D.8 PATHOLOGY AND LABORATORY MEDICINE SERVICE.pdf

Pathology

Laboratory

Medicine

Service Manual

D.8 ATTACHMENT 36C25622R0004 PATHOLOGY AND LABORATORY MEDICINE SERVICE

file:///C:/en/close-up?o=2813423&memlevel=C&a=c&q=lab&s=91&e=120&show=all&c=&cid=&findincat=&g=&cc=&page=4 file:///C:/en/close-up?o=900571&memlevel=B&a=c&q=microscope&s=151&e=180&show=all&c=&cid=&findincat=&g=&cc=&page=6

TABLE OF CONTENTS

General Information:

I. Introduction II. Pathology and Laboratory Medicine Service

Sections, Room Numbers and Telephone Extensions III. Ordering Clinical Laboratory Tests IV. Requests for Additional Laboratory Tests on Existing Blood Specimen V. Specimen Rejection Policy VI. Laboratory Changes in Methodology/Interpretations VII. Computer Failure and/or Scheduled Downtime

Anatomic Pathology:

I. General Information II. Surgical Specimens III. Cytology Specimens IV. Autopsy (Morgue) Procedures

Clinical Pathology:

I. Patient Identification II. STAT Phlebotomy Requests…….. …………………………………………….. … III. Phlebotomy Services IV. Blood Collection Procedure .... ……………………………………………………… V. Fingerstick Glucose/Whole Blood Glucose (WB FSG) VI.. Special Specimen Collection Protocols

A. Tolerance Tests B. Peak/Trough Orders for Antibiotics C. Special Coagulation Tests D. CSF and Other Body Fluids …………………………………………………..

E. Bone Marrow and LAP Stains ………………………………………………..

F. 24 Hour Urine …………………………………………………………………..

VII. Toxicology Requests …………………………………………………………… VIII. Guidelines for Specimen Transport IX. Turnaround Time Policy X. Critical Lab Values XI. Other Mandatory Notifications………………………………….………………...

XII. Transfusion Medicine

Microbiology

I. Microbiology Table of Contents…………………………………………………….

II. Ordering……………………………………………………………………………….

III. Specimen Collection………………………………………………………………… IV. Rejection of Unacceptable Specimens…………………………………………….

Ancillary Testing Laboratory:

Blood Gas Laboratory

Laboratory Alphabetical Test List

INTRODUCTION

This handbook is intended as a guide to the use of the laboratories at the G. V. (Sonny) Montgomery Veterans Affairs Medical Center, Jackson, MS. It is specifically intended to advise the user as to which tests are available, the procedures used to obtain these tests, what the laboratory needs from the user in order to perform the tests properly, and additional information that may be of value to the provider who uses the test result.

The Pathology & Laboratory Medicine Service is divided into two sections:

I. Anatomic Pathology - which is responsible for postmortem examinations, cytology, and surgical pathology.

II. Clinical Pathology - which is comprised of the following sections: Phlebotomy

Service, Chemistry, Hematology, Electrophoresis, Coagulation, Serology, Transfusion Medicine, Therapeutic Drug Monitoring, Urinalysis, and Microbiology.

In addition, there is an Ancillary Testing Laboratory (Blood Gases) that is not part of Pathology & Laboratory Medicine Service, but is included in this manual for completeness.

Cynthia Lynch, M.D. Acting Chief, Pathology & Laboratory

Medicine Service (Effective Nov. 1, 2016)

Elizabeth R. Cary, M.D. Chief, Clinical Pathology Section

Staff Pathologists:

Clay B. Calcote, M.D.

Julio Cespedes, M.D.

Celeste Cook-Glenn, M.D.

Cynthia Lynch, M.D.

PATHOLOGY & LABORATORY MEDICINE SERVICE SECTIONS

ROOM NUMBERS AND TELEPHONE EXTENSIONS

Location: Basement, East Wing Mail Symbol: 113 FAX Number: 364-1328 (Chemistry Lab)

364-1392 (Anatomic Pathology Office) 368-3916 (Mail-Outs)

GENERAL: ROOM EXTENSION

Chief, P&LMS............................................................... C-20 51631 Secretary ...................................................................... C-19 55727 Laboratory Manager..................................................... C-14C 51619 Barcode Coordinator (BCE)…………………………… I-08F 51982 ADPAC ......................................................................... C-14D 51627 Quality Manager ........................................................... I-08C 51624 Ancillary Testing Coordinator ...................................... 1-08H 55786 Education/ Safety Officer…………………………. ....... I-08I 51603

ANATOMIC PATHOLOGY:

Surgical/Cytology Clerk ............................................... C-19 51602 Histopathology Lab ...................................................... C-48 51626

CLINICAL PATHOLOGY:

Chief, Clinical Pathology .............................................. 1-08B 51623 Central Accessioning Area .......................................... C-14 55870 Chemistry Laboratory .................................................. F-50 51610/51611

Supervisor .............................................................. C-15 51612 Therapeutic Drug Monitoring ................................. F-50 51610 Electrophoresis ....................................................... F-54 51606 Urinalysis ................................................................ F-50 51610

Hematology Laboratory ............................................... F-53 51609 Supervisor .............................................................. F-49 5618 Coagulation ............................................................ F-54 51615

Microbiology ................................................................. F-47 51629 Supervisor .............................................................. F-48 51630 Mycology and Parasitology .................................... F-29 51607

Mail-Out/ Specimen Reception……………………….. . F-28 51238 Transfusion Medicine ................................................... C-10 51216

Supervisor .............................................................. F-52 51613 Serology ................................................................. C-10 56095

Phlebotomy .................................................................. C-52 51617/51415 Supervisor .............................................................. C-12 56766

ANCILLARY TESTING LABORATORY:

Blood Gas (Respiratory Care Service) ........................ L-403 51870 Cardiac Cath (Medical Service)………………….. ....... K-425 56500

ORDERING CLINICAL LABORATORY TESTS

(See Anatomic Pathology Section for Cytology/Surgical Specimens)

The provider’s orders must be entered into CPRS by the ward clerk, nurse, or physician.

