Introduction
A markedly abnormal blood result may indicate that the patient needs urgent treatment. The communication of such important results should be a priority, and in certain rare circumstances, could be lifesaving. To enable Severnside clinicians to assess the urgency of the situation, full and accurate information is essential. In order for this to be available there needs to be effective communication and organisation between the patient’s practice and out of hours primary care, and the laboratories.
Roles and responsibilities.
General Practice
- Ensure all demographic and clinical details are correct and included on request form (or computer database). To include:
- Name, Date of birth, Address
- Telephone number (essential)
- GP practice and telephone number
- NHS number (essential)
- Urgent samples from general practice should be marked/ bagged as such, to ensure that the laboratories prioritise processing before the end of the working day. This should enable concerning results to be phoned through to practices before they close, thereby supporting timely action and continuity of care.
- When a practice clinician anticipates a significantly abnormal result requiring urgent action but the result is not back before the practice closes, the practice clinician should contact Severnside via the Professional Line (0117 244 9283 after 6pm). The call handler will add the patient’s details to the OOH queue, to ensure review of the results and follow up actions if required out of hours. Correct contact details for the patient are vital. The mobile number of the requesting clinician is required in case there is a need for clinician-to-clinician consultation prior to contacting the patient.
- The patient should be advised that they may be contacted by an out of hours clinician if the results require urgent, out of hours action.
- The requesting clinician should ensure that a clear management plan is laid out in EMIS, and ensure that the patient has not refused record sharing.
- OOH consultation records are shared with practices as a ‘Post Event Message’ (PEM) soon after the Severnside clinician closes the case. Practices should seek to review these clinical notes to ensure no follow up actions are required. If practice follow up is required, the usual expectation would be that the patient initiates that themselves, but the OOH clinician may opt to book a call back via GP Connect if slots are available and urgent action is required.
Pathology
- Where possible the laboratory will try to telephone any abnormal result to the patient’s own practice within usual opening hours.
- The Royal College of Pathology provides nationally agreed thresholds for telephoning results, and the local laboratories publish their action limits reflecting these guidelines. (See Appendix).
- Abnormal results generated after hours will be communicated to Severnside via the Professional Line (0117 244 9283). The caller should share the patient identifiers, any background clinical information and/ or relevant previous results and contact details for the patient. The caller should record to whom the result was given. The full result should be provided wherever possible (eg sodium, potassium, creatinine, eGFR rather than just eGFR).
Severnside, during the out of hours period
- To accept the abnormal result when telephoned.
- The Severnside call handler should generate a new case on Adastra, recording all the patient demographics, clinical information and relevant previous results. They should note the laboratory, caller’s name and return telephone number. The case is added to the IUC Advice queue with a Pathology case tag, to enable easy identification of these cases in the queue.
- The Severnside clinician picks up the case from the queue. In order to understand the clinical background, the clinician should check EMIS first using “Emergency access” as the consent reason. Clinicians may need wider information about the results, and this may be accessible via EMIS, ICE or the Laboratory Results section on Connecting Care. If the full results have not been released by the lab, the operational team can call the relevant lab(s) to obtain the full results (eg phoning biochemistry if haematology has phoned through an FBC).
- The clinician will call the patient to take a history, including exploring the possible causes and symptoms associated with the abnormal result(s), severity and management options in the context of the patient’s wider healthcare needs, wishes and escalation plans.
- Guidance about the management of abnormal results is available on the clinical toolkit, including bespoke guidance for the out of hours management for some results (including the management of high INRs). If choosing an alternative management option, the rationale and discussion with the patient/ relative(s) should be clearly documented.
- When calling the patient and if there is no answer
- Leave a voicemail advising them of your role, and that you are calling to speak with them urgently. Provide the Patient Line telephone number (0117 332 0653) so the patient can call back
- Have a low threshold for texting this information, as well as leaving a voicemail
- Make repeated attempts in line with the failed contact SOP
- If the Severnside clinician is unable to contact the patient after three (two in escalation) failed contacts on each of the numbers available
- Check EMIS for alternative/ additional phone numbers. These can sometimes be found embedded within previous consultations.
- Seek advice from the operational team, who can search Adastra for alternative contact details at the same address or from previous contacts with the patient
- Check the Connecting Care dashboard (accessed via EMIS). This will show if the patient has presented to hospital since the blood test.
