Critical Value Policies Research Articles

Hemostasis critical values among Iranian clinical laboratories "National Survey of 157 Clinical Laboratories".

Immediate reporting of critical values or test results significantly outside the normal range has a growing role in the management of patients, especially in life-threatening conditions. Due to the lack of international consensus, diverse approaches are used for determination of thresholds, reporting, documentation, and follow-up. In this study, we assessed how Iranian laboratories manage critical values for hemostasis. We designed a standard questionnaire to assess different aspects of hemostasis critical values, including the number of coagulation tests with a defined critical value, critical values reporting, documentation, and follow-up policies. All results were self-reported and correctness of the data was not assessed by the authors. A total of 166 (66.4%) out of 250 laboratories completed the questionnaire; most (52.4%) were private. About 97% of responding laboratories had a critical values policy. These were defined for 64.3% (n: 27) of all coagulation tests (n: 42) performed in Iranian laboratories. Activated partial thromboplastin time (APTT), prothrombin time/international normalized ratio (PT/INR), platelet count, factor XI, and factor XIII assays had defined critical values among all laboratories performing these tests. Almost all laboratories reported critical values within 1hour, after confirmation of the result on the same sample (70% of the laboratories) or a new one (13.4% of the laboratories). State and private laboratories had the same critical value reporting policy for in and outpatients, with laboratory technicians reporting critical results to nurses, for the most part. Although critical value policy is widely used among Iranian laboratories, there is no consensus policy for the reporting of hemostasis critical values, or documentation, threshold determination, and follow-up processes. It is impossible to determine whether non-responding laboratories had any critical values reporting policy. Results thus are biased toward laboratories that did.

Customised Critical Limits Help to Achieve Efficient Use of the Laboratory’s Resources

Background: Customisation of critical value policies in laboratories with increasing workloads helps to achieve efficient use of laboratory’s resources. Methods: The critical value policy at an academic hospital was customised with the introduction of a new middleware (Sysmex Corporation, Kobe, Japan). The number of notifications over a one-month period was reviewed in order to determine the impact of customisation on laboratory resources and patient safety. Results: 1891 haematology critical values were identified. 1195 (63%) results did not require notification according to the customised policy. Of these, 1034 (55%) had a previous critical result, 89 (5%) were not phoned as per customer request and in 72 (4%) the critical result was already viewed by the clinician. Conclusion: Customisation resulted in a marked reduction in the critical results requiring notification. Laboratory information system middleware can be developed to consider factors such as, a change in the current result from previous results, patient location and requesting doctor to customise notification.

‘Why don't they ever call?’ Expectations of clinicians and pathologists regarding the communication of critical diagnoses in dermatopathology

Certain diagnoses in dermatopathology have significant implications for patient management and on occasion appropriate clinical care may be facilitated by a phone call from the reporting dermatopathologist to the referring doctor. Whether this is appropriate depends on a number of factors. The concept of 'critical diagnoses' is now well established in surgical pathology, having evolved from critical value policies in clinical pathology and haematology. However, only limited attempts have been made to assess perceptions among different clinical groups. We designed a survey to assess the attitudes of pathologists, dermatologists, surgeons and general practitioners as to what circumstances warrant telephone contact in addition to a standard written report, as well as their approaches to routine histology follow-up. The survey was distributed Australia-wide via a combination of specialist colleges, medical forums and collegiate contacts. A total of 262 responses were received, encompassing representations from all of the targeted specialties. Approximately 20% of respondents were aware of adverse outcomes or 'near misses' which they felt had been due in some part to inadequate communication of histopathology results. While most practitioners have formal systems in place to review histopathology reports, this practice is not universal. There were a number clinical situations where there was a discrepancy between the expectations of clinicians and those of pathologists, in particular with regard to a diagnosis of cutaneous melanoma as well as cutaneous lesions which might be associated with inherited cancer syndromes. It is our hope that the results of this study will facilitate discussion between pathologists and referring clinicians at a local level to minimise the potential for miscommunication.

