Ingalls Hospital



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|Ingalls Memorial Hospital |

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|Laboratory |Section |General |Policy |

| | |1/17 |

|Reviewed By |Marilyn Nelson, Director, Laboratory and Cardiac Services | |

| |Drusilla Brewer, Supervisor, Support Services | |

| |Lori Jones, Supervisor, Pathology | |

| |Suzan Al Rafati, Supervisor, Microbiology | |

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|Revised By |Marilyn Nelson, Director, Laboratory and Cardiac Services |1/17 |

| |Drusilla Brewer, Supervisor, Support Services | |

| |Lori Jones, Supervisor, Pathology | |

| |Suzan Al Rafati, Supervisor, Microbiology | |

|Approved By |Enric Solans, M.D., Chairman, Pathology and Laboratory Services |1/17 |

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|Title |Specimen Collection |Pages |20 |

COLLECTION OF SPECIMENS: This policy applies to all Ingalls Hospital staff and Ingalls FCC Staff who perform and/or evaluate or have demonstrated competency for specimen collection.

1. Early AM specimens will be collected seven days a week.

2. Clinical Laboratory Associates (CLA’s), ED Techs, OB Techs and RN’s (Nurse draw) will be responsible for primary collection of specimens.

3. Patient's identification armband must be checked before drawing specimen to confirm name, MR# and date of birth. (a handheld device may be used to confirm this information) Patient should be asked to verbally state their name if at all possible. A visual assessment of the patient must be made to confirm that information on band is correct. If the patient has no armband, an armband must be placed on patient prior to specimen collection.

A. For LTC Outreach patients: Patient’s identification armband must be checked before drawing specimen to confirm name, and date of birth. Patient should be asked to verbally state their name and date of birth if at all possible. A visual assessment of the patient must be made to confirm that information on band and requisition is correct. If the patient has no armband or cannot verbally or clearly identify themselves, a caregiver employed by the facility must identify the patient. Documentation, including a signature of the caregiver identifying the patient, must be recorded on the requisition prior to specimen collection.

4. All specimens must be labeled with the computer label, chart label, handheld label or manually written, after the specimen is drawn and before leaving the bedside. Labeled specimen must be rechecked against patient armband prior to leaving bedside. Label must include collection date, time and initials of phlebotomist, along with name, MR# and date of birth of patient.

5. Make no more than two attempts to obtain specimen. A finger stick may also be performed to collect specimens when minimum volumes can be used for testing purposes. If it is determined that there are no acceptable sites for draw in a patient’s arm or hand, specimens may be drawn from their foot or ankle if physician permits and order is documented.

6. Notify the nursing station when collections are unable to be completed.

7. Use "alcohol-wipe" and sterile gauze to prepare the venipuncture site, except for alcohol and blood culture specimens.

8. STANDARD PRECAUTIONS are to be used with ALL patients.

9. Observe proper technique with isolation patients.

10. Use PVP Iodine solution for alcohol specimens in lieu of "alcohol-wipe”. Do not use a ChloraPrep One-Step Frepp Applicator kit for alcohol, as this cleanser contains alcohol.

11. Use ChloraPrep One-Step Frepp Applicator kit for Blood culture specimens in lieu of “alcohol-wipe”. See below for full Blood Culture collection procedure.

12. Minimum specimen requirements are placed on collection labels to minimize unnecessary blood draw volumes. Please consult Policy on Hospital Intranet under General Laboratory (Blood Collection Vacutainer Tubes) if unsure of what volume of blood or type of tube to draw for specimen collection.

13. To perform the venipuncture: Secure tourniquet around the patients arm. Do NOT leave tourniquet secured for longer than one minute. If the tourniquet is removed and to be reapplied, two minutes must pass before reapplying the tourniquet. This will help to prevent hemoconcentration.

14. Select the appropriate vein by palpating. Veins will be elastic and have a spongy or bouncy feel.

15. Cleanse the site you have chosen with alcohol using a circular motion. Look at the pad and re-cleanse if the pad has become visibly soiled during the first cleaning.

16. The area must be allowed to AIR DRY. Do not blow, wave or wipe the area dry. It must air dry. Air drying of the alcohol on the skin is essential in cleansing the site. Prematurely drying the site will inhibit the cleansing action of the alcohol. NOTE: Leaving area moist can cause hemolysis of specimen.

17. Secure the needle into needle holder. Rotate until firmly seated. Insert tube into the holder. Advance no further than the guideline on the holder. Remove needle sheath and rotate orange needle protection device away from needle bevel to desired position prior to stick.

18. Using opposite thumb, anchor vein and insert needle at a 15-30 degree angle. The vein is entered with the bevel of the needle upward. Anchor the vein with the thumb, wrapping fingers around the back of the patient’s arm in an “L” hold.

19. The collection tube will be loose within the needle holder. Push the tube in as far as it will go keeping the needle holder as still as possible. The tube should be held in the needle holder with gentle pressure to keep the tube fully engaged to ensure correct fill. The tube should be filled until the vacuum is exhausted and the blood flow ceases, to ensure a correct fill. Do not overfill.

20. Recommended order of draw:

a. Blood Culture tube (Yellow SPS tubes)

b. Blue top Citrate tubes

c. Non-additive tube (Red top without gel separator)

d. SST Gel separator (gold or red clot activator tube)

e. Green top Heparin plain and plasma separator tubes

f. EDTA Lavender and Pink Blood Bank tubes

g. NOTE: If only a Blue top tube is needed, please draw an additional blue tube if drawing the patient with a winged infusion set (butterfly). This discard tube is needed to avoid air space in the tubing entering the Blue top tube. This will ensure correct fill. No discard tube is needed if using a needle and holder.

