patient representatives.
9. RECOMMENDATIONS
FOR FURTHER
ACTION
1. PCTs and GPs should have an explicit
agreement to ensure that a markedly abnormal test result can be
received out of hours and, if necessary, acted upon. In practice
PCTs are likely to negotiate a deputising service to cover several
Primary Care Centres and this should be one function of that deputising
service.
2. PCTs and GPs should have an agreement
on the handover of responsibility to any out of hours GP deputising
service and ensure that the laboratory is informed of the key
elements of that agreement.
3. It is the responsibility of the requesting
GP (or Community Midwife) to complete the request form with sufficient
patient details and clinical information to permit effective out
of hours communication between the laboratory and any deputising
service. Consideration needs to be given to confidentiality and
data protection issues relating to the inclusion of the patient's
telephone number on the request form.
4. Responsibility for communicating the
markedly abnormal test result to the GP or Midwife or deputising
service out of hours should be handed from a junior BMS staff
member on call to the designated senior member of the department
who is on call.
5. Laboratory staff should maintain detailed
records of all abnormal test results communicated out of hours.
6. GPs should examine practical ways to
assist deputising services to obtain access to patient records
out of hours.
Annex
ABNORMAL LABORATORY TEST RESULTS—TRIGGERS
FOR CONTACTING PRIMARY CARE SERVICES OUT OF HOURS
1. CLINICAL BIOCHEMISTRY
Typical action limits for contacting GPs out
of hours. These limits are based on the first abnormal set of
results for an individual patient with no known history that could
explain the results. Each laboratory is advised to agree specific
action limits and procedures with local primary care services.
| |
| |
| Analyte (Serum/Plasma) |
| Action Limits |
| | Below
| Above |
| |
| |
| Sodium | mmol/L | 120
| 160 |
| Potassium | mmol/L | 2.5
| 6.5 |
| Urea | mmol/L | -30
| |
| Creatinine | umol/L | -
| 500 |
| Glucose | mmol/L | 2.5
| 20 |
| Calcium adj | mmol/L | 1.8
| 3.5 |
| Magnesium | mmol/L | 0.4
| - |
| Phosphate | mmol/L | 0.3
| - |
| AST | U/L | -
| 750 |
| ALT | U/L | -
| 750 |
| Total CK | U/L | -
| 5000 |
| Amylase | U/L | -
| 1000 |
| Carbamazepine | mmol/L |
- | 100 |
| Digoxin | mmol/L | -
| 3.5 |
| Theophylline | umol/L | -
| 250 |
| Phenytoin | umol/L | -
| 150 |
| Phenobarbitone | umol/L |
- | 300 |
| Lithium | mmol/L | -
| 1.5 |
| |
| |
| |
| |
2. HAEMATOLOGY
The focus of the guidelines is those few tests where urgent
contact with GPs is required. Action required may include (i)
immediate medical intervention, including admission to hospital
or change in the patient's treatment or (ii) urgent referral for
assessment during the next working day. While the decision to
contact the primary care team will be based solely on the numerical
values obtained, the assessment and clinical decision will depend
on the clinical context. This is dependant on the input and knowledge
of the attending clinician.
Contact outside normal working hours often involves a deputising
service when access to the patient can be difficult. However,
this should not influence the decision to contact that should
be based on the need for urgent (ie immediate) or next day medical
intervention.
The clinical context is crucial in the ultimate decision
making and will not always be known to the laboratory and in these
circumstances it is best to err on the side of caution. If the
patient is known to the department and has had a similar result
within the previous seven days then urgent contact is not necessary
and the report can be processed as normal, whereas a "de
novo" finding should always be responded to.
If there is not an electronic link to the requesting clinician
there should be a set of triggers for contact with the practice
during the next working day.
2.1 Haemoglobin
Lower limit would depend on the type of anaemia.
< 5.0 microcytic and hypochromic
< 5.0 macrocytic
< 7.0 normochromic and normocytic (suggestive of bleeding)
There must be separate criteria for renal patients.
Upper limit (only require urgent referral if there are compounding
medical problems)
> 19.0 (or Hct > 54)
2.2 White Blood Cell count
Lower limit—Neutropenia < 0.5
Any presence of blast cells
Upper limit (requires urgent but not immediate referral)
Neutrophilia > 50
Lymphocytosis > 50
2.3 Platelets
Lower limit < 30
Upper limit (only require urgent referral if there are compounding
medical problems)
> 1,000
2.4 Clotting Studies
INR > 6.5 (on Warfarin)
2.5 Positive Malaria screen
3. MICROBIOLOGY AND
VIROLOGY
Some Microbiology and Virology results may need to be reported
urgently, particularly over a weekend or bank holiday, but also
when GP surgeries are closed during the working week. Microbiology
or Virology results may have additional implications for the public
health of a community, as well as the individual patient, and
would then need to be communicated to the local Health Protection
Team, as well as the Primary Care Team. Results may be of particular
significance if they relate to an outbreak of infection, possible
deliberate release or have been obtained from the investigation
of patients from an institutional setting, such as a school, prison
or care home, where there is a significant infection risk.
Increasing diversity of healthcare provision and patterns
of care will require inclusion of clear arrangements within service
specifications.
It is the responsibility of the biomedical scientist who
becomes aware of new results for primary care patients out of
hours in the following categories to inform the senior virologist
or microbiologist on call.
The acute infections with outbreak potential (1) and acute
hepatitis A or B (3) would also be notifiable to the local Health
Protection team out of hours, depending on local arrangements
with Health Protection Units. This would be a responsibility of
the senior virologist/microbiologist on call.
The following list is not exhaustive, but includes the most
frequent or important infections requiring urgent contact with
the primary care teams.
3.1 Acute infections with outbreak potential in close community
or residential setting
3.2 Acute infections in pregnancy that pose risk to pregnant/neonatal
contacts
— varicella-zoster virus; and
— acute bacterial infections in pregnancy and the
post partum period, for example Group A Streptococcus in a high
vaginal swab.
3.3 Acute viral hepatitis (A, B) and any newly diagnosed
hepatitis B for prophylaxis (HNIG/vaccine or HBIG)in some contacts.
3.4 Susceptibility to varicella in pregnant or immunocompromised
contact for prophylaxis with VZIG for significant exposure
3.5 Significant positive blood culture results from patients
who have been sent home for example from A&E or the Medical
Assessment Unit
3.6 Antibiotic assay results from patients who are self-administering
in the community.
June 2004
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