Veterans Affairs
Department of Veterans AffairsMemorandumDate: 12 March 2012 From: Chief, Pathology & Laboratory Medicine Service (113)Subj: Specimen Collection ManualTo: Physicians & Dentists Laboratory Staff Nurse Coordinators Ward Unit Managers Health Care ProvidersThis manual is a guide to VAMC Fayetteville Clinical and Anatomic Pathology Services. Included are tables and descriptions of tests, reference intervals, specimen collection instructions, and selected additional information. Information may also be accessed within CPRS or VISTA at the option TEST DESCRIPTION INFORMATION.Please contact P&LMS with questions concerning testing or comments regarding this manual’s content. We welcome suggestions for future editions.Robert M. Levy, M.D.Cytology Fine Needle Aspiration Biopsy (FNAB) Collection and Submission GuidelinesPrincipleCollection methods must ensure maximum cell preservation and recovery for optimal cytologic evaluation. Proper specimen collections require that specimen integrity is maintained by proper preservative where required, sample identification and patient identification is clearly labeled on the specimen container, and the sample is properly transported to the clinical laboratory in a timely manner. The information listed below is to assist with that objective. ProcedureGeneral Consideration Safety Specimens are to be handled in accordance with VHSO Medical Center Memorandum, XX-00-14, “Universal (Standard) Procedure and Transmission Based Precautions”. Use appropriate barrier protection (such as gloves and laboratory coat or gown) when collecting or handling specimens. If splashing may occur, protective eyewear, face masks, and aprons may be necessary.Minimize direct handling of specimens in transit from the patient to the laboratory. Use plastic zip-lock biohazard bags with a separate pouch for the laboratory requisition orders.When specimens are obtained by a physician using needle aspiration, the specimen may be submitted to the laboratory in the capped syringe without the needle. Ideally, however, smears should be prepared at the patient’s bedside along with flushing of the needle/ syringe into a Thin Prep vial containing CytoLyt Solution.General guidelines for proper specimen collectionSpecimen containers must be properly labeled at the time of collection with the following information:Patient’s full namePatient’s social security numberDate and time of specimen collectionSpecimen source (anatomic site)Multiple specimens from the same source should be labeled “A”, “B”, “C”, etc., for the different collection sites used (e.g., “A. Left Thyroid nodule” and “B. Left Neck nodule”) Utilize appropriate collection devices and transport containers.Thin Prep vials: Used for flushings from the syringe/ needle during the FNAB (CytoLyt Solution). Obtain from laboratory. WARNING: PreservCyt Solution is poisonous (contains methanol) and it must never come in direct contact with the patient. Alcohol Prep wipesNeedles (22 G x1 or 22 G x 1 ? )Syringes (20 mL) Gauzes pads (2 x 2)Tape Air dried slide: Must be labeled with the patient’s last name, first initial and last four of the social security number with hard lead pencil. Slide is submitted in a slide transport container.All Fine Needle Aspiration Biopsy must be accompanied by a Standard Form 515 when sent to the laboratory for processing. The SF 515 must contain the following information:Specimen submitted by (physician name and location)Date obtainedSpecimen type (multiple specimens should be listed with corresponding letter on the individual containers)Brief clinical history Preoperative diagnosisOperative findingsPostoperative diagnosisSignature of submitting physicianPrinted name of submitting physicianTitle of submitting physicianName of patientIdentification number (SSN)GenderDate of birthEach specimen container must be placed in a biohazard bag with the requisition in the outside pocket of the bag and transported to the laboratory for processing. All specimens brought to the laboratory will be time-date stamped upon delivery. The time-date stamp should be placed on the SF 515.Fine Needle Aspiration Biopsy collected for cytological examination must be sent to the laboratory immediately after collection and processed immediately after receipt in the laboratory. If unable to process specimen immediately, the specimen is placed in the refrigerator to slow down cellular deterioration.Cell blocks will be made from submitted body fluids whenever possible. Routine stains will be performed on all specimens submitted for cytological examination. Special stains, if necessary, will be ordered by the pathologist.Specimens are received only from licensed, authorized sources such as physicians, nurse practitioners and physician assistants that are associated with the VHSO.Collection instructions for Fine Needle Aspiration Biopsy (FNAB)General considerationsFine Needle Aspiration (FNAB) is a non-invasive procedure to obtain cell sample from a suspicious lesion for cytological examination to determine the true nature of the mass.FNAB can be performed on the patient’s first visit. FNAB does not require special preparation, and the procedure is almost painless.FNAB is a cost-effective technique with high diagnostic trueness.In general, FNAB is used for palpable masses, such as breast masses, thyroid nodules, parotid masses and enlarged lymph nodes, etc.Any privileged provider may perform the FNAB.Upon request from the primary physician, a pathologist will perform the FNAB on a palpable lesion. Appointments are arranged for the pathologist to be present during the radiological or ultrasound examination before the FNAB is performed.Prior to performing procedureThe patient is identified by asking him to state his name and social security number during iMed consent. The pathologist or privileged physician will explain the procedure along with associated risks involved to the patient. The consent form is signed at this time.Prior to the procedure, the aspirator should have the following information:Pertinent clinical historyAny relevant imaging studies and differential diagnostic considerationsPurpose of the studyHow to perform the procedure. The site of the nodule stated by the primary care provider is confirmed by the pathologist or licensed physician during the ultrasound scan before FNAB is performed.A direct physical examination of the nodule is performed on the patient. Position the patient for best access to the lesion/mass and maximal safety and comfort.Aspiration techniqueAntiseptic preparation for superficial FNABs includes hand washing, proper gloves and wiping the skin over the aspiration site with an alcohol swab.Before the puncture and during aspiration, the aspirator should stabilize the lesion/mass against deeper tissues with the index and middle fingers, or thumb and forefinger. To help stabilize, the skin over the lesion/mass may be stretched.Pull slightly (1mL of air) on the syringe before skin piercing.Using a smooth motion, pierce the skin and advance the needle carefully into the lesion/mass, without applying suction.Apply and maintain negative pressure by drawing back on the plunger of the syringe.Note: Do not pump back and forth on the syringe plunger during the aspiration.Move the needle back and forth in rapid 3-to-5mm strokes.Fifteen to twenty strokes are considered necessary to get adequate material within the needle.Discontinue aspiration after blood or material is visible in the hub of the needle.Release suction before removing the needle from the patient.Specimen Preparation of Air dried smearThe smears prepared at bedside. The pathologist or licensed provider will hand the syringe containing the FNAB specimen to the assistant to prepare the smears and specimen as follows:Aspirate 1-2 ml of air into the syringe. The needle should touch the slide, bevel side down while pushing the plunger forcible to express the material.Express only 1 to 2 drops of the specimen onto the slide near the label end.Prepare the smear by using a second slide in a “bread-and-butter” fashion to smear the specimen; allow the slides to air dry for Diff-Quik staining.To ensure the entire specimen in the needle is recovered flush the needle. Draw some fixative into the syringe by suction action and push back into the 50 mL pre-filled CytoLyt Solution tube through the needle; repeat a few times. Each pass (Note: A single pass is defined as one entrance into the skin using one new needle) on the same mass is submitted into the same CytoLyte Solution tube.Activate safety protective device and discard the needle into the sharps container.The Thin Prep smear and/or cell block are made from the specimen in the 50 mL pre-filled CytoLyt Solution tube. Label the tube with the patient’s name and their social security number.Different lesions should be place into separate CytoLyt Solution tubes. Write the location of the lesion on the tube. Label the slides with the patient’s last name, first initial, last four numbers of the patient’s social security number and pass number (e.g., 1st, 2nd, or 3rd) with a permanent solvent resistant pen while at the patient’s bedside. Specimen is delivered to cytology department for further processing.Rejection of Unacceptable SpecimensSpecimens that are received unlabeled, improperly labeled, or without a completed SF 515 may be rejected and returned to the point of origin. This may cause an unnecessary delay in the process of the specimen.ReferencesCLSI. Fine Needle Aspiration Biopsy (FNAB) Techniques; GP20-A2, Vol. 23 No. 27; Clinical Laboratory Standards Institute; Wayne, PA; 1999-08.ThinPrep 2000 System Operator’s Manual. Cytyc Corporation; Marlborough, MA. Manual Number 71005-001. Revision C.00, 2006.Patient IdentificationThe primary responsibility of the phlebotomist is to check the identity of the patients and match the correct patients with the correct specimens. Patients must be positively identified without any doubt before specimens are collected, labeled and delivered to the laboratory. At least two patient identifiers are used before taking any blood samples or other specimens for clinical testing. The patient’s room number or physical location is not used as an identifier. All containers used for blood and other specimens must be labeled in the presence of the patient.Outpatient Identification ProcessGreet patient and obtain Veterans Identification Card (VIC).Visually compare photo on VIC to patient.Scan VIC under Select Patient Name in VistA.Accept orders for current day.Print labels. Go to Order Test Status menu. Search pending orders +30 / -30 days.If there are other pending orders, go to Accession Menu. Accept pending orders, excluding coagulation studies, drug levels and lipid profiles.Print all labels.Pull labels from printer. Verify that all labels on strip are for the same patient. If any labels are missing, call “time out” until labels are found.Pull bottom label up to top label and verify patient name matches name on VIC.Return VIC to patient. Ask patient to state his full name and last four digits of his social security number (SSN), while at the same time, verifying that the printed name and SSN on the labels match the spoken name and SSN.Place labels on clipboard and ask patient to verify that all of the labels have his correct full name and social security number. Ask patient to initial one of the labels to confirm his check. Perform the phlebotomy.Initial all labels. Align the accession label over the top line of the label on the tube. Do not cover the lot number or expiration date of the specimen tube. Leave part of the specimen tube’s colored label showing so that the tube type can be distinguished. Place the urine label on the urine collection cup. Place the label initialed by patient on the workload sheet. Thank patient, give instructions for bandage removal and urine collection. If no urine testing is ordered, tell the patient that he may leave. Note: If orders are only for urine tests, follow steps 1 – 14 above, initial label and place on urine collection up. Instruct patient on appropriate urine collection.Outpatient Identification ProblemsNo Veterans Identification Card (VIC) If VIC is unavailable, the patient is required to present an identification card which contains two patient-specific identifiers.Acceptable identification cards are:Valid Driver's License Current Government ID (city, state or federal)VHSO Employee IDAcceptable patient-specific identifiers are:Full NameDate of Birth Social Security Number Address (must match what is listed in VistA under Patient Information Section) If patient does not have an appropriate identification card, take the patient to the emergency department reception area for identification using VistA Imaging.No ScannerIf scanner is unavailable, ask patient for the last four digits of his SSN. Type in patient’s first letter of his last name and last four digits of SSN under Select Patient Name in VistA.From the list of names that appear on the screen, select name matching VIC. Missing labelsIf any labels are missing, call “time out” until labels are found. Notify all phlebotomists in the room that there are missing labels, which will prompt them to check all labels at their stations. Call the other phlebotomy area to check if missing labels were sent to corresponding printer.Checking labels against spoken nameIf patient is unable to respond, ask the family member or accompanying attendant to state the patient’s full name and last four digits of SSN, while at the same time, verifying that the printed name and SSN on the labels match the spoken name and SSN.If patient is unable to respond and there is no accompanying family member or attendant, take the patient to the emergency department reception area for assistance.Visual label check by patient (active participation)If patient is unable to read the print, ask the patient to state his full SSN, while verifying the printed SSN on the label matches. If patient is unable to respond, ask the family member or accompanying attendant to verify that all of the labels have his correct full name and social security number.If patient is unable to initial the label, write NOT INITIALED (NI) across the label.Unable to obtain specimenIf phlebotomist is unable to obtain the specimen and a second phlebotomist is called to the station to perform another phlebotomy, the second phlebotomist must re-identify the patient and check the already printed specimen labels. This is performed as follows:Ask the patient for his VIC. Explain to the patient that for his safety, it is laboratory policy that the phlebotomist performing the draw must re-identify the patient and verify the printed labels are his.Ask the patient to state his full name and last four digits of SSN, while verifying the name and SSN on the labels and VIC match.Proceed with the phlebotomy.Work interruptionsLapses in concentration and vigilance characterize human behavior, but can lead to errors. Unnecessary talking, phone calls and work interruptions in the phlebotomy rooms must be held to a minimum.Inpatient and Emergency Department Identification Process All inpatients and patients in the emergency department must wear an identification armband that includes their last and first name, date of birth and social security number. Under no circumstances should blood samples or other specimens for clinical testing be collected from a patient not wearing an armband.Obtain test requisition from laboratory printer or nursing station. Do not collect specimens without a test requisition.Note: If desired, print single future collection labels under the Phlebotomy Menu in VistA to use in place of the test requisition and for specimen tube labeling.Greet patient and check that the patient is wearing an identification armband.Ask patient to state his full name and social security number (SSN) while looking at the pare stated last name, first name and SSN to the patient’s armband, and then to the test requisition. There must be a three-way match; the stated information should match that on the requisition and armband.Note: If using collection labels, there must be a three-way match with the stated last name, first name and SSN to the patient’s armband, and then to the collection labels.Note: If there are any discrepancies, do not collect the specimen until they have been resolved!Perform the phlebotomy.Write patient’s last name, first name, SSN and your initials on all specimen tubes. (If using collection labels, initial and place on all specimen tubes.)Write the collection time on the test requisition.Thank the patient and give instructions for bandage removal. Deliver the specimens to the laboratory for barcode accessioning as soon as possible.Inpatient and Emergency Department Identification ProblemsNo identification armbandIf the patient does not have an armband, ask the nurse responsible for the patient to positively identify the patient and place an armband on the patient.For unconscious or unidentified patients in an emergency situation, place a red Typenex armband on the patient, in collaboration with another staff member, to accurately identify the patient.Unresponsive patientIf patient is unable to respond, verify the identity of the patient by asking a family member or accompanying attendant for the patient’s full name and SSN.If patient is unable to respond and there is no accompanying family member or attendant, ask the nurse responsible for the patient to state the patient’s full name and SSN.Armband errors Document all armband errors, including type of error and resolution, on the laboratory requisition. Upon return to the laboratory, transfer this information to the Specimen Rejection and Problem Log.Early Morning Phlebotomy Identification ProcessAll inpatient laboratory tests that are ordered to be collected between 0500 hour and 0700 hour, the “Early Morning Collection”, appear on a collection list that automatically builds and prints at 0500 hour. Patients on this list are grouped by Wards. Accession labels are generated from this list and, along with the collection list, are carried to the patient rooms for placement on the specimen tubes at the patient’s bedside. Since this differs from other inpatient collections in which accession labels are generated after the specimen arrives in the laboratory, a different identification process is necessary.Retrieve the 0500 hour Collection List from printer I8030, located in room 2-212, and compare to the 0430 hour Lab Order Entry List. Look for any missing tests, additions and duplicates.Print accession labels. (See procedure “Inpatients, Early Morning Phlebotomy (0500 Hr)” located in the Phlebotomy Procedure Manual.)The labels will print in a long, continuous strip. Separate patients, keeping all accession labels of the same patient attached to each other as one strip. Group strips of labels by floor and fasten each group together with a paperclip. Proceed to the first patient’s room on the Collection List. Greet patient and check that the patient is wearing an identification armband.Remove the first patient’s labels from the paper clipped accession labels.Ask patient to state his full name and social security number (SSN) while looking at the pare stated last name, first name and SSN to the patient’s armband, and then to all of the patient’s accession labels. There must be a three-way match; the stated information should match that on all accession labels and armband. Note: If there are any discrepancies, do not collect the specimen until they have been resolved!Perform the phlebotomy. Align the accession label over the top line of the label on the tube. Do not cover the lot number or expiration date of the specimen tube. Leave part of the specimen tube’s colored label showing so that the tube type can be distinguished.Write the collection time and your initials on all specimen tubes. Discard any extra labels in the red biohazard waste container, which is shredded and incinerated.Mark the patient as complete on the Collection List. Thank the patient and give instructions for bandage removal. Deliver the specimens to the laboratory for accessioning as soon as possible. Early Morning Collection Patient Identification ProblemsSee Inpatient and Emergency Department Identification Problems.Specimens collected for tests not listed on 0500 hour Collection ListOccasionally patients on the 0500 hour Collection List may have an additional tests ordered for later in the day. If the collection time for the additional tests is “today”, then the specimens may be collected with the Early Morning Collection. Combining collections will prevent the patient from having unnecessary draws. The accession labels for the additional tests are generated upon return to the laboratory. Follow this protocol:Write the order number, test names and tube requirements for the additional tests next to the corresponding patient on the Collection List.Draw an extra tube(s) for these tests if necessary.Place an extra accession label on the tube. Write “extra” across the label.If extra labels are not available, write patient’s last name, first name, and social security number on all extra tubes. Write the collection time and your initials on all specimen tubes.ReferencesMedical Center Memorandum 10-00-83 “Patient Identification”. Dated August 31, 2010. Veterans Health Care System of the Ozarks, Fayetteville, Arkansas. 