D.36- LAB MANUAL WITH COVER AND TABLE OF CONTENTS 2021.pdf

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PATHOLOGY & LABORATORY

MEDICINE DEPARTMENT

DEPARTMENT OF VETERAN'S AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK AT

SYRACUSE, N.Y.

Attachment D.36 36C24224R0049

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2021 PATHOLOGY & LABORATORY MEDICINE SERVICE

DEPARTMENT OF VETERANS AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK AT SYRACUSE

TABLE OF CONTENTS

ORGANIZATIONAL LISTING Page:

GENERAL INFORMATION:

I. Laboratory Hours

II. Collection of Specimens . . . . . 1 - 12

III. Delivery of Specimens to Lab . . . . . 13 - 14

IV. Delivery of Laboratory Reports

V. General Description/Purpose for Tubes for Drawing Blood . . . 15

VI. Test Turn-Around-Times . . . . . 16 - 18

VII. Send Outs (Reference Lab Testing) . . . . . 18 - 21

VIII. Test Reference Range Levels 7 Panic Levels . . . . . 22 - 29

IX. Outpatient Laboratory Tests

X. Recurrent Problems & How to Avoid Them . . . . . 29 - 31

AUTOPSY INFORMATION:

I. Ward Clerks / Medical Administrative Assistant (MAA) . . . 32

II. Autopsy Permission . . . . . 32 - 36

III. Entry, Storage & Release of Bodies

IV. Canandaigua /Autopsy Procedure . . . . . 37 - 38

BLOOD BANK:

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I. Specimen Labeling – Bedside . . . . . 39 - 39

II. How to Use Forms . . . . . 39 - 41

III. Signing Out Blood & Components

IV. Signout Procedure

V. Blood /Blood Component Administration . . . 43 - 44

VI. Returning Blood / Blood Components

VII. Blood /Blood Components "On Hand" in Blood Bank

VIII. Blood /Blood Components Available through ARC

IX. Criteria for the Appropriate Use of Blood /Blood Components.. . . 44 - 45

X. Approximate Volume of Blood / Blood Component Units

XI. Blood Infusion Rate . . . . . 45 - 46

XII. Blood / Blood Component Expiration Times . . . . . 46 - 47

XIII. Emergency Use of Uncrossmatched Blood

XIV. Elective Surgery . . . . . 47 - 48

XV. Type & Screen

XVI. Other Crossmatch Orders

XVII. Length of time Crossmatch Held

XVIII. Ordering Blood / Blood Component . . . . . 48 - 49

XIX. Ordering Autologous Units

XX. Ordering Direct Coombs

XXI. Ordering Antibody Screen

XXII. Antibody Identification

XXIII. Emergency ARC Antibody ID Work-Up . . . . . 49 - 50

XXIV. Transfusion Reaction – Definition . . . . . 50 – 53

XXV. Transfusion Reaction - What To Do

XXVI. MSBO Guidelines . . . . . 54 - 57

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TABLE OF CONTENTS

Page:

CHEMISTRY:

I. Structure of the Chemistry Section

II. Quick Reference Guide to Volume Req. for Specimens . . . 58

III. Specimen Rejection Parameters . . . . . . 58 - 59

IV. Timed Urine Collections for Chemistry Tests . . . . . 59 - 60

V. Random Collection of Urine

CYTOLOGY:

I. Specimen Identification

II. Rejection Policy

III. Receipt of Specimens

IV. Request for Materials . . . . . 61 - 62

V. Collection of Specimens . . . . . 62 - 67

HEMATOPATHOLOGY:

I. Specimen Collection Tube Colors

II. Hematopathology Blood Collecting Tube Facts . . . . 68 - 70

HISTOPATHOLOGY:

I. Schedule for Surgical Tissue

II. Fixative & Containers . . . . . 71 - 72

III. Biopsy vs. Non-Biopsy Specimens . . . . . 72 - 73

IV. Frozen Sections

V. Electron Microscopy (EM)

VI. Special Tissues & Situations . . . . . 74 - 75

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VII. Tissue Immunoflorescence . . . . . 75 - 76

• IMMUNOPATHOLOGY:

I. Immunopathology Serology

II. Blood Collection Tubes

MICROBIOLOGY:

I. Microbiology Specimens . . . . . 77 - 78

II. Disease or Viral Agent & Recommended Specimen Type. . . . 78 - 79

III. Recommendations for Specimen Collection

IV. Procedure for Phlebotomy - Blood Cultures . . . . . 79 - 82

V. Ordering Restrictions . . . . . 82 - 83

VII. Instructions for Microbiologic Specimen Collection & Transport . . 83 - 90

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INFORMATION

I. LABORATORY: Address 800 Irving Avenue, Syracuse, NY 13210. Located: 3C (main building)

VA Hospital phone (315) 425-4400 Outpatient Phlebotomy x52123

Blood Bank x53325 Microbiology x53304

Core lab x56525 / x56526 Cytology x52217

Office phone (P&LMS) x54419 / x53312 Histology x53298

A. The Laboratory operates twenty-four (24) hours a day, seven (7) days a week.

B. Collection hours in Outpatient Phlebotomy are from 6:30 AM to 4:30 PM, Monday through Friday.

C. Regular Laboratory duty hours are 7:00 AM to 3:30 PM, Monday through Friday.

D. On weekends, holidays, and after regular duty hours, STAT testing is available with reduced staffing. There are two to four technologists on the evening shift, and one to three from

12:00 MIDNIGHT to 8:00 AM.

