Critical Laboratory Tests and Values

The Laboratory Calls The Following Abnormal Values:

All phone calls made to report critical values are documented in the Laboratory Information System. To comply with patient safety goals, the person taking the call must read back the patient’s name, the hospital number and all laboratory results.

Blood Bank Diagnostic Significant Values

The Pathology resident will notify the responsible physician in the following critical circumstances:
1.	Transfusion Reaction concerning any labeling errors, positive test results (including positive culture) or if hematuria/hemoglobinuria is checked on the symptom sheet.
2.	If crossmatch compatible Red Blood Cells cannot be found.

Blood Bank staff will notify the responsible physician:
1.	When Red Blood Cell antibodies are identified in a patient and the responsible physician has not ordered Red Blood Cells or the patient is having surgery.
2.	Positive culture results on transfused Apheresis Platelets.

Chemistry and Toxicology
	Less Than	Greater Than
Bilirubin, Total		10.0 mg/dL for first 24 hrs 13.0 mg/dL for 1-30 days
Calcium	6.0 mg/dL	13.0 mg/dL
Carbon Dioxide	10 mEq/l	50 mEq/l
Cortisol (*see below)	2.0 mcg/dL
Ethanol		300 mg/dL
Ethylene Glycol		10 mg/dL
Glucose Adults Peds	50 mg/dL 40 mg/dL	450 mg/dL 300 mg/dL
Isopropanol		10 mg/dL
Magnesium	1.0 mg/dL	4.7 mg/dL
Methanol		10 mg/dL
Phosphorus, Inorganic (*see below)	1.0 mg/dL
Potassium Adults > 16 years Peds (0-15 years)	2.8 mEq/l 3.0 mEq/l	6.2 mEq/l 6.5 mEq/l
Propylene Glycol		100 mg/dL
Sodium	120 mEq/l	160 mEq/l

*Cortisol serum/plasma concentrations less than 2.0 mcg/dL and phosphorus (inorganic) less than 1.0 mg/dL are treated
as significant (not critical) values.

Critical Care
	Less Than	Greater Than
Carboxyhemoglobin		10%
Glucose Adults Peds	50 mg/dL 40 mg/dL	450 mg/dL 300 mg/dL
Ionized Calcium	3.2 mg/dL	5.9 mg/dL
Blood Gases pH pCO2 Adults Peds pO2 Art Ven	7.20 20 20 40 20	7.60 70 55
Lactate (>16 years of age)		4.0 mEq/l
Potassium Adults > 16 years Peds (0-15 years)	2.8 mEq/l 3.0 mEq/l	6.2 mEq/l 6.5 mEq/l
Sodium	120 mEq/l	160 mEq/l

Results Called on these Critical Therapeutic Drug Levels:
Test Name	Greater Than
Acetaminophen	40 mcg/mL
Amikacin	35 mcg/mL
Carbamazepine	12 mcg/mL
Digoxin	2.1 ng/mL for adults
Gentamicin	15 mcg/mL
Lidocaine	5 mcg/mL
Lithium	1.4 mEq/l
Phenobarbital	60 ug/mL
Phenytoin	40 mcg/mL
Salicylate	40 mg/dL
Theophylline	20.0 mcg/mL
Tobramycin	10 mcg/mL
Valproic Acid	150 mcg/mL
Vancomycin	50 mcg/mL

Hematology
Critical values will be called to every patient care area and clinic location in addition to the computer filing of results. See the University of Iowa Hospitals and Clinics, Policy and Procedure Manual for Reporting of Critical Test Results.

	Less Than or Equal to	Greater Than or Equal to
Fibrinogen	80 mg/dL
Hematocrit	18%	55% (adult)
Hemoglobin	6 gm/dL	22 gm/dL (adult)
HIT (Heparin dependent antibody)	Results: Positive
INR (venous)		4.0
Platelet Count	10 k/mm3	1,000 k/mm3
PTT (Outpatient only)		50 seconds
White Blood Count (WBCT)	1.0 k/mm3	50.0 k/mm3

Microbiology
Critical or Significant values: patient results are called to the physician or service area as soon as results are available.