72703.The Joint Commission Accreditation Program: National Patient Safety Goals. The Joint Commission on Accreditation of Healthcare Organizations, 2011. VENIPUNCTURE COLLECTION AND SPECIMEN HANDLINGPrinciple:Blood collection procedures require skillful performance to ensure accurate laboratory values and preservation of patient vein integrity. Pathology and Laboratory Medicine Service (P & LMS) will utilize guidelines for safe and effective blood collection of specimens for laboratory analysis. Because of contacts with sick patients and their specimens, all persons performing blood collection must practice universal precautions. Only nursing staff may collect blood from arterial or venous lines.Equipment and Supplies: 1. Written or electronic lab request 2. Clean tourniquet 3. Non-latex powder-free gloves 4. Sharps Disposal Container: OSHA acceptable puncture-proof red container marked "Biohazardous" 5. Alcohol prep pads, 70% isopropyl alcohol 6. Iodine prep pads, povidone-iodine, 10% 7. ChloraPrep One-Step Frepp Applicator, single use Chorhexadine Gluconate 2% (w/v) Isopropyl Alcohol 70% (v/v) 8. Appropriate Greiner Bio-One Vacuette? blood collection vacuum tube a. Stopper Color: White/Black Volume of Blood Draw: minimum 0.5 ml Additive: None Use: Waste tube, drawn before coagulation tube b. Stopper Color: Light Blue/Black Volume of Blood Draw: 3.5 ml Additive: Sodium Citrate, 3.2% Use: Coagulation c. Stopper Color: Red/Black Volume of Blood Draw: 6 ml Additive: Clot Activator Use: Serology d. Stopper Color: Red/Yellow Volume of Blood Draw: 5 ml Additive: Clot Activator and Gel Use: Serum tubes for routine clinical chemistry tests and hormones, TDM e. Stopper Color: Green/Black Volume of Blood Draw: 4 ml and 5 ml Additive: Lithium Heparin Use: Plasma tubes for stat clinical chemistry tests, 4ml f. Stopper Color: Green/Yellow Volume of Blood Draw: 5 ml Additive: Lithium Heparin and Gel Use: Plasma tubes for routine clinical chemistry tests g. Stopper Color: Lavender/Black Volume of Blood Draw: 4 ml Additive: EDTA K3 Use: Hematology h. Stopper Color: Pink/Black Volume of Blood Draw: 6 ml Additive: EDTA K3 Use: Blood Bank i. Stopper Color: Grey/Black Volume of Blood Draw: 6 ml Additive: Potassium Oxalate and Sodium Fluoride Use: Blood sugar and lactate9. Appropriate BD Vacutainer? blood collection tube a. Stopper Color: White Volume of Blood Draw: 5 ml Additive: K2 EDTA, Gel PPT Use: HIV and HCV Genotyping, HCV Viral Load (tube can be frozen) b. Stopper Color: Yellow Volume of Blood Draw: 8.5 ml Additive: ACD Solution A Use: Whole blood/plasma tube, supplied by reference lab c. Stopper Color: Royal Blue Volume of Blood Draw: 7 ml Additive: NA2 EDTA, Silicone coated Use: Trace Elements, supplied by reference lab d. Stopper Color: Green Volume of Blood Draw: 10 ml Additive: Sodium Heparin Use: Plasma tube, FISH testing, supplied by reference lab 10. BD Vacutainer? One-Use Holder11. BD Vacutainer Eclipse? Blood Collection Needle, 21 gauge12. Appropriate syringes with BD SafetyGlide? Needle, 21 and 23 gauge13. BD Vacutainer? Blood Transfer Device14. BD Vacutainer? Push Button Blood Collection Set, 21 and 23 gauge15. BacT/ALERT? Blood Culture Bottles (aerobic and anaerobic)16. BacT/ALERT? Blood Collection Adapter17. Gauze, 2 X 2 inch18. Paper tape or bandaging material for site19. Accession Labels (Do not use for Blood Bank specimens)20. Ammonia inhalants (to revive patients who faint or become dizzy)21. Cold Compress (to revive patients who faint or become dizzy)22. 10% Bleach Solution23. Soap and water, Quik-Care, and/or IsagelSpecimen:Specimen requirements are listed in the Pathology and Laboratory Medicine Service Specimen Collection Manual and under the "Test Description" option in VISTA. HAZARDOUS MATERIAL USED IN THIS PROCEDURE INCLUDES HUMAN BLOOD OR REAGENTS. OBSERVE UNIVERSAL BLOOD PRECAUTIONS AS DESCRIBED IN THE SAFETY MANUAL AND CHEMICAL SAFETY AS DESCRIBED IN THE CORRESPONDING MSDS SHEET.Procedure:Preparing for the Blood Draw1. Lab Order a. Obtain a written lab request or order number. (No lab work may be drawn without a lab order.) b. Review complete request to determine the tests that are ordered.2. Reassuring the Patient a. Approach the patient in a friendly, calm manner. Provide for his comfort as much as possible, and attempt to gain the patient's cooperation. The patient's elbow should be supported so that it remains straight and in a downward position. Some patients may prefer lying down, in which case a reclining chair may be used. b. The phlebotomist should identify himself/herself and explain the procedure to be performed. c. Tell the patient that there will be a small amount of pain associated with the needle stick, and ask the patient if that is ok. d. Interview the patient briefly to determine if he/she is aware of any special circumstances that might affect the blood draw and/or lab tests. Check patient preparation. Certain specimens may require fasting or other patient preparation. If special preparations were necessary, verify and note that the patient followed the instructions. If preparation problems are identified, contact the provider to determine if the collection should be deferred until the patient is properly prepared, if the problem is not significant, or if the need for the collection outweighs the potential preparation problem and the collection may proceed. Notify medical technologist of all collections under non-standard conditions so that he/she may document this in the comments section of the patient report. e. If the patient refuses the blood draw, do not proceed. Notify nursing personnel of patient refusal.3. Patient Identification a. Confirm the patient's identity by using at least two patient identifiers. Ask him to state, not verify, his full name and social security number. If the patient does not know his social security number, ask him to state his date of birth. If the patient is not able to respond, a family member or guardian if available may offer the information. b. Compare the ID information listed on the lab order with: i. Information offered by the patient or family member/guardian. ii. The VA identification Card (VIC) (for out-patients).iii. The patient's armband (for in-patients). c. Patient identification is crucial. All ID information must match before proceeding with blood collection. 4. Assembling Supplies for the Blood Draw a. Wash hands and apply gloves. The phlebotomist may sanitize hands with Isagel or Quik-Care in lieu of washing hands with soap and water. Wash hands with soap and water after every 8 - 10 applications of the sanitizers. Always use soap and water if hands are visibly soiled or if they become sticky or tacky. i. To use Isagel: put small amount of product into palm of clean, dry hand, enough to thoroughly cover both hands. Rub vigorously approximately 30 seconds, until gel evaporates completely. ii. To use Quik-Care: put small amount of product into palm of clean, dry hand, enough to thoroughly cover both hands. Spread the product over hands and rub until dry. b. Assess the lab order(s) and the venipuncture site to determine which supplies are needed for the blood draw and where the venipuncture will be performed. c. When using evacuated blood collection tubes, select a disposable holder and a safety needle. d. When using a syringe, select an appropriate syringe with a safety needle, and a blood transfer device. e. When using a butterfly, select either a syringe and a blood transfer device or a disposable holder. f. Select appropriate blood collection tubes, keeping in mind the correct order of draw. Tubes required for each lab test and special collection/handling instructions are Listed under the "Test Description" option in VISTA and in the Pathology and Laboratory Medicine Service Collection Manual. g. The correct order of draw or fill is: i. Blood Cultures ii. Coagulation Tubes (Light Blue/Black)To avoid contamination with tissue thromboplastin, if only a coagulation tube is to be drawn, a non-additive (White/Black) tube must be drawn first and discarded. When collecting coagulation specimens with a butterfly collection set, the first tube drawn in the series will be under-filled. Therefore, as with a routine collection, a non-additive (White/Black) tube must be drawn first and discarded. iii. Serum Tubes with clot activator (Red/Black) iv. Serum Tubes with gel (Red/Yellow) v. Plasma Tubes with Lithium or Sodium Heparin (Green/Black) vi. Plasma Tubes with Lithium Heparin and gel (Green/Yellow) vii. K3 EDTA (Pink/Black or Lavender/Black) viii. Oxalate/Fluoride Tubes (Grey) ix. Others h. Always check the draw volume on coagulation tubes against the nominal fill mark () on the tube label or by holding tube up to Greiner Coagulation Tube Draw Volume Guide.Performing the Blood Draw1. Routine Venipuncture Using BD Vacutainer? One-Use Holder and Eclipse? Blood Collection Needle For routine blood draws, this is the product of choice. a. Wash hands and put on gloves prior to venipuncture. b. Apply tourniquet 3 to 4 inches above the puncture site. It should be restrictive enough to be slightly uncomfortable for the patient. c. Ask patient to make a loose fist. Any vigorous exercise like "pumping" must be avoided because it can affect test results. d. Select a good venipuncture site. Avoid scarred or bruised areas. Never draw above an IV. Recent IV sites and the arm on the side on which a recent mastectomy was performed should be avoided. The median cephalic vein should be used if possible. If more than a minute passes and no vein has been located, have the patient unclench his hand and release the tourniquet for at least three minutes. If a good vein cannot be located, the following techniques may help: i. Sharply tapping the inner elbow skin with the index and second finger may cause a vein to dilate. ii. Massaging the arm from wrist to elbow to force blood into the vein and cause it to distend. iii. Applying a warm wet towel to the arm for 5 minutes may cause the vein to dilate. iv. Have the patient dangle the arm for 5 minutes to distend the veins. Note: In any of these suggestions, it is important that the tourniquet not be left on for more than one minute as some test results may be affected. e. Clean the puncture site with the alcohol or povidone-iodine wipe and make a smooth circular pass of the puncture sited moving in an outward spiral from the zone of penetration. Allow the skin to dry before proceeding. Do not touch the puncture site after cleaning. Note: Use povidone-iodine wipe to cleanse skin when drawing a blood alcohol. f. Holding both the pink shield and green cap on the Eclipse? Blood Collection Needle, twist and remove white cap. g. While holding the needle firmly, screw holder onto needle until it fits securely. h. Rotate the pink safety shield back toward the holder. i. Twist and pull the green needle cap straight off to avoid damaging needle point. j. Insert needle into vein with bevel up. k. When in vein, insert evacuated collection tube into holder and push onto needle. Vacuum will pull in required amount of blood. Hold tube with the stopper uppermost to prevent tube additives from entering the patient. Make sure tube additives do not touch stopper or end of the needle during venipuncture. Blood should flow when the needle punctures the stopper. If it does not, then the needle is either too far in the vein or not in the vein. Backing the needle up a bit will work if the needle is too far in the vein. If it is not in the vein, shifting it should work. If you feel the needle is in the vein and the blood still does not flow, use another tube. l. Release the tourniquet as soon as blood starts to flow into tube and ask the patient to open his or her hand. m. If more than one tube is required, withdraw the filled tube from the holder and insert another tube into place in the holder. Continue in this manner until all required tubes are drawn. n. Gently invert each tube with additive 8 times (an exception is the coagulation tube, it must be inverted 4 times) immediately after blood collection to reach a proper mix of additive and blood. Turn the filled tube upside-down and return it to the upright position. This is one complete inversion. Do not shake the tubes. o. Place gauze just above puncture site, and quickly remove needle from patient's vein. Apply pressure with arm extended until bleeding is stopped for at least 2 minutes. Inspect the puncture site. When bleeding has stopped, apply tape to hold fresh gauze in place. Instruct the patient not to remove it for at least 15 minutes. p. Immediately after removing needle from vein, cover needle by pushing pink safety shield with thumb. An audible click may be heard. Lock into place and inspect. Do Not attempt to engage shield by pressing against hard surface. Do Not remove needle from holder. Dispose of the needle and holder as one unit into the nearest sharps container. Do Not reuse. q. Make sure the patient is all right. Confirm the bleeding has stopped and the patient feels normal. r. Remove gloves and wash hands.2. Venipuncture Using a Syringe with BD SafetyGlide? Needle A disposable syringe with a 21 to 23 gauge needle should be used for venipuncture on patients with difficult veins (fragile, thready, or "rolling" veins). The use of a syringe needle to transfer blood directly from the syringe to a blood collection tube or culture bottle is both a prohibited practice and a dangerous procedure. Always use the BD Vacutainer? Blood Transfer Device to fill tubes with blood from a syringe. Venipuncture using a syringe is performed the same as a routine venipuncture with the following procedural changes: a. When assembling the equipment, place a sterile, BD SafetyGlide? Needle onto the syringe. Rotate the syringe until the lever arm is up on the needle. b. Insert needle into vein with bevel up. Gently pull back on plunger of syringe to withdraw blood. c. After sufficient blood has been drawn, place gauze pad over insertion site, and remove needle from patient's vein. Apply pressure with arm extended until bleeding is stopped for at least 2 minutes. Apply tape to hold fresh gauze in place. Instruct the patient not to remove it for at least 15 minutes. d. Activate the safety mechanism immediately after removal from patient by pushing lever arm completely forward until needle tip is completely covered. Dispose of the needle into the nearest sharps container. e. Attach a BD Blood Transfer Device onto the syringe. Insert an evacuated blood collection tube into the transfer device. Allow the blood to transfer from the syringe to the tube using the tube's vacuum. Do not depress the plunger of the syringe. Transfer blood to appropriate evacuated blood collection tubes as soon as possible. Delay may result in improper coagulation. f. Dispose of the syringe and Blood Transfer Device as one unit into the nearest sharps container. g. Gently invert each tube with additive 8 times (an exception is the coagulation tube, it must be inverted 4 times) immediately after blood collection to reach a proper mix of additive and blood. Turn the filled tube upside-down and return it to the upright position. This is one complete inversion. Do not shake the tubes. h. Since this is a syringe draw, there is no need to fill a waste tube for coagulation tests.3. Venipuncture Using BD Vacutainer? Push Button Blood Collection Set Butterfly collection sets may be used on patient's with small veins, when collecting Blood cultures or when a smaller needle to skin surface angle is desired. Butterfly collection sets may be used with syringes, Vacutainer One-Use Holders or with BacT/ALERT? Blood Collection Adapter. CAUTION - Never use a butterfly without a holder or syringe attached. Instructions for using the BacT/ALERT? Blood Collection Adapter can be found in the "Collection of Blood Cultures" procedure found in this manual. Venipuncture using a butterfly is performed the same as a routine venipuncture with the following procedural changes: a. Use with a Syringe: i. Peel apart package and with thumb and middle finger, grasp the rear barrel of the wingset and remove from package. Remove sleeved needle from end of the set and discard into sharps container. ii. Attach syringe onto the multiple sample luer adapter on the end of the butterfly. iii. With thumb and index finger, grasp the wings together, remove needle cap, and insert into vein with the bevel up. iv. Proper access to the vein will be indicated by the presence of "flash" directly behind and below the button. v. Gently pull syringe plunger back to withdraw blood. vi. After sufficient blood has been drawn, place gauze pad over insertion site. Allow gauze pad to cover nose of front barrel. While the needle is still in the vein, grasp the body with the thumb and middle finger. Activate the button with the tip of the index finger. To ensure complete and immediate retraction of device, make sure to keep fingers and hands away from the end of the blood collection set during retraction. Do not impede retraction. Withdraw needle from patient's vein. Apply pressure with arm extended until bleeding is stopped for at least 2 minutes. Apply tape to hold fresh gauze in place. Instruct the patient not to remove it for at least 15 minutes. vii. Confirm that the butterfly needle is in shielded position and dispose of in sharps container. viii. Attach a BD Blood Transfer Device onto the syringe. Insert an evacuated blood collection tube into the transfer device. Allow the blood to transfer from the syringe to the tube using the tube's vacuum. Do not depress the plunger of the syringe. Transfer blood to appropriate evacuated blood collection tubes as soon as possible. Delay may result in improper coagulation. ix. Dispose of the syringe and Blood Transfer Device as one unit into the nearest sharps container. x. Gently invert each tube with additive 8 times (an exception is the coagulation tube, it must be inverted 4 times) immediately after blood collection to reach a proper mix of additive and blood. Turn the filled tube upside-down and return it to the upright position. This is one complete inversion. Do not shake the tubes. xi. Since this is a syringe draw, there is no need to fill a waste tube for coagulation tests. b. Use with BD Vacutainer? One-Use Holder i. Peel apart package and with thumb and middle finger, grasp the rear barrel of the wingset and remove from package. ii. Thread the Multiple Sample Luer Adapter into the Holder. iii. With thumb and index finger, grasp the wings together, remove needle cap, and insert into vein with the bevel up. iv. Proper access to the vein will be indicated by the presence of "flash" directly behind and below the button. v. Using the holder, collect into an evacuated tube in the same manner as a routine venipuncture. vi. After sufficient blood has been drawn, place gauze pad over insertion site. Allow gauze pad to cover nose of front barrel. While the needle is still in the vein, grasp the body with the thumb and middle finger. Activate the button with the tip of the index finger. To ensure complete and immediate retraction of device, make sure to keep fingers and hands away from the end of the blood collection set during retraction. Do not impede retraction. Withdraw needle from patient's vein. Apply pressure with arm extended until bleeding is stopped for at least 2 minutes. Apply tape to hold fresh gauze in place. Instruct the patient not to remove it for at least 15 minutes. vii. Confirm that the butterfly needle is in shielded position and dispose of the entire blood collection set and holder into the nearest sharps container. viii. Gently invert each tube with additive 8 times (an exception is the coagulation tube, it must be inverted 4 times) immediately after blood collection to reach a proper mix of additive and blood. Turn the filled tube upside-down and return it to the upright position. This is one complete inversion. Do not shake the tubes. ix. When collecting coagulation specimens with a butterfly collection set, the first tube drawn in the series will be under-filled. Therefore, as with a routine collection, a non-additive (White/Black) tube must be drawn first and discarded. 4. Blood Collection Using an Intravenous Line Draw All venous and arterial line draws will be obtained by nursing personnel only. The nurse must aspirate 10 ml of blood and discard. This will ensure that the line has been cleared of IV solution. In a separate syringe, the nurse will withdraw desired amount of blood required for the requested laboratory procedures. This is critical to avoid erroneous laboratory data from IV fluid contamination. There should be strict adherence to aseptic technique to avoid site and/or catheter contamination.5. When collecting blood culture specimens, follow steps listed in "Blood Culture Collection Procedure" located in this manual.6. When collecting 2 hour post-prandial and glucose tolerance tests, follow respective procedures located in this manual.7. When collecting Transfusion Medicine specimens, verification of patient ID must be performed BEFORE the specimen is collected. The sample may be drawn by personnel who have completed a training program in blood bank. The collector must initial the collection tubes and sign the SF-518, stating that all patient information on the SF-518, the patient's armband, and the collection tubes is accurate.Labeling the Specimen1. All tubes must be labeled immediately after collection by the phlebotomist who collects the specimen with the following information: a. Patient's full name b. Patient's full social security number c. Date and time specimen was collected d. Initials of person who collected the specimen2. On blood collection rounds, accession label(s) from collection list may then be placed on appropriate tube(s). Specimens are individually accessioned upon arrival back in the laboratory in accordance with the procedure listed in the specimen collection manual. Put the actual draw time in the computer when specimens are accessioned. 