What tests should be on the Alert List?

Transcription

1 What tests should be on the Alert List? Dr Que Lam On behalf RCPA-AACB High Risk Results Working Party: Alan McNeil, Grahame Caldwell, Craig Campbell, Penelope Coates, Robert Flatman, Andrew Georgiou, Andrea Rita Horvath, Hans Schneider May 11 th, AACB Harmonisation Workshop 2018.

2 Definitions Critical test: A test that requires immediate communication of the result irrespective of whether it is normal, significantly abnormal or critical. Critical risk results: Results requiring immediate medical attention and action because they indicate a high risk of imminent death or major patient harm. Significant risk results: Results that are not imminently life-threatening, but signify significant risk to patient well-being and therefore require medical attention and follow-up action within a clinically justified time limit. Alert threshold: Alert list: The upper and/or lower threshold of a test result or the magnitude of change (delta) in a test result within a clinically significant time period, beyond which the finding is considered to be a medical priority warranting timely action. A list of critical tests and tests with alert thresholds for high risk results ideally reflecting an agreed policy between the laboratory and its users for rapid communication within a pre-specified time frame and according to a procedure.

3 NO NUMBERS

4 Methodology List of highest frequency Chemical Pathology tests from the literature. Clinical Chemistry Nov 2016, 62 (11) Working Party members refined list and were polled re: CR, SR, exclude. Preliminary Alert List prepared and distributed. Laboratories polled at Harmonisation 2018 WP to finalise final Alert List recommendations and publish.

5 Voting outcomes YES on Alert List = any laboratory measuring this analyte should have this test on their Alert List. NOT on Alert List = test not recommended for Alert List. Decision left to individual laboratories. WP to re-consider

6 What questions are we asking? 1. Should this test be on the alert list? 2a. Is it a critical test? I must have this on my Alert List I have to call this result every time I perform the test. 2b. Is there a critical risk threshold, a significant risk threshold or BOTH? 3. Are there particular clinical conditions that should be noted? Is there a result that requires timely action? (NOTE: timely action for inpatient and outpatient may differ) I need a separate threshold for particular patients/situations.

7 SAMPLE TYPE CRITICAL SIGNIFICANT What can we achieve? TEST RESULT COMMENTS / CONDITIONS Low Sodium OPTIONAL High Sodium OPTIONAL Low Potassium OPTIONAL High Potassium OPTIONAL Same threshold for dialysis patients. Low Phosphate Low Glucose Separate critical risk threshold for neonates

8 Critical test: A test that requires immediate communication of the result irrespective of whether it is normal, significantly abnormal or critical. Test Result Xanthochromia (CSF) Critical Risk Glucose (CSF) Y 1 N 49 (RED) Significant Risk Conditions/Comments Do we agree?

9 SAMPLE CRITICAL SIGNIFICANT Electrolytes and Renal Function Tests TEST RESULT COMMENTS / CONDITIONS Low Na High Na Low K OPTIONAL OPTIONAL OPTIONAL High K OPTIONAL Same threshold for dialysis patients. Low HCO3 High HCO3? If respiratory acidosis, this will be known. If metabolic alkalosis, K will be abnormal. High Urea? Does this trigger dialysis? High Creat? Non-pregnant adults High Creat? Paediatric High Creat? Pregnant Low Osmolality High Osmolality? In an ED situation (for assessment of ingested/toxicity)

10 SAMPLE CRITICAL SIGNIFICANT Glucose and Calcium TEST RESULT COMMENTS / CONDITIONS Low Glucose All patients excluding neonates Low Glucose Neonates High Glucose All adults High Glucose Paediatric Low Glucose CSF???Critical Test Low Total Ca?? Only included if laboratories DON T report an adjusted calcium? Low Adjust Ca High Total Ca High Adjust Ca Low ica?? Non-pregnant adults High ica?? Paediatric

11 SAMPLE CRITICAL SIGNIFICANT Magnesium, Phosphate, cardiovascular, CRP TEST RESULT COMMENTS / CONDITIONS Low Mg High Mg Low PO4 High Trop I/T? Is significant risk threshold required for non-inpatients High CK High Lactate Where clinically important, most done point-of-care anyway. High BNP/NTPBNP? In an ED/ acute setting assessing SOB High CRP

12 SAMPLE CRITICAL SIGNIFICANT Liver related Tests TEST RESULT COMMENTS / CONDITIONS Low Albumin Paediatric only High Bilirubin Neonates + paediatric. Not required for adults High ALT High AST High Ammonia High Lipase High GGT High LDH High Amylase Does any lab measure amylase but not lipase? High Triglycerides

13 SAMPLE CRITICAL SIGNIFICANT Specific patient groups TEST RESULT COMMENTS / CONDITIONS High T.Protein U Pregnant and non-pregnant patients considered but both deemed not required. High UA?? Pregnant patients High HCG? For ED patients only Low GH In neonates, Low glucose is the critical abnormality here. High iron Paediatric High Lead WB Where clinically important, most done point-of-care anyway. High Lead WB In an ED/ acute setting assessing SOB High Asialotransferrin/ Beta Trace Fluid

14 SAMPLE CRITICAL SIGNIFICANT Hormones TEST RESULT COMMENTS / CONDITIONS High TSH Pregnant only Low TSH Low ft4 High ft4 Low ft3 High ft3 Low Cortisol Low ACTH

15 SAMPLE CRITICAL SIGNIFICANT Blood Gas TEST RESULT COMMENTS / CONDITIONS Low ph WB High ph WB High pco2 WB Low po2 WB

16 SAMPLE CRITICAL SIGNIFICANT Tumour markers TEST RESULT COMMENTS / CONDITIONS High CEA High CA125 High CA153 High CA199 High PSA High Metaneph P/U High Catechol High 5-HIAA High Paraprotein P/U U?New diagnosis?delta change

17 Drugs Digoxin Lithium Phenytoin Theophylline Phenobarbital Acetaminophen Carbamazepine Salicylate Vancomycin Amikacin Cyclophosphamide Everloimus Sirolimus Tacrolimus Tobramycin Cyclosporine Gentamicin Valproate Clozapine All in green on Alert List with Critical Risk Threshold. Gentamicin no threshold value? Other drugs?

18 Any other tests?

19 What now? Collate the votes. WP to review. Another round of voting? Ready to finalise?

20

21 Critical Values Comparison. A College of American Pathologists Q- Probes Survey of 163 Clinical Laboratories. Wagar EA, et al. Arch Pathol Lab Med. 2007;131:

22 What Alert Thresholds Should Be Used to Identify Critical Risk Results: A Systematic Review of the Evidence. Campbell et al., Clin Chem Nov 2016, 62 (11)