An interview with Christine Schmotzer, MDDefining, identifying, and rapidly communicating critical values is essential to the quality of care. But as the workload in clinical laboratories continues to increase and physicians face information overload, laboratories are forced to be more efficient without compromising patient safety. In this interview, Christine Schmotzer, MD, discusses how to design a critical value list and steps that labs can take to balance efficiency with patient safety. Schmotzer is the medical director of clinical chemistry at University Hospitals Case Medical Center and an assistant professor of pathology at Case Western Reserve University School of Medicine in Cleveland, Ohio.
Jaime Noguez, PhD, of the Patient Safety Focus editorial board conducted this interview.
Q What is the best strategy for establishing a critical value list and limits?
A Despite the importance of critical values in patient care and the emphasis on effective communication of these results in the past decade, there is no widely accepted guideline for defining which analytes should be on a critical value list and how the cutoffs should be assigned. Developing a critical value list remains at the discretion of each institution. In practice, a common group of tests—including glucose, potassium, hemoglobin, hematocrit, and platelets—appear on the critical value list of nearly every institution. The specific values for these commonly covered analytes, as well as other analytes that should be included beyond the common ones, vary considerably between institutions. The best strategy for your lab is to use all available data to guide your decision. This includes published literature, peer comparisons, local institutional data—especially the populations being served—and the local opinion and consensus of clinicians working at your institution.
A Despite the importance of critical values in patient care and the emphasis on effective communication of these results in the past decade, there is no widely accepted guideline for defining which analytes should be on a critical value list and how the cutoffs should be assigned. Developing a critical value list remains at the discretion of each institution. In practice, a common group of tests—including glucose, potassium, hemoglobin, hematocrit, and platelets—appear on the critical value list of nearly every institution. The specific values for these commonly covered analytes, as well as other analytes that should be included beyond the common ones, vary considerably between institutions. The best strategy for your lab is to use all available data to guide your decision. This includes published literature, peer comparisons, local institutional data—especially the populations being served—and the local opinion and consensus of clinicians working at your institution.
Ideally, labs would use outcomes literature to determine cutoffs at which a specific analyte value becomes life-threatening if an intervention is not taken. But outcomes literature is limited, due in part to the challenges of obtaining broadly applicable data in varied patient populations. A number of surveys and institutional case studies have been published on this topic emphasizing the institutional variability of critical value lists/cutoffs and the lack of a well-defined mechanism for establishing them (1–4). The availability of these surveys and studies allows laboratories to compare their lists to others and provides insight into whether your institution is over or under-restrictive in critical value calling. Survey data should be transferred with caution as it may not be current, and may not be a suitable match to your patient population.
| Achieving Balance in Critical Value Policies • Optimize critical value limits • Remove tests that do not meet "life-threatening" criteria • Discontinue repeat calls for select analytes with previous criticals • Discontinue calls to units where "critical" result is expected • Include regular review of critical value policies and data in test utilization management committee meetings |
Another approach to improving your critical value list is specific peer-to-peer comparisons. Peer comparison can enable a lab to select institutions with a similar patient mix and complexity of population which may lead to critical value lists that are more directly transferrable or comparable to your own institution. Peer comparison has been enabled in the last decade by widespread availability of current institutional critical value lists and cutoffs on the Internet (5–7). These are provided by national labs, university-based labs, and other hospital labs. In general, it is relatively easy to find a peer, either through the Internet or your professional network.
Regardless of your initial approach to data-gathering, developing a critical value list and cutoffs should include discussion among clinicians, nurses, laboratory directors, and staff representing various departments and specialties. It is in this setting that institution-specific practices and needs can be discussed and influence the critical value list. For example, if an institution performs all blood gases at the point-of-care rather than in a decentralized laboratory, it may not need pH or pO2 to be included on a critical value list. Without specific outcomes literature to guide decisions, institutional and personal experience can be solid guides to setting critical value cutoffs that best meet the needs and philosophy of an institution.
Q Are there any other factors that need to be considered when designing your critical value list?
A While literature review, peer comparisons, and consulting with your physicians are important, assessing your current state, including critical result distribution, call frequency, and reporting logistics can provide insight into opportunities for improving your critical call list and process. Determining the tests leading to the highest number of calls and the units receiving the most calls can lead to valuable insights. For example, we were surprised to find critical vancomycin levels were in our top 10 most called tests. Further exploration led to practice changes to enhance the relationship between time of draw and drug administration, as well as discussion on whether abnormal vancomycin levels met the definition of a critical—immediately life-threatening—value. An important but often overlooked factor in successful critical value policies and procedures is the capabilities of your laboratory information system (LIS) for helping you identify and flag critical results. Many LISs don't have the ability to assign unit-specific flags. For example, clinical consensus at your institution may show that the threshold for critically low potassium can be different for inpatients versus outpatients. If your LIS does not allow for different critical results based on inpatient or outpatient status, the critical result will likely be set at the most conservative cutoff.
A While literature review, peer comparisons, and consulting with your physicians are important, assessing your current state, including critical result distribution, call frequency, and reporting logistics can provide insight into opportunities for improving your critical call list and process. Determining the tests leading to the highest number of calls and the units receiving the most calls can lead to valuable insights. For example, we were surprised to find critical vancomycin levels were in our top 10 most called tests. Further exploration led to practice changes to enhance the relationship between time of draw and drug administration, as well as discussion on whether abnormal vancomycin levels met the definition of a critical—immediately life-threatening—value. An important but often overlooked factor in successful critical value policies and procedures is the capabilities of your laboratory information system (LIS) for helping you identify and flag critical results. Many LISs don't have the ability to assign unit-specific flags. For example, clinical consensus at your institution may show that the threshold for critically low potassium can be different for inpatients versus outpatients. If your LIS does not allow for different critical results based on inpatient or outpatient status, the critical result will likely be set at the most conservative cutoff.
Q How can labs improve their critical values notification efficiency without compromising patient safety? Read more here
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