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					                                                            Rapid Communication of Laboratory Results:
                                                        Critical Results, Critical Tests, and Courtesy Calls
                                                                      Department of Clinical Laboratories




POLICY:      Critical tests, critical results, and courtesy calls on inpatients, outpatients, and outreach
             patients will be communicated to a clinical professional responsible for the patient’s care, and
             notification documented, in a consistent and timely manner.

Critical Tests:
1. Critical tests are those tests which will always require rapid communication of the results, even if
    normal.
2. Critical test specimens should be delivered to the Clinical Laboratories within 10 minutes of
    order/collection.
3. Critical tests will be communicated to a clinical professional responsible for the patient’s care,
    regardless of the test result, within specified time interval from order/collection to reporting (see
    below). Such notification will be documented.

                                           CRITICAL TESTS
                                 Notification: Order/Collect To Result
                        Code Blue Whole Blood Gas Labs           30 minutes

                        Critical Care Whole Blood Gas Labs             30 minutes

                        Frozen Sections                                30 minutes

                        Intra-Operative PTH                            40 minutes


Critical Results / Critical Values
1. Critical results, also known as “critical values,” are test results that fall significantly outside the normal
    range and may represent life-threatening values, even if from routine tests.
2. Critical results (see Clinical Laboratories Critical Results Table below) will be communicated to a
    clinical professional responsible for the patient’s care within 20 minutes of completion of the test, and
    such notification documented as a component of the test results report.


Courtesy Telephone Notification
1. Courtesy telephone notification for other specified tests/results will be communicated to a clinical
   professional responsible for the patient’s care and such notification documented as a component of
   the test results report.


GENERAL PROCESS:
When rapid communication of laboratory results is required, testing and client services personnel of the
Clinical Laboratories notify a clinical professional (e.g. RN, physician, nurse practitioner, respiratory
therapist) responsible for the patient's care using the following general procedure.

1. Determine the location from which the patient specimen was sent. If the area that submitted the
   specimen is closed, the laboratory will call the ordering physician, attending physician, on-call
   physician, or designee (as indicated by the client).

2. Call the area that submitted the specimen and tell them you have a laboratory result to report. Ask
   for a clinical professional taking care of the patient. Report ALL of the following elements:

             a.   your first and last name and laboratory from which you are calling
             b.   patient's name
             c.   patient’s MRN
             d.   patient phone number: for all non-inpatients or non-ED patients’ notifications


Effective Date: June 7, 2011                                                                  Page 1 of 4
                                                          Rapid Communication of Laboratory Results:
                                                      Critical Results, Critical Tests, and Courtesy Calls
                                                                    Department of Clinical Laboratories


             e.   name of attending physician
             f.   collect date and time of specimen
             g.   test name(s)
             h.   test results

3. If the communication for an inpatient or ED patient is not to a physician and the clinical professional
   indicates that the patient has been discharged, request the name of the attending physician and notify
   them directly. If unable to notify the attending physician, proceed to Section 6.

4. Request read-back verification of the test result(s). This must include patient name, MRN, test
   name(s) and test result(s).

5. Document telephone communications / notifications. Include all of the following elements:

             a. First and last name and title (e.g. Dr. or RN) of person notified / who verified/read-back
                the results
             b. Date of notification
             c. Time of notification

6. If the appropriate person cannot be reached (especially after “business hours”), the laboratory staff
   will consult with the pathologist to determine whether the patient needs to be contacted directly and
   advised to seek medical attention. If so, the pathologist will contact the patient. If not, the laboratory
   will notify the appropriate person the next morning.




Effective Date: June 7, 2011                                                               Page 2 of 4
                                                                       Rapid Communication of Laboratory Results:
                                                                   Critical Results, Critical Tests, and Courtesy Calls
                                                                                 Department of Clinical Laboratories



         Notes Key:    Outpatients only (ED is outpatient)         Neonate/Pediatric only             James Patients only

