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 (first event in the hospital admission).

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
Ammonia (*see below)   150 (<18 years old)
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   20 mg/dL
Glucose >1 month old through adults
 50 mg/dL 450 mg/dL
Neonates (0-1 month old) 40 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 2.8 mEq/L 6.2 mEq/L
Peds (0-15 years) 3.0 mEq/L 6.5 mEq/L
Propylene Glycol   100 mg/dL
Salicylate   50 mg/dL
Sodium 120 mEq/L 160 mEq/L
Troponin T   >100 ng/L (outpatient only, excluding Emergency Department)

*Ammonia, 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.

**Also applies to glucose levels determined during glucose tolerance tests.

Critical Care

  Less Than Greater Than
Carboxyhemoglobin 10%
Glucose > 1 month old through adult 50 mg/dL 450 mg/dL
Neonates (0-1 month old) if not Special Care Nursery 40 mg/dL 300 mg/dL
Special Care Nursery 50 mg/dL 200 mg/dL
Hemoglobin 6.0 g/dL 22.0 g/dL
Ionized Calcium 3.2 mg/dL 5.9 mg/dL
Lactate    5.0 mmol/L
Methemoglobin   3.0%
Oxygen Saturation (Arterial) 70  
pCO2 Adults >18 years 20 mmHg 70 mmHg
Peds (0-18 years) 20 mmHg 55 mmHg
pO2 40 mmHg (Arterial)
20 mmHg (Venous) 		 
pH 7.20 7.60
Potassium Adults > 16 years 2.8 mEq/L 6.2 mEq/L
Peds (0-15 years) 3.0 mEq/L 6.5 mEq/L
Sodium 120 mEq/L 160 mEq/L
Troponin T   >100 ng/L (outpatient only, excluding Emergency Department)


Results Called on these Critical Therapeutic Drug Levels:
Test Name Greater Than
Acetaminophen 40 μg/mL
Amikacin 35 μg/mL
Carbamazepine 12 μg/mL
Digoxin 2.0 ng/mL for adults
Gentamicin 15 μg/mL
Lidocaine 5 μg/mL
Lithium 1.4 mEq/L
Phenobarbital 60 μg/mL
Phenytoin 40 μg/mL
Salicylate 40 mg/dL
Theophylline 20.0 μg/mL
Tobramycin 10 μg/mL
Valproic Acid 150 μg/mL
Vancomycin 30 μg/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 (<7 outpatients) 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 direct gram stain with hyphal forms seen, both sterile and non-sterile sites.
    e. 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
    f. Positive direct antigen tests
        1) Pneumocystis carinii
        2) Malaria
    g. Epidemiology considerations (call to floor)
        1) Methicillin-resistant Staphylococcus aureus (8JC; NICU; 4JPE; 7RC only)
        2) Vancomycin-resistant enterococci (8JC; NICU; 4JPE; 7RC only)
        3) ESBL (inpatient's)
    h. Epidemiology considerations (call floor and on-call epidemiologist pager)
        1) Acid-fast bacilli smear
        2) M. tuberculosis (culture or 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 - call floor inpatient's only
        7) Multi-drug resistant gram negative rods - inpatient's only
    i. 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
        5) Clostridium difficile - Inpatient's only
        6) Cryptococcus neoformans
    j. Positive ocular cultures (other than conjunctiva)
    k. Molecular detection or culture of stool pathogens
        1) Salmonella spp.
        2) Shigella spp.
        3) Campylobacter spp.
        4) Yersinia spp.
        5) Escherichia coli H7;O157
    l. Culture of potential bioterrorism agents
        1) Francisella tularensis
        2) Bacillus anthracis
        3) Brucella spp.
        4) Yersinia pestis
        5) Coccidiodes immitis
        5) Burkholderia mallei or pseudomallei

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 Comm log.

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

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
Blood Gases
   pH
   pCO2
7.25
30
7.65
70
Glucose 50 mg/dL 200
Hemoglobin 8.0 g/dL 22.0 g/dL
Ionized Calcium 3.0 mg/dL 6.5 mg/dL
Lactate    5.0 mEq/L
Methemoglobin    3%
Oxygen Saturation 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