Available online at www.sciencedirect.

com

Clinical Biochemistry 42 (2009) 1658 – 1661

Pediatric critical values: Laboratory–pediatrician discourse

Andrew C. Don-Wauchope a,⁎, Li Wang a , Vijaylaxmi Grey a,b
a
Department of Pathology and Molecular Medicine, McMaster University and Hamilton Regional Laboratory Medicine Program, Canada
b
Department of Pediatrics, McMaster University, Canada
Received 17 April 2009; received in revised form 23 June 2009; accepted 30 June 2009
Available online 15 July 2009

Abstract

Objectives: To review pediatric critical values after consultation with departmental pediatricians.
Methods: An electronic survey with the critical value list of 26 high or low abnormal chemistry laboratory values of 12 analytes was circulated
to pediatricians. The survey results were presented to a focus group of 3 pediatricians for comments and review.
Results: Thirty-one of 125 pediatricians affiliated with the Department of Pediatrics responded. Sixteen of 26 (61.5%) current values met the
agreement criteria. The procedures for calling high glucose levels in neonates and children, and the low magnesium and low ionized calcium
critical values were revised after discussion with the focus group.
Conclusions: This survey among the hospital's pediatricians resulted not only in a revised list of critical values, but also the procedure for
calling the user. The use of unique critical values for different areas of clinical practice within the children's hospital was identified as an area for
future development.
© 2009 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Keywords: Critical value; Pediatrics; Physician survey; Telephone limit; Laboratory management; Patient safety; Clinical chemistry

Introduction population whose normal physiology is far more variable than

The use of critical value levels has been recommended and
practiced for a number of years by clinical laboratories. These
are designed to relay life threatening or extremely abnormal
results to the requesting physician in a timely manner [1].
Pediatric critical values have been reported on a number of
occasions in the literature [2,3] and from these reports a wide
range of levels is apparent. The choice of value for critical
notification is made largely based on understanding of
pathophysiology and in discussion with the local users of the
clinical laboratory [4,5]. Inappropriate critical values could
result in information overload for the pediatrician and put a
strain on resources [6]. Pediatric laboratories have a patient
⁎ Corresponding author. Department of Pathology and Molecular Medicine,
McMaster University Medical Centre, 1200 Main Street West, Hamilton, ON,
Canada L8S 4J9. Fax: +1 905 577 0198.
E-mail address: donwauc@mcmaster.ca (A.C. Don-Wauchope).
0009-9120/$ - see front matter © 2009 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.clinbiochem.2009.06.029
the usual adult population, which has led to the use of different
critical value levels in the pediatric population [2,3,7].
Furthermore, the neonatal period is one during which the
adaptation to the extra-uterine environment results in some
extreme changes in certain parameters thus requiring a different
critical value in certain analytes.
Critical values have been proposed because it is understood
that telephoning critical values will improve patient safety.
The literature describing studies evaluating clinical outcomes
with the use of critical values is, however, poor [8–10].
Currently, the laboratory and hospital accreditation bodies
expect to see a list of critical values for use in each laboratory
analyzing clinical samples as part of the requirements for
accreditation [11,12].
Our critical value list was prepared six years ago in
consultation with specialists in neonatology, endocrinology,
pediatric critical care and general pediatrics. A review of these
levels was required to ensure that the levels continue to meet
clinical requirements. We report here the results of a survey
 A.C. Don-Wauchope et al. / Clinical Biochemistry 42 (2009) 1658–1661 1659

