The Test Tables portion of the Laboratory Manual provide information regarding the amount of specimen required for a test, the type of container in which it should be submitted, what preservative is needed, and how the sample should be handled. See "Urine Collection for Chemical Analysis" section for detailed information on urine preservatives and sample collection for various analytes.
Where a test is performed, the testing schedule, expected turnaround time, reference ranges, methodology and - where applicable - "critical" values, are also included in the individual test entries. Central Processing personnel (3-1667) and Send-out staff (3-1349) can also provide information regarding what time tests sent to reference laboratories are picked up. Note that for many send-out tests, sample stability and transport issues may make it inadvisable to draw samples for testing after 12:00 noon on Thursday and they should not be collected Friday, weekends or holidays except when absolutely necessary. In such instances it is advisable to contact the laboratory to discuss the needs with a resident or pathologist so that, if approved, arrangements for special handling can be made. The "collection instructions" listed in the Laboratory Manual for each test will have this information when applicable. For tests not listed in the laboratory manual it is advisable to contact laboratory Send-out staff (x3-1349) before collecting samples to determine the requirements for the test, when it may be drawn and any special requirements for referring the test to another laboratory.
All this information is kept up-to-date and is accessible electronically at our website (http://labmed.ucsf.edu/labman)
An extensive section of "Synonyms" is included in the on-line Laboratory Manual to facilitate the recognition of requests under variant names and abbreviations. If you have trouble finding a test using a "common" term or acronym, please contact the lab at 3-1667 and request the term be added to the synonym list.
Additional details of test performance, e.g., reagent and/or equipment vendor, method, accuracy, precision (including Levey-Jennings plots and coefficients of variation), sensitivity and linearity are available on request from the performing laboratory section. Please consult the individual test entries to determine the performing section and the section directory at the beginning of this Prologue.
Samples submitted to the UCSF Clinical laboratories do not go through a chain of custody process nor do we offer such a service. Therefore, the results of laboratory tests may not in general be used for Medico-Legal purposes. Testing that requires chain of custody must be directly arranged with external laboratories that offer this service.
The UCSF Clinical Laboratories provides testing in suppoort of research projects with test pricing that is significantly below the list price offered by the Medical Center. In order to provide this service we require the following:
- A current active research budget account to bill against
- A copy of the UCSF CHR approval letter for the study
Please note that research support provided by the UCSF Clinical Laboratories is strictly limited to tests that are performed in-house. We do not send research samples out for research testing and do not offer to package or ship materials out to other laboratories. Such arrangements must be made directly with the external laboratory that will perform the testing.
The UCSF laboratory tests are validated for and our normal ranges apply to human samples. We have not validated our tests on animal samples nor established normal ranges for animal samples. Typically, because of workload and patient testing priorities we do not offer animal testing, however, you may inquire of the section(s) that perform the testing of interest to see if they are willing to test such samples. The decision is entirely up to the director for the involved section. For testing on mice contact the Mouse Pathology Core at the Helen Diller Family Comprehensive Cancer Center for Assistance: http://cancer.ucsf.edu/research/cores/mouse Ph: 415-514-3500.
Please direct all research related inquiries to Mr. Steven Peacock, the laboratory Administrative Director at 415-353-3991.
Patients must be registered before their laboratory orders will be processed and their samples collected. Registration is performed as part of each clinic visit, or at the registration desks in the first floor lobby of the ACC, the first floor at 2330 Post St., UCSF/Mount Zion Cancer Center, and the third floor of the Conway Gateway Building at Mission Bay. Mount Zion Cancer Center patients must be registered in the clinic before presenting for phelebotomy as there are no centralized registration services in that building. Registration is abbreviated when there has been no change in demographic information or insurance coverage. Prior hospitalization at UCSF does not eliminate the requirement for registration.
Non-UCSF patients presenting for sample collection must also be registered before samples will be collected. Such patients must have written orders including the name, address and phone number of the ordering provider, the test(s) to be performed and all applicable ICD-9 diagnosis code(s)* that meet medical necessity requirements. Patients who present with requisitions that lack these items will be asked to call or return to their provider. Samples will generally not be collected until this information is available.
For UCSF providers, laboratory results are reported to and reviewed via the provider’s 'In-basket' in the UCSF APeX electronic health record. Hard copy outpatient laboratory reports for non-UCSF providers are directed to the provider's address listed in the Medical Staff Office database. It is imperative that this information be kept up to date to avoid mis-directed reports. The laboratory receives this address information via a nightly update from the Medical Staff Office, therefore any changes to the information must be made in the MSO database.
If a sample has been collected on an unregistered patient and any delays in processing would jeopardize the sample the laboratory can enter the sample and patient information into the laboratory information system using a temporary ID number. The patient should be registered as soon as possible so that the temporary number can be replaced. Note that results on samples identified with a temporary number do not broadcast to the APeX electronic health record. To obtain results on patients who have not been registered, contact the laboratory at 415-353-1667 and provide the patient's full name and date of birth. Although a hard copy report may be generated for an unregistered patient, their results will not appear in APeX until they have been registered and their records merged.
*Exceptions may be made in instances where the Medical Center bills the ordering practice rather than the patient
HOURS (M-F, except holidays)
|UCSF Ambulatory Care Center (ACC)||
|UCSF Hematology/Oncology Clinic (ACC)||
|2330 Post St. (Mount Zion)||
|UCSF Mount Zion Cancer Center||
|Mission Bay Conway Gateway Building||
The UCSF Clinical Laboratories do not offer weekend phlebotomy services.
Ambulatory patients sometimes appear at our various laboratories (5th floor Moffitt, 2nd Floor Mount Zion B bldg, Mission Bay) for nonemergency blood collection, particularly in the evening and on weekends. Laboratory personnel are not permitted to draw blood in these areas and the patient will be asked to return to one of our Specimen collection centers during the hours when routine services are provided.
Ambulatory patients should be referred to the ACC, Mission Bay Conway Gateway or 2330 Post St. sites for containers, and for any special collection instructions (for some of the more common tests, these are available in Chinese, and Spanish as well as English). Collection instructions are also available via the on-line lab manual either in the test entries themselves or from the following link: http://labmed.ucsf.edu/labmanual/mftlng-mtzn/test/pt_instructions.html
Bone marrow aspirations, Sweat Chloride, Glucose Tolerance and/or other procedures which require timed or sequential draws should be scheduled at least one day in advance. The 'Collection Instructions' in the individual test entries will indicate if the test needs to be scheduled in advance and provide information on how to schedule
Under California Business and Professions Code section 1288:
- "Any person conducting or operating a clinical laboratory may accept assignments for tests only from and make reports only to persons licensed under the provisions of law relating to the healing arts or their representatives…"
In order to be "licensed under the provisions of law relating to the healing arts", the healthcare practitioner must be licensed in the state of California as a physician and surgeon, or licensed as a healthcare provider with a scope of practice that authorizes ordering clinical laboratory tests. If the test results can be lawfully used by the healthcare provider to diagnose, manage or treat the patient, then it would likely be appropriate for that healthcare provider to order the test.
In order to be considered a "representative" of a healthcare practitioner, that person must be an employee of the person authorized to order tests, such as the ordering practitioner's physician assistant or registered nurse. A patient cannot be made a 'representative' of a physician in order to directly receive his or her own laboratory test results. Please do not request that the laboratory provide results directly to patients or tell patients that they may contact the laboratory to obtain their results. It is standing policy for the UCSF Clinical Laboratories to not provide reports directly to patients in compliance with the above regulations and laboratory staff are instructed to deny such requests and refer the patient back to his or her physician for their test results.
Patients who want to be able to receive their lab results should be directed to either call (415-514-6000) or email (UCSFMyChart@
Although in 2002 California state law (SB1131) made it allowable for patients to self-order laboratory tests that are normally available as over-the-counter tests from pharmacies. Due to payment and reporting constraints the UCSF Clinical Laboratories do not accept patient self-orders for laboratory tests. If patients wish to self-order tests they should be referred to a commercial laboratory that accepts such requests.
Furthermore, for reimbursement purposes, requests for outpatient testing must carry the name of an identifiable individual who is recognized as authorized to order tests in California. Unless charged to a budget/research account, outpatient orders cannot be submitted in the name of a medical student, nurse practitioner, registered nurse, licensed vocational nurse, or anonymously as "Fellow" or "Resident 1", etc.; in each case the laboratory order must include the name of an individual licensed provider who is taking responsibility for the orders.
Only tests which are considered "medically necessary," i.e., warranted by the medical condition of the patient, will be reimbursed by Medicare, MediCal and in general, most third-party carriers. Screening tests and general health examinations are typically not covered by most insurance and are specifically excluded from reimbursement (with minor exceptions) by both Medicare and MediCal.
Physicians are required by law to provide the laboratory with the ICD-9 (International Classification of Diseases [Clinical Modification], 9th edition) diagnostic code(s) for outpatients* that justifies the test(s) he or she has ordered. CMS and, increasingly, other carriers have developed guidelines for the use of many laboratory tests, and will not pay for these tests if an appropriate diagnostic code is not provided at the time the test is requested. APeX and all laboratory requistions have areas where the ICD-9 codes are to be entered.
