Harmonization of critical result management in laboratory medicine

Critical Results in Laboratory Medicine

BACKGROUND

Timely and accurate notification of critical results is crucial in laboratory medicine and mandated by accreditation standards like ISO15189. Alert lists do, however, vary widely and clinical laboratories typically rely on a combination of in-house agreed and/or literature-based critical values. Communication by phone is still the preferred method of notification, but digital communication could help improve communication of critical results.

CONTENT

We review the available evidence concerning critical result thresholds and critical result notification practices. The evidence is ranked using an adaptation of the Stockholm Hierarchy. In addition, we propose an evidence-based list of critical result thresholds for hospitalized patients that laboratories can use as a starter list and further customize based on the clinical needs of their patient population.

SUMMARY

A clear distinction between critical results and significantly abnormal results is essential for effective and timely healthcare interventions. Implementation of a policy using differentiated thresholds taking into account individual patient characteristics and how fast medical attention is needed, and the use alternative communication methods could enhance communication efficiency and reduce notification fatigue.

Critical test result management at Danish hospital laboratories: a national survey

Critical test results in clinical laboratories are crucial for timely patient care, serving as indicators of potentially life-threatening conditions. Despite their importance, a notable heterogeneity in management practices exists globally. This study investigates the current practices of managing critical results at Danish clinical biochemistry laboratories and identifies areas prone for improvement. A comprehensive online survey was distributed to all 21 Danish clinical biochemistry laboratories regarding their critical result management, including documentation practices, critical limit selection, and quality assurance measures. A total of 17 laboratories (81%) responded. The answers revealed a generally uniform approach to managing critical results, with all laboratories having 24-h reporting, local instructions and using the telephone as communication channel. However, variations were noted in documentation practices and critical limit selection. Notably, 23.5% of the laboratories reported that one out of every ten critical results was not reported, indicating a significant risk of delayed critical results. This is further complicated by the limited use of predefined timeframes for reporting and also, only few laboratories actively monitored response times. The findings emphasize the need for more standardized documentation and evaluation practices to align with international standards and to enhance patient safety. While the laboratories showed a commitment to standardized procedures, the study emphasizes the necessity of a National or Nordic guideline to supplement the ISO 15189:2022. This study is a step towards optimizing critical result management, not only in Danish clinical biochemistry laboratories but also across various laboratory specialties, thereby improving overall laboratory quality, efficiency, and patient safety.

Laboratory interpretative comments and guidance: clinical and operative outcomes on moderate to severe hyponatraemia patient management

AIMS

Hyponatraemia is the most common body fluid disorders but often goes unnoticed. Our laboratory incorporated a standardised procedure to help clinicians detect moderate/severe hyponatraemia. The study aims were to evaluate the outcomes on patient care and clinicians' satisfaction.

METHODS

The study, observational and retrospective, included 1839 cases, adult and paediatric patients, with sodium concentration <130 mmol/L. The procedure consisted of interpretative comments in the emergency and core laboratories report and the point-of-care testing blood gas network report. We evaluated hyponatraemia length in two equal periods: before and after the implementation. We conducted a survey addressed to the staff of the clinical settings involved to know their satisfaction.

RESULTS

The median hyponatraemia length decreased significantly from 4.95 hours (2.08-16.57) in the first period to 2.17 hours (1.06-5.39) in the second period. The lack of hyponatraemia patients follow-up was significantly less after the procedure implementation. The survey was answered by 92 (60 senior specialists and 32 residents) out of 110 clinicians surveyed. Ninety of them (98%) answered positively.

CONCLUSIONS

We have demonstrated the reduction in the time for diagnosing and management by physicians, the higher uniformity in the time required to solve hyponatraemia episodes following our laboratory procedure and the clinicians' satisfaction.

A New Perspective to Longstanding Challenges with Outpatient Hyperkalemia: A Narrative Review

Purpose of Review

Outpatient hyperkalemia is a common problem with potentially deadly consequences. Potassium level thresholds to treat outpatient hyperkalemia are unstandardized and variable, leaving health care providers to rely on their own clinical judgment. This narrative review highlights the challenges of outpatient hyperkalemia management and includes recommendations for future studies that may standardize treatment, improve patient outcomes, and optimize health care utilization.

Sources of Information

PubMed, Google Scholar, and the reference lists of identified articles were used to include English, peer-reviewed studies and guidelines for this review.

Methods

This narrative review examines outpatient hyperkalemia from both a laboratory and clinical perspective. In addition to peer-reviewed literature, guidelines and expert consensus statements were included to highlight the inconsistencies and paucity of evidence that health care providers rely on to make clinical decisions.

