Footnotes
Readers are encouraged to respond to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email: pblumen@stanford.edu
. 2007 Apr 13;9(2):11.
letter MedGenMed. 2007 Apr 13;9(2):11.
To the Editor,
Critical laboratory results require immediate action to protect patients from harm. As Dr. Lundberg mentioned in his WVE [Webcast Video Editorial],[1] he and his team are widely credited with implementing the panic or critical value call system,[2] which is now mandated by federal law.[3] Although laboratory-defined trigger points for critical values may vary from facility to facility, everyone agrees that they contribute to maintaining patient safety.[4]
What about the vital values that Dr. Lundberg mentioned? As a pathologist who has spent almost 40 years practicing pathology and laboratory medicine in various settings, I know that communicating important test information quickly to physicians is essential to quality patient care and is appreciated by busy, highly stressed practitioners.
Quest Diagnostics has implemented a priority call structure. Priority 1 values, or critical values, are called as soon as they are available 24 hours, 7 days a week. Priority 2 values, which correspond to Dr. Lundberg's vital values, are also important and called during regular office hours.
Serving a diverse group of physicians precludes using a rigid list of critical and vital values in a one-size-fits-all approach. Accordingly, the Quest Diagnostics laboratory information system allows physician clients to add or customize critical and vital values to accommodate their individual patient population and comfort level. The only caveat is that the custom critical values cannot be less stringent than Quest Diagnostics' defined critical values.
Quest Diagnostics Priority 2 value for hemoglobin is 6.1-7.0 g/dL for adults. A physician who considers this inappropriate for his/her practice can request a custom value of ≤ 8.0 g/dL, for example. The Quest Diagnostics LIS will send values of 8.0 g/dL or less to the client services department call log for that physician's account. The results are then called to the physician in accordance with the Quest Diagnostics Priority Result Reporting Policy and Procedure.
This approach has been well received by the physicians who use Quest Diagnostics for their laboratory testing needs. I receive several requests each week from physicians who want to customize their critical and vital values to suit their practice needs. The most common tests that clinicians want to customize in my laboratory are the prothrombin time INR [international normalized ratio] and hemoglobin. Most try to synchronize Quest Diagnostics priority values with their local hospital policy for consistency.
Communication and availability of information are extremely important in today's world. Tailoring the information to suit physician and patient needs is now feasible and available. All laboratories should implement this practice as a service to patients and their doctors.
References
- 1.Lundberg GD. It is time to extend the laboratory critical (panic) value system to include vital values. MedGenMed. 2007;9:20. Available at: http://www.medscape.com/viewarticle/551061 Accessed January 29, 2007. [PMC free article] [PubMed] [Google Scholar]
- 2.Lundberg GD. When to panic over abnormal values. MLO Med Lab Obs. 1972;4:47–54. [Google Scholar]
- 3.Center for Medicare and Medicaid Services, Department of Health and Human Services. 68 Federal Register 1047. Washington, DC: Center for Medicare and Medicaid Services, Department of Health and Human Services; 2003. Clinical Laboratory Improvement Amendments of 1988. Codified at 42 CFR & 493.1291 (g) [Google Scholar]
- 4.Paxton A. Critical thinking on critical values. CAP Today. September 2006.
letter MedGenMed. 2007 Apr 13;9(2):11.
To the Editor,
A system of “alerts,” or “critical/panic values” is indeed a necessity in providing “the best patient care possible.[1]” I must, however, query.
What is happening with the practice of medicine? With my “critical patients” I/my staff do not rest until we have received my STAT lab results. Have physicians become too busy, with the advent of managed care, to check the lab results that they have ordered?
Who is the physician? Just where does the “buck stop”? I must ask: Is this just another attempt to “share the blame” for our lawyer “friends”?
Having worked in a research lab and having performed lab analysis, after college and prior to graduating medical school some 35 years ago, the sheer volume and “pressure” to report the results were work enough. Interpretation of a result being critical with an “obligation” to action bespeaks practicing medicine without a license. A well-written computer program should be able to “flag” critical values and even phone a physician.
Again, this is very altruistic and it is needed; however, is it a commentary on the practice of medicine post managed care?
My wife decided to return to part-time employment as an RN [registered nurse] this past year. Our children are grown, and married. She felt as an early “baby boomer” a need to be productive and contribute “to society.” She is also pursuing her master's in nursing. After 39 years of marriage, I've learned not to question. Obviously, at the hospital she knows most of the physicians on a first-name basis. To get to the point in her words: It can be difficult enough to get many of the doctors to answer their pages, and when and if they do respond, it often results in a consult with another specialist. On the other hand, too many doctors expect the nurses to call; don't they assume responsibility for finding out the results on the tests that they've ordered? Why can't the physician call or check himself/herself? All this means more time for an already understaffed nursing department.
To illustrate, recently, a patient was sent to my office for consultation and treatment of a “new chief complaint.” The patient had been hospitalized on 3 separate occasions over the prior 2 months for a diagnosis other than what follows. I made my diagnosis and initiated treatment. I also had the hospital fax me the records of hospitalization. In reviewing the patient's hospital records, it was evident the patient was in renal failure. This was apparent on all 3 admissions, and the renal failure was exacerbating with each subsequent admission. Renal failure, however, was not the reason for the patient's hospitalizations. “Your approach” would certainly have rectified the urgency of this diagnosis, but the question remains: The data were there – laboratory I&O's. There was plenty of time to “react.” Where were the doctors?! (I do not know whether it is relevant, but the attending docs were 3-4 years past residency.)
Who did the training? Who sacrificed the hours? Who is the doctor and ultimately responsible?!
Respectfully,
Reference
- 1.Lundberg GD. It is time to extend the laboratory critical (panic) value system to include vital values. MedGenMed. 2007;9:20. Available at: http://www.medscape.com/viewarticle/551061 Accessed January 29, 2007. [PMC free article] [PubMed] [Google Scholar]
