DEPARTMENT OF PATHOLOGY HACKENSACK UNIVERSITY MEDICAL ...

DEPARTMENT OF PATHOLOGY HACKENSACK UNIVERSITY MEDICAL CENTER

30 PROSPECT AVENUE, HACKENSACK, NJ 07601 and

HACKENSACK UNIVERSITY MEDICAL CENTER AT PASCACK VALLEY

250 OLD HOOK ROAD, WESTWOOD, NJ 07675

MANUAL OF LABORATORY SERVICES

The procedures outlined in this manual will be followed unless a different procedure is specifically requested by the physician. A Pathologist must be contacted to approve any such deviation from standard protocol. These test reference ranges are valid as of the date of this revision. New test methodologies and instruments within the department may result in changes to these ranges. All patient reports are released from the department with current reference ranges on the report. Always refer to the patient report for the most updated reference range for a procedure.

2012 Revision

Ciaran M. Mannion, MD Chair, Department of Pathology and Laboratory Director

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LABORATORY SERVICES MANUAL DEPARTMENT OF PATHOLOGY

TABLE OF CONTENTS

TOPIC I. GENERAL INFORMATION A. Hours B. Location C. Telephone Directory

PAGE

5 5 5

II. TEST REQUESTS/COLLECTION OF SPECIMENS

A. Ordering Laboratory Tests

6

B. Specimen Collection and transport

7

Collections Sent Via Pneumatic Tube

9

Diagnostic Technician Beeper Distribution

11

C. Unsatisfactory/Sub-Optimal Specimen Policy

12

D. Routine Procedures

12

E. Timed Requests/Timed Collections.

13

F. Stat Procedures/ Draw Stats

14

Ordering Stat Procedures

14

Stat Procedure List

14

G. New Admissions

16

H. Pre-Admission Testing (PAT)

16

I. Pre-Operative Requests (Pre-Ops)

16

J. Point-of-Care Testing

17

K. Reference Laboratory Testing

17

L. HackensackUMC at Pascack Valley Testing

17

III. REPORTING RESULTS.

A. Turn Around Time

18

B. Availability of Laboratory Results

19

C. Critical Values Policy

19

Critical Value Lists (Adult and Children/Newborn)

23

IV. BLOOD BANK /TRANSFUSION SERVICE

25

A. Ordering Blood

26

B. Specimen Collection and Labeling

26

C. Trauma or Down time Numbers

27

D. Blood Requests for Surgical Procedures

27

E. Antibodies

27

F. Emergency Blood Transfusion Orders

27

G. Administration of Blood Products

28

H. Transfusion Reactions

29

I. Releasing Blood Products

29

V. CYTOLOGY SPECIMENS A. Body Cavity Fluid Collection B. Breast Smear/Nipple Discharge Collection C. Cerebrospinal Fluid Specimen Collection D. Colonic Brushing Specimen E. Direct Scraping Collection (Skin and Mouth) F. Esophageal and Gastric Brushing Collection G. Fine Needle Aspiration Collection H. Pap Smear Specimen Collection I. Respiratory Specimen Collection J. Sputum Specimen Collection K. Urine Specimen Collection L. Pelvic Washings M. Vitreous Fluid

VI. MICROBIOLOGY SPECIMENS A. Blood Cultures B. Cultures For Routine Bacteria

Body Fluids Catheters. Cerebrospinal fluid (CSF) Ear Eye G.C. Culture Genital Lower Respiratory Tract Nasopharyngeal Stool Throat Urine Wound C. Anaerobe Specimen Collection and Transport D. Smear For General Bacterial Stain E. Fungal Culture F. Fungal Smear G. T.B. Culture (AFB) H. Intestinal Parasites I. Blood Smears For Parasites J. Cryptosporidium K. Pinworm Prep L. Trichomonas

VII. MOLECULAR PATHOLOGY TESTING A. Monitoring Bone Marrow Transplantation B. Molecular Coagulation Panel

3

29 30 30 31 31 31 32 32 34 35 35 36 37

37 39 39 39 40 40 41 41 41 42 43 44 45 46 47 47 50 50 51 51 52 53 53 54 54

54 55

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C. B & T Cell Gene Rearrangement

55

D. BCR-ABL PCR

55

E. BCR ABL FISH

56

F. PML-RARA FISH

56

G. PML-RAR PCR

56

H. C-MYC FISH

56

I. 11-14 Translocation, FISH

57

J. T(14-18), FISH

57

K. Bordetella pertussis/para pertussis PCR

57

L. Mycobacterium tuberculosis (MTB) PCR

58

M. 16S rDNA sequencing for bacterial detection/identification

58

N. HER2/Neu gene amplification FISH

58

O. K-RAS Gene Mutation

58

VIII. SURGICAL PATHOLOGY SPECIMENS

59

1. Routine Histopathology Specimens

59

2. Histopathology Specimens Requiring Special Handling

59

3. Specimens Exempted from mandatory submission to

61

Pathology

4. Specimens that can be Ordered as "Gross Examination Only"

62

IX. PATIENT REQUESTS FOR LAB SPECIMENS

62

X. REFLEXIVE TESTING

63

XI. PEDIATRIC REFERENCE RANGES

66

X. ALPHABETICAL TEST LISTING ? starts on page

75

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I. GENERAL INFORMATION

A. HOURS

Hackensack campus: Mon-Fri: 7AM - 3PM FULL SERVICE 3PM - 7AM STAT SERVICE and selective routine testing.* Sat/Sun/Holidays: ALL SHIFTS - STAT SERVICE and selective routine testing.* (Refer to alphabetic listing of tests, Weekends/Holiday for test availability) * Routine testing is dependent on the Stat workload and staffing of the Department.

HackensackUMC at Pascack Valley - Westwood campus: The Laboratory at the Westwood campus provides 24/7 STAT SERVICE to the Satellite ED for a specific menu of tests (see pages 17-18). Other tests collected at this site will be forwarded to the Hackensack campus for analysis. Out-patient specimen collection is available Monday-Saturday, 7 AM ? 7 PM.

B. LOCATION

Hackensack campus: The Main Laboratory and the Stat Laboratory of the Department of Pathology are located on the first floor, East and West Pavilion Building. Westwood campus: The Laboratory at the North Campus is located on the first floor of the main building, just off the Entrance Lobby.

C. TELEPHONE DIRECTORY

Main Laboratory Number (Hackensack campus) 551-996-4860

Anatomical Pathology/Cytology Reports

551-996-4808

Blood Bank

551-996-4813

Blood Donor Room

551-996-4818 and 4819

Charting

551-996-4812

Chemistry

551-996-4862

Cytology

551-996-4852

Diagnostic Technicians Office/Phlebotomy (5 Main, Room 5645)

551-996-4829

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