Critical values in hematology of 862 institutions in China.
Ye Y Y,Zhao H J,Fei Y,Wang W,He F L,Zhong K,Yuan S,Wang Z G
International journal of laboratory hematology
INTRODUCTION:A national survey on critical values in hematology of China laboratories was conducted to determine the current practice and assess the quality indicators so as to obtain a quality improvement. METHODS:Laboratories participating were asked to submit the general information, the practice of critical value reporting, and the status of timeliness of critical value reporting. RESULTS:A total of 862 laboratories submitted the results. The majority of participants have included white blood cell count, blood platelet count, hemoglobin, prothrombin time, and activated partial thromboplastin time in their critical value lists. Many sources are used for establishing a critical value policy, and some of the laboratories consult with clinicians. The unreported critical value rate, late critical value reporting rate, and clinically unacknowledged rate in China are relatively low, and the median of critical value reporting time is 8-9 minutes. CONCLUSION:There exists a wide variety for critical value reporting in hematology in China. Laboratories should establish a policy of critical value reporting suited for their own situations and consult with clinicians to set critical value lists. Critical values are generally reported in a timely manner in China, but some measures should be taken to further improve the timeliness of critical value reporting.
10.1111/ijlh.12681
Derivation of Outcome-Based Pediatric Critical Values.
Du Hao,Markus Corey,Metz Michael,Feng Mengling,Loh Tze Ping
American journal of clinical pathology
OBJECTIVES:There is currently a lack of an outcomes-based definition of critical values for the pediatric population. This has contributed to a highly heterogeneous critical value reporting practice between laboratories. METHODS:Anonymized results were extracted from a laboratory information system for 10 biochemistry tests. The probability of high-dependency/intensive care unit admission (as a proxy for adverse outcomes) for each individual laboratory concentration was calculated and adjusted to fit using a polynomial function to model the probability trend. The laboratory value that intersected the 90% probability trend line was considered the critical value threshold. RESULTS:The critical value thresholds for the serum analytes were sodium (mmol/L: <131, >148), potassium (mmol/L: <2.4, >6.4), bicarbonate (mmol/L: <13, >37), chloride (mmol/L: <91, >115), urea (mmol/L: >12), creatinine (μmol/L: >129), glucose (mmol/L: >17.2), total calcium (mmol/L: <1.9), magnesium (mmol/L: <0.6, >1.2), and phosphate (mmol/L: <0.4, >2.6). CONCLUSIONS:This study described an approach to derive contemporary pediatric critical value thresholds.
10.1093/ajcp/aqx165
Critical values notification: A nationwide survey of practices among clinical laboratories across Nigeria.
African journal of laboratory medicine
Background:Critical value notification (CVN) entails notifying doctors or other laboratory users of aberrant laboratory results that threaten the patient's life and of any values for which reporting delays could negatively impact the patient's health. Critical value notification practices in clinical laboratories in Nigeria and sub-Saharan Africa are largely unknown. Objective:We conducted a nationwide survey to obtain baseline information on CVN practice by Nigeria's laboratories. Methods:This cross-sectional study was conducted among purposively selected secondary- and tertiary-tier, public and private clinical laboratories across northern and southern Nigeria between October 2015 and December 2015. Consenting senior laboratory staff completed and returned a structured questionnaire, that gathered data on respondents' demographics, designations, and institutional characteristics and practices regarding CVN. Results:One hundred and thirty-four laboratories responded to the questionnaires. Only 69 (51.5 %) laboratories practised CVN; only 23 (33.3%) had existing written policies guiding the practice. Most (43; 62.3%) laboratories use similar critical values (CVs) for adult and paediatric populations. Most laboratories (27; 39.1%) obtained their CVs by combining published literature and local opinions from stakeholders. Physical dispatch (42; 60.9%) followed by telephone calls (38; 55.1%) were the most common means of notification. Private laboratories, compared with public hospital laboratories, were likelier to have separate paediatric CV lists ( = 0.019) and practise telephone notifications ( < 0.001). Conclusion:Critical value notification practices vary and are often suboptimal in many clinical laboratories in Nigeria, which is exacerbated by the absence of guiding policies and national recommendations for post-analytical procedures. What this study adds:This study provides baseline information on CVN practice by Nigeria's laboratories. The study explores the causes of practice variations that can serve as a foundation for enhancing critical reporting and post-analytical services, particularly in clinical laboratories in sub-Saharan Africa.
10.4102/ajlm.v12i1.2249
Promptly reporting of critical laboratory values in pediatrics: A work in progress.
