36C25718R0247-031.docx

South Texas Veterans Health Care System

Pathology & Laboratory Medicine Service

Laboratory Guide

2016 - 2017

TABLE OF CONTENTS

PATHOLOGY CONTACT INFORMATION

Administration

Staff Pathologists

David Feldman, M.D.

14968

Muhammad Pathan, M.D.

17573

Huma Siddiqui, M.D.

17574

Shiwen Yang, M.D.

17571

Andrea Yunes, M.D.

17819

Surgical Pathology

Surgical Reports

14959/14960

FNA’s

(210) 203-4856

Resident On Call

(210) 693-5103

Phlebotomy & Receiving

Specimen Receiving

14998

Outpatient Drawing Room

16093/16099

Core Laboratory

Coagulation

16542

Urinalysis

16047

Hematology

14993

Sendouts

14996/17840

Chemistry

17863/16494/17859

Microbiology

Micro Lab

14802

TB Lab

17867

Transfusion Medicine Unit

Blood Bank

14988

Hematopoietic Stem Cell Processing Lab

17805

Apheresis Unit

17937/17938

Specialty Diagnostics Unit

Flow Lab

17523

FISH/Cytogenetics Lab

17524

Molecular

16039/16037

After Hours Operations

Kerrville Campus

North Central Federal Clinic

Lab

65740

Outpatient Clinics

Frank Tejeda Phlebotomy

65128

South Bexar Phlebotomy

64873

Victoria OPC Phlebotomy

65128

PATHOLOGY AND LABORATORY MEDICINE SERVICE

I. OVERVIEW

South Texas Veterans Health Care System (STVHCS) is 1A complex facility that serves 63 counties and is comprised of Audie L. Murphy VA Medical Center, Kerrville Campus, and several Community Based Outpatient Clinics. The Audie L. Murphy VA Medical Center offers 250 operating beds and provides the following Acute Care services: Medicine, Surgery, Mental Health, Physical Medicine & Rehabilitation, Geriatric, and Primary Care. STVHCS provides Specialty Services in: Spinal Cord Injury Center, Community Living Center, Polytrauma Rehabilitation Center, Substance Abuse Residential Rehabilitation Treatment Program, Bone Marrow Transplant, Open Heart Surgery, and Radiation Oncology. STVHCS offers a Level II research facility, ninth largest VHA research program with more than 400 projects.

The Department of Pathology and Laboratory Medicine Service offers comprehensive pathology services 24 hours a day, 7 days a week, in the following subspecialties at the Audie L. Murphy facility:

· Anatomic Pathology (Surgical pathology, Cytopathology, and Autopsy)

· Clinical Pathology (Core Lab, Microbiology, and Immunology)

· Transfusion Medicine (Blood Bank, Hematopoietic Stem Cell Processing Laboratory, and Apheresis Unit)

· Flow Cytometry

· Cytogenetics and Molecular Cytogenetics

II. ACCREDITATIONS

The department is fully accredited and in compliance with The College of American Pathologists (CAP) and AABB (formerly known as The American Association of Blood Banks), and the Foundation for the Accreditation of Cellular Therapy (FACT). The department is staffed by nationally reputable staff.

The goal of the Department of Pathology South Texas Veterans Healthcare System, Audie L. Murphy Division is to provide to both the patient and physician the highest quality laboratory service possible.

III. HOURS OF OPERATION AND LOCATION

The Specimen Receiving Area and main entry to the laboratory is located in Room T107. The specimen receiving area is open 24 hours a day, seven days a week for receipt of specimens. Regular business hours are 8:00 am to 4:30 pm, Monday through Friday. A limited staff is on duty after regular hours, weekends and holidays.

A. Outpatient Phlebotomy Services

An Outpatient Phlebotomy room is located the 1st floor located in room 132. The reception station will collect blood and urine specimens from any patient with a properly completed electronic request. This service will be provided from 6:00 a.m. to 5:00 p.m. Monday-Friday.

B. Inpatient Phlebotomy Services

The Pathology Laboratory collects blood specimens of inpatients each morning beginning at 4:00a.m. Tests requested for Ward Collection must be ordered in CPRS/VISTA by 3:45 a.m. in order to be on the 4:00 am collection list. An 11:30 am morning blood collection round is conducted Monday - Friday to the tower units. CPRS/VISTA orders must be received by 10:45 am for the second ward collection. Ambulatory patients may be sent to the laboratory, Room 132 from 6:00 a.m. to 5:00 pm, Monday - Friday. Contact the Phlebotomy Supervisor at ext. 17818 for additional information. Exceptions:

1. Phlebotomists on ward blood draws provide service to multiple floors and therefore are not available to deliver other specimens such as blood, urines, and cerebrospinal fluid to the laboratory. Such specimens should be hand delivered to the laboratory upon collection by ward personnel.

