Laboratory Leadership ...... 2 Deleted: 3 Outreach Laboratory Services: ...... 3 Deleted: 4 Courier Service: ...... 4 Deleted: 5 Prompt Reporting/Turn-Around-Time: ...... 4 Deleted: 5 Result Reporting ...... 4 Deleted: 5 Repeat Determinations...... 5 Deleted: 6 Cancellation Of Tests...... 5 Referred Tests ...... 5 Deleted: 6 Professional Courtesy: ...... 5 Deleted: 6 Standing Orders: ...... 5 Deleted: 6 Quality Assurance...... 5 Deleted: 6 Reportable Disease...... 6 Deleted: 6 Clinical Trials...... 6 Deleted: 7 Supplies:...... 6 Deleted: 7 Specimen Collection Stations ...... 6 Deleted: 7 Billing Services...... 7 Deleted: 7 Test Requisition Information ...... 9 Clinical Laboratory Specimen Colelction Materials……………………………………..12 Deleted: 8 Deleted: 10 Anatomic Pathology And Cytology ...... 13 Pathology Specimen Containers ...... 13 Cytology Specimens ...... 13 Gynecologic Cytology Specimen (Pap Smear) Collection and Requirements...... 14 Unacceptable Specimens ...... 14 Cytology Supplies...... 14 Quality Assurance...... 14 Non-Gyn Cytology Specimen Requirements...... 15 Appendix...... 18 Specimen Requirements: ...... 18 Critical Values ...... 36 Critical Tests ...... 39 Stat Tests:...... 40

1 Laboratory Leadership

Valley Pathology Medical Associates, Inc. Jerry Kolins, M.D. Medical Director Blesilda Singh, M.D. Bradley Harward, M. D. Lachlan McLeay, M.D. Saskia Boisot, M.D. Pamela Danque, M.D. Keith Lopes, PA Linda Petroff, M.D.

Palomar Pomerado Laboratory Services: Mark Reyes, MT (ASCP) MBA District Director, Lab Operations

Tim Barlow, MT (ASCP) Susan David Manager, Laboratory Services – PMC Phlebotomy Supervisor Pomerado

Gloria Austria, MBA/HCM, CLS Debra Mason, MT (ASCP) Manager, Laboratory Services – Pomerado POCT Supervisor

Ted Drescher Rose Pfliger Office/Phlebotomy Manager Anatomic Pathology Transcription Supervisor

Robert D’Orazio, MT (ASCP) Brian Bakerink Chemistry Supervisor Supervisor- Cyto/AP Assistants

Joane Barriteau, MT (ASCP) Evelyn Chua, MT (ASCP) Hematology Supervisor Evening Shift Supervisor - PMC

Rebecca Anderson, MT (ASCP) Susan DeWindt, MT (ASCP) Night Shift Supervisor - PMC Microbiology Supervisor Robert Sharpell, MT (ASCP) Sandy Lajeunesse, MLT (ASCP) Laboratory Info System Analyst – PMC Central Processing Supervisor Jim Peters, MT (ASCP) MaryAnn Snoke Laboratory Info System Analyst – Pomerado Phlebotomy Supervisor - PMC

2 Outreach Laboratory Services: PPLS Client Services Department: Phone: (760) 739-2867 or (858) 613-4282 Fax: (760) 739-2864 Ted Drescher, Office/Phlebotomy Manager (760) 739-3026

Hours of Operation: Monday – Friday 8:00 A.M. – 5:00 P.M.

Our Customer Service Representatives will gladly help you with your requests for test results, telephone orders, courier pick-ups, specimen requirements, turnaround times, and supply orders. After hours, please call the PPLS Client Services Department and follow the steps to be transferred to Palomar Medical Center or Pomerado Hospital.

Professional Consultation Our pathologists are always available to answer your questions, discuss test results and consult on unusual cases. Please call either Palomar Medical Center at (760) 739-3030 or Pomerado Hospital Laboratory at (858) 613-4649. Laboratory managers and technical staff are also available to answer your questions regarding clinical laboratory testing.

Fully Accredited Laboratories Palomar Pomerado Laboratory Services is acknowledged as a high quality laboratory and is accredited by the following: College of American Pathologists (CAP) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Centers for Medicare and Medicaid Services (CLIA) State of California Department of Health Services (DHS)

Pomerado Hospital Palomar Medical Center CAP # 23184-01 CAP # 23149-01 Federal Tax ID # 95-6003-843 Federal Tax ID #95-6003-843 FI Medicare Provider # 050636 FI Medicare Provider # 050115 California State License # CLF 3150 California State License #CLF1006 CLIA ID # 05D0668540 CLIA ID # 05D0671677 Medi-Cal Provider # ZZT40636F Medi-Cal Provider #ZZT40115F NPI 1376513754 NPI 1457321317

3 Courier Service: (760) 739-2867 or (858) 613-4282 Hours of Operations: Monday – Friday 8:00 A.M. – 8:00 P.M. Saturday – Sunday 8:00 A.M. – 4:30 P.M. *Holidays by special arrangement Whenever possible, courier pick-ups will be scheduled around your office hours. Lock boxes for after hours service are also available. * STAT courier services are available. In most cases a courier will be to your office within one (1) hour of your call.

Prompt Reporting/Turn-Around-Time: Specimens are processed and test results are reported to the client as soon as possible. Since reporting times vary, a testing schedule is available from the Outreach Laboratory office.

Result Reporting Routine Results are available within 24 hours. ASAP Results are available within four (4) hours after specimen is received in laboratory. STAT Results available within one (1) hour after specimen is received in the laboratory.

Lab Result Calling After Hours The CLS performing the test will call critical results with no time restrictions Calling Protime results: • The lab will order all Protimes as AS/AS unless otherwise requested by physician. • All STAT Protimes received after 4 PM shall be called to Physician or Institution. • ASAP Protimes with normal results shall not be called after 8:00 p.m. but must be called the next business day.

NOTE: The front office personnel will check the requisition for complete physician information including after hours contact number. In the event that the information is not available the laboratory personnel will: • Call the patient to get the physician information. ?? • If information is still not available, CLS will call the pathologist on call.

Result Faxing: All laboratory results will be automatically faxed to your office. This includes clinical, cytology and anatomic pathology reports.

4 Critical Value Handling The laboratory will immediately call results that fall within a range, which has been determined to be Critical or may have an effect in delaying surgery or need to be brought to the attention of the physician. You will find a list of the PPLS Critical Values in the Appendix.

“STAT” Test List: A complete list of Outpatient “STAT” tests can be found in the Appendix of this manual.

Repeat Determinations We will repeat a test without charge whenever the result does not correlate, in the physician’s opinion or with the clinical picture presented by the patient. Contact the Outreach Laboratory office with any requests for repeats. Follow-up or confirmatory testing is not considered a repeat determination, and such specimens will therefore be processed as a new request.

Cancellation Of Tests Cancellations received prior to test setup will be honored at no charge. Requests received following test setup or resulting cannot be honored.

Referred Tests PPLS is a full service laboratory. Most tests are performed in our laboratories; however, a few highly esoteric tests are referred to reliable reference laboratories. We use the services of ARUP Clinical Laboratories as our primary reference laboratory. The fees for referred tests are subject to change and a fee is added to cover handling expenses.

Professional Courtesy: California State and Federal Laws prohibits the offering of “professional courtesy testing”; therefore we cannot honor requests for this service.

Standing Orders: Standing orders are permitted at PPLS as long as they are valid, documented, medically necessary, and monitored for appropriateness. Standing orders must be in written form and must include a duration, frequency of testing, diagnosis, and physician’s signature and be no more than 6 months old. PPLS reviews standing orders on a regular basis and may send written notification requesting renewal of the order.

Quality Assurance PPLS utilizes state-of-the-art, technologically advanced diagnostic techniques. Participation in the College of American Pathologists (CAP) and other proficiency testing programs for every reported analyte assures our outstanding performance for accuracy and performance. We maintain continuous internal quality improvement audits throughout all departments and participate in health system-wide Professional Practice Improvement Teams.

5 Reportable Disease All reportable diseases are reported to the County of San Diego, Public Health Department as outlined by Title 17 California Code of Regulations (17CCR). Within 24 hours of identifying a reportable organism, a Confidentiality Morbidity Report (CMR) is completed and faxed to San Diego County Public Health.

Clinical Trials We are here to assist offices that are participating in a Clinical Trial Study. Contact the Outreach Laboratory office for further assistance, (760) 739-2867.

Supplies: PPLS will provide, at no charge, supplies necessary for the collection and transportation of specimens for analysis at our laboratories. We cannot provide supplies used for in office testing. To order supplies, simply fill out a Supply Request form and give to your lab courier or simply call the Client Services Line: (760) 739-2867 or (858) 613-4282. A list of supplies is located in the Appendix.

Specimen Collection Stations PPLS provides Specimen Collection Stations in the Escondido and Poway areas. Appointments are not necessary, however, they are appreciated for Glucose Tolerance testing. Locations: Escondido: Palomar Medical Center 555 E. Valley Parkway, 3rd Floor Phone: (760) 739-3030 Monday – Friday: 7:00 A.M. – 7:00 P.M. Saturday; 8:A.M. – 4:00 P.M. Sunday: 8:00 A.M. – 3:00 P.M. Six parking spaces are allocated for Laboratory patients. Please use the hospital entrance at Grand Avenue. Parking spaces are near the entrance for Rehabilitation/ Outpatient Services

Poway/Rancho Bernardo: Pomerado Outpatient Pavilion: 15611 Pomerado Road, 1ST Floor Phone: (858) 613-4282 Monday – Friday: 7:00 A.M. – 6:30 P.M. Saturday: 8:00 A.M. – 1:00 P.M. Sunday Closed Park in the parking garage behind the Outpatient Pavilion, at the north (far) end of the garage on the first floor. Use the walkway or wheelchair ramp to the Lab Specimen Collection Site on the first floor. For STAT testing after hours or Sundays, Pomerado Hospital Laboratory is available.