Listed below are the steps used for entering the request into CPRS:

With Quick Orders:

1. Select patient.

2. Select “Orders” tab.

3. Select the appropriate order set on the left side of the page.

4. Enter provider name and clinic appointment or hospital admission.

Without Quick Orders:

1. Select patient.

2. Select “Orders” tab.

3. Select “lab tests” on the left side of the page.

4. Enter provider name and clinic appointment or hospital location (example following).

When Writing Orders Under “Lab Tests,” Choose:

1. Lab Collect – use this for routine tests. This is for specimens to be drawn by the phlebotomy team on the early a.m. or evening p.m. NOTE: Microbiology, urinalysis, and body fluid analysis (all non-blood tests) must be ordered under Ward Collect or Send Patient.

Early a.m.: Enter orders in the computer by 4:15 a.m. Collection list prints out at 4:30 a.m. and rounds begin at 4:45 a.m.

Evening p.m.: Enter orders in the computer by 2:45 p.m. Collection list prints out at 3:00 p.m. and rounds begin at 3:15 p.m.

2. Ward Collect – Use this for tests ordered in SICU, MICU, CCU, all STAT lab requests, and whole blood glucose. Also, use for all microbiology, urinalysis, and body fluid analysis test requests.

3. Send Patient – Use this for outpatients only.

*NOTE: If a test cannot be entered in the computer, a call to the Mail-out (ph. 51238) should be made to determine the availability of the desired test. A written request on a miscellaneous lab slip (Standard Form 557), with full Veteran’s name, SSN, ward or clinic location, requesting provider, and test, should then be tubed to station #1.

Justification for non-standard testing must be noted in CPRS. A Pathologist may review the notes prior to authorizing the test.

REQUESTS FOR ADDITIONAL LABORATORY TESTS ON

EXISTING BLOOD SPECIMEN

Add-on test request slips can be found on the G. V. (Sonny) Montgomery VAMC’s webpage under Services→Path and Laboratory Medicine→Add Test (on the right side of page).

Add Test

Name: _______________________________________

Last 4: _______________________________________

CH: _(Found at the top of the comment section on completed labwork)_

Example: CH-0622-355

Add Test(s): __________________________________

Order #: _____________________________________

Contact Person: _______________________________

Extension: ___________________________________

Please fill out all information completely. Completed slips must be sent to the laboratory via the tube system or by courier. If the sample volume is not sufficient for testing, laboratory staff will notify the person notated on the slip.

SPECIMEN REJECTION POLICY

Laboratory personnel use the following general criteria for specimen rejection (more specific rejection criteria are available within each P&LMS section):

► The specimen is improperly labeled or unlabeled.

► The specimen is improperly collected and/or preserved.

► The specimen is submitted without a properly completed request form or electronic order.

► A discrepancy is noted between information listed on the specimen label and the request form or lab order.

► The outside of specimen container is contaminated.

► The patient has not properly prepared for specimen collection.

► The specimen is submitted from an unauthorized source.

The submitting location is notified of the error. Specimens that can be recollected will be recollected. For specimens that cannot be recollected (CSF, anatomic specimens, body fluids, etc.), the provider will be given the opportunity to render the specimen acceptable and sign a

Unlabeled/Mislabeled Specimen form. All deficient transfusion medicine samples must be recollected.

LABORATORY CHANGES IN METHODOLOGY/INTERPRETATIONS

1. Providers requiring information regarding test methodology, specifications, interpretations, and/or changes that may have occurred, can obtain data from the appropriate department supervisor or pathologist.

2. Currently, reference ranges that have been changed for specific tests are designated on each patient report. This includes the new ranges and the date the change occurred. This will print out on all results for that test for one year. If a major change occurs involving more detailed information, a memorandum is sent to all providers from the office of the Chief of Staff explaining the new methodology.

COMPUTER FAILURE AND/OR SCHEDULED DOWNTIME

In the event of computer failure or planned downtime, Pathology and Laboratory Medicine Service (P&LMS) will go to a manual back-up system.

1. All results for existing medical emergency requests will be called to the ward and/or nursing personnel. Critical values will be called to the provider.

2. The manual backup system will be implemented only after it has been determined that the computer system will be down for more than two hours. This determination will be made by OIT, P&LMS ADPAC, and other computer ADPACS of affected services.

3. Written request slips will be required after the down time has exceeded two hours.

P&LMS has provided file boxes to each ward/clinic area to be used during computer downtime. Each file box contains all the necessary request slips as well as information concerning proper tube type, lab section designations, and extension numbers to call for information. There is also a printable downtime lab request form located on the Jackson VA Intranet Home page under Clinical Resources called Clinical Pathology Form (Code VistA). All request slips must be submitted legibly written or stamped with the following information:

a. Patient’s full name

b. Social Security Number

c. Ward or Clinic Location

d. Requesting Provider

e. Date of Request

f. Test or Examination Requested

4. Samples collected by ward or clinic personnel must be properly labeled and accompanied by lab request slips.

5. Copies of completed test results will be available upon request during downtime.

Any critical value will be called per P&LMS Critical Value Notification Policy. All test results generated during computer failure, shutdown, or planned downtime will be entered into the system as soon as possible, when the computers are functional.

ANATOMIC PATHOLOGY

(Surgical Pathology and Cytology)

I. GENERAL INFORMATION:

A. All surgical and cytopathology specimens are received and processed by the Histopathology Laboratory (Room C-48). The Histopathology Laboratory is open for the delivery of specimens Monday through Friday from 6:00 a.m. to 4:00 p.m. During irregular hours, leave specimen in the Laboratory Accessioning Area, Room C-14.

