S02 - Attachment 8 - Spokane Laboratory Users Guide 2013.docx

Spokane VA Medical Center 4815 N Assembly Street Spokane, WA 99205

USERS GUIDE

SPECIMEN COLLECTION

INTERIM CHIEF OF STAFF: Scott Nye, MD

PATHOLOGIST, LABORATORY DIRECTOR: Caroline Yap, MD

ACCREDITATION/LICENSURE

College of American Pathologists (24856-01)

FOREWORD

The Pathology & Laboratory Medicine Service Reference Manual has been compiled to provide information for proper submission of specimens and laboratory request forms to the Laboratory.

All changes to the specimen collection manual must be reviewed and approved by the director or designee before implementation.

A current list of test methods, including performance specifications, is available for review upon request.

APPROVED:

Scott Nye, MD, FACS DATE:

Acting Chief of Staff

Caroline Yap, MD DATE:

Laboratory Director/ Consulting Pathologist

Reviewed: DATE:

Laboratory Manager

Reviewed: _____________________ DATE: _________

Reviewed: _____________________ DATE: _________

Reviewed: _____________________ DATE: _________

5. Wounds Effusions Abscesses, Exudates,

Instructions for Specimen Collection

GENERAL INFORMATION

· In the average adult male there are approximately 5 quarts (4.75 liters) of blood, composed of about 3 quarts (2.8) liters) of plasma and 2 quarts (1.9) of cells. The cells are suspended in plasma, which is made up of water and dissolved materials, including hormones, antibodies, and enzymes that are being carried to the tissues, and cellular waste products that are being carried to the lungs and kidneys.

· The major blood cells are classified as red cells (rbc, erythrocytes), white cells (wbc, leukocytes), and platelets (thrombocytes). The red cells are delicate, round, concave bodies that contain hemoglobin, the complex chemical that transports oxygen and carbon dioxide. If the thin protective membrane that encases the fragile red cell is ruptured by rough handling of a blood specimen, dilution, exposure to contaminants, or extremes in temperature, hemoglobin escapes into the plasma in the process called hemolysis.

· The primary purpose of the white cells is to fight infection. In a healthy person, the white cells respond to minor infections by increasing in number and destroying bacteria. Platelets are small fragments of special cells that aid in blood clotting.

· Either plasma or serum may be separated from the blood cells by centrifugation. The essential difference between plasma and serum is that plasma retains fibrinogen (the clotting component) that is removed from serum.

· Serum is obtained from clotted blood that has not been mixed with an anticoagulant (a chemical that prevents the clotting of blood). This clotted blood is centrifuged, yielding serum, which contains two types of protein, albumin and globulin. Serum is collected in RED TOP tubes, GOLD TOP tubes, and MARBLE TOP tubes.

· Plasma is obtained from blood that has been mixed with an anticoagulant in the collection tube and has therefore not clotted. This mixed blood is centrifuged, yielding plasma, which contains albumin, globulin, and fibrinogen.

· There are many coagulation factors involved in clotting of blood. Several different types of anticoagulants interfere with the activity of these factors to prevent clotting. Both anticoagulants and preservatives may be required for plasma specimens. The specified anticoagulant or preservative must be used for the test procedure ordered. Blood collected with one anticoagulant is suitable for the test described, but may not be for others.

· Many of the common errors in specimen collection are due to inadequate patient instructions.

· During specimen collection, preparation, and submission, (pre-Analytical) there is a much greater possibility of CRITICAL error than during actual testing or examination of the specimen.

· One of the MOST COMMOM and EXPENSIVE errors in specimen collection is an INSUFFICIENT SAMPLE for testing.

COMMON ERRORS:

1. Failure to separate serum from cells within 30-45 minutes.

2. Failure to mix sample and anticoagulant thoroughly.

3. Failure to collect a clean-catch, midstream urine sample.

4. Failure to add proper preservative to 24hr urine container.

5. Insufficient quantity

All tubes containing anticoagulant/preservatives MUST BE allowed to FILL COMPLETELY.

The patient’s response and cooperation is partly determined by your attitude and by the degree of self-confidence you show. If you appear to be organized, skilled, and attentive, the patient is more likely to cooperate, especially when an uncomfortable collection procedure is necessary.

Patients and specimens MUST be properly identified and labeled in the presence of the patient. Identify patient with two patient identifiers (Full name & Date of Birth or Full SSN), or if patient is unconscious ask the patient’s physician, nurse, relative or friend to identify the patient.

Lab tests contribute important and often vital information about a patient’s health. Correct diagnostic and therapeutic decisions depend, in part, on the accuracy of test results. Proper patient preparation, specimen collection, and handling are essential prerequisites for accurate testing.

REMEMBER to look up collection requirements before drawing sample. MAKE THIS PART OF YOUR DAILY ROUTINE!!! Use Specimen Processing Instruction in VISTA.

NEVER!!! Draw from ABOVE an I.V. site.

