University Hospital Limerick Laboratory User Manual, Edition 13

University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

UNIVERSITY HOSPITAL LIMERICK LABORATORY USER MANUAL

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Page 1 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

0 Amendment Table ...... 16 1 Foreword ...... 18 2 UL Hospitals Mission Statement ...... 19 3 UL Hospitals Statement of Vision ...... 19 4 UL Hospitals Statement of Values ...... 19 5 Quality Assurance ...... 19 6 The Quality Policy ...... 20 6.1. Quality Policy of the Department of Pathology of the UL Hospitals (Edition 11) ...... 20 6.2. Quality Policy of the Blood Transfusion department, UL Hospitals Edition 07 ...... 21 7 General Information ...... 22 7.1. Contact Details of Key Members of Pathology ...... 22 7.2. Laboratory Telephone Extension Numbers ...... 25 7.3. Hours of Operation of Pathology UHL ...... 26 7.4. ‘On-Call’ Service UHL ...... 26 7.5. Hours of Operation of Mortuary / Post Mortem (Autopsy) Services ...... 29 7.6. Out of Hours Contact Numbers for the Mortuary...... 29 7.7. Hours of Operation of Pathology Ennis Hospital ...... 29 7.8. Hours of Operation of Pathology Nenagh Hospital ...... 29 7.9. Hours of Operation of Pathology St. John’s Hospital ...... 30 8 Definitions and Abbreviations ...... 30 9 Location of the Laboratory UHL ...... 31 10 Access To Pathology Laboratory UHL ...... 31 11 Location of the Mortuary ...... 31 12 Location of Laboratory Ennis Hospital ...... 31 13 Location of Laboratory Nenagh Hospital ...... 31 14 UL Hospitals Pathology Policy on Request Form Completion and Specimen Labelling in the Acute Setting (Edition 07) ...... 32 15 UL Hospitals Pathology Policy on Request Form Completion and Specimen Labelling in the Community Setting (Edition 07) ...... 33 16 Terms and Conditions for Requesting Tests ...... 34 17 The Clinical Laboratory Sample Test Cycle ...... 35 18 Specimen Collection ...... 35 18.1. Blood Collection ...... 35 18.2. Order of Draw of Samples ...... 36 18.3. UL Hospitals Pathology Services Sarstedt S-Monovette Guide Order of Draw ...... 36 18.4. Specimen Tubes to Be Used For Collecting Blood ...... 36 18.5. Instructions for the S-Monovette System ...... 39 18.6. Guide for Handling Blood Specimens Following Collection ...... 41 18.7. Quantiferon TB Gold Tubes ...... 41 18.8. Collection of Urine / Faeces Specimens ...... 42 18.9. Instructions for completion of 24 hour urine collections ...... 42 18.10. Swabs for Microbiology and Virology Investigations ...... 43 18.11. Blood Culture Bottles ...... 44 18.12. Recommended containers for sampling for AFB/Mycobacterial testing and Bronchial Washings .... 45 18.13. Procedure for collecting Nasopharyngeal Swabs (NPS) for Respiratory Viruses ...... 46 18.14. Specimen Containers for Histology Specimens ...... 47 18.15. Collection, Handling and Storage of Histology Specimens ...... 47 18.16. Labelling of Histology Specimens ...... 48 18.17. Handling of Specimens ...... 49 18.18. Safe Disposal of Materials used in Specimen Collection ...... 49 19 Additional Examination Requests ...... 49 20 Repeat Testing Interval ...... 49 21 Patient Collected Specimens...... 49 22 Handling of samples post collection ...... 49 23 Ordering of Laboratory Supplies UHL ...... 49 24 Ordering of Laboratory Supplies Ennis Hospital ...... 50 25 Ordering of Laboratory Supplies St. Johns Hospital ...... 50 26 Delivery of Biological Specimens to Pathology UHL ...... 50 26.1. Delivery of Biological Specimens within UHL ...... 51

Page 2 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

26.2. Instructions on Use of the Pneumatic Chute System ...... 51 26.3. Delivery of Biological Specimens from GP Surgeries / ‘Off Site’ Hospitals and Clinics ...... 51 26.4. Transport System for scheduled routine collections ...... 53 26.5. Delivery of emergency samples / one off samples ...... 54 26.6. Emergency Response in the Case of an accident or leakage from the package...... 54 26.6.1. Formalin Spill ...... 54 26.6.2. Biological Hazard ...... 54 27 Delivery of Biological Specimens to Pathology Ennis Hospital ...... 54 28 Delivery of Biological Specimens to Pathology St. Johns Hospital...... 54 29 Reporting Of Laboratory Results ...... 55 30 Laboratory Reports to General Practitioners (GPs) ...... 55 31 Referral Laboratory Reports ...... 55 32 Policy of Faxing Results ...... 55 33 Healthlink ...... 56 34 Reports Received in Error ...... 56 35 Contact for Clinical Advice and Interpretation ...... 56 36 Post Mortem / Autopsy Service ...... 56 36.1. Post Mortem Reports ...... 56 36.2. Forensic Post Mortems ...... 56 37 Pathology Service Users ...... 57 38 User Satisfaction, Comments and Complaints ...... 57 39 Data Protection ...... 57 40 Consent ...... 57 41 Scope of Service Provision ...... 57 42 Biochemistry Service ...... 57 42.1. Summary of Blood Specimen Volume Requirements Biochemistry ...... 58 42.2. Test Profiles Biochemistry ...... 58 42.3. Reference Values Biochemistry ...... 59 43 Haematology Service ...... 59 43.1. Reference Intervals Haematology ...... 59 43.2. Coagulation specimen requirements ...... 59 44 Histology Service ...... 60 44.1. Overview of Services ...... 60 44.2. Critical Alert Results Histology ...... 60 44.3. Additional Requests Histology Specimens ...... 60 44.4. Referral Tests Histology ...... 60 44.5. Quality Assurance Histology ...... 60 44.6. Histology Reports ...... 61 45 Microbiology Laboratory ...... 61 45.1. Clinical Medical Microbiology Advice ...... 61 46 Serology / Immunology Laboratory ...... 61 46.1. Clinical advice and Interpretation Serology: ...... 62 46.2. Urgent Requests Serology ...... 62 46.3. Requests for Additional Tests Serology ...... 62 46.4. Consent Forms Serology Investigations ...... 62 46.5. Blood specimen volume requirements Serology ...... 62 47 Pathology Ennis ...... 63 48 Pathology Nenagh ...... 63 49 Scope of Service Blood Transfusion including test repertoire ...... 63 49.1. Background information Blood Transfusion ...... 63 49.2. Test Repertoire Blood Transfusion ...... 64 49.3. Sample and request form requirements Blood Transfusion ...... 64 49.4. Test Requirements Blood Transfusion: ...... 65 49.5. Transfusion laboratory request options: ...... 68 49.6. Blood Component issue: ...... 70 49.7. Blood Product Issue: ...... 70 50 iLAB (Laboratory Information System – Formerly APEX)...... 71 50.1. Logging on to the iLAB system from a PC ...... 72 50.2. Changing your password ...... 72 50.3. Looking up patient results using Ward Enquiry (WRNQ) ...... 72

Page 3 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

50.4. Results Screen Display ...... 77 50.5. Screen Printing ...... 79 50.6. Location Enquiry (LENQ) ...... 79 50.7. iLAB FAQs ...... 80 51 Test Repertoire ...... 81 A ...... 81 ABG (arterial blood gas analysis) ...... 81 Acanthamoeba ...... 81 ACE (Angiotensin Converting Enzyme) ...... 81 Acetaminophen (Paracetamol) ...... 81 Acetylcholine Receptor Antibodies ...... 82 Acid phosphatase ...... 82 ACTH (Adrenocorticotrophic hormone) ...... 82 Activated Protein C Resistance (APC-R) ...... 82 Acylcarnitine ...... 82 Adenovirus Stools ...... 82 Adenovirus Antibodies ...... 83 Adrenal Antibodies ...... 83 Adverse (Anaphylactoid) Reactions to Intravenous Drugs: Plasma Tryptase Assay ...... 83 AFP (Alpha–fetoprotein) ...... 84 ALA (delta aminolevulinic acid; aminolevulinic acid) ...... 84 Albumin ...... 84 Albumin Blood Product ...... 84 Alcohol (ethanol) ...... 84 Aldosterone ...... 85 Alkaline phosphatase ...... 85 Alkaline phosphatase isoenzymes ...... 85 Alpha-1-acid glycoprotein (orosomucoid) ...... 85 Alpha-1-antitrypsin ...... 85 Alpha-1-antitrypsin phenotyping ...... 85 ALT (Alanine aminotransferase) ...... 86 Aluminium ...... 86 Amikacin Assay ...... 86 Amino acids ...... 86 Amiodarone ...... 86 Ammonia ...... 86 Amniotic Fluid PCR (Prenatal Screen) ...... 87 Amoeba Antibodies ...... 87 Amphetamines ...... 87 Amylase ...... 87 Amyloid A protein...... 87 ANA (Antinuclear Antibodies) / Autoantibodies ...... 88 ANCA (p-ANCA/c-ANCA) Anti-Neutrophil Cytoplasmic Antibody ...... 88 Androgen profile (female patients) ...... 88 Androstenedione ...... 89 Antenatal group and antibody screen ...... 89 Antenatal antibody titration ...... 89 Antenatal anti-D quantitation ...... 89 Antenatal anti-c quantitation ...... 89 Anti Mullerian Hormone (AMH) ...... 89 Antibiotic Assay ...... 89 Antibody identification ...... 90 Antibody investigation referrals to reference laboratory ...... 91 Anti-D ...... 91 Anti-Factor Xa Level (Low molecular weight (LMWH) Heparin only) ...... 91 Anti-HBsAg /Hepatitis B Vaccine Immunity screen ...... 91 Antithrombin III (ATIII) ...... 91 Apolipoprotein E phenotype ...... 92 APTT (Activated Partial Thromboplastin Time) ...... 92 Arterial blood gas analysis (ABG) ...... 92 ASOT (Anti-Streptolysin O Titre) ...... 92

Page 4 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Aspergillus Antigen (Galactomannan Test & PCR) ...... 93 Aspergillus Precipitins ...... 93 AST (Asparate aminotransferase) ...... 93 Astrovirus (Stools) ...... 93 Serology ...... 93 Atypical Pneumonia Screen ...... 93 Avian Precipitins ...... 93 Azathioprine (for patients about to commence azathioprine, Imuran®, therapy) ...... 94 B ...... 94 B12 ...... 94 B2-microglobulin (beta-2-microglobulin) ...... 95 Barbiturates (Semi Quantitative) ...... 95 Bartonella Antibodies (Cat Scratch Disease) ...... 95 Bence Jones Protein ...... 95 Benzodiazepine (semi-quantitative, serum) ...... 95 Benzodiazepine (semi-quantitative, urine)...... 96 Beta-hydroxy butyrate ...... 96 Beta-2-microglobulin ...... 96 Beta 2 transferrin (Tau Protein; Rhinorrhoea Fluid Analysis) ...... 96 Bicarbonate (actual; BGA) ...... 96 Bicarbonate (serum/plasma) ...... 97 Bile ...... 97 Bile Acids ...... 97 Bilirubin (direct) ...... 97 Bilirubin (total) ...... 97 Biotinidase ...... 98 Blood Culture ...... 98 Blood film ...... 100 BNP (NT-proBrain Natriuretic Peptide)...... 100 Bone Marrow Aspirate (BMA) Processing ...... 101 Bone profile ...... 101 Bordetella Pertussis ...... 101 Bordetella pertussis Antibodies (IgM & IgG) ...... 101 Breast Milk ...... 102 Bronchoalveolar Lavage, and associated specimens ...... 102 Brucella Antibodies (IgG & IgM) ...... 102 C ...... 102 C1 Esterase inhibitor concentration ...... 102 C1 Esterase inhibitor: functional assay ...... 102 C282Y Mutation (Haemochromatosis Gene) ...... 102 C3 Complement ...... 103 C4 Complement ...... 103 CA 125 (alternative: OV-MA) ...... 103 CA 15.3 (alternative: BR-MA) ...... 103 CA 19.9 (alternative: GI-MA) ...... 103 Caeruloplasmin ...... 103 Caffeine ...... 104 Calcitonin ...... 104 Calcium (ionised) ...... 104 Calcium (total) ...... 104 Calcium / creatinine ratio in urine ...... 104 Calculus analysis ...... 105 Calprotectin ...... 105 CALR exon 9 mutations...... 105 Campylobacter jejuni Antibodies ...... 105 Cannabinoid (THC) ...... 105 Cannula / Intravascular Tips ...... 106 CAPD Fluid (Continuous Ambulatory Peritoneal Dialysis Fluid) ...... 106 Carbamazepine (Tegretol®) ...... 106 Carbapenamase Producing Enterobacteriaceae Screen (CPE/KPC) ...... 106 Carboxyhaemoglobin ...... 106

Page 5 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Cardiac / Striated Muscle Antibodies ...... 106 Cardiac enzyme profile ...... 107 Cardiolipin Antibodies / Phospholipid Antibodies ...... 107 Carnitine (Total and free)...... 107 Catecholamine /creatinine ratio (paediatric request; up to 12 years of age) ...... 107 CCP (Anti-Citric Citrullinated Peptide) Antibodies ...... 107 CD 4/8 Count (Flow Cytometry)...... 107 CD 19 Count (Flow Cytometry ...... 108 CEA (carcinoembryonic antigen) ...... 108 CellCept® (Mycophenolate) ...... 108 Chikungunya Serology ...... 108 Chlamydia/GC STI Screening ...... 109 Chlamydia pneumoniae / Chlamydophila pneumoniae Antibodies ...... 109 Chlamydiae psittaci Antibodies ...... 109 Chlamydia trachomatis Antibodies ...... 109 Chloride ...... 109 Cholesterol: Total ...... 109 Cholesterol: HDL fraction ...... 109 Cholesterol: LDL fraction ...... 110 Cholinesterase ...... 110 Cholinesterase Genotype / Phenotype ...... 110 Chromogranin A ...... 110 Chromosome Studies (Cytogenetics) / DNA Studies (Molecular Genetics) ...... 110 Ciclosporin (Cyclosporin) ...... 111 Citrate (citric acid) ...... 111 CK (creatine kinase) ...... 111 CMV Antibodies (IgG) ...... 111 CMV Antibodies (IgM) ...... 112 CMV Antigen (Urine) ...... 112 CMV PCR / CMV Viral Load ...... 112 CO2 Total (serum/plasma) ...... 112 Coagulation Factor Assays ...... 112 Coagulation Screen ...... 113 Cocaine metabolite ...... 113 Coeliac Screen (Tissue Transglutaminase IgA) ...... 113 Cold agglutinins ...... 113 Copper ...... 113 Complement Assay CH50/CH100 ...... 114 Cortisol ...... 114 COVID-19 (SARS CoV-2) ...... 114 Coxsackie Antibodies ...... 114 Coxsackie Virus ...... 115 Coxiella burnetti (Q-fever) IgM / IgG...... 115 Coxiella burnetti (Q-fever) PCR ...... 115 C-peptide ...... 115 Creatinine ...... 115 Creatinine Clearance ...... 116 Creutzfeldt-Jakob Disease (CJD) ...... 116 Crossmatch in the presence of a positive antibody screen ...... 116 Crossmatch using previous sample ...... 116 CRP (C-Reactive Protein) ...... 116 Cryoglobulins ...... 116 CSF (Cerebrospinal Fluid) ...... 116 CSF (Cytopsin for Haematology/Oncology patients Only) ...... 118 CSF Glucose ...... 118 CSF Immunophenotyping (Flow Cytometry) ...... 119 CSF Lactate ...... 119 CSF Oligoclonal IgG banding ...... 119 CSF Protein ...... 119 CSF Xanthochromia ...... 120 CTx (Crosslaps) ...... 120

Page 6 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Cyclosporin (Ciclosporin) ...... 120 Cystine ...... 120 Cystine (white cell concentration) ...... 120 D ...... 121 D-Dimer ...... 121 7-Dehydrocholesterol (in relation to Smith Lemli Opitz syndrome) ...... 121 Delta Aminolevulinic acid (ALA) ...... 121 Dengue Virus Serology ...... 121 Deoxypyridinoline ...... 122 DHEA sulphate (DHEAS) ...... 122 Diagnostic (Fluid) Cytology ...... 122 Digoxin ...... 123 Dihydrotestosterone (5-α dihydrotestosterone) ...... 123 Diphtheria Antibodies ...... 123 Direct antiglobulin test ...... 123 Dopamine ...... 124 Drugs of abuse in urine (DAU) screen ...... 124 Duodenal Aspirate (for the presence of parasites) ...... 124 E ...... 124 Ear ...... 124 EBV (Epstein-Barr virus) Antibodies ...... 124 eGFR (estimated glomerular filtration rate) ...... 125 Elastase-1 (Pancreatic) ...... 125 Electrolytes ...... 125 Electrophoresis (Serum Protein) ...... 126 Electrophoresis (Urine Protein) ...... 126 Emergency O RhD Negative uncrossmatched red cells ...... 126 Endomysial Antibodies ...... 126 Enterovirus/Enterovirus Antibodies ...... 126 Environment toxicology ...... 127 Epanutin® (Phenytoin)...... 127 Epilim® (Valproate, valproic acid) ...... 127 Erythropoietin (EPO) Levels ...... 127 ESR (Erythrocyte Sedimentation Rate) ...... 127 Estimated glomerular filtration rate (eGFR) ...... 127 Estradiol / Oestradiol ...... 128 Ethanol (alcohol) ...... 128 Ethosuximide (Zarontin®) ...... 128 Ethylene glycol ...... 128 Eye (Acanthamoeba, Conjunctivitis,Corneal scrapings,Intraocular fluids,Contact lens) ...... 129 F ...... 129 Factor concentrate...... 129 Factor II (Prothrombin) ...... 130 Factor V ...... 130 Factor V Leiden (FVL) ...... 130 Factor VII ...... 130 Factor VIII: C ...... 130 Factor IX ...... 131 Factor X ...... 131 Factor XI ...... 131 Factor XII ...... 131 Factor XIII ...... 132 Faeces ...... 132 Farmers lung (Micropolyspora faeni) Precipitins ...... 134 Fatty Acids, very long chain (VLCFA) ...... 134 FBC (Full Blood Count) ...... 134 Ferritin ...... 134 Fetal genotyping ...... 135 Fetomaternal haemorrhage (FMH) assessment ...... 135 FMH using Kleihauer Betke (KB) slide (Acid Elution) ...... 135 FMH using flow cytometry ...... 135

Page 7 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Fibrinogen ...... 135 Fibrinogen concentrate ...... 136 FK 506 (Tacrolimus, Prograf®) ...... 136 Flecainide (Tambocor®) ...... 136 Fluids (Sterile) ...... 136 Refer to: Diagnostic (Fluid) Cytology ...... 137 Folate (Folic Acid) ...... 137 Food Toxicology ...... 138 Free Light Chains (Kappa and Lambda) in serum ...... 138 Free Protein S ...... 138 Free T3 (triidothyronine free hormone) ...... 139 Free T4 (thyroxine free hormone) ...... 139 Frozen Sections ...... 139 Fructosamine ...... 139 FSH ...... 140 Fungal Microscopy and Culture ...... 140 G ...... 140 GAD (Glutamic Acid Decarboxylase) Antibodies...... 140 Galactose: disorders of galactose metabolism ...... 141 Gastric Aspirates (Neonatal) ...... 141 Gastrin ...... 141 GBM (Anti-Glomerular Basement Membrane) Antibodies ...... 141 Genetic Screening ...... 141 Genital Tract & Associated Specimens ...... 142 Gentamicin Assay ...... 145 GL-3 ...... 145 Glucagon ...... 145 Glucose ...... 145 Glucose (CSF) ...... 145 Glucose 6 Phosphate Dehydrogenase (G6PD) ...... 146 Glucose Tolerance Test (OGTT) ...... 146 Glutamine ...... 148 Gonadotrophins (FSH, LH) ...... 148 Gonococcal Complement Fixation Test (GCFT) ...... 148 Gonococcal PCR ...... 148 Group and crossmatch for massive haemorrhage ...... 148 Group and screen ...... 148 Group and serological crossmatch ...... 149 Group and electronic crossmatch ...... 149 Group B Streptococcus (GBS) Culture ...... 149 Group B Streptococcus (GBS) PCR ...... 149 Group specific, uncrossmatched blood ...... 150 Growth Hormone ...... 150 Gut hormone profile ...... 150 H ...... 150 Haematinics Screen ...... 150 H63D Mutation (Haemochromatosis Gene) ...... 150 Haemochromatosis Gene Testing (H63D, C282Y) ...... 150 Haemoglobin A2 (Hb A2) ...... 151 Haemoglobin F (Hb F) ...... 151 Haemoglobin S (Hb S) ...... 151 Haemoglobinopathy Screen ...... 151 Haemophilus Influenza B (HIB) Antibodies ...... 152 Haemophilus Species PCR Testing ...... 152 Hantavirus Serology ...... 152 Haptoglobin ...... 152 HbA1c ...... 152 hCG (human chorionic gonadotrophin, total) ...... 153 HDL-Cholesterol ...... 153 Heinz Bodies...... 153 Helicobacter Pylori ...... 153

Page 8 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Helicobacter pylori - Gastric/Antral/Duodenal biopsies ...... 153 Helicobacter pylori Antibodies ...... 153 Helicobacter pylori Stool Antigen ...... 153 Hepatitis Screen (Hepatitis A, B, C & E) ...... 154 Heparin Induced Thrombocytopaenia (HIT) Screen ...... 154 Hepatitis A Virus IgG Antibodies (Immunity Screen) ...... 154 Hepatitis A Virus IgM Antibodies ...... 155 Hepatitis B core Antibody (Anti-HBc) ...... 155 Hepatitis B Virus Antibody (Anti-HBs Immunity screen) ...... 155 Hepatitis B Virus Quantitative PCR ...... 155 Hepatitis B Virus Surface Antigen (HBsAg) ...... 156 Hepatitis C Virus Antibodies & HCV Antigen ...... 156 Hepatitis C Virus PCR / Molecular Quantitative / Genotyping ...... 156 Hepatitis Delta Virus (HDV) [Subviral Particle] ...... 156 Hepatitis E Virus (HEV) Antibodies IgM & IgG ...... 157 Hereditary Spherocytosis Screen (Flow cytometry) ...... 157 Herpes Simplex Virus 1 & 2 (Viral Culture / PCR) ...... 157 Herpes simplex Virus 1 & 2 Serology ...... 157 5 HIAA ...... 158 HIV 1 & 2 Antibody/Antigen ...... 158 HIV 1 & 2 PCR / Molecular Quantitative ...... 158 HLA Disease association (HLA B27, etc.) ...... 158 HLA Class I & II typing of transplant patients and family members ...... 159 HMMA (=VMA) ...... 159 Homocysteine ...... 159 HTLV (Human T-cell Lymphotropic Virus) Antibodies ...... 159 Human Chorionic Gonadotrophin (Total hCG) ...... 159 Hydroxyindole acetic acid (HIAA) ...... 160 Hydroxymethoxymandelic acid (HMMA or VMA) ...... 160 17-Hydroxy progesterone ...... 160 I ...... 160 IgE (allergen specific) ...... 160 IgE (total) ...... 161 IGF Binding Protein-3 ...... 161 IGF-1 (insulin-like growth factor-1, somatomedin C) ...... 161 IgG Subclasses ...... 161 IgG, IgA, IgM ...... 161 Immunohistochemistry ...... 161 Immunoreactive trypsin ...... 162 Industrial toxicology ...... 162 Infection Control Screening (MRSA, VRE, CPE/KPC, ESBL) ...... 162 Influenza A & B Antibodies ...... 163 Influenza Virus A & B PCR ...... 163 INR (International Normalised Ratio)...... 164 Insulin ...... 164 Insulin : C-peptide Ratio ...... 164 Insulin antibodies ...... 164 Insulin-like growth factor-1 binding protein-3 (IGF-1 BP3) ...... 165 Intravenous Immunoglobulins ...... 165 Intrinsic Factor Antibodies ...... 165 Iron ...... 165 Iron Stain (Perls Prussian Blue Stain) (Cytochemical Stain) ...... 166 Iron studies profile ...... 166 Islet Cell Antibodies ...... 166 J ...... 166 Janus Kinase 2 mutation (JAK2 V617F) ...... 166 K ...... 167 Kappa and Lambda Free Light Chains in serum ...... 167 Ketones ...... 167 L ...... 167 L.A.T.S. replaced by TBII (TSH-binding inhibiting immunoglobulin)...... 167

Page 9 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Lactate ...... 167 Lactate (CSF) ...... 167 Lambda and Kappa Free Light Chains in serum ...... 168 Laxatives screen ...... 168 LD or LDH (Lactate dehydrogenase) ...... 168 LDL-Cholesterol ...... 168 Lead ...... 169 Legionella Antibodies...... 169 Legionella Urinary Antigen ...... 169 Legionella Culture ...... 169 Leptospira Antibody (IgM)...... 170 Leptospirosis ...... 170 Leucocyte Esterase (Cytochemical Stain) ...... 170 LFT profile ...... 170 LH ...... 170 Lipase ...... 171 Lipid profile (state if fasting)...... 171 Lipoprotein(a) ...... 171 Lithium ...... 171 Liver-Kidney-Microsomes Antibodies (LKM) ...... 171 Lupus Like Anticoagulant (LLA) ...... 172 Lyme Disease (Borrelia burgdorferi) Serology (C6 Assay) ...... 172 Lymphocyte transformation test (LTT) ...... 172 Lysosomal enzyme analysis (White cell enzyme analysis) ...... 173 M ...... 173 Magnesium ...... 173 Malaria Antibodies ...... 173 Malaria Screen ...... 173 Manganese ...... 174 Measles Antibodies (IgG) ...... 174 Measles Antibodies (IgM) ...... 174 Meningococcal Antibodies ...... 174 Meningococcal PCR ...... 175 Mixing Studies ...... 175 Mercury ...... 175 Metanephrines ...... 175 Methadone Metabolite (EDDP) ...... 175 Methaemoglobin ...... 176 Methanol ...... 176 Methotrexate ...... 176 Meticillin Resistance Staphylococcus aureus (MRSA) ...... 176 Microalbumin ...... 176 Microalbumin/creatinine ratio ...... 177 Mitochondrial Antibodies (AMA) ...... 177 Monospot (Infectious Mononucleosis) ...... 177 Mother and baby samples from RhD negative mothers at delivery ...... 177 Mouth ...... 177 MPL Exon 10 mutation ...... 178 Mucopolysaccharides ...... 178 Mumps Antibodies (IgG) ...... 178 Mumps Antibodies (IgM)...... 178 Mycophenolate (CellCept®) ...... 179 Mycoplasma genitalium in genital specimens ...... 179 Mycoplasma pneumoniae Antibodies ...... 179 Mysoline® (Primidone) ...... 179 N ...... 180 Nasal Swab ...... 180 Neonatal alloimmune thrombocytopenia investigation ...... 180 Neurological Antibodies ...... 180 Norovirus (Stools) ...... 180 Nose Swab ...... 180

Page 10 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

N-Telopeptide (NTx) ...... 181 O ...... 181 Occult blood ...... 181 Oestradiol / estradiol ...... 181 Oligoclonal IgG banding (CSF) ...... 182 Opiate ...... 182 Organic Acids ...... 182 Orosomucoid (alpha-1-acid glycoprotein)...... 182 Osmolality ...... 182 Osteocalcin ...... 183 Oxalate ...... 183 Oxcarbazepine (Trileptal®)...... 183 Oxidative Burst Test ...... 183 P ...... 183 Pancreatic Polypeptide ...... 183 Paracetamol (Acetaminophen) ...... 184 Parainfluenza Virus ...... 184 Paraprotein studies ...... 184 Parasites ...... 184 Paraquat (quantitative) ...... 185 Paraquat Screen (dithionite test) ...... 185 Parental phenotype ...... 185 Parietal Cell Antibodies...... 185 Paroxetine (Seroxat®) ...... 185 Parvovirus Antibodies (IgM & IgG) ...... 186 PCP (Phencyclidine) ...... 186 Pemphigus / Pemphigoid Antibodies ...... 186 Anti-Phospholipase-A2-Receptor Antibodies ...... 186 pH (miscellaneous fluids) ...... 186 Phencyclidine (PCP) ...... 187 Phenobarbital ...... 187 Phenylalanine ...... 187 Phenytoin (Epanutin®)...... 187 Phosphate ...... 188 Placental alkaline phosphatase isoenzyme ...... 188 Plasma Viscosity ...... 188 Platelet alloantibody testing ...... 188 Platelet antigen testing ...... 188 Platelets ...... 188 Pneumococcal Antibodies ...... 189 Pneumococcal PCR ...... 189 Pneumococcal Urinary Antigen ...... 189 Pneumocystis jiroveci (carinii) ...... 190 PNH (Paroxysmal Nocturnal Haemoglobinuria) By Flow Cytometry ...... 190 Polio Virus Antibodies ...... 190 Polyoma Virus (JC / BK) ...... 190 Porphoblinogen ...... 190 Porphyrins...... 191 Potassium ...... 191 Pregnancy Test ...... 191 Primidone (Mysoline®) ...... 192 Procollagen peptide Type 1 (PINP) ...... 192 Procollagen peptide Type 3 (P111NP) ...... 192 Progesterone ...... 192 17-Hydroxy progesterone ...... 192 Prograf® (FK 506, Tacrolimus) ...... 193 Prolactin ...... 193 Prostate Specific Antigen, Free (fPSA) ...... 193 Protein ...... 193 Protein/creatinine ratio (urine) ...... 193 Protein (CSF) ...... 193

Page 11 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Protein C ...... 194 Protein Electrophoresis (Serum) ...... 194 Protein Electrophoresis (Urine) ...... 194 Protein S ...... 194 Protein S Profile ...... 195 Prothrombin complex concentrate ...... 195 Prothrombin Time (PT) ...... 195 Prozac® (Fluoxetine) ...... 195 PSA (Prostate Specific Antigen) ...... 195 PSA (Prostate Specific Antigen) Free ...... 196 PTH (Parathyroid Hormone) intact ...... 196 Purkinje Fibre Antibodies ...... 196 Pyruvate ...... 196 Q ...... 196 Q-Fever Antibodies (Coxiella burnetti) ...... 196 Quantiferon ...... 197 R ...... 197 Rapamune® (Sirolimus) ...... 197 Red Cell Folate ...... 198 Red Cell Membrane Analysis for Hereditary Spherocytosis ...... 198 Red cell phenotype ...... 198 Referral Tests Histology (Renal Biopsy, Bone, Brain, Skin for immunofluorescence, Muscle Biopsy for enzyme analysis, ) ...... 198 Renal profile ...... 199 Renin ...... 199 Reptilase Time...... 199 Reticulocyte Count...... 199 Rheumatoid Factor (RF) ...... 200 Rhinorrhoea Fluid Analysis (Beta 2 transferrin; Tau Protein) ...... 200 Ristocetin Co-Factor (RiCOF) ...... 200 Rotavirus (Stools) ...... 200 Routine Histology ...... 201 RPR Test ...... 201 S ...... 202 Salicylate ...... 202 Sapovirus ...... 203 Sex hormone binding globulin (SHBG) ...... 203 Sickle Screen (Sickledex) ...... 203 Sirolimus (Rapamune®) ...... 204 Sodium ...... 204 Solvent detergent plasma ...... 204 Solvent screen for toluene (glue), trichloroethane (Tipex®) and butane ...... 204 Special Stains ...... 205 Steroid Profile ...... 206 Stone analysis (stone with details of source) ...... 206 Sudan Black B (Cytochemical Stain) ...... 206 Sweat Test ...... 207 T ...... 207 T3 (triiodothyronine), free hormone ...... 207 T4 (thyroxine), free hormone ...... 207 Tacrolimus (Prograf®, FK 506) ...... 208 Tambocor® (Flecainide) ...... 208 Tau Protein (Rhinorrhoea Fluid Analysis; Beta 2 transferrin) ...... 208 TBG (thyroxine binding globulin) ...... 208 TBII (TSH-binding inhibiting immunoglobulin) ...... 208 Tegretol® (Carbamazepine) ...... 208 Teicoplanin Assay ...... 208 Testosterone/sex hormone binding globulin (SHBG) ratio ...... 209 Testosterone: females ...... 209 Testosterone: males ...... 209 Thalassaemia ...... 209

Page 12 of 231 16/11/2020 Approved By: Kevin O’Connell, Laboratory Manager and Dr. Denis O’Keeffe, Clinical Director, Diagnostics Directorate University Hospital Limerick Laboratory User Manual File Name: MP-A-GEN-USERMAN Edition No.: 13 Date of Issue: 16th November 2020

Theophylline ...... 210 Thiopurine S-Methyltransferase (Red Blood Cell Thiopurine S-Methyltransferase; TPMT) ...... 210 Throat Swab ...... 210 Thrombin Time (TT) ...... 210 Thrombophilia Screen ...... 211 Thyroglobulin ...... 211 Thyroid Antibodies (TPO) ...... 211 Thyroid hormone profile ...... 211 Thyroid Stimulating Hormone (TSH) ...... 211 Thyroid stimulating immunoglobulin (TBII, TSH-binding inhibiting immunoglobulin) ...... 212 Thyroxine binding globulin (TBG) ...... 212 Reference Guide for Use of Thyroid Function Tests in Primary Care ...... 212 TIBC (calculated) ...... 213 Tissue Transglutaminase (Anti-tTG IgA) - Coeliac Screen ...... 213 Tissues and Biopsies (Refer below for Orthopaedic Tissue) ...... 213 Orthopaedic Tissue ...... 213 Tobramycin Assay ...... 214 Tocopherol (Vitamin E) ...... 214 Total Vitamin D (25-Hydroxy vitamin D3; 25-Hydroxycholecalciferol) ...... 214 Toxocara Antibodies ...... 214 Toxoplasma Antibodies (IgM & IgG) ...... 214 Toxoplasma PCR ...... 214 TPPA Test ...... 215 TPMT (Thiopurine S-Methyltransferase) ...... 215 Trace Metal Monitoring (in patients on nutrition support, especially parenteral nutrition) ...... 215 Transferrin ...... 215 Transferrin saturation ...... 216 Transfusion reaction investigation ...... 216 Trichinella Antibodies ...... 216 Tricyclic antidepressants (semi-quantitative, serum) ...... 216 Triglyceride ...... 217 Triidothyronine, free hormone (Free T3) ...... 217 Trileptal® (Oxcarbazepine)...... 217 Troponin T (hsTnT) ...... 217 Trypsin, immunoreactive ...... 217 Tryptase Assay (plasma) ...... 218 TSH (Thyroid Stimulating Hormone) ...... 218 TSH-binding inhibiting immunoglobulin (TBII) ...... 218 Tuberculosis (TB) ...... 218 Tuberculosis (TB) PCR ...... 220 Type 3 procollagen peptide (P111NP) ...... 220 U ...... 220 U & E Profile (urea and electrolytes) ...... 220 Urea ...... 221 Ureaplasma urealyticum / parvum in genital specimens ...... 221 Uric Acid (Urate) ...... 221 Urine Analyses...... 221 Urinary Haemosiderin ...... 222 Urine Microscopy/ Culture (refer to TB section for TB requests on EMU) ...... 222 Urine Protein Electrophoresis ...... 225 V ...... 225 Valproate (valproic acid, Epilim®) ...... 225 Vancomycin Assay ...... 226 Vancomycin Resistant Enterococci (VRE) Screen ...... 226 Refer to: Infection Control Screening ...... 226 Varicella Zoster (VZV) Antibodies (IgG) ...... 226 Varicella Zoster (VZV) Antibodies (IgM) ...... 226 Vasoactive intestinal polypeptide (VIP) ...... 226 Very long chain fatty acids (VLCFA) ...... 226 Viral Studies (Stools) ...... 227 Viral Culture (Swabs) ...... 227

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Viscosity, plasma ...... 227 Vitamin A ...... 227 Vitamin B6: Pyridoxine...... 227 Vitamin B12 ...... 228 Vitamin C ...... 228 Vitamin E (Tocopherol) ...... 229 VMA ...... 229 vWF:Ag (von Willebrand Factor Antigen) ...... 229 vWF Screen (von Willebrand Factor Screen)...... 229 W ...... 229 Warfarin assay (PIVKA – Protein induced by Vitamin K absence antagonist) ...... 229 West Nile Virus Serology ...... 230 White cell cystine ...... 230 White cell enzyme analysis (Lysosomal enzyme analysis) ...... 230 Whipples disease: ...... 230 Whooping Cough ...... 230 Widal Test ...... 230 Wound ...... 230 X ...... 231 Y ...... 231 Yersinia Abs ...... 231 Z ...... 231 Zarontin® (Ethosuximide) ...... 231 Zika Virus Testing ...... 231 Zinc ...... 231

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University Hospital Limerick (UHL) Laboratory User Manual

The postal address of the UHL Laboratory Service is: Department of Pathology UL Hospitals Group, University Hospital Limerick, St. Nessan’s Road, Dooradoyle, Limerick, V94 F858

The postal address of the Ennis Hospital Laboratory Service is: The Pathology Department, Ennis Hospital, Ennis, Co. Clare.V95 HN29

The postal address of the Nenagh Hospital Laboratory Service is: The Pathology Department, Nenagh Hospital, Nenagh, Co.Tipperary. E45 PT86

The postal address of the St. John’s Hospital Laboratory Service is: The Pathology Department St. John’s Hospital St. John’s Square, Limerick, Co. Limerick, V94H272.

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0 Amendment Table

The UL Hospitals Laboratory User Manual(s) are controlled in accordance with local quality management system requirements. The changes to this revision are listed in the table below. Section(s) updated Reason for Revision Date of Issue: Section 7.1 – Contact  Update contact details of key members in Pathology Details of Key Personnel in Pathology

Section 45.1 – Clinical  Add the following text: References ranges are provided in this user manual Medical Microbiology where appropriate and clinical advice comments are included on microbiology Advice test reports where applicable/relevant.

Section 47 - Pathology  Update link to Laboratory User Manual - Ennis https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/staff/resour ces/pppgs/labmanual.html

Section 48 -  Update link to Laboratory User Manual - Pathology Nenagh https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/staff/resour ces/pppgs/labmanual.html

Test Repertoire  Standardise the colour of the specimen tubes for each test eg Gel Serum (Brown Top) , Lithium Heparin (Green Top) etc as appropriate throughout the test repertoire.

Anti-HBsAg /Hepatitis  Turnaround time: Remove Note: Note: Additional days are required for B Vaccine Immunity confirmation of ‘immunity low’ samples using a second anti-HBs assay screen – Turnaround  Reference Interval: >/=10 mIU/mL: Immune – No further action required. time, reference  Repeat testing interval: A result of >/=10 mIU/mL is immune-competent - no interval, repeat testing further testing required (refer to the latest edition of the immunisation interval guidelines of Ireland for advice on vaccination in immuno-compromised groups, dialysis patients). https://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/immunisationg uidelines.html

Blood Culture  Change turnaround time for final negative report to 5-7 days (7 days if endocarditis is suspected.

CAPD Fluid –  Change specimen containers from 50ml dialysate in two 25ml sarstedt sterile Specimen collection universal containers. To 3 x 30ml sterile Sarstedt universal containers of CAPD (dialysate) fluid approximately (25 -30ml in each container)

Covid-19  Replace test for Coronavirus (SARS) with Covid-19 (SARS CoV-2) (SARS CoV-2)

CSF (Cerebrospinal  Reference Interval: Include for Normal CSF Reference Values (Leucocytes Fluid) – Reference and Erythrocytes) interval, additional  Additional information – Add the following text and include reference to film information array: “Please note a negative result does not exclude infection. Where there is a high clinical suspicion of encephalitis please discuss with Clinical Microbiology Team as targeted single pathogen PCR may be more appropriate. The targets tested on FilmArray® are;”  Additional Information: Include Limits of Detection of the film array meningitis / encephalitis panel

D-Dimer  D Dimer Amend reference Interval from: 0 – 69 years: 0.01-0.50 ug/ml and 70 years and older: 0.01-1.00 ug/ml To

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Section(s) updated Reason for Revision Date of Issue: 0 – 69 years: 0.01-0.50 ug/ml FEU 70 years and older: 0.01-1.00 ug/ml FEU Faeces – Test Method  Test method: Add stools for Clostridium difficile and Additional  Additional Information: Include information on C.difficile positive and Toxin Information positive results.  Include information on C.difficile and Toxin negative results

Fluids (Sterile) -  Add reference interval(s) for Synovial Joint Fluids and other Sterile Fluids reference interval  Change turnaround time to read: Positive Culture 6-9 working days. Negative Culture 6 working days Infection Control  Section 3 - Carbapenamase Producing Enterobacteriaceae Screen Screening (MRSA, (CPE/KPC): Specimen Requirements - Change from a charcoal swab to VRE, CPE/KPC, Green Top Swab (Copan Fecal Swab; 502CS01) ESBL) – Section 3 Carbapenamase Producing Enterobacteriaceae Screen (CPS/KPC)

Mycoplasma  Add this to test repertoire genitalium in genital specimens

Quantiferon –  Update turnaround time to 6 working days from receipt of specimen Turnaround time

Sputum,  TAT for fungal cultures extended to 14 days from 7 days. Bronchoalveolar Lavage, and Associated Specimens – Turnaround time

Tuberculosis (TB) –  Specimen Requirements - Include hyperlink to section 18.12 - Recommended Specimen containers for sampling for AFB/Mycobacterial testing and Bronchial requirements and Washings sample volume  Sample Volume - Clarify rejection criteria for urine samples. A minimum of 60mls EMU collection each day over 3 consecutive days is required for AFB analysis in the Microbiology Laboratory. Boric acid/other preservative containers are not suitable and will be rejected.Insufficient Volumes will also be rejected  Ureaplasma  Add this to test repertoire urealyticum / parvum in genital specimens

Urine (Microscopy /  Update Specimen collection kits – 10ml BD Vacutainer with Boric Acid Culture) – Specimen  Include Testing Algorithm: Testing for uncomplicated Urinary Tract Infection in Collection Adults (>16 <65 Years old, no fever or flank pain  Include Testing Algorithm: Testing for for Urinary Tract Infection in long term residents over 65  Add urine reference ranges for interpretation of culture and microscopy 

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1 Foreword

The Pathology Department of the UL Hospitals Group is comprised of the following key disciplines in University Hospital Limerick: Blood Bank, Clinical Biochemistry, Haematology, Histopathology, Microbiology and Serology / Immunology. The Laboratory at Ennis Hospital provides a limited Clinical Biochemistry and Haematology service to hospital ‘in patients’ and outpatient clinics and to General Practitioners in County Clare. The Laboratory services for Nenagh Hospital consist of an ‘on-site’ STAT Laboratory to accommodate Hospital ‘inpatients’ i.e. Hospital Wards, OPD, LIU and Clinics, requiring Biochemistry and Haematology tests.

The purpose of this manual is to act as a reference guide for all users of the Pathology Service of the University Hospital Limerick, Dooradoyle, Limerick, Ennis Hospital, Nenagh Hospital and St. John’s Hospital. Included in the manual are details about the scope of service, location and hours of operation of the laboratory, contact details for key laboratory personnel, availability of clinical advice, and lists by laboratory section of the range of tests currently available, expected turnaround times and other relevant notes. The test repertoire of the Laboratories of University Hospital Limerick is incorporated into this manual alphabetically while the test repertoires of the Laboratories at Ennis Hospital and Nenagh Hospital are outlined in separate documents which can be accessed on the UL Hospitals Webpage via the following link: http://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/staff/resources/pppgs/labmanual.html

The test repertoire of the Laboratory at St. John’s Hospital is outlined on the St. John’s Hospital Pathology request form.

The Pathology Department strives to provide a service that consistently meets the needs and expectations of the medical profession, while contributing to patient well being. This user manual has been prepared for the benefit of our users and employees, in our capacity to provide continuous service improvements. Specific criteria for acceptance of requests for examination of patient specimens should be noted. If acceptance criteria are not fulfilled, the Laboratory regrets that it may not be in a position to process the specimen request.

Every effort has been made to ensure that information provided in this manual is current and accurate at the time of being issued. Medical Practitioners should use this manual as a guide to individual testing on the basis of clinical findings. Should amendments be required to be made to any section of this manual, which impacts on the service, the laboratory will endeavour to advise you.

This manual provides an overview of the Pathology Department; please do not hesitate to contact the relevant laboratory for further information and advice, if required.

We are committed to providing the very best service possible, and will where feasible, implement any improvements / suggestions put forward by our users.

Kevin O’Connell Laboratory Manager UL Hospitals Group, University Hospital Limerick, Dooradoyle, Limerick

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2 UL Hospitals Mission Statement "All of the staff of this hospital will work together in a respectful, caring and professional way to deliver the best possible patient experience in a safe and clean environment and in the most effective and efficient way possible. We are committed to achieving this each and every day."

3 UL Hospitals Statement of Vision "Be a valued, trusted and leading provider of excellence in healthcare which is patient centred, clinically integrated, team based and research driven.”

4 UL Hospitals Statement of Values "Caring, Courteous and Professional"

5 Quality Assurance The Laboratories of the Pathology department have an extensive internal quality assurance system and participate in external quality assessment schemes. The Laboratories strive to be accredited by the Irish National Accreditation Board (INAB) and be compliant with the International Standard titled “Medical Laboratories Particular Requirements for Quality and Competency” (ISO 15189). The scope of accreditation can be accessed on the INAB website www.inab.ie. Reference 303MT for the Pathology Laboratories and Reference 209MT for Blood Transfusion.

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6 The Quality Policy

6.1.1. Quality Policy of the Department of Pathology of the UL Hospitals (Edition 11)

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6.1.2. Quality Policy of the Blood Transfusion department, UL Hospitals Edition 07

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7 General Information

7.1.1. Contact Details of Key Members of Pathology General Pathology Name Position Tel. No. E.mail Mr. Kevin Laboratory Manager 061 - 48 2244 / [email protected] O’Connell 2756 Ms. Patricia Project Lead 087 - 6750755 [email protected] Kennedy Mr. Oliver Power Laboratory Information 061 - 48 5098 [email protected] Systems Manager Ms. Kathleen Pathology Quality 061 - 48 5075 [email protected] Keane Coordinator Ms. Leanne Pathology Quality 061 48 588719 Mangan Officer - Senior Medical Scientist Ms. Annette Neill Specialist Medical 061-588623 [email protected] Scientist – POCT Coordinator Blood Transfusion Name Position Tel. No. E.mail Dr. Hilary Consultant 061 - 48 2036 O’Leary Haematologist Dr. Denis Consultant 061 - 48 2642 O’Keeffe Haematologist Dr. Ruth Clifford Consultant 061 - 48 2618 Haematologist Dr. Aisling Nee Consultant 061 - 48 2618 Haematologist Dr. Eoghan Locum Consultant Molloy Haematologist Ms. Sheila Chief Medical Scientist 061 - 48 2035 [email protected] Joyce Blood Transfusion Blood Senior Scientific Staff 061 - 48 2267 Transfusion /2814 Laboratory Marie Carr Quality Manager 061 – 48 2703/ [email protected] 5342 Norma O’Brien Haemovigilance Co- 061 - 48 5341 [email protected] ordinator Haemovigilance Officer 061 - 48 2846 UHL Bleep 014 Haemovigilance team 061 - 48 5342 Document Controller 061 - 48 5342 Medical Scientist ‘On Contact No. Contact No. Post Midnight Call’ 8.00 p.m. – Internal users contact switch - Dial “9” and Midnight request laboratory on call contact person. 061 48 2267 External users dial 061 - 30 11 11 and request laboratory on call contact person

Clinical Biochemistry Name Position Tel. No. E.mail Dr. Ophelia Consultant Biochemist 061 - 482264 [email protected] Blake Mr. Antonio Principal Biochemist 061 - 588682 [email protected] Reche Martinez Ms. Jane A/ Chief Medical 061 - 48 2881 / [email protected] Fogarty Scientist Biochemistry 061 48 2834

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Medical Scientist ‘On Contact No. Contact No. Post Midnight Call’ 8.00 p.m. – Internal users contact switch - Dial “9” and Midnight request laboratory on call contact person. 061 48 2257/ External users dial 061 - 30 11 11 and bleep 809 request laboratory on call contact person Haematology Name Position Tel. No. E.mail Dr. Denis Consultant 061 - 48 2642 O’Keeffe Haematologist (Clinical Director Diagnostics Directorate) Dr. Hilary Consultant 061 - 48 2036 O’Leary Haematologist Dr. Ruth Clifford Consultant 061 - 48 2618 Haematologist Dr. Aisling Nee Consultant 061 - 48 2618 Haematologist Dr. Eoghan Locum Consultant Molloy Haematologist Ms. Carol Chief Medical Scientist 061 - 48 2847 [email protected] Lenihan Haematology Ms. Claire Senior Medical Scientist 061 - 58 8202 [email protected] Deering (Quality Officer) Medical Scientist ‘On Contact No. Contact No. Post Midnight Call’ 8.00 p.m. – Internal users contact switch - Dial “9” and Midnight request laboratory on call contact person. 061 48 2258 External users dial 061 - 30 11 11 and request laboratory on call contact person

Histology

Name Position Tel. No. E.mail Dr. Olubunmi Consultant 061- 48 2240 Ipadeola Histopathologist /2248 Dr. Vourneen Consultant 061- 48 2240 Healy Histopathologist /2248 Dr. Elizabeth Consultant 061- 48 2240 Mulcahy Histopathologist /2248 Dr. Peter Faul Consultant 061- 48 2240 Histopathologist /2248 To be Chief Medical Scientist 061- 48 2857 Confirmed Histopathology Ms. Kate Senior Medical Scientist 061 - 48 2356 [email protected] O’Connor / Quality Officer

Microbiology Dr. Nuala Consultant 061- 48 5099 O’Connell Microbiologist 061 (Associate Clinical 482246/2240 Director Diagnostics Directorate (Pathology))

Dr. Lorraine Consultant 061- 48 5099 Power Microbiologist 061 485656 Dr. Patrick Consultant 061-488654 Stapleton Microbiologist Ms. Maureen Chief Medical Scientist 061- 48 2840 [email protected] O’Hara Microbiology

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Ms. Maria Senior Medical Scientist 061 48 5096 [email protected] Hayes / Quality Officer Medical Scientist ‘On Contact No. Contact No. Post Midnight Call’ 8.00 p.m. – Internal users contact switch - Dial “9” and Midnight request laboratory on call contact person. 061 48 2502 External users dial 061 - 30 11 11 and request laboratory on call contact person

Serology Dr. Lorraine Power Consultant 061- 48 5099 Microbiologist 061 485656 Dr. Nuala O’Connell Consultant 061- 48 5099 Microbiologist 061 (Associate Clinical 482246/2240 Director Diagnostics Directorate (Pathology)) Dr. Patrick Stapleton Consultant 061-488654 Microbiologist Mr. Colm McDonnell Chief Medical 061 – 48 2797 [email protected] Scientist Serology Mr. Derry O’Rourke Senior Medical 061 – 48 2833 [email protected] Scientist Serology Medical Scientist Contact No. Contact No. Post Midnight ‘On Call’ 8.00 p.m. – Internal users contact switch - Dial “9” and Midnight request laboratory on call contact person. 061 48 2502 External users dial 061 - 30 11 11 and request laboratory on call contact person

Pathology Ennis Ms. Maeve O’Donnell Chief Medical 065 – 686 3146 [email protected] Scientist Ennis Pathology St. Johns Hospital Donnacha McCarthy Chief Medical 061-462286 / [email protected] Scientist 462141

Mícheál Ryan Senior Biochemist 061-462222 [email protected]

The Mortuary Ms. Sabrina Mullahy / Senior Anatomical 061 482933 / Pathology Hospital Switch Technician 061 301111 / Bleep 910 Mr. Oisin O’Neill Senior Anatomical 061 482933 / Pathology Hospital Switch Technician 061 301111 / Bleep 910 Laboratory Porters Mr. Alan Mackessey Laboratory 061- 48 2841 [email protected] Mr. Eugene Conway Porters Mr. Dermot McAuliffe Bleep 059

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7.1.2. Laboratory Telephone Extension Numbers The telephone enquiry service should be used for emergency enquiries only.

General Enquiries: Laboratory, UHL Tel. No. Fax No. Blood Transfusion 061 - 48 2267 / 2035 / 2814 061 - 482581

Clinical Biochemistry 061- 48 2256 / 2257 061 – 482362

Note: phone enquiries for test results are available from: 9.30 – 12.30 Monday to Friday only at 061 – 482256 / 482257 Haematology 061 - 482559 Results / General Enquiries 061- 48 2249 / 2258 Coagulation 061- 48 2851 Haematinics 061- 48 2853 Anticoagulation Clinic Anticoagulation Co- 061- 48 2270 ordinator Bleep # 180 Histopathology 061- 48 2356 / 2857 / 2253 061 - 485255

Microbiology 061 - 485127 General Enquiries 061 – 482240 Out of hours / ‘On Call’ 061 – 482502 hours Respiratory 061 – 482844 Urines 061 – 482277 Mycology 061 – 482839 Blood Cultures 061 – 482843 Faeces 061 – 482854 Routine Swabs 061 – 482842 Antibiotic Assays 061 – 482277 TB 061 – 464264 FAX Number 061 – 48 5127 Serology / Immunology 061- 48 2254 / 2833 061 - 485367

Laboratory Office 061- 48 2248 / 2435 / 2240 / 2303 / 5099 061 - 482631

Mortuary 061 482933 / Hospital Switch 061 301111 - Bleep 910

Phlebotomy UHL Calls only accepted from Clinicians N/A Margaret Carroll (GPs / Consultants) 061 585653 / Hospital Switch 061 301111 - Bleep 711

General Enquiries: Laboratory, Ennis Hospital Laboratory Office 065 - 6863230 / 6863243

Haematology 065 - 6863142 Biochemistry 065 - 6863147

General Enquiries: Laboratory, Nenagh Hospital Laboratory Enquiries 067 - 42355/42356

General Enquiries: Laboratory, St. Johns Hospital Laboratory Enquiries 061 – 462141

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7.1.3. Hours of Operation of Pathology UHL Hours of Operation of Pathology Reception Days Routine Hours Sample Deadline for receipt of all samples from Monday – Thursday 8.30a.m – 5.30p.m Primary Care Mon- Thurs: 9.00 a.m. – 4.00 p.m. Friday 8.30a.m – 5.00p.m Fri: 9.00 a.m. – 2.00 p.m. Hours Of Operation of Laboratory Services Days Routine Hours On Call Service Monday – Friday 8.00 a.m. – 8.00 p.m. Emergency On Call Service provided from (Biochemistry / (including lunchtime) 8.00 p.m. – 8.00 a.m. Haematology/ Blood Transfusion / Contact No. Post Midnight Microbiology) Internal users contact switch - Dial “9” and request laboratory on call contact person. External users dial 061 - 30 11 11 and request laboratory on call contact person. Histology 8.00 a.m.– 5.30 p.m. Contact Histopathologist on call Serology / Immunology 9.00 a.m.– 8.00 p.m. Emergency On Call Service. See service provided in ‘On Call’ / Emergency Service provided per discipline. Saturday 10.00 a.m. – 1.00 p.m. Emergency On Call Service provided from (Biochemistry / Haematology (Limited Service) 1.00 p.m. / Blood Transfusion / See service provided in ‘On Call’ / Microbiology /Serology) Emergency Service provided per discipline. Saturday (Histology) 8.00 a.m. – 1.00 p.m. Contact Histopathologist on call Sunday and Public Holidays Emergency On Call Service See service provided in ‘On Call’ / Emergency Service provided per discipline.

Note: If there is no response from the required laboratory ‘on call’, contact switchboard for contact telephone number.

7.1.4. ‘On-Call’ Service UHL An ‘on-call’ system operates outside normal hours for emergency work only i.e. non-deferrable tests necessary for decisions regarding patient management.

Urgent / Emergency samples must be delivered directly to relevant laboratories to ensure prompt processing. It is essential that the scientific staff on call are contacted using the relevant telephone number below when urgent / critical specimens are to be sent to the laboratory using the pneumatic chute / delivered directly to the laboratory. The on-call service is restricted to true emergencies. The turn-around time will be adversely affected if excessive demands are made on the service.

On-Call Contact Numbers UHL Department Contact No. 8.00 p.m. – Contact No. Post Midnight Midnight Blood Transfusion 061 48 2267 Internal users contact switch - Dial “9” and request laboratory on call contact person. External users dial 061 - 30 11 11 and request laboratory on call contact person. Clinical Biochemistry 061 48 2257 / bleep 809 Internal users contact switch - Dial “9” and request laboratory on call contact person or Bleep 809 External users dial 061 - 30 11 11 and request laboratory on call contact person.

Haematology 061 48 2258 Internal users contact switch - Dial “9” and request laboratory on call contact person. External users dial 061 - 30 11 11 and

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On-Call Contact Numbers UHL Department Contact No. 8.00 p.m. – Contact No. Post Midnight Midnight request laboratory on call contact person. Microbiology 061 48 2502 Internal users contact switch - Dial “9” and request laboratory on call contact person. External users dial 061 - 30 11 11 and request laboratory on call contact person. Serology / Immunology 061 48 2502 Internal users contact switch - Dial “9” and request Consultant Microbiologist on call. External users dial 061 - 30 11 11 and request laboratory on call contact person.

‘On-Call’ / Emergency Service Provided per Laboratory Discipline

Clinical Biochemistry General clinical Biochemistry tests. Troponin Test Blood gas performed as required. CSF / Fluid samples for Biochemistry analysis. Contact the Consultant Biochemist for tests outside of this scope. Clinical advice is available 24/7 for emergency situations.

Haematology The on-call service is provided to process non-deferrable/urgent test requests, the results of which will impact on immediate patient management.

Do not forward routine requests to the laboratory during on-call hours.

