Procedure Manual For Long Term Care Facilities Test Ordering & Specimen Collection

Transcription

1 Procedure Manual For Long Term Care Facilities Test Ordering & Specimen Collection December

2 Table of Contents 1. Introduction 2. Phone Numbers 3. Panel Descriptions 4. Patient Identification 5. Label Request Guidelines 6. Laboratory Requisitions 7. Stat Lab Work 8. Must Call Results 9. Specimen Refrigerator 10. General Specimen Collection Procedures 11. Routine Urinalysis 12. Urine for Culture and Sensitivity 13. Midstream Clean Catch Urine 14. Straight Catheter Specimen 15. Foley Catheter Specimen Hour Urine 17. Stool Specimens 18. Clostridium difficile 19. Stool for Occult Blood 20. Sputum Culture 21. Wound Culture 22. Throat Culture 23. Eye Culture 24. Methicillin Resistant Staphylococcus Aureus 25. Vancomycin Resistant Enterococcus 26. Extended Spectrum Beta Lactamase producing bacteria 27. Carbapenem Resistant Enterobacteriaceae 28. Influenza Rapid Test 29. Norovirus (Norwalk Like Virus)

3 Introduction This manual provides information to facilitate the processing of our mutual patients testing needs. Communication is the key to providing quality patient care and this manual is not meant to replace personal contact. If at any time there are questions, suggestions, or a need for clarification, we encourage and welcome your call. East Side Clinical Laboratory is fully accredited by the College of American Pathologists. Laboratory testing methods are determined by the Clinical and Laboratory Standards Institute and the American Society of Microbiology. P a g e 1 29

4 Telephone Numbers BOOKINGS (401) Monday Friday 7:30 AM 5:00PM After 5:00PM and on weekends, calls to connect directly to our answering service. The service contacts the on-call phlebotomist(s) available for stat work. Advance bookings are best done during normal business hours. TEST RESULTS... (401) Monday Friday 6:00 AM 11:30PM Saturday 8:30 AM - 5:30 PM Internet access for test results (password required) is also available. For instructions and password.... (401) SUPPLIES... (401) PRINTER/FAX ISSUES....(401) PATIENT LABELS (401) (prompt 1) ACCOUNT REPRESENTATIVE... (401) INFECTION PREVENTION CONSULTANT.. (401) EMERGENCY ALTERNATE ANSWERING SERVICE NUMBER ** (401) ** **This is a backup number to be used only after reasonable attempts to reach the answering service have failed. This is their direct line. PLEASE USE ONLY AFTER ATTEMPTING TO REACH US THROUGH THE REGULAR NUMBER. P a g e 2 29

5 Panel Descriptions COMPREHENSIVE METABOLIC PANEL CPT HEPATIC FUNCTION PANEL CPT LIPID PANEL CPT RENAL FUNCTION PANEL CPT BASIC METABOLIC PANEL CPT ELECTROLYTE PANEL CPT ACUTE HEPATITIS PANEL CPT ALBUMIN TOTAL BILIRUBIN CALCIUM CARBON DIOXIDE CHLORIDE CREATININE GLUCOSE ALKALINE PHOSPHATASE POTASSIUM TOTAL PROTEIN SODIUM AST (SGOT) ALT (SGPT) UREA NITROGEN (BUN) CALCULATIONS: no charge BUN/CREAT RATIO GLOBULIN A/G RATIO OSMOLALITY egfr ALBUMIN BILIRUBIN, TOTAL BILIRUBIN DIRECT PHOSPHATASE, ALKALINE PROTEIN, TOTAL AST (SGOT) ALT (SGPT) CHOLEROL HDL CHOLESTEROL TRIGLYCERIDES LDL ALBUMIN CALCIUM CARBON DIOXIDE CHLORIDE CREATININE GLUCOSE PHOSPHOROUS POTASSIUM SODIUM UREA NITROGEN (BUN) CALCULATIONS: no charge BUN/CREAT RATIO CALCIUM CARBON DIOXIDE CHLORIDE CREATININE GLUCOSE POTASSIUM SODIUM UREA NITROGEN (BUN) CALCULATIONS: no charge BUN/CREAT RATIO OSMOLALITY egfr SODIUM POTASSIUM CHLORIDE CARBON DIOXIDE HEPATITIS A ANTIBODY, IGM HEPATITIS B CORE ANTIBODY, IGM HEPATITIS B SURFACE ANTIGEN HEPATITIS C ANTIBODY P a g e 3 29