Billing Services Palomar Pomerado Health will bill all insurances on behalf of our customers for clinical laboratory services.

Valley Pathology Medical Associates, Inc. will bill for professional clinical and pathology services (histopathology and cytology).

It is the responsibility of the customer to check with his/her insurance company prior to using our service to assure that Palomar Pomerado Laboratory Services is a network provider.

The billing office is open Monday through Friday. For questions regarding billing feel free to contact them. Palomar Pomerado Health Billing: (858) 675-5360 Valley Pathology Medical Group, Inc. Billing (McKesson Corp.): (903) 450-4450

Billing Information: Palomar Pomerado Health Billing Department routinely bills most major medical insurance carriers, as well as smaller local carriers. In addition, we participate in many PPO/IPA/HMO managed care healthcare delivery systems.

Please check the appropriate boxes and submit all necessary billing information on the test requisition form.

Private Patient Medicare - Patient’s Complete Name - Patient’s Complete Name - Sex - Sex - Date of Birth - Date of Birth - Current address, including apt # - Current address, including apt. # - Telephone number - Telephone number - Name of responsible party, if other than - Medicare number patient - Copy of insurance card, both sides - Diagnosis (ICD-9 Codes) - ** Diagnosis (ICD-9 Code)

Bill Insurance Medi-Cal - Patient’s complete name - Patient’s complete name - Sex - Sex - Date of Birth - Date of Birth - Current address, including apt. # - Current address, including apt. # - Telephone number - Telephone number - Name and address of insurance company - Proof of eligibility (copy of current month eligibility or POE sticker) - Copy of both sides of insurance card - Diagnosis (ICD-9 Codes) - Diagnosis (ICD-9 Codes)

7 * Workman’s Compensation claims: Submit social security number, insurance identification number, and the exact date of injury.

* TriCare: Submit the patient’s identification number, sponsor’s status (active duty, retired, dependent) and expiration date and a copy of insurance card.

Bill Physician/Facility - Provide all patient demographics - Clearly mark the Bill To:” Physician Account” box

When at all possible, it would be very much appreciated if the patient’s Social Security Number (SSN) would be provided on the test requisition.

** NOTE: Advanced Beneficiary Notice (ABN): When ordering tests for which Medicare reimbursement will be sought, provide all applicable diagnosis codes to the tests that are being ordered. Tests ordered that are determined not “medically necessary”, will not be reimbursed by Medicare. “Medical Necessity” is determined by the use of a diagnosis (ICD-9) code appropriate for the test ordered.

8 Test Requisition Information PPLS provides three types of personalized requisition forms for your convenience. They include: • Clinical Laboratory testing - Blue/White form • Cytology testing – Purple • Tissue/Surgical testing - Green A request form or physician’s order must accompany each laboratory order or specimen you submit.

Filling Out the Palomar Pomerado Laboratory Requisitions: • Clinical Laboratory: Blue/White o Patient’s full name (last, first, middle initial) o Current address o Phone number o Date of Birth o SSN, if possible o Check appropriate billing category and attach a copy of insurance card o Provide ICD-9 code(s) or chief complaint. This is a federal requirement and failure to provide may result in insurance denial. o Clearly mark tests to be performed. If not listed, use the “Write-In” area. o Clearly label each specimen being submitted with patient’s name, date and time of collection. Use the identification labels provided. o Microbiology testing – please indicate the “source” of the specimen being submitted for culture. The back of the requisition contains a complete list of panel components, specimen collection tube codes and reflexive tests.

• Cytology: Purple o Patient’s full name (last, first, middle initial) o Current address o Phone number o Date of Birth o SSN, if possible o Date and time of collection o Check appropriate billing category and attach a copy of insurance card o Provide ICD-9 code(s) o For Pap smears indicate if you want HPV testing o Source of material submitted (cervical, endocervical, vaginal or other gyn or non-gyn site) must be provided o Patient history or clinical information is required. o Pap Smears: LMP, Date and Diagnosis of last Pap Non- Gynecological Cytology: urine, sputum, pleural fluid, etc. A brief clinical history MUST be provided at the time of specimen submission. ICD-9 codes, alone, are not acceptable.

9 • Tissue: Green o Patient’s full name (last, first, middle initial) o Current address o Phone number o Date of Birth o SSN, if possible o Date and time of collection o Check appropriate billing category and attach a copy of insurance card o Clinical information, please complete all areas that are related to the tissue specimen being submitted. Provide the operative procedure and presumptive diagnosis. Gynecological specimens require that any hormone therapy information be included. o Clinical History must be provided with all specimens. If not provided, the requisition will be returned to your office for this information thus delaying a final report. This information is invaluable to the pathologists as they make their diagnosis. o List all specimens being submitted. Identify the specific anatomic location for each biopsy.

• .

Clinical Laboratory Specimens Collection Materials We primarily use vacuum specimen collection tubes that are color-coded signifying the anticoagulant contained therein or the absence of preservative. The following is a brief description of tube color coding and additive: • Red top tube: no additive. o Required for testing for which serum is indicated as the specimen of choice. • SST - Serum Separation Tube. o Tube of choice for most in- house Chemistry tests, which are analyzed on direct-tube sampling instruments. Contains an inert barrier material. • Lavender top tube: K2EDTA 5.4 mg. o Whole blood used for hematology procedures where cell counting and pristine cell morphology necessary; also used for tests requiring EDTA plasma. EDTA removes calcium from whole blood via chelation (calcium essential for clot formation, consequently clot formation impeded). • Green top tube: lithium heparin 143 IU (crystal). o Used for testing where heparinized plasma is indicated as the specimen of choice. Heparin neutralizes the effect of thrombin and thromboplastin. Also used when methodology requires heparinized whole blood. Sodium heparin also available but should not be used for sodium testing (electrolytes). Green top tubes containing lithium heparin similarly should not be used for lithium level testing. • Grey top tube: sodium fluoride/potassium oxalate (crystal). o Used for chemistry testing where glycoinhibited specimen required, e.g. glucose testing. • Blue top tube: buffered sodium citrate. o 2.7 ml tube contains .3 ml of 3.2% (0.105 M) buffered sodium citrate o 4.5 ml tube contains .5 ml of 3.2% (0.105 M) buffered sodium citrate o Sodium citrate used when coagulation studies ordered requiring plasma specimens; e.g. Protime (PT), Partial Thromboplastin Time (PTT), fibrinogen testing, clotting factor testing (e.g. factor VIII, etc.) • Microtainers. o Used when absolute minimum sample size required or when collecting skin puncture specimens: • Red microtainer-no additive • Green microtainer-lithium heparin, 12.5 IU • Lavender microtainer-K3EDTA (crystal) • Arterial blood gas syringe/plastic: contains lyophilized lithium heparin. o Used for whole blood testing of arterial blood for pH, partial pressure of oxygen, carbon dioxide, and ionized calcium.

11 • Aliquot tubes/transfer pipets/sample cups. o Product insert must be reviewed for possible interfering substances. Review of clinical literature may also be used. Copy of insert and/or literature may be kept on file as evidence of review.

Ascertain and observe all testing requirements essential for the proper collection of lab specimens for specific testing. Depending on testing and testing methodology, tube color and size may vary. Several tests require special handling before and after collection; these must be observed to insure collection of the most appropriate specimen possible.

As appropriate, review clinical literature; evaluate information from manufacturers for inertness of blood collection containers and specimen contacting transfer pipets & aliquot tubes for any possible analytic interference. All volume specific tubes must be properly filled.

Specimen Size/Sample Size: Without adequate sample size, testing cannot be performed. This inadequate specimen collection is detrimental to patient and patient care. Computer generated labels/ requisitions contain recommended sample sizes, tube type and recommended handling; consult specific departments for questions regarding sample size, minimum sample volumes, specimen handling guidelines for tests not contained in this section.

12 Anatomic Pathology And Cytology

Pathology Specimen Containers

Biopsy specimens submitted to PPLS for analysis must be placed in Buffered Zinc Formalin containers. These can be obtained through your lab courier.

Label the container(s) as outlined in the “Specimen Collection” section. The specimen must NOT be allowed to dry before fixation. Place specimen in container promptly.

¾ Tissue Requisition: To process specimens in a timely and accurate manner, the following information must be provided on the “Tissue Requisition” form: 1) Social Security Number: The patient’s SSN must be included to ensure patient identification. 2) Patient Demographics: Patient’s complete Name, Gender, Date of Birth, Current address and phone number and current insurance information. Please include a copy of the patient’s insurance card (front and back). 3) Section 3 is for “Inpatient use, only”. 4) Clinical Information: Please complete all areas that are related to the tissue specimen being sent. GYN specimens being submitted require any hormone therapy information be included in this section. 5) Clinical History: Include a brief clinical history with all specimens. This provides valuable information for the pathologist as they make their diagnosis. Example: “Pt. has had abnormal bleeding for 3 months; abnormal Pap smear.” 6) Specimens: List anatomical location of all specimens being submitted. 7) Date and time of specimen collection and Name and Address of ordering physician, nurse practitioner, or physician’s assistant.

