Laboratory Services Manual, February 2020

LABORATORY SERVICES MANUAL TABLE OF CONTENTS

I LABRegOP7900 GENERAL INFORMATION I Laboratory Services at SHA Regina Sites ...... 1 II Hours of Operation ...... 2 III Laboratory Administration...... 2 IV Phlebotomy Services ...... 3 V Laboratory Requisitions...... 4 VI Test Priority ...... 6 VII Test Order Entry ...... 7 VIII Requisition Test Add-Ons or Changes ...... 7 IX Specimen Requirements...... 8 X Specimen Collection 1. Client Identification ...... 9 2. Transfusion Service Bands...... 10 3. Collection of Blood Specimens ...... 10 4. Specimen Labelling ...... 11 XI Transporting Specimens to the lab ...... 12 XII Specimen Rejection...... 12 XIII Laboratory Information System ...... 13 XIV Results Reporting...... 14 XV Types of Reports ...... 14 XVI Requests for Results ...... 15 XVII Availability of Tests “After Hours” ...... 15 XVIII Laboratory Tests Available on 24 Hour Basis ...... 16 XIX Turn Around Time ...... 16 XX Critical Values ...... 16 XXI Ordering Laboratory Tests ...... 17

APPENDIXES LABRegOP7109 Laboratory Specimen Portering Competency LABRegOP7109A1 Instructions for Portering Laboratory Specimens LABRegOP7109A2 Portering Laboratory Specimens Competency Quiz LABRegOP7109A3 Portering Laboratory Specimens Competency Quiz Answers LABPhlbOP7009A1 Sending Patient Specimens using the Pneumatic Tube LABAccnOP7027J1 Labeling requirements for CSF collection LABRegOP7900A3 Specimen collection Process FAQ LABRegOP7900A4 Lab Services for Inpatient Rehab and ECVAC Program LABRegOP7900A5 Specimen Collection Information for Health Care Practitioners Offices LABRegOP7900A6 Laboratory Common Test Quick Reference LABRegOP7900A7 Pediatric Collection Room Poster

Requisitions LABLisOP2001A2 Community Lab Requisition (RQHR 217) LABLisOP2003A4 RQHR Microbiology Community Requisition (RQHR 1275)

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LABLisOP2000A1 Rural/Referred-In Testing Lab Requisition (RQHR 1284) Semen Collection Fertility June 2019 RQHR 196 Semen Collection Post Vasectomy June 2019 RQHR 197

Critical Values: LABChemOP8200T1 Chemistry Critical Values LABHemaOP7019T1 Hematology Critical Values LABMicOP8000A1 Microbiology Critical Values LABTranOP7001W3Transfusions Critical Values LABHistOP1003 Anatomic Pathology Critical Results LABCytoOP7047Communication and Documentation of Cytopathology Critical Results LABRlabOP7900A2 Rural Lab Critical Results

Turn Around Times: LABChemOP8202C1 Chemistry Tests LABHemaOP7031C1 Guidelines for Expected TAT in Hematology LABMicOP8000A2 Anticipated TAT for Microbiology Tests LABTranQP7000W1 TAT for Requested Blood Products LABTranQP7000W2 TAT for Transfusion Tests LABRlabOP7900A3 Tests Performed at Rural RQHR sites

RQHR Policies and Procedures Identification of Client/Patient/Resident Policy Identification of Client/Patient/Resident Procedure

Roy Romanow Provincial Laboratory RRPL Test Request and Sample Requirements Poster RRPL Chemistry Requisition and Completion Instructions RRPL Microbiology Requisition and Completion Instructions

II LABChemOP7269 CHEMISTRY Purpose...... 1 Procedure ...... 1 Blood Specimens ...... 2 ACTH Stimulation Test (Rapid ACTH,Cortrosyn) ...... 2 Blood Ethanol...... 2 Blood Gases ...... 2 Dexamethasone Suppression Test ...... 3 Glucose Tolerance ...... 3 Growth Hormone Suppression Test ...... 4 Insulin...... 4 Urine Specimens…… ...... 5 Specimen Collection ...... 5 Urine Testing Notes ...... 6 Feces Specimens ...... 6 Feces Tests...... 6

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CSF Specimens ...... 7 Toxicology Specimens ...... 7 Fluid Specimens ...... 8 Specimen Collection ...... 8 Tests Performed ...... 8 Fluid Notes...... 8 Therapeutic Drug Testing ...... 9-11

LABChemOP7352A1 ACTH Stimulation Test LABChemOP7317A1 75 Gm Maternal Glucose Tolerance

III LABAccnOP7200 CYTOGENETICS I General Information ...... 1 II Blood Chromosome Studies...... 2 III Bone Marrow Studies...... 2 IV Amniotic Fluid Analysis...... 2 V Products of Conception Analysis ...... 3 VI Cord Blood Studies...... 3 VII Buccal Smears for Sex Chromatin Studies ...... 3 VIII Out Patient Services ...... 3

IV LABCytoOP7000 CYTOLOGY I Purpose...... 1 II Specimens – Types, Collection Methods, Identification and Labelling ...... 1 III Specimen Submission and Transportation ...... 2 IV Cytology Requisitions ...... 2 V Specimen Rejection Criteria...... 3 VI RQHR Cytology Laboratory Address and Hours of Operation ...... 3 VII General Techniques A. Pap Smears ...... 4 B. Sputum ...... 5 C. Bronchial Brushings ...... 6 D. Bronchial Washings ...... 6 E. Urine Specimens/Bladder Washings ...... 6 F. Serous Effusions (Pleural, Peritoneal, Pericardial Fluids) ...... 7 G. Cerebrospinal Fluids ...... 7 H. Abdominal and Pelvic Washings ...... 8 I. Gastrointestinal, Esophageal and Gastroesophageal Brushings ...... 8 J. Breast Secretions (Nipple Discharges) ...... 8 K. Joint Fluids ...... 9 L. Cyst Fluids ...... 9 M. Ocular Specimens ...... 9 N. Guided Fine Needle Aspiration Biopsies (Cat Scan, Ultrasound) Adequacy Check ...... 10 O. Fine Needle Aspiration Clinic, Pasqua Hospital...... 11

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V LABHemaOP7001 HEMATOLOGY Hematology I General Information ...... 1 II Requisition Forms ...... 1 III Collection of Specimens ...... 2 IV Bone Marrow Examinations ...... 2 V List of Tests Provided in Hematology ...... 3-4 VI Blood Required for Laboratory Tests ...... 5 VII Normal (Reference) Ranges ...... 6-9

LABHemaOP7037 Flowcytometry General Information ...... 1 Collection of Specimens ...... 1 List of Tests provided in Flowcytometry ...... 2

