S02 Attachment Twenty Four 24 Path and Lab Medicine Service Reference Manual.pdf

West Palm Beach

VAMC

Pathology

Laboratory Medicine Service

Reference Manual

Alpha-numeric code:

Lab-Gen-Pol#113-023d

Title:

P&LMS Reference Manual

Date written: 2/10/2016 Author: P. Chesnut-Via Date in Service: 2/22/2016 Computer Storage Location: U:\LAB_PATH\P&LMS Centralized Document Storage\Lab General Policy-Procedure\ Lab-Gen-Pol#113-023d P&LMS Reference Manual

Approved by Supervisor:

Signed original on file in lab office

Date:

Approved by Chief Pathologist:

Signed original on file in lab office

Date:

Rescission / Supersedes: Lab-Gen-Pol#113-023c P&LMS Reference Manual Dated: 2/10/2014

Biennial Review Reviewed by: Date:

Reviewed by: Date:

Date Removed from Service:

Attachment Twenty-Four (24)

36C24821R0092

Lab-Gen-Pol#113-023d

TABLE OF CONTENTS

Distribution and Review General/Phone Information Computer Information

Introduction CPRS Lab options Computer Frequently Asked Questions Computer Downtime Procedures

Laboratory General Test Orders Test Urgencies and Availability Phlebotomy Policies Venipuncture Procedure Fingerstick Procedure Venipuncture Procedure Blood Culture Collection Procedure Patient Identification Requisition Forms Specimen Identification Specimen Rejection Specimen Collection Feedback Specimen Transport Results Reporting Critical Values

Chemistry Hematology Microbiology Transfusion Medicine Surgical Pathology & Cytology Reference Testing Point of care Testing Critical Value Notification Critical Value Documentation

Individual Section Policies Blood Bank

Ordering Components Prospective Review Blood Consent Form Component Indication Suspected Transfusion Reaction

Chemistry Patient Challenge Testing Renal Vein Sampling 24 Hour Urine collection Therapeutic Drug monitoring

Flow Cytometry Hematology and Coagulation Microbiology Urinalysis Point of Care Testing Genetic Germline Testing Information Surgical Pathology and Cytology

Surgical Pathology Specimen Collection/Preparation Cytology Specimen Collection and Preparation Brushings (Bronchial, Esophageal, GI, Common Bile Duct Bronchial Washings/Lavage Sputum Cytology Urine Cytology

TABLE OF CONTENTS

GYN Cytology Fine Needle Aspirate Cytology Corneal and Conjunctival Scraping Tzanck Smears Autopsy Request Information

Panel Listing ................................................................................................................ Error! Bookmark not defined.

Reflex Testing Information Alphabetical List of Tests Appendix I, Viral Culture Information Appendix II Tolerance / Challenge Test Information Alphabetical Index

Distribution and Review

The Laboratory Reference Manual is managed under document control as Lab-Gen-Pol#023 and is distributed to all inpatient wards, outpatient areas, and community based outpatient clinics. Additionally, this manual is available on the Pathology & Laboratory tab in MedForms manager from all sites connected to the VAMC computer system. Click on the FORMS icon, and then click on the Pathology/ Lab tab, the volume is titled LABORATORY REFERENCE MANUAL. Once you have opened the document, you will be able to follow links in the table of contents to the appropriate page in the manual by clicking on the page number.

Effective with the August 2004 revision, the manual has undergone annual review, changed to biennial effective in 2015.

The review verifies that all aspects of the manual have been reviewed and are current. If no changes are made, the signature documenting this review will be maintained in the original document in the Pathology & Laboratory Medicine Service office. If any changes are made, all paper copies and the electronic copy on the MedForms Manager will be replaced with the updated version and this update is communicated to all staff via the electronic mail.

The Chief, Pathology & Laboratory Medicine Service has delegated the responsibility for annual review to the Manager, Pathology & Laboratory Medicine Service. The Chief, Pathology & Laboratory Medicine Service retains the responsibility of reviewing of all changes prior to implementation.

GENERAL/PHONE INFORMATION

The Laboratory Service is located on the fourth floor, east wing of the main hospital building.

Hours of Operation

Clinical Laboratory: daily, 24 hours Anatomic Pathology (Surgical Pathology, Cytology and Autopsy):

Mon - Fri, 0730 - 1630

If a technical problem occurs with the laboratory, you are asked to contact the appropriate section or section supervisor. In addition, a staff pathologist is available at all times for problems or consultations.

Pathology staff may be contacted from 0800 - 1630 on weekdays at extension 6822. On weekends and evenings, the "on call" pathologist's pager number is availa

Telephone and Room numbers:

Room # Phone Service Chief, S. Sridhar, MD. ..................................................... 4A-112 Secretary to the Chief ................................................................... 4A-110 Transcription/ Surgical Pathology support ................................... 4A-110 Laboratory Manager, Peggy Chesnut-Via .................................... 4A-116

Evening / Night calls ................................................................... 4A-201 Shift Supervisor, Frank Mandarano ............................................. 4A-201

Accessioning/Specimen Receiving .............................................. 4A-205 ......................... 6305/6306 Add-on tests requests ................................................................... 4A-205 ......................... 6305/6306 Supervisor, Ramon Alvarez ...................................................... 4A-203A

