D.26 Clinical Laboratory and Anatomic Pathology Manual.pdf

CLINICAL LABORATORY &

ANATOMIC PATHOLOGY MANUAL

Pathology & Laboratory Medicine

Abie Abraham VA Healthcare Center &

Community Living Center, Butler, PA

VETERANS AFFAIRS MEDICAL CENTER

Butler, Pennsylvania

Laboratory Policy Manual

This manual has been prepared by the staff of Pathology & Laboratory Medicine in order to apprise you of general policies and procedures for procurement of specimens and services provided by the

Laboratory. No part of this manual may be altered without the consent of the Medical Director, Pathology & Laboratory Medicine.

PATRICIA ENGELSIEPEN, MT (ASCP)

Laboratory Supervisor

SCOTT M KULICH, MD/PhD

Laboratory Director

TABLE OF CONTENTS

TABLE OF CONTENTS

LABORATORY POLICY MANUAL

I. General Information and Services A. Location B. People Who Care C. Services Provided D. Laboratory Hours of Operation and Staffing E. Keeping You Informed F. Accreditation G. Quality Assurance (QA) and Quality Control (QC) H. Dedication to Excellence II. General Information A. Laboratory Hours B. Requests for Laboratory Services C. Basic Turn Around Times for Testing

a. Stat Requests

b. ASAP Requests

c. Routine Requests

d. Entry of Orders for Laboratory Testing Within CPRS & Types of Orders

1. Send Patient to Lab

2. Lab Collect

3. Ward Collect

e. Orders for Fluid or Urine Testing

f. Staff Directory

f. Specimen Labeling Requirements & Procedure for Printing Labels in Vista & CPRS D. Laboratory Order Entry in CPRS E. Procedure for Entry of Fluid or Urine Testing F. Delivery of Specimens to the Clinical Laboratory G. Causes for Specimen Rejection H. Types of Unacceptable Specimens I. Request Forms and Labels J. Laboratory Request Slip K. Procedure for Send Out of Specimens to the Butler Memorial Hospital for Testing During Non-

Laboratory Hours

L. Laboratory Computer Contingency Plan & Flowchart M. Phlebotomy

a. Blood Collection Procedure

b. Patient Identification Procedure

c. Specimen Collection

d. Blood Collection & Tube Labeling Requirements

e. Blood Collection Tubes: Order of Draw

f. Instructions for the Collection of Sterile Urine Specimens N. Chemistry

a. General Information

b. Laboratory Profile Testing

c. Special Specimen Collection Procedures

Creatinine Clearance Glucose Tolerance Test & Gestational 1 Hour Glucose Tolerance Test

d. Therapeutic Drugs

e. Some Drugs with Physiologic Effect on And/Or Chemical Interference with

Commonly Ordered Constituents in Blood

f. Abbott Architect & Tosoh A1c Reference Ranges O. Hematology/Coagulation

a. General Information

b. Hematology Normal Ranges

c. Coagulation Normal Ranges

d. Sedimentation Rate & Reticulocyte Normal Ranges

P. Urinalysis

a. General Information

b. Test Information

c. Specimen Collection and Handling

Q. Microbiology a.General Information

b. Specimen Collection

1. General Considerations

2. Bactec Blood Culture Collection

3. BD Affirm Specimen Collection Procedure

4. Specimen Storage and Transportation

5. Specimen Rejection

6. Specimen Requirements Chart

7. Fungal Cultures

8. AFB Specimens

9. O&P

10. Antibody Tests

11. Viral and Rickettsial Diseases

c. Suggested Guidelines for Blood Culture Collection

d. Sofia Rapid Influenza A&B Testing

e. Sofia Rapid Strep Group A Testing R. Tests Sent to Reference Laboratories S. Histology

1. General Information

2. Procedures for Cytology Specimens

3. Specimen Collection of Surgical Pathology Specimens

4. Order Entry & Data Entry for Cytology & Surgical Pathology Specimens & Examples of Cytology &

Surgical Pathology Orders

5. Thin Prep PAP Test (Broom Device) Cytology Protocol

T. Ancillary Testing

1. Overview

2. Ancillary Testing & Competency Assessment

3. ACCU-CHEK Inform II Glucose Monitoring System Comprehensive Policies, Processes and Procedures Manual

4. Coaguchek XS Plus Policies & Procedures

5. Urine HCG Pregnancy Test

6. Afinion HbA1c Point of Care Assay

7. Key Split Drug Test Cup Screening Test for Drugs of Abuse

8. Drug Screen Result Entry into VistA

9. CBOC CAP Survey Testing Procedure

U. CBOC Procedures

1. General Blood Collection Procedure including a Diagram of Patient Arm Veins & Arteries

2. Points to remember when accessioning orders at the CBOC’s

3. Use of VistA Laboratory Order Retrieval, Accessioning Orders, Label Printing Instructions i.e.

Reprinting Labels, Printing VIC Labels & Printing Labels in CPRS

4. Examples of Lawrence County & Mercer CBOC Laboratory Specimen Manifests

5. CAP Survey Testing Procedure for Ancillary Testing Staff

6. CAP CBOC Air Bill

V. Reference Laboratory Testing

General Information and Services The Pathology & Laboratory Medicine performs a comprehensive range of Laboratory tests with our goal being to provide accurate and timely Laboratory test results in a cost-effective manner.

A. LOCATION

Pathology & Laboratory Medicine is located at the Abie Abraham VA Healthcare Center at 353 North

Duffy Road, Butler, Pennsylvania. It is located on the first floor (phlebotomy) room 1BD001-1BD014, and the main lab is located on the second floor, 2LB001-2LB012.

B. PEOPLE WHO CARE

The Laboratory is directed by a Pathologist and staffed by qualified Medical Technologists and

Medical Technicians who are committed to provide the highest level of quality and service. The staff has broad-based knowledge and technical expertise to assist with information regarding significance of test results, unusual cases, and technical matters.