3. In all other blood collections, the specimen is accessioned into VISTA in accordance with the procedure listed in the specimen collection manual, after it is collected. The accession label is retrieved and then placed on the tubes.4. Transfusion Medicine Specimens must be hand labeled by the collector. This information must match on all documents/specimens (SF-518, patient armband, specimen tubes). The requisition form SF-518 must also be signed by the collector. No accession labels will be used to label Transfusion Medicine Specimens.Problem Patient Reactions1. Fainting a. If the patient is sitting, lower head and arms. If the patient is lying down, elevate feet. b. Loosen any tight clothing. c. Apply cold compresses to the patient's forehead and back of neck. d. Try to revive the patient with ammonia inhalant. This should result in the patient coughing. e. Call an UCC nurse if there is no response for outpatients. Call the floor nurse for inpatients.2. Nausea a. Situate the patient comfortably with his or her head lowered. b. Instruct the patient to breathe deeply and slowly.3. Vomiting a. Roll prone patients on side. b. Give patient a basin. c. When vomiting ceases, assist the patient with water and towels. d. Inform the patient's provider.4. Excessive Bleeding a. Apply direct pressure to the venipuncture site while bleeding continues. Note this in the requisition slip. b. Record the time. c. If the bleeding persists more than 5 minutes, call the provider.5. Convulsions a. Place a soft, non-swallowable piece of material in the patient's mouth. b. Guard the patient from self-injury without completely restraining. c. Call the nurse for inpatients. Call an UCC nurse for outpatients.Handling ConsiderationsUniversal Precautions apply to all specimens of blood, serum, plasma, blood products, vaginal secretions, semen, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, and pericardial fluid. Any specimen of any type, which contains visible traces of blood, should be handled using Universal Precautions.Venous blood samples should be processed as soon as possible after being drawn. The following general precautions should be observed:1. Keep the specimen tubes capped. This should be done for safety reasons as well as for specimen preservation. 2. Avoid specimen agitation. Hemolysis (the breakdown of red blood cells) will occur when the specimen is agitated. A certain amount of hemolysis is unavoidable, but is should be minimal. Badly hemolyzed specimens are unacceptable for most chemistry and hematology procedures. Avoid shaking the specimen and always use gentle inversion to mix specimens. Always handle specimens with care. 3. Avoid specimen exposure to light. Certain analytes (bilirubin is the most noted) break down when exposed to light. 4. Adhere to specimen time constraints. Timing is critical in most chemistry and hematology procedures. Follow manufacturer's recommendations for minimum and maximum times which specimens may be left in the tube. Be aware that most hematology procedures require that the specimen remain in the tube for a minimum period of time to stabilize the anticoagulants. In general, hematology procedures involving an automated WBC differential are among the most time sensitive.5. Refrigerate specimens not tested immediately. Anticoagulated venous specimens should be stored at 2 - 8 degrees C. if they will not be tested within 4 hours. Heat may cause hemolyis.6. If testing is to be delayed for more than 24 hours, refer to specimen handling and storage instructions for the particular analyte being tested.7. Avoid repeated freezing and thawing. Mix thoroughly after thawing, by low speed vortexing or gently inverting to ensure consistency in the results. Specimens showing particulate matter, erythrocytes, or turbidity must be clarified by centrifugation before testing.Sources of Error1. Diet influences certain tests which require fasting prior to specimen collection. Prolonged fasting will influence certain test results as well. Blood drawn immediately after a meal will probably have different levels of potassium, phosphorus, glucose, triglycerides, and alkaline phosphatase than specimens taken 4 hours after eating.2. Tourniquets left on for more than 1 minute or vigorous hand exercise will elevate potassium and lactic acid levels and decrease blood pH.3. Anticoagulated specimens containing clots should be discarded.4. Hemolysis causes increased levels of acid phosphatase, bilirubin, CPK LDH, magnesium, potassium, AST, and ALT.References1. Tietz, N.W., "Specimen Collection and Processing; Sources of Biological Variation," Textbook of Clinical Chemistry, 2nd Edition, W. B. Saunders, Philadelphia, PA (1994).2. National Committee for Clinical Laboratory Standards, Procedures for the Handling and Processing of Blood Specimens, Approved Guideline, NCCLS publication H18- A, Villanova, PA (1990).3. Henry, J. B., Clinical Diagnosis and Management by Laboratory Methods, 18th Edition, W. B. Saunders, Philadelphia, PA (1991).4. "BD Eclipse? Hypodermic Needle and BD? Blood Transfer Device - Suggested Use for Venous Blood Collection" product information sheet, Becton, Dickinson and Co., Revision 2002.5. "BD Eclipse? Needles, Instructions for Use", Becton, Dickinson and Co., Revision 05/03.6. "BD Vacutainer? Push Button Blood Collection Set" product information sheet, Becton, Dickinson and Co., Revision 07/05.7. "BD Evacuated Blood Collection System" product information sheet, Bection, Dickinson and Co., Revision 08/04.8. "Vacuette? Evacuated Blood Collection System" product information sheet, Greiner Bio-One, Revision 03/04.9. The Compliance Primer. Hematronix, Inc., Plano, TX, 2002. 10. "BD SafetyGlide? Needle" product information sheet, Becton, Dickinson and Co., Revision 2003.MID-STREAM URINE COLLECTION INSTRUCTIONSFEMALES: Separate folds of urinary opening with thumb and forefinger and clean inside with towelettes, using front to back strokes only, keep separated during urination into container.Wash hands with soap.Open/remove towelette.Cleanse genital area with the towelette.Remove container from package/holder. DO NOT TOUCH INSIDE OF CONTAINER.Begin urination into toilet. As urination continues, bring container into stream. FILL SPECIMEN CONTAINER ONLY HALF WAY.Remove cap from package with thumb and forefinger. DO NOT TOUCH INSIDE OF CAP.Screw cap on container.MALES: Clean head of penis.Wash hands with soap.Open/remove towelette.Cleanse genital area with the towelette.Remove container from package/holder. DO NOT TOUCH INSIDE OF CONTAINER.Begin urination into toilet. As urination continues, bring container into stream. FILL SPECIMEN CONTAINER ONLY HALF WAY.Remove cap from package with thumb and forefinger. DO NOT TOUCH INSIDE OF CAP.Screw cap on container.Patient Instructions for 24 Hour Urine CollectionInstructions for 24 hour Urine CollectionStart 24 hour collection within two days before return appointment. Maintain normal fluid intake.On the morning of collection urinate into the toilet. (Do not collect this first specimen). Record date and time on label.From then on collect all urine passed during that day and night, including the first specimen on the following morning.Follow any special collection instructions given to you concerning mixing of urine and preservative, storage, protection from light, ETC.If for any reason a urine specimen is “MISSED”, the test must not be done since test results are based on total 24 hour collection. The 24 hour collection must be restarted. Please notify the laboratory and your provider if this occurs.Each specimen container must be carefully marked with the patient’s name, Social Security Number, date and time of collection.Bring the urine container and the test order sheet to the laboratory when you return to the Medical Center.Container must be kept refrigerated/room temperature during and after collection.Call VA Medical Center Laboratory if you have any questions.(479) 444-5088 or (800) 691-8387, ext. 5088TRANSFUSION SERVICE PATIENT IDENTIFICATION: THE TYPENEX BLOOD-RECIPIENT ARMBAND SYSTEMThe laboratory uses the Typenex Blood-Recipient System for transfusion purposes and to improve patient identification at the time of specimen collection. The person collecting the transfusion specimen is responsible for making a positive identification of the patient and for placing the armband on the patient. Normally, laboratory personnel will perform this task but on rare occasions a nurse anesthetist in the Operating Room may need to assume this responsibility. The following procedure is to be followed.PHLEBOTOMY/BEDSIDEPhlebotomists must determine if sample collection is necessary by consulting with the blood bank technologist for orders and specimens when confronted on the wards with a verbal order. An “extra” tube may NOT be used. The collection of the sample and the armband preparation must be done at the same time, after the CPRS order is written and printed. The CPRS order is given to the phlebotomist for identification and task purposes. Remove the old armband if present, and return to the Blood Bank.Verify the patient’s full name and full social security number (SSN) on the CPRS order against the hospital armband. Patients routing through the yellow clinic must have a hospital armband. Whenever possible, have the patient state out loud their social security number, in addition to verifying from written information. Collect the specimen in a 7 ml pink top (EDTA). A second witness identifying the patient will initial the tube of blood obtained.Write the patient’s full name, full SSN, date, time of collection, and initials of the collector on the tube and the long label located near the clip of the Typenex armband. Again, the tube must also contain the initials of the witness.Remove the completed self-sticking label and press onto the blood sample tube, taking car not to cover the witness initials. Information written on the label will be duplicated on the band.Wrap the band once around the patient’s wrist, with the number side out, so that the tape lies between both front and rear guides.Firmly close the clip. The armband becomes tamper proof when clip is closed.NOTE: THE BAND MUST REMAIN ON THE PATIENT FOR 3 DAYS AFTER THE COLLECTION TIME. The patient must be instructed not to remove the armband (this is especially important for outpatients returning at another time for transfusion).THE BAND IS NOT REMOVED WHEN THE PATIENT IS TRANSFERRED TO ANOTHER WARD OR IF THE PATIENT IS BEING TRANSFERRED TO ANOTHER HOSPITAL WHILE TRANSFUSION IS IN PROGRESS. Separate the remaining numbered labeled that extend past the clip by holding the clip firmly and tearing that portion of the band to one side without raising the band above the level of the clipThe strip of numbered labels is attached to the tube and returned to the lab with the transfusion requests.PHLEBOTOMIST IN THE LABORATORY:The phlebotomist returns to the lab and accessions the order into the VistA system and brings all of the barcodes, the order and the specimen (with the red-armband labels) to the blood bank.The entry in the Specimen/Phlebotomy Log is completed with one TAS label placed on the log and another one placed on the specimen. The phlebotomist signs the log and enters the witness initials.BLOOD BANK TECHNOLOGIST :Compare the labeled specimen tube with the CPRS order for identification (name, social security number). Inspect the orders.Place a barcoded UID label on a white-top (no additives) 7 ml tube. Transfer plasma from the original specimen tube to the 7 ml white top tube. Remove a coded label from the strip on the specimen tube and place on the 7 ml white top (no additives) tube.A red arm-band Typenex label is place on each BTRF (in the remarks section) and each caution tag prepared during testing in VBECS. If all the labels are used during the course of specimen eligibility, the number must be written on the caution tag and the BTRF.REMOVING BLOOD FROM THE LAB FOR TRANSFUSION PURPOSES:A copy of the CPRS transfusion order with the patient transfusion number from the Typenex armband must be presented by nursing to the laboratory whenever a unit is to be removed from the laboratory for transfusion purposes. This order sheet is checked against the caution tag, the BTRF and the issue information in VBECS. BEFORE TRANSFUSION/BEDSIDE:Before administering blood to a patient, the Typenex band label on the caution tag and the BTRF must be matched with the code on the patient’s armband, by the transfusing nurse and a second verifier. Match all identifying information: name, social security number, blood type, unit number and compatibility on the BTRF and Caution tag. Match unit information (type and unit number) with the information on the BTRF and Caution Tag.ERROR MANAGEMENTEach specimen brought to the lab is inspected by the assigned blood bank technologist. Any discrepancies are reported to the Blood Bank lead technologist. Any discrepancies found are addressed by obtaining a new specimen. In addition, the Blood Bank lead technologist or designee inspects all specimens on a weekly basis, comparing the BTRF information with the arm-band label. Any discrepancies found are reported: a local incident report is prepared and a Biological Deviation report is filed with the FDA. Appropriate action/retraining is taken.REFERENCESTypenex Original Blood Band technical information, . 2008JCHO National Patient safety Goals, 2010.JCHO Transfusion Safety Guidelines, 2008.Technical manual, AABB, 16th edition, Bethesda, MD, 2008.SPECIMEN COLLECTION AND TRANSPORTATIONPRINCIPLEIt is critical that the laboratory provide complete guidelines for the proper collection and transport of specimens to ensure quality patient care. All diagnostic information from the microbiology laboratory is contingent on the quality of specimen received. Consequences of poorly collected and/or poorly transported specimen include failure to isolate the causative microorganism and recovery of contaminants or normal microbiota, which can lead to improper treatment of the patient. Often, direct specimen smears are utilized to determine the quality of the specimen, to provide rapid information for diagnosis and therapy, and to allow the physician to determine if additional specimens should be collected.SUPPLIESAnaerobic Transport SystemOuter container contains hydrogen gas in an oxygen free atmosphere and a palladium catalyst.An indicator is saturated with buffered resazurin. It will be white when anaerobic and pink when exposed to oxygen.Store at 4-25 C. Do not expose to sunlight.Do not use past the expiration date or if the indicator is pink.Biohazard bags- zip lock for transporting specimensBlood Culture Bottles (aerobic and anaerobic)Contain 40 ml of media.Store at 15-30 C.Do not use past the expiration date. Do not use if the media is not clear or the disc on the bottom is yellow.Butterfly needle setsCastile Soap ToweletteChloraPrep applicators1.5 ml of Chlorhexidine Gluconate 2%(w/v) and Isoprpyl Alcohol 70% (v/v)Latex free spongeStore at room temperature 20-25 C.Do not use past the expiration date.Do not use on patients with known allergies to chlorhexidine gluconate or isopropyl alcohol.Do not use on open skin wounds or s a general skin cleanserFor external use only. Keep out of eyes, ears, and mouth.Flamable.Do not use with electocautery procedures.GEN-Probe Collection KitsTransport mediumDo not apply transport medium directly to the skin or mucous membranes or take internally.Store at room temperatureDo not use past the expiration date.Isopropyl Alcohol 70%FlamableDo not apply to mucous membranes, eyes or take internally.Occult Blood Test CardStore at room temperatureProtect from light, heat , and humidity.Do not store with volatile chemicals (e.g., iodine, chlorine, or ammonia).Do not use past the expiration date.Para-Pak C & S Vials15ml on non-nutritive transport media.Media is poisonous and an irritant, do no get on skin or in eyes.Store at room temperature.Do not use past the expiration date.Para-Pak ZN-PVA/Formalin vials Pink vial – contains 10% buffered neutral formalin (cancer agent)Grey vial –reagent alcohol (28%) in a stabilizing solution containing zinc sulfate and polyvinyl alcohol. Poisonous, avoid contact with skin and eyes.Store at room temperature. Do not use past the expiration date. Povidone-iodine 10% solutionSkin irritant – remove from skin to prevent burningScrew-Cap Containers (sterile)Sodium Chloride (nonbacteriostatic), sterile 0.85%Sterile tubesSwabs (CultureSwab)Liquid Stuart MediaStore at 5-25 C. Protect from direct sunlight.Do not use past the expiration date. SyringesVacuum collection tubesWhite top (no additives) – Store at room temperature, do not use past expiration dateGreen top (Na Heparin with out get) - Store at room temperature, do not use past expiration dateViral Transport System3ml of Transport mediumStore at 8 to -25 C.Do not use past the expiration date.PROCEDUREA. General Considerations: Safety:Follow universal precaution guidelines. Treating all specimens as potentially hazardous eliminates the need for warning labels.Use appropriate barrier protection (such as gloves and laboratory coat or gown) when collecting or handling specimens. If splashing may occur, protective eyewear, face masks, and aprons may be necessary.Do not contaminate the external surface of the collection container and/or its accompanying paperwork.Minimize direct handling of specimens in transit from the patient to the laboratory. Use plastic zip-lock biohazard bags with a separate pouch for the laboratory requisition orders.When specimens are obtained by a physician using needle aspiration, the specimen may be submitted to the lab in the capped syringe without the needle. Care must be taken not to aspirate air into the syringe if an anaerobic culture is requested. If an anaerobic culture is not requested, the specimen should be transferred to a sterile screw-cap container before transporting to the laboratory.If needle aspiration is used to collect a specimen and little material is obtained in the syringe, the physician should draw up a small amount of sterile nonbacteriostatic 0.85% NaCl prior to removal of the needle. 2. General guidelines for proper specimen collection:Collect an adequate amount of specimen. Inadequate amounts of specimen may yield false negative results.Specimen containers and request forms must be clearly identified with the following:Patient’s nameID number (Social Security number)Location of patient (Ward/Clinic)Attending physicianSite and source of specimenType of examination requested (test)Date and time of collection of the specimenTentative diagnosis is very helpful, especially when certain organisms are suspected, as special culture techniques are often needed.Identify the specimen source and/or specific site correctly so that proper culture media will be selected during processing in the laboratory.If a specimen is to be collected through intact skin, cleanse the skin first. For example, use Chlorhexidine Gluconate 2 %(w/v) (ChloraPrep) or 70% isopropyl alcohol followed by iodine solution (1 to 2% tincture of iodine or 10% solution of povidone-iodine [1% free iodine]). Tincture of iodine must be removed with alcohol after the procedure to prevent burns. Utilize appropriate collection devices and transport containers. Anaerobic Swab Transport System: These anaerobic swabs provide an anaerobic atmosphere for specimen transport. Do not use past the expiration date. Do not use if the indicator disc at the bottom of the tube is pink. Obtain from SPD.Pull the white plastic plunger out of the grey stopper. (DO NOT REMOVE THE GREY STOPPER.) Collect the specimen on the swab provided. If Liquid specimen, transfer the liquid aseptically to the inner tube.Replace the swab, push down gently on the plastic plunger forcing the inner glass tube into the outer glass tube. Depress the plunger away from the bed site. Plunger should be flush with the rubber stopper surface.Hold the tube at a 10-20 degree angle to the floor and rotate with a swirling motion. This is to facilitate the mixing of air in the inner tube with the hydrogen atmosphere in the outer tube.Transport to the laboratory at room temperature as soon as possible. Transport in an upright position if a liquid specimen is used.The anaerobes will remain viable for 72 hours if the device is not opened. Blood Culture Bottles: A set of blood cultures consists of 2 bottles (1 aerobic bottle and 1 anaerobic bottle). These bottles can also be used for specimen collection of other normally sterile body fluids such as bone marrow, pleural fluid, peritoneal fluid, pericardial fluid, synovial fluid, etc. (Note: blood culture bottles will not support growth of all organisms from sterile body fluids other than blood so a sample of the fluid must also be submitted for inoculation to other media and for stains.) The tops are not sterile, use 70% alcohol before use. Do not use past the expiration date. Transport to the laboratory at room temperature ASAP. Do not refrigerate or incubate. Obtain bottles from laboratory. GEN-PROBE Collection Kit: Use for collection of urethral, cervical, conjunctival, specimens for Chlamydia or N. gonorrhoeae by DNA probe. Available from laboratory. Do not use past the expiration date. Pink set for endocervical specimens and a blue set for urethral or conjuctival specimens. Use the swab provided to collect the specimen. (Refer to the anatomical site for culture instruction.) Fully insert one swab into the GEN-PROBE transport tube.Snap off shaft at score line. Use care to avoid splashing of contents.Cap the tube tightly.Transport at room temperature (2-25C). Must be to reference lab within 7 days of collection.Occult Blood Test Card: Used for occult blood screening of stool specimens. Obtain cards form SPD. Do not use past the expiration date. Physicians may develop their own cards; however, these results will not be available in the laboratory test file. When occult blood testing is performed by a physician, the test should not be ordered in VISTA or CPRS, and results should be entered in the progress note “Occult Blood Performed by Provider”. Using one of the applicators provided, collect a very small stool sample. Open the front flap of test slide and put a very thin smear inside box “A”.Reuse applicator to obtain a second sample from a different part of the stool. Put a very thin smear inside box “B” on the test slide.Close the cover flap. Dispose of the stick in the proper waste container.Transport to the laboratory at room temperature. Testing must be performed within 14 days.Para-Pak C & S Vials: Use for the collection of stool cultures, fecal leukocytes and parasite screens. Available from laboratory. WARNING: Solution is poisonous, avoid contact with skin and eyes. Do not use past the expiration date.Collect a stool specimen (refer to the anatomical site section)Open the vial. Using the collection spoon