36C24218R0169-052.pdf

RFP 36C24218R0169

D.24 SPECIMEN PROCESSING, GENERAL INFORMATION AND DUTIES

VA Western New York Healthcare System

Pathology and Laboratory Medicine

I. PURPOSE:

A. To provide guidelines for processing specimens and duties performed in Central Processing.

II. PROCEDURE:

A. The following are various requirements for specimen acceptance/processing. Refer to Center Memorandum 113-13 “Guidelines for Collection, Handling and Transport of Lab Specimens,” and “Specimen Acceptance/Rejection” SOP in this manual and in the Lab General manual for further instructions.

1. Each sample must be accompanied by an order number, a written requisition, or pre-labeled with a barcode. Accession those samples that are accompanied by a written requisition via “MU” Multipurpose Accessioning. Accept any ward collect samples (order #’s) via “WOE“ Ward Order Accessioning.

2. The written requisition or order number must indicate tests ordered, ordering location, provider, and must be stamped in using the date and time stamper.

3. The sample must be labeled with the patient’s full name, full social security number (or birth date), date time of collection, and the phlebotomist’s initials.

4. Ensure sample is the correct tube/collection type for tests ordered.

B. Centrifugation

1. For COAG specimens (blue top), spin in Stat Spin 3 minutes at 8500 RPM.

2. Serum and plasma samples must be separated from cells within 2 hours of collection.

3. Serum specimens should be allowed to clot before centrifugation.

4. Always balance the centrifuge and never centrifuge uncapped samples.

5. After centrifugation, if caps must be removed, use safety shield.

6. Pour off all required samples behind safety shield (ex: no gel tubes).

7. All STAT/priority samples must have a timer set when being spun.

8. All STAT/priority samples or any shared samples should have their label in front of the centrifuge.

NOTE: For spills and/or tube break, follow “Spill Control Procedures” found in the Laboratory Safety and Chemical Hygiene Plan available on the “G” drive.

Centrifuges available:

Stat Spin centrifuge is high speed centrifuge used for open heart samples.

Transfer blood from the red top tube using a plastic transfer pipette to small Stat Spin tube (different form Stat Spin for COAG specimens).

Centrifuge sample for 95 seconds at 15,800 rpm. Make sure to balance.

Silencer / Hettich centrifuges are used for routine and priority samples Set the speed at 3000 rpm and the time for 10 minutes.

C. STAT or Priority Samples

NOTE: It is the responsibility of all Central Processing staff to monitor and follow through with STATS and other priority samples. All priority specimens must be attended to immediately. This includes priority specimens sent through the pneumatic tube system. Work must be prioritized in such a way that STAT/priority specimens are processed before routine specimens.

NOTE: All STAT samples are placed in each area’s “STAT RACK” (if available). Verbal contact must be made by verbally saying “STAT” to the tech running the instrument.

1. Open Heart Samples

a) Immediately accession and centrifuge serum/plasma sample in the StatSpin centrifuge. Set a timer. CBC’s do not require centrifugation.

b) Deliver sample and barcode label with OR phone extension to the technologist performing testing, making verbal contact with technologist by saying ”STAT Open Heart sample”.

c) Centrifuge the remainder of the sample in the serum/plasma tube, pour off into a properly labeled and initialed tube and store in the CP refrigerator in extra samples rack.

2. OR Specimens

a) Accession, centrifuge, and process immediately.

b) Deliver sample and barcode label with OR phone extension to the technologist performing testing, making verbal contact with tech by saying “STAT OR sample”.

3. STAT and ASAP Specimens (ER, ICU, PACU, INFU, WARDS)

a) Accession, label tubes appropriately and spin chemistry samples in a centrifuge designated for STAT samples, process immediately. Labels should be left in front of the centrifuge and a timer set for all priority samples.

b) When multiple tubes are sent on the same patient, process and spin chemistry samples together, with the exception of lactic acid samples, which must be centrifuged immediately). Ensure chemistry receives serum/plasma that is not hemolyzed or the least hemolyzed sample if all samples are hemolyzed. Extra tubes are placed in the extra rack in the CP refrigerator. Red no gel tubes must be poured off into a properly labeled and initialed tube, avoid bubbles.

c) Deliver samples to the appropriate sections of Core Lab, place in STAT rack (if available) and make verbal contact with the technologist by saying “STAT”. In chemistry, a square label must be placed on the STAT board with the time of delivery and tech initials.

4. Lactic Acid

a) Gray Top (sodium fluoride) placed on ice must be delivered within 30 minutes of collection.

b) Centrifuge immediately upon arrival, set a timer.

c) Pipette plasma into to a 5 ml barcode labeled and initialed tube, avoid bubbles while pipetting. Deliver sample to CH work area.

d) Alert the tech to the fact that there is a lactic acid.

