D.5 LAB Ward Instruction Manual 21st Edition 2019.pdf

LABORATORY TESTING

INSTRUCTION MANUAL

FOR THE

PATHOLOGY AND

LABORATORY MEDICINE

SERVICE

21th EDITION Updated: 2/19/2019

Edited by:

William (WC) Wilkerson, Laboratory Manager

Jackie Slusher, Central Laboratory Supervisor

Puriefoy Milton, Histology Supervisor

Teresa Robertson, Microbiology Supervisor

Keith Testerman, Lead Blood Bank Medical Technologist

Tamara Sutphin, Team Leader Medical Technologist

Marie Tate, Phlebotomy Supervisor

Suzanne Stoneman, Laboratory Information Manager

Glyne Conner, Ancillary Testing Coordinator

Susan Amos, Quality Systems Technologist

Approved by: Lampros Karageorge, MD Date: 2/28/2019

Lampros Karageorge, M.D.

Chief, Pathology & Laboratory Medicine Service

D.5 LAB Ward Instruction Manual 21st Edition 2019 36C24621R0068

PATHOLOGY AND LABORATORY MEDICINE SERVICE

WARD INSTRUCTION MANUAL

TABLE OF CONTENTS

CHAPTER I: GENERAL Pages 6-9

A. Introduction

B. Scope of Care

C. Scope and Complexity of Patient Need

D. Administrative Staff Registry/Sections

E. Hours of Operation/After Hours Coverage

F. Laboratory Staffing and Availability by Shifts

G. Laboratory Quality Program

CHAPTER II: INFORMATION MANAGEMENT Pages 10-17

A. Laboratory Computer Menu Options

B. Ordering Laboratory Tests C. Order Urgency, Designation of Test Priority, LTE and STAT Test List D. Adding or Canceling Laboratory Orders E. Laboratory Results

F. Critical or Significant Results G. Computer Downtime

CHAPTER III: SPECIMEN COLLECTION, PREPARATION, AND HANDLING Pages 18-33

a) Safety

b) Test Description Information

c) Referral Laboratory

B. Preparation

a) Patient Preparation

b) Specimen Labeling

c) Problematic Specimens and Rejection Criteria

d) Avoiding Common Errors

C. Specimen Collection and Handling

a) Blood Collection Policies

b) Blood Collection Guidelines

D. Equipment/Supplies for Blood Collection

a) Blood Collection System

b) Specimen Containers

c) Order of Collection

d) Venipuncture Guidelines

e) Labeling of Tubes

f) Transportation

g) Special Blood Collection Situations

h) Special Tests

i) Arterial Blood Gases

j) Urine Specimen

k) Fluids

l) Other specimens

CHAPTER IV: ANCILLARY TESTING Page 34

A. Definition of Ancillary or Point of Care Testing

B. Patient Testing

CHAPTER V: BLOOD BANK Pages 35-48

A. General Policies

B. Products Available

C. Diagnostic Tests and Blood and Blood Components

D. Emergency Release

E. Administration of Blood or Blood Products

F. Transfusion Reactions

G. Miscellaneous Orderable Tests

H. Blood Bank Specimen Collection

I. Circular of Information

TABLE I: Categories and Management of Adverse Transfusion Reactions

TABLE II: Categories and Management of Adverse Transfusion Reactions (Acute Non-Immunologic)

TABLE III: Categories and Management of Adverse Transfusion Reactions (Immunologic)

TABLE IV: Categories and Management of Adverse Transfusion Reactions (Delayed Non-Immunologic)

Blood Bank Verification Form

Patient Safety: Transfusion of Blood Products Request Review

CHAPTER VI: CENTRAL LABORATORY (Hematology, Coagulation, Chemistry, Urinalysis) Pages

49-59

A. Overview

B. Specimen Collection

C. Special Considerations

a. Hematology

b. Coagulation

c. Chemistry

d. Urinalysis

e. Blood Gas Testing

D. Hepatitis and HIV Testing Algorithms

a. Hepatitis A

b. Hepatitis B (Surface)

c. Hepatitis B (Core)

d. Hepatitis C Reflex Testing Algorithm

e. HIV

CHAPTER VII: PATHOLOGY Pages 60-71

A. Postmortem Examination

B. Collection and Handling of Surgical Specimens

C. Collection and Handling of Cytology Specimens

D. Flow Cytometry

E. Methods of Collection

CHAPTER VIII: MICROBIOLOGY Pages 72-95

B. Specimen Collection Supplies

C. Microbiology Specimen Collection and Storage Guidelines

1. Abcess

2. Acid Fast Bacilli (AFB) - Mycobacteria

3. Anaerobic Culture

4. Bite Wound

5. Blood Bank Products from Transfusion Reaction

6. Blood Cultures

7. Bone

8. Bone Marrow

9. Burns

10. Bordetella pertussis

11. Carbapenem-resistant Enterobacteriaceae (CRE)

12. Catheter Tips

13. Cellulitis

14. Chlamydia

15. CSF

16. Decubitus Ulcer

17. Dental Culture

18. Ear

19. Eye

20. Feces

21. Fistulas

22. Fluids

23. Gangrenous Tissue

24. Gastric Wash or Lavage

25. Genital (Female)

26. Genital (Female/Male)

27. Genital (Male)

28. Gortex Graft

29. Hair

30. Helicobacter pylori

31. India Ink

34. Influenza A/B

35. KOH Prep

36. Legionella

37. MRSA

38. Mycology

39. Nail

40. Neisseria gonorrhoeae

41. Parasites

42. Pilonidal Cyst

43. Respiratory, Lower

44. Respiratory, Upper

45. Skin

46. Tissue

47. Urine

48. Wound

49. Virology

50. Microbiology Specimen Collection and Transport Devices

SECTION IX: SEROLOGY Page 96

Serology Specimen Collection and Storage Guidelines

APPENDIX A: ABBREVIATIONS Page 97

CHAPTER I

GENERAL

A. INTRODUCTION: The 20th edition of the Laboratory Testing Instruction Manual for The Pathology and Laboratory Medicine Service, better known as the Ward and Clinic Instruction Manual is prepared for use by the attending and resident physicians, nurses, outpatient, ward and Community Based

Outpatient Clinic (CBOC) personnel to promote efficient service and enhance communication for the best laboratory medical support in the care of our patients. End users of this product are encouraged to give feedback on its usefulness and clarity.

