UCSF Departments of Pathology and Laboratory Medicine | Lab Manual | Specimen Collection And Other Test Information x31667

Specimen Collection And Other Test Information x31667

The Test Tables portion of the Laboratory Manual answers most questions 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.

Where a test is performed, the testing schedule, expected turnaround time, reference ranges, methodology and - where applicable - "panic" values, are also included in the Tables. Central Processing personnel can also provide information regarding the time tests sent to reference laboratories are picked up.

All this information is kept up-to-date and is accessible electronically at our website (http://labmed.ucsf.edu/labman) and via STOR/CDS terminals and PCs distributed throughout the Medical Center (see LABORATORY INQUIRIES & REPORTS).

An extensive section of "Synonyms" is included in the on-line Manual to facilitate the recognition of requests under variant names and abbreviations.

Additional details of test performance, e.g., reagent vendor, method, accuracy, precision (including Levey-Jennings plots and coefficients of variation), sensitivity and linearity are available on request from the performing laboratory section.

Laboratory Services For Ambulatory Patients, Including Phlebotomy

A. Patient Registration

Patients must be registered before their laboratory orders will be processed and their samples collected. Registration is performed as part of eachclinic visit, or at the registration desks in the first floor lobby of the ACC, the first floor at 2330 Post St., and the first floor of the UCSF/Mount Zion Cancer Center. Registration is abbreviated when there has been no change in demographic information or insurance coverage. Prior hospitalization at UCSF does not eliminate the need for registration. Patients should bring the properly completed laboratory requisition with the current registraton label affixed to ensure optimal service. A legible ordering physician name, his or her UCSF physician number and applicable ICD-9 diagnosis code(s) are required on all outpatient requisitions. Patients who present with requisitions which lack these items will be asked to call or return to the clinic and obtain them from the person making the test order. Samples will generally not be collected until this information is available.

Occasionally, if a sample has been collected on an unregistered patient and delaying 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 UCare or the STOR clinical display system; the requesting physician will receive a written report in the usual manner or must call the laboratory, explain that a temporary number was used, and ask that the result be sought alphabetically in the laboratory information system.

B. Locations and Hours of Service

LOCATION	HOURS	PHONE
UCSF Ambulatory Care Center (ACC)	0730-1830	415-353-2736
UCSF Pediatric Clinic	0845-1715	415-353-2652
UCSF Hematology/Oncology Clinic	0800-1700	415-353-8068
2330 Post St. (Mount Zion)	0800-1700	415-885-7531
UCSF Mount Zion Cancer Center	0700-1700	415-885-7764
UCSF Donor Center (Milburry Union MU09)	Sat 0900-1545	415-353-1809

The UCSF Clinical Laboratories offers limited outpatient phlebotomy services at Parnassus on Saturday in The UCSF Blood Donor Center (MIlburry Union, I level, see above). Due to limited staffing, however, we ask that patients be drawn in clinics whenever possible and the samples transported to the 5th floor receiving area of the clinical laboratory.

Ambulatory patients sometimes appear at the 5th floor Moffitt main Clinical Laboratory for nonemergency blood drawing, particularly in the evening and on weekends. Laboratory personnel are not permitted to draw blood on the 5th floor, and the patient will be asked to return during the hours when routine services are provided.

C. Containers and Instructions

Ambulatory patients should be referred to the ACC or 2330 Post St. sites for containers, and for any special instructions (for some of the more common tests, these are available in Chinese, and Spanish as well as English).

D. Scheduling Special Tests

Bone marrow aspirations, Bleeding Time, Sweat Chloride, Glucose Tolerance and/or other procedures which require timed or sequential draws should be scheduled at least one day in advance (Mount Zion: x57500; UCSF x32736 except for sweat Chloride, x31755). Tests that require scheduling are listed in the Test Tables.

E. Who May Order Tests?

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 the healthcare practitioner, that person must work for a 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.

Although in 2002, California state law (SB1131 ) allowed for patient self-ordering of certain laboratory tests, due to payment and reporting constraints the UCSF Clinical Laboratories do not accept patient self-orders. If patients wish to self-order testing they should be referred to one of the commercial laboratories that accept such requests.

Furthermore, requests for outpatient testing must carry the name of an identifiable individual who is recognized for reimbursement purposes. Unless charged to a budget/research account, outpatient orders cannot therefore be submitted in the name of a medical student, nurse practitioner, registered nurse or licensed vocational nurse, or anonymously as "Fellow" or "Resident 1", etc.; in each case the request slip must bear the name of an individual licensed physician who is taking responsibility for the orders, e.g., the supervising physician of nurse practitioner or the attending physician instructing the student.