designed to assess the level of agreement with the current Results

critical values and to allow feedback from a wider group of
pediatricians.
Methods
A survey was prepared which included a brief introduction,
demographic information and a series of questions related to the
critical values currently in use. The questions were grouped
according to the type of analytes and a free text comment was
allowed with each group of analytes. We also included a
question about who should receive the critical value telephone
call. The options for each question were agree, disagree or
unsure (see Supplement for the survey).
A link to the web based survey was circulated by electronic
mail to members by the Department of Pediatrics at McMaster
University Children's Hospital. This list included both staff
pediatricians and a variety of other academic staff, including
residents, fellows and researchers. Our target population was the
staff physicians and the results are limited to this group of
respondents. No personal identifying data was collected and the
survey was anonymous. McMaster University Children's
Hospital serves central south Ontario with 2.3 million people.
The hospital has 186 beds including 124 acute care beds. More
than 140,000 children utilize the hospital each year.
We predetermined that at least 50% of the responses should
agree with the level and that less than 20% of the responses
should disagree for each level for the critical value to be
acceptable. There is no established method guide on how to set
an acceptable level of response in this type of survey. The level
of 50% agreement was chosen due to the variable nature of
pediatric practice and the wider range of reference intervals
compared to adults [13]. The level of 20% disagreement was
chosen to facilitate bringing critical values that were contentious
to the attention of the pediatricians. Once the results had been
tabulated and the comments reviewed a focus group meeting
was held with the heads of each division of pediatrics (5 invited)
to discuss the areas of disagreement and to reach a consensus for
a new critical value level.
Thirty-one (25%) of 125 pediatricians affiliated with the
Department of Pediatrics responded. The survey included
responses representing a broad range of activities for example,
7 neonatologists, 5 critical care pediatricians, 2 gastroentero-
logists, 1 urologist and 1 neurosurgeon. Sixteen of 26 (61.5%)
current values met the predetermined agreement criteria. The
disagreements were for the high level of glucose in neonates and
children, the high level for potassium in children, the low level
for arterial pO2, and both levels of magnesium, total calcium
and arterial/capillary pH (Table 1).
Some of these disagreements were explained in the 28 free
text responses made by 12 respondents. The number of
comments from each respondent was variable with between 1
and 5 responses per individual. Table 1 shows a summary of the
comments.
The question about who should get the telephone call
demonstrated a strong suggestion that a physician should get the
call with only 3 (11%) from 28 suggesting the nurse should take
the critical value call and 1 suggesting the nurse or resident. The
other 24 (86%) suggested that physician, either the staff
physician (10), combination of staff physician or resident/fellow
(3) and resident on-call or team resident (11) should receive the
call.
In addition to the values shown in Table 1, literature data
(included in Table 2) and data from a recent Canadian survey
(personal communication with Dr K. Adeli) were presented to
the focus group (3 of 5 in attendance). In terms of hyperkalemia
with hemolysis, it was decided that the result would be called
immediately and the decision for repeat testing would be based
on clinical judgment. Further, low critical values of magnesium
and ionized calcium were revised to 0.5 mmol/L and 0.8 mmol/L
respectively. The procedure for calling glucose was altered after
discussing the issue of calling repeated high values during the
same admission. The consensus was that the first high value
should be called rather than all the high values.
Interestingly, we noted different responses between intensi-
vists and general pediatricians, e.g., the levels of pH and pO2.

Table 1
Analytes that were discussed with the focus group of pediatricians following the survey.
Analyte n Agree (%) Disagree (%) Unsure (%) Comment summary
High glucose (b3 days of age) 29 48 38 14 Concerns with respect to unnecessary calls with
known diabetics
High glucose (N3 days of age) 26 52 26 6
High potassium (children) 29 61 23 10 Concerns with the impact of hemolysis on the number
and frequency of these calls
Low magnesium 29 39 35 19 Uncertainty about the clinical significance of magnesium
High magnesium 29 29 32 32
Low ionized calcium 29 68 16 10 The value is too close to the lower reference interval.
Low total calcium 28 52 26 13 Impact of albumin and correction for albumin
concentration were raised.
High total calcium 27 39 32 16
Low (arterial/capillary) pH 28 58 26 6 These values are case and location dependent and the first call
is valuable. Repeat calls for the same episode were questioned.
High (arterial/capillary) pH 28 55 29 6
Low arterial PO2 29 48 32 13
1660 A.C. Don-Wauchope et al. / Clinical Biochemistry 42 (2009) 1658–1661

