What do you do with critical lab values when they are called from the lab dept?

lapappey · Feb 10, 2005

Well, first, you read it, and then respond with "oh, @#$%" (rhymes with "crit"). Then we would document and call the MD to give a heads up see what they want done, which sometimes is more or less self-evident. "Critical lab values", IMHO, are not something to be sat upon till rounds time.

rstewart · Feb 10, 2005

Looking for what other hospitals are doing when the lab calls with a critical lab value. After you read back the value, then what? Where do you document what you did with it? Do you call the doctor with improving criticals? Do you save them until the MD rounds? I'm in a small rural hospital that the docs only round once a day, unless there are problems. I have one week to come up with a solution to as what we will do, so we can change our policy to say what we want it to say. HELP!

I would suggest that you keep it simple.......All critical lab values will be reported to the ordering physician immediately unless the original order directs otherwise.

Yes I know there will be renal docs who complain about being notified about chronically high BUNs or BUNs that are improving (but remain critically high); likewise for pulmonary docs with their chronically hypercapnic COPDers. The first few times I gently explain/repeat the policy and give suggestions/parameters to avoid a call. And most times (if I am not in the middle of something) I will prompt the physician when the order is being written for parameters to save him/her the inconvenience. But after an informal grace period I accept no complaints about my calls----they get the same policy review as above but the tone is clearly "you know the rules and don't pretend you are hearing them for the first time". And finally, never never apologize for calling critical lab values if that is what your policy requires.

PS Do not permit your docs to muddy up your policy with judgement stuff---

PPS Oh and while I'm on a rant, the same goes for cardiologists and runs of V-tach. They are the docs and if they don't want to cover a certain level of ectopy that's fine-------BUT, don't expect me to sit there and watch run after run without a witnessed written order as to how may beats you are willing to ignore before you want to be notified.

begalli · Feb 10, 2005

I agree with the above poster that these labs are not to be sat upon....they are being called to the RN because they are critical.

We almost always have electroyte replacement standing orders for kcl, cacl, and mag. If it's a lyte that's been called we replace right away. If no standing order, we always call to get one (or start the replacement and then call - but I wouldn't recommend that for a regular floor).

Sugars are done at the bedside so when they call a critical glucose, I always say thank you give my name and that's that because I already knew.

Those are really the ones that I'm most concerned with. Things like a critical bilirubin or even phorphorus waits until the docs round (which is MUCH more frequent as this is an ICU).

DutchgirlRN, ASN, RN · Feb 10, 2005

I write the value down and double check the morning labs I've got written down to see if it is improving or getting worse. If it's improving I don't do anything. If it's getting worse I call the doctor right away. If he decides not to do anything about it then that's his responsibility, the same with cardiologists and ectopy's. If I get an order than that's documentation enough that it's been addressed, if I don't get an order then I do chart that the doctor was notified and is aware that the BUN or whatever is 45 or whatever. We don't have a policy on how to handle critical labs.

UCDSICURN · Feb 10, 2005

I would hesitate to make a policy that blindly mandates a nurse to inform a physician. Critical thinking is the key here. If the physician needs to be notified, the nursing staff should have the critical thinking ability to be able to decide that. If it's a lack of knowledge that's the issue and you're trying to treat that with policy changes, I would rather opt for mandatory in-service training to improve the knowledge base of the nurses and give them the tools to make sound clinical decisions.

Keep in mind, the more rules there are, the more rules that can be broken. Having a policy for everything can actually backfire when litigation is involved.

Just my thoughts.

D.C.

Goofyfoot · Feb 10, 2005

I agree with UCDSICURN that critical thinking is key - because with this type of thing, it absolutely depends on a variety of factors.

On an oncology floor, for example, a good percentage of patients may have a 'critical' white count ... but this is a known entity and the docs would laugh you off of the phone if you called them.

Is it a known/expected value?

Will the current course of treatment correct the issue?

Is it a new admit?

Is it consistent with the disease process going on in the individual?

These questions mean "don't take action," but having the answers will lead you to the right action (e.g., ignore, using standing protocol, call doc, etc.).

Tweety, BSN, RN · Feb 10, 2005

Our lab is able to enter "called to Tweety at 0400" as documentation that the unit was notified, and when the labs print up on the floor, that notation is there. That way the lab is off the hook if the poop hits the fan.

Whoever takes the call then must notify either the charge nurse or the nurse in charge of the patient.

If the lab is critical enough we call the doc right then. If not we wait until daytime hours or when they round.

Personally, if a critical value doesn't need immediate attention in the wee hours of the night, I'll wait until 7am and call the doc then and document "MD made aware of lab values...." rather than turn it over to the day shift. That covers my butt. Other nurses let the charge nurse handle it and it's passed on to the day charge nurse. But I'm the RN and it's my patient, and I cover my butt. :)

The above, question "how does it compare to their individual normal lab values, based on their condition". For instance a sickle cell patient may have a low h&h that they will call and I'll do nothing. But a post-op patient with the same value needs attention.

NoCrumping · Feb 10, 2005

I would hesitate to make a policy that blindly mandates a nurse to inform a physician. Critical thinking is the key here. If the physician needs to be notified, the nursing staff should have the critical thinking ability to be able to decide that. If it's a lack of knowledge that's the issue and you're trying to treat that with policy changes, I would rather opt for mandatory in-service training to improve the knowledge base of the nurses and give them the tools to make sound clinical decisions.
Keep in mind, the more rules there are, the more rules that can be broken. Having a policy for everything can actually backfire when litigation is involved.
Just my thoughts.
D.C.

I agree.I had to think about it for a minute, I doubted myself briefly....These are the things we are trained and educated for... a policy for notifying an md for a critical lab sounds silly... its the rn's job to know when, and like others posted, alot of factors are involved, and thats where our critical thinking comes in......The "policy" should be, "have a trained and capable RN taking patient assignments at all times" I agree, if you feel a need for a policy of this nature, what you should really be focusing on is training, in servicing, etc.

General E. Speaking, RN, RN · Feb 10, 2005

Whatever your decision make sure you CYA,CYA,CYA! :uhoh21:

pk1 · Feb 11, 2005

I do appreciate all of the replies. Each one has given me something to think about and consider. Ideas are starting to surface!

KacyLynnRN · Feb 11, 2005

Where I work at, it is policy to call all critical lab values to the physician, no matter what time it is or how long it will be until they round.