Microbiology Critical Values

Microbiology Critical Values
Draft Proposal

Principle

The JCAHO and CAP require that criteria be established for the notification of clinicians when critical limits of specified test results are exceeded.

Purpose

To define critical values for the microbiology laboratories and to provide guidelines for notifying health care providers.

Definition

A "Critical Value" is a test result that suggests a serious medical condition that may require immediate attention for the patient. Test results that have epidemiologic implications are also considered critical so that the risk of secondary infection in health care providers and other patients is minimized.

Microbiology Critical Values

TEST	Result
AFB Smear, Culture, Susceptibility Test	Positive smear or culture All susceptibility test results
Sterile Fluid (except bile or urine)	All positive CSF specimens (smear or culture); First positive specimen (smear or culture) for other sterile fluids
Blood Culture	First positive result/specimen (smear or subculture)*
OR Specimens	All Gram smear results
Cryptococcal Antigen	First positive specimen (CSF or serum)
Rapid Bacterial Antigen	First positive specimen (CSF) Positive (Throat: Group A Strep)
Pneumocystis carinii smear	First positive specimen
O & P	First positive smear for pathogenic parasite(s)
Fecal Leukocyte Smear	First positive specimen
Clostridium difficile	First positive specimen
Syphilis serology	First positive specimen
Pathogenic bacteria	First positive result for: Bordetella pertussis Campylobacter Salmonella E. coli O157:H7 Shigella Vibrio Yersinia Neisseria gonorrhoeae Chlamydia trachomatis
Fungal Culture or Smear	Any positive from significant site or significant pathogen from any site
Viral Culture or Direct Smear	Positive result
Resistant Isolate	First isolate: MRSA VRE

*see comment below

Test Comments

STAT requests, if appropriate, are considered Critical Values.
Except for blood cultures and CSF specimens, subsequent specimens with the same Critical Value reported on an earlier specimen will not be called. Critical Values will be reported for all CSF and blood culture specimens.
Once a positive blood culture has been initially identified by smear or blind subculture, and called out, follow-up phone notification of culture results, identification, and/or susceptibility data will not be made.
If the Critical Value is a Blood Culture result of smear positive for Gram positive cocci in clusters detected dudring the night shift (midnight to 7am), the report may be delayed until the beginning of the day shift (for outpatients only).
Other test results not included in the table above may be considered significant or unusual and will be communicated to the patient’s provider at the discretion of the Laboratory Director or Manager.

Procedure

Critical Values must be called by a technologist immediately upon test verification.
The technologist report should identify the patient and test result, emphasizing that the result is a Critical Value.
Ideally, the report is communicated to a unit coordinator, nurse, or physician covering the floor or unit where the patient is located or received care. Two calls or pages, maximum, within ten minutes will be attempted.
If unable to report by step (3), call the patients attending physician. Two calls or pages, maximum, within ten minutes will be attempted.
If unable to report by step (3) or (4), contact the Clinical Pathology Resident on-call, or the Director of the appropriate laboratory section to determine further action.
All reports must be documented on the work card. Documentation should include name of the person receiving the report as well as the date and time of the report. The technologist must initial the documentation.

Procedure Comments

It is acceptable to communicate a Critical Value to an Outpatient Client’s secretary.
If you page a physician and someone else answers the page for that person, it is acceptable to communicate a Critical Value to responding individual.