C. SERVICES PROVIDED

Pathology & Laboratory Medicine provides Clinical Services.

• The Clinical laboratory offers a wide variety of testing being performed with sufficient rapidity to support inpatient care, outpatient services, outreach clinics and long-term health care monitoring.

The departments in the Clinical Laboratory include Chemistry, Therapeutic Drug Monitoring, Hematology, Coagulation, Serology, Urinalysis, and Molecular COVID-19 PCR testing. Each department provides a comprehensive menu of testing.

• Specimens for surgical pathology and cytology studies are collected at the Butler facility and are sent to the Pittsburgh VA laboratory histology section for analysis. Additionally, urine culture & sensitivity specimens are initially screened at our facility & if found positive are also sent to the

Pittsburgh VA microbiology section.

• Ancillary Testing Program Services includes establishing policies, standards, operation, quality management and medical appropriateness for all off site laboratory testing within the Medical

Center and its outreach functions.

D. LABORATORY HOURS OF OPERATION AND STAFFING

Laboratory technical coverage is available Monday through Friday from 6 am to 9 pm. The hours of operation are as follows:

1. Clinical Laboratory: Laboratory testing is available from 6 am to 9 pm, Monday through

Friday only.

2. Outpatient phlebotomy: Phlebotomy services are available from 6:30 am to 4 pm

E. KEEPING YOU INFORMED

The Laboratory will provide you with up-to-date information regarding current developments, new in-house tests, and any changes in test procedures.

F. ACCREDITATION

As of September 15, 2020, Pathology & Laboratory Medicine is accredited by Joint Commission. The contract number is 36C10G20D0064 with a period of performance 9/15/2020 to 9/14/2024.

G. QUALITY ASSURANCE (QA) AND QUALITY CONTROL (QC)

Quality Assurance (QA) and Quality Control (QC) are an integral part of daily operation. Internal and external proficiencies are utilized to monitor the accuracy and precision of each patient run for every assay performed.

Laboratory Standard Operating Procedures (SOP’s) have been written to include when to repeat testing to assure that reported test values are accurate and precise.

H. DEDICATION TO EXCELLENCE

The Laboratory has state of the art, automated and computerized equipment and an efficient and motivated workforce to provide services that are of high quality and customer focused.

GENERAL INFORMATION

Pathology & Laboratory Medicine is located at the Abie Abraham VA Healthcare Center on the 2nd floor. The phlebotomy area is located on the 1st floor at this same location. The main laboratory telephone number is 878-271-6899.

LABORATORY HOURS:

Monday through Friday:

6 am to 9 pm-Technical Staff on duty

6:30 am to 4 pm-Phlebotomy staff

REQUESTS FOR LABORATORY EXAMINATION

It is the responsibility of all those who request laboratory examinations to examine each request carefully for its need, and to exercise clinical prudence in test selection.

See the “Lab Order Entry” section for ward ordering procedures.

BASIC TURN AROUND TIMES FOR TESTING:

STAT: Stat requests are those that must be performed and have the results available within the required 1 hour turnaround time. Stat requests for tests during those hours other than normal duty hours must be of a truly emergent nature & are to be drawn by the PCC & are sent to Butler Memorial Hospital laboratory for testing. No test should be ordered for non-duty hours that could be deferred until the next workday. In cases where delays in testing are anticipated, the lab tech. will notify the ordering provider. Stat results are available within one hour from the time of collection. Specimen(s) delivered to the laboratory for “STAT” analysis should be given to a member of the laboratory staff—NOT placed on the specimen counter.

ASAP REQUESTS: ASAP requests will be initiated by the provider with results to be provided by the Laboratory within 4 hours. The entry of an ASAP urgency is limited within the lab package to certain tests which can have the potential to be a high urgency. The cooperation of the medical providers is solicited to use the ASAP requests to help reduce the time-consuming STAT requests.

ROUTINE REQUESTS: Routine requests are those that require no urgency in reporting. Requests processed by our laboratory will have results generated within 24 hours from the time of collection unless batch testing or confirmatory testing is indicated. Inpatients-Requests for routine laboratory examinations on inpatients should be placed on the day prior to that on which the test is be done. Lab collections on inpatients are only done on Monday & Thursday, at 6:30 am.

Entry of Orders for Laboratory Testing Within CPRS & Types of Orders:

There are three types of orders which are each used for different scenarios & they are as follows:

Send Patient to Lab-To be used for Outpatients only. If labwork has been ordered as send patient and the patient is then admitted, this labwork should be re-entered as lab collect, otherwise this testing may be missed by the lab.

Lab Collect-To be used for inpatient labwork scheduled at routine pick up times which are as follows: Mondays & Thursdays @ 6:30 am. These times are selected because they correlate with the more frequent timed orders currently requested by our medical staff.

Ward Collect-To be used for inpatient labwork which is to be collected as follows:

1. Used at all times other than the above scheduled times.

2. Used for all weekend and holiday laboratory orders.

3. Used for all STAT orders.

4. Used for all blood culture orders.

Tests that are ordered as “Ward Collect” are not included in the list of patients that are automatically printed in the laboratory to be routinely collected. For this reason, the Laboratory should receive notification of any test that is ordered as ward collect & that is not going to be collected by the ward i.e. any orders for blood work that is not ordered during the regularly scheduled lab pick up times i.e.

vancomycin troughs.

Orders for Fluid or Urine Testing:

Orders for fluid testing are generally ordered in CPRS by typing “fluid”. The available tests will then be displayed on the screen. Microbiology and Virology test orders are entered by typing in “C&S” or

“viral culture”, respectively. Orders for urine testing are generally ordered in CPRS by typing “urine”.

The available tests will then be displayed on the screen.