Cytology Specimens

¾ Cytology Requisition: 1) Patient’s Full Name (Last, First, MI) 2) Current address and telephone number 3) Date of Birth 4) Social Security Number (if able to obtain) 5) Date and time of specimen collection and Name and Address of ordering physician, nurse practitioner, or physician’s assistant. 6) Patient’s current Insurance information including a copy (front and back) of the insurance card. 7) Source of material submitted (cervical, endocervical, vaginal, or other gynecological or non-gynecological site)

13 8) Patient history or clinical information • Last menstrual period (LMP) • Hormonal status • Hormone therapy • Birth control pills, IUDs • DES exposure • History of abnormal cytology, gynecologic surgeries, cryosurgery, electrocautery or laser surgery. • Date of last gynecologic smear and PPLS accession number, if applicable. • Designate if the patient is at high risk for cervical cancer. History of dysplasia, human papillomavirus infection (HPV), grossly visible lesions, abnormal bleeding, etc.

State Law 1050(g) requires that the patient name be written on ALL accompanying slide(s) and liquid-based vials submitted for cytological review.

Unacceptable Specimens Specimens are deemed unacceptable when any of the following occur: 1) No patient information on requisition 2) Unlabeled slide(s) or collection vials 3) Patient’s name is different from the requisition and slide(s)/collection vials 4) Slide(s) are broken beyond repair or receipt 5) No source is indicated on non-gyn specimens 6) Incorrect requisition

Cytology Supplies Cytorich Red preservative solution (for non-gynecological specimens). Supplies may be ordered through PPLS Client Services or simply complete a supply request form.

Quality Assurance PPLS performs all cytopathology procedures in accordance with all state and federal regulations. An intensive internal Quality Assurance program is also followed.

Non-Gyn Cytology Specimen Requirements

Breast Secretion Smears: • Label numerous clean slides with patient’s name. Number slides successively by side (R1, R2, etc.; L1, L2, etc) • When a small drop of secretion appears at the nipple, smear and immediately place 95% ethanol fixative. Pap smear fixative of any type is also adequate.

14 • Repeat as long as secretion is obtained because the last drops frequently yield the best-preserved cells. • Properly label the 95% ethanol fixative container with the patient’s first and last name and date and time of collection. • A clinical history MUST be provided on the Cytology requisition.

Sputum Cytology: • A satisfactory specimen is crucial for adequate evaluation. A satisfactory specimen must be a DEEP COUGH specimen. Saliva and nasopharyngeal drainage are not acceptable. Specimens contaminated with a large amount of saliva and food particles are not acceptable. • The first morning DEEP COUGH specimen is considered the most desirable; however, specimens obtained at any other time of the day are equally acceptable. • The specimen should be expectorated into a clear container; a urine specimen cup is ideal. If this material is to be for a culture, the container MUST be sterile. • Properly label the container with the patient’s complete name, requisition ID number, and the date/time of collection. • A clinical history must be provided on the Cytology requisition. • Specimens should be received in the laboratory as soon as possible. If there is any delay, keep the specimen refrigerated. • In general, three (3) to six (6) separate specimens are recommended in order to increase diagnostic sensitivity and accuracy.

Urine Cytology • A clean non-sterile urine specimen container is acceptable unless the specimen is to be submitted for culture, also. In which case, a sterile container must be used. • Approximately 60-80 cc of fresh voided urine should be collected in the container. This should NOT be the first morning specimen. Any other freshly voided specimen is acceptable. Women should be instructed to avoid vaginal contamination. • If there is a delay in sending specimens to the laboratory, store specimens in the refrigerator for not greater than 24 hours. • In general, at least three (3) separate specimens are recommended in order to increase diagnostic sensitivity and accuracy. • Catheterized specimens must be labeled as such on the requisition. • Bladder washings/brushings and arterial washing/brushings should be handled in the same manner, again with appropriate identification of the specimen’s origin. Sterile physiologic fluid such as “Tissue-sol” is recommended as the irrigation fluid. Saline is also acceptable. • A clinical history MUST be provided on the requisition.

Fluids: Pleural and Peritoneal • Body fluid may be collected in tubes, syringes, or clean collection bags. It is recommended that approximately 5 – 10 units of heparin per ml of sample be added to prevent coagulation.

15 • In general, 200 cc of sample is sufficient for evaluation, although larger volumes may provide a better cell block. • Properly label specimen container with patient’s complete name and date/time of collection. • If there is any delay in sending the specimen to the laboratory, it should be refrigerated. • A clinical history must be provided on the requisition.

Cerebrospinal Fluids (CSF) • Place the collected specimen into a sterile CSF collection tube or a plain red top vacutainer tube. (Do Not SST) • A minimum of one (1) cc of fluid is considered the absolute minimum. The larger the volume of specimen, the greater he sensitivity and accuracy. • Properly labeled specimen containers with patient’s name and date/time of collection, is imperative. • Send the specimen immediately to the laboratory. Any delay has a significant negative impact on specimen quality.

¾ Aspiration Cytology Services Palomar Pomerado Laboratory Services is pleased to make available to our clients the valuable service of the interpretation of cytological material performed on outpatients using the fine needle aspiration technique. This interpretative service is available on a routine basis with turnaround times approximately equal to that of routine cervical-vaginal Pap smears.

The following procedures are strongly recommended to obtain well-fixed representative cytologic material from any source: • Label glass microscope slide with patient’s last name, first name and middle initial. • The target lesion is grasped and immobilized with the free hand while the needle position and vacuum are controlled with the other hand. • Using a 22-gauge needle or thinner, insert the tip of the needle through the skin and into the lesion. Local anesthesia is usually not necessary. • Apply full vacuum on the plunger of the syringe now that the needle head is complete within the target area. • Move the needle back and forth within the mass while varying its angle within the lesion. RELEASE THE VACUUM, and withdraw needle from patient. If blood flows into the syringe, stop immediately. • At this point, the cytologic sample should be entirely within the barrel of the needle. To retrieve the sample, first remove the needle from the syringe, and pull back on the syringe plunger to introduce air into the syringe. • Replace the needle on syringe, place tip of needle over a glass microscope slide and depress the plunger. The cytological material will be discharged onto the surface of the slide. • Two (2) smears can be prepared by gently touching two (2) slides together and quickly but gently sliding them apart. Immediate fixation of the smears is of

16 paramount importance. This is accomplished by immediate immersion in alcohol fixative. • If preparation of smears is difficult, we will provide CYTORICH (transfer media), which will support the cellular material until it can be prepared in the laboratory. If using the transport media, follow the directions through step #5. Then aspirate the media into the needle and syringe and rinse them back into the container. Make sure the tip is tight when finished. • Place the “business” side of each slide facing away from each other in the bottle of alcohol. Submit the slides to the laboratory still in fixative. • A clinical history and clinical impression must be provided on the requisition.

Re-capping or Re-sheathing used needles is strongly discouraged.

The laboratory WILL NOT accept syringes with a bare or exposed needle attached. The specimen will remain in your office until the needle is removed and properly disposed. This is in accordance with OSHA’s Blood-Borne Pathogen regulations.

17 Appendix

Specimen Requirements: Submission Test Requirements / Tube Special Handling Color ABG (Arterial Blood Gas) 1 ml Li Heparin syringe Mix/ ABO typing 7 ml/lavender ABORh 7 ml/lavender ACE (Angiotensin Converting Enzyme) 7 ml/SST Acetaminophen (Tylenol) 5 ml/PST / SST Acetone 5 ml/PST / SST Acetylcholine AB 7 ml/SST Acid Phosphatase (ACP) 5 ml/Plain red Freeze serum ASAP. ACTH (Adrenocorticotropic Hormone) 7 ml/lavender Freeze plasma ASAP. Adenovirus AB 6.5 ml/SST Albumin 5 ml/PST /SST Do not prep site with Alcohol, Ethyl (Ethanol) 5 ml/SST/PST alcohol; use acceptable Aldolase 5 ml/SST Aldosterone 5 ml/SST Freeze serum ASAP. Alkaline Phosphatase 5 ml/PST /SST Alkaline Phosphatase Isoenzymes 6.5 ml/SST Allergy Testing 1 ml serum / SST Special handling. See Alpha-Fetoprotein (AFP - maternal) 3 ml/SST AFP procedures. Alpha-Fetoprotein (AFP - tumor marker) 5 ml/SST Alpha Thalassemia 7 ml/lavender Alpha-1-Antitrypsin 5 ml/SST ALT (SGPT) 5 ml/PST / SST 3 Alpha, 17 Beta Androstanediol 6.5 ml/SST Glucoronide Assay (AG) 7 ml/royal blue - (No Aluminum level Additive Anticoagulant) Amebic AB (CIE) 6.5 ml/SST Amebic AB (IFA) 6.5 ml/SST Amebic AB (IHA) 6.5 ml/SST No SST - Consult policy Amikacin (Amikin) (peak or trough) 10 ml/red regarding pre/post dose. Amino Acid Quantitation 7 ml/green Amitriptyline 10 ml/red No SST. Ammonia (NH4) 3 ml/PST Deliver on ice - STAT.