B. Operating Room (OR) specimens (except amputated limbs) are picked up from the OR Workroom, Monday through Friday at 10:30 a.m., 1:30 p.m., and 3:00 p.m. Off-tour specimens may be left in the OR area for the next pick-up if they are placed in formalin.

C. Amputated limbs are to be placed in the designated refrigerated compart-ment in the morgue. After hours paperwork (SF 515) is to be left in the OR pick-up area.

D. Surgical and cytology final reports are available through CPRS two working days after specimen receipt.

NOTE: Tissue Examination forms, SF 515 for Surgical Pathology/Non- Gynecological Cytology and SF 541 for Gynecological Cytology have been added to the electronic ordering feature for all studies requiring the form.

The electronic form will self-populate some required information, however ordering providers will have to enter information in other mandatory fields to complete the form and order.

Once completed, the form must be printed to accompany the specimen to the Lab. The properly labeled specimen container (patient’s full name, full social security number, date and specimen source) should be placed into a biohazard transport bag and the completed form inserted into the side pocket.

II. SURGICAL SPECIMENS:

A. All tissue/materials removed during surgery are to be submitted to Anatomic Pathology.

B. All specimen containers must be labeled with a minimum of the patient's full name, social security number, date and source. Use a separate container for each source.

C. A completed Tissue Examination form (SF 515) must accompany the specimen. (Multiple specimens from the same patient require only one SF 515 listing each source.)

D. The specimen container should be placed into a biohazard transport bag with the SF-515, Tissue Examination form, inserted into the side pocket.

E. Malignant Breast Specimens

1. Specimens should be immersed in 10% formalin within one hour of the biopsy or resection.

2. If delivery of a resection specimen to the pathology department is delayed

(e.g. specimens from remote sites), the tumor should be bisected prior to immersion in fixative. In such cases, it is important that the surgeon ensure that the identity of the resection margins is retained in the bisected specimen; alternatively, the margins may be separately submitted.

3. The time of removal of the tissue from the body and the time of immersion of the tissue in fixative must be recorded and submitted to the laboratory.

F. All other tissues should be routinely placed in 10% formalin with the following exceptions:

1. Tissue for frozen section diagnosis.

2. Lymph nodes.

3. Muscle/nerve biopsies.

4. Renal biopsies.

5. Urinary tract stones.

G. Frozen Sections:

1. Tissue for frozen section diagnosis is submitted to Histopathology in a small labeled specimen cup without formalin.

2. Indicate on the Tissue Examination form (SF 515) the OR number and any special instructions.

3. The frozen section diagnosis will be verbally communicated to the OR by the responsible pathologist.

4. Off hours frozen section diagnoses are done by the pathologist on-call

(contact through the hospital operator).

H. Lymph Nodes:

1. Submit to Histopathology immediately in a small labeled specimen container.

2. May be wrapped in saline moistened gauze. All cultures should be obtained before submitting to Anatomic Pathology.

3. Lymph nodes for possible lymphoma should not be biopsied on Fridays or days proceeding a holiday.

I. Muscle Biopsies:

1. All muscle biopsies are submitted to Histopathology. Please notify lab at x51626 when scheduling a muscle biopsy. Actual specimen processing and examination are done by the Joint Pathology Center (JPC), Washington, DC, or UMMC.

2. Two separate specimens are required for a muscle biopsy and each should be approximately 2 cm. long and 0.5 to 1 cm. in diameter and attached to a tongue blade.

3. Both specimens should be wrapped in saline moistened gauze and placed promptly in a sterile labeled container.

4. Immediately bring all specimens, completed SF 515 which should include a detailed clinical history with neurological examination, electrophysiological studies (EMG), nerve conduction studies and serum CPK levels to Histopathology Lab for shipment.

J. Nerve Biopsy:

1. All nerve biopsies are submitted to Histopathology. Please notify lab at x51626. Actual specimen processing and examination are done by the Joint Pathology Center (JPC), Washington, DC, or UMMC.

2. A 1.5 - 2.5 cm segment of nerve should be attached to a tongue blade and placed in formalin unless immuno-fluorescence studies are desired (i.e., for immunoglobin depositions). In the latter case, the nerve should be submitted fresh and the tests desired clearly indicated.

3. Immediately bring the specimen and a completed SF 515 form, which includes a detailed clinical history including neurological examination and electrophysiological studies (EMG), nerve conduction studies and serum CPK levels, to Histopathology Lab for shipment.

K. Renal Biopsies:

1. All renal biopsies are submitted to Histopathology. Specimen is sent, processed and examined by the Pathology department at VAMC in Houston, TX.

2. The renal needle biopsies should be placed on a saline moistened telfa pad and then placed into a labeled container.

3. Bring immediately to Histopathology with a completed SF 515 form for shipment.

L. Urinary Tract Stones:

1. Urinary tract stones are submitted in small dry container.

2. If chemical analysis is desired, please indicate on the SF 515 form.

M. Criteria for Surgical Specimen Rejection:

1. Unlabeled specimen container.

2. Absent or incomplete Tissue Examination form (SF 515).

3. Inappropriate specimen preservation.

4. Major discrepancy between the container label and the SF 515 form, i.e., patient's name.

5. Every effort will be made to render the specimen acceptable. Submitting provider will be notified in case of specimen rejection.

N. The following is a list of surgical specimens approved by the Clinical

Executive Board which routinely will be given a gross only diagnosis (tissue will not be processed for microscopic examination). If a microscopic examination is desired, please indicate this on the SF 515, Tissue Examination form, along with an explanation.