The following list of tests has been approved by the clinical leadership as tests that may be ordered as an stat request:

Hematology CBC, Prothrombin Times & PTTs

Chemistry: Comprehensive Metabolic panel, electrolytes, antibiotic levels

Urinalysis: Urinalysis screening & microscopic Initial screen for urine culture

Microbiology: Blood cultures

On an extremely rare occasion, the provider may request tests other than those listed above, to be performed on an emergency basis. If the provider will communicate the request directly to the technician, these tests will be performed as expeditiously as possible. Read back of these orders by the technician is mandatory.

Requisition Forms: Tests ordered by the ward provider to be performed during non-scheduled, non-routine laboratory hours will be collected by the PCC & sent to Butler Memorial Hospital for testing.

Testing ordered during these times must be of a stat urgency.

NOTE: If there is any unexpected delay in testing i.e. instrument malfunction, every attempt will be made to provide results within this time frame. This may be accomplished by sending the specimen to

Butler Memorial Hospital for processing. Any instrument downtime will be communicated to the administrative assistant to the Chief of Staff.

Testing Methods- A list of current test methods and performance specifications are available upon request.

NOTE: For any testing performed in-house, performance specifications such as reference ranges, specimen type, are listed within this manual under the specific sections for each testing area of the laboratory.

STAFF DIRECTORY

NAME TITLE

EXTENSION

Scott Kulich, MD/PhD Butler VA Laboratory Director

412-360-6548

Patricia Engelsiepen Laboratory Supervisor x6880

Kelly Groebel Ancillary Testing Coordinator/Medical Technologist x6887

Dan Gerda Quality Assurance Technologist/Lab ADPAC/ Medical Technologist x6893

Sandy Tilko Medical Technologist x6890

Vaughn Lucas Medical Technologist x6891

Frances Hetrick Medical Technologist

X6892

Jensen Bachman Medical Technologist x6894

Afternoon/Evening Staff:

Ashley Tedrow Medical Technologist x6888

Brittanie White Medical Technologist x6889

Phlebotomy:

Marsha Wills Medical Technician x6972

Shanda McLay Medical Technician x6974

Heather Bell Medical Technician x6895

Patti Collins Medical Technician x6973

Main Laboratory Number: 878-271-6899

Laboratory Fax: 878-271-6896

Laboratory Order Entry in CPRS

Choose the Add Orders Menu from the left-hand side of the Orders tab, choose LABORATORY….

From the Add Orders Menu. This screen appears. Enter the desired lab test, select it, indicate the

Collection Type, Collection Date/Time and for inpatients indicate How Often and How Long the test is ordered.

To discontinue a Laboratory, select it from the Orders tab, right mouse click and choose Discontinue.

Choose the reason for the discontinuance.

To order Blood Culture, choose the Lab test that reads CULTURE (BLOOD)

Blood Cultures must be ordered in this way, so as to allow for proper resulting in the Lab package.

For Other Culture and Sensitivity orders, the Collection Sample and the Specimen must be chosen.

The list of Collection Samples will present to the user.

Laboratory Results are viewed from the Lab Tab. The default view is Most Recent.

Cumulative view of labs displays as follows:

Patient name

Patient name

Procedure for entry of Fluid or Urine Testing:

Orders for fluid testing are generally ordered in CPRS by typing “fluid”. The available tests will then be displayed on the screen. Microbiology and Virology test orders are entered by typing in “C&S” or

“viral culture”, respectively. Orders for urine testing are generally ordered in CPRS by typing “urine”.

The available tests will then be displayed on the screen. Special considerations:

DELIVERY OF SPECIMENS TO THE CLINICAL LABORATORY

Delivery to the Laboratory of specimens for laboratory testing should not be delayed since it is optimal to complete testing on a fresh specimen.

A. Normal working hours (Monday-Friday, 6 am – 9 pm)-All specimens should be placed in an impervious, biohazard bag with the request slip placed in the outer envelope of the bag. This bag should be placed in an “Igloo” container for transport to the laboratory. Personnel involved in the transport of specimens i.e. escort volunteers, are instructed not to reach into this container for any reason. Specimens, especially random urines for urinalysis should be checked to make sure that they are not leaking.

NOTE: The door to the laboratory is locked. You will need to ring the bell to summon the technologist on duty.

B. Other than normal working hours-Specimens should be refrigerated in the ward specimen refrigerator until these specimens can be delivered to the laboratory.

CAUSES FOR SPECIMEN REJECTION

Many factors influence the quality of laboratory assays. One of the most important factors and one wherein the laboratory has little or no control, is the collection of specimen (other than blood specimens). The quality of the specimen directly affects the quality of the test result. For this reason, Pathology & Laboratory Medicine reserves the right to reject any specimen that is suspect. Below are a few of the criteria that are cause for rejection. The laboratory staff realizes the time and discomfort spent in collect of these specimens. For this reason, rejection of the specimen will not be made without due cause. When specimens are rejected for testing or if the test results are in question due to specimen integrity, a comment will be entered into the Vista system i.e. specimen hemolyzed-unable to assay, specimen for urine culture leaking upon receipt in lab-may be contaminated, please recollect. Additionally, the laboratory will make every attempt to contact the patient’s nurse in an attempt to get a recollect of the specimen. Documentation of this contact will also be made through a comment within Vista. These comments will then become part of the patient’s medical records.

Types of Unacceptable Specimens:

1. Improperly labeled Specimens-Laboratory personnel will not assume the responsibility for identification of unlabeled or mislabeled specimens received within the laboratory. If identification cannot be secured by the person who obtained the specimen, it will be REJECTED. If the person who obtained the specimen is willing to verify that the specimen is from the intended patient, they will then be responsible for labeling the specimen with the proper label as identified within the

Request Forms and Labels section of this manual.

