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5"#-& 0' $3*5*$"- -*.*54


CLINICAL CHEMISTRY Test


Units Glucose Potassium Calcium


Sodium CO2


content Magnesium Phosphorus Bilirubin Chloride Osmolality Urea nitrogen Uric acid CSF glucose Creatinine Ionized calcium4 Lactate


HEMATOLOGY Hematocrit


Hemoglobin Platelets


WBC count PT


PTT Fibrinogen


mmol/L mg/dL


mmol/L


mmol/L mg/dL


mmol/L mmol/L


mmol/L mg/dL


mmol/L mg/dL


µmol/L mg/dL


mmol/L mmol/kg


mmol/L mg/dL


µmol/L mg/dL


mmol/L mg/dL


µmol/L mg/dL


mmol/L mg/dL


mmol/L mg/dL


L/L g/L


×109 ×109 s s


/L /L


ADULT LOW LIMIT


Mean (SD)


2.6 (0.4) 46 (7)


2.8 (0.3)


1.65 (0.17) 6.6 (0.7)


120 (5) 11 (2)


0.41 (0.16) 1.0 (0.4)


0.39 (0.10) 1.2 (0.3)


— —


75 (8) 250 (13)


— —


— —


2.1 (0.6) 37 (10)


— —


0.82 (0.14) 3.29 (0.56)


— —


Range


1.7-3.9 30-70


2.5-3.6


1.25-2.15 5.0-8.6


110-137 5-20


0.21-0.74 0.5-1.8


0.26-0.65 0.8-2.0


— —


60-90 230-280


— —


— —


1.1-2.8 20-50


— —


0.50-1.07 2.00-4.29


— —


0.18 (0.05) 0.12-0.30 66 (17) 37 (18) 2.0 (0.7) — —


40-120 10-100 1.0-4.0 — —


g/L


BLOOD GASES AND PH pCO2


pH pO2


mm Hg kPa


mm Hg 0.88 (0.17) 0.50-1.00 19 (3)


7.21 (0.06) 43 (6)


5.7 (0.8) 9-25


7.00-7.35 30-55


4.0-7.3 HIGH LIMIT Mean (SD)


26.9 (8.0) 484 (144)


6.2 (0.4) 8.0 (hemolyzed)


3.22 (0.22) 12.9 (0.9)


158 (6) 40 (3)


2.02 (0.82) 4.9 (2.0)


2.87 (0.48) 8.9 (1.5)


257 (86) 15 (5)


126 (12) 326 (18)


37.1 (21.1) 104 (59)


773 (119) 13 (2)


24.3 (11.4) 438 (206)


654 (380) 7.4 (4.3)


1.55 (0.19) 6.21 (0.76)


3.4 (1.3) 30.6 (11.7)


0.61 (0.06) 199 (27) 910 (147) 37.0 (20.7) 27 (9)


68 (33) 7.75 (2.63) 67 (6) 7.59 (0.03)


— —


Range


6.1-55.5 110-1000


5.0-8.0


2.62-3.49 10.5-14.0


145-170 35-50


1.03-5.02 2.5-12.2


2.26-3.23 7.0-10.0


86-513 5-30


115-156 295-375


14.3-107.1 40-300


595-892 10-15


13.9-38.9 250-700


177-1326 2.0-15.0


1.30-2.00 5.21-8.02


2.3-5.0 20.7-45.0


0.54-0.80 170-300 555-1000 10.0-100.0 14-40


32-150 5.00-10.00 50-80 7.50-7.65


— —


Adult table modified with permission by JAMA, Vol. 263, pp. 704-707, 1990. CSF, cerebrospinal fluid; WBC, white blood cell; PT, prothrombin time; PTT, partial thromboplastin time. Qualitative critical results for adults1


C


ritical limits define boundaries of life-threatening values of laboratory


test results. Critical results or values are those that fall outside high and low criti- cal limits. Urgent clinician notification of critical results is the lab’s responsibility. The system of critical value reporting was first implemented in a hospital by George


D. Lundberg, MD, and first published in MLO in 1972. These tables are based on three national surveys by Gerald J. Kost, MD, PhD, MS, FACB, of the University of California-Davis Health System. Adapted with permission from his articles,1-4


the


tables summarize critical limits used by 92 responding U.S. medical centers, includ- ing 20 trauma centers, and 39 children’s hospitals. Mean and standard deviation (SD) data are presented. The frequency with which critical limits were listed can be found in the original articles. As a rule of thumb, the “mean low” and “mean high” figures may be con- sidered the critical limits for each test listed. Each institution should establish its own set of critical limits and clinician notification policy. Dr. Kost conducted an independent na- tional survey of U.S. medical centers and children’s hospitals to determine ionized calcium critical limits.4


His extensive over-


view of critical limits and patient outcomes appeared in the March 1993 issue of MLO.3 Critical results of tests and diagnostic


procedures fall significantly outside the normal range and may indicate a life- threatening situation. The objective is to provide the responsible licensed caregiver these results without delay so that the patient can be treated promptly. The Joint Commission identifies critical values in current National Patient Safety Goals (NPSG).5


One goal is to report critical


results of tests and diagnostic procedures on a timely basis. Inspectors check for compliance on this topic.


Elements of Performance for NPSG.02.03.01: (1) Collaborate with organization leaders to develop written procedures for managing the critical results of tests and diagnostic procedures that address the following: the definition of critical results of tests and diagnostic procedures; by whom and to whom critical results of tests and diagnostic procedures are reported; the acceptable length of time between availability and reporting of critical results of tests and diagnostic procedures; (2) implement the procedures for managing the critical results of tests and diagnostic procedures; and (3) evaluate the timeliness of reporting the critical results of tests and diagnostic procedures. In “Global trends in critical values practices and their harmonization,”6


Kost include the following:


For blood bank and immunology—incompatible crossmatch, tests positive for syphilis (RPR or VDRL). For microbiology and parasitology—positive results from Gram stain or in culture from blood, cerebrospinal fluid, or body cavity fluid; posi- tive India ink preparation; positive rapid antigen detection by agglutination tests for Cryptococcus, group B streptococci, Haemophilius influenzae b, or Neisseria meningitidis, positive results from acid-fast bacillus stain or culture; Salmonella, Shigella, or Campylobacter on stool culture; presence of malarial parasites. For clinical microscopy and urinalysis—elevated white blood cell count in CSF; presence of malignant cells, blasts, or microorganisms in CSF or body fluids; combination of strongly positive test results for glucose and for ketones in urine; presence of pathologic crystals (urate, cysteine, leucine, or tyrosine) on urinalysis. For hematology—listed frequently are the presence of blasts on blood smear; new diagnosis or findings of leukemia; presence of sickle cells (or aplastic crisis). Listed occasionally are plasma cells, band cells, atypical lymphocytes, and abnormal reticulocyte count.


10 $-3 t .-0 t XXX DMS POMJOF DPN


and Hale investigate trends in critical values practices including improving pre- analytical processing, streamlining urgent notifications, assuring effective critical limits, assessing decision levels, and using visual logistics. Special considerations for pediatrics are addressed since newborns/ neonatals must adapt to the extrauterine environment with its demands for striking physiological changes. Identifying exist- ing personal adverse events clustered by time/location could be used to predict a patient’s future adverse events. Custom- izing critical values is possible for some unmet needs like comparing critical val- ues lists to national norms and clarifying protocols for repeat critical values testing. Also, site-neutral policies encourage timely


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