6 Patient Identification Two identifiers are required for patient and specimen identification. This laboratory policy is based on requirements from The College of American Pathologists (CAP), our accrediting body. Preferred identification is a wristband with patient name and date of birth. A location (e.g. room number) is not an acceptable identifier. For patients in long-term-care facilities, if the patient is wearing a wristband with more than the name as an identifier, the wristband is used for positive identification. Otherwise, a multi-question identity check is attempted, and if the patient is judged to be of questionable competence, then a member of the facility staff is asked to make the identification. The phlebotomist handwrites the patient name and date of birth on each tube. P a g e 4 29

7 Patient Label Request Guidelines Upon patient admission, please complete the New Patient Label Request form. Submit the completed form via fax to Labels will be printed and mailed to your facility. If labels are not received in one week, please contact the Road Team at (prompt 1). Upon receipt, please check labels for accuracy. If there are errors, please call the Road Team at (prompt 1) with the correction and new patient labels will be printed. PLEASE DO NOT USE INCORRECT PATIENT LABELS as this can lead to billing and reporting errors. Accuracy is vital. CAUSES FOR DELAY IN PROCESSING: Any missing information will delay the processing of patient labels. Please provide all of the requested data, including the full name of the facility. Please do not use abbreviations. Please be sure to include the first and last name of the patient s physician. Illegible handwriting. *Please be sure to print legibly. DECEASED/DISCHARGED/TRANSFERRED PATIENTS: If a patient expires, or is discharged permanently, discard the Patient Labels. If a patient is hospitalized, please retain the labels until return status is determined. If the patient is transferred to a different floor or unit, please transfer the patient labels as well. P a g e 5 29

8 Laboratory Requisitions For your convenience, a Lab Order Book is available to organize requisitions and provide a phlebotomist signature log. This large binder (one for each nursing unit), contains tabs for each day of the month and is prepared by the nursing staff. The phlebotomist signs in and removes the prepared requisitions. Before leaving, she/he records the number of draws and the number of specimens picked up. If your facility would like Lab Order Books, please call the account representative at (401) Follow the directions printed on the back of each requisition. Additional Information: ALWAYS USE THE PATIENT LABELS. Do not place the labels over the bar-coded portion of the requisition. Print first and last name of the physician. Hand write (Print) a slip only if the patient labels are not available. If hand written, complete all fields in the upper left hand corner of the requisition, including first and last name of the patient. Date of birth is essential for accurate patient identification. Please include insurance information for new patients or if insurance has changed. Clearly mark the tests being ordered. Using a red pen is very helpful. When a culture is ordered, ALWAYS INDICATE THE SOURCE. For urine cultures, check off the method of collection. If a test is needed which is not printed on the slip, please hand write the full name of the test in the Other Tests space at the bottom right of Part 3. When a patient is having blood drawn multiple times on the same day, separate slips for each time are required. Always provide diagnosis codes. The most frequently used codes are listed in Part 2 and should be checked off when the requisition is filled out. Other common diagnosis codes are listed on the back of the requisition. **Reminder - Bloodwork needed at a time other than the morning draws, as well as bloodwork on off lab days must be booked in advance. These advance bookings should be called in during normal business hours. P a g e 6 29

9 Stat Lab Work The following tests are available on a stat basis. This list applies to nights, weekends and holidays. Tests ordered that are not on this list, or that are ordered in conjunction with tests on this list will be performed on the next working day. During regular laboratory hours we will do our best to accommodate your needs on an individual basis. AMMONIA CHLORIDE DIGOXIN POTASSIUM AMYLASE CKMB DILANTIN PT/INR BLOOD CULTURES CO2 GLUCOSE PTT BNP CPK IONIZED CALCIUM SODIUM BUN CREATININE LIPASE TROPONIN CBC D-DIMER PLATELET COUNT VANCOMYCIN *URINALYSIS *URINALYSIS is available as a stat only if the physician is waiting for results before ordering an antibiotic. Otherwise, all urine specimens will be picked up the following day. 1. Please print the word STAT at the top of a completed requisition. 2. Call After normal office hours (M-F, 7:30am 5:00pm), connects to the answering service and the on-call phlebotomist will be dispatched. 3. Stat results are called to the facility and must be given verbally to a person (not voice mail). 4. A hard copy (printed or faxed) is also sent immediately. P a g e 7 29

10 ESL-CSD-P Title: Must Call Critical List CLIENT SERVICES ESCL MUST CALL CRITICAL RESULTS Value stated and less than Value stated and greater than Amylase 400 Calcium 6 13 CKMB Male 7.8 Female 4.4 CO CPK 400 Creatinine 5 CSF All Results (Cerebral Spinal Fluid) Cultures All Positives Acid Fast Culture Blood Cultures Stool Culture*E-Coli 0157* D-Dimer 0.51 Glucose Hemoglobin 7 Malaria/Babesia on peripheral smear Call/page all positive or suspicious results Platelet 20,000 1,000,000 Potassium Potassium (heparin) PT/INR 5 INR PTT 70 Sodium Therapeutic Drugs Digoxin 3 Dilantin 30 Lithium 2.0 Phenobarbital 50 Total Bilirubin 5 Troponin Call/page if abnormal WBC-Adult/child P a g e 8 29

