36C25019R0093-026.pdf

VA NORTHERN INDIANA HEALTH CARE SYSTEM (VANIHCS)

October 2019 POLICY NO. 113-06-19

STAT AND ROUTINE LABORATORY PROCEDURES

1. PURPOSE: To define and establish policy for the use, ordering, turnaround time, and reporting of STAT and Routine laboratory tests.

2. POLICY: It is the policy of the Department of Veterans Affairs Northern Indiana Health Care System (VANIHCS) that STAT testing will take precedence; however, all testing will be done in an expedient and timely manner to aid the medical staff in their diagnosis and treatment of the patient.

3. DEFINITIONS:

a. Clear, Usable Lab Order: Laboratory orders for blood, urine, sputum, and stool are valid for 60 days from the scheduled date of collection. Additionally, laboratory orders scheduled for collection within two weeks ahead of the date the Veteran presents to the laboratory service are considered valid and may be used. Orders dated outside of these timeframes are unclear and will not be used. Orders more than 90 days past the scheduled collection date are expired and will automatically change to a “lapsed” status in CPRS. Lapsed orders are not valid orders and cannot be used.

b. STAT Lab Orders: To be utilized when a patient’s condition is deemed to be life threatening or a critical medical decision is pending outcome of the test. Specimen collection and testing are the highest priority. A list of STAT eligible tests is included as Attachment.

c. ASAP Lab Orders: To be utilized when the patient’s condition is not life threatening or critical, but results are needed in a timely manner. Specimen collection and testing are prioritized after STAT orders, but before Routine orders.

d. Routine Lab Orders: To be utilized when the results are not time sensitive.

Specimen collection and testing will be prioritized after STAT and ASAP orders.

e. Lab Collection: This collection type is utilized when the specimen is to be drawn as part of the routine inpatient unit collections. It is automatically scheduled for the next morning collection unless a specific date is selected.

f. Timed Collection: These orders must be collected at a specific time and are ordered as an “Immediate Collect” collection type with the actual time of collection selected. They may be ordered as Routine, STAT or ASAP priority depending on how quickly after collection the result is needed.

g. Ward Collection: This collection type is utilized for specimens collected by the inpatient unit staff. For example, urine specimens or culture swabs.

POLICY NO. 113-06-19

h. Send Patient to Lab: This collection type is utilized when the patient will be sent to the Outpatient lab area for specimen collection.

i. Immediate Collect: This collection type is utilized when the specimen needs to be collected the same day it is ordered. All orders from the emergency room will be entered as Immediate Collect with a STAT, ASAP or Routine priority as determined by the provider depending on how quickly after collection results are needed.

j. Patient Identification: Verification of patient identification will be completed prior to all specimen collections according to the Patient Identification Process policy 00Q-11.

k. Accessioning: The computer process which accepts the order into the laboratory and changes the status from pending to active in CPRS.

4. RESPONSIBILITIES:

a. The Chief, Pathology and Laboratory Medicine Service (PALMS) or designee is responsible for:

(1) Education of providers on proper Laboratory order priorities and collection types;

(2) Education of laboratory staff on expectations for each priority and collection type;

(3) Ensuring the STAT list is appropriate for the VANIHCS population; and

(4) Ensuring turnaround times meet the expectations set forth in this policy.

b. Laboratory Staff are responsible for:

(1) Utilizing collection types to identify orders requiring collection;

(2) Utilizing order priorities to manage workload;

(3) Properly collecting, labeling and transporting blood specimens to the laboratory testing area; and

(4) Organizing workload to assure turnaround time expectations are met.

c. Primary Care Services is responsible for:

(1) Entering orders for laboratory services utilizing the appropriate collection type and priority; and

(2) Arranging for laboratory notification when indicated.

d. Patient Care Services is responsible for:

(1) Notifying laboratory of provider lab orders when indicated;

(2) Properly collecting, labeling and transporting non-blood specimens to the laboratory testing area;

(3) Properly collecting, labeling and transporting blood specimens collected by nursing staff to the laboratory testing area; and

(4) Providing laboratory collection and ancillary testing services to the Marion Campus during non-administrative hours.

5. PROCEDURES: Orders for laboratory testing entered with the appropriate priority and collection type designation ensures testing is completed as needed for patient care.

Testing available on a STAT basis is listed on the attached STAT list and is the same for all campuses; however, there are some procedures that must be sent out at each campus due to on site testing availability.

a. Fort Wayne Campus:

(1) Tests requested to be collected during routine morning inpatient collections must be entered into the computer by 4:00am the day they are to be collected to insure they appear on the laboratory’s collection list. They are entered with the collection type “Lab Collect”.