2. STAT specimens must be collected by ward personnel and hand delivered to specimen receiving area upon collection.

3. Blood cultures must be collected by the attending physician or nursing personnel and hand delivered to the laboratory upon collection.

4. Blood gas analyses is performed by the Anesthesiology Service (Ext. 15510) located on the second floor, near Surgery.

IV. CPRS LAB ORDERS

All laboratory test requests, with the exception of Blood Bank, Surgical Pathology and Cytopathology, must be entered electronically in CPRS by an authorized provider. Verbal orders will not be accepted. The CPRS order number is a unique number and is the only identifier for lab personnel to access orders for a unique patient. The CPRS order number must accompany the specimen to the laboratory. Additional information about the use of the CPRS system for ordering laboratory tests can be obtained by contacting your assigned CPRS trainer or by contacting one of the Clinical Application Coordinators at (210) 316-0348.

Unclear Orders consisting of non-standard or non-specific terms must be clarified prior to testing of the specimen. The ordering provider will be contacted for additional information and clarification on the test requested.

Specimen collection may be ordered as either: Ward Collect, Send Patient, Lab Collect.

A. Ward Collect

Specimens to be collected by ward personnel (medical staff, nursing staff) should be ordered in CPRS as “Ward Collect. Microbiology specimens must be collected by ward or clinic personnel.

B. Lab Collect

Inpatient specimen collection by Laboratory personnel should be ordered as “Lab Collect.” Orders must be entered for the next day’s collection by 3:45 a.m. (Sunday through Saturday) or 10:45 (Monday-Friday). Microbiology specimens must be collected by ward or clinic personnel.

C. Send Patient

The Send Patient” option should be used for ambulatory patients capable of walking to Outpatient Phlebotomy Room 132 for specimen collection. Outpatient Phlebotomy is open 6:00 a.m. to 5:00 p.m., Monday – Friday.

D. Add On Orders/No Verbal Orders

To add a test to a previously collected specimen, please contact the appropriate Laboratory Section. Provide a laboratory order number when contacting the Laboratory Section and personnel will advise you if specimen is acceptable for testing. Laboratory policy does not allow for the acceptance of verbal orders for original or add-on tests.

V. LABORATORY TEST PRIORITY

Laboratory tests may be ordered as:

A. Routine

The majority of tests ordered fall into this category and automatically default to this priority in CPRS. Test results are typically available within 4 hours.

B. STAT

STAT requests will be given the highest priority and will be completed within 60 minutes from the time of receipt. Test results will be available in VISTA/CPRS. STAT specimens must be received in the laboratory immediately after collection.

C. ASAP

For Blood Bank use only, ASAP orders are completed within 2 hours

D. Preop

For Blood Bank use only ordered for Surgery workup. Specimens are treated as routine tests are available within 4 hours.

VI. SPECIMEN COLLECTION REQUIREMENTS

The laboratory specimen receiving area is staffed 24 hours a day, seven days a week to receive routine and STAT specimens. It is important that the specimen type and the time collected placed on the specimen label by the collector. Special precautions that should be observed when collecting a specimen for laboratory examination are outlined below:

A. Patient Identification

Two identifiers must be used for confirming patient identification and the information must match exactly.

1. Inpatients

Inpatients are required to have a hospital wristband at all times. The wristband will contain the patient’s full name and date of birth along with patient flags. Flip the armband to locate the patient’s full social security number.

2. Outpatients

Outpatients do not have an armband with the exception of patients presenting for collection of a blood bank specimens. Patient identification will be verified by asking the patient for their Veterans Health Identification Card (VHIC) and other photo ID and SSN. Upon accession, the patient’s full social security number and patient picture identification will be verified. Prior to specimen collection, the phlebotomist will ask the patient to state their full name and full social and will be compared to the accession label.

B. Specimen Collection Device

Refer to VISTA or this guide to determine patient preparation instructions, volume required, and specimen collection device required for the tests desired. For additional information regarding specimen requirements, contact the appropriate laboratory section.

C. Specimen Labeling

All specimens must be labeled at the bedside or at the phlebotomy chair and prior to the patient leaving. Specimens submitted to the laboratory must be legibly labeled with the patient’s full name, full social security number, date and time collected, and the collector’s name. Place labels on tubes directly under cap; ensure labels are straight; labels used must not be larger than 1 inch x 2 5/8 inch. (See photo)

NOTE: For blood bank specimens, refer to the STVHCS Blood Administration Policy.

D. Specimen Requisition/Order Form

1. Inpatient specimens should be accompanied with a copy of the CPRS order. During Computer downtime, an overprinted VA Miscellaneous Requisition Form with the list of tests requested should be used.