21. After each tube is drawn, gently invert the tube at least 8-10 times. After tube(s) have filled, release the tourniquet. Tourniquets should not be left on for more than one minute. Hemoconcentration may occur if the tourniquet is left on for more than one minute.

22. Do not exit site before removing last tube from needle holder assembly. The tube must be disengaged and the tourniquet removed before removing the needle from the patient’s arm. This will prevent hematoma formation.

23. Engage safety device over needle, using one-handed technique, by pressing the sheath against a flat surface.

24. Place a clean gauze sponge over the venipuncture site and apply pressure until bleeding has stopped. After the bleeding has fully stopped, apply a bandage to the site appropriate to the patient’s needs.

25. Label tubes before leaving patients bedside with: *

• Full name of patient

• Date

• Date of birth

• Time

• 8 digit MR#

• Initials of person who drew specimen

*Note: For Nursing Home and Outreach patients, the minimum is first and last name and Date of Birth.

26. Labeled specimens must be rechecked against patient armband prior to leaving bedside.

27. Barcode labels should be placed over the manufacturer’s label, vertically on the tube so as not to obscure view of specimen.

28. Transport tubes to the Laboratory as soon as possible using appropriate biohazard transport bags. Dispose of used needle/safety device in Sharps Container and contaminated materials and supplies in designated biohazard containers. See hospital policy "Transport of Patient Specimens to Laboratory by Patient Care Services Personnel".

a. **Note: It is strictly prohibited to recap, bend or break needles, or remove needles from disposable syringes**

29. If phlebotomy is interrupted at anytime prior to completion of Step #19, specimen must be discarded. Restart procedure at Step #3.

COLLECTION INSTRUCTIONS FOR BLOOD CULTURES

Blood should be collected as soon as possible after the onset of fever or chills or whenever serious infection is suspected. Sets of blood cultures should be drawn at intervals at least 15 minutes apart due to the intermittent nature of most bacteremia. However, the ideal time interval between blood cultures has not been established. Blood cultures should be drawn before antibiotic therapy whenever possible. Each peripheral blood culture specimen should be obtained by a separate venipuncture stick using sterile technique.

Blood Volume recommendations:

1. Adults and Children ≥ 13 years old: 15-20 ml per blood culture venipuncture

2. Children 12 years and younger: 1-10 ml per blood culture venipuncture

Blood Collection:

Blood should be collected by venipuncture of peripheral veins or intravascular access devices, such as ports or catheters. Strict aseptic technique should be used and Standard Precautions observed.

A. Blood Culture Collection (Direct Inoculation of bottles via venipuncture)

1. Identify patient

2. Choose appropriate vein

3. Assemble equipment

a. Chloraprepp One-Step FREPP Applicator

b. Butterfly collection system

c. Phlebotomy supplies

d. Blood Culture Bottle(s)

1. Adults and children 13 years and older

a. Each blood culture order should include:

i. Once aerobic bottle (blue top)

ii. One anaerobic (purple top)

iii. Each bottle is inoculated with 8-10 ml. of blood

b. If < than 10 ml. is collected, inoculate aerobic bottle only.

2. Children 12 years and younger

a. Each blood culture order should include:

i. One aerobic bottle (blue top) only

3. Special Care Nursery

a. Blood volume drawn determined by physician/nurse collecting specimen.

b. Inoculate 1 pediatric (PF-yellow top) bottle

4. Disinfection of Skin

a. Remove chloraprepp One-Step FREPP Applicator from kit and hold by center handle.

b. Holding the foam surface down, pinch the handle to break ampule

c. DO NOT CONTINUE TO SQUEEZE HANDLE

d. Apply foam surface to the area to be cleansed. Depress against surface to saturate foam.

e. Clean area thoroughly for one minute and allow to completely air dry. Do not blow, wave air or wipe the area.

f. Remove plastic flip-top from blood culture bottle(s) and clean the tops with alcohol prep pads.

5. Perform venipuncture as described in step 13 of Collection of Specimens section of this policy.

6. Allow the cleanser to dry and then insert needle end of the device into vein. Insert other end into blood culture bottle.

7. Hold the blood culture bottle at a position below the patient’s arm with the bottle in an upright position.

a. Note: Monitor the direct draw process closely at all times during collection to assure proper flow is obtained and to avoid flow of the bottle contents into adapter tubing.

b. Note: Do not allow the blood culture bottle contents to touch the stopper or the end of the needle during the collection procedure.

8. Inoculate bottles as follows:

a. Adults and children 13 years and older

1. Collect 8-10 ml of blood in the aerobic bottle

2. Collect 8-10 ml of blood in the anaerobic bottle

b. Children 12 years and younger

1. Collect 1-10 ml of blood in the aerobic bottle only

9. If other tubes are being drawn at the same time for additional tests, draw the blood cultures first. Always draw the aerobic bottle of each blood culture order first in the event additional blood for the anaerobic bottle cannot be obtained and to ensure any oxygen trapped in the tubing will not be transferred to the anaerobic bottle.

10. Release the tourniquet as soon as blood starts to flow into the blood culture bottle or within 2 minutes of application.