*Exceptions may be made in instances where the Medical Center bills the ordering practice rather than the patient
If a test is ordered upon a Medicare patient that is unlikely to be reimbursed by CMS, the patient will be informed of the reason WHY coverage is unlikely and will be asked to sign an Advance Beneficiary Notice (ABN) acknowledging personal financial responsibility for the cost of testing if, as expected, reimbursement is refused. If the patient refuses to sign the form the test(s) in question will not be performed and a note to this effect will be entered into the computer.
Reasons for lack of coverage include:
- lack of an ICD-9 diagnostic code consistent with "medical necessity" guidelines;
- the diagnostic test is not approved for diagnostic use by the FDA and thus is deemed "experimental" by HCFA;
- prior refusal or announcement by Medicare of its unwillingness to cover the test.
- tests which have frequency limitations and for which the laboratory cannot determine the last time the patient had the test performed
Blood may be drawn on preoperative patients in the Ambulatory Care Center (hours noted above under Ambulatory Patient Blood Drawing). In-patient phlebotomy is provided via laboratory phlebotomists on acute inpatient wards. Nursing staff perform collections on all intensive care and neonatal units.
Inpatient blood drawing for laboratory studies is usually performed each morning between 0400 and 0800. APeX orders are transferred to Collection Manager devices used by phlebotomists and nursing staff to print container labels at the patient’s bedside. These labels prompt for the correct container type and greatly reduce labeling errors.
Point-of-Care Testing (POCT) is available in many inpatient units and outpatient clinics in order to provide rapid test results in support of patient care. The UCSF Point of Care Committee maintains oversight of all POCT within the UCSF system. Each site performing POCT is audited monthly for compliance with POCT testing policies and laboratory regulations by clinical laboratory staff (or clinic staff for remote sites). The results of these audits are monitored for each location and reported quarterly to the committee that in turn reports annually to the Clinical Performance Improvement Committee (CPIC). Sites found to be out of compliance on repeat audits may have their authorization to perform POCT suspended until such time as they can demonstrate compliance.
In the inpatient setting only licensed individuals who have been properly trained and demonstrated competency may perform POCT. Physicians may perform POCT utilizing visual endpoint tests without formal competency assessment, provided that each test is covered as part of the physician’s medical staff privileges. Physicians must demonstrate annual competency for any test using a testing device.
In the outpatient clinics non-licensed personnel may perform POCT classified as waived by the FDA provided they have received training and demonstrated annual competency for each test they perform. Non-licensed personnel may not perform non-waived testing.
Each location performing POCT classified by the FDA as "moderately complex" must enroll in and successfully perform proficiency testing (PT) for each such test. The results of all proficiency testing are reported to the Point of Care Committee. Sites that demonstrate unsuccessful PT performance may lose authorization to perform the test until they can demonstrate successful PT performance.
Provider Performed Microscopic Procedures (PPMP; KOH preps, Wet mounts, Fern testing, Urine sediment exam, Pinworm exam) require that each provider complete a PPMP Competency checklist annually and turn it in to the Medical Staff Office (MSO). The competency checklist includes completion of an on-line competency assessment in each area of PPMP that they wish to perform. After an initial competency assessment each provider must re-take and pass the competency assessment at 6 months and annually thererafter. Further, after demonstrating initial competency, each provider must apply for privileges in PPMP from the UCSF Credentials Committee. Providers who have not demonstrated competency via completing the annual competency checklist or who have not been granted PPMP privileges may not perform PPMP examinations.
New sites that wish to perform POCT or requests for new POCT from existing sites must be made in writing to the UCSF Point of Care Committee. The committee will evaluate the request and determine if the request will be approved. If testing involves a new analyte the UCSF Clinical Laboratories will assist in the evaluation of available test methods and in the validation of any test kit or device that is selected. No site may initiate POCT or expand their menu of tests without approval of the committee. Each POCT site maintains a list of the tests they are authorized to perform, signed by the relevant CLIA director.
Please visit the Point Of Care Testing Manual for specific test information.
|TOP||DRAW (mL)||INTERIOR COATING||TUBE CONTENTS|
|(Stoppers are silicone-coated unless otherwise specified)|
|1.8||none||0.109 M (3.2%) buffered citrate, 0.2 mL|
|2.7||none||0.109 M (3.2%) buffered citrate, 0.3 mL|
|6.0||none||sodium fluoride, 15.0 mg, potassium oxalate, 12.0 mg|
|4.0||none||sodium heparin, 60 USP units|
|Light Green (PST)
|4.5||none||inert polymer gel, with lithium heparin sufficient for a 4.5 mL draw|
|0.6||none||inert polymer gel, with lithium heparin sufficient for a 0.6 mL draw|
|5.0||silicone||Inert polymer gel and silica clot activator|
|6.0||none||EDTA (K2), 10.8 mg - BLOOD BANK use only (13x100 mm tube)|
|3.0||none||EDTA (K2), 5.4 mg|
|0.6||none||EDTA (K2), 0.75 mg|
|7.0||none||EDTA (Na2), 10.5 mg, trace metal-free (purple lettering)|
|0.7||none||no additive; for BLOOD BANK use or FOR CERTAIN DRUG OR ANTIBODY LEVELS ONLY|
|6.0||silicone||Silica clot activator. For drug and some antibody levels only.|
|0.6||none||plastic tube with inert polymer gel - NOT FOR BLOOD BANK|
|8.5||silicone||acid citrate dextrose solution (ACD A), 1.5 mL|
|3.0||Silicone||Acid citrate dextrose solution (ACD B), 406mg|
For certain tests, e.g., blood gases, plastic syringes containing 100U of heparin and drawing 3 mL, or 50 U of heparin and drawing 1 mL, are also available. Check tube expiration date prior to use. Do not use expired tubes for specimen collection.
The laboratory makes a sincere effort to minimize the amount of specimen required for analysis. A certain amount of specimen is required to perform each test, but because technical problems can occur and a test may have to be rerun, it is a good idea to submit a sample large enough to provide at least twice this minimum. The laboratory staff recognize that this is not always possible, particularly in infants and will make every effort to provide an answer on the sample submitted.
The Test Tables entries list the "Preferred volume" and "Minimum volume" for each test as well as the sample type (whole blood, serum, plasma, urine, etc.). The volumes refer to the amounts needed to perform each specific test, the total volume needed for multiple tests is the total of the individual volumes required for each test ordered. However, many common serum/plasma chemistry tests may be performed on a very small sample size, these tests are indicated in the Test tables with "Click here for Micro-determination info" that provides this information.
For tests performed on blood samples the Test Tables also list the "Amount to Collect", this is the volume of blood necessary to provide the 'Preferred' sample volume and varies by the sample 'type' needed for the test. Note that for tests that require serum or plasma the 'Amount to Collect' is 2x the 'Preferred volume'.
The Clinical Laboratories have a general policy for phlebotomists regarding the maximum amount of blood that can be collected at a given time based on the patient's weight. For children and small adults weighing < 45 kg (approx. 100 lbs) the maximum amount that will be collected without provider pre-approval is 1 mL/Kg. For adult patients > 45 Kg the maximum volume that will be collected without provider approval is 50 mL. When test orders are placed that require these guidelines to be exceeded the phlebotomists have been instructed to contact the ordering provider to clarify the order. The provider, based on his/her knowledge of the patient, may choose to have the full blood volume collected, delete one or more tests from the order in order to reduce the amount needed or instruct the phlebotomist to collect the 'minimum' blood volume for one or more tests.
Staff should avoid submitting quantities of blood greatly in excess of analytical requirements, particularly in complex or severely ill patients who are subject to repeated phlebotomy. Submitting excess sample does the patient a disservice and can lead to an otherwise unexplained "anemia of hospitalization".
Routine daily laboratory
testing should be discouraged unless the results are necessary for
patient monitoring and care decisions. Many tests ordered as 'daily
labs' are unnecessary unless the patient's status is changing and they
merely contribute to the developement of iatrogenic anemia.
1. Avoid hemolysis
A great many blood tests are affected by hemolysis, which can be avoided by careful technique:
- Avoid prolonged venous stasis prior to sample collection,
- DO NOT force blood from syringe through a needle into a vacutainer as the resultant jet may damage red cells, instead allow the sample to be pulled into the vacutainer by the vacuum in the vacutainer
- Mix specimens in the collection tubes by gentle inversion (x5), DO NOT shake.
2. Avoid a running IV line
DO NOT withdraw specimens from an extremity proximal to a running IV, nor from the IV line itself as this may result in contamination of the sample with the IV fluid. (see instructions below on "D. Drawing from Intravascular Catheters"). If it is necessary to draw proximal to an IV it is important that the IV be stopped and the vein allowed to clear (minimum 1 minute) before the sample is drawn. Laboratory phlebotomists have been instructed not to collect samples proximal to an IV, and will ask nursing personnel to stop the IV prior to phlebotomy and restart it after the samples have been collected.
