D.5 36C26126R0014 Laboratory Users Manual.pdf

VA NORTHERN CALIFORNIA HEALTH CARE SYSTEM

LABORATORY USERS MANUAL

2016 edition

Martha Goodwin, MT Laboratory Manager Cathy Woodman, Quality Manager Ivan Meadows, MD Chief, Pathology and Laboratory Medicine Service

Contents

1 GENERAL LABORATORY INFORMATION

1.1 HOURS OF OPERATION FOR OUTPATIENT PHLEBOTOMY

1.2 ADMINISTRATIVE ORGANIZATION AND WHO TO CONTACT

1.3 ORDERING LABORATORY TESTS

1.4 GETTING LABORATORY TEST INFORMATION IN CPRS

1.5 CRITICAL VALUES

1.6 ALERT VALUES

1.7 STAT/ASAP LABORATORY TESTS

1.8 TURN-AROUND TIMES (TAT) FOR LABORATORY TESTING

2 PREANALYIC ISSUES

2.1 REQUEST FOR LABORATORY WORK

2.2 REQUEST TO ADD-ON TO AN EXISTING LABORATORY ORDER

2.3 LABORATORY POLICY FOR PHLEBOTOMY

2.4 SPECIAL HANDLING AND DELIVERY OF SPECIMENS TO THE LABORATORY 20

2.5 CANCELED ORDERS

2.6 DUPLICATE ORDERS

2.7 PROPER SPECIMEN COLLECTION

2.8 SPECIMEN REJECTION

2.9 LABORATORY REFLEX TESTING

2.10 DOWNTIME PROCEDURES

2.11 OBTAINING LABORATORY RESULTS

2.12 AVAILABILITY OF CURRENT TEST METHODS

2.13 GUIDELINES FOR PROCESSING/STORAGE

2.14 TIMED DRAWS

2.15 PROPER ORDER OF VACUTAINER DRAW

2.16 VACUTAINER INFORMATION

2.17 MINIMIZING BLOOD DRAW VOLUME

2.18 24-HOUR (OR TIMED) URINE COLLECTIONS

2.19 ARTERIAL BLOOD GASES (ABG)

3 ANALYTIC - CHEMISTRY TESTS

3.1 TESTING MENU

3.2 BASIC METABOLIC PANEL

3.3 COMPREHENSIVE METABOLIC PANEL

3.4 LIPID TESTS

3.5 OTHER CHEMISTRY TESTS

3.6 FECAL IMMUNOCHEMICAL TESTING

4 ANALYTIC-HEMATOLOGY/COAGULATION TESTS

5 URINE DRUG SCREENS

6 SPECIFIC DISEASE TESTING

6.1 DIABETES TESTING

6.2 HEPATITIS B TESTING

6.3 HEPATITIS C TESTING

6.4 CARDIAC TESTING

6.5 HIV TESTING

7 POINT-OF-CARE TESTING

7.1 OPERATORS

7.2 TYPES OF TESTING AVAILABLE

7.3 OBTAINING A SPECIMEN FROM SKIN PUNCTURE

8 ANATOMIC PATHOLOGY

8.1 GYNECOLOGIC CYTOPATHOLOGY

8.2 THYROID CYTOPATHOLOGY

1 GENERAL LABORATORY INFORMATION 5

8.3 ANATOMIC PATHOLOGY SPECIAL STUDIES, SACRAMENTO MEDICAL CEN-

TER

8.4 SPECIFIC TUMOR CONSIDERATIONS

9 QUALITY ASSURANCE PROGRAM FOR THE LABORATORY SERVICE

9.1 QUALITY MONITORS

1 GENERAL LABORATORY INFORMATION

The purpose of this manual is to assist you in using the Laboratory efficiently. A complete list of tests can be found in VISTA/CPRS, and contains instructions for obtaining the correct specimen, and reference ranges.

Immediate-Response Laboratories (Stat Laboratories) are present at Redding, Sacramento, Martinez and Oakland. Blood drawing stations are maintained in Yuba City, McClellan and Fair-field and Mare Island. Specimens from these sites are transported to either Martinez or Sacramento for testing.

Currently, we are challenged for Laboratory space at the Mather Hospital and manage by doing some testing at the Martinez outpatient clinic e.g Hepatitis, HIV and Electrophoresis testing. In the future, we would expect to have a larger laboratory at the Mather Hospital but we manage with the space we have. Importantly, we are able to do Anatomic Pathology, Blood Bank, Microbiology and the core tests in Chemistry, Hematology and Urinalysis at the Mather Hospital.

The main (core) laboratories are located at the Martinez OPC and VA Sacramento Medical Center at Mather which also includes administrative offices. Staffing is Monday through Friday, 0730-1630 hours except where noted below. Specific locations are as follows:

1. Main Laboratories

(a) At Martinez OPC we have two laboratories. Our immediate response laboratory is in the Main clinic building on the second floor. Blood drawing is on the first floor. Our

1 GENERAL LABORATORY INFORMATION 6

second laboratory does testing for HIV, Hepatitis C antibody and special chemistry tests for all of VANCHCS. It is located in the Research Complex, Room R140.

(b) Sacramento Medical Center at Mather (10535 Hospital Way, BLDG 650, Mather, CA) (24/7 coverage).

(c) Oakland OPC (2221 Martin Luther King Jr. Way, Oakland, CA) Laboratory/Blood Drawing is in Room 216.

(d) Redding OPC (351 Hartnell Avenue, Redding, CA) Laboratory/Blood Drawing is in B 37.

2. Drawing Stations

(a) Mare Island Outpatient Clinic (Bldg. 201, Walnut Ave., Mare Island CA) Laboratory spaces are in room 2047.

(b) Fairfield Outpatient Clinic on the Travis Air Force Base(103 Bodin Circle, Fairfield, CA), Monday through Friday.

(c) McClellan OPC (5342 Dudley Blvd., Sacramento, CA)

(d) Yuba City Outpatient Clinic (425 Plumas Street, Yuba City, CA 95991)

(e) Chico OPC (280 Cohasset Road., Chico, CA) Monday through Friday.

Results of tests are available in the VISTA/CPRS system as soon as the tests are completed and verified by the Technologists. For instructions to assist you in retrieving lab data and general use of the Laboratory Information System (LIS).

Laboratory tests are expensive, especially those which are performed by outside contract labo-ratories.

The Laboratories are thoroughly inspected and accredited by the College of American Pathol-ogists (CAP) over a 4 day period every two years. Our inspection time window is fixed between March 19 and June 17 and occurs in even numbered years. Our next inspection time window is from March 19 - June 17, 2016.

We are here to provide accurate test results for your patients and to facilitate your efforts in patient care. If you have questions regarding any Laboratory function, please contact the respon-sible persons listed in the manual.

1 GENERAL LABORATORY INFORMATION 7

The 2016 edition of the Laboratory Users Manual represents the cooperative effort of many dedicated laboratory workers, and we hope that it will give you the necessary information in your daily practice.

