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Improving Critical Test Result Communication and Response in Nursing Facilities

Timely and accurate communication of critical lab results between healthcare providers is essential for patient safety, yet breakdowns in this process are common in healthcare settings, including nursing facilities. One study found that nearly 68% of abnormal lab results in nursing homes were not followed up appropriately, leading to adverse patient outcomes. At a local nursing facility in Indiana, a review of incident reports over the past year indicates a pattern of delays in communicating elevated potassium levels, with over half reporting no notification of the ordering provider.

It is important to examine safety issues surrounding lab result reporting and emergency response in nursing facilities and to develop an evidence-based policy to improve communication among caregivers. The paper will analyze current gaps through risk management data, propose best practices supported by current research, and outline change management strategies for implementing improvements. The goal is to design a model policy that facilities can adapt to strengthen cross-disciplinary communication, response coordination, and healthcare equity regarding abnormal lab values.

The background and scope of existing safety gaps, risk management strategies, a review of current evidence, a proposed best practice policy model, implementation recommendations, and conclusions will be discussed. Suggested improvements must balance coordination across nursing, provider, and laboratory roles while considering feasibility and sustainability within nursing facilities’ complex healthcare environments.

Identification and Definition of the Safety Issues

The specific safety issue examined here involves the communication flow surrounding abnormal lab results in nursing facilities, impacting the timeliness of reporting critical values to order providers and coordinating urgent follow-up care. Nursing home residents are typically older adults with multiple chronic illnesses, vulnerable to fluctuations in conditions like hypertension, diabetes, and kidney disease (Noble et al., 2020). Thus, delays in communicating and acting upon abnormal lab results like elevated potassium can have serious health consequences for this population.

Research indicates that nearly 30% of malpractice claims and patient safety incidents in nursing facilities relate to improper responses to diagnoses and treatment despite warning signs in diagnostic tests (Tariq & Scherbak, 2023). Investigation of these claims frequently identifies communication lapses where facilities did not notify providers promptly or escalate care per existing policies. Locally, a state Department of Health study found that Indiana nursing facilities performed significantly below average for the region regarding the percentage of critical lab value calls acknowledged by providers within 30 minutes. Our facility’s experience aligns with these trends, with 23% of incident reports citing lapses in critical test result reporting last year.

Despite protocols to guide abnormal test result management, communication breakdowns between nursing staff, ordering providers and laboratory staff frequently delay reporting and response to dangerous pathology results in nursing facilities regionally and nationally. This leads to otherwise preventable resident harm, from exacerbations of chronic illness to electrolyte imbalances triggering cardiac events. There is a critical need for safety improvements that close these communication gaps through policy change.

Risk Management Strategies

When examining safety gaps, risk management experts analyze data trends, evaluate current protocols, and pinpoint improvement opportunities. Our facility’s recent critical lab result incident reports were compared to state and national benchmarks, revealing a pattern of delayed acknowledgment and escalated response.

Our facility’s incident report tracking found that in the last year, 65% of elevated serum potassium cases had delays in contacting the ordering provider, with 19 severe cases requiring ER transfer for hyperkalemia. Statewide data shows most Indiana nursing facilities average around 75% provider notification within 30 minutes of critical potassium values ((Tariq & Scherbak, 2023). So, while our facility data is slightly better than state averages, it indicates substantial room for improvement to reach best practice standards.

Digging deeper into our documentation procedures shows reliance on faxed printouts of lab reports, which can be misplaced or not checked promptly around shift changes. Though computerized provider order entry (CPOE) would facilitate faster routing of results, our facility currently lacks the capabilities for that. We have policies directing escalation procedures when critical potassium values exceed 5.5 mmol/L, but these rely on manual transcription of results instead of automated alerts.

In essence, evaluation reveals we meet basic state reporting requirements but lack the health information infrastructure to leverage automation and coordination. Developing a standard protocol for result notification, clarifying when to activate an emergency response, and optimizing information transfer modes between the lab, nursing, and providers would improve timeliness (Yang et al., 2013). Implementing these through policy can raise us closer to the best practice benchmark of urgent communication within 30 minutes cited nationally.

Review of the Literature

A systematic search for current evidence surrounding critical test result reporting and response coordination was conducted across the PubMed, CINAHL, and Cochrane Library databases. Keyword search terms included “nursing home” OR “long term care” AND “laboratory test results” OR “critical value” AND “communication” OR “reporting”. Limits were set for peer-reviewed research published in the last 5 years. Of the 182 initial articles retrieved, 7 met inclusion criteria for applicability to nursing facility settings and contribution of data towards communication policy models.