11. Withdraw the needle from the patient’s arm, cover venipuncture site with sterile gauze pad and raise arm.

12. Dispose of used needle in sharps container, place gloves in the appropriate receptacle, and wash hands before leaving patient room.

13. Label blood culture bottles appropriately and transport to laboratory immediately.

B. Blood Culture Collection (Yellow top SPS tube(s) via Vascular Access Device)

1. Collect the following volume of blood in Yellow top SPS tubes for each culture order:

a. Adults and children 13 years and older: 2 yellow top SPS tubes (total volume of 15-20 ml)

b. Children 12 years and younger: 1 Yellow top SPS tube (total volume 1-10 ml)

2. Refer to the Blood Sampling section of the Nursing Vascular Access Device Policy and Procedure.

MICROBIOLOGY (For all specimens not listed below, please contact Microbiology at ext. 6767 for specific requirements)

All culture specimens should be transported to the lab immediately for processing

1. Routine bacterial culture (specimens other than stool)

a. Sterile container

b. Swab culturettes with liquid Amies or Stuart’s media

2. Anaerobic bacterial culture

a. Sterile Container

b. Specimens should be submitted in anaerobic transport media when possible

3. Stool Culture

a. Clean container

b. Transportation vial with Cary-Blair media

4. Fungal Cultures

a. Sterile container

b. Swabs

5. Mycobacteria Cultures (AFB)

a. Sterile Container

6. Viral Cultures

a. Sterile container

b. Sterile container with viral transport media

c. Swab in viral transport media

7. Genital Specimen for chlamydia and / or gonorrhea by amplified probe

a. Aptima Unisex Collection Swab

8. Urine Specimen for Chlamydia and / or gonorrhea by amplified probe

a. Sterile container with no preservatives

b. Aptima Urine Collection Tube

9. Specialized Microbiology Specimen

a. Contact Microbiology for specimen requirements

10. Genital specimens for HPV testing

a. Endocervical specimen in ThinPrep

11. Factor II and Factor V

a. Vacutainer with EDTA (purple top)

FASTING PROCEDURES

PLEASE NOTE: Fasting patients should be allowed a tumbler (6-8 oz.) of drinking water prior to any test if they desire it. Test results will NOT be affected. Fasting is 8-16 hours of no eating, drinking, or gum chewing. The patient may drink water or black coffee or black tea only.

Patients should fast for the following tests:

|Cholesterol |8 hours |

|Glucose (except post-prandial) |8 hours |

|High Density Lipoprotien (HDL) |8 hours |

|Lipid Profile |12 hours |

|Lipoprotien Phenotype |12 hours |

|Basic Metabolic Panel (BMP) |8 hours |

|Comprehensive Metabolic Panel (CMP) |8 hours |

|Tolerances (all, including D-Xylose) |8 hours |

CLINICAL DATA

Accurate clinical information must be obtained and documented when indicated. (e.g., maternal AFP, GFR, creatinine clearance, etc.).

PATIENT PREPARATION FOR SPECIAL TESTS

Homovanillic Acid

Aspirin may produce interfering fluorescence

Serotonin (5-Hydroxy-Indol-Acetic Acid)

Dietary restriction:

Falsely elevated values are caused by avocados, bananas, tomatoes, plums, walnuts, pineapples, eggplant, acetaminophen, and phenacetin.

Decreased values are caused by corticotropin, ethanol, imipramine, isoniazid, levodopa and methyldopa.

Vanillylmandelic Acid (VMA)

Dietary restriction: Coffee, tea, chocolate, banana, citrus fruit, vanilla containing foods and drugs (especially anti-hypertensive agents) should be restricted for three days prior to collection and during

collection.

CRITERIA FOR REJECTING SPECIMENS

1. Unlabeled specimens will be discarded. (See “special consideration for specimens from invasive procedures”).

2. Patient identification wristlet (name and number) must be checked before drawing specimen. If the patient has no armband, an armband must be placed on patient by the nursing staff following correct patient identification procedures prior to specimen collection.

3. Back-up labels may be placed on specimen, but patient name and MR# MUST also appear on the specimen.

4. All specimens must be labeled with the computer label or back-up requisition label, or hand written if a label is not available, after the specimen is drawn, and before leaving the bedside including patient name, unique identifying number i.e. MR# or date of birth (other than room number), phlebotomist’s initials and date and time of collection.

5. All specimens that are to be used in the Blood Bank must have a Secure link armband applied.

6. Grossly hemolyzed or incompletely filled evacuated tubes will not be accepted for analysis.

7. Improperly labeled specimens will be refused until corrected. (see category #1 below). Phlebotomist/nurse may make corrections and document and sign on Specimen Correction Form

8. All lab staff has authority to reject an improper specimen and request that a new one be obtained.

9. Lab will examine incoming specimen to determine if acceptable. If specimen is unsatisfactory, notify the nursing station or Clintech immediately.

Reason for Improper Specimen

Category 1:

• Specimen not properly labeled (position of label)

• Minor clerical error on specimen of requisition

Action To Be Taken: Nurse/phlebotomist must come to the laboratory to correct problem and document on Specimen Correction Form.

Category 2:

a. Quantity not sufficient (QNS)

Action To Be Taken: If quantity is not sufficient for multiple requests, i.e., fungal culture, AFB, smear and bacterial culture, call doctor and determine which type of culture has priority and request additional specimen.