2. Outpatient specimens should be accompanied with a copy of the CPRS order or VA Miscellaneous Requisition Form with the lists of tests requested.

3. Computer Downtime requires the use of the VA Miscellaneous Requisition Form. See Computer Downtime section of this manual.

E. Special Arrangements for Selected Procedures

Some procedures must be scheduled in advance or are not available at all times (i.e., glucose tolerance tests, frozen sections). Some procedures are performed only after consultation with the physician in charge of the laboratory. When in doubt call the laboratory for clarification.

VII. CRITERIA FOR REJECTION OF REQUESTS AND/OR SPECIMENS

A. Specimen is not labeled.

B. Specimen container is grossly contaminated on the outside with blood, CSF, urine

C. Specimen is unsatisfactory for the test requested.

D. Syringe with needle still attached, except for “minute” specimens that are entirely contained in the needle. Contact a pathologist or technologist when personally bringing this type specimen to the lab.

E. The wrong request form is submitted.

F. Leaking specimen containers.

G. The following information is absent, illegible, or ambiguous on the request slip:

1. Patient’s full name.

2. Order number.

3. Patient’s identification number (SSN).

4. Origin of specimen.

5. Examination requested.

6. Requesting physician’s name.

7. Date and time specimen collected.

H. Difficult specimens to collect such as Cerebral Spinal Fluid may be relabeled by the person who collected the specimen by coming to the laboratory and signing the attestation form and assumes full responsibility as to the accuracy of patient identification.

VIII. STAT TESTS

Calcium, Plasma

URINALYSIS

CK MB, Plasma

Phosphatase Alkaline, Plasma

Salicylates, Plasma

Troponin, Plasma

Unfractionated and LMW Heparin Assays Spinal Fluid Cell Count Fibrinogen Hemoglobin and Hematocrit Partial Thromboplastin Time Prothrombin Time/INR Platelets

IX. CRITICAL VALUES

Critical or “Panic” Laboratory Values are called to the ordering provider or authorized representative. Laboratory staff is required to obtain the name of the individual that receives the critical result and that the individual receiving the critical result reads the result back to the technologist.

*Repeat stable values will not be called

X. SECTION TURN-AROUND TIMES

A. STAT Tests:

Clinical Pathology can provide many chemistry, hematology toxicology and urinalysis tests on a STAT basis (see table on page 7), if medically necessary. Turnaround time is 60 minutes from time of receipt.

B. Routine:

Clinical Pathology processes all non-stat test requests within one working shift from receipt and all STAT procedures within one hour of receipt in the analytical section. STAT turn-around time averages less than 60 minutes. Routine cultures usually require 2 to 3 days to complete, and specialty tests that are shipped to reference laboratories may take 3 to 10 work days complete.

C. Blood Bank:

Type and Screen, Crossmatch, Direct Anti-globulin Test-have the following turnaround times:

STAT = 1 hour ASAP = 2 hours Preop = for Surgery cases, treated as Routine, 4 hour turnaround time Routine = 4 hours Any unexpected incompatibility or presence of unexpected blood group antibody(ies) can prolong turnaround time from hours to days (usually less than 12 hours, however).

Emergency released blood components and Immediate Spin crossmatches are available within 5-10 minutes from ordering.

E. Routine Surgical Pathology:

Routine Surgical Pathology cases are usually verified within 2 working days complicated cases within 10 working days.

F. Cytopathology:

Cytopathology will routinely issue a report within 5 working days from receipt of a specimen or slide.

G. Anatomic Pathology:

Anatomic Pathology will issue a preliminary report within two duty days for all autopsies, followed by a final report within thirty days for routine cases and a final report within 60 days for complicated cases.

XI. CONTINGENCY PLAN FOR SCHEDULED AND UNSCHEDULED COMPUTER DOWNTIME

The contingency plan will take effect when it is determined that the hospital computer system will be unavailable to users for a period of at least 2 hours or within 1 hour of sustained unresolved inconsistencies in lab processing data.

During scheduled downtime (weekly back-ups and monthly maintenance), the morning phlebotomy collection list will be built before downtime. Any tests entered after the list is built will be on the subsequent collection list.

During unscheduled downtime, all specimens delivered to the laboratory must come with a lab slips (Miscellaneous Standard forms 557). The following information should be included; patient’s name, SS#, provider’s name, tests, urgency, location and phone number.

OIT (Vista System) is responsible for alerting Vista computer users of downtime and the length of time the computer will be down. OIT is responsible for verifying by phone with P&LMS that computer functions are fully operational.

Wards clerks, clinic clerks and nursing staff area responsible for preparing lab slips (Miscellaneous Standard forms 557) to be used in Pathology and Laboratory service.

