They Called Me for a WBC of 10.2

At a recent meeting of physicians, nurse practitioners, registered nurses (RNs), and nursing home administrators, several providers commented about being called for slightly abnormal laboratory results. One provider was awakened at night for a report of a resident’s hemoglobin of 9.0 that was consistent with previous results for that individual for months.

What could explain the rationale for the unnecessary or inappropriate reporting of laboratory values? Facilities that have a policy requiring all abnormal laboratory results be reported to a provider immediately upon receipt will be more likely to encounter conflicts between nurses and prescribers, as the policy may not provide a reasonable opportunity to apply their nursing judgment, reserving calls for significant laboratory abnormalities or reports that are inconsistent for that individual resident.

A solution to this issue comes in the form of a laboratory reconciliation processes, in which the facility uses a process of identifying all orders for specimens in a given day, assuring that each order has a corresponding result. Before calling the result to the provider, the nurse would check the resident’s previous results and diagnoses to determine if the abnormal results are actually within normal limits for that individual. This process is completed on the 3-11 shift when the results of all the lab tests should be available.

Below are strategies for successful process implementation.

• Nursing facilities will need to have policies that support the lab reconciliation process that establishes the parameters of abnormal which goes beyond the laboratory’s reporting of normal/abnormal results and promotes nursing judgment in the relaying of information to prescribers.
• One or more dedicated RNs will need to be provided with education on and support in the process, with enough staff present to allow the process to be performed with minimal interruptions. 
• Providers will need to communicate effectively with the staff with regard to the lab parameters of individual residents, identifying what constitutes concern for a given person based upon history, diagnoses, and goals of treatment.

Well-coordinated care for facility residents is needed, not only for residents’ quality of life and health, but also for the personal and professional health of all facility staff and providers, who are often at risk for burnout in this demanding profession. Care must be administered with the highest degree of professionalism and competence. Calling providers at night with minor abnormalities of laboratory results runs counter to the needs of the facility.

Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, has been practicing nursing for 33 years, specializing in the care of geriatric patients. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.

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