36C24419R0052-019.pdf

PATHOLOGY & LABORATORY MEDICINE

MANUAL

FOR HOSPITAL WARDS AND CBOC’S

Prepared By: _______ _____________________ Date: ____1/9/19___________

Sharon Ford

Laboratory Manager

Approved By: ____________________________________ Date: ____1/11/19______

Hanna Kaspar, M.D.

Chief, Pathology & Laboratory Medicine

INTRODUCTION

Meaningful laboratory test results can only be obtained with proper preparation of the patient and/ or collection of specimens. On occasion, laboratory tests have to be repeated because of lack of proper preparation of the patient.

This new edition of our laboratory manual includes instructions that heretofore have been circulated as separate Hospital

Memorandums. A copy of these Hospital Memorandums will be provided in one portion of this manual. With the inclusion of pertinent policies into a single manual, the Laboratory Procedure Manual offers an invaluable aid to the clinician, to each nursing unit of the hospital and to each outpatient treatment care area.

The Laboratory would appreciate close compliance with the stated criteria in the Procedure Manual, since a complete quality control system must begin with the collection of the specimen.

Laboratory test ordering and results reporting are done through the VISTA computer package. Test requirements are also available via the computer. These are explained in the Computer section of this manual.

If at any time there are questions concerning proper specimen collection, result reporting or an other Laboratory concern, contact the appropriate department in the Laboratory. The following is a list of Laboratory Staff and their extensions.

TITLE NAME EXTENSION ROOM

Medical Director & Service Chief, Hanna Kaspar, M.D. 7532 N1-103A

Pathology & Laboratory Medicine 4302

Associate Chief, Path & Lab Husam Hamati 7334 N1-103

Laboratory Manager Sharon Ford 7535 N1-102

Supervisor, Chemistry & UA/ Ancillary Linda Stubb 7541 N1-104

Testing Co-ordinator

Supervisor, Blood Bank & Hematology/ Christine Kohanski 4014 N1-92

Ancillary Testing Co-ordinator

Laboratory Information Manager Regis Grattan 4869 N1-105

Chemistry Lead Technologist Marianne Telincho 4154 N3-106

Hematology Lead Technologist Catherine Gambo 4119 N3-106

Microbiology Lead Technologist Brenda Krammes 4360 N3-99

Administrative (office) Staff Barbara Helmbold 7531 N1-104A

The following is a list of phone extensions for the appropriate departments:

Laboratory Section Extension ROOM

Specimen Handling 7544 N3-106

Chemistry 7542, 7543 N3-106

Hematology 7537 N3-106

Coagulation 4913 N3-106

Blood Bank 7240 N3-106

Blood Bank Fax (Direct) 570-819-5199

Microbiology 7538 N3-98

Microbiology (PCR Testing) 7539 N3-100

Urinalysis 7536 N3-106

Histopathology 7540 N1-96A

Morgue 7180 EB-57

Phlebotomy 4310 for stats N3-75

AVAILABILIY OF LABORATORY SERVICES

WILKES-BARRE VAMC:

The Laboratory operates 24 hours/ day, 7 days per week including holidays and most testing is available during that time. Below are the services that are available 24/7.

HEMATOLOGY

COAGULATION

CHEMISTRY

URINALYSIS

BLOOD BANK

PHLEBOTOMY

HISTOLOGY AVAILABILITY: Monday through Friday 7AM – 4:30PM

MICROBIOLOGY AVAILABILITY: (7) Days per week, 8AM – 4:30PM. However, stat testing is available 24/ 7. Those

Microbiology Tests that are considered stat can be found on the STAT list in this section.

PATHOLOGIST CONSULTATION: A pathologist is on-site Monday – Friday 8AM – 4:30PM. However, a Pathologist is always on-call and can be reached for consultation 24/7. This includes consultation for Transfusion related issues.

AVAILABILIY OF PHLEBOTOMOY SERVICES

WILKES-BARRE VAMC:

STAT COLLECTIONS:

24 Hours a day: Phlebotomy services are provided by the Laboratory

IN- PATIENT ROUTINE COLLECTION TIMES:

The Laboratory will conduct routine blood sampling rounds during the following times:

Seven days a week including Holidays

6:00 AM

2:00 PM

It is requested that whenever possible, the Routine Laboratory collection times be utilized.

WILKES-BARRE VA OUTPATIENT HOURS

3rd Floor Phlebotomy : 6AM – 4:15PM

Drug Screens can only be done 8AM – 4PM

LABORATORY TESTING

Information regarding all laboratory tests may be found in the individual sections of this Manual as listed: Chemistry, Immunology, Microbiology, Hematology, Blood Bank and Anatomic Pathology. There is also a section for Patient Instructions that may be used when patients are to perform certain tests such as a Glucose Tolerance, a 24 Hr. Urine Test or Hemosure Testing.

Each individual section of the manual lists names of tests that may be ordered and provides information regarding the Test

Methodology, the specimen requirements, special instructions and reference ranges. Additionally, it includes the testing site. Testing may be performed on-site or it may be sent to the Philadelphia VA Laboratory or our Reference Laboratory, which in most cases is

Laboratory Corporation of America (LabCorp). In many cases, information is already provided for you regarding most testing.

Further information or for a more comprehensive listing of tests provided by LabCorp, you may go to their on-line directory of services as follows: http://labcorp.com/dos/index.html

This section of the Manual will provide for you General Laboratory Information regarding the following topics:

Laboratory Test Ordering including Verbal Orders

STAT and Routine Laboratory Tests and Turn-around-Times

Critical Value Lists

Laboratory Profiles and Tests included in these profiles

Information on Hepatitis Testing

Information on HIV Testing

Special Instructions for Collecting some Therapeutic Drugs—further information in the Chemistry Section

A Chart for 24-Hour Urine Preservatives

Venipuncture Collection Procedure

Blood Collection Tube Information

Listing of Fasting Lab Tests

Patient and Specimen Identification Requirements

Criteria for Rejection of Unsatisfactory Specimens

Specimen Transport and Delivery within the Hospital & from CBOC’s

Specimen Processing Information

Results Reporting Information http://labcorp.com/dos/index.html

LABORATORY TEST ORDERING

1. In order to comply with State and Federal regulatory agencies, the laboratory will only perform tests that are ordered by health care providers who are credentialed and privileged at the Department of Veterans Affairs Medical Center Wilkes-Barre.