11 Specimen Refrigerator A specimen refrigerator is provided by East Side Clinical Laboratory for the sole purpose of storing specimens until picked up by a laboratory employee. No other items (medication, food etc.) should be placed in this refrigerator. Refrigerate ALL specimen cups and vacutainers immediately after collection. This includes stools for Clostridium difficile, and stools for ova and parasites (O&P). Do not refrigerate bactiswab (eswab) or select occult blood cards. Keep these at room temperature before and after specimen collection or specimen may be unsuitable for testing. Refrigerator temperature should be checked daily by a facility employee. Unit Temperature Refrigerator 2 8 C ( F) Freezer C ( F) P a g e 9 29

12 General Specimen Collection Procedures 1. Prepare requisition form with patient label. Date on form should be date of specimen collection, not date the order was received. Check off tests being ordered. 2. Urinalysis is listed in Part 4, second column. Cultures are listed in Part When ordering a urine culture, be sure to check off the method of collection. 4. Identify the patient and explain procedure. 5. Wash hands before and after specimen collection. 6. Wear gloves during specimen collection. 7. Handle specimen containers carefully - touch only the outside to avoid contamination. 8. Collect specimen. (Specific procedures are outlined on the following pages.) 9. Replace caps securely to prevent leakage. 10. Label specimen container with patient label; if handwritten includes first and last name and date of birth. Add source of culture and date & time specimen was collected. Bactiswab (eswab) must be labeled on plastic tube, not outer packaging. 11. Place container in biohazard bag with requisition in outer pocket. Please keep specimen cups upright. 12. Refrigerate ALL specimen cups and vacutainers immediately after collection. This includes stools for Clostridium difficile and stools for ova and parasites (O&P). DO NOT refrigerate Bactiswab (eswab) or occult blood cards. Keep these at room temperature before and after specimen collection or specimen may be unsuitable for testing. P a g e 10 29

13 Routine Urinalysis REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: 8 ml in yellow-top vacutainer from midstream kit (preferred) OR ml in sterile cup with blue cap The best urinalysis specimen is the first morning void or urine that has been in the bladder for at least 4 hours. Peri-care before specimen collection helps to prevent contamination. 1. Remove blue cap from the cup - place on a clean surface with inside of cap facing up. 2. Have resident urinate directly into sterile cup. 3. Place the cup on a clean, flat surface and replace blue cap securely. Carefully peel back the white label on the cap, exposing the sampling device. This device is a sharp! 4. Remove the yellow-top vacutainer tube from the package. Fill vacutainer by placing the end with the rubber stopper over the sampling device. Press down on the vacutainer until the device has pierced the stopper. The vacutainer will draw 8ml of urine. Hold the vacutainer tube in position until the flow of urine has stopped. (If culture & sensitivity has also been ordered, fill the grey-top vacutainer first; see page 12.) 25cc of urine in the specimen cup is necessary for both vacutainers to fill. (1cc=1ml) 5. Remove the yellow-top vacutainer and label immediately. 6. Refrigerate yellow-top vacutainer until picked up by the laboratory. The specimen must be received by the laboratory within 24hrs of collection to ensure specimen integrity. 7. Carefully replace the white label on the blue cap. If there is insufficient urine to use the vacutainer, send the urine in the specimen cup (properly labelled). This container must be refrigerated and received laboratory within 24 hrs. to ensure specimen integrity. P a g e 11 29

14 Urine for Culture & Sensitivity Cultures are appropriate when a patient is symptomatic of an infection. Using guidelines from the Clinical and Laboratory Standards Institute and The American Society of Microbiology, the laboratory will work up one or two urinary tract pathogens in colony counts of 10,000 or greater. This work up includes organism identification and antibiotic sensitivities. Organisms present in smaller numbers, as well as normal flora, will not be worked up. To properly process all urine cultures, it is essential that the following information be on the requisition: Method of collection (clean-catch, straight cath, foley, suprapubic, other) Antibiotics the resident is receiving Relevant symptoms (temp, pain etc.) If the method is not indicated, the urine will be processed as a clean- catch specimen. The preferred container for a urine culture is the grey top vacutainer in the midstream specimen kit (collection procedures on following pages). If the vacutainer cannot be used, the sterile cup in the midstream kit will be accepted. P a g e 12 29

