Policy QPCMI15001.10
Page 1 of 6
Department of Microbiology
Quality Manual
Section: Process Control
Prepared by: QA Committee
Issued by: Laboratory Manager
Approved by: Laboratory Director
Subject Title: Reporting of Critical
and Urgent Result
Procedure
Original Date: October 16, 2000
Revision Date: February 20, 2004
Annual Review Date: May 09, 2014
REPORTING OF CRITICAL & URGENT RESULT
PURPOSE
This procedure lays out the responsibilities and steps for reporting critical and urgent
results in Microbiology.
For infection control reporting procedure, please refer to the “Reporting policy for
Infection Control”. (QPCMI15003)
For reporting procedure of reportable diseases to Ministry of Health, refer to “Reporting
procedure for MOH” (QPCMI16000)
DEFINITION
Critical results are results that are considered potentially life threatening unless acted
upon promptly.
Urgent results are results that are not critical but sufficiently significant to alert the
health care provider.
TIMEFRAME/ TURNAROUND TIME FOR REPORTING
Critical Results
Positive results from direct examination should be reported as soon as possible or within
one hour. (Refer to list below)
Positive results from culture should be reported as soon as possible or within one hour of
presumptive identification.
Urgent Results
Positive results from direct examination and from culture should be reported ASAP.
(Refer to list below)
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY"
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D:\106762574.doc
Policy QPCMI15001.10
Page 2 of 6
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Reporting of Critical
and Urgent Result
Procedure
LIST OF CRITICAL RESULTS


Positive results from direct examination (e.g., Gram stain) of normally sterile body
fluids/sites, including blood, CSF and tissue.
Positive culture results for normally sterile body fluids/sites, including blood, CSF
and tissue.
LIST OF URGENT RESULTS


Result of direct examination from all STAT specimens
Positive direct tests:














Cryptococcal Ag Latex Agglutination (CSF)
Hepatitis A IgM
Chlamydia results
CMV antigenemia
RSV and Influenza
Nucleic acid test for MTB complex
PCR from CSF and other sterile sites
Pneumocystis (pneumocystis carinii)
Acidfast bacteria smear
Fungal Stain (except yeast with pseudohyphae from respiratory secretions)
C. difficile toxin
Legionella results: DFA or antigen
HIV and Hepatitis B surface Ag from needle stick injury
Positive cultures (including bacterial, viral and fungal) from:
 Corneal scrapings with significant isolates
 Newborn cultures growing Group B Streptococcus
 Organ donor specimens growing potential pathogens (usually phoned to
MORE), e.g. donor lung or bronch
 Central catheter tips: Staphylococcus aureus, gram negative bacilli and yeast
in any amount
 Sterilities including Attest, chemspore and Proof (except positive controls)
 Significant systemic fungus results
 Legionella
 Viral isolations except Herpes simplex and CMV
 Mycobacteria tuberculosis
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY"
are not controlled and should be checked against the document (titled as above) on the server prior to use.
D:\106762574.doc
Policy QPCMI15001.10
Page 3 of 6
Department of Microbiology
Quality Manual
Section: Process Control

Subject Title: Reporting of Critical
and Urgent Result
Procedure
Significant organisms regardless of site of isolation:
 Group A Streptococcus
 Neisseria meningitidis (except throat, gyne)
 Neisseria gonorrhoeae
 M. tuberculosis
 Salmonella / Shigella / Campylobacter / E.coli 0157:H7 and other enteric
pathognes
 VRE
 Methicillin resistant Staph aureus (MRSA)
 ESBL
For any other result you feel is significant, check with Charge Technologist or
Microbiologist.
REPORTING PROCEDURE
It is the responsibility of the technologist reporting the test to note the critical or urgent
result and to call it within the timeframe defined above.
1. Identify critical or urgent results by referring to the list of tests/results considered to be
critical or urgent.
2. Call the patient care area and inform the physician or designated health care provider
(refer to definition below) of :
 the name of the patient
 the patient’s hospital number
 type of specimen and test performed
 date of specimen collection
 the critical / urgent result
 result to be read back to the caller to assure accurate transfer of information
3. Document the call in the electronic workcard: enter the full name of person to whom the
report was given. In case of unsuccessful attempt, document the time the attempt was
made.
4. After three unsuccessful attempts during regular hours, bring to the attention of the
Charge Technologist. In case of unsuccessful attempt in the notification of critical
results during off-hours, page the microbiologist on-call.
5. Notify other departments as required in notification protocol. (e.g. Infection Control,
Ministry of Health).
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY"
are not controlled and should be checked against the document (titled as above) on the server prior to use.
D:\106762574.doc
Policy QPCMI15001.10
Page 4 of 6
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Reporting of Critical
and Urgent Result
Procedure
6. All critical and urgent results should be sent for verification by the charge technologist
or Microbiologist.
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY"
are not controlled and should be checked against the document (titled as above) on the server prior to use.
D:\106762574.doc
Policy QPCMI15001.10
Page 5 of 6
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Reporting of Critical
and Urgent Result
Procedure
DEFINITIONS
Emergency Department, Ward, Unit, Clinic, Physician’s office, Health care
provider’s office
UHN, MSH, RIT,
CHC, Ajax
Riverdale
Clarke
Grace, QSM,
Baycrest
 Resident
 Nurse
 Nurse
 Lab Assistant
 Intern
 Nurse practitioner
 Nurse
 Midwife
 Physician’s office
secretary
 Nursing Resource
Person (Baycrest)
For contact numbers of the health care providers in each of the above institutions,
refer to the “CONTACT LIST”.
Patient care
area
Designated
health care
provider
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY"
are not controlled and should be checked against the document (titled as above) on the server prior to use.
D:\106762574.doc
Policy QPCMI15001.10
Page 6 of 6
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Reporting of Critical
and Urgent Result
Procedure
Record of Edited Revisions
Manual Section Name: Pre-analytical Process – Documentation of STAT
notification in Microbiology
Page Number / Item
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Date of Revision
May 1, 2004
May 4, 2005
July 23, 2006
August 13, 2007
June 16, 2008
June 16, 2009
May 31, 2011
May 31, 2012
May 31, 2013
May 09, 2014
Signature of Approval
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY"
are not controlled and should be checked against the document (titled as above) on the server prior to use.
D:\106762574.doc