VI LABHistOP1000 HISTOPATHOLOGY Hours of Operation 1 I Submission of Tissues for Examination ...... 1 1. Routine Pathological Examination ...... 1 2. Urgent or Overnight Reports ...... 1 3. Tissues for Microbiological Examination Prior to Pathological Examination ...... 1 4. Tissues for Quick Section ...... 2 5. Tissue for Electron Microscopy ...... 2 6. Photography ...... 2 7. Immunofluorescence for Bound Immunoglobulin ...... 2 8. Lymph Nodes and Open Lung Biopsies ...... 3 9. Testicular Biopsies ...... 3 10. Amputated Limbs ...... 3 11. Specimens Sent to Lab after 1630 Hours ...... 3 12. Muscle Biopsies for Enzyme Histochemistry ...... 3 13. Nerve Biopsies ...... 3 14. Flow Cytometry ...... 4 15. Chromosome Studies ...... 4 16. Kidney Biopsies ...... 4 II Autopsies ...... 4 1. Coroner’s Cases ...... 4 2. Hospital Autopsies ...... 5 3. Courtesy Autopsies ...... 5 Consent for Autopsy ...... 5

VII LABMicOP7204 MICROBIOLOGY Hours of Operation ...... 1 Scope of Service...... 1 Specimens for Microbiology ...... 2 Reporting Results...... 3

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APPENDIXES LABMicOP7204A1 Specimen Containers for Microbiology LABMicOP7204A2 Microbiology Collection and Test Compendium LABMicOP7204A3 Sputum Collection LABMicOP7204A4 Stool Collection CEAC1256 Mid-stream Urine Collection Instructions for ADULT Patients CEAC1307 Mid-stream Urine Collection Instructions for Pediatric Patients LABMicOP7204T1 Criteria for Rejection of Microbiology Specimens LABMicOP7021 Collection of Blood Cultures

VIII LABTranOP7001 TRANSFUSIONS I Legal Responsibility...... 1 II Supply of Blood ...... 1 III Ordering Blood Transfusions...... 1 IV Issue of Blood ...... 3 V Patient Notification ...... 3 VI Blood Infusion ...... 3 VII Canceling Blood ...... 4 VIII Shortages of Blood...... 4 IX Emergent and Routine Transfusions ...... 4 X Confirmatory Blood Group ...... 5 XI Crossmatches for Surgery ...... 5 XII Cord Blood ...... 5 XIII Exchange Transfusion...... 5 XIV Neonate Transfusion ...... 6 XV Autologous and Directed Donations ...... 6 XVI Blood Required for Laboratory Tests ...... 6 XVII Adverse Effects of Transfusions ...... 7 XVIII Product Information ...... 10

APPENDIXES  LABTranOP7011 Use of the Transfusion Service Blood Band System  LABTranOP7011J1 Transfusion Service Blood Band Label Position Job Aid  LABTranOP7001W1 Canadian Blood Services Circular of Information  Massive Transfusion Protocol Algorithm

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Subject/Title: LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Last Approved Time: 01/31/2020 Revision: 4.10 Approving Authority: Manager Regulatory Affairs, Laboratory Services Contact for Interpretation: Regulatory Affairs Phone: (306) 766-4470

Current Version on Print Date

Policy

Process Control

Purpose

The purpose of this procedure is to provide instructions for the proper collection and handling of laboratory specimens. These instructions have been developed for those collecting specimens to be submitted to Saskatchewan Health Authority (SHA) Regina Qu’Appelle laboratories for analysis.

Procedure I Laboratory Services at SHA-Regina Sites

The laboratory at the Wascana Rehabilitation Centre functions as a specimen collection service only. All specimens are referred to other laboratories for processing.

The laboratory at the Pasqua Hospital consists of a:  Centralized Histopathology Laboratory  Centralized Cytopathology Laboratory  Autopsy Suite  Rapid Response Lab which offers stat service for a limited test menu in clinical pathology (Chemistry, Haematology and Transfusions)  Flowcytometry  Phlebotomy service  Accession service

The laboratory at the Regina General Hospital consists of a:  Centralized clinical pathology service (Chemistry, Haematology, Transfusions, Microbiology, Chemistry Specialized Testing)  Satellite Cytopathology service  Satellite Histopathology service which performs quick sections only on surgical specimens  Autopsy suite  Phlebotomy service  Accession service

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

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II Hours of Operation

The Wascana Rehabilitation Centre laboratory operates from 0730 to 1600 hours, Monday to Friday. It is closed on weekends and statutory holidays.

The Regina General Hospital and Pasqua Hospital laboratories operate 24 hours a day, seven days a week. Full services are available Monday to Friday, 0730 -1600 hours (there may be some variation in hours from one lab discipline to another), while a limited test menu is available outside of regular hours.

Laboratory services must not be abused. Routine work, whenever possible should be requested during the day shift. The staffing level during evenings, nights and weekends is greatly reduced and cannot accommodate excessive routine requests without jeopardizing the laboratory’s ability to respond to emergencies in a timely fashion.

III Laboratory Administration

The Medical Head, Laboratory Services and the Director-Operations, Laboratory Services are ultimately responsible for the overall operation of laboratory services in SHA-Regina Qu’Appelle.

The Director-Operations, Laboratory Services is responsible for the operation of the Laboratory Services financial management and human resources for laboratory services within the SHA in Regina and is responsible for the regulatory and safety requirements for all laboratories within SHA Regina Qu’Appelle.

The Manager, Regulatory Affairs, Laboratory Services, with the assistance of one supervisor, is responsible for all issues related to quality assurance, safety and regulatory requirements at all sites.

The Manager, Laboratory Information System, with the assistance of one supervisor, is responsible for management of the Laboratory Information System at all sites.

There are six Unit Managers. Responsibility for each laboratory discipline is assigned to the Unit Managers as follows:

 Unit Manager, Chemistry, with the assistance of two supervisors, is responsible for Chemistry, Specialized Chemistry and Point of Care Testing at all sites.  Unit Manager, Haematology/Transfusions, with the assistance of two supervisors, is responsible for Haematology and Transfusions services at all sites and Support Services at RGH Lab.  Unit Manager, Histopathology/Cytopathology, with the assistance of two supervisors, is responsible for Histopathology, Cytopathology and Lab Office services at all sites, and Support Services at Pasqua Lab.  Unit Manager, Microbiology, with the assistance of one supervisor, is responsible for Microbiology services at all sites.  Unit Manager, Laboratory Procurement Services, with the assistance of one supervisor, is responsible for Phlebotomy and Accession at all Regina Sites.  Unit Manager, Rural and Inter-Regional Support is responsible for Laboratory Services at the SHA Regina rural sites. LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

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Each laboratory discipline is also under the direction of a Medical Section Head that is a medically qualified specialist in his/her field of laboratory medicine.

All issues and concerns related to specific disciplines or services should be directed to the Unit Manager or supervisor responsible. Physicians should direct their concerns to the Medical Section Head of the specific laboratory discipline or the Medical Head, Laboratory Services.

