Survey of Critical Value Reporting and Reduction of False-Positive Critical Value Results

Archives of Pathology & Laboratory Medicine, Oct 2008 by Dighe, Anand S, Jones, Jay B, Parham, Sue, Lewandrowski, Kent B

Context.-Reporting of laboratory critical values has become an issue of national attention because of important regulatory, medicolegal, and clinical concerns.

Objective.-To survey aspects of the laboratory criticalvalue reporting process at a broad range of institutions.

Design.-A survey was developed regarding the operational and information-technology aspects of critical value reporting.

Results.-More than 730 responses were obtained from a broad distribution of hospitals. In addition, we analyzed more than 700 written responses from survey participants.

Conclusions.-The survey results provide insight into the standard of practice and level of compliance with current Joint Commission and College of American Pathologists requirements for critical values, demonstrate considerable heterogeneity, and suggest areas for improvement. A common issue raised during the survey and follow-up teleconference was the incidence of outpatient false-positive critical values. In this report, we also demonstrate that attention to preanalytic transport and processing issues can assist in minimizing this issue.

(Arch Pathol Lab Med. 2008;132:1666-1671)

Critical value reporting was originally highlighted by Lundberg,1 who defined critical value as a result suggesting that the patient was in imminent danger unless appropriate therapy was promptly initiated. In the 30 years since Lundberg's observations, critical value reporting has been addressed in the Clinical Laboratory Improvement Amendments of 1988, and its recommendations were subsequently widely adopted by laboratory-accrediting agencies, such as the Joint Commission and the College of American Pathologists (CAP).2,3 Consequently, critical values are used in virtually all US clinical laboratories and are a frequent source of operational issues.

The recent national focus on patient safety has brought increased attention to the issue of laboratory critical value reporting. The Joint Commission and the CAP require health care organizations to track and improve the timeliness of reporting and receipt of critical test results by the responsible, licensed clinician. Moreover, the Joint Commission has defined critical values as not only laboratory tests but also imaging studies, electrocardiograms, anatomic pathology, and other diagnostic studies. Therefore, the process of critical value reporting is of interest across the health care organization.

Despite the nearly ubiquitous use of critical value reporting systems, the literature describing how critical value policies have been applied in practice is limited. The last comprehensive assessment of overall laboratory performance with critical values, to our knowledge, was a survey published in 2002 as a part of the CAP Q-Probes program (a voluntary quality improvement program).4 This survey of 623 institutions demonstrated that the critical value systems in place at various institutions were highly variable and costly in terms of time and labor expended. In the 5 years since the publication of the Q-Probes survey, critical value reporting has received increased attention. The Joint Commission has mandated the improvement of critical value reporting as part of national patient safety goal 2 for the years 2005 through 2008, and the CAP has raised the profile of critical value reporting with inclusion of new critical value-related items in the CAP checklists. Herein, we provide the results of a survey assessing the current state of operational, technologic, and compliance issues involving critical value reporting.

In the current survey, problems with outpatient critical value reporting were reported by the majority of respondents as their most difficult obstacle to success. Here, we discuss strategies and procedures that can improve this problematic issue. In addition to procedural and operational strategies, another important consideration is the unique preanalytic variables inherent in outpatient laboratory testing, particularly for potassium and glucose values. We demonstrate that improvements in the packaging and transport of specimens can have a tangible effect on the number of critically elevated plasma potassium values.

MATERIALS AND METHODS

Survey Construction

Using the SurveyMonkey (SurveyMonkey.com, Portland, Ore) online survey-generation tool, an online survey consisting of questions relating to the practice of reporting critical values was developed by the authors. Questions were chosen from lists of questions submitted to the American Association for Clinical Chemistry (AACC) by the faculty that presented the June 5, 2007, audio conference entitled Improving the Reporting of Critical Test Results. At the end of the survey, participants were asked to voluntarily provide their e-mail addresses. The survey was supported by an educational grant from Siemens Medical Solutions Diagnostics (Tarrytown, NY). A list of current Clinical Laboratory News subscribers, who had provided e-mail addresses to AACC and had not opted out of receiving e-mail from the organization, was generated from the AACC database. On May 17, 2007, an email requesting participation in the survey was sent to 19 132 Clinical Laboratory News subscribers. Survey participants were given 8 working days to complete the survey. No follow-up emails were sent. The AACC received 731 survey responses, for a response rate of 3.82%. Of these 731 respondents, 677 (92.6%) provided unique e-mail addresses, and 92.9% (629/677) of these e-mail addresses could be used to identify the location and the hospital system of the participant. Thus, despite the low overall response rate (3.82%), we were able determine that the survey responses represented more than 350 different hospitals and hospital systems, including representation from all regions of the country and from 10 of the top 20 hospitals listed in US News and World Report.5 Just 5% of e-mail addresses were for generic Internet service providers (eg, AOL, Yahoo) and could not be used to identify the individual hospital, 2.5% of e-mail addresses were from reference laboratories, and 1% of e-mail addresses were from other corporations (eg, regulatory agencies). All of the responses were included in the survey results presented here.