B. SCOPE OF CARE: Pathology and Laboratory Medicine Service (P&LMS) provides care to male and female veteran patients ranging in age from young through the older adult population. Routine and emergency testing capabilities are required due to the mix of patients seen at the Medical Center

(emergent, acute, intensive care, long term care and outpatient clinic). P&LMS is directed by a pathologist and is staffed 24 hours/day by disciplines and levels appropriate to workload requirements.

Services/care provided will include:

a) Clinical diagnostic testing support for inpatients, outpatients, emergent and long-term care patients.

b) Prompt and adequate examination in anatomic pathology, hematology, chemistry (including therapeutic drug monitoring), microbiology, clinical microscopy, parasitology, blood bank, serology, and blood gas results.

c) A referral service to a College of American Pathologists (CAP) and/or The Joint Commission (TJC) accredited laboratory for approved, non-routine, or rare tests.

d) A quality control system designed to assure medical reliability of laboratory data.

e) Review of specimen packages.

f) Oversight of the Ancillary Testing Program

g) Consultative services

h) Interaction with and/or teaching of residents, medical and allied health students.

C. SCOPE AND COMPLEXITY OF PATIENT NEED: P&LMS provides care to male and female veterans ranging from young adult (age 18) through the older adult (geriatric) population. Routine and emergency testing capabilities are required due to the mix of patients seen at the Medical Center

(emergent, acute and intensive care, long term care, and outpatient clinic).

D. ADMINISTRATIVE STAFF REGISTRY/SECTIONS:

VA PHONE PAGER

Chief Pathology and Laboratory Medicine 2293 1075

Staff Pathologist 2289

Staff Pathologist 2053

Laboratory Manager 2200

Secretary 2286

Central Laboratory Supervisor 2197 3520

Lead Medical Technologist Central Laboratory 2285 3521

Blood Bank Lead Medical Technologist 2198 1079

VA PHONE PAGER

Central Laboratory/Chemistry/Hematology 2290/2305/2306

Coagulation/Urinalysis/Blood Bank 2775/2307/2198

Phlebotomy Supervisor 2301

Phlebotomy 2303

Microbiology Supervisor 2196

Microbiology 2192/2194/2941

After-hours (Laboratory Contact) 2290/1390

Evenings/Midnight Supervisor 2285

Histopathology/Cytology Supervisor 2981

Histopathology/Cytology 2980/1687

Program Support Assistant 2302

Laboratory Information Manager 1424

Ancillary Testing Coordinator 1374 1020

Quality Systems Technologist 4585

Technical Specialist 3574

E. HOURS OF OPERATION/AFTER HOURS COVERAGE:

Laboratory in-house services - 24 hours per day; 365 days per year

Specialty Pathology Consultative services – on call 24 hours per day; 365 days per year within 15 minutes by telephone or 60 minutes in person

Surgical Pathology services for frozen section studies – on call 24 hours per day; 365 days per year within 60 minutes in person

F. LABORATORY STAFFING AND AVAILABILITY BY SHIFTS:

Staffing levels are based upon numbers of patients served, testing needs as determined by the Medical

Staff, and efficient utilization of resources.

a) First Shift: 12 midnight to 8am. This shift has very limited staffing. Specimen collection and testing is limited to Life Threatening Emergency (LTE) and STAT requests only. Timed specimens may be collected, workload permitting.

b) Second Shift: 7am to 3:30pm. The laboratory offers 2 rounds:

1. Routine Collection: (1) All routine requests for 6am Collection must be ordered in the computer via lab collect by 4:30am. (2) Requests for 1pm Collection must be ordered in the computer via lab collect by 12pm (noon).

2. Ward Collection: Between routine rounds any request for “On Ward” collection must qualify as a

STAT, LTE or Timed test. See the Phlebotomy Procedure Manual for the Collection of Blood

Specimens for Timed Tests or the Specimen Collection Section of this manual for more information concerning specific timed tests. These requests must be called to the laboratory since they do not print on the collection list.

c) Third Shift: 3:30pm to 12am (midnight). Limited staff. Guidelines for specimen collection and testing follow those of First Shift.

d) Weekends and Holidays: Limited staff. 6:00am and 1:00pm routine collections will be performed. Timed specimens may be collected, workload permitting. Specimen collection other than those times is limited to the STAT and LTE test list only.

e) Outpatient Collection:

1. The laboratory phlebotomy patient area opens at 7am Monday through Friday for specimen collection.

2. Ambulatory admissions, pre-ops, and outpatients will be routinely processed in the laboratory phlebotomy area from 7am to 4:30pm, Monday-Friday. Requests for special accommodations will be considered.

3. Orders must be entered into the computer system before sending the patient to the laboratory. In accord with the agreement for Ambulatory Care Outpatients arriving in the lab must have orders in the computer within the time frame of the date of visit plus three (3) days (T+3) and date of visit minus thirty (30) days (T-30). Patients not having orders within the thirty-three (33) day time frame will be requested to go to their clinic for orders.

4. Do not direct patients to come to the laboratory more than thirty (30) days before the date of the lab orders or more than fourteen (14) days after the date of the lab orders. Patients visiting the laboratory with orders outside the forty-four (44) day range, require clearance by the ordering physician, this significantly decreases the efficiency of the laboratory, and will cause the patient to experience delays.

5. Do not direct patients to wait in the laboratory area for test results.

G. LABORATORY QUALITY PROGRAM

a) Mission/Goals: P&LMS is dedicated to providing the highest quality technical and diagnostic information for the timely and appropriate treatment of our patients.

