Standard Operating Procedure

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1 Subject Urinalysis Clinitek Status and Visual Index Number Lab-1583 Section Laboratory Subsection Regional Clinic / Affiliate Hospital Laboratories Category Departmental Contact Darcy Goplin Last Revised 1/16/2018 References Required document for Laboratory Accreditation by the College of American Pathologists (CAP), Centers for Medicare and Medicaid Services (CMS) and/or COLA. Applicable To Employees of GLMC clinical laboratories, St. Joseph s Health Services laboratories, Gundersen Tri-County Hospital laboratories, Gundersen Boscobel Area Hospital Laboratories and Gundersen Palmer Lutheran Hospital and Clinic laboratories. Detail PRINCIPLE: Routine urinalysis consists of color, clarity specific gravity and a chemical examination including ph, albumin, glucose, ketones, bile, leukocyte esterase, nitrite, and blood. Microscopic examination, if indicated, includes cell identification, casts, crystals, bacteria, and miscellaneous. Reagent Strip Test Principles Bayer Multistix 10-SG Reagent Strips contain reagent areas for testing glucose, bilirubin, ketone, specific gravity, blood, ph, protein, urobilinogen, nitrite and leukocytes. Test results may provide information regarding the status of carbohydrate metabolism, kidney and liver function, acid-base balance and urinary tract infection. Individual test principles follow: Glucose: This test is based on a double sequential enzyme reaction. One enzyme, glucose oxidase, catalyzes the formation of gluconic acid and hydrogen peroxide from the oxidation of glucose. A second enzyme, peroxidase, catalyzes the reaction of hydrogen peroxide with a potassium iodide chromogen to oxidize the chromogen to colors ranging from green to brown. Bilirubin: This test is based on the coupling of bilirubin with diazotized dichloroaniline in a strongly acid medium. The color ranges through various shades of tan. Ketone: This test is based on the development of colors ranging from buff-pink, for a negative reading, to purple when acetoacetic acid reacts with nitroprusside. Specific Gravity: This test is based on the apparent pka (acid) change of certain pretreated polyelectrolytes in relation to ionic concentration. In the presence of an indicator, colors range from deep blue-green in the urine of low ionic concentration through green and yellow-green in urine of increasing ionic concentration. Page 1 of 17

2 Blood: This test is based on the peroxidase-like activity of hemoglobin, which catalyzes the reaction to diisopropylbenzene and 3,3, 5,5 -tetramethylbenzidine. The resulting color ranges from orange through green; very high levels of blood may cause the color development to continue to blue. ph: This test is based on a double indicator principle that gives a broad range of colors covering the entire urinary ph range. Colors range from orange through yellow and green to blue. Protein: This test is based on the protein-error-of-indicators principle. At a constant ph, the development of any green color is due to the presence of protein. Colors range from yellow, for "negative" through yellow-green to green to green-blue for "positive" reactions. Urobilinogen: DO NOT REPORT! Nitrite: This test depends upon the conversion of nitrate (derived from the diet) to nitrite by the action of gram negative bacteria in the urine. At the acid ph of the reagent area, nitrite in the urine reacts with p-arsanilic acid to form a diazonium compound. This diazonium compound in turn couples with 1,2,3,4- tetrahydrobenzo(h)quinolin-3-ol to produce pink color. Leukocytes: Granulocytic leukocytes contain esterase that catalyze the hydrolysis of the derivatized pyrrole amino acid ester to liberate 3-hydrozy-5-phenyl pyrrole. This pyrrole then reacts with a diazonium salt to produce a purple product. Instrument Principles: The CLINITEK STATUS Urine Chemistry Analyzer is a semi-automated, bench top instrument designed to "read" MULTISTIX 10-SG Reagent Strips for urinalysis. This instrument is a reflectance spectrophotometer that analyzes the intensity and color of the light reflected from the reagent pad area and prints the results in clinical units. No calculations are required. CLINICAL SIGNIFICANCE: The urinalysis is a composite examination that is usually carried out with a single specimen of urine performed and recorded in a systematic sequence. This examination offers many invaluable clues in the detection, differential diagnosis and evaluation of urinary tract disorders, especially in the areas of metabolic and renal disorders. Glucose: Glycosuria occurs when the blood glucose levels exceed the reabsorption capacity of the renal tubles. The condition may be a benign condition, renal glycosuria, occurring after ingestion of a carbohydrate ladened meal or in conjunction with emotional stress; or a pathological condition, diabetes mellitus, occurring from a marked elevation of the blood glucose and insulin resistance or by impaired insulin production. Bilirubin: Bilirubin in the urine is indicative of the presence of hepatocellular disease or intra - or extrahepatic biliary obstruction. Ketone: Ketones occurs in the urine when the body metabolizes increasing amounts of fatty acids found in conditions of impaired or restricted carbohydrate metabolism. These conditions include diabetes Page 2 of 17