Key Findings

There are multiple reasons why outpatient hyperkalemia management is both challenging and sub-optimal. Clinicians must discern if the potassium level result is accurate and, if so, does the result warrant referral to the emergency department. Factitious hyperkalemia, or falsely elevated potassium level results due to analytical errors, occurs frequently, but there are no ways to identify it other than for hemolyzed samples. Additionally, guidelines and expert panels are inconsistent on the thresholds for treatment and the management of hyperkalemia. Finally, there are inconsistencies between laboratories as to when and how providers are notified of results, and the suggested thresholds for urgent management. A study that integrates the expertise of clinical biochemists and clinicians is needed to inform evidence-based guidelines for the management of outpatient hyperkalemia.

Limitations

This was a comprehensive review of what is known and what still needs to be understood for the management of outpatient hyperkalemia. A formal tool to assess the quality of the included studies was not used and selection bias may have occurred.

Evaluation of a Newly Implemented Critical Thromboelastography (TEG) Value Callback System

OBJECTIVES

Thromboelastography (TEG) measures whole blood coagulation kinetics in real time and is useful in guiding blood product transfusion. At our institution, providers have immediate remote access to TEG results. However, some critical values are occasionally missed. Our patient blood management program implemented a critical TEG value callback system to improve patient management and blood product utilization.

METHODS

This retrospective, observational study assessed the data of trauma and critical care patients preimplementation (n = 20) and postimplementation (n = 100) of the callback system. Provider responses to callbacks and changes in TEG parameters after subsequent testing were compared between the two groups.

RESULTS

In response to callbacks, 42% provided appropriate management and 42% ordered a repeat TEG vs 28% and 33% in the historical group (P < .0001 and P = .0002, respectively). Following callback, 90% of the TEG parameters in the study group showed an improvement vs 57% in the control group (P = .011).

CONCLUSIONS

The increase in appropriate management and the improvement in TEG parameters upon repeat testing in the study group compared to the control group demonstrate the efficacy of the TEG callback system. Further studies are needed to evaluate the callback system effect on patient outcome.

The novelties of the regulation on health technology assessment, a key achievement for the European union health policies

Health technology assessment is a key tool for ensuring healthcare quality, accessibility, and sustainability. The novel European Union (EU) Health Technology Assessment (HTA) regulation of 15 December 2021, in harmonizing the laws of the Member States about the procedures and criteria for the evaluation of health technologies (i.e., medical devices and in vitro diagnostic tools), constitutes a significant achievement in the definition of EU health policies. On the one hand, for the European Union, it constitutes an essential driving force for the development of a competitive market for health technologies and, on the other, for European citizens, it guarantees the application of superordinate safety and quality standards with an impact positive on access to health technologies, including expressly also in vitro diagnostic medical devices classified in class D by art. 47 of Reg. (EU) 2017/746. As pointed out by the European Commissioner for Healthcare, the regulation identifies a new way for the Member States to cooperate on healthcare matters in the Union. The clinical efficacy and safety of drugs and devices are legal assets that today find their protection in a binding and directly applicable regulatory instrument, superordinate in the hierarchy of sources. Implementing the regulation will also be essential to achieve the objectives of the Union's pharmaceutical strategy and the European plan to fight cancer. The novel HTA European regulation, applicable from January 2025, will ensure inclusion and transparency in evaluating health technologies and increase the predictability of decisions for both Member State authorities and industry.

Improving the laboratory result release process in the light of ISO 15189:2012 standard

The ISO 15189:2012 standard section 5.9.1 requires laboratories to review results before release, considering quality control, previous results, and clinical information, if any, and to issue documented procedures about it. While laboratory result reporting is generally regarded as part of the post-analytical phase, the result release process requires a general view of the total examination process. Reviewing test results may follow with troubleshooting and test repetition, including reanalyzing an individual sample or resampling. A systematic understanding of the result release may help laboratory professionals carry out appropriate test repetition and ensure the plausibility of laboratory results. In this paper, we addressed the crucial steps in the result release process, including evaluation of sample quality, critical result notification, result reporting, and recommendations for the management of the result release, considering quality control alerts, instrument flags, warning messages, and interference indexes. Error detection tools and plausibility checks mentioned in the present paper can support the daily practice of results release.

Integrating quality control and external quality assurance

Effective management of clinical laboratories relies upon an understanding of Quality Control and External Quality Assurance principles. These processes, when applied effectively, reduce patient risk and drive quality improvement. In this Review, we will describe the purpose of QC and EQA and their role in identifying analytical and process error. The two concepts are linked, and we will illustrate that linkage. Some EQA providers offer far more than analytical surveillance. They facilitate training and education and extend quality improvement and identify areas where there is potential for patient harm into the pre-and post-analytical phases of the total testing process.

