1. Module 5 Postanalytical Phase of Laboratory Testing

2. Once an accurate test result is obtained the lab must O Report the result in a timely manner by: O Using an electronic process allowing for acceptable results to be transmitted electronically via an ‘interface’ between the analyzer and lab information system(LIS) and then via another ‘interface’ between the LIS and the electronic medical record (EMR) or…. O Transcribing accurately the results to a paper or written medical record O The vast majority of results are transmitted by the first mechanism Photo by Theresa Kristopaitis, MD

3. Case Scenario 1 O A 68-year old woman with atrial fibrillation chronically anticoagulated with warfarin presents for her monthly INR blood draw. She relates to the nurses that her husband died unexpectedly 3 weeks ago and she has had a very poor appetite since. Photo by Theresa Kristopaitis, MD

4. Case Scenario 1 Result Component Value Flag Reference Range PROTHROMBIN TIME 68.6 H 9.2 - 11.8 SEC INR RATIO 5.3 H Comment: SUGGESTED THERAPEUTIC RANGE FOR CONTROL OF ORAL ANTICOAGULANT THERAPY INR 2.0-3.0 FOR DVT/PE, TISSUE VALVE, ATRIAL FIB, MI-STROKE PREVENT INR 2.5-3.5 FOR MECHANICAL VALVE

5. Case Scenario 1 Per the laboratory guidelines, the INR result is considered a “critical result”. What is the next appropriate step taken by the laboratory technologist? A. Call the patient with the abnormal test result B. Communicate the INR result directly to the ordering physician or their designate C. Notify the coagulation laboratory director of the test result D. Order a STAT re-draw of the patient sample and notify the patient E. Rush the written result report into the medical record

6. “Critical Results” O “Critical results” of tests fall significantly outside the normal range, may indicate a life threatening situation, and may require immediate clinical action O Values are decided upon in collaboration with institution laboratory directors and physician leadership O The objective is to provide the responsible licensed caregiver with these results within an established time frame so that the patient can be promptly treated O The reporting of critical results in a timely basis is a 2013 JCAHO National Hospital Patient Safety Goal

7. “Critical Results” O Current regulations require that the person receiving the report of the critical result be asked to read back the results to the lab staff member to ensure correct information was communicated O This must be documented in the medical record Photo Theresa Kristopaitis, MD

8. Other Examples of Clinical Laboratory Critical Results Less than Greater than Hemoglobin O Ages 1 mo-adult 7.0 g/dL 19.0 g/dL O Ages 1 day – 1 mo 7.0 g/dL 20.5 g/dL O Ages 0 -1 day7.0 g/dL 24.0 g/dL Ionized Calcium (ICAL)0.85 mmol/L 1.50 mmol/L (Ages 0 - 6 months) 0.95 mmol/L 1.65 mmol/L Lithium (LI) 2.0 mmol/L (Toxic Range) Partial Thromboplastin Time (PTT)100 seconds Potassium (K) (serum or plasma) 2.8 mmol/L6.1 mmol/L Potassium (K) (whole blood) 2.5 mmol/L 6.5 mmol/L Critical Results in Microbiology The physician or designate is notified for: Positive CSF smears

9. It Starts and Ends with the Patient O Remember that the laboratory testing process begins and ends with patient care O All laboratory tests MUST be interpreted in light of the clinical situation O Although lab testing may yield unexpected results that are critical in guiding further patient evaluation and management, clinicians must be vigilant for the possibility of spurious results from improper specimen collection, mislabeled specimens, clerical errors and other preanalytic, analytic and postanalytic ‘misadventures.’

10. Laboratory Staff are Members of the Healthcare Team! O Clinicians should ALWAYS feel free to contact lab directors and/or clinical laboratory staff with questions about any lab test: O Interpretation of results O Assurance of quality of a test O Discussion of potential sources of error or variables to be considered in test interpretation O Determination of need for a specialized test

11. O Proceed to Module 6 “Normal Values”: How are Normal Reference Ranges Established?