Around 20 years ago I had to write the emergency evacuation plan for the pulmonary function lab. Like many other administrative duties I learned that I needed to do this when my new administrator asked where it was and whether I had documented that I had reviewed it with the lab staff. Since I didn’t even have a real procedure manual at the time (just reprints of pertinent articles and textbook chapters) I ended up getting a crash course in writing policies. Fortunately the manager of a nearby departments let me borrow their evacuation plan and I was able quickly to knock one out that met the requirements fairly quickly. Since then I’ve had to review it annually and update it every time the lab moved or when rooms were added or taken away.
Yesterday I was reading the recently published ERS/ATS technical standards for field walking tests (and if you perform 6-minute walk or incremental shuttle tests then you will probably need to read it and update your procedures). One important change has been that because a 6-minute walk test can evoke a VO2 and heart rate response similar to CPETs the same absolute and relative contraindications now apply. For the same reason in the table of equipment required for walking tests along with the stopwatch and pulse oximeter the ERS/ATS standard now includes “An emergency plan”.
We’ve always had a physician present when we perform exercise tests. The contraindications to exercise testing are in our procedures and are included in the letter we send patients informing them of their exercise test appointment. But because we have a physician present we’ve always relied on the physician to recognize and handle the (thankfully) infrequent problems that occur during exercise. When we perform 6-minute walks however, we’re (depending on how you look at it) a building or two away from any of the pulmonary physicians.
The hospital does have a medical emergency response team (Code Blue) and we’ve called them to the pulmonary function lab maybe once a year mostly because a patient has fainted during spirometry or had a vaso-vagal response during an ABG. This was common sense however, and there isn’t anything in our procedure manual about when this needs to be done. I’m not sure why I’ve had a blind spot about this but in retrospect it is obvious that we need a policy on medical emergencies.
We already have a policy on the contraindications to testing so what we need is something that includes signs and symptoms and most importantly, an action plan. I will put together a list of the more or less obvious signs (patient becomes unconscious or has a seizure) and an action plan (call a Code Blue) but will look to the lab’s medical director to help us to expand and refine this. Once the policy has been written and approved we will also need to go back and make sure all the existing test procedures include specific contraindications, specific signs and symptoms and a referral to the medical emergency policy.
Writing, maintaining and updating policies and procedures is always a PITA (particularly since there’s always something else that needs to be done that seems more immediately important), but they’re absolutely necessary for any number of reasons. On the plus side, I’ve found that writing them has improved my understanding of the ATS/ERS standards and has made it easier to talk to lab staff, physicians and patients about testing issues. In addition there is always a certain amount of personnel turnover and new staff needs to be oriented to all testing procedures and lab policies. Even “old” staff need to be able to review the official procedure when questions about testing performance arise.
I have to be honest and say that having policies and procedures is also a way to protect yourself and your lab. In most hospitals and clinics the basic job policies have probably already been written by Human Resources but these are usually only general policies on things like attendance, patient privacy and sexual harassment. A PFT lab needs specific job performance policies and I’ve written these not just on testing, but on patient appointments, billing and performing quality control. All lab staff have to “sign off” that they’ve read both the hospital’s and the lab’s policies and procedures, usually as part of orientation as a new hire but also when there is a new or updated policy. I’ve been fortunate to have had job performance issues with lab staff relatively rarely but when this has happened what has helped is that I’ve been able to point to the lab and hospital policies that have been acknowledged and signed-off when having to discuss problems with a staff member.
Despite all the complaints that patients make about what we do to them, the rate of medical complications in pulmonary function testing is quite low. I’ve been in the field for over 40 years and although I’ve sent a number of patients to the ER (usually for cardiac arrhythmias after a CPET), they all left vertically, not horizontally. Even so it is past time my lab had a policy about recognizing and managing medical emergencies.
By the way, you do have a lab policy and procedure manual, don’t you?
References:
Holland AE et al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respi J 2014; 44: 1428-1466.
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