Service goals include:

• Accurate and timely diagnostic testing results.

• Professional and compassionate care in service to our patients.

• Employment of state of the art testing methodologies and information management in order to maximize efficiency.

• Service excellences through teamwork in a work environment where employees are valued, ideas are shared, and achievements and innovation are recognized.

• Serve as an educational resource for patients, staff, students, and the Medical Center.

• Professional growth and development among our staff.

b) Vision: In P&LMS, it is our vision to be a center of technological excellence through:

• The timely and accurate delivery of diagnostic testing results by a highly trained staff, utilizing state of the art methodologies and information management.

• Integration with other Veterans Integrated Service Network (VISN) laboratories for the provision of more cost-effective services.

• Readiness for any Department of Defense (DOD) needs.

c) Dedication to Excellence: P&LMS voluntarily participates in external quality control programs and is inspected/surveyed regularly by:

• The College of American Pathology Commission on Laboratory Inspection and Accreditation

(CAP)

• Bureau of Biologics of the Food and Drug Administration (FDA)

• The Joint Commission (TJC)

• Occupational Safety and Health Administration (OSHA)

d) Quality Control: Test results from every section of the laboratory are routinely monitored for reliability, precision, and accuracy by both internal and external quality control programs.

1. Internal Quality Control: Samples with known analysis concentrations are routinely interspersed and analyzed with patient samples submitted for testing. Pathologist approved quality control rules are applied and evaluated by the technologist to identify statistical or clinical analytical anomalies should they occur. The technologist is charged with immediate and appropriate corrective action.

2. Proficiency Testing: P&LMS participates in externally-administered quality surveillance programs, including the CAP program. Continued acceptable performance on these surveys is a prerequisite for accreditation.

3. Personnel: Laboratory testing will be performed only by qualified personnel who have completed training and have been designated as competent for testing within the scope of their position.

4. Preventive Maintenance: Equipment and methodologies are “state of the art” and preventive maintenance schedules are followed per the manufacturer’s guidelines. Laboratory personnel, the

BioMedical Engineering Service and contracted outside service organizations perform maintenance.

5. Method Validation: When any test method is put into place for reporting patient results, preliminary testing validates this method for accuracy, precision, sensitivity, reference interval, specificity, analytical measurement range, clinical reportable range, and correlation to the previous method. Interested physicians or other healthcare professionals may review performance specifications by contacting laboratory supervisors.

e) Performance Improvement (PI): An integrated program of problem identification, resolution and monitoring and evaluation is utilized. PI is implemented according to the scope and complexity of the service in order to ensure the quality provision of services.

f) Communication/Education: Communication and education are critical to quality diagnostic testing and customer service. Policy and procedure development, educational programs, and performance improvement data and initiatives must be approached cooperatively in an atmosphere of respect and caring. A variety of communication and/or educational methods are utilized to meet internal and external needs. These include: newsletter, e-mail updates/requests/in-services, bulletin board presentations, conferences, one-on-one/small group/section based meetings or in-service, formal memorandums, educational modules, and minutes.

CHAPTER II

INFORMATION MANAGEMENT

A. LABORATORY COMPUTER MENU OPTIONS

a) The following menu options are used to check the status of laboratory orders or tests. They are available using Veterans Integrated System Technology Architecture (VistA) Lab Package options.

• Order/Test Status--displays status of tests which have been ordered, date of order, urgency, orders and accession numbers.

• Ward Collection Summary for Lab Orders--A summary of ward orders not yet accessioned.

Can be LAB COLLECT, WARD COLLECT, or SEND PATIENT orders.

• List of Lab Orders Not Collected--prints a list of orders for routine rounds that have been placed, but not yet collected. These are LAB COLLECT only.

• Test Description Information--displays, reference ranges, collection samples, etc.

b) The following Computerized Patient Record System (CPRS) Graphical User Interface (GUI) options are found on the REPORTS tab in the AVAILABLE REPORTS box and apply to Lab orders and results:

• Lab Status - the information displayed is the same as the, Order/Test Status above.

• Blood Bank Report - this report contains the patient’s ABO/Rh type, antibodies identified, diagnostic tests performed, component requests, and blood availability.

• Anatomic Path Report - Autopsy, Cytopathology, and Surgical Pathology reports.

• Health Summary - customized displays of test orders and results in various formats.

• Lab Test Information - can be found on the top menu bar in CPRS on the Tools menu. The information displayed is the same as the, Test Description Information above. For Referral

Laboratory Test please refer to current referral laboratory website for this information.

B. ORDERING LABORATORY TESTS

a) All requests for patient testing requiring phlebotomy must be authorized in writing or electronically before the phlebotomy is performed. All in-house tests and most send-off tests are orderable through CPRS. There is one notable exception:

Histology/Cytopathology -- users of the Surgery Module may enter testing information computer on an electronic Standard Form (SF) 515. The completed form will be printed on the nursing unit and submitted to the laboratory with the specimen. If the Surgery Module is not in use, manually complete the SF515 and submit it with the specimen.

b) CPRS (GUI) orders -- After selecting a patient, go to the ORDERS tab and select an item from the

WRITE ORDERS box. Items in the WRITE ORDERS box consist of Order Menus, Order Sets, Order Dialogues, and/or Orderable Items. Contents of the WRITE ORDERS box are customized to each user’s position and specialty. Common to many Order Menus is an item called “LAB ORDER

GROUPS…”. Selecting this item opens a list of menus that categorize tests for selection (i.e. AM

ROUTINE LAB COLLECT (M- F), WARD ORDER MICRO, PULMONARY LAB TESTS, etc.).

c) Blood Bank -- Blood Bank orders are comprised of two types: Diagnostic Tests such as Type and

Screen, direct antiglobulin test (DAT), etc. and Blood Components such as red blood cells, fresh frozen plasma, etc. After the Provider places the order in CPRS, the specimen is collected according to the specified collection type (i.e. Lab collect, Ward collect, Send patient). The properly labeled specimen must be accompanied by a Blood Bank Verification Form that is completed at the time of collection. For detailed instructions on how to place orders for Blood Bank please go to CPRS -

>Tools -> Info and Training Menu -> Info-> CPRS HELP -> Other ->Laboratory -> Blood Bank

VistA Blood Establishment Computer Software (VBECS) CPRS.ppt

d) There are three types of collection: LAB COLLECT (LC), SEND PATIENT (SP) and WARD

COLLECT (WC).

