Laboratory and Pathology Test Menu and Specimen Collection Guide

ARHS-SC-19.12

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Laboratory Services

Laboratory and Pathology Test Menu SUBJECT: DIRECTIVE #: ARHS-SC-19.12 and Specimen Collection Guide

DEPARTMENT: Specimen Collection EFFECTIVE DATE: 10/23/2017

FACILITY/LOCATION: Watauga Medical Center / Cannon Memorial Hospital

LABORATORY DIRECTOR: APPROVAL DATE: 10/23/2017 Steven J. Bredehoeft, MD, MPH

Title Page

Approvals - Table of Contents 2

Introduction 3

Laboratory Telephone Numbers 4

Venipuncture Collection 5

Capillary Collection 9

Specimen Labeling Policy 11

Clean Catch Urinalysis Collection Instructions 12

24 Hour Urine Collection Forms/Instructions 13

Stool Collection Instructions 16

Swab Collection 19

Therapeutic Drug Monitoring 22

Test Menu Guide 23

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Thank you for allowing ARHS Laboratory and Pathology Services to serve as your resource for laboratory testing. In this collection guide, you will find the pertinent information relating to all tests performed by an ARHS Laboratory, as well as, instructions for the collection of common specimens. Each test in this guide lists which ARHS Laboratory that has the ability to perform the test. For any test requested that is not listed in this collection guide, please contact the ARHS Laboratory you are using to obtain reference laboratory specific information/specimen requirements.

As noted above, ARHS Laboratory and Pathology Services have the ability to perform thousands of tests not listed in this collection guide. However, this requires the need to use multiple reference laboratories to supplement testing not performed in our own laboratories. Each reference laboratory has their specific specimen collection requirements; so again, please contact your ARHS Laboratory to obtain the correct collection information.

This directory is available to all ARHS Laboratory Services users either in print, on the ARHS Intranet or via the Laboratory Services website (www.apprhs.org)

How to use the guide: Test/Panel Name Basic Metabolic Panel (BMP)

Lab: WMC/CMH Chemistry Specimen: Serum , Use: to evaluate metabolic status, Availability: 24 hours TAT: heparinized plasma fluid/electrolyte balance. Routine, 4 hours Stat, 1 hour Tube: SST, Plain red or Green CMH ED - 44 min (Li hep.) Test Includes: glucose, BUN, Minimum volume: 5 ml creatinine, sodium, potassium, Collection: Routine chloride, CO2, calcium venipuncture Causes for rejection: Gross hemolysis, improper labeling, contamination with IV fluids, serum/plasma not removed from cells within 2 hours, wrong anticoagulant.

1. Lab – Facility performing test 1. Specimen requirements 6. Uses – background on test use 2. Availability – When testing is 2. Collection container required 7. Test limitations if present performed 3. Minimum Volume required 8. 13. Additional test information 3. TAT – average turnaround time for 4. Pertinent collection information results 4. Test Includes – tests included in a 5. 10. Reasons a sample may be panel rejected 5. Special Instructions/Notes

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Watauga Medical Center Telephone Numbers

Main Laboratory 262-4150

Transfusion Services 262-4146

Chemistry 262-4296

Hematology 262-4149

Microbiology 262-4148

Laboratory Fax 262-4147

Pathology Office 262-4106

Pathology Laboratory 268-9401

Histology 265-5028

Cytology 268-8923

Outpatient Laboratory 266-2495

LIS/IT 266-1163

Cardiopulmonary 262-4176

Cannon Memorial Hospital Telephone Numbers

Laboratory 737-7500

Laboratory Fax 737-7501

Pathology Associates of Boone Main Office 262-5569

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Venipuncture Collection Procedure

Principle A patient's veins are the main source of blood for laboratory testing as well as a point of entry for IVs. Since only a few veins are easily accessible to both laboratory and other medical personnel, it is important that everything be done to preserve their good condition and availability. Correct collection procedures are the first step to accurate laboratory testing. Collection must be performed on the correct patient, drawn in the correct tubes, and handled properly after collection to ensure accurate results.

Procedure 1. Review the request form(s) or labels. See what test(s) have been ordered and that you have the appropriate tubes.

2. When collecting an inpatient, be sure to knock on the patient's door before you enter the room.

3. Cordially greet the patient. Let them know your name, which department you’re from, and the purpose of your visit.

4. Access the patient’s ability to understand. Each inpatient has a Learning Readiness Assessment. If' needed, you may review the nursing assessment found in the patients room chart. You may find it necessary to seek additional assistance before attempting to obtain the sample.

a. What is the patient's primary language? b. What is the patient's education level? Your communication needs to be at a level that the patient can understand. If the patient asks you questions, keep your response at a level that the patient can understand. c. Does the patient have any learning impairments? i. Hearing ii. Sight iii. Speech iv. Cognitive Abilities

5. Identify the patient using the two unique identifiers detailed on ARHS-SC-02.

6. Sanitize hands before and after patient contact.

7. If a fasting specimen is required, verify that the patient has not eaten. Food trays are a good sign that the patient has eaten. If you believe that the patient is capable of understanding and answering the question, you may ask the patient if they have eaten within the specified fasting time. In some cases you may need to consult with the nursing department regarding the patients fasting status.

8. Reassure the patient. Be confident and display a positive attitude.

9. Properly position the patient: a. Inpatients should lay on their back in a comfortable position. Add support under the arm with a pillow if needed. Extend the arm to form a straight fine from the shoulder to the wrist. b. Outpatients should be comfortably seated in a venipuncture chair. The arm should be positioned on an armrest in a straight line from the shoulder to the wrist. The arm should not be bent at the elbow. c. Make sure the patient does not have anything in his/her mouth. d. Never perform a venipuncture on a patient who is standing.

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10. Prepare your equipment. Assemble your tube(s) and venipuncture supplies, alcohol prep, gauze, tape and tourniquet. Do not place the phlebotomy tray on the patient's bed. Determine the order of tube collection: 1. Blood Cultures 2. Discard tube (necessary if drawing only light blue top tube with a butterfly) 3. Royal blue 4. Light blue (Sodium citrate) 5. Red (no additive) 6. SST 7. Light green (Lithium heparin) 8. Green (Sodium heparin) 9. Lavender (EDTA) 10. Pink (EDTA) 11. White (gel EDTA) 12. Gray (Sodium fluoride) 13. Yellow (ACD)

11. Select site for venipuncture: a. Do not draw blood above an Intravenous (IV) Infusion. If the patient has an IV in one arm, look for a vein in the other arm. If IV's are located in both arms, blood may be drawn from ABOVE the IV site if the nurse can turn the IV fluids off for at least 2 minutes. Tourniquet use should be avoided in this situation and a discard of 3-5 ml of blood should be drawn before drawing the specimen(s) for testing. Discard waste tube in the biohazard waste. b. In most cases blood can be drawn from the median cubital vein, located in the Antecubital Fossa. The Cephalic, Basilic, Accessory Cephalic, Median Ante brachial and Radial veins in the arm or the Dorsal Hand Veins may be used. Do not use veins in the Ventral Wrist area. Leg and foot veins should be used only as a last resort and when we have a physician’s written order to draw from the foot or leg. A tourniquet should not be used in these cases. c. A tourniquet may be applied to help in locating a vein; however it should be left on no longer than 1 minute. d. You may ask the patient to make a fist to help make the vein more prominent, however in no case should the patient be allowed to pump the fist. Some laboratory results could be altered by the pumping action. e. Avoid scarred or bruised areas and if possible, the side on which a mastectomy was performed should be avoided.

12. Cleanse the venipuncture site with an alcohol prep using a circular motion from the center to the periphery. For blood cultures, cleanse site in a circular motion for 60 seconds using a chloroprep pad. Allow the area to air dry. While the site is drying, put on a clean pair of gloves. Gloves must always be donned in the presence of the patient.

13. Apply a tourniquet 3 to 4 inches above the venipuncture site. Hold one end taut and tuck a portion of the other end under to form a loop.

14. Perform the Venipuncture - Note, do not attempt to perform more then two venipuncture attempts on a patient. There should be no more than five attempts to collect blood from a patient. If the lab has been unable to collect a specimen, notify the nursing department and document in the LIS.

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Vacutainer a. Holding the vacutainer barrel in your dominant hand, remove the needle cap and position the needle with the bevel up. b. Pull the skin just below the puncture site tight using either the thumb or index finger of your non-dominant hand. Do not make a "window." c. Align the needle with the puncture site, keeping the needle at a 15° angle. Use a small quick thrust, puncture the skin and enter the vein in one smooth motion, if possible. d. Holding the barrel securely, push the first tube fully onto the needle assembly. Blood should flow when the needle punctures the tube cap. If it does not, the needle is either too far in the vein or not in the vein. Back the needle and reposition needle until you feel the needle is in the vein. If blood still does not flow, try another tube. e. Remove the tube when the blood flow ceases. If multiple tubes are needed, insert them in the order listed above. f. When all the blood necessary has been collected, release the tourniquet, remove the needle quickly and immediately apply a cotton ball or gauze pad on the puncture site. At the same time, make the needle safe by activating the protective device. Hold pressure to the cotton/gauze. Discard the needle in the sharps container.

Syringe a. Holding the syringe in your dominant hand, remove the needle cap. Position the needle with the bevel up. b. Grasp the patient's arm just below the puncture site with your non-dominant arm and pull the skin tight with your thumb. c. Align the needle with a 15-degree angle to the skin. Use a quick, but small, thrust to penetrate the skin and enter the vein in one motion, if possible. d. Holding the barrel of the syringe securely, pull back on the syringe plunger until a sufficient amount of blood fills the syringe. e. Release the tourniquet, remove the needle quickly and immediately apply a cotton ball or gauze pad on the puncture site. At the same time, make the needle safe by activating the safety device. Hold pressure to the cotton/gauze. Discard needle in the sharps container. f. Using a transfer device, transfer the blood from the syringe to the appropriate tubes immediately. Fill tubes containing anticoagulants first. Discard of the transfer device and syringe in the sharps container.

Butterfly a. Holding the butterfly by the "wings" in your dominant hand, remove the needle cap. b. Position the needle with the bevel up. c. Grasp the patient's arm just below the puncture site with your non-dominant arm and pull the skin tight with your thumb. d. Align the needle with a 15-degree angle to the skin. Use a quick, but small, thrust to penetrate the skin and enter the vein in one motion, if possible. e. Blood will enter the tubing attached to the needle once the needle is in the vein. The opposite end of the tubing can be attached to a syringe or an adapter can be used and it can be attached to a vacutainer barrel. f. When all the blood necessary has been collected, release the tourniquet, remove the needle quickly and activate the safety mechanism. Immediately apply a cotton ball or gauze pad on the puncture site. Hold pressure to the cotton/gauze. Discard the butterfly assembly in the sharps container. Using a transfer device, transfer the blood from the syringe to the appropriate tubes immediately. Fill tubes containing anticoagulants first. Discard of the transfer device and syringe in the sharps container.

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15. Apply a bandage to the site and advise the patient to leave it on for 1 to 2 hours. 16. In the presence of the patient, label tubes according to ARHS-SC-05.

17. For inpatients, return the patient area to the condition in which you found it - raise side rails, dispose of trash, lower the bed, etc.

18. Remove gloves and sanitize hands prior to leaving the room.

Adverse Reactions to Phlebotomy To ensure that any patient that has an adverse reaction such as fainting, seizure, or injury to phlebotomy will receive immediate care:

Inpatients: 1. The phlebotomist will call the nurse’s station for immediate assistance. 2. The patient’s nurse will be notified. 3. An occurrence report will be completed.

OPIC Outpatients: 1. Basic first aid will be administered. 2. Ammonia and a recliner are available when needed. 3. When indicated 911 will be called per EMTALA Policy.

Main Lab Outpatients: 1. Basic first aid will be administered. 2. Ammonia and a recliner are available when needed. 3. An intercom system is available to obtain assistance. 4. When indicated a CODE Blue will be called.

The following steps can be taken to assist the patient during adverse events: Fainting: 1. If the patient is sitting, lower head and arms. If lying down, elevate feet. 2. Try to revive patient with ammonia inhalant (draw trays and in draw rooms). 3. Loosen any tight clothing. 4. Apply cold compress to patient’s forehead and back of neck.

Nausea 1. Situate patient comfortably with head lowered. 2. Instruct patient to breathe deeply and slowly. 3. Offer water.

Vomiting 1. Roll prone patients on their side. 2. Give patient a basin. 3. When vomiting ceases, assist patient with towels and water.

Extensive bleeding 1. Apply direct pressure to venipuncture site and note time it takes to cease bleeding.

ORIGINAL AUTHOR: Wendy R. Williams ORIGINAL EFFECTIVE DATE: 12/30/2010 Venipuncture Collection Procedure

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Capillary Collection Procedure

Principle

Capillary blood specimens are especially important for hard to stick patients such as pediatric, obese, or geriatric patients. This procedure is also used for obtaining blood for bedside glucoses and PKU newborn screenings. Correct collection procedures are the first step to accurate laboratory testing. Collection must be performed on the correct patient, drawn in the correct tubes, and handled properly after collection to ensure accurate results.

Procedure

1. Review the request form(s) or labels. See what test(s) have been ordered and that you have the appropriate tubes. 2. When collecting an inpatient, be sure to knock on the patient's door before you enter the room. 3. Cordially greet the patient and/or patient’s family. Let them know your name, which department you’re from, and the purpose of your visit. 4. Access the patient’s ability to understand. Each inpatient has a Learning Readiness Assessment. If' needed, you may review the nursing assessment found in the patients room chart. You may find it necessary to seek additional assistance before attempting to obtain the sample. a. What is the patient's primary language? b. What is the patient's education level? Your communication needs to be at a level that the patient can understand. If the patient asks you questions, keep your response at a level that the patient can understand. c. Does the patient have any learning impairments? i. Hearing ii. Sight iii. Speech iv. Cognitive Abilities 5. Identify the patient using the two unique identifiers detailed on the Patient Identification procedure. 6. Sanitize hands before and after patient contact. 7. If a fasting specimen is required, verify that the patient has not eaten. Food trays are a good sign that the patient has eaten. If you believe that the patient is capable of understanding and answering the question, you may ask the patient if they have eaten within the specified fasting time. In some cases you may need to consult with the nursing department regarding the patients fasting status. 8. Reassure the patient. Be confident and display a positive attitude. 9. Prepare your equipment. Assemble your tube(s) and collection supplies, alcohol prep, gauze, and Band-Aid. Do not place the equipment on the patient's bed. 10. Finger stick collections: a. The preferred site is the middle or ring finger. Stick the palmar surface of the distal phalanx; do not stick the side or tip of the finger. b. Wash hands and put on gloves. c. If patient’s hand is cold, warm with a heel warmer or a warm wash cloth. d. Clean site with an alcohol pad and let it dry. e. Hold finger to prevent movement and perform puncture with appropriate safety lancet. f. The first drop of blood should be wiped away with gauze. g. To enhance blood flow hold finger downward and apply intermittent pressure. h. Touch collection device to 2nd drop of blood and allow blood to flow into microtainer tube or place drop on BSG strip. i. Gently tap tube if blood becomes lodged at top of tube.

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j. Fill tubes appropriately and invert tubes with anticoagulant. 11. Heel stick collections: a. The baby should be in a supine position. b. Puncture should be performed on the most medial or most lateral portion of the plantar surface of the heel. Do not puncture the posterior curvature or the central area of the heel. c. Wrap the heel in a heel warmer or a warm washcloth for 5 minutes. d. Clean the puncture site with an alcohol pad and allow to air dry. e. Open the tenderfoot blister pack and remove the safety clip from the device. f. Raise the foot above the baby’s heart level and carefully select a safe incision site. g. Place the blade slot surface of the device flush against the heel; both ends should make light contact. h. Depress the trigger and immediately remove the device. i. Gently wipe away the first drop with a gauze pad. j. Touch collection device to 2nd drop of blood and allow blood to flow into microtainer tube. k. Gently tap tube if blood becomes lodged at to top of tube. l. Fill tubes appropriately and invert tubes with anti coagulant. m. For PKU screens, allow blood to flow onto the circles on the form. Fill all circles completely. 12. Apply a bandage to the site and advise the patient to leave it on for 1 to 2 hours. 13. In the presence of the patient, label tubes or PKU form according to Specimen Labeling . 14. For inpatients, return the patient area to the condition in which you found it - raise side rails, dispose of trash, lower the bed, etc. 15. Remove gloves and sanitize hands prior to leaving the room.

ORIGINAL AUTHOR: Wendy R. Williams ORIGINAL EFFECTIVE DATE: 12/30/2010 Capillary Collection Procedure

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Specimen Labeling

Principle To ensure that all specimens are labeled in the same manner by all staff and that all necessary information is supplied with each sample.

Procedure The primary specimen container for all specimens must be labeled with the following: 1. Patient name (first and last) 2. Patient date of birth 3. Date of collection 4. Time of collection 5. Initials or ARHS employee number of person collecting specimen

Specimens may also include the location of the patient and the facility patient specific identification number.

Specimens received without date of birth on the label must be accompanied with a requisition or demographics sheet that includes the required patient identifiers.

Specimens are to be labeled in the presence of the patient at the time of collection.

LIS generated labels are to be placed on specimen tubes with the test names on the left and the patient name on the right. Labels are also to be placed over the manufacturer label in such a way that allows the sample to be seen. Specimen cups and tubs may have the label placed over supplied labeling area. Blood culture tubes should have the label placed at the bottom of the tube making sure not to cover up the barcode on the bottle. If tubes are labeled with labels other than those generated by the LIS, the LIS labels should be placed on the tubes in the same manner as above with care given to keeping the name on the original label visible.

Place the label on the correct tube as indicated on the label. Failure to place the correct labels on the correct tubes may result in delayed testing. Extra labels may be used to label extra tubes.

In the event of errors/discrepancies in specimen labeling, the best practice is to recollect the sample and ensure proper specimen labeling at time of recollection. For irreplaceable or difficult- to-obtain samples, corrections in labeling may be made by the original collector. In addition to the labeling correction, a Specimen Labeling Discrepancy Form must be completed by the original collector with a laboratory staff member witnessing the correction.

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Cannon Memorial Hospital PKU Labeling 1. Log onto Hearing Link site (wcs.ncpublichealth.com) 2. Choose patient by clicking on patient name in hospital queue. 3. In the green box, click New Specimen. 4. Scan or enter the barcode on the metabolic screening (PKU) form. 5. Fill in a. Specimen Status b. Date and time of collection c. Collector initials d. Facility 6. Click Submit Data. 7. Return to patient record and click Print Label. 8. Click OK to confirm patient information. 9. Click File then Page Setup then Landscape 10. Set margins at 0.5” for all sides (top/bottom/left/right) 11. Click Printer then Properties then select Labels as the paper type 12. Click OK to print. 13. Inspect label for accuracy. Place one label on each page of the PKU form taking care not to cover the barcode or the patient medical record number.