Quality Improvement in Critical Value Delivery at a Tertiary Care Center

BACKGROUND

Prompt notification of critical laboratory values to providers is essential for effective patient care. To improve the delivery of these critical values, a quality improvement project was initiated to determine the obstacles to prompt notification and to identify possible interventions to improve this process.

METHODS

Critical value call logs were retrieved, and delivery time, patient location, test name, and call time were abstracted and analyzed. All critical values with delivery times greater than 60 min were reviewed by 2 authors for 1 representative month in both the pre- and postintervention period.

RESULTS

Based on the results of the data review, a modification to the laboratory information system call center color-coded alerts was introduced to address delays attributable to the laboratory. The overall rate of calls greater than 60 min decreased from 3.4% ± 0.8% in the preintervention study period to 1.3 ± 0.3%, postintervention. The average number of values not delivered within 60 min decreased by 64% across all locations, following with an 82% decrease for values originating from inpatient locations, and a 39% decrease for outpatient values.

CONCLUSIONS

Low complexity interventions to critical value callback protocols can significantly increase the efficacy of communication between the laboratory and providers.

Gestión del proceso posanalítico en los laboratorios clínicos según los requisitos de la norma ISO 15189:2012. Consideraciones sobre la revisión, notificación y comunicación de los resultados

El objeto de este trabajo es establecer unas consideraciones para facilitar la gestión del proceso posanalítico respecto a la revisión, notificación y comunicación de los resultados, de acuerdo con los requisitos de la Norma UNE-EN ISO 15189:2013. El ámbito de aplicación incluye las actividades del proceso posanalítico del laboratorio clínico, así como el personal implicado en él (dirección y personal del laboratorio). Se indican los criterios y la información necesaria para realizar la revisión y validación de los resultados de las pruebas analíticas y así enviar a los destinatarios informes claros, asegurando siempre una transcripción fidedigna de los resultados e incluyendo toda la información necesaria para su correcta interpretación. Asimismo, se describen los requisitos para una correcta comunicación de los resultados del laboratorio, haciendo especial hincapié en la comunicación de aquellos resultados alarmantes o críticos. En algunos países de Europa es obligatoria la acreditación, total o parcial, de los laboratorios clínicos, siguiendo la Norma ISO 15189 y esta parece ser la hoja de ruta marcada en otros muchos países. Por ello, es indispensable la comprensión de sus requisitos para realizar una implementación progresiva y más fácil.

Management of postanalytical processes in the clinical laboratory according to ISO 15189:2012 Standard requirements: considerations on the review, reporting and release of results

The objective of this paper is to share some considerations about the management of postanalytical processes in relation to the review, reporting and release of test results in accordance with UNE-EN ISO 15189:2013 Standard requirements. The scope of this paper includes postanalytical activities and the personnel involved (laboratory management and staff). We describe the criteria and information required to review and validate analytical results and ensure that clear reports are sent to requesters. These criteria also guarantee that results are transcribed in a reliable way and that all necessary information is provided for the correct interpretation of results. Likewise, the requirements for the correct release of laboratory results are described, with special emphasis on the release of alarming or critical results. In some European countries, clinical laboratories are required to hold partial or full ISO 15189 accreditation, which is a global trend. Therefore, understanding ISO 15189 requirements is imperative for a progressive and more effective implementation of the Standard.

Recurring Critical Results and Their Impact on the Volume of Critical Calls at a Tertiary Care Center

BACKGROUND

When a test result is critically abnormal, laboratories notify the responsible caregivers immediately, usually with a phone call. If the same test was ordered repeatedly, our institution has a policy of not notifying the caregiver if the previous result was also critical and within 24 h. We compared our policy with those of several different laboratories in North America and estimated the impact of changing our current policy to calling for all critical results, regardless of the time interval.

METHODS

Several North American laboratories (n = 15) were surveyed regarding their critical result notification policy. For our institution, we performed a retrospective analysis focusing on critical values in a 5-month period for common chemistry tests. We estimated the effect on volume of calls and the impact on workload with regard to changing the critical result notification policy and critical thresholds.

RESULTS

A majority of surveyed laboratories had some form of restriction for calling about recurring critical results. In our institution, removing the restrictions would increase the average number of daily calls by 11%-155%, depending on the analyte. The choice of critical thresholds also has an effect on the number of calls, and the effect depends on the analyte and the threshold chosen.

CONCLUSIONS

Guidelines do not specify how recurring critical results should be communicated. Depending on the institutional resources, some laboratories call only the first critical result for one or more tests if certain criteria are met. Modification of these policies can lead to significant changes in the volume of calls made by the laboratory and can have numerous impacts related to workload, logistics, and patient care.

Turnaround times and modes of reporting critical results in Asian laboratories

BACKGROUND

Reporting critical results in a timely manner is a crucial role of clinical laboratories. Traditionally, these results were reported using the phone or fax system. However, there are now other modes of communication for this reporting. Quality improvement in any organization is driven by detection of errors and benchmarking against peers. In the case of critical result reporting, there are few current widely used Benchmarking schemes.