1. LAB COLLECT (LC) -- used to order tests for 6am and/or 1pm laboratory collection times only. The laboratory collection team will collect these orders from inpatients on the wards.

Orders for 6am “rounds” must be placed and signed by 4:30am, which is the computer cut-off time for the 6am Lab Collection List to build and print in the laboratory. Copies of Lab Collect orders are screened from printing on the ward. Orders for 1pm rounds must be placed and signed by NOON when the list automatically builds and prints in the laboratory. Please restrict orders for 1pm rounds to items on the STAT List. The computer displays “Next scheduled lab collection” as the default in the order dialogue, change this to “AM Collection…” whenever possible.

2. SEND PATIENT (SP) -- used when the patient is sent to the lab to have blood or random urine specimens collected. The ambulatory patient will present at the reception desk for the laboratory waiting room. Laboratory staff will review SP orders, and select order numbers for the time frame beginning TODAY + 3 days, and ending TODAY – 30 days. Please instruct outpatients to report no earlier than 14 days prior to the START date, Orders Tab of CPRS. The laboratory utilizes a computerized lab check-in system that checks for these pending orders, called

HOWDY.

3. WARD COLLECT (WC) -- used when ordering tests to be drawn on the ward at any time

EXCEPT standard collection times, which are 6am and 1pm rounds. These orders are considered

“On Demand/Stat” labs. The laboratory must be notified that the order was placed. These orders do not automatically print to the lab. Notify the laboratory by calling ext. 2303 between 7:00am and 3:30pm or ext. 2290 for all other times. Physician, nurse, or laboratory personnel may collect specimens. A copy of the order will automatically print on the WARD printer when orders are electronically signed in CPRS. If laboratory personnel are to collect the specimen, communicate this need to the ward personnel who will PHONE the Lab. Give the order copy to the phlebotomist when she/he arrives on the ward. Other than the PHONE request, the laboratory is not notified of a WC order (nothing prints in the laboratory). Do not present

WC copies to the phlebotomist on rounds without prior notification and approval of the laboratory. This restriction is required for staffing of rounds and to avoid delays in processing. If ward personnel collect the specimen, the WC copy must be sent to the laboratory with the specimen. WC is the type of collection selected for STAT requests.

C. ORDER URGENCY, DESIGNATION OF TEST PRIORITY, LTE AND STAT TEST LIST

A highest urgency allowed is assigned to each individual test in VistA and limits urgency selection during order entry. There are 6 urgencies available to designate test priority:

1) Life Threatening Emergency (LTE) -- The highest urgency available, used only in case of a medical emergency or for a Stroke Medical Emergency Team Code (STROKE MET CODE) during the business hours of Monday – Friday from 8am – 4pm (exclusive of holidays).

NOTE: A Laboratory Medical Technician is part of the STROKE MET CODE Team and will respond immediately. LTE is available for a limited number of tests involved in medical crisis management. Laboratory specimens will be collected, immediately transported to the laboratory, processed/performed, and the results will be available and/or reported within 45 minutes of initial notification/order.

LTE TEST LIST:

Arterial Blood Gas PT/INR

Basic Metabolic Panel (Glucose, BUN, Creatinine, Sodium, Potassium, Chloride, Calcium)

PTT

Cardiac Enzymes (Troponin I, CK-MB, CPK) CBC

Urine Drug Screen 7 (UDS7 Screen), Toxicology (In

House) - Amphetamines, Barbiturates, Benzodiazepines, Cannabinoids, Cocaine, Opiates, Phencyclidine

Urine or Serum BHCG, QUAL

(Screen) - for females of childbearing age

Crossmatch (provided there are no antibodies both historical and/or current)

2) STAT -- Results needed within a limited time frame. Laboratory will provide a 1-hour turn-around time. EXCEPTIONS: LTE & STAT Arterial Blood Gas results available within 15 minutes. LTE & STAT Crossmatch available within 30 minutes if a Type and Screen has been previously performed, provided there are no antibodies, both historical and/or current, and that the required blood is available in inventory.

STAT TEST LIST: All tests on LTE list plus:

Acetaminophen Digoxin Phosphate

Acetone Dilantin Pregnancy (HCG Quant)

Alcohol (Ethanol) Fibrinogen Procalcitonin

Amikacin (Kinetic) Gentamicin (Kinetic) Salicylate

Amylase Gram Stain Tegretol

Blood Cultures

(collection only)

Lactic Acid Theophylline

BNP (ER only) Lithium Tobramycin (Kinetic)

Cortisol (ICU Only) Magnesium Valproic Acid

CSF (Glucose and Protein) Osmolality Vancomycin (Kinetic)

D-Dimer Phenobarbital Employee Exposure Panel

3) Patient Waiting -- Alerts the laboratory that an outpatient is being inconvenienced solely due to the lack of a laboratory result. The laboratory will make every effort to report results in an efficient manner; however, orders with higher urgency will take precedence.

4) Intensive Care Unit (ICU) ONLY -- Traditionally, P&LMS has attempted to give requests from the

ICUs a priority during the morning collection.

5) Routine -- No special “need” is attached to these requests and they will be collected and analyzed in the usual manner. General Chemistry and Hematology tests will be reported within 4 hours during regular business hours (Monday through Friday). Batch testing is performed on lower volume/specialty tests and run periodically. Interval or day of testing may vary.

6) Point of Care (POC) -- Developed for POC testing only as a mechanism to suppress printing of interim reports. Bedside glucometer test, POC Activated Clotting Time (ACT), and POC Creatinine in

Radiology results are forced to this urgency, and will not print on the wards.

