D.2 SOP-Policies -Vernal 02.pdf

VA SALT LAKE CITY HEALTH CARE SYSTEM

VETERANS HEALTH ADMINISTRATION

DEPARTMENT OF VETERANS AFFAIRS

MEMORANDUM 113.07

REPORTING OF CRITICAL LABORATORY RESULTS

1. PURPOSE: To establish a process for reporting critical and urgent laboratory results to responsible providers, to facilitate timely clinical interventions for patient care, and to aid patients participating in health care decisions.

2. POLICY: All critical laboratory values as defined by Pathology & Laboratory Medicine

Service (P&LMS), in consultation with clinical services as appropriate, will be called and electronically reported into VISTA/CPRS within 60 minutes of result verification to a provider responsible for that patient’s care. The process for notification of Critical Values from contracted referral laboratory services is the same as Salt Lake City VA (SLC VA)

Laboratory.

3. DEFINITIONS:

a. CRITICAL VALUE: “Critical values” are those findings, even if from routine test orders, which require rapid verbal communication of those results to a responsible provider.

If the test ordered results in a critical value, the test result will be called to the responsible provider as per the detailed procedures in paragraph 5. The contact information and appropriate comment(s) will be entered into the patient’s chart after the result has been communicated to the responsible provider. The list of critical values is available upon request from the laboratory and available on the P&LMS SharePoint site.

b. CRITICAL TEST: “Critical tests” are those tests which will always require rapid communication of results within an established turnaround time, even if normal. SLC has only one critical test- Frozen Section.

All OR specimens for frozen section will be communicated to the provider directly within a target time of 20 minutes. This data is tracked on a monthly basis. All OR specimens for frozen section will be communicated directly to the provider within a target time of twenty minutes. Audits of compliance will be performed and reported to the HCIC Committee.

c. STAT TEST: Tests that are designated as critical by the provider (i.e. ordered as STAT).

STAT Test requests will be reported electronically and available in CPRS within 1 hour of receipt in the Laboratory.

d. Responsible Provider: Individual involved with the care of a patient who can affect the handling and treatment of a patient based on a critical result. The paged provider has the responsibility to contact the Laboratory in a timely manner.

D.2 SOP POLICIES - VERNAL

36C25923R0008

MEMORANDUM 2

e. On Call Directory: There are three lists On-Call Day and On-Call Night (M-f Nights only) and another On-Call Night (Weekend/Holiday Only). The on call directory is located on the Laboratory SharePoint and on the intranet directory (under the tab

“Directory then to the “On Call Directory”.)

f. Midlevel/Nurse Practitioner (PA)/Physician Assistant (PA): Medical Staff in SICU providing coverage who can take critical values.

g. Cross Cover: Medical staff who provide the Medicine Service coverage on nights, weekends and holidays.

4. RESPONSIBILITY:

a. P&LMS staff will recognize critical laboratory values and call the responsible provider within 60 minutes of verification of a critical value.

b. The responsible provider contacted is responsible for accepting the critical result and taking whatever clinical action is indicated.

c. A verification or “read back” is required from the responsible provider taking the critical lab results to confirm the information was understood correctly.

d. Each clinical service is responsible for maintaining accurate contact information for providers, on-call lists and computer based paging systems (i.e. smart web).

5. PROCEDURES:

a. VERIFY RESULT: Upon discovery of a critical value, the technologist will determine the validity of the test by comparing the obtained value to the relative value of other tests results and insure that internal quality control limits have been met. If required by the procedure, confirmatory testing will be performed.

b. NOTIFICATION

1) Inpatient Wards

a) 0700 to 1900 (7am to 7 pm)

(1) Page the ordering provider, if no response after 10 minutes, page the same provider again.

(2) If no response, page the ATTENDING provider. This number is found in

CPRS at the top of the Cover sheet.

(3) If no response after 10 minutes call the Chief of Service. Consult the On-Call

Day Directory. Each service is listed next to the ward name.

MEMORANDUM 3

(4) If the Chief of Service fails to call back in 10 minutes, please page again.

(5) If there is no response, call the Chief of Staff at extension 1249 or 801-618-

6785.

b) 1900 to 0700 (7 pm to 7 am) & Weekends or Holidays:

(1) MICU, 3A/IPU (Inpatient Psychiatry) or Rehab: Use the On-Call directory and page the listed provider up to two times. If no response, steps iii-v in item

b) above.

(2) Dialysis: Use the On-Call directory for Renal. If no response follow steps 2c-e from above.

(3) 3W, OR, Telemetry or 2E: Call the ward and ask what SERVICE the patient is on.

(a) MEDICINE:

I. Page the Cross Cover INTERN at ID# 10000954, if no response, page again in 10 minutes.

II. If still no response, call the Chief of Service. Consult the On-Call

III. If the Chief of Service fails to call back in 10 minutes, please page again

IV. If there is no response, call the Chief of Staff at extension 1249 or

801-618-6785.

(b) SURGERY:

I. Using the On Call Directory page the specific service in Surgery that the patient is being seen by (i.e. Thoracic, Vascular, Ortho, etc.), if no response, page again in 10 minutes.

II. If still no response, call the Chief of Service. Consult the On-Call

III. If the Chief of Service fails to call back in 10 minutes, please page again

IV. If there is no response, call the Chief of Staff at extension 1249 801-

618-6785.

(c) PTT Heparin Protocol: If the test is a PTT/Heparin Protocol critical, call the results to the RN on the unit.

MEMORANDUM 4

2) Community Based Outpatient Clinics (CBOC) EXCEPT WEST VALLEY

a) BEFORE 430 pm - Use the following list to call critical values to the CBOC:

When the extension is called, tell the person answering the phone (who should be a provider) that you have a critical value.