15 Midstream Urine REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: 4ml in the grey-top vacutainer from the midstream kit for culture 8 ml in the yellow-top vacutainer for urinalysis Peri-care prior to collection reduces contamination 1. Use bedpan, commode, toilet or urinal dependent on functional level and cooperation. 2. Remove cup with blue cap and towelettes from kit. Unscrew blue cap and place on clean surface with inside of cap facing up. Open towelettes. 3. Female *Open the labia with one hand and keep them open until specimen is obtained. *Cleanse one side of exposed area with first towelette, wipe front to back. Discard. *Cleanse other side of exposed area with second towelette, wipe front to back. Discard. Male *If patient is not circumcised, hold foreskin back before using towelettes. *Cleanse head of penis with first towelette, circular motion, one direction only. Discard. *Repeat with second towelette; be sure to clean the meatus. 4. Ask the patient to begin urinating. After flow of urine has started, hold specimen cup under patient to catch the midstream urine flow. Fill the container halfway if possible. 25cc of urine in the specimen cup is necessary for both vacutainers to fill. (1cc=1ml). 5. Place the cup on a clean, flat surface and replace blue cap securely. Carefully peel back the white label on the cap, exposing the sampling device. This device is a sharp! 6. Remove the vacutainer tubes from the package. Fill grey top vacutainer tube first by placing the end with the rubber stopper over the sampling device. Press down on the vacutainer until the device has pierced the stopper. The vacutainer will draw 4ml of urine. Hold the vacutainer tube in position until the flow of urine has stopped. 7. Remove the vacutainer and shake gently to mix the urine and the maintenance medium. Label the vacutainer. To ensure specimen integrity, grey-top tube must be received by the laboratory within 48 hours of collection. Refrigeration not required but will not damage spec. 8. Repeat procedure with the yellow top tube which draws 8ml. Refrigerate until picked up; must be received by the laboratory within 24 hrs. of collection to ensure specimen integrity. 9. Carefully replace the white label on the cap. If there is insufficient urine to use the vacutainer, send the urine in the specimen cup (properly labelled), for the culture and sensitivity. This container must be refrigerated and received by the laboratory within 24 hrs. to ensure specimen integrity. P a g e 13 29

16 Straight Catheter REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: 4ml in the grey-top vacutainer from the midstream kit for culture 8 ml in the yellowtop vacutainer for urinalysis. (Use specimen cup from the midstream kit supplied by the lab, not the cup in the straight cath kit.) Peri-care prior to collection reduces contamination. 25cc of urine in the specimen cup is necessary for both vacutainers to fill. (1cc=1ml) 1. Before preparing the sterile field, open the midstream kit and remove the blue-cap urine specimen cup. Unscrew the blue cap and place specimen cup and cap on accessible clean surface with inside of cap facing up. Or, have a coworker nearby, ready to hand you the cup. 2. Using sterile technique, clean the patient and insert the catheter. 3. After flow of urine has started, collect the mid-stream flow in the specimen cup. Do Not collect initial flow. Fill the cup halfway if possible. 4. Place the cup on a clean, flat surface and replace blue cap securely. Carefully peel back the white label on the cap, exposing the sampling device. This device is a sharp! 5. Remove the vacutainer tubes from the package. Fill grey top tube first by placing the end with the rubber stopper over the sampling device. Press down on the vacutainer until the device has pierced the stopper. The vacutainer will draw 4cc of urine. Hold the vacutainer tube in position until the flow of urine has stopped. 6. Remove the vacutainer and shake it gently to mix the urine and the maintenance medium. Label the vacutainer. To ensure specimen integrity, grey-top tube must be received by the laboratory within 48 hours of collection. Refrigeration not required but will not damage spec. 7. Repeat procedure with the yellow top tube, which draws 8ml. Refrigerate until picked up; must be received by the laboratory within 24 hrs. of collection to ensure specimen integrity. 8. Carefully replace the white label on the cap. If there is insufficient urine to use the vacutainer, send the urine in the specimen cup (properly labelled), for the culture and sensitivity. This container must be refrigerated and received by the laboratory within 24 hrs. to ensure specimen integrity. P a g e 14 29