We’ve included information for Anatomic Pathology which includes who to contact, how to contact us, and information on the different diseases we see as well as some diagnostic criteria and how we handle different specimen types.

1.1 HOURS OF OPERATION FOR OUTPATIENT PHLEBOTOMY

SITES TIMES DAYS

Martinez Lab 7:30AM - 4:30PM Monday through Friday

Oakland OPC 8:00AM - 1:00PM and 1:30PM - 4:30PM Monday through Friday

Redding OPC 7:30AM - 4:30PM Monday through Friday

7:00AM-4:30 Mon ,Tues , Thurs, Friday Sacramento Medical Center 7:00AM - 6:30PM Wed

8:00AM - 1:00PM Saturday

7:30AM - 4:00PM Monday through Thursday Chico OPC 7:30AM -3:30PM Friday

Mare Island 8:00AM - NOON & 1:00PM -3:00PM Monday through Friday

Fairfield 7:30AM - 1:00PM Monday through Friday

7:00AM - 6:00PM Monday McClellan 7:00AM - 4:30PM Tuesday through Friday

8:00AM - NOON Saturday

8:00AM - 3:30PM Monday through Thursday Yuba City 8:00AM - 2:30PM Friday

1.2 ADMINISTRATIVE ORGANIZATION AND WHO TO CONTACT

1. WHO TO CONTACT IN LABORATORY

The laboratory is a large service with personnel at each of the CBOCs and the Mather hospital. It may not always be clear who to contact with a request, problem or concern.

Our advice is as follows:

1 GENERAL LABORATORY INFORMATION 8

(a) If the question is about an individual patient, the best contact is the general laboratory number or the supervisor of the relevant clinic unless it involves an Anatomic Pathology specimen.

(b) For a question involving Anatomic Pathology, the best starting point is the Anatomic Pathology office at Mather. Call 351-9024 and you will get help. Alternatively, you may try 350-2140 or 351-9045.

(c) If the question, comment or request does not involve Anatomic Pathology, but involves an Administrative Issue or a concern about Laboratory Practice (”a big picture” item), the question or concern should be addressed to the Supervisor of the Clinic, the Laboratory Manager or Chief of Service.

2. ORGANIZATIONAL STRUCTURE OF THE PATHOLOGY AND LABORATORY MEDICINE

SERVICE

(a) ADMINISTRATIVE PERSONNEL, SERVICE LEVEL:

• CHIEF, PATHOLOGY AND LABORATORY MEDICINE SERVICE; Ivan Mead-ows, MD, Board Certified Pathologist in Anatomic and Clinical Pathology. Respon-sible for the function of the Laboratories throughout VANCHCS. Phone number is:

916-843-7294 (351-7294) direct. 350-2140 for Service program support assistant

• LABORATORY MANAGER; Martha Goodwin, MT. Martha manages contracting, personnel, and many of the safety items. She is the top administrative officer in the Laboratory Service. Phone number is: 916-843-7235 (351-7235)

• QUALITY ASSURANCE; Cathy Woodman-Speer, MT. She is stationed at Yuba City.

• ANCILLARY TESTING COORDINATOR, Linda Lew, MT. She is stationed at Martinez and handles ”Point of Care” testing. Phone number is: 925-372-2551 (350-2551)

• MATHER HOSPITAL AND MCCLELLAN SUPERVISOR; David Witthaus, MT Phone number is: 916-843-7015 (351-7015)

• REDDING AND CHICO LABORATORIES SUPERVISOR; Christina Johnson, MT; Phone number is: 530-226-7598 (354-7598)

• MARTINEZ, FAIRFIELD AND MARE ISLAND LABORATORIES SUPERVI-

SOR; Fausto Gacutan, MT. Phone number is: 925-372-2962 (350-2962)

• OAKLAND LABORATORY SUPERVISOR; Anne Keim, MT. Phone number is:

510-267-7833 or 7832 (358-7833)

(b) ANATOMIC PATHOLOGY:

PATHOLOGISTS who are Board Certified in Anatomic and Clinical Pathology but primarily work in Anatomic Pathology are stationed at the Mather hospital. They sign out Pathology cases, cover frozen sections, perform Fine Needle Aspirations (FNAs)and

1 GENERAL LABORATORY INFORMATION 9

are available to provide professional coverage and consultation with healthcare providers.

Pathologists at Mather are available on-site or by telephone, or by special arrangement.

The phone number for the Anatomic Pathology office is 351-9024.

Pathologist coverage in Martinez for fine needle aspirations needs to arranged in advance by calling 350-2140 (preferred) or e-mailing ivan.meadows@va.gov.

Pathologist coverage for FNAs, Frozen Section, Endoscopy, CT and Ultrasound proce-dures at Mather can be arranged by calling 351-9024, 351-7045 or the numbers below for individual Pathologists.

• Dr. Patricia (Patty) Dalton - Director of Anatomic Pathology. Phone is 351-7293

• Dr. Joan Bernard, board certified in Anatomic and Clinical Pathology as well as Cytopathology. Phone is 351-9152

• Dr. Frank Melgoza, board certified in Anatomic and Clinical Pathology. Dr. Mel-goza does about 90% of the autopsies. Phone is 351-7213

• Dr. Meighan Tomic, board certified in Anatomic and Clinical Pathology with fel-lowship in Cytopathology. Phone is 351-9093

(c) CLINICAL PATHOLOGY

• Chemistry —Karen Brown, MT; Mather Hospital 351-7188

• Hematology —Eve Katich, MT; Mather Hospital 351-7249

• Microbiology —Carol Fleming, MT; Mather Hospital 351-7182

• Blood Bank —Ralph Altman, MT temporary; Mather Hospital (Temporary assign-ment) 351-7288

• Bar Code Enhancement (BCE) coordinator —Ralph Altman, MT; Mather Hospital.

• Computer (ADPAC)—Lorenzo Gabiola, MT; Martinez OPC 350-3132

• Point of Care —Linda Lew, MT; Martinez OPC 350-2551

1.3 ORDERING LABORATORY TESTS

1. List of test methods in CPRS

2. Canceled Orders

3. Purging Orders: Purging is performed by the LIM on a monthly basis for the purpose of ensuring that lab order numbers are recycled and don’t get too high. This allows for lab accession number UIDs to be reused (as they are only unique for 10 years). The purge option will not purge the last 720 days of ORDERS/ACCESSIONS.

1 GENERAL LABORATORY INFORMATION 10

For blood collection, Old Orders/Accessions that are older than 150-days are removed from CPRS (lapsed)and not viewable by the Lab Accessioning staff. This means that orders older than 150 days from the ”draw by date” will not be seen by phlebotomy staff.

Purging has no effect on the availability of the result on the patient record, ONLY the ability to manipulate the orders and accessions using lab options.

4. Ordering unusual tests:

Most unusual tests (e.g. can’t find it in the laboratory ordering menu) can be ordered through the miscellaneous test order process. However, unusual orders that are likely to be extremely expensive (e.g. genetic tests) should be coordinated with the laboratory by contacting our send out department at the Mather Hospital. The contact is Ruth Weiser at 351-7014. When necessary she will need to get approval from a Pathologist before the test is sent out.