Chemistry General Chemistry ........................................................................ 4A-201 ......................... 5751/5657 Therapeutic Drug Monitoring ...................................................... 4A-201 Supervisor, Sally Pessagno ........................................................... 4A-201

Hematology Hematology .................................................................................. 4A-134 ......................... 6318/6321 Special Hematology/Coagulation ................................................. 4A-134 Flow Cytometry ............................................................................ 4A-207 Supervisor, Mari Maldonado ........................................................ 4A-201

Microbiology ................................................................................ 4A-136 ......................... 6315/6316 Urinalysis ..................................................................................... 4A-201 Serology .................................................................................... 4A-134A ......................... 6315/6316 Supervisor, James Fountain .......................................................... 4A-201

Immunohematology Blood Bank ................................................................................... 4A-203 ......................... 6303/6830 Viral Testing (Hepatitis/HIV) ...................................................... 4A-207 Supervisor, Ramon Alvarez ...................................................... 4A-203A

Surgical and Cytological Pathology Histology ...................................................................................... 4A-304 Cytology .................................................................................... 4A-304A Frozen Section/Grossing Room ..................................................... 4A306 Lead Histotechnologist, Heather Gallo ..................................... 4A-304B Pathologist Assistant, Jeannette Perry .......................................... 4A-138 Cytology, Hector Soto ............................................................... 4A-304A

GENERAL/PHONE INFORMATION

Cytology, Arthur Macatangay ................................................... 4A-304A

Laboratory Program Coordinators Point of Care Testing, Susan Weir ............................................... 4A-201 ADP (Computer Support), Michi Bowman .................................. 4A-316 BCE Coord / ADP /PA, Linda Birmingham ................................. 4A-138

COMPUTER INFORMATION

INTRODUCTION

The VA Hospital Information System, often referred to as VistA, is used in all Veteran's Affairs health care facilities in conjunction with the Computerized Patient Record System (CPRS) also known as the Electronic Medical Record (EMR).

CPRS LAB OPTIONS

The Computerized Patient Record System (CPRS) is accessed through a Graphical User Interface (GUI). The VistA system is an older system, which is no longer being supported for test ordering.

TO ACCESS CPRS

Click the CPRS button on your Window toolbar (usually at bottom of screen) or via the shortcut on your desktop. Sign on using VistA access and verify codes. Patient name can be called up by using first letter of last name and SSN last four.

Once the list of patients with this limited identifier is on screen, the correct patient must be selected utilizing the full name navigate between parts of the chart, use the tabs at the bottom of the screen.

ORDER ENTRY

ere you can enter a new order. There are numerous choices of

The different order menus have been customized to serve the needs of staff in ER, Primary Care, Medicine Specialty clinics and numerous other groups. Other order menus have been designed to group certain laboratory tests together such as Blood Bank for transfusion orders, Microbiology menu for cultures, Anatomic Pathology/Cytology for tissue and cytology orders.

Once you have selected the order menu to use, click on tests or groups of tests desired. Some order sets have complete defaults for date, type of order and urgency, but all orders can have these parameters edited. Once orders are placed, all orders must be and orders are placed.

TO VIEW LABORATORY TEST RESULTS

clicking on the different options on the left of the screen. All options will display the results with the reference (normal) ranges and interpretation. This section will not include results for Blood Bank or Anatomic Pathology.

Most recent This option is most often utilized to see re t or set of inpatient laboratories. Be aware that comments associated with the results are displayed in the comment window just below the actual results window.

Cumulative This option allows you to see numerous labs grouped together by type (Hematology, Chemistry, Coagulation) with multiple sets of results on a single page for trending over time. Once you have selected Cumulative on left hand side of Labs page, you can select the appropriate timefra

Graph This is an option to graph a test single result over time and can be useful for looking at trends of results.

Microbiology Displays all culture results. Each accession is listed on screen and user can double click to see the associated report.

Anatomic Path – All reports Displays all surgical and cytology results. Each accession is listed on screen and user can double click to see the associated report.

Blood Bank Report (Blood Bank/Blood Products Information):

This report gives a summary of blood bank activity including ABO, RH results, units crossmatched / available, component requests, results of antibody screening, a list of any antibodies detected, and a summary of units that have been transfused for a patient.

Autopsy Reports Autopsy reports are only available under the Cumulative reports, to go directly to AU report, click on Autopsy in the headings area in left side of screen.

LABORATORY COMPUTER RELATED FREQUENTLY ASKED QUESTIONS (FAQs)

Q. How can I tell the status of lab orders?

A. In the Orders Tab, the status of pending indicates that the specimen is awaiting collection. A status of active indicates that the specimen is either on a collection list awaiting collection or is in lab; to determine which, you may go to the Labs Tab, where the result area for the test will change to complete and results will be displays in the Labs tab.

Q. How soon are answers available in the computer?

A. As soon as a test is completed and verified/released by the technologist or pathologist, it can be viewed at any ward/clinic location within the VAMC West Palm Beach network.

Q. What do the symbols "*" and "H" or "L" by a test result mean?

A. An asterisk * means this result is a critical value; H or L designate results above (H = high) or below (L = low) the normal range.

Q. How can I find the "reference or normal range" for a test?

A. In CPRS click on Tools, Lab Test Information

Q. How do I look up a biopsy or cytology result?

A. In CPRS, click on laboratory tab, and then click on Anatomic Pathology or Cytology in the left hand column.

Q. What if I am interested in all lab work collected during the last 24 hours?

t. You can additionally set the time frame of recent results displayed to past day, week, year etc.

