med/tele orientee needs help with critical labs

[GraceNotes]

The other day my manager called me to the front desk. She was viewing labs & pointed out a critical value that was drawn on a previous shift (mine, a couple of days back) & never called to the doc. The patient wound up having an emergency CABG. I feel terrible that this happened. But it turned out after some investigation that the lab wasn't posted until 2 hrs after I went home. The only value I was able to review was wnl so next shift should have caught the critical new posting. The manager hasn't bothered to talk to me again since she found out the posting was so late.

I am still on orientation & feel I should have had more support. This is a learning experience, no doubt. I should mention that this was the first of an 8-hr serial lab, and manager and my preceptor said I should have called the lab for values. I didn't know that. I'm still figuring so much out, where/what things are, and finding my rhythm. I came home feeling like I had no business on a hospital floor.

Chances are my patient was in trouble and would have had the same outcome, but I wonder did I do something horribly negligent? Med/surg wasn't my first choice in nursing, but it's where the jobs are so I'm trying to put in my time and until this event, I was actually beginning to enjoy meeting the challenges of the day. Now I don't know...

[mama_d, BSN, RN]

I'd have to know a couple of things here before I would render judgement:

Why were the serial enzymes ordered? Was the patient having chest pain, were there EKG changes, etc.?

How long before the end of your shift were they drawn and sent?

Were they ordered stat or routine?

If the patient wasn't having any real symptoms, the labs were sent right before the end of your shift, and they were ordered routine, then I don't see where they would expect you to be on the horn to lab looking for results.

If the patient was having symptoms, the labs were sent within an hour or so of your shift ending, or else stat, then I could see where they would have possibly expected you to call lab to check up on them. There have been times when I've had to call lab when I sent a specimen down to tell them "I'm sending labs on Mrs. Jones in 208...is there any way to expedite the Trops b/c she's symptomatic?" Usually they're understanding about it.

You mentioned you have a preceptor, where were they during this situation? Why were they not instructing you on what was proper procedure before it could get to that point, or calling the lab for you as they explained what the expectations were?

[herring_RN, ASN, BSN]

Check regarding your hospital policy and procedure.

The JCAHO requires that critical "panic" test results be called and read back to the department.

I think at minimum the result must be called to a licensed person, such as the RN assigned to the patient, the charge nurse, or an LPN/LVN working with the assigned RN.

The lab needs to keep a log with the tome and the name of the licensed person called.

[GraceNotes]

Thanks for your replies. The patient was asymptomatic--troponin, vs & tele were all wnl at shift end and the patient reported no discomfort. I had 4 pts on my own-the preceptor had 3. The lab did not call, although it is policy to call critical values, & no new labs were posted during the shift. High troponin was posted 2 hrs AFTER end of shift--I don't know what time it was drawn. In my 5 wks of orientation I was taught to check lab results as they become available in the system.

Also wondering, the CABG was done approx 60-72 hrs after the event, which seems to me a long time in a critical situation--is it? I am taking responsibility--I don't want to ever recreate this situation. I feel frustrated & ashamed. As hard as I worked to be on top of things, it wasn't enough. Ashamed because the confrontation by my mgr was at the busy front desk and they'll probably never know the truth.

[Virgo_RN, BSN, RN]

If the patient was asymptomatic and the trops were WNL throughout your shift, what exactly are you taking responsibility for?

[GraceNotes]

I was told that because it was a serial lab, I should have called the lab for new findings even though they weren't posted. Yeah, I know... Thanks for pointing that out. I can only be responsible for what happens on my shift.

[WalkieTalkie, RN]

Our lab is notoriously bad at calling criticals. They're more than happy to call you a critical creatinine of 7.5 on a dialysis patient who has been in our hospital and had a creatinine level this high on several occasions. However, they seem to have problems actually calling critcial things, like the other day when my patient had a K+ of 2.2!

When I reviewed her labs, it was about 0430 in the morning. I already had 20 mEq infused by 0530, and still no call from lab! I ended up calling them to tell them that I already knew about the critical. LOL. This kind of crap happens all the time!

You just need to be aware of what you are drawing, the average turn around times for labs at your facility, and if the results are being posted in a timely manner. It's not uncommon for our lab to either forget to run something, lose a lab tube, or be running a "QC" in the middle of the night on machines for specific lab tests.

[Nightcrawler, BSN, RN]

Check regarding your hospital policy and procedure.

The JCAHO requires that critical "panic" test results be called and read back to the department.

I think at minimum the result must be called to a licensed person, such as the RN assigned to the patient, the charge nurse, or an LPN/LVN working with the assigned RN.

The lab needs to keep a log with the tome and the name of the licensed person called.

Positive cardiac enzymes have not been considered critical lab values at either of the hospitals that I have worked at, regardless of how high they rise. I have seen some truly amazing results with no peep from the lab and results that routinely take an hour or more to come back

[UM Review RN, ASN, RN]

Positive cardiac enzymes have not been considered critical lab values at either of the hospitals that I have worked at, regardless of how high they rise. I have seen some truly amazing results with no peep from the lab and results that routinely take an hour or more to come back

Same here. Then policy changed and they started calling in all elevated trops, which was even more of a pain, because more often than not, they were trending down. Naturally protocol called for a notification of the MD within an hour of being told. Oh boy, did they love that 3 am phone call. *sarcasm*Not.

I have no idea what the OP was supposed to have done in the case as it's described here. Seems to me you did everything correctly, OP, and once it was determined that you couldn't have seen a positive trop since it hadn't been posted, I don't know what else you could've done. If cardiac enzymes are not complete, I would report to the next nurse the times they were to be drawn so that they could be on the lookout for them, but other than that, I can't add anything to what you did.

Be a duck. Let that one roll off, ok? Sounds like you're doing fine.

[Virgo_RN, BSN, RN]

Positive cardiac enzymes have not been considered critical lab values at either of the hospitals that I have worked at, regardless of how high they rise. I have seen some truly amazing results with no peep from the lab and results that routinely take an hour or more to come back

Our lab won't call for a minor elevation, but will call for anything above 4, I believe. Usually though, it's an expected finding so the nurse simply checks the "expected finding" box and puts a sticker in the chart. I've only called the doc once for an elevation, in a patient who had an MI and was being followed by a hospitalist and was not getting any ASA or BBs. Our lab's turnaround time is actually pretty quick, usually within the hour from the time of collection.