Some tests ordered through this process may cost as much as $10,000. We may need to confirm that a high cost test is needed for appropriate clinical management and that a less expensive test wouldn’t be more appropriate.

1 GENERAL LABORATORY INFORMATION 11

1.4 GETTING LABORATORY TEST INFORMATION IN CPRS

1. In CPRS go to the tools menu

2. Lab Test Information is toward the bottom

3. Clicking Lab Test Information will get a search box

1 GENERAL LABORATORY INFORMATION 12

4. The search box brings up all tests including the discontinued tests. The box will have reference range information, specimen collection information and urgencies allowed, e.g. STAT versus routine

5. In some cases it will have information on the cost of the test to send out

1 GENERAL LABORATORY INFORMATION 13

1.5 CRITICAL VALUES

Physicians/healthcare providers will be notified immediately of the following critical values. Physi-cians, Doctors of Pharmacy, Physician Assistants and Nurse Practioners may accept critical values.

In the event that the ordering provider or designee is not available, follow the procedures contained in Policy Statement 11-51 and Attachments.

Test/Observation Less than Greater than

Sodium (mEq/l) 120 150

Potassium (mEq/l) 2.8 6.0

C02(mmol/L) 10 45

Glucose (mg/dl) 50 400

Calcium (mg/dl) 7.6 12.5

Creatine Kinase(IU/L) — 999 p02 (mm Hg) 60 — pC02 (mm Hg) 20 65 pH 7.2 7.55

Troponin-I (ng/ml) — 0.08

Creatinine (mg/dl) — 3.5

WBC (x1000/cu mm) 2.0 25

Platelets (x1000/ cu mm) 30 1,000

Fibrinogen (mg/dl) 100 —

Prothrombin Time, PT (sec) 24 (Not on coumadin*)

Therapeutic drugs Hemoglobin (g/dl) or decrease of 3 g/dl from previous result

8.0 19.0

Spinal fluid leukocyte count (#/c cm) — 10 Partial Thromboplastin Time, aPTT (sec)

— 60**

Positive Gram stain or culture of blood or spinal fluids, thoracentesis, paracentesis or joint fluids Positive Malaria smears Presence of blasts in Wright stains of blood or body fluid Positive acid fast stain or presumption tuberculosis culture

*For patients on Coumadin therapy the physician will be notified of INR ≥ 5.

**For patients on Heparin therapy, notification will be for PTT ≥ 100secs.

1 GENERAL LABORATORY INFORMATION 14

Reporting Procedures for Repeat Critical Values:

1. Repeat Creatinine values greater than 3.5 mg/dl do NOT have to be called to the provider.

The Technologist enters ”Creatinine result consistent with previous result” into VISTA.

2. Repeat critical low WBC does not need to be called unless the Absolute Neutrophil Count (ANC) is less than 700. The Technologist enters ”White blood cell result consistent with previous result” into VISTA.

3. Repeat critical high WBC does not need to be called if previous was called within previous two weeks or the WBC’s are predominantly well differentiated lymphocytes, i.e. CLL and the count is less than 100,000. The Technologist enters ”White blood cell count result consistent with previous result” into VISTA.

4. Presence of blasts in Wright stains of blood or body fluid need not be called if chronically elevated.

5. Guidelines for calling repeat Creatine Kinase critical values

(a) Call first time result greater than 999

(b) A repeat CK over 1000 does not need to be called unless it is greater than 3000 or the previous result was more than a week earlier

(c) Values greater than 3000 only need to be called once unless greater than 10000 or the previous result was more than a week earlier

(d) All values greater than 10000 need to be called

(e) CK not called, put in comment that ”CK consistent with previous result”.

6. Serum calcium less than 7.6 will be corrected for serum albumin using the formula: Cal-cium corrected = Calcium + 0.8*(4-Albumin). All values are serum/plasma values. The technologist enters ”Low Calcium corrected for Albumin, Corrected Calcium not critical”.

7. Repeat Troponin critical results do not have to be called when a critical Troponin result was called within the previous 3 days. The technologist enters ”Troponin called within past 3 days. By policy, no repeat call made.”

1.6 ALERT VALUES

Physicians/Healthcare Providers will be notified as soon as possible of the following test results.

These results are targeted at diseases and conditions that merit rapid detection and evaluation.

Notification can be either by telephone or e-mail.

1 GENERAL LABORATORY INFORMATION 15

• Monoclonal peak in serum electrophoresis.

• New non-skin malignancy in a biopsy or cytology specimen.

• Positive bronchoalveolar lavage (BAL)/sputum for Pneumocystis carinii, or positive culture for Coccidiodes immitis.

• Positive rapid antigen detection by latex agglutination test for Cryptococcus neoformans.

• Salmonella, Shigella, or Campylobacter on stool culture.

• Reactive RPR and confirmatory MHA-TP (3+-4+; first time).

• Gram negative intracellular diplococci consistent with gonorrhea.

• Growth or positive testing for group A streptococcus on throat cultures.

• Newly diagnosed cases of an HIV infection.

• Any Reportable Communicable Disease which is required to be reported to the public health department. Reportable diseases are listed in the Title 17, California Code of Regulations.

1.7 STAT/ASAP LABORATORY TESTS

The following table lists, by specialty, the tests available on a STAT basis, 8:00 am - 4:30pm, Monday through Friday in VA NCHCS Outpatient Clinic Laboratories; 24 hr/day, 7-day/week at VA Sacramento Medical Center.

1 GENERAL LABORATORY INFORMATION 16

Lab

MTZ

OPC Lab

Oakland OPC Lab

Redding OPC Lab

Mather Lab

CHEMISTRY

Sodium X X X X

Potassium X X X X

Chloride X X X X

Carbon Dioxide X X X X

Glucose (serum) X X X X

BUN X X X X

Creatinine (serum) X X X X

Blood gases X X X X

CSF Glucose X X

CSF Protein X X

Calcium X X X X

CK X X X X

CK-MB X X

Troponin X X X X

HIV (rapid) (After body fluid exposure) X X X X Pregnancy Test, Serum/urine

X X X

(urine only) X X X X

Ketones X X X

AST X X X X

ALT X X X X

LDH X X X X

Amylase X X X X

Magnesium X X X X

1 GENERAL LABORATORY INFORMATION 17

Lab

MTZ

OPC Lab

Oakland OPC Lab

Redding OPC Lab

Mather Lab

TOXICOLOGY

Digoxin X X X X

Dilantin X X X X

Ethanol X X

Phenobarbital X X

Theophylline X X

HEMATOLOGY

CBC Profile with platelets

X X X X

PTT X X

PT X X X X

Body Fluid cell count with differ-ential

X X X X

Manual Differen-tial

X X X X

URINALYSIS

Macroscopic and Microscopic Examination

X X X X

MICROBIOLOGY

Gram Stains X X

1.8 TURN-AROUND TIMES (TAT) FOR LABORATORY TESTING

1. The turn-around time (TAT) for the tests are defined as follows:

(a) MEDICAL EMERGENCY ”STAT”: TAT is one (1) hour or less after receipt of the specimen in the laboratory. This category is to be used for potentially life-threatening situations. Refer to list of tests offered on a STAT/ASAP basis.