Q. How can I identify a patient if I only know which ward he is located on?

A. At the Patient Selection screen in CPRS, click radio butt patients on the ward. You must still confirm patient identification is correct by confirming two identifiers prior to taking any action in the record.

Q. If I am repeatedly looking up results on one patient, can I streamline the inquiry process?

A. You can create lists of patients and save this as your default list, then you can easily select the patient. Also, you can set your default view to see all your clinic patients for the current day.

Q. In order to review all microbiology results, which option is best?

A. In the lab tab, click on Microbiology reports.

A. In CPRS, the space allotted for comments at the bottom of the screen is limited. When there are more than three comments or evaluation remarks, an up/down scroll bar appears at the right side in this lower area of the display.

Just press down to see more comments. Also remember that using the cumulative display shows all comments without the need for a scroll bar.

LABORATORY PLAN FOR COMPUTER DOWN-TIME

The following protocol has been established to accommodate computer downtime:

ORDERING / TRANSPORT OF LAB TESTS/SPECIMENS

Requesting locations will submit STAT requests on Lab-Gen-Form#100, Lab Computer Downtime Test Request Form if the system is down 5 minutes or longer. In the event that the system is down for 1 hour or longer, Lab-Gen-Form#100, Lab Computer Downtime Test Request Forms will be prepared for all other specimens by the wards and clinics. Downtime forms may be obtained from the laboratory, call ext.6305 or 6306. Orders submitted on the downtime forms are to be transported with the appropriate specimens to the Laboratory via an authorized courier, via the tube system or by using the TELECAR System which connects the first floor to the ACCESSIONING Area of the Laboratory.

REPORTING OF LAB TEST RESULTS

Lab test orders that are submitted manually (on computer downtime form) will be reported on manual paper forms and sent to ordering location via pneumatic tube or fax. After the system is back on line, Laboratory staff will enter the orders from the manual request forms generating a request for electronic signature from the requesting physician. Test results will be

Orders that are placed in the computer and received in the Lab will be fulfilled, but reported manually if the system is down for 1 hour or more after receipt of the specimen(s). After the system is back on line, the original electronic order will be accessioned and reported.

STAT results will be phoned or faxed.

EXTENDED DOWN-TIME

Protocol for re-entering lab test results into the system following periods of extended computer down-time will vary based on the length of time that the system is unavailable, workload, and staffing.

TEST ORDERS

Except during periods of computer inactivity when paper backup documents are utilized, ALL LAB TESTS must be ordered in the computer. Orders must be placed by a licensed and credentialed healthcare provider. Only authorized providers are given the keys to sign lab orders. The security settings on the CPRS system preclude anyone who does not meet these requirements from placi is performed at this time. Should there be tory requirements associated with this testing must be implemented prior to offering such testing.

All specimens must be accompanied by either paper requisitions of lab orders or by notation of order number linking to the electronic requisition. In outpatient phlebotomy clinics, patients who report for collection must have pending orders in the CPRS chart. Staff printing orders for collection will print orders that are up to one month in future and up to three months in past. Additionally, PT/INR coagulation orders are to be for a period within 2 weeks of the date of collection.

Most orders are entered by selecting a test from the lab test file. Certain tests such as those for Anatomic Pathology, Cytology and Flow Cytometry, may require the ordering clinician to fill in data to relay additional test requests or clinical information. If any of this information is unclear due to non-standard or non-specific terms, a lab staff member will contact the provider for clarification.

Verbal orders are NOT accepted by laboratory staff. If you wish to add on testing to a specimen currently in the lab, you must place the electronic order in CPRS and then call the laboratory Accessioning area at ext. 6305 or 6306 to notify them of the additional order.

TEST URGENCIES AND AVAILABILITY

LABORATORY GENERAL

Not all tests can be ordered for the highest urgency, due to their relative significance in emergency patient care, or to the limitations of laboratory staffing or facilities. Check the individual test listings for specific test availability information.

Laboratory test orders must specify a priority for test performance (Routine, ASAP, or STAT). All STAT test requests (STAT or ASAP) must be specified as such in the physician's written orders or they should be requested as routine.

°Routine Tests performed on the next Routine run which for most tests is the same day and a turnaround time of approximately 4-8 hours. Additionally, some tests are performed in batches on site with a turnaround time of 1- 5 days, and certain tests are sent to reference lab with anticipated turnaround time of 5-10 days.

°ASAP Tests performed STAT with an anticipated turnaround time of less than 2 hours.

°STAT Tests performed STAT with an anticipated turnaround time of less than 1 hour.

If the priority is required to be changed after tests are ordered in the computer you will have to reorder the test in the computer to reflect the change of urgency.

A physician may request any procedure to be performed STAT. If it is not usually available as a STAT request a phone call to the laboratory will be required, the laboratory personnel will determine if it can actually be performed STAT in-house or by another local hospital and then confer with a pathologist on duty who will contact the requesting physician.

The need to have a result paged to a physician may be relayed to the laboratory by notifying the appropriate laboratory section by phone, although due to volume this may not always be feasible.

If test reporting is to be delayed significantly from the above, the provider will be notified via phone or e-mail. For delays that affect multiple providers, a single e-mail to all medical staff may be sent.