18 Amoxapine(Asendin) 10 ml/red No SST. Amphotericin 10 ml/red Amphicillin 10 ml/red Amylase 5 ml/PST / SST Amylase Isoenzyme 6.5 ml/SST ANA (Antinuclear antibodies) 7 ml/ SST ANCA (Anti-Neutrohil Cytoplasmic AB) 6.5 ml/SST Ancef 10 ml/red Androstenedione 6.5 ml/SST Freeze serum. Angiotensin-1 Converting Enzyme (ACE) 5 ml/SST ANTI - ANYTHING 6.5 ml/SST (When in doubt.) Anti-Acetylcholine Receptor AB 6.5 ml/SST Antibody Screen 7 ml/lavender Anti-Cardiolipin 6.5 ml/SST Anti-Centromere 6.5 ml/SST Anti-Diuretic Hormone (ADH; 2x7 ml/lavender Freeze plasma ASAP. Vasopressin) Anti-DNA AB (DS) (ADH; Vasopressin) 6.5 ml/SST Anti-DNA AB (SS) 6.5 ml/SST Anti-ENA AB 6.5 ml/SST Anti-GBM AB (Glomerular Basement 6.5 ml/SST Membrane) Anti-HAV IgM(Hep A virus AB, IgM) 6.5 ml/SST Anti-HBC IgM (Hep B virus AB, IgM) 6.5 ml/SST Anti-HCV (Hep C virus AB) 6.5 ml/SST Anti-Histone AB 6.5 ml/SST Anti-MAG (Myelin Associated 6.5 ml/SST Glycoprotein) Anti-Microsomal AB 6.5 ml/SST Anti-Mitochon. AB 6.5 ml/SST Avoid hemolysis. Anti-Neutrophil Cytoplasmic AB 6.5 ml/SST Anti-Parietal Cell AB 6.5 ml/SST Anti-Phospholipid 6.5 ml/SST Anti-Platelet AB Indirect 10 ml/ Plain Red Freeze Serum ASAP Anti-RNP AB 6.5 ml/SST Anti-RO/LA AB(Anti-SSA/SSB) 6.5 ml/SST Anti-SCL 70 AB 6.5 ml/SST Anti-Smooth Muscle 6.5 ml/SST Anti-Sperm AB 6.5 ml/SST Anti-SSA/SSB AB 6.5 ml/SST Anti-Striated Muscle 6.5 ml/SST

19 Anti-Thyroglobulin 6.5 ml/SST Anti-Thyroid AB 6.5 ml/SST AP Isoenzymes(Alkaline Phosphatase) 6.5 ml/SST 3 ml/LT blue (4.5 ml/LT APTT Return to lab ASAP. blue preferred) Arbovirus AB Panel 6.5 ml/SST Arthritis Profile 5 ml/SST & 3 ml/lavender ASO Screen (Anti-Streptolysin) 6.5 ml/SST Aspergillus AB 6.5 ml/SST AST (SGOT) 5 ml/SST AT III (Qual/Quant) (Antithrombin 3) 4.5 ml/LT blue Freeze plasma ASAP. Aventyl 10 ml/red No SST. Freeze serum. B6, Vitamin 10 ml/Lavender B12, Vitamin 5 ml/PST / SST Bacterial Antigen 10 ml/red Barbiturate, Quant 10 ml/red 6 hr URINE collection after Bentiromide (PABA) dose of PABA. Patient must fast over-night. 7 ml/royal blue - (No Beryllium Anticoagulant) or 7 ml/royal blue - EDTA Beta-2-Microglob 6.5 ml/SST Beta HCG Maternal(Human Chorionic 5 ml/SST Gonadotropin) Beta HCG Tumor Marker 5 ml/SST Freeze serum ASAP. Bicarb (arterial) 3 ml/green Do not spin. Bile Acid(Cholylglycine) 6.5 ml/SST Fasting required. Bilirubin, Direct 5 ml/PST / SST Avoid hemolysis. 5 ml/PST / SST Bilirubin, Total Avoid hemolysis.

Blastomyces AB 7 ml/SST Blood Count (CBC - Complete Blood 3 ml/lavender Count) 8-10 ml/BACTEC Consult Departmental Blood Culture (aer grey bottle) 8-10 Procedure for additional ml/BACTEC (anaer purple instructions. bottle) 0.5-3 ml/BACTEC (Peds Blood Culture Peds aer pink bottle) Special instruct: If 10-20 Blood Culture ml, split evenly between

aer & anaer: 3-9ml add to aer; <3ml add all to peds

20 Blood Type (ABORh) 7 ml/lavender Bromide 7 ml/Plain Red Brucella AB 6.5 ml/SST BUN (Blood Urea Nitrogen) 3.5 ml/PST / SST Butabarbital 10 ml/red No SST. C 1 Esterase Inhibitor 7 ml/SST Freeze serum ASAP. CA-15-3 (Cancer Antigen 15-3) 5 ml/SST Freeze serum ASAP. CA-125 (Cancer Antigen 125) 5 ml/SST . CA 27.29 5 ml/SST . Calcitonin 6.5 ml/PST / SST Freeze serum ASAP. Calcium 3.5 ml/SST/PST Calcium, Ionized 3 ml/green lithium heperin Deliver on ice - ASAP. Candida AB 6.5 ml/SST Carbamazepine(Tegretol) 5 ml/PST / SST 7 ml/green or a Carboxyhemoglobin Deliver ASAP to CP. heparinized syringe Cardiolipin Antibody 5 ml/SST Protect from light and Carotene 6.5 ml/SST freeze. Collect on Ice. Freeze Catecholamines,Fractionated 2 x 7 ml/green plasma. CBC (Complete blood count) 3 ml/lavender 10 ml/lavender at room CD4/CD8 temp. CEA (Carcinoembryonic Antigen) 5 ml/SST Ceruloplasmin 6.5 ml/SST Chem 12(Na, K, Cl, Glucose, BUN, Creat, Calcium, T. Prot, Alb, AST, Alk 5 ml/PST / SST Phos, T. Bili Chem + HDL 5 ml/PST / SST Fasting required. Chlamydia Grp(Carcinoembryonic 6.5 ml/SST Antigen) Chloramphenicol (Chlormycetin) 10 ml/Plain Red Freeze serum ASAP. Cholesterol 5 ml/PST / SST Cholinesterase 6.5 ml/SST Cholinesterase, RBC 7 ml/Lavender Do not spin. Chromosome Analysis Child/Adult (Call Central Processing for requirements on 10 ml/SODIUM Heparin Do not spin or refrigerate. infants) Chromosome Analysis (Fragile X) 10 ml/Lavender Do not spin or refrigerate CK (CPK, Creatine Kinase) 5 ml/PST / SST 5 ml/PST / SST CKMB (CK Myocardial fraction)

21 Cl (Chloride) 5 ml/PST / SST Clonodine 10 ml/Plain red Clonopin(Klonopin, Clonazepam) 10 ml/Plain red Clorazepate(Tranxene) 10 ml/Plain red Cloxicillin 10 ml/Plain red 3 ml/LT Blue (4.5 ml/LT Coagulation tests (PT, PTT, fibrinogen) Blue preferred) CMV PCR(Quant) (Cytomegalovirus) 5 ml Lavender Freeze Plasma CMV, IgG/IgM 6.5 ml/SST Cocci AB 6.5 ml/SST Cocci Panel 6.5 ml/SST Cold Agglutinins 6.5 ml/SST Keep warm Clot for two hours, freeze Complement C 1Q 6.5 ml/plain red serum Freeze serum. Allow to Complement C3 6.5 ml/SST clot at room temperature Freeze serum. Allow to Complement C4 6.5 ml/SST clot at room temperature Clot 1hr @ Rm temp. Complement CH 50(Total) 10 ml/Plain red Freeze serum. Avoid hemolysis. Clot 1hr @ Rm temp. Complement CH 100 10 ml/Plain red Freeze serum. Avoid hemolysis. Coombs, Direct 7 ml/lavender Coombs, Indirect 7 ml/lavender 7 ml/Royal Blue (no Place serum in Trace-free Copper, Serum additive) aliquot tube Cortisol 5 ml/SST Coxsackie A9 or B AB 6.5 ml/SST Acute/Convalescent. CO2 (Bicarb) 5 ml/PST / SST Frozen serum. Fasting C-Peptide 6.5 ml/SST required. C-Reactive Protein 5 ml/PST / SST Freeze Serum; avoid Creatine 5 ml/SST hemolysis. Creatinine 5 ml/PST / SST Patient must be BB Cross-Match (Type and Cross) 7 ml/lavender banded. Store @ room temp 10 ml/red. Draw in pre Cryoglobulins (Quant & Qual) required. Clot one hour at warmed syringe. 37 degree C. Cryptococcus AB 6.5 ml/SST Serum; avoid hemolysis. Cryptococcus Ag 6.5 ml/SST