Critical values in hematology of 862 institutions in China.

A national survey on critical values in hematology of China laboratories was conducted to determine the current practice and assess the quality indicators so as to obtain a quality improvement. Laboratories participating were asked to submit the general information, the practice of critical value reporting, and the status of timeliness of critical value reporting. A total of 862 laboratories submitted the results. The majority of participants have included white blood cell count, blood platelet count, hemoglobin, prothrombin time, and activated partial thromboplastin time in their critical value lists. Many sources are used for establishing a critical value policy, and some of the laboratories consult with clinicians. The unreported critical value rate, late critical value reporting rate, and clinically unacknowledged rate in China are relatively low, and the median of critical value reporting time is 8-9minutes. There exists a wide variety for critical value reporting in hematology in China. Laboratories should establish a policy of critical value reporting suited for their own situations and consult with clinicians to set critical value lists. Critical values are generally reported in a timely manner in China, but some measures should be taken to further improve the timeliness of critical value reporting.

Optimization and quality improvement of critical value report procedures in emergency room laboratories

Critical value report procedures need to be improved rationally by urban space saving, post setting, and monitoring and analysis of historical data of critical value. Laboratory is required to develop and put into practice critical value policies and procedures by numerous regulatory agency standards, such as, International Standard Organization (ISO 15189), College of American Pathologists. Laboratories should implement and continuously improve quality management system for achieving the quality goals set by Laboratory and International Standard Organization.(Chin J Lab Med, 2015, 38: 431-432) Key words: Emergency service, hospital; Clinical laboratory information systems

Critical limits for urgent clinician notification at South African intensive care units.

Critical value policies are used by clinical laboratories to decide when to notify caregivers of life-threatening results. There, however, remains much debate regarding which tests should be included in critical value lists and clinically relevant limits. An electronic survey was designed to determine the critical value policies of specialists for haematology tests in South African intensive care units. Data collected included a demographic component, critical value policies and critical value reporting. There were 68 respondents who represented a range of specialists from different disciplines. Four key critical values were identified, namely white cell count (WCC), haemoglobin, platelet count and international normalised ratio (INR). Median low and high adult and paediatric critical limits for the most frequently listed tests were as follows: haemoglobin <7 and >20 g/dL, platelet count <50 and >1000 × 10(9) /L, WCC < 2 and >20 × 10(9) /L and INR > 4. Specific critical limits for neonates were reported by 20 of the respondents. Of the respondents, 95.92% indicated that it was important to be contacted with first-time critical results and approximately half for repeat critical values. The majority preferred that the person notified of the critical value be the caregiver directly involved with the patient's care. It is important for critical value policies to be reviewed by each discipline to ensure cut-offs are clinically relevant.

Critical values in Hematology

Critical values are life-threatening results that require immediate notification to the patient's healthcare provider. Accreditation bodies require laboratories to establish critical values. A survey of Ontario laboratories was conducted to determine current practice for critical values in hematology. The survey was sent to 182 participants questioning sources for establishing critical values, levels, review frequency, delta checks, and reporting. The survey was completed by laboratory managers, supervisors, technical specialists, senior technologists, and bench technologists working in hematology. The majority of participating laboratories have established critical values limits for hemoglobin, leukocyte counts, and platelet counts. Most laboratories also include the presence of malaria parasites and blast cells. Some laboratories reported the presence of plasma cells, sickle cells, schistocytes, and spherocytes as critical values. Multiple sources are used for establishing a critical value policy. There was variability for the frequency of critical values review. Rules may differ for a first-time patient sample vs. a repeat patient sample. Delta checks are seldom used to determine whether a result should be called a critical value. Most participants require the individual taking the critical result(s) to read back and confirm that they are directly involved with the patient's care. There is a lack of consensus for critical values reporting in hematology. As critical value reporting is crucial for patient safety, standardization of this practice would be beneficial.