ORIGINAL AUTHOR: Wendy R. Williams, MT (AMT) ORIGINAL EFFECTIVE DATE: 12/30/2010 Specimen Labeling

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Clean Catch Urine Collection

Principle To ensure proper collection from patients for clean catch specimens, the following instructions are provided to the patient.

Procedure When presented with an order for a test that requires a clean catch urine specimen, provide the patient with a specimen cup and a sterile antiseptic pad. If the patient is taking the container home to collect the specimen, also provide them with a specimen bag to transport the specimen in. Review the following instructions with the patient or direct them to the posted instructions in the collection restroom.

Instructions for the female patient: 1. If you are menstruating, first insert a fresh tampon or use cotton to stop the flow. 2. Separate the skin folds around the urinary opening then wash the urinary opening and its surroundings from front to back with a sterile antiseptic pad. 3. Begin urinating in the toilet, making sure to keep the skin fold apart with the fingers of one hand. 4. Wait until the urine stream is well established before moving the container to the genital area but do not touch container to genital area. 5. Replace lid when done collecting sample. 6. Label the container with your name, date of birth and the date and time of collection and place in the specimen window or deliver to laboratory as soon as possible. Refrigerate specimen if transport to the laboratory will be delayed.

Instructions for the male patient: 1. Wash the end of the penis well with a sterile antiseptic pad and allow to dry. 2. Begin urinating into the toilet. Wait until the urine stream is well established before moving the container into the path of the stream to catch the rest of the urine. Do not touch the container to the genital area. 3. Replace lid when done collecting sample. 4. Label the container with your name, date of birth and the date and time of collection and place in the specimen window or deliver to laboratory as soon as possible. Refrigerate specimen if transport to the laboratory will be delayed.

ORIGINAL AUTHOR: Wendy R. Williams, MT (AMT) ORIGINAL EFFECTIVE DATE: 12/30/2010 Clean Catch Urine Collection

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Clinical/Anatomic Pathology Laboratory

Facility/Department: ARHS Laboratory Services

24 Urine Collection Instructions For Use with Boric Acid

Tests Included: Aldosterone, C-peptide, Glucose, Human Growth Hormone (HGH), Hydroxycorticosteriods (17 OHCS), Hydroxyindoleacetic Acid (5-HIAA), Ketosteriods (17-KS)

Special Patient Preparation: Aldosterone Avoid diuretics, antihypertensives, estrogen, and licorice. Patient should be on restricted sodium diet prior to collection (consult MD). C-peptide Do not collect within 8 hours of last biotin dose. 17 OHCS (Hydroxycorticosteriods) Avoid all medications for 72 hours prior to collection if possible (Consult MD prior to stopping any medications). 5-HIAA (Hydroxyindoleacetic acid) Avoid bananas, avocados, plums, eggplant, tomatoes, plantains, pineapple, and walnuts. Avoid all medications for 72 hours prior to collection if possible (Consult MD prior to stopping any medications). 17-Ketosteriods Avoid all medications for 72 hours prior to collection if possible (Consult MD prior to stopping any medications). Collection Instructions: *Do Not Urinate Directly into Urine Container* CAUTION– The container contains a strong acid. Please read precaution instructions on container.

1. Label urine container with your name and date of birth if not already done. 2. On the first morning when you start collection, urinate as normal in the toilet and discard. 3. Write down the date and time this was done in the space provided below. This is the start of the collection. 4. Collect all urine your pass for the next 24 hours including the first specimen of the second morning. All of the urine passed must be added to the container. If any specimens are missed, the collection must be started over with a new container. 5. Write down the date and time of the last specimen added in the space provided below. This will be the date and time of the first urination on the second morning and is the end of the collection. 6. Take care not to touch the urine with a bowel movement or toilet paper. 7. The urine in the container should be kept cool during the 24 hour collection period. This may be done by putting the container in a pan with ice. 8. Once collection is completed, bring the container and this sheet to the laboratory.

Questions: Cannon Memorial Hospital 828-737-7500 Watauga Medical Center 828-262-4150

Patient Name: Patient Date of Birth: Date/Time Collection Started: Date/Time Collection Ended:

FA-SC-03.01 Printed: 3/14/2011 Page 1 of 1 Effective Date: 3/14/11

Clinical/Anatomic Pathology Laboratory

Facility/Department: ARHS Laboratory Services

24 Urine Collection Instructions For Use with No Preservative

Tests Included: Protein Electrophoresis, Porphyrines, Porphobilinogen (PGB), Immunofixation, Creatinine Clearance, Sodium, Potassium, Total Protein, Creatinine, Chloride, Heavy Metals*, Amylase, Cadmium*, Chromium*, Cobalt*, Copper*, Histamine, Lead*, Lysozyme, Mercury*, Microalbumin, Nickel*, Osmolality, Selenium*, Urea Nitrogen, Uric Acid, Zinc*

Special Patient Preparation: Calcium Patient should be on low calcium diet for 72 hours prior to collection. Avoid antacids, phosphates, diuretics, glucocorticoids, carbonic anhydrase inhibitors, and anticonvulsants (Consult MD before stopping any medications). All Heavy Metals* Avoid seafood and red wine for 72 hours prior to collection Uric Acid Maintain standard diet 24 hours prior to collection.

Collection Instructions: *Do Not Urinate Directly into Urine Container* 1. Label urine container with your name and date of birth if not already done. 2. On the first morning when you start collection, urinate as normal in the toilet and discard. 3. Write down the date and time this was done in the space provided below. This is the start of the collection. 4. Collect all urine your past for the next 24 hours including the first specimen of the second morning. All of the urine passed must be added to the container. If any specimens are missed, the collection must be started over with a new container. 5. Write down the date and time of the last specimen added in the space provided below. This will be the date and time of the first urination on the second morning and is the end of the collection. 6. Take care not to touch the urine with a bowel movement or toilet paper. 7. For all tests ordered other than metals, the urine in the container should be kept cool during the 24 hour collection period. This may be done by putting the container in a pan with ice.

*Collections for metal testing should be maintained at room temperature.

8. Once collection is completed, bring the container and this sheet to the laboratory. Questions: Cannon Memorial Hospital 828-737-7500 Watauga Medical Center 828-262-4150

Patient Name: Patient Date of Birth: _ Date/Time Collection Started:

Date/ Time Collection Ended:

FA-SC-02.01 Printed: 3/14/2011 Page 1 of 1 Effective Date: 3/14/11

Clinical/Anatomic Pathology Laboratory

Facility/Department: ARHS Laboratory Services

24 Urine Collection Instructions For Use with 6N HCL

Tests Included: Calcium, Catecholamines, Citric Acid, Cortisol (Free), Cystine, Homovanillic Acid (HVA), Hydroxyproline, Magnesium, Metanephrines/Normetanephrine, Oxalate, Phosphorus, Vanillylmandelic Acid (VMA), Hydrozyindoleacetic Acid (5-HIAA), Ketosteriods (17-KS)

Special Patient Preparation: 5-HIAA Avoid bananas, avocados, plums, eggplant, tomatoes, plantains, pineapple, and walnuts. Avoid all medications for 72 hours prior to collection if possible (Consult MD 17(Hydroxyindoleacetic-Ketosteriods acid) priorAvoid to all stopping medications any medications). for 72 hours prior to collection if possible (Consult MD prior to Calcium stoppingPatient should any medications). be on a low calcium diet for 72 hours prior to collection. Avoid antacids, phosphates, diuretics, glucocorticoids, carbonic anhydrase inhibitors, and anticonvulsants (Consult MD prior to stopping any medications). Catecholamines Avoid stress and caffeine. Avoid all medications for 14 days prior to collection if possible (Consult MD prior to stopping any medications). Homovanillic Acid Avoid aspirin, disulfiram, reserpine and pyridoxine for 48 hours and Levodopa for 14 days prior to collection (Consult MD prior to stopping any medications). Hydroxyproline(HVA) Patient should be on a collagen-free diet for 24 hours prior to collection. Avoid foods containing gelatin and meats. Avoid all aspirin-containing drugs (Consult MD prior to Metanephrines stoppingAvoid caffeine any medications). before and during collection. Avoid taking monamine oxidase inhibitors for 7 days prior to collection (Consult MD prior to stopping any medications). Oxalate Avoid Vitamin C supplements and Vitamin C enriched foods (fruits, broccoli, tomatoes, peppers, potatoes) for 48 hours prior to collection. Vanillylmandelic Acid Avoid all medications for 72 hours prior to collection if possible. Avoid caffeine, tea, chocolate, fruit (especially bananas) and any vanilla containing substance for 72 hours (VMA) prior to collection (Consult MD prior to stopping any medications). Collection Instructions: *Do Not Urinate Directly into Urine Container* CAUTION– The container contains a strong acid. Please read precaution instructions on container. 1. Label urine container with your name and date of birth if not already done. 2. On the first morning when you start collection, urinate as normal in the toilet and discard. 3. Write down the date and time this was done in the space provided below. This is the start of the collection. 4. Collect all urine your past for the next 24 hours including the first specimen of the second morning. All of the urine passed must be added to the container. If any specimens are missed, the collection must be started over with a new container. 5. Write down the date and time of the last specimen added in the space provided below. This will be the date and time of the first urination on the second morning and is the end of the collection. 6. Take care not to touch the urine with a bowel movement or toilet paper. 7. For all tests ordered other than metals, the urine in the container should be kept cool during the 24 hour collection period. This may be done by putting the container in a pan with ice. 8. Once collection is completed, bring the container and this sheet to the laboratory.

Questions: Cannon Memorial Hospital 828-737-7500 Watauga Medical Center 828-262-4150

Patient Name: Patient Date of Birth: Date/Time Collection Started: Date/Time Collection Ended:

FA-SC-04.01 Printed: 3/14/2011 Page 1 of 1 Effective Date: 3/14/11

Stool Collection

Principle To ensure proper collection from patients for stool specimens, the following instructions are provided to the patient. Two important aspects of collection that must be emphasized are the collection of the specimen before the administration of antimicrobial agents and the prevention of specimen contamination with externally present organisms or normal flora of the body.

Procedure The following collection and transportation guidelines should be followed in order to produce the best specimen for microbiology testing: 1. Apply strict aseptic techniques throughout the procedure. 2. Collect the specimen at the appropriate phase of the disease. 3. Make certain that the specimen is representative of the infectious process and is adequate in quantity for the desired tests to be performed. 4. Collect or place the specimen aseptically in a sterile container. 5. Label and date the container appropriately and complete the requisition with the patient’s clinical history when appropriate. Place the label on the container, not the lid. 6. Specify the specimen site or source. 7. Arrange for immediate transportation of the specimen to the laboratory, preferable within 2 hours of collection.

Outpatients must be given the appropriate sterile collection containers and a biohazard bag for transport of the collection specimen. The patient should also be instructed to label the containers with their name, date of birth and date and time of collection. Para Pak containers should be filled with stool up to the fill line located on the container. Instruct the patient not to overfill.

GI Panel This requires a fresh random stool. Stool specimens should be collected before the patient receives any oil laxative or barium. Specimen must not be contaminated with urine, barium, bismuth or mineral oil. Do not submit in a diaper. Stools collected in sterile containers must be partially transferred to an orange topped Para Pak Enteric container within 2 hours of collection. Submit both samples for testing.

Ova and Parasite Examination This requires a fresh random stool. Stool specimens should be collected before the patient receives any oil laxative or barium. Specimen must not be contaminated with urine, barium, bismuth or mineral oil. Do not submit in a diaper. Stools collected in sterile containers must be transferred to a pink topped and a gray topped Para Pak container (formalin and PVA) within 2 hours of collection.

C. difficile Examination This requires a fresh random stool. Stool specimens should be collected before the patient receives any oil laxative or barium. Specimen must not be contaminated with urine, barium, bismuth or mineral oil. Do not submit in a diaper. Specimen must be refrigerated or frozen within 2 hours of collection.

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Hemoccult This requires a fresh random stool. Stool specimens should be collected before the patient receives any oil laxative or barium. Specimen must not be contaminated with urine, barium, bismuth or mineral oil. Do not submit in a diaper. Hemoccult cards may be submitted for testing with stool already placed in the testing areas.

Test Container to Provide to Patient GI Panel Sterile container and/or Orange Para Pak container

Ova and Parasite Sterile container or Pink and Grey Para Pak container C. difficile Sterile container Hemoccult Sterile container

Notes 1. No more than 2 bacteriology specimens and 3 parasitology specimens per patient are recommended. 2. With the exception of Clostridium difficile, enteric cultures should not be performed after 3 days of hospitalization. 3. Parasitology exams should not be done after 4 days of hospitalization. 4. Physicians are encouraged to increase testing for Clostridium difficile in appropriate clinical settings (diarrhea and prior antibiotic administration).

ORIGINAL AUTHOR: Wendy R. Williams ORIGINAL EFFECTIVE DATE: 12/30/2010 Stool Collection

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Clinical/Anatomic Pathology Laboratory Facility/Department: ARHS Laboratory Services

Outpatient Stool Collection Instructions

Your physician has ordered the tests marked below. Please follow the collection instructions below for each test ordered. Bring collected samples back to an ARHS Laboratory or the Outpatient Imaging and Laboratory Center located at 1200 State Farm Road in Boone. The Outpatient Imaging and Laboratory Center is open from 7:00am to 5:00pm Monday through Friday. Watauga Medical Center and Cannon Memorial Hospital Laboratories can accept samples 24 hours a day, 7 days a week.

□ GI Panel Container Color: Orange/White □ Ova and Parasite (O&P) Container Color: Pink/Gray

Collect stool specimen in a clean, dry container. Do NOT mix urine with the stool sample. Open the Para Pak vial(s). Using the spoon attached to the lid of the vial, place small scoopfuls of stool from areas which appear bloody, slimy, or watery into the vial until the contents reach the red line on the label that reads “Add Specimen to this Line.” DO NOT OVERFILL. If the stool is liquid, carefully pour into the vial until contents reach the red line. If the stool is solid, add portions from the middle and ends to the vial. Replace lid and close tightly. Shake the vial vigorously until the contents are mixed. Label the vial with your name, date of birth, and date and time of collection. Repeat if more than one vial is provided. The sample(s) may remain at room temperature and must be delivered to the laboratory within 24 hours of collection.

*If more than one O&P is ordered, do not collect more than one set of vials per day.

□ C. difficile Toxin/Stool for WBCs/ Container Color: White/Clear Reducing Substances/Fecal Fat

Collect stool specimen in a clean, dry container. Do NOT mix urine with the stool sample. If not collected in the sterile container that was provided, transfer the stool specimen to the sterile container. Label container with your name, date of birth, and date and time of collection. If sample cannot be delivered to the laboratory within an hour, sample must be refrigerated. The sample must be delivered to the laboratory within 24 hours.

FA-SC-01.01 Printed: 3/14/2011 Page 1 of 1 Effective Date: 3/14/11

Swab Collection for Microbiology

Principle To ensure proper collection of cultures requiring swab collection, the following procedure is used. Two important aspects of collection that must be emphasized are the collection of the specimen before the administration of antimicrobial agents and the prevention of specimen contamination with externally present organisms or normal flora of the body.

Procedure The following collection and transportation guidelines should be followed in order to produce the best specimen for microbiology testing: 1. Apply strict aseptic techniques throughout the procedure. 2. Collect the specimen at the appropriate phase of the disease. 3. Make certain that the specimen is representative of the infectious process and is adequate in quantity for the desired tests to be performed. 4. Collect or place the specimen aseptically in an appropriate container. 5. Label with two patient identifiers and date and initials of collector. Place the label on the container, not the lid and complete the requisition with the patient’s clinical history when appropriate. 6. Specify the specimen site or source. 7. Arrange for immediate transportation of the specimen to the laboratory, preferable within 2 hours of collection. 8. Refer to the Swab Selection Chart below for collecting a particular specimen for microbiological analysis 9. Swabs are not recommended for collection of sample from significant infectious process. 10. Swabs must only be touched to the area of collection to avoid contamination.

Swab Type and Usage Name Color Storage/ Purpose Testing Site Transport Method UTM-RT Purple top Refrigerate 2-8° Viruses Culture All Pink media (including Herpes), Chlamydia (including child abuse) & Mycoplasma Copan Red Top/ Room Aerobic bacteria Culture All CultureSwab Sponge Temperature (red top) BBL Green Top/ Room Nasopharyngeal Culture Nasopharyngeal CultureSwab Sponge Temperature Cultures (green top) fFN White top Room Fetal Fibronectin Immunoassay Posterior formix transport/ Temperature Vaginal swab Cepheid GC Pink print Room Chlamydia/GC DNA Vaginal/Cervical only (Female) Temperature Genprobe Blue print Room Chlamydia/GC DNA Urethral only (Male) Temperature BBL Vacutainer Glass Room Anaerobic and Culture Anaerobic sites Anaerobic collection Temperature aerobic bacteria Collector kit

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Steps for collecting a swab specimen (all except BBL Vacutainer Anaerobic Collector): 1. Check for expiration date of swab. 2. Peel open the sterile package if required. 3. Remove swab from packaging. 4. Collect sample. 5. Remove lid to transport container and place swab inside. Close container. 6. Label properly with patient’s name, date of birth, date and time of collection and collector’s initials. 7. Transport to laboratory.

Steps for collecting anaerobic specimen (BBL Vacutainer Anaerobic Collector): 1. Check for expiration date of swab. 2. Peel open the sterile package and remove plunger with sterile swab attached. 3. Collect sample. 4. Replace swab through holes and into inner tube. 5. While holding at a 45° angle, press down on disc portion of plastic plunger forcing the inner tube into the outer tube. 6. Gently rotate tube in a swirling motion to facilitate mixing of air in inner tube and hydrogen in outer tube. 7. Label properly with patient’s name, date of birth, date and time of collection and collector’s initials. 8. Transport to laboratory.

Ear Using a sterile swab, gently enter the ear canal, rotate swab before removing. Avoid contact with other areas of the ear.

Eye Obtain purulent material from the conjunctiva or cornea. Avoid contact with other areas of the eye.

Nasal Gently insert swab into nostril until resistance is met (less than 1 inch). Rotate the swab then remove it.

Nasopharyngeal Pass a swab gently through the nostril until it passes the nasopharyngeal wall. Rotate the swab then remove it.

Throat The swab should be taken from the back of the throat. Keep swab free of saliva; do not touch teeth or tongue. If the isolation of C. diphtheriae is required, please contact the laboratory so that the appropriate transport media/container will be used. If testing for N. gonorrhoeae is desired, please inform the laboratory on the requisition so that the appropriate media can be inoculated.

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Wound– Deep Most often these are specimens from surgical sites; less frequently puncture wounds and some decubiti may contain anaerobes. These specimens are suitable for aerobe/anaerobe cultures.

Wound – Surface Debride area if necessary. Care should be taken not to touch surrounding skin surface. This is suitable for aerobic culture only.