II. COLLECTION OF SPECIMENS:

A. Greet the patient in a courteous manner and explain that you are to collect the blood specimen for tests which his doctor has ordered. If the patient is in the process of receiving a transfusion, then the phlebotomy should not be performed. Proper PPE, including gloves, must be worn during phlebotomy. See Laboratory Policy 20-03 for further information on PPE.

B. Positive identification of the patient must be established before the venipuncture is attempted. This is done by the following procedure:

1. First, ask the patient to give their FULL NAME and SOCIAL SECURITY NUMBER. Do not state the patient's name and ask him if it is correct.

2. Next, verify the patient's name and identification from their identification bracelet.

3. If the patient does not have an identification band attached to his body, the nurse will be requested to provide one. If he or she does not, the patient is not to be drawn.

C. Confirm that you have the correct tubes for the ordered tests. Assemble supplies so that they are within easy reach during phlebotomy. Label tubes with printed patient labels which includes the patient's full name, full social security number, ***PLEASE NOTE: ALL SPECIMENS RECEIVED IN THE LABORATORY MUST BE LABELED WITH THE

FULL NAME AND FULL SOCIAL SECURITY NUMBER OF THE PATIENT.***

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D. WHEN COLLECTING BLOOD BANK SPECIMENS:

a. Prior to accessioning a Blood Bank order, requisitions are to be printed from Outpatient

Phlebotomy through CPRS. Blood Bank specimens should only be drawn after a provider has entered an order.

1. During computer downtime, a downtime form must be used.

2. If the order was entered as Lab Collect, a downtime form must be used.

b. Once phlebotomist receives a patient who requires blood to be drawn for BB testing the phlebotomist will follow the directions as outlined in the ATTACHMENT: How to Print a Blood Bank Request for Outpatient Phlebotomy.

c. The phlebotomist will compare the name on the requisition and specimen labels. Another unique form of patient identification is mandatory prior to drawing blood bank specimens.

d. Unique patient identification may include, but are not limited to:

1. Driver’s License

2. Veteran’s Identification Card (VIC)

3. Armband (if available, can be used for patient ID)

4. VISTA Imaging (photo ID)

5. Recitation of Full Social Security number

e. The phlebotomist that verified patient identity should be the phlebotomist that draws the specimen (there are no exceptions to this rule).

1. If the phlebotomist that verified the patient identification has trouble collecting the specimen and requires the help of another phlebotomist, then the subsequent phlebotomist is required to re-verify the patient’s identification before phlebotomizing the patient. This subsequent phlebotomist is also required to start the phlebotomy process from the beginning.

2. Absolutely no pre-labeling of tubes should occur.

f. A second phlebotomist must be present as a witness to the patient identification and the blood draw of a type and screen specimen (see part i.).

1. In the event that there are no other phlebotomists available to witness the specimen collection, the phlebotomist must immediately contact the Blood Bank to request for a medical technologist to report to Outpatient Phlebotomy to witness the collection. The medical technologist will designate another appropriate technologist to witness the collection if they are unable to report to Outpatient

Phlebotomy at the time of the request.

g. Once the specimen has been collected the phlebotomist who performed the phlebotomy

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(verifier) is required to sign, date, and provide their DUZ# at the Signature of Verifier area of the Lab Requisition form (or a downtime form if during computer downtime).

Upon signing the requisition, the phlebotomist will attest the following:

I have performed positive identification of this patient. I compared the full name and social security number on the sample label and verified that they exactly match the identifiers on this form, and the patient’s armband or VIC card/Driver’s license. I labeled the sample before leaving the patient’s side.

h. The witness must confirm the correct patient identification and correct labeling of the specimen. After collection is complete, they are required to sign the requisition form as the witness at the Signature of Witness area and provide their DUZ#. They must also record the date and time of the draw. By signing as the witness, they attest to the following:

I witnessed the person above collect this blood sample. I have read the full name and social security number on the sample and verified that they exactly match the identifiers on this form and the patient’s armband or VIC card/Driver’s License before leaving the patient’s side.

i. The specimen and requisition must be placed in an appropriate bag and brought immediately to the Blood Bank laboratory. The phlebotomist must call Escort and verify that immediate pick-up is available. If Escort is unavailable, it is the phlebotomist’s responsibility to bring the specimen immediately to Blood Bank.

j. Any specimen collection concerns or questions should be directed to the personnel in

Blood Bank at x53325 or x53326

E. The patient must be lying down or seated comfortably so that if the patient faints, they will not be injured by falling. Never draw blood from a standing person.

F. Procedure:

1. Apply the clean tourniquet about halfway between the shoulder and elbow, tight enough to impede the venous return but not so tight that the arterial flow is restricted.

2. Ask the patient to close their hand so the veins will fill with blood and become more prominent.

G. The tourniquet should be left on only briefly while a vein is located, cleansed and punctured. If difficulty in locating a vein is encountered, release the tourniquet for a few minutes before performing the venipuncture, since certain test results can be changed by prolonged venous obstruction.

H. Select the venipuncture site. If any of the following conditions exist, a different site should

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1. Excessive scarring

2. Hematoma

3. I.V.

4. Posted Restrictions

Palpate the vein to ascertain that it is elastic and there is no pulse indicating the vessel is really an artery.

I. Cleanse the venipuncture site using a cotton ball saturated with 70% isopropyl alcohol. A circular motion should be used starting from the center of proposed site outward. Before attempting the venipuncture, allow the alcohol to dry. Failure to do so may cause hemolysis in the blood specimen and an uncomfortable burning sensation to the patient.

J. The vein should be held taut while the needle is inserted. This can be accomplished by pressing down and pulling the skin gently with the thumb of the free hand. The needle should be held at approximately a 45 angle during insertion. As soon as a blood flow is established, the tourniquet should be released. If the needle appears to have completely penetrated the vein, withdraw it slowly until a flow is established. Prolonged probing is discouraged, as it produces a great deal of pain and is usually not successful.