Elko 775-738-0188

Ely 775-289-3612 x131

Idaho Falls 208-522-2922

Nephi 435-725-1050

Ogden 801-479-4105

Orem 801-235-0953

Pocatello 208-232-6214

Price 435-613-0342

Roosevelt 435-725-1050

St. George 435-634-7608

b) AFTER 430 pm - Call the Emergency Department x1405 and give directly to a responsible provider. If no provider is available, call back in 10 minutes. After three attempts, notify the Chief of Staff at extension 1249 or 801-618-6785.

3) West Valley NON-Coumadin location

a) BEFORE 430 pm

(1) Page the ordering provider, if no response after 10 minutes, page the same

(2) If still no response, page the West Valley Doc of the Day. This is found on the Laboratory SharePoint page or intranet directory.

(3) If still no response after 10 minutes, call the Chief of Ambulatory Care at801-

755-2465.

(4) If still no response, page the Chief of Ambulatory Care again.

(5) If still no response, call the Chief of Staff at extension 1249 801-618-6785.

responsible provider. If ED is not available, call back in 10 minutes. After three attempts, notify the Chief of Staff at 801-618-6785.

4) West Valley Coumadin Location (WSLCoum)

(1) Call Extension 6503 and give results to RN.

MEMORANDUM 5

(2) If no response, page the ordering provider (RN), if no response after 10 minutes, page the same provider again.

(3) If still no response, page the West Valley Doc of the Day. This is found on the Laboratory SharePoint page or intranet directory.

(4) If still no response after 10 minutes, call the Chief of Ambulatory Care at801-

755-2465.

(5) If still no response, page the Chief of Ambulatory Care again.

(6) If still no response, call the Chief of Staff at extension 1249 or 801-618-6785.

responsible provider. If ED is not available, call back in 10 minutes. After three attempts, notify the Chief of Staff at 801-618-6785.

5) Outpatient Hospital Based Clinics

a) Before 5 pm

(1) If the patient is a Coumadin (BluCoum) ordering location, call to 2170. If no response or the patient is a Primary Care (PrimCar) or Women’s Clinic ordering location, proceed to step (2).

(2) Page the ordering provider, if no response after 10 minutes, page the same provider again. If no response, proceed to step (3).

(3) If no response and the patient is a Primary Care (PRIMCAR) or

OB/Gyn/Women’s Clinic ordering location, go to the DAY On-Call directory and page the “Doc of the Day”.

(4) For all other ordering locations, call the Chief of Service. Consult the On-Call

(5) If the Chief of Service fails to call back in 10 minutes, please page again.

(6) If there is no response, call the Chief of Staff at extension 1249 or 801-618-

6785.

b) AFTER 5 pm and Weekends or Holidays

(1) If the patient is a Coumadin or OB/Gyn Women’s Clinic ordering location, call results directly to the ED x1405 and give directly to a responsible provider.

MEMORANDUM 6

(2) If the patient is a PrimCar ordering location, page the ordering provider, if no response after 10 minutes, page the provider again. If no response call the

ED x1405 and give directly to a responsible provider.

(3) Outpatient Hospital Based Clinic other than Coumadin or

PrimCar,Women’s Clinic/OB/Gyn:

(a) Utilize the Night, Weekend & Holiday On-Call List for the ordering location posted as appropriate.

(b) If no response after 10 minutes, page the same provider again.

(c) If still no response, call the Chief of Service.

(d) If still no response after 10 minutes, page the Chief of Service again.

(e) If still no response after 10 minutes, call the Chief of Staff at 801-618-6785.

6) Home Based Primary Care

(1) Contact the ordering provider using contact information in CPRS and/or

Outlook, if no response after 10 minutes contact the same provider again using the same method.

(2) If still no response, call the Emergency Department x 1405 and provide result to a responsible provider. If ED is not available, call back in 10 minutes.

(3) If still no response after 10 minutes, call the Chief of Staff at extension 1249 or 801-618-6785.

b) AFTER 4:30 pm and Weekends or Holidays

(1) Call the Emergency Department x 1405 and provide result to a responsible provider. If ED is not available, call back in 10 minutes.

(2) If still no response after 10 minutes, call the Chief of Staff at 801-618-6785.

PLEASE NOTE: HBPC provider contact information is not accessible using computer based paging systems (i.e. SmartWeb).

7) Emergency Room

a) Call x1405 and ask to speak to a responsible provider to notify of a critical value.

b) If the provider is not available, call back in 10 minutes.

c) After three attempts, notify the Chief of Staff at extension 1249 or 801-618-6785.

8) Holistic Health/Pain Clinic: Call ED x1405 after hours

MEMORANDUM 7

9) Locations not on the List:

a) Page the ordering provider, if no response after 10 minutes, page the same

b) If no response after 10 minutes, call the Chief of Staff at extension 1249 or 801-

618-6785.

c. WRITE DOWN/READ BACK

1) The technologist will request the provider/nurse receiving the critical value to

"WRITE DOWN" the following information:

a) Patient's Full Name

b) Patient's Full Social Security Number

c) Test Name and Critical Value

2) Example Script:

This is ________________from the VA SLC Laboratory, I have a critical

Name of Tech value, please write down the following information:

Patient's Full Name Full Social Security Number

The Critical Value is a ______________ at _____________

Test Name Value

Can you please read back that information to me?

d. DOCUMENTATION

Laboratory personnel will document under "test comments” all of the contact information. Documentation must include the full name and title of the provider who received the critical result. Date & time called and initials of the tech that called the results and verified the "Read Back". If several steps were taken in the process to relay the critical value, each of those contact persons should be listed along with the time paged and the time the call was returned.

