When it comes to lab tests, interpreting the clinical
importance of an out-of-range result
depends on how much experience a physician has, suggests
research from the Johns Hopkins
Children's Center. The findings were reported at the
American Academy of Pediatrics Conference held in
October in San Francisco.
In the study involving 31 residents, six fellows and
10 senior attending physicians in the
neonatal intensive care unit at Johns Hopkins, the senior,
more experienced doctors (attending
physicians) were less likely to want certain abnormal
results reported to them immediately; by
contrast, the less experienced doctors (residents) were
most likely to want all out-of-range values
right away. Those in the middle of the experience curve
(fellows) fell in between.
"Theoretically, there should be no difference in which
abnormal values doctors consider critical
to get by instant pager, so we were quite surprised to see
how their views of 'critical' varied," said
lead investigator Theodora Stavroudis, a neonatologist.
The differences could mean that younger, less
experienced doctors are simply more anxious and
prefer to err on the side of caution, researchers
speculate.
Christoph Lehmann, senior investigator, said, "With
increased experience, you tend to learn
which alerts you can ignore safely and which ones you
can't. Unfortunately, this isn't something you can
teach in medical school, but it is something that comes
with experience."
Researchers asked doctors to define which out-of-range
lab values they considered critical
enough to require the lab to page them. Under the current
system, a lab technician reports the results
to a nurse, who then reports them to a doctor, which means
that up to 20 minutes can pass before a
doctor finds out about a patient's abnormal labs. In an
effort to cut lab-to-doctor time, streamline
communication and improve patient safety, the Johns Hopkins
Children's Center researchers are
preparing to launch a system that feeds critical lab values
directly into a doctor's pager.
To avoid overload, however, it was important that only
truly critical results — those signaling true
urgency or emergency in terms of clinical care — be
sent. But which out-of-range results require an
instant alert, and which ones can wait? Four out of 15
abnormal lab values — low ionized calcium, high
sodium, high potassium and high creatinine —
generated the most difference in opinion. Most attending
physicians said none of these required a page. Most fellows
said all but high creatinine should trigger a
pager alert. Most residents said pagers should go off for
all except high sodium.
The study also points to the need to define what truly
critical values are for newborns and to
stop extrapolating from "adult" lab values, an archaic,
roundabout system that is currently the status
quo in hospitals nationwide, researchers say.
Since last spring, when this study was conducted, the
Johns Hopkins neonatal intensive care unit
has moved on to use both the current and new systems side
by side, allowing researchers to compare
them "in action."
This study is part of Johns Hopkins' ongoing efforts
to prevent medical errors and improve
patient safety. Traditionally, intensive care units have
been the most vulnerable to errors because of
the severity of cases and the many distractions in the
environment.
Co-investigator in the study was Anusha
Hemachandra.
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