K. If the first attempt is not successful, use a new needle, since the first one is contaminated.

If the second attempt is not successful, do not attempt the venipuncture again. Have another phlebotomist/technologist attempt to obtain the specimen, or a "will-send" is requested. After obtaining the required specimen, make sure the tourniquet is released, the patient's hand is opened, and the tube is pulled off the needle. Gently withdraw the needle and immediately cover the puncture site with a dry piece of cotton. Instruct the patient to keep his arm straight and apply pressure on the puncture site with his other hand for about five minutes.

L. Before leaving the patient, inspect the venipuncture site. If the bleeding has stopped, apply an adhesive bandage. If the bleeding has not stopped, the help of Ward personnel may be sought.

Under no circumstances should the patient be left until the bleeding has stopped, or you have been relieved by the Ward Nurse or designee.

M. Record the date, time of the venipuncture, and your initials on the requisition or label. For Blood

Bank specimens, the signature and the specimen collectors’ DUZ number must be on the requisition.

The requisition must accompany the specimen.

N. If the blood from a patient is not drawn, the nurse must be notified of the patient's identity and the reason why the blood was not drawn. The order is marked 'NOT COLLECTED' in the computer and the reason is documented in the laboratory or collection list.

O. Both Inpatient and Outpatient Phlebotomy will now use disposable tube holders for drawing blood. This change has been necessitated by new OSHA regulations, which forbid the re-use of tube holders. The new disposable holders accommodate both BD Eclipse needle, as well as the BD Safety Butterflies. Contaminated needles should be placed in red puncture

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P. Observation of precautions for isolated patients is imperative. Take only minimal equipment in the room. Everything taken into an isolation room must be left there, except the specimen tubes.

Q. Phlebotomy Rounds: The Laboratory draws blood at 7:00 – 8:00 AM each morning. To ensure proper identification, patients must wear an identifying band (arm or leg). Technologists are not required to wait or look for patients who are not at their bedsides or at designated blood drawing areas. If the Technologist is unable to draw the blood, responsible ward personnel will be notified for arranging for the Clinical Staff to draw the blood. We do provide a troubleshooter (a skilled

Phlebotomist) during the week for difficult draws on the A.M collection list.

R. Blood Drawn by Clinical Staff: Because of Laboratory Staff limitations, the Laboratory can draw blood only once a day, and it is necessary for Clinical Staff to draw blood after the 7:00

AM phlebotomy rounds. Blood received by 9:30 AM can be processed more promptly, and routine specimens arriving in the Laboratory after 12:00 PM might not be completed that day.

S. Weekend, Holiday, & After Duty Hours Staffing:

It is urged that routine laboratory tests not be ordered during these times. A heavy load of non-emergent tests can delay turnaround times (TAT) of STAT testing, and your aid is solicited in limiting weekend testing to STATS only.

T. Collection of Other Specimens: Please deliver urines, feces, sputum, etc., to the Laboratory for processing. Refer to Computer Entry for each test for details of collection or call the laboratory for assistance. Remember that these specimens must also be labeled with the patient’s full name and full social security number.

U. When the lab receives specimens, the time and date of collection written on the specimen label is what is entered into the computer as the specimen collection date and time. If there is no collection time indicated, the lab uses “T@N” (time at now), which will enter the receipt time in the lab as the collection time. It is strongly encouraged to record the date and time of collection on the specimen labels.

The Laboratory’s internal protocol 20-03 outlines the specifics regarding the ordering of tests, phlebotomy and specimen collection:

Laboratory Protocol for Ordering Tests, Phlebotomy, and Specimen Collection:

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Department of Memorandum

Veterans Affairs

Date: March 10, 2020 LABORATORY PROTOCOL

20-03

From: Chief Pathologist, P&LMS 113

Subj: Ordering Laboratory tests, Phlebotomy, and Specimen Collection;

• Test request

• Patient identification

• Specimen collection and labeling

• Minimizing of Blood Volumes taken

• Inpatient and Outpatient Phlebotomy issues

To: P&LMS Staff

PURPOSE:

The purpose of this policy is:

1. To meet and exceed all appropriate regulations

2. To define acceptable practice for ordering tests, patient identification prior to phlebotomy, and acceptable specimen labeling

3. To address issues and concerns related to inpatient phlebotomy, to include:

• Provision of additional protective clothing and devices to be used as required for isolation patients.

• Provision of notice to P&LMS staff of AFB patients on the morning collection.

• Phlebotomy of patients receiving blood/blood product transfusion.

• Handling of patients with an IV or heplock.

• Safety related issues and practices.

• Phlebotomy in Dining rooms.

4. To define policy and address issues specific to the outpatient phlebotomy process

5. To minimize volume of blood collected for test requests

6. To ensure at least 2 sources of patient identification are used to identify patient prior to phlebotomy, and to label specimen containers.

PROTOCOL: (refer to Clinical Laboratory Manual for detail procedure and notes)

• Ordering Lab tests:

1. Lab orders should be placed in the computer. A lab slip may be used in an unusual circumstance.

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2. Lab orders must include the patient's name, social security number, patient location, ordering physician, and tests requested.

3. In the case of Blood Bank requests, a complete Laboratory Requisition form or the downtime form are required. Please refer to the Clinical Laboratory Manual or Medical Center Professional Memorandum for details.

4. STAT or PRIORITY requests must be indicated as such. Unless specified otherwise, all orders will be processed as ROUTINE.