METHODS

The Roche Clinical Chemistry Benchmarking Survey in 2019 added questions about critical result reporting including the mode of communication and turnaround time key performance index. This survey includes over 1100 laboratories from 20 countries.

RESULTS

The survey revealed a range of communication strategies with phone calls still the commonest followed by email. The key performance index for most laboratories was less than 10 min.

CONCLUSION

Benchmarking can provide key information for quality improvement activities, particularly pre- and postanalytical.

Necessity of Routine Repeat Testing of Critical Values in Various Working Shifts

Background & Objective:

Accurate and timely reporting of critical values is an important issue. There is some doubt whether repeat testing of critical values would offer any advantage over single testing or not. The aim of this study was evaluation of utility of routine repeat testing of critical values in our referral center and to compare probable variations in different working shifts.

Methods:

Clinical results of serum Potassium, Calcium, Blood Hemoglobin and Prothrombin Time (INR: International Normalized Ratio) were evaluated for three months.

Results:

Totally, 178, 96, 67 and 107 consecutive critical values for Potassium, Calcium, Hemoglobin and INR were reported, respectively. In potassium and Hemoglobin 5.05% and 1.17% of retest runs exceeded the accep1 tolerance limit. All of the calcium retest results were within the acceptable limit. For INR, 21/107 retest results did not meet the acceptable tolerance limit, nine still were critical. Afternoon working run performance was significantly better than the two others.

Conclusion:

Our observation suggests that routine repeat of hematology and chemistry critical test result is not necessary and may adversely affect patient safety measure. However, attention should be paid to results greater than analytical measurement range and all such results should be repeated before reporting.

Clinician's opinion about critical risk results proposed by the Croatian Chamber of Medical Biochemists: a survey in one Croatian tertiary hospital

Introduction

It has been recommended that each laboratory modify their critical result reporting practices to reflect the clinical needs of their patient populations. The aim of this survey was to assess how well critical laboratory values defined by the Croatian Chamber of Medical Biochemists (CCMB) correspond to the needs of the physicians at University hospital “Sveti Duh” (Zagreb, Croatia).

Materials and methods

We conducted a survey among physicians from five departments in our hospital. Physicians were asked general questions about critical risk results (if and how they want to be informed). A list of critical risk results defined by the CCMB was offered and physicians were asked to revise the existing critical risk results and suggest adding new parameters. Obtained data were presented as numbers. Where the number of observations was low, ratios were used.

Results

Survey response rate was 43% (52/121). Majority (48/52) wants to be informed of critical risk results, either personally (31/48) or through a colleague (32/48). They prefer to be informed about critical risk results of prothrombin time, platelet count, haemoglobin, glucose, creatinine, sodium and potassium. Revisions in the CCMB critical risk result list are proposed by 13 out of 48 physicians. Neonatologists approved the CCMB’s list.

Conclusions

Although most critical risk results defined by the CCMB correspond well to the needs of the physicians in our hospital, some revisions are necessary to meet the particular needs of individual departments. Communication of critical risk results to those who have requested laboratory testing is highly appreciated practice.

Terminology, units and reporting - how harmonized do we need to be?

Harmonization initiatives in laboratory medicine seek to eliminate or reduce illogical variations in service to patients, clinicians and other healthcare professionals. Significant effort will be required to achieve consistent application of terminology, units and reporting across laboratory testing providers. Current variations in practice for nomenclature, reference intervals, flagging, units, standardization and traceability between analytical methods, and presentation of cumulative result data are inefficient and inconvenient, or worse yet, patient safety risks. All aspects of laboratory service across the "total testing process" ultimately depend on concise, reliable communication. Clinical terminologies (e.g. SNOMED-CT, LOINC, IFCC/IUPAC NPU) provide a mechanism to correctly identify an analyte or panel of tests within a request for testing and communicate the results back to the clinician or electronic health record (EHR). Electronic systems for requesting and reporting laboratory testing are said to be interoperable when reliable connection and communication of content occur. Modern electronic reports and EHRs will provide greater flexibility and functionality, but also require effective guidelines or standards to ensure consistent representation of laboratory data. Programs to harmonize service in these areas require ongoing local, national and international efforts and should incorporate stakeholders from laboratories, medical staff, information technology and informatics specialists, patient representatives and government. The process of identifying harmonized best practice, then ensuring uptake across many laboratory testing providers, is generally iterative rather than "one off". New opportunities for additional harmonization will be generated as analytical performance, standardization and traceability, and diagnosis and treatment continue to evolve.

