D.5 Specimen Handling and Transporting From CBOCs 02.pdf

Pathology & Laboratory Medicine Service

D.5 SPECIMEN HANDLING AND TRANSPORTING FROM CBOCs 36C25923R0040 Jack C. Montgomery VAMC, Muskogee, OK and all associated Community Based Outpatient Clinics Date May 16, 2018

Specimen Handling and Transporting from CBOCs

(GEN.20374 .40100 .40491 .40492)

1. Purpose: To establish a protocol for handling and transporting specimens from CBOCs to main facility.

2. Principle: Specimens are collected by laboratory staff at the CBOCs. The specimens are then transported to the main facility for processing.

3. Procedures:

a. Ernest Childers Outpatient Clinic (ECOPC)

Specimens are collected, centrifuged and placed in a transport case by the laboratory staff. A manifest sheet is placed in the case, this sheet will note the time, date, condition of samples and initials of staff shipping the case. The case is locked. The case has a biohazard sticker on the outside of the case. The EOVACHS shuttle driver comes to the laboratory and collects the transport case. The case is then shuttled to the warehouse at

Jack C. Montgomery VAMC (JCMVAMC). Laboratory staff then go to the warehouse

And collect the transport case and take to lab for processing. The manifest sheet is filled out as receive time, date, condition of samples and initials of staff inspecting samples, the manifest sheet is then given to Ancillary Testing and retained for sixty days. Specimens are transported according to the following schedule arriving in the main facility warehouse approximately 45 minutes later.

Monday Tuesday Wednesday Thursday Friday Saturday

N/A 0815 0815 0815 0815 N/A

1045 1045 1045 1045 1045 N/A

1345 1345 1345 1345 1345 1200*

*Saturday transport is by contract courier

On Saturday, the contract courier will transport specimens and bring the specimens directly to the JCMVAMC lab. The contract courier will arrive at ECOPC between

11:30-12:00pm to transport specimens to main facility arriving no later than 14:00pm.

If a federal holiday falls on a day during the week (Tuesday- Saturday), the contract courier will pick up and transport specimens from ECOPC between 16:00-16:30pm the day before the federal holiday. The specimens will be brought to the JCMVAMC lab for processing arriving no later than 18:30pm.

a. Hartshorne and Vinita Community Base Outpatient Clinics

The contract courier will come to the JCMVAMC warehouse no earlier than 11:00am and pickup any supplies that need to be transported to the CBOCs (mail, supplies, etc.).

The contract courier will arrive at the CBOC to pick up prepared specimens. The lab staff will place the specimens in individual biohazard bags. The specimen bags are placed in the contract courier transport container and the container will be locked. A

36C25923R0040 Jack C. Montgomery VAMC, Muskogee, OK and all associated Community Based Outpatient Clinics Date May 16, 2018 manifest sheet will have a list of specimens, type and total number of specimens collected, time, date, condition of specimens, and initials for staff inspecting the specimens, this sheet will be locked inside the contractor transport bag. The contract courier will not leave the CBOC before 14:00pm. The specimens are then transported to

JCMVAMC lab arriving no later than 16:00pm. The specimens received are compared to the manifest sheet. The manifest sheet is filled out by the JCMVAMC laboratory staff as to receive time, date, condition of the specimens and initials of person receiving samples. Any other supplies (mail, supplies, etc.) are delivered to the warehouse. On the rare occasion that the contract courier is unable to arrive at the specified times, the

JCMVAMC laboratory will be contacted about the delay. It will be determined if arrangements must be made utilized a government vehicle to get the samples.

b. Idabel Outpatient Clinic

Idabel Outpatient Clinic is a contract clinic, the courier is provided by the contractor.

Specimens are packaged in individual biohazard bags and transported to JCMVAMC for testing. A manifest sheet will have a list of specimens, type of specimen collected, time, date, condition of specimens, and initials for staff inspecting the specimens.

Specimens arrive between 17:30 and 18:30 pm Monday thru Friday. The specimens received are compared to the manifest sheet. The manifest sheet is filled out by the

JCMVAMC laboratory staff as to receive time, date, condition of the specimens and initials of person receiving samples.

c. Once all specimens have been received and processed JCMVAMC laboratory will do a long form. The long form will show specimens that have been accessioned but not completed. The medical technologist will then check to see if the specimen was received and not processed or if the specimen is not received, the CBOC will be contracted for resolution.

b. SPECIMEN SUBMISSION:

a. General Labeling Instructions: Specimen containers are to be labeled with BOTH the patient’s name and full social security number (SSN). The outpatient clinics will be contacted if specimens are lacking required information and immediate corrective action is taken and documented.

b. Surgical Biopsy: Submit in 10% buffered formalin. Formalin/specimen volume ratio should be >10:1. Specimen containers must be labeled with patient name, SSN, biopsy location and biopsy date and accompanied by a histology requisition.

c. Slides: Air dried and fixed smears should be submitted in containers that protect against breakage. Slide containers are available in a variety of shapes, volumes and material.

Optimal design features include easily opened containers which stay closed during transport, shock resistant material and enough room to prevent slides from adhering to one another or the container. The slides should be marked clearly with the patient’s name as well as one other identifier specimen number, or SSN. Enclose in a transport bag indicating biohazardous contents.

d. Blood specimens: Each blood collection tube should be labeled with two identifiers, patient name and full SSN. Enclose in a transport bag indicating biohazardous contents.

36C25923R0040 Jack C. Montgomery VAMC, Muskogee, OK and all associated Community Based Outpatient Clinics Date May 16, 2018

Needles should never be transported with specimens. Large glass collection containers should be avoided.

e. Urine: Obtain a clean catch or bladder irrigation specimen. Transfer urine specimen from cup plastic tubes and Culture & Sensitivity Transfer Straw Kit make sure all caps are secure. Specimen cup must be labeled with patient name and SSN. Place the urine specimen tubes in a biohazard bag. Urine tubes can be included in same biohazard bags with the blood tubes.

BIBLIOGRAPHY/REFERENCES

1. College of American Pathologists. Commission on Laboratory Accreditation

Inspection Checklist 2017 edition, Northfield, Illinois.

4. Occupational Safety and Health Administration. Bloodborne pathogens.

Standard 1910.1030.

Effective Date: May 31, 2018

Author: Theresa Dawson, MSM MT (ASCP)

Laboratory Manager

Schedule for Review:

Initial Review: Chief, P&LMS

Biennial Review: Laboratory Manager

/s/ David Potts, M.D., Chief P&LMS 06/13/18

/s/ Rudolf Ulirsch, M.D., Chief P&LMS 10/22/18

Date: ____________________________Approved: _______________________

Date: ____________________________Approved: _______________________

Date: ____________________________Approved: _______________________

Date: ____________________________Approved: _______________________