• Acromion

• Artificial heart valves

• Bone removed for elective joint replacement for degenerative joint disease

• Bone segment removed for amputation revision

• Bunion and hammer toes

• Carotid endarterectomy specimens

• Cataracts

• Femoral head removed for AVN

• Foreign bodies (glass, wood, metal fragments, bullets*, suture material, stents, catheters)

• Hernia sac, cord lipoma

• Intraluminal thrombus from aneurysm

• Lens implant

• Nails

• Nasal septum

• Orthopedic hardware

• Pacemaker

• Penile prosthesis

• Rib/skull (removed for surgical exposure)

• Soft tissue from blepharoplasty

• Scar revision tissue

• Teeth

• Tissue removed in the repair of Ectropion and Entropion

• Torn meniscus

• Urinary tract stones (sent for crystal identification)

* All bullets, removed either in surgery (operating suites) or in the emergency room, must be accompanied by a Chain of Custody Form, VA Form 3524, (provided by Police Service) from the time of first visualization by any VA hospital personnel until it is locked and stored securely in a designated "lock box" within the jurisdiction of Police Services. The bullet must be properly contained, labeled, identified, recorded and transferred directly to a designated VA Hospital Security Officer. The role of the staff surgical pathologist will be to visualize and document the specimen by gross description in the form of a surgical pathology report, if requested by the staff surgeon or appointed police services personnel. Photographs may be taken. The specimen is not to be left in the hands of any surgical pathology personnel or in the pathology department unattended for any reason. The surgical pathologist is not required to sign a Chain of Custody Form, VA Form 3524, (provided by Police Service) but may do so if desired or requested.

III. CYTOLOGY SPECIMENS:

A. All cytology specimens should be brought to the Histopathology Laboratory

(Room C-48) immediately during routine work hours (6:00 a.m. to 4:00 p.m.). Please see specific specimen information below for instructions if the specimen delivery is going to be delayed or for off-hour specimens.

B. Specimen labels must include: Patient’s full name, full social security number and collection date, time and initials of person labeling/collecting the specimen along with the source.

C. A completed Tissue Examination form (SF 515) must accompany the specimen.

D. The specimen container should be placed into a biohazard transport bag and the SF 515 form inserted into the side pocket.

E. Sputum:

1. Please do not combine with microbiological studies. Send a separate specimen for cytology.

2. Collect early morning deep cough specimen in a small screw cap container.

3. Instruct patient to avoid oral contamination. Brushing the teeth or rinsing the mouth out prior to specimen collection is helpful. No saliva please.

4. Deliver to Histopathology Lab as soon as possible.

5. Off-hours specimens should be refrigerated. (May be delivered to

Laboratory Accessioning Area in Room C-14).

F. Bronchial Washing:

1. Deliver unfixed specimen to Histopathology Lab immediately.

3. May be added to the Tissue Examination form (SF 515) of the same patient's bronchial brush, transbronchial needle aspiration, and/or bronchioalveolar lavage.

4. Off-hours specimens should be refrigerated. (May be delivered to

G. Brush Specimens (Bronchial, Gastrointestinial):

1. ONLY FOR procedures from 7:00 a.m. to 3:00 p.m., Monday - Friday, retract brush tip in plastic sheath, place both brush and sheath into a biohazard bag, and send immediately to Histology Laboratory.

2. For procedures during 3:00 p.m. to 7:00 a.m., label frosted end of slide with patient's name and last four of social security number.

3. Make smear immediately after extraction of the brush by gently rotating the brush on a small area of the surface of the slide. Immediately place in coplin jar filled with 95% ethyl alcohol, available from Histopathology Lab. Do not allow to air dry.

4. May be added to the Tissue Examination (SF 515) form of the same patient's bronchial wash, transbronchial needle aspiration, and/or bronchioalveolar lavage.

5. Off-hours specimens should be delivered to Laboratory Accessioning Area in Room C-14.

H. Body Cavity Fluids (Pleural/Pericardial/Peritoneal):

1. Specimen may be collected and submitted in a vacutainer bottle, red stoppered tube or syringe. (Please remove the needle from syringe.)

2. Deliver to Histopathology Lab as soon as possible along with a completed SF 515.

3. Off-hours specimens should be refrigerated. (May be delivered to Laboratory Accessioning Area in Room C-14.)

I. Urinary Tract Specimens:

1. Washes and Urine: Deliver unfixed specimen to Histopathology Lab immediately.

2. Off-hours specimens should be refrigerated. (May be delivered to

J. Cervical/Vaginal Specimens

A. Cervical/Vaginal Specimens: (ThinPrep)

1. Label container with patient's name, social security number, date, and initials of collector.

2. Be sure name, SSN, provider, ward, LMP and other pertinent history is on SF515 Form

3. Send with SF515 Form

B. Cervical/Vaginal Specimens: (Conventional)

1. Label frosted end of slide with patient's name and last four of social security number.

2. Smear specimen thinly onto slide.

3. Fix immediately by placing in coplin jar with 95% alcohol or use

"cytospray" and place in cardboard mailer. Tape shut.

4. Be sure LMP and other pertinent history is on SF 515 form.

K. Cerebrospinal Fluid:

1. Submit unfixed specimen immediately in a black screw-top glass tube or the plastic screw top tube provided in the spinal tap tray.

2. Off-hours specimens should be refrigerated. (May be delivered to

L. Fine Needle Aspiration: Please call the cytotechnologist for assistance at extension 51602 or 55911.

M. Other Specimens or Special Studies: Please call the Cytology Lab at extension 55911 or the laboratory office at extension 51602.

N. Criteria for cytology specimen rejection:

1. Gross leakage of specimen into bag.

2. Unlabeled specimen container.

3. Absent or incomplete SF 515 form.

4. Inadequate/inappropriate fixative.

5. Slides broken beyond repair.

6. Submitted by unauthorized sources.

7. Major discrepancy between container label and SF 515 form (i.e., patient's name).

8. Every effort will be made to render the specimen acceptable.

Submitting provider will be notified in case of specimen rejection.