F. Medical Necessity

Only tests which are considered "medically necessary" by the patients insurance carrier, i.e., warranted by the medical condition of the patient, will be reimbursed by most third-party carriers generally, and in particular Medicare and MediCal; screening tests and general health examinations are not covered. Physicians are required by law to provide the laboratory with the ICD-9 (International Classification of Diseases [Clinical Modification], 9th edition) diagnostic code which justifies laboratory testing. 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. All laboratory requistions have areas where the ICD-9 codes are to be entered.

G. Advance Beneficiary Notice (ABN)

If a test which is unlikely to be covered is ordered upon a Medicare patient, the patient will be informed of the reason coverage is unlikely and will be asked to sign an Advenced Beneficiary Notice 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 a diagnostic code consistent with "medical necessity" guidelines;
the diagnostic test not having been approved for diagnostic use by the FDA and thus being 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

In-Patient Services

A. Admission, Preoperative and Other In-Patient Blood Drawing

Blood may be drawn on preoperative patients in the Ambulatory Care Center (hours noted above under Ambulatory Patient Blood Drawing). Nursing unit personnel are responsible for all in-patient phlebotomy, both routine and stat.

B. Routine A.M. Phlebotomy

Inpatient blood drawing for routine laboratory blood studies is usually performed each morning between 0400 and 0800. Labels are generated by the laboratory from a list of orders sent the night before or the orders are transferred to CareFusion devices used by phlebotomists to print labels at the patients bedside. These labels prompt for the correct container type and greatly reduce labelling errors. Preentry also increases the speed with which specimens can be processed upon receipt, decreasing test turnaround time.

Point-of-Care Testing (POCT)

Point-of-Care Testing (POCT) is available at many inpatient and outpatient clinic locations in order to provide rapid testing in support of patient care. The 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. The results of these audits are monitored for each location and reported quarterly to the committee which 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 a competency assessment, however, they must demonstrate annual competency for any test using a 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.

Each location POCT involving tests classified as moderately complex must enroll in and successfully perform proficiency testing. The results of all proficiency testing are reported to the Point of Care Committee. Sites that demonstrate unsuccessful PT performance will cease performing the unsuccessful test until they can demonstrate successful PT performance. Provider Performed Microscopy (PPM) requires that each provider take and pass an annual on-line competency assessment in each area of PPM that they wish to perform. Further, after demonstrating initial competency, each provider must apply for privileges in PPM from the UCSF Credentials Committee. Providers who have not demonstrated competency via the annual examination or who have not been granted PPM privileges may not perform PPM examinations.

New sites that wish to perform POCT or requests for new POCT from existing sites must be made in writing to the 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 UCVSF Clinical Laboratories will assist in the evaluation of available tests 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 Chair of the Point of Care Committee.

Please visit the Point Of Care Testing Manual for specific test listings.

Blood Drawing - Technical Issues

A. Collection Containers Available

TOP	DRAW (mL)	INTERIOR COATING	TUBE CONTENTS
(Stoppers are silicone-coated unless otherwise specified)
Blue (BD# 363080)	1.8	none	0.109 M (3.2%) buffered citrate, 0.2 mL
Blue (BD# 363083)	2.7	none	0.109 M (3.2%) buffered citrate, 0.3 mL
Gray (BD# 367925)	6.0	none	sodium fluoride, 15.0 mg, potassium oxalate, 12.0 mg
Dark Green (BD# 367871)	4.0	none	sodium heparin, 60 USP units
Light Green (PST) (BD# 367962)	4.5	none	inert polymer gel, with lithium heparin sufficient for a 4.5 mL draw
Dark Green-Micro (BD# 365969)	0.6	none	inert polymer gel, with lithium heparin sufficient for a 0.6 mL draw
Gold (SST) (BD#367989)	5.0	silicone	Inert polymer gel and silica clot activator
Lavender (BD# 367863)	6.0	none	EDTA (K₂), 10.8 mg - BLOOD BANK use only (13x100 mm tube)
Lavender (BD# 367856)	3.0	none	EDTA (K₂), 5.4 mg
Lavender-Micro (BD# 365973)	0.6	none	EDTA (K₂), 0.75 mg
Navy Blue (BD# 369736)	7.0	none	EDTA (Na₂), 10.5 mg, trace metal-free (purple lettering)
Pink-Micro (BD# 365962)	0.7	none	no additive; for BLOOD BANK use or FOR CERTAIN DRUG OR ANTIBODY LEVELS ONLY
Red (BD#367815)	6.0	silicone	Silica clot activator. For drug and some antibody levels only.
Red-Micro [SST] (BD# 365960)	0.6	none	plastic tube with inert polymer gel - NOT FOR BLOOD BANK
Yellow (BD# 364606)	8.5	silicone	acid citrate dextrose solution (ACD A), 1.5 mL

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.