P&LMS is responsible for calling critical values and delivering lab reports to units and clinics and ensuring critical lab reports are received by the respective units and clinics.

Lab test reports will be printed in duplicate; lab will keep one copy and the second copy will be periodically given directly to the respective during each shift as possible. Lab results during computer unavailability will be reported in the following manner:

· All critical values will be called to the requesting location as soon as available.

· Routine test result lab slips will be delivered to the units by lab personnel at least 4 times during the day shift (approx. 0930, 1130, 1330, and 1530) twice on the evening shift (1830 and 2130), and once on the night shift (0400). STAT results will be delivered to wards on the hour.

· Second copies of the lab slips will be kept in the lab processing section in folders sorted by unit for provider review. When the computer comes back on line, all Lab results will be entered to maintain data integrity.

· If VISTA/CPRS/VBECS computer system is unavailable for 48 hours or more, the current Laboratory Disaster Plan will be activated and lab staff recalled entering manual test results.

All test results will be entered into VISTA/CPRS /VBECS as soon as the system becomes available for use.

CORE LABORATORY

CHEMISTRY SECTION

PHONE: 617-5300 Ext: 17861

LOCATION: T110

MEDICAL DIRECTOR: Andrea Yunes, M.D., Ext: 17819

CORE LAB MANAGER: Oswald L. Johnson, Ph.D., Ext: 14799

LEAD TECHNOLOGIST: Veronica Gonzales, Ext: 14516

LEAD TECHNOLOGIST: Susan Coulthart, Ext: 14987

HOURS: Open 24 hours a day, 365 days

I. GENERAL INFORMAITON

The Core Lab Chemistry Section offers a variety of laboratory tests on a STAT, or routine basis in the general, and special chemistry areas on a range of specimens: plasma, serum, CSF, and urine.

II. SPECIMEN IDENTIFICATION

Full patient name and full social security number are the two mandatory patient identifiers for STVHCS. Unlabeled, mislabeled, incomplete patient identification, QNS, improperly handled and hemolyzed specimens will result in specimen rejection. Rejected specimens will be discarded and will require submission of a new specimen. Specimens difficult to recollect such as CSF may be corrected after the responsible person has come to the laboratory and signed the attestation sheet accepting responsibility for the correct identification of the specimen and the patient.

Note: If patient has been admitted via “Triage” unit, please consult chart before requesting laboratory work to avoid duplication of work and unnecessary venipuncture.

III. SPECIAL COLLECTION INSTRUCTIONS

A. Time Urine Collection (24 hrs.)

Have the patient empty his/her bladder at the time the collection period is to begin and discard this urine. Have the patient begin collection at this time and save all urine in the proper container for the next 24 hours. Be sure the patient empties his/her bladder at end of the time period and that urine is saved so that a complete specimen is obtained. Creatinine is assayed on all 24-hour urine specimens so that the validity of the complete collection can be verified (1.0-2.0 gm/day is normal).

Many compounds excreted into the urine have a normal diurnal variation, therefore, excreted at different rates during the timed collection period. It is, therefore, important that one not remove a portion of a timed urine specimen for a separate test analysis.

Many drugs interfere with test analysis. If possible, remove the patient from all drugs for 72 hours prior to and during collection.

B. Blood Ammonia

The specimen must be drawn in a green lithium heparin vacutainer and immediately placed in ice. Sample must be centrifuged within 10 minutes of collection. Note the exact time of collection on the request slip so that no more than 3 hours will elapse from the time of collection and icing and the start of analysis.

C. Lactate

Freshly drawn plasma or cerebrospinal fluids are the preferred specimens. Chill the specimen immediately. Blood should be drawn in a gray top tube (potassium oxalate/sodium fluoride) without stasis because venous stasis may cause lactate elevation. Samples must be centrifuged within 15 minutes of collection and must remain in ice prior to analysis.

D. Parathyroid Hormone Intra-operative (PTHIO)

1. An appointment must be made with the laboratory x 14516 or 14799 before this test is drawn to insure immediate processing when the specimen reaches the laboratory. Please bring tubes direct to the Core Lab Chemistry Section

2. The specimen must be drawn in a purple top EDTA vacutainer tube and immediately delivered to the lab for processing. Patient Full Name, full SSN, Date and Time must be on the tube. Additionally, each tube should indicate which specimen in the series (Baseline, #1 post baseline, #2 post baseline, #3 post baseline, etc.)

3. The Laboratory will order the test in VISTA after testing has been manually programmed and initiated.

E. Quantitative Urine for Calcium

1. Patient should be placed on a low calcium and neutral ash diet (no dairy products) for three days prior to collecting specimen. (Doctor may specify exact calcium intake). Instruct patient to eat no food other than that served by diet kitchen.

