BHARATI VIDYAPEETH (DEEMED TO BE UNIVERSITY)

MEDICAL COLLEGE & HOSPITAL, SANGLI.

Topic:Critical Value Alerts

Central Clinical
Laboratory
DEFINITIONS:

Normal:

A test result that is within the normal variation and does not require follow-up.

Non-Critical:

A test result that is beyond the normal variation and that:

1. Is not what is expected due to the patient’s current medication and/or disease
State.
2. May require follow-up to ensure stability, resolution, or further evaluation
3. May change the medical management of that patient.

Critical:

A test results beyond the normal variation with a high probability of a significant
increase in morbidity and/or mortality in the foreseeable future and requires rapid
communication of results for determination of intervention.
 Intimation of Critical Test Results

A critical value is defined as a value that represents a patho-physiological state at such

variance with normal (expected values) as to be life-threatening unless something is
done promptly and for which some corrective action could be taken.
NOTE: The critical values do not necessarily correspond directly with normal
reference values,
toxic ranges, or therapeutic ranges.
The laboratory shall establish & document critical limits for tests which require immediate
attention for patient management & the same shall be documented. This is done in concurrence
with concerned Consultants.
Critical results of outsourced investigations are also included
Laboratory in charge identifies suitable person to report critical results.
Results shall be communicated to the person from treating team at the earliest, but not later
than one hour of completion of test/report being ready. Hence in our hospital we have
defined within 15 minutes.
The intimation includes
•The name of the patient
•Unique id
•Date & time of sample collection
•Test name
•Result
•Measure unit & reference range
•The identity of recipient
•Read back and
•Date & time of acknowledgement.
Read back:
The individual accepting the critical test result must record and then read back the critical
test result, in its entirety, to the reporter at the time the result is given.

Communication tools:

 Electronic
 Manual
 Verbal

Order of Notification:
Ordering / Treating Physician /Residents/ Staff nurse on duty / Casualty Medical
Officer / The
attending staff physician.

Each department reporting critical values must have in place a defined process which
documents the reporting of pre-approved critical values.
Critical Test Results Reporting and Documentation

a.When a critical result is identified, the Laboratory Technologist contacts

the ordering physician or their assistant within 15 minutes of test readiness
via a phone / intercom.

b.For the patient who is no longer in the hospital, the Laboratory

Technologist contacts the ordering physician or their assistant within 15
minutes of test readiness.

c.If the ordering physician or their assistant is not reached within 15

minutes of test readiness, the Laboratory Technologist will follow the order
of notification.

d. Outsourced test critical results are also reported.

 Critical Value Results
Immediate intervention shall be taken & documented.
Things to do –
1. Once lab informs critical values, resident has to note it in
case paper. Stamp will be available on nursing counters.
Use stamp to notify the results.
2. Inform concerned consultant.
3. Advice given by Consultant to be mentioned in case notes.
4. Follow up of patient by resident.
5. Condition of patient to be evaluated.
 Pathology-Critical Value Alert for Adult
Patients
Parameter Critical value
Haematology
Haemoglobin < 7 gm% OR > 18 gm%
Total leucocyte count < 4000/cmm OR > 30,000/cmm
Platelet count < 20,000/cmm OR > 10,00,000/cmm
PT INR PT INR > 5
APTT APTT > 40 sec
PS for malaria Positive
Cytology
FNAC Positive for malignancy
CSF cytology – Total cell count > 30 cells/cmm
Fluids Fluid positive for malignancy
Clinical pathology
Urine for glucose Positive +++
Urine for ketone bodies Positive ++
Histopathology
Biopsy specimen Unexpected malignancy
Immunohaematology
DAT Positive
IAT Positive
 Pathology-Critical Value Alert for Paediatric Patients

Parameter Critical value

Haematology

Haemoglobin < 6 gm%

Total leucocyte count < 4000/cmm OR > 20,000/cmm
Platelet count < 50,000/cmm OR > 10,00,000/cmm
PT INR PT INR > 4
APTT APTT > 40 sec
PS for malaria Positive

