Laboratory and Ultrasound Management

Good processes for the management of laboratory and ultrasound results enable midwives to provide high quality, safe care to their clients. (1,2) Poor management of results can hinder a midwife’s ability to make a proper diagnosis. (3) As a result, the College of Midwives of Ontario requires that midwives ensure that “the results from all tests, treatments, consultations and referrals are followed up and acted upon in a timely manner.” (4)

Management of results requires good communication and understanding between practice members; a well-documented, standardized process for the management of results helps ensure that all results are managed appropriately.

Medico-Legal Risk and Client Safety

Mismanagement of laboratory and ultrasound results puts client safety at risk and exposes health care providers to medico-legal liability. (1-7) Risks can be mitigated by adopting and following a system that tracks every laboratory test or ultrasound, from the informed choice discussion about ordering the test to the discussion of results and follow-up plan with the client. (5) Describing this system in a practice protocol also provides an audit trail that tracks how, who and when each step of results management was performed. (5)

HIROC has identified key themes in incidents and claims involving midwives. (8) These include:

  • lack of standardized protocols and processes for results management
  • staff/students screening results as “normal” and filing without midwife sign-off
  • filing results without midwife sign-off or with the plan to review the results at the next client visit
  • poor coordination of ordering, tracking and communicating results, including unclear accountability (e.g. multiple midwives are involved)
  • scheduling and rescheduling clinic appointments and physician consultations, which may delay action on results (see AOM template protocol on rescheduling visits, under Client Relations)
  • lack of clarity in the chart about why routine and follow-up tests/ultrasounds were not ordered (e.g. no documentation of client discussion or decision)
  • loss of notes (e.g. sticky notes) and logs used to record instructions and client concerns

Creating Standardized Systems for Results Management

Practices that do not have a clear, standardized, documented and effective system for managing results can consider analyzing and standardizing their practice’s process (see the AOM’s template protocol, under General Clinical). Plan a meeting that includes all team members involved in the results management process (midwives, staff, volunteers, students, etc.) and consider:

  • standardizing and simplifying processes and procedures as much as possible
  • developing a system of reminders and alerts
  • defining a list of critical values and tests that require timely and reliable communication
  • prioritizing results with a coding system (e.g. Urgent, Pending Result, Critical)

To be successful, all practice members commit to using the standardized process for managing results. (4) While the ordering care provider is most responsible for ensuring timely and appropriate client follow-up, everyone is responsible for the care they provide. Extra procedural care is required when the midwife that will follow up on the result(s) is not the ordering midwife. (2)

A standardized process can cover many aspects of laboratory investigations and results management and ensure that results are received, reviewed and communicated in a timely, appropriate manner (see AOM template, under General Clinical). (3) A practice’s protocol may include descriptions of several standardized start-to-finish processes:

  • client decision-making, documentation and test ordering
  • specimen handling
  • phone calls and verbal orders
  • communication of urgent results to midwives 
  • initial receipt of results at the clinic by administrative team
  • initial review of results by midwife and student, if applicable
  • communication of normal results
  • communication of, and follow-up for, urgent/abnormal results 
  • double-checking that all pending results are received
  • communicating ongoing investigations and follow-up for results when midwives go on vacation or change roles within their team rotation  
  • documentation of these steps to ensure a clear audit trail

Clients who expect to hear about all of their results, whether between visits or at the next visit, can serve as an additional safeguard to ensure the reliable management of test results. (9) Consider advising clients that critical results will be shared promptly and normal results will be communicated at their next visit, and that clients are welcome to follow up on their own as well. (2) One midwife reports asking clients at every visit whether there are any results that they are waiting for.

Interprofessional Collaboration

When creating protocols and systems for managing lab and ultrasound results, investigating and incorporating the protocols of other organizations can help create effective systems that run smoothly. For example, consider local hospitals’ processes for communicating critical results when developing your practice’s results management protocol. (5)  It is also helpful to provide local hospitals, physicians, laboratories and ultrasound clinics with the practice’s most current contact information for office hours and after-hours use. This will help ensure that timely communication and follow-up for abnormal results can occur. (2)

When delivering an urgent result to a client, consider whether other care providers need to be updated. For example, if a midwife receives an urgent result ordered by a physician consultant, the midwife should make sure that the physician also received the result or update the consultant accordingly. (2) Other midwives on the team will need to be updated regarding the urgent result, in case the client contacts the office for further information.  