Table 2
List of pediatric critical values.
Analyte Standing critical value Range of critical values Updated critical value
in the literature [2,3]
Low glucose (b3 days of age) ≤1.7 mmol/L 1.1–2.8 ≤1.7 mmol/L
High glucose (b3 days of age) ≥16.7 mmol/L 16.7–27.8 ≥16.7 mmol/L a
Low glucose (N3 days of age) ≤2.5 mmol/L 1.7–3.3 ≤2.5 mmol/L
High glucose (N3 days of age) ≥20 mmol/L 13.9–55.5 ≥20 mmol/L a
Low sodium ≤125 mmol/L 110–130 ≤125 mmol/L
High sodium ≥150 mmol/L 150–170 ≥150 mmol/L
Low potassium (neonates) ≤2.0 mmol/L 2.5–3.7 ≤2.0 mmol/L
Low potassium (children) ≤2.5 mmol/L 2.0–3.5 ≤2.5 mmol/L
High potassium (neonates) ≥7.0 mmol/L 6.5–8.0 ≥7.0 mmol/L
High potassium (children) ≥6.0 mmol/L 5.0–8.0 ≥6.0 mmol/L
Low magnesium ≤0.55 mmol/L 0.41–0.49 ≤0.50 mmol/L
High magnesium ≥2.5 mmol/L 1.23–3.0 ≥2.5 mmol/L
Low ionized calcium ≤0.9 mmol/L 0.4–0.95 ≤0.8 mmol/L
High ionized calcium ≥1.6 mmol/L 1.35–1.8 ≥1.6 mmol/L
Low total calcium ≤1.7 mmol/L 1.25–1.87 ≤1.7 mmol/L
High total calcium ≥3.5 mmol/L 2.74–3.74 ≥3.5 mmol/L
Low (arterial/capillary) pH ≤7.25 7.10–7.30 ≤7.25
High (arterial/capillary) pH ≥7.6 7.50–7.70 ≥7.6
Low arterial PO2 ≤40 mm Hg 30–55 ≤40 mm Hg
High free T4 (neonates) ≥100 pmol/L ≥100 pmol/L
High ammonia (outpatients only) N200 μmol/L 25–200 N200 μmol/L
High salicylates ≥1.8 mmol/L ≥1.8 mmol/L
Bilirubin 24 h (≤1 day of age) ≥255 μmol/L 86–308 ≥255 μmol/L
Bilirubin 48 h (≤2 days of age) ≥289 μmol/L ≥289 μmol/L
Bilirubin 72 h (≤3 days of age) ≥315 μmol/L ≥315 μmol/L
Bilirubin 96 h (≤ 4 days of age) ≥323 μmol/L 86–342 ≥323 μmol/L
a
First occurrence only.