built into the lid of the tube place small scoopfuls of stool from areas which appear bloody, slimy, or watery into the tube until the contents rise to the red line. If the stool is formed (hard), sample small amounts from each end and the middle. Do not overfill.Mix the contents of the tube with the spoon, then twist the cap tightly closed and shake the tube vigorously until the contents are well mixed. Mark on the label the specimen consistency. Return vials to plastic bag.Transport to the laboratory at room temperature. Refrigerate if transport will be greater than 24h.Para-Pak ZN-PVA/Formalin Vials: Use for the collection of ova and parasites. Available from laboratory. WARNING: Fixative solutions are poisonous, avoid contact with skin and eyes. Do not use past the expiration date. Collect a stool specimen (refer to the anatomical site section)Open the vial. Using the collection spoon built into the lid of the tube place small scoopfuls of stool from areas which appear bloody, slimy, or watery into the tube until the contents rise to the red line. If the stool is formed (hard), sample small amounts from each end and the middle. Do not overfill.Mix the contents of the tube with the spoon, then twist the cap tightly closed and shake the tube vigorously until the contents are well mixed. Mark on the label the specimen consistency. Return vials to plastic bag.Repeat steps b-d for second vial.Transport to the laboratory at room temperature. Do not refrigerate. Screw-Cap Containers (Sterile Cups): Obtain from SPD or laboratory. It is essential that these cups are sterile and are leak proof. Be sure the caps are screwed on tightly and securely. These are best used for sputum, tissue, urines, stool, or other body fluids. Transport to the laboratory, refer to the anatomical site for timing and temperature of transport. Sodium Heparin without gel (green top): Vacuum tube with Sodium Heparin to prevent clotting. Used for bone marrows and other fluids. Clean top with 70% alcohol before use. Obtain from laboratory. Transport to laboratory immediately at room temperature.Sputum Collection System: Obtain from SPD. Instruct the patient to use the system as follows: Keep the unit upright at all times.Keep the funnel lid closed until ready to useOpen the funnel lid to expectorate – refer to sputum collection procedureClose lid securelyAt end of, pinch the two side flaps on the base with one hand. Remove the funnel by twisting at the stem with the other hand. Do not touch the funnel. Discard the funnel a biohazard trash receptacle. Remove the bottom cover and use it to cap the centrifuge tubeTransport to the laboratory immediately at room temperature. Do not transport with the funnel still on the system.Sterile tubes (white top vacuum tube): Useful for collecting of sterile fluids, drainage, brushes, hair skin scrapings, fingernails, wet preps and KOH preps. Obtain from laboratory.Swabs (CultureSwab and Transport System): Swabs are obtained from SPD. Do not use past expiration date. Swabs are the least desirable method of collection for many specimens. When culture swabs are to be used for collection of specimens for routine culture follow the anatomical site for collection instructions, then;Remove the lid from the culture tube and discard.Use the swabs to collect the specimen, ensure that both swabs are used.Insert swab into the culture tube, ensure that the lid is tightly secured.When swabs must be used for the collection of specimens, a separate CultureSwab must be submitted for routine, fungus, and AFB culture. When a wire swab is indicated (i.e. urethral) obtain the swab from the laboratory and after collection place the wire swab into the culture tube making sure the swab is in contact with the sponge, discard the swabs that came with the transport system place the lid securely on the tube. Transport at room temperature to the laboratory. Organisms will remain viable for 48 hours. If N. gonorrhoeae or S. pneumoniae is suspected they should be transported immediately. Syringe: When a sterile syringe used for the transport of fluids, the needle should be carefully removed using a needle removal device, and the capped syringe delivered to the lab immediately. Care must be taken that no air is aspirated into the syringe. Viral Transport System: These are available in Laboratory for collection of viral, Chlamydia, and Mycoplasma cultures. This system consists of a tube of viral transport media. The following collection guidelines should be followed:After specimen collection using Dacron swab, place swab in media and break off at least ? inch from the top of the tube. For use with body fluids, add 1-3 ml of the body fluid to the media.For use with whole feces, place a pea-sized portion into the media.For use with tissue or scrapings, place a small portion into the media.Specimens collected using the viral transport system should be transported to the Microbiology Laboratory immediately after collection. If a delay in transport to the lab is necessary, the specimen must be refrigerated at 4o C, except whole blood for HIV or CMV culture should be held at room temperature. TABLE 1: SPECIMEN TRANSPORT GUIDESOURCE AND TYPE OF SPECIMENTRANSPORT METHODBloodRoutine blood culture bottles. Bone MarrowHeparin vacuum tube with out gel. Catheter tipsSterile screw-cap SCSF or subdural fluidOmmaya fluidBrain abscessCNS biopsySterile screw-cap tube.Sterile screw-cap tube.Anaerobic swab transport system; or capped syringe without needle.Anaerobic swab transport system; or capped syringe without needle. Ifspecimen is small; send in a sterile cup or tube containing sterile nonbacteriostatic 0.85% NaCl.EyeConjunctival scrapingsCorneal scrapingsIntraocular fluidSend prepared smears and directly inoculated media; viral transport media,Gen-Probe (Chlamydia)Send prepared smears and directly inoculated media.Send prepared smears and directly inoculated media; anaerobic swabtransport system.Gastrointestinal systemFecesRectal swabGastric lavage orWashingDuodenal aspirateSterile screw-cap cup, ParaPak C&S, ParaPak ZN-PVA/Formalin.Swab transport (CultureSwab).Sterile screw-cap cup or sputum trap.Sterile screw-cap cup or sputum trap.Genital, Male Anal swabUrethralProstatic massageSemenPenile lesionSwab transport (CultureSwab); viral transport system.Swab transport (CultureSwab); viral transport system; or Gen-Probe.Sterile screw-cap cup or tube; or swab transport (CultureSwab).Sterile screw-cap cup or tube; or swab transport (CultureSwab).Capped syringe without needle; swab transport (CultureSwab); viral transport system; or Gen-Probe.Specimens for Neisseria gonorrhoeaeAnal, cervical, urethral,or vaginalSwab transport (CultureSwab)Upper Respiratory TractThroat swabNasal swabOral cultureTympanocentesis fluidSinus aspirateNasopharyngealSuctionNasal washingSwab transport (CultureSwab); or viral transport system.Swab transport (CultureSwab); or viral transport system.Swab transport (CultureSwab); or viral transport system.Anaerobic swab transport system; or capped syringe without needle.Anaerobic swab transport system; or capped syringe without needle.Sterile screw-cap cup; or viral transport system.Sterile screw-cap cup; or viral transport system.Lower Respiratory TractLung biopsyExpectorated sputumInduced sputumTracheal or endo-tracheal aspirateBronchoalveolarLavageBronchial washingTransbronchial biopsyBronchial brushTranstracheal aspirateLung aspirateSterile screw-cap cup with small amount of sterile nonbacteriostatic 0.85%NaCl to prevent drying. (Never place in formalin.)Sterile screw-cap cup or sputum collection system.Sterile screw-cap cup or sputum collection system.Sputum trap or sterile screw-cap container.Sputum trap or sterile screw-cap container.Sputum trap or sterile screw-cap container.Sterile screw-cap tube with 1-2 ml of sterile nonbacteriostatic 0.85% NaCl.Sterile screw-cap tube with 1-2 ml of sterile nonbacteriostatic 0.85% NaCl.Anaerobic swab transport system; capped syringe without needle; or sterilescrew-cap container.Anaerobic swab transport system; capped syringe without needle; or sterile screw-cap container.Sterile Body Fluids (Excluding CSF, Urine, Blood) Pleural, peritoneal,synovial (joint), pericardial fluidsSterile screw-cap cup or tube; capped syringe without needle; anaerobicswab transport system; or blood culture bottles.Subcutaneous Tissue and SkinUlcers or nodules, super-superficial wound (bacterial): Exudate BiopsyBurn specimensSuperficial fungallesion materialCapped syringe without needle; or anaerobic swab transport system.Sterile screw-cap cup or tube with a small amount of sterile nonbacterio-static 0.85% NaCl to prevent drying.Sterile screw-cap cup or tube.Sterile screw-cap cup or tube.Deep Wound, Aspirates, TissuesBite woundDeep wounds orabscessesSoft tissue aspiratesBonePunch skin biopsyAnaerobic swab transport system; or swab transport (CultureSwab).Sterile screw-cap cup or tube; anaerobic swab transport system; or cappedsyringe without needle.Capped syringe without needle; or anaerobic swab transport system.Sterile screw-cap cup or tube with a small amount of sterile nonbacterio-static 0.85% NaCl to prevent drying.Sterile screw-cap cup or tube with a small amount of sterile nonbacterio-static 0.85% NaCl to prevent drying.UrinesClean catchIleal conduitStraight catheterSuprapubic aspirateBilateral urethralcatheterizationSterile leak proof screw-cap cup.Sterile leak proof screw-cap cup.Sterile leak proof screw-cap cup.Capped syringe without needle; or anaerobic swab transport system.Sterile screw-cap cup or tube. (Be careful to label specimens with correcttimes and sites.)3. General guidelines for proper specimen transport:Transport all specimens to the laboratory promptly.Alternatives to prompt specimen delivery.Refrigerate most specimens at 2 to 8o C. The following are exceptions:If blood is cultured in broth (blood culture bottles), hold at room temperature until they can be delivered to the lab.Specimens that may harbor sensitive organisms such as Neisseria species should be left at room temperature.CSF specimens, blood for CMV culture, and specimens for anaerobic culture should be held at room temperature until they can be transported to the laboratory for processing.Place stool specimen (for culture, WBC, or parasites) in the appropriate ParaPak system. B.Collection instructions for different anatomic sites:1. Blood Cultures:Number and timing - A set of blood cultures is defined as one aerobic and one anaerobic bottle. Most cases of bacteremia are detected by using two sets of separately collected blood cultures. More than two sets of blood cultures yield little additional information. Conversely, a single blood culture may miss intermittently occurring bacteremia and make it difficult to interpret the clinical significance of certain isolated organisms. Obtaining blood cultures immediately before a temperature spike is ideal since the highest concentration of circulating organisms occurs at this time, but temperature spikes are not easily predicted. It has been found that the volume is more important than the timing. Acute sepsis - Collect 2 sets of blood cultures from separate sites for maximum volume (20ml/set) prior to starting antimicrobial therapy.Fever of Unknown Origin, Sub acute endocarditis – Collect a maximum of 3 sets of blood cultures of maximum volume. iii.Brucella - Collect a maximum of 3 sets of blood cultures of maximum volume. The lab must be notified of suspected Brucella since the blood cultures are held for 21 days before discarding. Fungus - Collect a maximum of 3 sets of blood cultures of maximum volume. Cultures are held 30 days.Patient on Antimicrobial Therapy - Collect the blood cultures when the antimicrobial agents are at their lowest concentration. NOTE: The anticoagulants and the dilution of blood in broth should diminish the effects of most antimicrobial agents. b. Volume of blood - No more than 10 ml of blood should be inoculated into each of the aerobic and anaerobic bottles. c. Blood culture collection - Blood culture can be collected by veni- puncture of peripheral veins, arteries, or from intravascular catheters, although the latter is the least desirable method and lends itself to increased contamination.Bottle Preparation:Inspect the bottle surface, the media, and the sensor. Ensure that the media is not outdated, the broth is clear, the sensor is intact and is blue-green in color. Do not use if the sensor is yellow. 2. Remove protective flip top over cap. Note: the septum is not sterile and must be disinfected.Cleanse the septum with 70% alcohol.Allow t dry 1 minute before inoculation.Skin PreparationSelect a venipuncture site.Select a different venipuncture site for each blood culture ordered.If poor access requires that blood be drawn through a port in an indwelling catheter, a second culture must be drawn from a peripheral site, because cultures drawn through catheters can indicate catheter colonization but may not be an active sepsis.Do not draw blood from a vein into which an IV solution is running.If the phlebotomy must be performed from the same site (usually because of bad veins), perform a second stick at that site for the next blood culture. After location of the vein, remove the ChloraPrep from its package. Pinch the wings on the applicator to break the ampule and release the antiseptic. Do not touch the sponge.Wet the sponge by repeatedly pressing and releasing the sponge against the venipuncture site until liquid is visible on the skin.Use repeated back-and-forth strokes of the applicator from 30 seconds. Completely wet the venipuncture area.Allow the area to air dry fro 30 seconds. Do not blot or wipe away.Do not re-palpate the vein.Venipuncture and Bottle InoculationDirect Draw with Blood Collection SetConnect the Adapter Cap to the luer connector of the blood culture set.Perform venipuncture. When the needle is in the vein, secure it with tape or hold it in place.Place the Adapter Cap on the aerobic (blue) blood culture bottle septum and press down to penetrate and obtain blood flow. Hold Adapter Cap down.Using the fill indicator lines on the label obtain 10 ml of blood.Move the Adapter Cap from the aerobic bottle to the anaerobic(purple) bottle and continue the collection. Obtain 10ml of blood.If additional blood is required for other tests, place the Adapter Insert into the Adapter Cap ad snap into place. This makes the cap compatible with vacuum collection tubes.After blood collection is complete, remove the Adapter Cap from the culture bottle and then remove the needle from the patient’s vein.Label each bottle with the patient’s name, ID number, the date and time the blood was put into the bottles, and your initials. This information is critical. Note whether or not the set was drawn from a line, arm, hand, etc., or if only one bottle was obtained. Do not write on or cover up the bar code on the bottle. Needle and SyringePerform veinipuncture using a needle and syringe.Directly inoculate the bottles, using the syringe makings markings as a guide for correct volume.Inoculate the anaerobic with 10 ml of blood.Inoculate the aerobic bottle with 10 ml of blood.Label as instructed above.IV CathetersUsing two separate alcohol preps, scrub the catheter hub connecter. Air dry.While wearing gloves, disconnect the tubing or cap of the catheter and attach a syringe to collect discard blood (3ml) which is not used for culture. NOTE: Avoid drawing from lines with in an hour of completion of an antibiotic agent.Using a new syringe, collect 2o ml of blood from the culture through the hub. Quickly reconnect the tubing.Attach a needle to the syringe. Inoculate the aerobic and anaerobic bottle with 10 ml each.Label as instructed above.NotesDo not overfill the bottles, as this may cause false positive readings. For best volume control, mark fill level on side of bottles prior to collection.When using Adapter Caps, be sure luer is connected firmly and the needle is straight when entering and leaving the septum. Twisting or turning the bottle may increase the chance that the sheath ma no retract and reseal.Recommended blood to broth ratio is 1:5 to 1:10. As the volume of blood drawn is increased, the yield of positive cultures increases. Optimally, 20 ml of blood should be drawn from adults (10ml per bottle). If 20 ml cannot be obtained, split the volume between the two bottles. If only two ml or less was obtained fill only the aerobic bottle. If there is going to be a delay in transport to the laboratory leave the bottles at room temperature. Do not refrigerate or incubate.Body Fluids (Excluding CSF, Urines, and Blood):Body fluid specimens collected by percutaneous aspiration for pleural, pericardial, peritoneal, and synovial.Note: Use care to avoid contamination with commensal microbiota.Clean the needle puncture site with ChloraPrep or alcohol, and disinfect it with an iodine solution (1 to 2% tincture of iodine or a 10% solution of povidone-iodine [1% free iodine]) to prevent introduction of infection. (If tincture of iodine is used, it must be removed with alcohol after the procedure to avoid burns.)Aseptically perform percutaneous aspiration with a syringe and needle to obtain pleural, pericardial, peritoneal, or synovial fluids.Immediately place a portion of the joint fluid or peritoneal fluid collected from patients with spontaneous bacterial peritonitis into aerobic and anaerobic blood culture bottles, retaining some (1 ml) in the syringe for Gram stain and direct plating. Do not put more than 10 ml in a blood culture bottle. If there is less than 5ml of sample do not place any in the blood culture bottles, send the entire syringe contents to the laboratory.Submit other fluids, and the remainder of specimens placed in blood culture bottles or one of the following:A sterile vacuum tube with no additives (white top) or if an anticoagulant is required a Na Heparin tube with out gel (green top).Anaerobic transport vial (for small-volume specimens).The collection syringe, form which the air has been expelled and the needle removed, using a protective device to avoid injury. Cap the syringe with a sterile cap prior to transporting to the laboratory. NOTE: Syringes that are capped with a Luer-Lock (with needle removed) are acceptable. Ensure that there is no leakage during transport, which could result in contamination of the culture. All of the transport methods listed above are acceptable for aerobic, anaerobic, fungal, and acid-fast bacillus (AFB) cultures, as well as stains.Bone Marrow: Useful in diagnosis of disseminated bacterial, fungal, and mycobacterial disease. May also be useful in diagnosis of parasitic infections such as leishmaniasis, trypanosomiasis, and occasionally malaria. a.The puncture site should be cleansed and disinfected with ChloraPrep or 70% alcohol and an iodine solution (1 to 2% tincture of iodine or a 10% solution of povidone-iodine [1% free iodine]). Tincture of iodine must be removed with alcohol after the procedure to prevent burns.The bone marrow specimen should be inoculated at bedside to a Na heparin tube with out gel. Catheter Tips: Semi-quantitative culturing of catheter tips is useful in assessing the relationship between catheters and sepsis. Intravascular catheters are an important source of bactericidal and fungicidal as well as local infectious complications at sites of catheter insertion.a.Collect two blood cultures, one through the catheter and one from a peripheral site at the time the catheter is submitted for culture. (A catheter culture and 2 blood cultures must be ordered)b. Clean the skin with 70% alcohol prior to catheter removal.c. Observing aseptic technique, hold the exposed end of the catheter and carefully remove the catheter from the patient with a sterile instrument, taking care to avoid contact with exposed skin. Holding the distal end over a sterile cup, cut the tip with a sterile scissors, dropping a 2-3 inch distal segment into the cup. Replace the cap.d.The specimen should be transported immediately to the laboratory to prevent excessive drying. Note: do not place in saline or any transport media.e.Foley catheter tips are unacceptable for culture and will be rejected.f. Submit catheter tips for culture only if there are signs of sepsis, or documented bacteremia in which the source is not apparent.g. For ventricular-peritoneal shunts, peritoneal or spinal fluid is preferred to the catheter tip.5.Central Nervous System (CNS) Specimens: a.CSF - Suggested volume of 1 ml each for routine, fungal, and AFB cultures, as well as 1 ml for each serology test ordered. Do not refrigerate.i. Lumbar puncture: The puncture site should be cleansed and disinfected with 0% alcohol and an iodine solution (1 to 2% tincture of iodine or a 10% solution of povidone-iodine [1% free iodine]). Tincture of iodine must be removed with alcohol after the procedure to prevent burns.Collect the sample and place the CSF into sterile leak proof tubes. Three tubes are generally required for Microbiology, Hematology, and Chemistry. The second tube generally goes to Microbiology. Note: Always send the most turbid tube to Microbiology.Ommaya reservoir fluid:Clean the Ommaya reservoir site with antiseptic solution and alcohol prior to removal of Ommaya fluid to prevent introduction of infection.Remove Ommaya fluid via the Ommaya reservoir unit, and place it in a sterile tube.Other CNS specimens:Brain abscess - A physician aspirates material from a lesion and sends it to the Microbiology Lab in an anaerobic transport system or in a capped syringe without the needle. Ninety percent of brain abscesses will grow anaerobic S biopsy samples - Obtain a biopsy sample from the lesion at surgery, and send it to the Microbiology Lab in an anaerobic transport system. Do not place in formalin.e. CNS specimen collection considerations are outlined in Table 2.TABLE 2CULTUREVOL(ml)COMMENTSBacteria1Send cloudiest CSF specimen to Microbiologyimmediately. Tube #2 is preferred. Fungus1Rule out Cryptococcus spp., Coccidioides immitis.Mycobacteria (AFB)1Mycobacterium tuberculosis, Mycobacterium avium/Intracellulare complex.AnaerobesN/ABrain abscess or CNS biopsy specimensParasitesN/ABrain abscess or CNS biopsy specimens for Entamoeba histolytica, Toxoplasma gondii, Naegleriaspp., Acanthamoeba spp.Virus1Send to laboratory on ice.6. Gastrointestinal Tract:Feces - Fecal specimens for routine culture are routinely examined for the presence of Salmonella, Shigella, Yersinia, Campylobacter, Vibrio, Aeromonas spp., Escherichia coli. Fecal specimens may also be submitted for parasite exam, fecal fat stain, fecal leukocytes, occult blood and Clostridium difficile toxin.Have the patient obtain a stool specimen by:Pass stool directly into a wide-mouth, leak proof container with a screw-top lid, orPass stool into a clean, dry bedpan, and transfer stool into a leak proof container with a screw-top fitting lid.If there is to be a delay in the transport time (more than 1 hour) to the Laboratory. Specimens for culture and fecal leukocyte should be placed in a ParaPak C & S vial. For parasites use the Para-Pak ZN-PVA/Formalin vials. Clostridium difficile specimen should be refrigerated.Rectal swabs - Submitted primarily for the detection of Neisseria gonorrhoeae, Shigella spp., and Herpes simplex virus. Pass the tip of a sterile swab approximately 1 inch beyond the anal sphincter. Carefully rotate the swab to sample the anal crypts, and withdraw the swab.Submit a single swab when requesting culture for enteric pathogens (Shigella).Document in the order if culture is to be set up for GC. Transport to lab immediately.Use viral transport kit for collection of viral culture for Herpes simplex.c. Gastric aspirates - The patient should fast prior to each of the following procedures.Gastric lavage - Submitted primarily for the detection of Mycobacterium tuberculosis in patients (most frequently children) unable to produce quality sputum.This procedure should be performed after the patient wakes in the morning, so that the sputum swallowed during sleep is still in the stomach.Pass a well lubricated tube orally or nasally through to the stomach of the patient, and perform the lavage. Before removing the tube, release the suction and clamp to prevent mucosal trauma and/or aspiration. 