There are two "canned" comments available for insertion into the contact comments:

1) "CRB" = Critical results called to and verbally confirmed by:

2) "NCRB" = Critical read back process not completed

MEMORANDUM 8

e. QUALITY ASSURANCE

The Laboratory Quality Assurance Coordinator will monitor and report compliance with this policy on a monthly basis to the Medical Director P&LMS and the Process

Improvement Committee (PIC).

6. REFERENCES:

• College of American Pathologists Laboratory Accreditation Program, General Inspection

Checklist, 2010.

• 2011 Comprehensive Accreditation Manual, Joint Commission on Accreditation of

Healthcare Organizations.

• VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, Department of Veterans Affairs, October 8, 2008.

• Include stat vs. routine

• Critical value list

7. RESCISSION: None

8. RECERTIFICATION DATE: Memorandum 113.07 is due for recertification on or before the last day of August 2021.

9. FOLLOW-UP RESONSIBILITY: Chief, Pathology & Laboratory Service (113).

Shella Stovall, MNA, RN

Director

DEPARTMENT OF VETERANS AFFAIRS (VA)

SALT LAKE CITY HEALTH CARE SYSTEM

Salt Lake City, Utah

MEMORANDUM 113.02 May 21, 2018

LABELING OF LABORATORY SPECIMENS AND

REJECTION OF UNACCEPTABLE SPECIMENS

1. PURPOSE:

To establish policy to insure the integrity and appropriateness of patient samples submitted for laboratory testing; communicate the requirements for proper identification and transport; and establish the criteria used to reject improperly submitted laboratory specimens.

2. POLICY:

Specimens received by Pathology and Laboratory Medicine Service (P&LMS) must have been

LEGIBLY labeled in the presence of the patient by the provider collecting the sample with at least the patient’s full name and full social security number (SSN). Specimens must be accompanied by a viable Computerized Patient Record System (CPRS) order number and/or a completed Pathology Consult. Time and date of collection are important parameters used to verify proper specimen collection transport times, assess specimen viability, document times for epidemiologic testing, and for the correct interpretation of test results. The documentation of anatomic site must be completed when orders are placed for specimens other than routine blood collections. All specimen labels must be initialed by the individual collecting the sample to provide accountability if needed.

Specimens that are unlabeled, mislabeled (wrong patient, name/SSN mismatch), partially labeled

(missing information) or accompanied by an incomplete Pathology Consult will not be accepted for laboratory testing, unless the specimen is determined to be irretrievable. The process for accepting a mislabeled irretrievable specimen is described in Paragraph. Specimens that are rejected will be discarded and re-collection will be required. The collecting ward, clinic, facility, ordering provider or person who collected the specimen will be notified in the event a specimen is rejected.

3. RESPONSIBILITY:

a. The Chief of Pathology & Laboratory Medicine Services provides clinical oversight of the Pathology and Laboratory Medicine Service and provides guidance to the

Laboratory Manager regarding appropriate specimen criteria for laboratory testing.

b. The Laboratory Manger is responsible for determining appropriate specimen criteria for laboratory testing and ensuring CAP and CLIA regulations are being adhered to.

c. The Laboratory Quality Assurance Coordinator is responsible for the tracking, collection and publication of quality assurance data in the monthly Quality Assurance

Report to include numbers of mislabeled and rejected specimens.

d. Department Lead Technologists are responsible for submitting changes in testing or specimen requirements and criteria to the Laboratory Manager.

e. Medical Technologists/Technicians: Responsible for the knowledge of appropriate specimen criteria for laboratory testing and for the procedures contained in this guideline.

f. Employees collecting specimens for laboratory testing: Responsible for the proper and appropriate collection of specimens for laboratory testing, and timely submission of samples to the Laboratory.

4. PROCEDURES:

a. LABELING: For proper identification and handling, the following information must be included on ALL specimens and any accompanying requisition (if required): This labeling must be performed in the presence of the patient.

• Full Name and Social Security Number

• CPRS assigned Order Number

• Date and Time of collection

• Initials of person collecting the specimen

b. TRANSFUSION SERVICES:

1) A Type and Screen Collection Form (VA Form 10-126) is required for a Type and

Screen Order and must be filled out completely and signed. The Blood Bank Arm

Band Number must be included on both the specimen and collection form. For patients who are being Typed and Screened for the first time in this facility, a second sample is required, and that second sample must be collected, properly labeled, and initialed by a different staff member than the first sample. The second staff member also needs to include their information and sign the Type and Screen

Collection Form (VA Form 10-126).

2) Exceptions to Rejection:

Phlebotomist’s Name not printed on BB Type & Screen Form

(VAF 10-126)

Allow correction

No initials on sample. Allow correction

No BB Armband # on VAF 10-126 but sample labeled correctly. Allow correction

No signature of phlebotomist on VAF 10-126 but tube has initials. Allow correction

c. PRE-ANALYTICAL REJECTION CRITERIA:

1) Unlabeled specimens: Will NOT be accepted, notification will be made IF the collection location is known or can readily be determined.

2) Mislabeled specimens: Will NOT be accepted, notification will be made.

3) Partially labeled specimens:

a) Full Name missing: Reject & Notify ordering location.

b) Full Social Security Number missing: Reject & Notify ordering location.

c) Date and/or time missing: Contact ordering location to acquire information.

d) Order Number missing or incorrect: Contact ordering location to acquire information.

e) Pathology Consult missing/incomplete: Contact ordering location to provide required documentation.

4) Specimen Integrity Issues: Reject & notify the ordering location when the following conditions are encountered. Specific sample collection, storage and transport requirements for each orderable test are available in CPRS and VistA system.

a) Specimens are attached to or accompanied by sharps (needle or scalpel).

b) Specimens exceed transport time or temperature limits.

c) Specimen received is not appropriate for testing ordered.

d) Specimen quantity is insufficient for testing ordered.

e) Specimen label is applied to a removable container lid.

f) Specimens are received in unapproved, leaking or grossly soiled containers.

d. ANALYTICAL REJECTION CRITERIA: Specimens are examined by the technologist performing the assay to determine the extent of interference and determine acceptance or rejection depending on the test(s) to be performed.