2. All test orders must include the patient’s full name, full social security number, the name of the provider and the name of the tests requested. The clinician should also state the date and time in which he/she wants the specimen collected.

To Place and Order

The following is a description on how to place an order in the computer through CPRS.

Some quick labs are available from the Add Order Screen. The collection time for these is usually the next routine lab collection, unless otherwise specified. To enter a lab request:

1. Type the name of the lab tests desired

2. Choose the time/ method of collection. Select one of the collection options, or enter a specific date and time, e.g., T+3@500, or

Now.

See the Example on the next page

EXAMPLE

Select Item(s):Done// 70 70

--Laboratory—

Delay release of these orders? No// <Enter>

Lab Test: glucose

1. GLUCOSE

2. GLUCOSE TOLERANCE (URINE)

3. GLUCOSE TOLERANCE TEST

4. GLUCOSE, OTHER

CHOOSE 1-4: 2 GLUCOSE TOLERANCE (URINE)

SEND TO LAB – Means the patient is ambulatory and will be sent to the

Laboratory draw room to have blood drawn.

WARD COLLECT – Means that either the physician or a nurse will be

Collecting

The sample on the ward.

LAB BLOOD TEAM – Means the phlebotomist from Lab will draw the blood on the

Ward. This method is limited to laboratory defined collection times.

SP Send patient to lab

WC Ward collect & deliver

LC Lab blood team

Collected By: Ward collect & deliver// <Enter>

Collection Date/Time: TODAY// <Enter>

Urgency: ROUTINE// <Enter>

How Often: ONE TIME//

Lab Test: GLUCOSE TOLERANCE (URINE)

Collected By: Ward collect & deliver

Collection Sample: URINE

Specimen: URINE

Collection Date/ Time: TODAY (11/25/2008)

Urgency: ROUTINE

How Often: ONE TIME

Order Checks:

>>>Duplicate order: GLUCOSE TOLERANCE (URINE) URINE WC [UNRELEASED]

(P)lace, (E)dit, or (C)ancel this order? PLACE// c CANCEL

……………order cancelled.

NOTE: The above example demonstrates Order Checking. A notice that this order is a duplicate of a previously placed order for this patient is displayed, with the option to place, edit, or cancel the order.

TIP: To change a lab urgency “on-the-fly”: When you select a quick order from the menu, enter the number of the item followed by =*.

VERBAL ORDERS

Often times a phone call is received by the Laboratory to add tests to a specimen that is already in the laboratory. In an effort to save the patient an additional phlebotomy draw and to reduce the amount of blood that is needed to be taken from a patient, it is practice to accept a verbal order if the following steps are taken:

1. It should be the ordering clinician making the phone call. In addition, the ordering clinician must identify himself/ herself for documentation.

2. The ordering clinician must agree to place the request for testing in the computerized patient record. Therefore, a new order number will be generated for the request. The clinician will have someone call the laboratory with the new order number.

3. The ordering clinician must have the patient’s entire name and full social security number. In addition, the location of the patient should be known. Results for the tests will not be available in the computer system until the order is received.

4. The technologist should read back to the clinician the patient’s full name and full Social Security number and the tests that are being requested. At that time, the technologist will check the computer to see what tests were previously ordered. This is so he/ she can see if we have the correct sample type in the laboratory. The technologist will pull the specimens that will be needed for testing.

5. When the order number is called to the laboratory, the technologist must check to see if the patient name and social security number match those that the ordering clinician requested verbally. If they do not match, the technologist will notify the ordering clinician. If they do match, the technologist may continue by accessioning the order.

6. When the order number is accessioned, the time and date of the original specimen should be put in the computer as the collection time.

Note: At no time will orders be accepted from a clinician that is not in the Wilkes-Barre VA Medical Center System. If they are an approved Wilkes-Barre VA clinician, they will be in the VISTA System.

LABORATORY STAT AND ASAP REQUESTS

The Laboratory will honor STAT and/ or ASAP requests for specified tests.

STAT REQUESTS:

1. Stat requests should be made for critical purposes and are available on a 24 hour basis.

2. Results will be provided within 1 hour for all tests identified as “STAT”.

3. STAT requests that are to be draw by the Laboratory should be ordered as Immediate Collect and queued to the Laboratory printer. To alert the laboratory that there is a STAT to be collected, a telephone call should ALWAYS be placed at the same time.

4. STAT requests that are drawn on the ward by the Physician or Nurse should be delivered to the Laboratory Immediately.

Upon arrival in the Laboratory, the person delivering the stat should time stamp the stat requisition and bring the specimen into the laboratory. If possible, the person delivering the stat should let someone know that they have brought a stat.

5. Results for all STAT requests will be available in the computer immediately after release by the technologist.

ASAP REQUESTS:

1. ASAP requests will be available on a 24 hour basis.

2. Results for ASAP requests will be provided within 4 hours.

3. ASAP requests that are to be drawn by the Laboratory should be ordered as such and queued to the Laboratory printer. A telephone call to the Laboratory is also necessary.

4. Results for ASAP requests will be available in the computer immediately after release by the technologist.

STAT AND ASAP LIST

The following is a list of tests that will be provide as STAT or ASAP upon request:

CHEMISTRY HEMATOLOGY MICROBIOLOGY

Acetaminophen

Alcohol CBC or any Portion Blood Cultures #

Ammonia Cell Count on Fluids* Cerebrospinal Fluid*

Amylase Gram Stains βHcG Procalcitonin

BNP FLU/ RSV by PCR

Comprehensive Profile MRSA by PCR (2 hr.)

CSF Protein* COAGULATION C. difficile by PCR

Digoxin Partial Thromboplastin Time Hemosure

Dilantin Prothrombin Time

FT4 D-Dimer

Lactic Acid Fibrinogen

Phenobarbital

Phenobarbital

Salicylate

Theophylline

Troponin-I

TSH BLOOD BANK URINALYSIS

Type and Crossmatch* Urinalysis

Type and Screen* Urine Pregnancy

* Denotes that tests are not collected at any CBOC or Outpatient Clinic

# Denotes that these tests are processed but preliminary results will be available in 24 hours.

ROUTINE LABORATORY REQUESTS

Routine Laboratory requests are any requests that are not needed for critical purposes. They are also requests that are not needed for any specific time frame.

