KNOWLEDGE  AND 
PRACTICE  ON  INTERPRETATION  AND 
COMMUNICATION  OF  CRITICAL 
VALUES  AMONG  NURES 
IN  NAZARETH  HOSPITAL.

CHAPTER 2.

LITERATURE REVIEW.

INTRODUCTION.

 Critical  results 
 is  defined  by  Lundberg  as  a  result  that  is
 so  extremely  abnormal  that  it
 is considered  life  threatening  or  that
 could  result  in  significant  morbidity  and  which, therefore,  requires  urgent  action.(Singh  H,  2010).
Commonly  used  alternative  terms  are ‘critical  values’ ,  ‘panic  values’ ,  ‘We  differentiate  life-threatening  critical  results  from 
significantly  abnormal  results ,  i.e.  non-life  threatening  results  that  need  attention  and follow  up  action
 as  soon  as
 possible,  but  for
 which  timing  is  not  as  crucial  as  for  a critical  result  (Singh H, 2010).  These are also termed as ‘vital’ or
‘life-altering’ or ‘markedly abnormal results of medical significance’. In the
absence of an internationally agreed terminology, we use the term significantly
abnormal  results throughout this paper. Critical
test refers to a test that requires rapid communication of the result
irrespective whether it is normal, significantly abnormal or critical (e.g.
Troponin results in all requests from the emergency department, or all
paracetamol results) (Singh H, 2010). Critical
limit refers to the upper and/or lower boundary of a result or the change of a
result within a critical time scale beyond which the finding is considered to
be a medically urgent critical result that warrants prompt action.

2.1 IDENTIFICATION OF CRITICAL RESULTS

Critical results are identified in laboratories by
technical staff when releasing results from analyzers. Therefore laboratory
staff must be appropriately trained to identify, verify and handle critical
results. Laboratories may have different levels of alarms and procedures in
place to check the validity of critical results. (Horvath, 2012
November)

It is common practice in clinical laboratories that
critically abnormal results are automatically repeated. Whilst
double-checking is still considered safe laboratory practice, many laboratories
have procedures in place whereby critical results are immediately phoned to
doctors while informing them that these preliminary results will be confirmed
by repeat testing and a final confirmatory call or report. This allows
clinicians to make rapid clinical judgments whether the test result fits the
patient’s condition and gives them time to prepare for appropriate actions when
it is clinically justified. (Horvath, 2012 November)

Laboratories may also employ different levels of
alarm systems, based on the clinical significance of the actual critical or
significantly abnormal results and the clinically required urgency of notification.
For example, the Massachusetts laboratories identified red, orange and yellow
zone results, where the ‘red zone’ refers to results that indicate imminent
danger of death, or significant morbidity and therefore clinicians must be
notified and treatment must be initiated immediately or, at a maximum, within 1
hour. ‘Orange zone’ results indicate significant abnormalities that do not
qualify for clinical emergency and physicians should be notified within 6–8
hours. ‘Yellow zone’ results indicate a significant abnormality that may
threaten life or cause significant morbidity, complications, or serious adverse
consequences at some stage, unless diagnosis and treatment is initiated in a
timely and reliable manner. Physician notification and acknowledgement occurs within
three days in such cases  (Hanna D, 2005). Laboratory
information management systems may assist in setting up these categories and
assembling different alarm lists that can be channeled to different personnel
with differing consultative skills.

2.2 TIMELINESS OF REPORTING.

The Massachusetts recommendation proposes that the
timeliness of reporting should be achieved by: setting notification time
parameters according to the level of urgency; utilizing a fail-safe plan to
identify an alternate clinician when the ordering clinician cannot be
contacted; and setting conditions where notification of a critical result is
not necessary (Hanna D, 2005)

Those involved in reporting results must have access
to regularly updated contact information for ordering providers and their
surrogates (RCPath, 2010. ).

 The Italian
recommendation proposes that laboratories should consider adopting the policy
that critical results should be communicated in less than 60 minutes after
validation, and that laboratories should consider a non-communication policy
for tests that have a guaranteed defined response time and the result is available
to the recipient promptly (Lippi G, 2008).  Such examples could be blood gases or cardiac
markers in emergency or intensive care settings.

2.3 HOW TO NOTIFY CRITICAL RESULTS.

Most guidelines and surveys demonstrate that phoning
directly by lab staff or via call centers is still the most utilized method of
communication of critical results. In Massachusetts it is recommended to
incorporate modern information technology solutions into the system to improve
its capabilities (Hanna D, 2005).

 The Veterans
Affairs Medical  Center (VAMC)
recommendation asserts that verbal notification of critical results is
essential, while at a minimum some form of mandatory electronic notification is
necessary for significantly abnormal results (Singh H, 2010).

The Italian recommendation is that the communication
may be performed electronically and/or verbally and in the latter, details of the
communication should be documented (Lippi G, 2008).

2.4 WHO  
SHOULD   RECEIVE THE RESULTS?

The Massachusetts recommendations suggest that
communication of the critical result must be directly to the responsible
caregiver; all details of the notification should be documented; and
confirmation should be received that the caregiver accepts responsibility for
follow up. If the ordering clinician is unavailable, the result should go to
the on-call primary care physician who was linked to the patient at admission.
They also recommend that reliability must be designed into the system by
forcing clinical information and clinician contact details to be provided
during test ordering, and by utilizing tracking systems to ensure that results
are communicated and followed up (Hanna D, 2005).

The VAMC recommendation states that policies should
clearly outline provider responsibilities, with the institution’s own policy identifying
the ordering provider as the person responsible for initiating follow-up of
abnormal results. For fail-safe communication, the VAMC sends every mandatory
test result to both the ordering provider and the permanent primary care
provider assigned to each patient in the electronic medical record system (Singh H,
2010).

The Italian recommendation declares that the result
must be communicated promptly to a person who can take appropriate clinical and
therapeutic action. The medical director of the laboratory must agree with the
local clinicians on who is considered ‘appropriate’ to receive the results (Lippi G,
2008).

The United Kingdom (UK) guidelines specifically
target out-of-hours notification in primary care and thus the patient’s general
practitioner (GP) or the GP deputizing service should receive the results. In
the case of the latter, the requesting GP should also be telephoned at the
first opportunity within normal working hours the next day (RCPath, 2010.
)

Australasian
laboratories agree with the recommendations that the ordering physician is
appropriate to receive the result (96%). However, most laboratories also
consider the nurse responsible for the patient (75%) acceptable, which is
reflected in the practice of the majority who deliver results to the wards
rather than to the doctors directly. Similarly high rates were found in United
States (US) laboratories (91%). Some laboratories deliver results also to
clerical staff (15%), which highlights the often encountered scenario of
difficulties of locating a responsible caregiver in a timely fashion. Regarding
the need for maintaining a reliable communication system, 27.5% of laboratories
have a compulsory field for the physician’s contact details in their request
form, while 51% have a non-compulsory field. Regular follow-up and monitoring
to identify critical results not yet delivered is performed by 33% of Australasian
laboratories.  It was interesting to find
that 23% of laboratories would attempt to contact the patient directly, and 15%
of laboratories would arrange for the police or ambulance to call in on the
patient (Horvath, 2012 November)