5. The information must be correct and legible.

6. In the case of an Order Entry request (OE):

a. The label with the order number on it is to be placed on the specimen in such a way as not to interfere with opening the specimen. The specimen should be delivered to the Laboratory promptly.

b. Laboratory staff will promptly accession all specimens. For regulatory purposes, the accession time is to be considered the time of receipt, as the difference is clinically insignificant.

c. Once a Lab order has been collected and sent to the Laboratory for processing that lab order number cannot be used again later when collecting a new specimen. New orders are required for future specimens.

7. In the event that there is a discrepancy between the patient identification information on the test request, on the specimen, or in the computer, (or that this information is absent/illegible), the Laboratory staff will request a new specimen.

*NOTE: ALL SPECIMENS SUBMITTED TO THE LABORATORY MUST BE PROPERLY

LABELED WITH THE PATIENT’S FULL NAME AND FULL SOCIAL SECURITY NUMBER.*

• Inpatient Identification – by lab staff on morning rounds:

1. The patient is found by matching ward, room, and bed numbers on the request. If this information is not recorded on the collection list, then ask at the nursing station.

2. Greet the patient and ask the patient to recite his/her name and social, if able. Do not state the patient’s name, and then ask the patient for confirmation of his/her name to determine if this is the correct patient. Patients have agreed to incorrect names, especially if hard of hearing.

3. If there is no ID band affixed to the patient, wait until a proper wristband is affixed to the patient. Never draw a patient without a wristband on their person (not on table or bed).

4. Verify the patient’s name and social security number from the patient's wristband. The information on the wristband should match the name and social security number on the request and/or labels.

5. Ask the patient to recite his/her social security number as a second verification of identity. If he/she is unable, The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed then refer to the patient's bedside chart, labeled IV/medication bag, or the patient directory board at the nursing station as a secondary source of identity. Verbal identification from a nurse is acceptable only as a secondary source of identity.

6. If there appears to be a discrepancy in the name or the social security number, check with the nursing station for possible error.

7. If the patient does not want his/her blood drawn, explain that the test was ordered by a doctor and that it is in his/her benefit to have it drawn. At all times be courteous. If the patient still does not want his blood drawn, do not argue. Thank the patient, and do not draw the blood.

8. In the case of patients with a large number of tests ordered, all efforts will be made to minimize the blood volume taken. The volumes needed are noted on the collection list, and any questions can be directed to more experienced staff in the appropriate lab sections.

9. Laboratory staff should discontinue phlebotomy efforts on a patient after two unsuccessful attempts and refer the test order to a troubleshooter.

10. The tubes should be labeled at the bedside immediately after the blood is drawn and the patients puncture site is tended to. Staff should never pre-label tubes.

11. Proper labeling of all non-blood bank specimens must include the patient’s full first and last name and the entire social security number. The phlebotomist’s initials must be written on the lab collection list. Each individual patient drawn should be initialed on the collection list, not just one set of initials for the entire list. The date and time of collection should be noted on all specimens, not just blood bank tubes. When date and time of specimen collection are not available on the specimen, the receipt time in the laboratory will be used as the collection time. Unknown collection time (T@U) will not be used.

12. Blood Bank specimens must include the phlebotomist’s initials, date, and time of draw on the label. They must be accompanied with the Lab Requisition form or the downtime form, which must include the date and time of draw, the patient’s full name and social security number, and the phlebotomist’s signature and DUZ number. Blood Bank specimens should only be drawn after a provider has entered an order.

• A second phlebotomist or nurse must be present as a witness to the patient identification and the collection of a Blood Bank specimen. The witness must confirm the correct patient identification and correct labeling of the specimen. After collection is complete, they are required to sign the requisition form as the witness at the Signature of Witness area and provide their DUZ#.

They must also record the date and time of the draw.

• It is the phlebotomist’s responsibility to locate a witness for the specimen collection. The patient’s bedside nurse or another medical technologist would be an appropriate witness.

13. If the phlebotomy on a patient is not successful, the Charge Nurse should be notified before leaving the ward. If the reason the patient was not drawn is that he/she is a difficult stick, this would apply after the trouble shooter makes an attempt. The patient information, tests/specimens needed, the reason the patient was not drawn, and the name of the Charge Nurse informed should be left as a communication on the ward. The reason the patient was not drawn and the name of the Charge Nurse should also be documented on the collection list and entered into the computer when the tests are canceled by the laboratory staff. If the Charge Nurse is unavailable, note this on the collection list and enter the name of alternate Nurse who was informed on the collection list and in

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• Additional Inpatient Phlebotomy Issues:

1. Phlebotomists will follow hospital policy and which protective garments must be worn for patients in various forms of isolation. If these garments are not provided outside the patient’s room, P&LMS staff will not enter the isolation room.

*Note that the CLC on the 8th floor uses “Lady Bug” signs to indicate precautions to maintain a home-like environment. Check with a floor nurse before entering any patient room with a Lady Bug sign to confirm what precautions are necessary before entering the room.

2. It is the responsibility of Infection Control to ensure adequate notification of patients on AFB isolation is provided. The “Airborne Transmission Precaution” sign must be placed prominently at the entrance of the patient room and must specify what precautions must be taken in order to enter the room. The only exception to the requirement of this sign is when the patient must be transported outside of the negative pressure room. In this case, verbal communication would be used with all involved in the transport of the patient. In the rare event that a nurse informs a phlebotomist that the patient is under AFB isolation precautions and there is no sign posted on the patient’s door, the phlebotomist should use proper precautions to draw the patient and then notify Infection Control that the sign was not posted on the door.

a. The notification of patients on AFB isolation is required to ensure that the personnel use the required proper respiratory mask. Phlebotomists should have these masks available in their cart if they are not supplied by the floor. Phlebotomists should be FIT tested to identify the correct style and size mask. It is each individual employee’s responsibility to ensure FIT testing is up to date. If FIT testing is expired, a Powered Air Purifying Respirator (PAPR) shall be used and is provided on each floor.

