D17 LOCAL PATHOLOGY AND LABORATORY MEDICINE SERVICE.rtf

GEN030.09.03.15

PLMS LAB MANUAL 2015

Central Arkansas Veterans Healthcare System Pathology and Laboratory Medicine Service

Pathology and Laboratory Medicine Services (P&LMS) Manual

John W. Theus, M.D. Chief, P&LMS Revised July 2015

ROOM AREA EXTENSIONS

LAB ADMINISTRATION

2E-149

CHIEF, P&LMS

76433 2E-145

ASST CHIEF, ANATOMIC PATH

76435 2E-129

ASST CHIEF, CLINICAL LAB

76445 2E-150

ADMINISTRATIVE OFFICER

76425 2E-153

LAB MANAGER

76450 2E-109

ASST LAB MANAGER

76449 2E-155

POINT OF CARE

76465 2E-155

LABORATORY INFORMATION MANAGER

76483

LITTLE ROCK LABORATORY SECTIONS

2D-175

BLOOD BANK

76452 2D-171

CHEMISTRY

76455 2D-159

CLIENT SVC./REFERENCE TESTING

74668 2E-105

CYTOLOGY

56449 2E-137

FLOW CYTOMETRY

76443 2D-183

HEMATOLOGY/COAGULATION

76460 2E-138

HISTOLOGY

56465 2E-112

MICROBIOLOGY

76447 2E-137

MOLECULAR DIAGNOSTICS

76443 2E-125

MYCOBACTERIOLOGY

76767 2E-116

MYCOLOGY

56453 1A-101

OUTPATIENT PHLEBOTOMY LAB

56496 2D-157

PROCESSING

76448 2D-176

SEROLOGY

56475 2D-158

URINALYSIS

54678

NORTH LITTLE ROCK LABORATORY SECTIONS

BLDG 66

NLR CLINICAL LAB

73057

BLDG 66

PHLEBOTOMY, NLR

53063 3F-109

PHLEBOTOMY, NLR

53069 Table of Contents

SECTION PAGE NUMBERS

I. P&LMS Demographics

II. Laboratory Staffing and Coverage

III. Requests for Laboratory Tests

IV. Computer Downtime 3 - V. Turnaround Times 4 - VI. Phlebotomy Services Provided By P&LMS

VII. STAT Tests Performed in the Clinical Laboratory

VIII. Phlebotomy Procedure 6 - IX. Specimen Identification, Labeling, and Transport

X. Critical Result Policy 11- XI. Reflex Test Policy 14 - XII. Test Descriptions

Anatomic Pathology 16 - Blood Bank 22 - Chemistry/Toxicology 37 - Drug Abuse Survey 53 - Coagulation 55 - Hematology 57 - Hepatitis and HIV Serology

Microbiology 63 - Molecular Diagnostics 80 - Serology 89 - Urinalysis 94 - Reference Lab 96 – P&LMS MISSION: It is the mission of the Pathology and Laboratory Medicine Service to provide our patients and healthcare professionals with timely, accurate analytical data, diagnostic and therapeutic services. State-of-the-art equipment and technology are used to achieve highest customer satisfaction. These services are enhanced through continuous quality improvement, medical education, and research. Successful accreditation by the College of American Pathologists, Joint Commission on Accreditation of Healthcare Organizations, FDA, and the American Association of Blood Banks, is essential.

P&LMS VISION: Central Arkansas Veterans Healthcare System Pathology and Laboratory Medicine Service will be a leader in the healthcare community and a center of excellence in both education and research.

P&LMS DEMOGRAPHICS

P&LMS provides both clinical and anatomical diagnostic care to acute and long term care medical and surgical inpatients and a large outpatient population, as well as psychiatric and drug rehabilitation care. The clinical laboratory provides on site testing at both facilities of the Central Arkansas Healthcare System. The patient population consists primarily of adult veterans characterized by a very significant number of older males, although the numbers of younger patients and numbers of females are increasing.

LABORATORY ACCREDITATION

The CAVHS Pathology and Laboratory Medicine Services of VISN 16 are accredited and inspected by the following organizations:

LABORATORY STAFFING AND COVERAGE

CAVHS Little Rock laboratories are staffed 24 hours a day, 7 days a week; however, laboratory staff and coverage varies at different times during the day and week. P&LMS provides full services Monday through Friday. A limited staff is on duty Saturday, Sunday, and Holidays providing essential services for quality patient care. The laboratory at North Little Rock is staffed Monday through Friday, 0700 to 1600.