D. ADDING OR CANCELING LAB ORDERS

a) Add-on Requests -- verbal requests for patient testing to orders already accepted into the laboratory can increase efficiency and decrease turn-around times. Taking time to call the laboratory to check on specimen availability can save a patient from the discomfort of unnecessary phlebotomy:

1. Before phoning the laboratory, look-up Lab Status on the REPORTS or LABS tab in CPRS, to obtain the following information:

Patient name/Social security number (SSN)

Tests already ordered

Order number and order status

Accession number (far right on display screen)

2. Laboratory personnel will locate the specimen using the accession number provided above.

3. Laboratory personnel will request the caller to generate an electronic order and print a copy to the laboratory, or communicate the order number over the phone. In rare cases, to maintain report continuity the technologist will add the test to an existing accession and note the order number in the comments.

b) Adding to, or canceling from, pending orders in CPRS:

1. New orders in CPRS will automatically combine with pending orders when the collection type is the same and the start date/time match within 15 minutes. Enter a new order, and target the

START date/time to combine.

2. To discontinue an order, select the order from the Orders Tab in CPRS. Click on the Action menu on the Menu bar and select Discontinue/Cancel from the list. Alternatively, you may select the

Order, then right click the Order, and click Discontinue.

E. LABORATORY RESULTS

a) Interim test results are available through CPRS and VistA Lab options as soon as they are completed. STAT results print automatically on the ward.

b) There are two steps to use when looking up laboratory results from the LABS tab in CPRS.

From the LAB RESULTS box:

1. Select the Lab Status item to be sure of the date that the test is complete.

2. Select the desired format for result display from the LAB RESULTS box.

c) Alternatively, the appropriate VistA Lab Package option may be used to find results:

Option Description

MICR Patient Report Microbiology reports for a specified time frame

PO Interim Report for Chosen Tests Patient reports for user selected test in inverse date order for a specified time frame

General Report for Selected Tests Summary of all results for a selected test and time frame in a cumulative format

Edit/print/display preselected lab tests Print/display user defined lab test panel results, also known as test “grids”

Cum Path Data Summary Final diagnosis for anatomical pathology per specimen for selected patients

Display Cytopath Report for a Patient Cytopathology report for a specific patient

Display Surg Path Report for a Patient Surgical Pathology report for a specific patient

d) Additional CPRS options/actions to display/print Lab results may be found on the REPORTS tab by selecting Health Summary from the AVAILABLE REPORTS box. The Blood Bank and Anatomic

Pathology reports from the LABS tab are repeated here.

e) When unexpected situations occur that effect timely reporting of critical laboratory tests, the service line chiefs will be notified.

F. CRITICAL OR SIGNIFICANT RESULTS

a) Critical Result Reporting:

1. P&LMS personnel upon detecting a critical result for inpatients and outpatients inclusive of

Community Living Center (CLC), Community Based Outpatient Clinic (CBOC) and Home Based

Primary Care (HBPC) will telephone results immediately to the requesting practitioner or surrogate.

NOTE: The Reference Laboratory will report critical results/priority values directly to laboratory personnel who will then telephone results immediately to the requesting practitioner or surrogate.

NOTE: The Laboratory has not identified any critical tests.

Communication should occur within 30 minutes of awareness and validation. Critical result notification is to be documented/recorded as test comments in the VistA system with the name of provider notified (documentation of the provider’s first name alone is not acceptable), called to and read back, date/time, and laboratory employee initials.

NOTE: A CPRS alert is also sent to the provider for the critical result.

In the event that the ordering provider or on-call provider cannot be reached, the technologists are to go up the chain of command promptly (Attending, Service Chief, Chief of Staff if necessary) to reach a provider who can make an immediate treatment decision for the care of the patient. For outpatient critical results/values that are identified after hours, the Administrator on Duty (AOD) is to be notified who will ensure appropriate emergency management through the Emergency

Department.

2. Critical Point of Care Glucose values will be called to the provider within thirty (30) minutes of validating the result. A “Critical Glucose Result Report” template must be completed in CPRS to document the provider notification.

3. High and Low Critical values for each applicable test can be found in VistA using the option “Test description information” and in CPRS using Lab Test Information on the Tools menu. The display will also include informative items such as synonyms, highest orderable urgency, reference values, collection samples and containers, and volume requirements. If you are unable to obtain necessary information from VistA, please contact the laboratory for additional assistance or consult the appropriate section of this manual.

b) Significant Pathology Reports: New positive/significant surgical and cytology malignancies (except basal cell carcinoma and skin-squamous cell carcinoma) will be telephoned to the physician by the reporting pathologist within one working day from the time the diagnosis is made. In the event that the requesting physician cannot be reached, the report will be telephoned to the Service Chief. The phone call will be documented on the report.

1. All new malignant cases (excluding skin squamous and basal cell carcinomas)

2. Malignancy in an uncommon location or specimen type (e.g. Hernia sac, intervertebral disk material, tonsil, etc.)

3. Change of a frozen section diagnosis after review of permanent sections

c) Mycobacterial, fungal or other significant organisms identified on special stains

CRITICAL RESULT LIST

ANALYTE CRITICAL RESULT ANALYTE CRITICAL RESULT

Arterial Blood Gas Coagulation pH < 7.3 or > 7.55 PT/INR > 45.2 Seconds/INR > 5.0 pCO₂ > 55 mmHG PTT > 104.0 Seconds pO₂ < 55 mmHG Fibrinogen < 100 mg/dl

Ionized Calcium < 1.05 or > 1.50 mmol/L

O₂Hb < 80% or > 100 % Hematology MetHB > 5 % WBC < 2.0 or > 25.0 K/cmm CoHB > 10 % HGB < 8.0 g/dl O₂ Sat < 89 % HCT < 24.0 %