PHLEBOTOMY POLICIES

Phlebotomy services for in-patients and patients seen in the out-patient clinics will be performed by nursing, medicine and primary care service personnel. Feedback regarding phlebotomy related problems (labeling, specimen quality) is relayed to phlebotomy staff via the nurse manager for each outpatient and inpatient area. Specimen requirements for specific tests/analytes can be found in the VistA computer system and/or this manual.

Phlebotomy volumes are reviewed periodically and updated in this manual with the goal of reducing unnecessary large collected. Reduced volume tubes have been added to stocks and should be drawn for all ICU patients, hematology/oncology patients, patients with known anemia and any patient getting frequent phlebotomy.

Prior to performing phlebotomy, it is important to verify that all necessary supplies are available and that all supplies are within the expiration date and have been stored according to manufacturer instructions. Phlebotomy supplies are stocked by staff members of the SPD service and by policy are stocked according to manufacturer instructions.

Always wear gloves and use Standard Precautions when collecting and handling blood and body fluids. Gloves must be changed and hands washed in between each patient, according to the Medical Center Memorandum, 548-99-134, Hand Hygiene Guidelines.

PROCEDURE FOR VENIPUNCTURE

Detailed instructions are contained in your Point of Care Testing Manual Materials:

1. Gloves

2. Safety blood collectors (vacutainer/needle combination with safety device)

3. Vacutainer Tubes

4. Tourniquets

5. Antiseptics (70% isopropyl alcohol is used routinely)

6. Sterile gauze and gauze pads.

7. Waste containers.

8. Adhesive bandage

Procedure:

1. Positive Identification - follow Patient Identification guidelines, using two patient identifiers as per MCM

548-99-102 to assure patient identity prior to phlebotomy.

2. Positioning Patient

Ambulatory patients -- The patient should be comfortable, seated and position his or her arm on the armrest.

Extend the arm to form a straight line from the shoulder to the wrist in a downward position to prevent reflux on blood flow back into the arm. Bring the elbow up so that the elbow is not bent when performing the actual venipuncture.

Bed patients -- a terry towel or a pillow is sometimes necessary to support the elbow. Have the patient extend the arm to form a straight line from the shoulder to the wrist in a downward position to prevent reflux or blood flowing back into the arm.

3. Re-verify paperwork, labels and tubes. Again, positive identification is crucial. Assemble all necessary supplies: gauze, 70% isopropyl alcohol, collection tubes, tourniquet, blood collection set.

4. Select a suitable vein. There are 2 main veins that are most often used. The median cubital and cephalic veins are preferred. Areas scarred from burns or intravenous drug use should be avoided. In the vein and making a selection will not be difficult. When encountering a difficult vein, sometimes applying very light pressure enables the phlebotomist to locate or palpate a vein. Tapping a vein sharply several times will cause the vein to dilate. Superficial veins are loosely fixed, look thin and will have a tendency to roll away as the needle tries to enter the vein, they also have a tendency to collapse due to the vacuum pressure and should be avoided.

Applying a warm washcloth for about 5 minutes may help to dilate the vein. Observe the following situations:

Mastectomy - Blood should be drawn from the opposite side of the mastectomy.

Hematoma - Specimens drawn from a hematoma area may cause erroneous test results. If another vein is not available the specimen is collected distal to the hematoma.

Tattoos - Avoid performing venipuncture through a tattoo site.

Intravenous therapy - Never collect a specimen from the same arm that is receiving intravenous therapy, this includes blood transfusions. If this is not possible, first check with the doctor before specimen is collected.

Never collect the blood above the I.V. site.

Other - Fistula or vascular grafts are used only after consulting nephrologist and by specially trained dialysis personnel.

5. Cleanse the venipuncture site with 70% isopropyl prep pads. Allow the area to air dry and DO NOT touch the area with any unsterile object. If the vein is palpated again, the site needs to be cleansed again.

6. Apply Tourniquet. Wrap the tourniquet around the arm 3 to 4 inches above the site. Tuck the end under the last round.

CAUTION: Do not leave tourniquet on for longer than 1 minute. Longer may cause hematomas, nerve damage and cause erroneous test results. If procedure is going to take longer, release the tourniquet and reapply after two minutes.

7. Inspect Equipment. All needle systems used for phlebotomy will include a safety system to contain the needle at the completion of the phlebotomy. Visually inspect the tip of the needle for burrs or hooks at the end of the point.

Occasionally there are defective needles. Tap all tubes to dislodge any additives from the stopper and wall. Insert the vacutainer only to the recessed guideline which does not puncture rubber stopper. Stabilize the entire assembly with one hand only. The other hand is then used for retracting and inserting other vacutainers during a multiple draw. The use of syringes should be avoided. If necessary to use a syringe, check to verify that the plunger moves with ease within the barrel of the syringe before attempting venipuncture.

8. Perform Venipuncture

a. Anchor the vein firmly both above and below the vein using the thumb and the index or middle finger.

b. At a 15 angle and with the bevel up, insert the needle into the skin following the geography of the vein.