Practice Protocol

The AOM has developed a template protocol on the management of lab and ultrasound results (under General Clinic). When considering your practice’s processes, imagine the path of theoretical results as they are received at the clinic. Your practice group can use the following questions as a guide to explore the complete process you currently have in place and identify inconsistencies and areas for improvement. 

Receiving Results

  • How do results enter the clinic? Are they received by fax, email, mail, telephone or electronically?
  • Who receives the results?
  • Are results stamped and initialed with date and time of receipt on the result?
  • How are the results passed on to a midwife?  
  • Is there a method of identifying the urgency of a result as it passed on (e.g. telephone call from lab with critical result, fax marked Urgent, an electronic system)?

First Assessment of Results by Midwife

  • Who is responsible for reviewing results? Is it the ordering midwife, a team midwife in clinic or on call, a coordinating midwife, a covering midwife, etc.?
  • How often are results reviewed?
  • If a student reviews the results first, how does the practice ensure that the responsible midwife sees the results in a timely manner?
  • Does the midwife sign off on the results with date and time and initials of review on the result?

Following Up on Results

  • How are urgent, non-urgent and critical results communicated to the client?
  • How are results communicated to other team members who provide care to the client?
  • When a client requires consultation or follow-up testing, how is this communicated to them? 
  • Who is responsible for following up on results with clients and arranging consultations?
  • How does the practice confirm that consultation appointments are scheduled in a timely manner?
  • How does the practice ensure that a client who is not reachable by phone receives their results?
  • Is there a process in place for cancelled appointments, to ensure that communication of results is not delayed?
  • Is there a process in place to ensure results are received at the clinic in a timely way?  Does this process ensure results aren’t missed because of faxing error or specimen loss?
  • How does the practice track and confirm that results are received in a timely manner?

Documentation and Communication

  • Is the client informed of the process for receiving results at start of care? Are they encouraged to call the clinic for their own results?
  • Where does the midwife document communication with the client about results (e.g. on the result paper, on the EMR, in a narrative note, on the antenatal record, etc.)?
  • Where does the midwife document the follow-up plan for results?
  • When does a normal result get communicated to the client, and how is this documented (e.g. at next clinic appointment, documented as “reviewed results with client” on OPR, with a date/time/initial stamp for “review with client”)?
  • How does the midwife communicate results to other midwives and/or students?

Consistency of Process

  • Are midwives and teams consistent about when results are reported to clients? Which results are reported immediately, and which ones can wait until the next clinic appointment?
  • Are there inconsistencies in the reporting of GBS, hemoglobin, first trimester screening and soft markers on ultrasound?
  • Are administrators and staff consistent in when to contact an on-call midwife or interrupt a clinic appointment, versus when to leave a note or result for a midwife when they get to it?
  • Are clients consistently made aware of the results communication process? Are they informed of when to expect results to be received by the practice, when to expect a phone call, the option to check results online with LifeLabs, etc.?

References

1. CMPA. How effective management of test results improves patient safety [Internet]. CMPA Perspective: 3 (2), June 2011 [cited 2017 June 10]. Available here.

2. CPSO. Test Results Management [Internet]. Policy Statement, February 2011 [cited 10 June 2018]. 

3. Graber, ML. Minimizing Diagnostic Error in health care: ten things you could do tomorrow.  Inside Medical Liability. January 2014.  22-26.

4. College of Midwives of Ontario. Professional Standards [Internet]. June 2018 [cited 3 July 2018].  Available here.

5. HIROC. Diagnostic imaging studies, EKGs and laboratory results: the importance of follow-up systems [Internet]. Claims and Risk Management Bulletin Issue # 24. March 2002 [cited 10 June 2018]. 

6. ACOG’s Committee on Patient Safety and Quality Improvement. Tracking and Reminder Systems [Internet]. ACOG. 546, December 2012 [cited 10 June 2018]. Available here.

7. HIROC. Diagnosis: Failure to Communicate. Risk Reference Sheet. 2012.

8. HIROC. Midwifery: Failure/Delay in Diagnosing.  Risk Reference Sheet. 2018 [cited 10 June 2018]. Available here

9. Association for Healthcare Research and Quality. 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet [Internet]. May 2017 [cited 20 June 2018].  Available here.

10. Kwan J, Cram P. Do not assume that no news is good news: test result management and communication in primary care. BMJ Quality & Safety, August 2015.