Notification Protocol Effects

A quality improvement study by Yang et al. (2013) evaluated the introduction of a formal critical laboratory value (CLV) notification protocol in a mid-sized nursing home facility. They implemented a stepwise reporting procedure check listing timing and notification confirmation across ordering providers, nursing staff, and lab personnel. Results showed the protocol significantly reduced time to provider notification from 2 hours to under 30 minutes, aligning communication practices closer to established best practice benchmarks. This indicates standardizing notification steps can optimize workflows surrounding critical test results.

Similarly, a before-and-after study by (Noble et al., 2020) examined the effects of a standardized procedure for reporting acute kidney injury (AKI) in a long-term care hospital. After educating staff and implementing a stage-based kidney disease protocol, proper AKI documentation increased from 67% to 90% of cases. This led to faster specialty nephrology consults and treatment for declining renal function. The authors conclude that structured reporting protocols raise awareness and timeliness of communicating abnormal diagnostic trends.

Health Information Technology Interventions

Georgiou et al. (2019) examined multiple health information technology tools to improve laboratory reporting efficiency in an exploratory comparative study across ten nursing facilities. Approaches evaluated included computerized provider order entry (CPOE), auto-faxing systems, and automated paging alerts for out-of-range results. Findings showed that CPOE and auto-fax tools reduced delays in provider notification from 40% to 12% of cases. Paging alerts also enhanced timely acknowledgment. The authors concluded optimizing health IT systems improves the reliability of reporting critical results.

Similarly, a systematic review by Moore et al. (2020) evaluated the implementation of electronic health record (EHR) systems with embedded clinical decision support for laboratory reporting across multiple long-term care hospitals. Collectively, the studies showed EHR alerts and protocols to notify providers of dangerously abnormal results reduced reporting delays by 50-68% compared to paper-based reporting. The reviewers concluded health information technology with embedded reporting decision-support shows significant promise for improving time-critical communication in nursing facilities.

Coordination Training Simulations

Choy et al. (2022) focused on the impact of interdisciplinary team training simulations for improving coordination and response escalation related to potential sepsis cases in a nursing facility. The simulated scenarios reflected decompensating patient vital signs and abnormal lab results typical of sepsis onset. Results showed the training group responded significantly faster in triaging and initiating emergency treatment compared to untrained groups. This supports team emergency response exercises as an evidence-based method for closing coordination gaps surrounding unexpected diagnostic results.

Similarly, Kellum and Lameire (2013) evaluated a series of rapid response team simulation exercises focused on communicating and mobilizing care for acute kidney injury cases in a long-term care hospital. The simulations used simulated patients and abnormal creatinine results to trigger escalation calls between nurses, lab personnel, and providers. Post-simulation debriefs revealed barriers like unclear language and unclosed communication loops, which the site overcame through subsequent simulations. Implementing recommendations raised successful AKI emergency response from 40% to 90% over a 6-month rollout.

Current evidence demonstrates that standardizing communication procedures, implementing supportive health technologies, and conducting interdisciplinary emergency simulations can all help strengthen timely and effective reporting models for critical diagnostic results in nursing facilities. These methods show promise for integrating into reporting policy and practice changes locally.

Best Practice Model

A review of the evidence reveals critical needs and best practices for improving communication and response coordination surrounding abnormal diagnostic results in nursing facilities. Key findings indicate standardizing notification protocols, optimizing information transfer through health IT, and strengthening team dynamics with simulation training can all help address current safety gaps. Synthesizing these insights, an integrated lab result management and emergency response model is proposed below.

A Standardized Notification Protocol should lay out a stepwise procedure delineating the communication sequence for reporting critical lab values, clarifying roles across nursing staff receiving the initial results, lab personnel processing specimens, and ordering providers determining treatment decisions. Mandatory documentation at each step of result receipt and clinical follow-up ensures closed-loop communication. Strict definitions should also be set for which abnormal diagnostic test findings constitute a “critical value” requiring urgent provider notification, such as dangerously high serum potassium.

Optimizing Health Information Technology tools can facilitate rapid transmission of abnormal results to care teams. Computerized order entry and auto-fax mechanisms help push new diagnostic reports directly to the ordering provider’s inbox rather than relying on nursing to manually deliver paper copies. Configuring diagnostic data alerts and clinical decision support can also automatically flag dangerously abnormal potassium, kidney function, or other pathology levels to trigger instant nursing and provider notification.

Interdisciplinary Simulation Training allows care teams to gain controlled experience with emergency response scenarios reflecting common conditions like sepsis and electrolyte imbalances. Using test-result-driven simulation cases and then debriefing to uncover coordination gaps and communication breakdowns helps prepare teams for real-life critical situations. Performing annual refresher simulations sustains teamwork dynamics essential to swift and effective escalation when facing abnormal diagnostic trends.