3 mellitus (ketoacidosis), fever, anorexia, fasting, starvation, vomiting, pernicious vomiting of pregnancy, and cachexia. Specific Gravity: Specific gravity measures the concentrating and diluting abilities of the kidney. Low specific gravity can occur in patients with diabetes insipidus, glomerular nephritis, pyelonephritis and various renal abnormalities where the kidney has lost the ability to concentrate the urine. High specific gravity can occur in patients with adrenal insufficiency, hepatic disease, congestive heart failure, fever, vomiting and diarrhea. Blood: Occult blood occurs in the urine as intact RBCs and hemoglobin which can occur during urological, nephrological and bleeding disorders. Blood is often found in the urine of menstruating females. ph: Urine ph is a general indicator of the acid-base balance of the body controlled in part by the kidney. Certain dietary conditions can produce acid or alkaline urines, which can be useful in the treatment of some calculi. Protein: Protein in the urine can be the result of urological and nephrological disorders, glomerular or tubular abnormalities and temporarily elevated in the absence of renal abnormality by strenuous exercise, orthostatic proteinuria, dehydration, urinary tract infections and acute illness with fever. Urobilinogen: Do Not Report! Nitrite: Many enteric gram-negative microorganisms possess the characteristic of conversion of dietary nitrates to nitrite and yield a positive nitrite when given adequate bladder incubation. Significant bacteriuria is probable with a positive nitrite result, but not ruled out with a negative nitrate result. Leukocytes: An increase in leukocytes is an indication of pyuria found in nearly all diseases / infections of the kidney and urinary tract. SPECIMEN: Patient Identification occurs by verbal verification of the patient's name and birthdate (outpatient setting), or the verification of the patient s name and MRN/clinic number found on the patient s ID armband (inpatient setting). Refer to Lab-1330 Patient Identification Including Blood Bank ID Requirements for procedural guidelines. Patient Preparation: N/A Type/Amount: 1-15 cc of clean voided, catheterized, or random urine (first voided morning specimen is the most concentrated) in a labeled container. The minimum specimen volume is 1.0 cc. Turbid specimens containing amorphous urates should be heated under hot tap water to dissolve crystals. Specimen should be refrigerated at 2-8 o C, if it is not run immediately. Urines should ideally be tested within 30 minutes, but up to two hours at room temp is acceptable. Urines stored in the refrigerator may be tested up to 24 hours after collection or within 72 hours in a Vacuette preservative tube. Any refrigerated or cold specimen must be allowed to return to room temperature and be mixed well before Page 3 of 17

4 testing. An aliquot should be saved for 48 hours for additional testing as needed in other areas in the lab. Unacceptable specimens: 1. Unlabeled specimens 2. Specimens kept at room temperature for more than 2 hours 3. Fecal contamination Refrigerated specimens greater than 24 hours old, or greater than 72 hours old in a preservative tube. Urine collection Vacuette Tube and Transfer Device 1. Collect urine specimen according to specimen collection procedure. 2. Place the "straw" end of the transfer device into the urine in the collection cup. 3. Insert vacuette tube into large yellow end of transfer device. 4. Push Vacuette tube to the end of transfer device. 5. The correct amount of urine will transfer to the tube automatically. 6. Label tube with collection information. 7. Refrigerate filled Vacuette. 8. Save and refrigerate an aliquot for 48 hours. 9. Discard transfer device in sharps container. REAGENTS / MATERIALS: Multistix 10-SG, Bayer Greiner tube vacuette # Centrifuge tubes, (Tubes have a 0.4 ml retention volume after decanting.) Plain glass slides Plastic pipettes Coverslips, 22x22 Store all reagents at room temperature. EQUIPMENT/INSTRUMENTATION: Clinitek Status Fixed head centrifuge Microscope - Phase contrast or bright field. The Clinitek Status is a bench top semi-automated urine chemistry analyzers. Designed to read Multistix 10-SG reagent strips for urinalysis. The Clinitek Status is a reflectance spectrophotometer that analyzes the color and the intensity of the light that is reflected from the reagent area. The results are then printed in clinical units and reported. No calculations are required. Calibration: Clinitek Status - Calibration is performed automatically each time a reagent strip is analyzed. Maintenance: The instrument must be kept clean to provide accurate test results and to operate properly. Operators must initial the daily log sheet to document maintenance. For daily cleaning and maintenance see Page 4 of 17