Tests performed on-call include:

• Full blood count and white cell differential • Reticulocyte count • Coagulation screen (PT, INR and APTT) • D-Dimer (All requests must include relevant clinical details) • Fibrinogen

Requests for all other tests MUST be approved by a member of the haematology on-call team; the Consultant requesting the test must contact the Haematology Consultant on call via the Hospital switchboard (Ext 2119). After midnight, laboratory on-call personnel must be contacted via Hospital switchboard (Ext 2119). Failure to do this may result in prolonged turnaround times for urgent requests. Clinical advice is available 24/7 for emergency situations.

Delivery of Samples ‘Out of Hours’ Samples may be delivered to the laboratory via the Pneumatic Chute system or by ‘hand’.

Samples delivered by hand should be left on the desk in the Haematology reception area. Samples left at other locations may not be noticed by personnel ‘On-Call’ resulting in a delay in processing of samples and provision of results.

Blood Transfusion The on-call service is provided to process non-deferrable/urgent test requests, the results of which will impact on immediate patient management. Do not forward routine requests to the laboratory during on-call hours.

Tests performed on-call include:

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• Group and hold • Crossmatch • Direct Antiglobulin Test • Antibody identification • Red cell phenotyping

Requests for all other tests MUST be approved by a member of the haematology on-call team; the Consultant requesting the test must contact the Haematology Consultant on call via the Hospital switchboard (Ext 2119). Clinical advice is available 24/7 for emergency situations. After midnight, laboratory on-call personnel must be contacted via Hospital switchboard (Dial “9”). Failure to do this may result in prolonged turnaround times for urgent requests.

Delivery of Samples ‘Out of Hours’ Samples may be delivered to the laboratory via the Pneumatic Chute system or by ‘hand’.

Samples delivered by hand should be left on the desk in the Blood Tranfusion laboratory reception area. Samples left at other locations may not be noticed by personnel ‘On-Call’ resulting in a delay in processing of samples and provision of results.

Histopathology Clinical advice is available from reporting Histopathologists, 24hours a day, 7 days of the week.

Microbiology Out of Hours: Contact with the Consultant Microbiologist on-call is available through the switchboard. This service is confined to consultant contact only. Clinical advice is available 24/7 for emergency situations.

Serology / Immunology The out-of-hours service in Serology/Immunology is for urgent requests only. All urgent requests must be approved by the Consultant Microbiologist before testing can proceed. It is the responsibility of the requesting doctor to contact the Consultant Microbiologist on-call through the hospital switch-board. If approved, the requestor must contact the Microbiology Laboratory with the patient’s details and investigation(s) required urgently.

The following urgent requests are available by arrangement outside the routine working hours:

• Needle-stick injury investigation • Urgent pre-dialysis screen • Organ donor serology screens • Urgent Hepatitis Screens • Urgent HIV requests • Determination of immune status in pregnant women exposed to Varicella Zoster (VZV) • Nasopharyngeal swabs (NPS) / Aspirates for RSV Antigen • Nasopharyngeal swabs (NPS) for Influenza A & B RNA Clinical advice is available 24/7 for emergency situations.

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7.1.5. Hours of Operation of Mortuary / Post Mortem (Autopsy) Services Hours Of Operation of Mortuary / Post Mortem (Autopsy) Services

Days Routine Hours On Call Service Monday – Friday 9.00 a.m.– 5.00 p.m. (including Emergency On Call Service provided lunchtime) from 5.00 p.m.to 9.00 a.m. Saturday, Sunday and Emergency only On Call Service Public Holidays Viewing of the deceased in the ‘Chapel of Rest’ is only via appointment with the Anatomical Pathology Technician on duty.

7.1.6. Out of Hours Contact Numbers for the Mortuary In an out of hour’s emergency situation, hospital staff must contact the Anatomical Pathology Technician (APT) on duty via Main Hospital Switch at 061 30 11 11.

7.1.7. Hours of Operation of Pathology Ennis Hospital Hours Of Operation of Laboratory Services Days Routine Hours On Call Service Monday – Friday 9.00 a.m. to 5.00 p.m. 5.00 p.m.to 8:00 p.m. (Biochemistry / Haematology) Emergency only On Call Service provided from 8.00 p.m.– 9.00 a.m. by UHL

Saturday 9.00 a.m. to 5.00 p.m.

Emergency only On Call Service provided from 5.00 p.m.– 9.00 a.m. by UHL

Sunday 9.00 a.m. to 5.00 p.m.

Emergency only On Call Service provided from 5.00 p.m.– 9.00 a.m. by UHL Public Holidays 9.00 a.m. to 5.00 p.m.

Emergency only On Call Service provided from 5.00 p.m.– 9.00 a.m. by UHL

7.1.8. Hours of Operation of Pathology Nenagh Hospital Hours Of Operation of Laboratory Services Days Routine Hours On Call Service Monday – Friday 9.00 a.m. to 5.00 p.m. Emergency On Call Service provided (Biochemistry / (excluding lunchtime 1.00 from Haematology/ p.m. – 2.00 p.m.) 5.00 p.m.– 9.00 a.m. by UHL

Saturday Emergency only On Call Service provided by UHL Sunday and Public Holidays Emergency only On Call Service provided by UHL

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7.1.9. Hours of Operation of Pathology St. John’s Hospital Hours Of Operation of Laboratory Services Days Routine Hours On Call Service Monday – Friday 8.00 a.m. to 5.30 p.m. Emergency On Call Service provided (Biochemistry / (including lunchtime 1.00 p.m. from: Haematology/ – 2.00 p.m.) 5.00 p.m.– 8.00 a.m. by UHL Mon-Fri Sample Deadline for receipt of all samples is 5.00 p.m

Saturday Emergency only On Call Service provided by UHL Sunday and Public Holidays Emergency only On Call Service provided by UHL

8 Definitions and Abbreviations ‘Analytical Turnaround’ Time (TAT): Turnaround time (TAT) is given as the maximum number of working hours/days between sample receipt and issuing a report either in the computer or by phone under normal operating conditions. In addition to the routine service each department operates an “urgent” system whereby the target turnaround time is shorter. The turnaround time for each investigation is given in the alphabetical listing in the test repertoire. Overuse of the urgent service will adversely affect the turnaround time for all urgent tests. Many specialised tests are performed on a weekly basis; if such tests are required urgently please phone the appropriate laboratory to discuss the request. TATs are routinely monitored as part of the laboratories quality improvement program. Specimens referred to external specialist laboratories for analysis are dispatched by courier service as appropriate. The turnaround times for receipt of hardcopy reports of tests referred to external specialist laboratories can take a number of weeks.

In Progress: Analysis Incomplete. Refer to particular test turnaround time in this manual.

Referral Laboratory: A referral laboratory is an external laboratory to which a sample is submitted for examination and report.

Emergency only On Call Service: On Call Service provided only for emergency specimens outside of core working hours.

Urgent: Samples labelled ‘URGENT’ will be prioritised in the laboratory process as appropriate, and on authorisation of results, results will be available on the Laboratory Information System.

Primary Sample (Specimen): The sample prepared for sending to, or as received, by the laboratory and which is intended for examination.

IPMS – Integrated patient management system BSHLAB - Bons Secours Hospital Limerick at Barrington's N/A Not Applicable NHIRL National Histocompatibility and Immunogenetics Reference Laboratory NBC National Blood Centre UHL University Hospital Limerick TAT Turnaround time D Days W Weeks Hr Hours

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9 Location of the Laboratory UHL

Within University Hospital Limerick, the Laboratory is located on the first floor of the Outpatients Department. Signage may read “Pathology” and / or Pathology Laboratory. The Laboratory can be accessed via the stairwell at entrance to the Children’s Unit / Ward or via the lift located in Outpatient’s Reception.

10 Access To Pathology Laboratory UHL

The Laboratory is controlled via security swipe card access for hospital staff. Access to Pathology Reception area is restricted to hospital personnel from 5.00 p.m. – 8.30 a.m.

Taxi drivers delivering samples to the Laboratory out of hours must obtain a temporary swipe access card from Hospital Security.

11 Location of the Mortuary The Mortuary is located on the ground floor of the hospital. Access to the Mortuary is restricted to authorised personnel only, and is controlled by security swipe access cards. The main Mortuary entrance is located to the rear of the hospital. Funeral Directors / Ambulance personnel access the “Receipt / Release of the Deceased” area via a security barrier near the Main Mortuary Reception entrance. Please Note: Access to the Mortuary is by prior arrangement only with the Anatomical Pathology Technician on duty.

12 Location of Laboratory Ennis Hospital

The Laboratory is located at the rear of the main hospital building in a one story block. Access to the Laboratory is controlled via security swipe card access for authorised personnel.

13 Location of Laboratory Nenagh Hospital The Laboratory is located in the left wing of the hospital, past Accident & Emergency and Radiology departments. At the end of this corridor take a right turn & the Pathology front entrance may be seen. The Laboratory is controlled via security swipe card access for authorised personnel.

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14 UL Hospitals Pathology Policy on Request Form Completion and Specimen Labelling in the Acute Setting (Edition 07)

 Date & Time of Sample Collection  Specimen Type and Anatomical Site of Origin where applicable  Appropriate Clinical Information  Investigations requested  All the information listed above must be completed on each  The safest way to label sample sample request form. tubes is with the labels generated from the Blood Track PDA device, otherwise sample tubes must be handwritten.  iPMS / PAS Labels are not suitable for use on Blood Specimen Collection Bottles Where a “Copy to” report is to be issued to another Clinician / GP, please provide full name and address of the Clinician / GP the copy report is to be issued to.

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15 UL Hospitals Pathology Policy on Request Form Completion and Specimen Labelling in the Community Setting (Edition 07)

Purpose of Policy The purpose of this Policy is to ensure that the correct results and blood products / components are always issued to the correct patient. The Policy applies to specimens being submitted for analysis across all laboratory disciplines at the UL Hospitals in Limerick, Ennis and Nenagh. Refer to the UHL Laboratory User Manual for the terms and conditions for requesting tests Required Information Failure to meet the requirements of this policy may result in the Laboratory being unable to process the request. In the case of Blood Transfusion requests, both the sample request forms and specimen labels must be handwritten. All requests and samples must be submitted using the UL Hospitals approved request forms and specimen containers. These can be obtained from the Pathology Services of the UL Hospitals. Sample Request Form Specimen Tube / Container  Patient’s First Name and Surname  Patient’s First Name and  Patient’s Date of Birth Surname  Patient’s Gender  Patient’s Date of Birth  Patient’s Ethnic Origin where requested on the form  Patient’s Hospital Number (desirable)  Patient’s Address  Date & Time of Sample  Patient’s Hospital Number (desirable) Collection  Name of requesting doctor  Specimen Type and Anatomical  Date & Time of Sample Collection Site of Origin as appropriate  Specimen Type and Anatomical Site of Origin where applicable  Appropriate Clinical Information  Investigations requested All the information listed above must be completed on each sample All the information listed above must be request form. completed on each specimen tube / container Note 1: General Practitioners may use addressograph-type labels giving full patient demographic details on the sample request form - Blood Transfusion and ESR samples excepted. Note 2: It is the responsibility of the requesting doctor(s) using printed labels to have safe procedures in place for controlling the printing, affixing and checking of such labels. If printed addressograph labels are used to label specimens, it is essential that (a) all the required information is clearly legible on the label, (b) the labels fit properly to the specimen container and will not conceal visibility of sample, i.e. the printed label should be no larger than the manufacturers’ specimen tube label. Note 3: There is a clear obligation on General Practitioners to ensure that the patient details on the specimen tubes agree completely with those on the request form. When this is not the case, the Laboratory will be unable to process the request. Note 4: General Practitioners are encouraged to use designated GP identification barcode labels which can be obtained by faxing order on consumables requesting form (LF-L-GEN-REQGPCONSUM) via the porter or directly to the Senior Medical Scientist in Central Reception email address [email protected] Note 5: Requests for tests on patients from Nursing Homes must clearly state the (a) full name of the GP requesting the test(s) / GP barcode label; (b) Nursing home details and (c) Patient’s home address Note 6: Where “Copy To” reports are required, please specify the full name / address of the Nursing Home / Clinician / GP the Copy to report(s) is to be issued to. Note: GP test requests for Biochemsitry and Haematology UHL should be completed on the UHL Blood Sciences Request Form, where applicable.

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16 Terms and Conditions for Requesting Tests  Requests for tests in the Pathology Laboratories of the UL Hospitals must be made by a registered Medical Practitioner or an appropriately qualified healthcare professional acting on the instructions of a registered Medical Practitioner. ‘Self referral’ (self testing) of own / family / relatives/ friends clinical specimens for Laboratory testing without instruction from a registered Medical Practitioner is prohibited.  The patient test request form must be completed in full as outlined in the Policy on request form completion and specimen labelling. Patient details such as age and gender are critical as the reference ranges of some tests are age and gender specific.  Information provided on the request form and the results of laboratory investigations will be stored by the laboratory in accordance with the policies of the Health Service Executive on data storage and document retention.  Requests for tests not performed in the Pathology Laboratories of the UL Hospitals will be referred to specialist external laboratories and will involve the communication of patient information and clinical details to the external laboratory. Details on referral laboratories can be obtained from the respective Pathology Laboratory.  University Hospital Limerick reserves the right to restrict specialised referral requests from General Practitioners. All specialised referral requests must be approved by the appropriate Consultant.  Issues concerning patient consent for laboratory investigations are the responsibility of the requesting doctor. The Pathology Laboratories assume that specimens submitted for testing were obtained with the consent of the patient for the performance of analysis to facilitate diagnosis and treatment.  The service provided by the Pathology Laboratories is intended to assist in the clinical management of patients, and is not provided for medico-legal or forensic purposes or criminal investigations.  The patient identification details given in laboratory reports are drawn from the Patient Administration Systems of the Health Service Executive (IPMS) and are based on the information supplied on the request form(s) by the requesting doctor.  Results are reported to the appropriate hospital Clinician or General Practitioner who can then explain their significance to the patient within the context of their discussions of the clinical problem as a whole.  Laboratory reports are copyright of the Health Service Executive.  Unless a specific request is made, a patient is deemed to accept the usual procedures of the Pathology Laboratories relating to the storage and disposal of specimens. Any such specific request must be practicable, reasonable and given with sufficient notice.

Change to Patient Demographics  The laboratory would appreciate if recent changes to patient demographics (e.g. change of Address, marriage status/maiden name etc) could be highlighted on the request form so that a new medical record is not established inappropriately, resulting in a ‘loss of historical results’.  Record Patient's Home address on all request forms to facilitate correct identification on the laboratory system and to avoid creation of a 'New' patient record which may result in prolonged turnaround times etc and loss of historic links to previous results on the laboratory system.  We discourage use of Residential/Nursing Homes, Prison, Psychiatric hospitals etc. as address of patient. Request forms should at least reference previous addresses so that records can be updated.

Clinical Details  All test requests referred to the Laboratory should include relevant clinical details and medications.

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17 The Clinical Laboratory Sample Test Cycle

[1] Doctor – Patient consultation

[14] Effect on patient care [2] Clinical question

[3] Selection of appropriate test [13] Management decision or action taken

[4] Generation of a laboratory request [12] Examination of report

[5] Collection of labeled [11] Delivery of report to appropriate specimen(s) requesting doctor

[6] Transport of request form(s) [10] Generation of report and specimen(s) to laboratory

[9] Authorisation of results [7] Reception, registration and preparation of sample for analysis

[8] Analysis / investigation

18 Specimen Collection  Please provide separate samples for each laboratory discipline. It is Pathology policy not to split samples between laboratories.  Please ensure that Biochemistry samples are received in the Laboratory within 12 hours of venesection. Sample integrity is compromised on samples over 12 hours old. This is applicable to samples received at UL Hospital Laboratory sites including Ennis.  One full blood sample (Clotted – Brown Cap) is sufficient for UHL Chemistry and Endocrinology tests.  It is essential that specimen and form labelling are clear and accurate and comply with the requirements of the Pathology Policy on request form completion and specimen labelling in previous section of this manual.  Please indicate if patient is a twin, where possible.  Please note specimens with a collection date exceeding 48 hours on arrival to the Microbiology Laboratory will be rejected due to reduced viability of organisms in the sample. Please do not submit specimens to the Microbiology Laboratory if it is known that the delay in arriving in the laboratory will exceed 48 hours.

18.1.1. Blood Collection Bleeding of patients is per current Approved Hospital Venepuncture Policy. Refer also to the following: (a) HSE National Clinical Policy and Procedural Guideline for Nurses and Midwives undertaking venepuncture in adults and (b) HSE National Clinical Policy and Procedural Guideline for Nurses and Midwives undertaking venepuncture in children. Always use blood collection tubes that are in-date. Blood taken into expired collection tubes may render the sample unsuitable, or impact on the reliability of the result.

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18.1.2. Order of Draw of Samples In order to avoid potential contamination of subsequent tubes, it is recommended that when blood is collected for several analyses from a single venepuncture, that the sequence (order of draw) outlined below is followed: 61 Blood Culture 62 Coagulation specimen tubes – coagulation studies, ESR 63 Clotted specimen tubes 64 Heparinised specimen tubes 65 EDTA 66 Glucose

Refer to the UL Hospitals Pathology Services S- Monovette Guide Order of Draw

18.1.3. UL Hospitals Pathology Services Sarstedt S-Monovette Guide Order of Draw

18.1.4. Specimen Tubes to Be Used For Collecting Blood Acknowledgement:  Sarstedt AG & Co., for permission to reproduce the images of Sarstedt tubes and needles and associated instructions for use of the S-Monovette blood collection system.  Cellestis Limited for kind permission to reproduce the images of Quantiferon TB Gold Tubes.

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Specimen Tubes for Routine Tests

Product No.: 04-1935001; 4.9ml S-Monovette Biochemistry: most routine tests except Glucose - must be first sample taken Serology / Immunology: Serology / Immunology tests. Haematology: B12, Folate, Ferritin. Microbiology: Antimicrobial assays

Product No.: 04-1907100; 2.6ml S-Monovette Emergency Biochemistry and all Biochemistry tests for dialysis patients. Some specialised tests including chromosome studies / karyotyping. Please mix sample well by inverting 4-5 times.

Product No.: 04-1918100; 2.7ml S-Monovette Glucose Sample Please ensure that full sample is taken and mix well by inverting 4-5 times.

Product No.: 04-1902100; 2.9ml Monovette All Coagulation Tests Please ensure that full sample is taken and mix well by inverting sample 4-5 times.

Product No.: 06-1690100; 3.5ml Sedivette Erythrocyte Sedimentation Rate (E.S.R.) Please ensure that full sample is taken and mix well by inverting sample 4-5 times. Used also for Paediatric Samples.

Product No.: 05-1167100; 2.7ml S-Monovette 04.1915.100; 2.7ml K2E S-Monovette Full Blood Count (F.B.C.) please ensure that full sample is taken and mix well by inverting sample 4-5 times.

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Haemoglobin A1c - separate specimen and request form to be sent directly to Biochemistry Laboratory. Viral PCR / Genotyping. DNA Studies, CF Genotyping. HLA Typing.

Product No.: 01-1605004; 7.5ml S-Monovette Routine Blood transfusion, Blood Group and Hold and crossmatch and Antibody Identification where appropriate.

Product No.: 02-1726001 Anti-D Quantitation and Antibody Identification where appropriate. Available on request from Blood Transfusion Laboratory.

Product No.: 01-1604400 Trace metal Analysis: See Biochemistry section of this book. Use with metal free Safety Monovette needle only (ref. No. 85.1162.600400). Specimen Tubes for Paediatric Tests

Product No.: 06-1667001; 1.1ml S-Monovette Paediatric Serum - Clinical Biochemistry Tests and Serology / Immunology Tests.

Product No.: 06-1668100; 1.4ml S-Monovette Paediatric Coagulation Tests Please ensure full sample is taken and mix well by inverting 4-5 times.

Product No.: 05-1167001013; 2.7ml S-Monovette for blood transfusion Paediatric Blood Transfusion; Blood Group and Direct Antiglobin Test.

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Product No.: 06-1666100; 1.2ml S-Monovette Serology / Immunology: Paediatric Tests for chromosome studies / karyotyping. Please mix sample well by inverting 4–5 times.

Product No.: 06-1665100; 1.2ml S-Monovette Paediatric Glucose sample. Please ensure that full sample is taken and mix well by inverting 4–5 times.

Sarstedt Safety Monovette Needles

Product No.: 85-1441-200; Safety Monovette Needle, 22G, 1”

Product No.:85-1162-600; Safety Monovette Needle 21G, 11/2” ,metal free needle for trace metal analysis using LH-metall-analytik specimen tube only (01-1604400).

Sarstedt Butterfly Needle

Product No.: 85-1640005; 23G, 3/4”. Butterfly Needle

18.1.5. Instructions for the S-Monovette System Instructions for the S-Monovette System are as outlined in the User Guide provided by Sarstedt.

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18.1.6. Guide for Handling Blood Specimens Following Collection

18.1.7. Quantiferon TB Gold Tubes

See Quantiferon test in Microbiology Section. Tubes for the Quantiferon test should be requested directly from the Microbiology Laboratory when the test has been authorised by the Consultant Microbiologist.

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18.1.8. Collection of Urine / Faeces Specimens

Collection of urine specimens / faeces / swabs specimens is described as appropriate in the respective Laboratory Test Repertoire section.

18.1.9. Instructions for completion of 24 hour urine collections

Approved containers for the collection of 24-hour urine are available from the Clinical Biochemistry Laboratory. Please ensure that the identification label on the container contains details of the patient’s name, date of birth, hospital number/address and the name of the requesting doctor.

Depending on the tests requested, the container might require a special preservative in either liquid or powder form. If required, such preservatives will be provided in the container by the laboratory. Specific requirements relating to the measurement of individual urine analytes is given in the section “Urine analyses” in the alphabetical test listing. Do not discard any preservative provided or wash out the container.

It is important that the following instructions are carried out with care; otherwise the results of the tests will be invalid.

Procedure:

1. Immediately before the beginning of the collection period (usually the morning) the bladder must be emptied and the urine discarded. Record the time and date on the container label.

2. All urine passed during the next 24 hours must be collected and added to the container.

3. At the end of the 24-hour period, the bladder must be emptied and the urine collected added to that already in the container. Record the time and date on the container label.

After completing the collection, arrange for the delivery of the container to the Clinical Biochemistry Laboratory accompanied by the laboratory request form or referral letter.

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18.1.10. Swabs for Microbiology and Virology Investigations

Black/Blue top Charcoal swab with AMIES transport medium for general Microbiology culture

Blue top flexible wire swab in Amies transport medium plus charcoal

For: ENT specimens & Perinasal / nasopharyngeal swab for Bordetella pertussis. (Note: Nasopharyngeal aspirate is the preferable specimen) Sterile dry swab for Acanthamoeba investigation

[available on request from Microbiology Lab]

Multi Collect Kit for Chlamydia and GC PCR

[Orange Cap swab]

Viral Swab Nasopharyngeal swab (NPS) for respiratory viruses, e.g. Flu, RSV

[Red cap Swab]

Viral Swab Skin swab for herpes simplex (HSV), VZV. Throat / Nasal swab for Flu in primary care

[Pink Cap swab]

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18.1.11. Blood Culture Bottles Blood Culture Bottle Label components:

1. User please apply patient information label or clearly handwrite in position 1 only . 2. User please do not obstruct this Aztec barcode position 2 below 3. User please note: All culture bottles will have a Fill Line (black bar running vertically down the right edge of the label marked in position 3. 4. IFU instructions for use reference number- for Laboratory reference marked in position 4 5. Unique Device Identifier (UDI) for compliance with both EU 2017/746 and Code of Federal Regulations (CFR) 21 801.3 standards, see position 5. 6. (!) Removable barcode for laboratory use only- please do not obstruct or remove see position 6.

Blood Culture Bottle Filling Requirements

All culture bottles have a Fill Line (black bar running vertically down the right edge of the label). See Number 3 above. This feature does not apply to the paediatric blood culture bottle due to the low fill volume and the optimal amount of blood collected from paediatric patients depends on their body weight.

The mark "Fill-to" is the white line - marked in yellow and indicates the level when the optimal blood volume of 10mL is reached (the red line refers to the media volume in an unused bottle). The amount of blood collected is an important variable for the detection of microorganisms in patients with suspected sepsis. With the correct blood volume in a blood culture bottle, the detection rate of the pathogens present in small numbers (bacteria, fungi) increases. The right amount of blood also reduces the likelihood of false positive results.

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18.1.12. Recommended containers for sampling for AFB/Mycobacterial testing and Bronchial Washings

Recommendation regarding use of Sarstedt Universal containers for Mycobacterial /AAFB /TB investigation.

For health and safety reasons when taking specimens for Mycobacterium spp. investigation, the TB Lab have requested that all samples submitted for Mycobacterial testing, be sent in the durable Sarstedt Universal containers (Figure 1 below) rather than the standard Sterilin Universal containers (Figure 2 below). This is to facilitate safe handling and processing of specimens for Mycobacterial investigation by laboratory staff. Your cooperation is appreciated.

Figure1 Figure 2 Recommended for TB / bronchial washing Not recommended for TB / bronchial washing samples/ Urine for TB samples

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18.1.13. Procedure for collecting Nasopharyngeal Swabs (NPS) for Respiratory Viruses (Reference: LI-L-SER-NPSCOLLECT, Edition 02)

1. Gently insert the swab along the nasal septum just above the floor of the passage to the nasopharynx until resistance is met. 2. Rotate the swab gently against the nasopharyngeal mucosa for 10-15 seconds then gently remove swab

3. After the swab is removed from the patient place it into the tube of UTM transport medium all the way to the bottom of the tube 4. Holding the swab shaft close to the rim of the tube, break the applicator shaft at the breakpoint indication line. Hold the tube opening away from your face. Write patient details on the collection tube label.

**Collection kits can be ordered from the Laboratory (061 482254)**

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18.1.14. Specimen Containers for Histology Specimens

Large Specimens Large specimens must be put into the 2.5 Litre, or 5 Litre specimen containers, as appropriate. Specimens must be fully immersed in formalin Single Placentas must be placed in 5 Litre Containers, fully immersed in formalin, Twin Placentas must be placed in 10 Litre Containers, fully immersed in formalin.

Figure: 1 Large Specimen Containers

Small Specimens Small specimens must be put into one of the following containers (Figure 2): • 20ml universal • 40ml red-topped • 120ml yellow-topped • 180ml white-topped container Note: Needle Biopsies should be placed in a Safe Cell Cassette which is closed and then placed in a formalin container

Figure: 2 Small Specimen Containers

18.1.15. Collection, Handling and Storage of Histology Specimens

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 Specimen collection is at the discretion of the Clinician.  Sharps used for specimen collection must be disposed of in appropriate sharps waste disposal bins.  Sharps must not be sent to the Histology Laboratory under any circumstances.  Routine Histology Specimens must be placed directly into formalin and can be stored at room temperature until transported to the Histology Laboratory.  Sample should be completely immersed in formalin to ensure results are not compromised due to drying artifact. .  Frozen Section specimens must be sent dry directly to the Histology Laboratory  A copy of Dental X-Rays to be sent in with all dental biopsies should a second opinion be required.  FNA slides for Cytology Referral should be stored at room temperature until transported to the Histology Laboratory.  Non-gynaecological fluid samples for Cytology Referral should be stored at 4-6°C until transported to the Histology Laboratory.  All samples should have date and time of sample collection recorded on the request form. This is especially important for CSFs which cannot be processed if >24 hours old.

18.1.16. Labelling of Histology Specimens  The most current edition of the University Hospital Limerick Histology Request Form and the approved Specimen Containers must be used in all cases. 1. Request Forms and Specimens must be labelled correctly with: • Patient’s Full Name • Hospital Number (N/A for GP’s) • Date of Birth • Ward / Location • Specimen Type Request Forms must also contain the following information: • Patient’s Full Address • Name of Requesting Clinician • Clinical Details 2. All details on the request form must correspond to those on the specimen container. 3. Specimen labels must be fixed onto the side of the specimen container, not the lid. (See figure 1) 4. Request forms must not be stuck onto specimen containers as an alternative to a correct specimen label Note 1: Specimens with request forms stuck onto container as an alternative to a correct specimen label will be treated as unlabelled and returned to the sender. Note 2: Any specimens received without clinical details will be returned to the sender.

Histology Specimen Rejection Criteria: Any request form that does not have: 1. Patients full first name* 2. Patients Surname* 3. Date of Birth 4. Hospital Number (n/a for GP’s) 5. Patient’s full address 6. Specimen type* 7. Clinical Details

* If specimen type is not labelled on the request form or container then sample should be rejected however if the container is labelled the sample can be accepted.

Any specimen that does not have 1. Patient’s full first name* 2. Patients Surname* 3. Date of Birth/ Hospital number 4. Specimen Type

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18.1.17. Handling of Specimens Always assume that all “blood and body fluids” are infectious for blood-borne diseases such as HBV (Hepatitis B Virus), HCV (Hepatitis C Virus) and HIV (Human Immuno-deficiency Virus). All blood and body fluids should be handled using universal precautions. Spillages of specimens should be dealt with in accordance with HSE UL Hospitals, Standard Precautions Guideline.

18.1.18. Safe Disposal of Materials used in Specimen Collection Materials used in specimen collection should be handled and disposed of per HSE MWA Infection Control Policy – “Occupational Exposure Management, including Sharps Policy and Procedure”.

19 Additional Examination Requests  Each laboratory discipline has a procedure on retention of specimens. It is advisable to contact the relevant laboratory discipline, if additional investigations are required to ensure sufficient sample is available and the sample is still viable.  When a verbal request for an additional test is received, the Laboratory will request the user to complete a sample request form and forward this to the Laboratory stating sample date and laboratory number, (if known).  Additional requests on Histology specimens must be made through the reporting Pathologist.  In the event of analytical failure, the laboratory will notify the requesting clinician / location should further samples be required.

20 Repeat Testing Interval

Minimal retesting intervals (MRI) are defined as the minimum time before a test should be repeated, based on the properties of the test and the clinical situation in which it is used. The minimum repeat testing interval is defined for the respective tests in the alphabetical test repertoire of this manual.

21 Patient Collected Specimens It is the responsibility of the requesting clinician to ensure that requests collected and submitted to the Laboratory by the patient are: fully labeled and in the correct specimen container; include a fully completed request form; meet required transport requirements and time frames for submission; are stored appropriately if same day submission is not possible. Details of collection and transport requirements are described in this manual.

22 Handling of samples post collection All specimens should be dispatched to the laboratory as soon as possible. Some samples require special handling i.e. protection from light, immediate freezing, transport within a temperature interval, within a time frame appropriate to the nature of the examination etc. If in doubt regarding the specimen container required or the special requirements when taking the specimen, please refer to the ‘special requirements and comments’ section of the relevant investigation or contact the laboratory for advice.

With reference to Microbiology specimens, all specimens >48hrs old on arrival in the Laboratory will be rejected. Refrigeration of specimens is undesirable for investigation of labile fastidious organisms or where sample quality will deteriorate if transport is delayed.

23 Ordering of Laboratory Supplies UHL Contact Personnel: Laboratory Porter Fax No.: 061 - 482631 Telephone No.: 061 – 482841 / Bleep 059 Minimum Notice Required: 2 Days The Laboratory Porter processes all requests for sample containers and request forms.

Requests for Supplies from General Practitioners in Limerick and Tipperary / Croom Hospital / University Maternity Hospital, Limerick / Nenagh Hospital etc.

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A minimum of two working days notice is required to fulfil an order. To ensure an efficient service is provided, please complete the appropriate Requisition Form which is available from the Pathology Department. This requisition can be faxed or posted to the Pathology Department. Completed orders will be left in the Pathology Reception area for collection, with the requesting destination marked on them.

The Laboratory requests that users of the service do not arrive at the Pathology Department with requests for supplies to be filled ‘while they wait’. Your co-operation in this matter will ensure a fast and efficient service.

Reference: Requisition Form Pathology Laboratory Consumables General Practitioners (GP List) Requisition Form Pathology Laboratory Consumables - Ward List Requisition Form Pathology Laboratory Consumables - Theatre List

Note: Blood collection consumables for GPs in North Tipperary are to be collected via Nenagh Stat Laboratory.

Supplies for UHL Wards The Laboratory Porter checks supplies on all wards in the University Hospital Limerick on a weekly basis.

24 Ordering of Laboratory Supplies Ennis Hospital Requests for supplies from Ennis Hospital and General Practitioners in Clare are to be sent to the Laboratory at Ennis Hospital. Supplies are to be ordered using the Ennis Laboratory supplies order form. The form can be sent to the Ennis Laboratory via post or email [email protected]

Forms are to be received by Tuesday, and the order will be ready for collection on Friday.

Reference: Blood Bottle / Request Form Order Sheet, Pathology Department, Ennis Hospital

25 Ordering of Laboratory Supplies St. Johns Hospital Requests for supplies from St. Johns Hospital and General Practitioners serviced by St. Johns Hospital are to be sent to the Laboratory at St. Johns Hospital.

26 Delivery of Biological Specimens to Pathology UHL Specimens may be delivered directly to the Pathology Reception area as follows:

Days Routine Hours Sample Deadline for receipt of all samples from Monday – Thursday 8.30a.m – 5.30p.m Primary Care Mon- Thurs: 9.00 a.m. – 4.00 p.m. Friday 8.30a.m – 5.00p.m Fri: 9.00 a.m. – 2.00 p.m.

It is essential that all specimens be transported safely and efficiently to the laboratory in order to ensure the safety of staff transporting samples, other staff, patients and members of the public, and to ensure that the specimens reach the laboratory in proper conditions, in a timely manner. All specimens should be dispatched to the laboratory as soon as possible. Some samples may require special handling.

Note: Where there are specific time and temperature requirements for testing of specimens once collected, these are indicated in the individual test requirements.

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26.1.1. Delivery of Biological Specimens within UHL a) Specimens may be delivered directly to main Pathology Reception during routine hours. Out of hours, specimens should be delivered directly to the laboratory where the tests will be performed. Or Specimens may be delivered internally within UHL to the relevant laboratory using the pneumatic chute system.

26.1.2. Instructions on Use of the Pneumatic Chute System 1. Place the labelled specimen(s) and sample request form in the designated ‘Red / Green / Blue capped Canisters’ for sample transportation. 2. Limit the number of samples to two or three per canister. 3. Ensure canister lid is fully closed. 4. Instructions on the operation of the chute are available at each chute station. 5. The chute is available for internal use for the transport of specimens only, to the listed laboratory per table below:

Laboratory Station Availability Weekdays Availability Weekends (Mon – Fri) (Sat – Sun)

Blood Bank Open 24 hours Open 24 hours Clinical Biochemistry Open 24 hours Open 24 hours Haematology Open 24 hours Open 24 hours Microbiology Open 24 hours Open 24 hours Serology / Immunology * 8.30 a.m. – 7.45p.m. 10.00 a.m. – 1.00p.m. (Saturday only) * Serology / Immunology samples outside of the above hours should be sent via the chute to the Microbiology Department only.

6. In the event of a breakdown of the pneumatic chute system, the following process must be followed: • Contact the Aerocom (APT) helpdesk on 01- 8413005 followed by an email to “Lab Chute” address on Microsoft Outlook with specific details of the problem. (Company support is provided 24*7). • Provide Zone and Station number as applicable. • Provide details of any error code as noted on display • Record log as provided by APT, if applicable.

If the chute system is out of commission for greater than one hour during routine working hours, the Laboratory Manager / Maintenance will contact the Facilities Manager to authorise Porters to cover the chute downtime and deliver specimens to the Laboratories. During ‘out of hours’ the head porter / designee will contact the night ADON to approve porter cover for delivery of specimens to the respective Laboratory disciplines.

Note 1: Critical / Irreplaceable samples should be ‘hand delivered’ directly to the laboratory e.g. CSFs. Note 2: Histology specimens must not be sent in the pneumatic chute to the laboratory Note 3: The laboratory returns all micro-chipped identified canisters received to the appropriate designated hospital location. Post midnight, the laboratory On-Call personnel should not be contacted for canisters. If none are available, the night Porter should be contacted for delivery of samples directly to the laboratory.

26.1.3. Delivery of Biological Specimens from GP Surgeries / ‘Off Site’ Hospitals and Clinics

Transport of biological specimens by public road must be in compliance with the current ADR transport regulations. It is the responsibility of the consignor to comply with these regulations. This standard is to safeguard the drivers of vehicles carrying diagnostic specimens on the road between sites and provides protection to passengers and / or the emergency services in the event that the vehicle is involved in a road traffic accident.

Note 1: An Post prohibits the sending of diagnostic specimens by regular mail. Note 2: The consignor is defined as:

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a. The routine courier contracted to transport specimens from General Practitioners Surgeries in accordance with ADR Transport Regulations. Or b. The GP surgery sending specimens when routine contracted courier is not used. Or c. The establishment ie hospital / nursing home / other sending specimens to a Laboratory in the Mid-Western Area

Note 3: Samples should be transported within ambient temperature range (2oC – 28oC). Samples should be transported directly to the Laboratory in a timely fashion from the point of collection. Samples should not be stored overnight in the transport vehicle. The Laboratory periodically audits sample transport times and temperature to verify ambient temperature conditions are met during transportation.

It is the responsibility of the consignor to ensure that transport containers are maintained in good condition and are cleaned regularly using detergent. Disinfection will be required in the event of a specimen spillage. Suitable disinfectants and dilutions of detergents are outlined in the UL Hospitals Infection Control Policy – Cleaning and Disinfection Guideline.

Note 4: Microbiology samples >48hrs old will be rejected. If there is a delay in transport post collection, refrigeration is preferable to storage at ambient temperature. Exceptions include Cerebrospinal Fluid (CSF) and Blood Cultures. Please refer to individual sample types for other sample specific special precautions.

Category B Biological Substances

Most samples can be transported as UN 3373 BIOLOGICAL SUBSTANCE, CATEGORY B in accordance with Packing Instruction 650. To comply with packing instruction 650 for road transport, the following requirements must be satisfied.

1. The specimen must be contained in a primary leak proof container. 2. The primary receptacle must be contained in a secondary leak proof container. 3. There must be sufficient absorbent between the primary and secondary container to absorb the entire amount of liquid in the primary containers should they leak. 4. Either the primary or secondary container must be able to withstand an internal pressure of 95 kPa – the primary container in use for the laboratories of the UL Hospitals satisfies this requirement. 5. The secondary container must be contained in an outer package with at least one minimum surface dimension of 100 x 100 mm.

6. The outer package must display the following markings:

7. Either the secondary or outer packaging must be rigid. 8. The assembled package should be capable of withstanding a 1.2 m drop test without leakage from the primary container.

Note: All 24 hr urine assays performed outside the University Hospital Limerick facility must be collected and transported in packaging that meets with current ADR transport regulations. To obtain the appropriate packaging please contact the Laboratory Porters per the ‘Ordering Laboratory Supplies’ section of this manual.

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26.1.4. Transport System for scheduled routine collections Commercial packaging systems are in place for collection of routine samples. These consist of a rigid secondary container capable of holding a significant number of primary receptacles and a rigid outer transport box.

When using such systems please ensure that: a. There is sufficient absorbent in the secondary container to absorb the entire amount of liquid that may be present in the primary containers. b. That the secondary container is properly closed. c. That there are no visible signs of damage to the outer container – all defective transport boxes should be removed from service. d. And that the correct UN 3373 BIOLOGICAL SUBSTANCE, CATEGORY B label is visible on the outer transport box.

Examples of secondary and tertiary containers which can be used when transporting by taxi / courier are as per Figures 1 & 2.

It is the responsibility of the consignor to purchase these containers.

Transport of Histology Specimens from Ennis, Nenagh and St. John’s Hospital is per LI-L-HIS- TRANSPORTENSTJ

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26.1.5. Delivery of emergency samples / one off samples

As it is often not practical to store sufficient transport boxes for one-off emergency samples, the following system may be used: a. Place the primary specimen in a rigid leak proof secondary container with sufficient absorbent. b. Place the secondary container in an envelope of minimum dimension 100 x 100 mm and label with the UN 3373 BIOLOGICAL SUBSTANCE, CATEGORY B marking to complete the package.

If further information is required on containers to use for transport of specimens, please contact Kathleen Keane (061 485075) or Kevin O’Connell (061 482244).

26.1.6. Emergency Response in the Case of an accident or leakage from the package If leakage is observed or a package is damaged as a result of an accident, contact the forwarding Location (GP Surgery / Hospital / Clinic) / Laboratory in the University Hospital Limerick for advice via (061 482838). Do not touch the package. If emergency responders have arrived on scene please advise them of the presence of UN3373 materials.

As soon as is practical, clean up as follows: 1. Wear gloves and protective clothing, including face and eye protection if indicated. 2. Cover any visible spillage with a cloth or paper towels to contain it. 3. Pour an appropriate disinfectant over the cloth or paper towels and the immediate surrounding area (5% bleach solutions are generally appropriate, and quaternary ammonium disinfectants may also be used). 4. Apply the disinfectant concentrically beginning at the outer margin of the spill area, working towards the centre. 5. After about 30 min, clear away the materials. Place the damaged package in a leak proof container e.g. yellow sack and remove to a controlled lab area to see if the samples can be salvaged. If there is broken glass or other sharps are involved, use a dustpan or a piece of stiff cardboard to collect the materials and deposit them into a puncture-resistant container for disposal (sharps bin). 6. Clean and disinfect the area of the spillage (if necessary, repeat steps 2–5). 7. Dispose of contaminated materials into a leak-proof, puncture-resistant waste disposal container.

26.1.7. Formalin Spill Cover small formalin spillages with disposable absorbent towels. For larger formalin spillages, use a formaldehyde Spill Kit (Spill-X-FP from VWR International), to polymerise the formalin. The area should then be wiped with disinfectant (Trigene 1:50 dilution).

26.1.8. Biological Hazard Known biohazard specimens, fresh tissue and cytology fluid spills should be cleaned with absorbent towel which must then be collected into an autoclave bag, and autoclaved before disposal. The area should then be wiped with disinfectant (Trigene 1:50 dilution).

27 Delivery of Biological Specimens to Pathology Ennis Hospital Specimens may be delivered directly to the Pathology Reception area Monday – Friday from 09.00 a.m. – 5.00 p.m – in-house samples only. Deadline for receipt of all samples from Primary Care is 4.00 pm Monday – Thursday and 2.00 pm on Fridays. It is essential that specimens be transported safely and efficiently to the laboratory in order to ensure the safety of staff transporting samples, other staff, patients and members of the public, and to ensure that the specimens reach the laboratory in proper conditions, in a timely manner. All specimens should be dispatched to the laboratory as soon as possible. Some samples may require special handling. Urgent specimens outside of these hours should be delivered to the respective laboratory discipline in Pathology UHL.

28 Delivery of Biological Specimens to Pathology St. Johns Hospital All Specimens should be delivered to Pathology Reception between 9.00 a.m. and 5.00 p.m., including lunch hour, Monday to Friday. Specimens should not be delivered outside of these hours. Urgent specimens outside of these hours should be delivered to the respective laboratory discipline in Pathology UHL.

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29 Reporting Of Laboratory Results Laboratory Results are available on the laboratory information system (iLAB / APEX) to all UL Hospitals who use the Pathology Service. Enquiries on laboratory results should be made through the “Ward Enquiry Function” of the laboratory information system (iLAB / APEX). Refer to the iLAB section of this manual.

Hard Copy reports are distributed twice daily to the wards within the University Hospital Limerick, Dooradoyle and Ennis Hospital.

Critical results are communicated as a verbal report by telephone to the clinical team or authorised health care professional. Critical results are defined in individual laboratory test repertoire sections. It is our policy to telephone apparently unexpected results which may immediately affect patient management.

General Practitioners are encouraged to provide a mobile telephone number to facilitate reporting of ‘urgent critical results’. Access to Histology reports on the Laboratory Information System (ILAB / APEX) is available to designated Consultants within the UL Hospitals.

Hard Copy reports are sent to the acute hospitals within the UL Hospitals group daily (Monday – Friday).

The laboratory is unable to provide results to patients/their relatives. Any requests for results by the patient/relative must be made via the requesting clinician. The laboratory may telephone results to an identified clinician as requested by the patient/relative as required.

30 Laboratory Reports to General Practitioners (GPs) Electronic reports are available from the Laboratory Information System via Healthlink. Please refer to ‘Paperless Laboratory Results Good Practice Guidelines for General Practitioners in the Mid-West Area.’ Hard copy reports are provided to GPs who do not have Healthlink. All service users are encouraged to avail of electronic reporting via Healthlink. (See Healthlink section for contact details).

31 Referral Laboratory Reports

Referral laboratory details are displayed on the Laboratory Information System while the test is in progress. Referral reports are available on ILAB & Healthlink for a limited number of referral laboratories that have an electronic interface with UHL. For referral laboratories with no interface with UHL, scanned copies of referral reports are available to ILAB users with access to DART. Hard copy referral reports are sent to the requesting clinician.

Note: For Microbiology referrals: Referral Laboratory contact details are available from microbiology where required. Some microbiology investigations may include referral of isolates for toxin testing or epidemiological typing where deemed appropriate by the clinical microbiologist, such referrals may occur in the course of investigations of outbreaks/ unusual community isolates or treatment failure incidences. If isolates are referred for further typing in the course of investigation this will be indicated on iLAB, however, contact details of reference laboratories may not be provided in these instances as results are largely used for academic purposes, please contact the microbiology laboratory if further information on any of these isolates is required

32 Policy of Faxing Results To comply with the HSE Electronic Communications Policy, Reports will only be faxed by the department if: a) No Alternative: There are no other means available b) Harm: In a medical emergency where a delay would cause harm to a patient/client/employee or the potential risk to a patient/client/employee is greater harm than the risk of disclosure of their personal information. Requests to fax results should identify  Clinical indication for need  Telephone & Fax numbers of intended recipient

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33 Healthlink Healthlink is the name given to a Department of Health and Children funded project which allows electronic links to be established between General Practitioners, Hospitals and the Health Service Executive to allow for the timely, secure transfer of patient related administrative and clinical data. Details on Healthlink can also be obtained from the Healthlink website: www.healthlink.ie or by telephone on 01-8825606.

34 Reports Received in Error Laboratory Reports may be issued to the incorrect requesting location in error resulting in delayed provision of results. Although every effort is made to avoid such occurrences through the use of GP ‘bar-coded location’ labels / PDA labels etc., errors may occur.

To alleviate the delays in reporting associated with such errors:  Return hardcopy report/copy of electronic report directly to the testing laboratory Or  Telephone the relevant laboratory advising them of the need to verify records and re-issue the report(s).  Healthlink reports received in error should be permanently removed from the patient record in the practice system. Please do not forward reports directly to the patient noted.

35 Contact for Clinical Advice and Interpretation Pathology results are reported with reference / therapeutic ranges. A guide to interpretation of results and clinical advice is given on report if appropriate. Information on medical indications and appropriate selection of available procedures, clinical advice and interpretation is available and can be obtained by contacting the appropriate Consultant / Laboratory. Details on current examination procedures including performance specification can be provided to clinical users on request by contacting the relevant laboratory discipline. The contact details for Consultant Staff are given in contacts section of this manual. Clinical advice relating to reports sent to external laboratories should be directed to the referral laboratory.

36 Post Mortem / Autopsy Service Post mortems / autopsies are carried out either following instruction from the Coroner (Coroner’s Autopsy) or at the request of the Clinician with responsibility for the patient’s care (Diagnostic / House Autopsy) per the UL Hospitals Post Mortem Examinations Policy, a copy of which should be located in each ward. Additional copies can be requested from the Anatomical Pathology Technician (Ext. 2933 / Bleep 910). An information leaflet, ‘Guide to the work of the Coroner’ can be requested from the Anatomical Pathology Technician.  All non-coroner and non-forensic ( i.e House) Post Mortems require Next of Kin Consent.  Next of Kin consent forms are available in each ward.  If no form is available in the ward a supply is available in the Mortuary, Bleep No. 910.  A fully completed Death Card (available on each ward) must accompany the deceased to the Mortuary.  On arrival at the Mortuary the deceased is transferred to an appropriately labelled fridge and the Mortuary Register is completed as instructed.

37 Post Mortem Reports  Coroner Post Mortem reports are sent only to, and are available only from, the presiding Coroner and the Gardaí associated with the case.  House / Diganostic Post Mortems are sent to the requesting Consultant only. Any queries will be forwarded to the requesting Consultant.

37.1.1. Forensic Post Mortems  All forensic Post Mortems are performed by the State Pathologist or Assistant State Pathologist.  Reports on these cases are not generated by the UL Hospitals Pathology Service.  Reports on these Post Mortems are not available from the UL Hospitals Pathology Service.

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38 Pathology Service Users Users of the laboratory service should ensure that their contact details i.e. name, address, telephone number are up to date. Any changes should be notified to the Pathology Quality Coordinator at 061 – 485075 or the Laboratory Manager at 061 482244.

39 User Satisfaction, Comments and Complaints The goal of the Pathology Department is to ensure that our users receive accurate, reliable, meaningful and timely laboratory results. If users encounter any problems with the services or have suggestions for service improvement, please contact the Chief Medical Scientist of the appropriate laboratory section or the Laboratory Manager or email the Pathology Quality Coordinator, Kathleen Keane at [email protected]

40 Data Protection The Pathology Laboratories of the UL Hospitals comply with the General Data Protection Regulation (GDPR) 25th May 2018, regarding patient information. It is the policy of the Pathology Department to manage personal data and information with the highest degree of integrity, security and confidentiality.

41 Consent Completion of consent forms is mandatory for all genetic tests and predictive tests for inherited diseases. Where consent forms are required to be completed, this is stated in the requirements for the particular test.

42 Scope of Service Provision

43 Biochemistry Service The term biochemistry (bio-chimie) was first coined by the French chemist and microbiologist, Louis Pasteur (1822-1895). The application of chemistry to the study of disease has a longer history beginning with the Irish physicist and chemist, Robert Boyle (1627-1697), who was born in Lismore, Co. Waterford.

The Clinical Biochemistry Department uses biochemical knowledge and techniques to understand human health and to assist in the detection, diagnosis and treatment of disease.

The Department’s work involves the provision of analytical results and observations and the conversion of this data into information for the requesting doctor.

The Department provides a comprehensive range of analytical results, observations and interpretation for the requesting doctor as well as clinical liaison and advice. The analytical service encompasses indices of fluid balance, liver function, renal function, carbohydrate and lipid metabolism, and various hormones, proteins, enzymes, therapeutic drugs, tumour-associated substances and many other chemical and biochemical compounds.

The provision of a clinical biochemistry service is dependent on highly automated analytical systems, electronic data processing and information technology.

The Department has an extensive internal quality assurance system and participates in national and international quality assessment schemes.

The Clinical Biochemistry Service is supported by on-going training programmes and by research focused on improving patient care.

This section of the handbook is designed to give you an easy to use reference to the broad range of clinical biochemistry tests and investigations. If you are unable to find information on what you require, please contact any of the senior members of staff.

The Clinical Biochemistry Laboratory is committed to providing requesting doctors with a service of the highest quality through adherence to laboratory procedures approved by appropriate regulatory bodies, staff competency, comprehensive internal quality control procedures, regular quality assurance audits and participation in many external quality assessment schemes.

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43.1.1. Summary of Blood Specimen Volume Requirements Biochemistry Specimen tubes to be filled to fill line. Please refer to the alphabetical test listing for specific information on the requirements for individual tests.

Test Details Patient Type Specimen Tube General biochemistry tests, for example Adult Patients One serum gel tube any selection from the following: Type: Sarstedt S-Monovette 4.9 mL Urea, electrolytes, creatinine, liver Colour code: BROWN “function” tests, cardiac enzymes, cholesterol, triglyceride, calcium, phosphate, uric acid, magnesium, total protein, albumin, endocrine and other specialist tests performed in-house. Volume requirements for specimen types for Specialist assays referred to external laboratories are provided in the ‘Special requirements or comments’ section in the alphabetical test listing. For emergency biochemistry and dialysis Adult Patients One lithium heparin gel tube. patients Type: Sarstedt S-Monovette 2.7 mL Colour code: GREEN Glucose analysis Adult Patients One glucose (sodium fluoride EDTA) tube. Type: Sarstedt S-Monovette 2.7 mL Colour code: Grey Hba1c analysis Adult Patients One EDTA tube. Type: Sarstedt S-Monovette 2.7 mL Colour code: Violet Paediatric Patients

The Sarstedt Monovette® enclosed blood collection system used throughout the hospital has tube sizes available for paediatric specimens. Sarstedt Micro Tubes are also available for paediatric and neo-natal specimens.

Requesting doctors are advised to liaise with the laboratory in advance of specimen collection when difficulties in obtaining blood specimens are expected. In these situations, tests requested should be ranked in order of priority.

43.1.2. Test Profiles Biochemistry

 The test profiles defined below are available to requesting doctors.  Non-specific and vague statements such as “bioprofile” should never be used in requesting tests. Likewise, terms such as “toxicology”, “hormone profile”, “tumour markers” or “routine tests” are vague and unfocussed and should not be used in requesting tests. The few extra moments required to carefully specify the tests needed are an integral part of quality patient care.

Profile Name Tests included in Profile Renal Sodium, potassium, chloride, CO2, urea, creatinine, Liver Total Protein, albumin, total bilirubin, alkaline phosphatase, Gamma GT, ALT Bone Calcium, phosphate, alkaline phosphatase, Total Protein, albumin ED Renal, Liver, Bone, CRP, glucose Lipid Total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride Iron studies Iron, Transferrin, Transferrin Saturation TFT (Thyroid function TSH, free T4 tests) GP Renal Profile Sodium, potassium, urea, creatinine, eGFR

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43.1.3. Reference Values Biochemistry

Almost all clinical biochemistry results are reported with reference interval values, which in some cases are gender and age related. The reference interval defines the values of a biochemical test found in 95% of apparently healthy subjects against which the patient’s value can be compared. The term “reference interval” is much more than a replacement for the old term “normal range”. It requires careful consideration of the characteristics of the reference population, of how the reference subjects are selected and how their state of health is assessed. It also requires knowledge of the performance of the analytical technique used, control of specimen collection and storage and a detailed understanding of data handling techniques and statistical tools. Almost all of the biochemistry reference intervals used by this laboratory are those approved by regulatory bodies such as the FDA (USA) for the analytical systems we use. The term reference interval is free from connotations of judgment and value and should lead to a more objective interpretation of laboratory data. The International Federation for Clinical Chemistry and Laboratory Medicine has developed the concept of reference values and ranges and published methods for their derivation.

The reference interval concept encounters difficulties with a test such as serum cholesterol since increasing risk of future cardiovascular events is associated with serum cholesterol values within the reference interval, for example, the risk doubles between serum cholesterol values of 5.2 and 6.7 mmol/L. In this situation, national or international bodies set target or recommended limits for use in clinical practice.

44 Haematology Service

The Haematology Laboratory provides a comprehensive range of laboratory tests and clinical support for the management of Haematological Disorders including Haematological Malignancies. It provides an oral anticoagulant monitoring service. The laboratory is the referral centre in the region for morphology, haematinics, immunophenotyping (of lymphoproliferative disorders and immune monitoring), thrombophilia screening and other bleeding disorders.

44.1.1. Reference Intervals Haematology Reference intervals quoted in this manual refer to adult intervals. Age and sex related intervals where applicable are quoted on the haematology test report form.

44.1.2. Coagulation specimen requirements Relevant anticoagulant therapy (medications) should be included with all Coagulation requests.

Relevant clinical details are required to facilitate D Dimer analysis. Requests may be rejected if no indication for testing is provided.

Samples will be rejected for the following reasons:  Under-filled samples i.e. any sample that is more than 4mm below the blue fill line indicated on the sample bottle.  Overfilled samples i.e. any sample that is more than 4mm above the blue fill level indicated on the bottle.  Any sample that is considered grossly haemolysed.  Partially activated or clotted samples  Lipaemic specimens for D-Dimers, Free Protein S, ATIII, Protein C, vWF:Ag and Anti-Xa requests  Indications for testing not provided against D Dimer requests.

Special precautions should be adhered to ensure coagulation samples are not contaminated with heparin or taken from a drip site.

Requests for non-routine coagulation tests for patients<16years are referred to OLHSC, Crumlin for analysis.

All non-routine coagulation tests require Consultant signature / approval on request form.

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45 Histology Service

The Department of Histology provides diagnostic surgical pathology and autopsy services to the UL Hospitals. Services are also provided to St John’s Hospital, Nenagh Hospital and Ennis Hospital, as well as to the local community of General Practitioners.

45.1.1. Overview of Services The Histology Department provides a comprehensive Histopathology and Autopsy service.

Facilities and techniques routinely available Include:  Routine processing  Frozen section  Special Histochemistry  Immunohistochemistry  Referral for Cytology, Gynae and non-Gynae  Referral tests (FISH)

The test repertoire and requirements are outlined in the test repertoire section of this manual.

Major Clinical Specialities Include:  Urology  Gastroenterology (Medical and Surgical)  Breast*  Oncology  Gynaecology  Dermatology  Endocrinology  Rheumatology  Paediatrics Note: *Breast Histopathology services are limited. There is no Consultant Histopathologist with an interest in Breast Histopathology on-site. Core biopsies are processed on-site and sent to referral laboratory. All bigger specimens are sent to a referral laboratory. Immunohistochemistry is performed on-site.

45.1.2. Critical Alert Results Histology Critical results are defined as follows;  Frozen section results  Urgent results as verified by the Consultant Histopathologist  Unexpected diagnosis

45.1.3. Additional Requests Histology Specimens  Additional requests must be made through the reporting Pathologist.

45.1.4. Referral Tests Histology Tests referred by Histology are described in the test repertoire section of this manual. See Referral Tests Histology in Test Repertoire.

