HANDLING GENERAL INFORMATION TEST REQUESTS TYPES OF TESTS TEST REQUEST FORM

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Jeffrey Higgins
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1 SECTION 3: SAMPLE COLLECTION & HANDLING GENERAL INFORMATION SAMPLE INTRODUCTION COLLECTION & HANDLING GENERAL results. INFORMATION The quality of laboratory test results depends greatly on the quality of the samples submitted for analysis. Proper patient preparation, sample collection, sample packaging and transportation are important factors in determining accurate test TEST REQUESTS Familiarisation with the Pathology Services A Practical Handbook (5 th Edition) on the availability of the types of tests in the different disciplines, laboratory operating hours, laboratory collection service, types of emergency/stat tests and many others would be very useful prior to placing test requests. In general, each sample should be accompanied by a test request form. Multiple test requests on a single sample, particularly panel tests, are acceptable for Biochemistry, Haematology, Cytogenetics, Immunology and Serology, and Virology. TYPES OF TESTS Please refer to Section 4 (Sample Collection and Handling Special Instructions, Laboratory Tests, Reference Values & Test Results) for the list(s) of tests performed in each discipline. TEST REQUEST FORM Please use the correct test request form to accompany the patient s sample so that it can reach the appropriate laboratory without unnecessary delay. All information requested in the form should be given as this is essential for proper processing of samples and correct interpretation of test results. The following forms are used in Singapore General Hospital when requesting for various laboratory tests. Samples of these forms are shown in the Appendix _PathoH_SL.indd 29 4/3/08 11:48:17 AM

2 PATHOLOGY SERVICES A PRACTICAL HANDBOOK Types of test requests Bacteriology, Mycology, Parasitology Biochemistry Blood Bank (Transfusion Medicine) Cytogenetics Cytology (Cervical PAP Smears) Cytology (FNA, body fluids, etc.) Haematology Histopathology Immunology, Serology, STD & Allergy Molecular Mycobacteriology Virology Client Services Request Form to use Request for Bacteriological Investigation Request for Biochemical Analysis Request for Blood and Blood Products Request for Immunohaematological Investigation Request for Cytogenetics Investigation Request for Cervical Pap Smear Cytology Request for Histopathological Investigation Request for Haematological Investigation Request for Coagulation Studies Request for Urinalysis Request for Special Haematological Investigations Request for Histopathological Investigation Request for Immunological Investigations Request for Virological Investigation Molecular Test Request for Bacteriological Investigation Request for Virological Investigation Request for Laboratory Services Please print all information clearly and legibly on all test request forms _PathoH_SL.indd 30 4/3/08 11:48:17 AM

3 SECTION 3: SAMPLE COLLECTION & HANDLING GENERAL INFORMATION PATIENT IDENTIFICATION Correct spelling of patient s name and other biodata given are essential to ensure that the sample collected and received by the laboratory comes from the correct patient. Patient s name Patient s NRIC number or Passport number Hospital Registration or Account number Date of birth Sex Nationality Others, e.g. first twin or second twin PATIENT LOCATION The patient s exact location should be stated clearly so that the laboratory can communicate promptly with the relevant referring clinic/ward/department/hospital should the need arise. Name of Hospital Name of Clinic/Department Ward number Bed number Non-hospital or clinic clients should include the name, address and telephone number of their organisation. An address and Fax number should be included if available for alternative means of communication. It is important to include the name of the contact person in the organisation for the return of reports, and the name and contact number/ address of the requesting doctor for discussion of the case if this is needed. CLINICAL HISTORY Clinical diagnosis Suspected disease/organism Brief clinical history Name, date and duration of treatment given Any previous test results with dates and previous laboratory numbers Patient s immune status (e.g. any underlying diseases, cancer chemotherapy, immunosuppressive treatment) Any other relevant patient or clinical data requested in Section 4 (Sample Collection and Handling Special Instructions, Laboratory Tests, Reference Values & Test Results) by each discipline. Sample may be rejected if no diagnosis or clinical history is written on the request form. This applies especially to Histopathology, Cytology, Cytogenetics and Virology investigations _PathoH_SL.indd 31 4/3/08 11:48:17 AM