A pathologist is on call 24 hours a day for consultation. The On-call resident can be contacted at pager 688-2820.

REQUESTS FOR LABORATORY TESTS

Laboratory tests can ONLY be performed on a Clinician’s order. Verbal orders are not permitted by hospital by-laws, with the exception of life-threatening emergencies. Any unclear orders will be investigated/confirmed with ordering clinician.

Clinical tests can be ordered using the following mechanisms:

Anatomic specimens require a complete and legible Tissue Examination form 515.

Test requisitions for both inpatients and outpatients MUST have the following information on the request.

Test or tests required Date and time of specimen collection if applicable Type and/or source of specimen, e.g., urine, sputum, chest fluid, culture of deep wound, etc.

“ADD-ON” tests to specimens already in the laboratory will be honored if specimen is less than 4 hours old and sufficient suitable sample is available. This practice helps reduce unnecessary phlebotomy “ADD-ON” tests must have an order number when the test is requested. Add-on order numbers are to be called to the appropriate testing section of the clinical laboratory.

Information about specimen collection and reference ranges for tests that are not listed in this manual are available through CPRS using the Tools drop-down menu and clicking on Lab Test Information. Information is also available by calling the laboratory at ext. 54543. Pathology consultation is available 24 hours a day for special test requests and result interpretation. The on-call resident can be contacted at pager 688-2820.

COMPUTER DOWN-TIME

When the computer is down due to routine preventive maintenance or unexpected power failure and lab test(s) requests are needed during this time, form 10-762 “Computer Downtime Requisition for Laboratory Tests” will be accepted, but must be filled out completely with the following information:

Patient name Social Security Number Ward location Requesting physician Test(s) required Date and time of collection

Blood Bank requests require a complete and legible Blood or Blood Component Transfusion form SF-518 for each component requested.

The Laboratory will order these test(s) in the computer when the computer becomes available.

TURNAROUND TIMES

POLICY: Pathology and Laboratory Medicine Service (P&LMS) will strive to have clinical laboratory results available in CPRS as quickly as possible. Turnaround times are from the time the specimen arrives in the laboratory until results are available in CPRS.

Processing time includes centrifuging and separation of samples into appropriate racks for delivery to each section. Peak workload times can cause slower times of result delivery to caregivers. Other considerations are verification of results that may be questionable or critical. STAT testing will be performed before routine specimens. Specimens that are routine and are already in the process of testing will continue and STATs will be placed in queue behind them. Some analytes require longer testing times than others and this is also considered in turnaround times. Any issues during any time frame will be documented.

EMERGENCY SPECIMENS – Turnaround time for a clinical laboratory STAT is 1 hour. EMERGENCY request can only be honored for tests on the approved list (see Page 6).

ROUTINE SPECIMENS – The turnaround time for routine testing is 4 hours. Tests that are batched (batch testing is done on certain days and/or times), microbiology testing, molecular and flow cytometry testing from CBOCs and send out testing are excluded from the routine turnaround time.

Turnaround times will be randomly monitored by the Quality Manager. A report on performance of turnaround times will be reviewed with the Chief, Pathology and Laboratory Medicine and section supervisors.

In the event of anticipated testing delays that would impact timely patient care, the section supervisor will notify Chief, P&LMS and appropriate clinical care teams.

PHLEBOTOMY SERVICE PROVIDED BY P&LMS

Outpatient phlebotomy in Little Rock Division (requests ordered as Send Patient) 1A-101 Hours are Monday – Friday 6:30am – 5:15pm North Little Rock Division (requests ordered as Send Patient)

Building 170, room 3F-109 serves as the main OP phlebotomy station. Hours are Monday – Friday 7:00am – 3:30pm Building 66 2nd floor Hours 8:00am –4:00pm Inpatient phlebotomy in Little Rock Division (Requests ordered as Lab Collect) P&LMS phlebotomists will procure blood from inpatients according to the following schedule. Lab Collect orders must be requested no later than 30 minutes prior to stated pulled time to be included on the laboratory collection list.

Monday – Friday 5:00 AM – Pulled @ 2:30 A.M.

1:00 PM – Pulled @ 12:30 P.M.

7:00 PM – Pulled @ 6:30 P.M

Monday – Friday 6:00 am – Pulled at 2:30 A.M.

1:00 pm – Pulled at 12:30 P.M.