ROUTINE REQESTS:

1. Routine collections will be provided by the laboratory seven days per week including Holidays at the following times:

6 AM

2 PM

2. To request routine lab collects, use the following procedure:

a. Requests for routine lab draws must be identified as such in the computer and can be accomplished by using the Lab order function.

b. Requests for routine lab draws must be made using the above stated times ONLY.

c. All requests for routine lab draws must be placed in the computer ½ hour prior to the lab collect times.

3. In all cases, requests for the lab to draw blood must be ordered as “Lab Collect”. Requests for “Ward Collect” are not drawn by the Laboratory.

TURN-AROUND TIMES FOR ROUTINE TESTS PERFORMED ON-SITE

The routine turn-around time is defined as the interval between specimen receipt by the processing Laboratory personnel and the results reporting.

4 HOURS 8 HOURS 8 HOURS 24 HOURS 3 DAYS 48 HOURS 5 DAYS

Body Fluid Cell Count

Body Fluid Differential

PT

APTT

B-hCG, Quant., Serum

FDP

Fibrinogen

D-Dimer

Carbamezepine

Digoxin

Ethanol

Phenobarbital

Phenytoin

Theophylline

Tobramycin

Vancomycin

Valproic Acid

Lithium

Acetaminophen

Salicylate

Troponin-I

CSF Protein

MRSA by PCR

C. difficile by PCR

Flu/ RSV

CT/NG

Acetone

Albumin

Alk Phos

ALT

Ammonia

Amylase

AST

Bilirubin, Direct

Bilirubin, TL

BNP

BUP

Calcium

Chloride

Cholesterol

CK

CO2

Creatinine

Ferritin

FT4

GGTP

Glucose

HDL

Iron

Lactic Acid

LDH

LDLD

Lipase

Magnesium

Microalbumin

Potassium

Phosphorus

Protein, Serum

Protein, Urine

Sodium

TIBC

Transferrin

Trig

TSH

Urea Nitrogen

Uric Acid

Vitamin D

Urine chem’s

Fluid chem’s

Urine Drug

Screens

CBC

CBC w Diff

Retic Count

Sedrate

ABO TYPE

Type & Screen

Type and XM

Platelets

FFP

Direct Coombs

Urinalysis

Urine Pregnancy

Gram Stains

AFB Smear

Blood Culture

(Prelimary Report)

Legionella Urinary

Antigen

Hemosure

HgbA1C

Routine

Culture &

Sensitivity

Routine Surgical

Pathology

Routine Non-

GYN Cytology

Blood Culture

Final Report

30 DAYS

Autopsy Final

Report

LABORATORY CRITICAL VALUES

Hospital and Laboratory accreditation standards require that criteria shall be established for the immediate notification of the practitioners responsible for the care of the patient when critical limits of specified test results are exceeded.

Immediate notification of the physician by appropriate Laboratory personnel will be accomplished when the results of the following tests exceed critical limits:

CHEMISTRY

Sodium 120 and below 150 and above MMOL/L

Potassium 3.0 and below 6.0 and above MMOL/L

Glucose 50 and below 400 and above MG/DL

Calcium 6.0 and below 14 and above MMOL/L

Lithium - 1.4 and above MEQ/L

Amylase - 250 and above U/L

BUN* - 60 and above MG/DL

Creatinine* - 6.0 and above MG/DL

Lactic Acid - 5.0 and above MG/DL

Ethanol - 150 and above MG/DL

Theophylline - 15 and above UG/ML

Dilantin - 25 and above UG/ML

Phenobarbital - 60 and above UG/ML

Digoxin - >2.0 NG/ML

Magnesium 1.0 and below 4.5 and above MG/DL

CO2 10 and below 40 and above MMOL/L

Phosphorus 1.0 and below 10 and above MG/DL

Troponin I - 0.04 and above NG/ML

Uric Acid 16 and above MG/DL

TSH < 0.1 > 40 mIU/ ml

Acetaminophen > 200 µg/ ml

Salicylate > 25 mg/dl

* Those tests marked with an asterisk, BUN and Creatinine, are not defined as emergent for any dialysis patient. Therefore, direct communication of these results is not necessary.

HEMATOLOGY

WBC < 2,000 OR >20,000

HGB < 8.0 G

HCT < 21% OR >60%

PLT COUNT < 50,000 OR >800,000

CSF* > 5 Mononuclear cells and any Polymorphonuclear cells

COAGULATION

APTT > 53.2 seconds

INR >5.0

BLOOD BANK

Any patient who is a POSITIVE ANTIBODY SCREEN

Any patient with INCOMPATIBLE UNITS ON A CROSSMATCH

REFERENCE LAB STUDIES

Positive HIV Results

Abnormal Cytogenetic Studies

Any Critical called by the Reference Lab

MICROBIOLOGY

Positive Blood Culture

Clostridium in Wound Culture

Positive CSF Gram’s Stain or Culture

Positive TB Smear or Culture

Stool – Culture Positive for any Enteric Pathogen

Positive Systemic fungus Culture

Positive Joint, Bone, Pericardial, Pleural, and Peritoneal Cultures

Eye – Pseudomonas, Staphylococcus aureus, or Pure Culture of Any Organism

Positive MRSA

Positive C. difficile

Positive FLU/ RSV

SURGICAL PATHOLOGY AND CYTOPATHOLOGY

All first time diagnosis of Malignant diagnoses in biopsy or cytology specimens

A change in diagnosis that would have a critical impact on patient management

(this would include any unexpected findings in Cytopathology or Surgical Pathology)

All infectious pathogens requiring immediate therapeutic intervention

PROFILE DEFINITIONS

COMPREHENSIVE METABOLIC PANEL: Draw (1) 5 ml green top lithium heparin

Glucose BUN Creatinine Sodium Potassium Chloride CO2 Total Bilirubin Alkaline Phosphatase

Total Protein Albumin AST ALT Calcium

RENAL FUNCTION PANEL: Draw (1) 5 ml green top lithium heparin

Glucose BUN Creatinine Sodium Potassium Chloride CO2 Albumin Calcium Phosphorous

BASIC METABOLIC PROFILE: Draw (1) 5 ml green top lithium heparin

Glucose BUN Creatinine Sodium Potassium Chloride CO2 Calcium

HEPATIC FUNCTION PANEL: Draw (1) 5 ml green top lithium heparin

Albumin Alkaline Phosphatase Total Bilirubin Direct Bilirubin Total Protein ALT AST

PROFILE DEFINITIONS

LIPID PROFILE: Draw (1) 5 ml green top lithium heparin

HDL Cholesterol Triglyceride LDL

CARDIAC PROFILE: Draw (1) 5 ml green top lithium heparin

CPK CKMB TROPONIN I

VIRAL HEPATITIS TESTING

The following is a list of accepted abbreviations for the components and corresponding antibodies of the Hepatitis B Virus.

