ADASP Survey on Communication of Urgent and Unexpected Values Paul N. Staats, MD Associate Professor of Pathology University of Maryland School of Medicine

Notice of Faculty Disclosure In accordance with ACCME guidelines, any individual in a position to influence and/or control the content of this ASCP CME activity has disclosed all relevant financial relationships within the past 12 months with commercial interests that provide products and/or services related to the content of this CME activity. The individual below has responded that he/she has no relevant financial relationship(s) with commercial interest(s) to disclose: Paul N. Staats, MD

What’s new since 2012? Let’s do a survey!

Survey Demographics - Vast majority of responses from academic medical centers - Multiple responses from the same email address suffix were censored (n=5)

Does your laboratory have a policy for communication of urgent and significant unexpected diagnoses (“Critical values”) in anatomic pathology?

Have you read the CAP/ADASP Consensus Statement on Effective Communication of Urgent and Significant Unexpected Diagnoses in Surgical Pathology and Cytopathology?

Do you use the CAP/ADASP terminology of “Urgent Diagnoses” and “Significant Unexpected Diagnoses” in your policy?

What diagnoses are considered “___ Diagnoses” in your laboratory? 17 12

What diagnoses are considered “___ Diagnoses” in your laboratory? *Malignancy in SVC syndrome; Neoplasms causing paralysis

What diagnoses are considered “___ Diagnoses” in your laboratory? Specific Situations: AFB Immunocompromised patient New/unexpected diagnosis Specific site: Heart valves Across the boards, slightly more organisms considered “urgent” than “Critical”

What diagnoses are considered “___ Diagnoses” in your laboratory? Specific Situations: Fungus Immunocompromised patient New/unexpected diagnosis Tissue invasion Specific site: Sinus, ENT Lung Heart valves CSF/CNS Specific fungi: Pneumocystis Not candida Across the boards, slightly more organisms considered “urgent” than “Critical”

What diagnoses are considered “___ Diagnoses” in your laboratory? Specific Situations: CMV Immunocompromised patient Unexpected or new diagnosis Specific site: Kidney Liver Placenta Lung Colon Across the boards, slightly more organisms considered “urgent” than “Critical”

What diagnoses are considered “___ Diagnoses” in your laboratory? Specific Situations: HSV Immunocompromised patient New/unexpected diagnosis Specific site/situation: Esophagus On Pap during pregnancy Across the boards, slightly more organisms considered “urgent” than “Critical”

What diagnoses are considered “___ Diagnoses” in your laboratory? Specific Situations: Toxoplasma Immunocompromised patient New/unexpected diagnosis Neonate Across the boards, slightly more organisms considered “urgent” than “Critical”

What diagnoses are considered “___ Diagnoses” in your laboratory? Specific Situations: Bacteria New/unexpected diagnosis Specific Sites: Cardiac valves Unexpected osteomyelitis CSF Pathologist judgement Across the boards, slightly more organisms considered “urgent” than “Critical”

What diagnoses are considered “___ Diagnoses” in your laboratory? Other: Transplant rejection (3) Crescentic glomerulonephritis (2) Absence of villi in POC (3)

What are acceptable methods of communicating ____ diagnoses in your laboratory? Other: -EMR Message -In person

If you use indirect communication (email, text message, fax), do you have a mechanism for confirming receipt of messages?

What is the expected timeframe for communication of ____diagnoses in your laboratory?

What is the expected timeframe for communication of ____diagnoses in your laboratory? Other: Urgent Significant Unexpected Critical Prior to signout (1) Immediately (1) Within 1day/24 hours (2) Within 1 day/24 hours (3) ASAP (1) Reasonable ASAP (4)

What is the expected timeframe for communication of ____diagnoses in your laboratory?

How do you document communication of _____ Diagnoses?

What elements are documented?

If your institution has clinical trainees, how does your policy define a “responsible physician” who can receive a critical value?

If a specimen is procured by a provider who is not part of the patient’s continuing care team (e.g. interventional radiology), does your policy specify who is the preferred physician to receive a critical value? Note – the responses here sum to 41, not 38 – need to ask Ryan to review data

Does your laboratory have a procedure for escalation if the initial contact person is unavailable? Does your laboratory have a procedure for auditing and quality assessment of reporting of urgent and unexpected diagnoses?

Caveats 38 total responses Predominantly academic Self-reported

Summary The vast majority of labs have a policy for AP “Critical” values Minority (~1/3) have distinct policies for “urgent” versus “significant unexpected” diagnoses Even when they do, little evidence that the two are handled differently Little consensus on what diagnoses qualify Major frozen-final discrepancy (~80%) New, unexpected malignancy (~80%) Little consensus on method or timing of communication But uniform agreement that phone call to provider is good Relative consensus on documentation In report Expected elements