Platelets < 30,000 K/cmm

Chemistry Glucose < 55 or > 400 mg/dl Microbiology Sodium < 125 or > 160 mmol/L CSF Culture/Gram Stain Positive Potassium < 3.0 or > 6.0 mmol/L India Ink Positive Ionized Calcium < 1.05 or > 1.50 mmol/L Blood Culture/Gram Stain Positive

Calcium < 7.0 or > 14.0 mg/dL

Carbon Dioxide < 10 or > 45 mmol/L Lithium > 1.5 meq/L Dilantin > 25.0 ng/ml Digoxin > 1.8 ng/ml Acetaminophen > 100.0 µg/ml Carbamazepine > 15.0 µg/ml Ethanol > 300 mg/ml

Gentamicin Trough > 2.0 µg/ml Kinetic > 10.0 µg/dl Peak > 10.0 µg/dl

Lactic Acid > 4.0 mmol/L Phenobarbital > 60.0 µg/ml Salicylate > 40 mg/L Troponin I > 0.080 ng/mL Theophylline > 20.0 µg/ml Valproic Acid > 150.0 µg/ml

Vancomycin Trough > 25.0 µg/L Kinetic > 45.0 µg/L Peak > 50.0µ g/L

Amikacin

Trough > 10 µg/mL

Kinetic > 30 µg/mL

Peak > 30 µg/mL

Tobramycin

Trough > 2.0 µg/mL

Kinetic > 10 µg/mL

Peak > 10 µg/mL

G. COMPUTER DOWNTIME

a) The computer system may be down for scheduled maintenance or software installation. These occurrences are announced in the computer, and scheduled for minimal impact on patient care.

The following guidelines apply when VistA is not operational.

b) Computer System Failure: Use forms listed below for Lab Orders:

Use the “Computer Downtime Laboratory Request Forms” for Clinical Lab Orders, the BLOOD BANK

VERIFICATION FORM (fill in lower section to indicate services requested) for Blood Bank, and the

SF 515 - TISSUE EXAMINATION form for Histology and Cytology requests. The form must include the patient's full name, the full Social Security Number, date, patient's location, ordering Provider, tests required, collection sample, urgency, and phone number if urgency is STAT or LTE.

NOTE: The Computer Downtime Laboratory Request Forms are available in the laboratory.

In-Patients/Units:

If the predicted downtime is short (less than 2 hours), limit ordering to LTEs and STATs. Complete the manual requisitions, notify the laboratory by phone and the laboratory will phone the results. If the downtime is prolonged (more than 2 hours) all required tests should be ordered manually. Complete the manual requisitions, deliver non-STAT requisitions to the laboratory. Laboratory personnel will continue to call LTE and STAT results to the ordering locations and critical results to the physicians as usual. When the computer comes back on-line, resume ordering by computer. Manual requisitions received in the laboratory before the computer returns will be collected on the next routine collection round and multipurpose accessioned by laboratory staff. The Nature of Order assigned to these tests by laboratory personnel will be SERVICE CORRECTION.

Outpatients/Clinics:

All required tests should be ordered manually. Complete the manual requisitions and hand them to the

Outpatient to carry to the laboratory. Laboratory personnel will call LTE, STAT, and critical results.

When the computer comes back on line, resume ordering by the computer.

c) A short lists of commonly ordered laboratory tests for each department is provided as an aid to use when manual requisitions are required.

CHEMISTRY CHEMISTRY HEMATOLOGY MICROBIOLOGY

Basic Metabolic Panel

(BMP) Osmolality Sedimentation Rate

Culture and

Susceptibility

Electrolytes (Lytes) Lactic Acid Cell Counts (fluid) Gram Stain

MG, PO₄ HIV Reticulocyte Anaerobic Culture

Hepatic Function Panel

(Liver)

Hepatitis B

(Ag, Ab, Core)

CBC/Auto Diff Blood Culture

CBC/no Diff C. difficile toxin

Ammonia Urinalysis Mycology Culture

Amylase, Lipase Urinalysis (Reflex) Ova & Parasite Screen

ETOH COAGULATION AFB Culture/Smear

Troponin I D-Dimer SEROLOGY Occult Blood FIT

Lipid Profile PT/INR HIV

(Exposure Panel) GC/Chlamydia

TSH PTT

Drug Levels VDRL (CSF)

d) Results During Prolonged Computer Downtime (>2 hours)

1. Laboratory personnel will make copies of laboratory reports if requested for delivery to the patient care areas. These copies are not intended for the patient chart and will be stamped PHYSICIAN

COPY. They will be in Building 143/Room 1A-1033 in the Central Laboratory.

2. For downtime occurring 7am-3:30pm Monday-Friday, the Nurse Manager on each ward will designate staff to retrieve the reports from the laboratory and deliver them to the ward. For downtime occurring after 3:30pm Monday-Friday and on holidays and weekends, the Nurse on Duty (NOD) will designate staff to retrieve the reports from the laboratory and deliver them to the wards. The reports will be placed on the wards in a location that is readily accessible to physicians and residents who wish to review the reports.

3. When the computer is operational, laboratory personnel will enter the downtime results as time and workload permit so that the patient's electronic record will be complete.

4. In cases of unplanned downtime, routine Chemistry samples will be processed to a stable state, but will not be tested. If results are needed for a patient with routine requests, notify Chemistry, extension

2290, of needed priority. Include phone number or pager for result notification.

CHAPTER III

SPECIMEN COLLECTION, PREPARATION, AND HANDLING

A. INTRODUCTION: Laboratory test results contribute vital patient health information to members of the treatment team. Correct information and therapeutic decisions rely, in part, on the timeliness and accuracy of test results. Adequate patient preparation, specimen preparation and specimen handling are necessary prerequisites for timely and accurate testing. The accuracy of test results is dependent on specimen integrity.

a) Safety Considerations: All healthcare personnel involved in specimen collection and preparation are responsible for adhering to current safety and infection control recommendations designed to maintain the safety of both patients and healthcare workers. Precautions regarding the use of needles and other sterile equipment and guidelines for the disposal of biological material and specimen collection supplies should be followed.

b) VistA Menu Option: Test Description Information: Descriptive information of tests offered by the laboratory may be found on-line by using this menu option. The display will include the following data fields: synonyms, highest orderable urgency, reference values, critical values (if applicable), collection samples and containers, and volume requirements. If you are unable to obtain necessary information from the VistA computer system or from this manual, please contact the laboratory for additional assistance.

c) Referral Laboratory: Unusual and/or low volume tests may be sent to a referral laboratory for testing. Only CAP accredited laboratories are utilized. High-cost referral laboratory tests and specialty tests are subject to pathologist review.