4 PATHOLOGY SERVICES A PRACTICAL HANDBOOK TEST REQUESTS Tick the appropriate box/boxes on the request form. To order tests that are not listed on the form, write the name of the test in the space marked Miscellaneous or Others. NATURE OF SAMPLE Identify sample source by checking the relevant box on the form or writing the specific body site from which sample had been taken. DATE AND TIME OF SAMPLE COLLECTION The actual date and time of sample collection should be indicated for proper evaluation of test results. NAME OF REQUESTING DOCTOR/CONSULTANT This information is important for the laboratory to contact the relevant physician when necessary. The MCR number of the requesting doctor should be indicated on the form. The sample will be rejected if the request form does not have the requesting doctor s name on it. EMERGENCY OR STAT TEST Clearly indicate this on the request form. Make sure that the telephone and fax numbers of the named person to whom results should be given are written on the form _PathoH_SL.indd 32 4/3/08 11:48:17 AM

5 SECTION 3: SAMPLE COLLECTION & HANDLING GENERAL INFORMATION SAMPLE COLLECTION Verify to ensure that the sample is collected from the correct patient by asking for the patient s name or by checking the patient s wristband for name and NRIC number. An adequate amount of sample must be collected to enable the test to be carried out. If multiple tests are ordered, make sure that sufficient sample is collected. If the sample is insufficient, the requesting physician should state which tests should be done in order of priority. Aseptic techniques must be employed during collection to prevent the introduction of micro-organisms into the patient s anatomical space, and to prevent the sample from being contaminated during the process of collection. All samples should be regarded as potentially infectious and standard precautions guidelines should be followed by all healthcare workers during sample collection and handling. Samples must be collected into appropriate containers before despatch to the laboratory. Be careful to check for cracks in the containers and to ensure that the lids of containers are properly tightened to prevent leakage of samples during handling and transportation. This can pose infection hazards to transport and laboratory staff. Ensure that the outer surfaces of the containers are not contaminated by the patients samples. Please see Section 4 (Sample Collection and Handling Special Instructions, Laboratory Tests, Reference Values & Test Results) of each discipline for more information including: How to prepare patients before sample collection When, how, where and how much material to collect Types of containers used e.g. sterile, plain, with preservative, anticoagulant or transport media Conditions of storage and transportation of samples to the laboratories _PathoH_SL.indd 33 4/3/08 11:48:17 AM

PATHOLOGY SERVICES A PRACTICAL HANDBOOK VACUTAINER SEQUENCE OF DRAW RECOMMENDED BY *CLSI (FORMERLY KNOWN AS NCCLS) Description BACTEC TM Blood Cultures Order of Draw Tube content Draw volume

7 ml PT/PTT PT/INR Platelets Function Test (PFT) (use 7 tubes for PFT) Red 3 Plain 6 ml Antibody identifications (Immunohaematology) Gold 4 SST (Plain with Gel) Green 5 Lithium Heparin Pink 6 K 2

8 mg 5 ml For Biochemistry tests(serum determinations) 4 ml Ammonia (send in with ice-pack) HLAB27 (use 2 tubes) Cytogenetic investigations 6 ml Strictly for Group X-Match Instructions Blood cultures

6 PATHOLOGY SERVICES A PRACTICAL HANDBOOK VACUTAINER SEQUENCE OF DRAW RECOMMENDED BY *CLSI (FORMERLY KNOWN AS NCCLS) Description BACTEC TM Blood Cultures Order of Draw Tube content Draw volume Determinations ml Aerobic & Anaerobic Cultures Blue 2 Sodium Citrate 2.7 ml PT/PTT PT/INR Platelets Function Test (PFT) (use 7 tubes for PFT) Red 3 Plain 6 ml Antibody identifications (Immunohaematology) Gold 4 SST (Plain with Gel) Green 5 Lithium Heparin Pink 6 K 2 EDTA 10.8 mg 5 ml For Biochemistry tests(serum determinations) 4 ml Ammonia (send in with ice-pack) HLAB27 (use 2 tubes) Cytogenetic investigations 6 ml Strictly for Group X-Match Instructions Blood cultures should be done separately. However, if blood samples need to be taken, then blood cultures are done first to avoid contamination by the other blood tubes. Allow tube to fill completely. x 4 x 5 x 5 x 8 x 8 Lavender 7 K 2 EDTA 5.4 mg Grey 8 Sodium Fluoride 3 ml FK506, Cyclosporin, G6PD, FBC, HbA1c, Homocysteine (send in with ice-pack) 6 ml Lactate (send in with ice-pack), Pyruvate, GTT x 8 x 8 *CLSI: Clinical Laboratory and Standards Institute; Reference: H3-A5 Vol. 23 No. 32 Replaces H3-A4 Vol. 18 No. 7 Blood Banking Pre-transfusion Tests (Blood Group, Antibody Screen, Compatibility test) Immunohaematology Tests including Antibody Identification _PathoH_SL.indd 34 4/3/08 11:48:17 AM