45.1.5. Quality Assurance Histology The Histology Laboratory is a member of the following external quality assessment schemes: UKNEQAS for Cellular Pathology Techniques UKNEQAS for Her 2 Immunohistochemistry UKNEQAS for Breast Hormone Immunohistochemistry UKNEQAS for Lymphoma Immunohistochemistry UKNEQAS for Routine ICC Immunohistochemistry UKNEQAS for Alimentary Tract Immunohistochemistry

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45.1.6. Histology Reports Histology Reports are now available on iLAB to authorised Consultants.

Cytology Reports are now available on Medibridge to authorized Users

46 Microbiology Laboratory The Clinical Microbiology laboratory provides a quality diagnostic service in the investigation of the causative agents of infectious disease and the provision of antimicrobial susceptibilities to its clients. This incorporates: a) General Microbiology including Mycobacteriology b) Faecal Parasitology c) Mycology (referred test) d) Therapeutic Drug Monitoring for aminoglycosides and glycopeptides e) Antimicrobial Susceptibility testing based on the EUCAST standards.

The laboratory also provides a consultative service in Clinical Microbiology, Infectious Disease and Infection Control. It provides a venue for the training of Medical Scientists, participation in on-going education and development, introduction of new methods (including molecular) and relevant clinical research leading to the provision of a timely and effective service. The laboratory practices an extensive internal quality control programme and participates in many external quality assurance programmes.

Note 1: Please note specimens with a collection date exceeding 48 hours on arrival to the Microbiology laboratory will be rejected due to reduced viability of organisms in the sample. Note 2: Please do not submit specimens to the Microbiology laboratory if it is known that the delay in arriving in the laboratory will exceed 48 hours Note 3: non-haemolytic group A streptococci may not be recognised in mixed cultures. Note 4: Non uniform distribution of microorganisms between test portions of samples, time of sampling, storage of samples and transport conditions may contribute to the quality of the final result. A negative result may not exclude infection. Note 5: Provision of clinical details and clear descriptions of sampled site is essential for appropriate testing of submitted samples.

46.1.1. Clinical Medical Microbiology Advice

Routine: Clinical medical microbiology advice is available Monday – Friday, 09.30am to 5.30pm.

NCHDs should always have the following basic information ready before seeking antimicrobial advice:  Name of patient and chart number, Date of admission, Age  Rural or urban dwelling, nursing home resident or long term care facility  Symptoms (including temp. pattern if relevant) and working diagnosis  Actual antimicrobials recently prescribed – iv or oral, dosage and frequency  Imaging results as appropriate  Surgical intervention history as appropriate  Microbiology results as appropriate (history of MRSA, CPE/KPC, ESBLs, C. difficile, etc.)  What lines and drains are in situ? Is patient on TPN? Immune function – splenectomy, HIV, haematological malignancy, recent chemotherapy, steroids, anti-TNF, etc.?  History of allergies? Systemic parameter results? Co-morbidities?  Recent travel history if relevant, occupation and social interests (water sports, animal contact, walking in woodlands, etc.), sexual history where relevant

Out of Hours: Contact with the Consultant Microbiologist on-call is available through the switchboard. This service is confined to consultant contact only. References ranges are provided in this user manual where appropriate and clinical advice comments are included on microbiology test reports where applicable/relevant.

47 Serology / Immunology Laboratory The Serology/Immunology Laboratory provides an extensive range of laboratory investigations and clinical support to assist in the diagnosis and treatment of viral and microbial infection. The department performs a

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47.1.1. Clinical advice and Interpretation Serology: Clinical advice is available by contacting Dr Lorraine Power (Ext 5656) or Dr Nuala O’Connell (Ext 2246). The Consultant Microbiologist on-call is available for clinical advice through the hospital switch-board. Comments or suggestions relating to the service should be directed to the Chief Medical Scientist.

47.1.2. Urgent Requests Serology Urgent requests must be identified in the priority section of the Serology/Immunology request form. It is advised that if a test result is required urgently then the laboratory should be contacted by phone. During routine working hour’s urgent requests for tests received which are available daily will be processed urgently.

A significant number of Serology/Immunology requests are run in ‘batches’ and are not processed urgently. Requests for urgent tests not routinely processed on the day of receipt need to be approved beforehand by the Consultant Microbiologist.

47.1.3. Requests for Additional Tests Serology Additional investigations may be added to an existing request for serum specimens submitted to the laboratory within the preceding 4 months. Additional requests for tests on requests for serum specimens sent to referral laboratories must be made within 4 weeks of submitting sample. Additional requests on specimen types other than serum samples should be discussed with the laboratory beforehand.

47.1.4. Consent Forms Serology Investigations Consent forms are mandatory for all genetic tests and predictive tests for inherited diseases. Consent forms for genetic testing are available from the laboratory (061 482254).

47.1.5. Blood specimen volume requirements Serology

Test Details Patient Type Specimen Tube General Serology/Immunology Adult Patients One filled serum gel tube blood tests/screens Type: Sarstedt S-Monovette 4.9 mL Colour: Brown

- It is recommended that a second serum specimen tube be sent if more than 6 investigations are required to ensure sufficient specimen volume to complete all requested investigations

- Tests which are sent to referral laboratories require a separate specimen tube and request form (refer to alphabetical test listing for information on tests sent to referral laboratories).

General Serology/Immunology Paediatric / Neo-natal One filled serum gel tube blood tests/screens Patients Type: Sarstedt S-Monovette 1.1 mL Colour: Brown

- It is recommended that a second serum specimen tube be sent if more than 4 investigations are required to ensure sufficient specimen volume to complete all requested investigations

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Test Details Patient Type Specimen Tube

- If difficulties in obtaining blood specimens are expected, it is advised that the requesting doctor would contact the laboratory prior to specimen collection so tests can be ranked in order of priority.

- Please note - The minimum specimen volume requirements to process a single test is 0.4 mL of blood (equivalent to half- filled paediatric tube).

Other All Volume requirements for specimen types other than blood samples are provided in the ‘Special requirements or comments’ section in the alphabetical test listing.

48 Pathology Ennis The Pathology Department at Ennis Hospital provides a limited range of Haematology (FBC including WBC differential, Coagulation Screen, INR, ESR Monospots, Reticulocyte count) and Biochemistry (renal, liver and cardiac function tests, lipid, glucose, protein and amylase levels) laboratory tests. It also acts a centre for the transfer of specimens to UHL Monday to Friday. The test repertoire for the Laboratory at Ennis Hospital is outlined in the Ennis Hospital Laboratory User Manual which can be accessed on QPulse and via the following link on the UL Hospitals Webpage: https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/staff/resources/pppgs/labmanual.html

49 Pathology Nenagh The Pathology Department at Nenagh Hospital provides a limited range of Haematology (FBC including WBC differential, D-Dimer, ESR, Reticulocyte count) and Biochemistry (renal, liver and cardiac function tests, lipid, glucose, protein and amylase levels) laboratory tests. It also acts a centre for the transfer of specimens to UHL Monday to Friday. The test repertoire for the Laboratory at Nenagh Hospital is outlined in the Nenagh Hospital Laboratory User Manual which can be accessed on QPulse and via the following link on the UL Hospitals Webpage: https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/staff/resources/pppgs/labmanual.html

50 Scope of Service Blood Transfusion including test repertoire The Blood Transfusion Department incorporates the Blood Transfusion laboratory, the Haemovigilance and Traceability functions, and the clinical transfusion consultancy service. The Blood Transfusion laboratory is responsible for serological testing, processing and storing of blood components/products for transfusion. Transfusion services are provided to the hospitals in the UL Hospitals, BSHLAB and Milford Care Centre.

This should be read in conjunction with the blood transfusion manual, which provides information, instructions and advice on • Procedures associated with blood transfusion and • Guidelines on use of blood and blood products. The blood transfusion manual is available on Q Pulse or on hard copy where Q pulse is not available. All users are reminded that they must have regular, updated, documented training before participating in any step in the blood transfusion chain.

50.1.1. Background information Blood Transfusion The Blood Transfusion Department includes the blood transfusion laboratory, the haemovigilance team and blood transfusion quality personnel. The laboratory is located in the University Hospital Limerick and provides a transfusion service to the following hospitals in the Mid-West Area:

• University Hospital Limerick • Ennis Hospital • Nenagh Hospital

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• Croom Hospital • University Maternity Hospital • St. John’s Hospital • Milford Care Centre • BSHLAB

The Blood Transfusion Department operates to the ISO 15189 quality management system including INAB terms and conditions, ensuring compliance with the relevant Directives (2002/98/EC, 2004/33/EC Annex IV, 2005/61/EC, and Statutory instruments 360 of 2005 and 547 of 2006). The quality management system is outlined in the Blood Transfusion quality manual (MP-A-BTR-QUALMAN).

50.1.2. Test Repertoire Blood Transfusion The tests provided include: • ABO and RhD group • Antibody screen and identification • Anti-D and anti-c quantitation (referred to National Blood Centre, Dublin) • Crossmatch (serological or electronic crossmatch) • Cold agglutinins • Direct Coomb’s test • Fetal maternal haemorrhage estimation by flow cytometry and acid elution • Fetal genotyping (referred to IBGRL Bristol) • Platelet alloantibody test (referred to National Blood Centre, Dublin) • Platelet antigen testing (referred to National Blood Centre, Dublin) • Patient and red cell concentrate phenotype • Product issue Albumin Solvent Detergent Plasma Factor VIIa Factor VIII Factor IX Intravenous Immunoglobulin Intravenous & intramuscular anti-D Antithrombin concentrate Prothrombin complex concentrate (PCC’s) e.g. Octaplex and Feiba Praxbind® (idarucizumab) C1 esterase inhibitor concentrate Fibrin sealant (Evicell) Fibrinogen

Refer to the blood transfusion manual for information on indications for selection of blood components/products.

50.1.3. Sample and request form requirements Blood Transfusion

Sample collection Please refer to HP-A-BTR-SAMPLEREQ available in the Blood transfusion manual and on QPULSE.

If specific preparation of the patient/sample/transport container is required, it will be specified in the relevant test section. Two types of sample bottles are provided for pre-transfusion testing:

ADULT: 7.5ml EDTA transfusion laboratory sample bottle PAEDIATRIC: 2.7 ml EDTA paediatric sample bottle

For referral tests a variety of sample types are required, these are specified in the appropriate section for each referral test.

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Electronic sample collection labels generated using Blood Track Tx are the preferable sample labelling method. Patient details can also be handwritten on blood transfusion samples. Please note addressograph self adhesive labels are not acceptable on the request form or sample.

Acceptance Inadequately/incorrectly completed sample or request forms will be rejected. Samples received > 48 hours after collection and not stored between +2°C and +8°C will also be rejected.

Sample storage Samples are stored in the blood transfusion refrigerator and are discarded after seven days, unless a request has been received to reserve the sample for a specific purpose.

Request forms There are five blood bank request forms available: Blood Bank 1 request form This form is used in hospitals to request tests and blood components/products. Blood Bank 2 request form This form is used for blood group investigations including all antenatal investigations. Blood Bank 3 request form This form is used for suspected transfusion reaction investigations. Blood Bank 4 request form This form is used in major emergencies. These forms are only available in the major emergency charts. Blood Bank 5 request form This form is used for blood group investigation and to request routine antenatal anti-D prophylaxis (RAADP) Blood Bank 6 request form This form is used for blood group investigation for unplanned pregnancy. For completion of request forms, refer to the HP-BTR-A-REQUEST procedure available in the Blood Transfusion Manual and on QPULSE.

Reports Electronic reports are available on iLAB and via Healthlink. Hard copy reports are delivered by post to the requesting location/consultant via the laboratory office or via a taxi/fax to offsite hospitals.

50.1.4. Test Requirements Blood Transfusion: Antenatal group Sample type 7.5 ml EDTA and antibody Request form Blood Bank 2 screen Turnaround time Next routine working day after receipt except for samples received on Friday, which will be tested on Monday.

Antenatal Minimum recommendation for antenatal testing: antibody testing • First antenatal visit (i.e. at about 12 weeks gestation) • Repeated again at 28 weeks gestation • If anti-D, c or K (or clinically significant antibodies with titre >32) are found, tests should be repeated at monthly intervals up to 28 weeks and every 2 weeks thereafter to monitor antibody levels. Paternal testing may also be required. • If the antibody concentration is increasing, referral to a specialist unit is indicated. • The blood transfusion laboratory will provide advice on the report regarding the frequency of testing for all clinically significant antibodies.

Comments: The blood transfusion report will inform the clinician responsible for patient care of the likely significance of the antibody (ies) with respect to the development of HDN and transfusion problems. Note: If a patient has an antibody, a repeat group and

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screen sample needs to be taken if patient admitted to hospital. Antenatal antibody Sample type 7.5 ml EDTA titration Request form Blood Bank 2 Turnaround time 1 day after receipt, except for samples received on Friday which will be tested on Monday.

Antenatal anti-D Sample type 7.5ml EDTA or Clotted Neutral Bottle (not gel). Fill to mark. quantitation Request form Blood Bank 2 Turnaround time 8-10 days - anti-D quantitations are performed on Monday, Wednesday and Friday by the National Blood Centre, Dublin.

Antenatal anti-c Sample type 7.5ml EDTA or Clotted Neutral Bottle (not gel). Fill to mark. quantitation Request form Blood Bank 2 Turnaround time 8-10 routine working days - anti-c quantitations are performed on Wednesday by the National Blood Centre, Dublin. Samples need to be collected on Monday of each week.

Antibody Sample type 7.5 ml EDTA identification Request form Blood Bank 1 or 2 as appropriate Turnaround time 1 day depending on priority Comment A second sample may be required for complex antibody identifications.

Antibody Sample type 7.5 ml EDTA investigation Request form Blood Bank 1 or 2 as appropriate referrals to Turnaround time 1 week depending on priority. reference laboratory Cold agglutinins Sample type 7.5 ml EDTA maintained at 37ºC Request form Blood Bank 1 Turnaround time Same day Monday to Friday only - the samples must be received before 1 pm. Reference Titres above 64 are considered elevated. Haemolytic Interval: anaemia due to cold reactive agglutinins rarely occurs unless the titre is >512.

Direct antiglobulin Sample type 7.5ml EDTA for adults, 2.7 ml EDTA for paediatrics test Request form Blood Bank 1 Turnaround time Same day Fetal genotyping Sample type 3 X 7.5ml EDTA and 7.5 ml EDTA from the putative father. Fill to mark. Please send Monday to Wednesday. The sample must reach IBGRL, Bristol within 48hrs of venepuncture.

Request form IBGRL referral form (F104) and Blood Bank 1 Turnaround time < 3 weeks - test is performed in the IBGRL, Bristol, UK. Fetomaternal Note Flow cytometry is suitable for estimation of fetomaternal haemorrhage (FMH) haemorrhage in RhD negative mothers who have delivered assessment RhD positive infants. Kleihauer Betke (KB) Slide is the acid elution test used when the blood group of the fetus is unknown.

FMH using Sample type 7.5ml EDTA Kleihauer Betke Request form Blood Bank 1 (KB) slide (Acid Turnaround time < 72hours

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Elution) Comment Not clinically indicated for RhD positive patients, except for >20 weeks gestation with IUD.

FMH using flow Sample type 7.5ml EDTA cytometry Request form Blood Bank 1 Turnaround time < 72hours. HLA Class I & II Sample type 5-10ml EDTA/ citrate typing of transplant Request form Blood Bank 1 patients and family Turnaround time 2-3 weeks - test is performed in the NHIRL, National Blood members Centre, Dublin.

Note The BT255 request form is completed by laboratory staff and forwarded with a copy of the Blood Bank 1 request form to the NHIRL in the National Blood Centre. Mother and baby Sample type 7.5 ml EDTA from mother and 7.5 ml EDTA cord sample samples from RhD Request form Blood Bank 1 negative mothers at Turnaround time Same day delivery Note The maternal sample for FMH should be taken when sufficient time has elapsed to allow the fetal cells to be distributed within the maternal circulation following delivery, manual removal of placenta or sensitising event. A period of 30-45 minutes is considered adequate. All samples must arrive in the transfusion laboratory at 10.00hrs for testing. Samples arriving after this time will be tested the following day. Neonatal Sample type Mother 20ml clotted and 7.5ml EDTA alloimmune Father 20ml EDTA thrombocytopenia Neonate 2.7ml EDTA investigation Request form Blood Bank 1 Turnaround time 2 weeks depending on priority (sent to the National Blood Centre, Dublin) Comment Discuss request with the consultant haematologist. Parental phenotype Sample type 7.5ml EDTA Request form Blood Bank 1 Turnaround time 1 day Comment If a pregnant woman has antibodies, sample from the putative father will be required to determine the probability of the fetus carrying the relevant antigen.

Platelet Sample type 5 ml serum alloantibody testing Request form Blood Bank 1 Turnaround time 2 weeks depending on priority (sent to the National Blood Centre, Dublin).

Platelet antigen Sample type 7.5 ml EDTA testing Request form Blood Bank 1 Turnaround time 2 weeks depending on priority (sent to the National Blood Centre, Dublin) Risk and This test is of no value in investigation or management of comments thrombocytopenia. Requests will be referred back to the requesting team for discussion with a consultant haematologist/registrar.

Red cell phenotype Sample type 7.5 ml EDTA Request form Blood Bank 1 or 2 as appropriate Turnaround time Same day Transfusion Sample type  7.5ml EDTA post transfusion sample reaction  Component pack with giving set attached

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investigation  Urine sample x 2 (immediately and 6 hours post reaction)  FBC  Coagulation screen  U&E, creatinine, bilirubin;  Pre- and post-transfusion samples for BNP (B-type naturetic peptide), in cases of suspected TACO or TRALI - samples should be taken within 2 hours of suspected TACO or TRALI reaction.  IgA levels in cases of suspected allergic reaction  Blood cultures (if fever is documented) Request form Blood Bank 3 Turnaround time  Serological testing is performed on the same day of receipt.  Blood culture where indicated may take up to 10 days before a report is authorized. Positive cultures are phoned immediately.  In cases of suspected TACO or TRALI, turnaround time may take several weeks.

Note  Reporting of transfusion reactions to the National Haemovigilance Office is mandatory. Refer to the relevant chapter of the blood transfusion manual for guidance on the clinical management and reporting of transfusion reactions.

50.1.5. Transfusion laboratory request options: Group and screen Sample type 7.5 ml EDTA Request form Blood Bank 1 Turnaround time Same day* *1 hour after receipt for urgent samples Comment A blood group and an antibody screen will be performed on the sample. (The same sample can be used to crossmatch blood up to 72 hours following sample collection, sampling.) Group and Sample type 7.5 ml EDTA serological Request form Blood Bank 1 crossmatch Turnaround time 1 – 2 hours after receipt Indication A serological crossmatch will be performed on patients that have no historic blood group and antibody screen and patients that have antibodies*. The blood laboratory need to be informed of the clinical conditions of the patients including sickle cell disease, thalassaemia and auto immune haemolytic anaemia .Ultimately the laboratory will decide patient suitability for serological/electronic crossmatch. *See section “Crossmatch in the presence of a positive antibody screen”.

Comment A blood group and an antibody screen will be performed on the sample and the sample will be serologically crossmatched for the number of units requested, or in the case of surgical patients, the number of units specified in the Maximum Surgical Blood Order Schedule (MSBOS). Any deviation from the agreed MSBOS needs to be clearly documented on the request form. Group and electronic Sample type 7.5 ml EDTA crossmatch Request form Blood Bank 1

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Turnaround time Maximum of 1hr from receipt of sample. Indication Applies to patients who have had more than one group and screen sample processed and have no history of antibodies. Auto immune haemolytic anaemia patients are ineligible for electronic crossmatch. The laboratory will decide if the patient fulfills suitability according to predefined criteria. Group and Sample type 7.5 ml EDTA crossmatch for Request form Blood Bank 1 massive Turnaround time Prioritised once a massive haemorrhage is declared. haemorrhage Notes  When a patient presents with potential major haemorrhage, the doctor must inform the transfusion laboratory immediately.  The medical scientist will immediately order platelets and thaw four to six units of solvent detergent plasma.  Group specific, uncrossmatched red cell concentrates may be released, if time doesn’t allow for a full crossmatch.  One individual needs to be identified as a liaison person to communicate with the transfusion laboratory until the haemorrhage is under control.  Please refer to the relevant guideline in the Blood Transfusion Manual.  Fibrinogen concentrate may also be required if the fibrinogen is <1.0 gm/l. Emergency O RhD Sample type A 7.5ml EDTA sample should be taken prior to negative transfusion. uncrossmatched red Availability time Immediately cells Comment If a delay is unlikely to result in a significant risk to the patient, it is better to give group specific, uncrossmatched blood to conserve O RhD negative stock. Risks O RhD negative emergency blood may not be compatible for patients with antibodies. Approximately, 2 - 4% of hospital patients may have a red cell antibody which can cause a haemolytic transfusion reaction.

Note Emergency O RhD negative red cells are located on the top shelf of the issue fridge in the blood transfusion laboratory. Emergency O RhD negative red cells are also available in the issue fridges in the following hospitals: • University Maternity Hospital • St John’s Hospital • Croom Hospital • Nenagh Hospital • Ennis Hospital • BSHLAB Group specific, Sample type 7.5ml EDTA uncrossmatched Request form Blood Bank 1 blood Availability time 10-15 minutes from receipt of blood sample in Blood Transfusion laboratory

Risks and Risks associated with use are identical to risks associated comments with use of O RhD negative uncrossmatched blood. Group specific blood is no safer, but uses resources better, i.e. unnecessary use of O RhD negative blood is avoided. Units are labelled “uncrossmatched blood, transfuse with care’’.

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Note An emergency crossmatch for 4 red cell units will take 45 minutes provided the antibody screen is negative - see section on RCC crossmatch in the presence of a positive antibody screen for further information, if necessary.

Crossmatch using Sample type Original sample previous sample Request form A new Blood Bank 1 form, delivered or faxed to the laboratory. Turnaround time 5- 30 minutes Specimen Previous sample must be <72 hours old. Blood requirements crossmatched from the sample must be used within 72 hours of sample collection time.

Crossmatch in the Availability time 90 minutes to several hours, depending on the antibody presence of a positive present*. antibody screen Risks and If blood is needed before compatibility testing is comments completed, haemolysis may occur, but transfusion should not be withheld if deemed absolutely necessary. A decision on whether to transfuse or /wait for fully crossmatched blood may need to be discussed with a haematology consultant/registrar. * Transport time not included

50.1.6. Blood Component issue: Blood components/products need to be requested by the doctor on a blood transfusion laboratory 1 request form. Refer to the specific guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual for guidance.

Platelets Sample type 7.5 ml EDTA. No sample is required if there is a current blood group on the laboratory information system. Request form Blood Bank 1 Availability time An emergency platelet concentrate is routinely held in the blood transfusion laboratory. However, requests should be placed in advance (if time permits) as it takes 2 hours for platelets to be delivered from Cork or 4 hours for platelets to be delivered from Dublin. Communication with the laboratory is essential if special requirements are being considered such as washed or HLA matched platelets. Platelets can be issued (if already in the blood transfusion laboratory) within 15 minutes, if there is a patient blood group on file or within 25 minutes if there is no patient blood group on file. Risk and Refer to the HG-A-BTR-PLATELET guideline available on comments Q Pulse ISSACUTE and/or the hard copy blood transfusion manual.

50.1.7. Blood Product Issue:  Solvent detergent Sample type 7.5 ml EDTA. No sample is required if there is a current plasma blood group on the laboratory information system. Request form Blood Bank 1 Availability time 30 minutes (for 3 units), if there is a blood group on file in the transfusion laboratory; one hour if blood group is not on file. Risk and Refer to the HG-A-BTR-SDPLASMA guideline available on comments Q Pulse ISSACUTE and/or the hard copy blood transfusion manual.  Anti-D Sample type 7.5 ml EDTA.

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Request form Blood Bank 1 Availability time < 72hours Risk and Refer to the HG-A-BTR-ANTID guideline available on Q comments Pulse ISSACUTE and/or the hard copy blood transfusion manual.  Albumin Blood Note 250ml 5% albumin and 50ml/100ml 20% albumin are Product available. Sample type None. Request form Blood Bank 1 Availability time Same day Risk and Refer to the HG-A-BTR-ALBUMIN guideline available on Q comments Pulse ISSACUTE and/or the hard copy blood transfusion manual.  Factor Sample type None. concentrate Request form Blood Bank 1 Availability time Same day Risk and Refer to the HG-A-BTR-rFVIIa guideline available on Q comments Pulse ISSACUTE and/or the hard copy blood transfusion manual. Refer to the product SPC for appropriate information on administration. Refer all requests to the consultant haematologist for appropriate use and dose.  Prothrombin Sample type None complex Request form Blood Bank 1 concentrate Availability time Same day Risk and Prothrombin complex concentrate’s (PCCs) should only be comments prescribed in accordance with the guideline HG-A-BTR- PCC available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Any requests not falling within the guideline will be referred to a consultant haematologist.  Praxbind® Sample type None (idarucizumab) Request form Blood Bank 1 Availability time Same time Risk and  Praxbind® (idarucizumab) is indicated in patients treated comments with Pradaxa (Dabigatran etexilate) when reversal of the anticoagulant effects of Pradaxa (Dabigatran etexilate) is needed and presecribed with the advice of the consultant haematologist.  For emergency surgery / urgent procedures.  In life-threatening or uncontrolled bleeding.  Fibrinogen Sample type None concentrate Request form Blood Bank 1 Availability time Same day Risk and Fibrinogen concentrate should only be prescribed in comments accordance with guideline HG-A-BTR-FIBN available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Any requests not falling within the guideline will be referred to the consultant haematologist.  Intravenous Sample type None Immunoglobulins Request form Blood Bank 1 Availability time Same day Risk and Flebogammadiff (5% and 10%) and 10% Kiovig are comments routinely stocked. Pentaglobin is not routinely stocked but available from Intrapharma on request. Refer to the HG-A-BTR-IVIG guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual.

51 iLAB (Laboratory Information System – Formerly APEX)

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51.1.1. Logging on to the iLAB system from a PC

 Double click on iLAB Icon.

 Username: enter your username

 Password: enter your password (User must change every 90 days).  Terminal I.D. If requested enter ZLN (must be typed in uppercase). Note the system should be configured so that the user is not required to type ZLN.  Login: If prompted for a login you must enter APEX - you will then be prompted for a username/password

51.1.2. Changing your password For security reasons user passwords are set to expire after 90 days. The username does not change.

When entering a new password you will be prompted to confirm it by re-entering it as outlined below.

 Current Password : enter

 Password (1st entry) : enter

 Password (2nd entry) : enter as above, validation check  Password expires on : view only field Password Criteria Password must be:  At least 8 characters. Usernames and passwords are not case sensitive  Must have at least 1 alpha character  Must have at least 1 numeric character  Cannot have more than 2 repeating characters i.e password containing 22 is OK but 222 is not.  A password can be repeated after 3 changes

Passwords must be changed every 90 days. The system will alert you on the 89th day that your password is due to expire the following day. You have a further 30 days to change your password after which time your account will be locked.

51.1.3. Looking up patient results using Ward Enquiry (WRNQ) Having logged onto the Ward enquiry menu, select/type 1 or WRNQ.

The following screen is then displayed:

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WARD ENQUIRY (WRNQ)

Pathology results are provided on individual patients and results are grouped by patient. Initially the patient is identified by supplying one of the following:

1. The PID/Chart number, plus at least the first two letters of the surname.

2. For an unknown PID/Chart number enter U in the Patient Number field and the patient's surname or date of birth, plus any other details if known.

Use option (b) if searching by the PID/Chart number fails to return the required patient or set of results.

 Use option (b) if on entering a PID, the system crashes; this is usually caused by a corrupt PID. These results can usually be retrieved by searching by DOB and surname rather than using the PID. Please notify the laboratory if such a crash occurs.

ACTION BAR OPTIONS: 1. Accept: Accept or reject selected details.

2. Select specs: The Select Specimens option provides a snapshot list of all specimens and tests requested, by date and specimen type, enabling rapid access to a specific result. Each line displays:

o Specimen No.

o Collection Date/Time

o Specimen Type

o Location Tests

o Result availability

3. Reject: Clear selection criteria.

4. Tabulated Enquiry: Enter appropriate enquiry code.(Use F11 to list options)

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5. Exit: Exit the Ward Enquiry.

IDENTIFY THE PATIENT OPTION A

1. Patient Number Enter either the PID/Chart Number - the cursor moves to the Surname field.

2. New NHS Number This is not used.

3. Surname Enter a minimum of the first two characters of the surname. iLAB searches for the patient registration number (PRN) and uses the surname (or whatever part has been entered) as a check.

If the PRN and surname match only one patient, then full details are displayed on the screen.

Note: The Forename, Date of Birth/Age, Sex, Ethnic Group, Location and Consultant fields on this screen are for display-only and not for data input.

4. Forename This field displays the patient's forename(s).

5. Date of Birth/Age The patient's date of birth is displayed. If registered by age rather than date of birth, then iLAB calculates the year of birth and displays "January 1st" of that year, eg. 01/01/1956*.

6. Sex The patient's sex is displayed as M, F, or U (unknown).

7. Location The current location is displayed. This is the most recent location from which a specimen has been ordered on iLAB.

8. Consultant The current consultant is displayed. This is the requesting clinician responsible for the most recent specimen ordered on iLAB.

9. From Date iLAB searches from the date displayed in this field, up to the present. This may be changed manually using the Change option.

10. Discipline This option may or may not be present depending on your specific Menu configuration. If this option is available use the to remove the discipline short code, enabling a search across ALL disciplines. Alternatively the search may be restricted by entering a discipline short code. Up to 3 may be selected.

Discipline short codes are as follows: B(Biochemistry),H(Haematology),M(Microbiology),S(Serology) and T(BloodBank/Transfusion).

OPTION B

If the patient PRN/Chart number is unknown to APEX enter U in the Patient Number field and press , this will allow an extended search via the Patient Search screen. The Patient Search Screen opens.

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PATIENT SEARCH SCREEN

1. Patient Number (PRN) iLAB performs a search for all patients whose details match those entered on this screen. Entering as much information as possible about the patient, reduces the number of matching patients to a minimum. However, this advice should be followed only when all details are known to be correct. Entering the minimum data, produces a larger choice.

The MINIMUM required, is either the surname (or at least the first 2 characters) or date of birth. (The patient’s gender should also be included so as to reduce the numbers of records the system must retrieve)

iLAB displays U by default.

2. NHS Number Tracing Status Not Used

3. Patients without NHS number Not used.

4. New NHS Number Not used.

5. Old NHS Number Not used.

6. Service Number Not used.

7. Surname Enter a minimum of the first two characters of the Surname, or press . The surname, or part of it, is accepted as a minimum entry, enabling the remaining fields on this screen to be skipped. MC GONAGALL, MC GON, SMITH, SM, etc.

8. Previous Surname Not used.

9. Soundex Search (Y/N) Not used.

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10. Synonym Search (Y/N) Not used.

11. Forename Enter any number of characters, or press . D, DA,DAVID, etc.

12. Date of Birth/Age Enter a valid date or age (numeric, in years). The date of birth, is accepted as a minimum entry, enabling the remaining fields on this screen to be skipped. 23 12 67, 03/4/48, 28), etc.

13. Extended Age Search (Y/N) The search may be extended to include patients with a date of birth or age, two years either side of that entered, by entering Y.

14. Sex Enter either M, F or U. (The patient’s gender should be include in all searches where the patient’s PID is unknown)

15. Location Enter a location code. Press F11 to list options. The search is not restricted to this location. However, if a match is found to the patient, but from a different location, then the patient's record is not amended.

16. Consultant Enter a clinician code. Press F11 to list options. The search is not restricted to this clinician. However, if a match is found to the patient, but from a different clinician, then the patient's record is not amended.

PATIENT SEARCH SCREEN OPTIONS AVAILABLE FROM THE ACTION BAR

 Accept: Searches for any patients matching criteria, if none found (therefore no results available), prompts - No matches found.

 Reject: Clears the screen, enabling re-entry of data.

 Change: Enables any field entry to be changed.

 New Patient: Not used.

 Swap Two of the most common errors in entering search data is either to mix up the surname and the forename, or, in the case of a hyphenated surname, to enter the two halves of the name in the wrong order. This facility corrects such faults automatically.

o Swap Surname/Forename Swaps surname with forename.

o Swap Hyphenated Reverses hyphenated names.

SUBJECT SEARCH SCREEN Subject Search Options

If the "unknown" search criteria match more than one patient, then the Subject Search screen displays a list of possible patients. Use the / keys to locate the required patient.

Note: Full demographics are displayed in the patient window at the bottom of the screen.

Three options are available from the action bar.

 Accept: Confirms correct patient and returns to first screen. The Confirm acceptance Y prompt, confirms this. N cancels acceptance, enabling an alternative election.

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 Details: Displays full patient details as confirmation. The Confirm details Y prompt, confirms this. N cancels the "details" selection.

 Quit: Rejects the search, enabling re-entry of details. The Confirm Quit Y prompt, confirms this, returning to the Result Enquiry screen, and displays full patient details. N cancels the "quit" selection.

The following codes are used to designate the availability of results.

 N/K: The authorization stati of the tests on this specimen are unknown.

 Requested: Requested but results not yet available.

 In Progress: Test results may be present, not yet authorized to the viewing level of the enquirer.

 Avlbl: Results available to the level of the enquirer.

Select the required specimen using the and keys.

51.1.4. Results Screen Display

PATIENT/SPECIMEN DEMOGRAPHICS The top three lines display patient and specimen information relevant to the specimen number currently viewed on screen.

The fourth line displays the specimen number and testing discipline:

Specimen No. HR000341Y (Haematology) for more

Below this, in the specimen bar, are the collection date/time and specimen type. The main body displays each test, result, test status and normal range, highlighting low and high values (specific colours on colour screens) and including any coded or free text comments.

if the report extends beyond the bottom of the screen.

RESULTS SCREEN OPTIONS 1. Date Enter a valid date. Any results from that date are displayed. Note the date refers to the specimen collection date.

o Earliest Displays the earliest results according to the search criteria entered. for later results. o Latest Displays the latest results according to the search criteria entered. for later results. 2. Report Sequence Not used.

3. DFT Not available.

4. Matches When an "unknown" patient number search has been performed, another patient may be selected from the Subject Search screen, using this option.

5. Spec Displays Specimen related details. Press to return to previous screen.

6. Verbose Verbose display for Blood Transfusion only.

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7. Cumulative Results Test results are displayed over a period of time. The screen displays up to six previous specimens in a vertical format. The specimens are displayed with the current one on the left and the previous ones to the right. They are displayed with the date, time and specimen number in the header. The tests are listed in the left hand column in test priority order with the relevant results displayed under their specific specimen numbers.

Note: Only tests which were present in the original specimen are displayed in Cumulative Enquiry. The current selected specimen is highlighted.

8. Cumulative Results Options o Scrolls the screen down to display further tests. o Scrolls the screen up to display further tests. o Scrolls the screen to the right to display older specimens. o Scrolls the screen left to display the more recent specimens. o Moves the highlight bar to the next specimen. o View Displays results from the current selected specimen. o Graph Prompts for single test to be graphed and displays the Graph Screen. 9. Select Test to Graph Enter the test code of the test to graph. The graph of the selected test is shown. The format of the graph depends on the type of terminal or monitor being used. The graph is either a bar chart or a line graph. The test being displayed is listed in the lower left corner of the screen. The left axis is "concentration", with intervals decided upon by iLAB. The right axis is "date/time" with the date being displayed. The following options are displayed.

o Print Not available

o Zoom Allows selection of a concentration range to be graphed. Two prompts are displayed in order, Upper Limit, then Lower Limit. Once this data is entered, the graph is re-displayed with the new scale.

o Unzoom Returns the scale to the original format and redraws the graph.

10. Telephone Not Used.

11. Baby's result Available for Blood Transfusion samples only.

FUNCTION KEYS/SHORTCUTS AVAILABLE IN ILAB

 Abort

 Short Help

 Long Help

 Refresh Screen

 Move to Next Mandatory Field

 Code List

 Supplementary Window - indicated by a caret >

 Scroll up code list

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 Scroll down code list

 Remove field entry

 < > Move between fields

 ? Find text

 # Flip code list

 { Abort

 } Return to logon menu

 X Log off - back to sign-on screen

Shortcuts in Date fields:

 T Today's date (Current system date)

 Y Yesterday's date

 n- Current date minus n days

51.1.5. Screen Printing It is recommended that the "Print Screen" function is not used and that "hard copy" reports received from the Laboratory are read and filed.

The Pathology Department cannot be held responsible for the accuracy or completeness of laboratory results printed via the "Print Screen" function.

51.1.6. Location Enquiry (LENQ) This module is used to retrieve a set of tabulated results from patients from one location for a specified period of time. The table may contain test results from one or more Pathology Departments.

Having logged onto the Ward enquiry menu, select/type3 or LENQ. The following screen is then displayed.

Use F11 key to list available options.

1. Location: Enter a location code such as AE, AKU and ICU etc. Use theF11 function key to list available locations, press .

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2. Test Group: Enter a cumulative table code such as UE, CHOL and CREAT etc., Use the F11 function key to list available locations, press .

3. From: Enter the start date. The default date is the current systems date. This is an inclusive date of specimen requests, press .

4. To: Enter the finish date. The default date is the current clock date. This is an inclusive date of specimen requests, press .

51.1.7. iLAB FAQs Question 1: When logging onto iLAB I get the following error message “3004-007 You entered an invalid login name” Answer 1: If prompted for a login you must enter APEX – you will then be prompted for a Username/Password.

Question 2: The system crashes when I enter the patient's PID or Chart Number. Answer 2: This is usually due to a corrupt PID/Chart Number pointer. The issue should be logged with IT support, in the meantime search for the patient using DOB and not PID/Chart number.

Question 3: The system says "Patient number & not known to APEX”. Answer 3: For a variety of reasons the details entered on iLAB may not match what you have. Try modifying your search criteria, instead use U as the PID and enter the patients surname and DOB.

Question 4: The system is "Unable to obtain a valid answerback" and looks for "Please enter Terminal ID (Answerback)". Answer 4: A valid answerback or terminal id is "ZLN", which must be typed in uppercase. Each computer can be configured with an automatic answerback, contact IT support if this is required. Question 4: I get one of the following error messages when I try to logon to iLAB.

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52 Test Repertoire A ABG (arterial blood gas analysis) Laboratory: Biochemistry Specimen type: Arterial blood in air-free heparinised syringe. Blood gas analysis sampling kits are available in each ward. Immediately after collection, expel any air from the sample and seal the syringe with the stopper provided in the sampling kit. Once the sample has been drawn, the blood gas syringe must be labelled with the patient’s full name, chart number, ward, date and time of collection. Labels suitable for affixing to blood gas syringes are made available to each ward. These labels display the URGENT alert message in a prominent manner.

Special requirements and The specimen should be brought to the Laboratory immediately. If delay between sample collection and comments: arriving in the laboratory is greater than 15 minutes send on ice. Blood gas syringes must not be sent to Biochemistry via the pneumatic chute. Turnaround time: 20 minutes.

Reference interval: On Biochemistry report or contact laboratory.

Acanthamoeba Laboratory: Microbiology Special requirements and Refer to Eye comments:

ACE (Angiotensin Converting Enzyme) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and ACE inhibitors, e.g. captopril, enalapril inhibit ACE activity. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Acetaminophen (Paracetamol) Laboratory: Biochemistry Specimen type: Serum: see special requirements.

Special requirements and Specimen should be drawn four hours post-overdose and preferably not later than 16 hours. Serum comments: values taken less than four hours post-ingestion are difficult to interpret due to the possibility of continuing absorption and distribution of the drug and may not represent the peak level.

Turnaround time: Urgent: 90 minutes. All other requests: 3hours.

Reference interval: On Biochemistry report or contact laboratory. PARACETAMOL RESULTS GUIDE: WARNING: please note that results are reported in mg/L Possible toxicity: >120mg/L at 4 hours, 60mg/L at 8 hours, or 30mg/L at 12 hours post-ingestion. Probable toxicity: >200mg/L at 4 hours, 100mg/L at 8 hours, or 50mg/L at 12 hours.

See paracetamol overdose treatment nomogram

Paracetamol overdose treatment nomogram

(Note that results are reported in mg/L) Reference: BNF November 2012

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Acetylcholine Receptor Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and This test is referred to the Neurology Laboratory, Churchill Hospital, Oxford, UK comments: Tel: +44 1865 225995

This test is not routinely available to general practitioners. Testing may be provided by arrangement only and following discussion with the Laboratory. Turnaround time: 2-3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Frequency determined by clinical context – every 6 months while on treatment

Acid phosphatase

Laboratory: Biochemistry Test information: Prostate Specific Antigen (PSA) has replaced this test in the investigation of prostate disease.

ACTH (Adrenocorticotrophic hormone) Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements and Collect specimen in ice-cold potassium EDTA tube (Violet FBC tube) and transport immediately to the comments: Clinical Biochemistry Laboratory. Please note that ACTH has a marked circadian rhythm.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Activated Protein C Resistance (APC-R) Laboratory: Haematology Test information: Generally requested as part of a thrombophilia screen. Thrombophilia screening requests must be sanctioned by the haematology team must include relevant clinical details. Thrombophilia screening is not performed on patients receiving warfarin and/or unfractionated heparin or novel anticoagulants.

Specimen type: 2 x Citrated plasma (Blue top) and 1 x EDTA (Violet Top) or if ordered as part of a thrombophilia screen 4 x Citrated plasma (Blue Top) and 1 x EDTA (Violet Top).

Special requirements and Sample must be sent to laboratory ASAP; time of collection must be noted on request form and/or comments: samples. Samples received in laboratory >4hrs post collection will be rejected.

Turnaround time: 4W

Reference interval: 120-300 seconds

Test / Profile code (iLab): APC-R / TPHIL

Acylcarnitine Laboratory: Biochemistry Specimen type: Four blood spots on a Guthrie Card or whole blood in paediatric lithium heparin specimen tube.

Special requirements and Appropriate clinical details required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Adenovirus Stools Laboratory: Serology Specimen type: Fresh stool sample collected in a sterile leak-proof universal container (white cap).

Special requirements and All stool samples sent for the investigation of viral gastroenteritis will have a PCR assay performed for comments: Adenovirus, Rotavirus, Norovirus, Sapovirus and Astrovirus.

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Turnaround time: 1 working day

Reference interval: Detected / Not Detected Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat testing to check for viral clearance is not indicated

Adenovirus Antibodies Laboratory: Serology Special requirements and This test is only available in specific circumstances and with prior approval of the Consultant comments: Microbiologist. Direct detection methods are recommended for the investigation of Adenovirus infection.

This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Specimen type: Gel Serum (Brown Top)

Turnaround time: Test Availability: By Arrangement

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Adrenal Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and Indications for testing and clinical information must be provided with the request. This test is referred to comments: the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 2 - 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Repeat testing of limited value – frequency to be determined by clinical context

Adverse (Anaphylactoid) Reactions to Intravenous Drugs: Plasma Tryptase Assay Laboratory: Biochemistry Specimen type: The preferred specimen is EDTA plasma (Violet Top) (at least 1 mL). It is possible to measure tryptase in serum if EDTA plasma is not available.

Special requirements and The first sample should be taken as soon as possible after commencement of the reaction and ideally comments: within the first 30 minutes. Further samples should be taken 3, and 24 hours after reaction.

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haematocrit), if available.

This documentation should accompany the plasma samples.

Telephone contact: At any stage of the reaction the user of the service is encouraged to telephone the Protein Reference Unit in Sheffield (00 44 114 271 5552) for advice. This advice is based on the cumulative experiences of NARCOS in the assessment of emergency situations. NARCOS provides a 24 hour advisory service via the Hospital switchboard (00 44 114 243 4343).

Store specimens at approximately +4 degrees Celsius prior to preparation for dispatch to referral laboratory.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

AFP (Alpha–fetoprotein) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details required. comments:

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

ALA (delta aminolevulinic acid; aminolevulinic acid) Laboratory: Biochemistry Specimen type: 24-hour urine collection; no preservative.

Special requirements and Protect the collection from light and keep refrigerated at 4-8°C. comments: Appropriate clinical details are also required. Random urine is suitable during a critical episode.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Albumin Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top) Urine albumin: Refer to: Urine Analyses for requirements, turnaround time and reference interval.

Special requirements and Assay is also available as part of the liver and bone test profiles. comments: Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: For more details, see RENAL / BONE section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Albumin Blood Product Laboratory: Blood Bank Test information: 250ml 5% albumin and 50ml/100ml 20% albumin are available.

Sample type: None

Request form: Blood Bank 1

Availability time: Same day

Risk and comments: Refer to the HG-A-BTR-ALBUMIN guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Alcohol (ethanol) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top), Li Hep plasma (Green Top), urine (random urine in Sarstedt Monovette Z 10mL urine container)

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Special requirements and This assay is intended to assist in the clinical management of the patient and is not provided for medico- comments: legal purposes or in relation to the Road Traffic Acts. Do not use alcohol swabs to clean venepuncture site. Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours.

Reference interval: On Biochemistry report or contact laboratory.

Aldosterone Laboratory: Biochemistry Specimen type: EDTA Plasma (Violet Top)

Special requirements and Appropriate clinical details required. Record specimen collection time and whether patient was ambulant comments: (Sampling in upright position after 1 hour of walking) or recumbent (sampling in the reclined position after 1 hour in supine position). Please list all current medications. The specimen when taken must be brought to the laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Alkaline phosphatase Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Assay is also available as part of the liver and bone test profiles. comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: See LFT section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Alkaline phosphatase isoenzymes Laboratory: Biochemistry Specimen type: Serum

Special requirements and Appropriate clinical details are required. Patient should be fasting. State Total ALP concentration. comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Alpha-1-acid glycoprotein (orosomucoid) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Alpha-1-antitrypsin Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Alpha-1-antitrypsin phenotyping Laboratory: Biochemistry

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Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details and the AAT concentration are required. comments:

Turnaround time: Requests for this test with an AAT concentration <1.0 g/L are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

ALT (Alanine aminotransferase) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements or This assay is available as part of the liver test profile. comments: Please ensure that specimens for the assay of transaminase activity (ALT or AST) are delivered to the Laboratory within 24 hours of sample collection.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: See LFT section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Aluminium Laboratory: Biochemistry Specimen type: Whole blood in trace metal-free tube. Trace metal-free needle must be used in conjunction with trace metal-free tube. Special requirements and This specimen should be collected first if other tests are requested to avoid contamination. comments: Please contact Clinical Biochemistry Laboratory for trace metal-free specimen collection tube and needle.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Amikacin Assay Laboratory: Microbiology Specimen type: Refer to Antibiotic Assay

Amino acids Laboratory: Biochemistry Specimen type: Lithium Heparin (Green Top) sample or 2 mL (minimum) of urine is required.

Special requirements and Appropriate clinical details are required. comments Ensure that specimen is sent to the laboratory without delay. Serum must be deproteinised for the measurement of sulphur containing amino acids - contact Clinical Biochemistry Laboratory.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Amiodarone Laboratory: Biochemistry Specimen type: 2.7mL potassium EDTA sample (fbc Violet Top) Gel tubes are not suitable. The time and quantity of last dose and sample collection time must be stated on request form.

Special requirements and Specimen should be drawn at least eight hours after the last dose. Amiodarone is strongly tissue–bound, comments: leading to a half-life of between 14 and 60 days. There is large inter-patient variability.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values. Ammonia Laboratory: Biochemistry

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Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met. Take at least 0.5 mL of blood into an EDTA specimen tube (Violet Top) standing in ice. See special requirements. Specimen must be sent to the laboratory immediately.

Special requirements and Plasma must be assayed immediately. Blood for plasma ammonia must be drawn, delivered to the comments: laboratory and entire assay completed within 60 minutes. Delay will result in a falsely raised plasma result. Appropriate clinical details are required.

Note: haemolysis will affect the reliability of the result.

Turnaround time: Once laboratory informed in advance results will be available in 90 mins.

Reference interval: On Biochemistry report or contact laboratory.

Amniotic Fluid PCR (Prenatal Screen)

Laboratory: Serology Specimen type: Amniotic Fluid

Special requirements and Requests for this test are referred directly from UMHL to The Doctors Laboratory, London comments: Refer to Fluids (Sterile) for food culture.

Turnaround time: 2 - 3 days for PCR 2 - 3 weeks for karyotyping

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Amoeba Antibodies Laboratory: Serology Specimen type: Gel Serum (brown top).

Special requirements and Please provide relevant clinical details with request. comments: This test is only available following prior arrangement with the Consultant Microbiologist.

This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 1 - 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Amphetamines Laboratory: Biochemistry Specimen type: Random urine collected without any preservative in ‘ BD Vacutainer 4ml urine container ( Beige Top)

Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference interval: On Biochemistry report or contact laboratory.

Amylase Laboratory: Biochemistry Specimen type: Gel Serum (Brown top) Urinary amylase: Refer to: Urine Analyses for requirements, turnaround time and reference interval.

Special requirements and None. comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Amyloid A protein Laboratory: Biochemistry

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Specimen type: Gel Serum (Brown top)

Special requirements and Ensure that specimen is sent to the laboratory without delay. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

ANA (Antinuclear Antibodies) / Autoantibodies Laboratory: Serology Specimen type: Gel Serum (Brown top)

Special requirements and Clinical details are required with all requests for ANA testing. comments: Note: ANA testing should not be requested without a clinical evaluation that leads to a presumptive diagnosis. Samples which are ANA positive are automatically titrated and reflex testing for ENA and Anti-dsDNA is performed.

**Please note that ANA testing is not available outside routine working hours. Urgent testing will only be performed on the next working day**

Turnaround time: 3 working days

Reference interval: Positive / Negative ANA titre and staining pattern are also reported Relevant interpretive comments are included on the report. Repeat testing interval: Generally, repeat ANA testing in patients who have tested negative for ANA in the past is not indicated. If the clinical course changes over time a repeat ANA test may be requested.

With the exception of antibodies to dsDNA, variation in the titre levels of other antibodies to nuclear antigens has not been shown to provide useful clinical information. Therefore, repeating tests which were previously reported positive (other than Anti-dsDNA), is not indicated.

ANCA (p-ANCA/c-ANCA) Anti-Neutrophil Cytoplasmic Antibody Laboratory: Serology Specimen type: Gel Serum (Brown top)

Special requirements and All requests for ANCA serology must have clinical details provided on the request form. Requests should comments: be supported by clinical data suggestive of an ANCA related vasculitis.

Turnaround time: 3 working days

Note: Urgent ANCA testing is available by arrangement with the laboratory. Urgent testing is available only during the following hours:  09:00 – 20:00 [Monday to Friday],  09:00 – 13:00 [Saturdays]  10:00 – 14:00 [Sundays & Bank Holidays].

Requests for urgent testing outside these hours cannot be facilitated.

Reference interval: Positive / Negative ANCA titre and staining pattern are also reported ANCA positive samples are automatically reflex tested for Anti-MPO and Anti-PR3 Relevant interpretive comments are included on the report.

Repeat testing interval: In cases of negative results: >3 weeks (if patient is symptomatic) In cases of ANCA positive results - On treatment: 6 months Off treatment: annually Androgen profile (female patients) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Profile includes testosterone, sex hormone binding globulin. Appropriate clinical details are required. comments: Turnaround time: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

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Androstenedione Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Morning specimen recommended. comments: Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Antenatal group and antibody screen Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 2 Turnaround time: Next routine working day after receipt except for samples received on Friday, which will be tested on Monday.

Minimum recommendation for  First antenatal visit (i.e. at about 12 weeks gestation) antenatal testing:  Repeated again between 28 weeks gestation  If anti-D, c or K (or clinically significant antibodies with titre >32) are found, tests should be repeated at monthly intervals up to 28 weeks and every 2 weeks thereafter to monitor antibody levels. Paternal testing may also be required.  If the antibody concentration is increasing, referral to a specialist unit is indicated.  The blood transfusion laboratory will provide advice on the report regarding the frequency of testing for all clinically significant antibodies.

Special requirements and The blood transfusion report will inform the clinician responsible for patient care of the likely significance comments: of the antibody (ies) with respect to the development of HDN and transfusion problems.

Note: If a patient has an antibody, a repeat group and screen sample needs to be taken if patient admitted to hospital. Antenatal antibody titration Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 2

Turnaround time: 1 day after receipt, except for samples received on Friday which will be tested on Monday.

Antenatal anti-D quantitation Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top) or Clotted Neutral Bottle (White top not gel). Fill to mark.

Request form: Blood Bank 2

Turnaround time: 8-10 days - anti-D quantitations are performed on Monday, Wednesday and Friday by the National Blood Centre, Dublin. Antenatal anti-c quantitation Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top) or Clotted Neutral Bottle (White top not gel). Fill to mark.

Request form: Blood Bank 2 Turnaround time: 8-10 routine working days - anti-c quantitations are performed on Wednesday by the National Blood Centre, Dublin. Samples need to be collected on Monday of each week.

Anti Mullerian Hormone (AMH) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Blood sample should be sent to the Laboratory within 4 hours of venesection comments: This assay is only available to Consultants within the UL Hospital Group.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Antibiotic Assay

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Laboratory: Microbiology Assay type: Gentamicin Tobramycin Amikacin Vancomycin Teicoplanin (Referred to the UK – by arrangement with consultant microbiologist only).

Specimen requirements and Gel Serum (Brown top) comments: Paediatric Gel Serum (Brown top) Time of sample, time of dose and dosing regime MUST be stated on the request form to assist interpretation. “Random samples” should not be submitted.

Sample volume: At least 1mL blood

Turnaround time: Same day. Routine specimens are batch tested in the laboratory at 12.00pm and 4.00pm. Only specimens from patients with unstable renal function will be processed outside of these scheduled times. Urgent assays are available outside of these times by contacting the Microbiology laboratory directly on 2502. Urgent assays between the hours of 11pm and 9am must be approved by the consultant Microbiologist on duty via switch prior to contacting the laboratory. It is the responsibility of the Registrar on call to contact the Microbiologist with such requests. See antimicrobial app and antimicrobial guidelines on Intranet (IHUB) for further information.

Reference internal: a) Aminoglycoside – Once daily dosing / Extended Interval / Pulse Dosing Trough Gentamicin < 1 mg/L Amikacin < 5 mg/L Tobramycin < 1 mg/L

b) Aminoglycoside – Conventional dosing / Multiple daily dosing Trough Peak Gentamicin – Infective Endocarditis < 1 mg/L 3–5 mg/L Gentamicin – other infections < 2 mg/L 5–10 mg/L Amikacin < 10 mg/L 20–30 mg/L Tobramycin < 2 mg/L 5–10 mg/L

c) Glycopeptides Trough Peak Vancomycin 15–20 mg/ *complicated infections such as bacteraemia, endocarditis, osteomyelitis, meningitis and hospital-acquired pneumonia caused by S. aureus.

Vancomycin – other infections 10–15 mg/L Teicoplanin- Infective Endocarditis 20–60 mg/L Teicoplanin- other infections 10–60 mg/L

NB: Trough and peak levels should not exceed above levels. Please refer to the MWRH Antibiotic Guidelines for further details on dosage requirements

OBI Additional information: . Random levels are not recommended by the consultant microbiologist because of difficulty with interpretation . Pre-dose (Trough) Level: Blood sample is drawn 30 mins before the dose is due to be given. . Post-dose (Peak) Level: Blood is drawn 1 hour after the start of a 30 minute infusion or 1hour after the administration of a slow intravenous injection. . Inactivation of aminoglycosides by ß-lactam antibiotics occurs; as a result it is recommended that if samples for aminoglycoside estimation cannot be assayed immediately they should be stored at 0°C - 5°C. . The Microbiology Laboratory requests the provision of a Microbiology request form and a separate clotted blood sample.

Antibody identification Laboratory: Blood Bank Sample type: 7.5ml EDTA (Red top)

Request form: Blood Bank 1 or 2 as appropriate

Turnaround time: 1 day depending on priority

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Comment: A second sample may be required for complex antibody identifications.

Antibody investigation referrals to reference laboratory Laboratory: Blood Bank Sample type: 7.5ml EDTA (Red top)

Request form: Blood Bank 1 or 2 as appropriate

Turnaround time: 1 week depending on priority.

Anti-D Laboratory: Blood Bank Sample type: 7.5ml EDTA (Red Top)

Request form: Blood Bank 1 Turnaround time: < 72hours

Risk and comments: Refer to the HG-A-BTR-ANTID guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Anti-Factor Xa Level (Low molecular weight (LMWH) Heparin only) Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and  Requests should be received by the laboratory within 1 hour of phlebotomy. comments:  Routine weekly anti Xa levels should be sent on Monday mornings.  Specimen should be taken 3 hours post dose.. The time of the last heparin dose must be stated on the request form.

Turnaround time: 1W

Reference interval: Ranges vary according to condition being treated and whether treatment is therapeutic or prophylactic.

Test / Profile code (iLab): ANTI-X

Anti-HBsAg /Hepatitis B Vaccine Immunity screen Laboratory: Serology Specimen type: Gel Serum (brown top).

Special requirements and Hepatitis B immunity screen should be requested in the ‘Investigations required’ section of the comments: Serology/Immunology request form. Repeat requests for Immuno-competent individuals with previous results of >100 mIU/mL are not indicated.

Post –vaccination serological testing – routine post-vaccination testing for anti-HBs is recommended 2 months after completing the course of vaccination for persons at risk of HBV exposure, e.g. health care workers, dialysis patients, sexual partners of HBsAg positive persons. This does not apply to children receiving routine childhood immunization with hepatitis B vaccine (Ref; Immunisation guidelines of Ireland, 2008)

Turnaround time: 2 working days Urgent requests are processed on the day of receipt.

Reference interval: <10 mIU/mL: Non-immune >/=10 mIU/mL: Immune – No further action required.

Relevant interpretive comments regarding further vaccination are included on the report.