All tests that are approved to be sent to other laboratories will be entered into the computer test list. Information on specific tests, inclusive of special handling, can be found under option “Test Description Information” in the VistA system. If the test is not in the computer, it must be researched by laboratory personnel or specimen processing and receive pathologist approval before being sent. Tests not in the computer test menu must be ordered as “MISCELLANEOUS (SEND OUT)”. In the “Enter order comment” section you will need to enter the name of the requested test, sample requirements, and reference lab test number. It is best to cross-reference specimen requirements with the referral laboratory manual or call the toll-free customer service number for highly unusual tests, or any test with a designated collection sample of “Special”.

Request forms are available for various referral sources. Refer to the Quality Systems Procedure Manual on the Public drive for detailed instructions for processing Referral Laboratory specimens (see the procedure “Collection, Labeling, Handling and Processing of Laboratory Specimens”). The Reference Laboratory courier routinely picks up referral samples on a daily basis.

B. PREPARATION: Prior to each collection, review the laboratory’s specimen requirement. Note the proper specimen to be collected, the amount, the collection materials, and the storage and handling requirements.

a) Patient Preparation: It is important to gain the patient’s understanding and cooperation in obtaining an acceptable specimen. As appropriate, provide the patient with information on the specimen collection procedure, including information on fasting, diet, and medication restrictions.

b) Specimen Labeling: All specimens must be properly collected and labeled in the presence of the patient. Specimen containers must have patient’s first and last name, social security number (SSN), date, exact time specimen was collected and the initials of the individual collecting the specimen. In addition, the proper request form must be submitted and filled out completely. This includes the patient’s full name, social security number, ward number, the provider ordering the test, source of the specimen and type of test required. Blood Bank specimens must be labeled at the time of specimen collection in the presence of the patient to include: patient’s complete social security number, full name, date/time and collector’s initials and accompanied by a complete Blood Bank Verification Form.

c) Problematic Specimens and Rejection Criteria: Providers will be notified if specimens were received improperly collected, are inadequate, or are unsuitable for laboratory analysis. Should laboratory personnel become aware of a potential error in patient identification or other significant data

(e.g. phlebotomist initials, date/time), it is best practice to reject the specimen, notify the requesting

Provider, and have the specimen recollected. When the specimen in question is difficult to collect [e.g.

cerebrospinal fluid (CSF), peritoneal, pleural fluid, etc.] label correction by the specimen collector may be permitted. However, this must be documented in the computer under “Comments”. A reasonable time frame will be allowed to correct the discrepancy; thereafter, the ordering healthcare Provider will be notified and the specimen will be discarded with the reasons noted in the computer. Record the information for any unacceptable or rejected specimen on the Specimen Rejection and Specimen

Problem Log (i.e. E-LOGS), located on the Public drive in the LAB folder, including the disposition of the unacceptable specimen.

Following is a list of specimens and requests that will not be accepted by P&LMS:

1. A specimen that is submitted in an unsanitary condition, thus posing unnecessary health hazard to all who handle the specimen. Containers must be tightly sealed with no external spillage.

2. Any unlabeled specimens.

3. Samples collected in an inappropriate container (i.e. fluid for pH not in red top tube), preservative or transport media.

4. Inappropriate test requests for specimen submitted.

5. Insufficient quantity of specimen to run the test [i.e. quantity not sufficient (QNS)].

6. Any specimen delayed in transport to the laboratory that would compromise quality of specimen.

d) Avoiding Common Errors: During specimen collection, preparation and submission, there is a much greater possibility of error than during testing. Errors in storage and handling compromise specimen integrity and thus the test results. Common errors affecting all types of specimens include:

1. Failure to label a specimen correctly and/or provide all types of pertinent information.

2. Insufficient quantity to run the test.

3. Failure to use the correct specimen collection container.

4. Failure to tighten specimen container lid resulting in leakage and/or contamination of specimens.

5. Inaccurate or incomplete patient instructions prior to collection.

C. SPECIMEN COLLECTION AND HANDLING

1) Blood Collection Policies, PAGE 25

2) Blood Collection Guidelines:

3) Patient Identification: Correct identification of patients who are having phlebotomy procedures performed is critical to patient care.

• Out-Patient Collection:

a) Patients who come to the laboratory for blood collection must present their Veteran Health Identification Card (VHIC) card at the reception desk.

b) The patient’s VHIC card is scanned into HOWDY where the patient’s name and SSN is used to access their laboratory orders. Orders are accepted for collection in the range of the date of visit plus 14 days (T+14) to the date of the visit minus 30 days (T-30). If no laboratory orders fall within the range of T+14 and T-30, then the patient is to return to their clinic for lab orders. If the patient’s condition prevents the patient from traveling the distance to their clinic, the provider will be contacted by phone.

NOTE: Blood Bank orders cannot be collected too soon prior to surgery. If you get a Blood Bank order make sure that it is not collected unless it is within a 3-day time frame of the current date.

NOTE: Instruct patients to report to the laboratory for blood collection no earlier than 14 days prior to the START date, Orders Tab of CPRS. Reporting to the laboratory outside this range causes substantial delay in the laboratory’s ability to provide service to the patients.

c) All patient samples for laboratory testing are collected utilizing a two-identifier process.