Hepatitis B Surface antigen HbsAG

Antibody to Surface antigen anti-HBs

Hepatitis B core antigen HgcAg

Antibody to core antigen IgM specific anti-HBc IgM

Hepatitis Be antigen HbeAg

Antibody to e antigen anti-Hbe

Hepatitis B Surface Antigen: It is first detected 4 to 12 weeks after exposure and, in 85% of patients, the surface antigen persists for less than 3 months. Patients categorized as a chronic carrier if surface antigen persists or more than 6 months.

Antibody to Surface Antigen: Usually appears during convalescence. It can persist for life, but in some patients it may disappear and only antibody to core remains. Patients with anti-HBs are not considered overly infectious, but they are not acceptable as blood donors.

Antibody o Core – IgM Specific: Virus specific IgM class antibody has been detected in most acute viral infections and is a reliable marker for acute disease. In some studies, anti-HBc IgM is the only specific marker for the diagnosis of acute infections with

Hepatitis B.

Hepatitis Be Antigen: It is typically detected 3 to 5 days after the appearance of surface antigen. At this time, patient is most infectious. Sera or other body fluids that are positive for e antigen are three to four times more likely to infect than those that are negative. The e antigen is usually detectable for 2 to 6 weeks.

Antibody to e Antigen: typically appears when the e antigen begins to disappear. Appearance of anti-Hbe has clinical importance because it almost always mean tht the acute viremic stage is ending and that the patient is unlikely to become a chronic carrier.

Antibody to e can persist for years, but it usually disappears sooner than anti-Hbs or anti-HBc.

SUMMARY: Five tests are now available for monitoring infections with HBV. Tests for HbsAG should be used to diagnose B hepatitis. Tests for anti-HBc confirm the diagnosis, identify silent carriers and detect past exposure to HBV. Tests for anti-HB confirm the resolution of the disease. Tests for HbeAg quantify infectivity. Tests for anti-Hbe indicate probable resolution of the infection.

SPECIAL INSTRUCTIONS FOR COLLECTING THERAPEUTIC DRUG LEVELS

DILANTIN: Specimen collected is a plain red top tube (6ml).

1. Peak levels should be obtained 3 – 9 hours after an oral dose or 2 – 4 hours after an IV loading dose.

2. Trough levels should be obtained immediately prior to the next dose.

3. Indicate date and time drawn.

THEOPHYLLINE: Specimen collected is a plain red top tube (6ml).

1. Blood Theophylline assays should be performed only after the planned dosage rate has been achieved.

2. Peak levels should be obtained 2-5 hours after oral dose

3. Trough levels should be obtained immediately prior to the next dose.

4. Include time and date drawn.

PHENOBARBITAL: Specimen collected is a plain red top tube (6ml).

1. Because of phenobarbital’s long elimination half-life, sampling time is unimportant; however, when making comparative measurements, the sampling times should be consistent.

2. Indicate the date and time drawn.

VALPROIC ACID: Specimen collected is a plain red top tube (6ml).

1. Peak levels should be drawn 1 – 3 hours after oral dose.

2. Trough levels should be drawn immediately before the next oral dose.

3. Indicate the date and time drawn.

4. Typically trough levels are collected for clinical use.

VANCOMYCIN: Specimen collected is a plain red top tube (6ml).

1. Peak levels should be drawn 1 hour after a dose given IM and 30 minutes after IV dose.

2. Trough levels should be drawn immediately before the next dose.

CARBAMAZEPINE: Specimen collected is a plain red top tube (6ml).

1. Peak levels should be drawn 2 – 4 hours after an oral dose

TOBRAMYCIN: Specimen collected is a plain red top tube (6ml).

1. Peak levels should be drawn 1 hour after a dose given IM and 30 minutes after IV dose.

3. Indicate the date and time drawn

DIGOXIN: Specimen collected is a plain red top tube (6ml).

1. Specimens should be collected no sooner than 5 – 6 hours after the dose is administered. However, serum levels can be drawn up to immediately before the next dose.

2. Indicate the date and time drawn.

SPECIAL INSTRUCTIONS FOR COLLECTING THERAPEUTIC DRUG LEVELS

ACETAMINOPHEN: Specimen collected is a plain red top tube (6ml).

1. Draw specimen 4 -6 hours postingestion for possible toxicity.

2. A second specimen should be collected 3 -4 hours after the initial specimen when looking for possible toxicity.

SALICYLATE: Specimen collected is a plain red top tube (6ml).

1. Collect specimen 2 – 6 hours after dosage.

2. For changes in dosage, collect 6 hours after the change.

COLLECTION OF 24 HOUR URINE

The following chart indicates the proper specimen preservative of the most common 24 hour urine collections. Procedures which share common preservative can be collected in the same 24 hour urine jug and will be analyzed together.

TEST REFRIG. ROOM

TEMP

6N HCL

30 ML

1 – 2 G

BORIC

ACID

NO

PRESERV.

Aldosterone X X

Calcium X X

Catecholamines X

Chloride X X

Citrate X

Copper X X

Cortisol, Free X X

Creatinine X X

Cystine Freeze to send

X

Glucose X X

5-HIAA X X

Immunoelectrophoresis X X

17-Ketosteroids X X

Lead X

Metals, Heavy X

Metanephrines, Fractionated X X

Methylmalonic Acid X X

Microalbumin X X

Oxalate X

Phlosphorus X X

Potassium X X

Protein Electrophoresis X X

Protein, Total X X

Sodium X X

Uric Acid X X

Urea Nitrogen X X

Vanilmandelic Acid

(VMA)

X

Zinc X

Indicates that this preservative can be used as an alternative to the one indicated

VENIPUNCTURE COLLECTION OF BLOOD

Procedure:

1. Assemble necessary equipment as follows: blood collection needles, safety shield needle holders, blood collection vacuum tubes, tourniquets, alcohol wipes, gauze, sharps disposal container, disinfectant, adhesive labels, waterless soap and powder free gloves.