- If no alternative contact details have been identified and the patient is not in hospital, a clinical review is required to determine the level of concern, risks and next steps. Clinicians managing abnormal results but unable to contact the patient are encouraged to seek advice from the Clinical Coordinator to support risk holding and shared decision making. Options may include:
- Closing the case, with PLS referral to the patient’s own GP for the practice to follow up the result the following day
- Consideration of further attempts to contact the patient by phone, rather than proceeding to close the case after two/ three attempts. If late/ overnight on a Friday/ Saturday, this may include forwarding the case to the Consult and Hold queue for the Clinical Coordinator to make further attempts the following morning.
- Consideration of a home visit as a welfare check. If there is no answer at the home, the visiting clinician should leave a note to advise that the patient needs to call back on the Patient Line number (0117 332 0653)
- If there are high levels of concern for the patient’s safety, consideration of police or ambulance involvement. This is unusual, and the clinical considerations and levels of risk should be clearly laid out in the notes.
- It should be noted that these cases often require complex decision-making, for which tailored guidance is limited or absent. This requires reasoned, holistic judgement calls which take central account of the patient/ family’s wishes, are informed by the information available and fully documented.
- If prompt follow up action is required by the practice the following day, then the Severnside clinician can arrange for a call back via GP Connect. Alternatively, patients or their representatives can be advised to call the practice. If there are concerns about their capacity/ understanding of the importance of this, the Patient Liaison Service can be used to support patient care.
APPENDIX – Pathology out of hours Reporting to out patients and Primary Care (Limits to be used once the GP practice is closed).
Biochemistry1
| Analyte | Action limit (s) | Units | ||
| Less than | Greater than | |||
| Sodium | <120 | or | > 150 | mmol/L |
| Potassium | < 2.5 | or | > 6.5 | mmol/L |
| Creatinine | > 400
(>200 in <16yo) |
|||
| Glucose | < 2.6 | or | > 20 | mmol/L |
| Adjusted Calcium | < 1.8 | or | > 3.5 | mmol/L |
| Magnesium | < 0.4 | or | > 2.0 | mmol/L |
| Phosphate | < 0.3 | mmol/L | ||
| Lipase | > 300 | U/l | ||
| Amylase | > 500 | IU/L | ||
| ALT | > 600 | IU/L | ||
| Total bile acids | >14 | umol/L | ||
| CK | > 1000 | IU/L | ||
| Ammonia | >40
>100 |
umol/L | ||
| Troponin T | ≥ 14 | ng/L | ||
| Lithium | > 1.5 | mmol/L | ||
| Digoxin | > 2.5 | ug/L | ||
| Paracetamol | > 20 | mg/L | ||
| Salicylate | > 100 | mg/L | ||
| Theophylline | < 3.5 | or | > 20 | mg/L |
| Phenytoin (adjusted) | > 40 | mg/L | ||
| Carbamazepine | > 25 | mg/L | ||
| CRP | >300 | mg/l | ||
1 Royal College of Pathologists Document ‘Out of hours reporting of laboratory results requiring urgent clinical action’ November 2010.
Haematology
| Test | Results that need phoning through to Severnside/ OOH |
| Hb | Less than 70 g/L |
| Drop of more than 40 g/L in last 2 weeks | |
| Hb Renal Patient | Less than 60 g/L |
| INR (Warfarin monitoring) | INR> 8.0
|
| Fibrinogen | Less than 0.5 g/l |
| Platelets | Less than 30 |
| WBC | Lymphocytosis > 50 or Neutrophilia > 50 |
| Neutrophils | Lower limit: neutropenia < 0.5 with any blast cells |
| Malaria/Parasites | Always telephone a positive (De Novo) result |
| D-Dimer | Positive results are NOT phoned through |
| PV | >5.0 mPa |
Microbiology
Microbiology laboratory service operates between 08:00 – 18:00 weekdays. An “on call” service operates outside of these hours. As these hours are similar to the opening times of the majority of primary care there is limited requirement for contact with out of hours deputising services. If a concerning abnormal result is identified out of hours, this is communicated to the Microbiology medical staff who review the information on a case-by-case basis and act accordingly. This may include contacting Severnside.
Related Documents
BrisDoc high INR guideline
Change Register
| Date | Version | Author | Change |
| 30th January 2014 | 2 | BD | Change of format. |
| 7th January 2019 | 3 | CD | Review document and make minor amendments to comply with current service |
| 19th October 2022 | 4 | AW | Review document, with updates to ensure relevance to current processes |
| 18th October 2024 | 5 | LW | Review document and make minor amendments to comply with current service |