22 Cyanide 7 ml/green Room Temp. Cyclosporine 10 ml/lavender Do not spin. D-Dimer 3 ml or 4.5 ml/lt blue Deoxycortisol 10 ml/Plain red Depakene Depakote, Valproic Acid) 5 ml/PST / SST Desipramine(Norpramin) 10 ml/red No SST. DHEA -S (Dehydroepiandrosterone-SO4 6.5 ml/SST Freeze serum ASAP. or Sulfate) Diazepam (Valium) 10 ml/Plain Red Dibucaine 6 ml/SST Dicloxicillin 10 ml/red Differential (included in CBC w/Dif) 3 ml/lavender Digitoxin 10 ml/Plain Red Digoxin 5 ml/PST / SST Collect >5hr post dose. Dilantin(Phenytoin, PTN) 5 ml/PST / SST Diptheria AB 6.5 ml/SST Disopyramide(Norpace) 10 ml/Plain red DNA AB DS (Native) 6.5 ml/SST DNA AB SS 6.5 ml/SST Doxepin (Sinequan) 10 ml/Plain red 7 ml/gray and 10 ml/Plain Drug Screen Blood red EBV Panel (Ebstein-Barr Virus) 6.5 ml/SST Echinococcus AB 6.5 ml/SST Echovirus AB 6.5 ml/SST Elavil(Amitriptyline) 10 ml/Plain Red Electrolytes (Na, K, Cl, CO2) 5 ml/PST / SST Erythropoietin 6.5 ml/SST ESR (Erythrocyte Sedimentation Rate; 3 ml/lavender Sed Rate) Estradiol 5 ml/SST Estriol 5 ml/SST Estrogen, Fract 6.5 ml/SST Freeze serum ASAP. Estrogen, Total 6.5 ml/SST Estrone 6.5 ml/SST Freeze serum ASAP. Ethosuximide(Zarontin) 10 ml/red No SST. Ethyl Alcohol 5 ml/Gray Deliver to hospital within Factor Assays 4.5 ml/lt blue 30 min. on ice. Farmer's Lung Screen (Hypersensitivity 7 ml/SST Panel)

23 2 ml/Special Black top FDP with yellow label Febrile Agglutinins 10 ml/Plain red Ferritin 5 ml/PST / SST Fibrinogen 4.5 ml/lt blue Fifth's Disease (Parvovirus B19) 10 ml/Plain red Flecainide (Tambicor) 10 ml/Plain red Fluoride 10 ml/Plain red Fluoxetine (Prozac) 10 ml/Plain red Folate/Vitamine B12 5 ml/SST/PST Folic Acid 5 ml/PST / SST Obtain HCT before Folic RBC 7 ml/lavender freezing. Do not spin. Freeze whole blood. Francisella AB 10 ml/Plain red Free T3 5 ml/SST Free T4 (Free Thyroxine, FT4) 5 ml/PST / SST Fructosamine 5 ml/SST FSH (Follicle Stimulating Hormone) 5 ml/SST FSH/LH (Follicle Stimulating Hormone / 5 ml/SST Luteinizing Hormone) 2 ml/Special Black top FSP (Fibrin Split Products; FDP) with yellow label FTA AB (Fluorescent Treponemal 6.5 ml/SST Antibodies) Fungal Panel 6.5 ml/SST G-6-PD (Glucose-6-Phosphate 7 ml/lavender or green Do not spin. Dehydrogenase) Galactose-1-Phosphate Uridyltransferase 7 ml/green Do not spin. Gastrin 10 ml/red Freeze serum ASAP. Gentamicin (tr or pk) (Garamycin) 5 ml/PST / SST GGT (Gamma-Glutamyl Transferase) 5 ml/PST / SST Glomerular Basement 7 ml/SST Pre-chill EDTA tubes with Glucagon 7 ml/lavender aprotanin. Freeze plasma. Glucose (Blood sugar) 5 ml/SST / SST / Gray Consult PG 50 collect Glucose, PG 50(post 50 gms Glucola) 5 ml/SST / SST / Gray procedures Glucose, 2 hr PP 5 ml/SST / SST / Gray Collect 2 hrs post meal. Glucose Tolerance test (Specify 3,4,5,6 Consult GTT collection 5 ml/gray ea hour hr) (GTT) procedure Glycine 7 ml/green Freeze plasma. Glycohemoglobin (Glycosylated 7 ml/lavender Do not spin.

24 Hemaglobin A1C) Growth Hormone (HGH) 6.5 ml/SST Haemophilus Influenza Antigen 10 ml/red No SST. Protect from light Haloperidol (Haldol) 10 ml/red during clotting. Haptoglobin 10 ml/red HBSAg 5 ml/SST HCG (Qual or Quant) 5 ml/SST HCG (Tumor marker) 6.5 ml/SST Freeze serum. HCV RNA 10 ml/red Freeze serum. HDL(High Density Lipoprotein) 5 ml/PST / SST Fasting required. HDL/LDL 5 ml/PST / SST Fasting required. Heavy Metals (Quant) 7 ml/royal blue EDTA Do not spin. Helicobacter pylori Ab IgG 10 ml/Plain red Hematocrit (HCT; included in CBC) 3 ml/lavender Hematology tests (CBC, sed rate, retic 3 ml/lavender count) Hemogram (H & H) 3 ml/lavender Hemoglobin ELP 7 ml/lavender Do not spin. Hemophilus Influenza AB 10 ml/Plain red Hepatic Panel (Liver panel) 5 ml/PST / SST Hepatitis Evaluation (or any Hepatitis Must be drawn in 5 ml/SST all = 7 ml/SST testing) separate tube. Hepatitis C RNA/PCR 6.5 ml/SST Freeze ASAP. Herpes AB tests (HSV, Herpes Simplex) 10 ml/red Heterophile Absorp 6.5 ml/SST Hgb A1C (Hemoglobin A1C) 3 or 7 ml/lavender Do not spin. Hgb ELP (Hemoglobin Electrophoresis; 7 ml/lavender Do not spin. Hgb A, C, F, S) Hgb F (Fetal Hemoglobin) (Hemoglobin 7 ml/lavender Do not spin. A1C) HGH (Human Growth Hormone) 10 ml/red H & H (Hemoglobin & Hematocrit - order 3 ml/lavender a Hemogram) Pre-chill tube, Collect on Histamine 7 ml/ Lavender ice Freeze Histoplasma AB, CF 10 ml/red Histoplasma AB, ID 10 ml/red Histoplasma AB, LA 10 ml/red HIV (Human Immunodeficiency Virus) AB 7 ml/ SST -. HIV RNA (Viral Load) 7 ml/EDTA Freeze plasma ASAP. HLA A, B, C 2 x 10 ml/yellow (ACD - A) Room temp.

25 HLA B-27 10 ml/green Room temp. Hydroxyprogesterone 6.5 ml/SST Hypersensitivity Panl (Pneumonitis) 6.5 ml/SST Hypothyroid Profile (T4, TU, FTI, TSH) 5 ml/PST / SST Imipramine 10 ml/red No SST. Immunoglobulins (IgG, IgM, IgA, IgE, 3 ml/red each IgD) Immunoelectrophoresis 6.5 ml/SST . Inorganic Phosphate 5 ml/PST / SST Insulin 5 ml/SST Freeze serum ASAP. Do not draw within 48hrs Intrinsic Factor AB 5 ml/SST of B12 injection.Freeze serum 3 ml/green(not gel tube ) Ionized Calcium Deliver on ice ASAP. /Heparinized syringe Iron 5 ml/PST / SST LA (Lactic Acid) 5 ml/gray Deliver on ice ASAP Lactose 5 ml/gray Fasting required. LAP (Leucine Aminopeptidase) 5 ml/SST Freeze serum L.A.P. Exam (Leukocyte Alkaline 7 ml/NA Heparin Whole blood room temp. Phosphatase stain) LD (Lactate Dehydrogenase; LDH) 5 ml/PST / SST Avoid hemolysis. LD Isoenzyme (LD isos) 5 ml/SST . LDL (Calculated) (See HDL/LDL) 5 ml/PST / SST Fasting required. Lead 7 ml/royal blue EDTA Whole blood. Legionella AB 7 ml/SST Leptospira AB 7 ml/SST 7 ml/EDTA & 2 x 10 Leukemia/Lymphoma Panel Room temp. ml/NaHeparin Leukocyte Alkaline Phosphatase (stain) 7 ml/NA Heparin Whole blood room temp. (LAP Exam) LH (Luteinizing Hormone) 5 ml/SST LH/FSH (Luteinizing Hormone / Follicle 5 ml/SST Stimulating Hormone) Librium (Chlordiazepoxide) 10 ml/Plain red Freeze serum ASAP. Lidocaine(Xylocaine) 10 ml/Plain red Always STAT. Lipase 5 ml/PST / SST Lipid Profile / Panel (includes: 5 ml/PST / SST Fasting required. Cholesterol, Trig, HDL, LDL, Risk Ratios) Lithium 5 ml/SST Liver Function / Panel (ALB, ALK PHOS, 5 ml/PST / SST AST, ALT, T Bili, LD, T Prot) Ludiomil(Maprotiline) 10 ml/red No SST. Freeze serum