Draw blood in the amount of 2.5 times the required serum amount. 10 ml RED TOP yields approximately 4 ml of serum.

DO NOT have patient clench and unclench fist. This will cause hemoconcentration (local increase of red blood cells).

You should always ask patient if he/she has eaten or drank, before you collect the blood specimen for collection of tests requiring fasting.

Lab personnel shall accept for testing only those specimens that are properly labeled with two patient identifiers (full name, and social security number, or date of birth).

SOME CAUSES FOR HEMATOMA:

1. Needle goes through vein.

2. Leaking around needle – caused by not having your hand secure – wiggling needle.

3. Leaving tourniquet on too long.

4. If pressure is not applied after removing needle.

When you see a hematoma forming IMMEDIATELY release the tourniquet, remove the needle and apply pressure.

COMMON REASONS FOR HEMOLYSIS:

1. Tubes filled too slowly.

2. Difficult veins

3. Collection problems

4. Too much pressure on syringe plunger.

5. Too small of needle.

6. Injecting blood forcefully through needle into tube.

Hemolysis occurs when the red cells are disrupted, and hemoglobin and other intracellular components spill into the serum.

Hemolysis serum is pink or red

Normal serum is a clear, light yellow, straw color.

Turbid or Lipid serum is cloudy or milky.

Lipemic serum may NOT be a true indicator of the patient’s basal physical state.

BASAL state means after a 12 to 14 hour fast.

Normal values are most frequently based on basal state collections.

Even moderate exercise can cause an increase in blood glucose, lactic acid, serum proteins, and some enzymes such as CPK.

Many commonly prescribed medications interfere with chemical determinations or alter levels.

If a patient cannot be taken off of all medications, its presence should be noted on test request form or in COMMENT SECTION of VISTA.

Tranquilizers should be discontinued 48-72 hours before and during collection of urine for steroid studies.

Drug effects usually cause False High values rather than False Low values.

PATIENT/SPECIMEN LOGIN & RECEIPT

1. Identification of the patient is the most important pre-analytical process that must adhere to the Patient Identification hospital policy.

2. Outpatients are to checking into Laboratory Blood Draw approximately 1 hour before the appointment time.

3. Patients must have at least their VA Identification Card, other picture ID, or an Armband (Inpatient only)

4. Identify the patient name to their identification. Ask DOB as secondary identifier.

5. Look up patient orders:

a. General Use Menu

b. Lookup orders for a patient: This option pulls +30days/-100days

c. Patient Name:

d. Write each order# on the manual log sheet that have not been accessioned (Only accession Oncology and Anti-Coagulation orders on date of or day before patient’s appointment)

i. Check patient appointment schedules by “Patient Inquiry” or CPRS coversheet.

e. If no orders are listed under LKUP, use “Order/Test status” option to search for orders. Begin with T+120 and go back 80 days from today’s date.

6. Generate Labels

a. Accessioning Menu

b. Accessioning tests ordered (ACT)

c. Select Order number: Enter the order number at the prompt

d. Is this the correct order? Yes// Verify name and order number

e. Collection date & time: // N for now or enter date and time

f. Do you have the entire order? Verify you have all specimen types

g. Print labels on: B101 main lab or BD L phlebotomy

h. Compare patient information to what is printed on the label/s.

IDENTIFICATION OF SPECIMENS

Order the tests in the computer that the health care provider has selected. Each test will be assigned an accession number that is printed on the barcode label and is a unique number for each specimen.

1. Specimens that are brought to the lab (i.e. pre-collected) will be processed first so that specimens can be immediately labeled negating the possibility of specimen mix-up or lost specimens.

2. When Outpatients arrive at the lab for testing, they will usually have their tests ordered in the computer. Labels are then generated by the login method on page 7. As the specimens are collected they are immediately labeled for positive identification.

REQUESTS FOR ADD-ON TESTS

Oral/telephone requests for add-on tests are to be handled in the following manner:

1. Physicians must have written order for tests prior to asking for the add-on. When they call they will provide the order number.

2. When an order for add-on test(s) is requested check the VISTA Order/Test Status to see what tests have already been ordered and then check to see if there is an adequate amount of specimen for the add-on.

3. Accession the order, making sure to enter the correct collection time.

4. Include the comment code ADDON which expands to Added to Specimen Originally Drawn at: and include the original draw time.

SPECIMEN COLLECTION

POLICY:

1. Blood drawing procedures shall be written and adhered to, to assure accurate and efficient collections of specimens from patients whether venous or arterial.

2. Phlebotomy practices will be reviewed annually to minimize blood volume. Minimum volume is noted in Laboratory Test Information Section.

3. Properly fitting gloves will be worn for touching blood and body fluids, non-intact skin of all patients, for handling items or surfaces soiled with blood and body fluids and for performing venipunctures.