2. Duodenal aspiration - Submitted primarily for the detection of Giardia species and the larvae of Strongyloides stercoralis and Ascaris lumbricoides.Pass a tube orally through to the duodenum of the patient.To aspirate a sample for giardiasis, the tube should be at least in the third portion of the duodenum.Parasite screens cannot be done on these specimens they must be sent to another laboratory for a parasite exam. 3. Esophageal, stomach, or duodenum specimens - Esophageal specimens are primarily used to detect Cytomegalovirus (CMV) and Herpes simplex virus (HSV). Duodenal specimens can be used for the detection of Giardia species and the larvae of S. stercoralis and A. lumbricoides and H. pylori. The patient should fast prior to each of these procedures. Pass an endoscope orally. Obtain specimens through a channel in the endoscope by using one of the following procedures:Using biopsy forceps, obtain samples. Place biopsy specimen for viral culture in the viral transport system or in rapid urea medium for H. pylori. Additional biopsy specimens may be obtained for histological exam.Perform a wash by injecting approximately 25-30 ml of sterile nonbacteriostatic 0.85% NaCl through the biopsy channel onto the lesion. Collect the specimen by aspirating the fluid through the scope into a sterile trap, which is connected to the suction tubing.7. Genital Tract Specimens:Female Bartholin gland Decontaminate the skin with povidone-iodine or ChloraPrep and aspirate material from the duct(s). Note: Bartholin glands are small mucous-secreting glands located beneath the posterior portion of the labia majora. 2. Order an aerobic and anaerobic culture.CervicalClear away vaginal mucous and exudate with large swab. Moisten speculum with warm water, not lubricants, which can be antibacterial. Using a culture swab inserted through a speculum, sample endocervical canal. Avoid the vaginal walls during collection. Order a culture for the suspected pathogen, i.e., DNA probe for Neisseria or Chlamydia, Viral for HSV, or a female urogenital culture for other bacteria.CuldocentesisAfter cleaning the vaginal wall with surgical disinfectant, such as povidone-iodine or ChlorPrep, perform transvaginal puncture of the cu-de-sac to aspirate fluid. Note: The cul-de-sac is the pouch between the anterior wall of the rectum and the posterior wall of the uterus. Collection is often done to diagnose PID without more invasive laparoscopy; however, results may not correlate with more invasive testing.Order aerobic and anaerobic abscess cultures.EndometriumInsert endometrial suction curette or catheter protected Dacron swab through the cervical os and transfer beyond the cervical opening into the uterine cavity. Collect sample from within the cavity.Order aerobic and anaerobic abscess cultures.Fallopian tubes and pelvic cavityObtain aspirates and biopsy samples during laparoscopy. Also sample the pelvic peritoneum. Biopsies often yield better diagnostic specimens.Order aerobic and anaerobic abscess cultures.Skene’s glandsDecontaminate the skin with surgical disinfectant, and aspirate material from the gland(s). Note: Skene’s glands are paraurethral glands located at both sides of the outer end of the urethra.Order a DNA probe or culture for N. gonorrhoeae .Vagina Use a speculum without lubricant. Collect secretions from the mucosa high in the vaginal canal with a sterile culture swab.Order a wet prep or female genitourinary culture.Vulva Collect only if pain, erythema, or edema is present.Clean the surface of the lesion with 0.85% NaCl and collect by one of the following methods.Sample exudate or area of erythema with swab for a yeast cultureIf there is a vesicle present, collect for HSV cultureUnroof vesicleCollect fluid with a sterile swab, orAspirate vesicular fluid with a 26- to 27-guage needles and syringeThen scrape the base of the vesicle with a sterile scalpel blade, and collect specimen with a Dacron swab by vigorously rubbing the base of the vesicle.Place the swab in the viral transport mediumIf there is a crust on the lesion, gently remove it.Moisten swab with saline and collect specimen by vigorously rubbing the base of the lesion for H. ducreyi culture. (Order a female genitourinary culture and comment that H. ducreyi is suspected.) NOTE: Laboratory must be notified in advance of collection so special media can be ordered.Alternatively, gently abrade the lesion with a sterile scalpel or needle until serous fluid emerges. (Try to avoid bleeding.) Irrigate with saline.For H. ducreyi culture, rub the base vigorously with a sterile swab or aspirate fluid with a needle and syringe.For Treponema pallidum, wipe away fluid, blood, and debris with sterile gauze. Apply gentle pressure to the base of the lesion until clear fluid is expressed. Touch a slide to the fluid, and cover the fluid on the slide with a coverslip. If no exudate is present add a drop of saline to the lesion or insert a needle and syringe at the lesion base, aspirate, and then draw a drop of saline into the needle. Express the material onto a slide. Order a dark-field microscopy. The laboratory must be notified before collecting this culture to ensure availability of the test.MaleEpididymis or testicular fluidNote: The specimen of choice for diagnosis of infected epididymis is urethral culture. If that does not yield a diagnosis, collect first-voided and midstream urine, and compare the yield from smear and culture of each specimen. Collect testicular fluid only if the diagnosis cannot be made otherwise.Disinfect skin surface with surgical disinfectant. Use a needle and syringe to aspirate material from the epididymis or testicles.Order an abcess culture if bacteria is suspected (usually Enterobacteriaceae or pseudomonads).Order an AFB culture if Mycobacterium tuberuculosis is suspected, generally occurring after involvement of the prostate or seminal vesicles.Order a DNA probe for Chlamydia trachomatis or N. gonorrhoeae.Penile lesion or vesicleClean the surface of the lesion with 0.85% NaCl and collect by one of the following methods.If there is a vesicle present, collect for HSV cultureUnroof vesicleCollect fluid with a sterile swab, orAspirate vesicular fluid with a 26- to 27-guage needles and syringeThen scrape the base of the vesicle with a sterile scalpel blade, and collect specimen with a Dacron swab by vigorously rubbing the base of the vesicle.Place the swab in the viral transport mediumb. If there is a crust on the lesion, gently remove it.Moisten swab with saline and collect specimen by vigorously rubbing the base of the lesion for H. ducreyi culture. (Order a male genitourinary culture and comment that H. ducreyi is suspected.) NOTE: Laboratory must be notified in advance of collection so special media can be ordered.Alternatively, gently abrade the lesion with a sterile scalpel or needle until serous fluid emerges. (Try to avoid bleeding.) Irrigate with saline.For H. ducreyi culture, rub the base vigorously with a sterile swab or aspirate fluid with a needle and syringe.For Treponema pallidum, wipe away fluid, blood, and debris with sterile gauze. Apply gentle pressure to the base of the lesion until clear fluid is expressed. Touch a slide to the fluid, and cover the fluid on the slide with a coverslip. If no exudate is present add a drop of saline to the lesion or insert a needle and syringe at the lesion base, aspirate, and then draw a drop of saline into the needle. Express the material onto a slide. Order a dark-field microscopy. The laboratory must be notified before collecting this culture to ensure availability of the test.Prostate a. After the patient urinates, perform a digital massage through the rectum.b. Have patient pass prostatic secretions in the urethra by urinating into a cup. Alternatively, pass the urethral genital wire swab several centimeters into the urethra. c. Order a male urogenital culture if bacteria is suspected. Order a wet prep for Trichomonas vaginalis or place in viral transport for Ureaplasma culture. c. Male or Female cultures i. Rectal culturesInsert swab past anal sphincter, move swab from side to side, allow 10 to 30 s for absorption, and withdraw.If contaminated with feces, recollect.Order a GC culture. Throat culturesDepress tongue gently with tongue depressor.Extend sterile swabs between the tonsillar pillars and behind the uvula, avoiding the tongue, inner cheeks, and uvula.Sweep the swab back and forth across the posterior pharynx, tonsillar areas, and any inflamed or ulcerated areas to obtain sample.Order a GC culture.Urethral dischargeExpress exudate onto swab from distal urethra.If there is no exudate, collect 1 h after urination. Wipe area clean, insert an urethrogenital swab 2 to 4 cm into the endourethra, gently rotate the swab, leave it in place for 1 to 2 s , and withdraw it.Order a GC culture.Abscess material (e.g., bubo, lymph node, etc.)Disinfect the skin with surgical disinfectant.Aspirate the lesion with needle and syringe.Order an abcess aerobic and anaerobic culture for bacteria, with a gram stain order if H. ducreyi is suspected. NOTE: Laboratory must be notified in advance of collection so special media can be ordered. Order a DNA probe if Chlamydia is suspected. 8.Ocular Specimens: a. General considerationsObtain viral and chlamydial samples before topical anesthetics are instilled.Obtain samples for chlamydial cultures or for viral cultures with swabs contained in viral transport system.iii.The Gen Probe Kit should be for Chlamydia DNA probe. iv.Send prepared smears and inoculated media to the laboratory immediately.v. NOTE: Specimen collection must be performed by a qualified physician. b. Conjunctiva (bacterial conjunctivitis) and lid margin (if staphylococcal blepharoconjunctivitis is suspected.) Obtain the specimen with a sterile, premoistened cotton or calcium alginate swab. Roll the swab over the conjuctiva before topical medications are applied.Culture both eyes with separate swabs.Immediately inoculate the material onto BAP and CHOC. Inoculate the swab from the right conjuctiva in horizontal streaks, and the swab from the left conjuctiva in vertical streaks, each on one half of the same agar plate.Inoculate specimens from the right and left lid margins, if collected, by making an R and an L to represent the representative sites on another agar plate.Repeat with the swab from the GENPROBE collection kit if Chlamydia is suspected.Obtain conjuctival scrapings for a smear preparation as follows.Instill 1 or 2 drops of proparacaine hydrochlorideUsing a Kimura spatula, gently scrape along the lower right tarsal conjuctiva.Smear the material in a circular are 1 cm in diameter on a clean glass slide.Immerse the slide in 95% methyl alcohol or 100% methanol for 5 minutes.Repeat steps on the left conjunctiva. c. Bacterial keratitisInstill 1 or 2 drops of proparacaine hydrochloride.Obtain conjuctival samples as described above, and then obtain corneal scrapings from the advancing edge of the ulcer by scraping multiple areas of ulceration and suppuration with a sterile Kimura spatula, using short, firm strokes in one direction. (Keep the eyelid open, and be careful not to touch the eyelashes.)Obtain approximately three to five scrapings per cornea.Inoculate each set of scrapings onto BAP and CHOC, using a C- formation for each scraping. Inoculate a Sabouraud tube also if yeast or fungus is suspected.Prepare smear by applying the scrapings in a gentle circular motion over a clean glass slide.Bacterial endophthalmitisCollect an aspirate of the vitreous fluid or perform a paracentesis of the anterior chamber using a needle aspiration technique to collect intraocular fluid.Collect specimens for conjunctival cultures along with the fluid to determine the significance of indigenous microbiota.If a small volume is collected, inoculate 1 or 2 drops of fluid onto culture media, BAP, CHOC, Sabouraud, Anaerobic BAP, and THIO.Alternatively, submit in anaerobic transport tube or capped syringe after replacing the needle with a Luer-Lock.Preseptal cellulitisCleanse the skin with alcohol and tincture of iodine.In the absence of an open wound, the physician makes a stab incision in either the upper or lower lid with a no. 11 Baird –Parke blade.If there is an open wound, collect the purulent material with a syringe and needle.Inoculate media BAP, CHOC and THIO. Prepare slides as described above for conjunctivitis.Inject some material into an anaerobic transport vial.Orbital cellulitisObtain aspirate or biopsy of the wound, and process as described for preseptal cellulitis.Collect blood cultures.DacryoadenitisCollect a specimen of the purulent discharge by using a swab, as described above for conjunctivitis. Inoculate media BAP, CHOC and THIO and make smear.CanaliculitisCompress the inner aspect of the eyelid to express pus.Follow the procedure outlined above for conjunctivitis.Inoculate BAP, CHOC, Sabouraud, and THIO, and prepare smear.Inject some material into an anaerobic transport vial.TABLE 4: COLLECTION CONSIDERATIONS FOR OCULAR SPECIMENSCULTURECOMMENTSBacteriaInoculate media directly at beside with ocular scrapings. If GC issuspected, inoculate a Martin-Lewis also.FungusInoculate media directly with ocular scrapings.AnaerobesUse anaerobic transport system.ParasitesSubmit smear for Acanthamoeba spp.ChlamydiaUse Gen probe for DNA probe; or Viral Transport System forChlamydia culture.VirusUse Viral Transport System for specimen collection.Mycobacteria (AFB)Submit smears for AFB stain and CultureSwab for AFB culture.9. Respiratory Specimens:a. General considerationsi. If Corynebacterium diphtheriae, Archanobacterium haemolyticum, Bordetella pertussis, N. gonorrhoeae, Legionella spp., Chlamydia trachomatis, or mycoplasma are suspected, the physician should contact the clinical Microbiology Laboratory prior to specimen collection because special techniques and/or media are required for the isolation of these agents.b. Lower respiratory tracti. Expectorated sputuma. Do not have the patient rinse mouth and gargle with nonsterile water prior to sputum collection, since this can introduce contaminating microbiota. NOTE: Commensal mycobateria from tap water can contaminate mycobacterial cultures but are rarely an issue for routine bacteriology culturing. For specialized cultures (e.g. mycobacteria and legionellae), use sterile saline or water to gargle prior to collection.b. Instruct the patient not to expectorate saliva or postnasal discharge into the container.c. Collect specimen resulting from deep cough in sterile screw-cap cup or sputum collection assembly.Induced sputum - This procedure is performed by respiratory care on a consultative basis. NOTE: the utility of induced sputum for detecting pathogens other than Pneumocyctis carinii or Mycobacterium tuberculosis is poorly established. a. Using a wet toothbrush and sterile water or saline, brush the buccal mucosa, tongue, and gums for 5 to 10 minutes prior to the procedure. Do not use toothpaste. b. Rinse the patient’s mouth thoroughly with sterile water or saline.c. Using an ultrasonic nebulizer, have the patient inhale approximately 20 to 30 ml of hypertonic (3%) NaCl.d. Collect induced sputum in a sterile screw-cap cup or a sputum collection assembly.e. Induced specimens for mycobacterium should be collected in the early morning on 3 consecutive days.iii. Tracheostomy and endotracheal aspirationsAspirate the specimen into a sterile sputum trap.Do not culture tracheostomy aspirate unless clinical pneumonia is present (fever and infiltrates). Tracheostomy is followed by colonization within 24 h of insertion, and results may not correlate with diseaseiv. Bronchoscopy specimens – collected by a pulmonologist or other trained physician.Bronchoscopy specimens include bronchoalveolar lavage (BAL), bronchial washing, and protected specimen brushing (PSB) and transbronchial biopsy specimens. b.Precautions:1. To avoid excess blood in the recovered fluid, obtain bronchial wash and BAL before brushing or biopsy specimens. Blood may alter the concentration of cellular and noncellular components2. Avoid suctioning through the working channel before retrieval of specimens to avoid contamination of the specimens.3. Avoid the injection of topical anesthetic agents as much as possible, as the injection method may lead to contamination of the specimen. Aerosol application of anesthetic agents is preferred. c. To obtain specimens, do the following.1. Bronchoalveolar washing or BAL sample NOTE: the difference between a BAL sample and a bronchial washing is not apparent from the appearance of the specimen. The BAL sample is from the distal respiratory bronchioles and alveoli. Bronchial washings sample the major airways, which is the same area sampled by an endotracheal aspirate.a. Pass the bronchoscope transnasally or transorally in nonintubated patients or via the endotracheal tube in intubated patients.b. Inject sterile nonbacteriostatic 0.85% NaCl (generally 5- to 20-ml aliquots) from a syringe through a biopsy channel of the bronchoscope.c. Collect the BAL sample by carefully wedging the tip of the bronchoscope into an airway lumen and instilling a large volume of sterile, nonbacteriostatic saline (grater than 140 ml). The sample returned contains secretion distal to the bronchioles and alveoli.d. Gently suction the recovered specimens into a sterile container before administering the next aliquot. (In general, 50 to 75% of the saline instilled is recovered in the lavage effluent.) Keep aliquots separate during collection.e. Discard the initial fluid as contaminated and submit the rest for culture and staining. NOTE: in the laboratory, aliquots from the same site may be combined for microbiology cultures and smears, but aliquots from separate sites (for example, right upper lobe and right lower lobe should be combined only after consultation with the physician of record. 2. Bronchial brush specimensa. Instill a brush to collect cellular material from the airway wall. This is the best specimen for viral culture and cytology studies.b. Only PSB are acceptable for bacterial culture. Obtain by inserting a telescoping double catheter plugged with polyethylene glycol at the distal end (to prevent contamination of the bronchial brush) through the biopsy channel of the bronchoscope.c. Place specimen in 1ml of nonbacteriostatic saline. 