Sterile Body Fluids Body fluids for culture should be placed in a sterile container. Do not put fluid into a swab.

ORIGINAL AUTHOR: Wendy R. Williams ORIGINAL EFFECTIVE DATE: 12/30/2010 Swab Collection for Microbiology

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Therapeutic Drug Monitoring

Recommended collection times for common therapeutic medications:

Peak Trough Therapeutic Drug (time after end of (time before next Range infusion/dose) dose) Aminoglycosides – IM – 1-1.5 hours Peak: 4-10 < 30 min Conventional dosing IV – 30 min Trough: <2.0 Aminoglycosides – Peak: 4-10 N/A <90 min Extended interval dosing Trough: <2.0 Peak: 30-40 Vancomycin IV - 60 min < 30 min Trough: 5-20 Peak: 10-20 Chloramphenicol IV/PO – 2 hours < 30 min Trough: 5-20 Carbamazepine N/A < 30 min 4-12 Phenobarbital N/A < 30 min 10-40 Phenytoin N/A < 30 min 10-20 Valproic Acid N/A < 30 min 50-100 Digoxin N/A < 30 min 0.8-2.0 Lithium N/A < 30 min 0.6-1.2 Theophylline N/A < 30 min 10-20

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ABO & Rh

Lab: WMC/CMH Transfusion Service Specimen: Whole Blood Use: To determine blood type Availability: 24 Hours Tube: EDTA and Rh. TAT: Routine:, 4 Hours (lavender/pink) Limitations: Certain clinical Stat, 1 Hour Minimum Volume: 5ml conditions may interfere with Collection: Routine venipuncture typing. Causes For Rejection: Improper labeling of sample, wrong sample type, hemolysis. Acetaminophen

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: monitor therapy, evaluate Availability: 24 Hours Tube: SST, Plain red or Green (Li Hep) toxicity TAT: Routine, 4 hours Minimum Volume: 2 ml Additional info: hepatic toxicity STAT, 1 hour Collection: Routine venipuncture may appear 3-5 days after Causes For Rejection: Improper labeling of sample, ingestion of a toxic dose. wrong sample type, hemolysis.

Albumin

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: evaluation of nutritional Availability: 24 Hours Tube: SST, Plain red or Green (Li hep.) status, blood osmotic pressure, TAT: Routine, 4 hours Minimum Volume: 2 ml renal disease with proteinuria, and other chronic diseases. STAT, 1 hour Collection: Routine venipuncture Causes for rejection: Improper labeling, wrong tube, Limitations: hemolysis and high gross hemolysis, contamination with iv fluids, or triglycerides can interfere with bacteria. testing. Alcohol (ETOH, Ethanol)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Storage: transport sample to Availability: 24 hours Tube: SST, Plain red or Green (Li hep.) laboratory immediately. Keep TAT: Routine, 4 hours Minimum volume: 2 ml tightly closed and store at 4˚C if STAT, 1 hour Collection: Routine venipuncture. Do not clean testing is delayed. venipuncture site with alcohol. Transport specimen to Use: evaluation of apparently laboratory immediately. intoxicated or comatose Causes for rejection: Collected from site cleaned patients. with alcohol.

Alkaline Phosphatase (Alk Phos)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Evaluation of liver function Availability: 24 Hours Tube: SST, Plain red or Green (Li hep.) and bone disease. TAT: Routine, 4 hours Minimum Volume: 2 ml Limitations: Bilirubin, STAT, 1 hour Collection: Routine venipuncture Methotrexate, & Nitrofurantoin Causes For Rejection: Mislabeled tube, wrong tube, can interfere with testing. gross hemolysis, contamination With IV Fluids, or bacteria.

ALT (SGPT)

Lab: WMC/CMH Chemistry Specimen: Serum or heparin zed plasma Use: evaluation of liver function. Availability: 24 Hours Tube: SST, Plain red Or Green (Li hep.) Limitations: ALT is less TAT: Routine, 4 hours Minimum Volume: 2 ml sensitive to alcoholic liver disease than AST. High total protein can STAT, 1 hour Collection: Routine Venipuncture interfere with testing. Causes For Rejection: Mislabeled sample, wrong tube, gross hemolysis, or contamination with IV fluids or bacteria. 24 ARHS-SC-19.03 6/18/2019 8:16 AM

AmniSure

Lab: WMC/CMH Specimen: Vaginal Swab Use: evaluation for rupture Microbiology Collection: non-speculum collection of fetal membranes Limitations: Gross hemolysis may Availability: 24 Hours Causes For Rejection: Mislabeled sample, wrong impair tests ability to detect PAMG-1 swab, specimen not mixed with solvent vial within 1 TAT: STAT, 30 hour minute following collection

Ammonia, Venous

Lab: WMC/CMH Chemistry Specimen: Heparinized plasma Use: Elevated in liver disease, Availability: 24 hours Tube: Green (Li hep.) inborn errors of metabolism, TAT: Routine, 4 hours Minimum volume: 2 ml indicated in neonates with STAT, 1 hour Collection: Routine venipuncture. Fill tube neurological deterioration. completely; keep tightly stoppered; place in an ice slurry; spin and separate within 15 minutes of collection. If testing is delayed place sample in refrigerator. Sample may be used up to 3 hours after collection if collected on ice, centrifuged immediately and kept on ice or refrigerated. Causes for rejection: Sample not on ice, wrong anticoagulant, hemolyzed specimen, mislabeled sample. Antibody ID (Panel)

Lab: WMC Transfusion Service Specimen: Whole blood Use: To identify clinically Availability: As needed Tube: EDTA significant unexpected TAT: Routine, 4 Hours (lavender/pink) antibodies detected in a Stat, 1 Hour Minimum Volume: 10ml positive antibody screen. Limitations: Antibodies to high or Collection: Routine venipuncture. Labeling: must low incidence antigens may Note: This test cannot be ordered have complete patient identification, including full require referral to a reference lab. name and MR number. individually. It is performed only as a A delay in providing compatible reflex to a positive antibody screen. Causes for rejection: Improper labeling of sample, blood may occur. wrong sample type, hemolysis.

Antibody Screen

Lab: WMC/CMH Transfusion Service Specimen: Whole blood Use: To detect unexpected Availability: As needed Tube: EDTA clinically significant antibodies. TAT: Stat: 1 Hour (lavender/pink) Routine: 4 Hours Minimum Volume: 5ml Collection: Routine venipuncture Causes for rejection: Improper labeling of sample, wrong sample type, hemolysis.

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Antibody Titer

Lab: WMC Transfusion Service Specimen: Whole blood Use: To determine the titer of Availability: As needed Tube: EDTA clinically significant identified TAT: Stat: 1 Hour (lavender/pink) antibodies. Routine: 4 Hours Minimum Volume: 5ml Collection: Routine venipuncture Causes for rejection: Improper labeling of sample, wrong sample type, hemolysis. Aspirations Of Various Sites for Cytopathology

Lab: Cytopathology Specimen: Aspirates from thyroid, breast, lymph Use: To establish the presence Availability: Mon. – Fri. 5:00 am – nodes and other palatable masses. of primary or metastatic 5:00 pm Minimum volume: Collect as many slides as a neoplasm. To aid in the TAT: 24-48 hours. specimen will allow up to 4. Aspirate remaining diagnosis of infection. aspirate in Cytolyt® solution pull 5 ml of solution back

Special instructions: please indicate on into syringe and wash out remaining aspirate. Submit requisition if patient has a history of to cytopathology. carcinoma. Container: Syringes are available from central supply. Cytolyt available in surgery suite or Storage: If collected after hours place in Cytopathology lab. Pathology rack in refrigerator in the main Collection: Label slides w/patient name. Place pea lab. size aspirate on slide and spread evenly. Let slides air dry. Causes for rejection: Improper fixation. Unlabeled slides or specimen. Coverslips on smears.

AST

Lab: WMC/CMH Chemistry Specimen: Serum , heparinized plasma Use: Increased AST activity Availability: 24 hours Tube: SST, Plain red or Green (Li hep.) commonly follows myocardial TAT: Routine, 4 hours Minimum volume: 2 ml infarction, pulmonary emboli, Stat, 1 hour Collection: Routine venipuncture skeletal muscle trauma, Causes for rejection: Mislabeled sample, wrong alcoholic cirrhosis, viral tube, gross hemolysis, or contamination with IV hepatitis, and drug-induced fluids or bacteria. hepatitis.

Basic Metabolic Panel (BMP)

Lab: WMC/CMH Chemistry Specimen: Serum , heparinized plasma Use: to evaluate metabolic Availability: 24 hours Tube: SST, Plain red or Green (Li hep.) status, fluid/electrolyte TAT: Routine, 4 hours Minimum volume: 5 ml balance. Stat, 1 hour Collection: Routine venipuncture CMH ED - 44 min Causes for rejection: Gross hemolysis, improper Test Includes: glucose, BUN, creatinine, labeling, contamination with IV fluids, serum/plasma sodium, potassium, chloride, CO2, calcium not removed from cells within 2 hours, wrong anticoagulant.

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Bilirubin, Direct

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Liver function test, useful in Availability: 24 hours Tube: SST, plain red or Green (Li hep) diagnosing and monitoring TAT: Routine, 4 hours Minimum volume: 2 ml hepatobiliary obstruction Stat, 1 hour Collection: Routine venipuncture Causes for rejection: Gross hemolysis, prolonged exposure to light.

Bilirubin, Neonatal

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Increased in hemolytic Availability: 24 hours Tube: SST, Plain red or Green (Li hep) disease of the newborn. TAT: Routine, 4 hours Minimum volume: 2 ml Stat, 1 hour Collection: Heelstick Causes for rejection: Gross hemolysis, prolonged exposure to light.

Bilirubin, Total

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: To evaluate hepatic Availability: 24 hours Tube: SST, Plain red, or Green (Li hep) function TAT: Routine, 4 hours Minimum volume: 2 ml Stat, 1 hour Collection: Routine venipuncture Causes for rejection: Gross hemolysis, prolonged exposure to light.

Blood Gases, Arterial (with or without CO-Oximetry analysis)

Lab: CMH Lab/WMC Cardiopulmonary lab Specimen: arterial blood Use: evaluate respiratory function Availability: 24 hours Container: heparinized syringe and acid/base balance. TAT: Routine, 4 hours Minimum volume: 1ml Stat, 1 hour Collection: gently agitate syringe to mix the heparin. Label with the patient’s name and date and deliver Test includes: pH, PCO2, PO2, immediately to the cardiopulmonary lab. bicarbonate, base excess, total CO2, O2, Causes for rejection: specimen not aerobic, not (total hgb, CO saturation, methhgb, and properly labeled, blood clots, air bubbles, insufficient vol %02, - only measured with co-ox sample. order).

Blood Gases, Venous

Lab: CMH Lab/WMC Cardiopulmonary lab Specimen: Venous blood Use: Evaluate respiratory Availability: 24 hours Container: heparinized syringe function, acid/base balance and TAT: Routine, 4 hours Minimum volume: 1ml estimate cardiac output Stat, 1 hour Collection: gently agitate syringe to mix the heparin. Label with the patient’s name and date and deliver Test includes: pH, pCO2, pO2, O2 immediately to the cardiopulmonary lab. saturation Causes for rejection: specimen not aerobic, not properly labeled, blood clots, air bubbles, insufficient sample.

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Blood Gases, Umbilical Cord Blood

Lab: CMH Lab/WMC Cardiopulmonary lab Specimen: Umbilical cord blood Use: To evaluate respiratory Availability: 24 hours Minimum volume: 0.3 ml status and acid/base balance of TAT: Routine, 4 hours Collection: gently agitate syringe to mix the heparin. the neonate. Stat, 1 hour Label with patient’s name and date and deliver to the cardiopulmonary lab immediately. Causes for rejection: specimen not aerobic, not properly labeled, blood clots, air bubbles, and insufficient sample.

Blood Urea Nitrogen (BUN)

Lab: WMC/CMH Clinical chemistry Specimen: Serum , heparinized plasma Use: Evaluate renal function and Availability: 24 hours Tube: SST, Plain red or Green top (Li hep) protein metabolism; to monitor TAT: Routine, 4 hours Minimum Volume: 2mL effectiveness of kidney dialysis STAT, 1 hour Collection: Routine venipuncture or capillary Additional Information: collection Elevated BUN levels occur in Causes For Rejection: Improper labeling, gross chronic glomerulonephritis, hemolysis. pyelonephritis, and other causes of chronic renal disease; muscle wasting may cause increase as well. Low BUN levels occur in normal pregnancy, decreased protein intake, with IV fluids, some antibiotics, and in some instances of liver disease.

BNP see (NT-proBNP)

Body Cavity Fluid Cytopathology

Lab: Cytopathology Specimen: Fresh body cavity fluid. Use: to establish the presence of Availability: Mon.-Fri., 5:00 am – 5:00 pm Container: Clean 50 ml container or collection primary metastatic neoplasms or TAT: 24-48 hours device uses for centesis. microorganisms. Limitations: Minimum volume: 50ml Lack of diagnostic cellular Collection: Gently agitate the bag as fluid is material or clotted material. collected to mix the heparin with the fluid. Label Additional info: Special stains with patient’s name, hospital number, room number, and and immunohistochemistries date. Deliver immediately to cytopathology laboratory. will be performed when Special instructions: Fluids should be submitted appropriate. fresh, unfixed, and heparinized. To provide well preserved, representative, diagnostic material. Add 3 units of heparin per anticipated 1ml of fluid (each 1ml of fluid contains 1000 units). Include pertinent clinical information. After hours store in the Pathology rack in the refrigerator in main lab.

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Body Fluid Cell Count see (Cell Count Body Fluid)

Body Fluid Chemistries

Lab: WMC Chemistry Specimen: Body fluid (synovial, ascetic, pleural, or Availability: 24 hours pericardial) TAT: Routine, 4 hours Tube: Plain red, sterile container, Green (Li Hep.) STAT, 1 hour Minimum volume: 5ml Collection: usual aseptic collection. Tube must be Test Includes: Albumin, Amylase, properly labeled. Cholesterol, Creatinine, Glucose, LDH, Causes for rejection: mislabeled specimen, wrong Total Protein, Triglyceride tube

Body Fluid pH and Occult Blood

Lab: WMC Urinalysis Specimen: Body fluid (synovial, ascetic, pleural, or Availability: 24 hours pericardial) TAT: Routine, 4 hours Tube: Plain red, or in clean specimen container - or STAT, 1 hour request Gastroccult card from lab for occult blood portion. Collection: usual aseptic collection. Tube must be properly labeled. Causes for rejection: mislabeled specimen

Bone Marrow (Aspirate/Biopsy)

Lab: WMC Hematology/surgical Specimen: Bone marrow aspirate and/or biopsy Use: To evaluate the bone pathology Minimum volume: 2ml of aspirate, 4cm core of marrow morphology; Availability: Mon.-Fri. 8:00am-5:00pm; marrow hematopoesis, myelopoiesis, after hours contact the pathologist Collection: Slides of aspirated marrow and touch myeloid/erythoid ratio, TAT: 24-48 hours preps of biopsy are made at the bedside by a megakaryocyte, cellularity, and technologist. The biopsy core is placed in B Plus marrow iron stores. Also to Additional info: Clinicians perform all solution and the clot in a separate container of B Plus evaluate platelet dependent biopsies. Call the clinical laboratory for solution. Both containers must be properly clotting dysfunction, and anemia. materials and assistance. labeled with the patient’s information, date and time Marrow culture can contribute to specimen was put in the solution. a study of fever of undetermined Causes for rejection: No marrow obtained origin and possible systemic infection, in particular histoplasmosis and TB. Can also establish presence of, classify, and serve as a follow up of neoplasia.

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Bronchial Brushing Cytopathology

Lab: Cytopathology Specimen: Brush from area of lesion obtained by Use: To establish the presence Availability: Mon.-Fri., 5:00 am-5:00 pm physician. of primary or metastatic TAT: 24-48 hours Container: Cytolyt® solution vial. neoplasms. To aid in the Collection: Place specimen brush in Cytolyt® solution. diagnosis of respiratory infections Make sure plastic sheath is removed. Label container with herpes virus, and submit all specimens to Cytopathology. cytomegalovirus, measles virus, Causes for rejection: Improper fixation. Plastic aspergillus, coccidioides, sheath left on brush. cryptococcus, histoplasma, blastomyces, phycomycetes, pneumecystis carinii, strongyloides, echinoccus, and paragonimus. Aid in diagnosis of lipoid pneumonia, sarcoidosis, hemosiderosis, and asbestosis. Limitations: Allowing brush to dry before placing in Cytolyt® will render specimen unsatisfactory.

Bronchial Washing Cytopathology

Lab: Cytopathology Specimen: Obtained by physician. Use: To establish the presence of Availability: Mon.-Fri., 5:00am- Container: Cell collection cup on bronchoscopy primary or metastatic neoplasms. 5:00 pm tray. To aid in the diagnosis of TAT: 24-48 hours Minimum volume: At least 2 ml of fresh unfixed respiratory infections with Herpes material. virus, cytomegalovirus, Measles

Special Instructions: Include pertinent Collection: Label bottle with patient name, hospital virus, Aspergillus, Coccidoides, clinical information, ie: previous number, room number and date. Submit the specimen to Cryptococcus, Histoplasma, carcinomas, on requisition. Indicate need Cytopathology. Be sure to indicate from which side and Blastomyces, Phycomycetes, to evaluate for Pneumocystis carinii or lobe the specimen was obtained. After hours place Pneumocystis carinii, fungal disease. specimens in the Pathology rack in the refrigerator in Strongyloides, Lipoid main lab. pneumonitis, Sarcoidosis, Causes for rejection: improper labeling or fixation Hemosiderosis, Asbestosis, and Alveolar proteninosis. Buprenorphine

Lab: WMC/CMH Chemistry Specimen: Freshly voided, untreated urine. Use: Rapid immunoassay test Availability: 24 hours Container: Urine sample cup. to detect a drug of abuse in Volume: 10 ml urine. TAT: Routine, 4 hours Stat, 1 hour Storage: Refrigerate up to 24 hours. Note: The length of time Cause for rejection: Improperly labeled following drug use for which a positive result may occur is Limitations: Adulterants added to urine specimen may dependent on several factors produce erroneous results. Substances and/or factors including the frequency and may interfere with the test and cause false results. Drug amount of usage, metabolic rate, levels below the analyte cut off may not be detected excretion rate, drug half- life and the user's age, weight, activity and diet. For quantitation or confirmation a GC/MS should be ordered.

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CA-125

Lab: WMC Chemistry Specimen: Serum or heparinized plasma Use: To monitor patients with Availability: 24 hours Tube: SST, Plain red or Green (Li hep) various types of malignancies, TAT: Routine, 4 hours Minimum Volume: 5 ml evaluate response to therapies, STAT, 1 hour Collection: Routine Venipuncture and as a possible indicator of Causes For Rejection: Gross hemolysis, improper recurrence and prognosis. labeling.