Holidays 7:00 am – 9:30 A.M.

Phlebotomy needs that arise after the collection list computer cutoff time on holidays may be added by contacting the technologist on pager 1129 or by contacting the NOD on pager 1490.

P&LMS phlebotomists at both divisions are NOT responsible for “Emergency” or timed collection orders. Emergency and/or timed collection requests are to be ordered as Ward Collect. If a phlebotomist cannot procure blood from a patient the nurse and/or provider will be notified.

The laboratory phlebotomists will not collect blood samples from IV lines or other indwelling devices, arterial samples, or femoral punctures. These samples should be collected from the attending physician or appropriately trained nursing personnel.

STAT Tests Performed in the Clinical Laboratory

ABO/RH Typing Blood Gases

CBC

PT

aPTT Fibrinogen D-Dimer

BMP

(Na, K, Cl, C02, BUN, Glucose, Creatinine, Total Calcium) Glucose Drug Screen (Urine) Pregnancy Test Troponin I

CK, CK-MB

Ionized Calcium Amylase Lipase Digoxin Tegretol Dilantin Methotrexate Total Bilirubin Alkaline Phosphatase

ALT

AST

Acetaminophen Salicylate Acetone Blood Alcohol Uric Acid Lactate Magnesium Phosphorus PSA (For Hem-Onc patient awaiting chemotherapy only)

PHLEBOTOMY PROCEDURE

Preparatory Phase

Order of Draw

CAP COLOR

MAIN TESTS

*Blood cultures SPS(*must be filled to indicator mark) *Blue (if using a butterfly, draw 2 blue top tubes) PT&INR, aPTT, Fibrinogen, Heparin, All Clotting Factors, D-Dimer, Heparin Antibody (*Tube must be filled to indicator mark) Red PSA, RPR, ANA, Hepatitis, SPEP, Lithium, RF, Prealbumin, C3, C4, CEA Green BMP, Lipid tests, CK, Troponin, TSH, Calcium, Magnesium, Phosphorus, Vancomycin, Dilantin, Digoxin, Gentamycin, Ionized Calcium, Glucose, Creatinine, BUN, Liver Enzymes Lavender CBC, Hgb, Hct, Differential, Hgb A1C, Retic, Flow Cytometry, Fluid Cell Counts, Cyclosporin Lavender/Yellow

BNP, PTH

White Viral Loads Pink Blood Bank Tests (ABO, Rh, Crossmatch, Type & Screen, Coombs) Grey Lactate Note: Using the correct order of draw eliminates erroneous test results due to carry over of the specimen with anticoagulants present in the tubes.

Verify diet restriction when indicated, i.e. fasting blood sugar. (5). Explain procedure and cooperation required.

Performance Phase:

Venipuncture using evacuated tubes:

Gently invert tube 5-10 times to mix blood with additives.

POTENTIAL ADVERSE PATIENT REACTION: Reactions to phlebotomy are rare, and when they do occur the phlebotomist should be able to recognize the symptoms and provide appropriate care. For these instances, the following measures should be used as a guideline to assist patients in need of special attention. Phlebotomists should keep in mind that special cases may arise from time to time and may warrant additional or differing measures than those mentioned in the procedure.

Cardiac Difficulties: If the outpatient’s actions suggest that they might be having difficulty breathing or chest pain, provide the following treatment:

Ask the patient if he/she is having chest pain

DO NOT HESITATE – PAGE THE RAPID RESPONSE TEAM AT 7788.

Keep the patient as comfortable as possible with a cool compress to the forehead or back of neck until assistance arrives.

Hematoma: If the outpatient begins to form blood under their skin at the site of phlebotomy provide the following treatment:

Fainting: If the outpatient begins to feel lightheaded or their actions suggest that they might faint, provide the following treatment:

Nausea and Vomiting: If the outpatient begins to feel nauseous or their actions suggest that they may vomit, provide the following treatment:

Apply a cool compress to the patient’s forehead or back of the neck Provide a proper receptacle if the patient vomits (lined trash can)

Twitching or Muscular Spasms: Extremely nervous outpatients may hyperventilate, causing faint muscular twitching or spasms of their hands or face. Phlebotomy staff should watch closely for these symptoms during and immediately following phlebotomy.

Seizures: If any patient begins to have seizures IMMEDIATELY PAGE THE RAPID RESPONSE TEAM AT 7788.