1) Hemolysis: Grossly Hemolyzed specimens will be rejected. Any degree of hemolysis in the specimen will affect the listed analytes and assay values will not be reported.

• ALC (alcohol) - decreased result

• AMON (ammonia) - increased result

• AST - increased result

• AMY- increased result

• CK (creatinine kinase) – increased result

• CTNI - decreased result

• Direct Bilirubin - decreased result

• FT4 - increased result

• GGT - increased result

• IRON - increased result

• K (potassium) - increased result

• LA (lactic acid) - increased result

• LDI (lactate dehydrogenase) - increased result

• LIP (lipase) - increased result

• MG (magnesium) - increased result

• MMB - decreased result

• PHOS - increased result

• SPEP/UPEP (serum or urine electrophoresis) - causes artifacts

• TOTAL PROTEIN - increased result

2) Lipemia: Lipemia is not necessarily cause for rejection but it can interfere with many test results.

3) Icterus: Icterus is not necessarily cause for rejection although moderate to gross icterus can interfere with many test results. Increased Bilirubin may affect the following Assays:

• Acetaminophen - decreased result

• Cholesterol - decreased result

• Salicylate - decreased result

4) Clotted Samples: Anti-coagulated samples for Hematology and Coagulation testing will be rejected if visibly clotted.

e. POST-ANALYTICAL REJECTION CRITERIA

1) I.V. contamination: Samples contaminated or diluted with intravenous fluid or medication will yield spurious results which are normally only apparent after the analysis is completed. Contamination will be investigated per QPOL-GEN-061 Delta

Check Protocol. Recollection of all samples drawn with the same collection time will be requested in all suspected instances after consultation with the provider.

2) Assay Limits: Certain analytes (esp. anions & cat ions) which breach assay limits may indicate sample unsuitability. Refer to the department specific assay procedure for guidance. Recollection will be performed after consultation with the provider.

3) Quantity Not Sufficient (QNS): Questionable specimens will be assayed to assist in evaluating sample integrity and determine acceptability. Partial results will be reported when necessary.

4) Platelet Clumps: When PLT and/or MPV are “flagged”, perform a slide scan to validate the suitability of the sample. Cancel the PLT and/or MPV per department policy.

5) Fibrin: Reject the sample, cancel the order and perform notification.

f. NOTIFICATION: A Staff Nurse, Charge Nurse or Provider at the ordering location will be informed of the reason a specimen requires reordering and recollection. Unless otherwise specified by policy the ordering location personnel will be contacted.

g. DOCUMENTATION: Specific & appropriate comments will be entered into CPRS when testing is cancelled, to include: Name and Title of individual notified, Time of notification and Technologist/Technician/Phlebotomist initials.

h. IRRETRIEVABLE SAMPLES: Some samples (i.e. CSF & Body Fluids, BAL, and Bone

& Tissue) cannot be easily recollected or replaced. In the event, any of the above criteria applies to an irretrievable sample contact the PROVIDER IMMEDIATELY for correction. If the provider does not respond promptly, contact the ordering location

Charge Nurse or Staff Nurse. Correction must occur prior to further processing of samples or initiation of testing. This may impact the suitability for testing if corrective action is delayed. Samples will be preserved in the most suitable manner.

i. SUPERVISORY ASSISTANCE: If a provider for any reason is not able to resolve an issue with the laboratory staff present, contact the laboratory manager or night manager for further assistance. In the event the situation is still not resolved, contact the On-Call

Pathologist. If there is still no resolution, contact the Chief, Pathology and Laboratory

Medicine Service.

5. REFERENCES:

• VHA Handbook 1106.01, October 2008

• College of American Pathologists Inspection Checklist, 2016

• VHA Directive 2009-035, July 22, 2009; “Pre-Phlebotomy Patient Identification, Specimen Identification and Labeling of Blood Bank Specimens”

• Clinical and Laboratory Standards Institute AUTO-12P, Specimen Labels:

Content and Location, Fonts, and Label Orientation; Proposed Standard

• Joint Commission National Patient Safety Goals 2012

6. RECISSION: Memorandum 113.02, “Labeling of Laboratory Specimens and Rejection of Unacceptable Specimens”, July 30, 2014.

7. RECERTIFICATION DATE: On or before the last day of May 2021

8. FOLLOW-UP RESPONSIBILITY:

a. Chief, Pathology & Laboratory Medicine Services (113) is responsible for administration and content of the program.

b. Service Chiefs of services which submit specimens to P&LMS have follow-up responsibility to ensure compliance and that all concerned employees are informed of the procedures.

//s//

Shella Stovall, MNA, RN

Director

Clinical Laboratory Service

George E. Wahlen V.A. Medical Center Salt Lake City, Utah 84148-001

Issue Date:

February 22, 2011

Document # QFRM-POC-025

CBOC Specimen Tracking Form

Authorized by: Dr. J Jackson Chief PLMS

UNCONTROLLED COPY IF PRINTED

CBOC LOCATION:

Roosevelt, UT (801-582-1565 ext. 1476) DATE: Page 1

Section Completed By CBOC

Total # of Specimens in Shipment Date, Time and Initials:

Specimens Packed

Refrigerated Date, Time and Initials:

Room Temp Courier Picked Up

Frozen

Section Completed By Lab

Total # of Specimens in Shipment Date, Time and Initials:

Specimens Received

Comments: Specimens maintained at proper temperature? Yes or No

Patient Information

Specimen Type

Other Blood Urine

Place Specimen Label in this section. Each Label must include the Patients FULL Name, FULL

SSN, Date/Time Collected and ALL ORDER #

Green/Yellow

P u rp le

P e a rl (P

P T

P o u r

O ff

-S p e c if y

S ru m o r P la s m a

B lu

M rb d

R d /y e llo w

Y llo w

/B la c k

G re

(c u lt u re ) 24 Hour

Total # of Samples

Red/Yellow e fr ig

F ro z n

V o lu

Comments? Or other Specimens shipped

Salt Lake City, Utah 84148-001

Issue Date:

February 22, 2011

Document # QFRM-POC-025

CBOC LOCATION:

Roosevelt, UT DATE:

Page 2 of

Patient Information

Specimen Type

Total # of Samples

Other Blood Urine

Place Specimen Label in this section. Each Label must include the Patients FULL Name, FULL

SSN, Date/Time Collected and ALL ORDER #

Green/Yellow

P u rp

P a rl (P

P T

P o u r

O ff

-S p e c if

S ru m o r P la s

B lu

M rb d d /Y e llo w

Y llo w

/B la c k

G re

(c u lt u re

Hour

Comments? Or other Specimens shipped

Red/Yellow

R e fr ig

F ro z n

V o lu

Salt Lake City, Utah 84148-001

Issue Date:

February 22, 2011

Document # QFRM-POC-025

Pathology & Laboratory Medicine VA Salt Lake City Health Care System, MC 113 Authorized by Chief of Pathology 500 Foothill Drive, Salt Lake City, UT 84148

Document Management Number: SOP-0938

Document Title: CBOC Specimen Collection Procedure

Policy:

Laboratory specimens that are sent to the Salt Lake City VA Hospital laboratory must be collected, stored, and shipped properly. Failure to collect, store, or ship samples adequately will be a cause for rejection by the Laboratory.

Purpose:

To ensure specimen integrity has been maintain during the pre-analytical phase of specimen analysis. Improper identification, collection, storage, and shipping can drastically alter laboratory results. It is imperative that all pre-analytical steps are followed to provide highly accurate results.

Procedure:

A complete procedure for a blood draw can be found in the VA SLC Laboratory

Venipuncture Procedure.

1. Identify the patient.

a. Before drawing blood from a patient their identification must be verified. Salt

Lake City HCS policy requires employees to ask the patient their FULL name and FULL social security number to properly identify patients. In cases where the patient cannot remember their own information, asking a patient’s family member to provide the information is acceptable. If the patient is alone, it is also acceptable to ask the patient their birth date and verify it in CPRS

2. Identify the requested tests in CPRS.

3. Obtain the correct quantity and type of tube for each of the tests requested by the provider.

a. There are several resources available to CBOC staff to determine proper specimen collection. These resources include:

• CPRS Tools – Lab Test Description

• ARUP or LabCorp Directory of Services

• Salt Lake VA Clinical Lab Specimen Receiving Department - ext. 1476

• Ancillary Testing Coordinator – ext. 1595

• Lab Supervisor – ext. 1988

3. Organize the tubes in the proper order of blood draw

• Blue Top

• Red/Yellow Top (Serum Separator or No Gel Barrier)

• Green/Yellow Top

• Lavender Top

4. Draw blood according to VAMC Laboratory Venipuncture Procedure

5. Label Specimens:

a. All specimens need to be labeled with the following information in the presence of the patient. If the tube does not reflect the information below the Laboratory may reject the specimen:

• FULL FIRST and LAST name

• FULL Social Security Number

• Date and Time of blood draw

• Initials of the person drawing the blood

• Order number(s)

6. Centrifuge specimens

a. All tubes except for CBC’s and PT/INR samples need to be centrifuged.

b. Allow specimen to clot for a minimum of 30 minutes but less than 2 hours.

Centrifuge the specimen the full time and preset speed. The serum/plasma will be separated from the cells by a gel barrier in green/yellow and red/yellow tubes. All other tubes will not have a gel barrier and must be poured off immediately into a serum/plasma transport tube unless otherwise directed.

***Note: Red/yellow tubes need to be allowed to clot prior to centrifugation while green/yellow tubes can be centrifuged immediately.

7. Store specimens correctly prior to shipment

• Lavender Tops: generally used for CBC specimens and HGB A1C, are stored in the refrigerator until shipping. They must be shipped in refrigerated conditions (cooler/shipping container with ice packs) o The specimens should be well mixed by gently inverting the sample 5-

10 times after the specimen is collected from the patient. Samples for

CBC testing need to have a smear prepared for possible microscopic verification. Allow the slides to air dry before placing them into the slide container for shipment. Each slide needs to be labeled with the patients’ full name, and full SSN. Leave the slides at room temperature.

o BNP specimens must be centrifuged. The plasma must be poured-off and frozen immediately following centrifugation.

• Blue Tops: are used for Coagulation Studies. PT/INR samples need to be stored and shipped at room temperature.

o The specimens should be well mixed by gently inverting the sample 5-

10 times after the specimen is collected from the patient.

o Specimens cannot be centrifuged prior to shipping

• Red/Yellow Tops: this is commonly used for Chemistry testing, Hormone levels, Toxicology or any test requiring serum, unless stated otherwise.

o Allow tubes to clot for 15-30 minutes.

o All tubes must be centrifuged prior to shipment.

o Follow CPRS, LabCorp or ARUP guidelines for test requirements. If the serum is to be poured-off, make sure the pour off tube is labeled properly. See the Labeling Requirements above.

o Store specimens upright in a rack according to temperature requirements.