5 Clinitek Status manual section 9. See the manual for any questions concerning the operation of the instrument. Fixed head centrifuge - Clean weekly, remove tube holders, wipe the holders and the centrifuge shell with appropriate disinfectant. Refer to Lab-0105 Safety: Biological if breakage occurs. Microscope-Phase contrast, phase alignment should be performed and documented weekly. General cleaning Keep the exterior free of dust by periodically wiping the exterior using a damp cloth and mild detergent. The display screen may be cleaned using a soft, non-abrasive cloth. (Do not use Kimwipes.) Do not spray with glass cleaner. Clinitek Status Daily Cleaning 1. Remove the test table strip pulling table straight out of instrument. 2. Clean the feed table and insert with a cotton- tipped swab that has been dampened with distilled water. Caution: Do not touch or scratch the white calibration bar/chip. 3. Inspect the white calibration bar for scratches, foreign material or dust. If visibly dirty, clean with a new swab that has been dampened in distilled water. Dry the table thoroughly (except for the calibration bar) with a soft cloth, allowing the calibration bar to air dry. 4. Gently reinsert the feed table about halfway. Clinitek Status Disinfection 1. Perform daily cleaning procedure. 2. Prepare 0.05% hypochlorite solution using Clorox bleach. Place 1 ml bleach into 99 mls water. 3. Fill an empty Multistix container to a depth of 4" with cleaning solution. 4. Immerse the test table insert or the test table into the solution making sure that the white calibration bar/chip remains above the liquid if inserting the test table. 5. Soak for a minimum of two minutes or a maximum of 10 minutes. 6. Rinse thoroughly with distilled water. 7. Dry the table thoroughly (except for the calibration bar) with a soft cloth, allowing the calibration bar to air dry. 8. Re-insert half way into analyzer. Weekly Clinitek Date and Time Check Weekly check the date and time on the Clinitek Status to ensure that it's one minute behind the date and time on the Gundersen Health network computer in the lower right hand corner of the computer screen. 1. Press the Instrument Setup Pad 2. Arrow to Date and Time 3. Press Select 4. Adjust the date and time as needed by using the arrow keys 5. Press Set 6. Press Done QUALITY CONTROL: BioRad quantify Levels 1 and 2 urinalysis controls for qualitative and semi-quantitative procedures. It is a stable control material made from human urine. Analyte levels are adjusted with various pure chemicals and preparations of erythrocytes, human leukocytes and hcg (Levels 1 and 2 only) from human source Page 5 of 17

6 material and simulated leukocytes. Available from Microgenics Corporation, Fremont, California or from Bio Rad Laboratories Hercules, California. Storage and stability Store vials at 2-8 o C. Unopened bottles are stable until the expiration date of the label. Preparation/Procedure Regional and affiliate laboratories performing urine microscopics: 120 ml bottles are mixed by gentle inversion and 12, 5 ml aliquots are poured off without allowing the primary bottle to warm to room temp. Once opened, an aliquot is stable for 30 days at 2-8 o C. Regional and affiliate laboratories performing urine macroscopics only: 12 ml bottles must be mixed prior to use and opened bottles may be stored at 2-8 o C. Unopened bottles are good until the expiration date on the bottle when stored in the refrigerator. Once opened, this product will be stable for 31 days when stored tightly capped at 2-8 o C. Procedure for both Non-waived and Waived testing labs 1. Allow aliquot or bottle to warm to room temp (approximately 1/2 hour). Thoroughly mix the contents of the aliquot or bottle before testing. 2. Print the QC label from the LIS. QC aliquot is tested the same as a patient and results are documented in lab LIS system. 3. Perform macroscopic and microscopic on both levels (micros in non-waived labs only). 4. QC is run and documented every 24 hrs in the LIS. 5. QC should be reviewed monthly by supervisor or technical leader. 6. Every new lot or shipment of Multistix must have QC performed and documented before patients are tested. Record lot, opened date and expiration date in LIS. Write the opened date on the bottle. 7. If new lot fails QC, in LIS the failed component is marked as rejected and repeat is requested and QC is retested. If still unacceptable, open a new bottle and test. If QC fails on the new bottle, then new lot is rejected. QC limits are established with each new lot of controls. Controls are run in parallel for a minimum of 20 data points from which new limits are established. QC is performed every day on which patient testing occurs, upon opening a new bottle of strips or whenever patient results are questioned. QC is recorded in LIS. QC is reviewed monthly by a lab supervisor or technical leader. Implementation Clinitek Status Start-Up 1. The main menu will display date, time, and four options including Instrument set up, Recall Results, Cassette Test and Strip Test. 2. Press Test Strip and note that the screen indicates use of Multistix 10 SG. 3. Select new Patient and scan QC barcode. 4. The prepare test screen appears indicating that the analyzer is ready to accept the strip. Page 6 of 17