B. General

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 premature infants and will make evry effort to provide an answer on the sample submitted.

One 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.

C. General Technique

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,
Mix specimens with the anticoagulant contained in the collection tubes by gentle inversion (x5), DO NOT shake.

2. Avoid a running IV line

Unless it cannot be avoided, DO NOT withdraw specimens from the arm proximal to a running IV, nor from the IV line itself as this may result in cantamination 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 ample is drawn.

3. Complete filling of vacutainers, especially coagulation testing:

Liquid-containing vacutainers should always be filled to their full draw volume for chemical analysis; this is particularly critical for coagulation testing; short filling will alter dilution factors and may interfere with recalcification of samples during measurement of clotting parameters. Therefore if a winged blood collection set ("butterfly") is used and the coagulation tube is the first tube drawn, a discard tube should be used to fill the deadspace volume of the line to assure adequate blood volume collection.

Specimens for coagulation testing may also be affected by an abnormal hematocrit. If the the hematocrit is above 55%, contact the Hematology laboratory (x31747) 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 a heparinized line.

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 which could produce spurious lab results.

Blood Culture*
Trace metal free tube with EDTA (NAVY BLUE TOP W/ PURPLE LETTERING)
... STOP!! If other tests are requested draw these from a separate venipuncture.
Citrate tubes for coagulation tests (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)
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). The only exception is if trace metal determination(s) (Navy blue top) are requested along with blood culture. In this circumstance, draw the Navy blue top first from one venipuncture, and proceed to perform the remaining collections from a second venipuncture.

5. When drawing ONLY a (light) blue top tube for coagulation studies:

If the draw of blood 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 draw is difficult with much searching for the vein, the blood flow slow, or the collection is made into a large syringe, the coagulation cascade may become activated; in that case the initial tube should be discarded and a second filled tube should be collected and submitted.

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 blue top tube is filled.
If the patient is <6 years old, one (1) mL of blood should be drawn and discarded before the 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.
If using a vacutainer, draw the amount of blood to be discarded into one tube, then change to and fill the blue top tube

6. DO NOT Transfer samples between vacutainer types:

Transferring blood from a one tube type when short of sample for other tube types is should NEVER be done. 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.

D. Drawing from Intravascular Catheters

Note: Blood is preferrably obtained by venipuncture and not from catheters.

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 an unrepresentative 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.

E. 'Micro' Determinations

Micro determinations are available for the following tests:

Group A (200 µL of serum/plasma minimum, 350 µL of serum/plasma for all)		Group B
Albumin	Creatinine	Ionized calcium (300 µL)
Alkaline phosphatase	GGT	Osmolality (100 µL)
ALT	Glucose	Salicylate (300 µL)
Amylase	Lactic Dehydrogenase
AST	Magnesium
Bilirubin, Total	Phosphorus
Bilirubin, Direct	Protein, Total
Calcium	Potassium
Chloride	Sodium
Cholesterol	Triglycerides
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. Microtainer capillary collectors for blood collection are available in the nurseries, the 6th floor Pediatrics wards, and the Emergency Department. These containers hold a maximum of 600 µL blood (approximately 300 µL serum).

Urine Collection For Chemical Analyses

The collection requirements may differ for many substances (see table below). Tests which have 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 Desk at the 5th floor Clinical Laboratories in Moffitt or at the blood drawing station on the 1st floor of the Ambulatory Care Center.

A blank cell indicates that preservative cannot be used.
SPOT urines do not have preservative although the aliquot may need to be acidified prior to testing.
It is preferable to keep all urines refrigerated during timed collections.
Acid washed container - supplied by reference laboratory or made by washing container using 1:1 mix of 6N HNO₃ & de-ionized water.