2. Wash hands and put on gloves

3. Ask patient to identify himself/ herself by name. Ask patient his/ her full Social Security Number. Confirm the name and

Social Security number for the patient with the order labels for the patient.

4. Check patient preparation. Certain specimens may require fasting or other patient preparation. If special preparations were necessary, verify and note that the patient followed the instructions.

5. Select the appropriate tubes and needle for the specimens to be collected. Any tubes containing additives should be tapped to dislodge additives from the walls of the tube and the stopper.

6. Establish specimen collection order. The following order should be used:

a. BLOOD CULTURES

b. Citrate tubes (light blue----Coag)

c. Serum tube with or without clot activator, with or without gel (yellow top SST or red top----IA)

d. Heparin tubes with or without gel plasma separator (green)

e. EDTA tubes (lavender—Hematology & pink – Blood Bank)

f. Oxalate/ fluoride tubes (gray)

NOTE: When using a blood collection set (butterfly) for venipuncture and a coagulation tube is the first tube to be drawn, a discard tube (with at least 3cc of blood) must be drawn first. The discard tube must be a coagulation (blue) tube.

Position the patient. Ask the patient which arm is best for drawing blood. The patient should be comfortably positioned with the sleeve rolled up and the arm extended and supported by the blood-drawing chair.

7. Apply the tourniquet 3 to 4 inches above the puncture site. It should be restrictive enough to be slightly uncomfortable for the patient.

8. Ask the patient to make a loose fist. Any vigorous hand exercise like “pumping” must be avoided because if can affect test results.

9. Select a good venipuncture site. Avoid scarred or bruised areas. The median cephalic vein should be used if possible. If a good vein cannot be located, the following techniques may help.

a. Tapping the inner elbow skin with the index and second finger may cause the vein to dilate.

b. Massaging the arm from wrist to elbow to force blood into the vein and cause it to distend.

c. Applying a warm wet towel to the arm for 5 minutes may cause the vein to dilate.

d. Have the patient dangle the arm for 5 minutes to distend the veins.

Note: In any of these suggestions, it is important that the tourniquet is not left on for more than one minute as some test results may be affected.

10. Clean the puncture site. Use the alcohol wipe and make a smooth circular pass of the puncture site. Moving in an outward spiral from the zone of penetration. Allow the skin to dry before proceeding. Do not touch the puncture site after cleaning.

11. Break the seal on the needle. Do not remove the needle cap. Screw the needle into the plastic Safety Shield vacutainer holder. Do not pierce the tube as this will result in a loss of vacuum pressure.

12. Perform the venipuncture:

a. Holding the needle/ tube assembly in your dominant hand, remove the needle cap. Position the needle with the bevel up. (your right hand is dominant if you are right handed) Be careful that the safety device is not in the way.

b. Grasp the patient’s arm just below the puncture site with your non-dominant arm and pull the skin tight with your thumb

c. Align the needle/ tube assembly with a 15-degree angle to the skin. Use a quick, but small, thrust to penetrate the skin and enter the vein in one motion.

d. Holding the plastic-tube holder’s flange with the tube below the puncture site, push the tube onto the needle and puncture the stopper. Keep the tube at an upright angle to prevent tube additives from entering the patient. Blood should flow when the needle punctures the stopper. If it does not, then the needle is either too far in the vein or not in the vein. Backing the needle up a bit will work if the needle is too far in the vein. If it is not in the vein, shifting it should work. If you feel that the needle is in the vein and the blood still does not flow, use another tube.

e. After blood starts to flow, release the tourniquet and ask the patient to open his/ her hand.

f. Constant forward pressure on the tube is necessary to keep the shut-off valve from closing.

g. Remove the tube when blood flow stops. The shut-off valve will close to prevent leakage. If multiple tubes are needed, they should be inserted in the proper order as described above.

13. Remove the needle. A 2x2 inch gauze should be held just above the puncture site. Remove the needle quickly to minimize pain and immediately apply the gauze. Ask the patient to apply pressure to the gauze for at least 2 minutes. When the bleeding stops, apply a fresh bandage, or gauze and tape. The patient should be instructed not to remove it for at least 15 minutes.

14. Dispose of the needle and safety-shield vacutainer holder in a biohazard sharps container.

15. Initial all labels from the patient. While initialing, verify again that all order labels belong to that patient.

16. Place the order labels on all tubes appropriately.

17. Make sure the patient is all right. Confirm bleeding has stopped and patient feels normal.

VENIPUNCTURE COLLECTION IMPORTANT POINTS

1. When doing a venipuncture, after cleansing the skin with alcohol, the skin should be allowed to dry in the air. No alcohol should remain on the skin because traces may cause hemolysis and invalidate test results.

2. When specimens are being drawn for Ethanol levels, alcohol should not be used to cleanse the skin; a nonalcohol-based cleanser should be used to cleanse the skin. Chloraprep is the preferred cleanser.

3. Blood drawn from Arterial Lines or any other type of medical line should noted on the specimen label and this notation will be entered into the computer report comments. Laboratory personnel will not draw from Arterial Lines.

4. Patients with IV’s running: An arm containing an intervenous line should be avoided if at all possible. If it is absolutely necessary to draw from an arm with an IV, the IV should be shut off for 3 – 5 minutes before obtaining the specimen and the blood should be drawn below the IV site. Proceed by drawing the first tube as a discard tube. All tubes after this should be labeled indicating they have been drawn from an IV arm. This notation will be entered into the computer report comments.

5. Indwelling Lines or Catheters: Laboratory personnel will not draw from Indwelling lines or catheters. If at all possible, collection of blood should not come from these lines. If the blood must be drawn from an indwelling line, possible heparin contamination and specimen dilution should be considered. When obtaining specimens from indwelling lines that may contain heparin, the line should be flushed with 5 ml of saline, and the first 5 ml of blood or 6-times the line volume (dead space volume of the catheter) be drawn off and discarded before the coagulation tube is filled.

6. Coagulation Tubes drawn with a Blood Collection Set (Butterfly Needle):

It is necessary to draw a discard tube prior to drawing the coagulation tube when using a blood collection set (also known as a butterfly). A blue top tube (coag tube) with at least 3 cc of blood must be drawn first and discarded due to the dead space of the tubing when using the blood collection set.