4. Blood Draw Order is as follows:

a. Blood Culture Bottles

b. Coagulation tubes (light blue)

c. Non-additive tubes (red, glass)

d. Gel Separated tubes (SST, tiger/marble top, Yellow)

e. Additive tube: Heparin (green)

f. Additive tube: EDTA (lavender)

g. Additive tube: Oxalate fluoride (grey)

5. Charts for Draw Order have been posted in all Phlebotomy locations.

REGULATIONS:

1. Identify the patient with two patient identifiers (Full name, SSN or DOB). Have him/her tell you their name and last four numbers of their social security number or date of birth. Compare information to name and picture on VA or other identification card (Driver’s License or Armband attached to the patient). Compare printed labels to patient information.

2. Label tubes in the presence of the patient immediately after collection of the specimen. Confirm the name on the tubes with the patient. Never leave the outpatient bench with unlabeled tubes. When computer labels are not available, write full name, SSN, order number, Phlebotomist initials and draw times.

3. It is a standing regulation that any time a technologists or phlebotomist fails to successfully obtain a specimen after two or three attempts, that person shall call for another technologists or phlebotomist to obtain the specimen.

4. Know and follow patient isolation requirements.

5. Never lose your temper at the doctors, nurses, or patients NO MATTER how justifiable it might seem. If a misunderstanding should occur, or you feel unduly harassed, then report the incident in full to the Lab Manager.

6. Do not discuss with the patient the test results of the tests the physician has ordered.

7. STAT means immediately, although it is important to develop good speed in your collections, do NOT sacrifice good technique and accurate labeling for speed.

8. Try to be organized. Have everything organized and easily reachable. This saves time.

9. Be cheerful and talk to the patients as you perform your duties as expeditiously as possible. Be patient with them.

10. When unable to obtain blood from a patient, take immediate action. Notify nurse in charge of patient that the Lab is unable to obtain the blood, and the physician in charge will have to determine the next course of action.

11. If a patient has a tendency to faint while having blood drawn. INSIST that they lie down before phlebotomy is performed.

12. Wash hands before and after blood collecting procedure.

13. Tourniquets are to be used once, discard after use.

14. Clean exposed chair surfaces between patients.

VACUTAINER PHLEBOTOMY

Vacutainer phlebotomy is the aseptic method of collecting and transporting a blood specimen. It works on the principle of a vacuum tube for drawing blood. A standard vacutainer multiple sample needle is used for venipuncture.

PROCEDURE:

1. Ask patient to extend and straighten arm. Patients may rest arm on table of the drawing chair. If patient has a history of fainting, lay patient down in the drawing chair.

2. Apply tourniquet using a knot that can be released easily with one hand. Using your fingertips palpitate antecubital areas of the arm, feeling for the spongy area of a filled vein.

a. If you are still unable to locate a suitable vein stroke arm from wrist toward elbow.

b. Slight hitting (gently - don’t beat them) antecubital area to make veins stand out. DO NOT HAVE PATIENT CLENCH AND UNCLENCH FIST. This will cause hemoconcentration (a local increase in red blood cells).

c. A warm pack or towel may be applied to the antecubital area to allow for increased blood flow to the area to increase vein visibility.

3. After your selection of the best vein, swab site with alcohol swab (70%) except when drawing blood cultures or blood alcohol levels; blood cultures require cleaning with chloraprep, and blood alcohol levels require cleaning with soap towlettes.

4. “Fix” the vein in position. Place thumb about an inch below where the needle is to enter and press down on arm, pulling the skin towards the hand. This stretches the skin and holds the vein taut.

5. With needle at an acute angle of 30-40%, quickly penetrate the skin about ½ inch below the point where you intend to enter vein. NEVER enter the skin and vein with the needle vertical or perpendicular to the skin surface. Venipuncture discomfort is mainly due to slow skin penetration: rapid entry is less painful.

6. Immediately upon vein entry, complete puncture of tube stopper by pushing tube forward. This initiates vacuum suction. Careful to hold vacutainer hub stationary to remain in vein.

a. If multiple specimens are being drawn, remove first tube from holder after blood flow ceases and gently insert second tube and puncture stopper to initiate vacuum suction.

7. When blood flow ceases pull tube off diaphragm. When all samples have been drawn remove tourniquet, apply gauze/cotton ball to needle area and remove entire assembly from arm. IMMEDIATELY apply pressure to puncture site for approximately 2 minutes.

8. After ensuring patient has stopped bleeding, apply COBAN over gauze/cotton ball.

SYRINGE VENIPUNCTURE

1. Assemble syringe with needle.

2. Place tourniquet around patient’s arm

3. By inspection and palpation locate desired vein.

4. Cleanse skin over vein with alcohol swab, in a circular motion moving outwards.

5. “Fix” the vein in position. Place thumb about an inch below where the needle is to enter and press down on arm, pulling the skin towards the hand. This stretches the skin and holds the vein taut.

6. Holding the syringe at approximately 30º angle insert needle through skin immediately adjacent to site to be punctured. Lower syringe and move needle parallel to vein for distance of about 1 inch. Move needle toward blood vessel and directly into lumen.