17 Foley Catheter REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: 4ml in the grey-top vacutainer from the midstream kit for culture 8 ml in the yellow-top vacutainer for urinalysis (Please use specimen cup from the midstream kit.) Peri-care prior to collection reduces contamination 25cc of urine in the specimen cup is necessary for both vacutainers to fill. (1cc=1ml). If current catheter has been in place for more than 2 weeks, the catheter should be changed before obtaining the specimen. Allow sufficient time for bladder to yield 25ml of urine before new catheter insertion and follow instructions for STRAIGHT CATHETER on previous page. The following procedure may be used if not inserting a new catheter. 1. Clamp drainage tubing (below sampling port) for sufficient time to yield 25ml urine. 2. Remove blue-cap urine specimen cup from kit. Unscrew the blue cap and place container and cap on accessible clean surface with inside of cap facing up. 3. Disinfect sampling port with alcohol wipe and obtain 25cc of urine. Expel urine into the cup. 4. Replace blue cap securely. Carefully peel back the white label on the cap, exposing the sampling device. This device is a sharp! 5. Remove the vacutainer tubes from the package. Fill grey top tube first by placing the end with the rubber stopper over the sampling device. Press down on the vacutainer until the device has pierced the stopper. The vacutainer will draw 4cc of urine. Hold the vacutainer tube in position until the flow of urine has stopped. 6. Remove the vacutainer and shake it gently to mix the urine and the maintenance medium. Label the vacutainer. To ensure specimen integrity, the grey-top tube must be received by the laboratory within 48 hours of collection. Refrigeration not required but will not damage spec. 7. Repeat procedure with the yellow top tube, which draws 8ml. Refrigerate until picked up; must be received by the laboratory within 24 hrs. of collection to ensure specimen integrity. 8. Carefully replace the white label on the cap and unclamp tubing. If there is insufficient urine to use the vacutainer, send the urine in the specimen cup (properly labelled), for the culture and sensitivity. This container must be refrigerated and received by the laboratory within 24 hrs. to ensure specimen integrity. P a g e 15 29

18 24 Hour Urine REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES PAGE 12 Specimen Requirements: ALL urine voided in a specified 24 hour period 1. PRINT specific test name under Other Tests section at bottom of Part 3 of the requisition. There are several tests which require 24-hour urines and a preservative may need to be added by the laboratory based on which test has been ordered. (Preservative will be added when urine specimen arrives at laboratory). 2. Call laboratory to request a 24-hour urine container. Label specimen container when it arrives with patient name and DOB. 3. Identify the patient and explain procedure. 4. Communicate to all shifts the 24-hour period selected (often 7AM 7AM) and that ALL urine is being saved. Follow your facility guidelines for HIPAA compliant communication. 5. When the collection is scheduled to start, have the patient void. DISCARD THIS URINE. This is to be sure the bladder is empty. The test will continue until the next day at the same time. This first voiding IS NOT included in the specimen. 6. Patient may void in bedpan, urinal or hat placed in toilet. Each time the patient voids, the urine must be poured into the 24-hour urine container immediately hour urine container must be kept refrigerated, or in ice if refrigeration not possible. 8. For the next 24 hours, SAVE ALL URINE voided by the patient. 9. At the end of the 24 hour period, have the patient void. INCLUDE THIS URINE IN THE 24-HOUR SAMPLE. 10. Notify laboratory when collection is complete. Labelled container with requisition will be picked up. ****Note - When a creatinine clearance is ordered, a blood creatinine level needs to be drawn within the 24 hour period of urine collection. This requires a separate requisition. **** P a g e 16 29

19 Stool Specimens REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: 2 Tablespoons in a sterile container 1. A sterile bedpan (if available) is best for collecting stool specimens. 2. Ask the patient not to urinate into the bedpan and not to put toilet paper into the bedpan. 3. Using a wooden tongue depressor, transfer 2 tablespoons of stool from the bedpan to the sterile container. For diarrhea, a second specimen container may be used as a scoop. 4. Replace cap securely on container and label with patient name and DOB immediately. 5. All stool specs collected in a regular sterile container must be refrigerated until picked up. This includes specimens for Ova & Parasites& Shigella Toxin Please keep container upright. 6. All stool specimens must be received by the laboratory within 24 hrs. of collection to ensure specimen integrity. All stool cultures positive for Salmonella, Shigella, Campylobacter and E. Coli 0157 are called to the facility. P a g e 17 29

20 Clostridium difficile Testing The test for C. difficile is an immunoassay that detects toxins A and B, and GDH (Glutamate Dehydrogenase antigen in a single assay. If the C. difficile toxin and GDH are discordant, we will automatically reflex and perform real- time PCR. This additional testing is a separate procedure involving an additional charge and use of CPT code. This test is not a culture, and is designed for use with unformed stools only. Check off Stool for Clostridium Difficile Toxin on the requisition. Collect diarrheal specimen as described above. The specimen should not be a formed stool. Label container with patient s name and DOB. The test cannot be performed on a swab. One specimen per patient per day is accepted. Positive results are called to the facility. If positive, a repeat test will not be performed for 7 days. P a g e 18 29