Repeat testing interval: A result of >/=10 mIU/mL is immune-competent - no further testing required (refer to the latest edition of the immunisation guidelines of Ireland for advice on vaccination in immuno-compromised groups, dialysis patients). https://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/immunisationguidelines.html

Antithrombin III (ATIII) Laboratory: Haematology Test information: Generally requested as part of a thrombophilia screen. Thrombophilia screening requests must be sanctioned by the haematology team and as such must include relevant clinical details.

Thrombophilia screening is not performed on patients receiving warfarin and/or unfractionated heparin or novel anticoagulants.

Specimen type: 2 x Citrated plasma (Blue Top) Or, if ordered as part of a thrombophilia screen, 4 x Citrated plasma (Blue Top) and 1 x EDTA (Violet Top)

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Reference interval: 80-120 U/dl Antithrombin III levels are affected by pregnancy

Test / Profile code (iLab): ATIII / TPHIL

Apolipoprotein E phenotype Laboratory: Biochemistry Specimen type: EDTA plasma (Violet Top)

Special requirements and Appropriate clinical details are required. comments: Turnaround time: Requests for this test are referred to an external specialist laboratory. Store specimen at approximately 4 degrees Celsius prior to preparation for dispatch to referral laboratory. Reference interval: The referral laboratory report provides appropriate reference values.

APTT (Activated Partial Thromboplastin Time) Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and APTT requests for heparin dosage assessment should be received by the laboratory within 2 hours of comments: phlebotomy. Samples for patients who are not on heparin must be received by the laboratory within 8 hours of phlebotomy.

Out of hour/urgent requests for this test originating from external sources to UHL must include clinician’s direct contact details and advance notice to the laboratory is advised.

Turnaround times: Urgent: 1 H Non GP: 4H GP: 8H

Reference interval: 28.0-40.0 seconds

Test / Profile code (iLab): APTT / COAG

Arterial blood gas analysis (ABG) Laboratory: Biochemistry Specimen type: Arterial blood in air-free heparinised syringe. Blood gas analysis sampling kits are available in each ward. Immediately after collection, expel any air from the sample and seal the syringe with the stopper provided in the sampling kit.

Once the sample has been drawn, the blood gas syringe must be labelled with the patient’s full name, chart number, ward, date and time of collection. Labels suitable for affixing to blood gas syringes are made available to each ward. These labels display the URGENT alert message in a prominent manner.

Turnaround time: 20 minutes.

Reference interval: On Biochemistry report or contact laboratory.

ASOT (Anti-Streptolysin O Titre) Laboratory: Serology Specimen type: Gel Serum (brown top).

Special requirements and Please provide relevant clinical details with request. comments:

Turnaround time: One working day

Reference interval: Adults: < 200 IU/mL Children: < 150 IU/mL Relevant interpretive comments are included on the report. Repeat testing interval: >2 weeks

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Aspergillus Antigen (Galactomannan Test & PCR) Laboratory: Serology Specimen type: Gel Serum (brown top) - Galactomannan Test 2 x EDTA (Violet Top) - Aspergillus PCR Special requirements and Note: Requests for Galactomannan and Aspergillus PCR must be discussed with the Consultant comments: Microbiologist / Infectious Diseases Consultant prior to requesting the test.

Requests for this test are referred to PHE Mycology Reference Unit, Bristol, Tel: +44 117 342 5028 Turnaround time: 2 – 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges, interpretive comments and advice on frequency of retesting.

Aspergillus Precipitins Laboratory: Serology Test information: This test is only available when ordered by a Consultant Respiratory Physician in ULHG. Requests not ordered by a Consultant Respiratory Physician are only availalbe following prior arrangement with the Consultant Microbiologist. Requests that are part of the Hypersensitivity Pneumonitis panel are sent to Biomnis Laboratories.

AST (Asparate aminotransferase) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Please ensure that specimens for the assay of transaminase activity (ALT or AST) are delivered to the comments: Laboratory within 24 hours of sample collection. Haemolysis invalidates the result.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Astrovirus (Stools) Laboratory: Serology Specimen type: Fresh stool sample collected in a sterile leak-proof universal container (white cap).

Turnaround time: 1 working day

Reference interval: Detected / Not Detected Relevant interpretive comments are included on the report.

Repeat testing interval Repeat testing to check for viral clearance is not indicated

Atypical Pneumonia Screen Laboratory: Serology Special requirements and Serology for Mycoplasma pneumonia and Chlamydia pneumonia is available by arrangement only comments: following discussion with the Microbiologists. For inpatients molecular detection by PCR on a respiratory sample may be indicated – discuss with Microbiology Laboratory.

A urine sample sent to the Microbiology Laboratory is recommended for the investigation of Legionella.

Avian Precipitins Laboratory: Serology Special requirements and This test is only available when ordered by a Consultant Respiratory Physician in ULHG. Requests not comments: ordered by a Consultant Respiratory Physician are only availalbe following prior arrangement with the Consultant Microbiologist.

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This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Specimen type: Gel Serum (Brown top)

Turnaround time: 1 - 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing interval: Not routinely required.

Azathioprine (for patients about to commence azathioprine, Imuran®, therapy) Laboratory: Biochemistry Test information: Requests for the measurement of Thiopurine S-Methyltransferase activity in patients about to commence azathioprine therapy. Specimen type: Two specimens of whole blood in potassium EDTA tubes (Violet Top). Specimen should be sent to the Clinical Biochemistry Laboratory.

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

B B12 Laboratory: Haematology Specimen type: Gel Serum (Brown top)

Special requirements and Requests should be received by the laboratory within 8 hours of phlebotomy, add on tests within 24 hours comments: of phlebotomy. Relevant Clinical Details required.

General principles 1. Measurement of vitamin B12, folate or ferritin should only be performed following clinical assessment, and in the presence of one of the specific indications listed below. 2. Fatigue and tiredness are not indications for vitamin B12, folate or ferritin measurement. 3. Vitamin B12, folate and ferritin testing should not be measured as part of a general health screen. 4. Patients who are pregnant/taking an oral contraceptive pill/taking Metformin can have falsely low vitamin B12 levels. 5. Vitamin B12 stores last over three years. Therefore, if a normal vitamin B12 result has been obtained in the previous six months, a further vitamin B12 test will not be processed unless discussed with a haematology consultant. 6. Folate stores last for a shorter period of time. Therefore, repeat folate testing may be necessary if one of the indications below is met. 7. Patients on parenteral vitamin B12 replacement therapy do not require repeat vitamin B12 measurement unless blood counts or neurological symptoms fail to improve. 8. Patients on folic acid replacement therapy do not require repeat folate measurement unless blood counts fail to improve. 9. The minimum interval for repeat testing of vitamin B12 and folate is generally 90 days. However, if appropriate new clinic details are provided, retesting may be performed within 90 days.

Indications for Vitamin B12 and Folate Measurement Haematological unexplained anaemia/other cytopenias unexplained macrocytosis haemolysis

Neurological subacute combined degeneration of the cord peripheral neuropathy dementia unexplained neurology Other glossitis pregnancy malabsorption previous gastric resection

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strict vegans alcoholism patients on dialysis

Medications Metformin therapy prolonged proton pump inhibitor or H2 receptor antagonist therapy anticonvulsant therapy Methotrexate therapy

Turnaround time: 3 D

Reference interval: Age and sex related. Refer to report form.

Test / Profile code (iLab): B12 / BFF

B2-microglobulin (beta-2-microglobulin) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Barbiturates (Semi Quantitative) Laboratory: Biochemistry Specimen type: Random urine specimen collected without any preservative – BD Vacutainer 4ml urine container (Beige Top) Special requirements and The assay is intended to assist in the clinical management of the patient and is not provided for medico- comments: legal purposes. The requesting doctor may need to consider whether a patient might avail of opportunities to alter or interfere with the integrity of the specimen.

Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference interval: On Biochemistry report or contact laboratory.

Bartonella Antibodies (Cat Scratch Disease) Laboratory: Serology Special requirements and Requests for Bartonella antibodies should be discussed with the Consultant Microbiologist / Infectious comments: Diseases Consultant prior to requesting the test. Please provide relevant clinical details with request.

This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545 Specimen type: Gel Serum (Brown top)

Turnaround time: 3 - 4 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Bence Jones Protein Laboratory: Biochemistry Specimen type: 20 ml urine in a universal container. No preservative required: keep refrigerated.

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Benzodiazepine (semi-quantitative, serum) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

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Special requirements and The assay is intended to assist in the clinical management of the patient and is not provided for medico- comments: legal purposes.

Turnaround time: Requests for this test are referred to an external specialist laboratory

Reference interval: The referral laboratory report provides appropriate interpretation of the result.

Benzodiazepine (semi-quantitative, urine) Laboratory: Biochemistry Specimen type: Random urine specimen collected without any preservative – BD Vacutainer 4ml urine container (beige top) Special requirements and The assay is intended to assist in the clinical management of the patient and is not provided for medico- comments: legal purposes. The requesting doctor may need to consider whether a patient might avail of opportunities to alter or interfere with the integrity of the specimen.

Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference interval: On Biochemistry report or contact laboratory.

Beta-hydroxy butyrate Laboratory: Biochemistry Specimen type: The Clinical Biochemistry Laboratory must be contacted before initiating the request so that all collection requirements can be met.

Special requirements and The Clinical Biochemistry Laboratory must be contacted before initiating the request so that all collection comments: requirements can be met. The specimen when taken must be brought to the laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Beta-2-microglobulin Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Beta 2 transferrin (Tau Protein; Rhinorrhoea Fluid Analysis) Laboratory: Biochemistry Specimen type: Nasal fluid accompanied by 1 mL of serum.

Special requirements and Appropriate clinical details are also required. comments: This assay differentiates CSF from other biological fluids.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Bicarbonate (actual; BGA) Laboratory: Biochemistry Specimen type: Arterial blood in air-free heparinised syringe. Blood gas analysis sampling kits are available in each ward. Immediately after collection, expel any air from the sample and seal the syringe with the stopper provided in the sampling kit.

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Reference interval: On Biochemistry report or contact laboratory.

Bicarbonate (serum/plasma) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top) Lithium Heparin Plasma (Green Top)

Special requirements and Blood sample to be received in the laboratory within two hours of collection. comments: This assay is also available as part of the electrolyte profile (in-house).

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours.

Reference interval: On Biochemistry report or contact laboratory.

Bile Laboratory: Microbiology Specimen requirements and Sterile universal container. comments: Bile may be collected in theatre or from a closed drainage system by aspiration with a needle and syringe.

Sample volume: Minimum volume of 1ml.

Special precautions: Deliver to the laboratory immediately. The volume of specimen influences the transport time that is acceptable. Large volumes of purulent material will maintain the viability of anaerobes for longer.

Suggested transport times for varying volumes of specimen when examining for anaerobes:

Volume of aspirated material Optimal time for transport to the Laboratory <1mL <10 min 1mL <30 min >2mL <3 h

The recovery of anaerobes is compromised if the transport time exceeds 3h.

Please specify on the request form if the patient is immunocompromised or if investigation for Salmonella spp is required.

If processing is delayed, refrigeration is preferable to storage at ambient temperature.

Turnaround time: Aerobic report: 2-3 working days. Anaerobic report: 5-7 working days

Bile Acids Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and As Bile acid levels can rise significantly after a meal, samples should preferably be taken before a meal, comments: after fasting for approximately 4 hours. Appropriate clinical details required

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Bilirubin (direct) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Samples should be protected from bright light. Measurement available when Total Bilirubin is raised. comments:

Turnaround time: Urgent sample: 90 mins. Wards: 3 hours.

Reference interval: On Biochemistry report or contact laboratory.

Bilirubin (total) Laboratory: Biochemistry

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Specimen type: Gel Serum (Brown top)

Special requirements and Samples should be protected from bright light. This assay is also available as part of the liver test profile. comments: Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: See LFT section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Biotinidase Laboratory: Biochemistry Specimen type: 1 mL of whole blood in lithium heparin specimen tube.

Special requirements and The specimen should be surrounded with ice and brought to the laboratory immediately. comments: Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Blood Culture Laboratory: Microbiology Test information: Note 1: If blood for other tests such as blood gases or ESR is to be taken at the same venepuncture, the blood culture bottles should be inoculated first to avoid contamination. It is preferable to take blood for culture separately.

Note 2: Please fill blood cultures to the optimal fill line marked on bottles. Refer to section 18.10 Note 3: Please ensure blood cultures are referred to the Microbiology Laboratory immediately after collection. Blood cultures must be placed on the continuous monitoring blood culture machine in the laboratory within a maximum of 4hr.

Note 4: Please state date & time of collection on request form.

Specimen requirements Adult Aerobic Bottle (Green) Anaerobic Bottle (Orange) Neo-nates Paediatric Bottle (Yellow) Infants Paediatric Bottle (Yellow) Pre-teen children Paediatric bottle (Yellow)

Sample volume Adult 5-10mL blood Neo-nates Paediatric 1-2mL blood Infants 2-3mL blood Pre-teen children 3-5mL blood

Sample Collection Department of Health Recommendations – Taking Blood Cultures Blood cultures should only be collected by members of staff (medical, nursing, healthcare assistant, or phlebotomist) who have been trained in the collection procedure and whose competence in blood culture collection has been assessed.

 Always make a fresh stab In patients with suspected bacteraemia, it is generally recommended that two sets of cultures be taken at separate times from separate sites.

Do not use existing peripheral lines/cannulae or sites immediately above peripheral lines. (If a central line is present, blood may be taken from this and from a separate peripheral site when investigating potential infection related to the central line; the peripheral vein sample should be collected first.) Identify a suitable venepuncture site before disinfecting the skin. Avoid femoral vein puncture because of the difficulty in adequate skin cleansing and disinfection.

 Thoroughly disinfect the skin before inserting the needle Thoroughly cleanse the patient’s skin before venepuncture. Use soap and water to clean visibly soiled skin and then clean your own hands. Use a 2% chlorhexidine in 70% isopropyl alcohol impregnated swab to disinfect the patient’s skin and allow to dry.

 Once disinfected, don’t touch the skin again To avoid cross-contamination from the collector’s fingers (even when gloved), it is vitally important not to palpate the site again once it has been disinfected.

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 Disinfect the culture bottle cap before transferring the sample Ideally, remove the plastic cover immediately before collecting the sample; the top of the bottle will be clean but not sterile. Disinfect the tops of the culture bottles with a 2% chlorhexidine in 70% isopropyl alcohol impregnated swab. Allow the alcohol to fully evaporate before proceeding with bottle inoculation.

NB: The use of blood collection adapter caps without winged blood collection sets is not recommended. It is not possible to accurately judge sample volume and there is the potential for possible backflow of blood culture media into patient veins.

1. Skin preparation Clean hands using correct hand hygiene technique (use of the World Health Organisation’s ‘5 moments of hand hygiene’ or the NPSA ‘Clean you hands campaign’ is recommended).  Clean any visibly soiled skin on the patient with soap and water then dry.  Apply a disposable tourniquet (if applicable) and palpate to identify vein.  Clean skin with a 2% chlorhexidine in 70% isopropyl alcohol impregnated swab and allow to dry.  Do not repalpate skin following cleaning  If a culture is being collected from a central venous catheter, disinfect the access port with a 2% chlorhexidine in 70% isopropyl alcohol impregnated swab.

2. Bottle preparation  Label bottles with appropriate patient information.  Ensure that barcodes on the bottles are not covered by additional labels and that any tear-off barcode labels are not removed.  Clean the tops of culture bottles with a 2% chlorhexidine in 70% isopropyl alcohol impregnated swab and allow to dry.

3. Sample collection - use either method A or B as follows:

A: NEEDLE AND SYRINGE METHOD  Clean hands again using correct hand hygiene technique (use of the World Health Organisation’s ‘5 moments of hand hygiene’ or the NPSA ‘Clean you hands campaign’ is recommended) or use alcohol hand rub and apply clean examination gloves (sterile gloves are not necessary).  Gloves and apron are worn (in line with local policy). Personal protective equipment (PPE) is disposed of correctly (in line with local policy) after use.  Insert needle. Do not palpate again after cleaning.  Collect sample and release tourniquet.  Cover the puncture site with an appropriate dressing.  If blood is being collected for other tests, always inoculate the blood culture bottles first.  Inoculate blood into culture bottles; do not change the needle between sample collection and  Inoculation; inoculate anaerobic culture first.  Discard needle and syringe in a sharps container.  Clean hands again using correct hand hygiene technique (use the World Health  Organisation’s ‘5 moment of hand hygiene’ or the NPSA ‘Clean Your Hands Campaign are recommended).

B: WINGED BLOOD COLLECTION METHOD  Clean hands again using correct hand hygiene technique (use of the World Health Organisation’s ‘5 moments of hand hygiene’ or the NPSA ‘Clean you hands campaign’ is recommended) or use alcohol hand rub and apply clean examination gloves (sterile gloves are not necessary).  Gloves and apron are worn (in line with local policy) Personal protective equipment (PPE) is disposed of correctly (in line with local policy) after use.  Attach winged blood collection set to blood collection adapter cap.  Insert needle into prepared site. Do not palpate again after cleaning.  Place adapter cap over blood collection bottle and pierce septum.  Hold bottle upright and use bottle graduation lines to accurately gauge sample volume and collect sample; inoculate aerobic culture first.  If blood is being collected for other tests, always collect the blood culture first.  Cover the site with an appropriate sterile dressing.  Discard winged blood collection set in a sharps container.  Clean hands using correct hand hygiene technique (use of the World Health Organisation’s ‘5 moments of hand hygiene’ or the NPSA ‘Clean you hands campaign’ is recommended) after removing gloves.

4. Number and time of collection – General guide Suspected sepsis or acute septic shock. In cases of suspected sepsis or acute septic shock or in individuals with any prosthetic material in situ (valve, hip etc), collect 2-3 separate venepunctures (two bottles each) immediately before starting treatment.

Suspected line sepsis

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Please ensure that a blood culture set is taken both peripherally and from the suspected line.

Infective endocarditis (IE) or chronically ill patients In suspected Infective endocarditis (IE) or chronically ill patients, obtain three blood culture sets during the first 1-2 hours of evaluation; if all are sterile 24 hours later, obtain three more sets. From patients who have received antimicrobial agents within two weeks prior to admission, obtain two separate blood cultures on each of three successive days.

Suspected bacteremia For suspected bacteremia in patients already on antimicrobial therapy, if therapy cannot be suspended for a few days, draw 2-3 cultures within the first 48 hours. Cultures should be taken immediately before the next dose of antimicrobial agent if the patient is receiving intermittent parenteral therapy.

Pyrexia of unknown origin (PUO) For fever of unknown origin (e.g., occult abscess, typhoid fever, or brucellosis), obtain two or three blood cultures initially. Then 24-36 hours later, obtain two more cultures immediately before the expected (usually afternoon) temperature elevation.

Sepsis of the newborn One to two blood cultures usually suffice for diagnosing sepsis of the newborn. The physician should determine the volume of blood. Inject 1-2mL into a paediatric bottle.

Blood culture for Mycobacterium sp. Please refer to the TB section in this manual.

5. Incubation Routine blood cultures are incubated for five days, unless the lab is notified to hold for a longer period (e.g., when IE, brucellosis or systemic fungal infections such as histoplasmosis are suspected). The routine 5-day incubation period is adequate for recovery of most yeasts (e.g., Candida species). Special precautions: DO NOT COVER BOTTLE BARCODE AS THIS IS SCANNED AS PART OF THE ANALYTICAL PROCESS  Ensure that the blood culture bottles have not exceeded their expiry date.  Sample is taken preferably before antimicrobial treatment is started.  Collect specimens as soon as possible after a spike of fever, except in endocarditis where timing is less important.  Indicate if specific organisms are sought e.g. endocarditis.  Blood cultures should be transported to the laboratory and incubated within a maximum of 4 hours  Do not refrigerate.

Turnaround time: Blood cultures are monitored continuously. Positive result Positive results are telephoned as soon as available to the requesting source. Final positive report is issued when all relevant investigations are complete.

Negative result 48 hour negative report available on line. Final negative report: 5 -7 days (7 days if endocarditis is suspected). Blood film Laboratory: Haematology Specimen type: EDTA (Violet Top)

Special requirements and Sample must be received within 2 hours of phlebotomy to avoid EDTA changes on the blood film. Please comments: include relevant clinical details. Blood films will be made, examined and reported on patients’ FBC results which satisfy the criteria laid in laboratory guidelines. Turnaround time: 3 D

Reference interval: N/A

Test / Profile code (iLab): FILM

BNP (NT-proBrain Natriuretic Peptide) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and This assay measures N-terminal pro B-type natriuretic peptide in human serum. comments: Appropriate clinical details are required.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

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Reference interval: NT-proBNP values need to be interpreted in conjunction with the medical history, clinical findings and other information. Based on a number of studies, serum NT-proBNP values below 125pg/mL (ng/L) are considered normal. Because of the high biological variability in NT-proBNP within an individual, caution should be exercised in interpreting changes of less than 100% as being related to medical therapy. Bone Marrow Aspirate (BMA) Processing Laboratory: Haematology Specimen type: Bone marrow spread on glass slides.

Special requirements and All BMA requests should be accompanied by an EDTA (FBC) sample. FBC/film should be requested on a comments: separate form. Bone marrow slides should be delivered to the laboratory fresh or should be fixed in methanol. Slides must be labelled on frosted side using a lead pencil. Identification details should include:  Patients full name.  PID / Chart number and/or DOB.  Specimen date. Accompanied by UHL haematology request form.

Turnaround time: 14 D

Reference interval: N/A

Test / Profile code (iLab): N/A. Search by discipline – Histology.

Bone profile Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Profile includes calcium, phosphate, alkaline phosphate, total protein, and albumin. comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: In non-acute setting unless there are other clinical indications, do not retest within 3 months. For more details, see BONE section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Bordetella Pertussis Laboratory: Microbiology Specimen type: Nasopharyngeal aspirate is the preferable specimen. Pernasal / nasopharyngeal swabs will suffice. (Amies charcoal swab- Flexible twisted wire - blue cap,Available from the microbiology laboratory, Tel: 061-482255) Cough Plates should not be used Specimen collection: A perinasal swab (Amies Charcoal - blue cap with flexible wire shaft) is inserted through a nostril and advanced along the floor of the nose until it reaches the nasopharynx. It has been suggested that the swab be held against the posterior nasopharynx for up to 30 seconds or until the patient coughs. In practice, it is more likely that a patient will only be able to tolerate this for a few seconds.

Note: Sampling of nasopharyngeal secretions in patients with whooping cough may precipitate a paroxysm of coughing and cause obstruction of the airways. Resuscitation equipment must be available if whooping cough is suspected. The specimen collector should avoid exposure to direct coughs from the patient.

Nasopharyngeal exudate may be obtained using a suction catheter (No.8 French) inserted through the nose. The exudate is collected in a sterile plastic trap in which the specimen is transported to the laboratory or in a sterile clear plastic universal container. Special precautions: Deliver to the laboratory immediately.

Turnaround time: Final report: 7–9 days. Positive isolates are telephoned when available to the requesting source.

Bordetella pertussis Antibodies (IgM & IgG) Laboratory: Serology Test information: Note: A perinasal swab / Nasopharyngeal aspirate for culture is recommended for the investigation of Bordetella pertussis infection. Refer to Bordetella Pertussis

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Specimen type: Gel Serum (Brown top)

Special requirements and Serology testing is only available following prior arrangement with the Consultant Microbiologist. comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545 Turnaround time: 1 - 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Breast Milk Laboratory: Microbiology Specimen type: Breast milk

Specimen collection: Express into a sterile universal container

Special precautions: N/A

Turnaround time: Final report 3-5 working days Bronchoalveolar Lavage, and associated specimens Laboratory: Microbiology Test information: Please refer to Sputum, Bronchoalveolar Lavage, and Associated Specimens

Brucella Antibodies (IgG & IgM) Laboratory: Serology Special requirements and Brucella serology is only available in specific circumstances and following prior arrangement and comments: discussion with the Consultant Microbiologist. Requests for Brucella serology require a Brucella Diagnostic Unit request form. This form is available by contacting the laboratory. Requests will only be referred to the referral laboratory on receipt of the completed request form.

This test is referred to the Brucella Reference Unit (BRU), Liverpool, UK Tel: +44 151 706 4404

Specimen type: Gel Serum (Brown top)

Turnaround time: 2 – 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

C1 Esterase inhibitor concentration Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Appropriate clinical details are required. comments: The specimen taken must be brought to the laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

C1 Esterase inhibitor: functional assay Laboratory: Biochemistry Specimen type: 5 mL of whole blood in sodium citrate tube (Blue Top) and 1 mL of Gel Serum (brown top)

Special requirements and Appropriate clinical details are required. comments: The Clinical Biochemistry Laboratory must be contacted before initiating the request so that all collection requirements can be met. The specimens when taken must be brought to the laboratory immediately. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

C282Y Mutation (Haemochromatosis Gene) Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top)

Special requirements and Refer to Haemochromatosis Gene Testing (H63D, C282Y) comments:

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Turnaround time: 45 D

Reference interval: N/A Test / Profile code (iLab): C282Y / HLAHP

C3 Complement Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Appropriate clinical details are required. comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values

C4 Complement Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values

CA 125 (alternative: OV-MA) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and IMPORTANT WARNING: comments: This assay is not validated for use as a screening test for cancer. The regulatory body approval for this assay states that it is intended strictly for in vitro diagnostic use as an aid in monitoring the response to therapy for patients with epithelial ovarian cancer, and in detecting residual ovarian cancer in patients who have undergone first-line therapy and would be considered for diagnostic second-look procedures.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

CA 15.3 (alternative: BR-MA) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and IMPORTANT WARNING: comments: This assay is not validated for use as a screening test for cancer. It has regulatory body approval for the quantitative measurement of CA15.3 antigen in human serum, as an aid in the detection of recurrence in previously treated stage 2 and stage 3 breast cancer patients, and in the management of metastatic breast cancer patients by monitoring disease progression or response to treatment.

Turnaround time: Urgent: 1 working day. Routine: 4 days.

Reference interval: On Biochemistry report or contact laboratory.

CA 19.9 (alternative: GI-MA) Laboratory: Biochemistry Specimen type: Gel Serum (Brown top)

Special requirements and IMPORTANT WARNING: comments: This assay is not validated for use as a screening test for cancer.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Caeruloplasmin Laboratory: Biochemistry

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Specimen type: Gel Serum (Brown top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values

Caffeine Laboratory: Biochemistry Specimen type: Lithium Heparin sample (Green Top)

Special requirements and Draw specimen at a consistent interval for the last dose. Please state exact time of specimen collection comments: and relationship to the last dose.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Calcitonin Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top). See special requirements and comments.

Special requirements and Appropriate clinical details are required. comments: A fasting specimen is required. Collect blood in an ice-cold serum gel tube. Mix by gentle inversion. Specimen should be surrounded with ice and brought to the Clinical Biochemistry Laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Calcium (ionised) Laboratory: Biochemistry Specimen type: Whole blood in air-free heparinised syringe. Balanced heparin must be used in the syringe.

Special requirements and The specimen should be surrounded with ice and brought to the laboratory immediately. comments:

Turnaround time: 20 minutes.

Reference interval: On Biochemistry report or contact laboratory.

Calcium (total) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top). Urine: See Urine Analyses specimen, requirements, turnaround time and reference interval.

Special requirements and Prolonged venous compression during blood collection will increase serum calcium. comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: See BONE / RENAL section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Important notes: Albumin is the principal binding protein for calcium. A decrease in serum/plasma albumin will lead to a fall in albumin-bound calcium and a decrease in total calcium concentration and vice versa. Therefore serum albumin should always be requested with serum calcium. Total serum calcium can be ‘adjusted’ to ‘correct’ for changes in serum albumin. This adjustment of total calcium is to that expected to be present at an albumin concentration of 40 g/L. The adjustment equation used in this laboratory is as follows:

Adjusted calcium (mmol/L) = {(40 – albumin) x 0.02} + measured calcium.

Calcium / creatinine ratio in urine Laboratory: Biochemistry

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Test information: See Urine Analyses specimen, requirements, turnaround time and reference interval.

Calculus analysis Laboratory: Biochemistry Specimen type: Stone(s).

Special requirements and Specimen should be washed free of tissue and blood, and submitted in a clean dry container. Include comments: relevant clinical information.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Calprotectin Laboratory: Biochemistry Specimen type: Approximately 20 gram of stools. Sample should be kept cool during transport to the laboratory.

Special requirements and Specimen should be sent to the laboratory immediately. comments: Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values. Store specimen at approximately 4 degrees Celsius prior to preparation for dispatch to referral laboratory.

CALR exon 9 mutations Laboratory: Haematology Specimen type: Peripheral blood (or bone marrow) sample taken into EDTA (Violet Top) or, if already extracted, a DNA sample

Special requirements and Prior arrangement with UHL laboratory (061 482258). comments: Review of clinical details and authorisation by a consultant haematologist/registrar. Consultant Haematologist signature/approval required on request form.

Referred to Cancer Molecular Diagnostics (CMD), St James Hospital. Tel.: 01 410 3575

Turnaround time: 60 D Haematology team may contact referral laboratory re urgent samples.

Reference interval: N/A

Test / Profile code (iLab): CALR

Campylobacter jejuni Antibodies Laboratory: Serology Serum sample (brown top). Gel Serum (Brown Top).

Turnaround time: 2 - 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Cannabinoid (THC) Laboratory: Biochemistry Specimen type: Random urine specimen in a ‘BD Vacutainer 4ml urine container (Beige Top) collected without any preservative.

Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference interval: On Biochemistry report or contact laboratory.

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Cannula / Intravascular Tips Laboratory: Microbiology Specimen type: Line tips, e.g. CVP or Hickman lines. Cannula associated swabs.

Tips should only be submitted to the laboratory when line sepsis is suspected. Urinary catheter tips, epidural tips and drain tips are NOT processed.

Specimen collection: Cannulae Disinfect the skin around the cannula entry site, remove cannula using aseptic technique, and cut off 4cm of the tip into a sterile universal container using sterile scissors

Swabs Sample the inflamed area around the catheter insertion site using a charcoal swab

Sample volume: N/A

Turnaround time: Final report: 2-4working days

CAPD Fluid (Continuous Ambulatory Peritoneal Dialysis Fluid) Laboratory: Microbiology Specimen requirements and 3 x 30ml sterile Sarstedt universal containers of CAPD (dialysate) fluid approximately (25 -30ml in each sample volume container)

If blood culture bottles are also used, they should be inoculated aseptically with 5-10ml of dialysate.

Turnaround time: Microscopy: <3 hours Final report: 5-7 working days Positive Microscopy results are telephoned to the requesting source as soon as available.

Special precautions: If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 12 hours are undesirable. Carbamazepine (Tegretol®) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and Specimen should be drawn before the next oral dose in a patient at steady state. comments:

Turnaround time: Routine: 4 days. Contact laboratory if urgent result required.

Reference interval: On Biochemistry report or contact laboratory.

Carbapenamase Producing Enterobacteriaceae Screen (CPE/KPC) Laboratory: Microbiology Test information: Refer to Infection Control Screening

Carboxyhaemoglobin Laboratory: Biochemistry Specimen type: Arterial blood in air-free heparinised syringe. Blood gas analysis sampling kits are available in each ward. Once the sample has been drawn, the blood gas syringe must be labelled with the patient’s full name, chart number, ward, date and time of collection. Immediately after collection, expel any air from the sample and seal the syringe with the stopper provided in the sampling kit.

Turnaround time: 20 minutes.

Reference interval: On Biochemistry report or contact laboratory.

Cardiac / Striated Muscle Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Special requirements and This test is referred to the BIOMNIS Laboratories, Dublin. comments: Tel: 01 299 0650 / 01 295 8545

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Turnaround time: 2 - 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Cardiac enzyme profile Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and Includes CK only. comments: Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Cardiolipin Antibodies / Phospholipid Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Special requirements and Requests for Cardiolipin are tested for IgG antibodies. comments: All requests for Cardiolipin Antibodies / Phospholipid Antibodies are also tested for antibodies to ß2- Glycoprotein-1 IgG. Turnaround time: 7 working days

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing interval: >1 year

Carnitine (Total and free) Laboratory: Biochemistry Specimen type: 1 mL of whole blood in a lithium heparin specimen tube (Green Top).

Special requirements and The specimen should be surrounded with ice and brought to the laboratory immediately. comments: Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Catecholamine /creatinine ratio (paediatric request; up to 12 years of age) Laboratory: Biochemistry Specimen type: 20 mL urine specimen Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements and Specimen must be brought to the laboratory immediately after collection. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

CCP (Anti-Citric Citrullinated Peptide) Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Special requirements and Sample testing positive for Rheumatoid Factor are automatically reflex tested for anti-CCP antibodies. comments:

Turnaround time: 7 working days

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing interval: >3 months

CD 4/8 Count (Flow Cytometry) Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top)

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Special requirements and Prior arrangement with laboratory; contact 061 482258. Flow cytometry requests will only be processed if comments: the clinical details are consistent with appropriate requesting guidelines, e.g. known HIV patient on HAART therapy,? Lymphoproliferative disorder (requesting restricted to haematology consultants only).

CD4/CD8s counts are processed once a week. Pre-booking is essential. Samples must arrive in the laboratory before 09.30 a.m on day of processing and may be collected for overnight storage in the laboratory the evening before the day of processing.. Urgent requests must be discussed with Senior Medical Scientist in flow cytometry prior to referral of samples.

Turnaround times: 7 D

Reference interval: See report form.

Test / Profile code (iLab): CD4/8

CD 19 Count (Flow Cytometry Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top)

Special requirements and Prior arrangement with laboratory, contact 061 482258. comments: Flow cytometry requests will only be processed if the clinical details are consistent with appropriate requesting guidelines, e.g. known HIV patient on HAART therapy, ? lymphoproliferative disorder (requesting restricted to haematology consultants only). CD19 counts are processed once a week. Pre booking is essential. Samples must arrive in the laboratory before 09:30am on day of processing and may be collected for overnight storage in the laboratory the evening before the day of processing.

Turnaround times: 7 D

Reference interval: See report form.

Test / Profile code (iLab): CD19 CEA (carcinoembryonic antigen)

Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and IMPORTANT WARNING: comments: This assay is not validated for use as a screening test for cancer. CEA is almost never raised in early malignancy. The regulatory body approval for this assay states that it is intended strictly for in vitro diagnostic use in the management of cancer patients and in the assessment of prognosis.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory. CellCept® (Mycophenolate) Laboratory: Biochemistry Specimen type: EDTA plasma (Violet Top) 4 mL of whole blood in a potassium EDTA specimen tube is required. The time and quantity of last dose and sample collection time must be stated on request form. Send specimen to laboratory immediately so that plasma can be separated within two hours.

Special requirements and Special request form for immunosuppressant drug monitoring should be used. comments: The date and time of specimen collection and the date, time and dosage of the last mycophenolate dose must be recorded on the request form. Appropriate clinical details are also required.

Turnaround time: Requests for this test are referred to an external specialist laboratory. Reference interval: The referral laboratory report provides appropriate reference values.

Chikungunya Serology Laboratory: Serology Special requirements and Note: Requests for this test requires prior arrangement with the referral laboratory. comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415

Specimen type: Gel Serum (Brown Top).

Turnaround time: Test Availability: By Arrangement

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Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Chlamydia/GC STI Screening Laboratory: Microbiology Specimen requirements and Abbott Multi-Collect™ specimen collection kits (Available from the Microbiology Laboratory) comments: Urine between min and max fill line (overfilled samples will be rejected) or Endocervical/Urethral swabs (males) Urine from Females are not tested for Chlamydia/GC send Endocervial swab

Turnaround time: Specimens are batched for processing, allow 7 working days.

Special precautions: Ensure that containers are labeled in accordance with the pathology specimen labeling policy.

Chlamydia pneumoniae / Chlamydophila pneumoniae Antibodies Laboratory: Serology

Test information: Serology testing is available by arrangement only following discussion with the Consultant Microbiologist. Molecular testing by PCR on respiratory samples may be considered in the inpatient setting following discussion with the Microbiology Laboratory.

Chlamydiae psittaci Antibodies Laboratory: Serology Special requirements and Requests for this test must be discussed with the Consultant Microbiologist / Infectious Diseases comments: Consultant prior to requesting the test.

This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Specimen type: Gel Serum (Brown Top).

Turnaround time: 2 - 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Chlamydia trachomatis Antibodies Laboratory: Serology Special requirements and Serology test for Chlamydia trachomatis is no longer available. Please send a urine sample/urethral swab comments: to the Microbiology Department. Refer to Chlamydia/GC STI Screening

Chloride Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and This assay is also available as part of the electrolyte profile. comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: For more details, see RENAL section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Cholesterol: Total Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and Prolonged venous compression during blood collection will increase serum cholesterol. comments: Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Cholesterol: HDL fraction Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

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Special requirements and Fasting specimen comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Cholesterol: LDL fraction Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and Fasting specimen comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Cholinesterase Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and Appropriate clinical details required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Cholinesterase Genotype / Phenotype Laboratory: Biochemistry Test information: Cholinesterase genotype, plasma cholinesterase genotype, BChE genotype.

Specimen type: 5 mL of whole blood in potassium EDTA anticoagulant (Violet Top)

Special requirements and The Clinical Biochemistry Laboratory must be contacted before initiating the request so that all collection comments: requirements can be met

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Chromogranin A Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and Deliver the specimen to the Clinical Biochemistry Laboratory within 2 hours of venepuncture. comments: Upon receipt in the laboratory, centrifuge the specimen without delay. Separate the serum immediately after centrifugation and store at minus 25 degrees pending dispatch to referral laboratory. The separated serum sample must remain frozen during transport to the referral laboratory.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Chromosome Studies (Cytogenetics) / DNA Studies (Molecular Genetics) Laboratory: Serology Specimen type: 2 x Lithium Heparin (Green Top) / 2 x EDTA (Violet Top) Lithium Heparin samples are required for the following tests: Newborn chromosome analysis, Karyotyping, FISH analysis, Down Syndrome – Trisomy 21, Trisomy 18, Turner Syndrome, Prader-Willi Syndrome, Angelman Syndrome, Di George Syndrome, Williams Syndrome.

EDTA samples are required for the following tests: Array CGH, DNA studies (Molecular genetics) for Fragile X, CF genotyping, Becker Muscular Dystropy, Friedrich’s Ataxia, Marfan Syndrome, Myotonic Dystrophy, Rett Syndrome.

Special requirements and Clinical details must be provided with all requests for Cytogenetics and Molecular genetics. Samples comments: should ideally be sent to Serology/Immunology from Monday to Thursday.

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Note: Consent forms are mandatory for all requests for Cytogenetics and Molecular genetics. Consent forms are available from the Serology/Immunology laboratory.

Where testing will predict the inheritance of a disease in a healthy person (e.g. Huntington Disease) counseling and consent are mandatory. Pre-symptomatic tests require specific request and consent forms which can be obtained by contacting the Serology/Immunology laboratory.

Adult requests for Chromosome studies / Karyotyping are referred to Biomnis Laboratories, France Tel: 01 299 0650 / 01 295 8545

Paediatric requests (< 18 years old) for Chromosome studies are referred to the National Centre for Medical Genetics (N.C.M.G.) Crumlin. Tel: 01 4096970.

Turnaround time: BIOMNIS Cytogenetics requests – 3 - 4 weeks N.C.M.G. Cytogenetics requests – 16 - 20 weeks N.C.M.G. Molecular Genetics requests – 16 - 20 weeks Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing interval: Performed only once

Ciclosporin (Cyclosporin) Laboratory: Biochemistry Specimen type: Whole blood collected in a specimen tube with potassium EDTA as anticoagulant (Violet Top)

Special requirements and Special request form for immunosuppressant drug monitoring should be used. comments: Trough levels should be monitored, i.e. 12-18 hours after oral dose, 12 hours after intravenous dose or immediately prior to the next dose. Do not centrifuge the specimen.

Turnaround time: Requests for this test are referred to an external specialist laboratory. Store specimen at approximately 4 degrees Celsius prior to preparation for dispatch to referral laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

Citrate (citric acid) Laboratory: Biochemistry Specimen type: 24-hour urine collection. No preservative is required. The collection should be kept cool / refrigerated during the collection period. Special requirements and On completion, the collection should be delivered to the laboratory without delay. comments: Do not undertake collection if a urinary tract infection is present.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference interval: The referral laboratory report provides appropriate reference values.

CK (creatine kinase) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and After the onset of myocardial infarction, the diagnostic window is from the 12th to the 24th hour. comments: Note that values may be raised by exercise, intramuscular injections and bruising. Haemolysis interferes with the assay resulting in falsely raised values.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

CMV Antibodies (IgG) Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Turnaround time: 2 working days

Special requirements and Note: Repeat requests for Immuno-competent individuals with previous results of >6 AU/mL are not comments: indicated.

Reference interval: CMV IgG <6 AU/ml = Negative CMV IgG ≥6 AU/ml = Positive Relevant interpretive comments are included on the report.

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Repeat testing interval: Once off for requests for CMV status

CMV Antibodies (IgM) Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Special requirements and Note: A urine sample and EDTA sample for PCR taken within 3 weeks of birth is the suggested comments: investigation for suspected neonatal CMV infection (see CMV Antigen (Urine) & CMV PCR).

Turnaround time: 2 working days Note: additional days are required for confirmation of positive/reactive samples. Positive samples are referred to NVRL, Dublin for further testing.

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

CMV Antigen (Urine) Laboratory: Serology Specimen type: Urine collected in a sterile leak-proof container. Minimum volume = 1ml.

Special requirements and Samples should be sent immediately to Serology/Immunology Monday to Friday (am) only. comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4415 / 716 4414.

Turnaround time: 1 - 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

CMV PCR / CMV Viral Load Laboratory: Serology Specimen type: 2 x EDTA (Violet Top) Urine sample in neonate < 3 weeks old

Turnaround time: 1 - 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

CO2 Total (serum/plasma) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top). Lithium Heparin Plasma (Green Top) Special requirements and Blood sample to be received in the laboratory within two hours of collection. comments: This assay is also available as part of the electrolyte profile.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours.

Reference interval: On Biochemistry report or contact laboratory.

Coagulation Factor Assays Laboratory: Haematology Specimen type: 3 x Citrated plasma (Blue Top). 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples

Special requirements and Prior arrangement with the coagulation department, contact 061 482851. comments: Refer to specific factor assays for special requirement details.

Turnaround time: 3 W

Reference interval: See individual assay.

Test / Profile code (iLab): Refer to specific Factor Assay.

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Coagulation Screen Laboratory: Haematology Specimen type: 1 x Citrated plasma (Blue Top).

Special requirements and Profile includes PT, INR (for patients on warfarin) and APTT. comments: Details of anticoagulant therapy required. Do not refrigerate INR samples.

Turnaround time: Urgent: 1 H Non-GP: 4H GP 8H

Reference interval: See individual assay.

Test / Profile code (iLab): COAG

Cocaine metabolite Laboratory: Biochemistry Specimen type: Random urine specimen in a BD Vacutainer 4ml urine container (Beige Top) collected without any preservative.

Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference interval: On Biochemistry report or contact laboratory.

Coeliac Screen (Tissue Transglutaminase IgA) Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Special requirements and Tissue Transglutaminase IgA is the appropriate serological screening test for coeliac disease. comments: Equivocal and positive anti-tTG samples will be automatically tested for anti-endomysial antibodies.

IgA deficiency is present in approximately 1:30 patients with coeliac disease. If there is a high clinical suspicion of coeliac disease and the Anti-tTG IgA result is negative the patient should be investigated for IgA deficiency. A sample should be sent to the Biochemistry Laboratory for Immunoglobulins and SPEP. Refer to igG,igM,igA The laboratory will identify patients with an IgA deficiency who were TTG IgA negative and will automatically reflex test these for EMA IgG. EMA IgG tests are referred to the Immunology Lab, St. James Hospital, Dublin. Turnaround time: 7 working days

Reference interval: <20 RU/ml – Negative ≥20 RU/ml – Positive Relevant interpretive comments are included on the report.

Repeat testing interval: Negative results: >3 months

In diagnosed coeliac patients follow-up IgA tTG can be used to monitor response to a gluten free diet. Adults: Retesting at 6–12 months depending on pretreatment value. Children: Retesting at 6 months in children Cold agglutinins Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top) maintained at 37ºC Request form: Blood Bank 1

Turnaround time: Same day Monday to Friday only - the samples must be received before 1 pm.

Reference interval: Titres above 64 are considered elevated. Haemolytic anaemia due to cold reactive agglutinins rarely occurs unless the titre is > 512. Copper Laboratory: Biochemistry Specimen type: Whole blood in trace metal-free tube. Trace metal-free needle must be used in conjunction with trace metal-free tube. This specimen should be collected first if other tests are requested so as to avoid contamination.

For urine copper a 24-hour urine collection without preservative in a metal-free acid washed container is required.

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Special requirements and Please contact Clinical Biochemistry Laboratory for trace metal-free specimen collection tube and needle. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Complement Assay CH50/CH100 Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Special requirements and This test is referred to the Immunology Lab, St. James Hospital, Tel. 01-4162925 comments: Turnaround time: 2 -4 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Performed once only

Cortisol Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and N.B.: Record specimen collection time on the request form. comments: Appropriate clinical details are required. Indicate on request form if the request is as part of a dynamic function test

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

COVID-19 (SARS CoV-2) Laboratory: Serology Special requirements and Viral swabs are available from the Laboratory by contacting the Laboratory Porter (see ‘Ordering of comments: Laboratory Supplies’ in the introduction section of the manual).

Viral swabs should be delivered to the laboratory as soon as possible after collection. Viral swabs may be refrigerated at 2 - 8°C overnight if same day delivery to the laboratory is not possible.

'Detected' results are indicative of SARS-CoV-2 RNA detection, but may not represent the presence of transmissible virus.

'Not Detected' results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions.

If patient has had consecutive Not Detected swab results within the past 7 days and if further testing is deemed necessary, this must only be carried out on a lower respiratory tract specimen. Suggest discussion with the duty microbiologist.

Specimen type: Combined nasopharyngeal/throat swab, sputum sample (in-house patients only). Refer to Procedure for collecting Nasopharyngeal Swabs (NPS) for Respiratory Viruses.

Note: The charcoal swab (Microbiology) is unsuitable for viral investigations.

Turnaround time: In house testing: <24 hours [requests from UL Hospitals, residential care settings, hospital and community healthcare workers, post-mortem requests]

NVRL/Enfer: 48 hours [Community Testing Centre requests]

Reference interval: Detected/ Not detected. Refer to report issued by Serology.

Note - Negative results do not preclude infection and should not be used as the sole basis for treatment or other patient management decisions.

Coxsackie Antibodies Laboratory: Serology Special requirements and Please note this test is only available following prior arrangement with the Consultant Microbiologist. comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

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Specimen type: Serum sample (brown top).

Turnaround time: 1 – 2 weeks Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Coxsackie Virus Laboratory: Serology Special requirements and Refer to: Enterovirus/Enterovirus Antibodies comments: Coxiella burnetti (Q-fever) IgM / IgG Laboratory: Serology Specimen type: Gel Serum (Brown Top).

Special requirements and Requests for Coxiella burnetti serology should be discussed with the Consultant Microbiologist or the comments: Infectious Diseases consultant prior to requesting the test. Please provide relevant clinical details with request.

This test is referred to the RIPL, UK PHE Laboratory, Porton Down. Tel: +44 1980 612224.

Turnaround time: 1 – 2 W.

Reference interval: The referral laboratory report provides appropriate ranges, interpretive comments and advice on frequency of repeat testing.

Coxiella burnetti (Q-fever) PCR Laboratory: Serology Specimen type: Gel Serum (Brown Top).

This test is referred to the SPRU, UK PHE Laboratory, Porton Down. Tel: +44 1980 612224.

Turnaround time: 1 – 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

C-peptide Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top).

Special requirements and Specimen for glucose assay (grey top) must be drawn at same time. Record specimen collection time. comments: The specimen when taken must be brought to the laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Creatinine Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top). Urine: See Urine Analyses listing for requirements, turnaround time and reference interval

Special requirements and In the case of blood specimens for creatinine assay, the serum should be separated from the red blood comments: cells within twenty four hours of venepuncture; otherwise substances are released from the red blood cells, which cause falsely raised serum creatinine concentrations. Both a serum specimen and a 24-hour urine collection are required for creatinine clearance.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: For more details, see RENAL section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

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Creatinine Clearance Laboratory: Biochemistry Special requirements and Urine: Refer to: Urine Analyses for requirements, turnaround time and reference interval. comments: Note: Blood sample for creatinine should be collected within the twenty four hour collection period.

Creutzfeldt-Jakob Disease (CJD) Laboratory: Microbiology Specimen type: Refer to CSF (Cerebrospinal Fluid)

Crossmatch in the presence of a positive antibody screen Laboratory: Blood Bank Availability time*: 90 minutes to several hours, depending on the antibody present.

Risk and comments: If blood is needed before compatibility testing is completed, haemolysis may occur, but transfusion should not be withheld if deemed absolutely necessary. A decision on whether to transfuse or /wait for fully crossmatched blood may need to be discussed with a haematology consultant/registrar.

* Transport time not included

Crossmatch using previous sample Laboratory: Blood Bank Sample type: Original sample

Request form: A new Blood Bank 1 form, delivered or faxed to the laboratory.

Turnaround time: 5- 30 minutes

Special requirements: Previous sample must be <72 hours old. Blood, crossmatched from the sample must be used within 72 hours of sample collection time.

CRP (C-Reactive Protein) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top) Lithium Heparin Plasma (Green Top)

Special requirements and Appropriate clinical details required. comments: Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Cryoglobulins Laboratory: Biochemistry Specimen type: The Clinical Biochemistry Laboratory must be contacted before initiating the request so that all collection requirements can be met. Special requirements and Two EDTA 2.7ml tubes (Violet Top) and two plain monovettes tubes (White Top) must be collected comments: prewarmed to 37 degrees Celsius, maintained at 37 degrees Celsius during clotting, centrifugation and separation of the serum fraction. Arrangements for the collection of a specimen for detection of cryoglobulins must always be discussed with the Clinical Biochemistry Laboratory prior to the commencement of specimen collection.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

CSF (Cerebrospinal Fluid) Laboratory: Microbiology Optimal time of Collection: Preferably before antimicrobial therapy is started, but therapy must not be delayed unnecessarily pending lumbar puncture and CSF culture

Specimen requirements: • CSF is normally collected sequentially into three or more separate universal containers which should be numbered consecutively (1, 2, 3, etc.) on the container. Do not Label Container Lid.

If xanthochromia is queried, wrap one specimen in tinfoil.

Sample volume: A minimum volume of 1ml of sample in each. For Mycobacterial testing, at least 10 ml where possible.

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Special precautions: • Specimens should be transported as soon as possible. Time between collection to microscopy and culture should occur within a maximum of 2 hours

• DO NOT USE PNEUMATIC CHUTE SYSTEM • HAND DELIVER ALL SPECIMENS TO THE MICROBIOLOGY LABORATORY

• PLEASE ALERT THE MEDICAL SCIENTIST “ON CALL” IF THE CSF IS SENT DURING THE “OUT OF HOURS” PERIOD.

• Specimens should be transported as soon as possible. Cells disintegrate and a delay may produce a cell count that does not reflect the clinical situation of the patient.

Turnaround time: Processed on receipt.

Microscopy report: <2 hours

Final negative culture report: Available electronically next working day post 48 hour incubation. Final positive culture report: Available on completion of organism identification and antimicrobial sensitivity testing.

Creutzfeldt-Jakob disease: 10 days upon receipt of the specimens by the referral laboratory. CSF samples for Creutzfeldt-Jakob disease (CJD) investigation are referred to the UK National CJD Surveillance unit Edinburgh by Beaumont Hospital. Samples will only be sent for analysis upon review of clinical data by a Neuropathologist in Beaumont. In the interim samples will be stored in Microbiology UHL at -80oC. Please contact the Microbiology laboratory (2255) for details.

Whipples Disease Referred test: Turnaround time 14 days from receipt of sample; PCR Detection for Tropheryma whipplei CSF samples requesting same are referred to: Molecular Pathology Laboratory Clinical Science Building St James’ university Hospital Beckett Street Leeds LS9 7TF Please contact the Microbiology laboratory (2255) for further details.

Reference Interval: Normal CSF Reference Values Ref: PHE SMI B27 Investigation of Cerebrospinal Fluid, Kastenbaum et al PEDIATRICS Volume 125, Number 2, February 2010 Leucocytes Neonates less 28 days ≤ 15 cells /ul Infants 29-56 days 4 cells/ul Infants 1 to 12 months 0-15 cells /ul Children/Adults 1 year + 0-5 cells /ul

Erythrocytes No RBCs should be present in normal CSF Additional information: All CSFs, with a leucocyte count >5/µl, will be routinely tested on the FilmArray® Meningitis/Encephalitis Panel for 14 pathogens 24/7. Please note a negative result does not exclude infection. Where there is a high clinical suspicion of encephalitis please discuss with Clinical Microbiology Team as targeted single pathogen PCR may be more appropriate. The targets tested on FilmArray® are;

Bacteria Viruses Fungi 1. Escherichia coli K1 7. Cytomegalovirus (CMV) 14. Cryptococcus 2. Haemophilus influenzae 8. Enterovirus neoformans/gattii 3. Listeria monocytogenes 9. Herpes simplex virus 1 4. Neisseria meningitidis (HSV-1) 5. Streptococcus agalactiae 10. Herpes simplex virus 2 6. Streptococcus pneumoniae (HSV-2) 11. Human herpesvirus 6 (HHV- 6) 12. Human parechovirus 13. Varicella zoster virus (VZV)

The exceptions are CSF samples submitted from Haematology / Oncology wards. CSF samples, which fall outside of these criteria, will need to be discussed with the consultant microbiologist(s) prior to testing. For TB PCR , please refer to the TB section

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Limits of Detections for FilmArray analysis are as outlined in below table:

CSF (Cytopsin for Haematology/Oncology patients Only) Laboratory: Haematology

Specimen type: CSF in universal container

Special requirements and Appropriate clinical details required. All CSF samples should be hand delivered without delay and be comments: accompanied by UHL haematology request form.

Volume: 200ul minimum CSF Turnaround time: 14 D

Reference Interval: N/A

Test / Profile code (iLab): N/A

CSF Glucose Laboratory: Biochemistry Specimen type: CSF (cell-free supernatant in plain tube)

Special requirements and CSF samples must not be sent to the laboratory in the pneumatic chute system comments: Note that it is Laboratory Policy that all CSF specimens must be delivered to the Microbiology Department for initial examination and processing. Refer to: CSF (Cerebrospinal Fluid

Appropriate clinical details required.

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Turnaround time: 90 mins.

Reference Interval: On Biochemistry report or contact laboratory.

Result should be interpreted in combination with plasma glucose result. CSF glucose should be 60 – 70% of the plasma glucose.

CSF Immunophenotyping (Flow Cytometry) Laboratory: Haematology Specimen type: Cerebrospinal Fluid (in RPMI) . Clinical Details required and referral authorised following consultation with Consultant Haematologist. . Separate specimen required to avoid unnecessary delay in transport to referral lab. Take further samples for Microbiology, Biochemistry, Histology tests as required.

Special requirements and Prior arrangement with UHL laboratory; contact 061 482258. comments: Consultant signature/approval required on request form.

Monday to Friday only - Requests should be received by the laboratory before 11:00 hours to facilitate same day transport to referral laboratory.

Referred to Haematology Laboratory, (Immunophenotyping), St James’ Hospital, James Street, Dublin 8. Tel: 01 4162909.

Turnaround time: 14 days (Routine)

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code (iLab): CSFIMR / CSFIMP

CSF Lactate Laboratory: Biochemistry Specimen type: CSF (cell-free supernatant in plain tube)

Special requirements and All CSF samples must be hand delivered to the Microbiology Department without delay for initial comments: examination and processing. CSF samples must not be sent to the laboratory in the pneumatic chute system

Turnaround time: 90 mins.

Reference Interval: On Biochemistry report or contact laboratory.

CSF Oligoclonal IgG banding Laboratory: Biochemistry Specimen type: CSF and serum obtained at the same time.

Special requirements and Appropriate clinical details required. comments: All CSF samples must be hand delivered to the Microbiology Department without delay for initial examination and processing. CSF samples must not be sent to the laboratory in the pneumatic chute system.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

CSF Protein Laboratory: Biochemistry Specimen type: CSF.

Special requirements and Appropriate clinical details required. comments Note that it is Laboratory Policy that all CSF specimens must be delivered to the Microbiology Department for initial examination and processing. CSF samples must not be sent to the laboratory in the pneumatic chute system

Turnaround time: 90 mins.

Reference Interval: On Biochemistry report or contact laboratory.

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CSF Xanthochromia Laboratory: Biochemistry

Specimen type: CSF Sample must be light protected.

Special requirements and Appropriate clinical details required. comments CSF Spectrophotometry request form must be completed (available from Biochemistry Lab)

Note that it is Laboratory Policy that all CSF specimens must be delivered to the Microbiology Department for initial examination and processing. CSF samples must not be sent to the laboratory in the pneumatic chute system

Turnaround time: Requests for this test are referred to an external specialist laboratory

Reference Interval: The referral laboratory report provides appropriate reference values and result interpretation.

CTx (Crosslaps) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Fasting specimen is strongly recommended. To minimise the influence of day-to-day variability, it is comments: important to maintain the same collection protocol. Serial samples should be collected at the same time of day on each occasion, e.g. before breakfast. Appropriate clinical details required. The specimen must reach the laboratory within two hours of collection from the patient.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Cyclosporin (Ciclosporin) Laboratory: Biochemistry Specimen type: See special requirements.

Special requirements and Special request form for immunosuppressant drug monitoring should be used. comments: Whole blood collected in specimen tube with potassium EDTA (Violet Top) as anticoagulant. Trough levels should be monitored, i.e. 12-18 hours after oral dose, 12 hours after intravenous dose or immediately prior to the next dose. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Cystine Laboratory: Biochemistry Specimen type: 24 hour urine collection. Keep refrigerated.