Liquid-containing vacutainers (e.g. Citrate; Blue tops & ACD; Yellow tops) should always be filled to their full draw volume for chemical analysis; this is particularly critical for coagulation testing. Short filling a citrate tube (Blue top) will alter the required 9:1 plasma:citrate ratio and may result in artifactually prolonged coagulation test results. Note that if a winged blood collection set ("butterfly") is used and the coagulation tube is the first tube drawn, a discard blue top tube should be used to clear the deadspace volume of the line or the line should be allowed to 'fill' prior to attaching the vacutainer adapter. This will assure than an adequate blood volume is collected.
Specimens for coagulation testing may also be affected by an abnormal hematocrit. If a patient's hematocrit is above 55%, contact the Hematology laboratory and request a tube adjusted to contain the appropriately decreased amount of citrate anticoagulant. There is no standard at present for adjusting the amount of anticoagulant for specimens with low hematocrits. Finally, specimen(s) for coagulation testing should NOT be drawn from heparinized lines.
4. Order in which multiple samples should be drawn:
Blood samples should be collected directly into vacutainer(s) in the following order to prevent cross contamination of one tube with the additive of another tube that could result in spurious lab results. Check the expiration date of all tubes prior to collecting samples and discard any expired tubes. DO NOT use expired tubes for sample collection.
- Blood Culture*
- Citrate tubes for coagulation tests (BLUE or LIGHT BLUE TOP)
- Gel (SST) tube with clot activator (GOLD TOP)
- Activated clot tube without gel (RED TOP)
- Sodium-heparin tube without gel (GREEN TOP)
- Lithium-heparin tube with gel (LIME GREEN TOP)
- Trace metal free tube w/EDTA (NAVY BLUE TOP W/ PURPLE LETTERING)
- EDTA tube (PURPLE TOP)
- Oxalate/fluoride tube (GRAY TOP)
- Acid-Citrate Dextrose tube (YELLOW TOP)
* In general, because of the risk of bacterial contamination, if blood cultures are needed they should always be drawn first (see the MICROBIOLOGY section in the following pages).
5. When drawing ONLY a (light) blue top tube for coagulation studies:
If the venipuncture is promptly successful with a good flow of blood directly into the vacutainer, that single, filled tube may be submitted for coagulation studies. If, by contrast, the venipuncture is difficult with much searching for the vein, the blood flow is slow, or the collection is made into a large syringe, the coagulation cascade may become activated; in that case an initial blue top tube should be filled, discarded and a second filled tube should be collected for testing.
When a second tube appears to be needed:
- If the patient is 6 years old or more, 5 mL of blood should be drawn and discarded before the second blue top tube is filled.
- If the patient is <6 years old, one (1) mL of blood should be drawn and discarded before the second blue top tube is filled, whether a syringe or a vacutainer is used.
- If using a syringe, draw the amount of blood to be discarded into one syringe, then use a second syringe to draw the sample which will be transferred to a blue top tube.
6. DO NOT Transfer samples between vacutainer types:
Never transfer blood from a one tube type to another to make up for short volume. The anticoagulants and clotting activators in each tube are specific for the type of sample necessary for testing. Transferring sample between tubes results in adulteration of the sample and will produce spurious test results.
Note: Blood is preferrably obtained by venipuncture and not from catheters. If blood is to be obtained from a catheter, it must be collected by nursing staff.
If blood is obtained from an intravascular line, it is important to clear the line of the fluid which has been infused through it or is "keeping it open" (e.g. heparin or saline). If this is not done, spurious results are likely to be obtained, e.g., an elevated PTT from residual heparin or a spuriously elevated glucose or potassium from the remnants of an intravenous solution.
To obtain a representative specimen uncontaminated by the initial contents of the line, a volume of blood at least six times (6x) greater than the catheter dead space should be removed and discarded prior to collecting the sample to be sent to the laboratory.
Micro determinations are available for the following tests:
(200 µL of serum/plasma minimum,
350 µL of serum/plasma for all)
|Albumin||GGT||Ionized calcium (600 µL)|
|Alkaline phosphatase||Glucose||Osmolality (100 µL)|
|Bilirubin, Total||Protein, Total|
|Calcium||Salicylate (300 µL)|
|CK, Total||Urea Nitrogen|
|CO2, Total||Uric Acid|
Any test in Group A requires a minimum of 200 µL of serum or plasma. If tests are ordered from Group A and from Group B, the serum/plasma requirements are additive. The minimum volumes for many other tests, including many drug levels, are now routinely in the "micro" range; see the entries in the Test Tables section of the Manual. Microtainers for blood collection are available from Material Services and are stocked in most pediatric units and the Emergency Departments.
The collection requirements may differ for many substances (see table below), highlighted tests require a preservative be used during collectioin. Tests which use the same preservative may be collected together unless required collection times are in conflict (i.e., 12-hour collection mandatory, spot collection mandatory, etc).
Collection containers containing the additives specified in the test tables are not stocked on the floors; they can be obtained from the Specimen Desks at the 5th floor Clinical Laboratories in Moffitt Hospital, the second floor laboratory at Mission Bay, the second floor laboratory at Mount Zion, the Mount Zion draw center at 2330 Post St., the Mission Bay draw center on the second floor of the Conway Gateway building or at the blood drawing station on the 1st floor of the Ambulatory Care Center.
- It is preferable to keep all urines refrigerated during timed collections.
- Acid washed container - supplied by reference laboratory or made in the clinical laboratory by washing container using 1:1 mix of 6N HNO3 & de-ionized water.
|Test name||Test code||Sample type||Container type||No Preserv||Acid wash||30 mL 6N HCl||10g Boric acid|
|5-Hydroxyindoleacetic acid, 24 hour urine||5HQT||24 hour urine collection||24 hour urine collection||X||X|
|Albumin (Microalbumin), 24 hour urine||AU24||24 hour urine collection||24 hour urine collection container||X||OK||OK|
|Aldosterone, urine||ALDU||24 hour urine collection||24 hour urine collection container||X|
|Arsenic, 24 hour urine||ASU||24 hour urine collection||Acid washed 24 hour specimen collection container||X||X|
|Calcium, total, urine||CAU||24 hour urine collection||24 hour urine collection container||OK||X||OK|
|Chloride, urine||CLU||24 hour urine collection||24 hour urine collection container||X||OK||OK|
|Chromium, urine||MOLT||24 hour urine collection||Acid washed 24 hour urine collection container||X||X|
|Citrate, 24 hour urine||CITU||24 hour urine collection||24 hour urine collection container||X||OK||OK||OK|
|Copper, 24 hour urine||COPU||24 hour urine collection||Acid washed 24 hour urine collection container||X||X|
|Cortisol, Unconjugated, urine||CRTF||24 hour urine collection||24 hour urine collection container||X||OK||OK||OK|
|Creatine, urine||CRTU||24 hour urine collection||24 hour urine collection container||X||OK|
|Creatinine Clearance||CRCL||24 hour urine collection or timed urine||24 hour urine collection container||X||OK||OK||OK|
|Creatinine, urine||CRU||24 hour urine collection or timed urine||24 hour urine collection container||X||OK||OK||OK|
|Delta-Aminolevulinic Acid Quantitative, 24 hour urine||ALAQ||24 hour urine collection||Brown 24 hour urine collection container||X||OK||X|
|D-Xylose Absorption, urine||MOLT||5 hour urine||24 hour urine collection container||X||OK|
|Free Catecholamines, Fractionated, Urine||UCAF||24 hour urine collection||24 hour urine collection container||X|
|Free Hydroxyproline||FHPR||24 hour urine collection||24 hour urine collection container||X||OK|
|Free Kappa & Lambda light chains, urine||FRULC||24 hour||24 hour urine container||X||OK|
|Glucose, urine||GLUU||24 hour urine collection||24 hour urine collection container||OK||OK||X|
|Histamine, urine||HISTU||24 hour urine collection||Brown 24 hour urine collection container||OK||X|
|Homovanillic Acid, 24 hour urine||HVA||24 hour urine collection||24 hour urine collection container||X|
|Hydroxycorticosteroids, 17-||17HS||24 hour urine collection||24 hour urine collection container||OK||X|
|Hydroxyproline, Total||HPRT||24 hour urine collection||24 hour urine collection container||X||OK|
|Immunofixation Electrophoresis, urine||IFEU||24 hour urine collection||24 hour urine collection container||X||OK|
|Iron, urine||FEU||24 hour urine collection||Acid washed 24 hour urine collection container||X||X|
|Ketosteroids, 17-||17KS||24 hour urine collection||24 hour urine collection container||X||OK||OK||OK|
|Lead, 24 hour urine||PBU||24 hour urine collection||Acid washed 24 hour urine collection container||X||X|
|Magnesium, 24 hour urine||MGU||24 hour urine collection||24 hour urine collection container||X||OK|
|Manganese, urine||MOLT||24 hour urine collection||Acid washed 24 hour urine collection container collected||X||X|
|Mercury, 24 hour urine||HGU||24 hour urine collection||Acid washed 24 hour urine collection container collected||X||X|
|Metanephrines, urine||METN||24 hour urine collection||24 hour urine collection container||X||OK|
|N-Telopeptide, urine||MOLT||24 hour urine collection||24 hour collection container||X||OK|
|Oxalic Acid, Urine||OXAU or MOLT (See processing Instructions)||24 hour urine collection||24 hour urine collection container||X||OK|
|Para-Aminobenzoic Acid||MOLT||6 hour urine||24 hour urine collection container||X||OK|
|Phosphorus, urine||PO4U||24 hour urine collection||24 hour urine collection container||OK||X||OK|
|Porphobilinogen, Quantitative, 24 hour urine||PBQT||24 hour urine collection||Brown 24 hour urine collection container w/ 5g sodium carbonate as preservative|
|Porphyrins, Fractionated, Urine||PORFU||24 hour urine collection||Brown 24 hour urine collection container w/ 5g sodium carbonate as preservative||OK|
|Potassium, Urine||KUR||24 hour urine collection||24 hour urine collection container||X||OK||OK|
|Pregnanetriol||PRTL||24 hour urine collection||24 hour urine collection container||X|
|Protein Electrophoresis, urine||PEU||24 hour urine collection||24 hour urine collection container||X||OK|
|Protein, Total, Urine||TPU||24 hour urine collection||24 hour urine collection container||X||OK||OK|
|Sodium, urine||NAUR||24 hour urine collection or random urine||24 hour urine collection container||X||OK||OK|
|Thallium, urine||MOLT||24 hour urine collection||24 hour acid washed urine collection container||X||X|
|Urea Clearance||URCL||24 hour urine AND serum||24 hour urine container AND Gold top vacutainer||X||OK||OK||OK|
|Urea Nitrogen, Urine||UNU||24 hour urine collection||24 hour urine collection container||X||OK||OK||OK|
|Uric Acid, urine||UCAU||24 hour urine collection||24 hour urine collection container||X||OK||OK|
|Vanillylmandelic Acid, urine||VMA||24 hour urine collection||24 hour urine collection container||X||OK|
|Zinc, 24 hour urine||ZINU||24 hour urine collection||Acid washed 24 hour urine collection container collected||X||X||OK|
Yellow shading = test that requires acid preservative
CSF should be collected and transported to the laboratory in the special vials provided in the lumbar puncture kit. If unavailable a plastic vial with a black screw top cap is acceptable. Each vial should be labeled with patient information (full name and medical record number are minimum requirements) and also list the name of the person who collected the specimen and the date it was collected. Note: CSF samples for Beta Amyloid 42/Tau Protein Analysis must be collected in a special polypropylene tube to prevent adherence of the protein to the sides of the tube. The tubes are stocked in the Memory & Aging clinic and are available from laboratory processing areas at each hospital.