(b) AS SOON AS POSSIBLE ”ASAP”: TAT is no more than two (2) hours after receipt of the specimen in the laboratory. This category of testing is to be used for less-than-urgent patient situations including ”patient waiting.” Refer to list of tests offered on a STAT/ASAP basis.

(c) ROUTINE: TAT is 3-7 hours. This category includes commonly ordered tests.

(d) SPECIALIZED/ESOTERIC TESTS; ALL OTHER ROUTINE TESTS: TAT will vary according factors such as the complexity of the tests, our level of staffing, the location the specimen is drawn, and location the testing is done.

2 PREANALYIC ISSUES 18

For example, HIV, Hepatitis and Electrophesis testing is done at Martinez due to lack of space at the Mather laboratory. Travel time may add two days for turnaround of an HIV test that is requested in Redding because the specimen is transfered to Martinez for analysis. Other considerations for turnaround are whether confirmatory testing is required, e.g. a positive HIV test or whether the test requires a manual step or profes-sional interpretation (e.g. Electrophoresis testing which is done at Martinez and read by a Pathologist).

(e) URGENT SEND OUT: This is for inpatients to alert the laboratory to send the test to UCD rather than LabCorp.

2. The Healthcare Providers will be notified when the TAT of a requested test is delayed, the reason for the delay, and the approximate time when the results will be available.

2 PREANALYIC ISSUES

2.1 REQUEST FOR LABORATORY WORK

1. Computer generated order forms INCLUDE:

(a) Patient’s name

(b) Patient’s full social security number

(c) Patient location

(d) Requesting healthcare provider’s name

(e) Date of collection

(f) Time specimen collected and initials of phlebotomist (Nurse, HCP etc). When trans-porting samples to the laboratory, all specimens must be placed in a plastic bag. Keep all paperwork separate to avoid contamination.

(g) Urgency Status (STAT, Routine, etc.)

(h) For timed collections, i.e., 24-hr urine or 2-hr post prandial glucose, etc., note collection times.

(i) For HIV antibodies, draw SST PLUS tube. The date, time of draw and initials of phlebotomist must be on the label. Send original tube (no pour-off tube). A signed consent form is no longer required. Verbal consent should be noted in CPRS by the ordering provider.

(j) For Hepatitis antibodies testing draw one SST and one PPT tube. The date, time of draw and initials of phlebotomist must be on the labels. Send original tubes to the Laboratory.

2 PREANALYIC ISSUES 19

2. Extreme care must be taken to assure proper identification of all specimens sent to the laboratory.

(a) All tubes and labels must contain, minimally: full name of patient, full SSN, date & time blood was drawn, and initials of phlebotomist.

(b) Blood Products: all samples for transfusions must contain patient’s full name and SSN, initials of phlebotomist, and date and time of draw.

3. Improperly labeled specimens WILL NOT be accepted for analysis (see Specimen Rejection Criteria).

4. Order laboratory tests in the computer. Use discretion when ordering multiple tests and STATs.

2.2 REQUEST TO ADD-ON TO AN EXISTING LABORATORY ORDER

1. Health Care Providers requiring additional Lab testing on patient specimens must submit a computer order and call the laboratory with the add-on request for additional laboratory testing. Every effort will be made to accommodate your request but in some cases there will be insufficient specimen or the required specimen type won’t be available. NOTE: A verbal request without an order cannot be accommodated.

2. Healthcare Providers may contact the respective laboratory Supervisors/Specialists for assis-tance, if necessary:

• Gacutan, Fausto - Martinez Lab Supervisor

• Kim, Ki - Martinez Lab Special Chemistry

• Gacutan, Fausto - Martinez Lab, Chemistry

• Goodman, Martha Sacramento Medical Center Lab Supervisor

• Keim, Anne - Oakland Lab Supervisor

• Johnson, Christina, Redding, Chico Lab Supervisor

2.3 LABORATORY POLICY FOR PHLEBOTOMY

1. Patient identification: All patients must be identified prior to specimen collection with at least two identifiers (full name and full social security number or date of birth).

2 PREANALYIC ISSUES 20

2. Each specimen for diagnostic testing will be in a container with a label that is applied in the patient’s presence (see VANCHCS PS11-15)and must contain at least the following informa-tion: Patient’s full name, full SSN, date and time of collection and initials of the person who drew the sample.

3. Never draw above an IV line. DO NOT draw from lower extremities. When drawing venous samples below the antecubital region and back of hand, use syringe or butterfly technique.

4. Do not draw blood samples from arm(s) with shunt(s) or fistula. Blood may be drawn below IV lines and heparin locks. Avoid drawing blood from from the arm of a patient on the side of a previous mastectomy.

5. Do not make more than two attempts at drawing blood from a patient.

6. When outpatients present to the Blood Drawing Room, the receiving personnel generates labels with patients’ name, SSN, test name(s) with type of tube to be drawn, order number and laboratory accession number.

7. Samples are processed prior to delivery to an appropriate laboratory for testing.

8. When body fluids other than blood or CSF are collected and place sample into the same type of tube as for the respective blood analysis. EXAMPLES:

• Fluid WBC and RBC count = EDTA (K2) lavender top tube

• Fluid Chemistry Glucose, Protein, LDH = Red top tube (no gel barrier)

• Crystals = EDTA (K2) lavender top tube or sodium heparin

9. Information is available later in this manual for proper blood tube to use for the different chemistry test.

2.4 SPECIAL HANDLING AND DELIVERY OF SPECIMENS TO THE

LABORATORY

1. General

(a) All specimens should be sent to the laboratory as soon as collected for accurate testing.

Additionally, some specimens require immediate special handling such as refrigeration.

(b) Please refer to the individual test in the Computer for special handling requirements.

(c) Deliver specimens and requests for all laboratory tests directly to Specimen Receiv-ing/Blood Drawing Room at the applicable site.

2. Urine Specimens:

2 PREANALYIC ISSUES 21

(a) Quantity not sufficient (QNS) sample. A volume of 10 ml urine is the absolute minimum for complete urinalysis. Timed urine specimens must contain the entire volume of urine voided during the stated collection times.

(b) Urine samples should be submitted clean catch into sterile container.

(c) Urine samples must be analyzed within 2 hours of collection or refrigerated up to 4 hours (w/o preservative).

(d) 24-hour urine collections submitted in containers other than those provided by the Lab-oratory may be subject to rejection.