Special requirements and Appropriate Clinical details are required comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Cystine (white cell concentration) Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements and 3 ml blood in lithium heparin tube (Green top); Do not refrigerate or centrifuge, Deliver to laboratory comments: without delay. Monday – Wednesday (only). Sample must be received by referral laboratory within 24hours of venepuncture. Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

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D-Dimer Laboratory: Haematology Specimen type: 1 x Citrated plasma (Blue Top).

Special requirements and In –patient requests: D-Dimer requests that are not accompanied by the ‘Suspected DVT/PE’ request comments: form, do not meet the appropriate Wells Score, or from a location not approved by the Haematology Team, will be rejected for testing.

External requests. All requests must include the relevant clinical details (QPE/QDVT /Wells Score) or be communicated directly to the Medical Scientist in Coagulation. D-Dimer testing should only be carried out in the community when assessing patients with low risk based upon a clinical score of a thrombosis (Well’s criteria for DVT assessment). . If the patients risk assessment indicates a high risk of thrombosis, the D dimer should not be requested and the patient should be referred into the Medical Assessment Unit for further investigation.

Requests should be received by the laboratory within 8 hours of phlebotomy. Lipaemic or haemolysed plasmas not suitable for analysis.

Out of hour/urgent requests for this test originating from external sources to UHL must include clinician’s direct contact details and advance notice to the laboratory is advised.

Turnaround time: 1 D

Reference Interval: 0 – 69 years: 0.01-0.50 ug/ml FEU 70 years and older: 0.01-1.00 ug/ml FEU

For patients over 70 years who have a D-dimer value below 1 ug/ml with low probability Wells clinical score, thrombosis can be considered excluded and no further investigation is required. It is important to note that this only applies to patients over 70 with a low risk of thrombosis who are not on anticoagulation and assessed in UHL only.

Test / Profile code (iLab): DDimer / COAGD

7-Dehydrocholesterol (in relation to Smith Lemli Opitz syndrome) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top) or Lithium Heparin Plasma (Green Top) Special requirements and Appropriate clinical details are required. comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Delta Aminolevulinic acid (ALA) Laboratory: Biochemistry

Specimen type: 24-hour urine collection; no preservative.

Special requirements and In a acute episode a random urine is adequate. comments: Protect the collection from light and keep refrigerated at 4-8°C.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Dengue Virus Serology Laboratory: Serology Special requirements and Note: Requests for this test requires prior arrangement with the referral laboratory. comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Specimen type: Gel Serum (Brown Top)

Turnaround time: Test Availability: By Arrangement

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

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Deoxypyridinoline Laboratory: Biochemistry Specimen type: Urine (‘Sarstedt Monovette Z’ 10mL urine container).

Special requirements and It is recommended that a carefully monitored second void collection is made; patients should be asked to comments: empty their bladders on waking and discard the urine. Then they should collect the next specimen (the second morning void) in the urine container (plain container, no additives). To minimise the influence of day-to-day variability, it is important to maintain the same collection protocol.

Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

DHEA sulphate (DHEAS) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements and Draw specimen in the morning. Appropriate clinical details are required. comments:

Turnaround time: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Diagnostic (Fluid) Cytology Laboratory: Histology

Test information: The Histology Laboratory processes Diagnostic - Non-Gynaecological Cytology (fluid cytology) samples from various Hospitals and outside sources. The samples are sent to the Cytology Laboratory, St. James Hospital, Dublin on a daily basis Monday to Thursday.

Non-Gynaecological Cytology (fluid cytology) samples received in Histopathology laboratory are referred onto the Cytology Laboratory, St James Hospital, Dublin.

Cytology Specimen Requirements for the Referral of Non-Gynaecological Cytology Specimens to St. James Hospital Specimen type: Specimen Type Volume Sample Container Fixation Comment

Bronchial Aspirate N/A Universal Container Unfixed Sample High risk patients must / BAL be identified

Brushes N/A Universal Container 10mls Cytolyt Cut brush off and place in (containing Cytolyt Fixation Cytolyt Fixative Fixative) CSF N/A Universal Container Unfixed Sample Laboratory staff to prepare cytospin slides for referral. CSFs greater than 24 Hours old cannot be processed

Fine Needle N/A Universal Container Expel aspirate One air dried slide can be Aspirates (containing Cytolyt and rinse needle submitted in addition to Fixative) in 10mls Cytolyt needle rinse in Cytolyt. Fixative Multiple slides are not to be submitted

Urine 20mls Universal Container Unfixed Sample No early morning/ first void of the day urines to be submitted. No full voided urines of 24 hour collections to be submitted. St. James Hospital have advised that one urine specimen per specimen is deemed sufficient as a

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screening tool, multiple urines will not be processed

Serous Fluid Approx. Universal Container Unfixed Sample No collection bags or 20-70mls / Small Pot large pots to be submitted

Special Precautions:  A sample of large aspirate must be transferred to a universal container for Cytology. Mix well before taking sample.  Samples must be appropriately labelled with patient details and sample type and location details  A Histology request form is used for Cytology Requests. Please tick the Cytology Box on the request form. Request forms must be appropriately labelled with patient details and sample type and location details  If other tests are also required on the sample, the non Cytology tests will need to be performed first. Some of these tests may affect the sample quality. For this reason it is recommended that a separate sample be sent for Cytology.  It is advisable to store fluid cytology in a fridge if collected ‘out of hours’.  Aspirate / FNA Slides must be labelled using pencil with Patient name, Chart no and Date of Birth. It is important to label the slide prior to spray fixation. If the label is written over the fixative film, processing will remove it.

Reports:  When reports are received they are forwarded to the requesting Location / Consultant.  Electronic copies of cytology reports are available on Medibridge  A hard copy of all reports is retained in the Pathology Laboratory Office.

Turnaround times: Turn around times for Diagnostic Cytology is 10-14 days. Digoxin Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements and The specimen should be drawn when digoxin is in equilibrium between plasma and the tissues. The time comments: to equilibrium following either oral or intravenous dose is usually 8 to 12 hours. Note: with normal renal function and regular dosage intervals, it takes 5 to 7 days to achieve a steady state of digoxin.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Dihydrotestosterone (5-α dihydrotestosterone) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top) (1-2 mL); in the case of neonatal and paediatric requests, the sample volume may be discussed with the referral laboratory.

Special requirements and Appropriate clinical details are required including a summary of prescribed medication. comments: The referral laboratory will undertake to assay both testosterone and dihydrotestosterone in order to advise on the interpretation of the testosterone/5- dihydrotestosterone ratio.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Diphtheria Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and This test is referred to the BIOMNIS Laboratories, Dublin. comments: Tel: 01 299 0650 / 01 295 8545

Note: Diphtheria antibody testing is used to check for vaccine related immunity and not for diagnostic purposes.

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Direct antiglobulin test Laboratory: Blood Bank

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Sample type: 7.5ml EDTA for adults, 2.7 ml EDTA for paediatrics

Request form: Blood Bank 1

Turnaround time: Same day

Dopamine Laboratory: Biochemistry Specimen type: 24-hour urine collection with 20mL of 6N HCI as preservative.

Special requirements and Appropriate clinical details and a list of all current medication are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Drugs of abuse in urine (DAU) screen Laboratory: Biochemistry Specimen type: Random urine specimen (BD Vacutainer 4ml urine container) collected without any preservative.

Special requirements and The assay is intended to assist in the clinical management of the patient and is not provided for medico- comments: legal purposes. The requesting doctor may need to consider whether a patient might avail of opportunities to alter or interfere with the integrity of the specimen. The following drugs are tested for as part of the DAU Profile: amphetamines, barbiturates, benzodiazepine, cocaine metabolite, methadone, opiate, cannabinoid (THC). Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference Interval: On Biochemistry report or contact laboratory.

Duodenal Aspirate (for the presence of parasites) Laboratory: Microbiology Specimen type: Duodenal drainage

Specimen requirements: Sterile Container

Sample volume: Minimum volume: 0.5 ml.

Special precautions: Specimens should be sent to the laboratory immediately.

Turnaround time: 3 hours E

Ear Laboratory: Microbiology Specimen requirements: Otitis - Externa Media Charcoal swab of any pus/ exudate

Fungal Scrapings from the ear canal are placed in DERMAPAKenvelopes. (Please contact the Microbiology Laboratory for same.) Sample Volume N/A Special Precautions: Dry swabs are NOT suitable. Delays of over 48 h are undesirable Turnaround time: Aerobic report: 2-3 working days Anaerobic report 3-5 working days Fungal culture: 14 days

EBV (Epstein-Barr virus) Antibodies Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements and Note: The EBV serology profile is an expensive, labour-intensive test and should not be employed as the comments: ‘front line’ test for the diagnosis of infectious mononucleosis. In patients with symptoms compatible with infectious mononucleosis, a positive Paul-Bunnell heterophile antibody test (Monospot - Haematology) result is diagnostic, and no further testing is necessary. Refer to: Monospot (Infectious Mononucleosis)

The EBV serology profile consists of three assays: EBV-CA IgG, EBV-CA IgM & EBNA-1 IgG

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Turnaround time: 3 working days

Repeat testing Interval: Once off for requests for EBV IgG status eGFR (estimated glomerular filtration rate) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and The serum should be separated from the red blood cells within six hours of venepuncture; otherwise comments: substances are released from the red blood cells, which cause falsely raised serum creatinine concentrations.

Note: calculation is based on the 4v-MDRD Formula and is only applicable to adults (i.e. patients greater than 18 years old).

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference Interval: Greater than 90 mL/min/1.73m2

Important notes on Estimated (1) Estimated GFR is calculated using the 4v-MDRD Formula (with creatinine assay calibration GFR in adults using formulae: traceable to ID-MS).

(2) Estimates of GFR are unreliable in acute renal failure due to the kinetics of creatinine accumulation. (3) GFR estimates between 60 and 89 mL/min/1.73m2 do not indicate CKD unless there is other laboratory/clinical evidence of disease. (4) Estimated GFR should be multiplied by 1.212 for African-American patients.

IDMS-traceable MDRD Study Equation for serum creatinine reported in SI units

eGFR (mL/min/1.73 m2) = 175 x (serum creatinine (µmol/L) x 0.011312)-1.154 x (Age)-0.203 x (0.742 if female) x (1.212 if African American)

The IDMS-traceable MDRD Study equation is for laboratories that use creatinine methods that have been calibrated to be traceable to IDMS.

For further information refer to KDOQI Guidelines on www.kidney.org

Elastase-1 (Pancreatic) Laboratory: Biochemistry Specimen type: Approximately 20 grams of stools required. Sample should be kept cool during transport to the laboratory.

Special requirements and Specimen should be sent to the laboratory immediately comments: Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Electrolytes Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top) Lithium Heparin Plasma (Green Top) Special requirements and The electrolyte panel includes sodium, potassium. comments: Blood specimens for potassium assay must be collected free of haemolysis. The serum must be separated within a period of two hours from venepuncture, since potassium is released from red blood cells during the transport and storage of whole blood specimens thus causing a falsely raised serum potassium concentration.

Primary Care Samples There is usually a delay (of about 4-6 hours) in blood samples from Primary Care reaching the Biochemistry Laboratory for processing. This delay can cause a falsely raised serum potassium concentration, due to the release of intracellular potassium from red blood cells, during transport and storage of whole blood.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

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Reference Interval: On Biochemistry report or contact laboratory. Minimum Retesting Interval: See RENAL section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Electrophoresis (Serum Protein) Laboratory: Biochemistry Specimen type: Serum

Special requirements and Appropriate clinical details required. comments:

Turnaround time: 4 working days.

Reference Interval: The laboratory report provides appropriate information.

Electrophoresis (Urine Protein) Laboratory: Biochemistry Specimen type: Untimed urine collection (in a ‘Sarstedt Monovette Z’ 10mL urine container).or a 24-hour collection. No preservative is required. Keep specimen refrigerated.

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory

Reference Interval: The referral laboratory report provides appropriate reference values.

Emergency O RhD Negative uncrossmatched red cells Laboratory: Blood Bank Availability time: Immediately Comments: If a delay is unlikely to result in a significant risk to the patient, it is better to give group specific, uncrossmatched blood to conserve O RhD negative stock.

Risks: O RhD negative emergency blood may not be compatible for patients with antibodies. Approximately, 2 - 4% of hospital patients may have a red cell antibody which can cause a haemolytic transfusion reaction.

Note: Emergency O Rh (D) negative red cells are located on the top shelf of the issue fridge in the blood transfusion laboratory. Emergency O Rh (D) negative red cells are also available in the issue fridges in the following hospitals: . University Maternity Hospital . St John’s Hospital . Croom Hospital . Nenagh Hospital . Ennis Hospital . BSHLAB

Endomysial Antibodies Laboratory: Serology Special requirements and Tissue Transglutaminase (Anti-tTG) has replaced Anti-Endomysial IgA (EMA) as the screening test for comments: Coeliac Disease. All samples which are Anti-tTG positive are automatically reflex tested for Anti-EMA.

Specimen type: Serum sample (brown top).

Turnaround time: 7 working days

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: Performed once only

Enterovirus/Enterovirus Antibodies Laboratory: Serology Special requirements and Note: Serology for Enterovirus is no longer available. Direct methods of viral antigen detection – viral comments: culture & viral PCR are the recommended tests for Enteroviruses. Please contact the laboratory, if necessary, for information on the appropriate sample required for the investigation of enteroviral infection.

Enterovirus requests are referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

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Environment toxicology Laboratory: Biochemistry Special requirements and The Clinical Biochemistry Laboratory does not provide an assay service for environmental, industrial or comments: occupational toxic agents or chemicals. The most appropriate agency to contact regarding these matters is the Environmental Protection Agency.; contact details: EPA Headquarters, PO Box 3000, Johnstown Castle Estate, Co. Wexford, Tel: 053-9160600; Fax: 053-9160699; Email: [email protected]; Lo Call: 1890 335599. Web site: www.epa.ie

Epanutin® (Phenytoin) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Specimen drawn before the next oral dose in a patient at steady state. comments: Turnaround time: Routine: 4 days. Contact laboratory if urgent result required.

Reference Interval: On Biochemistry report or contact laboratory.

Epilim® (Valproate, valproic acid) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements and Specimen drawn before the next oral dose in a patient at steady state. comments: There is no evidence that monitoring serum valproate levels can be valuable in the management of patients with epilepsy. Studies indicate that concentrations are no better a guide to clinical response than is dose. Measurement of serum levels may be useful in the assessment of compliance.

Turnaround time: Routine: 4 days. Contact laboratory if urgent result required. Reference Interval: On Biochemistry report or contact laboratory. Erythropoietin (EPO) Levels Laboratory: Haematology Specimen type: 2 x Gel Serum (Brown Top)

Special requirements and Restricted to patients attending renal/haematology departments. Test not available to general practice comments: patients or other specialties

Consultant signature / approval required on request form. Review of clinical details and authorisation by a consultant haematologist/registrar.

Referred to Haematology Lab, St James Hospital Tel: 01 416 2943 / 416 2944 (09.00 to 17.00)

Turnaround time: 14 D

Reference Interval: Refer to report issued by referral laboratory

Test / Profile code (iLab): EPOR / EPOP

ESR (Erythrocyte Sedimentation Rate) Laboratory: Haematology Specimen type: Sedivette/Sodium Citrate.

Hand write or Blood track labels can be used if placed precisely over manufacturer’s label. The use of larger addressograph labels can interfere with sample analysis and result in sample rejection.

Special requirements and Requests should be received by the laboratory within 6 hours of phlebotomy. comments:

Turnaround time: Urgent specimens <3 hours (when laboratory informed) Routine ward specimens: 8 hours, GP specimens: 2 days

Reference Interval: Age and sex related. Refer to report form.

Estimated glomerular filtration rate (eGFR) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

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Note: calculation is based on the 4v-MDRD Formula and is only applicable to adults (i.e. patients greater than 18 years old).

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference Interval: Greater than 90 mL/min/1.73m2

Important notes on Estimated (1) Estimated GFR is calculated using the 4v-MDRD Formula (with creatinine assay calibration GFR in adults using formulae: traceable to ID-MS).

IDMS-traceable MDRD Study Equation for serum creatinine reported in SI units

eGFR (mL/min/1.73 m2) = 175 x (serum creatinine (µmol/L) x 0.011312)-1.154 x (Age)-0.203 x (0.742 if female) x (1.212 if African American)

The IDMS-traceable MDRD Study equation is for laboratories that use creatinine methods that have been calibrated to be traceable to IDMS. For further information refer to KDOQI Guidelines on www.kidney.org

Estradiol / Oestradiol Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details required. comments: This assay has not been validated for use on neonatal samples.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Ethanol (alcohol) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top), Li Hep plasma (Green Top), urine (random urine in Sarstedt Monovette Z 10mL urine container) Special requirements and This assay is intended to assist in the clinical management of the patient and is not provided for medico- comments: legal purposes or in relation to the Road Traffic Acts. Do not use alcohol swabs to clean venepuncture site.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours.

Reference interval: On Biochemistry report or contact laboratory.

Ethosuximide (Zarontin®) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Specimen should be drawn before the next oral dose in a patient at steady state. Due to the long half-life comments: of ethosuximide, fluctuations in serum concentration are relatively minor. However, when making comparative measurements, it is advisable that the sampling time is consistent.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Ethylene glycol Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

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Special requirements and Assay is of value when ethylene glycol ingestion is suspected or when symptoms indicate that possibility. comments: Clinical details such as acidosis status and renal function must be provided on the request form.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Note: The out-of-hours toxicology call service at Beaumont Hospital is available to all hospitals in the Republic of Ireland, however “the service is restricted to checking only for drugs, which if taken in overdose require a specific antidote or treatment. It is not an aid to diagnosis nor to allow a patient to be discharged.” If the assay is required outside of normal working hours contact the switchboard at Beaumont Hospital and request to speak to the Principal Biochemist in Toxicology.

Eye (Acanthamoeba, Conjunctivitis,Corneal scrapings,Intraocular fluids,Contact lens) Laboratory: Microbiology

Specimen requirements: Routine Charcoal swab For neonates request Gram stain if required

Acanthamoeba sp Sterile Dry Swabs, please contact the Microbiology Laboratory at This test should only be 061-48 2842 for these swabs. requested where clinically indicated. Specimens are referred to Micropathology Ltd. Coventry, UK , Tel: Please contact Consultant 0044 24 76323222 Microbiologist prior to submitting specimen. Canalicular pus: Sterile leak-proof container in a sealed plastic bag.

Chlamydia trachomatis: Abbott Multi-Collect™ specimen collection kits (Available from Laboratory). Refer to the Chlamydia section within the manual

Corneal Scrapings and Sterile needles may be used to aspirate or scrape material, and Intraocular fluids: sterile scalpel blades to scrape material. Because of the small amounts of material involved, inoculation of plates and preparation of glass slides may need to be done at the patients’ side.(Agar plates and glass slides are available from the Laboratory). Place material in the centre of the agar plate using the scalpel.

Corneal scrapings should be of sufficient quantity to make a visible deposit on a microscope slide and to inoculate culture plates.

If there is insufficient specimen to make both a smear and perform inoculation of plates, cultures should be the priority. Contact lens: In contact lens case with fluid

Neisseria gonorrhoeae: Air dried smear in addition to swab.

Orbital cellulitis: Aspirates from the affected tissues into a sterile leak-proof container in a sealed plastic bag. Turnaround time: Routine Culture Final report: 2-5 working days

Anaerobic Culture 3-5 working days

Acanthamoeba sp. 24 hours upon receipt by the Referral laboratory Monday to Friday.

Actinomyces sp. Negative Report: 8-10 working days Positive report: 10-12 working days

Factor concentrate Laboratory: Blood Bank Sample type: None.

Request form: Blood Bank 1

Availability time: Same day

Risk and comments: Refer to the HG-A-BTR-rFVIIa guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Refer to the product SPC for appropriate information on administration. Refer all requests to the consultant haematologist for appropriate use and dose.

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Factor II (Prothrombin) Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 4 hours of phlebotomy. comments: Details of anticoagulant therapy required.

Turnaround time: 3 W

Reference Interval: 70-120 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples. Test / Profile code (iLab): FII / FIIP

Factor V Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 1 hour of phlebotomy. comments: Details of anticoagulant therapy required.

Turnaround time: 3 W

Reference Interval: 70-120 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples.

Test / Profile code (iLab): FV / FVP

Factor V Leiden (FVL) Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top)

Special requirements and Positive APCR / relevant family history required. In- house consultant approval required. comments: Referred for analysis to: Haemostasis Molecular Genetics, St Thomas’ Hospital, London. Tel: +44-207-188 2779

Turnaround time: 4W

Reference Interval: N/A

Test / Profile code (iLab): FVLR / FVLP

Factor VII Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 4 hours of phlebotomy. comments: Details of anticoagulant therapy required. Do not refrigerate samples.

Turnaround time: 3 W

Reference Interval: 70-130 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples.

Test / Profile code (iLab): FVII / F7P

Factor VIII: C Laboratory: Haematology

Specimen type: Citrated plasma (Blue Top).

Special requirements and Fresh Specimen required. Requests should be received by the laboratory within 1 hour of phlebotomy. comments: Turnaround time: 3 W

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Reference Interval: 60-150 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples.

Test / Profile code (iLab): FVIIIC / F8P

Factor IX Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 4 hours of phlebotomy. comments: Details of anticoagulant therapy required.

Turnaround time: 3 W

Reference Interval: 60-150 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples. Test / Profile code (iLab): FIX / FIX

Factor X Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and Samples are taken a minimum of 4 hours post heparin dose and requests should be received by the comments: laboratory within 2 hours of phlebotomy. Turnaround time: 3 W

Reference Interval: 70-120 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples.

Test / Profile code (iLab): FX / FXP

Factor XI Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 4 hours of phlebotomy. comments:

Turnaround time: 3 W

Reference Interval: 60-140 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples.

Test / Profile code (iLab): FXI / FXIP

Factor XII Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 4 hours of phlebotomy. comments:

Turnaround time: 3 W

Reference Interval: 60-140 u/dl

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples.

Test / Profile code (iLab): FXII / F12P

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Factor XIII Laboratory: Haematology Specimen type: 2 x Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 4 hours of phlebotomy.Monday to Friday only. comments: Requests should be received by laboratory before 10:00 hours to facilitate same day transport to testing laboratory. Referred to the National Centre for Hereditary Coagulation Disorders, St James. Tel.: 01-4162956

Turnaround time: 4 W

Reference Interval: Refer to report issued by referral laboratory.

Volume: 1-2 factor assays requires 2 samples; 3-4 factor assays requires 3 samples; more than 4 factor assays require 4 samples.

Test / Profile code (iLab): FXIII / FXIIIP

Faeces Laboratory: Microbiology Specimen type: • Faeces for routine Polymerase Chain Reaction (PCR) - previously culture and sensitivity • Faeces for Ova, Cysts and Parasites (OCP) • Faeces for Clostridium difficile (C.diff) Diarrhoeal specimens only suitable for C diff. Specimens must be delivered to the laboratory without delay as toxin degradation may occur with prolonged storage. • Sellotape slide/perianal swab for detection of Enterobius vermicularis (pinworm) • Schistosoma sp: Please refer to the urine section in the manual.

Specimen collection: Routine PCR/sensitivity/OCP/ C. difficile toxin B gene test

• Fresh sample in a clean, sterile, leakproof container. Faeces may also be collected from a sterile bedpan. However, if there is any contamination with urine, residual soap, detergent, or disinfectant in the pan, the sample is unsatisfactory.

• A minimum of three specimens collected on alternate days (48 hrs apart) is recommended for a complete OCP examination where parasite infestation is suspected as shedding of cysts and ova may be intermittent.

• Specimens of faeces should be transported to the laboratory and processed as soon as possible, because a number of important pathogens such as Shigella species may not survive the pH changes that occur in faeces specimens which are not promptly delivered to the laboratory, even if refrigerated. C. difficile toxin degradation may also occur.

• Please submit a separate sample to the Serology/Immunology Laboratory for virology testing.

• PLEASE NOTE: Specimens will not be processed for Salmonella, Shigella, Campylobacter or E.coli VTEC from patients who have been in-house >72 HOURS.

• *PLEASE NOTE: Specimens from patients < 2years of age are not routinely processed for C difficile.

• *Specimens from paediatric inpatients (2-16 years) in UHL ONLY will no longer be processed for C difficile unless specifically requested by the paediatric consultants.

Perianal swab/sellotape slide Sample between 22.00h and midnight, or early in the morning, before defecation or bathing.

• Sellotape slide Apply sellotape to the perianal region, pressing the adhesive side of the tape firmly against the left and right perianal folds several times. A tongue depressor can be used to wrap the tape around. Smooth the tape back on the slide, adhesive side down. Label slide with patient name and date of birth

• Perianal swab - cotton-wool swab in dry container. Spread buttocks apart, and rub the moistened cotton wool swab over the area around the anus, but do not insert into the anus. Place cotton wool swab back into its container (no transport medium required). Ensure container is labelled appropriately. Occasionally, an adult worm may be collected from a patient and sent in saline or water for identification.

Sample volume: Minimum volume: 1–2g Note: Additional testing requires additional material

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Turnaround time: Clinically significant isolates are telephoned when available to the requesting source.

Final report: Clostridium difficile toxin B gene: Processed daily Mon-Fri. Results available after 4pm. Please contact on-call scientist for any urgent requests after hours or at weekends.

Final Report: Routine PCR Negative PCR: 1-2 working days. Positive PCR: 1-2 working days. Confirmatory culture and sensitivities (if relevant) will follow.

VTEC PCR positive samples are referred to the Public Health Laboratory, Cherry Orchard Hospital, Dublin for verocytotoxin studies. Tel: 01 6206175 Samples are referred for confirmation and typing only under the following circumstances:  Samples VTEC positive for the first time  VTEC positive samples that have not been sent within the last month or every 4th VTEC positive sample  VTEC positive samples with a Cp value>35  Elevated negative (green sigmoidal curve) VTEC samples

The latter two points may indicate a true negative sample, hence referral for confirmation

Results are available after 2-3 working days.

Salmonella and Shigella sp isolates are referred to the National Salmonella, Shigella & Listeria Reference Laboratory of Ireland, Galway for typing. Tel: 091 544628

Results are available after 6 days. Interim findings/ results available electronically on the iLAB system.

Ova Cysts and Parasites 7-14 working days

Test method: Routine: Faeces will be tested for: Salmonella sp, Shigella sp Campylobacter sp, and Verotoxigenic E. coli

All patients > 2yrs (SEE NOTE* Clostridium difficile if specimen is above) diarrhoeal (i.e. taking shape of Specific request container)

Relevant clinical details Yersinia sp Vibrio parahaemolyticus Vibrio cholerae Aeromonas / Plesiomonas sp Cryptosporidium sp.

<15 years Stools for OCP: Ova, Cysts and Parasites Including Cryptosporidium sp

Stools for Clostridium difficile All requests liquid stool only Clostridium difficile Toxin B gene Toxin B gene: positive samples are further tested for the presence of GDH as an indicator of active toxin production. Toxin B Gene:

Perianal swab for detection of Perianal swab/ sellotape slide Ova of Enterobius vermicularis Enterobius vermicularis examined (pinworm/ threadworm) (pinworm): Additional information: Full clinical information should be provided on the request form, especially the presence and duration of symptoms, recent travel, shellfish ingestion and previous antibiotic therapy.

Specimens will not be processed for OVA, CYSTS and PARASITES unless clinical details are provided.

Campylobacter positive samples: This infection is usually self-limiting.Antibiotics are not recommended unless symptoms persist

Clostridoides difficile: All healthcare associated C.difficile isolates are sent for typing to the Public Health England C.difficle Reference laboratory, Leeds General Infirmary. Those patients with identical ribotypes who are epidemiologically linked have their isolates further typed (MLVA) to determine if cross transmission may have taken place.

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C. difficile positive and Toxin positive results- Results indicate C. difficile toxin is present; therefore active C. difficile disease is likely. Review current antibiotics and stop if possible. For symptomatic adult patients in the community, commence metronidazole 400 mgs PO TDS for 10-14 days and isolate with contact precautions. For hospitalised patients, commence ORAL vancomycin 125mg qds for 10-14 days and isolate with contact precautions. Contact Clinical Microbiology Team for advice if severe disease or relapsing/recurrent infection: see hospital antimicrobial guidelines for case severity definitions. Please Note: Test of clearance for C.difficile is not indicated repeat samples within 14 days of a positive result will not be tested.

C. difficile and Toxin negative results (any setting): Results indicate C. difficile which carries the toxin gene is present, however C. difficile toxin is NOT detected in stool. Active C. difficile disease is LESS likely, but is not outruled. Isolate patient with contact precautions. Review current antibiotics and stop if possible. If clinical features of active C. difficile disease present, commence metronidazole 400 mgs po tds for 10-14 days, or ORAL vancomycin 125mg qds for moderate/severe disease. See hospital antimicrobial guidelines for case severity definitions. Contact Clinical Microbiology Team for advice if severe or relapsing/recurrent disease. Test of clearance is not indicated; repeat samples within 14 days of a positive result will not be tested. Farmers lung (Micropolyspora faeni) Precipitins Laboratory: Serology Special requirements and From July 1st 2014 Farmers lung precipitin testing is no longer available in the Serology/Immunology comments: Laboratory. For the investigation of Farmers lung quantitative serum IgE & IgG levels using the FEIA method should be requested. Requests are sent to the Immunology Laboratory, St James’ Hospital.

Fatty Acids, very long chain (VLCFA) Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements and 1 ml blood in EDTA (Violet Top) / lithium heparin sample tube (Green Top); Do not refrigerate, Deliver to comments: laboratory without delay - Monday- Wednesday (only). Appropriate clinical details are required. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

FBC (Full Blood Count) Laboratory: Haematology Specimen type: EDTA (Violet Top)

Special requirements and After 24 hours, WBC differential and red cell indices are affected by EDTA changes. comments: WBC differential, haemoglobin and red cell indices are affected by pregnancy.

Ensure samples are not taken from a drip site as this results in haemodilution of the sample. Clotted EDTA samples will not be processed. It is not technically possible to process cord blood, pleural, ascites, CSF fluid etc. on a haematology analyser. Automated white cell/red cell counts cannot be provided on such fluids Includes White Cell Differential – Neutrophil, Lymphocyte, Monocyte, Eosinophil and Basophil counts.

Out of hour/urgent requests for this test originating from external sources to UHL must include clinician’s direct contact details and advance notice to the laboratory is advised. Turnaround time: Urgent: 1 H. Non GP: 4 H GP: 24 hours

Reference Interval: See report form.

Test / Profile code (iLab): FBCD / FBCDR

Ferritin Laboratory: Haematology Specimen type: Gel Serum (Brown Top)

Special requirements and Requests should be received by the laboratory within 8 hours of phlebotomy, add on tests within 24 hours comments: of phlebotomy.

Indications for Ferritin testing: General principles 1. Measurement of vitamin B12, folate or ferritin should only be performed following clinical assessment, and in the presence of one of the specific indications listed below.

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2. Fatigue and tiredness are not indications for vitamin B12, folate or ferritin measurement. 3. Vitamin B12, folate and ferritin testing should not be measured as part of a general health screen. 4. Patients who are pregnant/taking an oral contraceptive pill/taking Metformin can have falsely low vitamin B12 levels. 5. Vitamin B12 stores last over three years. Therefore, if a normal vitamin B12 result has been obtained in the previous six months, a further vitamin B12 test will not be processed unless discussed with a haematology consultant. 6. Folate stores last for a shorter period of time. Therefore, repeat folate testing may be necessary if one of the indications below is met. 7. Patients on parenteral vitamin B12 replacement therapy do not require repeat vitamin B12 measurement unless blood counts or neurological symptoms fail to improve. 8. Patients on folic acid replacement therapy do not require repeat folate measurement unless blood counts fail to improve. 9. The minimum interval for repeat testing of vitamin B12 and folate is generally 90 days. However, if appropriate new clinic details are provided, retesting may be performed within 90 days.

Indications for ferritin testing 1. Unexplained anaemia 2. Assessing response to iron therapy 3. Suspected haemachromatosis or unexplained liver disease 4. Assessment of iron stores in patients with suspected iron overload and/or hereditary haemochromatosis

Turnaround time: 3 D

Reference Interval: Age and sex related. Refer to report form.

Test / Profile code (iLab): FERR / BFF

Fetal genotyping Laboratory: Blood Bank Sample type: 3 X 7.5ml EDTA (Red Top) and 7.5 ml EDTA (Red Top) from the putative father. Fill to mark. Please send Monday to Wednesday. The sample must reach Bristol within 48hrs of venepuncture.

Request form: IBGRL referral form (F104) and Blood Bank 1

Turnaround time: < 3 weeks - test is performed in the IBGRL, Bristol, UK.

Fetomaternal haemorrhage (FMH) assessment Laboratory: Blood Bank Comments: Flow cytometry is suitable for estimation of fetomaternal haemorrhage in RhD negative mothers who have delivered RhD positive infants. Kleihauer Betke (KB) Slide is the acid elution test used when the blood group of the fetus is unknown. FMH using Kleihauer Betke (KB) slide (Acid Elution) Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 1

Turnaround time: <72hours

Comment: Not clinically indicated for RhD positive patients, except for >20 weeks gestation with IUD. FMH using flow cytometry Laboratory: Blood Bank

Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 1

Turnaround time: <72hours

Fibrinogen Laboratory: Haematology Specimen type: 1 x Citrated plasma (Blue Top).

Special requirements and Requests should be received by the laboratory within 8 hours of phlebotomy. comments: Include the following line under spec requirements/comments for Coag tests -PT/APTT/Fib/D-Dimer

Out of hour/urgent requests for this test originating from external sources to UHL must include clinician’s

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direct contact details and advance notice to the laboratory is advised. Turnaround time: 1 D

Reference Interval: 2.0-4.0 g/l

Test / Profile code (iLab): FIB

Fibrinogen concentrate Laboratory: Blood Bank Sample type: None Request form: Blood Bank 1

Availability time: Same day

Risk and comments: Fibrinogen concentrate should only be prescribed in accordance with guideline HG-A-BTR-FIBN available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Any requests not falling within the guideline will be referred to the consultant haematologist.

FK 506 (Tacrolimus, Prograf®) Laboratory: Biochemistry Specimen type: Whole blood in specimen tube with potassium EDTA (Violet Top) as anticoagulant.

Special requirements and Special request form for immunosuppressant drug monitoring should be used. comments: Trough levels should be monitored.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Flecainide (Tambocor®) Laboratory: Biochemistry Specimen type: 2.7mL potassium EDTA sample (fbc sample tube Violet Top)). Gel tubes are not suitable.

Special requirements and Appropriate clinical details required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Fluids (Sterile) Laboratory: Microbiology Specimen type: Fallopian Tube Aspirate / Tubo-Ovarian Fluid / Pouch of Douglas Fluid / Joint fluid / Synovial fluid / Bursa fluid, Peritoneal fluid / Ascitic fluid / Pleural fluid / Pericardial fluid, Amniotic fluid

Specimen requirements: Clean, sterile, leakproof container (universal container). Swabs are not a recommended specimen. Anaerobic cultures will not be performed on swab specimens. Total white cell count microscopy is not performed unless specifically requested with an accompanying EDTA specimen and in the case of ascites only where SBP is suspected. Please indicate? SBP on request form for ascites. NB: If Biochemistry testing is required on sterile fluid, please send a separate specimen (Sarstedt 4.9ml neutral tube) with a separate request form for Biochemistry tests. Exception; samples for pH must be sent in a blood gas syringe with the appropriate Biochemistry request form.

Preparation of patient and Disinfect overlying skin. specimen collection: Obtain specimen via percutaneous needle aspiration or surgery.

Aspirate fluids that collect in pericardial, pleural, peritoneal and synovial spaces with the utmost precaution to avoid introducing micro-organisms and to avoid contamination of the specimen.

If directly aspirating into a syringe (recommended), remove the needle and cap the syringe for transport. If the material cannot be aspirated into a syringe, place it into a sterile tube or container. Label the specimen. Inoculate ascitic fluid specimens (in spontaneous bacterial peritonitis) at the bedside into blood culture bottles. Put 10ml of fluid into aerobic and anaerobic blood culture bottles (20ml total). Submit additional fluid in a sterile container, as much as possible for Gram stain and additional lab processing (e.g., acid- fast bacilli [AFB], fungal cultures). Sample volume: A minimum volume of 1ml

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Special precautions: • Deliver immediately to the laboratory. • The volume of specimen influences the transport time that is acceptable. • Large volumes of purulent material maintain the viability of anaerobes for longer. Results from delayed samples must be interpreted with caution bearing in mind the difficulties in isolating anaerobes from these samples. Turnaround time: Cell Count/ Uric Acid Crystals: Same day Gram stain: Same day Negative Culture: 6 working days Positive Culture: 6–9 days

Test method: • Total White Cell Count, (two part differential leucocyte count if cell count > 250/μl) • Uric Acid crystals (joint fluids or topheous aspirate only) • Gram Stain • Culture for pathogenic organisms Additional information: Fluids may also be sent to the Microbiology Department in blood culture bottles. If cytology for malignancy is required please send a separate specimen for Cytology. Refer to: Diagnostic (Fluid) Cytology

Reference Range: SYNOVIAL/JOINTFLUID

FINDINGS NORMAL NON INFLAMMATORY SEPTIC INFLAMMATORY Colour Clear Yellow Yellow-Green Yellow Clarity Transparent Transparent Opaque Opaque Viscosity High High Low Variable WBC /ul <200 200 – 2000 2,000 – 150,000 15,000-200,000 PMNs <25% <25% >50% >75% WBC: White Blood Cells PMNs: Polymorphonuclear Cells

Other Sterile Fluid Findings Fluid Type Clinical Conditions Cell type Total cell Interpretation count /µl Pericardial Normal Leucocyte <1000 Fluid Abnormal Leucocyte >1000 Peritoneal Normal Leucocyte <300 Fluid Erythrocyte <100,000 Abnormal Spontaneous Leucocyte >300 Bacterial Peritonitis (SBP) %Neutrophil PMN) >50%PMN

Erythrocyte >100,000 Pleural Fluid Normal Leucocytes <1000 Abnormal Leucocytes >1000

References: Color Atlas of Body Fluids. An Illustrative Field Guide, Based on Proficiency Testing. K. A. Galagan (MD), D. Blomberg (MD), P.J. Cornbleet (MD, PhD), E.F. Glassy (MD).2006 (available on reading bench as reference text)

Note: The presence of >100 Leucocytes/µl in CAPD fluid closely correlates with infection. Ref: ISPD Peritonitis Recommendations, HPA Standard Operating Procedure (Investigation of Continuous Ambulatory Peritoneal Fluid SMI B25.

Note: Reference ranges for Bile are not applicable

Folate (Folic Acid) Laboratory: Haematology Specimen type: Gel Serum (Brown Top)

Special requirements and Requests should be received by the laboratory within 8 hours of phlebotomy, add on tests within 24 hours comments: of phlebotomy. Relevant Clinical Details required.

Indications for Vitamin B12 General principles and Folate testing: 1. Measurement of vitamin B12, folate or ferritin should only be performed following clinical assessment, and in the presence of one of the specific indications listed below. 2. Fatigue and tiredness are not indications for vitamin B12, folate or ferritin measurement. 3. Vitamin B12, folate and ferritin testing should not be measured as part of a general health screen.

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4. Patients who are pregnant/taking an oral contraceptive pill/taking Metformin can have falsely low vitamin B12 levels. 5. Vitamin B12 stores last over three years. Therefore, if a normal vitamin B12 result has been obtained in the previous six months, a further vitamin B12 test will not be processed unless discussed with a haematology consultant. 6. Folate stores last for a shorter period of time. Therefore, repeat folate testing may be necessary if one of the indications below is met. 7. Patients on parenteral vitamin B12 replacement therapy do not require repeat vitamin B12 measurement unless blood counts or neurological symptoms fail to improve. 8. Patients on folic acid replacement therapy do not require repeat folate measurement unless blood counts fail to improve. 9. The minimum interval for repeat testing of vitamin B12 and folate is generally 90 days. However, if appropriate new clinic details are provided, retesting may be performed within 90 days.

Indications for Vitamin B12 and Folate Measurement Haematological unexplained anaemia/other cytopenias unexplained macrocytosis haemolysis Neurological subacute combined degeneration of the cord peripheral neuropathy dementia unexplained neurology Other glossitis pregnancy malabsorption previous gastric resection strict vegans alcoholism patients on dialysis Medications Metformin therapy prolonged proton pump inhibitor or H2 receptor antagonist therapy anticonvulsant therapy Methotrexate therapy Turnaround time: 3 D

Reference Interval: Age and sex related. Refer to report form.

Test / Profile code (iLab): FOL / BFF

Food Toxicology Laboratory: Biochemistry

Special requirements and The Clinical Biochemistry Laboratory does not provide an assay service for toxic agents or chemicals in comments: food or food products. The most appropriate agency to contact regarding these matters is the Food Safety Authority of Ireland; contact details: Food Safety Authority of Ireland, Abbey Court. Lower Abbey Street, Dublin 1 Phone 01 817 1300 ; Fax 01 817 1301; Email [email protected] Web address www.fsai.ie

Free Light Chains (Kappa and Lambda) in serum Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top) Assay is not available for urine.

Special requirements and Appropriate clinical details are required including reason for request. comments: This assay is available to Consultant Haematologists / renal consultants and their teams. The assay should be regarded as experimental. Important diagnostic and patient management decisions should not be made on the basis of serum free light chain assay results only.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Free Protein S Laboratory: Haematology Specimen type: 2 x Citrated plasma (blue top), or, if ordered as part of a thrombophilia screen, 4 x Citrated plasma (Blue

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Top) and 1 x EDTA (Violet Top).

Special requirements and Requests should be received by the laboratory within 4 hours of phlebotomy. comments: Details of anticoagulant therapy required.

Generally requested as part of a thrombophilia screen. Thrombophilia screening requests must be sanctioned by the haematology team and as such must include relevant clinical details. Thrombophilia screening is not performed on patients receiving warfarin and/or unfractionated heparin.

Turnaround time: 4 W

Reference Interval: 57-122 U/dl

Test / Profile code (iLab): FPROTS / TPHIL

Free T3 (triidothyronine free hormone) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details and a list of all current medication are required. comments: FT3 is not included in TFT profile and is used to monitor patients on T3 hormone replacement. When indicated the Biochemistry Laboratory reflex FT3 measurement.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Free T4 (thyroxine free hormone) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details and a list of all current medication are required. comments: Refer to: Reference Guide for Use of Thyroid Function Tests in Primary Care

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Frozen Sections Laboratory: Histology Special requirements and  Frozen Sections must be pre-booked with the Histology Laboratory comments:  Frozen Sections will not be processed on patients with TB, Hepatitis B, C or HIV. If a suspicion of such infection exists, clinical staff must inform the laboratory.  Contact the Laboratory directly at 061-482253  The Scientist taking the call will ask questions relating to the specimen and will ensure that a Histopathologist is available for the stated time before confirming the booking  Samples must be sent in a dry container – no fixative, via porter to the laboratory. Samples for frozen sections should never be sent via the Chute system  The normal turn around time for frozen sections is 20-30 minutes after arrival in the laboratory however if multiple specimens are received the turn around time will be exceeded.  Please write contact number for phoned report  Frozen Section reports will be phoned by the reporting Histopathologist to either the Consultant Surgeon or staff at the given contact phone number.  When phoning the report the Histopathologist will state the Name and Chart Number of the Patient and the Type and Location of the biopsy and will note the identification of the person receiving the report before dictating the report.  It is important to cancel a frozen section if it is no longer required as Laboratory Staff will be on hold awaiting its arrival.

Fructosamine Laboratory: Biochemistry Specimen type: 2.7mL potassium EDTA sample (fbc sample tube (Violet top)

Special requirements and Appropriate clinical details are required with reasons why HbA1c result is not adequate for the comments: management of the patient.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

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FSH Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Fungal Microscopy and Culture Laboratory: Microbiology Specimen type: Non Systemic Infection: Skin / Scalp scrapings Nail scrapings Hair

Systemic infection: All specimens

Note: Skin / scalp scrapings, nail scrapings and hair specimens are not suitable for routine bacteriological investigation. Specimen Requirements: Scrapings / Hair should be placed in DERMAPAK Envelopes (Contact Microbiology Laboratory at 482255) This investigation is referred to Biomnis Laboratories Tel: +353 1 295 8545 and is restricted to Dermatology Consultants

Specimen Collection: It is often helpful to clean the lesions of the skin or scalp (and sometime nail) with surgical spirit or 70% alcohol prior to collection of samples as this improves the chances of detecting the fungus by microscopy and also reduces the likelihood of contamination of subsequent cultures. Prior cleaning is essential if greasy ointments or powders have been applied to the region.

Scalp Specimens from the scalp are best obtained by scraping with a blunt scalpel. The contents should include hair stubs, the contents of plugged follicles and skin scales. Hair may also be plucked from the scalp with forceps (infected hairs are usually easy to remove in this way). Cut hairs are unsatisfactory as the focus of infection is usually below or near the surface of the scalp.

Nail clippings Nail clippings should be taken from any discoloured, dystrophic or brittle parts of the nail. These should be cut as far back as possible from the free edge of the nail and include its full thickness, scrapings can also be taken from beneath the nail to supplement the clipping sample.

Skin Skin samples should be collected by scraping outwards from the edges of the lesions, with either a blunt scalpel blade or with the edge of a glass microscope slide. The edge of the lesion is where there is likely to be the most fungus.

Special precautions: - Loose slides should not be used. - Do not use fixatives.

Turnaround time: Microscopy Performed twice weekly

Culture Final report: 28 days G

GAD (Glutamic Acid Decarboxylase) Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments: This test is referred to BIOMNIS Laboratories, Dublin (IDDM requests) or to the Neurology Laboratory Oxford for neurological GAD investigation. Biomnis Tel: 01 299 0650 / 01 295 8545 Oxford Tel: +44 1865 225995

Requests for IDDM-1 antibody serology are part of a profile that includes anti-GAD anti-IA2A and anti- ZNT8.

This test is not routinely available to general practitioners. Testing may be provided by arrangement only and following discussion with the Laboratory.

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Turnaround time: 3 - 4 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Repeat testing not routinely required

Galactose: disorders of galactose metabolism Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Note that galactosaemia is included in the National Newborn Screening Programme.

Special requirements and a. Blood Galactose: (National Neonatal Screening Programme) 4 Blood spots on a Guthrie card comments: and 2 mL of fresh urine. b. Beutler Test (galactose 1-phosphate uridyltransferase assayed on a Guthrie card): 4 blood spots on a Guthrie card c. Quantitative enzyme assays (galactose 1-phosphate uridyltransferase; galactokinase, UDP- galactose epimerase): 3 mL of blood in lithium heparin tube (Green Top) for enzyme of interest d. Monitoring of treatment (Glactose 1-phosphate; galactitol): 2 mL of blood in lithium heparin tube (Green Top) and 10 mL of urine.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Gastric Aspirates (Neonatal) Laboratory: Microbiology Specimen requirements: Sterile universal container

Sample volume: N/A

Special precautions: Specimens should be collected <4h post delivery and before feeding.

Turnaround time: Final report: 2 – 3 working days

Gastrin Laboratory: Biochemistry Specimen type: 2.7ml Potassium EDTA sample (FBC sample tube (Violet Top)

Special requirements and Patient should be fasting overnight. The specimen should be surrounded with ice and brought to the comments: laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

GBM (Anti-Glomerular Basement Membrane) Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments: Turnaround time: 7 working days Note: Urgent anti-GBM requests are available by arrangement with the laboratory. Urgent testing is available only during the following hours: - 09:00 – 20:00 [Monday to Friday], - 09:00 – 13:00 [Saturdays] - 10:00 – 14:00 [Sundays & Bank Holidays].

Requests for urgent testing outside these hours cannot be facilitated.

Reference range: < 20 RU/mL – Negative ≥ 20 RU/mL – Positive Relevant interpretive comments are included on the report.

Repeat testing Interval: In cases on anti-GBM positive results: every 3–6 months while on treatment

Genetic Screening

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Laboratory: Serology Specimen requirements: See Chromosome Studies

Genital Tract & Associated Specimens Laboratory: Microbiology

Specimen type: High Vaginal (See decision tree below) Cervical Urethral Rectal IUCDS (Intra Uterine Contraceptive Devices) Pus Chlamydia (Refer to Chlamydia/GC STI Screening) Urine from females is not tested for Chlamydia/GC send endocervical swab

Specimen requirements: High Vaginal Charcoal Swab Cervical Charcoal Swab Urethral Air- Dried smear plus swab is useful. Amies Charcoal - aluminium wire - orange cap. Rectal Charcoal Swab Bacterial Vaginosis A pH should be performed and a value submitted. An air-dried smear of vaginal discharge may be sent in addition to the swab Trichomonas HVS IUCD’S Sterile universal container Pus Sterile universal container Fluids Sterile universal container

DIAGNOSIS OF ABNORMAL VAGINAL DISCHARGE IN FEMALE PATIENTS OF REPRODUCTIVE AGE WITH STI RISK

Vaginal Discharge

STI risk present HIV, Hep B and Syphilis serology

Endocervical swab for chlamydia and gonnorrhoea PCR plys HVS charcoal swab

Proceed based on results (BASHH.org guidelines)

NB. Positive GC PCR Trichomonas No significant Request GC C/S - Candida Isolated Suggestive of BV take a charcoal positive findings swab for GC C/S before treatment is initiated. Consider STI Clinic referral

Candida isolated Consider other causes Give empirical Consider referral to Give empirical Physiological therapy GUM UHL Diagnose therapy refer if Foreign body STIs Treatment of choice Contact trace Bacterial Vaginosis recurrent >4/yr Streptococcal/ for GC is Ceftriaxone Treat as per (most common) Give skin care Staphylococcal and Azithromycin guidelines advice infections

Send charcoal HVS Contact trace and Send charcoal HVS Give empirical for culture take a swab for GC Consider referral to to lab for TV & other therapy Also send: PCR as test of cure GUM UHL if STIs Microscopy & endocervical swab (TOC) after 6/52 recurrent candida note ?STD as clinical culture NOT for chlamydia and weeks detail required gonorrhoea PCR

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DIAGNOSIS OF ABNORMAL VAGINAL DISCHARGE IN FEMALE PATIENTS OF REPRODUCTIVE AGE WITH LOW STI RISK

Clinical and Sexual History Low or no risk of STI

Vaginal pH helps in diagnosis 3,6-8 Use a swab to collect discharge from the lateral vaginal wall and rub it onto narrow range pH paper.

pH ≤ 4.5 pH > 4.5

White curdy discharge Yellow, green Other signs: No other Thin, grey/white frothy discharge Discharge has other Vulval itching symptoms homogeneous discharge Fishy/offensive appearance or soreness coating the vaginal walls odour Erythema/vaginitis Fishy/offensive odour +/- pruritis, Fissuring Not generally sore vaginitis, Dyspareunia Dysuria

Consider other causes No further Diagnose Diagnose Diagnose Physiological investigations Bacterial Vaginosis Trichomoniasis Candida Foreign body needed (most common) (less common) STIs Streptococcal10/ Staphylococcal infections Re-evaluate risk of STI/ contact status

Send HVS for culture Give empirical therapy Give Metronidazole Reassure that Refer to GUM Also send: endocervical Culture not needed unless empirical therapy probably Send charcoal HVS to lab swab for chlamydia recurrent >4/yr - then refer Microscopy & culture physiological for TV & other STIs and gonorrhoea and to GUM UHL NOT required Include ?STD in clinical serum for HIV, Hep B, details syphilis See STD decision tree

Request Gram stain for BV if confirmation required

Specimen collection:  Please note there is no rationale for HVS sampling unless a discharge is present.  Most episodes of Vaginal Discharge are physiological and empirical treatment for candidiasis and Bacterial Vaginitis (BV), if suspected, is appropriate. Please note exceptions to this in notes at the bottom of the decision tree.  Gram stains on HVS specimens are used as a diagnostic tool for Bacterial Vaginosis (BV).  If microbiological confirmation of BV is desired Gram stain only will be performed on HVS samples received with clinical details of ‘suspect BV/suggestive of BV’ included on the request form (i.e. no culture will be undertaken) as this can be used as a diagnostic tool for BV.  If the clinical details of ‘suspect BV/suggestive of BV’ are not included on the request form a gram stain will not be performed.  Provision of appropriate clinical details will direct the laboratory’s testing repertoire (i.e. culture and/or gram) and provide the best service for the patient. Clinical details such as pregnancy, recurrent candidiasis (as defined in the decision tree), intra menstrual /post coital bleeding, pelvic pain, and ‘suspect BV/suggestive of BV’ allow us to test each specimen appropriately. If clinical details are not provided on the request form, the specimen will not be processed.  HVS samples processed in the laboratory for culture will not be cultured for gonorrhea as an endocervical swab for Chlamydia and Gonorrhea PCR is the preferred sample type.  Pre-insertion of Intrauterine device (IUD) / IUD in situ: An STI screen should be offered to all women who are identified as being at risk of STIs if they are pre-insertion of an IUD or have an IUD in situ; a single vulvovaginal or endocervical sample for Chlamydia / Gonorrhoea PCR is adequate. There is no requirement to take routine High Vaginal Swabs for culture unless a discharge is present. Specimens submitted with clinical details of ‘Pre-coil’ or ‘IUD / Coil in situ’ will not be processed for culture. Provision of additional appropriate clinical details (as defined in the attached decision tree) will direct the laboratory’s testing repertoire (i.e. culture and/or gram) and provide the best service for the patient. Samples for Chlamydia / Gonorrhoea PCR may be taken using the Multi-Collect kit and placed in the orange cap bottle containing sample transport buffer. See details of Swabs for Microbiology and Virology Investigations in this user manual.  The decision trees above are provided in an effort to illustrate the rationale behind this approach and

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to assist in your clinical assessment and management of the patient  The pH is a helpful aid for your diagnosis however, there are other clinical parameters outlined re. discharge type, odour and patient history that will aid your decision to collect a HVS specimen and inform your approach to clinical detail provision  Please see HVS advisory memo reissued 2018.  For detection of viruses: separate samples should be collected into appropriate transport media Contact the Serology / Immunology laboratory at 061-482797

Cervical swabs Cervix (endocervix): Wipe the cervix clean of vaginal secretion and mucus. Use a speculum without lubricant - it may be toxic to certain bacteria. Under direct vision, gently compress the cervix with the blades of speculum, and use a rotary motion with a culture swab. Obtain exudate from endocervical glands. Alternatively, insert the swab into the cervical os, allow it to remain in place for a few seconds, and remove it. Return the culture swab to the Amies transport medium with charcoal base or Abbott Multi- Collect™ specimen collection kit

High vaginal swabs After the introduction of the speculum, the swab should be rolled firmly over the surface of the vaginal vault. The swab should then be placed in transport medium with charcoal.

Urethral swabs Contamination with micro-organisms from the vulva or the foreskin should be avoided. Thin swabs are available for collection of specimens. The patient should not have passed urine for at least 1 hour. For males, if a discharge is not apparent, attempts should be made to “milk” exudate from the penis. The swab is gently passed through the urethral meatus and rotated. Place the swab in transport medium with charcoal.

Intrauterine contraceptive devices (IUCDs) The entire device should be sent.

Rectal swabs Rectal swabs are taken via a proctoscope. If a proctascope is not available consider blind swabs.

Throat swabs Throat swabs should be taken from the tonsillar area and/or posterior pharynx avoiding the tongue and uvula.

Fluids and pus These are taken from the fallopian tubes, tubo-ovarian and Bartholin’s abscesses etc during surgery.

Extragenital samples for PCR Confirmatory testing is performed to confirm GC results. Confirmatory testing is a referred test.

FEMALE – ASYMPTOMATIC with SEXUAL RISK Specimen type: Cervical Swab for Chlamydia and Neisseria gonorrhoeae

Specimen requirements: Cervical Swab Abbott Multi-Collect™ specimen collection kits - (Available from the Microbiology laboratory)

MALE – DISCHARGE PRESENT / DYSURIA with SEXUAL RISK Specimen type: Urethral Swab for culture Urine for Chlamydia and Neisseria gonorrhoeae Note: Urine for Chlamydia/ GC PCR testing is an optimal specimen for men. (Overfilled specimens will be rejected). Specimen requirements: Urethral Swab Amies Charcoal - aluminum wire - orange cap. (Available from the Microbiology laboratory) Urine Abbott Multi-Collect™ specimen collection kits. (Available from the Microbiology laboratory) Consider rectal swabs as determined by patient history

MALE – ASYMPTOMATIC with SEXUAL RISK Specimen type: Urine for Chlamydia and Neisseria gonorrhoeae

Specimen: Urine Abbott Multi-Collect™ specimen collection kits requirements (Available from the Microbiology laboratory)

Sample volume: Between max and min fill line. (overfilled specimens will be rejected)

Turnaround time: Final Report: 3-4 working days for HVS/ Penile other specimen types require extended incubation.

Additional information genital tract and associated specimens:

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Additional information:  Please test for syphilis in patients with genital ulcer disease (test may be negative if tested within 2 weeks of chancre, there is no facility for dark ground microscopy locally), generalised maculopapular rashes, aseptic meningitis, bearing in mind the multiple possible clinical manifestations of syphilis.  Routine syphilis, Hepatitis B and HIV serology should be offered to all patients getting a sexual health screen as standard of care.  Where Neisseria gonorrhoeae (GC) is detected via PCR, please request swabs for GC culture.  Low vaginal swabs are discouraged because the presence of high numbers of commensal flora makes them difficult to interpret  Self taken vulval / vaginal swabs for chlamydia/ GC have better yield than urine in women.  Maternity Patients: re gram staining on HVS samples from maternity patients Gram stain performed only if Query bacterial vaginosis (?BV) is noted on request form as a clinical detail. Refer to memo 01.06.17 sent to UL Maternity Hospital.