Prevent the patient from harming themselves by a self-inflicted injury.

During severe seizures, the patient may be difficult to restrain.

If possible, hold the patient in the phlebotomy chair.

If unable to restrain the patient in the phlebotomy chair, place the patient on the floor.

Try to prevent injury to the patient and to yourself.

SPECIMEN IDENTIFICATION, LABELING AND TRANSPORT

Prior to collecting specimen, the identification of the patient MUST be verified using two identifiers. Check the patient’s wristband verifying that the full name and full SSN are the same as that on the request slip or preprinted label. Date of birth may also be used as an identifier in place of the social security number. If the patient is able, have them verbally recite their identifiers.

All specimens must be labeled with the following information: (See Nursing Policy #22)

For certain types of specimens, additional information is needed before the specimen can be processed. In Cytology and Surgical Pathology, the precise source of the specimen and an abbreviated clinical diagnosis must be on the requesting slip (SF-515, Tissue Examination Form). Microbiology requests should have the source and pertinent history.

Specimens received with incorrect patient information will be rejected. The order will be deleted and the ordering location notified.

There will be exceptions when recollection is not possible and information will be corrected, i.e. specimens requiring invasive procedures for collections, bone marrow, CSF, etc. In these cases the physician making the correction will be required to document changes by signing “P&LMS NON-REPLACEABLE SPECIMEN RELABELING FORM.”

Little Rock Division Specimen Delivery (regular hours, irregular hours, weekends, and holidays) Deliver specimens as follows:

North Little Rock Division Regular Hours Specimen Delivery Deliver Specimens to Building 66, 2nd floor.

North Little Rock Division Irregular Hours, Weekends, and Holidays Emergency specimens and microbiology specimens are transported to Little Rock by taxi. This is the responsibility of the requesting location through the NOD.

All specimens should be transported to the laboratory in a re-sealable plastic biohazard labeled bag along with the proper request slip.

Specimen containers that leak are a safety hazard and will be rejected.

CRITICAL RESULT POLICY

Patient results, whether “EMERGENCY” or “ROUTINE” defined as critical (listed on the following page) will be verified and the clinical personnel responsible for care notified WITHIN ONE HOUR by verbal communication. The individual receiving the critical clinical laboratory value will be required to read back the critical information.

Anatomic pathology specimens diagnosed as first time malignancy will be called to the patient’s provider.

CLINICAL LABORATORY CRITICAL VALUES

CHEMISTRY

LESS THAN

GREATER THAN

Protein, Serum

12.0 g/dL CSF Protein

75 mg/dL Sodium 124 mmol/L 160 mmol/L Potassium

2.8 mmol/L

6.0 mmol/L

PO4

1.0 mg/dL

Glucose 50 mg/dL 400 mg/dL CSF Glucose 35 mg/dL

Calcium, Total

6.5 mg/dL

13.0 mg/dL Calcium, Ionized

0.8 mmol/L

1.6 mmol/L Magnesium

1.0 mg/dL

4.0 mg/dL

HEMATOLOGY & COAGULATION

LESS THAN

GREATER THAN

Hematocrit 21% 60% Hemoglobin 7 g/dL 20 g/dL Platelets 25 x 10³/µL 1000 x 10³/µL

WBC

2.5 x 10³/µL 50 x 10³/µL WBC (Hematology-Oncology) 800/µL 75 x 10³/µL WBC (GI- Interferon/Ribavirin)

1.5 x 10³/µL 50 x 10³/µL aPTT

140 sec

INR

(≥) 5.0

THERAPEUTIC DRUGS & TOXICOLOGY

LESS THAN

GREATER THAN

Acetaminophen

300 µg/mL Amikacin, trough

10 µg/mL Tobramycin, trough

5 µg/mL Salicylate

50 mg/dL Lithium

2.0 meq/L Phenobarbital

50 µg/mL Phenytoin

30 µg/mL Procainamide

12 µg/mL Quinidine

10 µg/mL Theophylline

25 µg/mL Gentamicin, trough

5 µg/mL Digoxin

2.5 ng/mL Vancomycin, trough

30 µg/mL Amitriptyline

500 ng/mL Desipramine

500 ng/mL Doxepin

500 ng/mL Ethanol

500 mg/dL Imipramine

500 ng/mL Nortiptyline

500 ng/mL

MICROBIOLOGY

Positive blood cultures Positive gram stain on CSF and other body fluids Gram stain result on surgical specimens Positive CSF Cryptococcal antigen test

OTHER MANDATORY NOTIFICATIONS

Certain other laboratory results, although not considered critical values, must also be verbally communicated to the patient’s clinical provider/physician. These notifications will be documented in the same manner as described for critical values.