3. Transbronchial biopsy samplesObtain the biopsy sample through the biopsy channel of the bronchoscope, and transport it in a sterile container with a small amount of nonbacteriostatic sterile saline. Do not put specimens for culture in formalin.v. Lung aspirations – collected by a trained physiciana.Use a computed tomography scan to obtain lung aspirates by inserting a needle through the chest wall into the pulmonary infiltrate. b. Aspirate material from the lesion. If the lesion is large or if there are multiple lesions, collect multiple specimens from representative sites. Immediately transport capped syringe without needle to the lab for culture.vi. Lung biopsies – collected by trained physiciana.Obtain a 1 to 3 cm3 piece of tissue if possible. If the lesion is large or if there are multiple lesions, collect multiple specimens from representative sites.b.Submit in sterile container(s) without formalin. c.Upper respiratory tract infectionsi. Otitis a. External ear1. Insert sterile swab into ear canal until resistance is met.Rotate swab and allow fluid to collect on swab. Tympanocentesis NOTE: Because of the invasive nature of the collection process, these specimens are usually submitted primarily to diagnose middle ear infections only if previous therapy has failed.Clean the external ear canal with a mild detergent.Using a syringe aspiration technique, the physician will obtain the fluid from the ear drum.Send the specimen in a sterile container or in the syringe capped with a Leur-Lok and with the needle removed.If the eardrum is ruptured, collect exudate by inserting a sterile swab through an auditory speculum. Bordetella culturesNOTE: Cough plates and nasal swabs, previously thought to be ideal specimens, are no longer recommended for culture of Bordetella.NOTE: Laboratory MUST be notified prior to collection of cultures. Media must be special ordered.Timing Collect as soon as possible after symptoms develop.Collect specimens up to 4 weeks after onset, provided that antimicrobial therapy has not been started. NOTE: The organism is rarely found by culture after the fourth week of illness, and the percentage of positive culture results decreases with time. Positive results have been reported using PCR with specimens collected as late as 60 days after the onset of symptomsCollection of nasopharyngeal specimenNOTE: B. pertussis exhibits a tropism and binds specifically to ciliated respiratory epithelial cells, since the nasopharynx is lined with these cells, it is a far superior site for detection of the bacterium.Nasopharyngeal swabUse a calcium alginate or Dacron swab in a fine flexible wire. Bend the wire so that it mimics the curve of the nasal airway and gently pass the swab through the nostril t the posterior nospharynx. Do not force the swab, resistance will be felt when the posterior nasopharynx is reached.Rotate the swab and leave it in place for up to 30 s or until the patient coughs. Withdraw as quickly as possible.Repeat the procedure through the second nostril.Submit both swabs for culture(place swabs in a culture transport tube) and/or PCR(place swabs in viral transport media) testing3.Nasal washingsi. Nasal wash: syringe methodUse a 3- to 5-ml syringe with a 2-in 18-gauge tubing attachment. Fill the syringe with saline.Instruct the patient not to swallow during the procedure.With the patient’s head hyperextended (approximately 70 degree angle), quickly instill approximately 5 ml of sterile 0.85% NaCl into one nostril.Immediately aspirate the saline solution back into the syringe, orTilt the head forward and allow the fluid to run out of the nares into a sterile container, orAspirate the fluid by inserting a rubber bulb syringe into each nostril.Place the specimen in a sterile container.Nasal wash: bulb methodSuction 3 to 5 ml of sterile 0.85% NaCl into a 1- to 2-oz tapered rubber bulb.Instruct the patient not to swallow during the procedure.With the patients head hyperextended (approximately 70 degree angle), insert the bulb into one nostril until the nostril is occluded.Quickly instill the sterile saline into the nostril with one squeeze of the bulb.Immediately release the bulb to collect the nasal wash specimen.Empty the bulb contents into a sterile container and transport.Nasal aspirate: vacuum assist Connect a mucus trap (i.e., Luken’s tube) to a suction pump and catheter, turn on suction, and adjust to suggested suction pressure (adult: 14 catheter with 120-150 mmHg)Insert the end of the catheter through the external nares to the posterior pharynx.Apply suction while slowly withdrawing the catheter, allowing the catheter to remain in the nasopharynx no longer than 10 s.After aspiration, flush material out of the catheter with a small volume (1 to 1.5ml) of sterile saline.Note: Nasopharyngeal aspiration or wash yields sufficient material for numerous diagnostic procedures and gives 11% higher yield on culture than nasopharyngeal swabs. Aspirate specimens are easily divided and saved, are suitable for all testing methodologies, and can be frozen for long periods. e. Specimen transportCultures should be planted at the bedside or transport to Microbiology lab immediately.PCR should be transported to lab ASAP.Corynebacterium diphtheriae culturesContact the Microbiology department prior to specimen collection for diphtheria, because special techniques and/or media are required for the isolation of these agents.In case of respiratory diphtheria, obtain material for culture on the swab in the diphtheria transport device from the inflamed areas in the nasopharynx.If membranes are present and can be removed, swab from beneath the membrane.Collect from several areas to increase sensitivity.Collect nasopharngeal swabs from suspected carriers.For details, see Specimen collection for throat cultures.If cutaneous diphtheria is suspected, collect skin (aspirate/swab), throat (swab), and nasopharynx(swab) specimens.Place swabs into the transport package as directed on the package. Transport to the laboratory as soon as possible.iv. Throat (pharyngeal specimens) - Submitted primarily for the detection of group A streptococci.Do not obtain throat samples if epiglottis is inflamed, as sampling may cause serious respiratory obstruction.Place gentle pressure on the tongue gently with tongue depressor.Extend sterile culturette swab between the tonsillar pillars and behind the uvula. (Avoid touching the cheeks, tongue, uvula, or lips.)Sweep the swab back and forth across the posterior pharynx, tonsilar areas, and any inflamed or ulcerated areas to obtain sample.v. Nasal swabs - Submitted primarily for the detection of staphylococcal carriers (primarily MRSA). Insert a sterile swab into the nose until resistance is met at the level of the turbinates (approximately 1 inch into the nose.)Rotate the swab against the nasal mucosa.Repeat the process on the other side of the nose using the second swab in a two-swab culturette.Submit both swabs together in the same culturette as a single culture. vi. Nasal Sinus cultures – collection is performed by an otolaryngologist a. Rigid endoscopyi. Provide the patient with an intranasal decongestant and then a topical anesthetic.Identify the middle meatus adjacent to the macillary sinus ostium ipsilateral to the side to be aspirated.Collect drainage from the middle meatus with a small swab on a wire.Place the swab into a swab transport device.Maxillary sinus puncture and aspirationClean the anterior nares with antiseptic solution.Apply topical anesthetic.Punture the maxillary antrum and aspirate secretions with a needle and syringe.If no material is aspirated, irrigate with 2 ml of nonbacteriostatic saline.Transport syringe to the laboratory with the needle removed and a Luer-Lok in place. vii. Oral cultures - Use to prepare smears for the detection of yeast or fusospirochetal disease.a.Rinse mouth with sterile saline.b.Wipe the lesion with dry sterile gauze.c.Swab areas of exudation or ulceration using a sterile culturette swab.TABLE 5: COLLECTION CONSIDERATIONS FOR RESPIRATORY SPECIMENSCULTUREVOL (ML)COMMENTSBacteriaN/AContact lab if Legionella is suspected. Submit sputum only; saliva is unacceptable.Fungus3-5Collect three early morning fresh specimens resultingfrom deep cough or sputum induction. Lung biopsy specimens or lung aspirates are also appropriate.Anaerobes1Sinus aspirate, tympanocentesis fluid, transtrachealaspirate, and lung aspirates or biopsy specimens are appropriate.Mycobacteria (AFB)5-10Collect three early morning fresh specimens resultingfrom deep cough or sputum induction. Lung biopsy specimens or lung aspirates are also appropriate.Pneumocystis2Use induced sputum, bronchoalveolar lavage fluid orlung biopsy specimens and submit to Anatomic Pathology.Parasites3-5Sputum or bronchial washing/lavage specimens can beexamined for amoebae, helminth eggs (Paragonimus westermani), hooklets of Echinococccus, larvae of hookworm, and Ascaris and Strongyloides.10.Urines:a. General considerations:Never collect urine for culture from a bedpan or urinal.Thoroughly clean the urethral opening (and vaginal vestibule in females) prior to collection procedures to ensure that the specimen obtained is not contaminated with colonizing microorganisms in this area.Soap rather than disinfectants is recommended for cleaning the urethral area. If disinfectants are introduced into the urine during collection, they may be inhibitory to the growth of microorganisms.Twenty-four hour urine collections are unacceptable for any type of culture.Sterile screw-capped cups are used for transport.Instruct the patient on proper cleaning and collection of specimen.Ensure that lids to these containers are screwed on securely and tightly to prevent leakage of the specimen during transport. Deliver to the laboratory ASAP for processing. The specimen must be delivered to the lab within 2 hours.Specimen collection techniques:Clean-voided midstream urine collectionPreparationFemalesWhile the labia are held apart cleanse the vulva thoroughly with a Castile Soap towelette from front to back. Repeat with a second towelette. Special attention should be paid to the urethral meatus.Rinse the vulva well with sterile water or saline wet gauze wipes.Allow a few milliliters of urine to pass. (Do not stop the flow of urine.)Collect the midstream portion of urine in a sterile container.NOTE: Collection of midstream urine specimens should be avoided during menses.Circumcised males: No preparation for midstream specimen.Uncircumcised malesRetract the foreskin, and wash the glans penis thoroughly with two successive castile soap towelettes, paying special attention to the urethral meatus.Rinse the glans area well with two successive gauze pads soaked with sterile water or saline.Collect the midstream portion of urine in a sterile container.Have the patient collect voided urine directly into the container, instructing the patient to not halt and restart the urinary stream for a “midstream” collection but preferably move the container in the path of the already voiding urine and to remove it before halting.Females should void while keeping their labia held apart.Uncircumcised men should keep their foreskin retracted while voiding.Catheter urineUsing a needle and syringe, collect urine through the catheter port, after cleaning with alcohol. Transfer the urine into a sterile leakproof container. Do not send urine obtained from a catheter bag.A straight catheter (in and out) is used by a physician or trained health care worker to obtain urine directly from the bladder.This procedure must b carried out with aseptic technique, to avoid the risk of introducing microorganisms into the bladder.Discard the initial 15 to 30 ml of urine and submit the next flow of urine for culture. When ordering the culture order it as a cath urine.IIeal conduit urine.Remove the external urinary appliance, and discard the urine within the appliance.Gently swab and clean the stomal opening with a ChloraPrep or70% alcohol pad and then with an iodine solution (1?to 2% tincture of iodine or a 10% solution of povidone-iodine [1% free iodine]). Remove tincture of iodine with alcohol after the procedure to avoid burns.Using sterile technique, insert a double catheter into the stoma. (A double catheter helps to minimize contamination of the specimen with skin flora.)Catheterize the ileal conduit to a depth beyond the fascial level.Collect the urine drained into a sterile container.When ordering the culture order it as a cath urine.Suprapubic Aspiration (SPA) of the urinary bladder. This is performed by a physician or a trained health care worker. SPA is useful in determining urinary infection in adults in whom infection is suspected and for whom results from routine procedures have been equivocal and diagnosis is critical. SPA is also useful in pediatric patients when clean-catch urine specimens are difficult to obtain.Before SPA, the patient should force fluids until the bladder is full.Shave and disinfect the suprapubic skin overlying the urinary bladder.A small lance wound through the epidermis, just above the symphysis pubis may be made.Aspirate urine from the bladder by using a needle aspiration technique. Submit capped syringe without needle ASAP to lab for culture. Be sure the specimen is labeled as a suprapubic aspiration.Cystoscopy: bilateral ureteral catheterization. Bilateral ureteral catheterization is useful in determining the site of infection in the urinary tract. This procedure is usually performed in specialty designated areas such as specialty clinics or surgery.Prior to cystoscopy, have the patient force liquids until the bladder is full.Clean the urethral area (and vaginal vestibule in females) with soapy water, and rinse the area well with sterile water.Insert a cystoscope (obturator in place) into the bladder.With sterile technique, collect approximately 5 to 10 ml of urine from open stopcock into a sterile container.Label this sample CB, for catheterized bladder urine, and refrigerate it. Then irrigate the bladder. (Use sterile nonbacteriostatic 0.85% NaCl to irrigate the bladder.)After irrigation of the bladder and insertion of the ureteral catheters, collect irrigating fluid passing from the bladder through the ureteral catheters by holding the ends of both catheters over an opened sterile container.Label this sample WB, for washed bladder urine, and refrigerate it.Pass the ureteral catheters to each midureter or renal pelvis without introducing additional irrigating fluid. Open both stopcocks of the cystoscope to empty the bladder.Discard the first 5 to 10 ml of urine from each ureteral catheter.Collect four consecutive paired cultures (5 to 10 ml each) directly into opened sterile containers.Label these specimens LK-1, RK-1, LK-2, RK-2 (LK for left kidney and RK for right kidney). Submit all samples to the clinical Microbiology Laboratory for culture.Prostatic massage is used primarily to diagnose acute or chronic prostatitis. For both diseases, gram negative enteric organisms are the most frequently isolated pathogens. Neisserisa gonorrhoeae is found infrequently but is sometimes implicated in acute prostatitis. Fluid can also be used to demonstrate Trichomonas in males who act as vectors.Perform digital massage through the rectum.Collect the specimen in a sterile tube or on a sterile swab.Label clearly (e.g., “EPS” for [expressed prostatic secretions]) for proper culturing.Urine specimen collection considerations are summarized in Table 8.TABLE 8: COLLECTION CONSIDERATIONS FOR URINE SPECIMENSCULTUREVOL (ML)COMMENTSBacteria0.5-1Do not collect 24 hr. specimen. After propercleansing of patient, use first morning midstream void.Fungus>20Do not collect 24 hr. specimen. First morningvoid is recommended.Mycobacteria (AFB)>20Do not collect 24 hr. specimen. First morningthree consecutive voided urine specimens are recommended.Anaerobes1Use suprapubic aspirate. Send in anaerobictransport system.Virus10-50Do not collect 24 hr. specimen. First morningvoid is recommended. Useful for adenovirus, mumps, and CMV detection. Send on ice, and transport to lab immediately.Parasites24 hr.collect.Use for detecting Shistosoma haematobium eggs, Trichomonas vaginalis trophozoites in males, and Onchocerca volvulus microfilariae.Note: Amounts are guidelines. In general, greater volumes increase The chance of organism recovery.11.Wound and Soft Tissue Cultures:General considerationsPreferably collect specimen prior to initiation of therapy and from wounds that are clinically infected or deteriorating or that fail to heal over for a long period. Cleanse the skin or mucosal surfaces.For closed wounds and aspirates, disinfect as for a blood culture collection with ChloraPrep.For open wounds, debride, if appropriate, and thoroughly rinse with sterile saline prior to collection.Sample viable infected tissue, rather than superficial debris.Avoid swab collection if aspirates or biopsy samples can be obtained.ContainersAnaerobic transport vial for small tissues.Sterile cup for large tissues with non-bacteriostatic saline on a gauze pad to keep moist.Syringes with safety devices to protect from needle exposure.Expel the air from the syringe, remove the needle after activating the safety apparatus, and cap the syringe with a sterile Leur-Lok.Alternatively, place the aspirated contents in a sterile vacuum tube without any additives (White top).Swabs use the CultureSwab system and the Anaerobic swab transport system if anaerobic cultures are ordered.Specimen collection after proper disinfectionClosed abscessesAspirate infected material with needle and syringe.If the initial aspiration fails to obtain material, inject sterile, nonbacteriostatic saline subcutaneously. Repeat the aspiration attempt.Remove the needle and submit with Luer-Lok on the syringe or place contents in sterile vacuum collection tube with no additives.Fine needle aspirateInsert the needle into the tissue, using various directions, if possible.If the volume of aspirate is large, remove the needle and submit with Luer-Lok on the syringe.If the volume is small, draw up sterile nonbacteriostatic saline into the syringe until the specimen goes into the barrel of the syringe, remove the needle and submit with Luer-Lok on the syringe.Open WoundsCleanse the superficial area thoroughly with sterile saline, changing sponges with each application. Remove all superficial exudates.Remove overlying debris with scalpel and swabs or sponges.Collect biopsy or curette sample from base or advancing margin of lesion.PusAspirate the deepest portion of the lesion or exudate with a syringe and needle.Collect biopsy sample of the advancing margin or base of the infected lesion after excision and drainage.For bite wounds, aspirate pus from the wound, or obtain it at the time of incision, drainage, or debridement of infected wound. (Do not culture fresh bit wounds, as there is generally not yet evidence of infection. These wounds will harbor the resident respiratory microbiota introduced from the bite, but cultures cannot predict if they will cause infections.)Submit as for closed abscesses.Tissue, bone and biopsy samplesCollect sufficient tissue, avoiding necrotic areas. Collect 3-4-mm biopsy samples.Place small pieces of tissue in anaerobic transport vial; place larger pieces of tissue in a sterile container.Collect a 3-5-mm piece of bone without surrounding tissue. Place in a sterile container with sterile nonbasteriostatic saline.Collect swabs only when tissue or aspirate cannot be obtained.Limit swab sampling to wounds that are clinically infected or those that are chronic and not healing.Remove superficial debris by thorough irrigation and cleansing with nonbacteriostatic sterile saline. If wound is relatively dry, collect with two cotton-tipped swabs moistened with sterile saline.Gently roll over the surface of the wound approximately five times, focusing on an area where there is evidence of pus or inflamed tissue.If anaerobic and aerobic culture is indicated also use an anaerobic culture device.NOTE: Organisms may not be distributed evenly in a burn wound, so sampling different areas of the burn is recommended. Blood cultures should be used to monitor patient status. Deliver aspirates and tissues to the laboratory within 30 minutes for best recovery.Keep tissues moist to preserve organism viability. Do not refrigerate or incubate before or during transport. If there is a delay, keep the sample at room temperature, because at lower temperature there is likely to be more dissolved oxygen, which could be detrimental to anaerobes.Subcutaneous tissue and skin specimen collection considerations are summarized in Table 6.TABLE 6: COLLECTION CONSIDERATIONS FOR SUBCUTANEOUS TISSUE AND SKIN SPECIMENSCULTURECOMMENTSBacteriaSyringe aspirates or biopsy specimens are preferable to swabspecimens.AnaerobesUncommon in burn, ulcer, nodules, or superficial skin infections;useful following bites and trauma.FungusUseful in diagnosing dermatophytes, yeast, filamentous fungi, anddimorphic fungi.MycobacteriaUseful in diagnosing Mycobacterium marinum, M. fortuitum, and M. chelonei.VirusUseful in diagnosing HSV and varicella-zoster virus.Note: Rate of recovery of HSV and varicella-zoster virus is highest from the youngest lesions (vesicles), then from pustules, ulcers, and crusted lesions, in that order.Deep wound, aspirate, and tissue specimen collection considerations are summarized in Table 7. CULTURETABLE 7: COLLECTION CONSIDERATIONS FOR DEEP WOUND, ASPIRATES, AND TISSUE SPECIMENSBacteriaBiopsy specimens or aspirates are better than swab specimens.AnaerobesUseful in diagnosing actinomycosis; send in anaerobic transport system.FungusUseful in diagnosing Pseudoallescheria boydii, Bipolaris spp., Exophiala spp., and Fusarium spp.C. Rejection of Unacceptable Specimens1. Policy for rejected specimens (handling and notification):To assure the accuracy, reliability, and usefulness of patient test results, all specimens with orders received in laboratory accessioned on receipt and then examined carefully to establish that required collection, labeling, and transport criteria have been met.If there is a condition that makes the specimen unacceptable, the sender is notified with the reason for rejection. If the problem can be resolved by the sender then accession the specimen, if not the test is canceled and flagged “Not Performed,” and the reason for rejection is entered.If the specimen is on an outpatient, is a surgical specimen, or is a specimen obtained through an invasive procedure, the physician/nurse is notified of the problem by phone. Every effort is made to correct the problem without actually rejecting the specimen.All rejected specimens are refrigerated and held in the laboratory for 1?week before discarding, unless the specimen must be routed to another location for testing.2. Reasons for rejection:Unlabeled/Mislabeled Specimen - Specimens must be labeled with the patient’s name, social security number, and specimen source.No Time of Collection – Call the Ward/Clinic of origin and try and get a collection time. Urine and sputum specimens for routine culture are rejected when no time of collection is noted. Time of collection is critical because growth from these specimens is quantitated, and delay in delivery of these specimens to the lab may result in falsely high quantitation of reported organisms. These specimens are refrigerated and held in the lab for one week before discarding. Specimen Leaked in Transport - When screw cap specimen container lids are not properly seated on the container and tightened, liquid specimens leak presenting a biohazard to the technologist and possibly allowing contamination of the specimen itself. Delay in Transit - When stool specimens (not in a ParaPak system) are delayed