Gentamicin Assay Laboratory: Microbiology Specimen type: Refer to Antibiotic Assay

GL-3 Laboratory: Biochemistry Explanatory note: This test is used in the management of patients with Fabry Disease

Specimen type: The Clinical Biochemistry Laboratory must be contacted before initating the request so that all collection requirements can be met.

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory. Store specimen at approximately 4 degrees Celsius prior to preparation for dispatch to referral laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Glucagon Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Collect 5 mL of blood into an ice-cold EDTA tube (Violet Top) containing 0.1 mL of TRASYLOL (aprotinin; 20,000 klUmL).

Special requirements and Patient should be fasting overnight. The specimen should be surrounded with ice and brought to the comments: laboratory immediately. Note: haemolysis invalidates this assay.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Glucose Laboratory: Biochemistry Specimen type: Glucose specimen tube containing sodium fluoride EDTA as anticoagulant.(Grey Top)

Special requirements and Record specimen collection time and state whether the specimen is fasting, post-prandial or part of a comments: glucose tolerance test.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Glucose (CSF) Laboratory: Biochemistry Specimen type: CSF

Special requirements and Note that it is Laboratory Policy that all CSF specimens must be delivered to the Microbiology Department comments: for initial examination and processing. CSF samples must not be sent to the laboratory in the pneumatic chute system.

Appropriate clinical details required.

Turnaround time: 90 mins.

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Reference interval: On Biochemistry report or contact laboratory.

Note: Result should be interpreted in combination with plasma glucose result. CSF glucose should be 60 – 70% of the plasma glucose.

Glucose 6 Phosphate Dehydrogenase (G6PD) Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top)

Special requirements and Authorisation by Consultant Haematologist/Registrar comments: Referred for analysis to: Haemolytic Anaemia Laboratory, St James. Tel.: 01 416 2394

Turnaround time: 30 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code (iLab): G6PD / G6PDP

Glucose Tolerance Test (OGTT) Laboratory: Biochemistry Specimen type: See special requirements and comments section

Special requirements and Oral Glucose Tolerance Test (OGTT) using Rapilose® solution comments: An OGTT need only be considered to establish a diagnosis of diabetes if blood glucose values fall into an equivocal range (e.g. IFG or IGT) and is not necessary if the diagnostic criteria for diabetes are present.

OGTT is not necessary if the diagnostic criteria for Diabetes are present outside pregnancy. The OGTT is a diagnostic procedure; therefore patients with a pre-existing Type 1 or 2 Diabetes do not require this test. OGTT in pregnancy should be done at weeks 24-28.

The patient should consume their normal diet for 3 consecutive days prior to test. The patient should be advised not to alter their diet prior to test. Perform OGTT after at least 3 days of unrestricted diet (> 150g CHO daily).The patient should fast (no food or fluids except water) overnight (8-12 hours). Procedure: 1) Confirm patient has fasted for at least 8-12 hours 2) Collect first venous Blood sample (Fasting glucose) into Fluoride EDTA bottle (Sarstedt, grey cap) and label this bottle with PID, date and time. 3) Patient must drink the full content of the Rapilose OGTT solution pouch (300mL) over 5-10 minutes 4) The patient must sit quietly during the test and refrain from smoking. 5) 1 hour later take a second venous Blood sample collected into a Fluoride EDTA bottle (grey cap); label tube with PID, Date and Time 6) 2 hours post glucose drink collect third venous Blood sample (2 hr post prandial glucose) into a Fluoride EDTA (grey cap); label tube with PID, Date and Time 7) Refer to HSE 2010 Guidelines for the Management of Pre-gestational and Gestational Diabetes Mellitus from Pre-conception to the Post natal period for the OGTT procedure and the diagnostic interpretation of OGTT in pregnancy. Rapilose® NDC Stock item: 12MX1013 Notes on Oral Glucose Preparations for OGTT:  For oral glucose tolerance testing, the standard dose for an adult is one pouch of Rapilose® OGTT Solution (300mL / 75g anhydrous glucose). However, it can be easily adjusted to paediatric applications based on body mass.  The dose for children that weigh less than 43kg is 7mL (1.75g anhydrous glucose) per kg of body weight. The total children's dose should not exceed 75g.  Each 300mL pouch of Rapilose® OGTT Solution contains exactly 75g anhydrous glucose, which is the adult dose recommended by the World Health Organisation.  Rapilose® OGTT Solution is produced in a ready to drink format in a 300mL aluminium foil pouch with a tamper evident twist off cap.  Rapilose® OGTT Solution is a pleasant tasting orange flavoured drink that is non-carbonated and contains no colour additives. It is also gluten, lactose, fat, caffeine and alcohol free.  Rapilose® OGTT Solution has an 18 month shelf-life, when stored unopened at room temperature

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Polycal® Liquid (neutral or orange):  Polycal liquid may also be used as the 75 g glucose load for OGTT  This 75g load is prepared by mixing 113mL of Polycal® with 250-300mL of water. Criteria for diagnosis of Gestational Diabetes in pregnancy A diagnosis of gestational diabetes is made when one or more values are met or exceeded on the 75 g OGTT in Pregnancy:  Fasting Glucose > 5.1 mmol/L  One hour glucose ≥ 10.0 mmol/L  Two hour glucose ≥ 8.5 mmol/L Post natal Women with GDM should be offered advice on:  Diet and lifestyle  Risk of GDM in subsequent pregnancies  Risk of Type 2 Diabetes in future  The need for 6-12 weeks postpartum and annual OGTT

Blood glucose monitoring in the postnatal period:  Once the placenta is delivered, maternal blood glucose and insulin levels may rapidly return to normal.  Insulin therapy should be discontinued immediately postpartum.  Capillary blood glucose monitoring should be discontinued once blood glucose returns to normal levels.  Overt type 1 or diabetes should be suspected and investigated if hyperglycaemia persists.  A 75g OGTT, using the WHO criteria for the non-pregnant population should be performed at 6- 12 weeks postpartum and yearly thereafter as an increased risk of developing diabetes and cardiovascular disease exists.  If normal these women should have lifelong screening for pre-diabetes or diabetes development every 3 years Note: Following delivery, women diagnosed with GDM should be screened for persistent Diabetes 6-12 weeks postpartum, as an increased risk of developing type 2 Diabetes, type 1 Diabetes and cardiovascular disease exists. If normal these women should have lifelong screening for pre-diabetes or diabetes development every 3 years

Turnaround time: The waiting time for performing a glucose tolerance test in UHL (phlebotomy) is about one week. Result available in laboratory on day of test

Reference Interval: Criteria for diagnosis of Diabetes, IFG and IGT in the non-pregnant adult:

Procedure:

Similar as above but only need to collect venous blood in Fluoride EDTA bottles (grey cap) : 1) Fasting sample taken prior to glucose drink 2) Sample taken 2 hours post glucose drink Label tubes with PID, Date and Time and send to Biochemistry as soon as possible.

*IFG & IGT have an increased risk of future diabetes and cardiovascular morbidity  Advise on healthy eating, regular exercise and avoidance of obesity  Check Fasting Blood Glucose annually  Treat co-existing coronary risk factors aggressively, as are at increased risk of developing cardiovascular disease.

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The pregnant women who meet the above criteria are considered to have overt type 2 diabetes mellitus Glutamine Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met. 1-2 mL of blood in a lithium heparin tube (Green Top).

Special requirements and A specimen for glutamine assay must be sent to the laboratory immediately after it is drawn. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Gonadotrophins (FSH, LH) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Routine: 4 days. Contact laboratory if urgent result required.

Reference interval: On Biochemistry report or contact laboratory.

Gonococcal Complement Fixation Test (GCFT) Laboratory: Serology Special requirements and Gonococcal complement fixation test (GCFT) is no longer available in the Serology/Immunology comments: Laboratory. Please send appropriate sample(s) to the Microbiology Laboratory for culture / molecular testing. Refer to:Gonococcal PCR

Gonococcal PCR Laboratory: Microbiology

Specimen requirements: Abbott Multi-Collect™ specimen collection kits. (Available from the Microbiology Laboratory)

Note: Note: Endocervical swabs preferred specimen for women, urine is not tested. Urine for Chlamydia/ GC PCR testing is an optimal specimen for men.

Turnaround time: Specimens are batched for processing, allow 7 working days.

Special precautions: Ensure that containers are labeled in accordance with the precautions specimen labeling policy.

Group and crossmatch for massive haemorrhage Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 1

Turnaround time: Priortised once a massive haemorrhage is declared

When a patient presents with potential major haemorrhage, the doctor must inform the transfusion laboratory immediately. The medical scientist will immediately order platelets and thaw four to six units of solvent detergent plasma. Group specific, uncrossmatched red cell concentrates may be released, if time doesn’t allow for a full crossmatch.

One individual needs to be identified as a liaison person to communicate with the transfusion laboratory until the haemorrhage is under control. Please refer to the relevant guideline in the Blood Transfusion Manual.

Fibrinogen concentrate may also be required if the fibrinogen is <1.0 gm/l.

Group and screen Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 1

Turnaround time: Same day*

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*1 hour after receipt for urgent samples

Comment: A blood group and an antibody screen will be performed on the sample. The same sample can be used to crossmatch blood up to 72 hours following sample collection, sampling.)

Group and serological crossmatch Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 1

Turnaround time: 1 – 2 hours after receipt

Indication: A serological crossmatch will be performed on patients that have no historic blood group and antibody screen and patients that have antibodies. The blood laboratory need to be informed of the clinical conditions of the patients including sickle cell disease, thalassaemia and auto immune haemolytic anaemia .Ultimately the laboratory will decide patient suitability for serological/electronic crossmatch. *See section Crossmatch in the presence of a positive antibody screen

Comment: A blood group and an antibody screen will be performed on the sample and the sample will be serologically crossmatched for the number of units requested, or in the case of surgical patients, the number of units specified in the Maximum Surgical Blood Order Schedule (MSBOS). Any deviation from the agreed MSBOS needs to be clearly documented on the request form. Group and electronic crossmatch Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 1

Turnaround time: Maximum of 1hr from receipt of sample.

Indication: Applies to patients who have had more than one group and screen sample processed and have no history of antibodies. Auto immune haemolytic anaemia patients are ineligible for electronic crossmatch. The laboratory will decide if the patient fulfills suitability according to predefined criteria.

Group B Streptococcus (GBS) Culture Laboratory: Microbiology

Specimen requirements: Vaginal swab

Specimen collection: Swab the lower vagina (vaginal introitus) and the rectum with the same swab or two different swabs Cervical swabs are not recommended

Swabs in Amies transport medium with charcoal

Special precautions: If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 48h are undesirable

Turnaround time: 2 working days

Group B Streptococcus (GBS) PCR Laboratory: Microbiology Specimen type: Blood sample

Specimen requirements: Blood: EDTA sample (Violet Top)

Sample volume: Blood: Minimum volume 1ml

Special precautions: Deliver immediately to the Laboratory

Turnaround time: Group B streptococcus (GBS) PCR will only be carried out on blood from infants <7 days old. For children over 7 days of age it should be discussed with the laboratory.

Group B streptococci PCR results are available 24 hours after receipt by the referral laboratory Monday- Friday.

On receipt of the result, the Microbiology Laboratory telephones all positive results to the requesting source.

Final written report: 5 days Additional information: Specimens are referred to the Irish Meningococcal and Meningitis Reference Laboratory (IMMRL), Temple St, Dublin for testing.

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Refer to CSF (Cerebrospinal Fluid) for Film Array PCR

Group specific, uncrossmatched blood Laboratory: Blood Bank

Sample type: 7.5ml EDTA (Red Top)

Request form: Blood Bank 1

Availability time: 10-15 minutes from receipt of blood sample in Blood Transfusion laboratory.

Risk and comments: Risks associated with use are identical to risks associated with use of ORhD negative uncrossmatched blood. Group specific blood is no safer, but uses resources better, i.e. unnecessary use of O RhD negative blood is avoided. Units are labelled “uncrossmatched blood, transfuse with care’’.

Note: An emergency crossmatch for 4 red cell units will take 45 minutes provided the antibody screen is negative - see section on RCC crossmatch in the presence of a positive antibody screen for further information, if necessary. Growth Hormone Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top) (Fasting)

Special requirements and Specimen must be brought to the laboratory as soon as possible (less than three hours). comments: Physiological state (e.g. fasting, sleep, feeding, and activity) should be noted on the request form.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Gut hormone profile Laboratory: Biochemistry Special requirements and This includes Gastrin, Pancreatic Polypeptide, Vasoactive Intestinal Polypeptide and Glucagon comments: Please refer to specific requirements for individual gut hormones. H

Haematinics Screen Laboratory: Haematology Specimen type: Gel Serum (brown top).

Special requirements and Profile includes B12, Folate and Ferritin. comments: Requests should be received by the laboratory within 8 hours of phlebotomy. Relevant Clinical Details required for B12 & Folate requests. Guidelines on Vitamin B12 and Folate Testing are available. The laboratory may not process specimens where the indications for B12 & Folate testing are not provided.

Turnaround time: 3 D

Reference Interval: See individual assays.

Test / Profile code (iLab): BFF

H63D Mutation (Haemochromatosis Gene) Laboratory: Haematology Specimen type: 2 x EDTA (violet top).

Special requirements and See Haemochromatosis Gene Testing. comments:

Turnaround time: 45 D

Reference Interval: N/A

Test / Profile code (iLab): H63D / HLAHP

Haemochromatosis Gene Testing (H63D, C282Y) Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top).

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Note: Screening requirements pre genetic analysis.

Special requirements and Accompanied by completed Consent Form for Haemochromatosis Genetic Testing. comments: Referred to Biomnis Ireland, Three Rock Rd, Sandyford Business Estate, Sandyford, D18 Tel: 01 295 8545

Referrals for genetic testing will only be accepted with a clear indication of the reason for testing. The patient must either have a fasting transferrin saturation > 45% or a first degree relative who is currently being venesected for haemochromatosis.

Turnaround time: 45 D

Reference Interval: N/A

Test / Profile code (iLab): HLAHP

Haemoglobin A2 (Hb A2) Laboratory: Haematology Specimen type: EDTA (Violet Top).

Special requirements and Accompanied by UHL haemoglobinopathy request form. Refer to: Haemoglobinopathy comments: Screen Turnaround time: 42 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code (iLab): HBEL-A (Adults) / HBEL-P (Minors <16 years)

Haemoglobin F (Hb F) Laboratory: Haematology Specimen type: EDTA (Violet Top).

Special requirements and Accompanied by UHL haemoglobinopathy request form. Refer to: Haemoglobinopathy Screen comments: Turnaround time: 42 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code (iLab): HBEL-A (Adults) / HBEL-P (Minors <16 years)

Haemoglobin S (Hb S) Laboratory: Haematology Specimen type: EDTA (Violet Top).

Special requirements and Accompanied by UHL haemoglobinopathy request form. Refer to: comments: Haemoglobinopathy Screen Turnaround time: 42 D

Reference Interval: 0 g/dl

Test / Profile code (iLab): HBEL-A (Adults) / HBEL-P (Minors <16 years)

Haemoglobinopathy Screen Laboratory: Haematology Specimen type: 1 x Gel Serum (Brown Top), 2 x EDTA (Violet Top).

Special requirements and Accompanied by UHL haemoglobinopathy request form comments: Includes Haemoglobin A, A2, F & S etc. Adult samples (>16 years) are referred to Haematology Lab, St James. Tel.: 01 416 2909. Paediatric samples (<16 years) are referred to Haematology Lab, OLHSC, Crumlin. Tel.: 01 409 6432

Full Blood Count and serum ferritin reports are provided to the relevant referral lab with all requests to facilitate interpretation of results. Samples may not be referred for analysis if red cell indices are suggestive of iron deficiency in the absence of a serum ferritin result. Alpha thalassaemia trait cannot be excluded where iron deficiency exists. Turnaround time: 42 D Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code (iLab): HBEL-A (Adults) / HBEL-P (Minors <16 years)

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Haemophilus Influenza B (HIB) Antibodies Laboratory: Serology Special requirements and This test is available by arrangement only following discussion with the Consultant Microbiologist. comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Specimen type: Gel Serum (Brown Top)

Turnaround time: 3 - 4 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Haemophilus Species PCR Testing Laboratory: Microbiology

Specimen type: EDTA (Violet Top) sample

Specimen requirements: Blood: EDTA (Violet Top)sample

Sample volume: Blood: Minimum volume 1ml

Special precautions: Deliver immediately to the Laboratory

Turnaround time: • PCR results are available 24 hours upon receipt by the referral laboratory Monday-Friday

• Specific group available after 2 working days.

• On receipt of the result the Microbiology Laboratory telephones all positive results to the requesting source.

• Final written report: 5 days

Additional information: Specimens are referred to the Irish Meningococcal and Meningitis Reference Laboratory (IMMRL), Temple St, Dublin for testing.

Hantavirus Serology Laboratory: Serology Special requirements and Note: Requests for this test requires prior arrangement with the referral laboratory. comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415

Specimen type: Gel Serum (Brown Top)

Turnaround time: Test Availability: By Arrangement

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Haptoglobin Laboratory: Haematology Specimen type: Gel Serum (Brown Top)

Special requirements and Monday to Friday only. comments: Requests should be received by the laboratory before 13:00 hours within 24 hours of phlebotomy. Haemolysis of the sample will affect the reliability of the result.

Referred to Biomnis Ireland, Sandyford, Dublin 18. Tel: 01 2958545 Turnaround time: 14 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code (iLab): HAPTR / HAPTP

HbA1c Laboratory: Biochemistry Specimen type: Whole blood in potassium EDTA tube (as for FBC Violet Top).

Special requirements or comments: Turnaround time: Urgent: 1 working day. Routine: 4 working days.

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Reference interval: On Biochemistry report or contact laboratory. HbA1c traceable to IFCC Reference Measurement Procedure hCG (human chorionic gonadotrophin, total) Specimen type: Serum

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Urgent: same working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

HDL-Cholesterol Laboratory: Biochemistry

Specimen type: Serum

Special requirements and Fasting specimen comments: Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval LOW risk cases for IHD assessment, MRI of 3 years (MRI): Higher risk cases for IHD assessment and those on stable treatment, MRI of 1 year

For more information, see LIPID section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Heinz Bodies Laboratory: Haematology Specimen type: EDTA (Violet Top)

Special requirements and Sample must be in receipt of laboratory within 2 hours of phlebotomy. comments: Turnaround time: 1 W

Reference Interval: N/A

Test / Profile code (iLab): HEINZ

Helicobacter Pylori Laboratory: Microbiology Test method: Preferred test is Antigen Detection in Faeces. Refer to the: Helicobacter pylori Stool Antigen Helicobacter pylori - Gastric/Antral/Duodenal biopsies Laboratory: Microbiology Specimen Type: Please contact the Microbiology laboratory prior to taking of biopsies to arrange collection of DENTS medium. A stock of Dents cannot be maintained in the Microbiology Laboratory due to its short shelf life.

At least two weeks’ notice is required to obtain Dents medium from the UK. Alternatively, biopsies can be placed in a small volume of saline.

If several biopsies are taken they should each be placed in an individual vial of DENTS medium or saline.

Turnaround time: 15 days

Additional information: Specimens are referred to Public Health England, 61 Colindale Avenue, London, NW9, 5HT Helicobacter pylori Antibodies Laboratory: Serology

Special requirements and The Helicobacter pylori serology test is no longer available. Refer to the:Helicobacter pylori Stool comments: Antigen Helicobacter pylori Stool Antigen Laboratory: Serology

Specimen type: Fresh stool sample collected in a clean, sterile, leak-proof container. Please submit samples in a standard universal container (white cap).

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Special requirements and A minimum sample volume of 5g is required. comments: Samples should be submitted within 24 hours of collection.

Pre-treatment: Antimicrobials, proton pump inhibitors and bismuth preparations are known to suppress H. pylori and ingestion of these prior to testing may give a false negative result. The aforementioned compounds should be discontinued 2 weeks prior to sample collection.

Post-treatment: Testing to monitor the efficacy of eradication therapy should only be requested > 4 weeks after completion of therapy.

As per ESPHGAN & NASPGHAN guidelines, testing for H pylori stool antigen in children and adolescents (<18 years of age) is NOT recommended. The stool antigen test does not differentiate between H pylori colonisation and H pylori infection. Endoscopic biopsy is the recommended diagnostic test for investigation of H pylori disease.

Turnaround time: 7 working days

Reference interval: Detected / Not Detected Relevant interpretive comments are included on the report.

Repeat testing Interval: The negative predictive value of the stool antigen test is >95%. Therefore, provided sample collection complies with the pre and post treatment requirements, then there is no need to retest for H. pylori unless there is an imperative clinical requirement. Treat as functional dyspepsia. Low dose PPI or H2A for one month, then as required (BIA / PHE Guidelines).

Hepatitis Screen (Hepatitis A, B, C & E) Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and Testing for Hepatitis A Virus (HAV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Hepatitis E (HEV), comments: is recommended in patients in whom an abnormal liver chemistry profile (LCP) has been recorded, assuming no other obvious cause, and in those displaying signs or symptoms of acute hepatitis.

Abnormal LCP can be defined as an increase of twice the upper limit of the normal (ULN) range.

Testing for HCV in those who do not necessarily have an abnormal LCP should be performed in accordance with the National HCV Screening Guidelines (2017).

If at the time of presentation, the LCP abnormalities are known to be present for more than 6 months in an immunocompetent individual, then testing for HBV and HCV only is reasonable (with reflex testing for HDV if HBV infected). Ref: National Lab Handbook for Investigation of Viral Hepatitis (May 2018).

Turnaround time: Two working days Note: additional days are required for confirmation of positive/reactive samples. Urgent requests are processed on the day of receipt

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Heparin Induced Thrombocytopaenia (HIT) Screen Laboratory: Haematology Specimen type: 2 x Gel Serum (Brown Top) Special requirements and Prior arrangement with the UHL Coagulation Department. Contact 061 482851. comments: St James NCHCD request form must be completed by requesting source Fresh specimens must be received before 10.00 a.m. Referred to Coagulation Laboratory, National Centre for Hereditary Coagulation Disorders, St James’ Hospital. Tel: 01-4162956 / 4103569.

Turnaround time: 30 D

Reference Interval: N/A

Test / Profile code (iLab): HITR / HITP

Hepatitis A Virus IgG Antibodies (Immunity Screen) Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and Please indicate ‘Immunity check’ in the clinical details section of the Serology/Immunology request form comments:

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Turnaround time: 2 working days

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Hepatitis A Virus IgM Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and None comments: Limitation A negative HAV IgM result on a sample taken within 5 days of onset of symptoms does not exclude recent HAV infection. HAV IgM can remain detectable for 6 months following primary infection

Turnaround time: 2 working days

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: >1 week

Hepatitis B core Antibody (Anti-HBc) Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and None comments: Turnaround time: 2 working days Note: additional days are required for confirmation of positive/reactive samples.

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: For positive results – performed once only.

Hepatitis B Virus Antibody (Anti-HBs Immunity screen) Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Turnaround time: 2 working days Note: Additional days are required for confirmation of ‘immunity low’ samples using a second anti-HBs assay

Reference interval: <10 mIU/mL: Non-immune. 10 – 100 mIU/mL: Immunity low – Booster required. >100 mIU/mL: Immune – No further action required.

Relevant interpretive comments regarding further vaccination are included on the report.

Hepatitis B Virus Quantitative PCR Laboratory: Serology Specimen type: 2 X Gel Serum (Brown Top)

Special requirements and Requests for viral PCR must be separated and frozen within 6 hours of venepuncture. Please ensure comments: arrangements are in place prior to taking samples to ensure that they can be submitted to the laboratory within this time frame. If samples are being sent for viral PCR outside core working hours the laboratory should be contacted in advance. See section on ‘Out-of-Hours’ service.

This test is referred to the National Virus Reference Laboratory, Dublin.

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Tel: 01 716 4414/ 716 4415 Turnaround time: 2 - 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Hepatitis B Virus Surface Antigen (HBsAg) Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and Samples testing positive for HBsAg are automatically tested for Hepatitis D (Delta). Requests for HDV are comments: referred to NVRL, Dublin.

Turnaround time: 2 working days Note: additional days are required for confirmation of positive/reactive samples.

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Hepatitis C Virus Antibodies & HCV Antigen Laboratory: Serology Specimen type: Gel Serum (Brown Top) Special requirements and None comments:

Turnaround time: Anti-HCV: 2 working days HCV antigen: 3 working days Urgent requests are processed on the day of receipt.

Anti-HCV reactive / HCV antigen negative samples are referred for confirmation to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415

Notes: additional days are required for confirmation of positive/reactive samples.

**Patients who are confirmed as anti-HCV positive / HCV antigen negative must have a HCV RNA test performed to confirm past / resolved infection**

Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: In cases of significant exposure to HCV positive material:  If negative test at 12 and 24 weeks for HCV antibody  Test at 6 weeks and 12 weeks by HCV NAAT

Hepatitis C Virus PCR / Molecular Quantitative / Genotyping Laboratory: Serology Specimen type: 2 X EDTA (Violet Top) / 2 X EDTA/K2 Gel 4.9mL (Red Top)

This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Hepatitis Delta Virus (HDV) [Subviral Particle] Laboratory: Serology Special requirements and Note: Hepatitis D (Delta) testing is performed automatically on all newly confirmed HBsAg positive comments: samples. This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415

Specimen type: Gel Serum (Brown Top)

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Turnaround time: 2 - 3 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Hepatitis E Virus (HEV) Antibodies IgM & IgG Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and HEV IgM testing will be automatically performed with all requests for Hepatitis A IgM. Positive HEV IgM comments: samples will be tested for HEV IgG and the sample will also be referred to NVRL for HEV RNA testing.

Turnaround time: 3 working days

Reference interval: Positive / Negative Relevant interpretive comments are included on the report. Repeat testing Interval: >1 week

Hereditary Spherocytosis Screen (Flow cytometry) Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top).

Special requirements and Prior arrangement with Consultant Haematologist and Laboratory, contact 061 482258. comments: Consultant signature / approval required on request form.

All requests must be accompanied by FBC, Reticulocyte Count, Blood Film and Bilirubin reports as specified by the Referral Laboratory. Referred to National Centre for Medical Genetics, Cytogenetics Laboratory, Our Lady’s Hospital for Sick Children, Crumlin Tel: 01-409 6432 Samples must be received by 10.00 a.m. to ensure same day delivery to Dublin.

Turnaround times: 30 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code (iLab): RCM1R / RCM1P

Herpes Simplex Virus 1 & 2 (Viral Culture / PCR) Laboratory: Serology Specimen type: Skin / lesion swab - Viral Transport Swab (pink cap)

Note: The charcoal swab (Microbiology) is unsuitable for viral investigations.

Special requirements and Appropriate clinical details are required. comments: Note: Viral transport swabs are available from the Laboratory by contacting the Laboratory Porter (see ‘Ordering of Laboratory Supplies’ in the introduction section of this user manual) Viral transport swabs should be delivered to the laboratory as soon as possible after collection. Viral transport swabs may be refrigerated at 2 - 8°C overnight if same day delivery to the laboratory is not possible.

This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415

Turnaround time: 1 - 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Herpes simplex Virus 1 & 2 Serology Laboratory: Serology Specimen type: Gel Serum (Brown Top) Special requirements and This test is referred to the National Virus Reference Laboratory, Dublin. comments: Tel: 01 716 4414/ 716 4415

Note: Herpes simplex virus serology is not recommended for investigation of HSV. Patients who are symptomatic should have a viral swab for Herpes simplex taken, or alternatively, should be referred to the Infectious Disease OPD / STI/GUM clinic, UHL. The clinical indication for HSV serology testing must be discussed with the Consultant Microbiologist / Infectious Diseases Consultant prior to submitting a request to the Laboratory. Turnaround time: 1 – 2 weeks

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Reference interval: Positive / Negative Relevant interpretive comments are included on the report.

5 HIAA Laboratory: Biochemistry Specimen type: 24-hour urine collection with 20 mL of 6N HCI as preservative. The presence of acid preservative is essential.

Special requirements and Appropriate clinical details and a list of all current medication are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

HIV 1 & 2 Antibody/Antigen Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and None comments: Turnaround time: 2 working days Urgent requests are processed on the day of receipt Note: additional days are required for confirmation of positive/reactive samples.

HIV reactive samples are referred for confirmation and HIV typing to the National Virus Reference Laboratory (NVRL), Dublin. Tel: 01 716 4414/ 716 4415

Reference interval: Nonreactive results are reported as ‘Negative’ (see guide below for interpretation and follow-up of negative results). Reactive results are reported as ‘Preliminary Positive’ and referred to NVRL for confirmation. A follow-up sample is requested Grayzone results are reported as ‘Equivocal’ and a follow-up sample is requested

Repeat testing Interval: Interpretation and follow-up of HIV ‘Negative’ results (PHE Guideline V11):

a) Recent exposure but no HIV related signs or symptoms – recommend retest according to the window period of infection. Refer to the BASHH statement on HIV seroconversion window period. Contact the Laboratory for further advice if required. b) No known recent exposure and no HIV related signs or symptoms – regular testing is recommended for those who remain at risk of infection. c) HIV infection related signs or symptoms – Please send a further sample taken at least 7 days after the most recent sample if HIV infection is still suspected.

HIV 1 & 2 PCR / Molecular Quantitative Laboratory: Serology

Specimen type: 2 X EDTA (Violet Top) / 2 X EDTA/K2 Gel 4.9mL (Red Top)

Turnaround time: 1 - 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

If samples are being sent for viral PCR outside core working hours the laboratory should be contacted in advance. See section on ‘Out-of-Hours’ service. This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415

HLA Disease association (HLA B27, etc.) Laboratory: Serology Specimen type: 2 X EDTA (Violet Top) Note: HLA tissue typing requests for transplantation are handled by the Blood Transfusion Laboratory, UHL. Please refer to HLA Class I & II typing of transplant patients and family members

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Special requirements and In order to select the most appropriate test, clinical information and reason for request must be included comments: on the request form. The specific HLA disease association test should be specified on the request form.

HLA disease association requests are referred to the Doctors Laboratory (TDL), London. Tel: 01 293 3690 (Med Lab Pathology)

Turnaround time: 1 - 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Performed once only

HLA Class I & II typing of transplant patients and family members Laboratory: Blood Bank Sample type: 5-10ml EDTA/ citrate

Request form: Blood Bank 1

Note: The BT255 request form is completed by laboratory staff and forwarded with a copy of the Blood Bank 1 request form to the NHIRL in the National Blood Centre. Turnaround time: 2-3 weeks - test is performed in the NHIRL, Dublin.

HMMA (=VMA) Laboratory: Biochemistry Specimen type: 24-hour urine collection with 20 mL of 6N HCI as preservative. The presence of acid preservative is essential. Special requirements and Appropriate clinical details and a list of all current medication are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Homocysteine Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met. At least 2 mL of blood in a lithium heparin tube (Green Top)

Special requirements and Specimen should be delivered to the laboratory immediately after collection (within 15 minutes). It is comments: necessary for General Practitioners requiring this test to arrange for their patient to attend the Laboratory’s Phlebotomy Department at the University Hospital Limerick.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

HTLV (Human T-cell Lymphotropic Virus) Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Turnaround time: 1 - 2 weeks

Reference interval: The referral laboratory report provides appropriate ranges and interpretive comments.

Human Chorionic Gonadotrophin (Total hCG) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Urgent sample: same day. Routine: 4 working days.

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Reference interval: On Biochemistry report or contact laboratory. Hydroxyindole acetic acid (HIAA) Laboratory: Biochemistry Specimen type: 24-hour urine collection with 20 mL of 6N HCI as preservative. The presence of acid preservative is essential. Special requirements and Appropriate clinical details and a list of all current medication are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Hydroxymethoxymandelic acid (HMMA or VMA) Laboratory: Biochemistry Specimen type: 24-hour urine collection with 20 mL of 6N HCI as preservative. The presence of acid preservative is essential.

Special requirements and Appropriate clinical details and a list of all current medication are required. comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

17-Hydroxy progesterone Laboratory: Biochemistry Specimen type: Serum: The specimen (1.0 – 1.5 mL of blood) should be drawn between 8 and 9 am and before the day’s medication is taken. Note that serum assay is required for initial diagnosis of congenital adrenal hyperplasia. Newly-born should be at least 48 hours old before being tested.

Saliva (for monitoring adequacy of therapy but not for initial diagnosis): For saliva assay, special collection devices, tubes and instructions are available from the Clinical Biochemistry Laboratory or the Paediatric Secretaries, Children’s Ark, Mid-Western Regional Hospital. Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Blood spot samples on special filter paper cards (for monitoring adequacy of therapy but not for initial diagnosis): Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements and Appropriate clinical details and a list of all current medication are required. comments: Newly-born should be at least 48 hours old before being tested.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

IgE (allergen specific) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements and This is an expensive test as it is referred to an external Laboratory. In general, the external Laboratory will comments: test no more than 3 allergens. Due to constraints of the UHL Pathology Department Laboratories, it is suggested that all allergy/specific IgE requesting is restricted to Medical Consultants only.

The Referral Laboratory requires individual allergens to be requested. Appropriate clinical details are required. Note: These tests should not be considered diagnostic for a given allergen - they are merely assays for specific IgE. The medical history and clinical judgment are essential for assessing the significance and relevance of positive and negative test results.

The following link may be accessed for allergy education http://www.allergyeducation.co.uk The Irish Food Allergy Network has launched their website shortly with comprehensive guidelines on ‘Testing for food allergy & food intolerance’. http://ifan.ie/testing-for-food-allergy-food-intolerance/

Turnaround time: Requests for this test are referred to an external specialist laboratory. Allow two/three weeks for receipt of report.

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Reference Interval: The laboratory report provides appropriate reference values.

Minimum Retesting Interval: Not routinely required

IgE (total) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments: Measurement of total IgE does not contribute much to an allergy-focused evaluation. (Ref: Joint position statement from Irish Food Allergy Network (IFAN) and Irish Association of Allergy and Immunology (IAAI) 2013).

Turnaround time: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Minimum Retesting Interval: Repeat testing of limited value.

IGF Binding Protein-3 Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements and Specimen when taken must be brought to the laboratory immediately. comments: Appropriate clinical details are required. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

IGF-1 (insulin-like growth factor-1, somatomedin C) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements and The specimen when taken must be brought to the laboratory immediately. comments: Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values

IgG Subclasses Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements and Appropriate clinical details are required. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

IgG, IgA, IgM Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details required. andcomments: Turnaround time: Urgent: 1 working day. Routine: 4 working days. Immunohistochemistry Laboratory: Histology  The Histology Laboratory provides an Immunohistochemistry service for the UL Hospitals.  There is a broad range of antibodies available including Breast Receptors, Lymphoma Panels and Routine Screening Panels.  Immunohistochemistry requests are usually requested by the Pathologist / Haematologist or by the Oncologist in charge of the Patient.  Any other requests for specific Immunohistochemistry must be made through the reporting

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Pathologist. Immunoreactive trypsin Laboratory: Biochemistry Specimen type: Specimen is a heel prick whole blood sample – three blood spots on a prelabelled Newborn Screening Card.

Special requirements or Patient should not be more than six weeks old. comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Industrial toxicology Laboratory: Biochemistry

Special requirements and The Clinical Biochemistry Laboratory does not provide an assay service for environmental, industrial or comments: occupational toxic agents or chemicals. The most appropriate agency to contact regarding these matters is the Environmental Protection Agency.; contact details: EPA Headquarters, PO Box 3000, Johnstown Castle Estate, Co. Wexford, Tel: 053-9160600; Fax: 053- 9160699; Email: [email protected]; Lo Call: 1890 335599. Web site: www.epa.ie Infection Control Screening (MRSA, VRE, CPE/KPC, ESBL) Laboratory: Microbiology

Refer to the Infection Prevention and Control Policies for up to date screening protocols for alert organisms; Methicillin Resistance Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE), Carbapenem-Resistant Enterobacteriaceae (CRE / (KPC) and Extended-Spectrum Beta-Lactamases (ESBLs). HSE Intranet link: http://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/ipc/

1. METICILLIN RESISTANCE STAPHYLOCOCCUS AUREUS (MRSA)

MRSA screening is ONLY available to GP/Community/Day Hospitals in cases of pre op or where agreed in consultation with Consultant microbiologists. If these details are not clearly written on the request form these specimens will be rejected.

For Inpatients, routine MRSA screening is only processed Monday to Friday. Weekend processing is targeted and limited to urgent requests on ICU, HDU, Neonatal, Oncology and Orthopaedic patients and where agreed by the Consultant Microbiologist.

Please do NOT send routine MRSA screens over the weekend as they will exceed 48 hours on the next working day (Monday) and will not be processed. Routine screening samples sent Sunday evening will be processed on Monday. Routine screening Samples sent on Monday of Bank Holiday weekends will be processed on Tuesday.

Specimen type: Screening sites on Admission Bilateral nares (same swab) for Adults and Children over One Year who fulfil Groin criteria for screening. (Refer to the UHL MRSA (same swab) policy)

Once MRSA has been identified a full screen from the following sites is performed:  Nares  Groin or perineum  Any wound sites or abnormal skin  Sputum if present

 CSU (if catheterised)

 Medical devices sites  Throat if MRSA is persistent despite attempts at decolonisation Screening sites on Admission Bilateral nares (same swab) for Neonates and Infants Under BilateralUmbilicus Nares One Year who fulfil criteria for UmbilicusPerine um (same swab) Screening. (Refer to the UHL MRSA policy) Perineum Specimen requirements: Charcoal Swab Sputum Urine Sample volume: Urine: Minimum volume: 1ml

Special precautions: N/A

Turnaround time: Negative result: Final report 2 working days

Positive result: Final report 3 working days

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Additional Information:  To check for MRSA clearance, request an MRSA investigation only.  Do not request C/S.  Please ensure that all clinical details are provided on the request form.

2. VANCOMYCIN RESISTANT ENTEROCOCCI (VRE) SCREEN VRE screening is only performed on specimens from ICU/ HDU/ DIALYSIS or as agreed with the Consultant Microbiologist

NB: there is no need to check for clearance if the patient is previously VRE positive.

Specimen type: Faeces/Swab of faeces/ Illeostomy swab / Rectal swab Specimen Sterile leak-proof container. requirements: Charcoal swab.

Turnaround time: Negative report: 2 working days Positive report: 4 working days 3. Carbapenamase Producing Enterobacteriaceae Screen (CPE/KPC) Specimen type: Faeces/Swab of faeces/ Illeostomy swab / Rectal swab / Stool. Other samples as per Infection Control Policy.

Specimen Green Top Swab (Copan Fecal Swab; 502CS01 requirements: Special precautions: Please Indicate if the patient was previously CPE positive.

Turnaround time: Negative report: 1 working day Positive report: 3-4 working days

Additional Information: Please ensure that all clinical details are provided on the request form.

4. Extended Spectrum Beta Lactamases (ESBL) ESBL screening is only performed on specimens from:  Neonatal patients  Postpartum mothers at the UMH Limerick when their baby is being admitted to Neonatal Intensive Care Unit  Dialysis  Or as agreed with the Consultant Microbiologist Specimen type: Faeces/Swab of faeces/ Illeostomy swab / Rectal swab /Urine. Specimen Charcoal Swab requirements: Faeces Urine Sample volume: Minimum volume: 1mL

Special precautions: Please Indicate if the patient was previously ESBL positive. Turnaround time: Negative report: 2 working days Positive report: 4 working days Influenza A & B Antibodies Laboratory: Serology

Special requirements Influenza A & B serology is no longer available. See Influenza Virus A & B PCR for details on testing for Influenza. and comments:

Influenza Virus A & B PCR Laboratory: Serology

Specimen type:  In house testing – A nasopharyngeal swab (NPS) is the recommended sample type  Refer to Procedure for collecting Nasopharyngeal Swabs (NPS) for Respiratory Viruses  Other suitable sample types are: Viral Throat Swab / Viral Nasal Swab / Nasopharyngeal Aspirate / Broncho- alveolar Lavage. These requests are referred to NVRL, Dublin.  Note: The charcoal swab (Microbiology) is unsuitable for viral investigations.

Special requirements  Samples should be taken before 6pm Monday-Friday and sent immediately to the Laboratory. and comments:  The molecular assay used at UHL for Influenza RNA detection includes RSV RNA. Therefore, requests for either Influenza or RSV will be automatically tested for all 3 targets – Influenza A RNA; Influenza B RNA and RSV RNA.

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 This test is available at weekends and public holidays by contacting a member of the ‘on call’ staff via the Microbiology Laboratory (061 482502).  **Testing for viral clearance is not indicated**  Nasopharyngeal swabs are available from the Laboratory by contacting the Laboratory Porter (see ‘Ordering of Laboratory Supplies’ in the introduction section of the manual).  Viral swabs should be delivered to the laboratory as soon as possible after collection.  Viral swabs may be refrigerated at 2 - 8°C overnight if same day delivery to the laboratory is not possible.

Turnaround time: UHL: 1 working day Urgent requests during routine working hours: TAT= 3hours NVRL: 2 working days

Reference range: The Flu PCR profile includes: Flu A RNA; Flu B RNA & RSV RNA Results are reported as Detected / Not Detected Note - Negative results do not preclude influenza virus infection and should not be used as the sole basis for treatment or other patient management decisions.

Repeat testing Interval: Testing for viral clearance is not indicated

INR (International Normalised Ratio) Laboratory: Haematology

Specimen type: Citrated plasma (Blue Top).

Special requirements  Only performed on patients receiving Warfarin therapy and as such this must be specified on the request and comments: form. PT / INR requests for Warfarin dosage assessment must be received by the laboratory within 24 hours of phlebotomy.  Details of anticoagulant therapy required. **Do not refrigerate INR samples**  Out of hour/urgent requests for this test originating from external sources to UHL must include clinician’s direct contact details and advance notice to the laboratory is advised.

Turnaround time: Non GP: 4 H GP: 24H Non GP: 4 H GP: 24H

Reference Interval: N/A

Test / Profile code PTINR / COAG (iLab): Insulin Laboratory: Biochemistry

Specimen type: Fasting Gel Serum (Brown Top)

Special requirements Specimen for glucose assay (Grey Top) must be drawn at same time. Record specimen collection time. Specimen or comments: should be delivered to the laboratory within two hours of venepuncture.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values

Insulin : C-peptide Ratio Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top) . Specimen for glucose assay (Grey Top) must be drawn at same time.

Special requirements Record specimen collection time. Specimen should be delivered to the laboratory immediately after venepuncture. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Insulin antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top)

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Special requirements Appropriate clinical details are required. and comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Repeat testing not routinely required

Insulin-like growth factor-1 binding protein-3 (IGF-1 BP3) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements The specimen when taken must be brought to the laboratory immediately. or comments: Appropriate clinical details are required. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Intravenous Immunoglobulins Laboratory: Blood Bank Sample type: None

Request form: Blood Bank 1

Availability time: Same day

Risk and comments: Flebogammadiff (5% and 10%) and 10% Kiovig are routinely stocked. Pentaglobin is not routinely stocked but available from Intrapharma on request. Refer to the HG-A-BTR-IVIG guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual.

Intrinsic Factor Antibodies Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Requests for intrinsic factor are automatically tested for parietal cell antibodies. and comments:

Turnaround time: 7 working days

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat testing not routinely required

Iron Laboratory: Laboratory: Biochemistry Biochemistry

Specimen type: Gel Serum (Brown Top) Special requirements A fasting specimen is required. Iron specimens must be sent to the Clinical Biochemistry Laboratory immediately or comments: after venepuncture. Blood should be drawn before other specimens that require anticoagulated tubes. Serum iron displays a marked circadian rhythm. Marked haemolysis invalidates results Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory. Minimum Retesting Iron deficiency diagnosis: Repeat measurement not required unless doubt regarding diagnosis Interval: Iron profile in a normal patient: Minimum retesting interval 1 year Iron profile in patients on parenteral nutrition: Minimum retesting interval 3-6 months

Ref: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

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Iron Stain (Perls Prussian Blue Stain) (Cytochemical Stain) Laboratory: Haematology

Specimen type: Bone marrow spread on glass slides.

Special requirements: All BMA requests should be accompanied by a FBC sample. FBC/Film should be requested on a separate form. Bone marrow slides, must be delivered fresh to the laboratory, or be fixed in methanol. Slides must be labelled on frosted side using a lead pencil, include: . Patients full name. . PID / Chart number and/or DOB. . Specimen date. Accompanied by UHL haematology request form.

Turnaround time: 1 W

Reference Interval: N/A

Test / Profile code N/A. Search by discipline – Histology. (iLab):

Iron studies profile Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top) Patient must be fasting.

Special requirements Includes iron, transferrin, TIBC and transferrin saturation. or comments: Blood should be drawn before other specimens that require anticoagulated tubes. Serum iron displays a marked circadian rhythm.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Iron deficiency diagnosis: Repeat measurement not required unless doubt regarding diagnosis Interval: Iron profile in a normal patient: Minimum retesting interval 1 year Iron profile in patients on parenteral nutrition: Minimum retesting interval 3-6 months

Ref: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Islet Cell Antibodies Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details are required. and comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 2 - 3 weeks Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Repeat testing not routinely required

Janus Kinase 2 mutation (JAK2 V617F) Laboratory: Haematology

Specimen type: 9 mL EDTA (Violet Top)

Special requirements: Prior arrangement with UHL laboratory (061 482258). Review of clinical details and authorisation by a consultant haematologist/registrar. Consultant signature/approval required on request form.

Referred to Cancer Molecular Diagnostics (CMD), St James Hospital. Tel.: 01 410 3575 Requests must be completed on CMD request forms including adequate clinical details e.g. ? PPP, ET, CML, etc.

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Bone Marrow samples must be received by 10.00am to ensure same day delivery to Dublin.

Note: CMD routinely reject JAK2 requests on patients who have been previously tested and may not issue a report to that effect.

Turnaround time: 45 D Haematology team may contact referral laboratory re urgent samples.

Reference Interval: N/A Test / Profile code JAK2R / JAK2P (iLab): K

Kappa and Lambda Free Light Chains in serum Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top) Assay is not available for urine samples.

Special requirements Appropriate clinical details are required including reason for request. or comments: This assay is only available to Consultant Haematologists / renal consultants and their teams. The assay should be regarded as experimental. Important diagnostic and patient management decisions should not be made on the basis of serum free light chain assay results only.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Ketones Laboratory: N/A

Specimen type: Urine.

Special requirements Test immediately after collection. This test is performed as a ward/surgery side-room test. Use ward-based urine or comments: analysers. Ketones in blood should be measured on ketone meters (POCT)

L.A.T.S. replaced by TBII (TSH-binding inhibiting immunoglobulin) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details are required. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values. Lactate Laboratory: Biochemistry

Specimen type: Plasma fluoride EDTA anticoagulant (grey top. i.e. use the same tube as for glucose specimens.

Special requirements Specimen should be sent to the laboratory immediately after being drawn. or comments:

Turnaround time: 20 mins if laboratory contacted in advance.

Reference interval: On Biochemistry report or contact laboratory.

Lactate (CSF) Laboratory: Biochemistry

Specimen type: CSF in universal container

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Special requirements All CSF samples must be delivered to the Microbiology Department without delay for initial examination and or comments: processing CSF samples must not be sent to the laboratory in the pneumatic chute system

Turnaround time:. 90 mins.

Reference interval: On Biochemistry report or contact laboratory.

Lambda and Kappa Free Light Chains in serum Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top) Assay is not available for urine.

Special requirements Appropriate clinical details are required including reason for request. or comments: This assay is available only to Consultant Haematologists / renal consultants and their teams. The assay should be regarded as experimental. Important diagnostic and patient management decisions should not be made on the basis of serum free light chain assay results only.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Laxatives screen Laboratory: Biochemistry

Specimen type: 20 mL of urine, ideally from three consecutive days. Stool specimens may also be used.

Special requirements Appropriate clinical details are required. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference range: The referral laboratory report provides appropriate reference values.

LD or LDH (Lactate dehydrogenase) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top), Pleural fluid, ascitic fluid

Special requirements Note: haemolysis invalidates the assay. or comments: Samples for LDH analysis must be hand delivered to Biochemistry department and NOT sent via pneumatic tube system. LDH values may be falsely elevated in samples sent via pneumatic chute system.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

LDL-Cholesterol Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Fasting specimen or comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting LOW risk cases for IHD assessment, MRI of 3 years Interval (MRI): Higher risk cases for IHD assessment and those on stable treatment, MRI of 1 years

For more information, see LIPID section of:

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https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html Lead Laboratory: Biochemistry

Specimen type: Whole blood in trace metal-free tube. Trace metal-free needle must be used in conjunction with trace metal-free tube.

Special requirements This specimen should be collected first if other tests are requested to avoid contamination. or comments: Please contact Clinical Biochemistry Laboratory for trace metal-free specimen collection tube and needle.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Legionella Antibodies Laboratory: Serology

Special requirements Serology testing is available by arrangement only following discussion with the Consultant Microbiologist. and comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Note – Legionella Urinary Antigen is the recommended test for the diagnosis of Legionella Infection. Refer to Legionella Urinary Antigen

Specimen type: Gel Serum (Brown Top)

Turnaround time: 2 – 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Legionella Urinary Antigen Laboratory: Microbiology

Specimen type: Urine collected in a sterile leak-proof container

Sample volume: Minimum volume = 1ml.

Specimen Only tested for ICU / HDU patients and where appropriate clinical details are provided. requirements: Urine specimens should be delivered to the laboratory as soon as possible after collection. Specimens may be refrigerated at 2 - 8°C overnight if same day delivery to the laboratory is not possible.

Turnaround time: Same day

Comment: The Legionella urinary antigen test is for detection of Legionella pneumophilia serogroup 1 antigen and for epidemiological investigations if antigen is detected. Culture is recommended to detect causative agents other than L. pneumophilia serogroup 1. Refer to Legionella Culture

Urinary antigen detection is a very convenient method of diagnosing Legionnaires’ disease. Antigen becomes detectable soon after onset of symptoms and the test may remain positive for several weeks, even after other tests have become negative. Antigen detection is a highly specific method (>99%) of diagnosing legionellosis, its sensitivity being similar to that of culture (80-85%).

Legionella Culture Laboratory: Microbiology Specimen type:  Pleural Fluid  Broncho-Alveolar Lavage (BAL).  Bronchial/tracheal aspirate,  Transtracheal aspirate  Lung biopsy/tissue, pleural fluid, transtracheal aspirate Special Precautions: Test method does not recommend the use of sputum samples. Deliver immediately to the Laboratory.

Approval required from the Consultant Microbiologist

Specimen Sterile sealed container requirements: Sample volume: Pleural Fluid: Minimum volume 1ml BAL: Large a volume as possible Tissue and Biopsies: Specimens should ideally be large enough to carry out all microscopic

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preparations and cultures Turnaround time: Final report: 11 days Positive cultures are telephoned immediately to the requesting source.

Leptospira Antibody (IgM) Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details are required. and comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Note: Positive / Reactive samples for Leptospira IgM are referred by NVRL for confirmation and typing to the Rare & Imported Pathogens Laboratory, PHE, Porton Down, UK Tel: +44 1980 612348 Turnaround time: 4 working days Turnaround time for referred requests for confirmation and typing: 2 – 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Leptospirosis Laboratory: Microbiology Test method: Direct microscopy for Leptospira is no longer performed in the Microbiology Laboratory. Leptospiral IgM testing is recommended. Refer to Leptospira Antibody (IgM)

Leucocyte Esterase (Cytochemical Stain) Laboratory: Haematology

Specimen type: Bone Marrow Aspirate on slides.

Special requirements: Prior arrangement with Consultant Haematologist and Laboratory (061 482258). This test will only be processed with authorisation by a consultant haematologist / registrar.

Referred to St James Hospital for pre-analytical staining. Turnaround times: 45 D Haematology team may contact referral laboratory re urgent samples. Reference Interval: Refer to Report.

Test / Profile code NCAE (iLab): LFT profile Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Includes bilirubin, alkaline phosphatase, gamma GT, ALT, Albumin and Total Protein. or comments: Please ensure that specimens for the assay of transaminase activity (ALT) are delivered to the Laboratory within 24 hours of sample collection.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days. Urgent sample:

Reference interval On Biochemistry report or contact laboratory.

Minimum Retesting See LFT section of: Interval: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

LH Laboratory: Laboratory: Biochemistry Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details are required. or comments: Appropriate clinical details are required. Turnaround time: Urgent: 1 working day. Routine: 4 working days.

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Reference interval: On Biochemistry report or contact laboratory.

Lipase Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details are required. or comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Lipid profile (state if fasting) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top) see special requirements

Special requirements Ideally, the patient must be fasting for 10 hours and have been on a stable diet for the previous two to three or comments: weeks Alcohol should not be consumed in the three days before the test. The profile includes; total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglyceride. Non- fasting sample is also acceptable. Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Low risk cases for IHD assessment, MRI of 3 years Interval (MRI): Higher risk cases for IHD assessment and those on stable treatment, MRI of 1 years

For more information, see LIPID section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Lipoprotein(a) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements The patient should be fasting for 10 hours. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Lithium Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Draw specimen at a consistent interval from the last dose, 6-12 hours is recommended. or comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Liver-Kidney-Microsomes Antibodies (LKM) Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Requests for anti-liver-kidney-microsomes (LKM) are automatically tested for anti-smooth muscle antibodies and comments: (ASMA), anti-mitochondrial antibodies (AMA) and anti nuclear antibodies (ANA)

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Turnaround time: 5 working days

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat testing of limited value – frequency to be determined by clinical context

Lupus Like Anticoagulant (LLA) Laboratory: Haematology

Specimen type: 3 x Citrated plasma (Blue Top).

Special requirements: Requests should be received by the laboratory within 4 hours of phlebotomy. Details of anticoagulant therapy required.

Unless requested by:  A Neurologist  A Rheumatologist  Miscarriage clinic  Gynaecologist for investigation of recurrent miscarriage/fertility treatment Lupus screening requests must be sanctioned by the haematology team. Lupus screening is not performed on patients receiving warfarin and/or unfractionated heparin or novel anticoagulants.

Turnaround times: 4 W

Reference Interval: N/A

Test / Profile code LLA / TPHIL (iLab): Lyme Disease (Borrelia burgdorferi) Serology (C6 Assay) Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Notes: and comments:  Erythema migrans (EM) is a clinical diagnosis. Antibody testing is NOT recommended in patients presenting with EM due to the low sensitivity of antibody testing in early lyme borreliosis (LB)

 Serology testing is useful for the investigation of disseminated or late LB

 Serology testing has a low Positive Predictive Value (PPV) when the a priori chance of LB is low

Appropriate clinical details are required with all requests for Lyme serology. Positive / Reactive samples are referred for confirmation to the Rare & Imported Pathogens Laboratory, PHE, Porton Down, UK. Tel: +44 1980 612100

Turnaround time: 5 working days Turnaround time for referred confirmatory / follow-up results: 1 – 2 weeks

Reference interval: Positive / Weak Positive / Negative Relevant interpretive and advice comments are included on the report.

Repeat testing Interval: In cases of negative results: >2 weeks In cases of confirmed positive Lyme serology – no further antibody testing required.

Lymphocyte transformation test (LTT) Laboratory: Haematology

Specimen type: 20mls of blood taken in EDTA bottles (Violet Top) stored at room temperature

Special requirements Test referred to Prof K.P Ringel’s diagnostic laboratory in Germany. and comments: Letter of clinical history and drugs required for testing. Samples sent Monday to Thursday only. Sample should reach referral lab within 24 hours.

Test sensitivity 60-70%, specificity 85%. Lymphopenia can affect the result. Test must be done < 1 week for SIS/TEN or morbilliform drug eruptions. DRESS should be done 5-8 weeks after rash develops.

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Approval by Consultant Dermatologist and Haematologist required.

Volume: 20mls of blood taken in EDTA bottles Turnaround time: 1W

Reference interval: Refer to report

Test / Profile code MISCP (iLab): Lysosomal enzyme analysis (White cell enzyme analysis) Laboratory: Biochemistry

Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements 5 mL blood in lithium heparin tube (Green Top); Do not refrigerate or centrifuge, Deliver to laboratory without or comments: delay. Monday – Wednesday (only). Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Magnesium Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top) Urinary magnesium: See Urine Analyses for specimen, requirements, turnaround time and reference interval.

Special requirements Blood specimens for magnesium assay must be collected free of haemolysis. or comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Malaria Antibodies Laboratory: Serology

Special requirements Note: This test has limited value in the diagnosis of patients with clinical symptoms of malaria. If patient is febrile and comments: the appropriate sample(s) should be sent to the Haematology Laboratory. Please refer to the Malaria Antigen Test and Malaria Screen for further information.

This test is referred to the BIOMNIS Laboratories, Dublin.Tel: 01 299 0650 / 01 295 8545 Specimen type: Gel Serum (Brown Top)

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Malaria Screen Laboratory: Haematology

Specimen type: EDTA (Violet Top), Fresh Blood Films.

Special requirements: Travel history and clinical details, including medication details are essential. The malaria screen includes  Malaria antigen Test for the qualitative detection of Plasmodium Falciparum, Plasmodium Vivax, Plasmodium Malariae and Plasmodium Ovale and a blood film stained for malaria parasites. A fresh sample is required for malaria screens and preferably should be obtained when the patient is at the peak of a febrile attack.

 If the Malaria antigen test is negative a malaria molecular assay is performed. This assay targets a region of the Plasmodium genome that is conserved across Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi.

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 Thick and thin blood films are stained with a Giemsa stain for malaria. Negative films do not exclude a diagnosis of Malaria. Repeat films should be requested after 12-24 hours and again after a further 24 hours if clinically indicated

Turnaround times: 3 D

Reference Interval: N/A

Test / Profile code MALA (iLab): Manganese Laboratory: Biochemistry

Specimen type: Whole blood in trace metal-free tube. Trace metal-free needle must be used in conjunction with trace metal-free tube. Special requirements This specimen should be collected first if other tests are requested to avoid contamination. or comments: Please contact Clinical Biochemistry Laboratory for trace metal-free specimen collection tube and needle.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Measles Antibodies (IgG) Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Requests for patients previously reported Measles IgG positive should not be repeated. An appropriate comment and comments: will be attached to reports for unprocessed repeat requests for Measles IgG.