Post-analytical laboratory work: national recommendations from the Working Group for Post-analytics on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine

The post-analytical phase is the final phase of the total testing process and involves evaluation of laboratory test results; release of test results in a timely manner to appropriate individuals, particularly critical results; and modification, annotation or revocation of results as necessary to support clinical decision-making. Here we present a series of recommendations for post-analytical best practices, tailored to medical biochemistry laboratories in Croatia, which are intended to ensure alignment with national and international norms and guidelines. Implementation of the national recommendations is illustrated through several examples.

Outcome-Based Critical Result Thresholds in the Adult Patient Population

OBJECTIVES

To derive outcome-based critical result thresholds in the adult patient population.

METHODS

We extracted deidentified laboratory results and outcomes (death or discharged) of patients 18 years and older from the Medical Information Mart for Intensive Care database. The lower and upper critical result thresholds were obtained from the nearest minimum and maximum laboratory values, which corresponded to predicted probability of death at 90%.

RESULTS

The critical value thresholds were sodium (<123, >153 mmol/L), potassium (<2.2, >6.6 mmol/L), bicarbonate (<15, >49 mmol/L), chloride (<82, >121 mmol/L), urea (>20 mmol/L), creatinine (>1,052 μmol/L), glucose (<1.5, >23.8 mmol/L), total calcium (<1.62, >2.95 mmol/L), magnesium (<0.37, >1.48 mmol/L), phosphate (<0.19, >2.52 mmol/L), pH (<7.22, >7.57), lactate (>5.0 mmol/L), hemoglobin (<4.6 g/dL), WBCs (>32 × 103/μL), prothrombin time (>90 seconds), and international normalized ratio (>10).

CONCLUSIONS

The indirect approach described in this study is a pragmatic way to obtain threshold values that are clinically and operationally meaningful.

Development of Statistical Software for the Korean Laboratory Accreditation Program Using R Language: LaboStats

BACKGROUND

In Korea, the Korean Laboratory Accreditation Program (KLAP) has set minimum standards for verification of clinical test performance. This verification process is time-consuming and labor-intensive when performed manually. We developed a free, statistical software program for KLAP, using the R language (R Foundation for Statistical Computing, Vienna, Austria).

METHODS

We used CLSI guidelines for the algorithm. We built graphic user interfaces, including data input, with Embarcadero Delphi EX4 (Embarcadero Technologies, Inc., Texas, USA). The R Base Package and MCR Package for Method Comparison Regression were used to implement statistical and graphical procedures.

RESULTS

Our program LaboStats has six modules: parallel test, linearity, method comparison, precision, reference interval, and cutoff. Data can be entered into the field either manually or by copying and pasting from an MS Excel worksheet. Users can print out precise reports.

CONCLUSIONS

LaboStats can be useful for evaluating clinical test performance characteristics and preparing documents requested by KLAP.

National survey on current situation of critical value reporting in 973 laboratories in China

Introduction

The aim of the study was to investigate the state-of-the-art of the performance of critical value reporting and provide recommendations for laboratories setting critical value reporting time frames.

Materials and methods

The National Centre for Clinical Laboratories in China initiated a critical value reporting investigation in 2015. A questionnaire related to critical value reporting policy was sent to 1589 clinical laboratories in China online. The questionnaire consisted of a set of questions related to critical value reporting policy and a set of questions related to timeliness of critical value reporting. The survey data were collected between March and April 2015.

Results

A total survey response rate was 61.2%. The critical value unreported rate, unreported timely rate, and clinical unacknowledged rate of more than half of participants were all 0.0%. More than 75.0% of participants could report half of critical values to clinicians within 20 minutes and could report 90.0% of critical values to clinicians within 25 minutes (from result validation to result communication to the clinician). The median of target critical value reporting time was 15 minutes. “Reporting omission caused by laboratory staff”, “communications equipment failure to connect”, and “uncompleted application form without contact information of clinician” were the three major reasons for unreported critical value.

Conclusions

The majority of laboratories can report critical values to responsible clinical staff within 25 minutes. Thus, this value could be recommended as suitable critical value reporting time frame for biochemistry laboratories in China. However, careful monitoring of the complete reporting process and improvement of information systems should ensure further improvement of critical value reporting timeliness.

An evaluation of adult critical result policies in haematology in a teaching hospital in China

Background

Critical result (CR) reporting is one of the core policies in China, yet it varies in different hospitals. In addition, few reports of the evaluation of CR policies have been published. This study aimed to evaluate the adult CR policies for haematology in a teaching hospital.

Methods

The consistency was compared between CR policies in a tertiary hospital in China and the current standards, consensuses and literature. The incidences for the alert thresholds of white blood cells (WBC), haemoglobin (HgB), and platelets (PLT) and the turn-around time (TAT) for different phases of CR reporting in 2017 were investigated. On-site observation of the staff was used to assess CR implementation and compliance with CR policies.