21 Stool for Occult Blood Specimen Requirements: 2 thin fecal smears applied to the Occult Blood card Occult Blood cards (without the developer) are provided ONLY to those facilities requesting the laboratory to interpret the results and provide a report to the facility. Facilities which perform the test in-house provide their own supplies. This is a CLIA- waived test. A high residue diet is recommended starting 2 days prior to and continuing through the test period. Food intake should not include any red or rare meat or raw fruits and vegetables containing high peroxidase activity turnip, broccoli, horseradish, cauliflower, cantaloupe, parsnip and red radishes. Aspirin and other inflammatory medicines should be avoided for 7 days prior to and during testing. For 2 days prior to and during testing, do not use rectal administrations containing Vitamin C (ascorbic acid) in excess of 250 mg per day. (Information taken from test kit insert.) 1. Print "OCCULT BLOOD" in the space at the bottom of Part 3 on the requisition, under Other Tests (Specify). Do Not Check off Stool Culture. 2. Complete the patient identification information on the front of the Occult Blood card. 3. Open this front flap OPEN TAB. 4. A clean, dry bedpan should be used for stool collection. 5. Ask the patient not to urinate into the bedpan and not to put toilet paper into the bedpan. 6. Using the applicator stick that comes with the Occult Blood card collect a small amount of stool. 7. Apply a VERY THIN smear inside Box A of the Occult Blood card. 8. Reuse applicator stick to obtain second sample from different part of stool. Apply a VERY THIN smear inside Box B of the Occult Blood card. 9. Allow the smears to air dry and then close the cover. 10. Return the card to the laboratory for testing. 11. DO NOT refrigerate the card. It should be maintained at room temperature until picked up by the laboratory. After being applied to the card, the specimen is stable for 10 days. P a g e 19 29

22 Sputum Culture REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: 2 Tablespoons in a sterile container Morning is usually the best time to obtain a sputum specimen. Mouth care prior to collection helps to prevent contamination. 1. Remove cap from container and place on a clean surface with inside of cap facing up. 2. Have resident cough up as much sputum as possible directly into the container. Taking several deep breaths first may help. THE MATERIAL MUST COME FROM THE LUNGS. The resident may need to cough several times to bring up enough sputum. 3. Replace cap securely and label container with patient name and DOB immediately. 4. Refrigerate specimen until picked up by the laboratory. 5. To ensure specimen integrity, sputum cultures must be received by the laboratory within 24 hours of collection. 6. Material on a culture swab labeled SPUTUM is NOT an acceptable specimen. Tuberculosis Testing Check off Acid Fast on Part 4 of the requisition and print sputum as source. Do not check Sputum in the 2 nd column. Sputum for AFB (ACID FAST BACILLUS, SMEAR/CULTURE) is tested at the state laboratory. The state lab accepts specimens on Monday through Friday from 8:30AM until 3PM. Sputum specimens for AFB must be received at the main lab by 1:30pm on Friday to ensure timely transport to the state. Positive smear results will be called to the facility by East Side Lab and are generally available within 48 hours (business days). Culture results take 6-8 weeks. Positive smear indicates the genus Mycobacterium, culture results identify the species. (Mycobacterium tuberculosis is the pathogen for tuberculosis; there are other species.) P a g e 20 29

23 Wound Culture REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen requirements: Fresh drainage obtained by use of a sterile swab (eswab supplied by laboratory) Levine technique (described below) is recommended. A sterile swab wiped across the surface of any wound may yield only surface organisms (often contaminants), as opposed to organisms within the tissues. If a wound culture is ordered, please try to obtain fresh drainage from viable tissue within the wound, avoiding wound edges, necrotic tissue and eschar. 1. Clean gross debris and old drainage from the wound. 2. Remove eswab from package. 3. Rotate the swab over a 1 centimeter square area of the wound for 5 seconds. Use sufficient pressure to express fluid from within the wound tissue. (Levine technique). 4. Replace swab in transport tube. 5. Label transport tube with patient name and DOB, not the plastic wrapper. 6. DO NOT REFRIGERATE THE eswab/transport TUBE. KEEP AT ROOM TEMP UNTIL PICKED UP BY THE LAB. 7. Wound cultures should be received by the laboratory within 24 hrs. of collection to ensure specimen integrity. P a g e 21 29

