What values are critical?

Chemistry and hematology laboratories long ago developed policies and procedures for so-called " critical values. " These policies ensured timely verbal communications for pre-defined test results understood to reflect life-threatening therapeutically remediable conditions. The critical values concept has penetrated anatomic pathology but only in specific limited settings, usually when an abnormal or important finding is anticipated by the procedure itself, such as a frozen section request or biopsy to evaluate rejection in a kidney transplant. In this scenario, expedited communication is highly driven by context, typically in the form of pretest notification via clini-cian contact with laboratory personnel. Hence, an important distinction between anatomic and clinical pathology testing environments is that a critical value can be defined more precisely in the latter setting, outside of test indication. In other words, certain blood test values are defined as critical because they are presumed to reflect, rather than depend, on the clinical picture. For example, there can be little doubt that a cancer diagnosis in a tissue biopsy is important. However, should it ever be considered a critical value in the sense of patient acu-ity and need for verbal communication? Inherent to the concept of critical value is linkage with communication. Always a problem even under ideal circumstances , chemistry laboratories can often convey information by finding the location of an inpatient area and then interacting with nursing or on-call physicians assigned specifically to that area. One of the barriers to communication of anatomic pathology critical values is the problem of who should be contacted. For example, what if a critical value is an unexpected biopsy finding generated from an outpatient clinic by a physician who is not responsible for patient follow-up and treatment? How do we know who is the best person to contact when we want to convey these results by phone? How do we know that our written report will find the appropriate physician? In today's fractured patient care settings, with off-site pathology laboratories and specialized surgery centers, communication becomes an increasingly complex problem with multiple, sometimes unknown, variables. This applies to results we surgical pathologists may consider " routine, " such as a colon biopsy showing invasive adenocarcinoma. If our diagnosis fails to reach the appropriate medical provider, or the patient for that matter, should we agree that a routine but " missed " cancer diagnosis (ie, one that is not acted on because our report did not …