7 SECTION 3: SAMPLE COLLECTION & HANDLING GENERAL INFORMATION SUMMARY OF GUIDELINES ON SPECIMEN COLLECTION GENERAL 1. Label all tubes & specimen bottles. 2. State source of specimen(s) & test(s) required. 3. Fill in patient location. 4. Fill in doctor s name. 5. Fill in date of collection, and time. 6. Use the appropriate bottle and tube. 7. Use EDTA tubes for HbA1c. Some tests need special tubes and need to be sent in ice. Pls refer to instructions on lab request forms (e.g. Biochemistry tests). 8. PT/PTT tubes: Should fill to blue mark. 9. FBC tubes: Should fill to white mark. SWABS Gram Stain and Culture: Send 2 separate swabs for (i) Gram stain and smear (ii) Aerobic Bacterial Culture, if both Gram Stain and Culture are required. Anaerobic culture: Use transport media or swab with gel. Mycobacteria (TB, AFB) smear and culture: (a) Send separate specimens (Sputum, Swab etc) and request forms if Mycobacteria (TB) and Bacteria are required. (b) Do not send laryngeal swab, send sputum instead and state the source of specimen. Neisseria gonorrhoeae (G.C.): Do not send the swab. Obtain G.C. plate from lab (Tel: ), inoculate on plate and send back to the lab. TB TESTS Quantiferon Test: Collect 1 ml of blood in each of the three Quantiferon tubes supplied. Use green Bacteriology form for TB molecular tests (TB-PCR or ProbeTec), and not the red Molecular test form. HISTOPATHOLOGY TESTS Indicate doctor s name and department. All Histopathology specimens to be hand carried to the laboratory. MOLECULAR TESTS Indicate date and time of sample collection on the request form. Send specimens within 24 hours of collection. If delay is expected, refrigerate at 4 o C and indicate on the request form that sample has been refrigerated. For routine tests, do not collect specimens on Saturday afternoons, Sundays and public holidays, when the Molecular Lab is closed. (Molecular lab operating hours: Mon Fri 8.30 am to 5.30 pm, Sat 8.30 am 1.00 pm, closed Sunday and public holiday) Swabs Send dry swabs (i.e. no transport media). Refer to PCR/Molecular Tests for more details. Do not send laryngeal swabs. Blood Blood for molecular tests must be sent in EDTA tubes, not plain blood tubes _PathoH_SL.indd 35 4/3/08 11:48:18 AM

Swab in Hanks virus transport medium for viral antigen + virus culture (with ice-pack, hand-delivered to lab).

8 PATHOLOGY SERVICES A PRACTICAL HANDBOOK VIROLOGY TESTS Swabs No dry swab. Swab in sterile saline for viral antigen test. Swab in Hanks virus transport medium for virus culture (with ice-pack, hand-delivered to lab). Swab in Hanks virus transport medium for viral antigen + virus culture (with ice-pack, hand-delivered to lab). Blood At least 6 ml in EDTA tube for CMV pp65 antigen (room temperature) or CMV culture (with ice-pack, 4 o C, handdelivered to lab). 5 ml in plain tube for viral antibody test (room temperature). EDTA tube for CMV pp65 Do not use plain tube for CMV pp _PathoH_SL.indd 36 4/3/08 11:48:18 AM