Sergi Consolato
World journal of clinical pediatrics
In the 21 century, the determination of alert thresholds remains the most challenging and controversial issue in clinical pediatrics. Pre-analytical, analytical, and post-analytical matters will consolidate or undermine the fate of any laboratory process. Pre-analytical issues need to be cleared off before the laboratory physician can dispatch the result to the pediatrician in charge. Once it is cleared off, the classification of essential laboratory results is paramount. It is more than an academic exercise and may be subdivided in the order of priority we handle it to inform promptly and safely the primary physicians. Currently, we are applying new modes of making sure relevant information is transmitted without interrupting the standard workflow of the primary physicians in charge for the child, who eventually need a fast line of action for results that may be life-threatening.
10.5409/wjcp.v7.i5.105
Analysis of laboratory critical values at a referral Spanish tertiary university hospital.
Arbiol-Roca Ariadna,Corral-Comesaña Sofía,Cano-Corres Ruth,Castro-Castro María José,Dastis-Arias Macarena,Dot-Bach Dolors
Biochemia medica
INTRODUCTION:The aim of this study was to analyse critical value data from our laboratory and compare our critical value reporting policy with others in the literature. MATERIALS AND METHODS:Analysis of critical values was performed on data obtained over a 6-month period in a tertiary university hospital. RESULTS:We identified 5723 critical values, of which approximately 80% came from STAT testing (4577), 15% from routine inpatients testing (884) and 5% from routine outpatients testing (262). The highest proportion of critical values corresponded to oxygen partial pressure (17.7%), followed by potassium ion (17.6%) concentrations. The parameters associated with the highest critical value notification percentage in emergency patients were pH, haematocrit, glucose, potassium ion and haemoglobin concentrations. In inpatients, these parameters were glucose, phosphate, haemoglobin, sodium ion and potassium ion concentrations. In outpatients, they were calcium and potassium concentrations. CONCLUSIONS:The analysis of critical values in our hospital is in accordance with that reported in the literature. Our findings demonstrate the importance of incorporating improvement actions not only in critical value notification, but especially in the registration of this activity.
10.11613/BM.2019.010704
Assessment of Intensive Care Unit Laboratory Values That Differ From Reference Ranges and Association With Patient Mortality and Length of Stay.
Tyler Patrick D,Du Hao,Feng Mengling,Bai Ran,Xu Zenglin,Horowitz Gary L,Stone David J,Celi Leo Anthony
JAMA network open
Importance:Laboratory data are frequently collected throughout the care of critically ill patients. Currently, these data are interpreted by comparison with values from healthy outpatient volunteers. Whether this is the most useful comparison has yet to be demonstrated. Objectives:To understand how the distribution of intensive care unit (ICU) laboratory values differs from the reference range, and how these distributions are related to patient outcomes. Design, Setting, and Participants:Cross-sectional study of a large critical care database, the Medical Information Mart for Intensive Care database, from January 1, 2001, to October 31, 2012. The database is collected from ICU data from a large tertiary medical center in Boston, Massachusetts. The data are collected from medical, cardiac, neurologic, and surgical ICUs. All patients in the database from all ICUs for 2001 to 2012 were included. Common laboratory measurements over the time window of interest were sampled. The analysis was conducted from March to June 2017. Main Outcomes and Measures:The overlapping coefficient and Cohen standardized mean difference between distributions were calculated, and kernel density estimate visualizations for the association between laboratory values and the probability of death or quartile of ICU length of stay were created. Results:Among 38 605 patients in the ICU (21 852 [56.6%] male; mean [SD] age, 74.5 [55.1] years), 8878 (23%) had the best outcome (ICU survival, shortest quartile length of stay) and 3090 (8%) had the worst outcome (ICU nonsurvival). Distribution curves based on ICU data differed significantly from the hospital standard range (mean [SD] overlapping coefficient, 0.51 [0.32-0.69]). All laboratory values for the best outcome group differed significantly from those in the worst outcome group. Both the best and worst outcome group curves revealed little overlap with and marked divergence from the reference range. Conclusions and Relevance:The standard reference ranges obtained from healthy volunteers differ from the analogous range generated from data from patients in intensive care. Laboratory data interpretation may benefit from greater consideration of clinically contextual and outcomes-related factors.
10.1001/jamanetworkopen.2018.4521
Identification and characterization of critical values in therapeutic drug monitoring: a retrospective analysis.