1. Critical value patient results include:
    a. Positive direct examination from sterile body fluid/site
        1) Cerebrospinal fluid
        2) Joint fluid
        3) Pericardial fluid
        4) Pleural fluid
        5) Peritoneal fluid
    b. Positive blood culture (initial gram stain report)
    c. Positive Legionella pneumophila antigen (also page on-call epidemiologist)
    d. Positive Cryptococcus neoformans antigen
    e. Positive malaria smears

2. Significant patient results include:
    a. Positive STAT gram stain results
    b. Negative STAT gram stain results from the Operating Room. If patient is out of the Operating Room when
        results become available, results will not be called.
    c. Positive direct examination from intraoperative specimens
    d. Positive culture of sterile body fluid (Do not call identical result within 5 days)
        1) Cerebrospinal fluid
        2) Joint fluid
        3) Pleural fluid
        4) Pericardial fluid
        5) Peritoneal fluid
        6) Intraoperative body fluids
    e. Positive direct antigen tests
        1) Pneumocystis carinii
        2) Streptococcus agalactiae
        3) Cryptosporidium spp.
        4) Giardia lamblia
        5) Herpes Simplex (HSV)
        6) Varicella-Zoster (VZV)
        7) Rotavirus
        8) Malaria
    f. Epidemiology considerations (call to floor)
        1) Methicillin-resistant Staphylococcus aureus
        2) Vancomycin-resistant enterococci
    g. Epidemiology considerations (call floor and on-call epidemiologist pager)
        1) Acid-fast bacilli smear
        2) M. tuberculosis (culture or UHL PCR)
        3) Legionella pneumophila (urine antigen or growth from environmental culture)
        4) Neisseria meningitidis (CSF gram stains with gram negative diplococci or growth from normally sterile site)
        5) Category A bioterrorism agents (Bacillus anthracis, Yersinia pestis, Francisella tularensis,
            Clostridium botulinum toxin, Smallpox, Viral hemorrhagic fever)
        6) Extended spectrum B-lactamases
        7) Multi-drug resistant gram negative rods
    h. Culture or molecular detection of following organisms from any source:
       (If patient is from OB/GYN do not call results unless the organism is isolated from blood or normally sterile body fluids.)
        1) Streptococcus pyogenes
        2) Virus Detection
        3) Herpes Simplex (HSV), or Enterovirus PCR
        4) Dimorphic fungi
    i. Positive ocular cultures (other than conjunctiva)
    j. Culture of stool pathogens
        1) Salmonella spp.
        2) Shigella spp.
        3) Campylobacter spp.
        4) Yersinia spp.
        5) Escherichia coli H7;O157
    k. Culture of potential bioterrorism agents
        1) Francisella tularensis
        2) Bacillus anthracis
        3) Brucella spp.
        4) Yersinia pestis
        5) Coccidiodes immitis

3. Calling Algorithm:
Follow Department of Pathology guidelines (500.020) entitled "Reporting Critical Tests and Critical Values." This policy defines authorized staff that may accept critical values and provides a detailed calling algorithm. The results must be "read back" by the authorized staff and the call documented in body of LIS report using the CALL template.

For OB/GYN patients only smear or culture results from blood cultures and normally sterile body fluid specimens are phoned on a STAT basis.

Significant results called to physicians or service areas must be documented in a CALL report.

Ocular Pathology
Unexpected surgical pathology findings (such as unexpected malignancy or unexpected pathogen): the pathologist will report findings to the contributing physician. Verbal communication will be documented in the “Comments” section of the written report.

Special Care Nurseries
	Less Than	Greater Than
Glucose	50 mg/dL	200
Ionized Calcium	3.0 mg/dL	6.5 mg/dL
Lactate		5.0 mEq/L
Methemoglobin		3%
Blood Gases pH pCO2	7.25 30	7.65 70
Potassium	3.0 mEq/l	6.5 mEq/l
Sodium	130 mEq/l	155 mEq/l
Total Bilirubin		>10.0 mg/dL for first 24 hrs >13.0 mg/dL for 1-30 days