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Calcium

Lab: WMC/CMH Chemistry Specimen: serum or heparinized plasma Use: Diagnosis of endocrine & Availability: 24 hours Tube: SST, Plain red or green top (Li hep) metabolic diseases Limitations: TAT: Routine, 4 hours Minimum Volume: 2 mL Sodium citrate, EDTA, and STAT, 1 hour Collection: Routine venipuncture sodium fluoride interfere. Gross Causes For Rejection: Specimen improperly hemolysis falsely elevates labeled, improper tube, gross hemolysis, results. Additional contamination with IV fluids. Information: Serum calcium levels will by 0.4-0.5 mg/dL within 30 minutes of a patient changing from upright to a supine position.

Carbamazepine (Tegretol)

Lab: WMC Chemistry Specimen: Serum or heparinized plasma Use: Carbamazepine has Availability: 24 hours Tube: SST, plain red, Green (Li hep) powerful antiepileptic properties TAT: Routine, 4 hours Minimum Volume: 2 mL and is effective alone or with other STAT, 1 hour Collection: Routine venipuncture; Peak level: 3 antiepileptic hours after a dose drugs in partial seizures. Trough: immediately prior to next dose Additional Information: Causes for Rejection: Gross hemolysis, improper Leukopenia may be dose related, labeling and necessitates stopping the drug if the absolute neutrophil count falls to <1000/mm3. Hyponatremia may occur, especially in older patients. Patients in the first month of pregnancy are at an increased risk of neural tube defects. Carbamazepine may interfere with the actions of oral contraceptives, oral anticoagulants and theophylline.

Carcinoembryonic Antigen (CEA)

Lab: WMC Chemistry Specimen: Serum Tube: Use: To monitor patients with Availability: 24 hours SST or plain red Minimum various types of malignancies, TAT: Routine, 4 hours Volume: 5 mL evaluate response to therapies, Stat, 1 hour Collection: Routine venipuncture and as a possible indicator of Causes for Rejection: gross hemolysis, improper recurrence and prognosis. labeling Limitation: CEA levels are elevated in smokers; CEA is not a screening test for occult cancer.

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CBC / CBC With Auto Diff + Platelet (Plt)

Lab: WMC/CMH Hematology Specimen: Whole blood Tube: Use: To diagnose and monitor Availability: 24 hours EDTA (lavender) only Minimum disease states TAT: Routine: 2 hours Volume: 2 mL Collection: Routine Limitations: Age and Sex Stat: 1 hour venipuncture dependent CMH ED: 30 min Causes for Rejection: Wrong sample type, clotted sample, gross hemolysis, improper labeling, tube not filled to minimum volume.

Cell Count Body Fluids

Lab: WMC Hematology Specimen: Body fluid (synovial, ascitic, pleural, or Limitation: Traumatic (bloody) Availability: 24 hours pericardial) tap may make interpretation TAT: Routine, 2 hours Tube: EDTA (lavender) difficult. Clotted sample will Stat, 1 hour Minimum Volume: 1 mL permit only a qualitative Collection: Usual aseptic collection, DO NOT STORE: examination. TRANSPORT IMMEDIATELY TO THE LABORATORY Causes for Rejection: Clotted specimen, improper labeling, specimens not received in proper tube.

Cell Count, CSF ( CSF - Cell Count )

Lab: WMC Hematology Specimen: Spinal Fluid Use: To aid in diagnosis of Availability: 24 hours daily Container: Sterile plastic tube provided in lumbar kit infections of meninges, TAT: Routine, 2 hours Minimum Volume: 1 mL CSF subarachnoid hemorrhage, Stat, 1 hour Collection: Normal lumbar puncture using malignancies of central nervous established aseptic technique - performed only by system and demyelinating *CSF specimens from patients with physicians disorders suspected Creutzfeldt-Jakob Disease (CJD) Storage: CSF must be refrigerated if testing is not will be sent to the NC State Lab for testing. performed immediately. The sample will not be opened prior to shipping.

Cerebrospinal Fluid (CSF) Cytopathology

Lab: Cytopathology Specimen: Fresh fluid. Use: To establish the presence of Availability: Mon.-Fri., 5:00am - Container: Sterile tube from lumbar puncture tray. primary or metastatic neoplasms. 5:00 pm Minimum Volume: At least 1 ml. Also to establish the presence of TAT: 24-48 hours Collection: Label container with patient’s name, microorganisms such as hospital number, room number, date, and time of Cryptococcus neoformans. collection. Submit specimen to Cytopathology, After hours, place in Pathology rack in main lab refrigerator. *CSF specimens from patients with suspected Creutzfeldt-Jakob Disease (CJD) No anticoagulant or fixative is to be added. will be sent to the NC State Lab for testing. Causes for Rejection: Improper fixation The sample will not be opened prior to shipping.

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Comprehensive Metabolic Panel (CMP)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Typically used as a basic Availability: 24 hours Tube: SST, Plain red or Green (Li hep) screening panel for nutritional TAT: Routine, 4 hours Minimum Volume: 5 mL and metabolic purposes. STAT, 1 hour Collection: Routine venipuncture Sometimes used to monitor CMH ED - 44 min Causes for Rejection: Gross hemolysis, improper hyperalimentation therapy. labeling, contamination with IV fluids, serum/plasma Test Includes: glucose, BUN, calcium, not separated from cells within 2 hours of collection, creatinine, total protein, total bilirubin, wrong anticoagulant. alkaline phosphatase, AST, ALT, sodium, potassium, chloride, CO2

Chloride

Lab: WMC/CMH Chemistry Specimen: Serum or Heparinized plasma Use: Evaluation of Availability: 24 hours Tube: SST, Plain red, or Green(Li hep) fluid/electrolyte balance TAT: Routine, 4 hours Minimum Volume: 2 mL Additional Information: Chloride Stat, 1 hour Collection: Routine venipuncture is increased in dehydration, renal Causes for Rejection: Improper labeling, tubular acidosis, and excessive contamination with IV fluids. infusion of normal saline. It is decreased in over hydration, CHF, vomiting, chronic respiratory acidosis, and in some cases of diuretic therapy. Limitation: Bromide and Iodide from therapeutic drugs can interfere.

Cholesterol

Lab: WMC/CMH Chemistry Specimen: Serum or Heparinized plasma Use: Evaluation of lipid status, Availability: 24 hours Tube: SST, Plain red, or Green (Li hep) nutritional, and metabolic TAT: Routine, 4 hours Minimum Volume: 2 mL disorders. Collection: Routine venipuncture Additional Information: Serum Causes for Rejection: Improper labeling cholesterol concentration is the consequence of the relative role of cholesterol synthesis, clearance, and dietary intake.

Cholesterol, HDL

Lab: WMC/CMH Chemistry Specimen: Serum or Heparinized plasma Use: Helpful in determining the Availability: 24 hours Tube: SST, Plain red, or Green (Li hep) risk of coronary heart disease. TAT: Routine, 4 hours Minimum Volume: 2 mL Limitation: Ascorbic acid, Collection: Routine venipuncture dipyrone, dopamine, and N- Causes for Rejection: Improper labeling acetyl cysteine can interfere.

34 ARHS-SC-19.03 6/18/2019 8:16 AM

Clostridium difficile (C. diff) Toxin Assay

Lab: CMH/WMC Microbiology Specimen: Stool, fresh (< 1 hour old) Use: To aid in the diagnosis of Availability: 24 hours Container: Sterile container antibiotic associated diarrhea. TAT: 24 hours (Outpatient) Minimum Volume: 5 mL liquid or walnut size Additional Information: 3 hours (Inpatient) unformed stool Antibiotic associated diarrhea has

Collection: Collect stool specimen in a clean, dry been shown to result from

Testing performed at WMC/CMH container. Specimen must be refrigerated if testing the toxins produced by C. difficile. It cannot be performed immediately. is recognized that this disease can Causes for Rejection: Improper storage, mislabeled be caused by virtually any antibiotic. specimen, specimen contaminated with urine, specimen The detection of the toxin, rather contaminating outside of container, formed stool, than culture of the organism, is preserved specimen. important in the diagnosis of the disease.

CK (Creatinine Kinase) (CPK)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: To test for occurrence of Availability: 24 hours Tube: SST, Plain red, or Green (Li hep) myocardial infarction, and for TAT: Routine, 4 hours Minimum Volume: 2 mL skeletal muscle damage. CK levels STAT, 1 hour Collection: Routine venipuncture are elevated in muscular Causes for Rejection: Hemolysis, wrong sample dystrophy, muscle stress or type, improper labeling. trauma, and myocarditis. The CKMB test will be run if the CK is found to be greater than 75 IU/L if performed at WMC. Limitation: IM injections increase serum CK activity. CK is elevated following exercise and normal at onset of AMI unless patient has been exercising.

CKMB

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Diagnosis of AMI, and to Availability: 24 hours Tube: SST, Plain red, Green (Li hep) evaluate the extent of AMI TAT: Routine, 4 hours Minimum Volume: 2 mL Additional Information: CKMB STAT, 1 hour Collection: Routine venipuncture increases have been reported with Causes for Rejection: Hemolysis, wrong sample entities which cause damage to type, improper labeling the myocardium (eg: myocarditis, malignant hyperthermia, etc.) however CKMB does not generally abruptly rise and fall in such no- acute MI settings as it does in AMI. Limitation: The diagnosis of AMI should not be based solely on MB isoenzyme, but rather should be supported by other clinical findings.

35 ARHS-SC-19.03 6/18/2019 8:16 AM

Cord Blood

Lab: WMC Transfusion Service Specimen: Cord blood Use: To determine the blood Availability: 8:00am-4:30pm Daily Tube: EDTA (lavender) group and Rh of the newborn, TAT: 2-4 Hours Minimum Volume: 4 mL in each tube and to evaluate the potential for Collection: The physician or designee collects cord HDN. blood at the time of delivery. Label with the baby's Additional Information: An name, mother's name, date and time of collection, and eluate is preformed on the cord blood if the DAT is positive, to initials of the collector. Use the green cord blood determine if the mother’s label for this purpose. antibodies are bound to the Causes for Rejection: Improper labeling baby’s cells.

C - Reactive Protein, Quantitative

Lab: WMC Chemistry Specimen: Serum or heparinized plasma Use: Can be used to test for Availability: 24 hr TAT: Tube: SST, Plain Red, Green (Li hep) inflammatory diseases, Routine, 4 hours Minimum Volume: 1ml serum Collection: infections, and neoplastic Stat, 1 hour Routine Venipuncture diseases. Causes for rejection: Gross hemolysis or lipemia, mislabeled specimen

Creatinine, Blood

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Evaluation of renal function. Availability: 24 hours Tube: SST, Plain red, or Green (Li hep) Levels are elevated in renal TAT: Routine, 4 hours Minimum Volume: 2 mL damage and/or disease that STAT, 1 hour Collection: Routine venipuncture cause a decrease in glomerular Causes for Rejection: Wrong sample type, improper filtration. Limitation: Avoid the labeling, gross hemolysis, contamination with IV fluids use of oxalate/fluoride, citrate, and EDTA anticoagulants. Lidocaine and dipyrone interfere.

36 ARHS-SC-19.03 6/18/2019 8:16 AM

Creatinine Clearance

Lab: WMC/CMH Chemistry Specimen: Serum/heparinized plasma and aliquot of Use: To evaluate renal function, Availability: 24 hours 24 hour urine collection estimate glomerular filtration rate, TAT: Routine, 4 hours Tube: SST, Plain red or Green (Li hep) evaluate renal function in small, or Urine: 24 hour urine container without preservative wasted subjects, and Minimum Volume: Serum/plasma - 2 mL to follow progression of renal Urine - 10 mL aliquot of 24 hour collection disease. Collection: Serum/plasma- routine venipuncture; Urine- Limitation: Exercise may cause refer to appropriate 24-hour urine collection form for increased clearance. The collection instructions. Container must be labeled with the glomerular filtration rate is patient’s name, date of birth. date and time collection substantially increased in started and completed. pregnancy. Ascorbic acid, ketone bodies, hydration, Causes for Rejection: No blood creatinine collected, numerous cephalosporins, and improperly labeled specimen. glucose might influence creatinine determinations.

Creatinine, Urine

Lab: WMC/CMH Chemistry Specimen: Urine, 24 hour collection Use: Renal function test when Availability: 24 hours Container: Clean plastic 24 hour urine container, no used as part of creatinine TAT: Routine, 4 hours preservative clearance. Minimum Volume: 10 mL aliquot of 24 hour urine Additional Information: Urine specimen creatinine is not generally Collection: Instruct patient to void and discard specimen ordered alone. Creatinine at 8:00a and then collect all urine for 24 hours including clearance, which requires a serum the last specimen at 8:00a at the end of the collection creatinine level, offers useful renal period. Urine should be kept on ice or refrigerated during function data. Serum creatinine collection and until delivery to the lab. Transport urine to alone is not the laboratory immediately after collection is complete. an adequate index of Container must be labeled with the patient’s name, date glomerular filtration rate. birth, date and time collection was started and Limitation: Completeness of completed. Causes for Rejection: Times not indicated, urine collection requires vigilance improperly labeled specimen on the part of nursing personnel. Ingestion of meat may increase urine as well as serum creatinine levels. Drugs can interfere with tubular creatinine secretion. Creatinine reabsorption occurs with very low urine flow rates.

37 ARHS-SC-19.03 6/18/2019 8:16 AM

Crossmatch

Lab: WMC/CMH Transfusion Service Specimen: Whole blood Use: To ensure the compatibility Availability: 24 Hours Tube: EDTA (lavender) of red blood cells for patients in TAT: Routine, 2-4 Hours Minimum Volume: 5 mL need of transfusion. Stat, 1 Hour Collection: Routine venipuncture. Specimen must be Additional Information: labeled with Blood Bank Band including patient's full Abnormal proteins and cold or name, Date of Birth, MR number or SS number, date and warm auto agglutinins, or time of collection, and initials of person collecting the unexpected antibodies in the specimen. Blood Bank Band must be completed at time patient's blood may cause delays of sample collection. in the crossmatching process. Causes for Rejection: Improper labeling of sample, wrong sample type, hemolysis. For routine pre-operative use of type and screen is recommended. In the vast majority of cases this will allow adequate time to rule out any compatibility problems.

GC/Chlamydia (CTNG) Lab: WMC Microbiology Specimen: Swab or urine Use: To aid in the diagnosis of Availability: 24 hours Container: Sterile container Neiserria gonorrhoeae or TAT: 24 hours (Outpatient) Minimum Volume: 5 mL urine or single swab Chlamydia trachomatis 3 hours (Inpatient) Collection: Use Cepheid CTNG collection kits only. Additional Information: Causes for Rejection: Improper storage, mislabeled

Test uses PCR methodologies. Testing performed at WMC specimen, sample not sufficient quantity

Culture, Anaerobic

Lab: WMC/CMH Microbiology Specimen: Pus, tissue, or other material properly Use: Isolate and identify Availability: 24 hours obtained from an abscess, biopsy, aspirate, drainage, anaerobic and aerobic TAT: 24-72 hours exudate, lesion or wound pathogens

Collection Device: Sterile container for tissue. Port- Test Includes: Anaerobic culture, A-Cul vial for pus and aspirate. BD Anaerobic Collection aerobic culture, and a Gram stain. Device for swabs. If using swabs, you must include an aerobic swab. Testing performed at WMC. Minimum Volume: Swab in anaerobic device, or 0.5 mL in appropriate anaerobic transport device. Collection: Disinfect overlying and adjacent areas to eliminate contamination with indigenous normal flora. Collection of pus or other fluids through intact skin by needle aspiration is ideal. Avoid exposure to air. Deliver immediately to lab. Causes for Rejection: Specimen not received in anaerobic transport device, refrigerated specimens, improper labeling

38 ARHS-SC-19.03 6/18/2019 8:16 AM

Culture, Blood

Lab: WMC/CMH Microbiology Specimen: Whole blood Use: Isolate and identify Availability: 24 hours Tube: BacT/Alert blood culture bottles (aerobic and potentially pathogenic organisms TAT: 24-72 hours anaerobic) causing bacteremia; establish Negative cultures are incubated for 5 Minimum Volume: Optimum sample is 10 mL in each the diagnosis of endocarditis and days of two BacT/Alert™ blood culture bottles (aerobic and other specific infectious anaerobic). If less than 10 mL is collected inoculate diseases. only the aerobic bottle. If more than 10 ml is collected, Limitation: Two sets of

inoculate both bottles with equal amounts. negative blood cultures in the Testing performed at WMC. Collection: Remove the plastic cap from blood absence of antimicrobial therapy culture bottles and cleanse tops with ChloraPrep sponge are usually sufficient to exclude or sterile alcohol swab. Select vein of choice in an area the presence of free of skin lesions. Using a ChloraPrep sponge (or bacteria. One set is seldom equivalent), scrub venipuncture site with repeated back sufficient. Prior therapy may and forth strokes for 30 seconds. Allow to dry for 30 cause negative cultures or seconds. Perform venipuncture. Inoculate appropriate delayed growth. Improper site bottles. preparation may lead to false Draw with bottle at downward angle, using a butterfly or positive blood cultures. in a syinge. Do not allow liquid in bottle to directly touch 1. For adult patients, two the vacutainer needle due to possible induction of liquid separate samples (2 into bloodstream. venipunctures) are required. 2. For pediatric patients, smaller samples are acceptable. 3. For newly admitted patients, it is desirable to collect all blood cultures before antimicrobial therapy is started. According to QA protocol this should occur within 4 hours of patient arrival. 4. A-lines are in place in many patients in the Critical Care areas. It is permissible to collect one blood culture from the A-line. It is recommended that the second culture be collected by venipuncture.

39 ARHS-SC-19.03 6/18/2019 8:16 AM

Culture, Body Fluid

Lab: WMC/CMH Microbiology Specimen: CSF, synovial fluids, thoracentesis fluids, Use: Isolate and identify Availability: 24 hours etc., collected under aseptic conditions. pathogenic organisms from TAT: 24-72 hours Tube: Sterile tube as appropriate, or syringe (with normally sterile body fluids. needle removed)

Minimum Volume: 1 ml

Testing performed at WMC. Collection: Disinfect skin over puncture site with 2% tincture of iodine in concentric circles. Iodine should remain in contact with skin for at least one minute prior to *CSF specimens from patients with puncture to insure complete antisepsis. Immediately suspected Creutzfeldt-Jakob Disease (CJD) will be sent to the NC State Lab for testing. transfer specimen to sterile container and close tightly to The sample will not be opened prior to avoid leakage. shipping. Additional Information: If anaerobes are suspected, order anaerobic culture (listed separately). Storage: Maintain at room temperature.