IV Phlebotomy Services

Wascana Rehabilitation Centre

Collections begin at 0730 hours each morning on days the laboratory is in operation. Fasting blood work is collected first, followed by the remainder of the requests according to collection schedule. Additional requests that arise during the day should have requisitions delivered to the Lab Collection Centre for accessioning by 1200 noon.  Do NOT call the lab to inform them of NON-STAT orders. All requisitions are to be taken to the Lab by 1200 for same day testing and 1500 for next day testing.  Unit Clerk / Charge Nurse will call for STAT blood collection, STAT ECG or STAT x- ray to the Lab STAT call line 5555. Therefore, there may be interruptions in the scheduled work flow due to STAT lab work.

Refer to LABRegOP7900A4 Standard Work: Lab Services for Inpatient Rehab and EC/VAC Program

Regina General Hospital

Daily collection rounds are as follows:

0630 hours - all routine collections for which requisitions have been received are collected.

1030 hours - any routine orders that have accumulated between 0630 and 1030 hours will be collected during this round.

1300 hours - any routine orders that have accumulated between 1030 and 1300 hours will be collected during this round.

 Timed requests will be collected at the times specified throughout the day. STAT and URGENT requests will be collected throughout the day as the need arises.  Phlebotomy staff will respond STAT to Massive Transfusion Protocol, Trauma, Stroke, MI (Myocardial Infarction) and Other Life Threatening alerts.  Urgent requests for Initial Workup, Changed Condition, Medication Change, Missed or Lost Lab Work will be responded in a timely manner.  All routine orders will be batched according to the above schedule unless instructions to the contrary are communicated to the phlebotomists.

Pasqua Hospital

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 3 of 18 Last printed 1/31/2020 9:04 AM 0630 hours - all routine collections for which requisitions have been received are collected.

0900 hours and hourly until 2200 hours - all routine collections for which requisitions have been received in the laboratory are collected on each collection round.

V Laboratory Requisitions

1. All specimens must be accompanied by a completed requisition. Laboratory requisitions serve as a mechanism for placing a client test order in the Laboratory Information System (LIS).

RQHR Print- The following requisitions are available: shop order# RQHR In Hospital Chemistry / Hematology green 210744 RQHR Hospital Microbiology white 210746 Transfusions pink RQHR 1274 Semen for Fertility white RQHR 196 Semen for Post Vasectomy white RQHR 197 Flow Cytometry salmon RQHR 243 Surgical Pathology Consultation cream RQHR 221 Gastrointestinal Biopsy yellow RQHR 239 Prostate Biopsy cream RQHR 184 Women’s Health Centre Pathology cream RQHR 183 Cytology – Non Gynecologic canary RQHR 220 Cytology - Gynecologic mauve RQHR 694 RQHR Community Chemistry/Hematology blue RQHR 217 RQHR Community Microbiology grey RQHR 1275 Rural Referred In Testing Requests white RQHR 1284 choose appropriate Roy Romanow Provincial Laboratory requisition

2. To order requisitions contact the SHA Regina Print Shop at 306-766-5290.

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 4 of 18 Last printed 1/31/2020 9:04 AM 3. Orders for tests, which are referred to Roy Romanow Provincial Laboratory, must be submitted on the appropriate RRPL requisition. Do not use RQHR requisitions. To request requisitions for RRPL, call 306-787-3131 and select #7.

4. When completing requisitions:  Stamp the top right-hand corner for RQHR requisitions and top left hand corner for RRPL Requisitions with the client’s addressograph. In the absence of an addressograph, legibly print the required information. Be sure to include all of the following information:  Client’s first and last name  Date of birth (day/month/year)  MRN / HSN  Client’s address, and telephone number  Stay Number if In Patient  Gender  Ordering physician’s full first name, last name and address. Must print legibly.  In-patient location, or physician address for out-patients and referred-in specimens  indicate “copy to” physician, if required. Clearly indicate this physician’s full first and last name and location or return address. Must be printed legibly.  indicate the priority, i.e. stat, urgent, routine or timed  indicate date and time to be collected (when required)  indicate the diagnosis and other relevant information such as anticoagulant therapy, antibiotic therapy, therapeutic drug dosage or client’s height and weight.  If the specimen is for Flow Cytometry, record the nature of specimen, clinical history, clinical diagnosis, and procedure date. The requisition must be legibly signed by the physician performing the procedure.  if the specimen is for Surgical Pathology or Microbiology also record the nature of specimen, site of origin and complete relevant clinical history  if the specimen is for Cytology (Pap smear or Non-gynecological specimen), the nature of the specimen, the clinical history and treatment section of the requisition must be completely filled out  Cytopathology and Surgical Pathology requisitions must be legibly signed by the physician performing procedure.  indicate tests required. If test order is uncommon or unclear, verify test order for accuracy. For unusual test requests refer to the Laboratory Specimen Requirements in the Test Compendium on the RQHR Intranet or on the SHA internet website-RQHR. For tests not listed in the test compendium, contact the RRPL for client preparation and specimen collection requirements.

Following is a list of the more common tests referred to the Roy Romanow Provincial Laboratory:

ACTH (Adrenocorticotrophic hormone) Aldosterone ANCA Anti-Streptolysin O

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 5 of 18 Last printed 1/31/2020 9:04 AM Catecholamine Celiac Panel Chlamydia

DHEA-SO4 Fructosamine (Glycosylated Protein) Hantavirus Heavy Metals (lead, copper, mercury) – must specify HbsAg HCV Hepatitis A, B and C – must specify HIV Insulin Maternal testing (HIV, Rubella, VDRL, Hepatitis screen) Metanephrines Mycobacterium Culture (TB) Pertussis Culture PKU Testosterone Thyroid Antibodies Urine Drugs of Abuse Screen VDRL Viral Isolation Viral Serology – Rubella, Torch Screen (ToRC), Cytomegalovirus (CMV), Herpes, Legionella, Epstein- Barr virus, West Nile – must specify Viral Studies – respiratory and stool Vitamin D VMA, Catecholamine, 5HIAA (24 hr. Urines)

For more information regarding specimen collection and handling the RRPL compendium can be accessed in the link below:

https://rrpl-testviewer.ehealthsask.ca/

 all changes made to a requisition must be authorized and initialled by the nursing staff making the change.

VI Test Priority

The terms STAT, Urgent, Routine and Timed Collection will be used consistently when ordering laboratory tests.

STAT - refers to life threatening medical emergencies. Laboratory staff give top priority to STAT requests at the expense of other orders, therefore this priority should only be used when absolutely necessary.

Urgent - refers to tests that are required as soon as possible but are not involved in life threatening medical emergencies.

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 6 of 18 Last printed 1/31/2020 9:04 AM Routine – these specimens are processed after STATs and Urgent collections.

Timed - used when specimens are to be collected at specified times of the day as indicated on the requisition. Timed collections are ordered in the following instances only: - pre-op bloodwork - special procedures (eg: angioplasty, ACTH stimulation tests) - TPN bloodwork - timed drug levels - INR - timed due to medication adjustment - CK, Troponin ordered as per physician request for CCU protocol

VII Test Order Entry for In Hospital Collections

In SHA Regina Laboratory Services, laboratory test orders must be data entered (accessioned) into the Laboratory Information System (LIS) before the blood specimen is collected. At the RGH and Pasqua sites, patient identification will be confirmed at the time of collection using the SoftID electronic identification system.