24 Throat Culture REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: Drainage material from affected throat area (usually back of throat and/or tonsil area) eswab supplied by laboratory When Group A Strep Only is checked off on the requisition, the Direct GAS test is performed. This is a molecular method for the detection of Streptococcus pyogenes (Group A Streptococcus or GAS), the primary pathogen for pharyngitis. Results are available in 24 hours or less rather than hours for a traditional culture method. To test for other pathogens from a throat source via the traditional culture method, please check off Complete Throat Culture on the requisition. If yeast is suspected in the throat, please order a fungal culture. If gonorrhoeae is suspected, please order a gonorrhoeae culture. 1. Remove eswab from the package. 2. Use tongue depressor to visualize affected throat area. 3. Swab area with circular motion, avoiding teeth, tongue and inner mouth as much as possible. 4. Replace swab in transport tube. 5. Label transport tube with patient name and DOB, not the plastic wrapper. 6. DO NOT REFRIGERATE THE eswab /TRANSPORT TUBE. KEEP AT ROOM TEMP UNTIL PICKED UP BY THE LAB. 7. Throat cultures should be received by the laboratory within 24 hrs. of collection to ensure specimen integrity. All throat cultures positive for Group A Streptococcus are called to the facility. P a g e 22 29

25 Eye (Conjunctiva) Culture REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: Fresh conjunctival drainage obtained by use of a sterile swab eswab supplied by laboratory) If both eyes are affected, use a separate swab for each eye, indicating right or left on the labels. 1. Clean the eye(s) by removing any exudate or mucous. Replace gloves. 2. Remove eswab from package. 3. Place one finger below eyelashes and gently pull lower eyelid down. 4. Gently rotate swab over lower conjunctiva. 5. Replace swab in transport tube. 6. Label transport tube with patient name and DOB, not the plastic wrapper. Indicate right eye or left eye. 7. Repeat with second swab if both eyes affected. 8. DO NOT REFRIGERATE THE BACTISWAB/TRANSPORT TUBE. KEEP AT ROOM TEMP UNTIL PICKED UP BY THE LAB. 9. Eye cultures should be received by the laboratory within 24 hrs. of collection to ensure specimen integrity. P a g e 23 29

26 Methicillin Resistant Staphylococcus aureus Identification of MRSA in Cultures Staphylococcus aureus identified in a culture and present in amounts that suggest infection for the particular body site is tested for methicillin resistance. Culture orders are appropriate when a patient is symptomatic of an infection. MRSA Screens MRSA SCREEN is the appropriate order when looking ONLY for the presence or absence of methicillin resistant Staphylococcus aureus. Common reasons for MRSA SCREENS include looking for colonization (often done for nares) and for follow ups after treatment of a MRSA infection. When MRSA SCREEN is ordered, any Staphylococcus aureus - regardless of amount- will be tested for methicillin resistance. Specimen Collection for MRSA Screens 1. Collect specimens as described on previous pages. 2. Check only the box for MRSA SCREEN in Part 4 of the culture section of the requisition. Indicate the source of the specimen in the space next to MRSA SCREEN. 3. DO NOT CHECK OFF ANY OTHER CULTURE INFORMATION WHEN ONLY A SCREEN IS ORDERED. Sensitivities will be reported on positive MRSA screens. MRSA Screen Nares Obtain specimen with the eswab supplied by the laboratory. Remove eswab from package. Place swab gently in each nostril and rotate several times. THE SAME SWAB IS USED FOR BOTH NOSTRILS Place swab in transport tube. Label transport tube, not the plastic wrapper. DO NOT REFRIGERATE THE CULTURESWAB/TRANSPORT TUBE. KEEP AT ROOM TEMP UNTIL PICKED UP BY THE LAB. All positive MRSA results are called to the facility. P a g e 24 29

27 Vancomycin Resistant Enterococcus Identification of VRE in Cultures Enterococcus identified in a culture and present in amounts that suggest infection for the particular body site is tested for vancomycin resistance. Culture orders are appropriate when a patient is symptomatic of an infection. VRE Screens VRE SCREEN is the appropriate order when looking ONLY for the presence or absence of Vancomycin Resistant Enterococcus. Common reasons for VRE SCREENS include looking for colonization (often done for stool/rectal) and for follow ups after treatment of a VRE infection. When a screen is ordered, any enterococcus- regardless of amount - will be tested for vancomycin resistance. Specimen Collection for VRE Screens 1. Collect specimens as described on previous pages. 2. Check only the box for VRE SCREEN in Part 4 of the culture section of the requisition. Indicate the source of the specimen in the space next to VRE SCREEN. 3. DO NOT CHECK OFF ANY OTHER CULTURE INFORMATION WHEN ONLY A SCREEN IS ORDERED. Sensitivities will be reported on positive VRE screens.vre Screen Rectal Obtain specimen with the eswab supplied by the laboratory. Remove eswab from package. Pass swab just beyond the anal sphincter and gently rotate several times. Place swab in transport tube. Label transport tube, not the plastic wrapper. DO NOT REFRIGERATE THE CULTURESWAB/TRANSPORT TUBE. KEEP AT ROOM TEMP UNTIL PICKED UP BY THE LAB. All positive VRE results are called to the facility. P a g e 25 29