Unless otherwise specified, requested tests will be done on selected tubes as follows:
Tube #1 Chemistry & Immunology tests
Tube #2 Microbiology cultures/tests
Tube #3 Cell counts and differentials
Tube #4 Cytologic examination (done by pathology)
Cell counts are preferably performed on Tube #3 to reduce the impact of blood contamination secondary to the procedure itself. Counts on multiple tubes are rarely required unless Tube #3 is visibly bloody at
which point a cell count on Tube #1 may be requested. A decrease in counts between Tube #1 and Tube #3 suggests a traumatic tap. In this circumstance cell counts should be interpreted with caution. Note: cell counts will not be performed on tube #1 if that sample is grossly more bloody than tube #3.
Non-routinely Orderable Tests
It is not always practical or feasible to validate laboratory tests on all specimen types (e.g. body fluids and stool). However, when necessary for clinical management such non-routinely orderable tests may be performed at the provider's request and clinical laboratories' discretion. In submitting such an order, the provider should understand that tests on these specimen types are not FDA approved or validated by the UCSF Clinical Laboratories and that the results should be interpreted with caution and should not be used without other supporting data for medical decision making. Further, reference ranges that may be showing with the test result are not applicable to these sample types. With respect to body fluid testing, comparison of test results to a concurrent serum sample may be beneficial.
Supplies For Specimen Collection
A. In-Patient Nursing Units
Material Services, (Parnassus: 3-1837, Mt. Zion 5-7255), provides
procurement supplies for collection of clinical laboratory specimens.
These supplies are furnished only to the nursing stations in Moffitt
and Long Hospitals and are delivered daily.
B. Laboratory orders & requisitions
UCSF Providers should place orders for laboratory tests in APeX as this allows them to be transmitted to the laboratory electronically and for the results to route to the order that was placed. Tests results from orders that are not placed in APeX are received by APeX as ‘unsolicited’ and, therefore, may be more difficult to locate in the electronic medical record.
For non-UCSF providers or in downtime situations, PDF's of laboratory requisitions can be found on the web at:
Although written requests for laboratory tests can be made on
virtually any form (so long as the necessary information is provided)
we prefer the use of the standard UCSF laboratory requisitions. These
forms contain test codes, collection information and special
instructions for most commonly ordered tests and greatly improve both
the speed and accuracy of our staff's ability to enter test orders into
our computer system.
Routine laboratory requisition: This form lists the most commonly ordered laboratory tests and is the form that should be used for ordering most hematology, chemistry and immunology tests on blood samples. The back of the form lists many other tests of interest. DO NOT use this form for ordering stat tests, tests on body fluids, microbiology tests or blood products.
Routine Pediatric requisition: This form lists the most commonly ordered pediatric laboratory tests and is the form that should be used for ordering most hematology, chemistry and immunology tests on pediatric blood samples. The back of the form lists many other tests of interest. DO NOT use this form for ordering stat tests, tests on body fluids, microbiology tests or blood products. Note that this form contains specific pediatric test codes in order to makes sure the correct test is ordered. This form should NOT be used for ordering tests on adult patients.
Urine & Body Fluids: This form is used for ordering routine tests on urine, and body fluid samples (CSF, pleural, peritoneal. joint, amniotic fluid, etc.)
Emergency (Stat): This form is used to request emergency testing on blood and body fluids. It lists the tests that are available on an emergency basis without approval. While additional tests could be performed on an emergency basis these are generally not necessary for immediate patient care and require approval of a laboratory medicine resident or pathologist. Order ONLY emergency tests on this form. Routine tests on samples drawn together with the stat samples should be ordered on a routine (white) requisition.
Microbiology: This form is for ordering microbiologic tests and requires the specimen type and tests desired be entered. Use a separate form for each sample submitted for testing. Include clinical information whenever possible as this greatly aids the laboratory in the appropriate handling of the specimen.
Blood Bank: This form is used for ordering blood products.
ID Serology & Molecular Testing:
This form contains the most commonly ordered Infectious Disease tests. Some tests are duplicated on the Routine requisition. This form also has an area for provider attestation of informed consent for HIV testing. The
ordering care provider should sign in this area when requesting tests used to diagnose HIV to provide
documentation that consent was obtained. If unsigned the laboratory will perform the requested testing, however, the provider is then responsible for documenting consent in the patient record.
Molecular Genetics requisition:
This form contains the curently available in house
genetic tests for inherited and neoplastic disorders and should be used
for ordering these studies. There is an area for the provider to
document that genetic counseling was offered to the patient for
non-neoplastic genetic tests. Note that for presymptomatic Huntingtons
and BRCA-1 or BRCA-2 testing, genetic counseling is REQUIRED before
testing will be performed and the name of the genetic counselor who
provided it must be listed. Requests for these two tests received
without this information will be held until it is provided.
To ensure that laboratory results on your patient are returned to the proper location, provide the following information on all test requests:
- Medical Record Number (MRN)
- Patient's Name
- Patient's Date of Birth
- Clinic (ward, clinic name, or full address if private practitioner)
- Date of Service
- Physician's Name and 5-digit UC Provider Number (required for outpatients)
- ICD-9 Code(s) (required for outpatients)*
- Test(s) Desired
- *Exceptions may be made in instances where the Medical Center bills the ordering practice rather than the patient
If for some reason a specimen must be/has been collected before the patient has been registered, the patient's name and date of birth should be written on the sample. The patient identification should also be verified from a current California driver's license or other picture ID, if possible.
Specimen Identification And Labeling
Whoever obtains a specimen should label it. Do NOT give an unlabeled specimen to another individual to be labeled as this greatly increases the chance for mis-labeling.
THE LABEL ON A SPECIMEN FOR BLOOD TYPING OR CROSSMATCHING, ON A TISSUE BIOPSY OR ON AN INVASIVELY-COLLECTED SPECIMEN FROM A NORMALLY STERILE AREA (e.g., CSF, joint fluid, amniotic fluid, bone marrow) MUST DISPLAY THE LEGIBLE NAME OF THE INDIVIDUAL COLLECTING THE SPECIMEN AND THE DATE ON WHICH THE SPECIMEN WAS DRAWN. This rigorous labeling is desirable for all other specimens, particularly those that are invasively collected and not readily recollected, but is not required.
APeX or Collection Manager labels are preferred, but the specimen must in any case be clearly labeled with the patient's first and last names and the correct full unit number including the visit number. If adhesive labels are not available, use white tape. Do NOT use gummed paper labels which must be moistened to adhere; they dry out and fall off, resulting in an unlabeled specimen.
When multiple samples of the same type are collected at intervals (e.g. glucose tolerance test, provocative testing) or when multiple samples are collected from multiple sites (e.g. tumor localization) it is imperative to label each sample with a sample identification number or letter, the time it was drawn or the location from which it was taken. This avoids problems with sample mix-up in these situations.