7 5. Run QC. Clinitek Status Routine Operation Testing should be performed on fresh urine or urine in a preservative tube. If urine has been refrigerated, allow to warm to room temperature o C. All urines should be tested as soon as they arrive and should not be routinely placed in the refrigerator. Note: Only Multistix 10 SG should be used for strip testing. Use of any other strip will cause erroneous results. 1. Press strip Test. 2. Scan patient s UA label. 3. Press the Start button (make sure that you have your strip out, urine uncovered and paper towel ready) you will now have 8 seconds to prepare and load your sample. 4. While avoiding the ID band, completely immerse all reagent areas of the Multistix 10 SG reagent strip in fresh well mixed urine. While removing, run the edge of the strip against the side of the urine container to remove the excess urine. Edge blot the strip by touching the edge of the strip to the paper towel to remove excess urine. Note: do not drag the strip across the paper towel or lay the pads on the paper towel. 5. Place strip on test table with the reagent areas up. Urine strip will automatically be pulled into instrument. Once the strip has been pulled into the analyzer the Clinitek will automatically calibrate followed by analysis. 6. Select urine color (press next) and clarity (press next). 7. Results will appear on screen for two minutes. Results will not print or be displayed until after the color and clarity have been entered. 8. Touch "Done" to complete the test and return to the main select screen. 9. Discard Multistix strip after each test is completed. Wipe feed table with a water dampened kim wipe. Note: If you need to re-dip your specimen to check a parameter, reject the parameter in LIS, request repeat, and re-dip before verifying the results. Visual Method Testing should be performed on fresh urine or urine from a preservative tube. If urine has been refrigerated, allow to warm to room temperature o C. All urines should be tested as soon as they arrive and should not be routinely placed in the refrigerator. 1. Mix urine well before testing. 2. Remove strip from the bottle and replace the cap. Do not touch test areas. Completely immerse Multistix 10 SG reagent strip in the urine. Remove immediately running the edge of the strip along the rim of the urine container. Edge blot the strip by touching the edge of the strip to the paper towel to remove excess urine. Note: do not drag the strip across the paper towel or lay the pads on the paper towel. Hold strip in a horizontal position to reduce running of reagents. 3. Test timing begins when the testing areas on the strip become wet with urine. 4. Hold the strip close to the chart and carefully match the color on the strip to that on the chart at the appropriate time. Page 7 of 17

8 5. Proper read time is crucial for optimal results. Protein and ph may be read at any time up to two minutes after immersion into urine. Read glucose at 30 sec, bilirubin at 30 sec, ketones at 40 sec, specific gravity at 45 sec, blood and nitrite tests at 60 sec and leukocytes at 2 minutes. DO NOT REPORT THE UROBILINOGEN TEST RESULT. 6. Color changes that occur after two minutes are not to be reported. 7. Report all results following uniform reporting guidelines established under the interpretation guidelines. PROCEDURE NOTES: Troubleshooting Common reasons for strip rejection by the instrument include: 1. Reagent strip improperly positioned on table. 2. Reagent strip is missing a test pad. 3. Wrong LIS barcode label scanned. For instrument error codes please see troubleshooting for Clinitek Status section Computer Downtime During a computer downtime, continue to dip urine samples on the Clinitek Status. When the computer comes back up, go to the Main Menu on the Status, select "Recall Results" and then select "Send All Data". CALCULATIONS: N/A INTERPRETATION: Color: The color of urine is affected by many components (concentration, food pigments, dyes, blood or various pathological conditions). The intensity of the color of normal urine is dependent on the concentration of the urine. Yellow or amber color is due to the presence of a pigment called urochrome. Substances that cause abnormal urine color affect the readability of the test strip. These substances include visible levels of blood or bilirubin and drugs containing dyes [e.g., Pyridium, Azo Gantrisin, Azo Gantanol, nitrofuranatin (Macrodantin or Furadantin)], and riboflavin. Defer these specimens to the laboratory for complete urinalysis. Reporting choices: Colorless Yellow (defined as all shades - straw to dark yellow urines) Amber (Yellow-Brown color). Choose "other" on the Clinitek Status. Green ( Methylene Blue) Orange (Uristat), order a urine microscopic. If tested on the Clinitest Status, the individual tests will be resulted as CANCEL with the comment "Not reported due to interfering substances." Red (Blood) Brown (Aged blood) Limitations: Page 8 of 17

