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Laboratory critical values policies and procedures: a college of American Pathologists Q-Probes Study in 623
Peter J Howanitz1, Steven J Steindel, Nan V Heard
1Department of Pathology, State University of New York, Downstate Medical Center, Brooklyn 11203, USA. phowanitz@netmail.hscbklyn.edu
Insights
Critical values lists are medically important but vary widely. Recommendations include standardized policies and automation for improved patient care notification systems.
Area of Science:
- Clinical Pathology
- Laboratory Medicine
- Healthcare Quality Improvement
Background:
- Critical values lists are essential for timely notification of life-threatening results.
- Despite long-standing use, critical values lists have been understudied.
- Variability in critical values practices impacts patient care.
Purpose of the Study:
- To investigate critical values lists and practices in participating institutions.
- To identify areas for improvement in critical values reporting systems.
- To provide evidence-based recommendations for critical values management.
Main Methods:
- A multipart study involving 623 institutions in the College of American Pathologists Q-Probes program.
- Data collection included questionnaires, monitoring critical values calls, and surveying healthcare professionals.
- Analysis focused on critical values lists, notification processes, costs, and outcomes.
Main Results:
- Significant variation exists in critical values lists for routine analytes, though critical results like positive cultures are consistently reported.
- Most critical values were reported by testing personnel, with nurses receiving most inpatient reports and physician office staff receiving outpatient reports.
- While nursing supervisors found lists less helpful, physicians largely valued them; over 45% of critical values were unexpected, and 65% led to therapy changes.
Conclusions:
- Critical values systems are medically significant but exhibit wide variability and incur costs.
- Recommendations include medical staff approval of lists, standardized policies for initial and repeat critical values reporting, and automation.
- Improved critical values management is crucial for patient safety and effective healthcare delivery.
Context:
Critical values lists have been used for many years to decide when to notify physicians and other caregivers of potentially life-threatening situations; however, these lists have not been studied widely.
Objectives:
To investigate critical values lists in institutions participating in the College of American Pathologists Q-Probes program and to provide suggestions for improvement.
Setting:
A total of 623 institutions voluntarily participating in the Q-Probes program.
Design:
A multipart study in which participants responded to information from preprinted lists, collected information about current practices, completed a questionnaire, monitored critical values calls, reviewed patients' medical records, and surveyed nursing supervisors and physicians about critical values.
Main Outcome Measures:
Defining critical values systems, including lists, personnel, costs, processes, usefulness, and related medical outcomes.
Results:
Critical values lists were determined for routine chemistry and hematology analytes and were found to vary widely among participants. In contrast, more than 95% of participants reported positive blood cultures, cerebrospinal fluid cultures, and toxic therapeutic drug levels as critical values. Based on more than 13 000 critical values, participants' data showed that most critical values reports (92.8%) were made by the person who performed the test, and that 65% of reports for inpatients were received by nurses. For outpatients, physicians' office staff received the largest percentage (40%) of reports. The majority of participants (71.4%) had no policy on how repeat critical calls should be handled. On average, completion of notification required about 6 minutes for inpatients and 14 minutes for outpatients. Slightly greater than 5% of critical value telephone calls were abandoned, with the largest percentage abandoned for outpatients. More than 45% of critical values were unexpected, and 65% resulted in a change in therapy. Although only 20.8% of 2301 nursing supervisors thought critical values lists were helpful, 94.9% of 514 physicians found critical values lists valuable.
Conclusions:
Critical values systems were medically important, highly variable, but also costly practices for participants. We propose a number of recommendations for improvement, including that the critical values list should be approved by the medical staff, each laboratory should develop a written policy for handling initial and repeat critical values reports, a foolproof policy should be established to report results from calls abandoned, and efforts at automating the process should become widespread.