Rodrigo C. Rodrigo, M.D.

,FPSP,MHA

values that may be indicative of lifethreatening conditions requiring rapid clinical intervention.

Published literature sources Nonlaboratory medical staff recommendations Other sources

internal studies interlaboratory comparisons manufacturers' recommendations

TERM Routine Tests Critical Tests

DEFINITION not identified as urgent. Standard testing intervals are defined for all tests in the laboratory reference manual identified by the institution as critical to patient care for monitoring and trend analysis for improvement

Critical Values
Significant Findings Read Back

that may be indicative of imminently life-threatening conditions requiring rapid clinical intervention
indicative of critical diagnoses or unexpected findings that would not be considered imminently lifethreatening when laboratory values are reported, the receiver writes the results and then reads back what is written to the reporter to confirm the message has been accurately understood

How Verification Procedures Work

take time to double-check that an emergency does indeed exist before phoning an alert to the attending physician

1.

2.
3. 4. 5.

Check specimen Check controls Rerun controls and specimen Check results on other specimens Check previous values

6.

7.
8. 9. 10.

Call the nursing floor Redraw the patient Test the redrawn specimen Call the attention to the problem Call results

Check for abnormalities

e.g. clotting, hemolysis and lipemia

Right anticoagulant Time the specimen was drawn

e.g. blood glucose, arterial blood gas

Specimen may have to be diluted to bring it back into the assured range

Control values and specimen are rerun Check controls were diluted properly If possible, recheck with a backup instrument or method
Can unearth an instrument problem as the cause of erroneous results

Several specimens within the same run may intermittently show grossly abnormal values, even though controls are within limits Possibly caused by a clog--usually a protein buildup--or a mechanical problem. Run a series of six to 10 controls to determine if the instrument is malfunctioning.

Values may be consistent with a patient's earlier abnormal or critical values. Complete test histories can be recalled on laboratory computer terminals.

Ask if a patient is undergoing any special treatment that could affect test results
e.g. glucose, insulin or electrolytes

Obtaining an admitting diagnosis or current clinical picture from the floor can provide clues to the validity of critical values.

Obtain the physicians permission Initial specimen might have been improperly withdrawn
Drawn above I.V. Presence of glucose or electrolyte solution Not an arterial specimen Capillary specimen from infants drawn on ice, mixed and immediately transported to the laboratory for blood gas analysis

Same: report it as an
accurate value

Different: report the

redrawn specimen as the correct result (assuming the controls are within range and the other requirements discussed are met)

All double-checked critical values are reported to the department supervisor. The questionable ones are then routed to the clinical pathologist for his interpretation. The supervisor and the pathologist go over the verification process, the patient's clinical picture, quality control, and instrument operation. This systematic approach helps prevent transmission of any erroneous results to physicians

To benefit the patient, the values must reach the physician promptly. We lodge responsibility for notification with the technologist who discovers and verifies the abnormality.

Recommendations for Good Critical Values Management

Devise a clearly written operational critical values and critical tests procedure Multiple resources:
Published critical values Medical staff recommendations Inter-laboratory comparisons Internal studies

Notification should be to the attending physician rather than to clerical staff Reporting to clerical staff was associated with a lesser improvement in critical values reporting over time

An acceptable time interval between test completion and caregiver notification may be 15 to 30 minutes Involve medical staff in the design and approval process

Should be aware of and develop a fuller understanding of the use of critical values, critical tests, red/yellow/green alert systems, and other proposed mechanisms for informing physicians of important test results.