MICROBIOLOGY

TEST NAME

RESULTS

AFB Culture or Smear Positive AFB Culture / Smear M. tuberculosis Culture or PCR Positive M. tuberculosis Culture / PCR

ANATOMIC PATHOLOGY

AP Specimens First Time Malignancy

CHEMISTRY

Troponin ≥0.5 ng/mL (Communicate to Emergency Department only)

ELECTRONIC ALERT NOTIFICATIONS

The following positive tests have been flagged as critical, prompting an electronic alert to the ordering provider:

Positive Fecal Occult Blood file_0.png file_1.wmf

P&LMS Critical Tests

Critical laboratory tests are those tests that have been determined should be assayed and completed within a specified time frame.

Those that currently are monitored include:

REFLEX TESTING

PATHOLOGY AND LABORATORY MEDICINE SERVICES

Initial Test Reflex Criteria Reflex Test(s) AFB smear Positive

MTB PCR

Bilirubin Total is > 1.5 mg/dl Bilirubin, Direct Dipstick Urine Positive Dipstick Criteria met Urine Microscopy CBC with Automated Differential Pertinent CBC Criteria met Manual Differential

CK

> 250 IU/L

CK-MB

C. diff Panel C. diff Antigen Positive and C. diff Toxin Negative C. diff PCR Cryptococcal Antigen Positive (Initial test only) Cryptococcal antigen titer Culture, aerobic Possible anaerobe in broth Anaerobic culture Culture Samples Positive for organism Identification Culture Samples Positive Identification Susceptibility Studies, based on established protocol Culture growing an Enterobacteriaceae Ertapenem MIC>2μg/ml and resistant to cefotaxime, ceftazidime, &/or ceftriaxone Hodge test for carbapenemase production ESBL screen Positive ESBL confirmation Hepatitis B Core antibody Total antibody is reactive Hepatitis B Core, IgM Hepatitis B Surface antigen Positive Screen: >1 and < 5 Hepatitis B surface antigen confirmation Hepatitis C (HCV) antibody Positive HCV viral load and HCV genotype (newly diagnosed patient) HCV Genotype No HCV Viral Load w/in 30 days HCV Viral Load HFE (gene for hereditary hemochromatisis) 1st mutation (Cys282tyr) 2nd mutation (His63asp)

HIV I/II EIA

Positive Multispot HIV Genotype No HIV Viral Load w/in 30 days HIV Viral Load Positive DAT Elution Antibody Identification Positive IAT DAT if auto control positive; Elution if DAT positive Antibody Identification Protein Electrophoresis – serum Suspect Monoclonal Gammopathy Total Immunoglobulins (IgG, IgM, IgA, and kappa and lambda free light chains); Immunofixation Electrophoresis on new patients with no previous record Protein Electrophoresis – urine Suspect Monoclonal Gammopathy Immunofixation Electrophoresis on new patients with no previous record Initial Test Reflex Criteria Reflex Test(s)

PSA Screen Test code- SPSA Total PSA is >4.0 ng/ml and <10.0 ng/ml.

Free PSA PTT Mixing Study Abnormal mixing study Thrombin Time Syphilis IgG Reactive RPR Titer Rocky Mountain Spotted Fever (RMSF) antibody Positive EIA

RMSF IFA

Thin Prep Pap Smear ASC/US or ASC/H Diagnosis High Risk HPV DNA Test Calculated LDL Triglyceride >400 mg/dL Direct LDL

TSH

< 0.4µlU/ml or > 5.5 µlU/ml Free T4 Bone Marrow Aspirate No Reticulocyte, CBC or Differential ordered Reticulocyte, CBC, Differential

ANATOMIC PATHOLOGY

CYTOLOGY

General Specimen Collection Techniques

ALL SPECIMENS (PREPARED SLIDES AND FLUID SPECIMENS) FOR CYTOPATHOLOGY MUST BE PROPERLY LABELED WITH THE PATIENT’S NAME AND IDENTIFICATION NUMBER

Fixatives:

Prepared slides: e.g., Pap smears, FNAs, Bronchial brushings, etc.