26 ASAP. Freeze plasma ASAP. Lupus Anticoagulant 4.5 ml/lt blue Double spin Lupus Panel 10 ml/red Lyme AB 10 ml/red

Lysozyme 7 ml/SST Magnesium 5 ml/PST / SST 7 ml/Royal blue (no Manganese Keep at room temp anticoagulant) Maprotiline (Ludiomil) 10 ml/Plain red Measles Virus AB (Rubeola Virus IgG) 7 ml/SST Meperidine (Demerol) 10 ml/Plain red Mephenytoin (Mesantoin) 10 ml/Plain red Meprobamate (Miltown) 10 ml/Plain red Mercury 7 ml/royal blue EDTA Keep at room temp. Metabolic Screen 20 - 50 ml urine Methaqualone (Quaalude) 10 ml/Plain red Metharbital (Gemonil) 10 ml/Plain red Methemalbumin 10 ml/red Separate serum ASAP. Methemoglobin 7 ml/green Deliver on ice. Methicillin 10 ml/red Protect from light. Freeze Methotrexate 10 ml/red serum ASAP. Methsuximide (Celontin, 10 ml/red No SST. Normethsuximide) Do not use alcohol prep Methyl Alcohol (Methanol) 5 ml/gray to prepare puncture. Metronidazole 10 ml/red MEVACOR Panel 10 ml/red Mexiletine 10 ml/red No SST. Mini Panel (Na, K, Cl, CO2, BUN, 5 ml/PST / SST Creatinine, Glucose) Mono Spot 5 ml/SST Morphine 10 ml/red Keep at room temp. Multiple Sclerosis Panel 10 ml/red & 6 ml/CSF Freeze ASAP. Mumps AB 10 ml/red Indicate if patient is Myasthenia Gravis Eval 7 ml/SST immunosuppressed. Mycoplasma Pneumo (AB / CF or IFA) 7 ml/SST Myelin AB 10 ml/red Myocardial AB 10 ml/red

27 Myoglobin 10 ml/red Mysoline(Primidone) 10 ml/Plain red Na (Sodium) 5 ml/PST / SST Nafcillin 10 ml/red NAPA (N-Acetyl Procainamide - see 5 ml/PST / SST Procainamide) Pre/post dose required; Nebcin (trough or peak) (Tobramycin) 5 ml/PST / SST consult schedule policy. Nembutal (Pentobarbital) 10 ml/Plain red Neomycin 10 ml/red 7 ml/royal blue (No Nickel Keep at room temp. anticoagulant) Nicotine 10 ml/Plain red Keep at room temp. Norfluoxetine 10 ml/red Normethsuximide 10 ml/Plain red Norpace (Disopyramide) 10 ml/Plain red Norpramin (Desipramine) 10 ml/red No SST.. Nortriptyline (Aventyl) 10 ml/red No SST. Novadex (Tamoxifen) 10 ml/red Nucleotidase, 5' 7 ml/SST O2 Saturation (Oxygen % Saturation) 2 ml/Heparinized syringe OB Profile (Includes: HBsAg, CBC, 3ml lavender & 2 6 ml

Rubella, RPR, ABORh, Antibody Screen) SST Osmolality, Serum 5 ml/PST / SST Osteocalcin 6.5 ml/SST Freeze serum ASAP. Oxacillin 10 ml/red Oxazepam (Serax) 10 ml/Plain red Keep at room temp Oxycodone 10 ml/Plain red keep at room temp Pamelor (Nortriptyline) 10 ml/red Pancreatic Islet Cell AB 10 ml/red Pancreatic Polypeptide 6.5 ml/SST Freeze plasma. PAP (Prostatic Acid Phosphatase) 5 ml/SST Freeze serum ASAP Parainfluenza Virus AB (Types 1-4) 10 ml/red Recommend acute/conv. Parathyroid Hormone () 10 ml/red Freeze serum ASAP. Parietal Cell AB 6.5 ml/rSST Draw a red top tube 1st. Partial Thromboplastin Time (PTT, APTT) 3 ml/lt blue Deliver to lab ASAP. Parvovirus AB 6.5 ml/SST No longer done buy the Paternity Testing (Parentage testing - lab. Refer to DNA only) SART/Forensic Dept. pCO2-Arterial 2 ml/Heparinized syringe

28 Pemoline 10 ml/red Pemphigus/Pemphigoid 10 ml/red Penicillin 10 ml/red Pentobarbital (Nembutal) 10 ml/red No SST.Send out STAT Collect specimen 1 hr. PG 50 5 ml/SST post 50 gms glucola. pH-Arterial 2 ml/Heparinized syringe pH-Venous 7 ml/green Phencyclidine (PCP) 10 ml/red No SST. Room Temp. Phenelizine (Nardil) 10 ml/red Phenobarbital (Luminal) 6 ml/red ONLY No SST. Phensuximide 10 ml/red No SST. Room Temp. Phenylalanine (NOT "PKU Newborn 5 ml/green Freeze plasma ASAP. Screening") Phenytoin (Dilantin; Diphenylhydantoin) 6 ml/PST / SST Phosphorus (PO4) 6 ml/PST / SST Phospholipids 6.5 ml/SST Fasting required. Phospholipid Antibody (cardiolipin 5 ml/SST antibody) Piperacillin 10 ml/red PKU (skin puncture) (Phenylketonuria - Fill 5 circles on special

"Newborn Screening") filter paper. Placidyl (Ethylchlorvynol) 10 ml/Plain red Keep at room temp. Double spin. Freeze Plasminogen Activity 4.5 ml/LT blue plasma ASAP. Double spin. Freeze Plasminogen Antigen 4.5 ml/LT blue plasma ASAP. Platelet Circulating AB 10 ml/red Anti-Platelet AB 10 ml/Plain red Freeze serum Platelet IgG Assoc AB (Direct) 10 ml/lavender Keep at room temp. Platelet count (PLT; included in CBC and 3 ml/lavender Hemogram) Check with CP section for Platelet Aggregation special testing requirements. Pneumococcal AB 6.5 ml/SST Collect pre/post inject. pO2-Arterial 2 ml/Heparinized syringe Poliomyelitis Eval(Poliovirus Types 1, 2, 6.5 ml/SST 3 AB) 7 ml/Royal blue no Do not spin. Protect from Porphyrins RBC additivis light. Potassium (K+) 5 ml/PST / SST Avoid hemolysis. Prealbumin 5 ml/PST / SST

29 Pregnancy (Qual) 5 ml/SST Prenatal HbsAg 5 ml/SST Primidone (Mysoline) 10 ml/Plain red Procainamide (Pronestyl; includes 5 ml/PST / SST NAPA) Progesterone 10 ml/red ProInsulin 7 ml/SST Freeze serum Prolactin 5 ml/red Propafenone 10 ml/red Propoxyphene (Darvon) 10 ml/Plain red Keep at room temp. Propranolol (Inderol) 10 ml/Plain red Prostate Specific Antigen (PSA) 5 ml/SST Prostatic Acid Phosphatase 5 ml/SST Freeze serum ASAP Double spin. Freeze Protein C 4.5 ml/ LT blue plasma ASAP. Protein ELP 5 ml/ SSt Double spin. Freeze Protein S 5 ml/ LT blue plasma ASAP. Protein, Total 5 ml/PST / SST Prothrombin Time (PT; Protime) 3 ml/ LT blue Deliver to lab ASAP. 7 ml/Royal blue no Protoporphyrins (Free Erythrocyte; FEP) Do not spin. additive Protoporphyrins (Zinc, ZPP) 7 ml/Royal Blue EDTA Do not spin. Protriptyline (Vivactil) 10 ml/red No SST. Prozac 10 ml/Plain red PSA (Prostate Specific Antigen) 5 ml/SST Pseudocholinesterase 6 ml/SST Psittacosis AB (Chlamydia Trachomatis 10 ml/red IgG AB) PTH 6.5 ml/SST Freeze serum ASAP. Protect from light. Freeze Pyridoxal Phosphate (Vitamin B-6) 7 ml/lavender plasma ASAP. Pre-chill tube. Special Pyruvate 7 ml/green instructions with pyruvate tube Pyruvate Kinase (Erythrocytes) 10 ml/lavander Do not spin Q-Fever AB (Coxiella Burnetti, Phase I/II) 6.5 ml/SSt Quaalude (Methaqualone) 10 ml/Plain red Keep at room temp. Quinidine 5 ml/Plain red RF (Rheumatoid Arthritis) 5 ml/PST / SST Raji Cell Assay (Circulating Immune 6.5 ml/SST Freeze serum ASAP. Complex)

30 Rapid Plasma Reagin (RPR) 5 ml/SST RAST Allergens 1 ml/red per ANTIGEN Make sure to specify RAST Panel 7 ml/red which Allergy Panel is ordered. RBC Count (Red Blood Count; included 3 ml/lavender in CBC & Hemogram) Obtain HCT. Freeze RBC Folate 7 ml/lavender whole blood Consult Send-Out RBC Fragility Department prior to collection. Renal Panel (Na, K, Cl, CO2, Glucose, 5 ml/SST Creat, Uric Acid, Calcium, Phos) Freeze plasma ASAP. Patient must be upright or Renin Activity 7 ml/lavender standing for at least 2 hours prior to draw. Respiratory Syncytial Virus AB (RSV) 6.5 ml/SST Respiratory Virus 6.5 ml/SST Reticulin AB 6.5 ml/SST Reticulocyte Count (Retic) 3 ml/lavender Rickettsial IgG AB (Rocky Mountain 6.5 ml/SST Spotted Fever / Murine Typhus AB) Freeze serum. Draw 1-3 Ritalin 10 ml/Plain red hours post dosage Double spin. Freeze Ristocetin Cofactor 4.5 ml/ LT blue plasma ASAP. RPR (Rapid Plasma Reagin) 5 ml/SST Rubella AB (IgG, or IgM) 5 ml/ SST Rubeola AB IgG (Measles) 5 ml/ SST Salicylate 5 ml/PST / SST Salmonella Agglutin (Febrile Agglutinins) 10 ml/Plain Red Scleroderma AB (SCL-70) 6.5 ml/SST Secobarbital (Seconal) 10 ml/red No SST. Sedimentation Rate (Sed Rate; ESR) 3 ml/lavender 7 ml/royal blue (No Selenium anticoagulant) Room Temperature