It is the responsibility of the client service area to ensure that requisitions for routine, timed and urgent blood tests are sent to the laboratory well in advance of the required time of collection.

Requisitions should be in the laboratory no later than 2100 hours the day prior to collection to facilitate processing the AM blood work.

Requisitions received after 2100 hours may not be entered in time for collection on the first A.M. collection run. Occasional exceptions may occur for critical care areas.

Requisitions for blood work on new admission patients should be delivered to the lab. When this is not possible due to work load during the night shift, mark the requisition with “New Admission” and FAX it to the lab to be data entered into the LIS for the Morning Collection.

The requisitions for next day collections are accessioned into the LIS throughout the day and evening. A daily log of patients entered into the LIS is printed each morning at 4:00 AM to Phlebotomy. Phlebotomy faxes this daily log to the nursing units so that they can confirm which requisitions have been sent to the lab for the AM Collection run (morning swarm). The daily log can be used to avoid sending duplicate requisitions for patient collection, thus avoiding patients being collected twice for the same order.

Urines and Microbiology swabs will be entered into the LIS post-Collection.

For STAT collections:

1. First - FAX all STAT requisitions to the Lab for data entry into the LIS. RGH FAX 766-4307 Pasqua FAX 766-2223 2. Second - Call the STAT phone number to notify the Phlebotomist of the STAT collection. LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 7 of 18 Last printed 1/31/2020 9:04 AM RGH phone 766-1658 Pasqua phone 766-8412

The phlebotomist will always confirm that the STAT requisition has been faxed to lab for data entry into the Laboratory Information System.

VIII Requisition Test Add-Ons or Changes

Call the Laboratory, as indicated below, with any additions or changes to tests on a requisition that has already been sent to the laboratory. These additions must be data entered into the LIS before collection, if additional specimen tubes are required.

At the RGH, For Add-On tests: BEFORE the specimen has been collected, call Accession at 4495

AFTER the specimen has been collected, call: Chemistry at 4490. Select option 2 to add on orders. OR Hematology at 4477

At the PASQUA, For ALL Add-On tests, call: Chemistry at 2256. Select option 2 to add on orders. OR Hematology at 2631

Tests Which May be Added On

Chemistry tests can be added on to previous chemistry orders, in most circumstances. However, Ammonia, Blood Gases, ETOH, High Sensitivity Troponin I, Lactate, BNP and certain drug levels cannot be added on.

Blood Cultures cannot be added onto previously collected test requests.

Coagulation tests (INR, APTT, D-Dimer) cannot be added onto a previously collected order unless a blue top coagulation tube was drawn. If the coagulation tube has been opened, a D-Dimer may be added for up to 4 hours after the time of collection. If the coagulation tube has not been opened, a D-Dimer may be added up to 24 hrs. after the time of collection.

Hematology tests may be added onto a previously collected Hematology EDTA tube within the last 24 hours.

IX Specimen Requirements

Care must be taken to ensure the appropriate specimen container or media is submitted when collecting all Laboratory tests. (e.g. APTIMA media is used for Sexually Transmitted Infections, eSWABs are used for certain Microbiology tests).

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 8 of 18 Last printed 1/31/2020 9:04 AM Specimens that are being sent to a referral lab such as Roy Romanow Provincial Lab (RRPL) must be collected and handled according to the referral lab’s requirements, including the use of the correct requisition.

A chart containing the container/ tube type, and collection instructions for commonly ordered lab tests can be found in the appendixes to this procedure LABRegOP7900A6 Laboratory Common Test Quick Reference.

Many of the specimen requirements for laboratory tests can be found in the Test Compendium (RQHR Lab Specimen Requirements) which is found in the Laboratory Services Manual located on the RQHR Intranet and can be accessed in the link below:

https://rqh.labqms.com/labFrame.asp?DID=4194&FLDVr=293

or on the SHA Website-RQHR by accessing the below link:

http://www.rqhealth.ca/service- lines/master/files/rqhr_lab_specimen_requirements.pdf

The requirements for Microbiology specimens are located on the RQHR Intranet under Laboratory and can be accessed in the link below:

http://rhdintranet.rqhealth.ca/lab/public/Manuals/Manual/LABMicOP7204A2%20MICR OBIOLOGY%20COLLECTION%20and%20TEST%20COMPENDIUM.pdf

or on the SHA Website- RQHR at the following link:

http://rhdintranet.rqhealth.ca/lab/public/Manuals/Manual/LABMicOP7204A2%20MICR OBIOLOGY%20COLLECTION%20and%20TEST%20COMPENDIUM.pdf

Microbiology specimen collection requirements for testing referred to Roy Romanow Provincial Laboratory can be found on the back of the RRPL Microbiology requisition or by accessing the link below which provides requirements for all specimens referred to RRPL and RRPL requisitions:

https://rrpl-testviewer.ehealthsask.ca/

X Specimen Collection

1. Client Identification

Client identification must be confirmed using two client identifiers by all physicians and staff prior to the collection of all laboratory specimens.

Client identification is a process that includes confirmation of at least two client identifiers through observation of documented identifiers, then requesting the client to recite their first and last name and date of birth when the client is able to participate in the identification process. Best practice for client identification is to actively involve the client. LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

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Two client identifiers include the first and last name, and a unique identifying number. The unique identifying number consists of the Health Services Number (HSN) or Medical Record Number (MRN). For Transfusions specimens also include the client’s date of birth as a third identifier.

Confirm the client’s identity by checking the first and last name and the MRN (or HSN) on the requisition against the first and last name and MRN (or HSN) on the client’s armband.

The client’s room or bed number must not be used as an identifier.

Clients presenting to a Specimen Collection area without an armband, must present their pink form completed by Registration and Information Services (In Hospital) or HSN card to confirm their first and last name and HSN. Ensure the identifiers match the corresponding identifiers on the requisition.

Long Term Care residents without an armband must be positively identified by a staff member who is familiar with the client. Identification must be documented by a signature of the identifier on the requisition prior to specimen collection. Requisitions signed only by the specimen collector will denote responsibility for both identification and specimen collection.

2. Transfusion Service Blood Band

A Transfusion Service Blood band must be used when a group and antibody screen is ordered on a patient who is not staying in the hospital (pre-admission, outpatient transfusion, Emergency, Wascana Rehab Centre) or on a patient who may be transferred to another facility for diagnostic procedures.

For instructions on using the Transfusion Service Blood Band, refer to the procedure LABTranOP7011Use of the Transfusion Service Blood Band System found in the Transfusions section of this Manual.

3. Collection of Blood Specimens

When drawing blood from indwelling line (e.g. arterial, PICC, Hickman, etc.), discard at least the first 7 ml of blood in the case of an adult and 3 ml of blood in the case of a child. It will often be contaminated with heparin, which will interfere with many analyses.

