Addressing Criticial Values

7/30/2019 Addressing Criticial Values

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Rodrigo C. Rodrigo, M.D.,FPSP,MHA


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values that may be indicative of life-threatening conditions requiring rapid clinicalintervention.


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Published literature sources Nonlaboratory medical staff

recommendations

Other sources internal studies

interlaboratory comparisons

manufacturers' recommendations


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Routine Tests not identified as urgent. Standard testing intervals aredefined for all tests in the laboratory reference manual

Critical Tests identified by the institution as critical to patient care

for monitoring and trend analysis for improvement

Critical Values that may be indicative of imminently life-threateningconditions requiring rapid clinical intervention

Significant

Findings

indicative of critical diagnoses or unexpected findings

that would not be considered imminently life-threatening

Read Back when laboratory values are reported, the receiverwrites the results and then reads back what is writtento the reporter to confirm the message has been

accurately understood


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How Verification ProceduresWork


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take time to double-check that an emergencydoes indeed exist before phoning an alert tothe attending physician


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1. Check specimen2. Check controls

3. Rerun controls and

specimen4. Check results on other

specimens

5. Check previous values


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6. Call the nursing floor7. Redraw the patient

8. Test the redrawn

specimen9. Call the attention to

the problem

10. Call results


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Check for abnormalities e.g. clotting, hemolysis

and lipemia

Right anticoagulant

Timethe specimen wasdrawn e.g. blood glucose, arterial

blood gas


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Specimen may have tobe diluted to bring itback into the assured

range


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Control values and specimen are rerun Check controls were diluted properly

If possible, recheck with a backup instrumentor method Can unearth an instrument

problem as the cause

of erroneous results


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Several specimens within the same run mayintermittently show grossly abnormal values,even though controls are within limits

Possibly caused by a clog--usually a proteinbuildup--or a mechanical problem.

Run a series of six to 10 controls

to determine if the instrument is

malfunctioning.


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Values may be consistentwith a patient's earlierabnormal or critical values.

Complete test histories canbe recalled on laboratorycomputer terminals.


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Ask if a patient is undergoingany 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 ofcritical values.


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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


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Same:report it as anaccurate value

Different:report the

redrawn specimen as thecorrect result (assumingthe controls are withinrange and the other

requirements discussedare met)


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All double-checked critical values arereported to the department supervisor. Thequestionable ones are then routed to theclinical pathologist for his interpretation.

The supervisor and the pathologist go overthe verification process, the patient's clinicalpicture, quality control, and instrumentoperation.

This systematic approach helps preventtransmission of any erroneous results tophysicians


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To benefit the patient, thevalues must reach thephysician promptly.

We lodge responsibility fornotification with thetechnologist who discoversand verifies theabnormality.


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Recommendations for GoodCritical Values Management


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Devise a clearly written operational criticalvalues and critical tests procedure

Multiple resources: Published critical values

Medical staff recommendations

Inter-laboratory comparisons

Internal studies


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Notification should be to the attendingphysician rather than to clerical staff

Reporting to clerical staff was associated witha lesser improvement in critical valuesreporting over time


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An acceptable time interval between testcompletion and caregiver notification may be15 to 30 minutes

Involve medical staff in the design andapproval process


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Should be aware of and develop a fullerunderstanding of the use of critical values,critical tests, red/yellow/green alert systems,and other proposed mechanisms for

informing physicians of important testresults.


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Addressing Criticial Values

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