Place on ice. Transfer to Serotonin 3 ml/ Lavender special tube and freeze. Sex Hormone Binding Globulin 5 ml/SST SGOT (AST) 5 ml/PST / SST SGPT (ALT) 5 ml/PST / SST Sickle Cell 3 ml/lavender Sjogrens AB (SS-A & SS-B) 5 ml/PST / SST Skeletal Muscle AB 10 ml/red Skin AB (Pemphigus/Pemphigoid AB) 10 ml/Plain red Smooth Muscle AB 7 ml/SST SM RNP (Anti ENA) 7 ml/SST Sodium (Na+) 5 ml/PST / SST 10 ml/Plain red or seminal Sperm AB Panel fluid 10 ml/Plain red or seminal Sperm AB (IgG, IgM, IgA) fluid SSA (RO)(ENA)AB 5 ml/SST SSB (LA)(ENA) AB 5 ml/SST Strep B Antigens 10 ml/red Streptomycin 10 ml/red Streptozyme 6.5 ml/SST Striated Muscle AB 6.5 ml/SST Whole blood. See Sulfhemoglobin 7 ml/lavender procedure. Sulfonamides 7 ml/lavender Tambicor (Flecainide) 10 ml/Plain red Tamoxifen (Novadex) 10 ml/red T-3, Free 5 ml/SST T-3, Total 5 ml/SST T-3, Uptake 5 ml/PST /SST T-4, Free (FT4, Free Thyroxine) 5 ml/PST / SST T-4, Total (Thyroxine) 5 ml/PST / SST TBG (Thyroxine Binding Globulin) 6.5 ml/SST Freeze serum Tegretol (Carbamazepine) 5 ml/PST / SST Teichoic Acid AB 7 ml/SST TdT - Terminal Deoxynucleotidyl 7 ml/sodium heperin Check with Send-Outs Transferase Thyroxine Binding Globulin 5 ml/SST Freeze serum ASAP. Theophylline (Aminophylline) 5 ml/PST /SST Document time last dose. Protect from light. Freeze Thiamine (Vitamin B-1) 7 ml/green plasma.

32 Thiocyanate 10 ml/Plain red No SST. Protect from Thioridazine (Mellaril) 10 ml/red light. Freeze serum. Thiothixene (Navane) 10 ml/red No SST. Freeze serum. Thorazine (Chlorpromazine) 10 ml/red No SST. Thyroglobulin 6.5 ml/SST Thyroglobulin AB 6.5 ml/SST Thyroid Auto AB 6.5 ml/SST Thyroid Microsomal AB 6.5 ml/SST Thyroid Stimulating Hormone 5 ml/PST / SST Thyroxine (T4) 5 ml/PST / SST TIBC (Total Iron Binding Capacity) 5 ml/PST / SST Tissue AB Screen 10 ml/red Peak/trough collection; Tobramycin (Nebcin) 5 ml/PST / SST consult policy. Tocainide (Tonocard) 10 ml/Plain red Protect from light. 2 hr fast Tocopherol (Vitamin E) 6.5 ml/SST required Tofranil (Imipramine) 10 ml/red No SST. Torch Panel (Toxoplasma, Rubella, 6.5 ml/SST Cytomegalovirus, Herpes) Total Bilirubin 5 ml/PST / SST Avoid hemolysis. Total Iron Binding Capacity (TIBC) 5 ml/PST / SST Total Protein 5 ml/PST / SST Toxoplasma AB (IgG, IgM) 6.5 ml/SST Transferrin 5 ml/PST / SST Tranxene (Clorazepate) 10 ml/Plain red Trazodone (Desyrel) 10 ml/Plain red Treponema Pallidium AB by MHA 6.5 ml/SST Triavil (Amitriptyline) 10 ml/Plain red Triazolam (Halcion) 6.5 ml/SST Keep at room temp. Trichinella AB (IgG, IgM) 6.5 ml/SST Tricyclics Screen 10 ml/Plain red Triglycerides 5 ml/PST / SST Fasting required. Triiodothyronine (T-3) Reverse Free or 5 ml/SST Freeze serum. Total Trimipramine (Surmontil) 10 ml/Plain red keep at room temp. Troponin 5 ml/PST / SST Trypsin 7 ml/SST Freeze serum ASAP. 7 ml/Plain red Tryptophan Freeze serum ASAP.

33 TSH 5 ml/PST / SST Tularemia Antibody 6.5 ml/SSt Avoid hemolysis. Tumor Markers (Dianon) Breast 5 ml/SST Freeze serum ASAP. CA 15-3 5 ml/SST Freeze serum ASAP. CA 19-9 5 ml/SST Freeze serum ASAP. HCG 5 ml/SST Freeze serum ASAP. LASA-P 5 ml/SST Freeze serum ASAP. Leukemia/Lymphoma 5 ml/SST Melanoma 5 ml/SST Freeze serum ASAP. Ovary 5 ml/SST Freeze serum ASAP. Prostate 5 ml/SST Freeze serum ASAP. Uterus 5 ml/SST Freeze serum ASAP. Tylenol (Acetaminophen) 5 ml/PST / SST Typhus (Murine) AB 6.5 ml/SST Urea Nitrogen (BUN) 5 ml/PST / SST Uric Acid 5 ml/PST / SST Urinalysis 1 ml/urine (minimum) Urine Culture 1 ml/urine (minimum) Uroporphyrinogen-1 Synthatase (U1S) 3 ml/lavender Do not spin. Whole blood Valium (Diazepam) 10 ml/Plain red Valproic Acid (Depakene; Depakote) 5 ml/PST / SST Peak/trough collection; consult policy; contact Vancomycin (Vancocin) 5 ml/PST / SST nursing staff prior to collection. VAP 5 ml/SST Varicella-Zoster Virus (VZV) AB 5 ml/SST Contact central processing Vasoactive Intestinal Polypeptide (VIP) special tubes. Vasopressin (ADH; Antidiuretic 7 ml/lavender Critical frozen Hormone) VDRL (RPR) 5 ml/Plain red Velbatol 10 ml/Plain red Verapamil (Isoptin; Calan) 10 ml/Plain red Viscosity 10 ml/red 12 hr fast required. Protect Vitamin A (Retinoids) 7 ml/SST from light.during collection and transport Freeze plasma ASAP. Vitamin B6 (Pyridoxol) 7 ml/lavender Protect from light.during collection and transport

34 Vitamin B12 5 ml/PST / SST Vitamin B12/Folate 5 ml/PST / SST Protect from light. Freeze Vitamin C (Ascorbic Acid) 10 ml/Green plasma. Special Handling Vitamin D (2 kinds: Vit D 25 DH and Vit D 6.5 ml/SST 1,25) 12 hr fast required. Freeze Vitamin E (A, B & Gamma Tocopherol) 10 ml/green serum ASAP. Protect from light. Vivactil (Protriptyline) 10 ml/red No SST. Double Spin. Freeze Von Willebrand Factor Antigen 4.5 ml/lt blue Plasma Double Spin. Freeze Von Willebrand Multimeric Analysis 4.5 ml/lt blue Plasma Double Spin. Freeze Von Willebrand Panel 2 X 4.5 ml/lt blue Plasma WBC (White Blood Count: included in 3 ml/lavender CBC & Hemogram)

Western Blot (in conjunction with HIV) 10 ml/red Xylocaine (Lidocaine) 10 ml/Plain red See procedure regarding Xylose Absorption 5 ml/gray & 5 hr urine scheduling and admin of D-xylose. Yersinia 10 ml/red Zarontin (Ethosuximide) 10 ml/red No SST. 7 ml/royal blue No Zinc Serum Keep at room temp additive Zinc Protoporphyrin (ZPP) 7 ml/royal blue EDTA Protect from light Zoloft 10 ml/Plain red

35 Critical Values Chemistry:

Test Range Units Nursing Comments Alcohol >350 mg/dl Bili, Indirect >20.0 mg/dl Bili, total (thru 3 months) >15.0 mg/dl Calcium < 6.0 or > 13.5 mg/dl

CO2 < 10 or > 50 mmol/L <40- Per Standardized Procedure Glucose < 40 or > 500 mg/dl >500- Call if treatment have not been initiated.