7. Withdraw plunger slightly to make certain needle is in the vein. Collect blood holding syringe secure to ensure a steady pull of the plunger for an even blood draw. Pulling to fast may result in hemolysis of the red blood cells.

8. Release tourniquet. Then place a gauze/cotton ball over venipuncture site, withdraw the needle. Immediately after withdrawing apply pressure to site for approximately 2 minutes.

9. Engage safety device over needle until the needle is completely covered.

10. Remove the needle and attach the Blood Transport device to the end of the syringe.

11. Place Vacutainer tubes one at a time in the transport device. Vacutainer tubes will fill by puncturing the stopper and allowing the tube to fill. Otherwise, remove stopper from top of tube and needle from syringe (after engaging safety device) and fill tube by running blood down the side of the tube to the fill mark on the label. Do not over fill tube.

12. Discard in the “Sharp’s” container available in phlebotomy areas and on portable collection trays.

CAPILLARY PUNCTURE

1. Identify the patient by using two patient identifiers.

2. When possible, apply hot compresses or massage area to be punctured, since cold and cyanotic skin is a source of error.

3. The puncture site is rubbed well with an alcohol swab to remove dirt and epithelial debris and increase the blood flow at the site.

4. After the site is dry, make a firm quick puncture 3-4mm deep with a lancet. A deep puncture is not more painful than a superficial puncture and makes it unnecessary to repeat the procedure, so do not hesitate when making the puncture.

5. Do not squeeze the site tightly, because the liberated tissue juices dilute the blood.

6. Wipe away the first drop of blood to avoid tissue juice contamination and apply gentle pressure in a “milking” fashion to obtain a free flow of blood. Free flow of blood is essential to obtain reproducible results comparable to those of venous blood.

7. After needed blood is obtained, pressure is applied until bleeding has stopped and a band-aid is placed over the site.

8. Label capillary tube with computer label or place label on transfer tube with capillary tube inside.

BLOOD COLLECTION FROM IV LINE

1. The Laboratory personnel will not collect specimens from an IV line unless patients Physician or nurse is consulted.

2. Never shut off or interrupt any solution to obtain specimen without assistance from patients Nurse.

3. Inform Nurse of specimen needed from IV, central IV line or PIC line ask for assistance in flush after procedure.

4. Cleanse end of IV line connector with isopropyl alcohol.

5. Do not allow cleansed connector to come in touch with anything before connecting leur-lock syringe.

6. Connect 10 ml syringe to connector remove three to five (3-5) ml of blood and fluid for discard. This clears the IV line of contaminating substances (medication, or fluids).

7. Remove discard syringe, discard in sharps container. Connect new syringe for specimen.

8. Withdraw appropriate amount for specimen processing.

9. Using vacutainer syringe adapter or butterfly adapter to transfer blood into vacutainer tubes for processing. Label tubes with patient information using accession labels.

10. Notify Nurse of completion of collection so they may flush or otherwise attend to the IV line.

11. Discard all syringes in sharps container.

CRITERIA FOR SPECIMEN REJECTION

SPECIMENS COLLECTED BY THE LAB:

1. UNLABELED specimen will NOT be accepted. (All blood and urine specimens are to be labeled immediately after collection.)

2. HEMOLYZED specimen will NOT be accepted for:

a. Hemolysis will be noted on final report along with which analytes are affected.

b. Coagulation studies.

3. HEPARIN specimen will NOT be accepted for:

a. Lithium, B12, Folate and PreAlbumin.

b. Coagulation Studies.

3. CLOTTED EDTA, CITRATE or HEPARINIZED specimens for testing in Hematology and Coagulation will NOT be accepted.

4. Blue Topped Tubes (Citrate) that are under filled will not be accepted.

SPECIMENS SUBMITTED BY HOSPITAL OR PHYSICIAN’S OFFICE.

1. Each specimen must be accompanied with a request and all pertinent patient information.

2. Specimens must be labeled with patient’s name, social security number or birth date, and date/time collected. Unlabeled specimens must be rejected or the submitting personnel must be called to identify the specimen and assume the responsibility of proper identification. Correction of labels is not allowed.

3. Urine specimens submitted with incorrect preservatives are to be checked by Laboratory personnel and rejected if so advised.

a. Urines must be processed within 1 hour of collection. If the specimen is not processed within an hour after collection, store at 2-8° C. Refrigeration stability of 4 hours. If processing is delayed transfer specimens to appropriate preservative tube.

i. C&S – Boric Acid Tubes (Stable for 48 hours w/o refrigeration)

4. Specimens dated prior to date of receipt shall be checked further. Some examples: enzymes (on cells), CBC, glucose (on cells without NaFI) will be rejected.