Fetal sample labels must show the mother's first and last name and the mother's unit number. The label must have "FETAL" clearly written on it. In addition, the date and time the specimen is collected and the initials of the person doing the collection should be included on the label.
Donor Sample labels must show the donor's first and last name labeled "DONOR" and the recipient's first and last name and unit number labeled "RECIPIENT." In addition, the date and time the specimen is collected and the initials for the person doing the collection should be on the specimen.
- DONOR: Jones, Tom RECIPIENT: Smith, John 23456183 9/15/01 14:30 LR
Processing Of Mislabeled And Unlabeled Specimens
All labels must show at least the patient's first and last names and the correct unit number. Specimens with less information are inadequately identified, and will not be processed until the deficiencies are corrected. If an inadequately labeled specimen is brought to the laboratory by someone from the nursing unit or office, that individual will be asked to supply the missing information.
Specimen Desk personnel will not accept a specimen without orders for the testing to be performed.
- When the identification of a sample submitted for analysis is in any way questionable, the laboratory will recommend that, if feasible, a new specimen should be obtained.
- If the laboratory is unable to determine from who a sample has been collected with a reasonable degree of certainty, a new sample must be obtained. For example, if two unlabeled samples arrive from the same nursing unit at the same time, the samples must be recollected.
- All specimens submitted to the Transfusion Service (for blood typing, crossmatch, etc.) must be properly labeled. Mislabeled, unlabeled or unsigned samples will not be accepted.
- When an unlabeled sample is received AND the sample can be identified with a reasonable degree of certainty we will allow the sample to be labeled by the person who obtained the specimen. The patient's physician must acknowledge that the sample identity was questioned in writing and the test result in the patient's chart will carry the notation that the sample was "REC'D MIS(UN)LABELED-RUN AT MD'S REQUEST"
- When there is a mismatch between the name on the requisition and on the sample (Mislabel) the sample should, in virtually all circumstances, be recollected. Similarly, if a sample is received and there are no apparent APeX orders for the name of the patient on the label the sample should be recollected as a potential mislabel. In cases where a mislabeled sample is irretrievable or where re-collection would jeopardize patient care (e.g. invasively collected samples, intra-operative samples, timed samples, etc.) AND the sample itself can be identified with reasonable certainty exceptions to the above policy may be made. These decisions will be the responsibility of a Laboratory Medicine resident on duty or a laboratory director. In cases where the sample is approved for testing the patient's physician must accept responsibility in writing for the specimen being processed. The test result in the patient's chart will carry a notation that sample was "REC'D MIS(UN)LABELED-RUN AT MD'S REQUEST"e; and under some circumstances an entry may be made in the progress notes by laboratory staff further describing the relevant circumstances. A copy of the waiver may be sent to the patient's Attending Physician and, if a pattern of recurrent problems is apparent, to the Chief of Service as well.
Reporting Results on tests ordered in error
If a test is ordered and performed due to an error by laboratory staff the charge for the test will be credited. A comment indicating that the test was ordered in error will be appended to each test result. The patient's physician will be contacted, appraised of the error and informed that the results will be released to the patient's record but not charged for. If the patient's physician has an issue with this or the test required prior patient consent the Laboratory Director or designee will be involved in the discussion and final decision.
Note that only in extreme circumstances will the results of a mis-identified sample be transferred to the record of the patient from whom the sample was actually obtained. As the true identity of the patient from whom the blood was collected is in question, moving the results may simply compound the error. Requests to move results are reviewed on a case-by-case basis and require the authorization of the named CLIA Laboratory Director, or Acting CLIA Director if the Director is not available.
The UCSF Clinical Laboratory will try to honor requests from the ordering physician to cancel a test(s) up to the point that testing has begun. After that point a test cannot be cancelled or the result removed from the patient record.
If a test is cancelled the patient will not be charged for the cost of the test, although there may be a specimen collection and processing charge for the sample. If the test was referred to an outside laboratory and cancelled before a result was generated, any charges incurred by UCSF for shipping the sample or charged by the outside laboratory will be passed on to the patient.
Exceptions to this policy must be authorized by the named CLIA Laboratory Director, or Acting CLIA Director if the Director is not available.
Charging Tests To Another Patient's Account
Under exceptional circumstances, we will perform a test on a secondary individual, for example a relative, and charge the patient. These situations will be evaluated on a case-by-case basis, but can occur:
- when HLA Typing a related prospective renal or marrow transplant donor (third-party payers apparently accept such charges).
- when the sample is from an unborn fetus
- when the patient's diagnosis can be made only by testing someone else, and is likely to alter management. A patient with partially-treated bacterial diarrhea, from whom a pathogen is not isolated, could have an untreated, mildly symptomatic relative who still may have a positive culture, permitting better management of the culture-negative case.
- when the results from one or both parents are needed in order to interpret the results of test on their child for inherited genetic disorders
Tests will NOT be charged to another patient's account when it will not be reimbursed by insurance carriers or other third parties, such as:
- for typing the blood of a potential designated donor who is unwilling to donate at a community blood bank and thereby be typed without charge.
- for the convenience of other ill members of a group or family who do not want to go to the trouble of registering.
A specimen should NEVER be intentionally labeled with the wrong name, even when it is proper to charge another patient's account; the risk that action could be taken or that treatment could be given for a condition the patient does not have is unacceptable.
Tests will be ordered on the recipients medical record number/account and will appear in APeX, in the laboratory system and on laboratory reports under that number. The result field for donor samples will contain" PERFORMED ON DONOR SAMPLE, SEE COMMENT" with the actual results listed in a comment following the result line. This clearly identifies the results as belonging to a donor and not the recipient.
Tests will be ordered on the mother's medical record number /account
and will appear in APeX, in the laboratory system and on laboratory reports under
the mother's medical record number. The result field for fetal samples
will contain" PERFORMED ON FETAL SAMPLE, SEE COMMENT" with the actual
results listed in a comment following the result line. This clearly
identifies the results as belonging to a fetus and not the mother.
Samples from Another Individual:
When a diagnosis requires testing another person: The individual on whom the test is to be performed must be registered and given a distinct unit number separate from that of the patient, or given a temporary unit #. This prevents the result of the test from being posted to the patient's record and accidentally mistaken for their result. The test will be billed to the patient's account.
Needle-Bearing And Other Hazardous Specimen Containers And Requisitions
A. Needle-Bearing Syringes
Because needlestick injuries are a major source of serious
infections, the UCSF Clinical Laboratories will NOT
accept specimens in syringes with needles attached. If a specimen is
submitted in a needle-bearing syringe, it will not be processed
until the individual submitting the specimen or their agent removes the
needle and seals the syringe with a suitable cap (the latter are
available from Materiel Services, along with plastic clamps for needle
removal). An exception will be made only for specimens which have been
obtained by Fine Needle Aspiration and are such a small volume
that the entire specimen is contained within the needle cavity. These
specimens, typically submitted for culture, should be brought directly
to the Microbiology processing area at each hospital.
B. Externally Contaminated Specimen Containers and Requisitions
Hospital employees who handle laboratory specimens have relatively high risks of acquiring work-related infections, particularly hepatitis. Loosely-capped containers and soiled requisitions pose a significant hazard to all who come in contact with these contaminated materials. Therefore, messengers, clerks and laboratory staff are instructed to refuse soiled laboratory requisitions and/or leaking specimen containers. If a messenger finds a leaking container and/or soiled requisition at the pickup station on the floor, the messenger will leave the contaminated materials there, inform the personnel at the nursing station of the problem, and request a new specimen.
Specimen Transport And Messenger Service
A. Specimen Transport General Considerations
All patient samples are considered biohazardous and should be handled as such using appropriate Personal Protective Equipment (PPE) such as impermeable gloves. For transport to the laboratory specimens should be placed into special biohazard plastic bags that prominently display the biohazard warning emblem on the outside. All containers should be tightly capped, placed into a biohazard bag any any accompanying paperwork placed in the external pocket of the bag. Placing the paperwork in the bag itself may result in contamination and sample rejection.
Note: specimens for Stat testing must be sent in the red or purple 'STAT' biohazard bags available on each unit. If the red or purple bags are not used laboratory staff will be unlikely to recognize the samples as 'STAT' and they may be processed as routine orders.
B. Automated Transport to the Laboratory
At Parnassus, a Dumbwaiter system is available from the floors and is useful for transport of both supplies and samples. The southernmost of the three dumbwaiters near the Moffitt nursing station is dedicated to the delivery of laboratory specimens, and is highly recommended for bulk or multiple specimen deliveries. When in working order and not already in use it usually takes less than one minute to arrive when called. Place the biohazard bagged specimen with its accompanying requisition in the box provided in the dumbwaiter to minimize the very small likelihood of the sample falling off into the dumbwaiter shaft.
A suitable pneumatic tube delivery system is available in some units for sample transport. At Parnassus, the pneumatic tube is primarily intended for STAT samples, while at Mission Bay both STAT and routine samples can be transported. The system should NOT be used for transport of any of the following:
- Liquid > 2 liters in volume
- Items heavier than 4 kg
- Pathology or cytology samples
- Stool samples
- Glass items
- Radioactive materials
Additionally, Note: Samples for Platelet Aggregation studies, Platelet Function Analysis (PFA-100) and Thromboelastograph (TEG) testing should not be sent via the pneumatic tube system as it will cause platelet activation and result in altered test results.