Timed collections are entered as a Routine, ASAP or STAT priority, as determined by the ordering provider, with the date and time of collection specified and the collection type “Immediate Collect”. The laboratory will receive a printed copy of the order:

(a) Timed Troponins are ordered as any other time draw and may be ordered as Routine, STAT or ASAP depending on the patient’s condition. They must NEVER be ordered as a Lab Collect specimen;

(b) Nursing staff will maintain a log of timed collections for each day;

(c) Laboratory staff will initial the log after the specimen has been collected;

and

(d) Log will be forwarded to the Lab supervisor at the end of each administrative day in a secure and confidential manner.

(2) STAT/ASAP orders are entered with the appropriate priority and a collection type of “Immediate Collect”. The laboratory will receive a printed copy of the order;

however, the laboratory must be called to alert them to the order and insure a timely response for laboratory collected specimens:

(a) Inpatient/ER collections by laboratory staff:

1 Nursing staff will notify laboratory by calling 71903 (Administrative hours) or 71741 (Non-Administrative hours);

2 STAT collections should be completed within 20 minutes of telephone notification. If the laboratory staff will be unavailable to perform the collection within 20 minutes, the ward will be contacted within 10 minutes of the page/call and an estimated time of collection will be provided;

3 Orders are accessioned at the time of notification so that lab barcode labels are available for specimen labeling. Time of collection and collector’s initials are added to the specimen labels by the collector; and 4 After collection and proper labeling, laboratory staff will transport specimens to the testing area or arrange for transport if additional collections in the area are required.

(b) Collections by nursing staff with IV starts:

1 Nursing staff will make every attempt to collect blood at the same time as starting an intravenous line:

a Blood will be collected by nursing staff at the time the intravenous line is initiated;

b Orders will be entered into CPRS; and c Blood specimens will be immediately transported to the testing section of the laboratory service (Rm. 249).

2 Preprinted patient labels will be utilized for specimen labeling. Date and time of collection along with collector initials must be added to the label;

3 After collection and proper labeling, nursing staff will immediately transport or arrange for transport to the testing area by a unit staff member.

4 The order will be accessioned immediately upon arrival in the laboratory.

5 If the specimen is not received in the laboratory within thirty minutes after the order prints, laboratory staff will contact the ward to determine the collection status of the order.

(3) Ward collections are collected by nursing staff in the patient care areas:

(a) Preprinted patient labels will be utilized for specimen labeling. Date and time of collection along with collector initials must be added to the label;

(b) After collection and proper labeling, nursing staff will transport or arrange for transport to the testing area by a unit staff member; and

(c) Orders are accessioned upon arrival of the specimen in the laboratory.

(4) Outpatient laboratory services are available during administrative hours. It is essential that orders for outpatient laboratory testing be clear, unambiguous, and within the established timeframes for a clear, usable order (scheduled for collection no more than six months in the past or two weeks in the future) when the patient presents for service.

b. Marion Campus:

(1) Tests requested to be collected during routine morning inpatient collections must be entered into the computer by 4:00am the day they are to be collected to insure they appear on the laboratory’s collection list. They are entered with the collection type “Lab Collect”;

(2) The laboratory is available for routine inpatient specimen collections during administrative hours. Requests for collections must be entered with the collection type of “Immediate Collect” and the order number called to the laboratory staff;

(3) Timed collections are entered as a Routine priority with the date and time of collection specified and the collection type “Immediate Collect”. The laboratory must be called with the order number and the desired time of collection;

(4) STAT/ASAP orders are entered with the appropriate priority and a collection type of “Immediate Collect”. The laboratory must be called with the order number to initiate the collection; and

(5) Ward collections are collected by nursing staff in the patient care areas:

(a) Preprinted patient labels will be utilized for specimen labeling. Date and time of collection along with collector initials must be added to the label; and

(b) After collection and proper labeling, nursing staff will transport or arrange for transport to the testing area by a unit staff member.