Use a fairly fast and smooth motion. Do not hesitate once insertion has begun in order to minimize pain.

c. If using a vacutainer, it will fill automatically to the predetermined amount. AVOID - blood should not make contact with the stopper during phlebotomy. A rocking motion may cause blood to flow back into

d. The use of syringes should be avoided. If a syringe is being used, pull back slowly. AVOID forcefully pulling back on the plunger as this will cause hemolysis or collapse the vein.

e. When a good blood flow has started, release the tourniquet. Have the patient relax the fist after all blood has been drawn.

f. When collecting multiple tubes during one phlebotomy, the order of tube draw is:

1. First - blood culture bottle or tube (yellow or yellow-black top)

2. Second - coagulation tube (light blue top). If just a routine coagulation assay is the only test ordered, then a single light blue top tube may be drawn. If there is a concern regarding contamination by tissue fluids or thromboplastins, then one may draw a non-additive tube first, followed by the light blue top tube. When using a butterfly collection device and drawing a coagulation tube; prime the tubing with a discard tube prior to collection. Air in the tubing displaces the volume of blood required in the coagulation tube and may render the sample inadequate for testing.

3. Third - non-additive tube (red top without clot activator or dark blue tube with red label)

4. Last draw - additive tubes in this order:

i. Clot Activator tube (red top tube with white residue in tube)

ii. SST (red-gray or gold top). Contains a gel separator and clot activator.

iii. Sodium heparin (dark green top)

iv. PST (light green top). Contains lithium heparin anticoagulant and a gel separator.

v. EDTA (lavender top)

vi. ACDA or ACDB (pale yellow top). Contains acid citrate dextrose.

vii. Oxalate/fluoride (light gray top)

g. Once phlebotomy is complete remove the needle in a single smooth motion and engage the safety device.

h. Place a clean sterile gauze or cotton ball over the site and with-draw the needle in the same direction that was used for insertion to minimize trauma to surrounding tissue. Place a Band-Aid over the site and instruct the patient to apply pressure for several minutes. If the patient is unable to perform this task, it is the responsibility of the phlebotomist to apply pressure until bleeding has stopped.

9. Mix all tubes. INVERT GENTLY about 5 -7 times. Do not shake. Appropriately label all tubes before leaving the patient using the correct label on the correct tube.

10. Label all tubes according to the guidelines in the specimen identification section.

11. Make sure bleeding has stopped, patient is O.K. and not feeling faint. If bleeding persists longer than 5 minutes, the primary provider should be notified.

12. Follow special handling instructions, e.g., chilling the specimen, exposure to light.

13. Dispose of all contaminated material following the Medical Center Infection Control Policy. For example, observe protocol when leaving an isolation room, sharps disposal, syringes, gauze, etc.

Limitations and special considerations:

1. Do not attempt a venipuncture more than twice. Have another person try. If still unsuccessful on third attempt, side to side looking for a vein. It is very painful to the patient and destructive to surrounding tissue.

2. Gel separator tubes (SST) must not be used for Blood Bank and other special tests.

3. Always stand tubes upright to reduce hemolysis.

4. When drawing a specimen for alcohol, do NOT use alcohol to cleanse the arm (e.g., soap).

5. Indwelling Lines/Catheters -- these lines are generally flushed to reduce the risk of thrombosis with heparin.

About 5 ml of blood should be withdrawn prior to drawing a blood specimen to prevent the specimen from being diluted with the flush solution. Dialysis catheters may NOT be used/accessed except by specially trained dialysis nursing guidelines for using sterile techniques. It is not recommended that indwelling lines or catheters be used unless absolutely necessary, and especially for coagulation studies. If a coagulation test is being collected withdraw a 10 ml sample prior to sample collection.

6. Intravenous fluids including blood transfusions -- when a patient has an I.V. solution being administered draw from the opposite arm. Blood drawn from an I.V. arm will be diluted. Test results will be erroneous and misleading to the physician. If no site is available notify the charge nurse or doctor.

7. Fistulas and grafts are permanently implanted in the arms of dialysis patients. Only specially trained dialysis personnel should draw from this site if unable to use other arm.

8. Isolation - Be familiar with Medical Center Infection Control Policies before entering a patient isolation room.

FINGERSTICK PROCEDURE

Detailed instructions are contained in your Point of Care Testing Manual

Materials:

1. Gloves

2. 70% Isopropyl alcohol pads.

3. 2 x 2 sterile gauze.

4. Sterile single-use Lancet device.

Note: There are a variety of lancet devices. They all perform in a similar manner. Use according to the in this facility is the SurgiLance safety lancet.

5. As needed per test order: strips for whole blood glucose testing, i-STAT testing cartridges and necessary supplies specific to procedure.

6. Biohazard waste containers

Procedure:

1. Gather all necessary materials, recheck orders, properly identify the patient according to protocol.

2. Prepare the lancing Device: For Surgilance safety lancet

a. Remove clear plastic cap.

3. Sites for Collecting Skin-Puncture Blood

a. Palmar surface of the distal phalanx of a finger. The puncture shall be on the palmar surface of the distal phalanx and not the side or tip of the finger because the tissue on the side and tip of the finger is about half as thick as the tissue in the center of the finger. The fifth finger shall not be punctured because the tissue is considerably thinner than the tissue of the thumb, index, middle, and ring fingers.

b. The earlobe is not recommended.

4. Prepare the Finger /Skin Puncture Site

a. Cleanse the finger (site) with 70% isopropyl alcohol in a non-callused area and usually off to the side. Allow to air dry or use a sterile gauze pad to dry.

b. Hold the hand below the level of the heart when performing the puncture.