3. Coagulation Studies:

(a) Specimen drawn in incorrect tubes

(b) Clotted specimens

(c) Incorrect ratio of blood to anticoagulant

(d) Hemolyzed plasma

(e) Stability compromised:

2.5 CANCELED ORDERS

2.6 DUPLICATE ORDERS

1. How to avoid duplicate

2 PREANALYIC ISSUES 22

2.7 PROPER SPECIMEN COLLECTION

1. PATIENT IDENTIFICATION Ask patient to state two identifiers before starting collection

(a) Full name (first and last names) and

(b) Full SSN or full DOB

(c) IF PATIENT UNABLE TO VERBALIZE HIS IDENTIFIERS

i. Correct identification by caregiver/family member

ii. Check a second ID card such as a VIC card, social security card, or drivers license

iii. In person verification with staff who know the patient using wristband and 2 iden-tifiers.

2. DO NOT DRAW ABOVE AN IV SITE WILL CAUSE CONTAMINATION OF THE

SPECIMEN

(a) Consequences include:

i. Possible dilution of sample can cause a low Hemoglobin and Hematocrit (H&H).

Patient could get blood unnecessarily

ii. Draw above a line with glucose running; Glucose in Chemistry is erroneously high.

Patient could get wrong dose of insulin

3. PROTOCOL FOR DRAWING FROM A LINE

Be aware that dilution or heparin contamination are possibilities. Flush line and discard a minimum volume of 5 mL of blood.

4. TOURNIQUET PLACEMENT

(a) Do NOT leave in place longer than one minute because of hemoconcentration and pos-sible hemolysis

(b) Do NOT have patient clench their fist multiple times as this can cause hemolysis

(c) Remove the tourniquet prior to removing the needle from the vein to avoid hematoma formation

5. EQUIPMENT

(a) Obtain correct tubes for tests ordered with corresponding labels

(b) Check that all tubes are within expiration date

(c) Avoid taking blood from an IV start if possible

(d) If using a syringe, unseat plunger prior to use to avoid excessive pressure which can cause hemolysis

2 PREANALYIC ISSUES 23

(e) Needle gauge is important: in a study it was found that using a 24 gauge needle=100% hemolysis; a 21g = 4% hemolysis

(f) If using a butterfly set remember the dead space, so the first tube will NOT fill com-pletely, so use it as a discard tube

6. TUBE VOLUME

Tubes must be filled adequately to ensure the proper blood to additive ratio. Under filling tubes can impact sample integrity giving erroneous results. Under filled Coagulation tubes can give falsely long clot times, perhaps leading to an incorrect medication adjustment.

7. MIXING

Always mix tubes IMMEDIATELY and with gentle inversion 8-10 times

2.8 SPECIMEN REJECTION

1. Improper Labeling - All specimens MUST BE LABELED with the patient’s first and last name, and full social security number. Labels on Samples required for transfusions MUST contain patient’s full name, full SSN, phlebotomist’s initial, and date & time of draw. Spec-imens improperly labeled or without labels will not be accepted. Each patient’s specimens MUST be in a separate transport bag. No corrections will be made on an improperly la-beled specimen unless it is a difficult to obtain or irretrievable specimen (refer to section on LABORATORY PROCEDURE FOR MISLABELING ERRORS OF IRRETRIEVABLE SPECIMENS). A new sample MUST be submitted with proper identification. Other labels must be dated, timed, and initialed by individual obtaining the specimen.

2. Urine Specimens

(a) Quantity not sufficient (QNS). A volume of 10 mL of urine is the absolute minimum for a complete urinalysis. Timed urine specimens must contain the entire volume of urine voided during the stated collection time.

(b) Urine specimen should be submitted as a clean catch and into a sterile container.

(c) Urine samples must be analyzed within 2 hours of collection or refrigerated up to 4 hours (w/o preservative).

(d) 24-hour urine collections submitted in containers other than those provided by the Lab-oratory may be subject to rejection.

(e) Laboratory approved preservative containers may be used (follow package insert guide-lines)

3. Coagulation Studies:

2 PREANALYIC ISSUES 24

(a) Specimen drawn in incorrect tube

(b) Clotted specimen

(c) Incorrect ration of blood to anticoagulant

(d) Hemolyzed plasma

(e) Stability compromised by incorrect storage or processing (see Guidelines for Process-ing/Storage)

2 PREANALYIC ISSUES 25

4. HEMOLYSIS Hemolysis is a cause for specimen rejection because it causes artifactual in-creases and decreases of test results for potassium, sodium, etc. It typically isn’t detected until the specimen is spun down. Check out the difference between these two specimens!

(a) Non-Hemolyzed Specimen

(b) Hemolyzed Speci-men

Fig. 1: Comparison of Hemolyzed and Non-Hemolyzed Specimens

5. Hemolyzed Specimens - Hemolysis interferes with the following tests:

(a) Lactate dehydrogenase (LDH)

(b) Iron

(c) Potassium

2 PREANALYIC ISSUES 26

(d) Phosphorus

(e) Creatine Kinase (Not Creatinine)

(f) Acid phosphatase

(g) Folate, B12

(h) Myoglobin

(i) AST

(j) ALT

(k) Albumin

(l) Glucose

(m) Magnesium

(n) CBC

(o) Coagulation Studies

6. LABORATORY PROCEDURE FOR REJECTED SPECIMENS

(a) An unlabelled specimen will be canceled and the specimen discarded immediately unless the specimen is a difficult to recollect, e.g CSF or irretrievable specimen(see below). The responsible person at the ordering location will be notified.

(b) Other incorrectly mislabeled specimens will be held for 24 hours pending investigation.

(c) Difficult to recollect or an irretrievable specimen will be thoroughly investigation before patient identification is accepted, e.g. an unlabeled CSF specimen from a site where only one had been done in the previous several days. Final decision will typically be made by the Chief of Pathology or another Pathologist. NOTE: (In some rare circum-stances, DNA analysis may be necessary to identify patient identification, e.g. unlabeled prostate specimens, one of which has cancer and the other does not.)

2.9 LABORATORY REFLEX TESTING

The following reflex testing is performed in order to provide maximum information back to the provider quickly and, in the process, avoiding a second blood-draw from the patient. This effort is considered especially valuable for our dispersed system of medical care sites.

1. Manual blood cell differential and/or slide review if appropriate.

2 PREANALYIC ISSUES 27

2. Direct bilirubin is performed if total bilirubin ≥1.3.

3. IFE if there is a previously unidentified spike on the protein electrophoresis or the beta region is 2+ or greater.

4. Free T4 if the TSH is abnormal.

5. Hepatitis B core IgM and Hepatitis B surface antigen confirmation if Hepatitis B surface antigen is positive and has not previously been confirmed.

6. Confirmatory testing if HIV antibody is positive.

7. Urine microscopic examination if urine is not clear or if protein, occult blood, leukocyte esterase, or nitrates are positive on dipstick examination.

8. Urine culture if WBC or nitrates are >trace on dip-stick examination.

9. Treponema pallicum particle agglutination (TP-PA) if RPR is reactive and patient has not been previously reactive.

10. Hepatitis C PCR (qualitative) if Hepatitis C antibody is positive.

2.10 DOWNTIME PROCEDURES

Occasionally, VistA is ”off-line”

2.11 OBTAINING LABORATORY RESULTS

1. Test results are available in the computer as soon as the tests are completed and verified by the technologist (see Computer Section for how to obtain results).