Category 3:

a. Specimen in wrong container

b. Container damaged or contaminated

c. No specimen with requisition.

d. Specimen contaminated.

e. No label on specimen

f. Any reason to believe that it did not come from indicated patient

Action To Be Taken: Inform the nurse/phlebotomist that specimen cannot be processed and will be discarded. Arrange to have specimen recollected.

NOTE: All AFB specimens must be submitted in approved leak-proof containers, placed in a water tight plastic bag.

Guidelines for Testing Sub-Optimal Specimens

1. Sub-optimal specimens include, but are not limited to hemolysis, lipemia, icterus and hard-stick short draws.

2. Occasionally physicians will request testing of sub-optimal specimens. When a physician requests such testing, the following steps should be followed:

a. Explain to physician/R.N. that results may be affected by the condition of the sample and recommend collecting a new sample.

b. If the physician/R.N. insists on running a sub-optimal specimen:

1. Add a comment to the result explaining possible inaccuracy of the result due to the condition of the sample. Use Comment Code XIS.

2. Explain which condition of the sample was objectionable (e.g., hemolyzed, icteric, or lipemic specimen, etc.) and record the dialog which was held with physician/R.N. including physician’s name, date, time and notation limiting test result interpretation, such as:

a. (condition of sample) specimen. Called to physician/R.N. (name) at (time) on (date) by (tech). Possibly inaccurate result. Interpret result with caution. Suggest repeat testing if clinically indicated.

Special considerations for specimens from invasive procedures:

If a specimen is received from an invasive procedure or cannot be recollected it should be brought to a Supervisor, Director or Pathologist who will investigate and make a decision if it should be accepted. All actions will be documented on the Specimen Correction Form.

MID-STREAM URINE COLLECTION

1. Obtain specimen collection system from desk.

INSTRUCTIONS TO PATIENTS:

2. Wash hands.

3. Unscrew cap of urine specimen cup. Place cap on counter with "straw" facing upwards.

• TO AVOID CONTAMINATION, DO NOT TOUCH THE INSIDE OF CUP, CAP OR STRAW.

4. Using towelette, cleanse perineal area.

a. Females:

i. Separate the labia.

ii. Wipe inner labial folds front to back in a single motion with the towelette. Repeat with the other two towelettes.

iii. Keeping labia separated, urinate a small amount into toilet.

iv. Place specimen collection cup under the stream and fill at least ½-full with urine.

b. Males:

i. Wipe head of penis in a single motion with first towelette; repeat with other the two towelettes.

ii. If not circumcised, hold foreskin back before cleansing.

iii. Urinate a small amount into toilet.

iv. Place specimen collection cub under the stream and fill the cup at least ½-full with urine.

5. Finish voiding into toilet.

6. Replace cap on cup. Tighten cap securely. DO NOT REMOVE LABEL FROM CUP.

7. Give specimen to appropriate personnel

24- HOUR URINE COLLECTION

Special light proof collection bottles are prepared in the Chemistry section.

1. Upon arising in the morning, urinate into the toilet, emptying the bladder completely. DO NOT COLLECT THIS SAMPLE. Note the exact time and write it on the container label.

2. Collect all urine voided after this time for 24 hours in the container provided.

3. Keep the collection bottle refrigerated.

4. At exactly the same time on the following morning, void completely, and add the specimen to the collection bottle. Note the time on the label.

5. The container should be brought to the laboratory with the test requisition as soon as possible.

NOTE: All medications should be discontinued for 48-72 hours prior to starting the collection as the doctor's orders indicate. Dietary restrictions, if required, are included under the “Fasting Procedure” section and “Patient Preparation for Special Tests” Section in this policy.

COLLECTION FOR RSV TESTING

PURPOSE:

Respiratory syncytial virus (RSV) is a respiratory virus that infects the lungs and breathing passages. Most otherwise healthy people recover from RSV infection in 1 to 2 weeks. However, infection can be severe in some people, such as certain infants, young children, and older adults. RSV is the most common cause of bronchiolitis and pneumonia in children under 1 year of age in the United States. In addition, RSV is more often being recognized as an important cause of respiratory illness in older adults. RSV is most prevalent in our region from mid-November until the beginning of April although it can change from year to year. The tests performed at Ingalls Laboratory for the detection of RSV are:

1. RSV, Rapid Antigen: Rapid lateral flow EIA test performed 24 hours a day 7 days a week. Turn around time 45 minutes. Only performed on children 5 y/o submit for respiratory pathogen panel only.

The Virus Culture is the “Gold Standard” for RSV detection but is time consuming and has a longer time to detection and is a send-out test. The Rapid Antigen test is faster and easier to perform but has a lower sensitivity than the Virus Culture. A negative Rapid Antigen test does not preclude infection with RSV and should be followed up with a respiratory pathogen panel when indicated. With either test the key to highly accurate results is the proper collection, transport and processing of the patient specimen.

PROCEDURE:

Acceptable specimen types for either test are Nasopharyngeal (NP) Washing and Nasopharyngeal Swabs.

Nasopharyngeal Wash Collection

1. Using standard precautions, 1-2 cc of sterile saline is flushed into the nasal passage by using a pediatric blue bulb syringe or a sterile syringe to which thin plastic tubing has been attached. Be sure the infant/child’s head is angled back with support for neck during the flush.

2. The flushed saline should be aspirated using the bulb or syringe used to introduce the saline into the passage.

3. The wash is then transferred to a sterile plastic tube. The tube is then properly labeled with the correct patient information and immediately transported to the laboratory for processing.