IV. AUTOPSY (MORGUE) PROCEDURES:

A. When bringing a body to the Morgue:

1. When a body is brought to the morgue, it must be accompanied by the proper paperwork and identification card. A VA form SF 523A, Disposition of Body, should be stamped with the patient’s name. The top part of the form is filled out by the person receiving the body in the morgue. During normal working hours, laboratory personnel will assist in receiving the body. Be sure the logbook, on the desk in the morgue is filled out completely and legibly. Leave the VA form SF 523A, Disposition of Body, near the workbook.

2 Be sure the body has an identification wristband and a “red” toe tag, if appropriate. The body is left on the gurney and placed in the refrigerated compartment. Place an index card (available on the desk) with the Veteran’s name and last four in the door slot.

B. Releasing a Body from the Morgue:

1. Releasing a body to the funeral home is the responsibility of Medical

Administration Service. However, during normal working hours, laboratory personnel will assist in releasing a body.

2. The body’s identification must be verified by the armband. DO NOT RELY ON THE CARD IN THE DOOR. Complete the bottom half of VA form SF F523A, Disposition of Body, which is located on the desk in the morgue and fill out the logbook appropriately.

3. During regular hours, give the SF 523A (Disposition of Body Form) to the Anatomic Pathology Section secretary in Room #C-19. If after regular hours, leave the form on the desk in the morgue.

C. Postmortem Examination (Autopsy)

When a postmortem examination (autopsy) is desired, permission must be obtained from the next of kin. VA form SF 523, Authorization for Autopsy, must be completed. During regular duty hours the details clerk (extension 51220) will assist with the paperwork. During off hours, please contact the administrative officer on duty for assistance.

PATIENT IDENTIFICATION

It is the policy of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, MS, that all patients are identified with at least two verifiers prior to any invasive procedure including phlebotomy or any other type of specimen collection. (Center Policy: B-136- 10 “Patient Identification”).

Before performing any invasive procedure, ask the patient the following questions (for inpatients who cannot respond, the questions should be asked to a family member/guardian or caregiver):

1. What is your full name?

2. What is your full social security number?

3. If he/she cannot state his/her social security number, then ask, what is your date of birth?

4. If the patient is not able to respond, the information may be offered by a family member, guardian or caregiver.

THIS APPLIES TO ALL PATIENTS – inpatients as well as outpatients. For instructions on how to collect transfusion medicine samples, please see Transfusion Medicine Section.

Even if a patient presents his/her VIC card (for outpatients) or has an armband (for inpatients), he/she must still be asked to state the above information. The information that is stated should then be compared to the information listed on the request form, and the patient’s VIC card or armband.

If an outpatient reports to the lab without his/her VIC card, THE SAMPLE CAN STILL BE COLLECTED if he/she or a family member/guardian (where appropriate) can accurately state his/her full name and either his/her full social security number or his/her date of birth.

If an inpatient reports to the lab without an armband, ward personnel will be notified to come and place an armband on the patient.

Specimens should be labeled at the time of collection in the presence of the patient with the patient’s full name, full social security number, date/time of collection, and initials of the person collecting the sample. Do not prelabel specimens.

A CPRS pre-procedure checklist has been approved for use throughout the medical center for any procedure performed outside the OR which requires informed consent.

The checklist contains steps required by Joint Commission Patient Safety Goal 1, which must be carried out BEFORE performing any procedure requiring informed consent.

STAT PHLEBOTOMY REQUESTS

Please call Phlebotomy immediately at extension 51617 or 55334, or pagers 1073, 1583, or 1133 to draw STAT/Emergency labs. Orders must still be placed into the computer before results can be reported. Blood may be drawn by Nursing personnel or provider and brought to the laboratory.

STAT PHLEBOTOMY REQUESTS

The following laboratory tests may be ordered, and will be drawn by P&LMS Phlebotomy, on a STAT/Medical Emergency basis.

ACETONE, QUALITATIVE MAGNESIUM

AMYLASE PLT (PLATELET)

BASIC METABOLIC PANEL POTASSIUM

BILIRUBIN, DIRECT PROTEIN, CSF

BILIRUBIN, TOTAL PT

BLOOD CULTURES PTT

BUN SODIUM

CALCIUM TROPONIN

CARBAMAZEPINE TYPE & SCREEN*

CBC PROFILE VALPORIC ACID

CPK

CREATININE (INCLUDES EGFR)

CROSSMATCH*

D-DIMER

DIGOXIN

DILANTIN

ELECTROLYTES

ETHANOL

GLUCOSE

FINGERSTICK GLUCOSE

HCT

HGB

HIV-RAPID (Exposure only)

LACTIC ACID

LIPASE

* Armband required.

PHLEBOTOMY SERVICES

Room C-45 Extension 51617 or 55334 Pagers 1073, 1583, or 1323 If no answer, please call 51610, 51609 or 51216

DAILY ROUNDS:

Early a.m., put orders in the computer by 4:15 a.m. (for lab collection lists).

Collection list prints at 4:30 a.m. and rounds begin at 4:45 a.m.

Afternoon p.m., put orders in the computer by 2:45 p.m. (for lab collection lists). Collection list prints at 3:00 p.m. and rounds begin at 3:15 p.m.

REDRAWS:

Phlebotomists are limited to two attempts to obtain a blood sample. After two unsuccessful attempts, the phlebotomist must call another phlebotomist.

If the second phlebotomist is unsuccessful, the provider or responsible nurse is notified. A copy of the collection list or ward collect order is left on the ward and a copy is returned to the laboratory.

BETWEEN ROUNDS COLLECTION:

“STAT/medical emergency requests”, critical care units, timed specimens, cross match specimens, and whole blood (fingerstick) glucose specimens will be drawn by Pathology and Laboratory Medicine on an as needed basis. Please call the Phlebotomy Unit after the order has been placed in the computer.

Routine laboratory work should not be ordered “STAT”.

SPECIMEN LABELING POLICY:

General Lab: When specimens are sent to the lab, they must be in the proper collection container and labeled with the following: patient’s full name, full social security number, type of specimen if other than blood or urine, date, time, and location of collection, and initials of the person who collected the specimen.