Occupy Call Street? Reconsidering a Microbiology Critical Action Value Policy

Critical action value (CAV) policies for microbiology test results are regulated by the same mandates that govern critical values for other laboratory testing. Policy revisions and updates are left to the discretion of laboratory directors, in conjunction with their clinical communities. The published literature on CAV policy has limited discussion of infectious disease testing, necessitating the use of other information as a guide. The reconsideration of one's CAV policy benefits from an organized approach and the recognition and reconciliation of different perspectives and resources. A recent experience and considerations for the future are presented.

Critical value reporting: A survey of 36 clinical laboratories in South Africa

Critical value policies are used by clinical laboratories to decide when to notify caregivers of life-threatening results. Despite their widespread use, critical value policies have not been published locally. A survey was designed to determine critical value policies for haematology tests in South Africa. A survey was carried out on 136 identified laboratories across South Africa in January 2013. Of these, 36 responded. Data collected included critical value policies, critical values for haematology parameters, and critical value reporting. Of the 36 laboratories surveyed, 11.1% (n=4) were private, 33.3% (n=12) were affiliated to academic institutions and 55.6% (n=20) were peripheral or regional National Health Laboratory Service laboratories. All the laboratories confirmed that they had a critical value policy, and 83.3% of such policies were derived from local clinical opinion. Mean low and high critical limits for the most frequently listed tests were as follows: haemoglobin <6 and >20 g/dl, platelet count <41 and >1 000 ×10(9)/l, white cell count <2 and >46 ×10(9)/l, activated partial thromboplastin time >101 seconds, and international normalised ratio >6. In almost all cases critical value reporting was performed by the technologist on duty (97.2%). The majority of laboratories required that the person notified of the critical value be the doctor who ordered the test or the caregiver directly involved in the patient's care (83.3%); 73.3% of laboratories indicated that they followed an algorithm if the doctor/caregiver could not be reached. Each laboratory is responsible for establishing clinically relevant critical limits. Clinicians should be involved in developing the laboratory's critical value policy. The findings of this survey may be of value to local laboratories that are in the process of establishing or reviewing critical value policies.

From critical values to critical diagnoses

The concept of critical values in the medical laboratory found its roots in clinical pathology nearly 40 years ago. The goal of this review was to trace the evolution of the critical value concept from clinical into anatomic pathology with specific emphasis on cytopathology. Difficulties in the meaningful application of the critical value concept in the practice of cytopathology are reviewed along with ambiguities that have yet to be fully resolved. Suggestions that may enhance the operational success of critical value policies in cytopathology and a central role for the cytotechnologist are presented. Cooperation between key pathology and clinical organizations is essential for improvement in the critical value process.

Assessment of critical values policies in Italian institutions: comparison with the US situation

Critical value reporting is considered an essential tool to ensure the quality of medical laboratory services. Important issues include defining cut-off values, assessing responsibility for communication and adopting information technology solutions to improve notification. Here, we report the state of critical value reporting in a large cohort of Italian laboratories and comparison with Q-Probes surveys from the College of American Pathologists as representatives of the US situation. To compare critical value policies and procedures, formulation of critical values list with critical values limits and monitoring tools, a web-based questionnaire was formulated for 389 institutions participating in the External Quality Assessment Schemes of Veneto Region, in Italy. A total of 90 clinical laboratories submitted data. Accredited laboratories represented 82.2% of participants, but written procedures for reporting were indicated by 70.5% of participants. Relevant differences between US and Italian policies have been observed, particularly regarding who provides the notification and on the formulation of the cut-off threshold for critical values. Accreditation according to international standards can decrease differences regarding the management of critical values across laboratories of different countries. However, the issues concerning critical limits should be debated and a consensus critical values list should be considered. Automated systems could offer improvements regarding some issues, such as who makes the notification, reducing the time spent in notification of critical values. Surveys for comparing and improving existing policies regarding critical values should be promoted at an international level.