(6) Outpatient laboratory services are available during administrative hours. It is essential that orders for outpatient laboratory testing be clear, unambiguous, and within the established timeframes for a clear, usable order (scheduled for collection no more than 60 days in the past or 14 days in the future) when the patient presents for service;

and

(7) During non-administrative hours, STAT tests, selected from the STAT list, are performed as ordered by the provider. Orders are entered with a priority of “STAT” and the collection type “Immediate Collect”:

(a) Tests not on the STAT list may be run STAT; however, the provider must first contact the Chief, Pathology and Laboratory Medicine Service (PALMS), or designee, with special requests;

(b) Non-administrative hours’ laboratory collections are performed by trained nursing personnel and sent to Parkview Wabash Hospital for testing. Nursing personnel trained in phlebotomy can be contacted through the Nurse Coordinator; and

(c) Laboratory results are faxed from Parkview Wabash Hospital directly back to VANIHCS Marion Triage and given to the provider for review.

c. St. Joseph County VA Clinic (SJCVAC), Mishawaka:

(1) SJCVAC provides routine and stat testing for basic hematology, coagulation, chemistry and urinalysis during administrative hours for outpatients;

(2) Stat testing for emergency situations may be ordered by the clinicians.

Nursing will call the lab at 79617,79618, or 79383 to notify the lab staff that a stat order has been placed; and

(3) STAT/ASAP orders are entered with the appropriate priority and a collection type of “Immediate Collect”. The laboratory must be called with the order number to initiate the collection.

(a) Preprinted patient labels will be utilized for specimen labeling. Date and time of collection along with collector initials must be added to the label; and

(b) The patient should be sent to the lab for specimen collection. If the clinician feels the patient cannot be sent to the lab, a phlebotomist will go to the patient location and draw the specimen.

(4) Outpatient laboratory services are available during administrative hours. It is essential that orders for outpatient laboratory testing be clear, unambiguous, and within the established timeframes for a clear, usable order (scheduled for collection no more than 60 days in the past or 14 days in the future) when the patient presents for service.

d. Result Reporting:

(1) All laboratory test results are reported via the computer, and any critical (panic) values are called per the Critical Value Policy;

(2) Test results for testing performed during non-administrative hours at the Marion Campus, either as ancillary testing or at Parkview Wabash Hospital, are entered into the VANIHCS computer system as soon as possible by laboratory staff during administrative hours;

(3) STAT turnaround time for in house testing has been defined as one hour after the order is accessioned in the laboratory. Do not call the Laboratory for results unless there has been more than a reasonable delay. Unnecessary calls interrupt procedures and delay testing;

(4) ASAP turnaround time for in house testing has been defined as two hours after the order is accessioned in the laboratory. Do not call the Laboratory for results unless there has been more than a reasonable delay. Unnecessary calls interrupt procedures and delay testing;

(5) Routine turnaround time for in house testing has been defined as less than or equal to one day. This may be extended in the event of instrument malfunctions that cannot be resolved within one day;

(6) Any specimen determined to be unsuitable for testing will be rejected. The ordering provider, provider responsible for the patient at the time of this determination, or charge nurse (for inpatients) will be notified that the testing cannot be performed. A new order will be requested if necessary;

(7) Any result determined to be non-reportable will be reported out with an appropriate comment. The ordering provider or provider responsible for the patient at the time of this determination will be notified that the testing cannot be performed;

(8) Tests offered by the Laboratory will not be sent out to a fee basis laboratory, except in an emergency. Authority for such must come from the Chief, PALMS, or designee; and

(9) Tests not performed in house and sent to reference laboratories have had turnaround times defined in the bidding process.

6. REFERENCES:

a. College of American Pathologists General Checklist, revised 2015

b. VHA Handbook 1106.1, Pathology and Laboratory Medicine Service (PALMS) Procedures, dated January 29, 2016

7. RESCISSIONS: Medical Center Policy 113-06, Stat and Routine Laboratory Procedures, dated September 30, 2015 will be formally rescinded with the publication of this revised version. The processes and procedures outlined in 113-06-15 will remain in effect until that time.

8. REVIEW DATE: September 29, 2022

9. FOLLOW-UP RESPONSIBILITY: Chief, Pathology and Laboratory Medical Service

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X Susan M. Sorensen, MD

SUSAN M. SORENSEN, MD

Chief, Pathology and Laboratory Medicine S...

Signed by: Susan M. Sorensen 175695

10/8/2019

X Audrey L. Frison, RN

AUDREY L. FRISON, DM, MHA, BSN, RN

Associate Director Patient Care Services Signed by: people

10/9/2019

X choudry

PERVAZ M. CHOUDRY, MD

Acting Chief of Staff

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X James queener (Acting For)

JOHN PHILLIP SHEALEY, DBA, MBA, HFMA, A...

Associate Director Signed by: james.queener@va.gov

X Teresa I. Calhoun (Acting For)

DAVID M. MILLER

Acting Assistant Director Signed by: Teresa I. Calhoun 118213

X Michael E. Hershman

MICHAEL E. HERSHMAN, MHA, FACHE

Director

Link to Attachment