Blood Bank Specimens: For special labeling requirements refer to Transfusion Medicine section of this manual for sample requirements.

BLOOD COLLECTION PROCEDURE

Specimen:

Specimen requirements, including collection container and special instructions, are listed in the “Laboratory Alphabetical Test List” section of this manual and under the “Test Description” option in VISTA. Hazardous material used in this procedure includes human blood or reagents. Observe universal precautions.

Personnel performing patient blood collection must be trained in the proper selection and use of equipment/supplies and collection techniques prior to drawing blood samples from a patient.

Procedure:

I. Preparing for the Blood Draw

A. Lab Order

1. Obtain a lab order number or written lab request. (Lab work may not be drawn without a lab order.)

2. Verbal requests for lab tests will be accepted only in extreme emergencies. In such cases, verbal orders will be written down and read back to verify accuracy, and the sample will be collected; however, an order number or written request must subsequently be submitted by the requester ASAP, not to exceed 30 days from date of request.

3. Review complete request to determine the tests that are ordered.

B. Reassuring the Patient

1. Approach the patient in a friendly, calm manner.

2. The phlebotomist should identify himself/herself and explain the procedure to be performed.

3. Tell the patient that there will be a small amount of pain associated with the needle stick, and ask the patient if that is acceptable.

4. Interview the patient briefly to determine if he/she is aware of any special circumstances that might affect the blood draw and/or lab tests.

5. If the patient refuses the blood draw, do not proceed.

6. Patients who experience adverse reactions to phlebotomy must be cared for in accordance with Center Policy F-00-17 “Medical Center Assistance Codes”. In case of cardiac arrest, the patient will be cared for as in Center Policy F-111-14 “Cardiopulmonary Arrest – Code Blue”.

C. Patient Identification

1. Confirm the patient’s identity by asking him to state, not verify, his full name and full social security number. If the patient does not know his full social security number, ask him to state his date of birth. If patient is not able to respond, the information may be offered by a family member or guardian if available.

2. Compare the ID information listed on the lab order with:

• information offered by the patient or family member/guardian

• the VA Identification Card (VIC) (for out-patients).

• The patient’s armband (for in-patients).

3. All ID information must match before proceeding with blood collection.

D. Assembling Supplies for the Blood Draw

1. Wash or sanitize hands and apply gloves.

2. When using vacutainer collection tubes, select a disposable tube holder and a safety needle.

3. When using a syringe, select an appropriate syringe with a safety needle.

4. Select appropriate collection tubes, keeping in mind the correct order of draw. Tubes required for each lab test and special collection/ handling instructions are listed under the “Test Description” option in VISTA and in the “Laboratory Alphabetical Test List” section of this manual.

5. The correct order of draw is:

a. Blood cultures should be collected before any other blood sample to reduce the risk of contamination (see blood Culture Collection Procedure).

b. Blue-top (3.2 % citrate) tube. Mix by inversion 8 to 10 times. For Special Coagulation testing draw a “dead tube” and discard. For PT & APTT the first tube drawn may be used, except when using a winged-tip needle. If a winged-tip needle is used, discard the first tube.

c. Red-top tube (Gel Serum Separator or Clot Activator). Mix by inversion 8 to 10 times.

d. Green-top Lithium or Sodium Heparin tube. Mix by inversion 8 to 10 times.

e. Purple-top K3 EDTA tube (black rubber ring insert). Mix by inversion

8 to 10 times.

f. Pink-top K2 EDTA tube. Mix by inversion 8 to 10 times.

g. Gray-top Oxalate/Fluoride tube. Mix by inversion 8 to 10 times.

Collection Tube

Additives/ Anticoagulant Volume of

Blood Draw

Examples for Use

109M (3.2%) Sodium Citrate

3.5 ml.

Plasma for Coagulation studies

Gel Serum Separator

Clot Activator (Silica) 5 ml.

Serum for Chemistry and Immunology studies

Clot Activator (Silica) 6 ml. and

9 ml.

Serum for Blood Banking

Lithium Heparin 5 ml.

Plasma or whole blood for Chemistry studies

K3EDTA 4 ml.

Whole blood or plasma for Hematology, Blood Bank or Chemistry studies

K2EDTA 6 ml.

Immunohematology (Blood Bank) Blood Donor Screening

Sodium Fluoride Potassium Oxalate

5 ml.

Plasma for Chemistry

II. Performing the Blood Draw

A. Venipuncture Using a Vacutainer Collection Set

1. Apply tourniquet and clean patient’s arm with alcohol or ChloraPrep® applicators. Allow to air dry.

2. Ask patient to clench his fist.

3. Remove cover from short end of vacutainer needle. Holding both colored shields, twist and remove the white shield.

4. Screw needle into disposable holder. Rotate safety shield back.

5. Twist and pull needle shield straight off to avoid damaging needle point.

6. Insert needle into vein with bevel up, at or less than a 30 degree angle.

7. When in vein, insert vacutainer tube into holder and push onto needle.

Vacuum will pull in required amount of blood; allow the tube to fill completely.

8. If more than one tube is required, withdraw the filled tube from the holder and insert another tube into place in the holder. Continue in this manner until all required tubes are drawn.

9. Release tourniquet.

10. Place gauze/cotton ball over insertion site, and remove needle from patient’s vein. Apply pressure with arm extended until bleeding is stopped. Apply tape or Coban to hold gauze/cotton ball in place.

11. Activate the needle safety device. Discard holder with needle attached into sharps container.

12. Discard tourniquet.

13. Remove gloves and wash or sanitize hands.

B. Venipuncture Using a Syringe

1. Apply tourniquet and clean patient’s arm with alcohol or ChloraPrep® applicators. Allow to air dry.

2. Ask patient to clench his fist.

3. Peel apart package and attach safety needle to syringe.

4. Pull shield straight off needle to avoid damaging needle point.

5. Insert needle into vein with bevel up, at or less than a 30 degree angle.

6. Watch for blood return. Release tourniquet.

7. Gently aspirate the amount of blood needed.

8. Place gauze/cotton ball over insertion site, and remove needle from patient’s vein. Apply pressure with arm extended until bleeding is stopped. Apply tape or Coban to hold gauze/cotton ball in place.