2. Incomplete Request Slips-If the order request form is incomplete, the ward will be notified to supply the necessary information. Please see the Request forms and Labels section of this manual for the necessary information to be included on this form.

3. Insufficient Quantity- The volume of the specimen required is specified in the Test Chart section of this manual. For tests not listed or unusual requests, please contact the laboratory.

4. Leaking Specimens- All specimen containers should be tightly sealed. The outside of the container should be free of any blood or body fluid. Each specimen should then be placed in a separate biohazard bag and sealed. The CPRS order form should be placed in the outer envelope of this bag.

Any infractions of these guidelines with regard to specimen leakage or soiled requisitions may constitute grounds for specimen rejection.

5. Condition of Specimen-Hemolysis must be avoided in all specimens. In emergency situations where hemolysis would not affect determination of the analyte requested, a comment will be entered

“Specimen Hemolyzed”.

6. Improper Conditions for Collection-Specimens requiring collection on ice, refrigeration, freezing, protection from light, pre-weighed cans, or containers with special preservatives, are indicated in the

Test chart section of this manual. Also included are appropriate suggestions to facilitate transport to the laboratory i.e. blood ammonia, etc.

7. Delay in Processing-Specimens should be submitted to the laboratory promptly after collection.

Inordinate delays between time of collection and submission to the laboratory can affect the validity of analytes and could be an indication for recollection. For the collection of urine samples, urines that are kept at room temperature cannot be held for more than 2 hours. If urines have been refrigerated, they are only acceptable if they have not been refrigerated for longer than 4 hours. If the storage of any urines exceeds these storage criteria, they will be rejected by the laboratory.

8. Unusual Specimens-i.e. viscous fluids, etc. Requests for analysis on unsatisfactory specimens, viscous fluids which will cause specimen physical problems with instruments or analytical problems due to methodology will be discussed with the patient’s clinician and may need to be referred to another laboratory for processing.

9. Improper Containers and Material-The appropriate container and material to be analyzed for each test is indicated in the Test Chart Section of this manual. Inappropriate containers and material constitute grounds for recollection.

It is important to recognize that these steps take unnecessary time on the part of the ward and laboratory personnel, so avoidance of this situation is recommended. If in reasonable time the laboratory has been unable to secure the information requested, the specimen will be discarded, and the ward notified.

The requesting ward will be notified by telephone is any specimen is rejected. Documentation of this contact will be made within the comments section in Vista.

REQUEST FORMS AND LABELS

A. REQUEST FORMS-CPRS generated forms will be submitted with specimens delivered to the laboratory. The minimum information for each request should include:

a. Patient’s complete name-last, first and middle initial

b. Patient’s FULL social security number

c. Patient location

d. Name of clinician ordering the test

e. Date of order

f. Date & time of collection

g. Specimen type i.e. blood, urine, stool, etc.

h. Test(s) ordered. PLEASE DO NOT USE ABBREVIATIONS

NOTE: Only CPRS generated forms should be submitted. Handwritten forms are unsatisfactory. When the computer system is down, a manual requisition may be used when ordering laboratory testing. This manual requisition can be found on the following page.

B. LABELS-Specific labeling instructions can be found in the “Specimen Labeling

Requirements & Procedure for Printing Labels in Vista & CPRS” procedure that can be found in the phlebotomy section of the Laboratory Policy manual which is available in the

Butler VA Medical Center sharepoint site. It is important to note the following in regards to specimen labeling:

LABELING MUST BE DONE IMMEDIATELY FOLLOWING THE VENIPUNCTURE

PROCEDURE & IN THE PATIENT’S PRESENCE. IF AN INPATIENT IS BEING

DRAWN, LABELING OF THE SPECIMENS MUST BE DONE BEFORE LEAVING

THE PATIENT’S BEDSIDE. IF NURSING IS DOING THE VENIPUNCTURE, VIC

LABELS MAY BE USED TO LABEL THE SPECIMENS DRAWN AND MUST ALSO

BE DONE AT THE PATIENT’S BEDSIDE. THE NURSING STAFF MUST LABEL

THE SPECIMEN WITH THE DATE & TIME OF COLLECTION, THE NAME OF

THE TEST AND THE INITIALS OF THE COLLECTOR. FOR THIS REASON IT IS

PREFERABLE TO USE A CPRS LABEL SINCE IT ALREADY PROVIDES THE

TEST NAME. THE DATE & TIME OF COLLECTION & THE INITIALS OF THE

COLLECTOR WILL STILL NEED TO BE PROVIDED.

SPECIMENS FOR BLOOD BANK TESTING: Specimens submitted should either be labeled with a Vista-generated label. These specimens are only to be drawn and labeled by laboratory personnel. All of the following information must be provided on the specimen label: FULL name, FULL social security number, patient location, date and time of collection and the phlebotomist’s initials.

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

BUTLER, PA

LABORATORY REQUEST SLIP

BLOOD MENU

HCFA 2000 Panels 26. Alkaline Phosphatase 55. ANA

1. Basic Metabolic Panel 27. SGOT (AST Drug Levels

2. Comprehensive Metabolic Panel 28. SGPT (ALT) 56. Theophylline

3. Renal Function Panel 29. Gamma-GTP 57. Digoxin

4. Hepatic Function Panel 30. Total bilirubin 58. Dilantin

5. Electrolyte Panel 31. Direct bilirubin 59. Phenobarbital

6. Lipid Panel 32. LDH 60. Lithium

7. Acute Hepatitis Panel 33. CPK 61. Procainamide/

Hematology Tests 34. Troponin I NAPA

8. CBC (w/ plts & diff) 35. Magnesium 62. Carbamazepine

9. Sedimentation rate 36. Cholesterol (Tegretol)

10.Reticulocyte count 37. Triglyceride 63. Valproic Acid

11. PT 38. HDL/LDL (Depakene)

12. PTT 39. Hemoglobin A1c 64. Vancomycin

Chemistry Tests 40. TSH Trough)13.13

13.Glucose 41. Thyroxine (T4) 65. Vancomycin

14.Urea Nitrogen 42. T-Uptake 66. Gentamicin

15.Creatinine 43. PSA (Trough)