Urine Preservative Table
Analyte	Misys Order Code(s)	None	6N HCl	10 g boric acid	Acetic acid 50% (25 mL)	Na₂CO₃	Toluene	No preservative use acid washed container and aliquot tube	Handling and other issues
Albumin (see Microalbumin)	AU24 and AUR
Acylglycine profile	MOLT	OK							Freeze, goes to MAYO
Alcohol, ethyl	ALCO
Aldosterone	ALDU			OK	OK		OK		Freeze
Aldosterone + sodium	ALDU + NAUR			OK	OK		OK		Freeze for aldosterone
Amino acids	AAQU	OK					OK		Spot, no preservative; if a timed urine is ordered use toluene
5-aminolevulinic acid	ALAQ	OK			OK				No preservative, need dark container for collection, REFRIGERATE, protect aliquot from light
Amylase	AMYU	OK							2-hour collection preferred
Anabolic steroids	MOLT	OK							Spot, no preservative, refrigerate
Arsenic	ASU	OK						OK	No preservative use acid washed container and aliquot tube
Arylsulfatase A	MOLT	OK							Spot, no preservative, refrigerate, do not freeze
Calcium	CAU	OK	OK	OK	OK		OK		Spot OK
Catecholamines	UCAF		OK	OK	OK				pH < 3
ßHCG	HCGU	OK							Spot only, no preservative
Chloride	CLU	OK							No preservative, spot or timed OK
Chromium	MOLT	OK						OK	No preservative use acid washed container and aliquot tube
Citrate	CITU	OK	OK	OK	OK		OK
Copper	COPU	OK						OK	No preservative, use acid washed container and aliquot tube
Cortisol, unconjugated	CRTF	OK	OK	OK	OK		OK
Creatine	CRTU	OK	OK	OK	OK
Creatinine	CRU (CRCL)	OK	OK	OK	OK
Cystine	CUQT	OK					OK		Spot only, freeze aliquot
Diuretic screen	MOLT	OK
Drug screen, rapid	DAU, ABUS NABU	OK							Spot only
Glucose	GLUU	OK					OK
HCG for pregnancy	HCGU	OK							Spot only
Hemosiderin	HMSU	OK							Spot only, 50 mL required
Histamine	MOLT		OK
Homogentistic acid	AKU	OK							Spot, freeze
Homovanillic acid	HVA (Chem) & MOLT (spot)	OK	OK		OK				pH < 3; if spot w/o preservative freeze
17-hydroxycorticosteroids	17HS			OK
5-hydroxyindolacetic acid	5HQT		OK	OK	OK				pH < 3
Hydroxyproline, free	FHPR		OK				OK
Hydroxyproline, total	HPRT		OK	OK	OK	OK	OK
17-ketosteroids	17KS		OK	OK	OK
Laxative screen	MOLT	OK							Spot only
Lead	PBUR	OK						OK	No preservative use acid washed container and aliquot, timed of 24, 48 or 72 hrs OK
Magnesium	MGU		OK	OK	OK		OK
Manganese	NICH?	OK						OK	No preservative use acid washed container and aliquot tube
Mercury	HGU	OK						OK	No preservative use acid washed container and aliquot tube
Metanephrines	METN		OK	OK	OK		OK		pH < 3
Methylmalonic acid	MOLT	OK							Spot only
Microalbumin	AU24 or AUR	OK		OK			OK		Spot recommended, timed OK
N-acetylaspartate, quantitative	MOLT	OK							Spot only
Nitrogen	UNU	OK	OK		OK	OK	OK		Spot or timed
Organic acids, qualitative	OAX	OK
Orotic acid, quantitative	MOLT	OK
Osmolality	OSMU	OK							Toluene interferes
Oxalic acid (oxalate)	OXAU		OK	OK	OK		OK		pH < 3
PABA (para-aminobenzoic acid)	MOLT	OK							6 hour collection required
Phosphorus	PO4U	OK	OK
Pipecolic acid	MOLT	OK							Spot only
Porphobilinogen, quantitative	PBQT					OK			Must be protected from light during and after collection, freeze aliquot
Porphyrins, fractionated	PORFU					OK			Must be protected from light during and after collection, freeze aliquot
Potassium	KUR	OK		OK
Pregnanetriol	MOLT				OK				pH 4.0 - 4.5
Protein, total	TPU	OK		OK		OK	OK		Timed or spot
Pteridin profile	MOLT	OK							Spot, must be protected from light during and after collection, freeze aliquot
Sialic acid, free	MOLT	OK							Spot only
Sialic acid, containing oligosaccharides	MOLT	OK							Spot only
Sodium	NAUR	OK		OK					Spot or timed
Telopeptide, N-collagen crosslinked	NTX (spot) & MOLT (timed)	OK							Sspot or timed
Thallium	MOLT	OK						OK	No preservative use acid washed container and aliquot tube
Trace metal	see individual analytes	OK						OK	No preservative use acid washed container and aliquot tube
Urea nitrogen	UNU	OK	OK		OK	OK	OK
Uric acid	UCAU	OK		OK		OK	OK
Urinalysis	UA, UAWM, UMIO	OK							Spot only
Vanillylmandelic acid	VMA		OK	OK	OK				Timed preferred, spot OK pH < 3
Xylose (absorption)	MOLT	OK							5-hr urine specimen transferred (5 mL) to a gray top tube (fluoride and oxalate)
Zinc	ZINU	OK						OK	No preservative use acid washed container and aliquot tube