It is preferrable to transport samples from only 1-2 patients at a time in the pneumatic tube. Each set of patient samples should be in an individual biohazard bag with any corresponding paperwork in the external sleeve. Make sure that all containers are tightly capped, especially urine cups, and place into the transport container along with the included foam inserts. DO NOT remove the foam inserts to make more room in the transport container, use a second container if necessary. Close the transport container making sure that nothing is sticking out and that the latches are completely closed. When samples are properly contained and the transport container is closed there is little risk of sample contaminating the tube system even if the sample container itself should leak. Leaking of patient sample into the tube system will result in shutdown of the system until decontamination procedures can be completed.
Once the container is ready to send through the system follow the procedure for use of the tube making sure that the right receiving station is selected. Inadvertent transport of samples to the wrong location almost universally results in sample loss or unacceptability by the time it finally reaches the laboratory.
C. Laboratory Messengers
During the day shift, laboratory messengers pick up in-patient specimens every 1-2 hours from the laboratory refrigerators and soiled utility areas in Moffitt and Long Hospitals, and (on weekdays) every 15-30 minutes from the ACC labs. A laboratory messenger also makes inpatient rounds from 4:00 p.m. until midnight each evening.
D. Night Messenger Service
From 11:30 PM to 4:00 AM the laboratory does not provide a specimen pick-up service. Nursing staff are responsible for ensuring that samples collected during this time are transported to the laboratory for testing.
Laboratory couriers will pick up samples collected during the morning draw every 45 minutes from 0400-0815 hours on 14L ,14M, 13L, 12L, 11L, 10L, 10S, 9L, 8L, and 8S . Samples from other units and all stats should be transported to the Laboratory by pneumatic tube or by nursing staff.
E. Laboratory Refrigerators
Refrigerators designated specifically for storage and pickup of laboratory specimens are located in the utility area of each major nursing unit. Laboratory messengers are instructed to bring to the 5th floor laboratory any (non-leaking) specimens found in the laboratory refrigerators. Food as well as specimens which cannot be identified will be discarded. Please do not store food, medications, or other materials not intended for laboratory analysis in the laboratory refrigerators.
F. Laboratory Messenger Schedules
The messenger schedules which follow are posted on the laboratory refrigerators:
WEEKDAY PARNASSUS INPATIENT SPECIMEN PICKUP
Approximate Schedule for Clinical Laboratory Messengers
Last pick up Saturday and Sunday is around 1430.
WEEKDAY ACC SPECIMEN PICKUP
Approximate Schedule for Clinical Laboratory Messengers
A pickup box is situated to the left of the accession window outside the ACC phlebotomy station at A 122 for dropoff of specimens collected on site in the clinics. Specimens in this box will be picked up and transported to the Main 5th floor laboratory as part of the regular messenger runs from 0750-1825 Monday-Friday.
|B||12:00 to 13:00||LUNCH||BREAK|
A-Day Shift Messenger 07:00-15:30 P.M (In patient Courier)* Holiday Run.
*Last run on Holiday @ 16:30 p.m will be done by ACC staff.
B-ACC Day Shift Messenger 09:00 to 17:30 P.M
D-Evening Shift Messenger 15:30 to 24:00 In house and ACC (until 18:30 P.M)
WEEKEND IN-PATIENT SPECIMEN PICKUP
Approximate Schedule for Clinical Laboratory Messengers
a. Breaks between 0955-1015
b. Lunch between 1045-1140
Add-On Requests (x3-1667) And Retention Of Specimens
Tests may be added on to existing samples provided that an appropriate sample type is available and the stability period for the test(s) being requested has not been exceeded. APeX allows for two type of test add-on's:
- "Add on" only: selecting this prints a paper request in the laboratory. Laboratory staff will determine if a sample is available to test. If a sample is available the test will be added to the accession # for that sample, run and reported. If a suitable sample is not available the test is ordered and immediately cancelled with a comment that no sample was available for testing. The test should be placed as a new order in APeX and a new sample collected
- "Add-on & Redraw": This option functions as above but allows the provider to have a new sample obtained without additional input/orders. If a samples is not available for testing, the laboratory will contact the unit/clinic and request that a new test order be placed into the system.
ApeX does not have an automated process to add orders to already collected samples. If an outpatient add-on is desired please contact the laboratory at (415-353-1667) and request an add-on test. The order will be transmitted to Processing staff who will determine if there is a sample available for testing. If a sample is available the test will be added to the accession # for that sample, run and reported. If a suitable sample is not available the test is ordered and immediately cancelled with a comment that no sample was available for testing and a new order should then be placed in APeX.
For orders that are not placed in APeX (e.g. non-UCSF providers) we do accept telephone add-ons by calling the laboratory at 415-353-1667. Such orders will be handled as described above. Federal regulations require that verbal requests for additional tests be supported by written documentation. The Clinical Laboratories will request that a new laboratory requisition be submitted whenever we are asked to perform additional tests upon a specimen already in the laboratory. Complete the specimen collection information on the new requisition using the date and time of the specimen given to you by the laboratory when you made your telephone request. Check the appropriate test box or write in the name of the additional test and include the following: "ADD-ON TO SAMPLE ALREADY IN LAB" in the space in the lower right hand corner of the form. Where it is not expedient to wait for the receipt of the written confirmation, the additional tests will be processed in a timely manner to ensure that specimen integrity and quality of patient care are not jeopardized; note that the written request must match the verbal orders.
The laboratory will try to honor requests for STAT add-on tests, however, due to the additional steps required to locate a single specimen and get it to the correct section for testing we cannot guarantee the actual turn-around-time for such a test order. If the clinical situation is critical we suggest that a new sample be obtained and sent to the laboratory for testing.
Blood gas, culture specimens, and tests that depend upon intact cellular function or morphology cannot usually be saved. Many hematologic parameters (e.g., coagulation tests and sedimentation rate) are unstable after a few hours. Many chemical assays also cannot be performed on residual specimens because of instability of the analyte(s) (acid phosphatase, ionized calcium, intact parathormone (PTH) and many enzymes). If the leftover specimen has been uncapped or its volume is less than 1 mL, the specimen is unsuitable for quantitative assay because of evaporation.
Chemistry assays which require specimens collected in blue, gray, dark green, lavender or navy top vacutainers are often unsatisfactory for add-on tests, and add-on requests will not be performed on leftover specimens unless approved by a Chemistry supervisor or a laboratory physician; approval by a supervisor or the resident on call is required for any tests requested on an unrefrigerated specimen or if more than 48 hours have elapsed since a specimen was received (24 hours for carbon dioxide [CO2]). With the exceptions noted, tests requested on at least 1 mL of separated, capped and refrigerated serum can be added-on without approval.
Because of limited facilities for storage, the laboratories are unable to save specimens for as long as we would like, for the uncommon occasion when it would be useful to repeat a test on the original sample. Specimens are retained according to the following schedule:
|Blood Bank||2 weeks (cord blood-1 week)|
|Hematology||24 hours (smears-2 weeks, factors/inhibitors-1 month)|
|Microbiology||1 week (isolated pathogens)|
|Neonatal Clinical Physiology Laboratory (NCPL)||Not applicable|
|Reference Laboratories||variable (Quest: 30 days)|
|San Francisco Health Dept.||6 months|
* Due to known problems with handling, samples from localization studies will be retained for one month at refrigerator temperature.
Samples are generally destroyed after the above retention period. Occasionally the lab receives requests to release samples for other uses. In general there are two instances in which the laboratory may release samples:
- When requested to do so by the medical examiner for forensic testing purposes. In such cases, the sample information (patient name, MR#, accession #, sample type and date of collection of each sample to be released) is documented and the medical examiner staff will be asked to sign this document for our records.
- When the UCSF CHR has approved the release of specified types of samples for research purposes. If such samples are to be released before the end of our stated retention time then there must be contact information provided to the laboratory on how to retrieve such samples should additional clinical testing or forensic testing be required.
Laboratory Results & Reports x3-1667
Laboratory results are reported electronically to the APeX electronic health record as soon as they are completed. The only exceptions to this are: (1) certain restricted genetic results that are only reported to genetic counselors, (2) research results sent in as coded samples and (3) text reports from reference laboratories. In the latter case the test is resulted as 'See attached report' and the report is scanned and attached to the result as an image (attachments are indicated by a 'paperclip' icon adjacent to the result.
Information about test availability, methods, sample collection-handling-storage requirements, reference ranges, testing schedules, expected turnaround time, etc., is given in the Test Tables of this Lab Manual, the electronic version of which is up-to-date and always accessible on-line from campus PC's (Icon on APeX desktop and from order entry screens). Users with internet access can browse a web-based version at http://labmed.ucsf.edu/labman/.
Web access to APeX is also available to authorized staff. For additional information about electronic access, contact the Medical Staff Office, your supervisor, or Medical Center IT (514-4100); for problems that appear to represent failure of campus equipment, call the "Help" desk (514-4100).