• Green/Yellow Tops: this is commonly used for routine Chemistry testing, Hormone levels, and any other test requiring plasma.

o These are anticoagulated blood specimens and will not clot. The specimen should be centrifuged as soon as possible.

o All tubes must be centrifuged prior to shipment.

o Follow CPRS, LabCorp or ARUP guidelines for test requirements. If the plasma is to be poured-off, make sure the pour off tube is labeled properly. See the Labeling Requirements above.

o Store specimens upright in a rack according to temperature requirements.

• Urine Samples:

o For a complete procedure to obtain and process urine samples follow the Clean Catch Urine Specimen Collection, Urine Chemistry

Specimen Processing Procedure, and the Urine Microscopic Specimen

Collection Procedure.

Common Urine Test Quick guide:

Test Tube Special Requirements

EMIT Greiner Bio-one

Vacuette® Urine

Tube(yellow-black)

Microalbumin Greiner Bio-one

Vacuette® Urine Tube

(yellow-black)

UPEP Greiner Bio-one

Vacuette® Urine Tube

(yellow-black)

If 24 hr urine, put Total

Volume on tube and tracking log

24 Hour urine tests Greiner Bio-one

Vacuette® Urine Tube

(yellow-black)

Total Volume on tube and tracking log

Urinalysis w/Microscopic BD Vacutainer®

Urinalysis (marble red-yellow top)

Culture & Sensitivity BD Vacutainer Urinalysis grey culture tube

8. Transport specimens

• Only use the plastic container with the foam inserts to transport specimens to the laboratory.

• Prior to sending samples, make sure that the CBOC Laboratory Tracking

Form is included with the shipment.

• Refrigerated samples need to be placed upright in a cooler/shipping container with at least two ice packs.

• Frozen samples are placed in a separate cooler/shipping container. Dry ice on the bottom – cardboard (barrier) – frozen patient samples- cardboard – dry ice.

• Room Temperature samples need to be placed upright into a separate container, containing no ice or refrigerated ice packs.

***Note: Holidays send CBC’s locally to LabCorp for testing. Freeze serum samples for the Salt Lake VA and ship on the next business day.

Procedural Notes

• Special Handling or STAT Specimens o Send the patient with a requisition slip to LabCorp for the following:

▪ ALL PTT’s

▪ Any CBC samples collected on a Friday (this applies to CBOC’s that do not have a courier service)

▪ STAT test requests from the provider

▪ Any sample tests that may not make it to the Salt Lake VA Lab in a timely manner (Holidays)

▪ Any samples that won’t be stable for shipping to Salt Lake

• Tracking Requirements o CAP requires that all samples must be shipped with a tracking form, this form must be included with the specimen shipment, and the following is acceptable:

a. On a CBOC Laboratory Tracking Form, place a duplicate sticker with the patients’ information as listed above (see Labeling Requirements) for each patient. The label on the specimen must also include the order number for each test requested as well on the CBOC Laboratory

Tracking Form.

• CBOC Specimen Results o The Salt Lake VA will enter the results of all CBOC tests into CPRS once testing is complete. CBOC testing will be completed within 24hrs of draw time so long as specimen stability isn’t compromised. Salt Lake VA does not perform STAT testing for CBOCs. For any samples that are sent to

LabCorp, the following will occur:

▪ LabCorp sends a copy of the report to the CBOC, and the Salt Lake

VA Lab.

▪ The CBOC will place a copy of the lab report into the patients chart and inform the provider of the patients’ results, until the result has been entered into to CPRS by the Salt Lake VA Lab Staff.

▪ The Salt Lake VA Lab Staff will enter the results into CPRS as quickly as possible. This may take up to 72 hours after the final report has been received from LabCorp. Please DO NOT FAX any reports to the Salt Lake VA during that time. This may cause duplicate results in the CPRS system.

▪ The Salt Lake VA Lab only has a contract with LabCorp and ARUP for testing. Results from any other lab will not be entered into CPRS.

Revision History

Section Change Date Requester Approver

Header

Update header

12/21//2016

Hung Ho

E. Hart MD

Font, Size

New Time Roman, 12

12/21/2016

Procedure notes

Updated CBOC test turnaround times

04/20/18 Josh Hastings K Walsh MD

Document Management Number: SOP-0939

Document Title: CBOC Tracking Log Procedure

Policy: The CBOC Tracking Log will be used by CBOC specimen processing in order to provide accountability for specimens shipped to the Salt Lake City

VA hospital laboratory. Specimens shipped to the SLC VA Laboratory not properly documented on this form may be rejected.

Purpose: To ensure adequate tracking and accountability of specimens shipped from

CBOC to the Salt Lake City VA Laboratory.

1. Place the date at the top of the Tracking Log.

2. After drawing a patient, be sure all of the patient samples are properly labeled.

This includes FULL name and FULL social security number, date and time collected, and order number.

3. Place one of the patient labels on the Patient Information section of the

Tracking Log.

4. This label should include patient’s full name, full social security number, date and time of collection, and ALL order numbers.

5. Place a number in the appropriate box to indicate what type of tube and the quantity being sent for each patient.

6. Write down the total number of samples for that specific patient. Place the samples in the foam inserts in the order they are drawn.

7. Under the “other” section include special testing or tests that need to be excluded under the same order number.

8. Count the total number of samples that will be in the shipment. Write the total where it says “total # of specimens in shipment”.

9. Write the date and time that the samples were packed and the initials of the person who prepared the shipment.

12/21//2016

12/21/2016

Document Management Number: SOP-0945

Document Title: Hospital Glucometer Procedure

Principle

The Precision XceedPro (PXP) Glucose System has been developed to allow rapid measurement of blood glucose (D-Glucose) by using an electrochemical detection technique. This biosensor system employs a disposable dry reagent strip technology, based on the glucose oxidase method for glucose determination. Each test strip features an electrode containing the enzyme glucose oxidase (Aspergillus Niger). When a blood drop is applied to the target area of the test strip, the glucose oxide catalyzes the oxidation of glucose in the drop to produce gluconic acid. During the reaction, an electrochemical mediator transfers electrons to the electrode surface. This will generate a current that is measured by the system. The size of the current generated is proportional to the amount of glucose present in the blood drop, thus giving an accurate reading of the blood glucose concentration.