16. Sodium 44. Ferritin 67. Gentamicin

17. Potassium 45. Iron (Peak)

18. Chloride 46. TIBC 68. Quinidine

19. Calcium 47. B12 Drugs of Abuse

20. Phosphorus 48. Folate 69. Urine Drug Screen

21. Uric Acid 49. Testosterone 70. Ethanol

22. Total Protein 50. LH Additional Tests

23. Albumin 51. FSH 71. RPR

24. Amylase 52. Prolactin 72. RA (Rheumatoid

25. Lipase 53. CEA Factor)

54. Cortisol 73. Serum Protein

Electrophoresis

Drawn by: (please check): VNA: ______ Other: _______

MISC. ______________________________________ Antibiotic Dosing Info.:

____________________________________________ Date of Dose _________________

Time of Dose _________________

Requesting Provider (if ordering provider is from the Pgh. VA, please note): _______________________

If drawing specimens for orders placed by a Pgh.VA provider please note: The Pgh. VA Lab has some specimen requirements that differ from the Butler VAMC Lab’s. If a Basic Metabolic panel, a

Comprehensive Metabolic panel or a Chem-19 panel are to be drawn, please draw these tests in a green, marbled, lithium heparin tube with a gel separator.

Patient ID: Check Urgency

STAT _____ Routine _____

OP-28/136B July 1994 rev.8/94; 1/95; 5/00 Please be sure to label specimens with the patient’s FULL name, FULL social security number, the date & time that the specimen(s) were drawn and the initials of the person who collected the specimen(s)

Laboratory: 724-287-4781 x4298 or 724-285-2443, fax: 724-285-2480, Mon-Fri: 7 am to 11 pm

Procedure for the Send Out of Specimens to the Butler Memorial Hospital for Testing that is

Needed During Hours Not Staffed by the Butler VA Laboratory

This procedure is to be used for stat lab work that is ordered for CLC inpatients during hours when the

Laboratory is not staffed which is as follows:

Monday through Friday: 9 pm to 6 am

Weekends: Starting Friday evening at 9 pm until Monday morning at 6 am

Holidays

This procedure is also to be used for outpatients reporting to the Abie Abraham VA Healthcare Center

(HCC) during clinic hours on Saturdays.

Venipuncture Procedure:

After it has been determined that there are specimens to be collected, assemble the required collection supplies to draw the patient’s blood i.e. venipuncture tubes, tourniquet, tape, alcohol wipe & gauze.

It is advisable to call the Butler Memorial hospital (BMH) transport dept. at 724-284-4594 or the main laboratory at Butler Memorial at 724-284-4500 to make sure that transport will be available once the specimens have been collected. If this courier is not available to deliver specimens, the Butler VA fire department can be called to deliver these specimens. They can be reached at x5055 to request delivery.

Collect the required specimens & label them. If labeling with a VIC label, be sure to indicate the time

& date of collection, your initials and the testing that is needed on the label. If labeling the specimens with a CPRS-generated label, the date & time of collection and your initials will still be required to be written on the tubes. These are also the labeling requirements for any other types of specimens i.e.

urine cups, etc. that may be collected & sent to the BMH laboratory. Once the specimens have been labeled, put them into the zip lock compartment of the biohazard bag. Do not put any order sheets, etc.

into this same part of the biohazard bag. If documentation is to be sent, put it into the outer pocket of the biohazard bag.

At this time, BMH’s 2-page hard copy requisition entitled “Laboratory Services” will need to be completed, a copy of which follows this procedure. Please follow the complete instructions that are included with the attached requisition by completing all areas that are highlighted in yellow. The desired testing must also be checked & the label that is shown on the requisition which indicates “VA

Medical Center, Register Insurance to OGVABUTLER” needs to be put on the requisition in the upper right-hand corner. These labels are available from the laboratory or can be obtained from the PCCs. It is also very important to provide both the phone number & the fax number on this requisition. This is needed so that hard copies are faxed to the correct location but also so that if any critical values are obtained, they can be reported to either the outpatient provider for outpatients or to the PCC for inpatients. Once completed, the top white-colored sheet of this requisition should be put into the outer pocket of the biohazard bag to be shipped with the specimens. The second yellow-colored copy should be kept & once the results are received via fax from BMH, a copy will need to be sent with the yellow copy of the BMH requisition to the laboratory. This is needed so that these results can be manually entered into the patient’s medical record on the next business day that the laboratory is staffed.

LABORATORY SERVICE COMPUTER CONTINGENCY PLAN

The Laboratory Service at VAMC Butler has been computerized since March 17, 1986. The lab system provides for test ordering, receiving, processing, and results reporting. The sections of the lab which are currently computerized are chemistry, hematology, therapeutic drug monitoring, send-outs, coagulation, microbiology, and serology. To ensure the integrity of patient data generated by the lab system, laboratory considers manual back-up procedures to be a vital part of laboratory computerization.

I. For laboratory, a short downtime period is defined to be from the time lab receives notification that the system will be down for up to 4 hours past notification.

A. The following manual procedures will be implemented by the laboratory immediately for all sections of the laboratory that use the VISTA system.