9 Variations from the normal shades of yellow may be due to drugs containing azo dyes, abnormal metabolic functions, excessive physical activity, ingested materials or foods (B vitamins), or pathologic conditions. Abnormally colored or very dark urine may interfere or obscure reagent strip results. If such a specimen is submitted, results should not be reported and an explanation given on the report form. If urine is orange, the tech should cancel the macroscopic and order a microscopic. An orange urine will discolor the reagent strip, while an amber urine will not. Grossly bloody urines - spin the urine and dip the supernatant. If the supernatant is pink tinged or yellow, the occult blood should be resulted as 3+. If the supernatant is still red, use the comment.beakuagrosslybloody- unable to result, for glucose, ketones, albumin, nitrate, bilirubin, ph and leukocytes. The blood is resulted as 3+ and a refractometer specific gravity is resulted. Specimens requiring refractometer specific gravity must be sent to LaCrosse campus for the refractometer specific gravity. Verification of other results should occur. You can leave the SG blank. These will be resulted and verified in LAX. Enter a note in the lab comments (yellow box) saying, "SG sent to LAX" This will at least provide a method type for the test (CAP reg). You cannot put this on a packing list so you must send to LAX and call to let folks know it's coming. If you are unable to perform a microscopic please refer to La Crosse. Clarity Normal freshly voided urine is usually clear or transparent, but may also have a cloudy or turbid appearance due to the formation of amorphous crystals. Abnormal turbidity may also occur with urinary tract infections or upon refrigeration. Reporting Choices: Clear (No turbidity seen, no particles seen). Slightly Cloudy (Light turbidity, few solid particles seen, hazy appearance) Cloudy (Obviously turbid, unable to see through urine) Turbid (Unable to see through urine, clumps or precipitate present, cannot see print through urine) Glucose Normal Range - Negative Report results from all reading methods as Negative, Trace, 1+, 2+ or 3+. Sensitivity: mg/dl Limitations: **If screening for galactosemia is desired, a urine specimen should be submitted for a urine galactose. If a request for urine reducing substances is made by a clinician, contact ordering provider to confirm that urine galactose testing is appropriate. ***Old urine increases in alkalinity. Ascorbic acid levels and moderately high ketone levels reduce the sensitivity of the glucose test. Glucose test reactivity is decreased when the urine is colder than room temperature. Bilirubin Normal Range - Negative Report results from all reading methods as negative, 1+, 2+ or 3+. Page 9 of 17

10 Sensitivity: mg/dl Limitations: Indoxyl sulfate can produce a yellow-orange to red color that may interfere with the interpretation of a positive or negative bilirubin. Metabolites of Lodine (etodolac) may cause false positive or atypical results. All positive results will include the following attached comment in LIS: "False positive bilirubin reactions can occur due to Etodolac". Ascorbic acid concentrations of 25 mg/dl or greater may cause false negatives. Ketones Normal Range - Negative Report all results from all reading methods as negative, trace, 1+, 2+ or 3+ (Report any 4+ Ketone as a 3+, not to exceed our standard reporting criteria). Note: The RALS interface will automatically convert the 4+ to 3+. Sensitivity: 5-10 mg/dl aceto acetic acid Limitations: False positive results may occur with highly colored urine or urines containing drugs including levodopa metabolites or mensa compounds. Specific Gravity Normal Range Reportable visual reading range Reportable instrument reading range Sensitivity Limitations: Visual method: If the ph reading is 6.5 or higher, the specific gravity must be corrected by adding.005 to the reading. Instrument methods: Strips read by an instrument automatically adjusted for the ph. All results are not affected by glucose or the presence of radio opaque dyes. Elevated specific gravity may be obtained in the presence of moderate amounts of protein (2+ or 3+). Blood Normal Range - Negative Report results from all reading methods as negative, trace, 1+, 2+, or 3+. Sensitivity: Hemoglobin concentrations of mg/dl (approximately 5-20 intact cells per ml). Limitations: Elevated Specific gravity may reduce reactivity. False positives may be caused by bleach contaminants, Catopril (an ace inhibitor), or microbial peroxidase activity associated with urinary tract infections. Grossly bloody urines - spin the urine and dip the supernatant. If the supernatant is pink tinged or yellow, the occult blood should be resulted as 3+. If the supernatant is still red, use the (Grossly bloody) to result glucose, ketones, albumin, nitrite, bilirubin, ph and leukocytes. The blood is resulted as 3+ and a refractometer specific gravity is resulted. Specimens requiring refractometer specific gravity must be sent to LaCrosse campus for the refractometer specific gravity. ph Normal Range Page 10 of 17