**NOTE: It is essential that prepared slides be labeled with the patient’s name prior to fixation. Alcohol fixation must be accomplished immediately after the slide is prepared. Even minimal air drying of samples to be stained with Pap stain will alter the cellular detail and compromise specimen quality.

DO NOT SUBMIT SYRINGES WITH NEEDLES ATTACHED

All specimens submitted to Cytopathology must be accompanied by a Tissue Examination Form (SF-515) or equivalent printed electronic doctor’s order form (found under Lab Orders in CPRS). The following information MUST be provided on the form: NAME AND TELEPHONE (OR PAGER) NUMBER OF THE SUBMITTING PHYSICIAN, DATE OF COLLECTION, ANATOMIC SITE OF THE SPECIMEN, PREVIOUS/CURRENT THERAPY, AND PERTINENT CLINICAL HISTORY.

For Gynecological specimens (Pap smears), the Gynecologic Cytology Form (SF-541) or equivalent printed electronic doctor’s order (found in CPRS under lab order) must accompany the specimen. In addition to the required information listed previously, the DATE OF LAST MENSTRUAL PERIOD (LMP), AGE, PREGNANCY STATUS, GRAVIDA, PARA AND INFORMATION REGARDING ANY PREVIOUS ABNORMAL CYTOLOGIC EXAMINATION OR GYNECOLOGIC SURGERY must be included on the SF-541.

Specific Specimen Collection Techniques Ascites – See “Body Cavity Fluids”

Cytology Lab, Room 2D-185, during normal business hours (7:00 a.m. – 4:30 p.m., Monday through Friday). After Normal Business Hours, (nights, weekends, and holidays) the specimens must be sent to the Processing Lab, Room 2D-157.

Cytology fixative is NOT required IF the specimen is to be processed within 12 hours. If processing is delayed, the specimen should be mixed with an equal volume of Saccomanno (green) fluid. Formalin must NEVER be added to body fluids, as it interferes with staining quality. NOTE: If a large volume of fluid is collected, only a Representative Portion of the Fluid should be submitted to the laboratory, up to 200 ml. Denote the total volume of fluid collected on the Standard Form SF515, submit a representative portion, and discard the remaining portion in a biohazard container.

Cytology specimen containers can be obtained from the Cytology Lab, Room 2D- 185, or the Histology Lab, Room 2E-138.

***NOTE: Immunophenotypic studies by flow cytometry and/or immunoperoxidase can be performed on FNA material. Consult the Cytopathology department personnel for further assistance.

**NOTE: A maturation index cannot be given in the presence of endocervical elements, an inflammatory process, pre-neoplastic changes, or carcinoma.

Precaution: Do not use lubricants in examining the patient before the specimen is taken or on any instrument used to obtain the specimen. It is not recommended that specimens be taken within 24 hours after douche, or 6-8 weeks after biopsy, curettage, cone biopsy, or cauterization. Do not take specimens before 6 weeks post-partum. Not indicating the above conditions may impede correct interpretation of the specimen. Please provide all pertinent clinical information on the request slip including: date of last menstrual period, age, use of IUD, or hormonal therapy.

approximately equal volumes of specimen and fixative. Mix the specimen with the fixative thoroughly. Refrigerate the specimen if processing will be delayed 8 hours or more.

GUIDELINES FOR SPECIMEN ADEQUACY

The term “non-diagnostic” is generally used to indicate that a non-gynecologic specimen is inadequate.

Unsatisfactory for Diagnosis: Indicates that the specimen is unreliable for the detection of cervical epithelial abnormalities.

**If abnormal cells are detected, the specimen is never categorized as unsatisfactory.

Satisfactory for Evaluation but Limited By..

Lack of pertinent clinical information (age and LMP minimum).

Satisfactory for Evaluation: indicates that the specimen has all of the following:

REJECTION OF IMPROPER CYTOLOGY SPECIMENS

Gross Examination:

Specimens will be examined for correct and adequate identification, external cleanliness, timely submission, clotting, appropriate fixation, and correctly prepared requisition slips.

Microscopic Examination:

A. On microscopic examination, the pathologist may judge a preparation to be “unsatisfactory” or “limited.” This judgment will be made on the basis of the number of cells present for examination, the types of cells present (i.e., lack of representative cell types for a given site, contamination by cells of extraneous origin, or the presence of obscuring inflammation or blood), cellular distortion due to poor or improper fixation.