1. Test Ordering – For all patient orders i.e. inpatient & outpatient: Test orders will be able to be reviewed through the Vista Read Only icon which is present on all Laboratory desktops. This icon looks like:

2. To review patient orders, use the following procedure:

>Access VistARO via the icon on your desktop, Double-click

>The VistARO Home Page appears, on the left-hand side

>Choose #4

>Choose Butler

>Enter VistA Access/Verify Codes

>Click Login

>Patient Entry/Selection Screen appears

>Enter Patient, Click Find, Select Patient, Verify, Click OK >Any of the Selections to the left may be queried and information displayed/printed. Any document that is printed and to be filed must have a patient identifier on each page. To review orders, click on “Orders” on the left side of the screen. Click on

“Current Orders” to view pending Laboratory orders.

>Choose Logoff when Finished

NOTE: Pending Laboratory orders will be able to be viewed. This is with the exception of orders that the provider is requesting during Vista downtime. Since orders cannot be entered during downtime, a hard copy requisition must be provided to the Laboratory to determine which testing is to be collected. Patient samples will need to be manually labeled using handwritten labels. Labels should provide the following information: Patient’s full name, full social security number, date and time of collection, the provider name, and the name of the tests that are being requested.

2. Test Processing - Tests will be processed using the information from the specimen label or the requisition slips, if the order is unable to be entered due to Vista downtime. All patient demographic information as supplied on these slips will be manually entered into the instrument.

3. Test Results Reporting – All patient results will be programmed and run manually. The corresponding reports will be reviewed for any critical values. All STAT and critical value test results will be called by the lab staff to the Provider.

Documentation of this notification should be noted on the printed copy of patient results. Copies of all reports will be made and delivered to the inpatient and clinic locations and a copy will remain within the laboratory. This notification should be then entered when the VISTA system again becomes available. Normal test results will be reported by the system upon recovery.

4.Request for Results Lookup - Lab personnel needing test results stored in the computer database from a patient’s record will be able to use the Vista Read Only site to find and view test results.

II. A long period of downtime is defined as any time the system will be down for a period of greater than 4 hours

A. The following manual procedures will be implemented by lab immediately for all sections of the laboratory that are presently computerized for the following situations:

1. IT (formerly IRM) notifies the laboratory to implement manual back-up procedures and the estimated downtime is in excess of 4 hours;

OR

IT previously notified lab of short-term downtime, the short-term procedure was implemented, the 4 hours expires, and IT notifies lab that downtime will be extended.

a. Lab will implement or continue to implement the short-term procedure.

b. As results are generated from lab instrumentation, copies will be made. One copy will be sent to the patient’s provider and one copy will be kept in the laboratory.

c. One copy of the instrument printout will be saved in a daily log for the length of the computer downtime (see below).

B. The following procedure will be implemented to restore lab data to the VISTA database upon recovery from a short downtime period:

1. Test Ordering - Lab test orders that were unable to be ordered on the system will be ordered by the Primary Care

Provider or his equal. These orders will then be accessioned by the laboratory as usual. Orders that had been ordered for which the laboratory was able to review will also be accepted during this time period.

2. Test Results Processing –All testing which was done during the VISTA downtime will be re-run and verified within

VISTA.

III. The following procedure will be implemented to restore lab data to the VISTA database upon recovery from a long downtime period:

1. Lab will implement the short-term recovery procedures.

IV. Training of laboratory personnel in the computerized procedures and manual procedures are given as a part of job orientation. Laboratory personnel will be responsible for these procedures when computer downtime occurs.

V. The Laboratory Applications Coordinator, will be on hand for assistance in these procedures and to resolve any problems, as able, when computer functions are again restored.

Lab testing during the computer downtime will be order manually using the Laboratory Request Slip which has been provided in this document on a previous page.

FLOWCHART FOR LABORATORY PROCEDURES DURING COMPUTER DOWNTIME

It is important to first determine the length of the computer downtime. This should be able to be accomplished through contact with Information Systems.

Or Or

For short downtime period

(less than 4 hours)

For Long downtime period

(greater than 4 hours)

For Inpatients

For Outpatients

For Inpatients

For Outpatients

Test Ordering-If orders are unable to be entered due to downtime, hard copy requisitions should be received indicating testing to be drawn

If patient has had orders previously entered into

Vista, these will be able to be viewed in the Vista

Read Only icon on the desktop. Orders are reviewed and appropriate samples are collected.

Upon notification from Information

Systems that downtime will be extended, the Laboratory will continue to implement short term procedures

Specimens are hand labeled with patient’s full name, full social security number, order number, test name, date and time drawn and provider name. Specimen and/or requisition given to lab for processing.

Tests are processed according to manual requisitions

Result Reporting-a hard copy of all results from the instrument during downtime will be saved.

Results will be reviewed for any critical values which will be called to the patient’s provider and noted on the report. A copy will be made and delivered to the ward or clinic locations.

Once Computers are again functioning, samples will be rerun so that results are automatically transmitted. Any needed critical value documentation will be made from notations made on result printout.

All Laboratory results generated during downtime period will be retained in a daily log. Once computer service is restored, the daily log of results will be replaced by the computer generated daily supervisor’s summary report.

GENERAL BLOOD COLLECTION PROCEDURE

PRINCIPLE:

Phlebotomists, nurses, technologists, and technicians come in contact with patients during the process of blood collection. Patients in the hospital are often anxious about their physical condition, fearful because they do not know what is to happen next or physically uncomfortable due to their illness or injury. It is essential for the individual drawing blood to show kindness and understanding to the patient.

Obtaining blood is an art developed by study, observation and practice. Skill, patience and understanding are the qualities of a good blood collector.

UNIVERSAL PRECAUTIONS:

Universal precautions must be followed by all employees. Properly fitting gloves must be worn when performing all venipunctures. If gloves become torn or contaminated, during the venipuncture procedure, they are to be replaced immediately. After drawing patient's blood, remove gloves and wash hands in presence of patient just drawn, when possible. GLOVES ARE NEVER TO BE WASHED OR

DISINFECTED FOR REUSE. Put new gloves on in presence of next patient to be drawn. The

Laboratory's Dress Code Policy also requires that employees wear a lab coat when performing all venipunctures.