Phone inquiries may interfere with staff performing testing and should therefore only be made when there is an urgent need for test results or the need to speak with the staff regarding a specific sample or test. When necessary, test results may be obtained by telephoning 415-353-1667. Inquiries concerning specimen collection and processing, validity of laboratory results, discrepancies in the data, and other problems will be referred to the appropriate section or to a laboratory physician.
Laboratory results are stored in the Laboratory Information System (LIS) by the patient's unit number and by most recent date and time of collection. To ensure that the correct patient is selected when laboratory data are requested, please provide the patient's medical record number. If the medical record number is not available, please give the patient's first and last names and date of birth. At present our LIS stores results in an immediately accessible fashion for 1 year (after an inpatient has been discharged or after the last test has been completed for an outpatient episode of care). Results are available for an additional 3- 4 years from our LIS archive area, however, these results are not as easily retrieved.
Historical results are also available in APeX going back to 1997.
For non-UCSF practices that
do not have access to electronic reports (APeX) the UCSF
Clinical Laboratories will make every attempt to relay the results of
STAT tests by phone if a request to phone the results and an
appropriate number are indicated on the STAT requisition. However, as
this involves manual processes by the lab staff we cannot guarantee
that all results will be phoned when requested.
Results of certain routinely requested tests may suggest an immediate threat to life. Chemistry results which exceed defined critical limits, which we have established in concert with SFGH and VAMC, are automatically called to the physician's office or nursing unit whenever found.
Critical results for some Hematology tests (e.g WBC, ANC, Platelet counts, PTT) generally result from more chronic conditions or therapy and are not as susceptible to immediate correction; a Hematology critical value for these tests will automatically be telephoned if not already reported within the previous 24 hours (however, all Platelet counts <10,000 and PTT results ≥ 80 seconds will be phoned).
Due to the potentially critical nature of these reports, critical results for hospital units will only be given to a licensed individual (e.g. MD, RN, NP, PA). For ambulatory clinics (including the ED), critical values will preferably be provided to a licensed individual, however, if none is immediately available the result may be reported to other clinic staff.
If the recipient is not a physician or nurse, who can immediately act on the critical value he/she assumes responsibility to notify a physician or other caregiver who can immediately respond to the result. The clinical laboratory staff will ask the recipient to read back and confirm the result(s) we provide and will document this in the computer.
If a critical result is obtained for a clinic patient after the clinic has closed, we will notify the individual on-call for the clinic, usually reached via an answering service or delegated to the resident or fellow on call for the service involved.
If the UCSF Clinical Laboratory receives a critical result from a reference laboratory it will be handled in the same way as an in-house critical result and immediately relayed to an appropriate care provider even though the test may not have a critical value approved by the UCSF EMB.
CHEMISTRY CRITICAL VALUES
|Base excess||< -10 (cord samples only)|
|Bilirubin, total||Only applicable for infants < 30 days old:
Age in days Critical value
0 > 6 mg/dL
1 > 9 mg/dL
2 > 12 mg/dL
3 > 15 mg/dL
4 > 18 mg/dL
5-30 > 21 mg/dL
Note: Criticals are not called to MIN, West, East, North 15ICN per prior agreement. Repeat critical values within 30 days of an initial critical report will not be called.
|Calcium, Ionized**||<0.80 or >1.55 mmol/L|
|Calcium, Total||<6.5 or >13.5 mg/dL|
|CO2, Total||<15 or >40 mmol/L|
|Glucose, CSF||<30 mg/dL|
|Glucose, serum||<50 or >500 mg/dL|
|<30 or >170 mg/dL|
|Glucose, POCT||<60 or >400 mg/dL|
|<40 or >150 mg/dL|
|Magnesium||<1.0 or >4.5 mg/dL|
-for Birth Center
|<1.0 or >8.0 mg/dL|
|Osmolality||<240 or >320 mOsm/Kg|
|pCO2, Arterial||<25 or >65 mmHg|
|pCO2, Venous||>75 mmHg|
|pH, Arterial||<7.20 or >7.55|
|pH, Cord blood||<7.0|
|<40 or >100 mmHg|
|Potassium||<3.0 or >6.0 mmol/L|
-or Procainamide + NAPA total
|Sodium||<125 or >155 mmol/L|
|Troponin I ***||≥0.05 µg/L***|
- Mt Zion POCT
|Valproic Acid||>150 mg/L|
* Reference lab test
** Panic results from post-filter samples will not be phoned
*** The first elevated troponin for a patient will be called. Subsequent elevated Troponin levels for the same patient in the next 72 hrs after the initial report will not be called.
HEMATOLOGY CRITICAL VALUES
|Absolute Neutrophil Count (ANC)||see Neutrophils below|
|Argatroban||> 2.0 µg/mL|
|Cell Count & Differential Body Fluid||Samples positive for microorganisms from normally sterile sites|
|Fibrinogen||≤100 mg/dl if new finding within previous 24 hours
≤50 mg/dL is always phoned
|Hematocrit, Spun||< 25% or > 65%|
|Hemoglobin (includes POCT)||≤7.0 g/dL|
|Heparin, Unfractionated||> 0.7 Anti-Xa U/mL|
|Heparin, Low Molecular Weight||> 2.0 U/mL|
|INR (includes POCT)||≥5.0|
|Peripheral Smear||Blasts (first time)
|Platelets||≤25,000 /µL (25 x109/L)**|
|Neutrophils (ANC)||≤1,000 /µL (1.0 x109/L)***|
|PTT||≥60 sec* (does not apply to infants < 6 days old, ie. 0-5 days)|
|WBC||≤1,500 or ≥100,000 /µL (<1.5 or >100 x109/L)***|
(See the Test Tables for the relevant assay units)
* PTT results from 60.0-79.9 seconds are phoned only if no previous critical value in last 24 hours; PTT ≥ 80.0 seconds are always called
** Platelet results from 11-25 x109/L are phoned only if no previous critical value in the last 24 hours. Platelet counts <10 x109/L are always called.
*** WBC and ANC criticals are not called if a prior critical value was reported in the preceding 24 hours.
MICROBIOLOGY CRITICAL VALUES
The Microbiology and Virology Laboratories will call initial results for life-threatening infections and those that are of public health concern. All results are promptly entered into the laboratory information system and are available in the electronic health record.
All STAT gram stains requests on specimens from the OR will be called.
In addition, the following results will be called:
|Positive Gram stains of samples from normally sterile sites and OR samples|
Blood cultures: Only Gram stain results from the first positive blood culture for each patient (call again if a different organism is isolated on same or subsequent culture or if >7 days since last call). Includes Differential Time to Positivity Cultures.
|Positive CSF cultures|
|Stool cultures positive with E coli O157:H7, Vibrio cholerae, Salmonella typhi, Salmonella paratyphi A or Salmonella cholerasuis|
|Shiga toxin detected|
|Positive USP cultures|
|Bordetella spp. DNA detected by PCR|
|First Burkholderia cepacia isolate on a CF patient|
|Burkholderia mallei and pseudomallei|
|Group A streptococci from sterile sites|
|Group B streptococci from patients in Labor and Delivery|
|Neisseria gonorrhoeae (culture or DNA) from sterile sites|
|Neisseria meningitidis from sterile sites|
|First positive AFB smear; first positive AFB culture if smear negative or no smear; first isolate of M. tuberculosis; positive M. tuberculosis PCR; first isolate of Nocardia (call again if subsequent positive specimen is from a different site or if >2 months since last call)|
|Positive AFB culture on CSF|
|Biphasic fungi isolated (e.g., Coccidioides immitis)|
|Zygomycetes (e.g., mucormycosis)|
|KOH if C. immitis spherules present or non-septate hyphae suggestive of Zygomycetes|
|CSF cultures that yield a fungus|
|Positive CSF cryptococcal antigen|
|Parasites identified from normally sterile sites|
|Entamoeba histolytica, except from stool or intestinal specimens|
|Positive Clostridium difficile toxin assay from inpatients & ED|
|Positive HSV or VZV DFA from inpatients & ED|
|HSV from sterile sites|
|VZV from sterile sites|
|Influenza A and B from inpatients & ED|
|Parvovirus B19 DNA detected by PCR, unless patient has a previous positive result in the prior 3 months|
|RSV from inpatients & ED|
|Positive Enterovirus PCR or culture from sterile sites|
|Positive HIV Rapid Screen|
REFERENCE LAB TESTS WITH CRITICAL VALUES
Although UCSF does not have approved critical values for some of the tests we send out for reference lab testing, the labs that we send to have implemented their own critical values for these tests. If the UCSF laboratory is contacted by a reference laboratory with a critical value we will relay that value to the appropriate care provider.