Cytology

FNAC Positive for malignancy

CSF cytology – Total cell count > 30 cells/cmm Fluid
Fluids
positive for malignancy

Clinical pathology

Urine for glucose Positive +++

Urine for ketone bodies Positive ++
 Critical Value Alert for
Biochemistry
Units ICU Medical Ward NICU
Paed ward
/PICU
Ammonia µg/dl More than 120 More than 120 More than 120 More than 120
AST (SGOT) IU/L More than 400 More than 400 More than 400 More than 400
ALT ( SGPT) IU /L More than 400 More than 400 More than 400 More than 400
1st day more than 102nd day
BilirubineTotal mg% Adult – 3.0 Adult – 3.0 more than 15 More than 3
3rd day more than 18
Bilirubine
mg% Adult – 2.0 Adult – 2.0
Direct
Albumin gm% Less than 3.0 Less than 3.0 Less than 3.0 Less than 3.0
Less than 7.0 Less than 7.0 Less than 7.0 Less than 7.0
Calcium Total mg%
More than 11 More than 11 More than 11 More than 11
Mmole
Calcium Ionic Less than 1.0 Less than 1.0 Less than 1.0 Less than 1.0
s/L
CK-MB IU/L More than 25 More than 25 More than 25 More than 25
CK-NAC IU/L More than 200 More than 200 More than 200 More than 200
Urea mg% More than 100 More than 100 More than 80 More than 100
Creatinine mg% More than 2.0 More than 2.0 More than 2.0 More than 2.0
CRP mg/L More than 10 More than 10 More than 30 More than 10
More than 150 More than 150 More than 150 More than 150
Sodium mEq/L
Less than 120 Less than 120 Less than 125 Less than 120
More than 6.5 More than 6.5 More than 6.0 More than 6.0
Potasium mEq/L
Less than 2.5 Less than 2.5 Less than 2.5 Less than 2.5
Less than 45 Less than 45 Less than 45 Less than 45
Glucose – More than 300With More than 300With More than 300 With ketone More than 300With
mg%
F,PP,R ketone ketone bodies ketone
bodies in urine bodies in urine in urine bodies in urine
cholinesterase mg% Less than 4500 Less than 4500
U/gm
G6PD Less than 6.7 Less than 6.7
Hb
Amylase IU/L More than 150 More than 150
Procalcitonin ng/ml More than 2.0 More than 2.0
Trop I Positive Positive
Phosphorus mg% More than 6 More than 6
LDH IU/L More than 500 More than 500
Lipase IU/L More than 200 More than 200
 Critical Value Alert for
Microbiology
Sr. no. Sample Test
Gram positive bacilli with Chinese letter pattern
Gram stain appearance suggestive of
1 Throat swab Corynebacteriumdiphtheriae seen.
Diphtheria like organisms with meta chromatic
Albert stain
granules seen.
Darting motility of organisms suggestive of
2 Stool Hanging drop
Vibrio cholera seen.
Gram positive cocci in pairs S/O Streptococcus
pneumuniae; / Gram negative cocci S/O
Gram stain
Neisseria meningitidis; Gram negative bacilli
orGram positive bacilli seen.
3 CSF ZN stain Acid fast bacilli seen.
India ink/negative Capsulated budding yeast cells S/O
staining Cryptococcusspp. Seen.
Latex agglutinationtest for cryptococcal Positive for cryptococcal antigen.
antigen
Pus / wound Gram positive bacilli of box car appearance
4 Gram stain
exudate/ tissue suggestive of Clostridium spp. seen.
ALERT
Sputum, body
5 ZN stain Acid fast bacilli seen.
fluid, pus
Bactec blood Gram positive cocci/ bacilli, Gram negative
6 Gram stain
culture cocci/ bacilli, yeast cells seen.

7 Serum HbsAg, HCVAb, HIV, Positive

Dengue, Chickungunya
Any clinical Culture
8 Multi drug resistance isolates.
sample and
sensitivity
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