Specimen Handling and Precautions

Universal precautions will apply when working with the Precision XceedPro whole blood glucose meter. Gloves and other Personal Protective Equipment (PPE) that is considered appropriate for the patient setting are worn when obtaining blood specimens from finger sticks and when performing the whole blood glucose tests.

All blood specimens and any used reagent strips are considered to be potentially infectious. Used lancets need to be disposed of in an appropriate biohazard sharps container. Lancets are for single use only. Dispose of used gloves and other PPE appropriately. See VAMC Infectious Control Manual for detailed instructions. Meters contaminated with blood must be disinfected. Meters must be disinfected between each patient use.

Equipment, Supplies, Reagents & Controls

Equipment:

Precision XceedPro Glucose Meter

Supplies

• Alcohol wipes

• Disposable lancets (single use only).

• Disposable gloves and PPE are needed

Note: Single use lancets must be used. Lancets cannot be used for more than one patient.

Reagents:

Precision Exceed Pro test strips:

• Use before the expiration date

• Do not use if strips are wet, bent, scratched or damaged

• Use immediately after opening foil packet

• Do not scan packet barcode and use test strip from a different packet. Always use the same strip that you scan and open.

Maintenance:

To keep the Precision Xceed Pro meter working correctly it is important to keep the instrument clean. Before using the meter make sure the port protector (old style meter) is seated securely. Also, ensure that it is not contaminated with control solution or patient blood. If there is a small amount of contamination wipe off with alcohol wipes. If the port protector is grossly contaminated contact the Ancillary Testing Coordinator for a new one.

Quality Controls:

Medisense Hi and Lo glucose control solutions

• Store control solutions at room temperature with their bottle caps tightened.

• Do not freeze.

• Each bottle of control solution is stable for 90 days after opening, or the date on the bottle if it is sooner, if tightly closed after each use. When you first open a new bottle, write the new expiration date on the bottle label. Discard all unused solution

90 days after opening.

• Invert the control solution bottle several times to ensure thorough mixing before use.

• Invert and tap the capped control solution bottle to remove air bubbles from the nozzle of the bottle.

• After each use, replace the cap immediately.

• Do not use control solutions after the expiration date printed on the bottles and the box. The Precision XceedPro meter does not accept control solutions that have passed their manufacturer expiration date.

Quality Control

Quality control must be performed at least once per 24 hrs of use, before patient testing is done. The Precision XceedPro meters will lock out any testing until QC has been run and passed. Additional QC checks must be performed each time a new lot of test strips is used and to investigate possible instrument damage or reagent deterioration.

Quality control consists of performing a high and low glucose control using Medisense

Hi and Lo glucose control solutions. If the high or low control solution fails, repeat the test. Repeat the control only once after it has initially failed, the first test may have had too little control reagent on the testing site. If the control still fails, throw the control set

(high and low controls) away and begin with a fresh set of controls. Controls should pass, if controls continue to fail set the meter aside with a note stating it should not be used and call the Ancillary Testing Coordinator to replace the meter. Patient samples must be run by alternate methods (i.e. send specimens to the lab or use another meter).

Note: The most common error made when performing daily QC, is running the high control when the meter is prepared for the low level, or low control when the meter is prepared for the high

Performing quality control

1. Turn instrument on by pressing the On/Off button

2. Press 2 for Control Test

3. Press scan to scan in your operator ID barcode on the back of VA ID badge, or manually enter the badge ID number it is the long number beginning with

“25757” located just above the barcode and press Enter. You will be prompted to re-enter the badge number if entered manually.

Note: When manually entering in the Operator Badge ID number; leave off the last digit in the sequence of numbers. This number is not programmed into the meter, it is a check digit.

4. Following the prompt on the display screen; scan or manually enter the low control solution lot number, press Enter

5. Following the prompt on the display screen; scan or manually enter the test strip lot number, press Enter

6. Following the prompt on the display screen; open foil test strip, remove strip and insert it into the meter’s test strip port with the contact bars facing up.

7. Following the prompt on the display screen; gently invert the required control solution 3-4 times to mix the control. Apply a drop to the white target area on the test strip.

8. The display screen will start a countdown from 20 seconds when sample is accepted.

9. Note the results – PASS or FAIL

10. The operator may select one of the following: Press 1 to continue and test the next level if PASS is noted on the meter. Press 2 to repeat the control if FAIL is noted on the meter. Enter the reason code 1.

* Repeat the control only once if it has initially failed, the first test may have had too little control reagent on the testing site. If the control still fails, throw the control set (high and low controls) away and begin with a fresh set of controls. Controls should pass, if controls continue to fail set the meter aside with a note stating it should not be used and call the Ancillary Testing

Coordinator to replace the meter.

Patient samples must be run by alternate methods (i.e. send specimens to the lab or use another meter

11. Once controls have been run, and both the low and high controls have PASSED, the meter is ready for patient testing.

12. Turn off monitor once testing is done to preserve the batteries.

Specimen

Fresh capillary whole blood from a finger stick

Patient Preparation and Assessment

Wash the patient’s hand with soap and water and dry thoroughly. Warm water stimulates the flow of blood to the fingers, making it easier to obtain a sample for testing. Having the patient hang his or her arm down to the side for 10-15 seconds before the finger stick will also make the procedure easier. Cleanse the site with alcohol prep and allow the area to dry.

