Management of High-risk Results Outside of Normal Opening Hours Policy

1. Policy

This practice ensures that clinically significant and life-threatening results identified outside of our normal opening hours are managed in a timely, safe, and effective manner to protect patient safety and continuity of care.

We recognise our responsibility under the RACGP Standards for General Practices (5th Edition – GP2.3, GP4.1, GP6.1) to have clear arrangements for high-risk result management, including defined responsibilities for follow up, documentation, and communication with patients.

2. Definition of High-risk Results

High-risk results are those that may represent an immediate or serious threat to patient health if not acted upon promptly. These include but are not limited to:

• Critical pathology results (e.g. severe electrolyte imbalance, abnormal INR, critical infection markers).
• Malignant or urgent imaging findings.
• Results requiring urgent public health notification.
• Any other result identified by the reporting provider as requiring urgent action.

3. Procedure

• Pathology and radiology providers (e.g. 4Cyte Pathology, Capital Radiology) are given an up-to-date contact list of our general practitioners, including after-hours contact details.
• If the primary GP is unavailable, the provider is instructed to escalate to the nominated alternative clinician.
• The GP (or covering clinician) who receives the result must:

1. Review the result immediately.
   1. Attempt to contact the patient (or their carer/guardian) without delay using available contact details.
   1. Provide appropriate clinical advice, including referral to emergency services if required.
   1. Document the result, the clinical decision, the communication attempts, and any actions taken in the patient’s electronic health record as soon as practicable.
2. If the patient cannot be contacted:
   1. Multiple contact attempts (phone/SMS/registered mail if needed) must be made and documented.
   1. If there is an imminent threat to life, emergency services or next of kin should be contacted.

4. Responsibility

• General Practitioners: Responsible for receiving, reviewing, and acting on high-risk results.
• Practice Manager: Ensures the after-hours contact list is accurate and updated regularly, and that providers are notified of any changes.
• All Clinical Staff: Must be aware of escalation pathways and documentation requirements.

5. Monitoring and Review

• All incidents related to after-hours management of high-risk results will be reviewed at clinical meetings for quality improvement.
• This policy will be reviewed annually, or earlier if system or provider arrangements change.