5. Specimens incorrectly stored will not be accepted, e.g., frozen or not frozen.

6. Fecal stool older than 30 minutes for culture will be rejected unless submitted refrigerated.

7. Tissue for culture submitted in formalin or other preservatives will be rejected.

8. Sputum for culture collected in tissue paper will not be accepted. Sputum that resembles spit will be rejected.

REJECTION PROCESS:

SPECIMEN COLLECTED BY LAB PERSONNEL:

1. Recollect specimen, if possible.

2. Notify section supervisor for instructions.

3. Notify nurse, or requesting physician depending on severity of situation.

4. Enter in VISTA reason for cancellation of testing, who was notified and time.

SPECIMEN NOT COLLECTED BY LAB PERSONNEL:

1. Notify section supervisor for instructions.

2. Notify submitting nurse, or requesting physician.

3. Generate cancellation requisition or note in COMMENT section of VISTA, clearly defining problem and who was notified and date and time of notification.

Discarding or rejection of sub-optimal/unsuitable specimens will only occur after notification of the requesting physician and discussing whether testing is still appropriate after considering the condition and appropriateness of the specimen. If the physician feels that some benefit can still be derived from results obtained, a notation of the specimen condition and limitation in test results will be noted at the time of test result verification.

Laboratory will note in VISTA the reasons for rejection. Log rejection and reason on the Specimen Rejection Log located in each laboratory section. A new specimen and order must be submitted.

SPECIMEN ANALYSIS

After the specimens are accessioned they are taken to the appropriate department for analysis.

All aliquots and dilutions will be identified with a specimen label.

SEND OUT TESTING

When requisition and specimen are brought to processing area, look up requirements for specimen - specimen requirement, whether to refrigerate or freeze, etc., listed in the specimen processing or Test Description menu in the VISTA system.

Follow the reference labs guidelines for properly filling out the request form, correct labeling of specimens, proper packaging and storage.

TRANSPORT SPECIMENS TO THE LAB

Specimens collected outside of the laboratory and delivered to the lab must meet the following requirements:

1. All specimens must be placed in a tight, leak proof container.

2. The leak proof container must be properly labeled with the patients name and birth date or SSN, specimen source, health care provider, date and time of collection and collection location.

3. Each specimen must be accompanied by an approved requisition that has the following information:

a. Patient’s Name

b. Date of Birth

c. Sex

d. Ward or location of facility sending specimen

e. ID Number

f. Physician

4. The container must be in an approved labeled BIOHAZARD plastic, sealable bag, with a separate pocket for the requisition.

5. Specimens must meet the requirements in Lab’s “Spec C&P 003.02 – 014.00” procedures.

6. Specimens that require special handling procedures may require notification of the laboratory and/or rapid transport to the lab to obtain valid results.

7. Inpatient specimens may be transported to the lab by whatever means is convenient (volunteer, etc.) provided the specimen has the approved container, bag, label, and requisition.

8. Outpatient specimens are transported to the lab via contracted courier services.

a. Community Based Outreach Clinics pick up

1. Wenatchee: Mon-Fri between 3 and 4pm

2. Coeur d’Alene: Mon-Fri 3pm

b. Rural Health Clinics pick up

1. Libby: Mon-Fri 3pm

2. Sandpoint: Tue and Thru 3pm

3. Colville: Mon-Fri 4pm

4. Republic: Mon-Fri 4pm

5. Tonasket: Mon-Fri 4pm

GUIDELINES FOR OBTAINING SPECIMENS

Principle: The quality of the results produced by the Laboratory can be no better than the quality of the specimen received. In order to collect optimal specimens, it is necessary that collection procedures be tailored to the type of specimen being collected. A brief resume of specimen collection techniques follows:

1. Nasopharyngeal - A sterile flexible swab should be inserted through the anterior nares all the way to the posterior pharynx, rotated and withdrawn. Alternatively, a swab may be bent at right angles close to the bud and inserted into the nasopharynx through the oral cheeks. Place the swab in a suitable transport media and send to the laboratory.

2. Throat - Have the patient rinse their mouth with water before collection. Using a sterile swab and sterile tongue depressor if necessary, swab the posterior pharyngeal wall, tonsils (if present) and any reddened or exudative areas adjacent thereto. Avoid touching the tongue or cheeks with the swab. Collect the specimen before the patient has eaten or used antiseptic mouthwash or gargle. Place the swab in suitable transport media and send to the laboratory.

3. Sputum - Have patient rinse mouth with water prior to collection. Advise the patient of desired specimen requirements: the product of a deep cough, not saliva, phlegm, or nasal discharge. Most patients have generally more production of sputum when first arising. Do not collect the specimen after the use of an antiseptic mouthwash or gargle. In some cases where a patient is repeatedly unproductive in sputum, inhalation of sterile nebulized normal or 0.5N saline may be effective in enabling the patient to produce a suitable sputum specimen. Following inhalation treatments may also increase sputum production.