3. Patients that are in the process of being transfused blood or blood products will not be phlebotomized by the lab during the transfusion.

4. When a patient has an IV or heplock, the other arm should be used for phlebotomy. If this is not possible, then a site BELOW the IV or heplock can be used. For example, a patient with a heplock in their forearm/wrist area must only be drawn in the hand on that arm (if the opposite arm is not able to be drawn), and not in the antecubital area. If there is not an adequate site below the IV/heplock, the patient will not be drawn.

5. All staff will utilize the appropriate personal protective equipment while performing phlebotomy, as defined in the standard operating procedures. The following practices will be required:

a. Gloves will be changed between all patients, and hands washed/decontaminated.

b. Recapping of needles will not be allowed.

c. Tourniquets will be discarded between patients.

6. Phlebotomy will not be allowed in dining rooms.

• Outpatient Phlebotomy

1. All patients must fill out a sign-in slip with their name and the last four digits of their social security number, or alternate ID and give the slip to facilitator through the window. The phlebotomist/technologist will locate lab orders and print out specimen labels after patient arrival.

(Labels will not be pre-printed). If there is an incorrect order location, the phlebotomist should correct the order or central accessioning should be contacted to correct the order and/or suggest the appropriate tubes to draw.

2. All patients should be greeted promptly and courteously; addressing them by title (Mr./Ms./Mrs.)

followed by their last name.

3. Once the patient is in the phlebotomy chair the patient should be asked to recite their full social security number as one form of identification. Additional or alternate forms of identification can be the patient's Veteran’s Identification Card (VIC) or driver’s license for a positive patient identification.

4. Proper labeling of all specimens will include the patient’s name, the entire social security number, date and time collected. Staff will initial the sign-in slips for each patient drawn and document time drawn. The sign-in slips will be saved for the entire shift and then shredded at the end of each workday. Initialing the (non-Blood Bank) tubes on outpatients drawn is not necessary if the slips are initialed as required.

Blood Bank draws

k. Prior to accessioning a Blood Bank order, requisitions are to be printed from

Outpatient Phlebotomy through CPRS. Blood Bank specimens should only be drawn after a provider has entered an order.

1. During computer downtime, a downtime form must be used.

2. If the order was entered as Lab Collect, a downtime form must be used.

l. Once phlebotomist receives a patient who requires blood to be drawn for BB testing the phlebotomist will follow the directions as outlined in the

ATTACHMENT: How to Print a Blood Bank Request for Outpatient

Phlebotomy.

m. The phlebotomist will compare the name on the requisition and specimen labels. Another unique form of patient identification is mandatory prior to drawing blood bank specimens.

n. Unique patient identification may include, but are not limited to:

6. Driver’s License

7. Veteran’s Identification Card (VIC)

8. Armband (if available, can be used for patient ID)

9. VISTA Imaging (photo ID)

10. Recitation of Full Social Security number

o. The phlebotomist that verified patient identity should be the phlebotomist that draws the specimen (there are no exceptions to this rule).

3. If the phlebotomist that verified the patient identification has trouble collecting the specimen and requires the help of another phlebotomist, then the subsequent phlebotomist is required to re-verify the patient’s identification before phlebotomizing the patient. This subsequent phlebotomist is also required to start the phlebotomy process from the beginning.

4. Absolutely no pre-labeling of tubes should occur.

p. A second phlebotomist must be present as a witness to the patient identification and the blood draw of a type and screen specimen (see part i.).

2. In the event that there are no other phlebotomists available to witness the specimen collection, the phlebotomist must immediately contact the

Blood Bank to request for a medical technologist to report to Outpatient

Phlebotomy to witness the collection. The medical technologist will designate another appropriate technologist to witness the collection if they are unable to report to Outpatient Phlebotomy at the time of the request.

q. Once the specimen has been collected the phlebotomist who performed the phlebotomy (verifier) is required to sign, date, and provide their DUZ# at the

Signature of Verifier area of the Lab Requisition form (or a downtime form if during computer downtime). Upon signing the requisition, the phlebotomist will attest the following:

I have performed positive identification of this patient. I compared the full name and social security number on the sample label and verified that they exactly match the identifiers on this form, and the patient’s armband or VIC card/Driver’s license. I labeled the sample before leaving the patient’s side.

r. The witness must confirm the correct patient identification and correct labeling of the specimen. After collection is complete, they are required to sign the requisition form as the witness at the Signature of Witness area and provide their DUZ#. They must also record the date and time of the draw. By signing as the witness, they attest to the following:

I witnessed the person above collect this blood sample. I have read the full name and social security number on the sample and verified that they exactly match the identifiers on this form and the patient’s armband or VIC card/Driver’s License before leaving the patient’s side.

s. The specimen and requisition must be placed in an appropriate bag and brought immediately to the Blood Bank laboratory. The phlebotomist must call Escort and verify that immediate pick-up is available. If Escort is unavailable, it is the phlebotomist’s responsibility to bring the specimen immediately to Blood

Bank.

t. Any specimen collection concerns or questions should be directed to the personnel in Blood Bank at x53325 or x53326.

5. In the case of patients with many tests ordered, all efforts should be made to minimize the blood volume taken. The volumes needed are noted in the computer, and any questions can be directed to the appropriate lab sections.