Culture, Bronchial Washing/ Bronchial Brush

Lab: WMC/CMH Microbiology Specimen: Bronchial Washing / Bronchial Brush Use: Screen for bacterial Availability: 24 hours Container: Sterile Container growth. TAT: 24-48 hours Note: Samples are also Minimum Volume: 1 ml processed for AFB and Fungi. Collection: Performed by Physician Testing performed at WMC. Causes for Rejection: Improperly labeled specimen.

Culture, Ear

Lab: WMC/CMH Microbiology Specimen: Swab or Fluid Use: Screen for bacterial Availability: 24 hours Collection Device: BBL Culture Swab (mini- growth. TAT: 24-48 hours tip/aluminum shaft) or sterile container

Minimum Volume: 1 Swab or 0.5ml Testing performed at WMC. Collection: Sample usually collected by physician. Causes for Rejection: Improperly collected or labeled specimen.

Culture, Eye

Lab: WMC/CMH Microbiology Specimen: Swab or Plates Use: Screen for bacterial Availability: 24 hours Collection Device: BBL Culture Swab (mini- growth TAT: 24-48 hours tip/aluminum shaft) or plates inoculated by MD. Minimum Volume: 1 Swab or plates Collection: Sample usually collected by physician.

Testing performed at WMC. Causes for Rejection: Improperly collected or labeled specimen.

40 ARHS-SC-19.03 6/18/2019 8:16 AM

Culture, Stool (GI Panel)

Lab: WMC/CMH Microbiology Specimen: Stool, fresh (<1 hour old); stool in Use: Screen for pathogenic Availability: 24 hours appropriate transport (available in lab) bacterial, viral and parasitic TAT: 24-48 hours Container: Clean, dry plastic container, Meridian Para- organisms using PCR technology. Pak™ Enteric Plus vial or equivalent.. Diapers are not acceptable. Limitation: GI Panel should not Minimum Volume: 5 mL or walnut size sample be done for patients Collection: Specimen should be collected in a sterile hospitalized for more than 3 Tests for 14 bacterial pathogens, 4 bedpan, not contaminated with urine, residual soap, or days. See C. difficile toxin. parasites and 5 viral pathogens. disinfectants. Those portions of stool which contain pus, blood, or mucus should be transferred to a sterile specimen container. Storage: Refrigerate Causes for Rejection: Specimens sent on a diaper or tissue, unlabeled specimen, frozen specimen, specimen contaminating outside of container.

Culture, Group B Strep

Lab: WMC/CMH Microbiology Specimen: Vaginal/rectal swab. Use: Isolate and identify group Availability: 24 hours Collection Device: BBL CultureSwab. B beta streptococci. TAT: 24-48 hours Minimum Volume: One swab Collection: Using dual swab system, collect vaginal sample with one swab and rectal sample with the

Testing performed at WMC. second swab. Return both swabs to original container. Storage: Maintain at room temperature.

41 ARHS-SC-19.03 6/18/2019 8:16 AM

Culture, Sinus

Lab: WMC/CMH Microbiology Specimen: Swab, Fluid, or Aspirate Use: To determine bacterial Availability: 24 hours Collection Device: Sterile container or BBL Culture infections of the sinus cavities. TAT: 24-48 hours Swab (mini-tip/aluminum shaft) Minimum Volume: 1 swab or 0.5 ml

Collection: Specimen usually collected by physician.

Testing performed at WMC. Causes for Rejection: Specimen not labeled properly.

Culture, Sputum

Lab: WMC/CMH Microbiology Specimen: Sputum Use: Isolate and identify Availability: 24 hours Container: Sterile screw cap container pathogens of the lower TAT: 24-48 hours Minimum Volume: 5-10 mL sputum respiratory tract. Limitation: An adequate Collection: Most samples will be collected by the Test Includes: Culture and Gram stain Cardiopulmonary Department. Expectorated and sputum specimen should induced sputa are screened for quality in the lab. contain many WBC’s and few to Causes for Rejection: Contaminated sample, no epithelial cells. The latter

mislabeled specimen Testing performed at WMC. are indicative of contamination with saliva. Results obtained without proper screening for contamination may be misleading.

Culture, Throat (Group A Strep)

Lab: WMC/CMH Microbiology Specimen: Material from posterior pharynx, tonsils, or Use: Establish the diagnosis of Availability: 24 hours other inflamed area strep throat. TAT: 24-48 hours Collection Device: Copan Culture Swab sterile culture Note: Culture will not be done

collection system or equivalent. without a previous negative Testing performed at WMC. Minimum Volume: One swab Strep Screen. Collection: Swab both tonsillar pillars and the oropharynx. Do not allow swab to touch the tongue. Storage: Maintain swab at room temperature

42 ARHS-SC-19.03 6/18/2019 8:16 AM

Culture, Urine

Lab: WMC/CMH Microbiology Specimen: Urine Use: To investigate possible Availability: 24 hours Container: Sterile urine collection container or urine urinary tract infection (UTI); TAT: 24-48 hours collection device, which contains boric acid as a monitor treatment for UTI. Limitation: Hair from the stabilizer. Testing performed at WMC. Minimum Volume: 1 ml urine or properly filled perineum will contaminate the Boric Acid Tube specimen. The stream from a Collection: Urine for culture may be midstream clean male patient may be voided, from catheter, I/O or indwelling (line only, freshly contaminated by bacteria from voided) or a suprapubic specimen collected via syringe beneath the prepuce. Bacteria (by physician only.) Early morning specimens yield from vaginal secretions, vulva, or highest bacterial counts from overnight incubation in the distal urethra may contaminate bladder, and are the best specimens for culture. the specimen, as might bacteria Storage: Specimen must be refrigerated or placed in from the hands or clothing. transport device containing boric acid. Causes for Rejection: Room temperature for more than two hours or in boric acid tube over 48 hrs, specimen contaminated with fecal material.

Culture, Wound

Lab: WMC/CMH Microbiology Specimen: Aspirates or swabs. Reference Range: No growth. Availability: 24 hours Collection Device: Copan Culture Swab, sterile transport Use: Isolate & identify potentially TAT: 24-48 hours tube for aspirates. See Culture, Anaerobic if anaerobic pathogenic organisms. Test Includes: Culture and Gram stain culture is ordered. Limitation: Only rapid-growing, Minimum Volume: Swab or 0.5 mL nonfastidious aerobic organisms Collection: Disinfect contiguous areas of skin or can be recovered & identified by mucus membrane containing resident normal flora routine methods. Often only prior to collection of culture material. Collect exudates Testing performed at WMC. organisms which predominate will from the interior of productive lesions. be identified. Anaerobic, fungal, & Storage: Maintain specimen at room temperature. mycobacterial pathogens should be Transport to lab immediately. considered, and appropriate cultures requested if indicated. Normal skin flora may be coagulase- negative staphylococci & Corynebacterium sp

D-Dimer

Lab: WMC/CMH Coagulation Specimen: Citrated plasma Use: Elevated levels of D-dimer Availability: 24 hours daily Tubes: Sodium citrate (blue top) tube are found in such clinical TAT: Routine, 2 hours Minimum Volume: fill mark on tube conditions as deep vein Stat, 1 hour Collection: Routine venipuncture. Fill tubes until thrombosis (DVT), disseminated vacuum is exhausted. intravascular coagulation (DIC), Storage: Citrated plasma may be stored at room and pulmonary embolism. temperature for up to 8 hours, or frozen at -20 Additional Information: D- degrees Celsius for up to one month. dimer levels rise with age, Causes for Rejection: hemolysis, specimen not pregnancy, and in malignancy, stored properly, specimen improperly labeled, among other conditions. specimen contaminated with IV fluids. 43 ARHS-SC-19.03 6/18/2019 8:16 AM

Digoxin

Lab: WMC Chemistry Specimen: Serum Use: To monitor drug levels. Availability: 24 hours daily Tube: SST, Plain red TAT: Routine, 4 hours Minimum Volume: 2 mL Stat, 1 hour Collection: Routine venipuncture Causes for Rejection: hemolysis, specimen not stored properly, specimen improperly labeled, specimen contaminated with IV fluids.

Direct Coombs (DAT)

Lab: WMC Transfusion Service Specimen: Whole blood Use: For the detection of IgG Availability: 24 Hours Daily Tube: EDTA (lavender) antibodies and/or complement TAT: Routine, 2-4 Hours Minimum Volume: 1 mL components bound to patient's Stat, 30 Minutes (WMC) Collection: Routine venipuncture or capillary red blood cells. collection. Additional Information: Positive Testing performed at WMC Causes for Rejection: Improper labeling of sample, tests with monospecific anti-IgG wrong sample type, hemolysis. reagents are found in warm autoimmune hemolytic anemia, hemolytic disease of the newborn (HDN), transfusion reactions, and with the use of certain drugs, especially methyldopa (Aldomet), penicillin, and cephalosporins. Complement coating may also occur in these situations. Positive tests only with anti- complement reagents may be found in warm autoimmune hemolytic anemia, cold agglutinin disease, paroxysmal cold hemoglobuinuria, and with such drugs as quinidine, insulin, sulphonamides, and phacetin. An eluate will be performed on all positive DATs.

ECO2 (Carbon Dioxide)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Evaluate acid-base

Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) disorders. CO2 is generally TAT: Routine, 4 hours Minimum Volume: 2 mL increased in respiratory acidosis, Stat, 1 hour Collection: Routine venipuncture metabolic alkalosis, and

Causes for Rejection: Gross hemolysis, wrong sample excessive alkali intake. CO2 is type, insufficient volume for testing, contaminated with IV generally decreased in fluid, improper labeling, Serum or Plasma in contact with compensated respiratory cells for more than 2 hours. alkalosis, metabolic acidosis, and in renal disorders.

44 ARHS-SC-19.03 6/18/2019 8:16 AM

Electrolytes

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Monitor electrolyte status. Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) TAT: Routine, 4 hours Minimum Volume: 2 mL Stat, 1 hour Collection: Routine venipuncture Test Includes: sodium, potassium, Storage: Remove Serum or Plasma from cells if plain chloride, CO2 red tube is used; store in plastic transfer tube in refrigerator if testing is not to be performed immediately. Causes for Rejection: Gross hemolysis, wrong sample type, insufficient volume for testing, contaminated with IV fluid, improper labeling, Serum or Plasma in contact with cells for more than 2 hours.

Esophageal & Gastric Brushing Cytopathology

Lab: Cytopathology Specimen: Esophageal and gastric brushing Use: To establish the presence of Availability: Mon-Fri, 5:00-5:00 pm collected by physician. primary or metastatic neoplasm, TAT: 24-48 hours Collection: Place brush in Cytolyt® vial. Make sure reactive processes or infectious plastic sheath is removed. Label with patient name, disease. hospital number, room, and date. Submit to Limitation: Non-diagnostic if Cytopathology. After hours place in Pathology rack in gastric epithelium is not refrigeratory in main lab present or if the specimen is contaminated with food or barium sulfate.

Estradiol

Lab: WMC Chemistry Specimen: Serum or heparinized plasma Use: For the evaluation of Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) normal sexual development, TAT: Routine, 4 hours Minimum Volume: 5 ml causes of infertility, and Stat, 1 hour Collection: Routine Venipuncture menopause. Storage: Separate serum from RBC’s; may be stored up to 2 days at 2-8˚ C

45 ARHS-SC-19.03 6/18/2019 8:16 AM

Ferritin

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Diagnose hypochromic, Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) microcytic anemias. TAT: Routine, 4 hours Minimum Volume: 2 mL Additional Information: Collection: Routine venipuncture Decreased in iron deficiency Storage: 4˚C. If testing is to be delayed and plain tube is anemia and increased in iron used, separate serum from cells and transfer to a plastic overload. Ferritin levels tube. correlate with and are useful in Causes for Rejection: Improperly labeled specimen. evaluation of total body iron stores. In hemochromatosis, both ferritin and iron saturation are increased. Limitation: Ferritin escapes from necrotic hepatocytes. In the presence of liver disease, inflammatory diseases such as rheumatoid arthritis, malignancy, or iron therapy, iron deficiency may not be reflected by low serum ferritin.

Fetal Fibronectin (FFN)

Lab: WMC Hematology Specimen: Cervicovaginal Secretions Use: It is used as an aid in Availability: 24 hours Tube: Adeza Biomedical Specimen Collection Kit assessing the risk of preterm TAT: Routine, 2 hours Minimum Volume: Swab delivery in less than or equal to Stat, 1 hour Collection: Collect during a speculum exam. Lightly 7 to 14 days in pregnant women rotate the sterile swab across the posterior fornix of the with signs of early pre term vagina for 10 seconds. Place swab in buffer and break labor, intact amniotic the shaft at the score. membranes and minimal Tips for proper collection: cervical dilatation (<3cm), 1. Collect prior to collection of specimen for culture, sampled between 24 weeks, 0 digital cervical exam, or vaginal probe ultrasound. days and 34 weeks, 6 days 2. Do not contaminate with soaps, lubricants, gestation. disinfectants or Monistat Cream. Limitation: It should not be 3. Do not collect if patient has had sexual intercourse interpreted as absolute evidence within 24 hours. for the presence or absence of a 4. Do not use with moderate or gross vaginal process that will result in delivery bleeding. in less than or equal to 7 to 14 5. Do not collect if membranes are ruptured, placenta days. abruption or placenta previa. Causes for Rejection: Sample not properly labeled. Expired specimen collection device. Specimens not properly stored.

46 ARHS-SC-19.03 6/18/2019 8:16 AM

Fetal Hemoglobin Stain

Lab: WMC Transfusion Service Specimen: Whole blood Use: To detect the presence of Availability: 24 Hours Tube: EDTA (lavender) fetal red blood cells in an adult TAT: 2-4 Hours Minimum Volume: 2 mL female’s circulation and to Collection: Routine venipuncture. determine the post partum dose Causes for Rejection: mislabeled specimen of RHIG for Rh Negative females with a positive fetal screen.

Fibrinogen

Lab: WMC Hematology Specimen: Plasma, citrated Use: Identify congenital Availability: 24 hours daily Tube: Blue (sodium citrate) afibrinogenemia, disseminated TAT: Routine, 4 hours Minimum Volume: 4.5 mL or 2.7 mL whole blood, intravascular coagulation (DIC), Stat, 1hour depending on tube being used for collection. Tube and fibrinolytic activity. must be filled to fill line. Limitation: Increased in patients Storage: 8 hours at Room Temp. One month in on oral contraceptives. freezer at -20˚C. Interpretations of results may be Patient Preparation: The patient should not receive limited if patient is receiving heparin within 1 hour of collection. anticoagulant therapy, depending Collection: Routine venipuncture. Collect blue top tube on method of analysis. after Ir tube to prevent the contamination of the specimen Additional Information: with tissue thromboplastin. Allow tube to fill until vacuum Increased levels may be seen is exhausted. with inflammation and Causes for Rejection: Gross hemolysis or clotted pregnancy. Congenital sample, mislabeled specimen hypofibrinogenemia may be responsible for mild hemorrhagic symptoms; fibrinogen levels are usually <100 mg/dL, and screening tests (PT, PTT) may be normal or only slightly prolonged.

Folate, Serum (Folic Acid)

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Detect folate deficiency; Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) monitor folate therapy, TAT: Routine, 4 hours Minimum Volume: 2 mL evaluate megaloblastic and Collection: Routine venipuncture. Avoid hemolysis macrocytic anemia. and exposure to light. Limitation: Folate will Storage: Separate serum from cells and refrigerate at deteriorate on exposure to 40C, protected from light. light. Causes for Rejection: Hemolysis, prolonged Additional Information: Serum exposure to light, improperly labeled specimen. folate levels are affected by dietary intake. Drugs such as methotrexate and pentamidine, may induce deficiency. Some drugs (oral contraceptives, phenytoin, and ethanol) impair absorption.

47 ARHS-SC-19.03 6/18/2019 8:16 AM

Free T3

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: A physiologic index of Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) metabolic activity that TAT: Routine, 4 hours Minimum Volume: 2 mL correlates with Free T4 and Stat, 1 hour Collection: Routine venipuncture. TSH. Storage: If plain tube is used, allow to clot and centrifuge within 45 minutes of collection. Remove serum and store in a plastic transfer tube at 4° C until testing is performed. Causes for Rejection: Improper labeling.

Free T4

Lab: WMC Chemistry Specimen: Serum (CMH can also accept heparinized Use: A physiologic index of Availability: 24 hours daily plasma) metabolic activity that TAT: Routine, 4 hours Tube: SST or plain red (CMH- green (Li. hep) correlates with TSH. Stat, 1 hour Minimum Volume: 2 mL Collection: Routine venipuncture. Storage: If plain tube is used, allow to clot and centrifuge within 45 minutes of collection. Remove serum and store in a plastic transfer tube at 4° C until testing is performed. Causes for Rejection: Plasma specimen (except CMH), improper labeling.

Frozen Tissue Section

Lab: Surgical Pathology Specimen: Fresh tissue with no added fixative. Limitation: Bone and heavily Availability: Mon-Fri, 8:00am-5:00pm; Container: Plastic specimen container calcified tissue cannot be frozen. after hours call pathologist. Frozen Collection: Label with patient’s information, Additional Information: sections must be scheduled with the operating room, date and requesting surgeon. Pathologist calls physician with Pathology Department. Causes for Rejection: Specimen submitted in diagnosis. TAT: ~20 minutes fixative

48 ARHS-SC-19.03 6/18/2019 8:16 AM

Genital Cytopathology , Routine

Lab: Cytopathology Specimen: Endocervical brush, cervical scrap or brush. Use: Availability: Mon-Fri, 5:00am - Vaginal cuff scrap. For lesions of the vagina or vulva, 1) To establish the presence 5:00 pm scrapings made directly from lesions are desirable. of primary or metastatic TAT: 24-48 hours Container: ThinPrep PreservCyt® vial may be neoplasms. 2) To aid in the diagnosis of obtained from the cytopathology department. Special Instructions: Submit pertinent Patient Preparation: Patient to avoid douches 48- genital infections with HPV, clinical history: age, LMP, history, PMP, 72 hours prior to examination. Patient needs to Herpes virus, Candida, surgery, HRT, abnormal vaginal bleeding, reschedule if there is excessive menstrual bleeding. Trichomonas vaginalis, and previous abnormal paps, oral Collection: Label ThinPrep PreservCyt® vial with two Actiniomyces. contraceptives and IUD usage etc. patient identifiers. Submit to cytopathology. Sampling:

1) Endocervix Brush is obtained by inserting brush Limitation: Failure to obtain Notes: Ancillary testing may be ordered into cervical os and rotating, then rinse material into adequate ectocervical, from same ThinPrep PreservCyt® vial i.e. the ThinPrep PreservCyt® vial. Make sure material enodcervical or vaginal cell HPV testing. Call Cytopathology with any is off the brush. population Ih is suboptimal for questions about ancillary testing from the 2) Ectocervical scrape with spatula or broom evaluation. Use of lubricating jelly ThinPrep PreservCyt® vial . thoroughly the entire ectocervix with emphasis on the on the vaginal speculum will squamo-columnar junction. Rinse material into the interfere with cytologic ThinPrep PreservCyt® vial . Make sure material is off examination. the brush. 3) Vaginal specimen obtain specimen by lightly scraping the vaginal cuff spatula Rinse material into the ThinPrep PreservCyt® vial. Make sure material is off the brush. Causes for Rejection: Fixation in FORMALIN. Specimen not labeled properly.