2. On the fourth day of the specific diet, collect a 24-hour urine specimen. Have patient empty bladder and discard urine. Begin specimen collection at this time. Be sure patient empties bladder at end of 24 hours so that you will collect a complete 24-hour output.

3. Patient should remain on a specified diet until all urine collections are completed. Any change in calcium intake during this time should be noted on laboratory request.

4. Keep specimen in refrigerator during collection. HCL should be used as a preservative.

F. Cortisol, Serum

1. Peak cortisol level is reached between 6-9 am, and minimum level occurs at midnight.

2. The exact time of collection must be provided.

3. Collect specimen in red top tube and send specimen to laboratory immediately.

G. Creatinine Clearance

1. Have the patient void and discard this specimen.

2. Collect a 2, 12, or 24-hour specimen and record the exact time of starting and completing the collection. Keep cold during collection.

3. Collect a small green gel tube of blood during the urine collection period.

4. Send both urine and blood to laboratory.

H. Oral Glucose Tolerance Test (OGTT)

1. Schedule the OGTT with laboratory. If the patient is ambulatory, we prefer to have the patient in the collection room during the tolerance period. If the patient is not ambulatory, then specimen must be collected by the physician or other ward personnel.

2. The patient must be fasting 8 – 12 hours; the patient may have water only. No food, coffee, tea, soft drinks or tobacco are allowed.

3. The laboratory will draw a fasting blood glucose. The Fasting Blood Glucose must be 140 mg/dL or lower to proceed with the OGTT and to administer glucola to drink.

4. Seventy-five grams of glucose will be given the patient. Blood will be collected at 1 hour, 2 hour, and 3 hour intervals after glucola has been ingested unless otherwise specified by the physician.

5. The patient will be allowed water as desired, but no food. Patient will remain in the waiting room/drawing room until released by phlebotomy staff.

6. If the patient has been on a low carbohydrate diet or intake preceding the test, the test should be performed after at least three (3) days of preparation with the daily diet of 300 grams or more of carbohydrates, unless the patient has clinically proven diabetes.

I. Alcohol (ETOH)

The specimen must be drawn in a gold top (clot activator and serum gel for separation) vacutainer tube. Nonalcoholic germicidal solution is used to swab the venipuncture site and to clean any equipment used to collect and process the specimen. Specimen tubes are to be kept closed at all times and in a vertical position. Samples must reach the laboratory within 1.5 hours of collection. The samples are manually centrifuged upon receipt and analyzed without delay and immediately after opening the sample tube.

J. Lipid Test

The specimen must be drawn in a green lithium heparin vacutainer tube. Patient should be fasting for 12-14 hours before specimen is drawn.

IV. SPECIAL CHEMISTRY

A. IFOBT:

Patients, if given the Immunochemical Fecal Occult Blood Test (IFOBT) kit, you should remind patients to ensure they include their full name and full SSN and collection date/time if mailing the collection kit/cartridge back to the laboratory for testing. Sample stability is 15 days at room temperature. Specimens must be submitted within 15 days of collection or sample will be rejected.

B. HIV:

The specimen must be drawn in a pearl top (plasma gel for separation) vacutainer tube. All positive screens will automatically be reflexed to the confirmatory test.

C. Hepatitis C Screen:

The specimen must be drawn in two pearl top vacutainer tubes. All positive screens will automatically be reflexed for confirmation. All other Hepatitis tests require one gold top tube for analysis.

D. Needlestick Protocol for Employees (with patient source option):

The needlestick protocol for an employee who is accidentally stuck by a needle or broken glass that has been in contact with a patient’s blood can have the needle stick protocol ordered for the employee. This requires 2 pearl top (plasma gel for separation) and 1 gold top (clot activator and serum gel for separation) vacutainer tubes. The following tests will be performed: HIV 1/2; HBsAB; HBsAG; and Hepatitis C antibody screen.

The needlestick protocol for the patient source requires submission of 2 pearl top (plasma gel for separation) and 1 gold top (clot activator and serum gel for separation) vacutaine tubes. The following tests will be performed: HIV 1/2; HBsAG; and Hepatitis C antibody screen.

E. Hemoglobin A1C:

The specimen must be drawn in a 3 ml purple top (K2 -EDTA) vacutainer tube.

F. Electrophoresis:

The specimen can be serum, random urine or 24-hour urine. If serum is submitted, sample must be drawn in a gold top (clot activator and serum gel for separation) vacutainer tube. All Serum Protein Electrophoresis (SPEP) or Urine Protein Electrophoresis (UPEP) will be reviewed by the Clinical Pathologists. The Pathologists will order the sample be reflexed to Immunofixation electrophoresis (IFE) or Immunotyping (IT) as needed.