To ensure that specimen integrity is maintained collect the specimen tubes in the following order:

 Blood cultures (Aerobic then Anaerobic)  Blue top tube with citrate for coagulation (completely fill the tube)  Serum tube with or without clot activator, with or without gel-

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 10 of 18 Last printed 1/31/2020 9:04 AM Yellow Serum Separator Tube (SST) with gel, or Red top tube, or Orange Rapid Serum Tube (RST)  Green top tube with heparin  Mauve top tube with EDTA  Tube with other additives (e.g. grey top tube)

Gently invert all the tubes 5 times to mix the blood with the additives immediately after collection. To invert turn the filled tube upside-down and then return it to an upright position.

When using a winged blood collection set (butterfly) for drawing a coagulation (citrate) tube by venipuncture, a partially filled discard tube must be used first. This discard tube will draw blood into the air space of the tubing which would otherwise be drawn into the citrate tube and displace blood volume. The use of a discard tube or a serum tube for other laboratory tests prior to drawing a citrated blue top tube for coagulation will ensure the correct blood-to-additive ratio.

If blood is to be drawn into a syringe and transferred into a vacutainer tube, the transfer should occur immediately following phlebotomy. If there is a delay, the specimen will begin to clot or cellular elements will begin to separate from the plasma leading to erroneous results.  Use the BD Blood Transfer Device (female luer adapter).  Collect the blood into the syringe and ensure that the safety mechanism has been activated.  Disconnect the syringe from the needle and discard the needle.  Attach the Transfer Device to the syringe.  With the syringe tip facing down, insert the vacutainer tubes into the transfer device. Allow the blood to transfer from the syringe to the tube using the tube’s vacuum. Do not depress the plunger of the syringe.  Do not unthread syringe from the transfer device after use. Dispose of the syringe and transfer device as one piece in a sharps container.

4. Specimen Labelling

Do not pre-label the tubes

Label all specimens in the immediate presence of the client at the time of collection.

 Blood samples: Label tubes from the armband / requisition with the client’s first and last name and the MRN (or HSN). Specimens for crossmatches, group and reserve serum or group and Rh, DAT, Transfusion Reaction Investigation and Cold Agglutinin Testing must also be labelled with the client’s date of birth.

The signature of the person collecting the specimen, and the date and time of collection must be recorded on each requisition when the collection has been completed. For Pink Transfusion requisitions, the person performing the phlebotomy MUST sign the requisition with the date and time of collection.

Record if the specimen was collected from a “line” on the requisition. LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

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 Cord blood specimens: Label cord blood gases with the mother’s last name and the mother’s MRN. Label cord blood specimens with the baby’s last name and the baby’s MRN. Record the date and time of collection on the requisition.

 Blood gases, urines, swabs, blood cultures, stools and body fluids are collected in containers that do not lend themselves to easy labelling. Specimens collected within the hospital will be accepted if labelled with the numbered tear-off requisition label from the in-hospital requisitions and the client’s first and last name and MRN is recorded on the label. Record the date and time of collection and the initials of the person collecting the specimen on the requisition. For all other specimens must be labelled from the armband / requisition with the client’s first and last name and the MRN (or HSN).

 Tissue specimens for Histological examination must be labelled with first and last name of client, MRN/HSN, surgeon/physician, nursing unit/clinic, nature of specimen, site of origin and date of surgery/collection. See section V. Laboratory Requisitions for requisition completion instructions.

 Specimens for Cytology must be labelled with: Pap smear:  first and last name  health services number or date of birth or medical record number  labelling must be done with a lead pencil on the frosted end of the glass slide (pen-type inks tend to fade/wash off during processing)

Non-gynecological specimens:  first and last name  health services number or date of birth or medical record number  date of collection  nature of specimen

 Cerebral Spinal Fluids are collected and labelled according to the order they are collected. The Lumbar Puncture Tray is equipped with four prelabelled specimen vials numbered 1 to 4 on one side, and marked for measurement in ml on the other. For accurate testing, it is important to indicate the order in which the CSF tubes have been collected (e.g. #1, #2, #3, #4), so that the appropriately numbered tube is used for each test as requested. This can be achieved by using the prelabelled tubes in the correct order or by writing the number on the adhesive labels from the requisition. In addition to indicating the order of collection number on each tube, ensure the specimens are labelled with the patient’s first and last name and MRN. Refer to the appendix to this procedure LABAccnOP7027J1 Labelling requirements for CSF collection.

Physician’s offices should refer to LABRegOP7900A5 Specimen Collection Information for Healthcare Practitioners Offices for additional information.

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 12 of 18 Last printed 1/31/2020 9:04 AM Please refer to Individual Lab Sections following this document, in the Lab Services Manual, for additional information.

XI Transporting Specimens to the Lab

All laboratory specimens and containers should be considered contaminated. Ensure that all containers with screw cap lids have the lid threaded properly and ensure the lid is tightly sealed. Gross contamination of specimen containers must be removed prior to transport (i.e. wipe visible contamination from specimen container with cotton ball soaked in 0.5% hypochlorite solution or Oxivir/Virox working solution or use an alcohol swab). Each specimen should be placed in a sealed clear plastic zip lock bag and the corresponding requisition should be placed in the side pouch of the clear plastic zip lock bag. Always perform proper Hand Hygiene following handling of specimens.

For further information concerning the delivery of specimens to the laboratory, refer to the appendix for LABRegOP7109A1 Instructions for Portering Laboratory Specimens.

XII Specimen Rejection

Specimens must be correctly labelled, of acceptable quality and quantity and be accompanied by a correctly completed requisition before they can be accepted for processing. When specimens do not meet the criteria established by Laboratory Services, a decision must be made to accept or reject the specimen based on the type of the discrepancy, whether it can be resolved satisfactorily, and the nature of the specimen and the degree of difficulty in obtaining another specimen.

XIII Laboratory Information System

Laboratory Services has a Laboratory Information System (LIS) in place. The LIS is a vital component to laboratory consolidation in the city of Regina and allows Laboratory Services to centralize clinical pathology at the Regina General Hospital and anatomic pathology at the Pasqua Hospital. LIS has also been implemented at SHA-Regina Qu’Appelle Lab Services Rural Sites.

The use of bar code labels reduces the risk of specimen identification errors. The process of ordering laboratory tests is simplified through the use of standardized requisitions that combine many tests into fewer forms.

The Regina General Hospital and Pasqua Hospital laboratories are fully computerized. Specimens referred to either site from the community, centres outside of Regina, or other hospitals will be processed in a computerized environment. Therefore, standardized requisitions should be used to order tests and users can expect to see test results on computer generated reports. Many physicians in Regina and throughout Saskatchewan receive laboratory results by EMR (Electronic Medical Record).

Glossary of Terms

LIS - Laboratory Information System

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 13 of 18 Last printed 1/31/2020 9:04 AM Accession - the process whereby an order is entered into the laboratory computer system and assigned an Order Number. This is a function performed by laboratory personnel. The Order Number will appear on reports.