6. If a urine specimen is required, the urine cup should be labeled prior to giving it to the patient, and the patient directed to the rest room within Outpatient Phlebotomy. If that restroom is already occupied, then the patient should be directed to the next nearest restroom. The patient should also be instructed where to drop off the specimen when they are through.

7. If patients are to report to additional departments, instruct them as to the proper location.

8. The following tools will be posted and available in phlebotomy for handling problem requests and ensuring coverage:

a. List of clinics, phone extensions, hours of operation

b. Schedule for departmental coverage and phone extensions

c. Facilitator schedule and phone extensions

9. Efforts will be made to keep the patients waiting period under 20 minutes. In the event of heavy workload, if the waiting period exceeds 20 minutes, a call for departmental assistance will be made.

10. Phlebotomists will utilize the appropriate personal protective equipment while performing phlebotomy, as defined in the standard operating procedures. The following practices will be required:

a. Gloves will be changed between all patients, and hands washed/decontaminated.

b. Recapping of needles will not be allowed.

c. Visibly contaminated tourniquets or blood drawing equipment will be disposed.

• Truncated Patient Names on Specimen Labels

On occasion, patient names have too many characters to fit onto a specimen label and are truncated. They may only be accepted under certain circumstances:

1. When drawing blood:

i. These labels may be used for specimen labeling after phlebotomy if the full social security number is visible on the specimen label and it matches the verbally recited full social security number (when applicable) and the printed number on the patient’s wristband.

2. When receiving labeled specimens:

i. These labels may be accepted in the laboratory for specimen testing if the full social security number is visible on the specimen label and it matches the patient’s full social security number that is listed with the lab order number.

ii. These labels may be accepted in the Blood Bank for testing if the full social security number is visible on the specimen label and it matches the patient’s full social security number that is listed with the lab order number and it matches the patient’s full social security number that is on the requisition form. The visible characters of the patient’s name on the specimen label must also be compared to the full name listed on the requisition form.

• Specimen Identification in the Laboratory

1. After properly labeled specimens have been received in the lab, the lab will maintain adequate identification on specimen containers throughout all phases of testing. This includes, but is not limited to, aliquots, dilutions, tubes, slides, blocks, culture plates, and other secondary specimens created during specimen processing and/or testing and will be defined by section procedures.

RESCISSIONS: 07-01, 08-01, 11-01, 12-02, 13-10, 16-10, 17-03, 18-02, 19-06

RESPONSIBILITY: The responsibility of ensuring compliance with this policy is delegated to the technical staff performing the phlebotomy, and the Section Supervisors. Overall responsibility resides with the Chief Pathologist, P&LMS.

REVIEW & REVISION SCHEDULE:

• Annual review by Lead Pathologist

• Revision every 3 years: Due 2023

Yiran Dai, MD

Chief Pathologist, Pathology and Laboratory Medicine 113

Henry D. Friedman, MD

Blood Bank Medical Director Pathology and Laboratory Medicine 113

III. DELIVERY OF SPECIMENS TO THE LABORATORY:

A. Escort Service: Within the medical center, Escort Service (x53205) provides specimen delivery at frequent intervals when needed. Please do not let specimens accumulate for delivery at the convenience of ward personnel. Please ensure that gloves are available for their use in transporting the specimens.

B. Transportation of Specimens:

• Using Universal Precautions as a guide, all specimens are considered potentially hazardous, therefore, a biohazard label is not required.

• Specimens are to be handled in a manner which prevents contact of the specimen or the specimen container with bare hands.

• Gloves are to be used during specimen collection, and zip-lock bags are to be utilized during transport of all specimens to the Laboratory. Do not put the requisition/labels inside the zip-lock bag with the specimen. If leakage of the specimen occurs, the requisition will be contaminated. Specimens are to be transported to the Laboratory in well-constructed containers with a secure lid to prevent leakage during transport.

• If a specimen leaks or the outside of the transport container becomes contaminated, the specimen container is to be placed into a leak-proof bag.

• Hands are to be washed after completion of collection or transport of specimens.

C. Collection Sites: During regular duty hours, please deliver specimens to the central receiving area in the Core Lab, Room C-375, Third Floor and place them on the orange tray.

D. Request Forms & Labeling: It is mandated by Medical Center Professional

Memorandum 11-214: “Specimen Identification”, and by laboratory accrediting agencies that the Laboratory test only specimens which are PROPERLY LABELED and accompanied by an electronic order into CPRS by Order Entry.

1. Specimens require an adhesive label with:

a) Patient's FIRST and LAST NAME

b) Full Social Security Number

c) Date and Time of Draw

d) Initials of Phlebotomist e.) Special precautions labels must be affixed to specimens when necessary to inform staff and ensure safe handling and disposal. Patients with known or suspected Prion Disease, must be labeled as “Prion Disease” or “CJD Precautions.”

Specimens collected while patients are presently undergoing radiation or chemotherapy must be indicated on a label by using the word “Radioactive” or

“Chemotherapy Precautions.”

2. Laboratory personnel are NOT permitted to process improperly labeled laboratory requisitions or specimens.

EMERGENT SITUATION ONLY

a) In the event that there is an emergency and a discrepancy is found with the patient identification on the order request, the specimen, or in the computer, all measures will be taken by the laboratory to give verbal, preliminary results according to laboratory protocol (if applicable). However, final results will not be released into the patient’s medical record until a resolution to the discrepancy is finalized. If a new specimen is not submitted, or if the ward physician disagrees with the policy, the Section Chief of the involved area of the Laboratory will be informed. The ultimate decision of sample disposition rests with the

Laboratory.

b) Exceptions: Blood Bank has exceedingly strict, regulated, guidelines to abide by. It will be left to the discretion of Blood Bank authority as to the degree of leniency that will be utilized, if any.

c) We solicit your cooperation to make this policy work. The policy is based on Medical Center Memorandum and Regulatory Agency standards.