4. Urine - All urine specimens for routine Urinalysis shall be collected using “Midstream” method.

a. Midstream (not clean-catch): Advise male patients to retract foreskin, if present, and female patients to part the labia. Instruct the patient to void a stream of urine and to collect the middle portion of that stream into a clean (not necessarily sterile) container. These routine specimens will be screened for appropriateness of culture and Lab personnel will order culture if needed.

b. Clean-catch, Midstream: Advise male patients to retract foreskin, if present, and female patients to part the labia. Instruct the patient to use the cleansing betadine or other wipes two times. Instruct the patient to void a stream of urine and to collect the middle portion of that stream into a sterile container. If the patient is unable to collect the midstream portion of the urine it may be acceptable to collect the whole specimen in a sterile container. If the urine is collected in a sterile bedpan or urinal it is acceptable if the above requirements are met. However, a notation to this effect should be made on the specimen requisition and container.

Note: The method of collection of urine must always be indicated on the microbiology or cytology requisition. If the urine was obtained by cystoscopy it should be noted whether the urine came from the left or right ureter. All urine specimens should be sent to the lab immediately within one (1) hour but if there is delay they may be refrigerated for up to four (4) hours. Alternative method for stabilization of urine for culture if delay is known, collect urine in Urine C&S Transport kits supplied by the laboratory and refrigerate. Urine collected in transport tubes is appropriate for testing for 48 hours from collection for culture and 72 hours for routine urinalysis.

c. Catheterized Urine: Acceptable catheterization technique should be used. Urine after collection should be placed in a sterile container or a capped syringe. Remove urine from port nearest patient body not the collection bag. Note whether the specimen is indwelling or straight catheter on requisition.

d. Other urine specimens: may be collected through the use of a suprapubic tap or by a cystoscopy.

e. Patient Instructions: How to collect a “24-hour Urine Specimen” Your physician has asked you to provide a 24-hour urine specimen. Testing is to be performed on the specimen you provide, and your help can insure the accuracy of the tests by following these instructions:

1. Avoid alcohol beverages, vitamins and other medication (if possible) for at least 24 hours before you start collecting the specimen and during the collection period.

2. Your specimen container may have a preservative in it. Be sure that the urine is well mixed with the preservative. Do not dispose of the preservative and be sure to keep the container out of the reach of children.

3. Do not exceed your normal intake of liquids during the day before and the day of collection unless your physician gives you specific directions to do otherwise.

4. The 24-hour collection period begins when you get up in the morning to empty your bladder. Do NOT COLLLECT THIS URINE: But do record the time and date of this Voiding on the specimen container label.

5. Be sure to collect all urine – day and night for the next 24 hours. Do not throw out sample during this time. Make your final collection when you empty your bladder the next morning, approximately 24 hours from the time marked on your specimen container.

6. Keep specimen collection container cool, refrigerate or keep on ice.

7. Please call your physician for instructions if specific problems arise.

8. Return the specimen as soon as possible to the VA Medical Center Laboratory.

f. Urine Drug Screens: Collected for medical purposes only. A random urine specimen (20 ml) collected in a plastic container free from preservative is adequate. Employee drug testing (legal) requires a special procedure. Contact Laboratory for arrangements.

5. Wounds Effusions Abscesses, and Exudates, Joint Fluids ECT. - Whenever possible, if an abscess is present, a portion of its wall, as well as a syringe full of the pus should be collected for culture. If the amount of pus is minimal, the area or abscess cavity can be irrigated with bacteriostat-free saline and the fluid aspirated with a syringe. The material may be sent in a capped syringe.

6. Fecal material, Stool and rectal swabs - Stool specimens for culture must be obtained directly from the patient and not collected out of the toilet bowl. Stool must be placed in a sterile container and delivered to the lab immediately. Collection for culture and susceptibility may include a series of specimens up to 3 and may be collected at daily intervals if no pathogen is isolated on the first specimen. Specimens that cannot be delivered within one hour are to be submitted refrigerated. It is recommended that stool specimens be tested for C. difficile toxin for all patients with clinically significant diarrhea and a history of antibiotic exposure. Submit the specimen in a clean sterile container within 8 hours or 24 hours if refrigerated.

Stool specimens for occult blood should be submitted on Hemoccult Sensa II Fecal Occult Blood cards. A kit is available from SPD with mailer for outpatients.

For other stool specimens please see instructions in VISTA system or contact the laboratory.

7. Stool for Ova and Parasite - Stool for Ova and Parasite will be sent to Specialty Laboratories for processing. Collection for Ova and Parasite (O&P) detection may include a series of three or more specimens that must be collected at least daily or every other day collection. Stool for O&P may not be collected after Barium studies until the barium is cleared from the system (3-4 days), and while the patient is taking anti-diarrheal medication such as Kayopectate.

If the specimen cannot be delivered to the laboratory immediately specimens are to be placed in an Ova and Parasitology transport media.

8. Eye - Eye cultures must be taken before ophthalmic antimicrobials are used. A sterile swab should be touched carefully to the inflamed area or exudate. The swab is then placed in appropriate transport media. Deliver to the lab immediately.