Gentamicin

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: To monitor gentamicin Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) therapy to maintain effective TAT: Routine, 4 hours Minimum Volume: 2 mL levels but avoid toxic side Stat, 1 hour Collection: Routine venipuncture or capillary effects. collection. Specimens should be collected prior to the fourth dose for trough levels and 30 minutes to 1 hour after fourth dose for peak levels, depending on mode of administration. See nursing Gentamicin Protocol. Storage: Refrigerate specimens if testing is not to be performed immediately. Causes for Rejection: Improper labeling. Samples MUST be labeled as peak or trough.

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Gestational Diabetes Screening (O'Sullivan)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Investigate the possibility of Availability: Mon. - Fri. (7a-5p) Tube: SST, Plain red or Green (Li hep) Gestational diabetes. TAT: 2-4 hours Minimum Volume: 2 mL Limitations: A normal result Collection: Routine venipuncture 1 hour after does not assure that diabetes will glucola. not develop. Patient Preparation: 50 grams of oral glucose given without regard to time of day or last meal. Storage: Separate serum / plasma from RBC’s and maintain specimens at room temperature. Causes for Rejection: Patient in a stressed condition (surgery, infection, corticosteroids) or improper labeling.

GGT (Gamma Glutamyl Transferase)

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: GGT is a biliary enzyme useful Availability: 24 hours TAT: Tube: SST, Plain red or Green (Li hep) in the diagnosis of obstructive Routine, 4 hours Minimum Volume: 2 mL jaundice, intrahepatic cholestasis, Stat, 1 hour Collection: Routine venipuncture pancreatitis, and metastatic Storage: Separate serum from cells if plain red tube is carcinoma of the liver. GGT parallels used. Refrigerate if testing is not to be performed ALP in liver disease but is not immediately. elevated in bone disease. Causes for Rejection: Improper labeling. Limitation: GGT is elevated in patients on anticonvulsives and barbiturates. Acetaminophen can cause an in-vivo increase. GGT is sensitive to ethanol intake. Additional Information: GGT is more specific for hepatic disease than ALP. GGT has no origin in bone or placenta, unlike ALP. GGT is highest in obstructive liver disease. Commonly elevated in patients with cirrhosis, carcinoma of liver and pancreas, hepatitis, stone, pancreatitis, and CHF.

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GI Panel (see Culture, Stool)

Glucose (Blood Sugar)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Diagnosis diabetes mellitus; Availability: 24 hours Tube: SST, Plain red or Green (Li hep) evaluate disorders of carbohydrate TAT: Routine, 4 hours Minimum Volume: 2 mL metabolism; evaluate acidosis and Stat, 1 hour Collection: Routine venipuncture ketoacidosis. Storage: If tube other than SST is used, remove Limitation: Mild glucose serum/plasma from cells ASAP and refrigerate if impairment can exist with fasting testing is delayed. glucose within normal range. Causes for Rejection: Gross hemolysis, in contact Specimen not handled properly with cells for prolonged periods of time, collected can lead to falsely depressed above IVs levels (serum/plasma left in contact with cells for extended time.) Additional Information: A fasting glucose of >140 mg/dL on more than one occasion is virtually diagnostic of diabetes mellitus; likewise a 2-hour post- prandial glucose level >200 mg/dL is also virtually diagnostic, obviating the need for a GTT.

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Glucose, CSF

Lab: WMC Chemistry Specimen: CSF Availability: 24 hours daily Tube: Sterile plastic tubes provided in the Lumbar TAT: 1 hour puncture tray. Minimum Volume: 1 ml Collection: CSF specimens are collected only by *CSF specimens from patients with physicians or designee using established aseptic suspected Creutzfeldt-Jakob Disease technique. (CJD) will be sent to the NC State Lab Storage: CSF specimens are not stored. Testing is for testing. The sample will not be performed immediately to avoid utilization of opened prior to shipping. glucose in the specimen by bacteria or cellular components.

Glucose Tolerance (GTT)

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma, whole Use: Investigate the possibility of Availability: Mon-Fri, times set at blood diabetes mellitus. Tube: SST or Green (Li hep) scheduling Limitation: Slight hyperglycemia TAT: Fasting level will be performed Minimum Volume: 2 mL is seen in patients on oral before glucose beverage is given to the Collection: Routine venipuncture, capillary puncture contraceptives. Failure to have patient (approximately 30 minutes.) Patient Preparation: Patient must be fasting. Collect patient on a 3- day high Testing will be completed within 1 hour of fasting specimen wait for results. If results of the fasting carbohydrate diet may result in a the collection of the final specimen. specimen are less than 140 mg/dL continue with the false positive GTT. Impaired testing. If the fasting results are greater than glucose tolerance is NOT Note: Glucose tolerance testing will not be 140 mg/dL contact the physician for further equivalent to diabetes mellitus, started after 0900, nor will it be performed instructions. If testing is to continue, have the patient neither does a normal result on weekends. Outpatient testing must be drink the glucose tolerance beverage according to assure that diabetes will not scheduled in advance. the following instructions: non-pregnant adult-75 develop. grams; pregnant female-100 grams; child-1.75g/kg Contraindications: FBS >140 body weight, not to exceed 75 grams. mg/dL on two occasions or Storage: Separate serum/plasma from RBCs and postprandial blood glucose maintain specimens at room temperature. >200 mg/dL on two occasions in Causes for Rejection: Patient not fasting; patient in a a non-stressed patient are stressed condition (surgery, infection, corticosteroids) indicative of diabetes mellitus and should not have a GTT; improper labeling; fasting results obviate the need for a GTT. GTT greater than 140 mg/dL unless physician instructs is also contraindicated in the otherwise, obvious diabetes mellitus. presence of obvious diabetes mellitus.

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HCG, Beta Quantitative - Pregnancy Test

Lab: WMC/CMH Chemistry Specimen: Serum or plasma Use: To determine the presence Availability: 24 hours daily Tube: Plain red, SST or Green (Li Hep.) of hCG in patients with gestational TAT: Routine, 4 hours Minimum Volume: 1.0 mL trophoblastic disease, evaluate Stat, 1 hour Collection: Routine venipuncture. and monitor males with testicular Cause for Rejection: gross hemolysis, improperly tumors; follow pregnancy. The labeled specimen quantitative hCG assay should also be used for non-routine detection of hCG (eg. ectopic pregnancy, threatened miscarriage, or very early pregnancy).

HCG, Qualitative Serum - Pregnancy Test

Lab: WMC/CMH Hematology Specimen: Serum Tube: Use: Early detection of Availability: 24 hours daily Plain red or SST Minimum pregnancy TAT: Routine, 4 hours Volume: 0.5 mL Limitations: A number of STAT, 1 hour Collection: Routine venipuncture. conditions other than pregnancy Cause for Rejection: gross hemolysis, improperly may cause elevated levels of labeled specimen, plasma specimen hCG. These diagnoses should be considered if appropriate to the clinical evidence.

HCG, Qualitative Urine - Pregnancy Test

Lab: WMC/CMH Hematology Specimen: Urine Use: Early detection of Availability: 24 hours daily Container: any clean, dry plastic or glass container pregnancy TAT: Routine: 4 hours Minimum Volume: 1.0 mL Limitations: A number of STAT: 1 hour Storage: 2-8°C; if testing is to be delayed for more than conditions other than pregnancy 48 hours, the specimen should be frozen. Cause for may cause elevated levels of Rejection: improperly labeled specimen, improper hCG. These diagnoses should storage be considered if appropriate to the clinical evidence.

Hemoglobin (Hgb)/Hematocrit (Hct)

Lab: WMC/CMH Hematology Specimen: Whole blood Use: Evaluate anemia, blood Availability: 24 hours Tube: EDTA-lavender top loss, hemolysis, polycythemia, TAT: Routine: 2-4 hours Minimum Volume: 2.7 to 4.5 mL, depending upon and response to treatment Stat: 1 hour size of tube being used. Limitation: Hyperlipemic plasma Collection: Routine venipuncture. Mix thoroughly may falsely elevate hemoglobin but gently. result, with corresponding Storage: Maintain specimen at room temperature for up increase in MCH. Cold agglutinins to 24 hours may also interfere with Causes for Rejection: Clotted specimen, insufficient hemoglobin measurement. quantity, hemolysis, improperly labeled specimen.

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Hemoglobin A1C (Hgb A1c)

Lab: WMC Chemistry Specimen: Whole blood Use: The level of hemoglobin Availability: 24 hours TAT: Tube: EDTA (lavender) A1C is proportional to the level of Routine: 4 hours Minimum Volume: 2.7 to 4.5 mL, depending on size of glucose in the blood over a Stat: 1 hour tube being used. period of approximately 2 Collection: Routine venipuncture. Mix thoroughly but months. Thus, hemoglobin A1C gently. is accepted as an indicator of the Storage: Room temp for up to 24 hours mean daily blood glucose over Causes for Rejection: Clotted specimen, insufficient the preceding 2 months. Regular quantity, hemolysis, improperly labeled specimen. measurement of hemoglobin A1C leads to changes in diabetes treatment and improvement of metabolic control as indicated by lowering of hemoglobin A1C values.

Hepatic Function Panel (LFT / HFP)

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: To evaluate liver function, Availability: 24 hours Tube: SST, Plain red or Green(Li hep) investigate abdominal pain. TAT: Routine, 4 hours Minimum Volume: 2 mL Stat, 1 hour Collection: Routine venipuncture. Storage: Remove serum from cells if tube other than Test Includes: albumin, total bilirubin, SST is used, store at 4°C in refrigerator, protect from direct bilirubin, alkaline phosphatase, light. AST, ALT Causes for Rejection: Prolonged exposure to light, improper labeling

Hepatitis B Surface Antibody (HBsAb)

Lab: WMC Chemistry Specimen: Serum Tube: Use: Indicator of clinical recovery Availability: 24 hours Plain red or SST Minimum and subsequent immunity to TAT: 24 hours Volume: 5 mL hepatitis B virus. Limitation: Collection: Routine venipuncture Presence of HBsAb is not an Storage: 4˚C. If tube other than SST is used, separate absolute indicator of resolved serum from cells and transfer to a plastic transfer tube hepatitis infection, nor of prior to shipping or storing. protection from future infection. Causes for Rejection: Recently administered Since there are different serologic isotopes. subtypes of hepatitis B virus, it is possible for a patient to have antibody to one surface antigen type and to be acutely infected with a virus of a different subtype. Thus, patients may have co- existing HBsAg and HBsAb. Transfused patients or hemophiliacs receiving plasma components may give false positive results for HBsAb.

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Hepatitis B Surface Antigen (HBsAg)

Lab: WMC Chemistry Specimen: Serum, Plasma Use: Hepatitis B surface antigen Availability: 24 hours Tube: SST, Plain red or Green (Li hep) is the earliest indicator of the TAT: 24 hours Minimum Volume: 5 mL presence of acute infection. Collection: Routine venipuncture Also indicative of chronic Note: All indeterminate samples will be Storage: 4˚C. Remove Serum or Plasma from cells if infection. Useful in the sent to Ref Lab for confirmatory testing. tube other than SST is used. Test within 48 hrs. Causes differential diagnosis of for Rejection: Improperly labeled specimen. hepatitis. Limitation: Patients who are negative for HBsAg may still have acute type B viral hepatitis. There is sometimes a “window” stage when HBsAg has become negative and the patient has not yet Id the antibody.

Hepatitis C Antibody

Lab: WMC Chemistry Specimen: Serum Tube: Use: Evaluation panel for Availability: 24 hours Plain red, SST Minimum patients with symptoms or TAT: 24 hours Volume: 5 mL clinical history that suggest Collection: Routine venipuncture Hepatitis C infection. Note: All indeterminate samples will be Storage: If tube other than SST is used, separate sent to Ref Lab for confirmatory testing. serum from cells and store in a plastic transfer tube. Causes for Rejection: Insufficient volume, improperly labeled specimen.

Histopathology

Lab: Surgical Pathology Specimen: Fresh tissue or tissue fixed in formalin. Limitation: Fixed tissue cannot Availability: Mon-Fri, 5:00am-5:00 pm Container: Plastic formalin filled specimen container. be used for culture and certain after hours call pathologist Collection: Container must be properly labeled with types of histochemistry. TAT: 48 hours; tissue requiring the patient’s information, date and time of collection, and Additional Info: Lymph nodes decalcification and/or special stains-48- physician’s name, time placed in formalin. The complete suspected of lymphoma should be 72 hours. requisition form should accompany the specimen to submitted on saline moistened pathology. gauze. Muscle biopsies are sent Causes for Rejection: Unlabeled or mislabeled to lab fresh, without any fixative. specimen.

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Human Immunodeficiency Virus Screen (Rapid HIV-1/2, p-24 Ag)

Lab: WMC/CMH Chemistry Specimen: Serum Use: Investigate possible Availability: 24 hours daily Tube: SST that has not been opened exposure to human TAT: Routine, 4 hours Minimum Volume: Full tube immunodeficiency virus. Collection: Routine venipuncture. Additional Information: HIV, Test Included: HIV antibody screen and Storage: 4˚C the etiologic agent of the confirmation by Western Blot if indicated by acquired immunodeficiency positive screening result syndrome (AIDS) is a cytopathic retrovirus. Sera which are repeatedly reactive in two of three tests are subject to confirmatory testing by the Western blot method. Some individuals may be initially reactive by the screening and negative or indeterminate by Western blot. This may be caused by other viral antibodies or autoantibodies , although this is extremely rare.

Influenza A And B (Flu A / B)

Lab: WMC/CMH Microbiology Specimen: Nasal/Nasopharyngeal swab Use: Confirm the diagnosis of Availability: 24 hours daily Minimum Volume: 1 foam tipped or flocked swab influenza A & B TAT: 1 hour Storage: Room Temperature Rapid Antigen Test: Initial test Collection: Nasal swab for patients over 3 years old. Additional Information: is performed using rapid antigen Rotate swab against the nasal wall and return to Presentation of influenza infection detection container. Nasopharyngeal Swab for under age 3. Insert ranges from mild respiratory swab in the posterior nasopharynx and rotate. Remove illness to fatal pneumonia. In

and return to container. For nasal wash, flush one nostril addition, secondary infection can with 1.0 to 2.5mL normal saline. Allow fluid to run out of be a serious complication. People nostril into sterile container. at high risk from infection include Causes for Rejection: mislabeled specimen the elderly and patients with underlying health problems.

Intact PTH (Parathyroid Hormone)

Lab: WMC Chemistry Specimen: Plasma Use: Important marker to Availability: 24 hours Tube: EDTA (full) spin and separate diagnose the disease of the Intra-operative Intact PTH scheduled Storage: 2-8°C if tested within 24 hrs; parathyroid gland and the TAT: OR, 30 minutes Freeze if testing is delayed > 24 hours. kidney. iPTH is used to judge Routine, 4 hours Causes for rejection: Improperly filled, improperly success or failure of surgery in labeled or collected in wrong tube. the removal of malignant parathyroid gland, and to monitor postoperative recovery.

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Iron Panel

Lab: WMC Chemistry Specimen: Serum Tube: Use: Differential diagnosis of Availability: 24 hours TAT: Plain red or SST Minimum anemia, especially with Routine, 4 hours Volume: 5 mL hypochromia and/or low MCV; Stat, 1 hour Patient Preparation: Specimen should be drawn work up hemochromatosis in which iron is increased and fasting in the morning. Specimen should be drawn Test Includes: before transfusion or before patient is given saturation is high; evaluation of Total Iron, Total Iron Binding Capacity, therapeutic iron. iron poisoning and overload in % Saturation [(Fe/TIBC) x 100] Collection: Routine venipuncture. renal dialysis patients or patients Storage: 4˚C. If plain red tube is used, allow to clot and with transfusion dependent centrifuge within 45 minutes of collection. Remove serum anemia. and store in a plastic transfer tube until testing is done. Causes for Rejection: Gross hemolysis, plasma specimen, improperly labeled specimen.

Ketones (Serum/Plasma)

Lab: WMC/CMH Urinalysis Specimen: Serum or Plasma Use: To detect ketoacidosis Availability: 24 hours TAT: Tube: SST, green (Li. Hep), or plain red Routine, 4 hours Minimum Volume: 0.5 mL Stat, 1 hour Collection: Routine venipuncture Storage: 4˚C Causes for Rejection: Improper tube or labeling

Lactic Acid

Lab: WMC/CMH Chemistry Specimen: Heparinized plasma Use: Elevated lactate levels can Availability: 24 hours Tube: Green occur as a result of tissue TAT: Routine, 4 hours Minimum Volume: 2 mL hypoxia, diabetes mellitus, Collection: Routine venipuncture, drawn on ice. phenformin therapy, Stat, 1 hour Plasma must be separated from cells within 15 malignancies, glycogen storage minutes of collection. Sample may be used up to 3 disease, ethanol, methanol or hours after collection if collected on ice, centrifuged salicylate ingestion and metabolic immediately and kept on ice or refrigerated. acidosis. Causes for Rejection: Not collected and or labeled properly.

LDH (LD/Lactate Dehydrogenase), Blood

Lab: WMC Chemistry Specimen: Serum or heparinized plasma Use: Differential diagnosis of Availability: 24 hours Tube: SST, Plain red or Green (Li hep) cardiac and liver disorders, TAT: Routine, 4 hours Minimum Volume: 2 mL evaluation of hemolytic Stat, 1 hour Collection: Routine venipuncture. Avoid hemolysis. disorders. Storage: Specimen should be stored at room Limitation: Hemolysis falsely temperature. elevates LDH results. Ascorbic Causes for Rejection: Hemolysis, wrong sample acid can decrease LDH values. type, dilution of sample with IV fluids, improper Elevated total protein >12 g/dL storage (associated with Multiple Myeloma) can interfere with LDH analysis.

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Lipase

Lab: WMC/CMH Chemistry Specimen: Serum or heparinized plasma Use: Evaluate Availability: 24 hours Tube: SST, plain red or Green (Li hep) diseases/disorders of the TAT: Routine, 4 hours Minimum Volume: 2 mL pancreas. Stat, 1 hour Collection: Routine venipuncture Causes for Rejection: Improperly labeled specimen.

Lithium

Lab: WMC/CMH Chemistry Specimen: Serum Use: Monitor therapeutic drug Availability: 24 hours Tube: Plain red or SST level TAT: Routine, 4 hours Minimum Volume: 2 mL blood Stat, 1 hour Collection: Routine venipuncture. Storage: Refrigerate. Separate serum from cells if plain red tube is used; store in plastic transfer tube. Causes for Rejection: Collection in green lithium heparin tube, improperly labeled specimen.