MRN / HIN - clients are given a seven digit Hospital Identification Number (HIN) when they enter a hospital in the Regina Qu’Appelle Health Region. In the LIS, all references to the HIN are noted as MRN (Medical Record Number). These terms are used interchangeably.

Stay Number - is an eight-digit number generated by SHA-Regina hospital computer systems (Admission/Discharge/Transfer systems) and is unique to each client stay in the hospital.

Interim Report - contains partial results from a single order. Biochemistry/Haematology reports will be flagged in the top right-hand corner as “INTERIM”. In the case of Microbiology reports, each individual test result will be identified as “INTERIM” or “FINAL”.

Final Report - contains all results from a single order. It contains all of the information that has been previously reported on an Interim Report. It is flagged with “FINAL” in the top right-hand corner of the report. All new results that have not previously been reported will be flagged with an asterisk (*).

HSN – is a nine digit Provincial Health Services Number

XIV Results Reporting

Printers are in place on most nursing units at the Regina General Hospital, Pasqua Hospital, Wascana Rehabilitation Centre and some physician offices. Results print directly to the nursing unit in these locations.

The following wards are paperless and only receive patient reports through SCM (Sunrise Clinical Manager):

D-3B, D-3BO, D-3D, D-3DO, D-4A, D-4AO, D-4B, D-4BO, D-MSU, C-3E, C-5E, C-5EO, C-6F, C-6FO, C-NC, C-SCN.

The ER does not attach Lab reports to patient charts any longer. Nursing units are instructed to look up patient lab results on SCM.

Many physicians in Regina and throughout Saskatchewan receive laboratory results by EMR (Electronic Medical Record) or by verified fax. Any locations not having a printer/fax or EMR will have reports delivered via the Mail Messenger service, pneumatic tube system or Canada Post.

Results from STAT, Urgent, Timed and Routine requests print or are available in SCM as soon as they are verified.

1. Biochemistry/Haematology Report

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 14 of 18 Last printed 1/31/2020 9:04 AM Biochemistry and Haematology results are combined on the same report. The reference range for each test will be shown in the right-hand column of the report. The range shown is appropriate for the age and sex of the client. Abnormal results are flagged with abnormal codes such as “C”, “L” or “H”. A key at the bottom of the report explains each code.

2. Microbiology Report When a specimen culture yields a pathogenic organism, a list of antibiotics to which the organism is sensitive is recorded at the bottom of the report.

Each individual test on a Microbiology report will be flagged as “interim” or “Final”.

3. Transfusion Report The Blood Bank Report is cumulative in nature for a given order. The report contains the Blood Group, Rh and antibody screen and a list of blood products which are available, issued or transfused.

A “Transfusion Record Tag” (a 2 part record) is issued with each blood component/product. If the component/product is infused, the “Transfusion Record Tag” is permanently filed in the client’s Health Record by attaching it to a Laboratory Reports form.

XV Types of Reports

The LIS provides the following four types of reports; Interim, Final, Cumulative and Discharge Report. The type of report will be indicated in the top-right corner of the report.

Interim - contains partial results of an order. It can be discarded when the Final Report is received.

Final - contains all results for an order (except tests referred to Roy Romanow Provincial Laboratory). Results not previously printed are flagged with an asterisk (*).

Cumulative Report - available upon request only. This is a report, which is formatted in four columns containing results of the last four orders on a client.

Discharge Report - prints upon discharge. This report prints in Health Records only and is a summary of all Chemistry and Haematology tests done during a client in hospital stay. New results obtained after discharge will be reported and sent to the physician and Health Records on a report called “New Results after Discharge”.

XVI Requests For Results

Laboratory test results are printed or are available in SCM as soon as they are verified. Check the “Lab Results Viewer” if available. Do not phone for results unless there is an unusual delay in receiving a report.

When it is necessary to phone for:

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 15 of 18 Last printed 1/31/2020 9:04 AM  clinical pathology (Chemistry, Haematology, Microbiology, Transfusions) results call the Inquiry Centre at local 8900  anatomic pathology results call local 2240

XVII Availability of Tests “After Hours”

The laboratory is staffed continuously seven days a week. After 1600 - 0015 hours, staff is considerably fewer in number than the daytime staff and after 0015 hours only limited staff are on duty. IT IS IN EVERYONE'S INTEREST TO RESTRICT TESTING AFTER HOURS TO ESSENTIAL WORK ONLY. Clinicians gain by getting improved turn round times on urgent tests; the laboratory gains by increased efficiency.

Please refer to section XVIII for tests available on a 24-hour basis. Several points should be noted when ordering tests from this list during the evening and night shifts.

1. The tests listed should only be used when the performance is necessary for the diagnosis or therapy at the time the request is made.

2. From time to time there may be an urgent need for tests not on the list. When this is the case, the clinician in charge should phone the pathologist or professional on call for the relevant laboratory section. If the test is needed and can be performed he/she will then authorize the technologist to perform the test. It will be understood that this provision must be used sparingly. The name and cell phone number for the individual on call is available on the SHA Regina (RQHR) Intranet Home page by clicking on the on-call lists tab on the left hand side of the screen or can be obtained by calling laboratory personnel.

3. When it is possible to predict that an esoteric test will be required out-of-hours, advance warning should be given to the professional head of the laboratory section concerned.

XVIII Laboratory Tests Available On 24-Hour Basis

A. Chemistry

Refer to “CHEMISTRY TESTS” in the appendix for 24 hr. test availability.

B. Hematology

Refer to “GUIDELINES FOR EXPECTED TURN AROUND TIMES IN HEMATOLOGY” in the appendix for 24 hr test availability.

C. Transfusions

1. Group and screens 2. Direct antiglobulin test 3. Transfusion Reaction Testing

D. Microbiology

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 16 of 18 Last printed 1/31/2020 9:04 AM 1. Stat Gram stain and culture of the following: - all aspirated fluids including CSF - all tissues - other specimens on physician’s request 2. Processing of positive blood cultures

XIX Turn Around Time (TAT)

TAT for the purpose of this document and unless otherwise indicated is defined as the interval between the time the specimen is collected by phlebotomy to reporting of the test result.

Lab services will strive to meet this target for at least 90% of STAT orders. The reader must be aware that circumstances will occasionally arise that will limit the ability to meet these deadlines i.e. equipment failure, excessive volume of STAT orders, limited staff coverage on certain shifts.

The expected Turn Around Times for the Chemistry, Hematology, Microbiology and Transfusions departments are listed in the appendix to this procedure. These TAT are for in hospital clients. For clinic or referred in specimens, the routine TAT is 24-72 hours.

XX Critical Values

When results fall within ranges identified as “Critical”, laboratory staff will telephone verified results to the nurse on the unit concerned or to the physician, or in the case of out-patient or referred-in specimens to the Requesting Physician’s clinic or office to communicate the results. A statement will be made to the effect that the result is seriously abnormal and that the Requesting physician should be notified immediately. Each critical value communicated verbally or by phone will be verified by having the listener read back each result to confirm the accuracy of the transmission.