NOTE: IT IS IMPERATIVE WHEN PERFORMING VENIPUNCTURE ON LATEX ALLERGIC

PATIENTS THAT NO PRODUCTS CONTAINING LATEX COME IN CONTACT WITH THESE

PARTICULAR PATIENTS. LATEX-FREE TOURNIQUITS ARE AVAILABLE FOR THESE

PATIENTS. ALSO LATEX-FREE GLOVES ARE THE ONLY GLOVES NOW AVAILABLE

WITHIN THE CLINICAL LABORATORY AND ALSO WITHIN THE PATIENT CARE AREAS

OF THE FACILITY.

PROCEDURE:

1. Patient's diet restrictions:

Some tests require the patient to fast and/or eliminate certain foods from the diet prior to blood collection.

2. Identify the patient according to the Patient Identification Procedure.

A. INPATIENT

Always check the patient's identification. Compare the name and the patient Social

Security number on the patient's wrist band with the name and Social Security number on the collection label. The patient should also be asked to state his FULL name and FULL social security number. This information should be verified against the information on the label that will be used for labeling the blood work. If the patient is unable to state the above information, the full name and full social security number should be verified against the information on the wristband. The patient’s nurse can also verify the patient’s identity. If the patient does not have a wristband, bloodwork cannot be drawn. Go to the nurses' station to request that a wristband be placed on the patient.

B. OUTPATIENT

After the patient is seated in the phlebotomy chair, ask the patient's full name and full Social Security number. Compare this to the name and Social

Security number on the patient's VA card. This acts as a confirmation of the patient's

ID. Special care must be taken with specimens collected for Blood Bank testing.

Never ask the patient "Are you Mrs. Jones?" Always ask the patient, "What is your name?

NOTE: When drawing and labeling blood from patients having the same first and last name:

1) Always verify the Social Security number prior to drawing.

2) Each patient will have different specimen numbers for resulting the ordered tests.

3. Reassure the patient:

The patient should be told that the venipuncture will be slightly painful but of short duration.

4. Position the patient:

The patient's arm should be extended to form a straight line from the shoulder to the wrist.

5. Assemble supplies:

A. Test tubes, adaptor, tourniquet, alcohol, gauze and tape. Check expiration date on tube, if outdated, discard tube.

B. Select the appropriate type needle. Available needle types include:

1) 21 gauge 1 1/4 - standard use

2) 22 gauge 1 1/4 - standard use or difficult venipuncture

3) Butterfly 21 gauge - difficult venipunctures

4) Butterfly 23 gauge - difficult venipunctures

6. Apply tourniquet:

PRECAUTION - NEVER LEAVE THE TOURNIQUET ON FOR LONGER THAN

ONE MINUTE.

To do so may result in either hemoconcentration or a variation in the blood test results.

7. Close the patient's hand:

Vigorous hand "pumping" should be avoided.

8. Select a vein site:

A. Palpate the veins several times.

B. Medial cubital and cephalic veins are larger, fuller and remain fixed.

C. If veins are not apparent:

1) Massage arm from wrist to elbow.

2) Hang arm over side of bed without the tourniquet to allow veins to fill to capacity.

3) Examine veins in the other arm.

4) Apply warm washcloth to site.

D. Factors to consider when selecting a vein site:

1) If the patient has extensive scarring, a hematoma, a canula for dialysis or has had a mastectomy - Always draw blood from the other arm.

2) If it is necessary to draw blood above an IV, have the nurse shut off the IV for

2-3 minutes; then draw the sample. Blood should only be drawn above an IV in life threatening situations, if both hands contain IV's, or if one arm may not be used, while the other contains an IV. Make every attempt to draw the blood below the IV site. Place the tourniquet distal to the IV site, and perform the venipuncture distal to the tourniquet, at the wrist or hand. Always remember to tell the nurse when the stopped IV can be restarted.

Any time a specimen has been collected above an IV, DOCUMENT THIS ON THE

SPECIMEN LABEL

NOTE: No Laboratory employees are permitted to stop or start IV's. In order to prevent serious injury to a patient, the employee must ask the nurse to shut off the IV.

9. Cleanse the venipuncture site:

A. To prevent chemical or microbiological contamination.

B. Cleanse vein site with circular motion from the center to the periphery with 70% isopropyl alcohol solution, except for blood alcohol. When collecting blood for blood alcohol, wipe arm with betadine.

C. Allow the arm to dry to prevent hemolysis and/or burning sensation to the patient

D. DO NOT repalpitate the cleansed area unless the probing finger is cleansed before touching the site.

10. Inspect the needle- Determine if needle is sharp, free from hooks at the point and if the opening is clear.

11. Grasp the patient's arm:

Draw skin taut below site to anchor vein.

12. Perform Venipuncture:

A. Evacuated System - (Always fill EDTA tube last)

1) Thread appropriate needle into holder.

2) Tap tubes to dislodge additives.

3) Push tube into needle to the guideline on holder.

4) Line up needle with vein.

5) Turn needle so that bevel is in upward position.

6) Push needle into vein and tube to end of holder.

7) Remove tourniquet as soon as blood flow is established.

8) Mix tubes (not vigorously) that contain additives according to the manufacturer’s instructions for the recommended number of inversions. This information can be found in the “Mix by Inverting” column on the Becton Dickinson Order of Draw Chart. This document, in turn, can be found in the Phlebotomy manual and in the online Laboratory

Policy manual within the Phlebotomy section. This document recommends 8-10 inversions however inversion times of 5 minutes is more suitable.

B. If unable to obtain a blood sample:

1) Change the position of the needle.

2) Try another tube.

3) Loosen the tourniquet.

4) Probing is not recommended.

5) Never attempt a venipuncture more than twice (another technician or doctor may try.)