2. Reports can be obtained through CPRS, our system-wide computer program.

3. Life threatening (critical) values are reported directly to the healthcare provider by phone or in person. The healthcare provider MUST read the values back. An appropriate comment is entered into the computer indicating to whom, date, time and by whom report is given, and that the results were read back.

2 PREANALYIC ISSUES 28

2.12 AVAILABILITY OF CURRENT TEST METHODS

All current testing methodologies performed in the clinical laboratories of the Pathology and Laboratory Medicine Service including our performance specifications are available to Healthcare Providers and to all clients upon request.

Many of the current laboratory methods are listed in this manual under ”Analytic- Chemistry” and Analytic-Hematology”.

2.13 GUIDELINES FOR PROCESSING/STORAGE

1. Coagulation PT, centrifuged or uncentrifuged, unopened tube.

18 − 24 ◦C (room temp) = 24 hrs

APTT, (non-heparinized patients), centrifuged or uncentrifuged, unopened tube.

2 − 4 ◦C (refrig) = 4 hrs 18 − 24 ◦C (room temp) = 4 hrs

APTT, (heparinized patient), centrifuged within one hour.

2 − 4 ◦C (refrig) = Assay within 4 hrs of collection.

18 − 24 ◦C (room temp) = 4 hrs

Other Assays, centrifuged.

2 − 4 ◦C (refrig) = Assay within 4 hrs of collection.

18 − 24 ◦C (room temp) = 4hrs

Plasma samples for PTT, APTT and other assays are stable frozen.

−20 ◦C = 2 weeks −70 ◦C = 6 months

Recommend: Process and Assay all Coag samples as soon as feasible.

Reference: CLSI Guidelines.

2. CBC Tests:

2 PREANALYIC ISSUES 29

(a) Quantity Not Sufficient (QNS); EDTA tubes must be at least 1/2 full.

(b) Incorrect tube collection.

(c) Clotted, or contains clots.

(d) Hemolyzed.

3. Microbiology specimens will be rejected for: See the Microbiology Section of this manual.

4. Miscellaneous

(a) Blood gas samples with bubbles or clots will not be analyzed.

(b) Quantity not sufficient (QNS) to perform test(s) requested.

(c) Specimen rejection criteria for tissues or cytological material are described in the Anatomic Pathology Section of this manual.

(d) Specimens received by the laboratory improperly stored or after delays could be subject to rejection.

(e) Specimens improperly preserved, collected into incorrect tubes, or into which the appro-priate stabilizer has not been added may be rejected.

2.14 TIMED DRAWS

THINK ABOUT FASTING!!!!

1. For specimens, patients must abstain from eating 8 hours for glucose and 10-12 hours for lipids prior to blood draw. Patients may have water. For special dietary restrictions and additional directions see the individual test requirements in the computer.

2. For outpatients who are on the following oral medications, draw samples for therapeutic mon-itoring of these drugs during the time periods listed below:

(a) Carbamazepine ≥ 2 hours after last dose

(b) Cyclosporin ≥ 8 hours after last dose

(c) Digoxin ≥ 6 hours after last dose

(d) Lithium ≥ 8 hours after last dose

(e) Primadone ≥ 2 hours after last dose

(f) Procainamide ≥ 2 hours after last dose

2 PREANALYIC ISSUES 30

(g) Quinidine ≥ 2 hours after last dose

(h) Salicylates ≥ 2 hours after last dose

(i) Theophylline ≥ 3 hours after last dose

(j) Dilantin ≥ 2 hours after last dose

(k) Phenobarbital ≥ 2 hours after last dose

(l) Valproic Acid ≥ No less than 10 hours after last dose; trough only.

3. Note: Phlebotomist MUST annotate on specimen tube label the time of patient’s last dose and time sample is drawn (if known).

2.15 PROPER ORDER OF VACUTAINER DRAW

1. Blood Culture bottles (Must use sterile collection procedure described in the Microbiology Section of the manual.)

2. Coagulation tubes (light blue)

(a) When using a winged blood collection set for venipuncture, and a coagulation tube is the first tube to be drawn, a discard tube should be drawn first. The discard tube must be used to fill the blood collection tubing dead space and to assure maintenance of the proper anticoagulant/blood ratio and need not be completely filled. The discard tube should be a nonadditive or a coagulation tube.

(b) Studies have shown that the PT (INR) and APTT results are not affected if tested on the first tube drawn. Since it is not known whether other coagulation testing is affected, it may be advisable to draw a second tube for other coagulation assays.

3. Serum tube with or without clot activator, with or without gel (e.g., red closure) Gel separator tubes with clotting activators or anticoagulants are classified as additive tubes. These tubes should be drawn after the coagulation tube (blue stopper) and before other additive tubes (green, lavender, gray). All additive tubes should have a complete draw (see section 8.9.1[10] of HC-A5).

(a) Red top serum tubes

(b) SST tubes; gel separator or clot activator (gold top)

4. Heparin, sodium or lithium (Green top). Read label carefully to identify the type of heparin tube.

5. Citrate dextrose, ACD-A, ACD-B (Yellow)

2 PREANALYIC ISSUES 31

6. EDTA (Lavender, Dark Blue for Pb or Hg, PPT), read label carefully!

7. Erythrocytes Sedimentation Rate tubes (Black closure)

8. Glycolytic inhibitor (e.g., oxalate/fluoride / gray closure)

References:

1. CSLI Document H3-A6, October, 2007, section 8.10. (Procedures for the Collection of Diag-nostic Blood Specimens by Venipuncture: Approved Standard-Sixth Edition)

2. CLSI Document H21-A4, December 2003, section 4. (Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays: Approved Guideline-Fourth Edition)

2.16 VACUTAINER INFORMATION

Please refer to Tab. 1 and Tab. 2 for detailed information.

2.17 MINIMIZING BLOOD DRAW VOLUME

RE-THINK THIS!!!! Laboratory processes are geared to minimize the amount of blood to be drawn when multiple tests are requested.

1. Consolidation of tests with identical sample requirements: When the laboratory accessions orders for multiple tests, the laboratory computer package aligns tests ordered by the same provider which have the same specimen requirements and are performed on the same analyzer with a single specimen.

2. When a patient returns to the Blood Draw Station the same day for additional tests, follow these guidelines:

(a) Ascertain if additional tests could be added to previous sample, e.g., adequacy to add-on chemistries. NOTE: At times, additional tests cannot be added to the original sample depending on time, lag interval, medication taken, etc.