Scientific reports
Therapeutic drug monitoring (TDM) is a crucial clinical practice that improves pharmacological effectiveness and prevent severe drug-related adverse events. Timely reporting and intervention of critical values during TDM are essential for patient safety. In this study, we retrospectively analyzed the laboratory data to provide an overview of the incidence, distribution pattern and biochemical correlates of critical values during TDM. A total of 19,110 samples were tested for nine drug concentrations between January 1, 2019, and December 31, 2020. Of these, 241 critical values were identified in 165 patients. The most common critical values were vancomycin trough (63.4%), followed by tacrolimus trough (16.9%) and digoxin (15.2%). The primary sources of drug critical values were the department of general intensive care unit (ICU), cardiology, and surgery ICU. At baseline or the time of critical value, significant differences were found between the vancomycin, digoxin, and tacrolimus groups in terms of blood urea nitrogen (BUN), creatinine, N-terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and lymphocyte percentage, P < 0.05. Therefore, it is important to prioritize and closely monitor drug concentrations to reduce laboratory critical values during TDM.
10.1038/s41598-024-62402-7
From volume to value: a watershed moment for the clinical laboratory.
Clinical chemistry and laboratory medicine
The clinical laboratory is often evaluated for the volume of testing. However, it is undeniable that laboratory tests affect clinical decision-making and are included in many clinical guidelines, meaning their contribution to determining clinical outcomes. Therefore, the clinical laboratory professional has the task of enhancing laboratory tests by optimizing the request and reporting phase and addressing patient outcomes. This opinion paper, presenting practical examples of managing value-based health care in the clinical laboratory context, underlines the need to shift towards value-based management to optimize outcome-based health care.
10.1515/cclm-2023-0870
Relative criticalness of common laboratory tests for critical value reporting.
Yang Zhutian,Tan Eng Hooi,Li Yingda,Lim Brian,Metz Michael Patrick,Loh Tze Ping
Journal of clinical pathology
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.
10.1136/jclinpath-2018-205549
Outcome-Based Critical Result Thresholds in the Adult Patient Population.
Tan Eng Hooi,Yang Zhutian,Li Yingda,Metz Michael P,Loh Tze Ping
American journal of clinical pathology
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.
10.1093/ajcp/aqz026
Choosing which in-hospital laboratory tests to target for intervention: a scoping review.
Clinical chemistry and laboratory medicine
INTRODUCTION:Some laboratory testing practices may be of low value, leading to wasted resources and potential patient harm. Our scoping review investigated factors and processes that developers report using to inform decisions about what tests to target for practice improvement. METHODS:We searched Medline on May 30th, 2019 and June 28th, 2021 and included guidelines, recommendation statements, or empirical studies related to test ordering practices. Studies were included if they were conducted in a tertiary care setting, reported making a choice about a specific test requiring intervention, and reported at least one factor informing that choice. We extracted descriptive details, tests chosen, processes used to make the choice, and factors guiding test choice. RESULTS:From 114 eligible studies, we identified 30 factors related to test choice including clinical value, cost, prevalence of test, quality of test, and actionability of test results. We identified nine different processes used to inform decisions regarding where to spend intervention resources. CONCLUSIONS:Intervention developers face difficult choices when deciding where to put scarce resources intended to improve test utilization. Factors and processes identified here can be used to inform a framework to help intervention developers make choices relevant to improving testing practices.
10.1515/cclm-2022-0910
Establishing an evidence base for critical laboratory value thresholds.
Doering Travis A,Plapp Frederick,Crawford James M
American journal of clinical pathology
OBJECTIVES:Critical values denote laboratory test results indicating a life-threatening situation. The outcomes of this premise have not been rigorously evaluated. METHODS:Five years of inpatient admissions were examined for critical or "near-critical" results (total admissions = 165,066; total test results = 872,503). In-hospital mortality was examined as a function of time and degree of test result abnormality. RESULTS:Some critical value thresholds appropriately identified patients at risk for death (eg, elevated potassium). Other thresholds were too conservative (elevated hematocrit, hemoglobin) or not conservative enough (elevated lactate). Mortality risk for most critical values was time dependent, but some critical values showed no temporal effect on mortality (elevated activated partial thromboplastin time [APTT], international normalized ratio [INR], and glucose). Following an initial critical result, further worsening was associated with increased mortality. Prior hospital admission within 30 days was a predictor of lower mortality for some (elevated APTT, INR, potassium, and sodium; low glucose, hematocrit, hemoglobin, and potassium) but not other critical values (elevated lactate, glucose, hematocrit, and hemoglobin; low sodium). CONCLUSIONS:Only a subset of laboratory critical value thresholds was optimally chosen for increased risk of in-hospital mortality, with a time urgency for most but not all critical values. For many tests, a prior hospital admission imparted a decreased risk of in-hospital death.
10.1309/AJCPDI0FYZ4UNWEQ