Some newborns with persistent pulmonary hypertension are
known to have a low pO2 and pH, so the critical value is not as
appropriate for the intensivists and they would prefer to get
called with lower pH values. In general, intensivists accepted
more extreme critical values than general pediatricians. The
final list of pediatric critical values is shown in Table 2.
Discussion
To avoid information overload and unnecessary strain on
both laboratory and clinical resources laboratories should review
and update their critical value lists with appropriate clinical input
and this should be done periodically [4,5]. We reviewed our
critical values list after an initial survey of the members of the
department and then discussed the proposed changes with a
focus group represented by neonatology, pediatric critical care,
and general pediatrics before preparing a list of final changes.
The response to our survey was representative of the many (16
from 21) subspecialties in the department. In this survey we
considered a critical value suitable if more than 50% agreed and
when less than 20% disagreed with the level. This is a subjective
assessment and the numbers chosen were based on our
knowledge of the variety of pediatric practice and the experience
of a similar survey in adults [13]. The critical values that did not
meet these levels were then discussed with the focus group and
the final list of changes was moderated by this discussion. Our
findings are not necessarily transferable to another setting as the
nature of practice and internal protocol will vary from hospital to
hospital [7].
From the survey and subsequent discussion a few points of
interest were raised that impacted on the critical value levels.
The pediatricians expressed concern that high glucoses on a
known diabetic were considered critical. It was suggested that a
reflex test for β-hydroxybutyrate would be useful. For this
reason the decision to call high glucoses only when it is a first
occurrence on each admission was well received. A similar
policy is already in place for hemoglobin in our laboratory. This
is in keeping with the idea that further calls may not assist in
clinical decision making and could have a negative impact on
clinical–laboratory relationships and result in poor time
utilization for both laboratory and clinical staff [6].
The bilirubin critical value was changed to meet the new
Canadian Pediatric Society (CPS) guidelines on neonatal
hyperbilirubinemia [14]. These new values were presented in
the survey and were chosen based on the need for exchange
transfusion at a particular age in the term baby. The telephone
call for a critical bilirubin level was limited to the outpatients
because it is understood that in the hospital setting providers of
care would be waiting for this information to allow discharge of
the neonate according to the guideline [14]. In the outpatient
setting the baby is in the care of providers who may not have
access to the result immediately and the neonate may be at
home.
The differences between pediatricians practicing in different
types of care suggest that it would be sensible to have sets of
critical values linked to location. This has been suggested in
previous studies between hospitals [2,7] and could be extended
to a hospital environment with different levels of acute, critical
 A.C. Don-Wauchope et al. / Clinical Biochemistry 42 (2009) 1658–1661
and chronic care [2]. Currently our laboratory information
system and laboratory policy would make instituting a
differential critical value policy very difficult. However, we
do feel that this would be an important development for the
future.
The literature is lacking in outcome studies demonstrating
that critical values have either a positive or negative impact on
patient management [9]. Critical values that have been agreed
between the laboratory and the pediatric staff will provide a
good base for considering the impact of these results on patient
care. In particular, in keeping with the patient safety goals
advocated by the joint-commission in the United Sates [12],
duration of time to make the call, compliance with making calls
and receiving the calls and time to act on the call could be
evaluated.
Conclusion
Clinical practice guidelines as well as technological
advances necessitate periodic review of the practice of reporting
critical values. This survey resulted in a revision of the critical
values list that better meets the needs of the clinician and the
laboratory. Further it improves dialogue with the clinicians
using the service and allows opportunity to revise old
procedures and implement new procedures that improve the
flow of results from the laboratory. A survey such as the one we
carried out is a useful tool in reviewing the critical value list.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at doi:10.1016/j.clinbiochem.2009.06.029.
1661
References
[1] Lundberg GD. When to panic over abnormal values. MLO Med Lab Obs
1972;4:47–54.
[2] Wagar EA, Friedberg RC, Souers R, Stankovic AK. Critical values
comparison: a College of American Pathologists Q-Probes survey of 163
clinical laboratories. Arch Pathol Lab Med 2007;131:1769–75.
[3] Kost GJ. Critical limits for emergency clinician notification at United
States children's hospitals. Pediatrics 1991;88:597–603.
[4] Lundberg GD. Critical (panic) value notification: an established laboratory
practice policy (parameter). Jama 1990;263:709.
[5] Howanitz PJ, Steindel SJ, Heard NV. Laboratory critical values policies
and procedures: a College of American Pathologists Q-Probes study in 623
institutions. Arch Pathol Lab Med 2002;126:663–9.
[6] Dighe AS, Rao A, Coakley AB, Lewandrowski KB. Analysis of laboratory
critical value reporting at a large academic medical center. Am J Clin
Pathol 2006;125:758–64.
[7] Lum G. Critical limits (alert values) for physician notification: universal or
medical center specific limits? Ann Clin Lab Sci 1998;28:261–71.
[8] Kost GJ. The challenges of ionized calcium. Cardiovascular management
and critical limits. Arch Pathol Lab Med 1987;111:932–4.
[9] Jenkins JJ, Mac Crawford J, Bissell MG. Studying critical values: adverse
event identification following a critical laboratory values study at the Ohio
State University Medical Center. Am J Clin Pathol 2007;128:604–9.
[10] Howanitz JH, Howanitz PJ. Evaluation of serum and whole blood sodium
critical values. Am J Clin Pathol 2007;127:56–9.
[11] Center for Medicare and Medicaid Services, Department of Health and
Human Services. Clinical Laboratory Improvement Amendments of 1988.
[12] Joint Commission on the Accreditation of Healthcare Organizations:
National Patient Safety Goals, 2009: http://www.jointcommission.org/
PatientSafety/NationalPatientSafetyGoals/09_lab_npsgs.htm. (Accessed
March 2009).
[13] Don-Wauchope AC, Chetty VT. Laboratory defined critical value limits:
how do hospital physicians perceive laboratory based critical values?
Clin Biochem 2009;42:766–70.
[14] Guidelines for detection, management and prevention of hyperbilirubi-
nemia in term and late preterm newborn infants (35 or more weeks'
gestation)—summary. Paediatr Child Health 2007;12:401–18.