2 PREANALYIC ISSUES 32

Tab. 1: Vacutainers blood drawing tubes commonly used at VA NCHCS laboratories

Stopper Color/Type

Vendor/ Part#

Size Volume of Blood Draw

Anti- Coagulant/ Additive

Primary Use

Blue label and remov-able ring / rubber stopper

Biomerieux BactT/ Alert

SN REF

259790

40 mL 10 mL 40 mL media

Blood Cultures Aerobic sterile collection pro-cedure

Purple la-bel and removable ring/ rubber stopper

Biomerieux BactT/ Alert

SN REF

259789

40 mL 10 mL 40 mL media

Blood Cultures Anaerobic ster-ile collection procedure

Blue/ Hemogard

BD Plus Blood Col-lection tube

REF 363083

2.7 mL

2.7 mL (Fill to within dashed min-imum and maximum fill lines)

3.2% Na3C6H5O7 (Sodium Citrate)

Coagulation studies

Gold/ Hemogard

BD Plus SST Blood Col-lection tube

REF 367986

5 mL 5 mL Clot Activa-tor; Gel bar-rier

Chemistry, Serology, Hepatitis, HIV

Red/ Hemogard

BD Plus Blood Col-lection tube

REF 367815

6 mL 6mL Clot Activa-tor

Chemistry, Therapeutic Drugs, Blood Bank, Serol-ogy, Body Fluids

Green/ Hemogard

BD Blood Collection tube REF 367871

4 mL 4 mL Na Heparin Troponin, Cardiac Panel;

Fluid crystals

Green/ Hemogard

BD Blood Collection tube REF 367884

4 mL 4 mL Li Heparin Troponin, Cardiac Panel;

Fluid crystals

Black/ rub-ber stopper

Excyte

REF 10205

1 mL 1 mL 0.13 mg/L Na citrate

Erythrocyte Sedimentation Rate

2 PREANALYIC ISSUES 33

Tab. 2: Continuation of Table for Vacutainers tubes commonly used at VA NCHCS laboratories

Stopper Color/Type

Vendor/ Part#

Size Volume of Blood Draw

Anti- Coagulant/ Additive

Primary Use

Lime Green/ Hemogard

BD Plus PST Blood Col-lection tube

REF 367960

3 mL 3 mL Lithium Heparin Gel barrier

Cardiac panel, Chemistry, Stat K, Stat glucose, vari-ous tests (May be used for Therapeutic drugs except Lithium and Valproic Acid)

Lime Green/ Hemogard

BD Plus PST Blood Col-lection tube

REF 367962

41 mL 41.0 mL Lithium Heparin Gel barrier

Chemistry, Stat K, Stat glucose, vari-ous tests (May be used for Therapeutic drugs except Lithium and Valproic Acid)

Yellow/ rub-ber stopper

BD Blood Collection tube REF 364606

81.0 mL 6 mL ACD A T4/T8

(CD4/CD8)

Yellow/ rub-ber stopper

BD Blood Collection tube REF 364816

6 mL 6 mL ACD B

T4/T8 (CD4/

D8)

Lavender/ Hemogard

BD Plus Blood Col-lection tube

REF 367861

4 mL

4 mL (must be at least full)

K2 EDTA

Crystals ID & Fluid Cell Counts Hema-tology Blood Bank

Dark Blue/ Hemogard

BD Blood Collection tube REF 369736

7 mL 7 mL Na2 EDTA Heavy Metals

Pearl Top/ Hemogard

BD PPT

Blood Col-lection tube

REF 362788

5 mL 5 mL K2 EDTA Molecular Di-agnostic Test Methods

Gray/ Hemogard

BD Blood Collection tube REF 367922

4 mL 4 mL

NaFK2C2O4 (Sodium fluoride-potassium oxalate) Special Order

Lactic Acid

Gray/ Hemogard

BD Blood Collection tube REF 367729

7 mL 7 mL

NaF (Sodium fluoride)

Serum drug screen

2 PREANALYIC ISSUES 34

(b) Explain to patient why additional blood samples need to be drawn (VERY IMPOR-

TANT).

2.18 24-HOUR (OR TIMED) URINE COLLECTIONS

1. Notify the laboratory concerning which test is desired in order that the appropriate labeled container can be prepared. If urine volume may exceed 2,000 ml, additional containers can be provided. Tests requiring different preservatives must be collected separately in a different 24 hour period and labeled properly indicating preservative and test(s) requested.

2. Collect the urine for a timed period as follows:

(a) Patient empties bladder and discards urine. The timed collection then begins immedi-ately after the patient has voided.

(b) Begin timing and collect all urine voided up to and including the voiding at exactly the end of the timed period.

(c) Urines containing fecal material or other contaminants are not acceptable.

3. Label container with date(s) and time of collection, name, social security number, age and sex, if indicated for test. Specimens should be returned directly to the Laboratory as soon as collection is completed. If it is found that the collection is other than 24 hours in duration, the specimen can be accepted with a three-hour deviation, and the test results will be entered in a comment field with the actual collection time.

2.19 ARTERIAL BLOOD GASES (ABG)

1. Arterial taps for Blood Gas determinations are performed by Physicians and Respiratory Therapists only, and at the Martinez CLC by A nurse practitioner or a nurse certified to perform arterial taps for blood gas determinations.

2. It is their responsibility to insure that the Allen’s test, if required, is performed and docu-mented before collecting the specimen.

3. Arterial taps are NOT performed by Laboratory personnel.

4. Laboratory testing for Arterial Blood Gases (ABG) is performed by the Pulmonary Service at VA Sacramento Medical Center; by the laboratory service at Martinez, Oakland and Redding Outpatient Clinics; and by designated nurse practitioners or nurses at the Martinez CREC, if necessary, when the Martinez laboratory is closed.

3 ANALYTIC - CHEMISTRY TESTS 35

3 ANALYTIC - CHEMISTRY TESTS

3.1 TESTING MENU

CHEMISTRY

Laboratory MATHER MTZ OPC OAK OPC RED OPC

Albumin X X X X

Ammonia X X

Amylase X X X X

AST X X X X

ALT X X X X

ALP X X X X

B12/Folate X X X

Beta HCG X

Bilirubin:Total & Direct X X X X

Blood Gases X X X

BNP X X X

BUN X X X X

Calcium X X X X

Carbon Dioxide X X X X

CEA X

Chloride X X X X

Cholesterol X X X X

Cortisol X

Creatine kinase(CK) X X X X

CK-MB X X

Creatinine X X X X

C-reactive protein(High Sens) X X X

Iron X X X

Ferritin/Transferrin X X X

FSH X

Glucose X X X X

Hemoglobin A1C X X

Ketones X X X

HDL/LDL X X X X

IgG/IgM/IgA X

Luteinizing hormone(LH) X

LD X X X X

Lactate X

Lipase X X X

Magnesium X X X X

Myoglobin X X

Osmolality X

3 ANALYTIC - CHEMISTRY TESTS 36

CHEMISTRY (cont)