|Send out Test name||Critical value|
|Amitriptyline||Quest Priority-1*: Amitriptyline + Nortriptyline >= 1000 ng/mL
Quest Priority-2**: 600-999 ng/mL
|Arsenic, blood||Quest Priority-2: > 60 µg/L|
|Cadmium||Quest Priority-1: >= 50 µg/L
Quest Priority-2: 40.0-49.9 µg/L
|Clomipramine||Quest Priority-1: >= 600 µg/L|
|Amikacin||UC Irvine has critical values for Amikacin:
Age Amikacin Critical value
< 12 months > 30.0 µg/mL
>= 12 months > 35.0 µg/mL
Age Amikacin level
< 12 months >= 10.0 µg/mL
>= 12 months >= 8.0 µg/mL
|Cyanide||Quest Priority-1: >= 1.0 mg/L
Quest Priority-2: 0.5-0.9 mg/L
|Desipramine||Quest Priority-1: >= 600 µg/L|
|Diazepam||Quest Priority-1: Diazepam + Norazepam >= 3.0 mg/L|
|Digitoxin||Quest Priority-1: >= 45 ng/mL|
|Disopyramide||Quest Priority-1: >= 7.0 mg/L|
|Doxepin||Quest Priority-1: Doxepin + Nordoxepin >= 600 µg/L|
|Flecainide||Quest Priority-1: >= 1.0 mg/L|
|Ibuprofen||Quest Priority-1: >= 100 mg/L|
|Imipramine||Quest Priority-1: >= 600 ng/mL|
|Mercury, 24 hour urine||Quest Priority-1: >= 150 µg/L|
|Mexiletine||Quest Priority-1: >= 5 µg/mL
Quest Priority-2: 2.0-4.9 µg/mL
|Nortriptyline||Quest Priority-1: >= 500 µg/L|
|Serotonin Release Assay||Quest Priority-2: >= 20 % release|
|Thallium, 24 hour urine||Quest Priority-1: >= 200 µg/L|
|von Willebrand Factor Cleaving Protease||Quest Priority-2: Absent activity|
|Levetiracetam||Quest Priority-2: peak > 70 µg/mL or troµgh > 37 µg/mL|
|Mercury, random urine||Quest Priority-1: >= 150 µg/g creatinine|
|Mycophenolic Acid (New test)||Mycophenolic acid:
Quest Critical 1 < 0.5 µg/mL
Quest Priority 2 < 1.0 µg/mL or > 3.5 µg/mL
Priority 2 < 35 µg/mL
* Quest priority 1 = values are called as soon as they are identified 24x7
** Quest priority 2 = values are called from 7AM to 7PM daily
The results of some tests, while not immediately life threatening, are considered to pose a significant risk if not addressed in a timely fashion. The UCSF Task Force on Test Results has approved the following list of laboratory tests that meet this concept of a ‘subcritical result’. Positive results of these tests will be called to the UCSF Relay Center for positive transmission to the subject patient’s provider(s) within 1 business day of the result being finalized.
- Hepatitis B surface Antigen (HBsAg)
- HBV Core IgM Ab
- Hepatitis C Antibody (HCV Ab)
- HAV Ab, IgM
- Human Immunodeficiency Virus Antibody (HIV Ab)
- Human Immunodeficiency Virus Antibody Differentiation (HIVD)
- Rapid Protein Reagin (RPR)
- Treponema pallidum Antibody (TPAB)
- VDRL, CSF
- Coccidiodes immitis Ab
- Blood Lead levels ≥ 15 µg/dL
- Triglyceride levels ≥ 2000 mg/dL
- Positive cultures from sterile sites (not including Blood and CSF which are already 'Critical' results)
- Diseases reportable to San Francisco Department of Public Health
- Positive Clostridium difficile toxin from outpatients
- CMV, Quant. PCR
Results for most procedures are reported by computer; an effort is being made to incorporate those results which currently are not. Problems involving delayed, missing or incorrectly addressed reports should be directed to 415-353-1667.
1. Inpatient Ward Reports:
Because laboratory results are routinely obtained via the APeX, printed reports are not routinely generated.
Whenever Clinical Laboratories has been notified by Hospital Information Technology that the APeX system is not functioning for at least 3 hours, reports will be printed and distributed to units on an hourly basis. Production of these reports will continue until APeX is again operational. The reports are posted at each nursing station, and contain all computer-processed results since approximately 0100 of that day. STAT results for the OR and ED will be phoned during these periods as well as all critical values.
In the event of an APeX breakdown, PLEASE CONSULT THESE REPORTS BEFORE CALLING THE LABORATORY.
2. Cumulative Summaries:
Cumulative Summary reports of all results for a hospital admission are not routinely printed. If for any reason a cumulative summary is needed for a particular patient, contact the laboratory at 415-353-1667 and request that one be produced and tubed to the nursing station, which can be done within several minutes.
3. Ambulatory Patient Reports:
For UCSF outpatient clinics, laboratory results are routed to the ordering provider's APeX in-basket and we have ceased printing hard copy reports for most practices.
For laboratory tests results ordered by Non-UCSF providers, a hard copy report will be printed and sent via U.S. Mail when all the orders are completed.
If additional copies of results are required for other or Non-UCSF providers, this should be indicated in the APeX orders by entering the full name and UC number for the provider in the Copy-To area in the APeX orders screen.
For non-UCSF providers requests to send copies of the results to other providers should be indicated in writing on a paper requisition.
The UCSF Clinical Laboratories are often requested by patients or providers to fax copies of laboratory reports to physicians other than the one ordering the test(s). As we have limited automatic faxing capabilities in the laboratory computer system it is very problematic for us to honor such requests.
Generally, the easiest way to fax report to another provider is to use the built-in faxing functionality in APeX.
The Laboratory Information System (LIS) is in a high availability configuration with two linked computers that automatically failover in the event of a crash, thus minimizing the likelihood that an LIS crash will result in a prolonged downtime. However, if a downtime is incurred, the nursing units are notified and interim reporting arrangements are implemented.
If the downtime is likely to last longer than 2-3 hours, we will prepare and deliver handwritten reports to the nursing stations (for Microbiology, only handwritten antimicrobial susceptibility reports are generated). These handwritten reports are difficult to duplicate; please retain them until after the computer is again in operation, and the results in APeX are again up-to-date. Most crashes are resolved within 1-2 hours; on the rare occasions when they are more prolonged (longer than 6-8 hours) we usually are able to partially restore function.
Critical (panic) values and stat results are telephoned to the floors during a crash. Routine telephoning policies for microbiology results are observed: all positive cultures from normally sterile sites are called, as well as isolates of beta-streptococci, gonococci, enteric pathogens, and acid-fast bacilli.
The impact of an LIS breakdown varies with the time of day at which it occurs. Although our instrumentation can operate independent of the LIS, the large volume of data, the need to manually assign and record specimen numbers, and the slowness of manual filing and retrieval of results combine to significantly decrease the speed with which we can turn out reports during a crash. Our ability to look up the results of previously completed tests is severely impaired, and medical and nursing staff must depend heavily upon APeX and its content of results generated prior to the downtime. Except in emergencies, it generally is not practical for us to look up results that have already been reported; if such results are required obtaining them will be a very slow process. Tests which were completed but not reported prior to the crash may have to be rerun, which may require collection of additional samples.
Please do not come to the laboratory to obtain routine results. Avoid calling the laboratory except for those results needed to implement current patient care decisions; record these results carefully in APeX progress notes because it is difficult to recover them in the laboratory.
Expected turn-around times are listed for each test in the Test tables section of this Manual. In general, because of redundant equipment for the high volume routine tests required for most operational needs, only a mild-to-moderate slowdown in the availability of important test results is ever seen. Problems judged to affect a wide variety of users are announced to the clinical staff via a message posted in APeX that will be seen at login and/or distribution of written memos to the nursing units.
If prolonged equipment or methods failure is anticipated to delay results which are needed within hours to several days, we will arrange for testing to be performed at the laboratories of our sister institutions (e.g., UCSF/Mount Zion or SFGH) or - for tests not offered by those laboratories - at one of our contract commercial vendors. Notification in the latter case will depend upon whether the test is of special interest to some subgroup of physicians, of universal interest, or of little or no interest.
In all cases, the report will carry the name of the performing laboratory and call attention to any temporary changes in reference ranges.
With the exception of results from reference laboratories where the UCSF Clinical Laboratory made the test referral, it is the policy of the UCSF Clinical Laboratories to NOT enter patient results from other institutions into our Sunquest laboratory information system. The reasons for this are twofold:
- It would require hand ordering and entry of the results which is prone to mis-entry and,
- Results from other laboratories and/or institutions may not have been performed with the same methods employed at UCSF, may not have the same reference ranges, linearity, etc. and my therefore not be directly comparable with results produced at UCSF.
Although the laboratory will not enter such results into our Sunquest laboratory information system, individuals or services may contact the medical center Chief Information Officer regarding the entry of such results into the electronic medical record (APeX). Such results should be entered into a segrgated area of the medical record and clearly indicate that they did not originate from the UCSF Clinical Laboratories.
Comments or Complaints About Service x3-1667
If the complaint involves a specific instance or patient issue please provide as much information about it so that appropriate follow-up can occur. The location, date and time, patient information (Name, MR#, DOB) and if known, the names of any involved laboratory staff should be included.
If you feel your problem is urgent and has not been resolved by laboratory personnel or their supervisors, please promptly bring it to the attention of the Laboratory Director or Manager. Do not accumulate complaints; we can best serve you if any difficulties are reported promptly. When the "trail" is still fresh, the cause of trouble can usually be identified and often remedied.