Lipid Profile

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: Evaluation of hyperlipidemia Availability: 24 hours Tube: SST, Plain red or Green (Li hep) as an index to coronary heart TAT: Routine, 4 hours Minimum Volume: 5 mL disease. Limitation: Triglyceride

Collection: Routine venipuncture. levels greater than 400 mg/dL Test Includes: Storage: 4˚C invalidate the calculations of LDL Total cholesterol, HDL cholesterol, Causes for Rejection: Insufficient volume, wrong and VLDL and a comment must triglycerides, LDL cholesterol, VLDL sample type, improper labeling. be made that these parameters cholesterol (calculated), are invalid. cholesterol/HDL ratio

Magnesium (Mg)

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: Magnesium deficiency Availability: 24 hours Tube: SST, plain red or Green (Li hep) produces neuromuscular TAT: Routine, 4 hours Minimum Volume: 2 mL disorders. Increased Stat, 1 hour Collection: Routine venipuncture. magnesium levels relate mostly to Storage: Remove serum from cells if plain tube is patients in renal failure. used. Refrigerate at 4oC. Magnesium is used as an Causes for Rejection: Gross hemolysis, anticonvulsant in pre-eclamptic patients.

Meningitis Panel Lab: WMC/CMH Microbiology Specimen: CSF Use: Screen for pathogenic Availability: 24 hours Tube: Clear CSF container bacterial, viral and parasitic TAT: Routine, 24 hours organisms using PCR Minimum Volume: 1 mL Stat, 4 hours technology. Collection: Normal lumbar puncture using established

aseptic technique. Lumbar punctures are performed only Testing performed at WMC by physicians. Storage: CSF should be refrigerated if testing is not performed immediately. Be sure to freeze all extra CSF in reference transfer tube in case more testing is ordered later. Causes For Rejection: Improper labeling. 58 ARHS-SC-19.03 6/18/2019 8:16 AM

Mono Test (Infectious Mononucleosis)

Lab: WMC/CMH Serology Specimen: Serum or Plasma (WMC) Use: A serological test to Availability: 24 hours Whole Blood (CMH) support the diagnosis of infectious mononucleosis. TAT: Routine, 4 hours Tube: Plain red, SST, or EDTA Stat, 1 hour (WMC), EDTA only (CMH) Minimum Volume: 0.5 mL Collection: Routine venipuncture. Storage: Remove plasma/serum from cells and refrigerate at 4˚C if testing is to be delayed. Causes for Rejection: Hemolysis, contamination with IV fluids, bacteria, etc.

MRSA Screening Lab: CMH/WMC Microbiology Specimen: Swab Use: To aid in the diagnosis of Availability: 24 hours Container: Sterile container or colonization with MRSA TAT: 24 hours (Outpatient) Minimum Volume: single swab Additional Information: 3 hours (Inpatient) Collection: Collect by swabbing inside of the nares Test uses PCR methodologies. Causes for Rejection: Improper storage, mislabeled

Testing performed at WMC/CMH specimen, sample not sufficient quantity

Mycoplasma pneumoniae IgM Antibody

Lab: WMC Microbiology Specimen: Serum Use: Aid in the serodiagnosis of Availability: 24 hours Tube: Plain red or SST M. pneumoniae infection. TAT: 4 hours Minimum Volume: 0.2 mL Additional Info: Mycoplasma Collection: Routine venipuncture. pneumoniae is the cause of the Storage: 4˚C relatively common “primary Causes for Rejection: Hemolysis, lipemia, gross atypical pneumonia.” bacterial contamination, improperly labeled Mycoplasma is more difficult to specimen. culture than ordinary bacteria and the serologic confirmation of the diagnosis is often desirable.

Nipple Discharge Cytopathology

Lab: Cytopathology Specimen: Nipple discharge Use: To establish the presence Availability: Mon-Fri 05:00am- Container: Cytolyt ® Vial of primary or metastatic 5:00 pm Collection: Gently grip subareolar area and nipple with neoplasm. TAT: 24-48 hours thumb and fore finger. When secretion occurs, allow

discharge to drip into the Cytolyt® vial. Label vial and Special Instructions: Specify nipple submit to Cytopathology. Causes for Rejection: Improper fixation or discharge and from which breast. Include pertinent clinical date, history of mislabeled vial. carcinoma on requisition.

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NT-proBNP (BNP)

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: The concentration indicates Availability: 24 hours Tube: SST, Plain red or Green (Li hep) the prognosis for left ventricular TAT: Routine, 4 hours Collection: Routine venipuncture. Spin and dysfunction and is useful in Stat, 1 hour separate, Samples may be used up to 3 days. assigning symptoms to cardiac or Causes for rejection: Hemolysis, turbidity, non-cardiac causes. mislabeled specimen.

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Obstetric Panel (OB Panel)

Lab: WMC Chemistry, Hematology, Specimen: Serum, EDTA whole blood Use: Prenatal screening

Blood Bank Tube: SST, 2 EDTA Availability: 24 hours Collection: Routine venipuncture. Spin and Note: Please refer to individual TAT: Routine, 4 hours separate SST. tests for additional information.

Causes for rejection: Hemolysis, incorrectly labeled Panel consists of: specimen, or clotted EDTA specimen. CBC, RPR, Type (ABO/Rh) & Antibody Screen, Hepatitis B Surface Antigen

Occult Blood (Hemoccult)

Lab: WMC/CMH Microbiology Specimen: Feces (stool) Use: It is a qualitative screening Availability: 24 hours Container: Hemoccult slide or a clean dry plastic test for the detection of fecal TAT: Routine, 2 hours container. occult blood which may be Minimum Volume: Pea size amount or thin smear of indicative of gastrointestinal stool on both boxes of hemoccult slide disease. Collection: Fresh stool specimen free of gross blood. Limitation: Patient should When inoculating hemoccult slides use applicator to avoid red meat and vitamin C in apply a thin smear of stool to box A. Reuse applicator to excess of 250mg for 3 days apply a thin smear of stool from a different part of the before collecting samples. Non- specimen to box B. steroidal anti-inflammatory drugs Causes for Rejection: Contamination of specimen should be discontinued for 7 days with urine or toilet bowel cleaner; mislabeled prior to collecting samples. specimen. Storage: Hemoccult slides once inoculated can be stored at room temp for up to 14 days

Osmolality, Serum

Lab: WMC Chemistry Specimen: Serum, Tube: Use: Evaluate electrolyte and Availability: 24 hours daily SST or Plain red Minimum water balance, hyperosmolar TAT: Routine, 4 hours Volume: 2 mL status, hydration status; evaluate Stat, 1 hour Collection: Routine venipuncture. seizures; clue to alcoholism, Storage: Separate serum from cells as soon as clot methanol toxicity, ethylene glycol forms. Refrigerated samples may be used for up to ingestion. Additional Info: High three days. osmolality can result from Causes for Rejection: Hemolysis, plasma specimen, hypernatremia, dehydration, insufficient volume, improper labeling. hyperglycemia, mannitol therapy, azotemia, ingestion of ethanol, methanol, and ethylene glycol. Low osmolality may result from over hydration, hyponatremia.

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Osmolality, Urine

Lab: WMC Chemistry Specimen: Urine, random or 24-hour Use: Evaluation of Availability: 24 hours Container: Plastic urine container, no preservative concentrating ability of the TAT: Routine, 4 hours Minimum Volume: 10 mL kidneys, evaluate electrolyte Stat, 1 hour Collection: Centrifuge urine sample after collection for and water balance. 5 minutes to remove gross particulate matter. Storage: Refrigerate up to 3 days. Causes for Rejection: Improper labeling

Oxycodone Urine Drug Screen

Lab: WMC Chemistry Specimen: Freshly voided, untreated urine. Use: Rapid immunoassay test Availability: 24 hours Container: Urine sample cup. to detect a drug of abuse in TAT: Routine, 4 hours Volume: 10 ml urine. Stat, 1 hour Storage: Refrigerate up to 24 hours. Cause for Note: The length of time rejection: Improperly labeled, Limitations: Adulterants following drug use for which a added to urine specimen may produce erroneous positive result may occur is results. Substances and/or factors may interfere with the dependent on several factors test and cause false results. Drug levels below the including the frequency and analyte cut off may not be detected amount of usage, metabolic rate, excretion rate, drug half- life and the user's age, weight, activity and diet. For quantitation or confirmation a GC/MS should be ordered.

Phenytoin (Dilantin)

Lab: WMC Chemistry Specimen: Serum or plasma Use: To monitor therapeutic Availability: 24 hours Tube: SST, Plain red or Green(Li hep) drug level. TAT: Routine, 4 hours Minimum Volume: 2 mL Stat, 1 hour Collection: Routine venipuncture Causes For Rejection: Incorrect tube or improperly labeled specimen.

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Phosphorus

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Evaluation of phosphorus Availability: 24 hours Tube: SST, Plain red or green (Li hep) metabolism, calcium/ TAT: Routine, 4 hours Minimum Volume: 2 ml phosphorus balance. Stat, 1 hour Collection: Routine venipuncture Causes For Rejection: Wrong sample type, improper labeling

Platelet Count (Plt Count)

Lab: WMC/CMH Hematology Specimen: Whole blood Use: Quantitation of platelets, Availability: 24 hours Tube: Purple (EDTA) evaluation of bleeding disorders, TAT: Routine, 4 hours Minimum Volume: 2 ml in EDTA tube, 0.5 in a aid of evaluation of Stat, 1 hour Microtainer chemotherapeutic agents in the Collection: Routine venipuncture or capillary management of malignant collection disease states, evaluation of Storage: Count cannot be performed if sample is platelet transfusions. Additional held at room temperature for more than 8 hours or Information: Some patient’s more than 24 hours refrigerated. exhibit clumping of platelets when Causes For Rejection: Incorrect specimen the specimen is container, clotted specimen, hemolysis, specimen collected in EDTA containers. In collected above IV, insufficient volume. these cases, specimens should be collected in citrate (blue top) tubes. If a capillary puncture is performed, large free flowing drops of blood must be obtained in order to avoid a clotted specimen or clumping. Specimen must be well mixed during and immediately after collection.

Platelet Function Screen

Lab: WMC Coagulation Specimen: Whole blood Use: Screening test to evaluate Availability: 24 hours Tube: 2 Blue - Citrate DO NOT SPIN platelet function. Can distinguish TAT: Routine, 4 hours Minimum Volume: 2 tubes patients on aspirin therapy from Stat, 1 hour Collection: Routine venipuncture those with a true platelet Causes For Rejection: Specimen is over 2 hours old. dysfunction. Limitations: Low Specimen has been spun down. Improperly labeled hemoglobin can interfere with specimen or a clotted sample. testing.

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Potassium, Blood

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: Monitor electrolyte status Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) Additional Information: Samples TAT: Routine, 4 hours Minimum Volume: 2 ml in contact with RBC for prolonged Stat, 1 hour Collection: Routine venipuncture periods of time will produce Storage: Separate serum or plasma from cells. erroneously high Refrigerate if testing is not to be performed levels of potassium. Some immediately. anticoagulants contain Causes For Rejection: Wrong anticoagulant, gross potassium, e.g., EDTA, which hemolysis, sample in contact with cells for more will lead to falsely elevated than 4 hours, diluted with IV fluids, improper levels. labeling, insufficient volume.

Potassium, Urine

Lab: WMC/CMH Chemistry Specimen: Urine, Random or 24 hr Use: May be elevated with Availability: 24 hours daily Minimum Volume: 10 ml Collection: dietary increase, TAT: Routine, 4 hours No preservatives, on ice. hyperaldosteronism, renal Stat, 1 hour Causes For Rejection: Improperly labeled tubular acidosis and at the specimen. onset of alkalosis.

Pregnancy Test - See HCG

Prolactin

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: To help with the diagnosis Availability: 24 hours Tube: SST, Plain red or Green (Li hep) of disease states such as TAT: Routine, 4 hours Minimum Volume: 2 mL infertility, gonadial disorders, and Stat, 1 hour Collection: Routine venipuncture others. Causes For Rejection: Improperly labeled specimen or grossly hemolyzed.

Procalcitonin

Lab: WMC/CMH Specimen: Serum, heparinized plasma Use: To help with the diagnosis of Chemistry Tube: SST, Plain red or Green (Li hep) sepsis, septic shock and antibiotic Availability: 24 hours Minimum Volume: 2 mL efficacy. TAT: Routine, 4 hours Collection: Routine venipuncture Stat, 1 hour Causes For Rejection: Improperly labeled specimen or grossly hemolyzed. Note: Same specimen type must be use for all serial testing. Testing must be performed within 4 hours after collection.

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Protein, CSF

Lab: WMC Chemistry Specimen: Spinal fluid Use: A reliable, but non-specific Availability: 24 hours Container: Sterile plastic transfer tubes provided in indicator of CNS pathology, TAT: Stat, 1 hour lumbar tray. including meningitis, brain Minimum Volume: 1 ml CSF abscess, CVA, MS, and other Collection: Normal lumbar puncture using established degenerative processes causing aseptic technique. Lumbar punctures are performed only neurologic disease. *CSF specimens from patients with suspected Creutzfeldt-Jakob Disease (CJD) by physicians. Limitations: Fresh blood in will be sent to the NC State Lab for testing. Storage: CSF should be refrigerated if testing is not specimen will invalidate the The sample will not be opened prior to performed immediately. Be sure to freeze all extra CSF protein result. Turbid samples shipping. in reference transfer tube in case more testing is ordered may exhibit a positive later. interference. Hemolyzed or Causes For Rejection: Improper labeling. See also xanthochromic samples may Limitations falsely depress results.

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Protein, Total Serum/Plasma

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: Evaluation of nutritional Availability: 24 hours Tube: SST, Plain red or Green (Li hep) status, to investigate edema TAT: Routine, 4 hours Minimum Volume: 2 ml Additional Information: Causes Stat, 1 hour Collection: Routine venipuncture of high total protein: dehydration, Storage: Separate serum from cells within 45 some cases of chronic liver Calculate Globulin: minutes. Refrigerate at 4˚ C disease, including chronic active TP – Albumin = Globulin Causes For Rejection: Hemolysis, improperly hepatitis and cirrhosis; A/G Ratio: Albumin divided by globulin labeled sample. neoplasms, especially myeloma. Causes of low total protein: pregnancy, IV fluids, cirrhosis or other liver disease, including chronic alcoholism; prolonged immobilization, heart failure, nephritic syndromes, glomerulonephritis; neoplasia, Crohn’s disease and chronic ulcerative colitis, starvation, malabsorption or malnutrition, hyperthyroidism; burns, severe skin disease; and other chronic diseases. Very low total protein, (<4 g/dl) and low albumin cause edema.

Prothrombin Time (PT)

Lab: WMC/CMH Coagulation Specimen: Citrated plasma Use: Evaluation of extrinsic Availability: 24 hours Tube: Sodium citrate (blue top) coagulation; screen for TAT: Routine, 2-4 hours Minimum Volume: Full tube , volume depends on congenital deficiencies of STAT, 1 hour tube factors II, V, VII, X; prothrombin CMH ED, 44 min Collection: Routine venipuncture. Fill tube until deficiency, dysfibrinogenemia, vacuum is exhausted. heparin, effect, coumarin effect, Synonyms: INR Storage: Test within 8 hours. liver failure, DIC, vitamin K Causes For Rejection: Clotted specimen, hemolysis, deficiency. under filled tubes, lipemia, improperly labeled sample. Limitations: Prothrombin

Protocols for anticoagulants are posted on times collected less than 2 hours the ARHS Intranet and are available to all after heparin administration will clinicians. Any clinician contacting the be prolonged. Many drugs laboratory for anticoagulant information will modify the effect of coumarin, be told the in-house testing available and including salicylates, then referred to the intranet/pharmacy for protocols or to the pathologist for further barbiturates, quinidine, questions. antacids, many antidepressants, and antibiotics.

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PTT (APTT)

Lab: WMC/CMH Coagulation Specimen: Citrated plasma Use: Evaluation of extrinsic Availability: 24 hours Tube: Sodium citrate (blue top) coagulation; screen for TAT: Routine, 2-4 hours Minimum Volume: full tube, volume depends on congenital and acquired STAT, 1 hour tube deficiencies of factors VIII, IX, Collection: Routine venipuncture. Collect blue tube after XI, and XII. Also the test used to Synonyms: APTT, Activated Partial another tube. This procedure avoids contamination of monitor heparin therapy. Thromboplastin Time the specimen with tissue thromboplastin. Fill tube until Limitations: PTT samples vacuum is exhausted. Storage: Test within 4 hours at collected less than 2 hours after room temperature. Causes For Rejection: Specimen heparin administration will be Protocols for anticoagulants are posted on older than 4 hours, clotted specimen, hemolysis, under prolonged. the ARHS Intranet and are available to all filled tubes, lipemia, improperly labeled sample clinicians. Any clinician contacting the laboratory for anticoagulant information will be told the in-house testing available and then referred to the intranet/pharmacy for protocols or to the pathologist for further questions.

PSA (Prostate Specific Antigen)

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Used to monitor disease Availability: 24 hours Tube: SST, Plain red or Green (Li hep) status in prostate cancer TAT: Routine, 4 hours Minimum Volume: 2 ml patients. Stat, 1 hour Collection: Routine venipuncture Additional Information: Storage: Separate serum from cells immediately. Elevated levels are found in Causes For Rejection: Improper labeling, wrong men with benign prostatic sample type. hypertrophy.

Renal Function Panel (RFP)

Lab: WMC/CMH Chemistry Lab Specimen: Serum or plasma Note: Please refer to individual Availability: 24 Hours Tube: SST, Plain red, Green (Li hep) tests for additional information. TAT: Routine, 4 Hours Minimum Volume: 5 ml Stat, 1 hour Collection: Routine venipuncture Causes For Rejection: Gross hemolysis, improperly Test Includes: Albumin, BUN, Calcium, labeled specimen

Chloride, CO2, Creatinine, Glucose, Phosphorous, Potassium, Sodium

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Respiratory Panel

U Lab: WMC/CMH Microbiology Specimen: Nasopharengeal Swab in UTM Availability: 24 Hours Tube: UTM Collection: Nasopharengeal collection TAT: Routine, 24 Hours Storage: Maintain specimen at room temperature for up to 24 hours Stat, 4 hour Causes For Rejection:, improperly labeled specimen, specimen not placed in transport within 1 hour after collection L a b

Reticulocyte Count

Lab: WMC/CMH Specimen: Whole Blood Use: Evaluate erythropoietic Hematology Tube: EDTA (lavender top tube) activity. Increased in acute and Availability: 24 Hours Minimum Volume: 2 ml Collection: chronic hemorrhage and TAT: Routine, 4 Hours Routine venipuncture hemolytic anemias. Evaluate Stat, 1 hour Storage: Maintain specimen at room temperature for response to antianemic therapy up to 24 hours Limitations: Reticulocytes may Causes For Rejection: Clotted specimen, hemolysis, decrease on a dilutional basis in specimens more than 24 hours old, insufficient transfused patients. volume, improperly labeled specimen.