Note: Evidence of protection for individuals born since 1978 is documented evidence of two doses of measles vaccine. Serology testing is not indicated.

Turnaround time: 7 working days

Reference range: Positive / Negative / Borderline Borderline results are referred to NVRL, Dublin. Tel: 01 716 4414/ 716 4415 Relevant interpretive comments are included on the report.

Repeat testing Interval: Performed once only. Serology testing post vaccination is not indicated.

Measles Antibodies (IgM) Laboratory: Serology

Specimen type: Gel Serum (Brown Top) / Saliva (Oral Fluid)

Special requirements Note: Prior arrangement is required with the Consultant Microbiologist and the laboratory for all requests for and comments: Measles IgM, Tel: 061 482254.

Saliva collection swabs are available from the Department of Public Health, Limerick. Tel: 061 483337.

Measles IgM requests are referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415 Turnaround time: 1 – 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Meningococcal Antibodies Laboratory: Serology

Special requirements Note: Prior arrangement is required with the Consultant Microbiologist and the laboratory for all requests for and comments: Meningococcal antibodies, contact 061 482254.

This test is referred to the BIOMNIS Laboratories, Dublin.Tel: 01 299 0650 / 01 295 8545 Specimen type: Gel Serum (Brown Top)

Turnaround time: 3 - 4 weeks

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Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Meningococcal PCR Laboratory: Microbiology

Specimen type: Blood sample

Specimen Blood: EDTA sample (Violet Top) Requirements:

Sample volume: Blood: Minimum volume 0.5ml

Special precautions: Deliver immediately to the Laboratory

Turnaround time: • Meningococcal PCR results are available 24 hours after receipt by the referral laboratory Monday-Friday.

• Specific meningococcal group available after 2 working days.

• On receipt of the result, the Microbiology Laboratory telephones all positive results to the requesting source.

• Final written report: 7 days

Additional Information: Specimens are referred to the Irish Meningococcal and Meningitis Reference Laboratory, (IMMRL), Temple St, Dublin for testing.

Mixing Studies Laboratory: Haematology

Specimen type: Minimum 2 coagulation specimens

Special requirements: Blood samples must be collected with a minimum of trauma and stasis and processed within 2 hours.

Turnaround times: 4 HRS

Reference Interval: N/A

Test / Profile code MXPT, MXAPTT (iLab): Mercury Laboratory: Biochemistry

Specimen type: Whole blood in trace metal-free tube. Trace metal-free needle must be used in conjunction with trace metal-free tube. This specimen should be collected first if other tests are requested to avoid contamination. Urine: 24-hour collection in metal-free acid washed container. No preservatives required.

Special requirements Please contact Clinical Biochemistry Laboratory for trace metal-free specimen collection tube and needle. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Metanephrines Laboratory: Biochemistry

Specimen type: 24-hour urine collection with 20 mL of 6N HCI as preservative. The presence of acid preservative is essential.

Special requirements Appropriate clinical details and a list of all current medication are required. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Methadone Metabolite (EDDP) Laboratory: Biochemistry Specimen type: Random urine specimen (in a ‘Sarstedt Monovette Z’ 10mL urine container).collected without any preservative.

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Special requirements The assay is intended to assist in the clinical management of the patient and is not provided for medico-legal or comments: purposes. The requesting doctor may need to consider whether a patient might avail of opportunities to alter or interfere with the integrity of the specimen.

Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference Interval: On Biochemistry report or contact laboratory.

Methaemoglobin Laboratory: Biochemistry

Specimen type: Arterial blood in air-free heparinised syringe. Blood gas analysis sampling kits are available in each ward. Once the sample has been drawn, the blood gas syringe must be labelled with the patient’s full name, chart number, ward, date and time of collection. Immediately after collection, expel any air from the sample and seal the syringe with the stopper provided in the sampling kit.

Special requirements The specimen should be brought to the Laboratory immediately. If delay between sample collection and arriving or comments: in the laboratory is greater than 15 minutes send on ice. Blood gas syringes must not be sent to Biochemistry via the pneumatic chute.

Turnaround time: 20 minutes.

Reference Interval: On Biochemistry report or contact laboratory.

Methanol Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details are required. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory. Toxicology Laboratory, Beaumont Hospital, Beaumont, Dublin 9. Tel: 01 809 2673; 01 809 2671; 01 809 2675

Beaumont Laboratory operates a strict policy of not transmitting reports by fax.

The current out-of-hours toxicology call service at Beaumont Hospital is available to all hospitals in the Republic of Ireland. “The service is restricted to checking only for drugs, which if taken in overdose require a specific antidote or treatment. It is not an aid to diagnosis nor to allow a patient to be discharged.” If the assay is required outside of normal working hours contact switchboard at Beaumont Hospital and ask for the Principal Biochemist in Toxicology to be contacted. Consultant: Dr. W. Tormey

Reference Interval: The referral laboratory report provides appropriate reference values.

Methotrexate Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Sampling time will vary according to the dosing protocol. Details of time of dose, time of specimen collection, or comments: dosage regimen and mode of administration must be included with request.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Meticillin Resistance Staphylococcus aureus (MRSA) Laboratory: Microbiology

Refer to Infection Control Screening

Microalbumin Laboratory: Biochemistry

See urine section in alphabetical listing for specimen, requirements, turnaround time and reference interval.

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Refer to Urine Analyses

Microalbumin/creatinine ratio Laboratory: Biochemistry Refer to Urine Analysesin alphabetical listing for specimen, requirements, turnaround time and reference interval.

Mitochondrial Antibodies (AMA) Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Requests for mitochondrial antibodies (AMA) are automatically tested for anti-smooth muscle antibodies (ASMA) and comments: and anti-liver-kidney-microsomes (LKM).

Turnaround time: 5 working days

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat AMA testing is of limited value – frequency to be determined by clinical context Anti-M2 antibody testing is performed once only.

Monospot (Infectious Mononucleosis) Laboratory: Haematology

Specimen type: EDTA (Violet Top) or Gel Serum (Brown Top)

Special requirements: N/A

Turnaround times: 2 D

Reference Interval: Negative or positive.

Test / Profile code MONOSP (iLab): Mother and baby samples from RhD negative mothers at delivery Laboratory: Blood Bank

Sample type: 7.5 ml EDTA (Red Top) from mother and 7.5 ml EDTA (Red Top) cord sample

Request form: Blood Bank 1

Turnaround time: Same day

Note: The maternal sample for FMH should be taken when sufficient time has elapsed to allow the fetal cells to be distributed within the maternal circulation following delivery, manual removal of placenta or sensitising event. A period of 30-45 minutes is considered adequate. All samples must arrive in the transfusion laboratory at 10.00hrs for testing. Samples arriving after this time will be tested the following day. Mouth Laboratory: Microbiology

Specimen type: Mouth swab

Specimen collection: Sample pus if present, otherwise sample any lesions or inflamed areas. A tongue depressor or spatula may be helpful to aid vision and avoid contamination from other parts of the mouth.

Specimen Charcoal swab requirements:

Sample volume: N/A

Turnaround time: Aerobic Report: 2-3 working days

Test method: Routine Swab: Cultured for Yeasts. Stained for Vincent’s organisms if indicated by clinical details

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Clinical details of Mouth ulcers: ß-haemolytic streptococci Staphylococcus aureus Additional Information: Please state on request form if fungal investigation is required Please include clinical details of halitosis/bad breath/poor oral hygiene or suspected gum disease- Gram stain for Vincents organisms will only be performed if these details are present

MPL Exon 10 mutation Laboratory: Haematology Specimen type: Peripheral blood (or bone marrow) sample taken into EDTA (Violet Top) or, if already extracted, a DNA sample

Special requirements Prior arrangement with UHL laboratory (061 482258). and comments: Review of clinical details and authorisation by a consultant haematologist/registrar. Consultant Haematologist signature/approval required on request form.

Referred to Cambridge Molecular Malignancy Laboratory / Haemato-Oncology Diagnostics Service (HODS) Turnaround time: 60 D Haematology team may contact referral laboratory re urgent samples.

Reference interval: N/A

Test / Profile code MPL10 (iLab): Mucopolysaccharides Laboratory: Biochemistry

Specimen type: 1-5 mL of urine (in a ‘Sarstedt Monovette Z’ 10mL urine container). Specimen should be sent to the laboratory immediately.

Special requirements The initial screen (at the Children’s Hospital, Temple Street, Dublin) is for total glycosaminoglycans. If positive, or or comments: if a clinical suspicion exists, electrophoresis is carried out.

Enzyme analysis is performed at The Willink Biochemical Genetics Unit, Royal Manchester Children’s Hospital (Tel 00 44 161 7272137 or 7272138) when an abnormal mucopolysaccharide pattern has been identified in urine. For these investigations, 5 mL of blood in a potassium EDTA tube is required. Do not refrigerate and deliver to the Clinical Biochemistry Laboratory immediately. Note that dispatch to Manchester needs to be on Monday – Wednesday (only). Full clinical details must accompany these requests.

Contact the Clinical Biochemistry Laboratory before initiating such a request so that all collection requirements can be met.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Mumps Antibodies (IgG) Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Requests for patients previously reported Mumps IgG positive should not be repeated. An appropriate comment and comments: will be attached to reports for unprocessed repeat requests for Mumps IgG.

Note: Evidence of protection for individuals born since 1978 is documented evidence of two doses of MMR. No Serology testing is necessary.

Turnaround time: 7 working days

Reference range: Positive / Negative / Borderline Borderline results are referred to NVRL, Dublin. Tel: 01 716 4414/ 716 4415 Relevant interpretive comments are included on the report.

Repeat testing Interval: Performed once only. Serology testing post vaccination is not indicated.

Mumps Antibodies (IgM) Laboratory: Serology

Specimen type: Gel Serum (Brown Top) / Saliva (Oral Fluid).

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Special requirements Appropriate clinical details are required on all requests for Mumps IgM. and comments: Saliva collection swabs are available from the Department of Public Health, Catherine Street, Limerick. Tel: 061 483337.

Mumps IgM saliva (oral fluid) requests are referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Turnaround time: Serum IgM Test: 7 working days Mumps IgM oral fluid test: 1 – 2 weeks

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: >1 week

Mycophenolate (CellCept®) Laboratory: Biochemistry

Specimen type: EDTA plasma (Violet Top) 4 mL of whole blood in a potassium EDTA specimen tube is required. The time and quantity of last dose and sample collection time must be stated on request form. Send specimen to laboratory immediately so that plasma can be separated within two hours.

Special requirements Special request form for immunosuppressant drug monitoring should be used. or comments: The date and time of specimen collection and the date, time and dosage of the last mycophenolate dose must be recorded on the request form. Appropriate clinical details are also required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Mycoplasma genitalium in genital specimens Laboratory: Microbiology Specimen Abbott Multi-Collect™ specimen collection kits (Available from the Microbiology Laboratory) requirements and Urine between min and max fill line on males (overfilled samples will be rejected) or Endocervical/Urethral swabs comments: Straight urine in universal container or Charcoal swabs can be tested, but not preferred

Turnaround time: 2 days from day of receipt by the referral laboratory Mon-Thurs. Special precautions: Ensure that containers are labeled in accordance with the pathology specimen labeling policy.

Mycoplasma pneumoniae Antibodies Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Special requirements Serology testing is available by arrangement only following discussion with the Consultant Microbiologist. and comments: Molecular testing by PCR on respiratory samples may be considered in the inpatient setting following discussion with the Microbiology Laboratory. See Sputum, Bronchoalveolar Lavage, and Associated Specimens

Patients <20 years old Mycoplasma serology requests are referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415. Requests for patients >20 years of age are referred to Biomnis Laboratories; Tel: 01 299 0650 / 01 295 8545

Turnaround time: 1 – 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Mysoline® (Primidone) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Specimen should be drawn before the next oral dose in a patient at a steady state. When making comparative or comments: measurements, it is important that the sampling time be consistent. Phenobarbital should also be measured since it is an active metabolite of Primidone.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

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Reference Interval: The referral laboratory report provides appropriate reference values.

Nasal Swab Laboratory: Microbiology Sample type: Refer to Nose Swab

Neonatal alloimmune thrombocytopenia investigation Laboratory: Blood Bank

Sample type: Mother 20ml clotted and 7.5ml EDTA Father 20ml EDTA Neonate 2.7ml EDTA

Request form: Blood Bank 1

Turnaround time: 2 weeks depending on priority (sent to the National Blood Centre, Dublin)

Comments: Discuss request with the consultant haematologist.

Neurological Antibodies Laboratory: Serology

Specimen type: Gel Serum (Brown Top)

Tests include:

Neuro-immunology diagnostics (including MuSK Abs; Voltage gated Ca2+ channel Abs; Voltage gated K+ channel Abs; Aquaporin-4 Abs; NMDA receptor Abs; Glycine receptor Abs; Ganglioside Abs; Myelin Associated Glycoprotein Abs, Neuronal Abs; Anti-Myelin Oligodendrocyte Abs; Special requirements Tests are referred to the Neurosciencses Lab, Oxford University Hospitals, England. or comments: Tel: 00 44 1865 225995

Turnaround time: 2-4 weeks depending on the test.

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Repeat testing of limited value – frequency to be determined by clinical context

Norovirus (Stools) Laboratory: Serology

Specimen type: Fresh stool sample collected in a clean, sterile, leak-proof container.

Special requirements All stool samples sent for the investigation of viral gastroenteritis will have a PCR assay performed for Adenovirus, and comments: Rotavirus, Norovirus, Sapovirus and Astrovirus.

Turnaround time: 1 working day

Reference range: Detected / Not Detected Relevant interpretive comments are included on the report.

Repeat testing Interval: Testing for viral clearance is not indicated

Nose Swab Laboratory: Microbiology

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Test Information: Nasal cultures do not predict the etiologic agent of sinus, middle ear or lower respiratory tract infections and should not be submitted in lieu of specimens from these sites.

Adult Nasal swabs are rejected except for investigation of MRSA carriage for infection control screening of inpatients and pre operative screening only in the Community setting.

Specimens indicating the presence of a lesion, or taken from children <15 years are routinely examined only for Staphylococcus aureus and beta-hemolytic Streptococci. If diphtheria and rhinoscleroma are suspected discuss with the Clinical microbiologist prior to requesting investigation for Corynebacterium diphtheriae and Klebsiella rhinoscleromatis respectively.

Specimen type: Nose / Nasal swab

Specimen Charcoal swab requirements: Specimen Collection: Obtain a culture swab. A nasal speculum may be needed for some patients. Carefully insert the swab at least 1cm into the nares. Firmly sample the membrane by rotating the swab and leaving it in place for 10-15 seconds. Withdraw the swab and place it in the transport charcoal medium.

Sample volume: N/A

Special precautions: Full clinical information should be provided on the request form, especially recent travel.

Turnaround time: Final report: 2-4 working days

N-Telopeptide (NTx) Laboratory: Biochemistry

Specimen type: Urine (in a ‘Sarstedt Monovette Z’ 10mL urine container); specimen must be delivered to laboratory without delay.

Special requirements It is recommended that a carefully monitored second void collection is made; patients should be asked to empty or comments: their bladders on waking and discard the urine. Then they should collect the next specimen (the second morning void) in the urine container (plain container, no additives). To minimise the influence of day-to-day variability, it is important to maintain the same collection protocol.

Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Occult blood Laboratory: Biochemistry

Specimen type: Stool specimen.

Special requirements The following food should not be consumed in the 3 days before the test: red meat, radish, and liver. or comments:

Turnaround time: Availability of assay: three working days.

Reference Interval: Negative result.

Oestradiol / estradiol Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details required. or comments: This assay has not been validated for use on neonatal samples.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

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Oligoclonal IgG banding (CSF) Laboratory: Biochemistry

Specimen type: CSF and serum obtained at the same time.

Special requirements Appropriate clinical details required. or comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Opiate Laboratory: Biochemistry

Specimen type: Random urine specimen in BD Vacutainer 4ml urine container (Beige Top) collected without any preservative.

Turnaround time: Routine: 4 working days. Contact laboratory if urgent result required.

Reference Interval: On Biochemistry report or contact laboratory

Organic Acids Laboratory: Biochemistry

Specimen type: At least 2 mL and ideally 5 mL of urine (in a ‘Sarstedt Monovette Z’ 10mL urine container) collected without preservative. The specimen must be sent to the laboratory immediately so that it can be frozen at minus 25 degrees Celsius as soon as possible.

Special requirements Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be or comments: met.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Orosomucoid (alpha-1-acid glycoprotein) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details are required. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate referance values.

Osmolality Laboratory: Biochemistry

Specimen type: Gel Serum (brown top); Urine (in a ‘Sarstedt Monovette Z’ 10mL urine container) without preservative.

Special requirements Specimen should be sent to the laboratory without delay. or comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory Urine osmolality results should be interpreted in conjunction with the patient’s renal function hydration status, serum osmolality and clinical condition.

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Osteocalcin Laboratory: Biochemistry

Specimen type: Gel Serum (brown top)

Special requirements To minimise the influence of day-to-day variability, it is important to maintain the same collection protocol. Serial or comments: samples should be collected at the same time of day on each occasion, e.g. mid-morning.

Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Oxalate Laboratory: Biochemistry

Specimen type: Urine: 24-hour urine collection is required with 20mL of 6N HCI as preservative.

Special requirements Appropriate clinical details are required. or comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Oxcarbazepine (Trileptal®) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top) Lithium Heparin Plasma (Green Top)

Special requirements Specimen drawn before the next oral dose in a patient at steady state. or comments: Store specimen at approximately 4 degrees Celsius prior to preparation for dispatch to referral laboratory.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Oxidative Burst Test Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top). Special requirements: This test will only be processed with authorisation by a consultant haematologist. Consultant signature/approval required on request form. Prior arrangement with laboratory also required (061 482258).

Referred to Haematology Lab, OLHSC, Crumlin. Tel.: 01 409 6432. Samples must be in receipt of referral laboratory within 4 hours of phlebotomy. Referrals accepted Monday – Wednesday.

Turnaround time: 30 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code NBT1 / NBTP (iLab): P

Pancreatic Polypeptide Laboratory: Biochemistry Specimen type: Collect 5 mL of blood into an ice-cold lithium heparin tube containing 0.1 mL of TRASYLOL (aprotinin: 20,000 KlU/mL). Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements Patient should be fasting overnight. The specimen should be surrounded with ice and brought to the laboratory

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Reference Interval: The referral laboratory report provides appropriate reference values.

Paracetamol (Acetaminophen) Laboratory: Biochemistry

Specimen type: Gel Serum (brown top): see special requirements.

Special requirements Specimen should be drawn four hours post-overdose and preferably not later than 16 hours. Serum values taken and comments: less than four hours post-ingestion are difficult to interpret due to the possibility of continuing absorption and distribution of the drug and may not represent the peak level.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. Reference interval: On Biochemistry report or contact laboratory.

PARACETAMOL RESULTS GUIDE: WARNING: please note that results are reported in mg/L Possible toxicity: >120mg/L at 4 hours, 60mg/L at 8 hours, or 30mg/L at 12 hours post-ingestion. Probable toxicity: >200mg/L at 4 hours, 100mg/L at 8 hours, or 50mg/L at 12 hours. See paracetamol overdose treatment nomogram

Paracetamol overdose treatment nomogram (Note that results are reported in mg/L) Reference: BNF November 2012 Parainfluenza Virus Laboratory: Serology

Specimen type: Nasopharyngeal aspirate / viral swab

Special requirements Samples should be taken before 3pm Monday-Friday and sent immediately to Serology /Immunology. and comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Turnaround time: 1 – 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Paraprotein studies Laboratory: Biochemistry

Specimen type: Gel Serum (brown top) and urine (in a ‘Sarstedt Monovette Z’ 10mL urine container - no preservative required; keep refrigerated).

Special requirements Appropriate clinical details. and comments:

Turnaround time: Availability of assay: 4 working days.

Reference Interval: The laboratory report provides appropriate information.

Parasites Laboratory: Microbiology

Specimen Type: Refer to: Faeces. Specimens will not be processed for OVA, CYSTS and PARASITES unless clinical details

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are provided. Specimen Referral for parasites and amoeba Requirements: Please refer to the Hospital for Tropical diseases website for further information on services offered, sample type and turnaround times (see uclh.nhs.uk). Samples can be sent to the microbiology laboratory that will refer them to the Hospital for Tropical Diseases.

Specimens requiring referral for parasites/amoeba are sent to the: Dept of Clinical Parasitology Hospital for tropical diseases Mortimer Market Capper Street London WC1E 6JB Tel: 020 3447 5418

Turnaround time: Results are available 8-10 working days depending on the test required.

Paraquat (quantitative) Laboratory: Biochemistry

Specimen type: Gel Serum (brown top), urine (in a ‘Sarstedt Monovette Z’ 10mL urine container); see special requirements.

Special requirements This assay is available at the Toxicology Laboratory, Beaumont Hospital, Dublin. (Telephone 01 809 2673 or 01 and comments: 809 2675). The current out-of-hours call service at Beaumont Hospital is available to all hospitals in the Republic of Ireland. “The service is restricted to checking only for drugs, which if taken in overdose require a specific antidote or treatment. It is not an aid to diagnosis nor to allow a patient to be discharged.” If the assay is required outside of normal working hours, contact the switchboard at Beaumont Hospital and ask for the Principal Biochemist in Toxicology to be contacted.

Reference Interval: The laboratory report provides appropriate information.

Paraquat Screen (dithionite test) Laboratory: Biochemistry

Assay not available.

Parental phenotype Laboratory: Blood Bank

Sample type: 7.5ml EDTA (Red Top)

Request form: Blood Bank 1

Turnaround time: 1 day

Comments: If a pregnant woman has antibodies, sample from the putative father will be required to determine the probability of the fetus carrying the relevant antigen.

Parietal Cell Antibodies Laboratory: Serology

Specimen type: Gel Serum (brown top)

Special requirements Requests for parietal cell antibodies are automatically tested for intrinsic factor antibodies. and comments:

Turnaround time: 7 working days

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat testing is not routinely required

Paroxetine (Seroxat®) Laboratory: Biochemistry

Specimen type: Gel Serum (brown top)

Special requirements Details of dosage regimen required.

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Parvovirus Antibodies (IgM & IgG) Laboratory: Serology

Specimen type: Gel Serum (brown top)

Special requirements Appropriate clinical details are required. and comments: This test is referred to the National Virus Reference Laboratory, Dublin.Tel: 01 716 4414/ 716 4415.

Turnaround time: 1 – 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

PCP (Phencyclidine) Laboratory: Biochemistry

Specimen type: Random urine specimen collected without any preservative.

Special requirements The assay is intended to assist in the clinical management of the patient and is not provided for medico-legal and comments: purposes. The requesting doctor may need to consider whether a patient might avail of opportunities to alter or interfere with the integrity of the specimen. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The cut-off threshold for a positive result for phencyclidine is 25 ng/mL. A positive result for phencyclidine indicates only the presence of phencyclidine and does not necessarily correlate with the extent of physiological and psychological effects. A negative result indicates that phencyclidine is either not present or is present at levels below the cut-off threshold for this test.

Pemphigus / Pemphigoid Antibodies Laboratory: Serology

Specimen type: Gel Serum (brown top)

Special requirements Appropriate clinical details are required. and comments: This test is referred to the St James’ Immunology Laboratory, Dublin. Tel: 01 4162907 / 01 4162928

Turnaround time: 1 - 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: On treatment: 6 months Off treatment: annually

Anti-Phospholipase-A2-Receptor Antibodies Laboratory: Serology

Specimen type: Gel Serum (brown top)

Special requirements Indications for testing and clinical information must be provided with the request. This test is available to the renal and comments: consultants only. This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545 Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Repeat testing Interval: Repeat testing of limited value – frequency to be determined by clinical context pH (miscellaneous fluids) Laboratory: Biochemistry

Specimen type: Pleural and peritoneal fluids: Collect the sample of fluid in a syringe pre-rinsed with 0.2 mL of heparin or in a syringe from the BGA sampling kit available in wards. Immediately after collection, expel any air from the sample and seal the syringe with the

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stopper provided in the BGA sampling kit. The Laboratory will not, for safety reasons, accept syringes with any form of needle or resheathed needle attached. Once the sample has been drawn, the syringe must be labelled with the patient’s full name, chart number, ward, date and time of collection. Labels suitable for affixing to blood gas syringes are made available to each ward. These labels display the URGENT alert message in a prominent manner. The specimen should be surrounded with ice-water and brought to the Laboratory without delay. Blood gas syringes must not be sent to Biochemistry via the pneumatic chute.

Urine: Random urine specimen (in a ‘Sarstedt Monovette Z’ 10mL urine container).collected without preservative and transported to the laboratory on ice-water. Turnaround time: Urgent: 90 mins. Routine: same day.

Reference Interval: The laboratory report provides appropriate reference values.

Phencyclidine (PCP) Laboratory: Biochemistry

Specimen type: Random urine specimen (in a ‘Sarstedt Monovette Z’ 10mL urine container) collected without any preservative.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Phenobarbital Laboratory: Biochemistry Specimen type: Gel Serum (brown top)

Special requirements Specimen drawn before the next oral dose in a patient at steady state. and comments:

Turnaround time: Routine: 4 days. Contact laboratory if urgent result required.

Reference Interval: On Biochemistry report or contact laboratory.

Phenylalanine Laboratory: Biochemistry

Specimen type: Serum; 24-hour urine collected without preservative.

Special requirements Specimen should be sent to the laboratory immediately and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Phenytoin (Epanutin®) Laboratory: Biochemistry Specimen type: Gel Serum (brown top)

Special requirements Specimen drawn before the next oral dose in a patient at steady state. and comments:

Turnaround time: Routine: 4 days. Contact laboratory if urgent result required. Reference Interval: On Biochemistry report or contact laboratory.

Additional Information: Note: Approximately 92% of serum/plasma phenytoin is bound to protein. The binding of phenytoin to serum proteins may decrease in conditions associated with hypoalbuminaemia. Some drugs, most notably, valproate may displace phenytoin from serum proteins and increase its free fraction.

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Phosphate Laboratory: Biochemistry

Specimen type: Gel Serum (brown top) Urinary phosphate: See Urine Analyses in alphabetical listing for specimen, requirements, turnaround time and reference interval.

Special requirements Blood specimens for phosphate assay must be collected free of haemolysis. The serum must be separated within and comments: a period of two hours from venepuncture, since phosphate is released from red blood cells during the transport and storage of whole blood specimens thus causing a falsely raised serum phosphate concentration.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting For more details, see RENAL / BONE section of: Interval: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Placental alkaline phosphatase isoenzyme Laboratory: Biochemistry

Specimen type: Gel Serum (brown top)

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Plasma Viscosity Laboratory: Haematology

Specimen type: EDTA (Violet top).

Special requirements This test is only available if one of the following applies: and comments: 1. Patients with a significant paraprotein (IgG >30g/l; IgA>20g/l; IgM>15g/l). 2. Patients having plasmapheresis for a lymphoproliferative disorder 3. Patients where the test has been discussed with, and authorised by a haematology registrar/consultant haematologist Requests should be received by the laboratory within 6 hours of phlebotomy. Samples MUST NOT be refrigerated. Turnaround time: 3 D

Reference Interval: 1.13-1.27mPa@37 ºC

Test / Profile code PVISC (iLab): Platelet alloantibody testing Laboratory: Blood Bank Sample type: 5 ml serum

Request form: Blood Bank 1

Turnaround time: 2 weeks depending on priority (sent to the National Blood Centre, Dublin).

Platelet antigen testing Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top) Request form: Blood Bank 1

Turnaround time: 2 weeks depending on priority (sent to the National Blood Centre, Dublin)

Risk and comments: This test is of no value in investigation or management of thrombocytopenia. Requests will be referred back to the requesting team for discussion with a consultant haematologist/registrar. Platelets Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top). No sample is required if there is a current blood group on the laboratory information

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system. Request form: Blood Bank 1

Availability time: An emergency platelet concentrate is routinely held in the blood transfusion laboratory. However, requests should be placed in advance (if time permits) as it takes 2 hours for platelets to be delivered from Cork or 4 hours for platelets to be delivered from Dublin.

Communication with the laboratory is essential if special requirements are being considered such as washed or HLA matched platelets.

Platelets can be issued (if already in the blood transfusion laboratory) within 15 minutes, if there is a patient blood group on file or within 25 minutes if there is no patient blood group on file. Risk and comments: Refer to the HG-A-BTR-PLATELET guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Pneumococcal Antibodies Laboratory: Serology

Special requirements Note 1: Pneumococcal Urinary Antigen is the recommended test for the diagnosis of Pneumococcal and comments: infection. Note 2: Pneumococcal antibody serology is not recommended for the investigation of pneumococcal infection. Measurement of specific pneumococcal antibodies is clinically useful in two settings: 1. To determine protective status (immunity) of patient. 2. To assess B-cell functionality in a patient with recurrent infection.

This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545 Specimen type: Gel Serum (brown top)

Turnaround time: 3 - 4 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Pneumococcal PCR Laboratory: Laboratory: Microbiology

Specimen type: Blood sample

Specimen Blood: EDTA sample (Violet Top) requirements: Sample volume: Blood: Minimum volume 1ml

Special precautions: Deliver immediately to the Laboratory

Turnaround time: • Pneumococcal PCR results are available 24 hours after receipt by the referral laboratory Monday-Friday. • Specific meningococcal group available after 2 working days. • On receipt of the result the Microbiology Laboratory telephones all positive results to the requesting source. • Final written report: 5 days

Additional information: Specimens are referred to the Irish Meningococcal and Meningitis Reference Laboratory (IMMRL), Temple St, Dublin for testing. Pneumococcal Urinary Antigen Laboratory: Microbiology

Specimen type: Urine collected in a sterile leak-proof container

Sample volume: Minimum volume = 1ml.

Specimen Only tested for ICU / HDU patients and where appropriate clinical details are provided. requirements and Urine specimens should be delivered to the laboratory as soon as possible after collection. comments: Specimens may be refrigerated at 2 - 8°C overnight if same day delivery to the laboratory is not possible.

Turnaround time: Same day

Comment: A negative Streptococcus pneumoniae test does not exclude infection with S.pneumoniae. Therefore, the results of this test as well as culture results, serology or other antigen detection methods should be used in conjunction with clinical findings to make an accurate diagnosis.

It is not recommended to perform this test within 5 days of receiving the S.pneumoniae vaccine.

Pneumococcal urinary antigen testing is not performed on children under 5.

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Pneumocystis jiroveci (carinii) Laboratory: Microbiology

Specimen type: Bronchoalveolar lavage / sputum

Specimen Sterile universal container requirements and Specimens are referred to NVRL, Dublin. comments:

Sample volume: Bronchoalveolar lavage: 30ml Induced sputum: 2-4ml

Turnaround time: 1-2 days from day of receipt by the referral laboratory Mon-Thurs. Positive results are telephoned to the requesting source.

PNH (Paroxysmal Nocturnal Haemoglobinuria) By Flow Cytometry Laboratory: Haematology

Specimen type: EDTA x 3 (Violet Top).

Special requirements Prior arrangement with Consultant Haematologist and laboratory, contact 061 482258. and comments: Consultant signature / approval required on request form.

Samples must be within receipt of laboratory by 10:00 hours. Referred for analysis to: Haematology Lab, St James. Tel.: 01 416 2909 Turnaround times: 30 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code PNHR / PNHP (iLab): Polio Virus Antibodies Laboratory: Serology

Special requirements Polio virus serology is used to determine the immunity status of an individual as a result of either previous and comments: infection or previous vaccination. This test is only available by arrangement following discussion with the Consultant Microbiologist. This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Note: The diagnostic test of choice for acute poliovirus infection is viral culture performed on two stool specimens collected 24 - 48 hours apart and within 14 days of the onset of paralysis (see Viral Studies - Stools). Specimen type: Gel Serum (brown top)

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Polyoma Virus (JC / BK) Laboratory: Serology

Specimen type(s): • Gel Serum (brown top) • Urine sample collected in a sterile sealed container - Minimum volume required = 1ml. • CSF (Cerebrospinal Fluid).

Special requirements Samples should be sent immediately to Serology /Immunology. and comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Turnaround time: 1 - 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Porphoblinogen Laboratory: Biochemistry

Specimen type: Urine; keep cool and protect from light using e.g. aluminium kitchen foil.

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Special requirements Specimen should be sent to the laboratory without delay. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Porphyrins Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met. Appropriate clinical details are required.

Special requirements The following specimens are required and must be delivered to the laboratory immediately. and comments: Urine: 20 mL of fresh early morning urine and a 24-hour collection, keep refrigerated and protect from light using e.g. aluminium kitchen foil.

Stools: 5 – 10 grams specimen, refrigerate and protect from light using e.g. aluminium kitchen foil.

Blood: Two 2.7 mL blood specimens in potassium EDTA tubes (Violet Top) and 2.6 mL blood in one lithium heparin tube; protect from light using e.g. aluminium kitchen foil.

Note: “The key to effective investigation of the porphyrias is the appropriate analysis of correctly chosen samples taken when the patient is symptomatic, taking into account the clinical presentation.” All Wales Clinical Biochemistry Audit Group: Standards for Investigation of Porphyria Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values. Urinary phosphate: See urine section in alphabetical listing for specimen, requirements, turnaround time and reference interval.

Potassium Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top), plasma Lithium Heparin (Green Top), Urinary potassium: Refer to Urine Analyses in alphabetical listing for specimen, requirements, turnaround time and reference interval.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting For more details, see RENAL section of: Interval: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Pregnancy Test Laboratory: Microbiology

Specimen Sterile universal container requirements:

Sample volume: Urine: Minimum volume: 1ml

Special precautions: DO NOT USE BORIC ACID CONTAINERS

Turnaround time: Urgent samples: < 30 mins Routine samples: same day Additional Information: Inconsistent urine hCG results may occur in the following circumstances:  *Conditions other than pregnancy that cause elevated levels of urinary hCG.  *If the patient is on treatment with drugs containing hCG

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 *In patients with abnormal bladder or kidney function (e.g.  enterocystoplasties and renal failure)  *If the urine sample contains excessive amounts of bacteria

Please note that if the test result is non-consistent with clinical evidence, further evaluation may be required.

NB: Serum HCG levels are performed in the Biochemistry Department.

Primidone (Mysoline®) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Specimen should be drawn before the next oral dose in a patient at a steady state. When making comparative and comments: measurements, it is important that the sampling time be consistent. Phenobarbital should also be measured since it is an active metabolite of Primidone.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Procollagen peptide Type 1 (PINP) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top), Special requirements 1mL of separated serum required - refrigerate and comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Procollagen peptide Type 3 (P111NP) Laboratory: Biochemistry

Specimen type: Clotted blood sample. The specimen should be sent to the laboratory immediately. The sample should be centrifuged and the serum separated within 1-2 hours of collection (maximum no more than 4 hours).

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Progesterone Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top),

Special requirements Appropriate clinical details required. and comments:

Turnaround time: Urgent: 1 working day (Contact laboratory). Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

17-Hydroxy progesterone Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top): The specimen (1.0 – 1.5 mL of blood) should be drawn between 8 and 9 am and before the day’s medication is taken. Note that serum assay is required for initial diagnosis of congenital adrenal hyperplasia. Newly-born should be at least 48 hours old before being tested.

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Special requirements Appropriate clinical details and a list of all current medication are required. and comments:

Prograf® (FK 506, Tacrolimus) Laboratory: Biochemistry

Specimen type: Whole blood in specimen tube with potassium EDTA (Violet Top) as anticoagulant. Special request form for immunosuppressant drug monitoring should be used.

Special requirements Trough levels should be monitored. and comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Prolactin Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top)

Special requirements Appropriate clinical details and a list of all current medication are required. and comments: Prolactin levels are increased by stress and by drugs that deplete dopamine or block its action.

Turnaround time: Urgent: 1 working day (Contact laboratory). Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Prostate Specific Antigen, Free (fPSA) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top); specimen must be delivered to the laboratory immediately.

Special requirements This assay is only performed on requests from Urologists and authorised by a Consultant. and comments: Specimens must be delivered to the laboratory within four hours of venepuncture.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Protein Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top), plasma Lithium heparin (Green Top); Urinary protein: Refer to: Urine Analyses for specimen, requirements, turnaround time and reference interval. Protein may also be assayed in other fluids such as CSF, pleural fluid, ascitic fluid.

Special requirements Prolonged venous compression during blood collection will increase serum protein. and comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting For more details, see BONE / LFT section of: Interval: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Protein/creatinine ratio (urine) Laboratory: Biochemistry

Special requirements See urine section in alphabetical listing for specimen, requirements, turnaround time and reference interval. and comments: Protein (CSF) Laboratory: Biochemistry

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Specimen type: CSF

Special requirements Appropriate clinical details required. and comments: Note that it is Laboratory Policy that all CSF specimens must be delivered to the Microbiology Department for initial examination and processing. CSF samples must not be sent to the laboratory in the pneumatic chute system

Turnaround time: 90 mins.

Reference interval: On Biochemistry report or contact laboratory.

Protein C Laboratory: Haematology

Specimen type: 2x Citrated plasma (Blue Top). Or, if ordered as part of a thrombophilia screen, 4 x Citrated plasma (Blue Top) and 1 x EDTA (Violet Top). Special requirements  Generally requested as part of a thrombophilia screen. Thrombophilia screening requests must be and comments: sanctioned by the haematology team and as such must include relevant clinical details.  Thrombophilia screening is not performed on patients receiving warfarin and/or unfractionated heparin or novel anticoagulants  Requests should be received by the laboratory within 4 hours of phlebotomy.  Urgent requests must be approved by a Consultant Haematologist.  Details of anticoagulant therapy required.

Turnaround times: 4 W

Reference Interval: 70-130 u/dl

Test / Profile code PROTC / TPHIL (iLab):

Protein Electrophoresis (Serum) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top);

Special requirements Appropriate clinical details required. and comments: For specimens from Primary Care, refer to UHL Guidance on Management of MGUS in Primary Care.

https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/staff/resources/pppgs/labmanual.html

https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/ulh/staff/resources/pppgs/uhl-guidance- management-of-mgus-in-primary-care-edition-march-2019.pdf Turnaround time: 4 working days.

Reference Interval: The laboratory report provides appropriate information.

Protein Electrophoresis (Urine) Laboratory: Biochemistry Specimen type: Untimed urine collection (20ml urine in a universal container) or a 24-hour collection. No preservative is required. Keep specimen refrigerated.

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory

Reference Interval: The referral laboratory report provides appropriate reference values.

Protein S Laboratory: Haematology

Specimen type: 2x Citrated plasma (Blue Top). Or, if ordered as part of a thrombophilia screen, 4 x Citrated plasma (Blue Top) and 1 x EDTA (Violet Top).

Special requirements Generally requested as part of a thrombophilia screen. Thrombophilia screening requests must be sanctioned by and comments: the haematology team and as such must include relevant clinical details. Thrombophilia screening is not performed on patients receiving warfarin and/or unfractionated heparin or novel anticoagulants

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Requests should be received by the laboratory within 2 hours of phlebotomy. Details of anticoagulant therapy required. Turnaround times: 4 W

Reference Interval: 65-140 u/dl Protein S levels are affected by pregnancy Test / Profile code PROTS / TPHIL (iLab):

Protein S Profile Laboratory: Haematology

Specimen type: 2 x Citrated plasma (Blue Top).

Special requirements Requests should be received by the laboratory within 2 hours of phlebotomy. and comments: Details of anticoagulant therapy required. Test includes Protein S & Free Protein S. Turnaround time: 30 D

Reference Interval: Protein S: 65-140 u/dl, Free Protein S: 57-122 U/dl

Test / Profile code PROTS / FPROTS (iLab): Prothrombin complex concentrate Laboratory: Blood Bank

Sample type: None

Request form: Blood Bank 1

Availability time: Same day

Risk and comments: Prothrombin complex concentrate’s (PCCs) should only be prescribed in accordance with the guideline HG-A- BTR-PCC available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Any requests not falling within the guideline will be referred to a consultant haematologist. Prothrombin Time (PT) Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements PT / INR requests for Warfarin dosage assessment must be received by the laboratory within 24 hours of and comments: phlebotomy. Details of anticoagulant therapy required. Do not refrigerate PT samples.

Reference Interval: Refer to report form.

Test / Profile code PTINR / COAG (iLab): Prozac® (Fluoxetine) Laboratory: Biochemistry

Specimen type: Gel Serum (Brown Top);

Special requirements Details of dosage regimen required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

PSA (Prostate Specific Antigen) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top); specimen should reach laboratory within eight hours of venepuncture.

Test information: This assay has regulatory body approval for the quantitative measurement of PSA in human serum, as an aid in the detection of prostate cancer when used in conjunction with digital rectal examination in men aged 50 years or older. This assay is also likely to be of value as an adjunctive test to aid in the management of prostate cancer

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patients.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory. Refer to NCCP Guidelines for Age Specific Ranges. (WHO calibrated assay)

Minimum Retesting See guidance on PSA testing in NCCP guidelines at: Interval: https://www.hse.ie/eng/services/list/5/cancer/profinfo/resources/gpreferrals/nccp-prostate-cancer-gp-referral- guideline.pdf

PSA (Prostate Specific Antigen) Free Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top); specimen must be delivered to the laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

PTH (Parathyroid Hormone) intact Laboratory: Biochemistry

Specimen type: Separate sample EDTA blood sample (Violet Top).

Special requirements A calcium request must accompany a PTH Request. and comments: A separate FBC sample must be taken at the GP practice for PTH request. The date and time of phlebotomy must be provided.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Purkinje Fibre Antibodies Laboratory: Serology

Specimen type: Gel Serum (Brown Top);

Special requirements Appropriate clinical details are required. and comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 3 - 4 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Pyruvate Laboratory: Biochemistry

Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements Add 1.5 mL of 5.1% perchloric acid to specimen tube. Weigh tube. Add 0.5 mL of whole blood to the weighed and comments: tube. Mix thoroughly by inverting several times. Weigh tube again and calculate the exact weight of blood added. Centrifuge tube at 4 degrees Celsius. Remove supernatant and store at minus 25 degrees Celsius pending dispatch to Reference Laboratory.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Q-Fever Antibodies (Coxiella burnetti) Laboratory: Serology

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Specimen type: Gel Serum (Brown Top);

Special requirements Samples for Coxiella burnetti IgM and/or IgG are referred to the RIPL, UK PHE Laboratory, Porton Down. and comments: Tel: +44 1980 612224.

Requests for Coxiella burnetti should be discussed with the Consultant Microbiologist or the Infectious Diseases consultant prior to requesting the test.

Turnaround time: 1 – 2 weeks

Reference range: The referral laboratory report provides appropriate ranges, interpretive comments and advice on frequency of retesting.

Quantiferon Laboratory: Microbiology

Special requirements This is a referred test: Please contact the microbiology laboratory @ Ext 2843 for specimen containers and and comments: designated request form.

The samples should be taken early in the morning in order to be incubated by the laboratory prior to referral for testing.

Specimen Quantiferon –TB Gold Plus tubes requirements 1. Nil Control (Grey cap) 2. TB Antigen (Red cap) 3. TB2 Antigen (Yellow Cap) 4. Mitogen Control (Violet cap)

Contact the clinical microbiology laboratory at Ext 2255 for same Specimen collection For each patient collect 1ml of blood by venepuncture directly into each of the Quantiferon-TB Gold IT blood collection tubes. Blood should be collected into the Nil tube (Grey) first then the TB1 Antigen tube (green), followed by the TB2 (yellow) & finally the Mitogen tube (Violet).

As 1ml tubes draw blood relatively slowly, keep the tube on the needle for 2-3 seconds once the tube appears to have completed filling, to ensure that the correct volume is drawn.

The black mark on the side of the tubes indicates the 1ml fill volume.

If a butterfly needle is being used to collect blood a purge tube should be used to ensure that the tubing is filled with blood prior to the Quantiferon-TB Gold tubes being used.

Antigens have been dried onto the inner wall of the blood collection tubes so it is essential that the contents of the tubes be thoroughly mixed with the blood.

Mix the tubes by turning the tube end-over-end 8-10 times or shaking the tubes for 5 seconds ensuring that the entire inner surface of the tube has been coated with the blood.

Label tubes & the designated quantiferon request form noting date & time sample taken.

The tubes must be transferred to a 37°C incubator as soon as possible. Do not refrigerate or freeze the samples prior to incubation.

Any queries regarding the collection and transport of samples please phone the Microbiology Laboratory @ 061- 482843 / 482842

Test method: Samples are referred to: Medlab Pathology Ltd, Unit 3, Sandyford Business Centre, Sandyford Business Park, Dublin 18, Ireland., Tel: + 353 (0)1 2933690

Turnaround time: 6 working days from receipt of specimen

Rapamune® (Sirolimus)

Laboratory: Biochemistry Specimen type: Whole blood in a potassium EDTA tube (=FBC tube Violet Top).

Special requirements Special request form for immunosuppressant drug monitoring should be used. and comments: The date and time of specimen collection and the date, time and dosage of the last Sirolimus dose must be recorded on the request form. Appropriate clinical details are also required.

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Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Red Cell Folate Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top) + Gel Serum (Brown Top)

Special requirements Monday to Friday only. and comments: Requests should be received by the laboratory before 13:00 hours and within 3 hours of phlebotomy.

Referred to Biomnis Ireland, Sandyford, Dublin 18 Tel: 01 2958545

Turnaround times: 14 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code RCFR / RCFP (iLab): Red Cell Membrane Analysis for Hereditary Spherocytosis Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top).

Special requirements Prior arrangement with Consultant Haematologist and Laboratory, contact 061 482258. and comments: Consultant signature / approval required on request form.

All requests must be accompanied by FBC, Reticulocyte Count, Blood Film and Bilirubin reports as specified by the Referral Laboratory. Referred to Haematology Laboratory, Our Lady’s Hospital for Sick Children, Crumlin Tel: 01-409 6432 Samples must be received by 10.00 a.m. to ensure same day delivery to Dublin.

Turnaround times: 30 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code RCM1R / RCM1P (iLab): Red cell phenotype Laboratory: Blood Bank

Sample type: 7.5 ml EDTA (Red Top)

Request form: Blood Bank 1 or 2 as appropriate

Turnaround time: Same day

Referral Tests Histology (Renal Biopsy, Bone, Brain, Skin for immunofluorescence, Muscle Biopsy for enzyme analysis, ) Laboratory: Histology

Special requirements 24 hours notice must be provided to the Histology Laboratory in order to arrange appropriate transport. and comments: For the following tests the laboratory acts as a dispatch centre only. Reports are sent from the Referral Centre directly to the requesting location and Consultant only. Referral specimens are entered on the Laboratory Information System (iLAB) and copy of reports are available on iLAB via the DART Scanner. Turnaround times of referral specimens are monitored.

Tissue Specimen Requirements Referral Centre Contact Details Renal Biopsy Unfixed dry renal biopsy Department of Renal Pathology, Dr. Tony Dorman Beaumont Hospital, Dublin 9 01-8092634 (office) 01-8092353Renal pathology, (Laboratory) 01-8092634

Bone Formalin Fixed Bone Histology Laboratory, Mater Public Dr. Conon O’Keane Hospital, Dublin 01-8032110 Ext: 2111 Brain Formalin Fixed Brain Samples Department of Neuropathology, Dr. Niamh Bermingham Cork University Hospital 021-4922520 021-4922519

Skin for Unfixed Skin Biopsy and a formalin Histology Laboratory, St. James Dr. Niamh Leonard

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Immunoflourescence fixed skin biopsy Hospital, Dublin 01-4162063

Muscle Biopsy for Fresh Muscle Biopsy wrapped in Department of Neuropathology, Dr. Niamh Bermingham Consultant Enzyme Analysis cling film Cork University Hospital Neuropathologist 021-4922520 or Linda Moloney, SMS 021-4922519

Blocks and slides N/A Histology Laboratory UHL 061 482356 Occassional unspecified N/A Histology Laboratory UHL 061 482356 referrals Renal profile Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top)

Special requirements Includes electrolytes, urea, creatinine, chloride and CO2 and comments: GP Renal Profile includes electrolytes, urea, creatinine and eGFR. Haemolysis invalidates some results in profile Blood specimens for potassium assay must be collected free of haemolysis. The serum must be separated within a period of two hours from venepuncture, since potassium is released from red blood cells during the transport and storage of whole blood specimens thus causing a falsely raised serum potassium concentration.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting For more details, see RENAL section of: Interval: https://www.rcpath.org/resourceLibr ary/g147-minretestingintervalsinpathology-dec15-pdf.html

Renin Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements Collect specimen in EDTA tube (=FBC tube Violet Top) and send to the laboratory immediately (less than10 and comments: minutes). 2 FBC samples are required if rennin / aldosterone ration is required. State whether the patient was ambulant or recumbent, and list of all current medication.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Reptilase Time Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements Requests should be received by the laboratory within 8 hours of phlebotomy. and comments: Results for this test are not released but are available for interpretative use if required by Consultant Haematologist.

Turnaround times: 30 D

Reference Interval: 12-20 Seconds

Test / Profile code REPT (iLab): Reticulocyte Count Laboratory: Haematology Specimen type: EDTA (Violet Top).

Special requirements Requests should be received by the laboratory within 12 hours of phlebotomy. and comments:

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Turnaround times: 4 H

Reference Interval: See report form

Test / Profile code RET / FBCDR (iLab): Rheumatoid Factor (RF) Laboratory: Serology

Specimen type: Gel Serum (Brown Top);

Special requirements Appropriate clinical details are required. and comments: Serial measurement of Rheumatoid Factor is not useful in monitoring the response to therapy. Where there is a strong clinical suspicion of Rheumatoid disease, and the RF is negative, anti-CCP testing should be requested. Samples testing RF positive are automatically reflex tested for anti-CCP antibodies.

Turnaround time: 1 working day

Reference range: <17 IU/ml – Negative 17 - 20 IU/ml – Borderline >20 IU/ml – Positive Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat testing is not routinely required

Rhinorrhoea Fluid Analysis (Beta 2 transferrin; Tau Protein) Laboratory: Biochemistry Specimen type: Nasal fluid accompanied by 1 mL of serum.

Special requirements Appropriate clinical details are also required. and comments: This assay differentiates CSF from other biological fluids.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Ristocetin Co-Factor (RiCOF) Laboratory: Haematology Specimen type: 3 x Citrated plasma (Blue Top).

Special requirements Prior arrangement with Consultant Haematologist and laboratory, contact 061 482851. and comments: Volume: 3 sample

Turnaround time: 4 W

Reference Interval: Refer to report form Test / Profile code RICOF / VWFP (iLab): Rotavirus (Stools) Laboratory: Serology Specimen type: Fresh stool sample collected in a clean, sterile, leak-proof container.

Notes: 1. Testing is restricted to the acute hospital, long stay unit and residential unit settings 2. The cut off time for receipt of samples in the Laboratory for same day testing will be 16:00 hours Monday to Friday and 12:00 on weekends and bank holidays. 3. A positive PCR result indicates the presence of viral DNA/RNA. It does not distinguish between viable and non viable virus. Consequently, results must always be interpreted in conjunction with other clinical and laboratory data. 4. Rotavirus requests in paediatrics - the assay detects rotavirus strains included in the commonly used rotavirus vaccines – Rotarix® (GSK) and RotaTeq® (Merck). Patients who recently received rotavirus vaccination may be shedding the virus in stool for as long as 15 days post-vaccination. Therefore, recent vaccination must be considered when interpreting rotavirus positive results.

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Turnaround time: 1 working day

Reference range: Detected / Not Detected Relevant interpretive comments are included on the report.

Notes: I. The antigen test is an acute-phase screening test. Stool specimens that are collected after this phase may contain antigen titres below the reagent’s sensitivity threshold. II. Results must be compared with all other available clinical and laboratory information.

Repeat testing Interval: Testing for viral clearance is not indicated

Routine Histology Laboratory: Histology Specimen  For fixation purposes, Samples (including bone marrows) for routine Histology must be sent in 10% Formalin requirements:  Pre-filled formalin pots are available for collection from the Laboratory for smaller biopsies  Larger specimens and organs should be sent in 2.5L and 5L containers with 10% formalin added *  For very large specimens, contact the Laboratory directly 061-482356 and an extra large specimen container (10L or 20L) will be provided.  Samples should be clearly labelled with Patient and specimen details  A copy of Dental X-Rays to be sent in with all dental biopsies should a second opinion be required  *Single placentas are only to be placed in 5L container, twin placentas to be placed in 10L containers only.

Specimen acceptance:  In house specimens for Histology are usually brought directly to the Laboratory by porter and are accompanied by a docket / record book that must be signed by a member of staff.  Specimens from Ennis, Nenagh and St. Johns Hospital are to be brought directly to the Histology Cut-Up Laboratory. The Register for Receipt of Histology Specimens must be signed on delivery of the specimens  Specimens from outside locations including Croom Hospital, University Maternity Hospital (UMHL) and GPs are received via Laboratory reception.  Nenagh Hospital, Ennis Hospital, Croom Hospital, St. Johns Hospital and UMHL specimens are accompanied by dockets that must be signed by a member of staff.  GP specimens do not have accompanying dockets.  If discrepancies are found, the specimen may be returned to its point of origin for correction along with the docket and request form. If the specimens are being returned to an outside source a return letter outlining the problem is included.

Urgent Samples: Urgent surgical specimens must be requested by consultation with Consultant Histopathologist on duty.

Turnaround times: Turnaround times are as follows:

Small biopsy Breast Needle Core 10 days Prostate Needle Core Lung Needle Core Liver Needle Core Lymph Node Needle Core GI Endoscopic biopsy 10 days Cancer Resection Breast Resection 10 days GI Resection Non-biopsy, Other Cervix Biopsy 10 days Skin Wedge of Lung, Liver Urinary Tract Lymph Node LLETZ 14 days

Notes:  Turnaround times for urgent processing is 2 working days after receipt (applies only to small biopsies).  Turnaround time for specimens requiring Special Stains or Immunohistochemistry may exceed times listed above. RPR Test Laboratory: Serology Special requirements See Syphilis Antibodies and comments: RSV (Respiratory Syncytial Virus) Laboratory: Serology Specimen type: Nasopharyngeal swab (NPS) / Nasopharyngeal aspirate (NPA)*

Special requirements Special requirements and comments: and comments: The molecular assay used at UHL for RSV RNA detection includes Influenza A & Influenza B. Therefore, requests for either Influenza or RSV will be automatically tested for all 3 targets – Influenza A RNA; Influenza B RNA and RSV RNA.

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Samples should be taken before 6pm Monday-Friday and sent immediately to the Laboratory. This test is available at weekends and public holidays by contacting a member of the ‘on call’ staff via the Microbiology Laboratory (061 482502).

Refer to: Procedure for collecting Nasopharyngeal Swabs (NPS) for Respiratory Viruses

The Physiotherapy Department, UHL have a written procedure for taking Nasopharyngeal aspirates (Ref; MWRHDOP0014). The protocol describes the procedure for preparing the patient, the equipment required and the detailed procedure for taking the sample. *Note – as local molecular testing is only validated for NPS samples any aspirates (NPA) received will be referred to NVRL, Dublin

Note: Local testing is only available routinely during the respiratory season week 40 to week 20 of the following calendar year. The laboratory notifies the users regarding local testing availability each season. Turnaround time: UHL: 1 working day Urgent requests during routine working hours: TAT = 3 hours NVRL: 2 working days

Reference range: Detected / Not Detected Relevant interpretive comments are included on the report.

Repeat testing Interval: Testing for viral clearance is not indicated

Rubella IgG Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top);

Special requirements None and comments:

Turnaround time: 2 working days

Reference range: 0 -5 IU/ml - Non Immune 6 -10 IU/ml - Immunity Doubtful >10 IU/ml - Immune Relevant interpretive comments are included on the report.

Repeat testing Interval: Serology testing post vaccination is not indicated.

Rubella IgM Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top);

Special requirements Appropriate clinical details are required. and comments: Note: Positive/Reactive samples are referred to the National Virus Reference Laboratory, Dublin for confirmatory testing. Tel: 01 716 4414/ 716 4415.

Turnaround time: 3 working days Turnaround time for Positive / Reactive results: 1 – 2 weeks

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: >1 week

Salicylate Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top);

Special requirements Peak serum level is reached 1-2 hours after oral administration. Note results are reported as mmol/L. and comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

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Sapovirus Laboratory: Serology Specimen type: Fresh stool sample collected in a sterile leak-proof universal container (white cap).

Special requirements All stool samples sent for the investigation of viral gastroenteritis will have a PCR assay performed for and comments: Adenovirus, Rotavirus, Norovirus, Sapovirus and Astrovirus.

Samples should be collected during the acute phase of illness. The assay is intended for use with liquid/loose stool samples submitted from symptomatic patients for investigation of viral gastroenteritis. A minimum sample volume of 5g is required. Notes: 1. Testing is restricted to the acute hospital, long stay unit and residential unit settings 2. The cut off time for receipt of samples in the Laboratory for same day testing will be 16:00 hours Monday to Friday and 12:00 on weekends and bank holidays. 3. A positive PCR result indicates the presence of viral DNA/RNA. It does not distinguish between viable and non viable virus. Consequently, results must always be interpreted in conjunction with other clinical and laboratory data.

Turnaround time: 1 working day

Reference interval: Detected / Not Detected Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat testing to check for viral clearance is not indicated

Schistosomal Antibodies Laboratory: Serology Specimen type: Gel Serum (Brown Top);

Special requirements This test is available by arrangement only following discussion with the Consultant Microbiologist. and comments: Appropriate clinical details are required. This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Sex hormone binding globulin (SHBG) Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top);

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Sickle Screen (Sickledex) Laboratory: Haematology Specimen type: 1 x Gel Serum (Brown Top), 2 x EDTA (Violet Top).

Special requirements Urgent pre-operative specimens only. and comments: Accompanied by UHL haemoglobinopathy request form. All Sickledex requests are referred for Haemoglobinopathy Screen for confirmatory analysis. Turnaround times: 3 D

Reference Interval: Positive or negative.