9 SECTION 3: SAMPLE COLLECTION & HANDLING GENERAL INFORMATION SAMPLE LABELLING AND DESPATCH After collection of the sample/s: 1. Label sample All sample containers should be labelled with the following: Patient s name and NRIC number/passport number Time and date of collection Source of sample Test requested 2. Specimen containers should be labelled at the time of collection and not deferred until a later time. 3. Make sure the correct Test Request Form has been completely and correctly filled (see Appendix). 4. Samples taken from patients with suspected or known contagious infections such as HIV or hepatitis B infection must be placed in special plastic bags with a Biohazard label Blood Precautions on it. Double bag it by attaching the corresponding form in a separate bag to the bagged sample. (Forms should never be placed within the sample bag to prevent spillage onto the form.) Also check that the number on the sample form tallies with the number on the sample tube or container. 5. Sample despatch Send sample with its accompanying form immediately for despatch to the laboratory or for collection by the Client Services transport. Specimens for Histopathology must not be sent to the laboratory by telelift. Please see Sample Collection Services in the Histopathology Section for details. Emergency/Stat samples, viral culture samples and samples for chromosome culture should be sent by hand, and not by telelift, immediately to the laboratory _PathoH_SL.indd 37 4/3/08 11:48:19 AM

PATHOLOGY SERVICES A PRACTICAL HANDBOOK SENDING SWABS FOR MICROBIOLOGY TESTS BACTERIA A. GRAM STAIN AND CULTURE 1.

Bacterial Culture 2. Anaerobic culture: Use transport media or swab with gel. (Swab with gel) B. MYCOBACTERIA (TB, AFB) SMEAR AND CULTURE 1.

or + Request for Bacteriological Investigations or + Request for Bacteriological Investigations To TB Lab 2. Do not send laryngeal swab.

Roll the swab on the GC agar in the shape of a Z, do not cut into the agar.

10 PATHOLOGY SERVICES A PRACTICAL HANDBOOK SENDING SWABS FOR MICROBIOLOGY TESTS BACTERIA A. GRAM STAIN AND CULTURE 1. Send 2 separate swabs for: Gram stain Aerobic Bacterial and smear Culture Request for Bacteriological Investigation (a) Gram stain smear (b) Aerobic Bacterial Culture 2. Anaerobic culture: Use transport media or swab with gel. (Swab with gel) B. MYCOBACTERIA (TB, AFB) SMEAR AND CULTURE 1. Send separate specimens (Sputum, Swab etc) and forms if Mycobacteria (TB) and Bacteria are required. or + Request for Bacteriological Investigations or + Request for Bacteriological Investigations To TB Lab 2. Do not send laryngeal swab. Send Sputum instead. To Bacteriology Lab (for aerobic bacteria) C. NEISSERIA GONORRHOEAE (G.C.) 1. Do not send swab. Obtain G.C. plate from lab (Tel: ) and inoculate at bedside. Roll the swab on the GC agar in the shape of a Z, do not cut into the agar. Request for Immunological Investigation VIROLOGY VIRAL CULTURE/VIRAL ANTIGEN 1. Do not use dry swab. (a) For Viral Culture: Swab in Hank s Viral Transport Media, secured on ice pack. (b) For Viral Antigen tests: Swab in Sterile Saline. Ice pack _PathoH_SL.indd 38 4/3/08 11:48:19 AM