5. Perform skin puncture

a. Place the red raised platform end of the Surgilance lancet firmly ag down to activate the lancet mechanism. The needle automatically retracts after use. Gently squeeze the

c. The first drop of blood should be wiped away with a gauze pad due to excess tissue fluid in the first drop for glucose meter testing.

Do not wipe away the first drop of blood prior to filling the test cartridge for i-STAT INR testing.

d. Avoid squeezing around the puncture site. Gently stroke the hand from wrist to palm of finger to form a large drop of blood. Hard repetitive pressure (milking the finger) should be avoided. This can cause hemolysis or contamination of the specimen with tissue fluid.

e. Remove disposable gloves and dispose of the lancing device and materials in the appropriate biohazard

BLOOD CULTURE COLLECTION

Materials

1. Routine blood culture: 1 BacT/Alert aerobic bottle (blue)* 1 BacT/Alert anaerobic bottle (burgandy) *If the patient is on antibiotics FAN bottle (light green) is used in place of the aerobic (blue) bottle. It can be obtained from the Microbiology Lab.

2. Fungal culture: Routine set

3. AFB blood culture (MAI): Wampole Isolator tube (yellow tube obtained from Micro)

4. Chlorohexadine Gluconate (CHG) swabs.

5. 2-3 70% isopropyl alcohol pads

6. Angel Wing BacT/Alert Blood Collection Set

7. Vacutainer holder/ needle assembly

8. 2X2 gauze and band-aid or tape

Procedure

A. ROUTINE BLOOD CULTURE

1. Positive Identification - follow Patient identification guidelines using two patient identifiers to assure patient identity prior to phlebotomy. Assemble materials required.

2. Determine which blood culture bottles to draw based on physi set of bottles for each site ordered (X2 means 2 sets of one each, aerobic and anaerobic bottles).

3. Select venipuncture site and scrub using CHG swab. Scrub vigorously for 60 seconds. Allow to air dry.

4. If further palpation of the vein is necessary during aspiration, a sterile glove must be worn or the site must be re-scrubbed with CHG swab.

5. Remove the plastic flip top from each bottle and disinfect the rubber tops with an alcohol pad. DO NOT USE IODINE

OR BETADINE.

6. Using vacutainer holder/needle assembly with the Angel Wing BacT/Alert Blood Collection Set, aseptically insert the aerobic bottle into the Angel Wing Collection set. When the desired amount has been injected into the bottle, remove the first bottle and insert the anaerobic bottle. Fill each bottle with 5-10 ml of blood.

7. Properly label each bottle with the full name of the patient, the full SSN, date and time initials. Also note where the blood was obtained: right antecubital, A-line, etc. If using printed label, do not cover barcode label. The blood culture system must use the label as a means of identification.

8. Transport bottles immediately to the laboratory.

B. AFB AND FUNGAL BLOOD CULTURE:

1. Clean the venipuncture site as described above. Clean the top of the Isolator tube with alcohol swab. Draw blood through basic venipuncture holder and needle apparatus. Allow the Isolator tube to fill, approximately 10 ml. Label and submit to Microbiology immediately.

Limitations:

1. Care must be taken to prevent contamination of the sample during collection and inoculation into the blood culture vial.

A contaminated sample will give a positive reading, but will not indicate a relevant clinical sample.

2. Optimal recovery of isolates will be achieved by adding maximum allowed amounts of blood. Use of lower volumes or volumes in excess of allowed, may adversely affect recovery and/or detection times.

PATIENT IDENTIFICATION

All inpatients and outpatients with blood bank orders (type and crossmatch, type and screen, FFP, platelets, etc.) are required to have a West Palm Beach VA wristband fastened on their wrists (or elsewhere on their bodies, e.g., ankles).

number is embedded. Check any paper requisitions or other documents and all labels against the wristband to assure that all information matches. Two identifiers (full name, DOB) are used for inpatient phlebotomy. For blood bank orders, prior to obtaining blood for compatibility testing, the person drawing the blood will scan the patient’s wristband to identify and confirm the patient / residents full name, full date of birth and full social security number.

All other outpatients must have identity verified by asking the patient to STATE their full name and social security number (SSN). As an alternative to having patient state their SSN in public areas, the date of birth (DOB) may be used as confirmation of ID in place of the SSN. This is then checked against a document which provides both the date of birth and the SSN as the SSN will still be required on the specimen label. This information is compared to the lab order sheet and all labels to be used by person obtaining specimen(s).

Once patient identification is assured, recheck all labels to be used on the specimens to assure that EACH LABEL matches with the confirmed patient identification. Assure that any paperwork to be submitted with the specimens matches with the confirmed patient identification.

REQUISITION FORMS (including Blood or Blood Component Transfusion Standard Form 518, Electronic Tissue Exam Standard Form 515, computer-generated source documents and laboratory requisition/report forms).

(1) All requisition forms must be legible and have at least the patient's full name (including middle name or initial), social security number, ward/clinic, name of physician or authorized person ordering the test, the test(s) ordered and time and date of specimen collection (if appropriate).

(2) In addition, the electronic surgical pathology and cytology requests require additional clinical date such as clinical history, pre-op/post-op diagnosis (if applicable), name of staff physician, and the source of tissue.

(3) Blood or Blood Component Transfusion Standard Form 518 requires name of the staff physician.