11 Reportable visual range Reportable instrument Range Sensitivity Limitations: Urine ph of > 9.0 will be resulted in LIS with the following comment:" Albumin assay may not be accurate due to high ph". Visual reading only - If the visual ph reading is 6.5 or higher, correct the specific gravity result by adding.005 to the result. It is important to drag the edge of the strip against the rim of the container removing excess urine. Excess urine may cause a "run over" effect in which the buffer from the protein test pad runs onto the ph pad causing the ph pad to become two-toned. In this situation visually compare the darkest shade with the color chart and report this ph reading. Protein Normal Range - Negative Report results from all reading methods as: negative, trace, 1+, 2+, or 3+. Sensitivity: mg/dl albumin Limitations: Highly buffered or alkaline urines (ph 9.0) may cause a false positive protein result. Urine ph of > 9.0 will be resulted in LIS with the following comment:" Albumin assay may not be accurate due to high ph". Contamination of the urine specimen with skin cleanser, antiseptics or detergents may cause a false positive result. Urobilinogen Results are not recorded. Nitrite Normal Range - Negative Results are reported from all methods as negative or positive. Sensitivity: 0.1 mg/dl nitrite ion. Limitations: Sensitivity of the nitrite test is reduced for urine with a high specific gravity. Ascorbic acid (>25 mg/dl) may cause a false negative result. A negative result does not rule out the presence of bacteria in urine. Negative results may occur in the presence of bacteria when the urine has not completed the 4 hour bladder incubation required for the conversion of nitrates to nitrites or if the bacteria is a non-nitrate producing bacteria. Leukocytes Normal Range - Negative Report results from all reading methods as negative, trace,1+, 2+, or 3+. Sensitivity: 5-15 WBC/hpf Limitations : Elevated glucose concentrations (>3+) or high specific gravity's can decrease test results. Certain drugs (cephalexin, cephalothin, and oxalic acid) can decrease test results. Page 11 of 17

12 Tetracycline may decrease test reactivity and cause a false negative reaction. Standardized Reporting for Urine Dipsticks ph >9.0 ** urine ph >9.0, albumin may be inaccurate add comment to report ** visually read urine ph >6.5, add to specific gravity Protein Neg, trace, 1+, 2+, 3+ Glucose Neg, trace, 1+, 2+, 3+ Ketones Neg, Tr, 1+, 2+, 3+ Bilirubin Neg, 1+, 2+, 3+ Urobilinogen Do not report Occult blood Neg, Tr, 1+, 2+, 3+ Sp. Gr. < >1.030 Leukocyte Esterase Neg, Tr, 1+, 2+, 3+ Nitrites Neg or Pos Color Yellow, green, orange, red, brown, amber (other) Orange Urines Cancel dipstick and reflex microscopic Clarity Clear, slightly cloudy, cloudy, turbid REFLEX TESTING: The lab will not be performing microscopic on specimens with normal dips, unless requested by a provider. If the dip is abnormal, the lab will reflex a microscopic. Providers will be able to order these three tests: 1. Dip only: Dip urine only, no microscopic. 2. Routine UA: Dip urine, if normal urine does not exceed criteria for color, clarity, leukocyte esterase, nitrite, protein or blood (no microscopic). If abnormal, a microscopic will be ordered by the laboratory as listed below. Note: Children under the age of 6 years will automatically receive both the macroscopic and microscopic urinalysis results. If a dip is ordered lab will charge and perform only a dip. If a Routine urinalysis is ordered lab will charge and perform only the dip if dip is normal, if dip is abnormal (according to protocol) lab will charge and perform microscopic (routine urinalysis). If the provider orders a routine urinalysis with microscopic lab will automatically perform both the dip and the microscopic and charge a routine urinalysis. Accredited regional clinic and affiliate hospital laboratories will perform a microscopic on any routine urinalysis that is positive for any of the following tests. Reflex Criteria Color Abnormal (red, amber, green, brown and orange) Clarity Turbid Leukocytes Trace, 1+, 2+, 3+ Page 12 of 17