Cerebrospinal Fluid (CSF) Collection

CSF should be collected and transported to the laboratory in the special vials provided in the lumbar puncture kit. 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.

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 inbterpreted with caution.

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.

Laboratory requisitions

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 (white): 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.

Urine & Body Fluids (goldenrod): This form is used for ordering routine tests on urine, and body fluid samples (CSF, pleural, peritoneal. joint, amniotic fluid, etc.)

Emergency (Stat) (pink): 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 director. 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 (white): 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 (white): This form is used for ordering blood products.

ID Serology & Molecular Testing(white): 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 the area provided when requestiing tests used to diagnose HIV as this will 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 (white): This form contains the curently avaialble in house genetic tests for inherited and neoplastic disorders and should be used for ordeting 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 befoe 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, complete the following information on the appropriate Clinical Laboratory requisition:

Unit (Medical record) Number

Patient's Name

Location (ward, clinic name, or full address if private practitioner)

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 and the patient's name, address, and referring physician's name and address should be supplied as well. The patient identification should also be verified from a current California driver's license or othr 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 which are invasively collected and not readily recollected, but is not required.

Addressograph-stamped or pre-printed 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 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 and requisition 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.

Example:

DONOR: Jones, Tom RECIPIENT: Smith, John 23456183 9/15/01 14:30 LR

Processing Of Mislabeled And Unlabeled Specimens

A. Specimen Labels

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.

B. Specimens Received Without A Requisition

Specimen Desk personnel will not accept a specimen without a requisition. If a specimen is received without a requisition, one will be requested.

C. Mislabeled and Unlabeled Specimens

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 whom a sample has been collected with a reasonable degree of certainty, a new sample must be obtained. For example, if two unlabeled samples accompanying two requisitions arrive from the same nursing unit at the same time, or if neither sample nor requisition bears any identification, 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 a sample is received with a properly completed requisition but the specimen is unlabeled 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 and the test to be run. 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. 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 certainly exceptions to the above policy may be made. These decisions will be the responsibility of the 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 the notation the sample was "REC'D MIS(UN)LABELED-RUN AT MD'S REQUEST 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 in error 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.

Test cancellation

The UCSF Clinical Laboratory will try to honor requests from the ordering physician to cancel a test(s) up to the point that one or more results have been released to the patient record. 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.

Charging Tests To Another Patient's Account

Under exceptional circumstances, we will perform a test on, e.g., 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.

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 the other patient's account; the risk that action will be taken based upon the result of a test upon the mislabeled specimen and that treatment will be given for a condition the patient does not have is unacceptable.

The laboratory handles such tests according to the clinical setting in which the test is ordered.

Donor samples:

Tests will be ordered on the recipients medical record number/account and will appear both on STOR/CDS and 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.

Fetal samples:

Tests will be ordered on the mother's medical record number /account and will appear both in STOR/CDS and on paper 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 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 so small in 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 on the 5th floor of Long 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. Automated Transport to the Laboratory

A suitable pneumatic tube delivery system is available in some units for STAT sample transport. Additionally, 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 delivery. When in working order and not already in use it usually takes less than one minute to arrive when called. Place the bagged specimen with its accompanying requisition in the box provided to minimize the very small likelihood of the sample falling off into the dumbwaiter shaft.