<30- Per Standardized Procedure Glucose NB (newborn) < 30 or > 300 mg/dl >300- Call if treatment have not been initiated Call if treatment orders have not been Ionized CA < 0.9 or > 1.4 mmol/L initiated Magnesium <1.0 mg/dl >6.9 mg/dl Phosphorus < 1.0 or > 12.5 mg/dl Follow protocol on Section E for procedure POCT Glucose < 40 or > 400 mg/dl “Accu-chek Inform Blood Glucose System"

Potassium < 2.8 or > 6.2 mmol/L Sodium < 120 or >160 mmol/L 1st time result only

36 Therapeutic Drugs:

Drug Level Range Units Nursing comments Acetaminophen >30 mcg/mL Carbamezepine >15 mcg/mL Prior to next dose ng/mL In the presence of cardiac instability or prior Digoxin >2.2 to next dose Gentamicin Pk >25 mcg/mL Gentamicin Tr >2 mcg/mL Lithium >1.5 mmol/L NAPA >10 mcg/dL Phenobarbital >50 mcg/mL Prior to next dose Phenytoin (Dilantin) >25 mcg/mL Proc + NAPA >30 mcg/dL Procainamide >12 mcg/dL Salicylates >30 mg/dL mcg/dL STAT if continuous infusion or prior to next Theophylline >20 dose Tobramycin Pk >25 mcg/dL Tobramycin Tr >2 mcg/dL Valproic Acid >200 mcg/dL Prior to next dose Vancomycin, Pk. >50 mcg/dL Vancomycin, Tr. >25 mcg/dL

37 Blood Gases:

Test Range Units Nursing Comments Carboxy hemoglobin > 10 %

HCO3 <10 or >50 mmol/L

HCO3 <1 month old <12 or >40 mmol/L Oxygen saturation <86 % Call only with complete ABG result and pH pCO >60 mm HG 2 less than 7.25 t pCO2 <1 month old < 20 or > 60 mm HG < 7.20 or pH > 7.60 pH <1 month old < 7.25 or > 7.60 pO2 < 50 mm HG pO2 <1 month old < 45 or >200 mm HG

Hematology:

Nursing Test Range Units Comments

Blasts -to include suspect blast-like cells counted in "other" 10% or category % 1st time result only more -applies ONLY on new patients with no history of leukemia

Gran ABS <0.6 x 1000/mm3 < 19.8 or Hct (pediatric) % >64 < 19.8 or Hematocrit % >70 < 6.6 or Hemoglobin g/dl >23 WBC <1.0 x 1000/mm3 1st time result only

38 Coagulation

Nursing Test Range Units Comments

INR > 4.0 If no orders to correct < 20 or > Platelets x 1000/mm3 1st time result only 1000 PT > 35 sec PTT > 150 sec If pre-printed heparin orders not initiated

Microbiology Test Range Comments Malaria smears Any positive Blood Culture Any positive CSF Gram Stain or culture Any positive Gram Stain on any Sterile Body fluid Any positive CSF Latex Antigens Any positive India Ink Any positive Gram stain or culture on visceral organs (ex. lung, liver or brain), tissues, abscesses and Any positive aspirates

Critical Tests The list below is not exclusive and may be updated as more tests and conditions are identified. Critical Tests List Range Comments Lab calls doctors' offices prior to surgery. Any abnormal All abnormal pre-op tests Lab staff see procedure 3220 tests Pre-Admit & Pre-Surgical Review for abnormal test results. Call immediately. If after hours, All confirmed for outpatients (Outreach) HIV tests positive call first thing next business day. Ketones or Clinitest in a newborn Any positive

39 Stat Tests: Orderable Section Subsection STAT FACILITY ABORh Blood Bank STAT Acetaminophen Level General Lab Chemistry STAT Acetone General Lab Chemistry STAT Albumin Level Blood General Lab Chemistry STAT Alcohol Level Blood General Lab Chemistry STAT Alkaline Phosphatase General Lab Chemistry STAT ALT General Lab Chemistry STAT Ammonia Level General Lab Chemistry STAT Amylase Blood General Lab Chemistry STAT Antibody Screen Blood Bank STAT AST General Lab Chemistry STAT Bilirubin Direct General Lab Chemistry STAT Bilirubin Indirect General Lab Chemistry STAT Bilirubin Total General Lab Chemistry STAT Blood Gas Arterial General Lab Chemistry STAT Blood Gas Arterial Cord General Lab Chemistry STAT Blood Gas Capillary General Lab Chemistry STAT Blood Gas Venous General Lab Chemistry STAT Blood Gas Venous Cord General Lab Chemistry STAT BMP-Mini Panel General Lab Chemistry STAT BNP General Lab Chemistry STAT Body Fluid Albumin General Lab Chemistry STAT Body Fluid Amylase General Lab Chemistry STAT Body Fluid Cell Count General Lab Hematology STAT Body Fluid Chloride Level General Lab Chemistry STAT Body Fluid Creatinine General Lab Chemistry STAT Body Fluid Crystal Exam General Lab Hematology STAT Body Fluid Glucose General Lab Chemistry STAT Body Fluid LD General Lab Chemistry STAT Body Fluid Osmolality General Lab Chemistry STAT Body Fluid pH General Lab Chemistry STAT Body Fluid Potassium Level General Lab Chemistry STAT Body Fluid Protein General Lab Chemistry STAT Body Fluid Sodium Level General Lab Chemistry STAT Body Fluid Specific Gravity General Lab Hematology STAT BUN General Lab Chemistry STAT Calcium Level Blood General Lab Chemistry STAT Calcium Level Ionized General Lab Chemistry STAT Carbamazepine Level General Lab Chemistry STAT Carbon Dioxide Blood General Lab Chemistry STAT Carboxyhemoglobin Blood General Lab Chemistry STAT CBC General Lab Hematology STAT CBC w/ Differential General Lab Hematology STAT Chem Panel General Lab Chemistry STAT Chloride Level Blood General Lab Chemistry STAT CK General Lab Chemistry STAT

40 CKMB General Lab Chemistry STAT Clost difficile tox A/B Ag by EIA Micro STAT PMC Cooximetry General Lab Chemistry STAT Creatinine Blood General Lab Chemistry STAT CSF Cell Count General Lab Hematology STAT CSF Chloride Level General Lab Chemistry STAT CSF Glucose General Lab Chemistry STAT CSF Lactic Acid General Lab Chemistry STAT CSF LD General Lab Chemistry STAT CSF Protein General Lab Chemistry STAT D-Dimer General Lab Coagulation STAT Digoxin Level General Lab Chemistry STAT Du test Blood Bank STAT Electrolyte Panel General Lab Chemistry STAT Eosinophil Count Total General Lab Hematology STAT Estradiol Level General Lab Chemistry STAT POM Fibrin Degradation Products General Lab Coagulation STAT Fibrinogen General Lab Coagulation STAT Fibronectin General Lab Chemistry STAT FSH General Lab Chemistry STATPOM Gentamicin Level Peak General Lab Chemistry STAT Gentamicin Level Random General Lab Chemistry STAT Gentamicin Level Trough General Lab Chemistry STAT GGT General Lab Chemistry STAT Glucose Blood General Lab Chemistry STAT Gram Stain Micro STAT HCG Qualitative General Lab Hematology STAT HCG Quantitative General Lab Chemistry STAT Hepatitis B Surface Antigen General Lab Chemistry STAT POM HIV Rapid 1 & 2 General Lab Chemistry STAT India Ink Micro STAT PMC Influenza A Virus EIA Micro STAT Influenza B Virus EIA Micro STAT Iron Level General Lab Chemistry STAT KOH Micro STAT Lactic Acid Blood General Lab Chemistry STAT LD Blood General Lab Chemistry STAT LH General Lab Chemistry STATPOM Lipase Level General Lab Chemistry STAT Lithium Level General Lab Chemistry STAT PMC Liver Panel General Lab Chemistry STAT Magnesium Level Blood General Lab Chemistry STAT Malaria Smear General Lab Hematology STAT PMC Methemoglobin General Lab Chemistry STAT Mono Screen General Lab Serology STAT Osmolality Blood General Lab Chemistry STAT Ova and Parasites (Direct Mount Only) Micro STAT PMC pH Blood Venous General Lab Chemistry STAT

41 Phenobarbital Level General Lab Chemistry STAT Phenytoin Level General Lab Chemistry STAT Phosphorus Level Blood General Lab Chemistry STAT Platelet Count Automated General Lab Hematology STAT Platelet Function Aspirin General Lab Coagulation STAT PMC Platelet Function Epinephrine General Lab Coagulation STAT Platelet Function P2Y12 (Plavix Inhibiti General Lab Coagulation STATPMC Potassium Level Blood General Lab Chemistry STAT Procainamide Level General Lab Chemistry STAT Progesterone Level General Lab Chemistry STAT POM Prolactin Level General Lab Chemistry STAT POM Protein Blood Total General Lab Chemistry STAT Protime General Lab Coagulation STAT PTT General Lab Coagulation STAT Renal Panel General Lab Chemistry STAT Respiratory Syncytial Virus by EIA Micro STAT Retic Count General Lab Hematology STAT Rh Typing Blood Bank STAT Rhogam Workup Blood Bank STAT Rotavirus by EIA Micro STAT PMC Salicylate Level General Lab Chemistry STAT Sed Rate General Lab Hematology STAT Sickle Cell Screen General Lab Hematology STAT PMC Sodium Level Blood General Lab Chemistry STAT Strep Gr A Rapid Immunoassay Micro STAT Testosterone Level General Lab Chemistry STAT POM Theophylline Level General Lab Chemistry STAT Tobramycin Level Peak General Lab Chemistry STAT Tobramycin Level Random General Lab Chemistry STAT Tobramycin Level Trough General Lab Chemistry STAT Troponin I General Lab Chemistry STAT TSH General Lab Chemistry STAT IP only Type and Cross Blood Bank STAT Type and Screen Blood Bank STAT Uric Acid Blood General Lab Chemistry STAT Urinalysis Screen Dipstick General Lab Urinalysis STAT Urinalysis Sedimentation Microscopic General Lab Urinalysis STAT Urine Drug Screen (In House Test) General Lab Chemistry STAT Valproic Acid Level General Lab Chemistry STAT Vancomycin Level Peak General Lab Chemistry STAT Vancomycin Level Random General Lab Chemistry STAT Vancomycin Level Trough General Lab Chemistry STAT WBC Smear Micro STAT Wet Mount Micro STAT I.