for more than 4?hours in transit to the lab, overgrowth of normal intestinal flora occurs, greatly decreasing the chance of recovering enteric pathogens. Duplicate Specimen/Order - Multiple samples of the same specimen source with the same date and time of collection and the same ordered test would not be processed. If multiple cultures are required, they should be collected at different times (i.e., sputums for AFB are best collected on different days using early morning collections).Quantity Not Sufficient - If an insufficient quantity of specimen is received to perform all the tests ordered on a particular specimen, recollection will be requested for those tests not done. If the specimen was obtained through an invasive procedure, the physician will be contacted concerning which tests to perform.Specimen Does Not Meet Lab Criteria - The lab has established criteria for performing certain microbiology tests. If these criteria are not met, testing will not be performed.Only 1 urine specimen for routine C&S will be processed per 24?hours.Only 1 sputum specimen for routine C&S will be processed per 24?hours.Separate samples from the same source with the same date and time of collection will be considered duplicates, and only 1 specimen will be processed. (In some instances, such as sputum specimens for AFB culture, they will be combined and processed as 1 specimen.)Only 1 stool specimen for C. difficile toxin testing will be processed every 72 hours. Culture for enteric pathogens will not be performed on stool specimens from patients who have been hospitalized >3 days without prior consultation.Parasite examination will not be performed on stool specimens from patients who have been hospitalized >4 days without prior consultation. No more than two stool specimens for culture and sensitivity or culture for enteric pathogens per patient per hospitalization or diarrheal episode will be processed without prior consultation.No more than two stool specimens for parasite exam per patient per hospitalization or diarrheal episode will be processed without prior consultation.Specimen Accessioned/No Specimen Received - This may occur when tests on multiple specimens are ordered under the same order number. Usually this represents a lab error in accessioning.Lab Error/Specimen Mishandled by Laboratory - This could be a broken or spilled specimen or may result if a specimen is refrigerated in error (i.e., stool for culture or specimen for anaerobe culture is refrigerated).Specimen collected incorrectly Anaerobic culturesReject if an aerobic swab is submitted.Reject if from an unacceptable bodysite:Throat or nasopharyngeal swabGingival swabsExpectorated sputumInduced sputumBronchoscopic specimensVoided or catheterized urineVaginal or cervical swabsSuperficial material collected form skin surface or edges of wounds.Fecal specimensBlood cultures – labeled blood cultures are not rejected even if medium is expired, volume or number of bottles is insufficient, or bottles were received >12 h after collection. Document the deficiency under the collection comments.Body fluids If only blood culture bottles are received, a Gram stain cannot be performed: cancel the gram stain.Do not submit specimens from drains after they have been infused with antimicrobial agents.Note in the specimen collection comments when fluid specimens are received on swabs. NOTE: Swabs afford the least desirable sample for culture of body fluids and should be discouraged as devices for transport, since the quantity of the sample may not be sufficient to ensure recovery of small number of organisms.Contact the physician if specimen is insufficient for the number of tests requested. NOTE: Routine bacterial culture is sufficient for culture fro Candida species, if blood culture bottles are used or specimen is centrifuged. Fungal cultures of joint and abdominal specimens are occasionally indicated (especially for Blastomysces dermatitidis and Histoplasma capsulatum) but should be discouraged routinely. AFB cultures should not be routine but should be limited to those with a clinical indication.Invasively collected specimens in leaky containers must be processed, but document the possibility of contamination in the collection comments.Catheter tipsDo not accept Foley catheter tips. Cancel culture order.Do not accept catheter tips which arrive in saline or transport medium. Cancel the culture order.Smears of catheter tips add little to the diagnosis of catheter-related sepsis. Cancel Gram stain orders.Skin swabs from the catheter site are not acceptable specimens. Call ward, if there is evidence of local tissue infection, an appropriately collected aspirate of the wound id preferable. Change the culture from a cath tip culture to a wound culture of the cath site.For ventricular-peritoneal shunts, peritoneal or spinal fluid is preferred to the catheter tip. If tip is submitted, culture it, but request submission of fluid.CSF culturesCall the physician to prioritize requests if there is insufficient volume. NOTE: Fungal and AFB cultures of the CSF are infrequently indicated in acute community-acquired meningitis. Since the fungal pathogens in CSF (Cryptococcus neoformans, Coccidioides immitis, and Histoplasma capsulatum) are best and most rapidly diagnosed by serologic methods or cultures of other sites, fungal CSF culture should be discouraged. However, the fungi that cause CSF disease grow will on the media inoculated fro routine culture. Incubate the plates for a longer period. M. tuberculosis is best diagnosed by PCR.Specimens in leaky containers must be processed, document the chance of contamination in the collection comments.Fecal specimensReject stools not in transport medium received >2 h after collection, as changes occur that are detrimental to most Shigella spp. If recollection is not possible and the doctor requests that the stool be processed, set up the cultures and enter a note: “Delay in specimen receipt by laboratory may compromise recovery of pathogens”.If specimen transport medium id delayed for more than 3 days at 4C or is delayed for more than 24 h at 25C, request recollection since yield will be compromised.Reject routine fecal cultures received from patients hospitalized for >3 days, unless the patient is known to be human immunodeficiency virus positive or in cases of cluster epidemic within the hospital.Reject parasitology requests from patients hospitalized for >4 days.Document in the collection comments if the transport vial is filled above the line, indicating that too mush specimen was submitted.If transport vial indicator has turned yellow, reject the specimen, since Shigella organisms are killed at low pH.Do not process hard, solid stools that cannot be sampled for inoculation.Do not process dry swabs.Do not process stools with barium.Reject more than three stools from the same patient in a 3-week period or multiple specimens received on the same day.Do not use specimens submitted in parasitology transport vials for bacteriology cultures. Specimens submitted in Para-Pak C&S vials may be used for parasite screens but not parasite exams sent to the reference lab.Specimens for Clostridium difficile:Must be refrigerated. May be held up to 4 days. If testing cannot be done in this time frame they must be frozen.Rectal swabs are not acceptable. A minimum of 3 ml or 3 g is required.Reject stools that are not liquid or soft.GenitalReject specimens not received in transport medium, since the agents of genital infections lose viability easily.Reject specimens for GC if the transport time was greater than 24h.OcularRequest that a swabbed specimen of the conjunctiva accompany any specimen collected by invasive technique.Even in case of suspected unilateral conjunctivitis, indicate that bilateral bacterial cultures are mandatory.When inoculated plates are delayed in transit, document in the collection comments that the culture may be compromised or contaminated.Lower Respiratory Do not accept repeat cultures at intervals of less than every 48 h.Reject the following specimens for diagnosis of lower respiratory disease.24-h sputum collectionContaminated sputum and endotracheal specimens per Gram stain rejection criteria.SalivaNasal washings and aspirates or swabs of nares.Throat specimensSpecimens for anaerobic culture, except transtrachial aspirates, PSB, biopsy samples, pleural fluid, or other uncontaminated specimens.Specimens delayed in transit more than 2 h without refrigeration, indicate in the specimen collection comment line that the delay in transit may compromise the culture results.Upper RespiratoryBordetella cultureLab must be notified before collection. Reject if prior notification not given.Corynebacterium diphtheriae culturesLab must be notified before collection. Reject if prior notification not given.Nasal swabs are not acceptable except for MRSA cultures.Urines Request the collection time when not provided.Reject specimens when there is no evidence of refrigeration and the specimen is >2 h old.Reject 24-h urine collections.Reject Foley catheter tipsReject urine from the bag of a catheterized patient.Reject specimens that arrive in leaky containers.Except for suprapubic bladder aspirates, reject requests for anaerobes.Wound and Soft tissueReject specimens for microbiological analysis in container with formalin.Reject swabs that have been delayed in transit more than 1 h if they are not in some transport system (CultureSwab or Anaerobic Collection System).For multiple requests (acid-fast, fungal, bacterial, and viral) but little specimen, contact the physician to determine which assays are most important and reject the others as “Quantity not sufficient.”Discourage submission of specimens to determine if an infection is present.REFERENCESBacT/Alert package insert; bioMerieux; Durham, NC; 9/03BBL CultureSwab package insert; Becton, Dickinson and Co.; Sparks, MD; 5/04BBL Vacutainer Anaerobic Specimen Collection package insert; Becton, Dickinson and Co.; Sparks, MD; 8/05Evergreen Sputocol package insert; Evergreen Scientific; Los Angeles, CA; 6/04Instacult package insert, MedTek LLC; Morrisville, NCIsenberg, Henry 2004, Clinical Microbiology Procedures Handbook, American Society fro Microbiology, Washington, DC.No Author, Jacksonville Veterans Hospital procedure manualPara-Pak Systems package insert; Meridian Bioscience, Inc; Cincinnati, OH; 6/03Test Directory for Referral TestingCollection specimens and instructions can be found in VistA and CPRS by utilizing the option “Test Description Information” in VistA and “Lab Test Information” in CPRS.To access “Test Description Information” in VistA”:This option is available on numerous VistA Menu’s. The easiest way to get to the option is to enter “^TEST DESCRIPTION”. This should bring up:Select LABORATORY TEST NAME: (At this prompt enter the name of the test that you are looking for.)Example: Select LABORATORY TEST NAME: C ANTIBODY HEPATITISLab test Highest allowed urgency CostC ANTIBODY HEPATITIS ROUTINE 12.00Synonym: HEPATITIS C ANTIBODY ANTI HEPATITIS C Ab ANTI-HCV HCAb HEPATITIS C Ab HEP C HPC HCVReference Values Ref Low Ref High Critical Low Critical High <--- --->SERUM NEGPLASMA NEGGeneral Ward Instructions:This test is sent to the Little Rock VA.TAT = 2-5 days for NEGATIVE results; 5-10 days for REACTIVE results.Collection Sample VA Lab Slip Container Vol Req(ml)SEND BLD (SERUM/REFR VALR SST/REF 1Ward Instructions:Lab test Highest allowed urgency CostC ANTIBODY HEPATITIS ROUTINE 12.00Ward Instructions:Draw specimen in RED/YELLOW top serum separator tube. Centrifugethe tube for 10 minutes, making sure that the cells are completelyseparated from the serum. After centrifugation place the tube in theLITTLE ROCK box in the refrigerator.CBOCs: Draw specimen in an SST tube. After centrifugation transfer seruman appropriately labeled plastic transport tube and freeze.Select LABORATORY TEST NAME:To access “Lab Test Information” in CPRS:Open up a patient’s file. From “Tools” select “Lab Test Information”:20574001842770From “Tools” select “Lab Test Information”00From “Tools” select “Lab Test Information”b) When the next window appears, enter the test name in the “Lab Test Description” box and then click on the test that you need information on. The information will appear in the area to the right. (Example on next page.)44577001257300Test information appears here.00Test information appears here.1143001714500Select your test from the list.00Select your test from the list.0914400Enter test name here.00Enter test name here.Collection and Submission of Tissue SpecimensProcedure: 301 NOTE: These instructions are required to be kept at all specimen collection locations.Procedure includes the following sections:General requirements for all submissionsRejection of specimensRoutine specimen preparationFrozen section tissue submissionLymph node submissionBone marrow core biopsy and aspirateAmputationTeethKidney or bladder stonesForeign bodyGeneral Requirements for All Tissue Specimens Submitted to Pathology For ProcessingAll specimens must be collected in a manner that insures absolute correct identification.Specimens are to be handled in accordance with MCM 00-14 Universal Body Substance Precautions.All containers must be properly labeled at the time of collection with the following information:Patient’s first and last namePatient’s full social security numberDate and time of specimen collectionSpecimen identification (gastric biopsy, gallbladder, skin of right arm, left lower lung, etc.)All tissue specimens must be accompanied by a Standard Form 515 when sent to the laboratory for processing. This information should match the information on the specimen container. The SF 515 should contain the following information and PLEASE WRITE LEGIBLY—Complete the SF515 form as follows:Date specimen Obtained (Right upper hand corner)Specimen Submitted By (First section on form after date. Who, not where. When this is entered into the computer for login, it will only accept Physician, PA or APN, who are authorized to submit specimens.)Specimen (Section below who submitted. What is the specimen/site? Multiple specimens should be listed with corresponding letter on the individual containers. For Example A, B, etc., not numbers). Be sure the specimen I.D. on the container matches the specimen I.D. on the requisition.When suture is used to mark orientation of specimen, designate the suture location(i. e. 12 o’clock margin)Brief clinical history Preoperative diagnosisOperative findingsPostoperative findingsSignature of Physician, PA or APN (Signature block on right side, middle of page. Please print name and sign)Patient’s identification label (including name, SS #, and date of birth). Place at bottom, left of page in “Patient Identification Section”. If multiple containers, for multiple specimen sites, are being submitted for one patient (all collected at the same encounter) the specimens should be labeled as “A”, “B”, “C” and so on to correlate with the requisition.Each specimen container must be placed in a biohazard bag—be sure specimen container is properly closed and not leaking. Leaking specimens will be reported in the Formalin Leak Specimen Log. The requisition is to be placed in the outside pocket of the bag, and transported to the pathology laboratory for processing. All specimens are entered into a log in surgery with patient information, date and time. The date, time and initials are entered into the log of the person picking up specimens and/or transporting to Histology. Specimens received from CBOCS are time-stamped on the SF 515.Rejection of SpecimensSpecimens will be rejected on the grounds of insufficient patient identification, improper collection and preparation, or without a completed SF515. All efforts will be made to obtain the required information in order to process the specimen. If the specimen is received unfixed or improperly prepared, the submitting physician will be contacted to determine whether or not another specimen can be submitted. All specimens received improperly will be reported in the Specimen Rejection Log.Routine Tissue Preparation:First ascertain that all appropriate cultures (if ordered) have been taken from the tissue sample (before fixative is added). Tissue samples submitted for routine processing (excluding frozen sections) are to be placed into an appropriately sized container with 10% formalin immediately. The ratio of formalin to the size of the tissue should be 20:1 for adequate fixation. If specimens are not properly fixed, drying and/or autolysis may occur which cannot be corrected and the quality of the specimen may not be adequate for diagnosis.All specimen containers must be clearly labeled as required. All specimens must be accompanied by an SF 515, which has been properly filled out. (See “General Requirements” above).Frozen Section Tissue Specimen Submission:The pathologist should be notified a day in advance, or as soon as possible, of a specimen being submitted for frozen section. Tissue specimens for frozen section must be transported, fresh, to the pathologist or histology technician immediately and must be properly labeled. A Standard Form 515 must accompany the specimen for frozen section and must contain the required information as well as the telephone extension number where the surgeon can be reached to be given the frozen section diagnosis by the pathologist. When the frozen section examination is completed the frozen section diagnosis will be phoned directly to the surgeon by the pathologist.Lymph Node Submission:The pathologist must be notified as soon as possible that a lymph node is being submitted for pathological examination. If flow cytometry testing or imprints of the lymph node are desired, the pathologist must be advised before the lymph node is submitted. Lymph nodes for flow cytometry cannot be submitted on Fridays as they cannot be sent to the appropriate testing facility in time to preserve the specimen integrity.Lymph nodes are to be submitted fresh and immediately delivered directly to the histology technician or pathologist. The container must be properly labeled at the time of collection and the accompanying SF 515 must contain the required information. Bone Marrow Core Biopsies and Aspirations:The laboratory must be notified in advance of a bone marrow collection.Bone marrow core biopsies must be submitted in 10% formalin. The container(s) must be properly labeled and accompanied by an SF 515. Bone marrow aspirate slides must be labeled with the patient’s name. Use a lead pencil for labeling the frosted end of the slide. A Medical Technician will prepare the aspirate slides and will give the remainder of the aspiration to the histology technician to prepare an aspirate cell block. Amputations:Amputated limbs are placed in a red biohazard bag without formalin. Specimens are taken to the histology laboratory room. Be sure the specimen is properly labeled and accompanied by an SF 515. Place the SF 515 in a specimen bag and tape to the bag containing the amputation.Do not leave specimen in Pathology department or lab area without contacting someone in the lab.Amputation specimens must be refrigerated.Teeth:Teeth should be placed in a container with 10% formalin. Label container and submit with an SF 515.Gold teeth: Teeth are put in water and the gold is placed in peroxide; the doctor is responsible for taking the gold when he/she leaves the operating room. Label container and submit with an SF 515.Kidney or Bladder Stones:Stones should be submitted in a container, dry. After gross examination by the pathologist, the stone(s) will be sent for chemical analysis. Label container and submit with an SF 515.Foreign Body:Foreign body specimens, such as wire, screws, bullets, etc. should be submitted in a container, dry. Label container and submit with an SF 515.Frozen Section Procedure and Quality AssurancePrincipleIntraoperative frozen sections are performed to provide information to surgeons that may dictate intraoperative and immediate post-operative clinical decisions.Collection and TransportThe pathologist should be notified a day in advance, or a soon as possible, of a specimen being submitted for frozen section.The specimen is delivered fresh to the laboratory with proper patient identification on the specimen container and completed SF515, including the telephone extension where the surgeon can be reached.ProcedureThe pathologist selects tissue for examination and places on the cryostat, then covers specimen with OCT. Tissue is cut within the cryostat by the pathologist and transferred to glass slides. Fixation and staining is performed via the following sequence:95% alcohol for 15 seconds.Rinse in tap water 10 seconds.Dip in Hematoxylin 45 seconds.Rinse in tap water until excess Hematoxylin is removed.Dip in Bluing Reagent 5-10 seconds.Dip in Eosin until desired staining is achieved.Dip in 70% alcohol for 5 seconds.Dip in 100% alcohol for 5 seconds.Dip in 100% alcohol for 5 seconds.Dip in Clearrite for 5 seconds.Dip in Clearrite for 5 seconds.The slide is coverslipped and interpreted by the pathologist. The pathologist speaks directly to the surgeon when reporting the diagnosis, with the surgeon repeat back the interpretation.The remaining frozen tissue is submitted for processing and permanent section preparation. The frozen section slides are re-examined with the permanent slides and filed with rest of the case.Frozen Section Documentation and Quality AssuranceThe following information is documented in the Frozen Section Logbook: Patient nameAccession number.Start timeEnd timeDiagnosis.The frozen section diagnosis is also documented within the final pathology report, and discrepancies between the frozen section diagnosis and final interpretation are noted. These discrepancies are reviewed at Tissue Committee. Turnaround times are also reviewed at Tissue Committee.90% of frozen sections are to be completed within 20 minutes. Cytology Specimen Collection and Submission GuidelinesPrincipleCollection methods must ensure maximum cell preservation and recovery for optimal cytologic evaluation. Proper