When critical results are sent electronically through the LIS or by FAX, the laboratory will telephone to confirm receipt of the critical result.

The physician/RN(NP)/clinical personnel responsible for the patient’s care, that receives the critical value will provide their first name and first initial of last name for documentation of communication.

For critical values listed by department, please refer to the appendix.

XXI Ordering Laboratory Tests

When ordering laboratory tests that are not on the requisitions consult the test compendium for abbreviations of laboratory tests or write the name in full. The abbreviations can be found in the Test Compendium by accessing the link below:

RQHR Laboratory Specimen Requirements-

http://www.rqhealth.ca/service- lines/master/files/rqhr_lab_specimen_requirements.pdf LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 17 of 18 Last printed 1/31/2020 9:04 AM

Related documents

1. LABRegOP2109 Review and Distribution of Lab Services Manual 2. LABRegOP3651 Triage and Treatment Manual 3. LABPhlbOP7017 Protocol for Performing a Venipuncture 4. LABLisOP8007T1 Test Compendium 5. RQHR Identification of Client/Patient/Resident Policy and Procedure http://rhdintranet/hsl/public/RQHRpolproman/612pol.pdf

Appendixes

1. LABRegOP7109 Laboratory Specimen Portering Competency 2. LABRegOP7109A1Instructions for Portering Laboratory Specimens 3. LABRegOP7109A2 Portering Laboratory Specimens Competency Quiz 4. LABRegOP7109A3 Portering Laboratory Specimens Competency Quiz Answers 5. LABPhlbOP7009A1 Sending Patient Specimens using the Pneumatic Tube 6. LABChemOP8200T1Chemistry Critical Values 7. LABHemaOP7019T1Hematology Critical Values 8. LABMicOP8000A1 Microbiology Critical Values 9. LABTranOP7001W3Transfusions Critical Values 10. LABHistOP1003 Anatomic Pathology Critical Results 11. LABCytoOP7047 Communication and Documentation of Cytopathology Critical Results 12. LABRlabOP7900A2Rural Laboratories Critical Results 13. LABChemOP8202C1Chemistry Tests (Tests, Turn Around Times, 24 hr Availability and testing site) 14. LABHemaOP7031C1Guidelines for Expected Turn Around Times in Hematology (Tests, Turn Around Times, 24 hr Availability and testing site) 15. LABMicOP8000A2Anticipated Turn Around Times for Microbiology Tests 16. LABTranQP7000W2Turn Around Time (TAT) for Transfusions 17. LABTranQP7000W1 Turn Around Time (TAT) for Requested Blood Products 18. LABRlabOP7900A3 Tests Performed by Rural Laboratories 19. LABAccnOP7027J1 Labelling CSF specimens at the time of collection 20. LABRegOP7900A3 Specimen Collection Process FAQ 21. LABRegOP7900A4 Standard Work: Lab Services for Inpatient Rehab and EC/VAC Program 22. LABRegOP7900A5 Specimen Collection Information for Health Care Practitioners Offices 23. LABRegOP7900A6 Laboratory Common Test Quick Reference

Revision History

Found in SoftTech Health Lab QMS™ Document Management System

Author

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 18 of 18 Last printed 1/31/2020 9:04 AM Revised Leanne Gammel, MLT

LABRegOP7900.4.1 LAB SERVICES MANUAL GENERAL INFORMATION Laboratory Services Regina QuAppelle Health Region

Page 19 of 18 Last printed 1/31/2020 9:04 AM

Subject/Title: LABRegOP7109.1.2 Laboratory Specimen Portering Competency Last Approved Time: 11/23/2018 Revision: 1.20 Approving Authority: Manager Regulatory Affairs, Laboratory Services Contact for Interpretation: Regulatory Affairs Phone: (306) 766-4470

Current Version on Print Date

Policy

Process Control

Purpose

This procedure provides instruction for competency assessment of portering staff members who are transporting patient specimens to the laboratory. All RQHR staff that transport patient specimens to the laboratory must read the instruction sheets for Portering Specimens and Sending Patient Samples using the Pneumatic Tube, then complete the quiz.

Procedure

STEP ACTION 1. Read LABRegOP7109A1 Instructions for Portering Laboratory Specimens 2. Read LABPhlbOP7009A1 Sending Patient Samples in Using the Pneumatic Tube 3. Complete LABRegOP7109A2 Portering Laboratory Specimens Competency Quiz using the e-Quiz function of the Intranet. Log onto RQHR Intranet e-Quiz/Attendance.

Related documents

1. LABPhlbOP7009A1 Sending Patient Samples Using the Pneumatic Tube

Appendixes (charts, form, job aids, labels, logs, tables, tags, worksheets)

1. LABRegOP7109 A1 Instructions for Portering Laboratory Specimens 2. LABRegOP7109 A2 Portering Laboratory Specimens Competency Quiz 3. LABRegOP7109 A3 Portering Laboratory Specimens Competency Quiz Answers

Revision History

LABRegOP7109.1.2 Laboratory Specimen Portering Competency Laboratory Services Regina QuAppelle Health Region

Page 1 of 2 Last printed 8/15/2019 11:03 AM

Found in Softtech Health Lab QMS™ Document Management System

Author

Marsh, Virginia, MLT, CAdmin, CCE Reviewed Laura Sanftleben, MLT Reviewed L. Gammel MLT

LABRegOP7109.1.2 Laboratory Specimen Portering Competency Laboratory Services Regina QuAppelle Health Region

Page 2 of 2 Last printed 8/15/2019 11:03 AM

Instructions for Portering Laboratory Specimens

Proper transportation of laboratory specimens is a vital link in providing RQHR patients with timely accurate test results. This document provides instruction on the safe transportation of laboratory specimens from the various departments and wards to the laboratory.

Precautions

 Confidentiality of patient information on specimens must be maintained during transport. (i.e. name should not be visible)  All laboratory specimens and containers are considered contaminated.  Prior to transport ensure that all specimen containers with screw tops and caps are securely fastened to prevent leaking.  Grossly contaminated specimen containers or requisitions should not be accepted for transport.  Each specimen should be in a sealed Biohazard bag and the corresponding requisition should be placed in the side pouch of the Biohazard bag.  Always perform proper Hand Hygiene following handling of specimens.

Transport

 Transport patient specimens directly to the laboratory.  Refer to the Lab Services Manual for specific specimen transport storage and time requirements.  Drop off all laboratory specimens at the Accession counter.  Exceptions include: o Blood gas specimens should be delivered directly to the chemistry department and a technologist notified of their arrival. o Pathology specimens which are delivered to the Histopathology / Cytology department. o STAT specimens physically handed over to a person within the laboratory.  Transport via pneumatic tube following the instructions Sending Patient Samples Using the Pneumatic Tube.  All specimens must be accompanied by an appropriately completed requisition.