5. Ammonia

a) Lithium Heparin tube must be delivered to lab immediately on ice.

b) Immediately spin down sample and deliver to CH work area with label, alert tech. Do not uncap.

c.) If not on ice, reject the sample, “NP” the test and notify the provider.

6. Body Fluid Samples

a) Accession and process ASAP, if CSF process immediately.

b) Deliver sample and labels to appropriate area in the Core Lab.

c) See “Body Fluid requests,” SOP, elsewhere in this manual.

7. Blood Gases

a) Balance Lithium Heparin syringe at room temperature, delivered within 30 minutes of collection.

b) Test immediately.

D. Routine Specimen Processing

1. AM Blood Team

a) Accession/accept any samples which are not barcoded.

b) Centrifuge samples appropriately.

c) Organize tubes according to accession area: COAG, HE, CH etc.

d) HE, hematology samples and labels must be organized in numerical order.

e) HE and COAG samples must be accompanied by a label.

f) Reprint any labels which are missing, not been placed properly on the tube and any labels needed for pour off tubes.

g) After tubes have been processed, deliver them to the appropriate area.

2. Outpatient Lab

a) Samples are typically delivered by pneumatic tube system.

b) The majority of samples arrive barcoded, ready for processing. Accession any samples accompanied by a requisition and/or accept any ward collect samples if necessary.

c) Scan all samples, STAT and routine, received from OPL using

^SCAN SPECIMENS INTO LAB.

d) Centrifuge all required tubes.

e) Sort samples by accession area.

f) Separate labels, save all HE, COAG, URINE, SENDOUTS and any CH pour-off labels.

g) Organize Hematology samples and labels in numerical order.

h) Deliver COAG, HE, and UA samples (with a label for every sample) to the appropriate area in the Core Lab.

i) Re-print any missing labels that are needed.

j) Any urine label without a sample should be saved as samples may arrive later.

k) After CH samples have spun, ensure there are no serum clots and deliver to chemistry area.

l) Pour off any required samples or shared samples into labeled and initialed tubes and deliver.

m) Send any SENDOUT or MICRO samples to Blood Bank via the tube system.

NOTE: All pour off tubes require the person who pours off the sample to initial the pour-off tube.

NOTE: All unused labels must be place in the Patient Confidentiality Bin

3. Community Based Outpatient Clinics (CBOC)

a) Samples will arrive centrifuged in a primary tube from Niagara Falls Clinic (NFC), Lockport, Lackawanna and Springville. Samples from Jamestown (JSN), Dunkirk (DNK), and Olean will arrive in pour off tubes.

(1) JSN, DNK, and OLEAN:

a) Samples arrive via UPS approximately 10:30 am Tuesday – Saturday.

b) Stamp in packing slip using date and time stamper.

c) Check samples against shipping manifest and initial when complete.

d) Accession (if necessary), process and store samples accordingly.

e) See “Instructions for Unpacking Samples Local and Out-of-Town

CBOC’s,” SOP, elsewhere in this manual, for detailed instructions.

NOTE: Any discrepancies/missing samples MUST be investigated.

(2) NFC, Lockport, Lackawanna and Springville:

a) Samples arrive via VA driver Monday-Friday between 3:00pm and 4:30pm.

b) Stamp in packing slip using date and time stamper.

c) Check samples against shipping manifest and initial when complete.

d) Accession, process, and store samples accordingly.

e) See “Instructions for Unpacking Samples Local and Out-of-Town CBOC’s,” SOP, elsewhere in this manual, for detailed instructions

4. Batavia / Warsaw:

a) Arrive via shuttle around 3-4 times per day (Warsaw Monday only)

b) Stamp in packing slip using date and time stamper.

c) Check packing slip for any priority samples. Priority samples must be delivered immediately to the lab area performing testing.

d) Samples will arrive in barcoded tubes. Centrifuge if needed, and pour off in a separate tube when necessary.

e) Check samples against shipping manifest.

f) Initial manifest when done.

g) Deliver to appropriate lab areas or storage racks.

5. HBPC

a) Samples are delivered throughout the day by HBPC nursing staff.

b) Samples are to be left in the wall mounted shelf.

c) Patient’s name and tubes delivered must be indicated on clip board above shelf by the nurse delivering the samples.

d) Process these samples ASAP to ensure they are spun within 2 hours of collection.