9. Transfer blood to appropriate vacutainer tube(s).

a. Do not hold vacutainer tube in hand to transfer blood.

b. Insert needle into top of tube(s) and allow vacuum to fill tube. Do not force blood into tube(s). Mix tubes by inversion required number of times if appropriate.

c. Do not recap needle

10. Activate needle safety device by pushing lever arm completely forward until needle tip is fully covered.

11. Discard syringe with needle attached into Sharps container.

12. Discard tourniquet.

13. Remove gloves and wash or sanitize hands.

C. Venipuncture Using a Winged Blood Collection Set (Butterfly)

1. Apply tourniquet and clean patient’s arm with alcohol or ChloraPrep® applicators. Allow to air dry.

2. Ask patient to clench his fist.

3. Peel apart package and screw adapter into holder.

4. Carefully remove the needle cap from the safety-winged needle.

5. Insert needle into vein with bevel up, at or less than 30 degree angle.

6. When in vein, insert vacutainer tube into holder and push onto needle.

Vacuum will pull in required amount of blood; allow the tube to fill completely. Mix tubes by inversion the required number of times if appropriate.

Note: When using a blue top tube, the first tube will be under-filled and must be discarded. A second blue-top tube must be filled to maintain proper anticoagulant/blood ratio.

7. If more than one tube is required, withdraw the filled tube from the holder and insert another tube into place in the holder. Continue in this manner until all required tubes are drawn.

8. Release tourniquet.

9. After completion of venipuncture, gently remove the needle while applying pressure to the puncture site.

10. After removing the needle, immediately activate safety device. The needle should be completely retracted into the winged protector.

11. Apply pressure with arm extended until bleeding is stopped. Apply tape or

Coban to hold gauze/cotton ball in place.

12. Discard needle in sharps container.

13. Discard tourniquet.

14. Remove gloves and wash or sanitize hands.

D. All venous and arterial line draws will be obtained by nursing personnel only.

The nurse must aspirate 10 cc of blood and discard. Change syringe and withdraw desired amount of blood.

E. When collecting coagulation specimens with a butterfly collection set, a waste tube must be drawn before the sample is collected.

F. When collecting Transfusion Medicine specimens, verification of patient ID must be performed BEFORE the specimen is collected. The two verifiers are required to be present during the entire verification process and collection process. The sample may be drawn by a lab phlebotomist/MLT/MT, RN, LPN6 (or higher), or provider, and may be verified by a lab phlebotomist/MLT/MT, RN, LPN, MD or NP. Once the specimen is collected, the collector and verifier must complete the specimen label and verification form entering the date, time and signatures, stating that all patient information on the Specimen Verification Form, the patient’s armband, and the collection tube label is accurate. **Medical students or Health technicians may not draw blood or verify identification for a type and crossmatch.

G. When collecting blood culture specimens, follow steps listed in “Blood Culture Collection Procedure” located in this manual.

H. When collecting tolerance tests, follow steps listed in tolerance procedures located in this manual.

III. Labeling the Specimen

A. All tubes must be labeled at the time of collection in the patient’s presence by the phlebotomist (collector) with the following information:

1. Patient’s full name

2. Patient’s full social security number

3. Date and time specimen was collected

4. Initials of person who collected the specimen

5. An adhesive/addressograph label may then be placed, leaving the hand labeled information visible as much as possible.

B. Transfusion Medicine Specimens

1. Transfusion Medicine specimens must be hand labeled by the collector (lab phlebotomist/MLT/MT, MD, RN, LPN6 or higher) as in Section A above, and must also be labeled with the verifier’s signature and title, MD, NP, RN, LPN6 or higher (e.g. John Doe, RN, Jane Doe, MT) after the verification of the patient’s full name (first and last name) and full social security number and the collection of the patient’s specimen. This information must match on all documents/specimens (Specimen Verification Form, patient’s armband, specimen tube label). **Medical students or Health technicians may not draw blood or verify identification for a type and crossmatch.

2. The requisition form Specimen Verification Form must also be signed by the collector and the verifier.

3. No addressograph, accession, or other adhesive preprinted labels will be used to label Transfusion Medicine specimens.

ORDERING FINGERSTICK GLUCOSE (FSG)/

WHOLE BLOOD GLUCOSE (WBG)

NOTE: ** This system is NOT to be used on “Critically Ill”. Refer to “Critically Ill Guidelines” for testing protocol.

1. Fingerstick glucose (FSG) may be ordered only for patients who meet the criteria listed below. The appropriate criteria must be identified on the Diabetic Care order screen, under Medicine Order Set, Inpatient Menu.

a. Fingerstick Schedule for TPN/Enteral Feeding.

b. Fingerstick Schedule for Insulin Infusion.

c. Fingerstick Schedule for Oral Regimen.

d. Fingerstick Schedule for Sliding Scale.

e. Fingerstick Schedule for Split/Mixed Regime.

f. Fingerstick Schedule for New Insulin Regime.

2. CPRS Instructions:

a. WBG must always be entered as a “Ward Collect.”

b. Always order WBG’s using Quick Orders found under “Diabetic Care” on your menu. This will give the screens found on pages 25 and 26.

c. From these screens, FSG’s may be ordered for up to 3 days. First, choose the regimen of treatment this patient is on. Then select the order for the FSG’s.

d. Review patient orders to ensure appropriate criterion is selected. When giving a verbal order, please be sure to advise RN of the appropriate criterion.

e. If the patient is not on any of the six criteria listed, DO NOT order WBG --order serum glucose for the patient.

