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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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