6. Other VA Facilities (SYR, Bath, CN)

a) Samples arrive via UPS or shuttle driver centrifuged and poured off.

b) Remove samples from cooler.

c) Stamp in shipping manifests using date and time stamper.

d) Check samples against shipping manifest and initial manifest.

e) Scan samples into G Drive “VISN Samples’ archive spreadsheet.

f) Deliver to appropriate lab areas or storage racks.

g) Any missing samples must be investigated.

E. Chemistry Area Sample Guide

1. For Hemoglobin A1c; place tubes in a rack at the work area or in the appropriate rack in the central processing refrigerator

2. Look through the labels for pour off tests (SPEP, OSMO) or Ketones.

Ketones: Make sure the tube gets delivered to the Urinalysis tech. If other tests are requested on the same tube, communicate this information to the Urinalysis tech so that he/she can quickly perform the test and make sure that the next test(s) get delivered to the appropriate area.

3. Pour off tests: SPEP, OSMO. Label a 13x75 tube and pour a minimum of 1 ml. serum into it, cap it, initial it and put it in the appropriate storage area. Give OSMO to appropriate tech to run once poured off

4. Centaur chemistry testing: iPTH, Testosterone, SHBG, AFP, VitD, T3, Hepatitis.

Hepatitis samples are placed in the Central Processing refrigerator M-F. All other samples are placed in the Centaur rack near the instrument. Testing is not performed on weekends or holidays, samples must be poured off and frozen. Place samples in the Centaur labeled rack in the hall freezer.

5. For therapeutic drugs (Acetaminophen, Carbamazapine, Digoxin, Phenytoin, Salicylate, Theophylline, Valproic Acid, Vancomycin): samples must be spun within 2 hours of collection. Pour off about 1 ml. serum into a barcode labeled and initialed tube. Deliver to Chemistry.

6. For Ethanol: Do not remove the cap from the tube. Immediately after processing, deliver the tube to the Chemistry area and alert the technologist of its arrival.

F. Flow Cytometry

1. Flow CD4/CD8: yellow top ACD Soln A, deliver to Flow 227B

2. Flow Cytometry (Leukemia/Lymphoma Profile): Yellow top ACD Soln A, deliver to Flow 227B.

G. Sendouts / Serology

1. REFER TO “^F60” Inquiry to LAB TEST file, for individual handling procedures. Deliver spun and processed samples via tube system or pour off, if required, and store accordingly during non- administrative hours.

H. Sample Storage

1. Pour-off/extra samples are stored in the Central Processing refrigerator for the day. Be sure to use “PLASMA” and “NO GEL” stickers to accurately label specimen type.

2. During Non-ad/weekends/holidays; samples not tested must be poured off and stored refrigerated or frozen in the appropriately labeled rack.

3. Completed archived Chemistry racks, Chemistry extra rack, Blood gas and Urine samples are stored in the Core Lab hall refrigerator for 7 days.

4. Completed Hematology and Coagulation samples are stored at room temperature in the Hemo/Coag area of the Core Lab for 48 hours.

5. White top HCV ab samples are stored frozen in the hall freezer for 15 days.

I. Miscellaneous Processing Info

1. Alcohol levels should NOT have stopper removed until testing is performed.

2. Serum ketones should be processed as a STAT. DO NOT REMOVE tube stopper after centrifugation. Deliver to the urinalysis section.

3. All work areas should be wiped down with disinfectant minimally daily or when there is a spill.

4. If only one lavender or red top tube is received for multiple tests, place a shared sticker on the tube.

Deliver lavender to Hemo with labels for additional tests.

5. A “PALM Laboratory Problem Report” should be completed for all problem/discrepancies as per the

SOP;

J. Central Processing Duties

1. Technicians/technologists assigned to cover Central Processing are responsible for correctly processing routine and priority samples as outlined above.

2. Technicians/technologists assigned to cover Central Processing are responsible for answering the phone in CP within 3-4 rings. Calls must be triaged and not sent back to testing area unless necessary.

(For example; CP staff should add on and pour off additional tests requested; use ^F60 or G Drive SOPs to answer questions regarding specimen type and stability; ensure a sample has been received and processed; perform ‘LES’ release.)

3. Pneumatic Tube System STAT bullets must be addressed within 3 rings.

4. Process and run Blood Gas immediately.

5. Process and run any STAT iFOBT requests immediately.

6. Routine iFOBT samples should be processed and run after all afternoon CBOC samples have arrived and been processed.

7. Cleaning checklist must be completed every AM by CP staff.

III. REFERENCE:

A. NCCLs Document H18-A, Vol. 10, No. 12 Procedures for the Handling and Processing of Blood Specimens.

B. Laboratory General Manual, Pathology & Laboratory Medicine VHAWNY