9. Genital- Urethra – Vaginal - Urethral discharge may occur in both males and females. Females infected may have discharge that is less profuse and may be masked by vaginal secretions. A urogenital swab designed expressly for collection of such specimens is available in the laboratory. It includes a small rayon swab and Amies charcoal transport media. When profuse Urethral discharge is present (particularly in males) discharge may be collected without inserting the sampling device into the urethra. Separate specimens are required for Chlamydia and viral cultures and bacterial cultures. Special swabs and transport media are required and available in the laboratory.

a. Males: The swab is inserted approximately 2 cm in to the urethra and rotated gently before withdrawal. The swab is placed in the transport media and sent to the lab immediately or directly inoculated on to the appropriate media.

b. Female: The same urogenital swab as above is used. Cervical specimens are obtained after the cervix has been exposed by insertion of a speculum. The swab is inserted into the cervical canal and rotated and moved side to side for 30 seconds before removal. Care must be taken to minimize contamination of these specimens with vaginal secretions that contain great quantities of bacteria. Additional slide may be made for gram stain. Swabs should then be placed into suitable transport media and delivered to the lab immediately. Another method of vaginal culture specimen collection is by inserting the swab 2-cm into the vagina and gently rotating it before its withdrawal. Swabs should then be placed in suitable transport media and delivered to the lab immediately. Specimens collected for the identification of yeast or Trichomonas vaginalis should be collected using a swab as described. The swab should be placed in a tube containing 0.5 ml of sterile physiological saline. Direct wet mounts and cultures may be obtained from this specimen. Deliver these specimens to the lab immediately.

10. Blood Cultures

a. Blood Cultures specimens are collected by the laboratory personnel unless they are unavailable, then physicians and nurses may collect blood cultures.

b. Blood Cultures should be a minimum of two separate collections (2 sets) 30-45 minutes apart in a 24-hr period. More than 3 sets in a 24-hour period are rarely needed and will be collected only on consultation with the Laboratory.

c. Blood Cultures should be obtained prior to initiating antibiotic therapy. If this is not possible it may be helpful to draw blood immediately before administering the next dose.

d. Open the chloraprep pad or iodine solution using aseptic technique. Start from the location directly at the insertion point, and move the pad in concentric circles moving away from the central point.

e. Do not touch the pad with your glove.

f. Allow to air dry 1 minute.

g. DO NOT touch or palpate the area after cleansing.

h. Disinfecting Blood Culture Vials

1. Remove the flip-off caps from BACTEC culture vials.

2. Wipe top of each vial with a separate 70% isopropyl alcohol pad and allow to dry.

3. Do not use iodine or chloraprep to disinfect tops of vial.

i. Venipuncture of Blood Cultures

1. Avoid touching the venipuncture site. If it is necessary to touch the site after it has been cleaned, wipe your fingers with chloraprep before touching the site.

2. When using the Blood Collection Set (“butterfly”) the phlebotomist MUST carefully monitor the volume collected by using the 5 mL graduation marks on the vial label. If the volume is not monitored, the stated maximum amount collected may be exceeded. This condition may adversely create a ‘false’ positive result, due to high blood background.

3. If using a needle and syringe, typically a 20 mL syringe is used for adults. Draw 16 to 20 mL of blood for one blood culture set (aerobic and anaerobic). Aseptically inject 8 to 10 mL of specimen into each vial.

4. Continue to care for the venipuncture site following guidelines recommended in the venipuncture procedure.

5. The inoculated BacT vials should be transported as quickly as possible to the laboratory.

j. Volume of Blood Cultures

1. The volume of blood cultured is critical because the number of organisms per mL of blood in most cases of bacteremia is low, especially if the patient is on antimicrobial therapy.

Adult: 16 to 20 mL of blood per venipuncture. If it is impossible to draw the required amount, aliquot as follows:

NOTE: Optimum recovery of isolates will be achieved by adding 8 to 10 mL of blood. The use of lower or higher volumes may adversely affect recovery and/or detection times.

11. Pathology/Cytology Specimens

Pathology Tissue Specimens are collected and labeled at the time of collection (not before) with patient full name, full social security and date of birth, type of tissue and anatomical location.

Submission of specimens and tissue examination forms:

· All tissue removed for diagnostic or therapeutic purposes must be labeled and sent to the laboratory with a completed Tissue Examination Form (SF 515) (two signatures are required to document proper patient identification has been completed: physician performing the procedure and the assistant present for identification).

· Container label requirements include: Complete name of patient, complete social security number/Date of Birth, specimen type and location.

· Tissue examination forms are required to include: Complete name of patient, complete social security number, date of birth, specimen type and location must match labels on specimen containers, date of collection, name of provider, clinical history, pre & post op diagnoses, and clinic location.

· Specimens are brought directly to the Laboratory room A200.

· Small specimens are submitted in closed and labeled leak proof containers in 10% formalin unless special handling is required. See chart for special handling instructions.

Rejection of specimens:

Unacceptable specimens/requisitions include:

· Unlabeled or incompletely labeled specimen containers.

· Specimens received with incomplete SF 515.