IV. DELIVERY OF LABORATORY REPORTS:

A. Final laboratory results are available through VISTA and/or CPRS as soon as results are entered by the Laboratory personnel.

B. All STAT results, and all critical care areas results are automatically transmitted upon laboratory verification to printers in the appropriate areas unless the ordering location has printing options turned off.

C. Panic/critical values are telephoned to the ordering provider within 30 minutes of detection. Results can also be obtained through the VISTA or CPRS systems.

V. GENERAL DESCRIPTION / PURPOSE FOR COLLECTION TUBES

COLOR ANTICOAGULANT/ADDITIVE USUAL PURPOSE *

Red (no gel) None General Chemistry, Therapeutic Drug Level

Lavender EDTA (K3) CBC, Retic, Sed Rate, BNP, HgbA1c

Pink EDTA (K2) Blood Bank

Light blue Sodium Citrate, 3.2% Coagulation Tests

Dark Blue Sodium Heparin Trace Elements

Green Sodium Heparin Sendouts/Miscellaneous

Green Lithium Heparin (black ring on top) Ammonia/Ionized Calcium

Grey Sodium Fluoride/Thymol Glucose Tolerance Test, Lactic Acid

Yellow ACD-A DNA and Genetic Testing

Flow Cytometry PCR

Red/Grey

(Combat)

Thixotropic Gel General Chemistry and Serology

Yellow/Black

(Isolator)

3 Agents Quantitative Blood Culture

AFB Blood Culture

White Plasma Separator HCV PCR, HIV Viral Loads

* Purpose indicated here is for GENERAL INFORMATION ONLY. Please use the computer for detailed instructions before procuring any specimen. Also see “Quick Phlebotomy Guide” on SharePoint.

VI. TEST TURN AROUND TIMES:

A. RAPID TURN AROUND TIME (TAT) TESTS:

The following tests have been approved by the Clinical Executive Board as tests to be available with rapid TAT, 24 hours a day. TAT is one hour, except as noted. Please see below for specific details. Tests requiring clotting and spinning are identified by an asterisk (*), and the time required to clot and spin (20-25 minutes) is a factor in meeting

TAT.

• ABO/Rh, DAT, Antibody Detection test*

• Acetone (Qualitative, Serum or Urine)*

• Activated Partial Thromboplastin Time (APTT)

• Alcohol*

• Ammonia

• Amylase*

• Antibody Identification (4-12 Hrs)*

• Bilirubin*

• Blood Gases (1/2 Hour)

• Body Fluid Differential (3 Hrs); CSF Cell Count (2 Hrs). When a critical need exists, such as suspected meningitis or peritonitis, please notify the Laboratory, and if possible, results will be expedited.

• Body Fluid Glucose and Protein

• Calcium*

• Carbon Dioxide*

• Chloride*

• Complete Blood Count (CBC - Includes Platelet)

• Coombs (I For Indirect)

• COVID-19 (PCR testing for SARS-CoV-2) (2 hrs for in-house “rapid” test)

• CPK*

• Creatinine*

• Crossmatch – New sample is required every 3 days*

• Crossmatch add on – current sample already tested, negative antibody detection test, no history of antibody problem (10 min)

• Crossmatch – patient with positive antibody detection test and/or history of clinically significant antibody problems (2 hrs)

• Cryoprecipitate: 8-10 Units (1 1/2 Hrs)

• D-Dimer

• Direct Coombs and/or indirect Coombs.

• Differential Count (When Verbally Requested by a Physician)

• Fresh Frozen Plasma Unit (1/2 Hr)*

• Fibrinogen Level

• Frozen Blood, Crossmatch (4 Hrs) - Includes American Red Cross Prep. time*

• Glucose

• Gram Stain (1/2 Hour)

• India Ink

• Infectious Mono Screen*

• Influenza PCR

• Ionized Calcium (1/2 Hour)

• Irradiated Blood / Blood Components (2-10 Hrs)

• KOH Prep.

• Lactic Acid

• LDH

• Partial Prothrombin Time (PTT)

• Platelet Pheresis (1 1/2 Hrs)

• Potassium*

• Pregnancy Test (serum)*

• Prothrombin Time (PT/INR)

• Salicylates*

• Sodium*

• Thrombin Time (2 hrs)

• Transfusion Reaction (1 Hrs)

• Troponin*

• Unfractionated Heparin (Anti-Xa / UFH)

• Urea Nitrogen*

• Urinalysis

B. TEST CATEGORIES AND TURN AROUND TIME (TAT):

➢ RAPID TAT TESTS: To help the Laboratory meet TAT for these tests, please use these categories judiciously, as rapid TAT testing generally is less efficient than batch testing. Peak workloads can slow down the system and result in increased TAT. There is reduced staffing after 3:30PM.

➢ STAT: One hour or less, or as noted in list of tests. Every attempt will be made to shorten the TAT for these tests.

➢ ASAP/PRIORITY: One hour (or as noted) IF POSSIBLE. The Laboratory has shortened the TAT for patient/physician convenience from 2 hours to 1 hour, because of the importance of shortening clinic visits, but under current conditions, this TAT probably cannot be met uniformly.

➢ ROUTINE: Results of tests reaching the Laboratory by 8:00 AM (drawn by

Laboratory staff) should be available by 12:30 PM. Results of tests reaching the

Laboratory by 12:00 NOON (drawn by Clinical Services), will generally be available within 5 1/2 hours.

