SOP FOR CRITICAL VALUE
Issue date : 01.05.2024 Issue no.- 1
Revision date: NIL Revision No. 00
NABH Ref: Accreditation standard for Hospitals 3 rd edition
Document No.: BH/CRITICAL VALUE
The hospital has a policy to report critical values
Procedure:
All laboratory test results, which are so far from the reference range that they indicate a potentially dangerous
condition requiring immediate attention, will be intimated to the concerned consultant forthwith.
In case the consultant is not reachable the result will be brought into the notice of Duty Medical Officer.
The result will also be informed to the ward nurse if the patient is admitted to hospital.
In the case of an outpatient, the result will be intimated to the patient directly through available telephone or mobile
number.
The name of the person to whom the critical (panic) values are intimated will be documented on the register along
with time and date.
Hematology
Analyte Age Range Critical Values Units Policy
Hb Any age Less than 7 Gm% Immediately
WBC Any age Below 3000 and above 18000 Per cumm Immediately
Platelet Count Any age Below 50000 Per cumm Immediately
Peripheral smear Any age Blast cells Immediately
Biochemistry
Analyte Age Range Panic Values Units Policy
Serum glucose Any age <40 - >400 Mgm% Immediately
Total Bilirubin Any age >6 Mgm% Immediately
Serum urea Any age >150 Mgm% Immediately
Serum Creatinine Any age >6 Mgm% Immediately
Serum sodium Any age <115 Mgm% Immediately
Prepared By- Quality Cell Approved By- Managing Director Page 1
SOP FOR CRITICAL VALUE
Issue date : 01.05.2024 Issue no.- 1
Revision date: NIL Revision No. 00
NABH Ref: Accreditation standard for Hospitals 3 rd edition
Document No.: BH/CRITICAL VALUE
Serum potassium Any age >6.0 Mgm% Immediately
Urine analysis
Analyte Age Range Panic Values Units Policy
Ketone bodies Any age Present - Immediately
CSF Analysis
Analyte Age Range Panic Values Units Policy
CSF Cell Count Any age WBC Count >30 Immediately
VIRAL MARKERS
HIV,HCV OR HBSAg
Collection of Sample
The hospital has a policy to collect samples in an appropriate manner
Procedure:
The patients will be received in the sample collection area
Requisition form is checked by the Lab Technician
The Lab Technician Assesses precautions required for the test
The containers are labelled and blood is drawn
After blood is drawn band aid is applied to the injected area and post phlebotomy problems are explained to the
patient.
Finally it shall be confirmed that the patient is stable
Prepared By- Quality Cell Approved By- Managing Director Page 2
SOP FOR CRITICAL VALUE
Issue date : 01.05.2024 Issue no.- 1
Revision date: NIL Revision No. 00
NABH Ref: Accreditation standard for Hospitals 3 rd edition
Document No.: BH/CRITICAL VALUE
1.1 Collection of Urine Specimen
Purpose:
To aid in diagnosis of urinary tract infection
Ambulant Patient:
Instruct patient to wash with soap and water and dry with tissues
Instruct patient to void a little urine into toilet bowl and then void into sterile specimen bottle
Identification and Labeling Of Sample.
Procedure:
All samples will be identified by the name, UHID, age and sex
Identification labels will invariably be used to label the containers. However, in case of an emergency, the UHID /
name / other unique id written on the sample container will be utilized to identify the sample.
Empty vials are sent to all the wards and samples with request forms come from wards duly labelled with
name,UHID, age, sex and ward name.
Investigation required in OPD- As the request form is received a number is given on the vial and on the form for
blood/urine/stool or other samples.
All samples for tests outsourced to other laboratories will be transferred to sample bullets after labelling in case of
serum. Vacuum containers will be sent in case of whole blood samples.
Labelling on hazardous sample.
Handling and Safe Transport of Specimens
Procedure:
Samples are collected by using proper container and strict aseptic precautions like wearing gloves, aprons etc.
All samples as treated as infectious and hazardous.
Prepared By- Quality Cell Approved By- Managing Director Page 3
SOP FOR CRITICAL VALUE
Issue date : 01.05.2024 Issue no.- 1
Revision date: NIL Revision No. 00
NABH Ref: Accreditation standard for Hospitals 3 rd edition
Document No.: BH/CRITICAL VALUE
All the samples are kept in appropriate specimen transport box and immediately sent to lab.
proper disposal of Specimen
Procedure:
1. All specimens will be discarded as per the Biomedical Waste Management policy of the Hospital.
2. Urine and stool samples will be discarded every day.
3. Fresh samples will be taken for repeat examinations.
4. All blood samples will be stored for 48 hours in case of need of re-examination.
5. If request for repeat blood test arises after 48 hours fresh samples will be drawn.
6. The EDTA/citrate/serum vials and syringes without needles will be discarded in red bins.
7. Histopathological specimens will be discarded after two months in yellow bins and plastic container in
red bins.
8. Used or expired blood bags will be discarded in to YELLOW BINS after cutting.
Turn Around Time.
The hospital has a policy that defines the time frame for reporting of results
and the same shall be displayed in the lab at the respective areas where the test is being performed.
All the biochemistry and hematology/coagulation results shall be reported within the same day.
Certain tests like histopathology shall not reported on the same day due to some logistic reasons.
Samples from the emergency, OT shall be reported immediately.
Critically high or low result values are reported immediately to the concerned doctor and the same is documented in
the critical test entry register
Prepared By- Quality Cell Approved By- Managing Director Page 4