NOTE: “The use of a glucose meters for critically ill patients constitutes modification of the manufacturer’s instructions, unless the manufacturer specifically states the meter has been validated for use on critically ill patients. Since the validation process for this type of method modification is very extensive and beyond the capability of most VA laboratories THE VA DOES NOT RECOMMEND THE USE OF GLUCOSE METERS FOR CRITICALLY ILL PATIENTS”. (AT-20 Document Version:07)

Therefore, the glucose meters assigned/deployed in VA Salt Lake City Health Care

System should not be used for critically ill patients.

If a rapid glucose test is needed for a critically ill patient, then completely fill a green/yellow (lithium heparin) from an arterial line. Apply the arterial blood sample to the glucose strip by applying a small drop of blood with a pipette.

***Definition of critically ill patient for laboratory point-of-care testing***

A patient with a mean arterial pressure less than 60 mmHg despite the use of vasopressors.

Collection

1. Use disposable sterile lancets. Hold lancet firmly on side of the patient’s finger with moderate pressure.

2. Depress plunger with index finger to make a puncture. Immediately release plunger while holding lancet on site. Discard the lancet.

3. Gently squeeze the finger to obtain a drop of blood.

4. Avoid squeezing the puncture site excessively.

5. Capillary whole blood specimens must be tested immediately upon collection.

6. Apply the drop of blood directly to the target area of the test strip. Sample volume required is 0.6 µL.

* Note: A second drop may be applied within 30 seconds.

Patient Testing

1. Press On/Off to turn on monitor.

2. Press 1 to select Patient Test.

3. Following the prompt on the display screen; press Scan to scan the Operator ID barcode, or manually enter the Operator ID via the keypad, then press Enter. If entered manually, the Operator ID must be verified by entering it a second time.

4. Following the prompt on the display screen; press Scan to scan the Patient ID barcode, or manually enter the Patient ID (patient’s full SSN) via the keypad, then press Enter. If entered manually, the Patient ID must be verified by entering it a second time.

• NOTE: If the patient’s wristband appears to be scratched, or if the patient wristband does not scan into the instrument, please replace the patient’s wristband. This is to avoid any clerical errors with manually entering the patient’s full SSN into the meter.

5. Following the prompt on the display screen; press Scan to scan the test strip barcode, or manually enter the test strip lot number via the keypad, then press

Enter

6. Open the foil test strip packet at the notch and tear up or down to remove the test strip.

7. With the contact bars facing up, insert the test strip into the test strip port until it stops.

8. The operator will see the following: Apply Sample.

9. Apply a drop of blood to the target area on the test strip. The test will automatically start a 20 second countdown.

10. Note the result and whether it falls within the Action Range (<50 or >450).

11. Steps to take if the Patient is within the Action Range (<50 or >450):

• Repeat the test immediately.

● Draw a gray top tube and send it to the lab for verification.

• Notify Physician

• DOCUMENT in CPRS using the Finger Stick Glucose Critical Value template. (For help finding the template view the notes at the end of the procedure.)

12. If the result is above or below the Action Range, you will be directed to enter a

Comment Code – enter 1 to repeat test. Remove the strip from the monitor and repeat the test.

13. The operator can select one of the following options:

• press 1 – next patient

• press 2 – repeat test

14. If after repeating a test within of the Action Range (<50 or >450) and it repeats within of the Action Range, you will be directed to enter a Comment Code, enter

11.

15. Draw a gray top tube and send it to the lab for verification if the result is<50 or

>450. A gray top is used to stabilize the glucose by keeping it from being metabolized by the red blood cells, a marble top will not stabilize the glucose and the result will be decreased. Note: A second blood draw is not needed if gray top tube have since been sent to the laboratory in step 11.

• There are two ways to Find the Finger Stick Glucose Critical Value template:

New Progress Note or Addendum:

▪ While in the Notes tab in CPRS create a new progress note or addendum

▪ Type Critical and the following note will be displayed:

▪ Click OK when “CRITICAL <LAB RESULT CRITICAL VALUE>” is highlighted.

▪ This is the note that will appear:

▪ Click on the Finger Stick Glucose Critical Value Notification radio button and then click on OK.

▪ Complete the following template:

Note: Fields marked with an asterisk ( * ) are required information.

CPRS Template:

▪ While under the Notes tab in CPRS click on Templates

▪ Expand the Shared Templates menu and click on ANCILLARY LAB

TESTING (See below).

After clicking on Finger Stick Glucose Critical Value the template will appear. All fields marked with an asterisk are required information

▪ Repeat testing is required for all first-time critical/action results. Not performing repeat testing can be done after the physician is notified and action is being taken and monitored by subsequent glucose results. (e.g.

insulin drip, sliding scale insulin) If in doubt, repeat the test. If the patient is in the Medical Intensive Care Unit (MICU) and on a insulin drip, sliding scale insulin the physician does not need to be notified for each critical/action result.

16. If a result is inconsistent with the patient’s clinical picture repeat the test.

NOTE: Do not run tests on other employees. This is only to be done by Employee Health or the Emergency Department when an employee comes in needing care. Doing so can result in administrative action and in the loss of glucometer privileges

Emergency Testing:

In the event of an emergency where patient ID/barcode is not available (example: fallen visitor/employee, patient removed ID) you can enter in the patient ID with 111111111.

After the emergency event you MUST e-mail/call the Ancillary Testing Coordinator with the patient information so the result can be added to the patient chart. If notification is not made to the Ancillary Testing Coordinator within 24 hours of the event, disciplinary actions will be taken against the testing personnel.

Reporting Results

• Fasting Values 75-110 mg/dL.

• Results, date and time of collection, patients name and full Social Security

Number, physician, and operator name and ID number will automatically be uploaded from the meter to VISTA and the Precision…