7. Blood Cultures: For site preparation, vigorously cleanse the venipuncture site with a sterile choraprep starting in the center and wiping in an outward circular motion. Continue to make the circles wider until the entire area has been cleansed. Allow to dry for 30 seconds. Do not touch the venipuncture site after preparation and prior to phlebotomy. Use a venipuncture collection set (butterfly) for collection of blood. Allow for a minimum of 5ml of blood to ensure recovery of infectious organisms. Two sets of blood cultures should be drawn and they should be drawn from different sites.

BLOOD COLLECTION TUBES

The following is a list of tubes most frequently used in the collection of blood along with a brief description of each:

Yellow Top Serum Separator Tube:

-Vacutainer Brand tube with sterile interior

-SST Gel and Clot Activator

-5 ml size

-13 x00 mm

-Used for the collection of Serum

-The serum separator gel forms a barrier between the serum and the clotted red blood cells to keep them from contaminating the serum

-Invert the tube gently no more than 5 times (further inversion may cause altered sample integrity)

-Allow blood to clot for at least 20 min. but not longer than 1 hour

-Centrifuge a minimum of 10 minutes

-Used for the collection of most Serology and Immunoassay tests

Plain Red Top Tube (6ml size):

-Contains no additive (no anticoagulants or preservative)

-6 ml

-13 x 100 mm

-Used for the collection of serum

-Invert the tube gently after collecting about 5 times

-Used for the collection of All therapeutic drugs and drugs of abuse

Pink Top Tube:

-Vacutainer Brand (BD) tube with sterile interior

-Contains k2 EDTA (K2E) 10.8 mg

-6.0 ml size

-13 x 100 mm

-Used for the collection of plasma

- Tube must be inverted gently after collecting about 5 times to prevent the blood from clotting

-Centrifuge about 10 minutes

-Used for routine immunohematology testing (Blood Bank & BNP)

Lavender Top Tube:

-Contains (K2) EDTA 7.2 mg

-4 ml size

-13 x 75 mm

-Used for the collection of plasma and whole blood

-Invert gently 5 times after collection to prevent the blood from clotting

- Used for the collection of CBC’s, Ammonia levels, Glycosolated Hemoglobins, & HCV Viral Loads

Light Blue Top Tube:

-Vacutainer Brand Tube with sterile interior

-Contains 0.5 ml of 0.129 buffered citrate solution 9NC as an anticoagulant

-Vacutainer tube MUST be adequately filled with 2.7 ml of patient’s blood to ensure proper ratio between blood and anticoagulant sodium citrate

-13 x 75 mm

-Used for the collection of plasma

-Invert gently 5 times after collection to prevent the blood from clotting

-Used for the collection of Coagulation Studies

Gray Top Tube:

-Contains Potassium Oxalate 12 mg and Sodium Fluoride 15 mg

-6 ml size

-13 x 100 mm

-Used for the collection of plasma

-Tube must be inverted gently after collecting about 5 times to prevent the blood from clotting

-The potassium oxalate and sodium fluoride additives inhibit glycolysis

-Used for the collection of Plasma Glucose testing and Lactic Acids

Green Top Tube:

-Vacutainer Brand (BD) tube with Sterile interior

-Contains Sodium Heparin 158 USP units

-10 ml size

-16 x 100 mm

-Invert gently 5 times after collection

-Used for the collection of whole blood or fluids

-Used for the collection of fluids for cell count. Do not use for CSF.

-Also used for the collection T-spots

Mint Green Top Tube:

-Vacutainer Brand (BD) tube with sterile interior

-Contains Gel and Lithium Heparin

-4.5 ml size

-13 x 100 mm

-Tube must be inverted gently after collecting about 5 times to prevent the blood from clotting

-Centrifuge about 10 minutes; the gel will form a barrier between the red blood cells and the plasma

-Used for the collection of Ammonia levels, Troponins, and most Chemistries. Note: Ammonia Levels must be collected on ice.

White Top Tube:

-Vacuette tube (Greiner) with sterile interior

-Contains Gel and K2E EDTA K2

-5.0 ml size

-13 x 100 mm

-Tube must be inverted gently after collecting about 5 times to prevent the blood from clotting

-Centrifuge about 10 minutes; the gel will form a barrier between the red blood cells and the plasma

-Used for the collection of HIV Viral Loads and Intact PTH

Black Top Tube:

-Streck ESR-Vacuum Tube

-Contains 3.2% Sodium Citrate

-1.2 ml size

-Tube must be inverted gently, but thoroughly by inverting 8-10 times due to their smaller tube diameter and draw volumes

-Used for the collection of Sedrates (ESR) only

FASTING LABORATORY TESTS

The following is a list of the most commonly ordered fasting procedures:

4 Hour Fast

Catecholamine

8 Hour Fast

Carotene

Folate

Glucagon

Glucose (if patient is not a known diabetic)

Growth Hormone

Insulin

Iron & TIBC

Vitamin B12

12 – 14 Hour Fast

C-Peptide

Gastrin

PATIENT IDENTIFICATION

Proper patient identification is the first step in the Laboratory in assuring accurate and reliable test results. Therefore, before collecting a specimen, the technologist, phlebotomist, physician or nurse should follow this procedure:

Inpatients

1. Before collecting any specimens, a laboratory request must be in the computer.

2. It is necessary to identify all patients with (2) unique identifiers. The two unique identifiers are the patient’s full name and full social security number.

3. With a copy of the orders containing the patient’s name and Social Security number in hand, the collector will ask the patient his/ her full name. The collector will check the patient’s wristband and compare both the name and Social Security number with what is on the orders. For patients unable to respond, checking of the patient’s wristband with the requisition for the

EXACT information is sufficient. If patient does not have a wristband, but able to recite his/ her full name and full social security number, it is acceptable to draw all specimens with the exception of Blood Bank specimens.

If there is any doubt of patient identification, nursing personnel should be asked to identify the patient and a new wristband should be placed on the patient.

4. The specimen may only be collected when the patient’s proper identification has been established.

Outpatients

1. Before collecting any specimens, a laboratory request must be in the computer.

2. Each patient must be called upon individually by his or her name.

When the patient is in the phlebotomy room, the collector should ask the patient his/her full name and full Social Security number. If the patient is unable to give his/her full Social Security number, the collector must request to see the patients’ VA Picture identification card. This should ensure proper identification of each patient. The collector should pay close attention to making sure the name and Social Security number matches what is printed on the labels or order sheet that he/ she has.