Patients are called into the phlebotomy area in the order they arrive to the laboratory. Before blood is drawn, the patient is asked to state his/her first and last name and to enter their complete SSN into a calculator for privacy. The number is then deleted after identification has been verified.

NOTE: If a patient is unable to state his/her first and last name and SSN, at least 2 other patient identifiers can be used (ex: address, date of birth, etc.).

• In-Patient and Admissions/Outpatient (A/O)/Emergency Room Collection:

a) Patients who are admitted to the ward or being treated in the A/O must be identified by comparing the computer order with an Identification bracelet attached to the patient’s wrist or ankle. The patient is asked to state their first and last name and their full SSN. If a patient is unable to state his/her first and last name and SSN, at least 2 other patient identifiers can be used (ex: address, full date of birth, etc.). If the patient is unable to communicate, a staff member responsible for the care of the patient can identify the patient.

b) When the laboratory order is accessioned, name, SSN, and test requested are verified.

c) Any patient with Blood Bank orders is required to have a wristband bearing his/her complete name and social security number, accompanied by the Blood Bank Verification Form.

NOTE: Blood will not be collected if the identification of the patient cannot be validated using these standard laboratory guidelines.

D. EQUIPMENT/SUPPLIES FOR BLOOD COLLECTION:

a) Blood Collection System: The Medical Center utilizes the Vacutainer System for the collection of blood specimens. A needle and syringe assembly or blood collection set (butterfly) may also be used. Blood collection supplies are available from the Logistics Service. Blood Culture bottles are available from P&LMS by request.

b) Specimen Containers (Tubes): To ensure accurate test results, blood must be collected in the appropriate specimen container (tube). Refer to the computer option, “Test Description Information”, or the section, “Laboratory Test List”, of this manual for the selection of the proper tube. The tube descriptions listed below account for the majority of specimen collection tubes used at this facility. Some specialized tubes not listed below are provided by reference laboratories as needed and require interaction with the laboratory.

Red-stopper tube: Contains no anticoagulant or preservative.

Use: Serum. Most commonly used for therapeutic drug levels and ETOH. Can be used as alternate collection tube in place of gold SST tube.

Gold-stopper [serum separator tube (SST)]: Contains clot activator and inert gel barrier material separating serum from cells, but no anticoagulant. Always check the test description to determine whether a serum-separator tube is acceptable.

Use: Serum. Maybe used for assays requiring serum unless otherwise stated.

Lavender-stopper tube: 4 mL size - Contains liquid, K₂ Dipotassium salt of Ethylenediamine

Tetra-acetic Acid (EDTA) 7.2 mg.

Use: EDTA whole blood or plasma. Cell count procedures and HgbA1C

Lavender-stopper tube: 6 mL size - Contains liquid, K₂ Dipotassium salt of Ethylenediamine

Tetra-acetic Acid (EDTA) 10.8 mg.

Use: HIV viral load testing

Gray-stopper tube: Contains sodium fluoride (15mg), preservative, and potassium oxalate

(12mg) an anticoagulant.

Use: Sodium fluoride whole blood or plasma.

NOTE: Lactic acid must be collected and placed on ice.

Blue-stopper tube: Contains 3.2% buffered sodium citrate (0.109M). Fill to line on tube. Do not overfill or under fill blue stopper tubes. The dilution ratio is mandatory for testing.

Use: Sodium-citrate plasma. Most commonly used for coagulation studies.

Light Green-stopper tube: Contains lithium heparin (76 units) (sufficient for 4.5 ml of blood) and a gel separating serum from cells.

Use: Heparinized whole blood or plasma. Used for most STAT Chemistry testing including

BMP, CPK, CK-MB, and Ammonia.

NOTE: Ammonia must be collected and placed on ice.

Dark Green -stopper tube: Contains lithium heparin (68 USP units) (sufficient for 4.0 ml of blood) as an anticoagulant and contains no gel.

Use: Troponin I and Ionized Calcium (venous). Preferred tube type for LTE Troponin.

NOTE: Venous Ionized Calcium must be collected and placed on ice.

Yellow-stopper tube: Contains 1.5 ml acid citrate dextrose (ACD) Solution A.

Use: HLA phenotyping

Pink-stopper tube: Contains Dipotassium EDTA (K₂ EDTA 10.8 mg)

Use: Blood Bank procedures

Purple/Grey stopper tube: Contains 1.5ml Cyto Chex BCT reagent.

Use: T-cell panel studies for flow cytometry

NOTE: All tubes containing an anticoagulant or preservative must be allowed to fill completely.

Attempts to force more blood into the tube by exerting pressure can result in hemolysis. All tubes must be mixed by gently inverting the tubes.

c) Order of Collection: The recommended drawing order is as follows:

ORDER OF DRAW COLOR COLLECTION TUBE MIX BY INVERTING

1. Blood Cultures 8 to 10 times

2. Blue Top (citrate) 3 to 4 times

3. Red Top none for plain Red Top

4. Gold SST Gel Separator 5 times

5. Light/ Green Stopper (Heparin) 8 to 10 times

6. Lavender Stopper (EDTA) or Pink 8 to 10 times

(K₂EDTA) Lavender/Gray Stopper (Cyto-Chex)

7. Gray Stopper (Fluoride) 8 to 10 times

8. Yellow (ACD) 8 to 10 times

d) Venipuncture Guidelines: This section is presented as a guide for those trained in the collection of blood samples by venipuncture, and is not intended to train individuals in venipuncture technique.

• Greet patient. Explain that you will be collecting blood. Verify identification using a two-identifier process (full name and full SSN or full date of birth).

• Assemble supplies. Gloves, labels, needle, needle holder or syringe, tourniquet, appropriate tubes, gauze, alcohol pad, and adhesive strip. A 22 or 23-gauge needle is the smallest bore size recommended to avoid hemolysis.

• Select the puncture site.

• Apply tourniquet. Do not leave on longer than 1 minute.

• Decontaminate with alcohol. Allow alcohol to dry to avoid stinging the patient at venipuncture.

NOTE: If collecting for ETOH…