Note: AM fasting orders are defaulted to begin tomorrow a.m. and go for 1 day, 2 days, or 3 days.

FINGERSTICK –SELECT TIME

These orders will not auto-accept. Provider MUST change the “How often” parameter which has a current default of QD to whatever time.

Provider may change “How many times” parameter. Please note when making changes:

3 = three days x3 = three times

VERY IMPORTANT: This field is set to “number of days.” If a provider orders “WBG-q6h-72 hours,” the “72 hours” must be converted to “3 days”!

3. FSG’s can only be ordered for a period up to 3 days and then the physician is required to order additional FSG’s in CPRS as needed. If the physician writes an order for more than 3 days (i.e., frequency x 7 days), notify him/her that the lab orders are valid for 3 days only.

4. Phlebotomy performs FSG’s within +1 hour of the collect time, and will leave handwritten results with the appropriate nurse. A second copy will be delivered to the laboratory for result verification or documentation.

5. Serum glucose will be automatically performed on all WBG results that are less than 25 mg/dL or greater than 500 mg/dL. Critical serum glucose results will be called to the provider or the nurse. Critical WBG of 25 – 50 mg/dL will be reported to the RN with documentation on the order slip of the nurse’s name and time result reported. A copy of the report will be brought to the laboratory for documentation of critical value into VISTA.

Intensive Care Unit Serum Glucoses

1. All Intensive Care Unit serum glucoses <70 mg/dL will be called to the provider.

2. Documentation of this value will be placed into VISTA.

SPECIAL BLOOD COLLECTION PROTOCOLS

A. TOLERANCE TESTS:

Outpatient glucose tolerance testing must be scheduled Monday - Friday after approval of the pathologist. Glucose tolerance testing is discouraged; often the same information may be gained by ordering a fasting glucose and glucose 2 hours after a meal (postprandial). Inpatient glucose tolerance testing is often inappropriate and is discouraged.

B. PEAK/TROUGH ORDERS FOR GENTAMICIN, TOBRAMYCIN, AMIKACIN AND

VANCOMYCIN:

1. Antibiotic peak and trough serum concentrations are sampled as follows:

All Trough Concentrations: 15 minutes or less before the next designated dose.

Peak Concentrations:

Vancomycin 1 hour post-dose IV Gentamicin 30 minutes post-dose IV or 1.5 hours after IM injection Tobramycin 30 minutes post-dose IV or 1.5 hours after IM injection

Amikacin 30 minutes post-dose IV or 1.5 hours after IM injection

2. The patient’s nurse, physician, or other designated hospital personnel are responsible for notifying Pathology and Laboratory Medicine Service (Phlebotomy Section, Ext. 51617) regarding the collection of peak and trough concentrations.

3. Intensive Care Units may request a peak and/or trough serum concentration at any time with routine paperwork as follows:

Enter an order in CPRS for the appropriate level. Lab must be notified to draw.

A random level may be ordered if a level required is outside the time frame for trough or peak levels.

4. All Concerns regarding this peak/trough protocol should be referred to the Clinical Pharmacologist, extension 55539, digital pager 987-7825.

C. SPECIAL COAGULATION TESTS:

Special coagulation tests including hypercoagulability tests, factor assays, and tests for lupus anticoagulant should be ordered and drawn before anticoagulant therapy is started. When special coagulation tests are ordered, three blue top tubes should be drawn according to the laboratory’s Blood Collection Procedure.

Homocysteine testing requires an EDTA (purple top) tube placed in ice. A fasting sample is preferred. These samples should be delivered ASAP to the Hematology/Coagulation Department. A red top tube should be collected for ACL (anti-cardiolipin) testing and delivered to the Chemistry Department. A Hypercoagulation Evaluation must be completed (example of screens found below) should be completed through CPRS. Please telephone extension 51615 or 51609 for additional information.

Extensive work-ups are only performed Monday through Friday, 7:30 am to 3:30

pm. However, samples generally can be collected at any time and frozen for future testing. If a patient is to be anticoagulated, request that four (4) blue-top tubes and one (1) red top tube be drawn for testing since Heparin and Coumadin interfere with some tests. Please complete the Hypercoagulation Evaluation in CPRS.

Please telephone extension 51615 or 51609 to inform the staff of the consult and the date when the patient will be at this facility.

To request a Hypercoagulation Evaluation:

1. Click on the Consults Tab.

2. Click on New Consult.

3. From the Consults list, choose Special Coagulation (Lab)

4. In the Hypercoagulation Evaluation and Mixing study box choose either

Hypercoagulation Evaluation, Mixing Study Evaluation or Hypercoagulation Follow-up Evaluation.

5. Please fill in all boxes applicable in the Reason for Request box.

6. Accept the order for the evaluation.

7. The tests will begin auto ordering.

8. Choose done. Go into orders, highlight all orders and sign.

The following tests will be automatically ordered in CPRS to accompany the evaluation:

PT

PTT

Lupus Anticoagulant Anticardiolipin Antibodies Protein C APC Resistance Antithrombin III Protein S Homocysteine (fasting) Beta 2 Glycoprotein Fibrinogen

D. Cerebrospinal Fluid and Other Body Fluids

Cerebrospinal Fluid (CSF):

Collect CSF in sterile, screw-top, clear tubes.

1. Label the specimen tubes in order of draw. Tubes are labeled 1-5 as necessary.

2. Order the requested tests in the computer making certain to choose the default for sample type as CSF.

3. The following tests should be performed as clinically indicated:

Tube 1: 1 ml volume. Protein and Glucose.

Tube 2: 2 ml volume. Culture for bacteria, fungus, tuberculosis, and Cryptococcal antigen.

Tube 3: 1 ml volume. Cell count, differential, and xanthochromia.

Tube 4: 1 ml volume. VDRL.

Tube 5: Optional:

► Second cell count and…