Results

The clauses of adult CR policies in haematology were consistent with the requirements in the standards, consensuses and literature, and the CR items and alert thresholds were within the range reported in the literature. CRs in haematology were dominated by lower thresholds. The incidences of alerts due to WBC, HgB, and PLT levels were 37.5, 18.0 and 37.0 times/day, respectively. A total of 150 cases of CR implementation were observed on-site, and the procedures followed by the staff were consistent with the requirements of the polices. The TAT medians for CR verification in the outpatient, emergency and inpatient departments were ≤6 min.

Conclusions

The consistency and implementation of CR policies were both good, which ensures patient safety.

Relative criticalness of common laboratory tests for critical value reporting

We determined the relative strengths of association between 23 most commonly ordered laboratory tests and the adverse outcome as indicators of relative criticalness. The lowest and highest results for 23 most commonly ordered laboratory tests, 24 hours prior to death during critical care unit (CCU) stay or discharge from CCU were extracted from a publicly available CCU database (Medical Information Mart for Intensive Care-III). Following this, the Random Forest model was applied to assess the association between the laboratory results and the outcomes (death or discharge). The mean decrease in Gini coefficient for each laboratory test was then ranked as an indication of their relative importance to the outcome of a patient. In descending order, the 10 laboratory tests with the strongest association with death were: bicarbonate, phosphate, anion gap, white cell count (total), partial thromboplastin time, platelet, total calcium, chloride, glucose and INR; moreover, the strength of association was different for critically high versus low results.

Errors in the Extra-Analytical Phases of Clinical Chemistry Laboratory Testing

The total testing process consists of various phases from the pre-preanalytical to the post-postanalytical phase, the so-called brain-to-brain loop. With improvements in analytical techniques and efficient quality control programmes, most laboratory errors now occur in the extra-analytical phases. There has been recent interest in these errors with numerous publications highlighting their effect on service delivery, patient care and cost. This interest has led to the formation of various working groups whose mission is to develop standardized quality indicators which can be used to measure the performance of service of these phases. This will eventually lead to the development of external quality assessment schemes to monitor these phases in agreement with ISO15189:2012 recommendations. This review focuses on potential errors in the extra-analytical phases of clinical chemistry laboratory testing, some of the studies performed to assess the severity and impact of these errors and processes that are in place to address these errors. The aim of this review is to highlight the importance of these errors for the requesting clinician.

Delivering safe and effective test-result communication, management and follow-up: a mixed-methods study protocol

INTRODUCTION

The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems.

METHODS AND ANALYSIS

This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia.Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions.Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes.Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences.

External quality assessment of medical laboratories in Croatia: preliminary evaluation of post-analytical laboratory testing

Introduction

Proper standardization of laboratory testing requires assessment of performance after the tests are performed, known as the post-analytical phase. A nationwide external quality assessment (EQA) scheme implemented in Croatia in 2014 includes a questionnaire on post-analytical practices, and the present study examined laboratory responses in order to identify current post-analytical phase practices and identify areas for improvement.

Materials and methods

In four EQA exercises between September 2014 and December 2015, 145-174 medical laboratories across Croatia were surveyed using the Module 11 questionnaire on the post-analytical phase of testing. Based on their responses, the laboratories were evaluated on four quality indicators: turnaround time (TAT), critical values, interpretative comments and procedures in the event of abnormal results. Results were presented as absolute numbers and percentages.

Results

Just over half of laboratories (56.3%) monitored TAT. Laboratories varied substantially in how they dealt with critical values. Most laboratories (65-97%) issued interpretative comments with test results. One third of medical laboratories (30.6-33.3%) issued abnormal test results without confirming them in additional testing.

Conclusion

Our results suggest that the nationwide post-analytical EQA scheme launched in 2014 in Croatia has yet to be implemented to the full. To close the gaps between existing recommendations and laboratory practice, laboratory professionals should focus on ensuring that TAT is monitored and lists of critical values are established within laboratories. Professional bodies/institutions should focus on clarify and harmonized rules to standardized practices and applied for adding interpretative comments to laboratory test results and for dealing with abnormal test results.

Reaching consensus on communication of critical laboratory results using a collective intelligence method

Background:

There is no consensus in the literature about what analytes or values should be informed as critical results and how they should be communicated. The main aim of this project is to establish consensual standards of critical results for the laboratories participating in the study. Among the project’s secondary objectives, establishing consensual procedures for communication can be highlighted.

Methods:

Consensus was reached among all participating laboratories establishing the basis for the construction of the initial model put forward for consensus in conjunction with the clinicians. A real-time Delphi, methodology “health consensus” (HC), with motivating and participative questions was applied. The physician was expected to choose a numeric value within a scale designed for each analyte.