· Requisitions are required to contain the following legible information:

· The signatures of the physician performing the procedure and the assistant present during the procedure.

· Patients full name, full social security number and date of birth

· Name of provider submitting specimen

· All specimens listed by the number on the specimen container and including the type of specimen and the area from which the specimen was removed.

· Clinical history and pre- & post-op diagnoses.

· Corrections must be made by the provider or nursing staff.

· Specimen containers must have the lid secured.

Containers and fixative:

Specimen containers and fixative are supplied by the Anatomic Pathology Section. The container lid must be secure. 10% zinc formalin is the routine fixative.

Specimen handling guidelines:

Cytology Specimen identification and forms:

All specimens use SF 515. Forms are required to include: Complete name of patient, complete social security number, date of birth, specimen type and location must match labels on specimen containers (labels with the patient's full name and the full Social Security number), name of provider, clinical history, pre & post op diagnoses, and clinic location.

All slides must be labeled in pencil on the frosted end with the patient's last name and the last four digits of the Social Security number.

Please note when submitting a specimen for both a Pap Smear and a Wet Prep two specimens should be submitted. One specimen will be sent to DMC for process and the other should be submitted to lab personnel to complete the Wet Prep.

Rejection criteria:

· Unlabeled or incompletely labeled specimens

· Specimens received without properly completed SF 515

· Improper fixation

· Delayed delivery to laboratory, with specimen deterioration

Specimen Handing and Preservation Specimens Requiring Fixation:

The only specimens requiring fixation prior to submission to the laboratory are:

· Direct smears made by the clinicians, i.e., cervical-vaginal, endometrial material.

These must be fixed immediately to avoid any drying artifact which severely limits interpretation.

· Breast Expressions - Milk breast solution into slide, fix sample to slide with Cytology spray fixative or submit slide in 95% alcohol in leak proof container. Note the color and how many drops were collected on SF 515 Non-Gyn Cytology form.

Specimens To Be Submitted Fresh:

Unfixed material must be brought to the laboratory immediately. Any delay in processing causes specimen deterioration.

Specimens must be submitted in a sterile container with a secure lid.

Respiratory tract specimen collection

OUTPATIENT SPUTUM:

Technique: Instruct the patient in producing deep cough sputum. This should be expectorated into a sterile container. If the sample cannot be submitted to the laboratory within an hour, the container should be stored in the refrigerator. The sputum should be thoroughly mixed with Cytology liquid fixative (50% alcohol and 20% Poly ethyl alcohol) by a swirling motion once received in the lab. 20 ml of sputum is an appropriate volume.

Effusions - Specimen collection Submit aliquots of fluid in 120 cc sterile specimen container with a secure lid. Do not submit the large vacuum bottle. The amount and appearance of the fluid withdrawn should be indicated on the request form.

Urine tract specimens

URINE:

Do not submit first morning urine! Approximately 50-60 ml of fresh random urine should be placed in approximately 50-60 ml of cytology fixative. Specimens obtained by catheterization and/or cystoscopy should be marked accordingly.

BLADDER WASHINGS:

Vigorously irrigate the bladder five times with the same 50 ml of saline. Place the resulting solution immediately in an equal amount of cytology fixative.

Female specimens

VAGINAL POOL OF SECRETION:

Examination of smears made of this material is helpful as an aid to detection of possible endometrial lesions.

SCRAPINGS OF VAGINAL WALL:

A smear made of scrapings from the upper lateral vaginal wall is the material needed for estimating hormone effect.

INSTRUCTIONS FOR SPECIMEN COLLETION AND

TRANSPORT FOR BACTERIOLGIC CULTURE

Blood

Exudates

when delay anticipated. (Cary Blair)

INSTRUCTIONS FOR SPECIMEN COLLETION AND

TRANSPORT FOR BACTERIOLGIC CULTURE

(2)

Men: Urethra—swab may be

Urine

hours use Urine Transport tube.

Urine

INSTRUCTIONS FOR SPECIMEN COLLETION AND

TRANSPORT FOR BACTERIOLGIC CULTURE

(3)

the laboratory must be notified when Diphtheria, pertussis, or Gonococcal infection is suspected clinically so that appropriate selective media can be inoculated.

Respiratory tract

Transtracheal Aspirate Anaerobe Transport Container Collect with sterile needle

INSTRUCTIONS FOR SPECIMEN COLLETION AND

TRANSPORT FOR BACTERIOLGIC CULTURE

(4)

Viral Isolates Viral Transport media Use special Dacron swabs and transport media.

Include source, type of infection and/or suspected virus on requisition.

Chlamydia Chlamydia Transport media Use Special Dacron swabs and Transport media. Include source, type of infection.

SPECIMEN PROCESSING

Specimens are to sit upright for approximately 15 minutes after being drawn then centrifuged for approximately 10 minutes. Tubes with anticoagulant may be spun immediately.

Occasionally a specimen will need to be aliquoted into a transfer tube. Label a transfer tube with a sample label.