V. CHEMISTRY PANELS

A. Basic Metabolic Panel (BMP):

Calcium, Carbon Dioxide, Chloride, Creatinine, Glucose, Potassium, Sodium, Urea Nitrogen, Anion Gap, Osmolality-calculation

B. Comprehensive Metabolic Panel (CMP):

Alanine transferase, Alkaline Phosphatase, Aspartate aminotransferase, Albumin, Total Bilirubin, Calcium, Carbon Dioxide, Chloride, Creatinine, Glucose, Potassium, Protein-Total, Sodium, Urea Nitrogen, Anion Gap, Osmolality-calculation; eGFR

C. Drugs of Abuse Screen (VA Tox Panel):

Opiate Screen, PCP (Phencyclidine) screen, Amphetamines screen, Cocaine screen, Barbiturates screen, Benzodiazepines screen, Methadone screen, Marijuana screen, Oxycodone screen

D. Electrolyte Panel:

Carbon Dioxide, Chloride, Potassium, Sodium, Anion Gap

E. Hepatic Function (Liver) Panel:

Alanine Transferase, Albumin, Alkaline Phosphatase, Aspartate aminotransferase, Direct Bilirubin, Pre-albumin (reflex), Total Bilirubin, Total Protein

F. Hepatitis (Acute Hepatitis) Panel:

Hepatitis A Antibody IgM, Hepatitis B Core IgM, HBsAg, Hepatitis C Antibody Screen

G. Lipid Panel:

Cholesterol, HDL, Triglyceride, VLDL, LDL Direct

H. Needlestick Protocol:

Employee - HIV 1/2, HBsAB, HBsAG, Hepatitis C Antibody Screen Source - HIV 1/2, HBsAG, Hepatitis C Antibody Screen

I. Renal Function Panel:

Albumin, Calcium, Carbon Dioxide, Chloride, Creatinine, Glucose, Potassium, Phosphate, Pre-albumin (reflex), Sodium, Urea Nitrogen, Anion GAP, Osmolality – calculation, eGFR

J. Thyroid Screen (Thyroid Function Test):

TSH, Free T4 (reflex)

K. SHBG Profile (Sex Hormone Binding Globulin Profile):

Sex hormone binding globulin, testosterone, albumin

4 hrs

4 hrs

4 hrs

4 hrs

CO2 (Bicarbonate) Creatinine Green 24 Urine 21-31 M: 800-2000 mmol/L mg/24hr 4 hrs 4 hrs

F: 600-1800

4 hrs

Non Pregnant Female <0.5-2.9 Gestational Weeks: Ref. 0.2 - 1 5-50

1 - 2 50-500

2 - 3 100-5,000

3 - 4 500-10,000

4 - 5 1,000-50,000 5 - 6 10,000-100,000 6 - 8 15,000-200,000

8 - 12 10,000-100,000

(7-10mLs)

4 hrs

4 hrs

4 hrs

% Free PSA: >19.0% If Total PSA 4 – 10 ng/ml;

% Free PSA: 24.0%

Female: 18.2 – 135.5 Female (Post-Menopausal): 16.8 -125.2

4 hrs

4 hrs

4 hrs

4 hrs

HEMATOLOGY AND URINALYSIS SECTIONS

PHONE: 617-5300 Ext: 14993

LOCATION: T112

MEDICAL DIRECTOR: Andrea Yunes, M.D., Ext 17819

CORE LAB MANAGER: Oswald L. Johnson, Ph.D., Ext. 14799

LEAD TECHNOLOGIST: Susan Coulthart, Ext. 14978

LEAD TECHNOLOGIST: Veronica Gonzales, Ext. 14516

HOURS: Open 24 hours a day, 365 days

I. GENERAL INFORMATION

The section provides, STAT, routine and special tests with automated equipment procedures. Some of the main tests offered by Hematology are: CBC, Reticulocyte Count, Manual Differential, Body Fluid Cell Counts and Morphology, Prothrombin Time, aPTT, Mixing Studies, Heparin Assays, D-Dimer, Fibrinogen, Bone Marrow Aspiration and Biopsy. A Complete Blood Count consists of: WBC, RBC, HCT, HGB, MCV, MCH, MCHC, RDW, PLT, MPV and automated differential which includes % and absolute number of cell types. A manual differential is performed only if designated criteria or decision rules are met. All peripheral smears and body fluid preparations are kept for two weeks.

II. SPECIMEN STABILITY

A. Hematology specimens for CBC, ESR, and reticulocyte should be collected in K2EDTA top tube (PURPLE) with a minimum of 1 ml.