28 Extended Spectrum Beta Lactamase Producing Bacteria Identification of ESBL producing bacteria in Cultures Testing for ESBL production is automatic and built in to the specimen work up. The two organisms most likely to be ESBL producers are Escherichia coli and Klebsiella pneumoniae, although it can occur with other gram negative organisms. In addition to specific organism identification and sensitivities, the following message will be on the laboratory report when an ESBL producing bacteria has been identified: CONFIRMATORY TEST POSITIVE FOR EXTENDED SPECTRUM BETA LACTAMASE. RESISTANCE TO ALL PENICILLINS, ALL CEPHALOSPORINS, AND AZTREONAM. IMIPENEM IS THE CLSI RECOMMENDED DRUG OF CHOICE. ESBL Screens A screening test for ESBL producing bacteria is not available at this time. For follow ups after treatment of an ESBL infection, a full culture should be ordered. If the ESBL message does not appear on the report, NO ESBL producing bacteria have been identified. Specimen Collection for ESBL Follow-Ups 1. Collect specimens as described on previous pages. 2. Check off culture for the appropriate site in Part 4 of the requisition. 3. Print ESBL Follow Up at the bottom of Part 4. All positive ESBL results are called to the facility. P a g e 26 29

29 Carbapenem-resistant Enterobacteriaceae Identification of CRE (Carbapenem-resistant Enterobacteriaceae) in Cultures Testing for carbapenemase production is automatic and built in to the specimen work up. Initially found in Klebsiella pneumoniae (and initially called KPC), Carbapenemase production is now found in other members of the enterobacteriaceae family as well. A confirmatory test (The Hodge Test) is always performed before final identification of a CRE. In addition to specific organism identification and sensitivities, the following message will be on the laboratory report when a CRE has been identified: POSITIVE FOR CARBAPENEMASE PRODUCTION; THIS INDICATES RESISTANCE TO ALL CARBAPENEMS, AZTREONAM, CEPHALOSPORINS, PENICILLINS AND PENICILLIN/BETA LACTAMASEINHIBITOR COMBINATIONS. Per their request, the Rhode Island Department of Health is notified by the laboratory of any positive CRE identified. Carbapenemase Resistant Screens (CRS) CRS may be ordered as part of an outbreak investigation. This test is available for rectal swabs only. Specimen Collection for CRS 1. Collect rectal swab as described below. 2. Print CRS Screen in space at bottom right of Part 4 of the requisition. DO NOT CHECK OFF ANY OTHER CULTURE INFORMATION. 3. Sensitivities will be reported on positive CRS CRS Rectal Obtain specimen with the eswab supplied by the laboratory. Remove eswab from package. Pass swab just beyond the anal sphincter and gently rotate several times. Place swab in transport tube. Label transport tube, not the plastic wrapper. DO NOT REFRIGERATE THE CULTURESWAB/TRANSPORT TUBE. KEEP AT ROOM TEMP UNTIL PICKED UP BY THE LAB. P a g e 27 29

30 Influenza Rapid testing REVIEW GENERAL SPECIMEN COLLECTION PROCEDURES Specimen Requirements: Nares Swab (eswab supplied by laboratory) 1. Print RAPID FLU on the requisition. Do Not check off any cultures. 2. Preferred specimen is a nares swab 3. Remove eswab from the package 4. Tilt patients head back 5. While gently rotating the swab insert swab less than 1 inch into nostril (until resistance is met at turbinates). 6. Rotate the swab several times against the nasal wall and repeat in the other nostril using the same swab. 7. Place the tip of the swab into the sterile transport media tube and cut off the applicator stick. 8. Label the transport tube with patient name and DOB, not the plastic wrapper. 9. DO NOT REFRIGERATE THE eswab /TRANSPORT TUBE. KEEP AT ROOM TEMP UNTIL PICKED UP BY THE LAB. 10. Test results differentiate Type A and Type B influenza but are not specific for any particular strain. 11. In Rhode Island outbreaks are reported to the Department of Health at In Massachusetts outbreaks are reported to the Department of Health at Please contact the state health department for specific reporting criteria. P a g e 28 29

31 Norovirus (Norwalk Like Virus) 1. Testing for Norovirus in long-term-care facilities is generally coordinated through state health departments. 2. In Rhode Island, suspected outbreaks are reported to the Department of Health at In Massachusetts, suspected outbreaks are reported to the Department of Health at Please contact the state health department for specific reporting criteria. P a g e 29 29