                       CHEMISTRY                                                             HEMATOLOGY
        Analyte                     Critical Results                    Analyte                    Critical Results
Acetone-serum/plasma             Moderate or higher                WBC                  < 1.5      > 35.0 K/uL
ALT initial only                 > 1000 U/L                         BMT J8E, J8S        < 0.5      > 35.0 K/uL
AST initial only                 > 1000 U/L                         10J initial only
Amylase                          > 500 (> 400 under 18 yr) U/L      Known CLL                             > 100.0 K/uL outpatients only
Beta Hydroxybutyrate             > 1.1 mmol/L                       Other Oncology      < 0.5             > 35.0 K/uL
Bilirubin, total                 > 14.0 mg/dL (neonates only)      Hemoglobin           < 7.0             > 22.0 g/dL
BUN                              > 100 mg/dL                            Neonates        < 11.0            > 22.0 g/dL
   NEPH initial only             > 100 mg/dL                       Hematocrit           < 21.0            > 66.0 %
Calcium                 <6       > 12 mg/dL                             Neonates        < 33              > 66.0 %
Chloride                < 75     > 130 mmol/L                      Platelet             < 30              > 1,000,000 K/uL
CO2                     < 10     > 40 mmol/L                        Oncology            < 10              > 1,000,000 K/uL
Creatine Kinase                  > 500 U/L (outpatients only )     Bands + Segs Ratio   > 0.25 (Neonates only)
     GCRC Mendell: do not call                                     CSF WBC                                > 10 cells / uL
     Mendell ICD9 = 359.1outpatients: do not call                  Bacteria             Any intracellular on peripheral blood smear,
Creatinine                       > 10 mg/dL                                             Any on direct smear of any sterile body fluid OR
   NEPH initial only             > 10 mg/dL                                             count if direct smear is not already positive
Ethanol                          > 0.300 g/dL
Free T4 (ED only)                > 4.5 ng/dL
Glucose                 < 50     > 400 mg/dL
   Neonates             < 40     > 200 mg/dL                                                COAGULATION
CSF Glucose             < 30     > 300 mg/dL                              Analyte                        Critical Results
Lactate                          > 5.0 mmol/L                      INR                                > 5.5
Lithium                          > 2.0 mmol/L                      PTT                                > 150 sec (inpat)   > 60 (outpat)
Phosphorus              < 1.0    > 10 mg/dL                        Fibrinogen               < 75 mg/dL
Ionized Calcium         < 3.4    > 6.2 mg/dL                       Factor Activity          < 5%
Magnesium               < 1.0    > 4.4 mg/dL
Osmolality              < 250 > 325 mOsm/kg
Potassium               < 3.0    > 6.0 mmol/L                                                 URINALYSIS
   Neonates             < 3.0    > 7.0 mmol/L                             Analyte                           Critical Results
Sodium                  < 125 > 160 mmol/L                         Urine Microscopic        Any RBC casts
pH                      < 7.2    > 7.55                                                     Any WBC casts
pCO2                    < 20     > 65 mmHg                         Pediatric < 2 yrs        Positive for reducing substance
pO2                     <44      mmHg                              Children < 7 yrs         Positive for glucose
Troponin I              > 5.00 FIRST critical result, additional   Myoglobin                Positive
                        calls ONLY if no previous >5.00            Porphobilinogen          Positive
                        within past 24 hours.
TSH (ED only)                    >150.0 uIU/mL




           Effective Date: June 7, 2011                                                                   Page 3 of 4
                                                                     Rapid Communication of Laboratory Results:
                                                                 Critical Results, Critical Tests, and Courtesy Calls
                                                                               Department of Clinical Laboratories




      Notes Key:     Outpatients only (ED is outpatient)         Neonate/Pediatric only        James Patients only

                       MICROBIOLOGY                                                 THERAPEUTIC DRUGS
Positive Blood Culture                                                   Analyte                   Critical Results
Positive direct smear and/or culture of any sterile body fluid    Acetaminophen        > 150 ug/mL
Positive direct smear and/or culture from any central nervous     Amikacin             Peak > 60 ug/mL; Trough > 8 ug/mL
system specimen                                                   Carbamazepine        > 15 ug/mL
Positive Malaria smear                                            Digoxin              > 2.0 ng/mL
Positive AFB smear / Tissue section                               Free Phenytoin       > 3.0 ug/mL
Positive Fungal smear                                             Gentamicin           Peak > 20 ug/mL; Trough > 2.0 ug/mL
Cultures positive for M. tuberculosis, Brucella, Legionella,      Lidocaine            > 6.0 ug/mL
or any Class A reportable disease                                 Lithium              > 2 mmol/L
Neisseria meningitidis invasive disease                           Pentobarbital        > 45 ug/mL
Diseases of the newborn, e.g. Group B beta Streptococci, CMV,     Phenobarbital        > 45 ug/mL
HSV, H. influenza, Listeria spp., Neisseria gonorrhoeae,          Phenytoin            > 22 ug/mL
Chlamydia trachomatis                                             Salicylate           > 30.0 mg/dL
Positive Epstein-Barr Virus by PCR – blood or CSF                 Theophylline         > 20 ug/mL
Positive Clostridium difficile tests                              Tobramycin           Peak > 20 ug/mL; Trough > 2.0 ug/mL
Positive Influenza A/B tests: antigen, PCR and/or culture         Valproic Acid        > 150 ug/mL
                                                                  Vancomycin           > 20 ug/mL Trough

                               TRANFUSION SERVICES
Newborn Positive Direct Coombs Test      Positive Kleihauer-Betke stain
(DAT)                                    Titer > 32 in pregnancy
Hemolytic Transfusion Reaction           Suspected passenger lymphocyte syndrome
Clerical or technical error(s)




         Effective Date: June 7, 2011                                                              Page 4 of 4

				
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