SPECIMEN IDENTIFICATION

Every specimen coming to the laboratory must be properly labeled. This refers to ALL specimens including:

Blood collection tubes

Urine specimen containers

Culture Swabs

Blood Culture Bottles

Surgical Specimens

Cytology Specimens

Body Fluid Specimens

The patient identification label should be affixed directly to the bottle. Never affix labels to the lids of containers. All specimens

MUST be labeled in the presence of the patient.

ALL specimens submitted to the laboratory must contain the following information on the label:

1. Patient’s Full Name

2. Patient’s Full Social Security Number

3. Date and Time of Collection

4. Source of Specimen (if applicable)

5. Initials of the Employee collecting the specimen

All specimens forwarded to the laboratory should be placed in a two-part plastic biohazard bag. Place the labeled specimen in the ziplock portion of the plastic transport bag. Fold the orders into the pocket of the bag.

ALL specimens MUST be accompanied with orders.

CRITERIA FOR REJECTION OF UNSATISFACTORY SPECIMENS

Laboratory accuracy starts with a specimen that has been collected and handled properly. Recognizing this, the laboratory has established criteria for the rejection of unsatisfactory specimens. In the event that a specimen received by the Laboratory must be rejected, the ordering clinician will be notified. Documentation will be made in the comments of the computer that the clinician was notified and why the specimen was rejected.

However, for surgical and/or cytology specimens and for body fluids, the laboratory will make every effort to contact the collecting clinician to accurately identify the specimen. When the clinician can positively identify the specimen and knows the specimen cannot possibly from any other patient, the laboratory will allow the clinician to label the specimen. This process will be documented in the report in the computer.

The following is a list of criteria for rejection of unsatisfactory specimens:

The list does not pertain to body fluids, surgical and/ or cytology specimens.

1. Specimen Unlabeled

2. Specimen Mislabeled

3. Label hand written

4. Incomplete specimen identification

5. Specimen or container in which specimen was sent is grossly contaminated.

6. Specimen collected improperly

7. Specimen collected or submitted in improper container

8. Specimen of insufficient quantity

9. Sterility of specimen questionable

10. Specimen too long in transport

11. Specimen hemolyzed for a test where hemolysis will yield false results

12. Specimen clotted when it should not be

13. Specimens that should be frozen, received thawed

14. Specimen lacking preservative

15. Specimen containing improper preservative

16. Patient receiving medication which interferes with the test results

17. Patient not in a fasting state for tests requiring a fasting state

18. Patient not fasting for necessary period of time

19. Specimens received in a syringe.

(For example: joint fluids must be transferred to a heparinized tube immediately)

SPECIMEN TRANSPORT/ DELIVERY

FOR HOSPITAL WARDS

Specimen Container:

1. All specimens must be placed in a leakproof primary specimen container.

2. Care should be taken not to contaminate the outside of the primary container.

3. Plastic Bag: Before transporting to the laboratory, all specimens must be place into a plastic biohazard bag with a leakproof seal. Accompanying requisitions should be placed in the outside sleeve of the bag.

Delivery:

1. Transport specimens to the laboratory as soon as possible.

2. Certain tests require special immediate handling after collection. Refer to the test description option in the computer for appropriate handling and delivery requirements.

3. Time stamp all specimens (requisitions) delivered to the laboratory.

Communications:

1. Hand all CSF specimens directly to a laboratory staff member.

2. Notify laboratory personnel of the delivery of all STAT or time-dependent specimens

SPECIMEN PROCESSING

FOR OUTPATIENT CLINICS

SERUM PREPARATION:

1. Obtain a venous blood specimen. The following tubes will provide a serum specimen:

Yellow Top Serum Separator Tube 5ml, Plain Red Top Tube 6ml, and Plain Red Top Tube 10ml

2. Allow specimen to fully clot. Place a specimen vertically in a test tube rack as this will speed up the clotting action. When the clotting has completed, the blood will no longer “flow”. The clotting should be complete after 15 –30 minutes depending on the type of tube and patient condition.

3. Centrifuge the specimen at 3200 – 3400 rpm’s for a minimum of 10 minutes.

4. Serum should be separated from the red cells to avoid test interference. This should take place within one hour of collection.

Always avoid red cell contamination.

5. Refrigerate specimens not tested immediately at 2 – 8 C, unless otherwise specified. Refrigerate only after specimens are centrifuged.

6. Avoid specimen agitation. Hemolysis (the breakdown of red blood cells) will occur when the specimen is agitated. Avoid shaking the specimen and always use gentle inversion to mix specimens.

7. Avoid specimen excess exposure to light. Certain analytes (bilirubin is the most noted) break down when exposed to light.

PLASMA PREPARATION:

1. Obtain a venous blood specimen. The following tubes will provide a plasma specimen:

Lavender Top Tube containing K2 EDTA

Pink Top Tube containing K2 EDTA

Light Blue Top Tube containing Sodium Citrate

Green Top Tube containing Sodium Heparin

Mint Green Top Tube Lithium Heparin

2. Centrifuge the specimen at 3200 – 3400 rpm’s for a minimum of 10 minutes.

3. Plasma should be separated from the red cells to avoid test interference. This should take place within on hour of collection.

Carefully take off plasma with a disposal pipette, making sure not to enter the Buffy Coat of the specimen. Place plasma into a plastic pour off tube.

WHOLE BLOOD:

1. Obtain a venous blood specimen. The following tubes will provide a whole blood specimen:

Lavender Top Tube containing K2 EDTA

Pink Top Tube containing K2 EDTA

Light Blue Top Tube containing Sodium Citrate

Green Top Tube containing Sodium Heparin

2. If whole blood specimen is required, do not centrifuge.

HANDLING CONSIDERATIONS FOR BLOOD SPECIMENS

1. Keep the specimen tubes capped. This should be done for safety reasons as well as for specimen preservation.

2. Be sure to separate serum and plasma from the red cells prior to refrigeration.

SPECIMENS TO BE TRANSPORTED AS WHOLE BLOOD:

The following common tests are collected as whole blood and should be transported as whole blood. These tests will reach the laboratory the same day.