Laboratory MATHER MTZ OPC OAK OPC RED OPC

Potassium X X X X

Prolactin X

PSA X X X

PTH X

Prealbumin X

Testosterone X X X

Triglycerides X X X X

Total Protein X X X X

Troponin X X X X

TSH/T4(Free) X X X

Serum Pregnancy (Qual) X X X

Sodium X X X X

Uric Acid X X X X

Vitamin D-25OH X

Body Fluid: Creat, pH X X

CSF: TP, Gluc X X

TOXICOLOGY

Laboratory MATHER MTZ OPC OAK OPC RED OPC

Acetaminophen X X

Carbamazepine X X X

Digoxin X X X X

ETOH Serum X X

Gentamicin X X

Lithium X

Oxycodone X X X X

Phenobarbital X X

Phenytoin (Dilantin) X X X X

Salicylate X

Theophylline X X

Valproic Acid X X X

Vancomycin X X

3 ANALYTIC - CHEMISTRY TESTS 37

HEMATOLOGY/COAGULATION

Laboratory MATHER MTZ OPC OAK OPC RED OPC CBC (with Diff) X X X X

Crystal ID X X X X

Reticulocyte count X X X

ESR (Sed Rate) X X X X

Prothrombin Time X X X X aPTT X X

D-Dimer X X

Fibrinogen X

Parasite Screen X(ID)1 X X X

Fecal Leukocytes X X X X

Body Fluid-Cell Count X X X X

1Parasite ID done at Mather only

URINALYSIS/TOXICOLOGY

Laboratory MATHER MTZ OPC OAK OPC RED OPC Urinalysis X X X X

Urine Pregnancy X X X X

Urine Drug Screen (UDS) X X X X

UDS-Extended 1 X X X

Urine Creatinine X X X X

Urine Microalbumin X X X X

1AMPH, THC, COC, OPI, BARB, BENZO, MET, OXY

******CHECK URINE DRUG SCREEN

3 ANALYTIC - CHEMISTRY TESTS 38

SEROLOGY/MICROBIOLOGY

Laboratory MATHER MTZ OPC OAK OPC RED OPC HIV (Fingerstick)-Waived 1 X X X X

HIV X

Hepatitis X

HCV-Waived 2 X X X X

Rapid Strep X X

Occult Blood X X X X

Influenza Screen X

C Difficile X

AFB Culture and Smear X

Gram Stain X X

Fungus/Mycology Culture X

MRSA X

Bacterial Vaginosis(BD Affirm) X

FIT-Occult Blood X

KOH X X

Vaginal Wet Prep X X X

1Rapid test used for needlestick injuries/body fluid exposures and at stand-downs

2Used at stand-downs

TRANSFUSION SERVICE

Laboratory MATHER MTZ OPC OAK OPC RED OPC

ABO/RH X X

TYPE AND SCREEN X X

CROSSMATCH X X

ANTIBODY ID AND X

ANTIGEN TESTS

DIRECT ANTIBODY TEST X

3.2 BASIC METABOLIC PANEL

1. GLUCOSE

2. CALCIUM

3 ANALYTIC - CHEMISTRY TESTS 39

3. SODIUM

4. POTASSIUM

5. CO2

6. CHLORIDE

7. BLOOD UREA NITROGEN

8. CREATININE

1. GLUCOSE

(a) GLUCOSE TESTING AT VANCHCS LABORATORIES:

• Glucose testing on Serum/plasma is performed at Martinez, Mather, Oakland, Red-ding.

• Glucose testing on CSF is performed at Martinez and Mather.

• Glucose testing on urine specimens is referred to a reference laboratory.

(b) DAY(s) and TIME(s) TEST PERFORMED

(c) ANALYTIC TIME

(d) MAXIMUM LABORATORY TIME

(e) SPECIMEN RETENTION TIME

(f) NAME IN VistA/CPRS

(g) METHODOLOGY AND INSTRUMENTATION:

Glucose is run on the UniCel DxC 600/800 System at Mather Hospital and CBOCs at Oakland, Martinez, and Redding.

The SYNCHRON System(s) determines GLUCm concentration by an oxygen rate method employing a Beckman Coulter Oxygen electrode.

A precise volume of sample (10 microliters) is injected in a reaction cup containing a glucose oxidase solution. The ratio used is one part sample to 76 parts reagent. The peak rate of oxygen consumption is directly proportional to the concentration of GLUCm in the sample

(h) CLINICAL IMPORTANCE:

Glucose measurements are used in the diagnosis and treatment of carbohydrate metabolism disorders including diabetes mellitus, neonatal hypoglycemia, idiopathic hypoglycemia, and pancreatic islet cell carcinoma.

3 ANALYTIC - CHEMISTRY TESTS 40

(i) SPECIAL INSTRUCTIONS FOR PATIENT PREPARATION:

No special patient preparation is required for random glucose testing. For fasting glucose, instruct patient to fast for 10 hours prior to blood draw.

(j) REFERENCE RANGE:

• Serum or Plasma 74 —118 mg/dL

• CSF 40 —80 mg/dL

• Fasting ≤100 mg/dL

(k) CRITICAL VALUE: Serum/Plasma value Less than 50 mg/dL or Greater than 400 mg/dL.

2. CALCIUM

(a) CALCIUM TESTING AT VANCHCS LABORATORIES:

• Calcium testing on urine specimens is referred to a reference laboratory.

• Glucose testing on Serum/plasma is performed at Martinez, Mather, Oakland, Red-ding.

• Calcium testing on urine specimens is referred to a reference laboratory.

(b) DAY(s) and TIME(s) TEST PERFORMED

(c) ANALYTIC TIME

(d) MAXIMUM LABORATORY TIME

(e) SPECIMEN RETENTION TIME

(f) NAME IN VistA/CPRS

(g) METHODOLOGY AND INSTRUMENTATION:

The SYNCHRON System(s) determines total calcium concentration by indirect poten-tiometry utilizing a calcium ion selective electrode in conjunction with a sodium reference electrode.

In principle, a calcium ion selective electrode measures un-bound free calcium ions in solution. Total calcium can only be calculated from free calcium when the molar ratio between free and total calcium concentrations is constant. This constant molar ratio is achieved by the buffered solution which contains strong calcium complexing agents.

(h) CLINICAL IMPORTANCE:

Calcium measurements are used in the diagnosis and treatment of parathyroid disease, a variety of bone diseases, chronic renal disease and tetany (intermittent muscular con-tractions or spasms). Urinary calcium measurement is used in the differential diagnosis of absorptive hypercalciuria and hypercalciuria caused by hyperparathyroidism, hyper-thyroidism, Paget‘s disease or ”renal leak” type of calciuria as seen in renal tubular acidosis.

3 ANALYTIC - CHEMISTRY TESTS 41

No special patient preparation is required.

(j) REFERENCE RANGE:

• Serum or Plasma 74 —118 mg/dL

(k) CRITICAL VALUE: Critical Value = <7.6 or >12.5 mg/dL The laboratorian must follow the critical laboratory value reporting instructions.

Serum/Plasma calcium <7.6 will be corrected for serum albumin using the formula:

Calcium (corrected) = Calcium + (0.8*(4−Albumin)). Corrected Ca and albumin (if not ordered) needs to be added to the accession.

When the corrected calcium is not a critical value: The technologist enters CORCA in the comment section of the report, which will expand to read Low Calcium corrected for Albumin, Corrected Calcium not critical.

3. SODIUM

(a) SODIUM TESTING AT VANCHCS LABORATORIES:

• Sodium testing on Serum/plasma is performed at Martinez, Mather, Oakland, Red-ding.

• Sodium testing on urine specimens (including timed urine) is performed at…