Communication of Critical Laboratory Values: Optimization of the Process through Secure Messaging

Web-accessible critical limits and critical values for urgent clinician notification

OBJECTIVES

To survey the World Wide Web for critical limits/critical values, assess changes in quantitative low/high thresholds since 1990-93, streamline urgent notification practices, and promote global accessibility.

METHODS

We identified Web-posted lists of critical limits/values at university hospitals. We compared 2023 to 1990-93 archived notification thresholds.

RESULTS

We found critical notification lists for 26 university hospitals. Laboratory disciplines ranged widely (1-10). The median number of tests was 62 (range 21-116); several posted policies. The breadth of listings increased. Statistically significant differences in 2023 vs. 1990 critical limits were observed for blood gas (pO2, pCO2), chemistry (glucose, calcium, magnesium), and hematology (hemoglobin, platelets, PTT, WBC) tests, and for newborn glucose, potassium, pO2, and hematocrit. Twenty hospitals listed ionized calcium critical limits, which have not changed. Fourteen listed troponin (6), troponin I (3), hs-TnI (3), or troponin T (2). Qualitative critical values expanded across disciplines, encompassing anatomic/surgical pathology. Bioterrorism agents were listed frequently, as were contagious pathogens, although only three hospitals listed COVID-19. Only one notification list detailed point-of-care tests. Two children's hospital lists were Web-accessible.

CONCLUSIONS

Urgent notifications should focus on life-threatening conditions. We recommend that hospital staff evaluate changes over the past three decades for clinical impact. Notification lists expanded, especially qualitative tests, suggesting that automation might improve efficiency. Sharing notification lists and policies on the Web will improve accessibility. If not dependent on the limited scope of secondary sources, artificial intelligence could enhance knowledge of urgent notification and critical care practices in the 21st Century.

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.

Baseline assessment of staff perception of critical value practices in government hospitals in Kuwait

Background

Notification of laboratory-determined critical values is key for effective clinical decision making and is thus a consequential step in a patient’s health care and safety. This study presents an overview of staff reporting policies and procedures concerning critical values in Kuwaiti governmental hospitals.

Methods

A cross-sectional descriptive study design was adopted. Study subjects were affiliated with laboratories from five government hospitals (four general and one sub-specialty hospital). All laboratory staff in every hospital were included. The Statistical Package for the Social Sciences (version 23) was used to analyse the collected data at a significance level of ≤ 0.05. Quantitative data analysis included univariate descriptive (means, medians, standard deviations, frequencies, percentages) and bivariate (chi-squared, ANOVA and Kruskal–Wallis tests) analyses. These analyses provided associations between participating hospitals and staff perceptions towards the policies and procedures surrounding critical values.

Results

559 questionnaires were returned, a total response of 30.5% after those of 79 phlebotomists were excluded (eligible sample size n = 1833). The notification of critical values differs between participated laboratories in delivering protocol and time duration. Linked protocols between laboratories did not exist regarding policies and guidelines for applying the same procedures for critical value notification. There are differences in critical value limits among the participating laboratories.

Conclusion

This study is the first to survey laboratory staff perceptions of critical value practices in Kuwaiti government hospitals. Enhancing critical value reporting and policy is crucial for improving patient safety and to develop high-quality health services. The findings of this study can help policy makers implement future intervention studies to enhance laboratory practices in the area of critical values and improve patient safety and the quality of government hospital systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08329-z.

Engaging Pathology Residents in Clinical Chemistry: The Essential Ingredient Is a Committed Teacher

BACKGROUND

Pathology residents are thought to show a lack of interest in clinical chemistry, therefore potentially graduating from training programs unprepared to function as laboratory directors and clinical consultants.

METHODS

A structured program of tutorials based primarily on Henry's textbook, supplemented by recent review articles; a question bank of about 600 questions to emphasize key concepts; requirement for performing and presenting quality improvement projects; participation in on-site CAP inspections; review of reference laboratory test requests; and involving residents in scholarly activity have resulted in sustained, transferable, and significant improvements in engagement, knowledge, competence, and examination scores.

RESULTS

The primary parameter for measuring change in resident competence and engagement were improvements in resident in-service examination (RISE) scores, publications in peer-reviewed journals, and receipt of awards. The revised program produced significant improvement in RISE scores in clinical chemistry, over and above the improvements in the general residency program. The residents were authors on 12 publications in peer-reviewed PubMed listed journals in the 5-year period since revision in the clinical chemistry curriculum compared to no publications in clinical chemistry in the 5-year period before the new curriculum. Over the past 2 years, 6 of the 11 publications by graduating residents were in clinical chemistry, and 6 of 7 awards for research were garnered by residents engaged in clinical chemistry investigations. All of the residents passed their clinical pathology boards on first attempt since the change compared to 2 failures in the prior 5-year period.

CONCLUSIONS

The structured program described here is important as a template that could be adopted by any pathology training program. The question bank developed by this program is a valuable and transferable aid. However, success of such a program is dependent on the commitment of a knowledgeable, dedicated, and passionate teacher.