B. Coagulation specimens for PT/INR, PTT, Fibrinogen, D-dimer and heparin assays should be collected in 3.2% sodium citrate tube (2.7 ml BLUE). Tubes must not be overfilled or underfilled. Tube must be filled up to the fill line.

C. Many tests are time dependent after collection and must be delivered to the laboratory as soon as possible. Routine tests that require testing in a specific time period are:

1. ESR - within 4 hrs of collection or refrigerated at 2-8° C for 24hrs.

2. CBC & Differential - within 24 hours of collection at 15-30°C or 72 hours at 2-8°C

8. Procalcitonin Assay - within 4 hours of collection or refrigerated

9. Osmolality (Urine) - stable within two hours at room temperature; refrigerate for longer stability

10. Osmolality (Serum) - separated from cells within 2 hours of collection

11. Viscosity - within 4 hours of collection, centrifuged, separated and refrigerated

12. Measles, Mumps, Rubella and Varicella - specimens will be tested on Monday, Wednesday, and Friday. If not, samples can be stored at 2-8° C for up to 2 days and frozen at -20° C for longer stability.

13. Vitamin D - stable for 5 days stored at 2 – 8° C

14. Buprenophrine - stable for 4 days stored at 2 – 8 ° C

II. BONE MARROW REQUESTS

A. Routine bone marrow requests should be scheduled the day prior by calling ext. 14993.

B. A tissue examination form SF 515 must be completed by the performing physician.

III. SPECIAL COAGULATION

Special Coagulation testing such as factor assays require pathologist approval to send out testing to reference laboratories.

IV. URINALYSIS

A fresh clean catch urine specimen (<2 hours at room temperature) collected in a dry, covered container. If testing is delayed (> 2 hours after collection,) the specimen should be refrigerated for preservation. Minimum 10 ml specimen is required.

V. BODY FLUID CELL COUNTS

A. Body fluids must be delivered to the laboratory immediately upon collection to minimize cell degradation.

B. Cerebrospinal fluid must be collected in sterile screw cap tubes with a minimum of 1 ml for testing. All other body fluids may be collected in purple top tubes for cell count or crystal identification, green top tubes for fluid chemistries basic (glucose, protein, total) and gold top for fluid chemistries comp (glucose, protein, total, albumin, amylase, creatinine, LDH, cholesterol, and triglyceride). Body fluids submitted in a syringe are not acceptable.

VI. SPECIMEN REJECTION CRITERIA

A. Mislabeled, Unlabeled or incomplete patient name and social security number B. Clotted specimens C. Tubes overfilled or under filled for coagulation studies D. Specimen that exceeds specimen stability E. Improperly collected specimens

VII. HEMATOLOGY AND URINALYSIS REFERENCE RANGES

Heparin Assays Unfractionated

4 hrs.

F: 3.8 – 5.2

F: 12.0 – 16.0

F: 36.0 – 46.0

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

Urinalysis:

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

4 hrs.

Interpretation of PCT (Procalcitonin) values in Critical ICU Patients:

Miscellaneous:

Measles, Mumps, Rubella and Varicella: - Specimen Type gold top (clot activator and serum gel for separation)

Post Vasectomy Semen Analysis:

REFERENCE LABORATORIES

PHONE: 617-5300 ext. 14996

LOCATION: Room T112

MEDICAL DIRECTOR: Andrea Yunes, M.D., Ext. 17819

CORE LAB MANAGER: Oswald L. Johnson, Ph.D., Ext. 14799

LEAD TECHNOLOGIST: Susan Coulthart, Ext. 14987

LEAD TECHNOLOGIST: Veronica Gonzales, Ext. 14516

HOURS: Monday through Friday, 7:30 am 4:00 pm

I. GENERAL INFORMATION

To establish a consistent procedure in the proper handling and processing of specimens that has a laboratory test(s) ordered but not performed in this Laboratory. These specimens are sent to accredited laboratories that meet the College of American Pathologists (CAP) and The Joint Commission standards.

II. PROCEDURES AND APPROVALS REQUIRED FOR REFERRAL TESTING

A. Tests that are not performed in this laboratory require review and approval by a Pathologist or supervisor for referring the specimen to an accredited laboratory that can perform the test.

B. If test requested is not listed in VISTA/CPRS, contact the Send Out section at ext. 14996.

C. Specimens must be accompanied by a computer generated slips or the Send Patient Lab Order Form.

D. Specimens to be tested by a reference laboratory will be shipped Monday through Friday during normal business hours. Specimens will be stored under appropriate temperature conditions by the laboratory until ready for transport.

E. In special circumstances deemed appropriate by a Pathologist, provisions for STAT testing for certain tests (cyclosporines, etc.) will be available after normal business hours.