➢ ROUTINE BACTERIOLOGY: Most clinical specimens submitted to the Laboratory for culture and sensitivity requires a 16 to 24-hour incubation period to allow for sufficient bacterial growth before culture work can begin. In most cases, a preliminary report is sent after 24 hours and a final report within 48 to 72 hours.

➢ FUNGUS CULTURE: Preliminary report is sent immediately when significant growth occurs, followed by a final report when the isolate is identified. Cultures are held for four (4) weeks before being discarded as negative, with a preliminary no growth report at two weeks and a final report at four weeks.

➢ TB CULTURE: If no growth, preliminary report sent at four (4) weeks with a final report in eight (8) weeks. Acid fast smear results are sent out within 24 hours. If acid fast growth is detected, Ward or Physician is notified immediately, and the culture is referred to West Haven VAMC - report in 6 - 8 weeks.

➢ OVA AND PARASITES: Final report usually within 24 hours.

C. SPECIAL TESTS:

• Body Fluid Differential (3 Hrs); CSF Cell Count (2 Hrs)

• C-Reactive Protein - Batched

• Gastric Analysis - As Requested

• Glycosylated Hemoglobin - Unscheduled

• Hepatitis A,B,C - Batched

• Immunoglobulin Fixation - As Needed

• Protein Electrophoresis - Unscheduled (Batched)

• Total Complement C3 & C4 - Thursday - Sent to Albany

• Viscosity - As Requested – Send out

VII. SEND OUTS (REFERENCE LAB TESTING):

GENERAL INFORMATION:

1. Any questions regarding send out tests should be directed to Room C-381, Ext. 53294 during administrative hours. Voice mail is available for messages at any time.

2. Most specimens are sent out on Mondays - Thursdays. Most reference labs are not available on the weekends and therefore very few tests are sent out on Fridays. Turn-around-time is 3 to 10 days for most tests.

3. When the test is completed, the name of the reference lab that performed the testing will be included in the Comment Section of the test report.

4. For more detailed information regarding a specific send out test, please refer to the

“INQUIRY TO LAB TEST FILE” option in Vista or “Lab Test Information” in CPRS.

This is found by selecting Tools (on the top), and then Lab Test Information.

Following is a list of common send out tests. It is important to understand that send outs change

FREQUENTLY (test costs, reference labs, reference ranges, etc.). This list should ONLY be used as a reference. ALWAYS check the computer or call the lab for "up-to-date" information.

Abbreviations (LAB): Abbreviations (SPECIMEN):

AL Albany VAMC CFS Cerebral Spinal Fluid

BU Buffalo VAMC WB Whole Blood

LEX Lexington VAMC

SPT Sputum (Prefer Induced)

NYS NY State Dept. of Health LAV Lavender

Q Quest Diagnostics S Serum (Draw in Red Top w/gel)

LACNY Laboratory Alliance of CNY 24 HR UR 24 Hour Urine

SUNY SUNY Upstate Medical

Test: (A-C) Testing

Lab

Specimen Requirements

ACETYLCHOLINE RECEPTOR ABS Q S

AFP, ALPHA FETO PROTEIN BU S

ALDOLASE Q S

ALDOSTERONE (S) Q S

ALDOSTERONE (U) Q 24 Hour Urine

ALLERGEN SPECIFIC IgE AB Q S

ALPHA-1-ANTITRYPSIN Q S

AMIODARONE Q S

AMITRIPTYLINE Q S - Red No Gel

ANCA Q S

ACE, ANGIOTENSIN CONVERT.ENZYM Q S

ANDROSTENIDONE Q S

ANTI-MITOCHONDRIAL AB Q S

ANTI-PARIETAL CELL AB LEX S

ANTI-SMOOTH MUSCLE AB LEX S

ANTI-THROMBIN III, ACTIVITY Q Plasma (FULL light blue top)

BETA HCG, QUANT (Males only, females in-house) Q S

BETA-2-MICROGLOBULIN (S) Q S

C3 AND/OR C4 AL S

CADMIUM Q WB (Royal Blue)

CANCER AG 125 Q S

CARBOHYDRATE AG 19-9 Q S

CARDIOLIPIN AB Q Plasma (FULL light blue top)

CAROTENE Q S

CATECHOLAMINES (U) Q 24 Hour Urine on ACID CATECHOLAMINES (P) Q Plasma (2 green tops- SODIUM heparin, on ice)

CD4/CD8 COUNT BU WB (LAV top tube)

CEA AL S

CERULOPLASMIN Q S

CH50 (TOTAL COMPLEMENT) Q S

CITRATE/CITRIC ACID Q 24 Hour Urine

CMV AB PANEL LEX S

CMV CULTURE Q Swab in Viral Media

CORTISOL, FREE Q 24 Hour Urine

CRYPTOCOCCAL ANTIGEN (S) AL S

CRYPTOCOCCAL ANTIGEN (CSF) AL CSF

CYCLOSPORIN Q WB (LAV top tube)

CYTOGENETICS Q Marrow (Green top- Sodium Heparin)

Test (D – I) Testing

Lab

Specimen Requirements

DESIPRAMINE Q S (Red NO gel)

DHEA-S Q S

DNA, DOUBLE STRANDED Q S

DRVVT SCREEN/CONFIRM/MIX Q Plasma (FULL light blue top)

ENA SCREEN/PANEL LEX S

ENDOMYSIAL IgA AB Q S

ERYTHROPOIETIN Q S

ESTRADIOL Q S

FACTORS (II,V,VII,VIII ETC) Q Plasma (FULL light blue top)

FECAL FAT,…