Nasopharyngeal Swab (Culturette)

1. The collection device for nasopharyngeal collection is culturette consisting of a thin flexible wire with a small tightly rolled cotton tipped applicator at the end.

2. With one hand gently tilt the patients head backward and have them close their eyes for comfort.

3. Gently insert the swab and push straight-back to the nasopharynx until resistance is felt.

4. Rotate the swab gently and allow to remain for 20-30 seconds.

5. Gently remove the swab and place into transport tube included in the sterile kit.

6. Properly label the specimen with the patient’s information and specimen source and transport to the laboratory.[pic]

Procedural Notes:

Only 1-2 cc of saline is required for the flush as excess wash volume may result in decreased test performance.

Aspirates are acceptable and may be collected using bulb suction or a suction pump may be collected into a sterile Lukens tube.

Excessively bloody specimens are not acceptable as they may interfere with colorimetric test result interpretation.

Collected specimens delivered to the laboratory are processed immediately in the Microbiology department.

A negative Rapid Antigen test does not preclude infection with RSV and should be followed up with a respiratory pathogen panel when indicated.

Quality results depend on proper collection, transport and processing of the patient specimen

SPUTUM INDUCTION - PNEUMOCYSTIC CARINII PNEUMONIA (PCP)

General instructions:

1. An order from the physician for Respiratory Care to obtain a sputum specimen for Pneumocystic Carinii Pneumonia (PCP) must be obtained (the order will include the number of samples to be obtained usually 1 to 3).

2. The patient is to fast from food from midnight, if possible. Water may be ingested by the patient.

3. Prior to the beginning of the treatment the patient should brush teeth, gums, and tongue with toothpaste and rinse mouth with normal saline only.

4. Sputum for PCP must be brought to the lab for analysis on Monday through Friday, 7:00AM -11:00 AM only.

5. Sputum induction should be accomplished only on Monday through Friday between the hours of 6:30AM-10:30AM.

6. After the Respiratory Therapist obtains the sputum specimen, it must be transported immediately to the lab. Respiratory will collaborate with the Registered Nurse; if immediate transport to the lab is not possible, the Respiratory Therapist will act as back-up transport person.

NURSE DRAWS – SPECIMEN COLLECTION AND IDENTIFICATION OF CARE GIVER (BLOOD DRAWS)

Labeling or identification of specimens must occur immediately at patient bedside. Regulations require that all blood specimens obtained by physicians or nursing personnel contain the following information on the blood tube:

1. Patient name, MR # and location (A computer generated label containing patient information may be attached to the tube in lieu of handwriting this information.)

2. Date, time of specimen collection must be legibly written on the tube. Person who performed draw should write their initials on the blood tube, or write first initial and last name.

3. Specimens collected on nursing units and delivered to the Laboratory will be verified into the Laboratory computer. Laboratory staff will enter the ID of the R.N. collecting the specimen and the date and time of collection into the LIS

Documentation for Blood Draws from Venous Access Devices performed by RNs on Laboratory Outpatients:

1. Nursing personnel validated for accessing venous devices for blood draws must label the specimens as outlined above.

2. Laboratory personnel will provide necessary assistance by verifying the specimen into the LIS, entering the initials of the R.N. collecting specimen and the date and time of collection.

Laboratory Computer System Down: Protocol for Outpatient Documentation:

1. RN will identify specimen with patient name, MR #, location, date, time drawn, and his/her first initial, last name legibly printed.

2. RN will present specimen to laboratory staff. When the LIS is available, laboratory will enter initials of R.N. collecting specimen and date and time of collection into the LIS.

NURSE COLLECT SPECIMENS

1. See “Collection of Specimens”, Pages 1 - 3

2. Specimens collected by nursing, e.g. urines, stools, spinal fluids, etc., must be labeled with a floor label or a lab label. The patient identification may be manually written on the specimen and must include the patient’s full name, medical record number, initials of collector, date and time.

3. Transport specimen to the lab.

4. The CLA at the Central Processing station will verify printed labels with order in the laboratory system.

5. Staff member who collects specimen is responsible for labeling of specimen.

ISOLATION TECHNIQUE FOR VENIPUNCTURE

PURPOSE OF ISOLATION:

To prevent the spread of communicable disease from the infected patient to staff members and other patients. A communicable disease is an illness, due to a specific infectious agent or the toxic products, which arises through transmission of that agent from a reservoir to a host.

Refer to Infection Control policies for isolation.

ISOLATION UNIT:

• Usually a private room with private toilet and washing facilities.

• The door of the room must have a sign on it that states "ISOLATION" and an instruction sheet that informs everyone of the precautions that must be taken (mask, gown, needles, blood, etc.), for the type of isolation that has been designated.

• On the outside of the room is an isolation cart or a bedside stand that will contain the equipment or clothing necessary to care for the patient. If an item is missing, consult the R.N. in charge. If he/she is unable to obtain the equipment, notify your supervisor. DO NOT draw the specimen unless you have the equipment required on the isolation instruction sheet.