F. Critical values and STAT results from reference laboratories will be available and communicated to the ordering provider per hospital policy.

G. Reference ranges and additional information on a particular test(s) are available in VISTA/CPRS.

III. GENETIC TESTING

A. Chief of Staff approval will be required prior to sending the patient for genetic counseling services.

B. The primary care provider should enter a CPRS consult for fee services for genetic counseling.

C. Once approved, the patient will be referred to the genetic counselor and will generate appropriate forms for genetic testing if indicated, and will obtain and document patient consent.

D. The genetic counselor will forward the genetic test request and consent to Audie L. Murphy lab for pathologist review and approval.

E. Upon approval Audie lab personnel will contact the patient’s primary provider to schedule specimen collection. NOTE: If the test is not indicated, the primary care provider will be responsible for notifying the genetic counselor and the patient.

F. The patient will be instructed to present to Audie L. Murphy lab at scheduled time for specimen collection and bring the test requisition and signed consent.

1. The forms may be brought to Audie L. Murphy prior to blood draw or final approval.

2. Specimens for genetic testing will only be collected Monday through Wednesday, 7:30 am to 4:00 pm to allow for shipping.

G. Test results will be available in CPRS upon.

TRANSFUSION MEDICINE

BLOOD BANK

PHONE: 617-5300 Ext: 14988

PAGER: Ask blood bank staff to page the on-call physician

LOCATION: Room T106

MEDICAL DIRECTOR: David Feldman, M.D., Ext 14968, 884-6970

SUPERVISOR: Michael J. Noriega, Ext: 14989

HOURS: Open 24 hrs. a day, 365 days

I. ORDERING BLOOD AND BLOOD COMPONENTS

A. Obtain informed consent for Blood Products:

Refer to STVHCS Consent for Blood or Blood Component Transfusion 113-13-01.

B. Use of Blood Bank Ordering System in CPRS:

All blood products and diagnostic lab tests are to be requested by a licensed physician (or other authorized provider as defined in the provider’s scope of practice) in CPRS through the electronic blood bank ordering menu. The electronic process streamlines a lot backend work that may not be apparent to the provider. The streamlined process improves patient safety and will speed the time from order to transfusion. For complete description of blood ordering policies, such as emergency issue blood products, refer to the STVHCS Blood Administration Policy (113-13-04)

1. Scroll down the left hand side window of Write Orders until you see Transfuse Blood Products.

2. Click on Transfuse Blood Products.

3. The Blood Bank Menu opens.

4. Click Order Diagnostic Lab/Blood Products (for Blood Bank Orders)

5. Click on the Blood Bank Order tab.

a) If ordering blood products then select the appropriate blood component from the drop down menu under Blood Components menu. Enter the quantity of the component required in the field named Quantity.

b) You may enter any modifiers from the drop down menu under Modifiers.

c) Enter the Date/Time wanted in the field named Date/Time Wanted.

d) Enter the collection type in the field name Collection Type.

e) Enter the collection Date/Time in the field named Collection Date/Time.

f) Enter the Urgency of the transfusion in the field name Urgency. The reason for transfusion must also be indicated. Select your reason from the drop down menu under Reason for Request.

g) If ordering diagnostic lab tests then select the appropriate lab test from the drop down menu under Diagnostic Tests menu. Select from Type and Screen, ABO/Rh, Antibody Screen, Direct Antiglobulin Test or Transfusion Reaction Workup.

Note – Do not select Antibody Screen as a substitute for a Type and Screen.

h) Enter the collection type in the field name Collection Type. Outpatients should be sent to the lab. Inpatients should be collected by the nursing staff or other designated personnel.

6. Selected lab tests and/or blood products will appear in the Selected Components and Tests window. Orders can be removed using the Remove or Remove All button next to this window.

7. Enter comments if appropriate under the free text section named Comment.

8. When satisfied that the order is complete, click on the Accept Order button.

9. The order should appear on the CPRS Active Orders page at the top and in blue text. Order must be signed for requests to be acknowledged by the Blood Bank.

10. Patient’s Blood Specimen - There will be positive verification of the identity of the prospective recipient prior to securing the blood specimen. This will be carried out by checking the hospital wristband for name and social security number and by asking the patient to give his/her full name and SSN. The person securing the specimen will place and secure a Typenex® Blood Band on the patient’ arm with a preprinted label bearing the recipient’s full name and full social security number. A second person a physician or nurse who has positive knowledge of the patient’s identity will make the verification and sign in the Verifier Space of the Standard Form 518 (SF518) or equivalent. The individual securing the specimen will authenticate the SF518 or equivalent collection form by signing in the box labeled with the statement, “I have collected a blood specimen on the below-named patient, verified the name and I.D. No.