SPECIMEN IDENTIFICATION

(1) All Blood Specimen tubes must be properly labeled as soon as possible after the blood has been collected from the patient. This should be done at patient’s bedside (in presence of patient for outpatients) before obtaining blood from the next patient to avoid sample mix-ups. All label information listed below is mandatory.

(a) If a preprinted label containing Full Name and Full SSN is to be used

(1) Place the label on the tube so that the left edge of the label starts just below the tube stopper and extends straight down the tube. Do not wrap the label around the tube or spiral the label on the tube.

Label should be placed vertically on the tube. The patient name will then be at the top of the tube. Do not place the label with the name at the bottom of the tube. Do not place the label over the stopper.

(2) Phlebotomist's (your) initials.

(3) Time of draw. This time of draw must also be placed on the accompanying requisition.

(b) If a label is handwritten.

With the rubber stoppers pointing to the left, PRINT CLEARLY on the blank tube label near the top edge:

(1) Patient's last name, first name, social security number

(2) Phlebotomist's (your) initials.

(3) Date and time of draw. This time of draw must also be placed on the accompanying requisition.

(2) For Blood Bank, tubes must be properly labeled as soon as possible after the blood has been collected from the patient. This should be done at patient’s bedside before obtaining blood from the next patient to avoid sample mix-ups. All label information listed below is mandatory.

(a) If a preprinted label containing Full Name and Full SSN is to be used

(1) Place the label on the tube so that the left edge of the label starts just below the tube stopper and extends straight down the tube. Label should be placed vertically on the tube. The patient name will then be at the top of the tube. Do not place the label with the name at the bottom of the tube. Do not place the label over the stopper. Do not wrap the label around the tube or spiral the label on the tube.

(2) Phlebotomist's full signature - must be legible, if signature is not legible, please print phlebotomist name also be included on the SF-518.

(3) Date & time of draw. This time of draw must also be placed on the accompanying requisition

(SF-518).

(b) If a label is handwritten.

With the rubber stoppers pointing to the left, PRINT CLEARLY on the blank tube label near the top edge:

(1) patient's full name, including middle name and/or initial, and full social security number, i.e., Duck, Daffy Fat, xxx-xx-xxxx (This information must be identical to the wristband and SF-518).

(2) Phlebotomist's full signature - must be legible, if signature is not legible, please print phlebotomist name.

(3) Date & time of draw. This time of draw and signature must also be placed on the accompanying

SF-518. The verification boxes on the SF-518 must also be signed legibly and dated.

(3) For Blood Culture specimens:

(a) If there are pre-stamped labels containing Full Name and Full SSN: Attach pre-printed lab labels over the existing vial label. Do not cover the bar-code label on the blood culture bottle. PRINT CLEARLY:

1 phlebotomist's (your) initials.

2 date and time of draw.* 3 collection site (e.g. L arm, R arm, Line)*

* This information must also be placed on the accompanying requisition.

(b) If there are no pre-stamped labels: With the rubber stoppers pointing to the right, PRINT CLEARLY on the pre-fixed blank vial label near the upper edge:

1 patient's full name and full social security number 2 phlebotomist's (your) initials.

3 date and time of draw.* 4 collection site (e.g. L arm, R arm, Line)*

* This information must also be placed on the accompanying requisition.

(4) For surgical/cytology and other specimens:

(a) All specimens collected in the operating rooms or on the ward/clinic must be properly labeled and uniquely identified so as to minimize sample mix-ups. As with blood specimens, all labeling occurs after collection, in the presence of the patient. After coll

(b) Whenever possible, use pre-printed lab labels for the patient. These labels will include:

1 patient's full name including middle name or initial

2 patient's full social security number 3 specimen source for clinical lab specimens

(c) If pre-stamped labels are not available, PRINT CLEARLY on a blank label:

1 patient's full name including middle name or initial 2 the patient's full social security number 3 specimen source (urine, stool, specific tissue/site)

(d) Affix label on the specimen container.

(e) Print the following information on label:

1 Your initials 2 Date and time of collection.

3 Source of tissue/ * specimen sites, including laterality

This information should also be placed on the accompanying requisition, ensuring all specimen sites are listed and match site designations on containers.

SPECIMEN REJECTION

There are several problems that may lead to the rejection of a specimen including improper/inadequate specimen labeling, broken or leaking collection container, broken slides etc. Rejected specimens will not be discarded until the collector or ordering physician has been contacted by laboratory personnel. Unlabeled and mislabeled specimens are not acceptable and will not be used, nor is relabeling of mislabeled blood and urine specimens allowed. In the case of specimens which are unique or irretrievable (such as a surgical pathology specimen) or which are the result of invasive procedure (such as joint fluids or CSF), the person responsible for the specimen identification will be required to correctly label and sign a statement as documentation of the identification problem. Specimen containers with external contamination will be rejected.

SPECIMEN COLLECTION FEEDBACK

When issues of significance are detected that preclude a specimen from being accepted for testing and for all mislabeled specimens, feedback is given to the nurse manager who oversees the area of specimens collection.

This is done via e-mail communication. All mislabeled specimens are documented and submitted to Quality Management Service using the Patient Incident Worksheet (PIW). Additionally, these types of unacceptable specimens as well as trends in sub-optimal specimens are documented in Quality Assurance data that is presented to the Performance Improvement Board.