Test / Profile code SICKLE / SICKLP (iLab): Sinus Aspirate Laboratory: Microbiology Specimen Aspirate requirements: Specimen collection: The specimen will be collected by a specialist ENT surgeon.

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Sample volume: Minimum volume: 1ml

Special precautions: • The volume of specimen influences the transport time that is acceptable. Large volumes of purulent material maintain the viability of anaerobes for longer. • The recovery of anaerobes in particular is compromised if the transport time is delayed.

Test method: Routine: Gram stain. Culture for pathogenic organisms. Turnaround time: Final report: 2-3 working days Sirolimus (Rapamune®) Laboratory: Biochemistry

Specimen type: Whole blood in a potassium EDTA tube (=FBC tube Violet Top).

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Smooth Muscle Antibodies Laboratory: Serology

Specimen type: Gel Serum (Brown Top);

Special requirements Requests for anti-smooth muscle antibodies (ASMA) are automatically tested for anti-liver-kidney-microsomes and comments: antibodies (LKM), anti-mitochondrial antibodies (AMA) & anti nuclear antibodies (ANA). Turnaround time: 7 working days

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: Repeat AMA testing is of limited value – frequency to be determined by clinical context

Sodium Laboratory: Biochemistry Specimen type: Gel Serum (Brown Top), plasma Lithium Heparin (Green Top), Urinary sodium: Refer to Urine Analyses for specimen, requirements, turnaround time and reference interval.

Special requirements Blood specimen should be collected free of haemolysis. and comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting Inpatient monitoring of a stable patient: An inpatient with an admission sodium within the reference Interval should Interval: not have a repeat sodium within the average length of stay of 4 days. Inpatient monitoring of a stable patient on IV fluids, adults as well as children: Daily monitoring of U&Es and glucose. For more details, see RENAL section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Solvent detergent plasma Laboratory: Blood Bank Sample type: 7.5 ml EDTA (Red Top). No sample is required if there is a current blood group on the laboratory information system.

Request form: Blood Bank 1 Availability time: 30 minutes (for 3 units), if there is a blood group on file in the transfusion laboratory; one hour if blood group is not on file.

Risk and comments: Refer to the HG-A-BTR-SDPLASMA guideline available on Q Pulse ISSACUTE and/or the hard copy blood transfusion manual. Solvent screen for toluene (glue), trichloroethane (Tipex®) and butane Laboratory: Biochemistry

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Specimen type: Whole blood or serum or plasma.

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory. Toxicology Laboratory, Beaumont Hospital, Beaumont, Dublin 9. Tel: 01 809 2673; 01 809 2671; 01 809 2675

Beaumont Laboratory operates a strict policy of not transmitting reports by fax.

The current out-of-hours toxicology call service at Beaumont Hospital is available to all hospitals in the Republic of Ireland. “The service is restricted to checking only for drugs, which if taken in overdose require a specific antidote or treatment. It is not an aid to diagnosis nor to allow a patient to be discharged.” If the assay is required outside of normal working hours, contact the switchboard at Beaumont Hospital and ask for the Principal Biochemist in Toxicology to be contacted. Consultant: Dr. W. Tormey

Reference Interval: The referral laboratory report provides appropriate reference values.

Special Stains Laboratory: Histology  The Histology Laboratory provides a small selection of special stains which are performed at the request of the reporting Pathologist / Haematologist.  Requests for special stains by non Pathology Staff must be made through the reporting Pathologist.

Sperm Antibodies Laboratory: Serology Specimen type: Gel Serum sample (Brown Top).

Special requirements This test is referred to the BIOMNIS Laboratories, Dublin. and comments: Tel: 01 299 0650 / 01 295 8545

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Sputum, Bronchoalveolar Lavage, and Associated Specimens Laboratory: Microbiology Specimen type: Bronchial aspirate Bronchoalveolar lavage Bronchial brushings Transthoracic aspirate Bronchial washings Transtracheal aspirate Protected catheter specimen Cough swabs Sputum - expectorated

Specimen Sterile leak-proof container in a sealed plastic bag requirements: Specimen collection: For sputum specimens the material required is from the lower respiratory tract, expectorated by deep coughing. When the cough is dry, physiotherapy, postural drainage or inhalation of an aerosol before expectoration may be helpful.

Saliva and per-nasal secretions are not suitable.

Early morning specimens for examination of Mycobacterium sp. should be collected on at least 3 consecutive days. BAL and associated specimens need specialist collection according to local protocols.

Specimens include brushings (Bartlett protected brush), transbronchialbiopsies or bronchial secretions that are aspirated through the inner channel of the bronchoscope with or without an irrigating solution.

Sample volume: A minimum volume of 1ml

Special precautions: • Early morning freshly expectorated sputum is recommended for Mycobacterium species • Saliva and postnasal secretions are not suitable. • Please state on the request form if the patient is a Cystic Fibrosis patient. • A separate sample should be taken for cytology testing if required and sent to the Histology Laboratory.

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Turnaround time Negative routine culture: 3 working days Positive routine culture: 4 working days

Cystic Fibrosis: Routine culture/ Burkholderia sp culture: 5 days Fungal culture: 14 days

New Burkholderia sp isolates are referred to the Laboratory of Healthcare Associated Infections, Colindale, London for confirmation.

Additional information: • Sample should reach the laboratory within 4 hours. Any delay beyond this time may allow overgrowth of Gram-negative bacilli; additionally Haemophilus species and S. pneumoniae may not survive.

• If specimens are not processed on the same day as they are collected interpretation of results should be made with care. Steroid Profile Laboratory: Biochemistry Specimen type: Urine: 24-hour urine collection

Special requirements This assay is only performed on requests authorised by a Consultant. and comments: No preservative is required but urine should be kept cool. Store specimen at approximately 4 degrees Celsius prior to preparation for dispatch to referral laboratory.

Appropriate clinical details must accompany the request. Note: this assay is expensive. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Stone analysis (stone with details of source) Laboratory: Biochemistry Specimen type: Stone(s).

Special requirements Specimen should be washed free of tissue and blood, and submitted in a clean dry container. Include relevant and comments: clinical information.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Strongyloides Antibodies Laboratory: Serology Special requirements This test is available by arrangement only following discussion with the Consultant Microbiologist. and comments: Please provide relevant clinical details with request. This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Specimen type: Gel Serum sample (Brown Top).

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Sudan Black B (Cytochemical Stain) Laboratory: Haematology Specimen type: Bone Marrow Aspirate Slides, FBC sample (Violet Top)

Special requirements Prior arrangement with Consultant Haematologist and Laboratory, contact 061 482258. This test will only be and comments: processed with authorisation by a consultant haematologist.

Referred to St James Hospital for pre-analytical staining. Turnaround times: 45 D Haematology team may contact referral laboratory re urgent samples.

Reference Interval: N/A

Test / Profile code SBB (iLab):

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Sweat Test Laboratory: Biochemistry Specimen type: Sweat.

Special requirements Bookings for sweat tests may be made with Phlebotomy Department UHL. and comments: CF Newborn Screening Programme commenced July 1st 2011 in Ireland

Turnaround time: Sweat tests are usually performed within one week of booking. Sweat test analysis in laboratory on same day.

Reference interval: On Biochemistry report or contact laboratory.

Syphilis (Treponema pallidum) Antibodies Laboratory: Serology Specimen type: Gel Serum sample (Brown Top).

Special requirements Note: Confirmatory testing for positive / reactive Syphilis serology includes the RPR and TPPA test. and comments: Turnaround time: 2 working days Note: additional days are required for confirmation of positive/reactive samples.

Reference range: Positive / Negative Relevant interpretive comments are included on the report.

Repeat testing Interval: >2 weeks

T cell subsets, CD 4/8 Count (Flow Cytometry) Laboratory: Haematology Specimen type: 2 x EDTA (Violet Top).

Special requirements Prior arrangement with laboratory, contact 061 482258. and comments: Flow cytometry requests will only be processed if the clinical details are consistent with appropriate requesting guidelines, e.g. known HIV patient on HAART therapy? Lymphoproliferative disorder (requesting restricted to haematology consultants only). T cell subsets and CD4/CD8 counts are processed once a week. Pre booking is essential. Samples must arrive in the laboratory before 09:30am on day of processing and may be collected for overnight storage in the laboratory the evening before the day of processing.

Turnaround time: 7 D

Reference Interval: See report form

Test / Profile code CD4/CD8 (iLab): T3 (triiodothyronine), free hormone Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details and a list of all current medication are required. and comments: FT3 is not included in our TFT profile and is used to monitor patients on T3 hormone replacement. When indicated the Biochemistry Laboratory reflex FT3 measurement.

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

T4 (thyroxine), free hormone Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details and a list of all current medication are required. and comments: Refer to: Reference Guide for Use of Thyroid Function Tests in Primary Care

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

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Tacrolimus (Prograf®, FK 506) Laboratory: Biochemistry Specimen type: Whole blood in specimen tube with potassium EDTA (Violet Top) as anticoagulant.

Special requirements Special request form for immunosuppressant drug monitoring should be used. and comments: Trough levels should be monitored.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Tambocor® (Flecainide) Laboratory: Biochemistry Specimen type: 2.7mL potassium EDTA (Violet Top) sample (fbc sample tube). Gel tubes are not suitable.

Special requirements Appropriate clinical details required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Tau Protein (Rhinorrhoea Fluid Analysis; Beta 2 transferrin) Laboratory: Biochemistry Specimen type: Nasal fluid accompanied by 1 mL of serum. Special requirements Appropriate clinical details are also required. and comments: This assay differentiates CSF from other biological fluids.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values. TBG (thyroxine binding globulin) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements With appropriate clinical details. and comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

TBII (TSH-binding inhibiting immunoglobulin) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Tegretol® (Carbamazepine) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Specimen should be drawn before the next oral dose in a patient at steady state. and comments:

Turnaround time: Routine: 4 days. Contact laboratory if urgent result required.

Reference Interval: On Biochemistry report or contact laboratory.

Teicoplanin Assay Laboratory: Microbiology Specimen type: Refer to Antibiotic Assay

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Testosterone/sex hormone binding globulin (SHBG) ratio Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements This ratio is only applicable to female patients. and comments: Appropriate clinical details are required.

Turnaround time: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Testosterone: females Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details are required. and comments: Turnaround time: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Testosterone: males Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details are required. and comments: Turnaround time: 4 working days.

Reference Interval: On Biochemistry report or contact laboratory.

Tetanus Antibodies Laboratory: Serology Specimen type: Gel Serum sample (Brown Top).

Special requirements Measurement of specific Tetanus antibodies is clinically useful in two settings: and comments: 1. To determine protective status (immunity) of patient. 2. To assess B-cell functionality in a patient with recurrent infection.

This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Note: Tetanus antibody testing is used to check for vaccine related immunity and not for diagnostic purposes. Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Thalassaemia Laboratory: Haematology Specimen type: 1 x Gel Serum sample (Brown Top), 2 x EDTA (Violet Top).

Special requirements Accompanied by UHL haemoglobinopathy request form and comments: Includes Haemoglobin A, A2, F & S etc.

Adult samples (>16 years) are referred to the Haematology Lab, St James. Tel.: 01 416 2909. Paediatric samples (<16 years) are referred to the Haematology Lab, OLHSC, Crumlin. Tel.: 01 409 6432

Turnaround time: 42 D

Reference Interval: Refer to report issued by referral laboratory.

Test / Profile code HBEL-A (Adults) / HBEL-P (Minors <16 years) (iLab):

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Theophylline Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Sampling times: and comments: Oral trough: immediately before the next oral dose.

Oral peak: 2 hours after administration of a product with rapid release properties; 4-8 hours after administration of a product with sustained release properties.

Intravenous: (a) prior to intravenous infusion (b) 30 minutes after completion of loading dose to measure the adequacy of dose; (c) 4-6 hours after beginning continuous infusion therapy (pre steady state but used to establish a trend) or before the next infusion.

Turnaround time: Urgent sample: 90 mins (prior contact to department). Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Thiopurine S-Methyltransferase (Red Blood Cell Thiopurine S-Methyltransferase; TPMT) Laboratory: Biochemistry Specimen type: Two specimens of whole blood in potassium EDTA tubes (Violet Top). Specimen should be sent to the Clinical Biochemistry Laboratory.

Special requirements Appropriate clinical details are required. and comments: For patients about to commence azathioprine (Imuran®) therapy.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Throat Swab Laboratory: Microbiology Specimen type: Charcoal swab

Specimen collection: Throat swab taken from the tonsillar area and/or posterior pharynx, avoiding the tongue and uvula. Specimen to be taken at onset of symptoms or before antimicrobial therapy where possible.

Please note: repeat throat swabs submitted within 48 hours are NOT processed.

Special precautions: • If processing is delayed, refrigeration is preferable to storage at ambient temperature. • Delays of over 48 h are undesirable

Turnaround time: Aerobic report: 2-3 working days Anaerobic report (if clinical details of query quinsy): 5-10 days

Additional Information: Ideally, inoculation of specimens for N. gonorrhoeae should be made directly onto culture media at the time of collection and these should be incubated without delay. Transport time should be as short as possible.

Where quinsy is suspected please state on the request form. Pus is a more appropriate sample for this investigation. Please state on request form if patient suffers from recurrent throat infections. Please indicate if the patient is immunocompromised

Thrombin Time (TT) Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Volume: 1 citrated (Blue Top) sample.

Special requirements Requests should be received by the laboratory within 2 hrs for investigation of hep contamination/mixing studies and comments: and 8 hrs for investigation dysfibrinogenaemia. Details of anticoagulant therapy required.

Turnaround time: 30 D

Reference Interval: 14-21seconds

Test / Profile code TT (iLab):

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Thrombophilia Screen Laboratory: Haematology Specimen type: 4 x Citrated plasma (Blue Top), 1 x EDTA (Violet Top).

Special requirements Screen Includes: PT/INR, APTT, Fibrinogen, ATIII, Protein C, Protein S, Free Protein S, APC-R, Lupus Like and comments: Anticoagulant Requests should be received by the laboratory within 4 hours of phlebotomy. Clinical details required. Please provide patient and family history.

Appropriate for: Confirmed thrombotic event in persons <50 years if no clear precipitating factor; 1st degree relatives of patients with proven thrombophilia about to commence oral contraception or scheduled for surgery. Testing should not be done during acute thrombotic period or while the patient is on anticoagulant therapy. Consultant signature / approval required on request form.

Prior Haematology Team approval required with the exception of miscarriage clinic patients, rheumatology and neurology patients.

Volume: 4 samples (Blue Top).

Turnaround time: 4 W

Reference Interval: N/A

Test / Profile code TPHIL (iLab): Thyroglobulin Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details are required. and comments: Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Thyroid Antibodies (TPO) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Please provide appropriate clinical details and comments:

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting For diagnosis of autoimmune thyroiditis: Measure TPO Antibodies on one occasion, but not for monitoring. Interval: Do NOT test for TPO antibodies when TFTs are normal.

Thyroid hormone profile Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details are required. and comments: Panel includes TSH and free T4. Refer to: Reference Guide for Use of Thyroid Function Tests in Primary Care

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Thyroid Stimulating Hormone (TSH) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details are required. and comments: Refer to: Reference Guide for Use of Thyroid Function Tests in Primary Care

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

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Reference interval: On Biochemistry report or contact laboratory.

Thyroid stimulating immunoglobulin (TBII, TSH-binding inhibiting immunoglobulin) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top). Special requirements Appropriate clinical details are required. and comments: Refer to: Reference Guide for Use of Thyroid Function Tests in Primary Care Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values. Thyroxine binding globulin (TBG) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements With appropriate clinical details. and comments: Refer to: Reference Guide for Use of Thyroid Function Tests in Primary Care

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Reference Guide for Use of Thyroid Function Tests in Primary Care Reference Guide for Use of Thyroid Function Tests in Primary Care (Source: National Clinical Programme for Pathology Laboratory Handbook, Royal College of Physicians Ireland, 2015) Clinical Situation Recommendation Healthy asymptomatic individuals under 50 Screening for thyroid dysfunction in a healthy adult population is not warranted When to re-test healthy individuals with previous Not less than 3 years since a previous normal normal TFTs test in healthy asymptomatic individuals Use of TFTs when you When to Test: suspect Thyroid Symptoms suggestive of Hypothyroidism, especially Dysfunction in symptomatic women of menopausal age (or > 50 years old) Hyperthyroid symptoms

Use of TFTs for PRIMARY Patients stabilised on long-term T4 therapy Annually Hypothyroidism In stable patients, there may be no need to Monitoring alter thyroxine dosage for very minor abnormalities in TFTs. Instead enquire about non-compliance and whether there was an intercurrent illness.

After a change in thyroxine dosage. Do not re-check TFTs for at least 3 months.

Use of TFTs in Suspected new cases: Please discuss these cases This is because further endocrinologist and/or SECONDARY with your local chemical pathologist or laboratory evaluation is usually necessary. Hypothyroidism endocrinologist before commencing any treatment. Patients stabilised on Thyroxine therapy. Perform annual TFTS. *Note in patients with secondary hypothyroidism due to pituitary disease the TSH level should NOT be used to guide treatment (as it is often low) and therefore the Free T4 level should be used Use of TFTs to monitor Patients with subclinical hypothyroidism If treatment Confirm within 3-6 months to exclude subclinical is initiated see use of TFTs for primary transient causes of elevated TSH. hypothyroidism in adults hypothyroidism monitoring

Subjects with subclinical hypothyroidism who are TFTs checked annually TPO Antibody positive

Subjects with subclinical hypothyroidism who are TFTs checked every 3 years TPO Antibody negative

Use of TFTs to monitor These cases should be discussed with the chemical subclinical pathologist or endocrinology to decide a hyperthyroidism in adults monitoring/treatment plan

If treatment is initiated see use of TFTs for hyperthyroidism monitoring

If treatment not undertaken Check TFTs every 6-12 months.

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TIBC (calculated) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements A fasting specimen is required. TIBC specimens must be sent to the Clinical Biochemistry Laboratory and comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Ref: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Tissue Transglutaminase (Anti-tTG IgA) - Coeliac Screen Laboratory: Serology Specimen type: Gel Serum sample (Brown Top).

Special requirements Tissue Transglutaminase IgA is the appropriate serological screening test for coeliac disease. and comments: Equivocal and positive anti-tTG samples will be automatically tested for anti-endomysial antibodies.

The laboratory will identify patients with an IgA deficiency who were TTG IgA negative and will automatically reflex test these for EMA IgG. EMA IgG tests are referred to the Immunology Lab, St. James Hospital, Dublin.

Turnaround time: 7 working days

Reference range: <20 RU/ml – Negative ≥20 RU/ml – Positive Relevant interpretive comments are included on the report.

Repeat testing Interval: Negative results: >3 months

Tissues and Biopsies (Refer below for Orthopaedic Tissue) Laboratory: Microbiology Specimen type Tissue Biopsy

Specimen Sterile leak-proof container in a sealed plastic bag. requirements: Special Precautions •: Do not send dry tissue. Tissue samples for microbiology must not be placed in formalin. Turnaround time: Aerobic Culture: 5-10 working days Anaerobic culture: 5-10 working days

Orthopaedic Tissue Laboratory: Microbiology Specimen type: Tissue

Specimen Samples inoculated into cooked meat broth with beads. requirements: Contact the microbiology laboratory at (061)482255 for same. Special precautions: • The volume of the specimen influences the transport time that is acceptable. Larger pieces of tissue maintain the viability of anaerobes for longer. • If specimen is small, place it in sterile water to prevent desiccation. • Tissue samples for microbiology must not be placed in formalin. Turnaround time: Aerobic Culture: 7-10 days Anaerobic culture: 7-14 days

Positive reports are referred to the Consultant Microbiologist on Clinical duty

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Tobramycin Assay Laboratory: Microbiology Specimen type: Refer to Antibiotic Assay

Tocopherol (Vitamin E) Laboratory: Biochemistry Specimen type: Light protected NON GEL serum

Special requirements Protect from light, keep refrigerated. and comments: Specimen should be sent to the laboratory immediately

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Total Vitamin D (25-Hydroxy vitamin D3; 25-Hydroxycholecalciferol) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements 1 mL separated serum. Keep refrigerated. and comments: Turnaround time: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting  No clinical signs and symptoms: Do not retest (whatever the result as there may be no indication to test Interval: in first place).Consensus opinion of the relevant expert working group.  Cholecalciferol or ergocalciferol therapy for whatever clinical indication, where baseline vitamin D concentration was adequate: Do not retest, unless otherwise clinically indicated e.g. sick coeliac or Crohn's patient.  Cholecalciferol or ergocalciferol therapy for whatever clinical indication, where baseline vitamin D concentration was low and where there is underlying disease that might impact negatively on absorption: Repeat after 3–6 months on recommended replacement dose.  Vitamin D: calcitriol or alphacalcidol therapy: Do not measure vitamin D. Ref: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Toxocara Antibodies Laboratory: Serology Special requirements This test is available by arrangement only following discussion with the Consultant Microbiologist. and comments: Please provide relevant clinical details with request. This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Specimen type: Gel Serum sample (Brown Top).

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Toxoplasma Antibodies (IgM & IgG) Laboratory: Serology Specimen type: Gel Serum sample (Brown Top).

Special requirements Please provide relevant clinical details with request. and comments: Positive / reactive samples are referred to the National Virus Reference Laboratory and neonatal samples to the Toxoplasma Reference Unit, PHE Laboratory, Swansea, Wales. Tel: +44 1792 285055.

Turnaround time: 3 working days

Turnaround time for referred confirmatory / follow up results: 1 - 2 weeks

Reference range: <1.6 IU/mL = Negative; 1.6 - 3.0 IU/mL = Grayzone; >3.0 IU/mL = Positive Relevant interpretive comments are included on the report. Repeat testing Interval: Positive IgG results – repeat testing not indicated

Toxoplasma PCR Laboratory: Serology Specimen type: 2 x EDTA (Violet Top)

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Special requirements Samples should be sent immediately to Serology /Immunology. Requests for this test should be sent from Monday andcomments: to Thursday only. This test is referred to the Toxoplasma Reference Unit, Swansea. Tel: +44 1792 285055.

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

TPPA Test Laboratory: Serology Special requirements See Syphilis Antibodies and comments:

TPMT (Thiopurine S-Methyltransferase) Laboratory: Biochemistry Specimen type: Two specimens of whole blood in potassium EDTA tubes (Violet Top). Specimen should be sent to the Clinical Biochemistry Laboratory.

Special requirements Appropriate clinical details are required. and comments: For patients about to commence azathioprine (Imuran®) therapy.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Trace Metal Monitoring (in patients on nutrition support, especially parenteral nutrition) Laboratory: Biochemistry Specimen type: Whole blood in trace metal-free tube. Trace metal-free needle must be used in conjunction with trace metal-free tube. Please contact Clinical Biochemistry Laboratory for trace metal-free specimen collection tube and needle.

Special requirements This specimen should be collected first if other tests are requested to avoid contamination. and comments: Do not open or centrifuge the specimen tube.

Trace Elements Tested: Trace element Frequency of testing

Zinc Baseline, then every 2-4 weeks depending on results

Copper Baseline, then every 2-4 weeks depending on results

Selenium Baseline if risk of depletion. Need for further testing depends on baseline value

Manganese Every 3-6 months if on home parenteral nutrition

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Transferrin Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements A fasting specimen is required. Transferrin specimens must be sent to the Clinical Biochemistry Laboratory and comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Ref: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

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Transferrin saturation Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements A fasting specimen is required. Iron studies specimens must be sent to the Clinical Biochemistry Laboratory and comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Ref: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Transfusion reaction investigation Laboratory: Blood Bank Sample type:  7.5ml EDTA (Red Top) post transfusion sample  Component pack with giving set attached  Urine sample x 2 (immediately and 6 hours post reaction)  FBC (Violet Top)  Coagulation screen (citrated plasma Blue Top)  U&E, creatinine, bilirubin;  Pre- and post-transfusion samples for BNP (B-type naturetic peptide), in cases of suspected TACO or TRALI - samples should be taken within 2 hours of suspected TACO or TRALI reaction  IgA levels in cases of suspected allergic reaction  Blood cultures (if fever is documented)

Request form: Blood Bank 3

Turnaround time: Serological testing is performed on the same day of receipt. Blood culture where indicated may take up to 10 days before a report is authorized. Positive cultures are phoned immediately. In cases of suspected TACO or TRALI, turnaround time may take several weeks.

Special requirements Reporting of transfusion reactions National Haemovigilance Office is mandatory. Refer to the relevant chapter of and comments: the blood transfusion manual for guidance on the clinical management and reporting of transfusion reactions.

Trichinella Antibodies Laboratory: Serology Specimen type: Gel Serum sample (Brown Top).

Special requirements Note: Requests for Trichinella must be discussed with the Consultant Microbiologist / Infectious Diseases and comments: Consultant prior to requesting the test.

Please provide relevant clinical details with request. This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate reference values.

Tricyclic antidepressants (semi-quantitative, serum) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements The cut-off threshold for a positive result for tricyclic antidepressants is 100 ng/mL. and comments: A positive result for tricyclic antidepressants indicates only the presence of tricyclic antidepressants and does not necessarily correlate with the extent of physiological and psychological effects. Pharmokinetic studies have shown that there is a marked inter-individual variation in the therapeutic and toxic response to tricyclic antidepressants at similar blood concentrations.

A negative result indicates that tricyclic antidepressants are either not present or are present at levels below the cut-off threshold for this test. This assay is designed to detect the four major tricyclic antidepressants: amitriptyline, nortriptyline, imipramine, and desipramine.

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Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Triglyceride Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Serum triglyceride is subject to major increases following meals and may also be released after prolonged fasting. and comments: A 12-hour fast is essential for meaningful triglyceride measurements.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting LOW risk cases for IHD assessment, MRI of 3 years Interval (MRI): Higher risk cases for IHD assessment and those on stable treatment, MRI of 1 years

For more information, see LIPID section of: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Triidothyronine, free hormone (Free T3) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Appropriate clinical details and a list of all current medication are required. and comments:

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Trileptal® (Oxcarbazepine) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top).

Special requirements Specimen drawn before the next oral dose in a patient at steady state. and comments: Store specimen at approximately 4 degrees Celsius prior to preparation for dispatch to referral laboratory.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Troponin T (hsTnT) Laboratory: Biochemistry Specimen type : Gel Serum sample (Brown Top) or Lithium Heparin Plasma (Green Top)

Special requirements Two samples should be collected, at admission and 3 - 6 hours later. The Troponin analytical service is available and comments: in the acute setting only. The test is not routinely available for GPs.

Turnaround time: 90 mins.

Reference interval: On Biochemistry report or contact laboratory.

Limitations: Haemolysed samples are unsuitable for analysis as haemolysis interferes negatively with the hs-TnT assay

Trypsin, immunoreactive Laboratory: Biochemistry Specimen type: Specimen is a heel prick whole blood sample – three blood spots on a prelabelled Newborn Screening Card.

Special requirements Patient should not be more than six weeks old. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

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Tryptase Assay (plasma) Laboratory: Biochemistry

Adverse (Anaphylactoid) Reactions to Intravenous Drugs

Specimen type: The preferred specimen is EDTA plasma at least 1 mL (Violet Top). It is possible to measure tryptase in serum if EDTA plasma is not available. Special requirements The first sample should be taken as soon as possible after commencement of the reaction and ideally within the and comments: first 30 minutes. Further samples should be taken 3, and 24 hours after reaction.

Documentation required This should be comprehensive, but brief, and should include the following (although any other factor which the anaesthetist thinks could be a cause of the reaction should be indicated, eg surgical stimulation, undiagnosed hypovolaemia etc). • Surgical procedure, • Date of reaction, • Drugs administered (including premedication and sequences where possible), • Clinical manifestations, • Management of reaction and outcome (eg residual effects or death), • Previous medical and anaesthetic history if known, • Any particular risk factors? (eg known asthmatic, penicillin allergy, anaesthetic reaction or extremely anxious patient etc), • The haematological data (‘routine haematology’ including full differential white cell count and haematocrit), if available. This documentation should accompany the plasma samples. Telephone contact: At any stage of the reaction the user of the service is encouraged to telephone the Protein Reference Unit in Sheffield (00 44 114 271 5552) for advice. This advice is based on the cumulative experiences of NARCOS in the assessment of emergency situations. NARCOS provides a 24 hour advisory service via the Hospital switchboard (00 44 114 243 4343).

Store specimens at approximately +4 degrees Celsius prior to preparation for dispatch to referral laboratory.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

TSH (Thyroid Stimulating Hormone) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top)

Special requirements Appropriate clinical details are required. and comments: Refer to: Reference Guide for Use of Thyroid Function Tests in Primary Care

Turnaround time: Urgent: 1 working day. Routine: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

TSH-binding inhibiting immunoglobulin (TBII) Laboratory: Biochemistry

Specimen type: Gel Serum sample (Brown Top)

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Tuberculosis (TB) Laboratory: Microbiology Specimen type: • Bone Marrow • Bronchial washing, aspirate, brushing • Broncho-alveolar lavage (BAL) • Blood (Specific bottles available from the laboratory) • Cerebrospinal fluid (CSF), body fluids, aspirates

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• Gastric lavage fluid • Pus • Post-mortem specimens • Skin or tissue biopsies • Sputum • Urine NB: swabs are not recommended specimens for TB testing and will not be processed for same without agreement from the duty Clinical Microbiologist Specimen Sterile leak-proof container in a sealed plastic bag. requirements: Use of Sarstedt 30ml universal containers is essential to avoid leakage of specimen. Other transport containers not recommended. Refer to section 18.12 of this manual for diagram of appropriate container

Sample volume: BAL/Bronchial Washings: Minimum sample size is 5ml.

Bone Marrow: Add bone marrow directly to the culture medium. (Specific bottles required, please contact TB laboratory for same). As large a sample as possible should be obtained.

Blood: Add 1-5 ml (3-5 ml optimal) of blood to the culture medium. (Specific bottles required, please contact Microbiology laboratory for same) Please specify if routine mycobacterial culture or investigation for Mycobacterium chimaera is required. Advance notice must be given to Microbiology Laboratory to allow for request of specific culture bottles from relevant Referral Laboratory. Requests only accepted following discussion with Consultant Microbiologist on Clinical Duty. Inoculated culture bottle(s) must be returned to Microbiology Laboratory before 11am to facilitate return postage within 24 hours of inoculation. 3 cultures taken within 24 hours recommended for M.chimaera investigation.

CSF, body fluids, aspirates, pus: Collect aseptically as much as possible into a sterile container. A minimum volume of 5ml of CSF is required. Other fluids up to a maximum of 1 litre

Gastric lavage fluid: The laboratory MUST be informed prior to taking the sample. Samples need to be delivered to the Laboratory a.s.a.p. and within 4 hours of collection to avoid acidic degradation of organisms. Collect early in the morning (before breakfast) on consecutive days. Preferably, a minimum volume of 5-50ml per sample. Usually used for children where there are problems obtaining sputum.

Skin/tissue biopsy/post mortem Collect aseptically into a sterile container without preservatives. specimens: Select a caseous portion if possible. The majority of organisms will be found in the periphery of a caseous lesion. As large a sample as possible should be sent.

Sputum: Collect early in the morning on at least 3 consecutive days. Preferably, collect a minimum volume of 5ml per sample. Saliva and postnasal secretions are not suitable.

Urine: Collect the entire early morning urine on 3 consecutive days. Collect samples in 30ml sterile Sarstedt containers as per section 18.12. A minimum of 60mls EMU collection each day over 3 consecutive days is required for AFB analysis in the Microbiology Laboratory. NB: Boric acid/other preservative containers are not suitable and will be rejected. Insufficient Volume of Urine will also be rejected for this test. Urine is not an appropriate specimen for the diagnosis of pulmonary tuberculosis. Examination of urine should be restricted to those patients who are immunocompromised, suspected of having renal or disseminated tuberculosis or when sterile pyuria or haematuria have been demonstrated. Turnaround time: Microscopy: Within 24hrs of receipt of the sample (Mon-Thurs)

Culture: • Negative culture 6-12 weeks • Positive culture 1-12 weeks

Positive microscopy and positive cultures are communicated to the requesting source immediately.

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Positive isolates and specimens are referred to the Irish Mycobacterial Reference Laboratory (IMRL), St. James’ Hospital, Dublin, Tel: (01) 4162980 for species Identification and susceptibilities.

Turnaround times as follows:  M.tuberculosis complex: 10-14 days  Drug susceptibilities: 15-30 days  MOTT ID – Variable  GeneXpert MTB/RIF PCR: Result within 24hours of receipt. Positive results will be phoned. Blood/bone marrow culture: min. 6 weeks from receipt

Additional Information:  Please submit a blood sample for HIV testing to the Serology/Immunology Laboratory if submitting a sputum sample for TB investigation.  Following a positive microscopy/ culture a repeat sample is recommended during treatment at 4-6 weeks to check for resistance (i.e. compliance with treatment).  Note 1: Routine culture and sensitivity does not include TB culture, the investigation must be requested.

Limitations  Certain rare, fastidious mycobacteria may not grow or may grow slowly in the BacTalert MP culture medium used. If these fastidious atypical mycobacteria are suspected, alternative methods of isolation or culture media, processing without decontamination or extended incubation may be required for recovery. Examples include M.abscessus, M. haemophilum and M.malmoense. BacTalert culture bottles are incubated at 35°C precluding the recovery of mycobacteria that require other incubation temperatures (e.g. M.marinum, M.ulcerans, M.haemophilum). Recovery of such mycobacteria requires additional incubation at appropriate temperatures. Clinical input and advice re appropriate sample processing is recommended if these strains are suspected. Inclusion of appropriate clinical details on request forms is essential to ensure correct sample processing.

Recovery of Mycobacteria is dependent on the quality of specimen collected and the number of culturable organisms in the specimen. Collection over 3 consecutive days is recommended for respiratory infection.NB: Please send samples to the Laboratory as soon as they are taken – do not wiat to send all three samples together as overgrowth of commensals may compromise recovery of Mycobacteria.

Tuberculosis (TB) PCR Laboratory: Microbiology Special requirements CSFs may be referred for TB PCR. This test is referred to Micropathology UK, Tel: 0044 24 76323222- and comments: turnaround time: Mycobacterium genus DNA: 4 days

Respiratory samples referred to IMRL, St. James Tel: (01) 4162980 for MTBC PCR (GeneXpert) GeneXpert MTB/RIF PCR: Result within 24hours of receipt. Positive results will be phoned.

Specimens are only referred in consultation with the consultant microbiologist.

Type 3 procollagen peptide (P111NP) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top) The specimen should be sent to the laboratory immediately. The sample should be centrifuged and the serum separated within 1-2 hours of collection (maximum no more than 4 hours).

Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

U & E Profile (urea and electrolytes) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top) or Lithium Heparin Plasma (Green Top)

Special requirements Blood specimens for potassium assay must be collected free of haemolysis. The serum must be separated within and comments: a period of two hours from venepuncture, since potassium is released from red blood cells during the transport and storage of whole blood specimens thus causing a falsely raised serum potassium concentration. Primary Care Samples There is usually a delay (of about 4-6 hours) in blood samples from Primary Care reaching the Biochemistry Laboratory for processing. This delay can cause a falsely raised serum potassium concentration, due to the release of intracellular potassium from red blood cells, during transport and storage of whole blood.

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Reference interval: On Biochemistry report or contact laboratory.

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Minimum Retesting For more details, see RENAL section of: Interval: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Urea Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top) or Lithium Heparin Plasma (Green Top) Urinary urea: See urine section in alphabetical listing for specimen, requirements, turnaround time and reference interval.

Special requirements This assay is also available as part of the U+E test profile (serum or plasma) and comments:

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Minimum Retesting For more details, see RENAL section of: Interval: https://www.rcpath.org/resourceLibrary/g147-minretestingintervalsinpathology-dec15-pdf.html

Ureaplasma urealyticum / parvum in genital specimens Laboratory: Microbiology Specimen Abbott Multi-Collect™ specimen collection kits (Available from the Microbiology Laboratory) requirements and Urine between min and max fill line on males (overfilled samples will be rejected) or Endocervical/Urethral swabs comments: Straight urine in universal container or Charcoal swabs can be tested, but not preferred

Turnaround time: 2 days from day of receipt by the referral laboratory Mon-Thurs.

Special precautions: Ensure that containers are labeled in accordance with the pathology specimen labeling policy.

Uric Acid (Urate) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top) or Lithium Heparin Plasma (Green Top) Urinary uric acid: See urine section in alphabetical listing for specimen, requirements, turnaround time and reference interval. Joint fluid: send specimen to the Microbiology Department for Microscopy (detection of uric acid crystals).

Turnaround time: Urgent sample: 90 mins. UHL wards: 3 hours. GP: 4 working days.

Reference interval: On Biochemistry report or contact laboratory.

Urine Analyses Laboratory: Biochemistry Special requirements BD Vacutainer 4ml urine container is required for all urinary analyses of tests outlined in table below unless it is a and comments: 24 hour collection. See table below for specific requirements for urine samples and reference Intervals.

Turnaround time: Urgent sample: same day (with prior contact laboratory). Routine: 4 working days

Urinary Test Specimen Type Special requirements or Reference Interval comments Albumin Random spot urine No preservative required less than 30 mg/24 hours Albumin / Random Urine No preservative is required but Normal: Creatinine urine should be kept cool. Males: <2.5 mg/mmol. Females: <3.5 ratio mg/mmol.

Microalbuminuria Males: 2.5 – 29 mg/mmol. Females: 3.5 – 29 mg/mmol.

Albuminuria: >30 mg/mmol. Amylase Random spot urine / 24-hour No preservative required 24-408 U/24h collection. Calcium For urine calcium assay a 24-hour 20mL of 6N HCI as preservative 2.50 to 7.50 mmol/24hr urine collection is required. required. Available from the Preservative required. Clinical Biochemistry Laboratory.

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Calcium / The ratio is determined on the The specimen should be Ca/Creat ratio ≤ 0.4 mmol/mmol creatinine creatinine second urine passed in the brought to the laboratory ratio morning. Acid preservative is immediately. added upon receipt in the laboratory. Creatinine 24-hour collection No preservative required. Males: 7.1 – 17.7 mmol/24hr Females: 5.3 – 15.9 mmol/24hr Creatinine 24-hour collection No preservative required. Adults: Clearance Blood sample required for Males: 66 – 163 mL/minute/1.73m2 creatinine and should be Females: 66 - 165 mL/minute/1.73m2 collected within the twenty four hour collection period. Magnesium 24-hour urine collection is 20mL of 6N HCI as preservative 3.0 – 5.0 mmol/24hr required with 20mL of 6N HCI as required. Available from the preservative. Clinical Biochemistry Laboratory. Phosphate 24-hour urine collection is 20mL of 6N HCI as preservative 15 – 50 mmol/24hr required with 20mL of 6N HCI as required. Available from the preservative. Clinical Biochemistry Laboratory. Potassium A 24-hour collection is No preservative required. 25 – 125 mmol/24hr recommended.

Protein Untimed urine collection / 24-hour No preservative is required but 0.01 – 0.14 g/L (random) urine collection urine should be kept cool. 0.03 – 0.15 g/24hr

Protein / Untimed urine collection / 24-hour No preservative required but <15 mg/mmol creatinine urine collection urine should be kept cool. ratio Sodium Random urine / 24-hour urine No preservative required. 40 – 220 mmol/24hr collection. Urea 24-hour urine collection. No preservative required. 428 -714 mmol/24hr Uric Acid a 24-hour collection is required. No preservative required but 1.48 to 4.43 mmol/24h urine should be kept cool.

Urinary Haemosiderin Laboratory: Haematology Specimen type: Urine without any preservative. Special requirements A fresh early morning specimen is preferable. and comments: Review of clinical details and authorisation by a consultant haematologist/registrar. Consultant signature / approval required on request form. Turnaround time: 3-5 D

Reference Interval: N/A

Test / Profile code HAEMO (iLab): Urine Microscopy/ Culture (refer to TB section for TB requests on EMU) Laboratory: Microbiology Specimen type: MSU or bag specimen in

10ML BD VACUTAINER WITH BORIC ACD Sarstedt Monovette Z’ 10mL urine OR BD Vacutainer® Urine Tube without boric acid, 9ml if very small volume of urine available (available only in Peadiatric wards)

CSU specimens are only processed from the following wards: • Urology • ICU / HDU • Oncology OR Where the following clinical details are provided: • Dysuria • Fever / pyrexia • Haematuria • elevated systemic parameters • Part of septic screen

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• Sepsis • Rigors

Please Note: Repeat Urine specimens submitted within 48 hours are NOT processed (Exceptions include Paediatric specimens and specimens submitted from UMH Limerick). Specimen Please refer to algorithm below for guidance on requirements: when to take a sample from Adults in the 10ML BD VACUTAINER WITH BORIC ACD community and long term care residents over 65. Sarstedt Monovette Z’ 10mL urine OR BD Vacutainer® Urine Tube without boric acid, 9ml Routine Samples: - Mid-stream urine (MSU), Clean- if very small volume of urine available catch urine, Suprapubic aspirate, Catheter urine (CSU), Mix well. Bag, Ileal conduit – urostomy urine, Cystoscopy urine, nephrostomy

Note: Please refer to TB section for EMU for TB- (preservative free containers only accepted for TB and 60ml volume over 3 consecutive days required)

Urine for Schistosoma Haematobium (bilharziasis) Total urine collected between 10.00 -14.00h into sterile containers without boric acid preservative is required.

Specimen collection: Please use BD urine collection kit with transfer straw 10ML BD VACUTAINER WITH BORIC ACD Sarstedt Monovette Z’ 10mL urine OR BD Vacutainer® Urine Tube without boric acid, 9ml if very small volume of urine available

Collect urine specimens by the clean-voided midstream technique, by diagnostic catheterization, by supra-pubic aspiration or from an in dwelling catheter. The first morning specimen is preferred.

Urinary catheter tips are not cultured because the tip is contaminated as it is removed from the urethra.

A pooled, 24-hour collection is unacceptable for culture, as is more than one specimen within 24 hours.

Sample volume: 9ml of sample in boric acid container is optimum for bacterial pathogen detection. A minimum of 2ml is required for microscopy.

Special precautions: • Specimens should be transported and processed within 4h if possible unless boric acid preservative is used. • If boric acid is used it is important to mix well.

Turnaround time: Urgent Urine Microscopy: 4hours Microscopy: 1 working day Negative culture: 1-2 working days Positive culture: 2-3 working days

Reference Interval: Manual Microscopy:

Pyuria: ≥104 WBC/ml is significant, although higher numbers of WBC (white blood cells) may be found in healthy, asymptomatic women.

Urine Bacterial Growth:

Note: Interpretation of culture results must be made with care. Some patient groups (children and dysuric women) may have significant growth at lower levels ≥102 cfu/ml than those quoted below.

≥105 cfu/mL colony forming units: consistent with infection

≤105 cfu/mL colony forming units: usually indicative of contamination

104-105 cfu/mL colony forming units of pure growth: evaluated based on clinical information or confirmed by repeat culture.

Ref: PHE SMI B41 and PHE National User Manual U3

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Testing Algorithm: Testing for uncomplicated Urinary Tract Infection in ADULTS (>16 <65 Years old, no fever or flank pain)

Severe or ≥ 3 symptoms /signs of UTI ≤ 2 symptoms/signs of UTI . Urgency . Urgency . Polyuria . Polyuria . Haematuria . Haematuria . Dysuria . Dysuria . Frequency . Frequency . Suprapubic tenderness . Suprapubic tenderness

Use dipstick to rule out UTI (Reference: www.antibioticprescribing.ie)

PROBABLE UTI PROBABLE UTI Treat with Empiric Antibiotic Positive nitrite, and Negative nitrite Negative nitrite, Reference: leucocytes and blood Positive leucocyte leucocytes and blood www.antibioticprescribing.ie Or positive nitrite alone POSSIBLE UTI or negative nitrite and DO NOT routinely send Do NOT routinely send Send sample to leucocyte sample to MICROBIOLOGY sample to MICROBIOLOGY MICROBIOLOGY positive blood or protein

UTI UNLIKELY Consider other diagnosis Reassure and give advice on Management of symptoms DO NOT send sample to MICROBIOLOGY

Specific guidelines on testing and treatment are available for following patient populations from antibioticprescribing.ie (Section: Conditions and Treatments/Urinary) Pyelonephritis Recurrent UTI in women UTI in Children UTI in long term care residents over 65 UTI in pregnant women Exceptions to routine testing guideline in adults with probable or possible UTI

Send a urine for culture in the following cases:  failed antibiotic treatment or persistent symptoms  recent hospitalisation  Consider Males before treatment of UTI  Pyelonephritis Diagnosis of UTI in patients > 65 years requires a combination of Reliable clinical signs Only send urine for culture in patients who are symptomatic. Do not send urine for culture solely on the basis of urine odour or appearance

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Diagnosis of UTI in patients > 65 years requires a combination of reliable clinical signs Only send urine for culture in patients who are symptomatic. Do not send urine for culture solely on the basis of urine odour or appearance.

Do not perform urine dipsticks on > 65 years without symptoms

Half of older adults, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick and culture, antibiotics are not beneficial, and may cause harm See Diagnosis & management of UTI in long term care residents on www.antibioticprescribing.ie (Section: Conditions and Treatments/Urinary)

Urine Protein Electrophoresis Laboratory: Biochemistry Specimen type: Untimed urine collection (in a ‘Sarstedt Monovette Z’ 10mL urine container) Or a 24-hour collection. No preservative is required. Keep specimen refrigerated. Special requirements Appropriate clinical details are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory

Reference Interval: The referral laboratory report provides appropriate reference values.

Valproate (valproic acid, Epilim®) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top)

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Special requirements Specimen drawn before the next oral dose in a patient at steady state. and comments: There is no evidence that monitoring serum valproate levels can be valuable in the management of patients with epilepsy. Studies indicate that concentrations are no better a guide to clinical response than is dose. Measurement of serum levels may be useful in the assessment of compliance.

Turnaround time: Routine: 4 days. Contact laboratory if urgent result required.

Reference Interval: On Biochemistry report or contact laboratory.

Vancomycin Assay Laboratory: Microbiology

Specimen type and Refer to Antibiotic Assay Requirements: Vancomycin Resistant Enterococci (VRE) Screen Laboratory: Microbiology

Specimen type and Refer to: Infection Control Screening Requirements: Varicella Zoster (VZV) Antibodies (IgG) Laboratory: Serology Specimen type: Gel Serum sample (Brown Top)

Special requirements  Requests for patients previously reported VZV IgG positive should not be repeated. An appropriate comment and comments: will be attached to reports for unprocessed repeat requests for VZV IgG.  VZV IgG serology is not performed as part on the routine antenatal screen  Samples from pregnant patients who have been in contact with varicella zoster are processed urgently and results are available within 24 -48 hours. The request must be marked as ‘Urgent’ and the laboratory should be contacted (061 482254) prior to sending the sample.

Turnaround time: 7 working days (routine requests) 48 hours (urgent requests)

Reference interval: Positive / Negative / Borderline Borderline results are referred to NVRL, Dublin. Tel: 01 716 4414/ 716 4415 Relevant interpretive comments are included on the report.

Repeat testing Interval: Positive IgG results – repeat testing not indicated. Serology testing post vaccination is not indicated.

Varicella Zoster (VZV) Antibodies (IgM) Laboratory: Serology Special requirements ** Requests for investigation for chicken pox / shingles should be based on direct detection methods by PCR with and comments: a viral swab of the vesicular fluid from the lesion. Direct detection of VZV DNA from vesicular fluid is the most sensitive method of detection. Up to 50% of patients with primary acute varicella fail to produce detectable IgM antibodies so a negative IgM does not exclude a diagnosis of chickenpox. Furthermore, VZV IgM testing is not recommended for the diagnosis of shingles (Herpes Zoster) due to the difficulty of result interpretation** VZV IgM testing is still available at the reference lab in cases where swabs of the lesion are not available. Testing will be by arrangement only with the duty Microbiologist. Vasoactive intestinal polypeptide (VIP) Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements Patient should be fasting overnight. and comments: Collect 3 mL of blood into an ice-cold potassium EDTA specimen tube (Violet Top). The specimen should be surrounded with ice and brought to the laboratory immediately. Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Very long chain fatty acids (VLCFA) Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

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Special requirements 1 ml blood in EDTA (Violet Top) / lithium heparin sample tube (Green Top); Do not refrigerate, Deliver to and comments: laboratory without delay - Monday- Wednesday (only). Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Viral Studies (Stools) Laboratory: Serology Specimen type: Fresh stool sample collected in a clean, sterile, leak-proof container.

Special requirements Note: Please specify viral pathogen of interest in the tests required section of the request form. and comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4415/ 716 4416. Turnaround time: 1 - 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Viral Culture (Swabs) Laboratory: Serology Specimen type: Viral Transport Swab

Note: The charcoal swab (Microbiology) is unsuitable for viral investigations.

Special requirements Please provide relevant clinical details with request. and comments: Note: Viral transport swabs are available from the Laboratory by contacting the Laboratory Porter (see ‘Ordering of Laboratory Supplies’ in the introduction section of the manual).

Viral transport swabs should be delivered to the laboratory as soon as possible after collection. Viral transport swabs may be refrigerated at 2 - 8°C overnight if same day delivery to the laboratory is not possible.

This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Turnaround time: 1 - 2 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Viscosity, plasma Laboratory: Haematology Special requirements Please refer Plasma viscosity, under the letter P. and comments: Vitamin A Laboratory: Biochemistry Specimen type: Light protected NON GEL Neutral tube - serum

Special requirements Protect from light using e.g. aluminium kitchen foil. Keep refrigerated. and comments: Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Vitamin B6: Pyridoxine Laboratory: Biochemistry Specimen type: Whole blood in K-EDTA specimen tube (Violet Top).

Special requirements Specimen must be sent to the laboratory immediately. and comments: Protect from light, Keep refrigerated.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

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Vitamin B12 Laboratory: Haematology Specimen type: Gel Serum sample (Brown Top)

Special requirements and Requests should be received by the laboratory within 8 hours of phlebotomy, add on tests within 24 hours comments: of phlebotomy. Relevant Clinical Details required.

Indications for Vitamin B12 and Folate Measurement Haematological unexplained anaemia/other cytopenias unexplained macrocytosis haemolysis

Neurological subacute combined degeneration of the cord peripheral neuropathy dementia unexplained neurology Other glossitis pregnancy malabsorption previous gastric resection strict vegans alcoholism patients on dialysis

Medications Metformin therapy prolonged proton pump inhibitor or H2 receptor antagonist therapy anticonvulsant therapy Methotrexate therapy

Turnaround time: 3 D

Reference interval: Age and sex related. Refer to report form.

Test / Profile code (iLab): B12 / BFF

Vitamin C Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met. Note that Vitamin C is highly reactive and easily oxidised.

Special requirements Collect blood into two x 2.7 mL lithium heparin tubes (Green Top). Deliver the specimen to laboratory immediately and comments: so that further processing can take place to stabilise Vitamin C. This stabilisation must be completed within 30 minutes of specimen collection. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

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Vitamin E (Tocopherol) Laboratory: Biochemistry Specimen type: Light protected NON GEL Neutral Tube - serum

Special requirements Protect from light using e.g. aluminium kitchen foil. Keep refrigerated. and comments: Specimen should be sent to the laboratory immediately.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

VMA Laboratory: Biochemistry Specimen type: 24-hour urine collection with 20 mL of 6N HCI as preservative.

Special requirements Appropriate clinical details and a list of all current medication are required. and comments:

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values. vWF:Ag (von Willebrand Factor Antigen) Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements Requests should be received by the laboratory within 4 hours of phlebotomy. and comments: Volume: 1 sample Turnaround time: 28 D

Reference Interval: 60-150 u/dl VWF levels are approximately 25% lower in blood group O individuals than in non O (Gill et al, 1987).

Gill, J.C., Endres‐Brooks, J., Bauer, P.J., Marks, Jr, W.J. & Montgomery, R.R. (1987) The effect of ABO blood group on the diagnosis of von Willebrand disease. Blood, 69, 1691–1695. Test / Profile code VWF / VWFP (iLab): vWF Screen (von Willebrand Factor Screen) Laboratory: Haematology Specimen type: Citrated plasma (Blue Top).

Special requirements Requests should be received by the laboratory within 4 hours of phlebotomy. Consultant signature/approval and comments: required on request form

Volume: 6 samples Turnaround time: 28 D

Reference Interval: See specific tests included in screen for ranges – FVIII:C, RICOF, VWF:ag

Test / Profile code VWFP (iLab): W

Warfarin assay (PIVKA – Protein induced by Vitamin K absence antagonist) Laboratory: Haematology Specimen type: Gel Serum sample (Brown Top)

Special requirements Prior arrangement with the UHL coagulation department. Contact: 061-482851. and comments: Consultant signature / approval required on request form.

Details of anticoagulant therapy required. Referred for analysis to Centre for Haemostasis & Thrombosis, Guy’s & St Thomas’ Hospital, London. Tel.: +44- 207-401 3125 Turnaround time: 28 D

Reference Interval: Refer to report issued by referral laboratory. Test / Profile code WARFR (iLab):

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West Nile Virus Serology Laboratory: Serology

Special requirements Note: Requests for this test requires prior arrangement with the referral laboratory and comments: This test is referred to the National Virus Reference Laboratory, Dublin. Tel: 01 716 4414/ 716 4415.

Specimen type: Gel Serum sample (Brown Top)

Turnaround time: Test Availability: By Arrangement

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

White cell cystine Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements 3 ml blood in lithium heparin tube (Green Top); Do not refrigerate or centrifuge, Deliver to laboratory without delay. and comments: Monday – Wednesday (only) .Sample must be received by referral laboratory within 24hours of venepuncture. Appropriate clinical details are required.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

White cell enzyme analysis (Lysosomal enzyme analysis) Laboratory: Biochemistry Specimen type: Contact the Clinical Biochemistry Laboratory before initiating the request so that all collection requirements can be met.

Special requirements 5 mL blood in lithium heparin tube (Green Top); Do not refrigerate or centrifuge, Deliver to laboratory without and comments: delay. Monday – Wednesday (only). Appropriate clinical details are required. Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Whipples disease: Laboratory: Microbiology Special requirements Refer to CSF and comments: Whooping Cough Laboratory: Microbiology Special requirements Refer to Bordetella Pertussis and comments: Widal Test Laboratory: Serology Special requirements Widal test for Salmonella antibodies is no longer available in the Serology/Immunology Laboratory. Please send a and comments: stool sample and blood cultures to the Microbiology Laboratory. Refer to: Faeces.

Wound Laboratory: Microbiology Specimen type: Skin / Superficial wound Abscesses Post operative Deep wound Ulcer swabs Drain fluids (Drain tips are not processed)

Specimen Charcoal swab of pus or exudates. requirements: Samples of pus in a sterile leak-proof container is the preferred specimen.

Laboratory will not process any chronic ulcers or surgical wound swabs form non acute Hospitals unless the clinical criteria associated with infection as opposed to colonisation are clearly given on the request form. See chronic wound policy.

Sample Volume: A minimum of 1ml of pus in a sterile leak-proof container.

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Special precautions: • Specimens should be transported and processed as soon as possible. • The volume of specimen influences the transport time that is acceptable. Large volumes of purulent material maintain the viability of anaerobes for longer. The recovery of anaerobes is compromised if the transport time exceeds 3h. Turnaround time: Aerobic culture: 2–3 working days 4-5 working days if AST is performed on fastidious pathogens Anaerobic culture: 5–7 days

Additional information: Swabbing dry crusted areas are unlikely to be helpful. Specimens are processed according to the clinical details provided. Please provide clinical details. Swabs should not be repeated for testing unless there is a change in the clinical condition of the patient Anaerobic enrichment is only performed on samples of pus; please provide a sample of pus if available as opposed to sending a swab of pus. Ulcer swabs should not be submitted unless there is clinical evidence of infection. Anaerobic culture will not be performed unless there are appropriate clinical details to support this investigation

NB: swabs are not recommended specimens for TB testing and will not be processed for same without agreement from the duty Clinical Microbiologist.

Please Note: Repeat wound swabs submitted within 48 hours are NOT processed. X

Yersinia Abs Laboratory: Serology Specimen type: Gel Serum sample (Brown Top)

Special requirements Indications for testing and clinical information must be provided with the request.. and comments: This test is referred to the BIOMNIS Laboratories, Dublin. Tel: 01 299 0650 / 01 295 8545

Turnaround time: 2 - 3 weeks

Reference range: The referral laboratory report provides appropriate ranges and interpretive comments.

Zarontin® (Ethosuximide) Laboratory: Biochemistry Specimen type: Gel Serum sample (Brown Top)

Special requirements Specimen should be drawn before the next oral dose in a patient at steady state. Due to the long half-life of and comments: ethosuximide, fluctuations in serum concentration are relatively minor. However, when making comparative measurements, it is advisable that the sampling time be consistent.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

Reference Interval: The referral laboratory report provides appropriate reference values.

Zika Virus Testing Laboratory: Serology Special requirements At the time of this revision of the User Manual interim guidelines for the Laboratory Investigation of Zika Virus and comments: were published on the HPSC website. Please refer to the section ‘Guidance for Healthcare professionals’ which gives details on who should be tested, the time frame for testing and the sample requirements – www.hpsc.ie

It is advised that before submitting sample for Zika virus testing that the Lab should be contacted in advance to discuss indication for testing and sample requirements. Alternatively, the testing laboratory (NVRL, Dublin) may be contacted directly for advice: (01) 716 4414.

Zinc Laboratory: Biochemistry Specimen type: Whole blood in trace metal-free tube. Trace metal-free needle must be used in conjunction with trace metal-free tube. Special requirements This specimen should be collected first if other tests are requested to avoid contamination. and comments: Please contact Clinical Biochemistry Laboratory for trace metal-free specimen collection tube and needle.

Turnaround time: Requests for this test are referred to an external specialist laboratory.

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