specimen collections require that specimen integrity is maintained by proper preservative where required, sample identification and patient identification is clearly labeled on the specimen container, and the sample is properly transported to the clinical laboratory in a timely manner. The information listed below is to assist with that objective. ProcedureGeneral Consideration Safety Specimens are to be handled in accordance with VHSO Medical Center Memorandum, XX-00-14, “Universal (Standard) Procedure and Transmission Based Precautions”. Use appropriate barrier protection (such as gloves and laboratory coat or gown) when collecting or handling specimens. If splashing may occur, protective eyewear, face masks, and aprons may be necessary.Minimize direct handling of specimens in transit from the patient to the laboratory. Use plastic zip-lock biohazard bags with a separate pouch for the laboratory requisition orders.When specimens are obtained by a physician using needle aspiration, the specimen may be submitted to the laboratory in the capped syringe without the needle. Ideally, however, smears should be prepared at the patient’s bedside along with flushing of the needle/ syringe into a Thin Prep vial containing CytoLyt Solution.General guidelines for proper specimen collectionSpecimen containers must be properly labeled at the time of collection with the following information:Patient’s full namePatient’s social security numberDate and time of specimen collectionSpecimen source (anatomic site)Multiple specimens from the same source should be labeled “A”, “B”, “C”, etc., for the different collection procedures used (e.g., “A. Bronchial Brushing and “B. Bronchial Wash”) Utilize appropriate collection devices and transport containers.Screw-Cap Containers (Sterile Cups): Obtain from SPD or laboratory. It is essential that these cups are leak proof. Be sure the caps are screwed on tightly and securely. These are best used for sputum, urines or other body fluids. Evacuated containers and drainage bags: Obtain from SPD. The containers must be leak proof. These are used for large volumes of fluids. Lumbar puncture specimen vials: Obtain from SPD. These conical vials are contained in the lumbar puncture tray and are used for Cerebrospinal Fluid.Thin Prep vials: Useful for collection of brushings and the flushing of the syringe/ needle from FNA (CytoLyt Solution) and gynecological materials (PreservCyt Solution). Obtain from laboratory. WARNING: PreservCyt and CytoLyt Solutions are poisonous (contains methanol) and it must never come in direct contact with the patient.Thin Prep Sample Collection Kit: Useful for obtaining cervical cytology. Collection device can either be the endocervical brush/spatula or the Papette (broom). Obtain from laboratory.Air dried slide: Must be labeled with the patient’s last name, first initial and last four of the social security number with hard lead pencil. Slide is submitted in a slide transport container.All non-gynecological body fluid specimens must be accompanied by a Standard Form 515 when sent to the laboratory for processing. The SF 515 must contain the following information:Specimen submitted by (physician name and location)Date obtainedSpecimen type (multiple specimens should be listed with corresponding letter on the individual containers)Brief clinical history Preoperative diagnosisOperative findingsPostoperative diagnosisSignature of submitting physicianPrinted name of submitting physicianTitle of submitting physicianName of patientIdentification number (SSN)GenderDate of birthAll gynecological specimens must be accompanied with a Standard Form 541 when sent to the laboratory for processing. The SF 541 must contain the following information:Name of patient and social security numberPatient’s age and/or date of birthDate of collectionSource of material (cervix, endocervix, vagina)Healthcare provider’s name and locationLMP first dayPregnancyGravida/ParaPrevious abnormal cytologyPhysical examination (pelvic findings, etc.)Clinical history (surgery, drugs, hormones, radiation, etc.)Each specimen container must be placed in a biohazard bag with the requisition in the outside pocket of the bag and transported to the laboratory for processing. All specimens brought to the laboratory will be time-date stamped upon delivery. The time-date stamp should be placed on the SF 515 and SF 541.Non- gynecologic specimens collected for cytological examination must be sent to the laboratory immediately after collection and processed immediately after receipt in the laboratory. If unable to process specimen immediately, the specimen is placed in the refrigerator to slow down cellular deterioration.Cell blocks will be made from submitted body fluids whenever possible. Routine stains will be performed on all specimens submitted for cytological examination. Special stains, if necessary, will be ordered by the pathologist.Specimens are received only from licensed, authorized sources such as physicians, nurse practitioners and physician assistants that are associated with the VHSO.Collection instructions for different anatomic sites Genital Tract SpecimensGeneral considerationsPatient should be advised to schedule her gynecological examination two weeks after the first day of her last menstrual period and preferably not when she is menstruating.Patient should not use vaginal medication, vaginal contraceptives, or douches during the 48 hours before the appointment.Intercourse is not recommended the night before the examination.Lubricant jellies should not be used to lubricate the speculum.Remove excess mucus or other discharge present with folded gauze pad before taking the sample.The cervix should not be cleaned by washing with saline or it may result in loss of cellular material.The sample should be obtained before the application of acetic acid.Instructions for using Thin Prep Sample Collection Kits with Thin Prep vials containing PreservCyt SolutionCollection using the Papette (broom) deviceObtain an adequate sampling from the cervix using the Papette. Insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix. Push gently, and rotate the broom in a clockwise direction five times. Rinse the broom as quickly as possible into the PreservCyt Solution by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. Swirl the broom vigorously to further release material.Discard the collection device.Tighten the cap so that torque line on the cap passes the torque line on the vial.Collection using the endocervical brush/spatula deviceObtain an adequate sampling from the ectocervix using the plastic spatula, then rinse as quickly as possible into the PreservCyt Solution by swirling the spatula vigorously in the vial 10 times.Discard the spatula.Obtain an adequate sampling from the endocervix using an endocervical brush device. Insert brush into the cervix until only the bottom-most fibers are exposed. Slowly rotate ? or ? turn in one direction. DO NOT OVER-ROTATE.Rinse the brush as quickly as possible in the PreservCyt Solution by rotating the device in the solution 10 times while pushing against the PreservCyt vial wall.Swirl vigorously to further release material.Discard the brush.Tighten the cap so that the torque line up on the cap passes the torque line on the vial.Body Fluids: Pleural (Thoracic), Peritoneal (Ascites), Pericardial, Cyst, and SynovialGeneral considerations:Preferred specimen volume is 20 - 50 mL. Large volume specimens requiring multiple tests should be sent to the different departments (i.e., Microbiology, Hematology, and Chemistry, etc.) in separate tubes.Small specimens that require multiple tests may be sent in one tube. The tube should be sterile if a culture is ordered. All specimens should be promptly refrigerated to retard cellular degeneration and transported as soon as possible to the laboratory.WashingsWashing should be collected in balanced salt solution (e.g., Ringer’s).Submit specimen in a clean container.Cerebrospinal Fluid Cell preservation is very important. Fresh specimens are preferred.A minimum of 1 mL of CSF should be collected; 2 to 3 mL is preferred.One tube of CSF should be sent to cytology laboratory, a separate tube should be sent for other chemistry tests or culture whenever possible. Each tube should specify which department for routing.The tube and requisition should be clearly marked when one single tube is ordered for different tests.Specimen should be refrigerated.Lesion SpecimensTouch preparationsTouch preparations are obtained from surgical specimens, lymph nodes, and exposed body surfaces such as wounds, lesions, open vesicles or sores.These slides are prepared by touching a wet tissue with a glass slide; cells adhere to the glass as they exist on the surface of the lesion. Slides must be labeled with the patient’s last name, first initial and last four of the social security number with hard lead pencil.Slides may be air-dried or wet-fixed by immersion into a Thin Prep vial containing CytoLyt Solution.Tzanck smear Certain viral infections can be recognized on cytologic preparations made directly from a lesion, such as:CytomegalovirusHerpes Simplex and Herpes ZosterHuman PapillomavirusCotton swabs or other similar material should not be used.Direct scrape procedure is preferred.Procedure for Tzanck smearChose a fresh vesicle that has not been ruptured or crusted. Lesion is premoistened with saline. With a disposable needle, carefully open the fresh vesicle or remove the crust from a ruptured lesion.Using the edge of a metal spatula, scalpel blade, or glass slide, scrape the margin of the lesion. The edges of the lesion will have the best yield of cells.Transfer obtained material onto a microscopic slide. Place a second microscopic slide on top of the slide containing the specimen. Using a minimum amount of pressure, pull the slides apart horizontally.Place the two smears back-to-back and immediately place into the Thin Prep vial containing CytoLyt Solution. The smears may also be allowed to air dry and submitted in a slide transport container.The scraping tool may be rinsed in Thin Prep vial containing CytoLyt Solution and submitted to the laboratory.The smears should be labeled with the patient’s last name, first initial and last four of their social security number.Ocular AreaSince only small volumes of fluid are recovered, the specimen should be sent to the laboratory, for immediate processing.Respiratory TractGeneral considerationsCell preservation is very important. Fresh specimens are preferred.Transport specimens to the laboratory quickly to maximize cell preservation.Specimen integrity is maintained for approximately four hours at room temperature (22°C).If the specimen is delayed for more than 4 hours, refrigerate the specimen at 2 - 8°C.Do not use Sacomanno or other solutions containing carbowax.Expectorated sputumThe patient should be instructed to clear the throat of postnasal secretions by gargling and rinsing the mouth to remove food residue.Sputum should ideally be an early morning or “first cough” specimen. Patient is instructed to cough deeply (from the diaphragm) and expectorate all sputum into the clean cup.Patient continues the deep coughing and expectoration until the specimen is collected, or for 30 minutes.Immediately take the sputum collection to the laboratory.The procedure should be repeated once a day for three consecutive days to improve the yield of cytology detections.Label consecutive specimens with #1, #2 and #3, corresponding to the collection dates.Induced sputum – These specimens are collected by respiratory therapy.Induced sputum is recommended if unable to collect expectorated sputum after 30 minutes of vigorous coughing. After breathing the aerosol mist for three minutes, instruct the patient to cough deeplyThe expectorated material is collected in the clean cup.This procedure is repeated until the specimen is collected, or for 30 minutes.Immediately take the sputum collection to the laboratory.The procedure should be repeated once a day for three days to improve the yield of cytology detections.Label consecutive specimens with #1, #2 and #3, corresponding to the collection dates.Bronchoscopy specimens - These specimens are collected by a physician.Bronchoscopy specimens include bronchioalveolar lavage (BAL), bronchial wash, and bronchial brush.The bronchioalveolar lavage (BAL) is collected from the distal respiratory bronchioles and alveoli. The Bronchial wash is collected from the major airways which is the same area sampled by an endotracheal aspirate. Washing should be collected in balanced salt solution (e.g., Ringer’s).Submit specimen in a clean container. The Bronchial brush specimen is collected from the airway wall. After collecting specimen from endoscopy, cut the end of the brush approximately 1.5 inches and place the entire brush tip into the Thin Prep vial containing CytoLyt Solution.PrecautionsTo avoid excess blood in the recovered fluid, obtain bronchial wash and BAL before brushing or biopsy.Avoid suctioning through the working channel before retrieval of specimens to avoid contamination of the specimens.Avoid the injection of topical anesthetic agents as much as possible, as the injection method may lead to contamination of the specimen. Aerosol application of anesthetic agents is preferred.Urinary TractGeneral considerations The ideal specimen is a clean catch from the second urination of the morning, preferably following ingestion of several glasses of water. First morning or 24 hour collection urines must never be collected as the cells lie in the acidic urine for extended periods and undergo extensive degenerative changes. Urine collected by catheterization or suprapubic bladder puncture is acceptable; however, to avoid false positive results indicate any instrumentation collection on the Standard Form 515. Urine specimensInstruct the patient on the proper collection of midstream clean catch urine. The specimen should be at least 50-100 mL, but a smaller amount can be examined, if necessary. The specimen must be refrigerated immediately after voiding and the collection should be timed so that transportation to the laboratory will be within 24 hours. The specimen is collected in sterile screw-capped labeled container without fixative. Ensure that lids to these containers are screwed on securely and tightly to prevent leakage of the specimen during transport. Bladder WashingsBladder washings are collected by the urologist at cystoscopy by introducing a balanced salt solution via a larger volume syringe which is connected to the port of a cystoscopy device or catheter.The fluid is usually withdrawn and reinjected with a moderate amount of force to dislodge epithelial cells. The resultant fluid is then sent to the laboratory.The specimen is collected in a labeled container without fixative. The specimen must be refrigerated immediately. Breast SecretionBreast cancer may be the reason for an unexpected nipple discharge, especially if the discharge contains blood. Examination of the discharge may yield a rapid diagnosis.Collection Gently express the nipple and subareolar area only using the thumb and forefinger.Allow “pea-size” drop of fluid to collect upon the nipple tip.Note: If no secretion appears at the nipple with this gentle compression, do not manipulate further.Immobilize the breast and using the nipple, smear the material across a slide.Immediately drop the slide into the Thin Prep vial containing CytoLyt Solution.Repeat the complete procedure until all available secretion is used. The slide should be labeled with the patient’s last name, first initial and last four of their social security number. Submit slides in a slide transport container.Fine Needle Aspiration (FNA)Fine Needle Aspiration (FNA) is a non-invasive procedure to obtain cell sample from a suspicious lesion for cytological examination to determine the true nature of the mass.In general, FNA is used for palpable masses, such as breast masses, thyroid nodules, parotid masses and enlarged lymph nodes, etc.Upon request, the pathologist will perform the FNA on a palpable lesion.Any privileged physician may perform an FNA.Appointments are arranged for the pathologist to be present during the radiological or ultrasound examination before the FNA is performed.Rejection of Unacceptable SpecimensSpecimens that are received unlabeled, improperly labeled, or without a completed SF 515 or SF 541 may be rejected and returned to the point of origin. This may cause an unnecessary delay in the process of the specimen.ReferencesCLSI. Nongynecologic Cytologic Specimens: Collection and Cytopreparatory Techniques; Approved Guideline; GP23-A, Vol. 19 No. 14; Clinical Laboratory Standards Institute; Wayne, PA; 1999-08.CLSI. Papanicolaou Technique; Approve Guideline – Second Edition; GP15-A2, Vol. 21 No. 17; Clinical and Laboratory Standards Institute; Wayne, PA; 2001-11.ThinPrep 2000 System Operator’s Manual. Cytyc Corporation; Marlborough, MA. Manual Number 71005-001. Revision C.00, 2006.Interpretive Guidelines for Selected TestsHeparin Reference RangesReference range for patients on heparin anti-coagulation:PTT: 48.0 – 100.0 secondsHeparin therapeutic ranges:0.1 - 0.3 u/mL = 48 - 65 seconds 0.3 - 0.7 u/mL = 65 -100 secondsLipid Profile InterpretationTestDesirableBorderlineIncreased RiskCHOL<200 mg/dL200-240 mg/dL>240 mg/dLTRIG<150 mg/dL150-199 mg/dL200 + mg/dLHDL>=60 mg/dL35-59 mg/dL<35 mg/dLLDL<130 mg/dL130-160 mg/dL>160 mg/dLLDL(Known CAD)<100 mg/dL100-130 mg/dL>130 mg/dLOral Anticoagulant Therapy GuidelinesSuggested Therapeutic Guidelines for Oral Anticoagulant (Warfarin) Therapy*Prevention of DVT INR 2.0 - 3.0 (deep vein thrombosis)Acute MIINR 2.0 - 3.0Peripheral Arterial DiseaseINR 2.5 - 3.0Atrial fibrillation INR 2.0 - 3.0Cardiac valve replacementTissue valves INR 2.0 - 3.0MechanicalINR 2.5 - 3.5Antiphospholipid antibodySyndrome INR 2.5 - 3.5(recurrent DVT or arterial thrombosis)*Guidelines adapted from published statistics "Chest Vol. 102, Oct. Suppl."Certain cases will require individualized target ranges for anticoagulant combined with other therapeutic agents (aspirin or other antiplatelet drugs).The INR should be used to monitor stably anticoagulated therapy with reproducible Prothrombin Time. IMMUNOLOGIC COMPLICATIONSType of Complication Description of Complication Risk per unit of bloodAcute Hemolytic Red cell incompatibility causing chills, 1:70,000 - 1:38,000 Transfusion Reaction fever, back pain, pain and oozing at IV site, resulting in kidney damage. Fatal Acute Hemolytic Severe Acute Hemolytic Reaction resulting in 1:100,000,000 Transfusion Reaction death.Delayed Hemolytic A gradual breakdown of red blood cells, 1:11,000 - 5,000 Transfusion Reaction resulting in weakness, high bilirubinFebrile Non-hemolytic Fever, headache, vomiting (lessened 1:200 (Red cells) Tranfusion Reaction with leukocyte reduction) 1:100 (Platelets) Allergic Reaction Rash, itching and hives (welts). 1:33 - 1:100Anaphylactic Reaction Very severe allergic reaction that can cause 1:50,000 – 1:20,000 shock and death.Alloimmunization Immune response to RBC antigens 1:100 (delayed risk)Transfusion-Related Acute Leakage of fluids into alveolar spaces usually 1:190,000 – 1:5,000 Lung Injury (TRALI) within 6 hours of transfusion, leading to respiratory failure and hypotension NON-IMMUNOLOGIC COMPLICATIONSType of Complication Description of Complication Risk per unit of bloodCirculatory Overload The heart is not able to pump the blood, resulting less than 1:100 severe shortness of breath, high heart rate, cough with pink sputum, headachePost Transfusion Purpura Sudden decrease in platelets 7-10 days after rare (PTP) transfusionGraft vs Host disease (GVHD) Rejection of one’s one cells rareHypothermia Sudden chills, arrhythmia high volumes of rbs in a short time IINFECTIONS CARRIED BY BLOODInfecting agent Type of Infection/Symptoms Risk per unit of bloodHepatitis B Either acute (causing nausea, vomiting 1: 63,000 and jaundice) or chronic (which can lead to cirrhosis and liver failure)Hepatitis C Same as Hepatitis B chronic 1: 600,000Hepatitis A Same as Hepatitis B acute 1: 100,000HTLV I and II T-cell lymphoma-leukemia , neurology 1: 641,000 HIV AIDS 1: 9,000,000Cytomegalovirus Hepatitis or pneumonia in non-immune Risk is low if not a transplant transplant patients. Mono-like symptoms recipient in others. Bacterial Contamination Fever, shock 1:1,000 (rbc) 1:2,000(platelets)Malaria Fever, chills, headache and hemolysis 1:1,000,000 Babesia Chills, headache, hemolysis, blood in urine 1:1,000,000 (1:1800 for NE USA)Parvovirus Severe anemia in patients with certain 1:40,000-3,300 hemolytic disordersCJD Degenerative brain disorder theoreticalReferences: 1. American Association of Blood Banks Technical Manual, 14th edition, 2002. 2. “Infectious Risks of Blood Transfusions” Blood Bulletin of America’s Blood Centers, December, 2001. 3. Circular of Information; American Association of Blood Banks, America’s Blood Centers American Red Cross, July, 2002.Post Vasectomy Semen Analysis, Appendix APost Vasectomy Sample Collection Instructions and Delivery FormUrology Clinic Contact Number for any questions: 479-443-4301, ext 5693Patient Name: _________________SS#: _________________________ Label in this box →Semen Analysis, Post VasectomyOrder Number _______________Delivered to Lab within 8 hours? Yes NoTime collected: _______________Test Instructions for Post Vasectomy Patient:1. Do not collect sample for post vasectomy testing until you have had 12 – 15 ejaculations, as instructed by your Urology Clinic doctor.2. TEST SAMPLE: Collection of Post Vasectomy Semen for Testing a. Do not have sex or ejaculate for 2 – 5 days prior to collecting sample that will be tested. b. Masturbate, but do not use lubricants, gels or condoms. c. Ejaculate complete specimen into cup provided. d. Be sure your name and ID Number are on the sample cup.3. Deliver sample (within 8 hours of collection) with form to the Fayetteville VA Hospital laboratory, 2nd floor, Rm 212 and give sample to laboratory employee. ................
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