SPECIMEN TRANSPORT

(1) For specimens collected on all nursing wards, outpatient clinics, ER and urgent care areas, specimen delivery to the receiving window in the 4A hallway is the responsibility of specimen collection personnel. Each biohazard specimen bag with appropriate order information provided either on the specimen label or accompanying the specimen in the form of paper requisition. These specimens must be transported in an approved well-constructed transport container with a closed, secure lid.

Insulated biohazard transport bags are provided to the trained escort staff, patient care areas, and outpatient collection areas for this use. Specimen transport for routine specimens is to occur within two hours of collection unless otherwise preserved.

(2) For specimens collected in the operating rooms and recovery area, transport of routine specimens for histology and cytology, STAT (frozen section or clinical lab test) and return of units for the Blood Bank are performed by operating room personnel utilizing the dumbwaiter or by hand delivery to room 4A304.

(3) Specimens may be transported by means of transport to 4A specimen receiving window, TELECAR system from

1A area, dumb waiter transport from OR area, and for small specimens in biohazard bags inside of bubble wrap bags, the pneumatic tube system may be used. The pneumatic tube system is not to be used for urine specimens in specimen cups, blood cultures, or any other large volume specimen, or for transporting blood components. In the event of a spill within a pneumatic tube, the tube is removed from service for decontamination. Initial decontamination is done by absorbing the spill, disinfecting with 10% bleach solution. The tube is then submitted to processing and decontamination section of patient support service for steam sterilization.

(4) Specimens transported from outlying clinics (CBOCs, PSL, and Rural Health sites) must be processed (centrifuged and/or refrigerated) to ensure specimen stability and packaged according to the following:

a. All tubes with gel barriers (light green tube, yellow top serum tube, and marbled top serum tube) require centrifugation in a swinging head centrifuge at sufficient speed to allow for adequate separation of serum or plasma from cells prior to storage and transport. Centrifugation is to occur not less than 15 minutes and not more than 2 hours after collection. A minimum centrifugation time of 10 minutes is necessary for most centrifuges. Follow manufacturer guidelines for specific centrifuge operation.

b. After centrifugation, all blood specimens for a single patient are to be packaged together using either of the two methods below (single patient bagging for sites sending 3 or less patients, rack packaging for sites who have 4 or more patient specimens).

i. Individual Patient Bag: in a single biohazard bag and refrigerated until transport, this requires tubes that do not require centrifugation be re-packaged with tubes from the same patient that were centrifuged. Care must be taken to verify two identifiers in this re-packaging process. Urine specimens must be in a separate bag. Each specimen must be submitted with appropriate order information provided either on the specimen label or accompanying the specimen in the form of paper requisition in the outer pouch of the sealed plastic bag.

ii. Rack packaging:

1. After collection of specimens for a patient, place a patient label in CBOC transport log, noting the specific rack number on the log and matching the specific row number with the row number (1-24) that the blood specimens are placed in rack.

2. Place all blood specimens in the row that corresponds to the row number on the log. If there are more than three blood specimens for a single patient, use two rows and mark this on the transport log.

3. Specimens that require centrifugation are removed from rack for centrifugation and returned to same row after centrifugation. It is critical to verify that specimens are returned to the correct row.

4.

specimen will be in the same order in the rack as on the accompanying CBOC transport log, a notation of position for each patient is noted on the transport log.

5. Other specimens such as urine specimens in cups, stool cards, or other larger liquid specimens for each patient are place individually in a separate zippered biohazard bag (with an accompanying requisition in the outer pouch if applicable).

6. The need to submit paper requisition is eliminated if all order numbers for which testing is desired are present on the transport log and the specimen containers.

Cytology requisitions must be submitted in the paper form.

7. To pack specimen in transport cooler: Place each rack into a large biohazard back designed to hold a rack or multiple specimens.

8. Place all other bagged specimens for the same transport time in a separate large biohazard bag.

9. Place each rack in the bottom of the cooler to retain in upright position and place the bagged specimens on top of beside the racked specimens. All urine specimens will now be in two bags to prevent leakage into cooler.

10. Check the transport log to verify that the rack number for each sheet is filled in, put packager initials, and the date and time packaged on the top sheet, staple all sheets for a single delivery together, and had to courier.

c. HBPC specimens may be dropped off at CBOC sites for delivery to VA West Palm Beach. When these specimens are delivered to CBOC, they should be checked prior to the HBPC staff member departure so that any labeling deviations can be addressed. These specimens are to be processed in the same manner as CBOC specimen, but can be bagged separate from the specimens in the rack. It is important to reflect these specimens on the transport log with a notation that these are HBPC specimens.

d. Transport personnel or collection site personnel place all bagged or racked specimens into the transport azard Laboratory Specimens, VAMC Laboratory West Palm Beach, FL

e. Cooler is placed into trunk of transport vehicle during transport. If cooler is to be placed in passenger compartment, it must be secured closed and secured in place in the rear seat. No back seat passengers are allowed with the cooler.

f. When transport vehicle arrives at Medical Center, deliver specimens in coolers to specimen receiving window in the 4A hallway, or directly into lab accessioning room 4A205. Laboratory personnel will unload the specimens.

g. All Deliveries from CBOCs must be accompanied following information: Date and time of packaging, initials of packaging staff member, initials of courier, and a…