11 SECTION 3: SAMPLE COLLECTION & HANDLING GENERAL INFORMATION (c) For Viral Culture & Viral Antigen: Swab in Hank s Viral Transport Media, secured on ice pack. Ice pack Request for Virological Investigation PCR / MOLECULAR TESTS 1. Swab specimens must be sent dry (i.e. no transport media), and sent within working day. Refrigerate if delay expected. No media. 4 C if delay. Request for Virological Investigation Molecular Test MATERIALS AND SUPPLIES Hospitals, clinics and laboratories are to use their own sample collection devices like containers, tubes, swabs and others for sample collection. The Department of Pathology supplies the following transport media/containers to Clinical Laboratories of restructured and government hospitals for routine use: Virus transport medium (VTM) for virus isolation. Urine culture bottle for cytomegalovirus (CMV) and adenovirus. Transport medium for chorionic villi (CV) / products of conception (POC) cytogenetic tests. Transport media for culture of Mycoplasma/Ureaplasma, Haemophilus ducreyi and Neisseria gonorrhoeae and Teflon-coated slides for the detection of Chlamydia trachomatis from swab samples by the direct immunofluorescence method. Blood culture vials for aerobic bacteria, anaerobic bacteria, mycobacteria and fungi. Dipslide for urine culture. Other users can request for the above items from the Client Services Section of the Department of Pathology. LABORATORY REPORTS 1. All reports of laboratory test results will be computer printed and will contain all patient identification data, patient location and other relevant information as provided in the Test Request Form. 2. Results will be reported with reference ranges, abnormal panic flags, etc., where applicable. 3. Emergency/stat test results, abnormal critical results and results of pathogenic organisms isolated from blood and cerebrospinal fluid or of public health importance such as V. cholerae and Salmonella typhi will be reported by telephone to the staff nurse or doctor-in-charge of the patient, or faxed to the relevant patient location as indicated in the Request Form. Telephone reporting should be considered an interim step and requires confirmation with a printed report. 4. Please see the turnaround time of each test as listed in individual discipline in Section 4 (Sample Collection and Handling Special Instructions, Laboratory Tests, Reference Values & Test Results) to get an idea of when to expect test results _PathoH_SL.indd 39 4/3/08 11:48:20 AM

12 PATHOLOGY SERVICES A PRACTICAL HANDBOOK 5. Enquiries on test results can be made to the Client Services of the Department of Pathology. Enquiries of cytogenetics, haematological and blood transfusion tests should be made direct to the Cytogenetics, Haematology, and the Blood Bank Laboratories, respectively. 6. The type of report e.g., preliminary, final or duplicate will be indicated on the form. 7. Results of tests from all clinical laboratories are transmitted on-line to the hospital Electronic Medical Record (EMR) system for viewing in SGH wards and clinics by clinicians and relevant healthcare workers. Biochemistry and Haematology reports are currently being printed in SGH wards. All other clinical reports are printed by the respective laboratories and despatched by Client Services to the wards. 8. Reports for other hospitals, clinics, laboratories and organisations are despatched by our department s Client Services. 9. Please see Myobacteriology section for details on Mycobacteriology reports. 10. Reports from Food and Water and Pharmaceutical Microbiology laboratories are either collected by hand or sent out by post. 40 CRITERIA FOR UNACCEPTABLE SAMPLES Some samples may not be accepted. Reasons for not accepting such samples include: No patient data on request form Sample without request form No sample accompanying request form Sample without label Nature/source of sample not indicated Name on form/sample do not match Test request/s on form/sample does not match Serial numbers on form/sample do not match No diagnosis, clinical history or requesting doctor s name on request form Blood lysed/clotted Unsuitable sample: e.g., sample sent without or in incorrect transport medium/ anticoagulant/preservative Sample sent in wrong/inappropriate container Contaminated sample Broken or leaking container or spilt sample Insufficient sample Delayed sample Test/s not available in SGH Labs The laboratory will try not to reject a sample unless it poses a health hazard or if results of tests done on such a sample will not be meaningful. Attempts will be made to contact the ward staff/laboratory user to try and solve any problem(s) especially for samples obtained via invasive procedures. However, if any doubt remains as to the identity or source of a sample, it will be rejected, and another sample requested. The rejected specimen/s will be logged using the Laboratory Information System (LIS) or the Rejection of Specimen Form will be sent to the ward/laboratory user. Rejected specimen/s will not be returned. In the case of Food and Water Microbiology Laboratory, approval from clients will be obtained prior to sample rejection _PathoH_SL.indd 40 4/3/08 11:48:20 AM

SECTION 13.0 SPECIMENS FOR LABORATORY EXAMINATION

SECTION 13.0 SPECIMENS FOR LABORATORY EXAMINATION Introduction Collection of Specimens for Microbiological Examination: Safe Handling of Specimens Packaging & Transportation of Specimens Specimen Rejection