Results:

The medians of critical results obtained represent the consensus on critical results for outpatient and inpatient care. Both in primary care and in hospital care a high degree of consensus was observed for critical values proposed in the analysis of creatinine, digoxin, phosphorus, glucose, international normalized ratio (INR), leukocytes, magnesium, neutrophils, chloride, sodium, calcium and lithium. For the rest of critical results the degree of consensus obtained was “medium high”. The results obtained showed that in 72% of cases the consensual critical value coincided with the medians initially proposed by the laboratories.

Conclusions:

The real-time Delphi has allowed obtaining consensual standards for communication of critical results among the laboratories participating in the study, which can serve as a basis for other organizations.

Towards a new paradigm in laboratory medicine: the five rights

A body of evidence collected in the last few decades demonstrates that the pre- and post-analytical phases of the testing cycle are more error-prone than the analytical phase. However, the paradigm of errors and quality in laboratory medicine has been questioned, analytical mistakes continuing to be a major cause of adverse clinical outcomes and patient harm. Although the brain-to-brain concept is widely recognized in the community of laboratory professionals, there is lack of clarity concerning the inter-relationship between the different phases of the cycle, interdependence between the pre-analytical phase and analytical quality, and the effect of the post-analytical steps on the quality of ultimate laboratory information. Analytical quality remains the "core business" of clinical laboratories, but laboratory professionals and clinicians alike should never lose sight of the fact that pre-analytical variables are often responsible for erroneous test results and that quality biospecimens are pre-requisites for a reliable analytical phase. In addition, the pressure for expert advice on test selection and interpretation of results has increased hand in hand with the ever-increasing complexity of tests and diagnostic fields. Finally, the data on diagnostic errors and inappropriate clinical decisions made due to delay or misinterpretation of laboratory data underscore the current need for greater collaboration at the clinical-laboratory interface.

What Alert Thresholds Should Be Used to Identify Critical Risk Results: A Systematic Review of the Evidence

BACKGROUND

Pathology laboratories are required to immediately report results which indicate a patient is at critical risk, but there is little consensus about what values are deemed critical. The aim of this review was to systematically review the literature on alert thresholds for common chemistry and hematology tests in adults and to provide an explicit and ranked source of this evidence.

METHODS

The literature search covered the period of 1995–2014. Evidence sources were critically appraised and ranked using the 1999 Stockholm hierarchy for analytical performance specifications in laboratory medicine modified for establishing decision limits.

RESULTS

The 30 most frequently reported laboratory tests with alert thresholds are presented with evidence rankings. Similar thresholds were reported in North America, Europe and Asia. Seventy percent of papers reported thresholds set by individual institutions, while 18% contained thresholds from surveys of laboratories or clinicians. Forty-six percent of the papers referred to 1 or both of the 2 American laboratory surveys from the early 1990s. “Starter sets” of alert thresholds were recommended by 6 professional bodies, 3 of which were collaborations between pathologists and clinicians. None of the 9 outcome studies identified dealt with confounding factors.

CONCLUSIONS

Recommendations by professional bodies based on outdated surveys of the former state of the art or consensus are currently the best sources of evidence for laboratories to build their alert list. Well-designed outcome studies and greater collaboration between clinicians and the laboratory are needed to identify the most appropriate alert thresholds that signify actionable, critical or significant risk to patient well-being.

Standardization of haematology critical results management in adults: an International Council for Standardization in Haematology, ICSH, survey and recommendations

INTRODUCTION

These recommendations are intended to develop a consensus in the previously published papers as to which parameters and what values should be considered critical. A practical guide on the standardization of critical results management in haematology laboratories would be beneficial as part of good laboratory and clinical practice and for use by laboratory-accrediting agencies.

METHODS

A working group with members from Europe, America, Australasia and Asia was formed by International Council for Standardization in Haematology. A pattern of practice survey of 21 questions was distributed in 2014, and the data were collected electronically by Survey Monkey. The mode, or most commonly occurring value, was selected as the threshold for the upper and lower alert limits for critical results reporting.

RESULTS

A total of 666 laboratories submitted data to this study and, of these, 499 submitted complete responses. Full blood count critical results alert thresholds, morphology findings that trigger critical result notification, critical results alert list, notification process and maintenance of critical results management protocol are described. This international survey provided a snapshot of the current practice worldwide and has identified the existence of considerable heterogeneity of critical results management.

CONCLUSION

The recommendations in this study represent a consensus of good laboratory practice. They are intended to encourage the implementation of a standardized critical results management protocol in the laboratory.