Pneumatic Tube Stations at Parnassus

Station Location	Floor & Bldg.	Station Type	Station Number	Phone Number
Pharmacy	Basement Moffitt	Ultrastation (2 inlet/outlet)	100 and 200	3-1028 3-1154
ED	1st Long	Recessed (1 inlet/outlet)	210	3-1238
OR	4th Moffitt	Recessed (1 inlet/outlet)	240	3-1545
PACU	4th Moffitt	Recessed (1 inlet/outlet)	241	3-1292
Blood Bank - Clinical Labs	5th Moffitt	Counter Top (1 inlet/outlet)	252	3-1313
Chemistry - Clinical Labs	5th Long	Recessed (1 inlet/outlet)	151	3-1501
Clinical Labs & Central (Specimen) Processing	5th Moffitt	Ultrastation (2 inlet/outlet)	150 and 250	3-1667
Hematology - Clinical Labs	5th Moffitt	Counter Top (1 inlet/outlet)	251	3-1747
6PICU	6th Moffitt	Recessed (1 inlet/outlet)	160	3-1352
7ICU	7th Moffitt	Counter Top (1 inlet/outlet)	270	3-9140 3-1955
8ICU	8th Moffitt	Recessed (1 inlet/outlet)	180	3-8534
9ICU	9th Moffitt	Counter Top (1 inlet/outlet)	190	3-1621
10ICC	10th Moffitt	Counter Top (1 inlet/outlet)	910	3-1007
11NICU	11th Moffitt	Recessed (1 inlet/outlet)	911	3-1480 3-1873
15ICN - RN station	15th Moffitt	Recessed (1 inlet/outlet)	915	3-1565
15ICN - lab	15th Moffitt	Counter Top (1 inlet/outlet)	916	3-1755
ACC Laboratory (phlebotomy station)	1st ACC	Counter Top (1 inlet/outlet)	211	3-2736
ACC Hem/Onc Clinic	5th ACC	Counter Top (1 inlet/outlet)	253	3-2252 3-2070

Pneumatic Tube Stations at Mt. Zion

Station Location	Floor & Bldg.	Station Type	Station Number	Phone Number
HS046 Radiology	Basement CC building	Recessed (1 inlet/outlet)	Sub Station 1	3-9966
H1044 CC Draw Station	1st floor CC draw station	Recessed (1 inlet/outlet)	Sub Station 2	5-1664
Clinical Labs & Central (Specimen) Processing	2nd Floor MZ B212	Recessed (1 inlet/outlet)	Clin Lab B212	5-7845
H2508 Breast CC	2nd CC building	Recessed (1 inlet/outlet)	Sub Station 3	3-7070
H3508 GYN-Oncology	3rd floor CC building	Recessed (1 inlet/outlet)	Sub Station 4	3-7172
H4508 General ONC	4th floor CC building	Recessed (1 inlet/outlet)	Sub Station 5	3-7105
H5310 Infusion Center	5th floor CC building	Recessed (1 inlet/outlet)	Sub Station 6	3-7108

B. Laboratory Messengers

During the day shift, laboratory messengers pick up in-patient specimens every 1-2 hours from the laboratory refrigerators 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.

C. Night and Emergency Messenger Service

Between midnight and 7:00 a.m., laboratory messenger service is generally unavailable except through the use of a nursing unit's own Patient Service or Patient Care Assistants.

D. 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 partially complete urine collections, food, medications, or other materials not intended for laboratory analysis in the laboratory refrigerators.

E. Laboratory Messenger Schedules

The messenger schedules which follow are posted on the laboratory refrigerators:

WEEKDAY INPATIENT SPECIMEN PICKUP

Approximate Schedule for Clinical Laboratory Messengers

R T E	RUN NO.	LV MAIN	15-6 M/L	HEM A510A, GYN A95D	PED A220	ACC LAB A122	PSEP L170	ARR MAIN
A	1	0700	0705					0730
A	2	0800	0805			0830	0835	0840
A	3	0925	0930					0955
A	4	0955				1005		1010
A	5	1020	1025					1050
X				Lunch	Break
A	6	1200			1205	1210	1215	1220
A	7	1240	1245					1310
A	8	1400	1405					1430
A	9	1450				1455	1500	1510
D	1	1530	1535					1600
D	2	1610		1620*		1625	1630	1635	*Pick up Blood Bags
D	3	1635				1640	1655	1655
D	4	1655		1705	1710	1715		1725
D	5	1725			1730	1735		1740
D	6	1740	1745					1810
D	7	1810				1805		1810	Monday-Thursday only
D	8	1815				1825		1840	Monday-Thursday only
X				Lunch	Break
D	9	1945						2000
D	10	2000	2005					2035
D	11	2035						2100
D	12	2145	2150					2215
D	13	2215				2045		2050	Monday-Thursday only
D	14	2145	2150					2215
D	15	2215						2300
D	16	2300						2330

X-Break or Meal

PED lab closes at 1615; later pickups are from corridor

WEEKDAY ACC SPECIMEN PICKUP