13 Nitrite Positive Protein 1+, 2+, 3+ Blood Trace, 1+, 2+, or 3+ MICROSCOPIC (Non-waived locations) 1. Pour 10 cc of fresh, well mixed urine into a urine centrifuge tube. Tubes have a 0.4 ml retention volume after decanting. For unspun microscopic and QNS comment. 2. Centrifuge specimen for 5 minutes at 1,800 RPM - 2,000 RPM. 3. If no additional tests are to be done, decant supernatant by tipping tube. Do not shake. Approximately 0.4 cc of sediment should remain in the tube. 4. Mix sediment well using pipette. 5. Hold pipette upright, placing one free falling drop on a clean slide. Apply one 22x22 cover slip. Place only one patient per slide to avoid reporting incorrect results. 6. Examination of sediment a. Examine sediment under low power screening around the edges of the cover slip looking for casts and large elements. b. Examine under high power to identify cells and smaller elements. c. Report RBC's and WBC's as average number/hpf. Over 100 will be reported as >100 cells/hpf. d. All other structures, cells and casts are reported under high power. e. Each result should be reported following the uniform guidelines in this procedure. 7. Microscopic elements a. Microscopic elements in an extremely cellular sediment can be identified by using a large coverslip (22x40) to spread the sample thinner; multiply the results by 2 to compensate for the larger coverslip. A 1:2 dilution can be made using saline and the results multiplied by two. b. Correlate microscopic findings of casts, bacteria, WBC's and RBC's with strip results of positive protein (look for casts), nitrite (look for bacteria), leukocytes (look for WBC's) and occult blood (look for red cells). c. If occult blood is negative and RBC's are found microscopically, ascorbic acid interference should be suspected. Be sure the formed elements are RBC's, not yeast or unusual Ca oxalate crystals. d. If the occult blood is positive but no RBC's are seen microscopically, check for low specific gravity indicating a hypotonic solution which may lyse RBC's. e. Leukocyte esterase - generally when the leukocyte esterase is positive, = or > 5 WBC/hpf will be seen microscopically. Primary exception: If leukocyte esterase is positive an = or >5 WBC/hpf are not detected microscopically; check for low specific gravity ( ) indicating a hypotonic solution which may cause WBC's to lyse. Large numbers of eosinophils or significant infestation with the vaginal parasite Trichomonas Vaginalis may provide sufficient esterase to give a positive result. f. Generally when the leukocyte esterase is negative, <5 WBC/hpf will be seen microscopically. Primary exception: If the leukocyte esterase is negative and = or >5 WBC/hpf are detected microscopically, check for high specific gravity ( ) indicating a hypertonic solution which may crenate the WBC's thereby preventing the WBC granules from reacting with the test pad. Page 13 of 17

14 g. If fat globules are suspected, perform both the Sudan Fat Stain (see Lab-8160) and examine with polarized microscope. Specimens requiring the Sudan Fat Stain must be sent to La Crosse for testing. h. Increased number of or abnormal casts must be accompanied by proteinuria, also the degree of proteinuria can vary. In contrast, proteinuria may occur without cast formation. i. Hyaline Casts: Hyaline casts are the result of solidification of Tamm-Horsfall mucoprotein which is secreted by the renal tubular cells and they may be present without significant proteinuria. A few may be seen in the urine of a healthy person. They may be seen in increased numbers after strenuous exercise and in some renal diseases. ii. Mixed Cellular Casts: A cellular cast may be composed of any of the cells found in the urine sediment such as RBC, WBC, epithelial cells. Bacterial cell casts have also been described. iii. RBC Casts: RBC's may be found in a cast either as the result of leakage of RBC's through the glomerular membrane or by bleeding into the tubules at any point along the nephron. Other forms of RBC cast include hemoglobin cast, which are the result of degeneration of RBC's with the cast matrix. The cells are no longer visible, yet the remaining hemoglobin pigment imparts a characteristic orange-yellow or red-brown color, which distinguishes them from waxy cast. Dipstick should have positive blood and protein. iv. WBC Casts: usually composed of neutrophils. Dipstick findings are positive protein, leukocyte esterase and nitrite if nitrite reducing bacteria are present. v. Epithelial Casts: Composed of renal epithelial cells. A serious pathologic finding, associated with acute tubular necrosis, viral disease such as infection with cytomegalovirus, and exposure to nephrotoxic substances such as mercury, ethylene glycol and various drugs. They may be difficult to distinguish from WBC cast, especially as they begin to degenerate into granular cast. Because of this, vi. report with caution. Granular Casts: Are the result of degeneration of cells in cellular casts. Their significance lies with the cast from which they were formed. Granular cast may also be seen following periods of stress and strenuous exercise. No distinction will be made between coarse and fine granular. vii. Waxy Cast: Represent the final stage in the degeneration of cells within a cast - - from cellular to granular to waxy. Associated with severe chronic renal disease and renal amyloidosis, waxy casts are only rarely seen in acute renal disease. Waxy casts are homogeneous, like hyaline casts, but they are more refractile, with sharper outlines and they tend to have broken or blunt ends and fissure or cracks along the sides. It is important that waxy cast not be confused with fibers from disposable diapers or other contaminants. The presence of protein on the reagent strip and lack of polarization of the waxy cast with polarized light help with this distinction. viii. Fatty Casts: Contain globules of fat, either as triglyceride or normal fat, which can be stained with Sudan Stain, or as cholesterol which will polarize as a Maltese cross. Page 14 of 17

