D42 Ancillary Testing Policy - Draw Only.pdf

PATHOLOGY & LABORATORY MEDICINE SERVICE

4300 West 7 th

Street, Little Rock, AR 72205

Issue Date:

04/05/18

Document # :

CBOC.013

Owner: Karen McNulty Revision:

Primary Approver: Kim Rose, Lab Manager

Document Status: Approved for Operational Use - Not Document Controlled if Printed

Title: Transportation of Laboratory Specimens

Principle:

Transportation from the site of collection to the appropriate laboratory responsible for analysis shall be done in such a manner as to minimize accidents, and to contain spills if such accidents do occur. All primary specimen containers will be transported in a secured secondary container.

Definitions:

1. Diagnostic specimen: Any human or animal material including, but not limited to, excreta, secreta, blood and its components, tissue and tissue fluids, being shipped for purposes of diagnosis. All fresh, unfixed human biological materials are considered specimens.

2. Infectious Substance (Etiologic Agent): Substances known to contain or reasonably expected to contain pathogens. Pathogens are microorganisms (including bacteria, viruses, rickettsia, parasites, fungi) or recombinant microorganisms that are known or reasonably expected to cause infectious disease in humans or animals. A shipper’s declaration for dangerous goods must accompany these types of specimens.

3. Primary Container: Blood collection tube or plastic transport tube in which the specimen has been poured. They must be watertight and leak proof.

4. Secondary Container: A plastic zip lock biohazard bag or rigid plastic container with a tight sealing lid. They must be watertight and leak proof.

5. Shipping Manifest: An Excel spreadsheet is available to each CBOC on the Service Drive for the Laboratory under CBOC-Evening Shift Manifest. CBOC employees that do not access to the Laboratory Service drive have a link created for their desktop to scan in the list of lab specimens being transported from the Community Based Outpatient Clinic to the Little Rock Laboratory. Each barcoded sample to be transported to the Little Rock VA laboratory should be barcoded into the SHIPPED column of manifest using a barcode scanner. The UID number for the scanned specimen will be listed. After each specimen is scanned, the daily manifest is saved as the date of shipment in a folder for the appropriate CBOC listed under the CBOC-Evening Shift Manifest.

All fresh, unfixed human biological materials are considered specimens NOTE: Specimen tubes that are being prepared for transport should not be filled more than seven-eighths (7/8) full. If additional specimen amount is required for a particular test analysis, multiple tubes that are properly labeled should be used. Requisitions and any th

Street, Little Rock, AR 72205

Primary Approver: Kim Rose, Lab Manager other paperwork accompanying specimens must be separated from the specimen container by a fluid proof barrier. If such separation is not achieved, paperwork must be handled as though it is contaminated.

Procedure:

Transport of the patient specimens is performed by the Crosstown Courier Service from the Community Based Outpatient Clinic to the CAVHS Little Rock laboratory:

Specimens that are transported to the Little Rock Laboratory must be monitored for extreme variations in temperature. The temperature is checked by evening shift laboratory personnel at the CAVHS Little Rock laboratory and recorded on the electronic manifest for each shipment. The temperature of the specimens should be within the range of 2° to 26 ° C.

Specimens with temperatures >26° C and < 31°C will be evaluated for testing. Specimens >31°C will be rejected. Frozen specimens must be transported with frozen ice blocks.

1. Store patient samples appropriately for pick up by the courier. Specimens should be stored in the CBOC laboratory refrigerators until pickup by the courier service unless specified in specimen instructions (ex: frozen, or room temperature).

2. A manifest will be prepared by using a barcode scanner to scan the barcodes of each sample into the electronic manifest Excel spreadsheet for the appropriate CBOC. The UID number for each specimen will be displayed on the manifest.

Each CBOC has a folder listed on the Laboratory Service drive under CBOC- Evening Shift Manifest. The total number of samples included in each shipment will be displayed on the electronic manifest under the SHIPPED column after scanning is complete. Any additional comments regarding the shipped specimens (FROZEN, ROOM TEMPERATURE, PAP SPECIMEN, etc.) can be noted in the COMMENT section of the electronic manifest.

3. Once the scanning of all samples to be transported to the LR Laboratory is complete, place primary specimen containers (plastic tubes) into a specimen bag. Seal the bag and place into the leak proof plastic container. Place the container into the specimen transport bag, place one to two ice packs around the leak proof plastic container inside the transport bag. Lock the bag using the locks provided by CAVHS to protect patient information. All CBOC personnel and the evening shift personnel at the LR laboratory have keys to unlock the courier bag locks.

4. The courier service shall take responsibility for actual transport conditions and the courier bag in which the primary and secondary containers are placed.

th

Street, Little Rock, AR 72205

Primary Approver: Kim Rose, Lab Manager

5. Upon arrival at the CAVHS Little Rock laboratory, the evening shift laboratory personnel will receive in the specimens from the CBOCs. After unlocking the specimen transport bag, the samples will be checked with a laser thermometer for acceptable transport temperatures, (see above) removed from the specimen transport bags, and scanned with a barcode scanner into Excel spreadsheets (CBOC-Evening Shift Manifest) on the S:drive for the laboratory.

The temperature of the specimen shipment, the status of the security of the shipment (locked or not locked) and the initials of the laboratory staff processing the CBOC specimens will be noted on the electronic manifest for each CBOC as it is processed. The evening shift will open up the folder for the appropriate CBOC in the Laboratory Service drive under CBOC-Evening Shift Manifest. The tech will locate the current date shipment manifest, scan each sample into the RECEIVE column on the spreadsheet. As each specimen in scanned in the RECEIVE column, it will be removed automatically from the SHIP column. If a specimen is missing from the shipment, it will be listed in NOT RECEIVED column on the spreadsheet. If an additional specimen is received in the shipment (a specimen that was not scanned into the manifest by the CBOC staff) it will be listed in the NOT SCANNED column of the manifest after being scanned by the evening shift. The specimens listed in NOT RECEIVED and NOT SCANNED should be investigated for any discrepancies between the shipping location and the receiving location.

6. The courier service is responsible for training their couriers in the transport of biohazard materials.

7. The courier service will provide documentation that the training issues have been addressed.

PATIENT CONFIDENTIALITY

This department is required to follow all patient and privacy release of information policies as established in MCM 136-4 “Privacy and Release of Information”.