13. Position the gauze pad.

14. Disengage the tube within the adapter.

15. Remove the needle and flip the orange shield of the safety adaptor over the needle, an audible click should be heard.

16. Apply pressure, ask the patient if he is on any blood thinner. If he is, then additional time should be used to apply pressure to the venipuncture site.

17. Bandage the arm.

18. Invert tube several times (5-6 times for serum tubes, 8-10 times for tubes with anticoagulant).

Dispose of the needle and adaptor in a sharps container. NEVER CUT OR BREAK THE NEEDLE OR

REMOVE THE NEEDLE FROM THE ADAPTOR.

19. Label tube with patient's name, Social Security number, date and test by placing the correct specimen label on the appropriate tube. The labels are generated by

VISTA. When two patients with the same first and last name are in the hospital, always double check the Social Security numbers to be certain it is the correct patient.

FOR THE PROCEDURES ABOVE IT IS IMPERATIVE THAT THE SPECIMENS BE

LABELED IMMEDIATELY AND IN THE PRESENCE OF THE PATIENT. THIS LESSENS

THE LIKELIHOOD OF ANY PATIENT IDENTIFICATION ERRORS. THE

PHLEBOTOMIST MUST ALSO INITIAL, AND INDICATE THE DATE & TIME OF

COLLECTION ON THE SPECIMEN TUBES.

NOTE:

1. The venipuncturist should not draw blood from or above any indwelling lines.

2. Before leaving a unit, let one of the nurses know if there is a collection problem with a patient. In the same fashion, if you go back to a unit to obtain blood on a patient who was missed, let a nurse know that you did get the blood.

REFERENCES:

1. So You're Going to Collect a Blood Specimen - An Introduction to Phlebotomy.

College of American Pathologists, Seventh Edition, 1996.

2. NCCLS Committee for Clinical Laboratory Standards, 1991. H3-A3 Standard

Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, Villanova, PA.

PATIENT IDENTIFICATION PROCEDURE

Patient identification is one of the most important steps inpreparing for proper blood collection.

It is absolutely mandatory that a blood specimen is collected from the right patient. You, and only you, can make sure the right person's blood is in the tube that you return to the Laboratory. Hence, specific guidelines must be followed whether drawing an inpatient or an outpatient.

Inpatient:

1. Upon entering the correct room number as listed on the patient's collection labels, ask the patient, "WHAT IS YOUR NAME?" Never ask ARE YOU MRS. JONES?"

" Patients often reply "YES" to any question when they are not certain what was asked. An ill patient on medication may mistakenly answer "yes."

2. Prior to any specimen collection, the patient MUST be correctly identified by his or her identification bracelet. This is the band on the patient's wrist (or in rare cases on the ankle) which lists the following:

a) Patient's name

b) Patient's Social Security Number

3. Make sure the full name the patient has given you matches the identification band. Then be certain the full name, Social Security number are identical to those on the collection labels. The person drawing the blood is responsible for matching the labeled tube with the patient's arm band to insure the information matches.

NOTE: When two patients are identified with the same first and last name: Always verify the FULL Social Security number prior to drawing.

4. If the patient does not have an identification bracelet on their wrist or ankle, you MUST go to the nurses' station and ask them to please place an identification band on the patient, so you may draw the patient's blood.

Without this bracelet on the patient, his/her bloodwork cannot be drawn.

If it becomes necessary to remove a bracelet (for any reason) from a patient once they are on their unit, another one must be immediately affixed.

5. NEVER use the name on the foot of the bed, on the wall above the bed or on the patient's chart lying on the bedside table for identification purposes. It is easy for such cards to be in error or another patient's chart to have been misplaced.

6. REMEMBER, always double check the name on all of the collection labels (on the tubes) to be certain they agree with the identification bracelet. Also, check the Social Security number and room numbers on the collection label, as two patients with the same first and last name could be in the hospital.

7. Once the patient has been positively identified, proceed with the venipuncture as stated in "Venipuncture Procedure #1" of the Phlebotomy Procedure Manual.

8. For those residents who should not have venipuncture, IV insertion, BPs or injections performed on an affected arm (e.g. secondary to shunt/fistula placement, mastectomy or some other reason) a protocol for their identification is as follows:

a. A sign should be posted above the patient’s bed indicating which arm is not to be drawn.

NOTE: YOU SHOULD NEVER DRAW ABOVE AN IV SITE!

OUTPATIENT:

1. The registered outpatient is called to the Lab drawing area by a phlebotomist.

2. The outpatient enters the drawing area and sits at one drawing stations. The phlebotomist will ask the patient their name and their FULL Social Security Number. The FULL Social Security Number will be compared to that on the patient's VA card. This will positively identify the patient.

3. If the Social Security Number is incorrect on the VA card, the patient cannot be drawn. This issue must be resolved before proceeding.

4. Once the patient has been identified by name and FULL Social Security Number, double check the name, FULL Social Security number on each collection label, as two patients could be in the hospital with the same first and last name. Once positive identification has been made, proceed with the venipuncture as stated in "Venipuncture Procedure #1" of the Phlebotomy Procedure

Manual.

FOR THE PROCEDURES ABOVE IT IS IMPERATIVE THAT THE SPECIMENS BE

LABELED IMMEDIATELY AND IN THE PRESENCE OF THE PATIENT. THIS LESSENS

THE LIKELIHOOD OF ANY PATIENT IDENTIFICATION ERRORS. THE

PHLEBOTOMIST MUST ALSO INITIAL, AND INDICATE THE DATE & TIME OF

COLLECTION ON THE SPECIMEN TUBES.

ERRORS IN PATIENT IDENTIFICATION: Any errors in patient identification discovered after the patient’s specimens have been collected must be reconciled. All necessary attempts will be made to find the error in identification and to correct it.