A formal, numbered cytology report will be generated with the interpretation noting the “limited by” or “unsatisfactory” state of the specimen. This report will be circulated, as all cytology reports, to the chart to be included as a part of the permanent record. Thus, the attending physician is notified of the “unsatisfactory” or “limited” specimen via the routine pathology report process with a hard copy available in the chart and the report available for review via the computer system locations and are viewable by computer upon verification.

HISTOLOGY

PHONE: 76482

SURGICAL PATHOLOGY SPECIMENS

All specimens will be fixed in 10% buffered formalin. Bottles containing formalin may be obtained from the Histopathology section, Room 2E-141.

SURGICAL TISSUE & TRANSFER SLIDES

All surgical tissue specimens and surgical transfer slides will be submitted with Tissue Examination Form SF-515 to Room 2E-141. (The Histopathology Section will not be accountable for specimens submitted without a properly filled out label or for specimens left in other laboratories).

BIOPSIES

Submit properly labeled, with above requisition form. They will be read out the following work day.

FROZEN SECTIONS

Tissues for frozen sections from the surgical suite will be transported to Room 2E-141. Other tissues for frozen sections from individual wards or clinics will be transported directly to Room 2E-141. All tissues submitted must be properly labeled and with a SF-

515. Scheduling will expedite the results. Call Ext. 76438 for information pertaining to, or the results of, frozen sections.

BLOOD BANK

GENERAL INFORMATION

Specimen Requirements

Patient specimens for pretransfusion testing, including patients with autologous or directed donations, must have a blood specimen collected and tested within 72 hours of an intended red cell transfusion. Specimens must meet the following requirements:

A new patient sample must be collected if any of the above information is omitted from the patient specimen. NOTE: A second specimen collected at a separate time will be requested if patient requires blood transfusions and the patient does not have an ABO/RH test on record. This is a Joint Commission and CAP Patient Safety requirement.

Plasma or platelet transfusions do not require a current blood specimen, provided patient has more than one CAVHS ABO/Rh test on record and the most recent testing is within 14 days.

3 Printed copy of the providers CPRS order signed by the phlebotomist must accompany specimens collected by the wards.

Type and Crossmatch vs. Type and Screen A type and screen order (TAS) includes a determination of the patient’s blood type and the presence of any atypical antibodies. It does not include crossmatching. If red blood cell units are needed, the Blood Bank will be able to crossmatch units using the patient’s type and screen specimen. Red blood cell products must be requested in the CPRS Blood Bank Orders (VBEC) Menu.

Type and screen orders are preferred for surgery patients whose procedures historically do not require transfusion on patients not meeting transfusion criteria. Red cell units can be readily available in an emergency. A type and screen should be ordered for patients who may need a red cell transfusion in the next 72 hours, but whose current hemoglobin and hematocrit values exceed recommended transfusion criteria.

Surgery Patients See Memorandum No. 113-4, Pre-operative Blood Orders for information and the recommended maximum surgical blood order schedule.

Emergency Release In an emergency situation, red blood cells may be requested prior to the completion of pretransfusion testing. Notify the Blood Bank that emergency released blood is needed. If patient’s blood specimen is unavailable or if there is no time to collect and determine the patient’s ABO-Rh type, group O red cell units, Rh negative/positive will be released. If there is a Blood Bank specimen collected from the patient in the past 72 hours, type specific red blood cell units will be issued without crossmatching. An emergency release form, available from the Blood Bank or from the ward, must be signed by the requesting provider. This form should be signed before products are released, but may be signed later, but not more than 24 hours after the request was made. A specimen should be collected and sent to the Blood Bank as soon as possible so that compatibility testing can be performed and the patient can be given group specific blood products.

Circular of Information Information regarding blood products can also be found in the “CIRCULAR OF INFORMATION FOR THE USE OF HUMAN BLOOD AND BLOOD COMPONENTS,” which can be viewed on the CAVHS Website/Department/Pathology and Laboratory Medicine Service/Circular of Information for Blood Bank. Printed copies are also available upon request from the Blood Bank.

HOW TO REQUEST BLOOD BANK DIAGNOSTIC TESTS AND BLOOD PRODUCTS

Blood Bank Orders will be electronic through CPRS. Verbal orders will not be accepted unless an emergency exists.

Requests will be initiated by a provider. Orders must be placed in CPRS before any testing may proceed. If the transfusion of blood or blood components is desired, a separate Nursing order must be placed indicating the type of product, number of units, and when products are needed.