Assessing Clinical Laboratory Quality: A College of American Pathologists Q-Probes Study of Prothrombin Time INR Structures, Processes, and Outcomes in 98 Laboratories

Context

The anticoagulant warfarin has been identified as the second most frequent drug responsible for serious, disabling, and fatal adverse drug events in the United States, and its effect on blood coagulation is monitored by the laboratory test called international normalized ratio (INR).

Objective

To determine the presence of INR policies and procedures, INR practices, and completeness and timeliness of reporting critical INR results in participants' clinical laboratories.

Design

Participants reviewed their INR policies and procedure requirements, identified their practices by using a questionnaire, and studied completeness of documentation and timeliness of reporting critical value INR results for outpatients and emergency department patients.

Results

In 98 participating institutions, the 5 required policies and procedures were in place in 93% to 99% of clinical laboratories. Fifteen options for the allowable variations among duplicate results from different analyzers, 12 different timeliness goals for reporting critical values, and 18 unique critical value limits were used by participants. All required documentation elements were present in 94.8% of 192 reviewed INR validation reports. Critical value INR results were reported within the time frame established by the laboratory for 93.4% of 2604 results, but 1.0% of results were not reported. Although the median laboratories successfully communicated all critical results within their established time frames and had all the required validation elements based in their 2 most recent INR calculations, those participants at the lowest 10th percentile were successful in 80.0% and 85.7% of these requirements, respectively.

Conclusions

Significant opportunities exist for adherence to INR procedural requirements and for practice patterns and timeliness goals for INR critical results' reporting.

Croatian survey on critical results reporting

INTRODUCTION

Poor harmonization of critical results management is present in various laboratories and countries, including Croatia. We aimed to investigate procedures used in critical results reporting in Croatian medical biochemistry laboratories (MBLs).

MATERIALS AND METHODS

An anonymous questionnaire, consisting of 24 questions/statements, related to critical results reporting procedures, was send to managers of MBLs in Croatia. Participants were asked to declare the frequency of performing procedures and degree of agreement with statements about critical values reporting using a Likert scale. Total score and mean scores for corresponding separate statements divided according to health care setting were calculated and compared.

RESULTS

Responses from 111 Croatian laboratories (48%) were analyzed. General practice laboratories (GPLs) more often re-analyzed the sample before reporting the critical result in comparison with the hospital laboratories (HLs) (score: 4.86 (4.75-4.96) vs. 4.49 (4.25-4.72); P=0.001) and more often reported the critical value exclusively to the responsible physician compared to HLs (4.46 (4.29-4.64) vs. 3.76 (3.48-4.03), P<0.001). High total score (4.69 (4.56-4.82)) was observed for selection of the critical results list issued by the Croatian Chamber of Medical Biochemistry (CCMB) indicating a high harmonization level for this aspect of critical result management. Low total scores were observed for the statements regarding data recording and documentation of critical result notification.

CONCLUSIONS

Differences in practices about critical results reporting between HLs and GPLs were found. The homogeneity of least favorable responses detected for data recording and documentation of critical results notification reflects the lack of specific national recommendations.

Predictive medicine: outcomes, challenges and opportunities in the Synergy-COPD project

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a major challenge for healthcare. Heterogeneities in clinical manifestations and in disease progression are relevant traits in COPD with impact on patient management and prognosis. It is hypothesized that COPD heterogeneity results from the interplay of mechanisms governing three conceptually different phenomena: 1) pulmonary disease, 2) systemic effects of COPD and 3) co-morbidity clustering.

OBJECTIVES

To assess the potential of systems medicine to better understand non-pulmonary determinants of COPD heterogeneity. To transfer acquired knowledge to healthcare enhancing subject-specific health risk assessment and stratification to improve management of chronic patients.

METHOD

Underlying mechanisms of skeletal muscle dysfunction and of co-morbidity clustering in COPD patients were explored with strategies combining deterministic modelling and network medicine analyses using the Biobridge dataset. An independent data driven analysis of co-morbidity clustering examining associated genes and pathways was done (ICD9-CM data from Medicare, 13 million people). A targeted network analysis using the two studies: skeletal muscle dysfunction and co-morbidity clustering explored shared pathways between them.

RESULTS

(1) Evidence of abnormal regulation of pivotal skeletal muscle biological pathways and increased risk for co-morbidity clustering was observed in COPD; (2) shared abnormal pathway regulation between skeletal muscle dysfunction and co-morbidity clustering; and, (3) technological achievements of the projects were: (i) COPD Knowledge Base; (ii) novel modelling approaches; (iii) Simulation Environment; and, (iv) three layers of Clinical Decision Support Systems.

CONCLUSIONS

The project demonstrated the high potential of a systems medicine approach to address COPD heterogeneity. Limiting factors for the project development were identified. They were relevant to shape strategies fostering 4P Medicine for chronic patients. The concept of Digital Health Framework and the proposed roadmap for its deployment constituted relevant project outcomes.