ENTERING THE UNIT:

1. Equipment

a. Isolation patients are identified by Patient Care staff when entering orders by a comment that will cross into the hand held phlebotomy devices.

b. Plastic "baggie" and Betaine/Acetin wipes will be kept in the top drawer of the isolation cart outside of the patient's room. Consult the RN in charge if they are not available there. The wipes shall be used to wipe the outside of the blood tubes. The wiped tube shall be placed in the baggie outside of the patient's room.

c. Open the baggie and make a cuff so that you will not have to touch the inside of the bag when closing it. Arrange the baggie so you can easily deposit the specimen inside the bag as you exit the room. The baggie DOES NOT enter the isolation unit.

d. A tourniquet shall be left in the room by the first laboratory technician who draws from the patient in isolation.

e. The only equipment that shall be taken into the isolation unit is the specimen container, necessary needles, Betaine/Acetin wipes, and a tourniquet if indicated and a separate baggie for the hand held phlebotomy device. Trays DO NOT enter the room. Phlebotomy trays should not be left on top of isolation carts while in room. Store at nurse’s station.

2. Clothing (Remove rings and wristwatch and place in your own pockets.)

a. The mask, if indicated, can be found in the bedside stand outside of the room. The metal nose brace should be away from the face and should be molded to fit closely around the bridge of the nose. BOTH TIES should be tied at the back of the head and neck. The mouth and chin should be covered and the sides of the mask must fit as close to the face as possible.

b. The gowns can also be found on the bedside stand outside of the room. They must have long sleeves. The gown MUST COVER all clothing both front and back. The waists of the gown have draw strings that may be tightened for a better fit. The ties must be at the back of the gown. Be sure to overlap the gown in the back before securing the neck and waist ties.

c. Gloves are required, and are located on the bedside stand and should be applied last, with the cuffs of the gloves covering the cuff of the gown.

LEAVING THE UNIT:

3. When you have completed the draw, wash hands, open Acetin wipe and wipe off blood tubes. Place the wiped tubes on the paper towel.

4. Remove Lattice device from baggie and discard baggie in patient’s room.

5. Pick up wiped blood tubes from clean paper towel and label with label printed from portable printer (outside of room).

6. Place labeled tube in baggie outside of the room and transport to the laboratory.

STANDARD PRECAUTIONS

See Infection Control Standard Precautions

Appropriate precautions shall be taken during handling of ALL patient specimens.

PROCEDURE FOR TRANSPORT OF SPECIMENS:

1. All specimens of blood and body fluid shall be put in a well-constructed container with a secure lid to prevent leakage during collection, handling, processing, transporting and shipping. In addition, for storage and transport and shipping outside of the facility, the container shall be labeled or color coded to denote biohazard material and have a secure lid. Care shall be taken to avoid contaminating the outside of the specimen container and the laboratory form accompanying the specimen.

2. If the outside of the specimen container is visibly contaminated with blood, the specimen container shall be placed within a second container which is labeled or color-coded and prevents leakage during storage, transport or shipping.

3. If the specimen could puncture the primary container, it shall be placed in a secondary container that is puncture resistant, prevents leakage and is labeled or color-coded.

4. All specimen collection trays or containers shall be labeled with the BIOHAZARD sign to indicate a potential biohazard requiring care and transport.

PRE ADMISSION TESTING ON SCHEDULED SURGICAL PATIENTS

1. The Medical Staff has established pre-surgical testing protocols appropriate to the types of surgery performed.

2. The Admitting Department shall contact each scheduled patient to arrange for pre-admission testing 2 to 7 days prior to admission. Orders will be initiated in the Admitting Department in accordance with the physician's pre-admit orders.

3. Upon completion of testing, reports will be transmitted to printer located in Pre-Admission Testing area, for review by the Surgical Order Nurse.

4. Any completed lab order is available via computer terminal.

SPECIMENS SENT TO REFERENCE LABORATORIES

Specialized procedures which require reagents, controls, standards or equipment not readily

available, or procedures which are ordered so infrequently that proficiency and quality

control cannot be assured, will be sent to a reference laboratory approved by the Pathologists

and approved by the Executive Committee of the Medical Staff.

Any reference laboratory selected must be accredited by the College of American Pathologists (CAP), JCAHO or be CLIA-88 certified for high complexity testing in the specialty or sub specialty. The Laboratory properly follows all requisition, collection and handling specifications of the reference laboratory.

The original report will be filed with the laboratory copy of the requisition. All work sent to reference laboratories will be reviewed by a Pathologist.

CYTOLOGY

REQUIREMENTS FOR CYTOLOGY GYNECOLOGIC SPECIMENS

1. Preferably performed between the 12th and 16th days of the menstrual cycle.

2. Contraceptives, douches or vaginal medication should be avoided for 22 hours as well as abstention from sexual intercourse the night before.

3. Sampling should include the transformation zone (squamocolumnar junction) and cervical mucosa.

4. Wood or plastic spatulas, applicators, swab, cytobrush or suction pipette may be used.

5. Water and saline are the preferred lubricants. Other lubricants may interfere with the adequacy of the results.

SPECIMEN COLLECTION OF THE THIN PREP PAP TEST

1. Insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix.

2. Press firmly against the cervix and rotate the broom in a clockwise direction five times.

3. Rinse the broom into the PreservCyt Solution vial by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. As a final step, swirl vigorously to further release material. Discard the collection device.

4. Tighten the cap of the vial so that the torque line on the cap passes the torque line on the vial.

5. Record the patient's name and Date of Birth on the vial and use patient label whenever possible.

6. Complete cytology requisition by filling in all patient information and medical history, including LMP and previous pap results.

7. Place the vial and requisition in a specimen bag for the transport to the laboratory.

FINE NEEDLE ASPIRATIONS

1. If technical assistance is requested, the cytology department should be informed at least 1 hour prior to start of procedure.

