Use of computer terminals on wards to access emergency test results: a retrospective audit

Potential limitations of study

Our conclusions would be flawed if test results, for whatever reason, were still being communicated to clinicians but that this action was not being recorded on the pathology computer. For example, this could happen if the laboratory staff making or receiving a telephone call did not follow protocol and record on the computer that the results had been passed on verbally. However, our survey of patient notes confirmed that in most (83%) of the cases with severe hypokalaemia or hyperkalaemia there was no evidence of this having occurred. These abnormal results are the very ones that laboratory staff would be most likely to telephone despite knowing that they would be available on a ward terminal. Thus, for the patients who did not have such abnormal biochemistry it would be reasonable to expect that there was even less than a 17% chance that their results would have been telephoned.

Reasons for staff not accessing results

A proportion of patients attending the accident and emergency department might not have their test results reviewed because they have left the department by the time the results are available. Shift working among clinicians in this department is especially common, so tests requested by one group of doctors may not always be followed up by a subsequent group. For these reasons, we also included another ward area in our study for comparison with the accident and emergency department. However, we found that even on the main medical assessment ward, where patients are expected to stay for days rather than hours, over a quarter of emergency laboratory results are not reviewed by electronic means.

The reasons for the failure to access results promptly or at all are speculative. It is possible that our findings primarily reflect the proportion of urgent requests for biochemistry tests that are not truly urgent (or have become less important with subsequent clinical events) and so do not require immediate attention. Alternatively, we may have shown how the introduction of an additional hurdle in obtaining results (a ward terminal) deterred clinicians from looking for their patients' urgent test results. Certainly, with the ward terminals in our study, users had to know that a patient had had blood taken and had to actively seek their results. Even then, the users had to estimate when the results were likely to become available. We found 93 examples of where it was obvious that the results had been looked for on several occasions before they had become available, only for the clinician to have “given up” looking by the time they ultimately appeared.

Implications of study

Whatever the reasons for staff not viewing test results, there could be considerable medical consequences for a patient if abnormal results were not acted on promptly. Likewise, there might be legal and financial consequences for the clinician responsible and hospital trust if it transpired that harm to a patient could have been prevented if their emergency results (whether perceived urgent at the time or not) had been viewed in a timely manner. In our audit, up to 3% of the accident and emergency results that were never looked at could have led to an immediate change in patient management. This equates to more than one patient per week.

It is difficult to determine how transferable our findings are to other hospitals. Although a recent benchmarking exercise involving 104 UK biochemistry laboratories reported that most are capable of transmitting results to ward terminals,3 the actual number doing so is not known precisely. However, 30 other UK laboratories use the same laboratory computer system as the one in this audit.4 Some other laboratory and hospital computers prompt users (when they log on) to view all the results for their ward that have not yet been accessed. This should reduce the likelihood of tests never being looked at, but it might have less impact on reducing the delays in accessing results after they become available.

To our knowledge, only one other study has assessed the delay in viewing emergency laboratory test results with a ward terminal.5 In that study, in a US hospital, the time to access urgent inpatient haematology blood counts was shorter than we found (64% within one hour), and this finding was used to justify the need for local hospital laboratories rather than off site analysis. Curiously, however, no mention was made of the proportion of results that were never seen at all on screen by clinicians.

Solution to the problem

The problems we identified were solved in Hull by introducing “trickle” printers to the high intensity areas included in our audit that would print out an interim report on any patient in the ward or department as soon as the results became available. This introduced several benefits. Firstly, clinicians had immediate access to a patient's results even if they did not know that blood had been taken or, indeed, that the patient was present on their ward. Secondly, the printed record reduced the risk of errors occurring in transcribing results from the terminal screen into the case notes. Staff in the accident and emergency department also agreed to forward results by telephone should the relevant patient have left the department by the time the results were printed. In other wards with computer access the telephoning of results was reintroduced if the results lay outside critical limits.

Conclusions

The electronic communication of emergency laboratory results should not be assumed to be inherently superior to traditional communication methods, since hospital staff cannot be relied on to look at many urgently requested results if they have to access a computer to do so. Hospitals that have implemented, or are about to implement, a similar strategy to the one we audited need to satisfy themselves that the system is of as much benefit to clinicians and patient care as it is to laboratory staff.