RPR - VDRL

Lab: WMC Hematology Specimen: Serum or Plasma Use: Screening test for syphilis Availability: 24 hours Tube: SST, plain red, lavender, or green Note: If positive reflexes to TAT: 2 days Minimum Volume: 2 mL quantitative RPR and a Collection: Routine venipuncture confirmatory MHA-TP. Storage: 4oC Causes For Rejection: Hemolysis, lipemia, gross bacterial contamination, mislabeled specimen

RSV

Lab: WMC/CMH Microbiology Specimen: Nasopharyngeal swab Use: For the diagnosis of RSV Availability: 24 hours Minimum Volume: swab infections. TAT: Routine, 4 hours Collection: Nasal swab - insert swab into nostril (1 Stat, 1 hour inch), rotate swab against the nasal wall then remove.. Nasopharyngeal Swab - insert swab in the posterior nasopharynx and rotate then remove. For nasal wash, flush one nostril with 1.0 to 2.5mL normal saline. Allow fluid to run out of nostril into sterile container. Storage: Room temp Causes For Rejection: mislabeled specimen.

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Rubella

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Recommended for immune Availability: 24 hours Tube: SST, Plain red, or Green (Li hep) status determination. Additional TAT: 24 hours Minimum Volume: 2 mL Information: Rubella virus is the Collection: Routine venipuncture cause of German measles, Storage: 4˚C up to 7 days usually a mild exanthema, often Causes For Rejection: Hemolysis, lipemia, gross subclinical, however, when bacterial contamination acquired in utero, rubella virus can cause the congenital rubella syndrome, deafness, and mental retardation. For this reason, it is very important to immunize women before they have children. If a woman has antibodies against rubella, even of low titer, demonstrated by any of multiple methods, she need not worry about infection during subsequent pregnancy. If she is not immune, and is not pregnant, she can receive the rubella vaccine.

Salicylates, Serum

Lab: WMC/CMH Chemistry Specimen: Serum (CMH/WMC), heparinized Use: In the diagnosis of Availability: 24 hours daily plasma (WMC only) salicylate overdose and in TAT: Routine, 4 hours Tube: SST, Plain red (CMH/WMC); Green (Li hep. / monitoring salicylate therapy. Stat, 1 hour WMC only) Minimum Volume: 2ml Collection: Routine Venipuncture Causes For Rejection: improper labeling.

Sedimentation Rate (ESR)

Lab: WMC/CMH Hematology Specimen: Whole blood Use: Evaluate the non-specific Availability: 24 hours daily Tube: EDTA (lavender) activity of infections, inflammatory TAT: Routine, 4 hours Minimum Volume: 4 mL states, autoimmune disorders, Stat, 1 hour Collection: Routine venipuncture and plasma cell dyscrasias and

Storage: Room temperature for up to two hours; autoimmune disorders. Synonoms: Sed rate, Westergren Sed refrigerate at 4 °C up to 12 hours if testing is to be Additional Information: Rate, Erythrocyte Sedimentation Rate delayed Elevations in fibrinogen, alpha- Causes For Rejection: Obvious hemolysis, clotted and beta-globulins, and specimen, under-filled tube, specimen older than 12 immunoglobulins increase the

hours, improperly labeled specimen sedimentation of RBCs through Note: Best results are from blood less plasma. The test is important than 4 hours old. in the diagnosis of temporal arthritis, as well as its management.

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Semen Analysis

Lab: WMC Urinalysis Specimen: Semen must be collected after Use: Used as part of a fertility Availability: Mon-Fri 8am-4pm abstinence of at least 48 hours, but no more than 7 investigation, to aid diagnosis days of prostatic disease, and for the Container: Clean wide mouth plastic or glass presence of sperm after Container. Condoms are unacceptable as vasectomy. spermicides and lubricants interfere with test results Minimum Volume: Entire ejaculate Storage: Specimen must be kept warm (body temperature) and delivered to the lab within 30 minutes (4 hours for post vasectomy specimens). Causes For Rejection: Collected in unacceptable Container, improperly labeled, and not delivered to lab within required time frame.

Sodium, Urine

Lab: WMC/CMH Chemistry Specimen: Urine, random or timed Use: Work up depletion, acute Availability: 24 hours Container: Plastic urine Container, no preservative. renal failure, and acute oliguria. TAT: Routine, 4 hours Collection: For timed specimen, have patient void at 0800 and discard the first specimen, then collect all urine, including last specimen for the specified collection period. Label Container with patient’s name, date of birth, date and time started, date and time finished. Storage: Measure and record total volume on requisition, transfer aliquot (at least 5 mL) to a transfer tube, and label. Store at 4˚C. Causes For Rejection: Improperly labeled or collected specimen

Synovial Fluid Crystal Exam

Lab: Cytopathology Specimen: Synovial fluid. Use: Intracellular monosodium Request Form: Cytopathology Container: Specimen may be left in syringe (needle urate (MSU) crystals are observed Availability: 7am-5:00pm must be removed). in acute gouty arthritis. TAT: Same day, usually within an hour of Minimum Volume: 0.5 ml Methodology: Polarized light receiving the specimen. Collection: Aspirate must be label with two patient microscopy. Test Includes: Microscopic identifiers. examination of specimen for crystals Storage: Sample should be examined as soon as and inflammatory cells. possible. After hours refrigerate in Pathology rack in main lab refrigerator.

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Theophylline

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: monitor therapeutic drug Availability: 24 hours Tube: SST, Plain red or Green (Li hep) level. TAT: Routine, 4 hours Minimum Volume: 2 ml Limitations: Troleandomycin & Stat, 1 hour Collection: Routine venipuncture erythromycin may slow theophylline Storage: 2-8˚C elimination. Heart failure, liver Causes For Rejection: Hemolysis, gross lipemia, disease, prolonged fever, and improper labeling. obesity may have similar effects. Prolonged half-life occurs in premature infants. By contrast, half life is shortened in smokers, variable with Phenobarbital use.

Thyroid Profile

Lab: WMC Chemistry Specimen: Serum Use: A physiologic index of Availability: 24 hours TAT: Tube: SST or Plain red metabolic activity that correlates Routine, 4 hours Minimum Volume: 2 mL with free thyroxine (T4). Stat, 1 hour Collection: Routine venipuncture

Storage: If plain tube is used, allow to clot and Test Includes: Free T4, TSH centrifuge within 45 minutes of collection. Remove serum and store in a plastic transfer tube at 2-8˚C until testing is performed. Causes For Rejection: Plasma specimen , improper labeling

Tobramycin

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: To monitor drug levels Availability: 24 hours Tube: SST, Plain red or Green (Li hep) during therapy. TAT: Routine, 4 hours Minimum Volume: 2 mL Stat, 1 hour Collection: Routine venipuncture Causes For Rejection: Improperly labeled specimen.

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Triglycerides

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: Evaluation of Availability: 24 hours daily Tube: SST. Plain red or Green (Li hep). hyperlipidemia TAT: 4 hours Minimum Volume: 2 mL Limitations: The most Patient Preparation: Patient should be fasting for common cause of triglyceride 12-14 hours prior to specimen collection. increase is inadequate patient Collection: Routine venipuncture fasting. Storage: 4˚C. Separate serum from cells within 45 Additional Information: High minutes of collection. concentrations may occur with Causes For Rejection: Non-fasting specimen, hypothyroidism, nephrotic glycerinated tube used for collection, improper syndrome, glycogen storage labeling. diseases, and diabetes mellitus. Extremely high triglycerides are common in acute pancreatitis.

Troponin I

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: As part of the clinical Availability: 24 hours daily Tube: SST, Plain red or Green (Li hep) picture in the diagnosis of AMI. TAT: Routine, 4 hours Minimum Volume: 2 mL Limitations: Heterophilic Stat, 1 hour Collection: Routine venipuncture antibodies are known to cause CMH ED, 50 min Causes For Rejection: Incorrect specimen type or interference with immunoassays. improperly labeled specimen.

Type And Screen (ABO/Rh and Antibody Screen)

Lab: WMC/CMH Transfusion Service Specimen: Whole blood Use: To determine patient's blood Availability: 24 Hours Tube: EDTA (lavender) group and Rh and to detect the TAT: Routine, 4 Hours Minimum Volume: 5 mL presence of unexpected clinically Stat, 1 Hour Collection: Routine venipuncture. Specimen must significant antibodies, so that be labeled with patient's full name, Date of Birth, MR blood can be available quickly if a Test Includes: Blood group (ABO), Rh, number or SS number, date and time of collection, and crossmatch is required. and Antibody screen. initials of person collecting the specimen. Blood Bank Limitations: Abnormal Band must be completed at time of sample collection if proteins and cold or warm auto agglutinins, or unexpected sample will be used for crossmatch. antibodies in the patient’s Causes For Rejection: Improper labeling of sample, blood may cause delays in wrong sample type, hemolysis. interpretation. May not detect antibodies to low incidence antigens. Additional Information: If transfusion is expected the appropriate number of units must be ordered to be crossmatched.

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Tzanck Prep for Cytopathology

Lab: Cytopathology Specimen: Scraping of viral lesion. Use: In diagnosis of herpes Request Form: Cytopathology Container: Cytolyt® Vial or PreservCyt® ThinPrep vial. simplex virus. Availability: 5:00 am-5:00 pm Minimum Volume: 25 ml Collection: Scrap lesion with plastic applicator and rinse in Cytolyt® Vial or PreservCyt® ThinPrep vial. Specimen must be label with two patient identifiers. Storage: After hours put in Pathology rack in main lab refrigerator.

Uric Acid

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Uric acid is the end product Availability: 24 hours Tube: SST, Plain red or Green (Li hep) of purine metabolism. Elevations TAT: Routine, 4 hours Minimum Volume: 2 mL in uric acid occur in renal failure, prerenal azotemia, gout, lead Stat, 1 hour Collection: Routine venipuncture Patient Preparation: At least a 4-hour fast is poisoning, excessive cell preferred for routine testing. destruction (e.g., Storage: 2-8˚C. Separate cells from serum prior to chemo), hemolytic anemia, CHF storing. and after myocardial infarction. Causes For Rejection: Improperly labeled specimen

Urinalysis

Lab: WMC/CMH Urinalysis Specimen: Urine, random Use: Screen for abnormalities Availability: 24 hours Container: A clean plastic urine container is of urine, diagnose and manage TAT: Routine, 4 hours preferred renal disease, urinary tract infections, and systemic Stat, 1 hour Collection: A mid-stream, clean-voided specimen is preferred; catheterization diseases

Storage: Refrigerate if testing is to be delayed more Limitations: Insufficient Test Includes: Biochemical screening than 1 hour volume may limit extent of tests only. Microscopic examination is performed. Metabolites of performed if any screening tests are Causes For Rejection: Insufficient volume, pyridium may cause color positive or if otherwise indicated. bacterial overgrowth, improperly labeled specimen. interference with the dipstick reactions. High vitamin C intake may cause an underestimate of glucosuria, or a false negative nitrate test. Low osmolality, alkalinity, and lack of refrigeration decrease survival of WBC.

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Urinalysis-Complete

Lab: WMC/CMH Urinalysis Specimen: Urine, random Use: Screen for abnormalities of Availability: 24 hours Container: Sterile, plastic urine collection urine, diagnose and manage renal TAT: Routine, 4 hours container. disease, urinary tract infection, Minimum Volume: 12 mL is the standard amount used systemic diseases Limitations: Stat, 1 hour for testing to insure consistency, and all normal values Insufficient volume may limit are based upon a volume of 12 mL. extent of tests performed. Test Includes: Biochemical screening Collection: A mid-stream, clean voided specimen is Metabolites of pyridium may and a microscopic evaluation of formed preferred; catheterization cause color interference with the elements Storage: Refrigerate if testing is to be delayed more dipstick reactions. High vitamin C than 1 hour. intake may cause an Causes For Rejection: Decomposition or underestimate of glucosuria, or a overgrowth of bacteria, insufficient quantity, false negative nitrate test. Low improperly labeled specimen. osmolality, alkalinity, and lack of refrigeration decrease survival of WBC.

Urine Cytopathology

Lab: Cytopathology Specimen: Fresh urine or urine in Cytolyt ® Use: To establish the presence Request Form: Cytopathology container. of primary or metastatic Availability: Mon-Fri 5am-5:00 pm Container: Specimen Container available in neoplasms. To aid in the TAT: 24-48 hours cytopathology or central supply. diagnosis of infections. Minimum Volume: Not less than 10 ml. Clean Special Instructions: Be sure to catch voided or cath specimen. indicate on requisition whether Storage: If collected after hours, place in the specimen is voided or catheterized, Pathology rack in main lab refrigerator. from bladder, ureter, renal pelvic, Causes For Rejection: Improper fixation, 24 hour urethra, or bladder washing. collection.

Urine Drug Screen (Oxycodone ordered separately- see Oxycodone UDS)

Lab: WMC/CMH Chemistry Specimen: Urine Use: The detection of drugs of Availability: 24 hours Container: Clean plastic urine cup. abuse in urine TAT: Routine, 4 hours Minimum Volume: 10 ml Collection: The length of time following Stat, 1 hour Freshly voided sample drug use for which a positive Storage: If not tested immediately refrigerate for up to result may occur is dependent on 48 hours. several factors including the Drugs Tested: Causes For Rejection: Improperly labeled frequency and amount of usage, WMC : APAP, COC , MTD, AMP, OPI, specimen. metabolic rate, excretion rate, MAMP, PCP, BAR, THC, BZO and Limitations: Adulterants added to urine specimen may drug half-life and the user's age, TCA produce erroneous results. Substances and/or factors weight, activity and diet. may interfere with the test and cause false results. Drug For quantitation or confirmation CMH: AMP, BARB, BENZ, COC, OPI, PCP, levels below the analyte cut off may not be detected. a GC/MS should be ordered. Methadone and THC

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Valproic Acid (Depakote)

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Valproate controls absence, Availability: 24 hours Tube: SST, Plain red or Green (Li hep) myoclonic, and tonic-clonic TAT: Routine, 4 hours Minimum Volume:2 mL seizures in generalized, idiopathic, Stat, 1 hour Collection: Routine venipuncture. Peak: 1-4 hours and symptomatic epilepsy. after dose (influenced by meals); Trough: Additional Information: Synonyms: immediately prior to next dose (possibly more Hepatotoxicity may be fatal, but is Depakene, Depakote, Valproate useful than peak levels). idiosyncratic and not preventable Storage: Separate serum from cells and refrigerate by routinely monitoring liver at 2-8˚C. enzymes. Hepatotoxicity occurs in Causes For Rejection: Hemolysis, lipemia very young children, usually those on multiple anticonvulsants. Valproate cytopenias may be dose-related and warrant monitoring of CBCs during therapy.

Vancomycin

Lab: WMC/CMH Chemistry Specimen: Serum, heparinized plasma Use: To monitor drug therapy Availability: 24 hours Tube: SST, Plain red or Green (Li hep) TAT: Routine, 4 hours Minimum Volume: 2 mL Stat, 1 hour Collection: Routine venipuncture Causes For Rejection: Improperly labeled specimen.

Vitamin B12

Lab: WMC Chemistry Specimen: Serum, heparinized plasma Use: Detect B12 deficiency as in Availability: 24 hours Tube: SST, Plain red or Green (Li hep) pernicious anemia, diagnose folic TAT: 4 hours Minimum Volume: 2 mL acid deficiency, evaluate Collection: Routine venipuncture hypersegmentation of Storage: Separate serum from cells; store at 4˚C. granulocyte nuclei, diagnose Causes For Rejection: Improperly labeled macrocytic anemia, diagnose specimen, wrong specimen type or sample not megaloblastic anemia, evaluate properly stoppered. alcoholism, prenatal care, evaluate malabsorption, neurological disorders, or the elevation of B12 as seen in liver cell damage or myeloid leukemia. Limitations: Drugs capable of

interference with B12 and/or folic acid absorption include chemotherapeutic agents, diuretics, antibiotics, anticonvulsants, sedatives, oral contraceptives, and many others.

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Vitamin D Total (25-OH) Lab: WMC Chemistry Specimen: Serum Clinical Significance: Vitamin D is synthesized from Availability: 24 hours Tube: SST, Plain red TAT: 4 hours cholelsterol upon skin exposure to Minimum Volume: 5 mL UVB sunlight or through dietary intake. Vitamin D is hydroxylated in Patient Preparation: Fasting specimen preferred; the liver to form 25-OH Vitamin D must collect prior to Schilling’s test, transfusions, or which is further hydroxylated in the initiation of B12 therapy kidney to form the biologically active Collection: Routine venipuncture form, 1,25-(OH)2 Vitamin D. The active form is tightly regulated by plasma parathyroid hormone levels Storage: Separate serum from cells; store at and calcium and phosphorous 4˚C; specimen stable for 24 hours only levels. The active form, 1,25-(OH)2 Causes For Rejection: Improperly labeled Vitamin D, increases the intestinal specimen, wrong specimen type absorption of calcium and phosphorous, both are required for regulating bone metabolism. Vitamin D metabolites are bound to vitamin D binding protein and are circulated throughout the body. The concentration of 1,25(OH)2Vitamin D is 1000 times lower than 25-OH Vitamin D and has a half life of 4 hours. Due to its half life of 2-3 weeks, 25-OH Vitamin D is the metabolite that is the most reliable clinical indicator of vitamin D status. Also, 25-OH Vitamin D levels are indicative of the body’s storage levels of vitamin D and correlate with the clinical symptoms of vitamin D deficiency.

Wet Prep / KOH

Lab: CMH Urinalysis Specimen: Vaginal swab, nail clippings, hair, skin Use: Potassium hydroxide Availability: 24 hours scrapings digests or lyses epithelial cells, TAT: 4 hours Collection: WBCs, RBCs, mucus, and various other proteinaceous Vaginal Swab - swab the vaginal region and immerse debris, bleaches many pigments the swab into a vial containing 2mLs of 0.9% NaCl Nails and dissolves the “cement” that - clean with 70% alcohol, scrap away outer portion and holds keratinized cells together. obtain scrapings from the deeper infected areas. Place This permits detection of fungal in sterile container or on slide. Hair - remove at least 10 elements (yeast and pseudohyphae) that are intact hairs from infected area. Place in between two present in vaginal secretions glass slides. and keratinized tissue. Most Skin - clean with 70% alcohol. Scrap away the outer fungi can be demonstrated in portion and obtain scraping from the deeper infected the KOH preparation. areas. Place on a slide. Wet preps allow for microscopic observation of unfixed “wet Causes For Rejection: Improperly labeled mounts” of clinical specimens for specimen, vaginal swab not received in saline. the rapid detection of the presence of bacterial, fungal, and parasitic organisms. The presence of white blood cells and “clue cells” may also be identified.

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