2. All materials required for preparing the slides will be provided by the Cytology Department.

3. Slides must be labeled at the time of procedure with patient’s first and last name and a second patient identifier, usually date of birth (use pencil). Unlabeled slides will be rejected.

4. Submit at least two air dried and two fixed smears. Place smears to be fixed immediately in 95% alcohol, or a spray fixative may be used.

5. The syringe is then rinsed in Cytolyt solution for later processing. Label all containers with patient name and DOB at the time of the procedure.

6. The cytology back-up requisition form must accompany the FNA smears and should include patient name, patient number, date of birth, physician, and source of specimen. Any previous history of malignancy or HIV positivity and clinical impression of attending physician and /or radiologist should be included on cytology requisition form. Also, any known/suspected pathogens or infections; i.e., TB, must be noted on the requisition.

7. If an immediate evaluation is required, this procedure should ideally be performed on weekdays and received by cytology, between the hours of 8:00 a.m. to 4:00 p.m. The specimen and back-up requisition forms are brought immediately to the Pathology Department for immediate processing and determination of adequacy.

8. If procedure is performed on weekends, or received after 4:00 PM on weekdays, it is assumed that an immediate evaluation is not required. The specimen should therefore be dropped off in the Pathology laboratory and will be prepared the following work day. If an immediate evaluation is required, contact the pathologist on call.

REQUIREMENTS FOR CYTOLOGIC EXAMINATION

1. Fluid/CSF (Cerebral Spinal Fluid)

a. Complete cytology back-up requisition. This must include patient name, patient number, date of birth, physician and source of specimen, including specific site if applicable.

b. Tear off identification label from cytology requisition form and secure it to specimen container/vial and label with patient’s name.

c. Fluid should be sent fresh. Do not add any fixative.

d. Send specimen and corresponding requisition to Pathology laboratory.

e. Fluid specimens obtained on weekends and after 4:00 PM on weekdays should be dropped off in the Laboratory. The Laboratory personnel should then place specimen in the pathology refrigerator in histology.

2. Bronchial Brushing Collection for Cytologic Examination

a. Cut off brush and put inside centrifuge tube containing 30cc of Cytolyt solution. The tube should be labeled with patient’s name and 12 digit hospital number (at least two unique patient identifiers).

b. Fixed smears may be made prior to putting brush in Cytolyt solution, if desired. Ensure fixed smears are placed in 95% alcohol immediately (alcohol and cytolyt can be obtained from the Cytology Lab). Label smears with at least two unique patient identifiers. Unlabeled slides will be rejected.

c. Send centrifuge tube and fixed smears with the completed cytology back-up requisition to the lab.

3. Tzank Smear Collection (Used for assisting in the diagnosis of herpetic lesions)

a. Tzank smears can be obtained for either alcohol fixed or air dried evaluation.

i. 95% alcohol fixed smears: Scrape ulcer base margins of freshly punctured lesion with the end of a wooden spatula and smear onto glass slides, place immediately in fixative. A spray fixative may be used.

ii. Air-dried smears: Scrape ulcer base margins of a freshly punctured lesion with the end of a wooden spatula and smear onto glass slides. Leave slides to air dry.

b. Complete back up cytology requisition specifically requesting “Please check for Herpes”.

c. Send specimen and requisition to Cytology Lab.

Note: All slides and containers must be labeled with patient name and DOB at the time of the procedure. Unlabeled slides will be rejected.

REQUESTS FOR CYTOLOGICAL EVALUATION

Glass-slides made from smears/touch imprints during surgery must be labeled with at least 2 unique patient identifiers. Fixed smears should be placed into 95% alcohol immediately for proper fixation and optimal results (a spray fixative is acceptable, but slides should be marked “fixed” so they are not processed as “air-dried”). Fluids submitted for cytological evaluation should be sent in a CYTOLYT (fixing/lysing solution) tube or an empty container (exception: Body fluids aspirated in gross amounts, such as peritoneal fluids (ascites) or pleural fluids). All specimens submitted must be labeled at time of collection with two unique identifiers accompanied by a completed cytology requisition—Form 652. Indicate the precise source, method of collection (FNA, Wang-needle, paracentesis, cyto/bronchial brush, etc.), the pre-op diagnosis and the first/last names of the physicians listed on the requisition.

LABORATORY SERVICE SURGERY

Statement:

Each patient can expect to have their surgical specimen collected properly, efficiently and protected by Operating Room Staff in collaboration with the Clinical Laboratory and Pathology.

Policy:

Tissue - Ordering

Specimens from Surgery must be properly labeled and accompanied by a paper (back-up) requisition. Each specimen container must be labeled at the time of the procedure with at least two unique identifiers, the numbered adhesive tag obtained from the back page of the requisition and patient’s first/last name are most commonly used. If there are multiple specimens from the same patient each specimen must be placed in it’s own container and marked, A, B, C… and the precise source for each must be indicated on the requisition; and each container must be labeled A, B, C... in correspondence with the requisition. When a specimen is sent from surgery to pathology for immediate evaluation it is termed IOC/Frozen Section procedure. In these cases, a Tissue requisition (660) and an IOC/Frozen Section requisition (1686) must be completed and will always accompany the specimen to be evaluated. Specimens received that have a discrepancy (info on container does not match info on requisition) will be rejected. Before specimens are sent to pathology for processing all containers must have two identifiers or more and requisitions must have:

1. Patient name and medical record number

2. Patient's DOB and gender

3. Precise source of the specimen

4. First & Last name of each physician listed (ensures report goes to right location/physician)

5. PRE-OP/Post-OP DIAGNOSIS is very important when available.

6. Date of procedure (must be on or after the date on printed pre-admission label)

Specimen inside container must be consistent with what is described on the requisition. The patient’s printed label may be applied to the requisition provided that all the above information is included on the requisition and the label is on all copies of the requisition. The date on printed labels should reflect the date of the procedure or before, but never a future date that has not occurred.