TEST TUBE SPECIMEN TYPE

CBC Lavender, EDTA Whole Blood

Hemoglobin A1C Lavender, EDTA Whole Blood

Protime Light Blue, Sodium Citrate Whole Blood

SPECIAL HANDLING FOR SOME SERUM SPECIMENS

The following common tests are collected in a plain red top tube. The specimen will be allowed to clot, then centrifuged.

After centrifugation, the serum will be pipetted off into the proper plastic transport tube and properly labeled.

Therapeutic Drugs Plain red Serum

RANDOM URINE SPECIMENS:

Random urine specimens should be poured off into the proper conical shaped tube with the cap tightly secured.

URINE CULTURE SPECIMENS:

Urine culture transport kits are available. Using Asceptic Technique, simply insert the vacutainer system into the urine specimen. Put the vacutainer tube containing preservative on the system.

REPORTS

You can view or print reports and results from either the Results Reporting option on the Clinician Menu or from the Reports tab on the Chart Contents Screen. The Reports tab only lets you print for individual patients. The RR option lets you select more than one patient at a time.

1. Select Chart Contents from the Cover Sheet

2. Select Reports from Chart Contents

Shortcut: Select CC; R

Cover Sheet Dec 27, 2007 17:41:44 Page: 1 of 2

Smith, J XXX-XX-1234 2B Jan 1, 1951 (46) <CWA>

Item Entered

Allelrgies/ Adverse Reactions

1 Moderate reatction to STRAWBERRIES (rash) 10/23/05

Patient Postings

4 CRISIS NOTE 02/24/07 08:28

Recent Vitals

B/P: 120/80 02/24/07 11:45

Pulse: 80 02/24/07 11:45

Immunizations

Tuberculosis 02/24/07 12:00

+ Enter the numbers of the items you wish to act on. >>>

Cover Sheet Orders Imaging Reports

Problems Meds Consults

Notes Labs D/C Summaries

Select chart component: R

Searching for the patient’s Chart…………….

Reports Dec 28, 2007 16:24:28 Page: 1 of 2

Selected date range: 12/28/06 thru 12/28/07

____________Report_____________________________________________________Date____________________________Status_______

1 Health Summary

2 Adhoc Health Summary

3 Vitals cumulative

Lab

4 Lab Cumulative

5 Lab Results by Day

6 Lab Results by Test

7 Lab Test Status

8 Lab Graph

9 Blood Bank Report

10 Anatomic Path Report

Orders

11 Daily Order Summary

+ Enter the numbers of the items you with to act on. >>>>

OR Other Reports… CV Change View… SP Select New Patient

AD Add New Orders CC Change Contents… Q Close Patient Chart

Select: Next Screen// <Enter>

Reports Dec 28, 2007 16:24:28 Page: 2 of 2

Selected date range: 12/28/06 thru 12/28/07

____________Report_____________________________________________________Date____________________________Status_______

12 Order Summary for Date Range

13 Custom Order Summary

14 Chart Copy Summary

15 Outpatient RX Profile

Dietetics

16 Dietetic Profile

Imaging____(08/26/06 to 08/26/07,___Limit__10)_____

Summary of Patient Procedures_____________________

+ Enter the numbers of the items you with to act on. >>>>

OR Other Reports… CV Change View… SP Select New Patient

AD Add New Orders CC Change Contents… Q Close Patient Chart

Select: Chart Contents// 2

Lab Cumulative Example

Report Display Mar 27, 1997 17:44:44 Page: 1 of 2

Lab Cumulative

---- BLOOD BANK -----

ABO Rh: A POS

Unit assigned/ xmatched: Exp date Loc

1) V11111 CPDA-1 RED BLOOD CE A POS APR 28, 1995 Blood Bank

Component requests Units Request Date Date wanted Requestor By

CPDA-1 RED BLOOD CELLS 4 03/29/95 16:33 03/29/95 16:33 KIL DM

ACD-A RED BLOOD CELLS 2 02/22/95 16:29 02/23/95 08:00 BOB DM

--------- AHG (direct) -------- ---AHG (indirect)------

Date/time ABO Rh POLY IgG Interpretation (Antibody screen)

+ Enter? For more help. >>>

+ Next Screen UP Up a Line PS Print Screen

- Previous Screen DN Down a Line PL Print Data

FS First Screen GO Go to Page Q Close

LS Last Screen SL Search List

Select Action: Next Screen// <Enter>

RESULTS REPORTING

You can print reports for multiple patients (e.g., all of the patients in a ward, or all of the patients on a Personal or Team List) through the Results Reporting option on the Clinician Menu.

See the next page for the Order summary for Date/ time Range Example

Order Summary for Date/ Time Range Example

OE CPRS Clinician Menu

RR Results Reporting Menu

AD Add New Orders

RO Act on Existing Orders

PP Personal Preferences …..

Select Clinician Menu Option: Results Reporting Menu

1A ward list

1 DOE, WILLIAM C. (6572) A-2 9 REGISTER, N P (9200) B-2

2 FEET, SMELL E. (1990) - 10 SCHWARTZ, ARNOLD (9022) -

3 HOOD, ROBIN (2591) - 11 SIMPSON, HOMER (9999) A-5

4 KIMINATOR, THE (3241) - 12 STONE, JERRY (2432) A-6

5 LAY, FRITO (8333) B-5 13 TRAT, JACK (2342) B-1

6 MUFFET, L M (7689) B-4 14 WINCHESTER, C E (0167) -

7 NEW, PATIENT (1234) - 15 ZORRO, MIGUEL (1414) B-3

8 NIVEK, SIGMA (2379) -

Select Patient (s): 12-13 STONE, JERRY (2432) A-6

TRAT, JACK (2342) B-1

R E S U L T S R E P O R T I N G

---Main Results Menu ---

1 Health Summary 8 Daily Order Summary

2 Lab Results (Interim) 9 Order Summary for Date/ time Range

3 Graph lab Tests 10 Customized Order Summary

4 Blood Bank Report 11 Print Chart Copy Summary

5 Anatomic Pathology Report 12 Work Copy Summary

6 Vitals SF511 Report 13 OUTPATIENT Pharmacy action profile

7 Vitals Cumulative Report

Select Item (s): 9 Order Summary for Date/ time Range

----Order Summary for Date/ time Range-----

Start Date (Time): T// t-30 (OCT 26, 1997)

Ending Date (Time) (inclusive): OCT 26, 1997 23:59// t (NOV 25, 1997)

DEVICE; HOME// ALPHA