15 Standardized Criteria for Reporting Urine Micros WBC & RBC Average # of cells. No ranges will be used. Highest reportable value >100/hpf WBC CLUMPS OCC 0 2/HPF FEW 2 5 /HPF MOD 5 10/HPF MANY >10/HPF EPITHELIAL CELLS NONE SEEN NOTE: Quantitate renal epis the same as squamous OCC 0 2/HPF epis and report as non-squamous epithelial cells. Do FEW 2 5/HPF not report as renal cells. MOD 5 10/HPF Do not report clue cells in urines MANY >10/HPF PRESENT: use with comment re: field obscured by WBC s BACTERIA NEG <10/hpf BORDERLINE (+/-) /hpf POSITIVE (+) >100/HPF MUCOUS THREADS DO NOT REPORT CASTS 1 10/hpf Reported by type per HPF. NOTE: Please note if broad forms of casts are present as these are clinically significant. Broad forms are 2-3 x Normal size. < 1/hpf >10/hpf CRYSTALS Leucine, cysteine and tyrosine will be reported as rare, occ, few, moderate or many. All other crystals will be reported as few, moderate or many. *Unidentified crystals must be sent to the La Crosse lab for identification. SPERM Report in all specimens. OVAL FAT BODIES & FAT DROPLETS YEAST CLUE CELLS VOLUME OCC FEW MOD MANY 0 2/hpf 2 5 /hpf 5 10 / hpf >10 hpf PRESENT OR NOT PRESENT PRESENT PRESENT ** Do not report clue cells in urines. The volume of urine will be reported on all urines that reflex a microscopic an are less than 10cc. Microscopic Normal Range: WBC RBC Bacteria (0-5 / HPF) (0-2 / HPF) (<10 / HPF) Urine specimen comments available for use: Dysmorphic RBC No specimen collected Page 15 of 17

16 Fecal contamination Menses Grossly Bloody Field Obscured by WBC or RBC ph >9.0: Albumin may not be accurate due to high ph Catheterized sample QNS unspun micro ORANGE URINES: (perform micro) and report comment: Unable to report due to interfering substances Recording Results Patient test results are transferred into the patient's electronic/permanent medical record via LIS interface or manual LIS entry. Report format options include dictation or manual documentation of the urine dip result into the OB flow sheet. Critical Call values are not required for these test parameters, in accordance with Lab-0130 Critical Call Values, Lab Reporting Protocol. Proficiency Testing All proficiency testing samples are run as patient samples. To properly identify these samples, use the Status keypad and enter the bottle number being tested. Example: testing bottle XU 11. Touch the ABC pad and enter XU, touch the space pad, touch the ABC pad again and enter 11. Special Notes See manufacturer s product insert for a complete explanation of all test limitations. Multistix 10 SG test results are transferred electronically as a test profile. If a result within the defined profile is missing, the complete profile will fail to transfer to the electronic chart. If the ID test pad on the Multistix 10 SG becomes wet during the dipping process, the potential is for the Clinitek Status to read the test pads as if a Multistix Pro exists. In this case, the strip is identified a multistix PRO and the specific gravity and ph are missing on the printout. If this happens, test results must be discarded and the urine dip must be repeated. Any Multistix 10 SG test demonstrating an error code message on the Clinitek Status is permanently blocked from data transfer into the electronic chart. REVIEW AND CHANGES: This document and all attached forms should be reviewed optimally on an annual basis, with 2 years as the maximum review date. Review will be done by the Technical Leader, Supervisor, Manager, Medical Director or designated person. Changes require retyping document or form and review by the Medical Director. REFERENCES: 1. Multistix 10 SG Reagent Strips package insert, revised 02/92, Bayer Corporation, Elkhart, IN Operating Manual Clinitek Status revised 05/08 Bayer Corporation Elkhart, IN Clinical Laboratory Technical Procedure Manuals, NCCLS, wnd Ed, Approved Guidelines, July 1992, Vol. 12, No Urinalysis and collection, Transportation, and Preservation of Urine Specimens; Approved Guidelines, NCCLS, GP16A, Vol. 15, No. 15 Page 16 of 17

17 5. Urinalysis and Body Fluids, Ringsrud and Linne 6. Fundamentals of Urine and Body Fluid Analysis, Brunzel, Nancy, WB Saunders & Co, Page 17 of 17