The Healthcare Manager: Critical test results in laboratory – Policy and process for identification and communication

Medical laboratory and Imaging frequently come across critical results or finding of a patient’s diagnostic tests which requires immediate intervention from the doctor to bring the patient out of the criticality. Hence, a hospital must have a policy and procedure in place for identification and quick communication of such results. This posts describes critical test results in medical laboratory (Check critical findings in imaging–policy and procedure).

Critical test results in laboratory are the findings in the lab tests of a patient which indicates that condition of the patient may be critical or even life-threatening. Such results, when found shall urgently be informed to the treating physician of the patient so that required interventions can be carried out on time and patient can be saved from any possible adversities. To be able to do so, a hospital needs to have a well-developed process of ‘identification and urgent communication of critical test results in lab’. The process should be able to achieve following objectives.

1. Critical test results gets identified within the lab as soon as the test results are obtained
2. No critical test results gets missed from identification
3. Non-critical test results do not get identified as critical
4. The treating doctor of the concerned patients gets to know about the critical test result on an urgent basis

Any lapses in identification and/or communication of critical test results to concerned doctor may lead to severe consequences for patient, including death. Hence, in addition to the process, hospitals must have a policy that mandates compliance to this process by laboratory staff. Following points shall be taken into consideration for policy and system on identification and communication of critical test results in laboratory.

Policy:

Policy shall clearly state that ‘all laboratory staff involved in performance or supervision of the test must understand the process of identification and urgent communication of critical test results. The process shall compulsorily be complied with in all routine and non-routine tests performed in lab.

Defining critical test results:

Critical test results must be defined by the hospital/laboratory for a uniform understanding of all staff in the lab. This is important also because other terminologies such as critical values, panic values, panic findings etc. are also used for the same situation. A good definition of ‘critical test result’ is,

‘Critical test results are defined as laboratory test results that exceed the specified upper or lower limits¹, or meet the specified qualitative findings. The test results going beyond specified limits or meeting the specified qualitative findings are indication that there can be an immediate risk to the life or health of the patient, and hence needs an urgent clinical intervention’

It shall also be clarified that critical test results are not same as abnormal results. There can be test results that are outside the laboratory’s reference intervals, which may be considered abnormal, but they may not necessary be ‘Critical’.

List of critical test results:

The hospital/laboratory must specify and list the limits or conditions when a given test must be considered ‘critical’. This can be done either through discussion and consensus between clinicians and pathologists, or by taking a good and relevant reference source that defines critical results and doing necessary modifications. Click here or here to get two such reference documents. Some examples of critical test results are given below,

Parameter	Critical value/condition	Effect
Haemoglobin	< 6.6 g/dl > 19.9 g/dl	Inadequate supply of oxygen to heart muscles Hyperviscosity syndrome such as visual disturbances, vertigo, seizures and even coma
pCO2	< 19 mm Hg > 67 mm Hg	Hyperventilation Hypoventilation
pH	< 7.2 < 7.6	Severe alkalosis Severe acidosis
pO2	< 43 mm Hg	Very low haemoglobin oxygen saturation and can be life-threatening
Platelet count	< 20,000/ml > 1 million / ml	Risk of haemorrhage Risk of thrombosis
Ethanol Concentration in blood	> 3.5 g/l (76 mmol/l) OR	Blood alcohol concentrations of 3-4 g/l can be fatal
Chloride	< 75 mmol/l > 125 mmol/l	Indicates metabolic alkalosis Indicates massive metabolic acidosis
Glucose level	< 45 mg/dl (2.5 mmol/l) > 500 mg/dl (27.8 mmol/l)	Effect can range from impairment of cognitive function to loss of consciousness Diabetic come due to insulin deficiency
Cerebrospinal fluid	· Increased cell count · Leucocytosis · Presence of tumour cells · Detection of pathogens	Can cause neurological disorders
Differential blood count	· Suspected leukaemia · Suspected aplastic crisis · Sickle cells · Malarial parasites

Care shall be taken to differentiate between the critical test result values and conditions for adult and paediatric patients

Timely updation of critical test results:

The process shall also include a periodic updation of the list of critical test results and as and when new tests are introduced in the lab. The critical values and the condition must be reviewed jointly by pathologists and clinicians and update the same as per latest research or new discoveries in the field of diagnostics. The review and updation shall be done at-least once a year.

Identification of critical test results in patients’ laboratory tests:

The laboratory staff who performs tests, shall be aware of the policy and the process of critical test results. The list of critical test results shall be available/accessible to each staff. After performance of the required test and immediately after obtaining the result, the testing staff should check if the result matches the critical condition as specified in the list. This shall be done for all tests conducted by him/her without fail.

If a critical result is identified, the testing staff should immediately inform the same to the pathologist. The pathologist should review the result and confirm if the result is critical or not.

Confirmation of critical test results:

On the discretion of the pathologist, the test where the result was found to be critical shall be re-done, to weed out any possibility of error in conducting the test. If the repeat test also confirms criticality then it should be considered as critical and immediately be informed to the treating physician of the patient. If a confirmation test is not done, the first test result itself shall be considered critical and shall be informed to the treating physician of the patient.

Communication of critical test results:

As soon as the test result is confirmed to be critical, the treating physician of the concerned patient shall be informed through the quickest mean possible. This communication shall preferably be done by the pathologist, however, if the pathologist is not available at the time, the staff who did the test must directly inform the physician.

In case physician is not immediately available to receive the communication, the resident doctor on duty must be informed about the critical result.

The verbal/telephonic communication shall be complete and incorporate following information

Name of the patient
Test performed
Result of the test (i.e. value or condition)

It shall be assured that the physician or the resident doctor have understood the communication. A written report of a critical test result shall be prepared on priority and should be dispatched following the verbal/telephonic communication.

Documentation:

To ensure compliance, a register shall be maintained in the lab to record all critical test results that were identified. Following information shall be recorded

Date
Patient name and UID
Test performed
Time of obtaining the result
Critical value or condition found
Time of detection of critical result
Whether repeat test was done for confirmation
Communication sent to (treating physician/resident doctor)
Time at which communication was sent
Any other remark

The Healthcare Manager

25 September 2018

Critical test results in laboratory – Policy and process for identification and communication