Tissue – Handling

Place tissue into the appropriate container ensuring that the specimen does not stick to transferring instrument and that transfer is successful. Specimens are ordinarily placed in 10% Formalin solution, which can be obtained from pathology. Specimen should be submerged entirely in formalin; large and or fatty tissue i.e. colon and breast should be placed in large containers and hand-filled with formalin until tissue is floating then place gauze on top. Specimens too large to be placed in formalin, i.e., limbs, may be sent fresh, tightly wrapped and labeled appropriately.

Specimens sent as FRESH (inside empty sterile container):

Specimens submitted for chromosome studies, lymphoma protocol, IOC/Frozen Sectioning and other ancillary studies (which may include, but are not limited to, Kidney stones, ureteral stones, bladder stones, gallbladder stones, common duct stones, muscle tissue, renal tissue, lymph/sentinel nodes…) are to be submitted inside an empty sterile container and labeled “fresh specimen”; when in doubt always call pathology (x5765) or send fresh. For optimal test results, a fresh specimen must never be left at room temperature for extended periods of time. If a procedure is performed after hours of operation (M – F 7:30 – 4:00, Sat. 8:00 – Noon) the specimen should be kept refrigerated until pathology reopens.

Lymph nodes, whether they are sentinel nodes or for routine examination, are to be submitted as a FRESH SPECIMEN and are NOT submitted in formalin-filled containers. The tissue is to be immediately wrapped in a saline-soaked gauze and placed in a sterile container. Contact pathology to let them know a FRESH SPECIMEN is being sent and place the container with the completed Tissue requisition (660) and a Frozen Section requisition (1686) in the service elevator (dumb-waiter

Specimens submitted for IOC/Frozen Section procedure is always sent fresh and is accompanied by a completed IOC/Frozen Section requisition (1686). Surgery will call pathology (x4330) immediately to inform them that a specimen is being sent for “frozen” or “IOC”. A pathologist will be notified immediately and a pathologist will contact the surgeon to provide results. After hours of operation surgery will call laboratory’s front office (x5783/x5784) to have the on-call pathologist paged. Frozen Section specimens are never submitted in a preservative/fixative solution. The numbered adhesive requisition tag as well as the printed patient label must be placed on the container that the specimen is sent in. If a specimen is submitted for “frozen” whereby x-ray is necessary, i.e. breast tissue, developed film should be sent along with the specimen and requisitions.

Small and tiny biopsies, i.e., scrapings, needle biopsies, polyps, etc., should be handled with extra care and caution not to squeeze, crush or rough-handle the specimen due to microscopic artifactual problems.

Miscellaneous Requisition Form 657

Foreign material, with or without possible legal implications, such as a bullet, is submitted to pathology in labeled containers with two patient identifiers. The material is identified by the laboratory, dictated and retained in accordance with hospital and accreditation requirements.

NOTE: After hours all fresh body fluids and fresh tissue should be placed inside the refrigerator by the front entrance of the lab.

Request for Clinical Procedures

Requisition Form 2111 - Immunology, Virology, Microbiology, Molecular

Requisition Form 657 - Miscellaneous

CSF and Fluid Ordering Sheet - Fluid for Cell Count / chemistry procedures

Specimens for culture and virology studies must be sent in a sterile container or on transport swabs accompanied by the appropriate requisition with the specimen source, the tests requested and names of each doctor who is to receive a copy of the report. Fluid for cell count or chemistries must be accompanied by a completed CSF and Fluid Ordering Sheet with the tests requested indicated.

COLLECTION AND TRANSPORT OF SPECIMEN FROM SUSPECTED EBOLA PATIENT

Recommendations for specimen collection by Ingalls’ staff: Any person collecting specimens from a patient with a case of suspected Ebola virus disease should wear gloves, water-resistant gowns, full face shield or goggles and masks to cover all of nose and mouth—additional PPE may be required in certain situations. Specimens should be placed in biohazard bags and walked to the laboratory. Do not send specimens through the pneumatic tube system. Please contact the Laboratory for further instructions.

BLOOD BANK

Each patient who receives blood or blood products must have a Blood Bank arm band applied prior to drawing a specimen or initiating any blood or blood product transfusions. A Blood Bank arm band with patient’s name, medical record number, date of birth, phlebotomist’s identification and date of collection is applied to the patient’s arm at the time a specimen is collected for (Type/Screen, Type & Crossmatch, Hold clot or order for Platelets, Cryo, Plasma, RhoGam). After positive identification by asking the patient to verbally verify his/her name and date of birth, the base arm-band label from the Securelink card is applied to the specimen and then the patient label is applied over the base. The specimen must be dated and initialed. All must be done before leaving the patient’s bedside. No blood sample for pretransfusion testing will be accepted into the lab without an arm-band number and will be discarded. No blood product will be issued without an arm-band number. All dated blood bank arm bands are good for three (3) days. Arm bands older than three (3) days must be removed, and a new band must be applied when a new specimen is collected.

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