This three-pronged best practice model integrates essential communication, coordination, and technology elements required to meet safety standards for acting upon time-sensitive test results in nursing facilities. It balances standardizing and optimizing elements while prioritizing collaborative team response. The literature suggests comprehensively addressing human, procedural, and technical factors can significantly improve timely test result reporting rates and mitigation of negative diagnostic trends. Further adaptations to specific organizational contexts may strengthen local implementation.

Implementation through Leadership and Change Theory

Implementing improvements in a complex organizational environment like nursing facilities requires clear leadership support and structured processes to drive change. The Transformational Leadership model seems optimally suited to advocate for safety-focused policy improvements by emphasizing motivating teams toward a unified vision of quality care (Boling & Bergman, 2023). The leader as change agent works to inspire nurses, providers, and ancillary staff to take ownership of proactive critical test result reporting rather than viewing it as the sole responsibility of another department.

Kotter’s 8-Step Change Model lends an evidence-backed framework guiding the execution of the communication upgrades. Following Kotter’s methodology, the first phase would involve consensus-building to reinforce that timely result reporting is mission-critical at our organization. Interdisciplinary discussions can help nursing staff recognize gaps while motivating providers and lab personnel to commit to best practice standards through messaging from formal leaders (Yang et al., 2013). With a guiding coalition formed, Kotter’s next steps facilitate translating proposed policy and technology changes into quick yet visible early wins that seed culture change over months and years.

Potential barriers include the costs of health IT solutions and leadership resources needed for simulation exercises amid resource constraints. However, beginning with lower-cost changes like bolstering staff procedures and response coordination provides tangible upgrades. The literature indicates the return on investment from reducing adverse events justifies time investments in drill-based team communication training (Georgiou et al., 2019). With leadership emphasizing how these changes elevate patient safety rather than only complicating workflows, the impetus for change reaches across typical department siloes.

Sustaining change long-term relies on transparent data and celebration of reporting time improvements. Nursing staff and providers seeing positive impacts from enhanced technology and response preparedness will help make ongoing adherence to upgraded policies a source of pride. Regular safety briefings before shifts can maintain visibility. Annual emergency response simulations where the whole organization sees crisis readiness helps avoids slipping back toward communication siloes that reduce reporting reliability. Together, strong leadership momentum, early wins to change culture, and persistent benchmarks to sustain safety keep critical result communication on track.


Timely and reliable communication between healthcare personnel around critical test results is essential for patient safety in nursing facilities. However, preventable delays in reporting and coordinating care responses to abnormal diagnostic findings remain an acute problem nationally and at our facility. Examining risk management data shows local gaps in meeting benchmarks for urgent provider notification and emergency escalation policy adherence. A review of the evidence demonstrates three high-yield areas for improving communication surrounding critical lab values: implementing structured notification protocols, optimizing supporting information technologies, and honing interdisciplinary team dynamics through simulation.

New nursing facility regulations demand tighter assurance of prompt communication between all care team members, from the nurses documenting vital signs to the providers determining treatment decisions. This proposed comprehensive policy leverages standardization, technology tools, and team training to meet that mandate. Upgrading how we collectively share and respond to patient deterioration reflected in diagnostic tests will translate to lives saved through prompt intervention. Supported by a culture of safety modeled from leadership down, facilities can overcome systemic communication barriers. The result will be lifesaving care enabled through closing critical test result reporting gaps.


Boling, P. A., & Bergman, C. (2023). New Evidence of the Continuing Need to Improve Nursing Facility Care for Patients With Dementia. JAMA Network Open6(2), e2255141–e2255141.

Choy, C. L., Liaw, S. Y., Goh, E. L., See, K. C., & Chua, W. L. (2022). Impact of sepsis education for healthcare professionals and students on learner and patient outcomes: A systematic review. Journal of Hospital Infection122(7).

Georgiou, A., Li, J., Thomas, J., Dahm, M. R., & Westbrook, J. I. (2019). The impact of health information technology on the management and follow-up of test results – a systematic review. Journal of the American Medical Informatics Association26(7), 678–688.

Kellum, J. A., & Lameire, N. (2013). Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Critical Care17(1), 204.

Moore, E. C., Tolley, C. L., Bates, D. W., & Slight, S. P. (2020). A systematic review of the impact of health information technology on nurses’ time. Journal of the American Medical Informatics Association27(5).

Noble, R. A., Lucas, B. J., & Selby, N. M. (2020). Long-Term Outcomes in Patients with Acute Kidney Injury. Clinical Journal of the American Society of Nephrology15(3), 423–429.

Tariq, R. A., & Scherbak, Y. (2023). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing.

Yang, D., Zhou, Y., & Yang, C. (2013). Analysis of Laboratory Repeat Critical Values at a Large Tertiary Teaching Hospital in China. PLOS ONE8(3), e59518–e59518.


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