University Hospital Limerick Laboratory User Manual, Edition 13
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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 Test Directory (A-Z) Quick Link (press Ctrl and Select letter) A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 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.............................