LABRegOP7109A1.1.6 Instructions for Portering Lab Specimens Page 1 of 2 Laboratory Services Regina Qu'Appelle Health Region Last printed 9/1/2017 5:03 PM

After Hours

 Regular day shift hours are 0730-1600.  RGH – Outside of day shift hours continue to deliver specimens to the Accession desk in Laboratory Services. If you cannot access the laboratory, ring the buzzer at the door and wait for lab staff to answer. If the lab staff are unavailable, please call 4490 or 4477.  Pasqua – Outside of day shift hours, continue to deliver specimens to the Accession desk in Laboratory Services. If you cannot access the laboratory, ring the buzzer and wait for lab staff to answer. If lab staff are not available and the specimen is not stat please call 2256 or 2200. If the specimen is STAT and lab staff are unavailable please call 8426.  RQHR employees that require frequent access to the lab, are encouraged to obtain card access.  Transport via pneumatic tube following the instructions LABPhlbOP7009A1.2 Sending Patient Specimens using the Pneumatic Tube.

Compromised Specimens

 When a laboratory specimen is dropped and broken, or damaged during transport:

o Alert the next RQHR Employee passing by to contact Housekeeping. Do not leave the damaged specimen unattended. o Immediately notify the department or ward about the damaged specimen so the requesting physician can be notified and the specimen can be recollected if possible. o Fill out an Employee Report of Incident/Hazard and an Incident Investigation with your supervisor. Submit to Employee Health.

Note: It is important for laboratory specimens to be delivered in a timely manner to ensure specimen integrity, viability and prompt turn around times.

LABRegOP7109A1.1.6 Instructions for Portering Lab Specimens Page 2 of 2 Laboratory Services Regina Qu'Appelle Health Region Last printed 9/1/2017 5:03 PM

Portering Laboratory Specimens Competency Quiz

Name: ______Contact Number: ______

1. When specimens are transported in a Biohazard bag are gloves required? a. Yes b. No

2. What is the importance of delivering patient specimens directly to the laboratory? a. Assurance of specimen integrity and viability. b. Prompt turn around times of testing results. c. Ensure specimens are not misplaced and confidentiality compromised. d. Biohazard material is not accessible in public or designated clean areas. e. All of the above.

3. Where are patient specimens delivered during the day shift? a. Accession area of the laboratory, except Blood gases, Pathology and STAT specimens. b. To the Out-patient collection laboratory.

4. Is it acceptable practice to leave patient specimens in public areas such as hallways, elevator foyers, waiting rooms, etc? a. No b. Yes

5. If a patient specimen is dropped, broken and spilled on route to the laboratory, what should be done? a. Carry on with your deliveries, leaving the broken specimen in the corridor. b. Alert the next RQHR Employee passing by to contact housekeeping. Do not leave the damaged specimen unattended. Immediately notify the department or ward about the damaged specimen so the requesting physician can be notified and the specimen can be recollected if possible. c. Recover the specimen remains and deliver to the laboratory.

LABRegOP7109A2.1.4 Portering Lab Specimens Competency Quiz Page 1 of 1 Laboratory Services Regina Qu'Appelle Health Region Last printed 9/1/2017 6:02 PM

Portering Laboratory Specimens Competency Quiz Answers

1. When specimens are transported in a Biohazard bag are gloves required? b. No

Rational: All laboratory specimens and containers are considered a potential source of infection. The primary specimen container should be placed into a sealed, leakproof secondary container/packaging, (ex. Biohazard bag) which will contain the specimen if the primary container breaks or leaks in transit.

Rational: Patient specimens must be delivered promptly to the laboratory to ensure specimens do not deteriorate. The accuracy of the patient test results depends on the specimen reliability.

3. Where are patient specimens delivered during the day shift? a. Accession area of the laboratory, except Blood gases, Pathology and STAT specimens.

Rational: It is important to deliver laboratory specimens to the appropriate receiving area, so that specimens are not misplaced or lost. STAT specimens should be physically handed to a person in the laboratory to allow priority processing.

4. Is it acceptable practice to leave patient specimens in public areas such as hallways, elevator foyers, waiting rooms, etc? a. No

Rational: It is unacceptable to leave patient specimens in public areas due to considerations such as: breach of confidentiality, accessible biohazardous material, and misplaced or lost specimens.

LABRegOP7109A3.1.4 Portering Lab Specimens Competency Quiz Answers Page 1 of 2 Laboratory Services Regina Qu'Appelle Health Region Last printed 9/1/2017 6:05 PM

5. If a patient specimen is dropped, broken and spilled on route to the laboratory, what should be done? b. Alert the next RQHR Employee passing by to contact housekeeping. Do not leave the damaged specimen unattended. Immediately notify the department or ward about the damaged specimen so that the requesting physician can be notified and the specimen can be recollected if possible.

Rational: To ensure patient, staff and visitor safety, it would be unacceptable to leave the biohazardous spill unattended. Safe work practices would be ensured by contacting appropriately trained staff with safety equipment specific to the task to clean up a biohazardous spill. In addition, some specimens are either of a timely nature or collected by an invasive technique and the ward/department must be notified immediately of the damaged specimen so the requesting physician can be contacted and recollect if possible.

LABRegOP7109A3.1.4 Portering Lab Specimens Competency Quiz Answers Page 2 of 2 Laboratory Services Regina Qu'Appelle Health Region Last printed 9/1/2017 6:05 PM Sending Patient Samples Using the Pneumatic Tube

Precautions: • All Staff handling specimens must wear gloves as defined by routine practice. • Sharps and/or contaminated sharps are NOT to be transported in the pneumatic tube transport system.

1) Place Specimens in Biohazard Ziploc Bag • Bags must contain a sheet of absorbent material (supplied by lab). • Ensure lids on specimens are completely closed. • Secure Vacutainers cork to cork and eliminate free movement using either option demonstrated. • Send urine specimens separately from blood specimens. • Do not overload the bag (6 tubes maximum). • Fully seal Ziploc closure.

2) Load Pneumatic Tube • Place Biohazard bag within the zippered insert. • Zippered insert MUST contain the inner foam lining. • Requisitions must accompany the specimens. • Place insert inside the Pneumatic Tube.

3) Sending the Tube • Place pneumatic tube in tube system - bottom side up. • Close door, turn handle vertically, and push the “Send” button. • Only send one pnuematic tube at a time.

DO NOT RETURN BLOOD PRODUCTS IN THESE PNEUMATIC TUBES

 PHONE TRANSFUSIONS 8865-09 Designed by Medical Media Services - HS

JOB AID

LABAccnOP7027J1 CSF LABELLING AT TIME OF COLLECTION

The order in which CSF tubes are collected determines which test is to be performed on each tube due to the invasive nature of collection.

 Tube 1 is used for Chemistry – glucose and protein  Tube 2 is used for Microbiology – gram stain and C&S (less likely to contain possible skin contaminants)  Tube 3 is used for Hematology – cell count (least likely to contain red blood cells due to the trauma of collection)  Tube 4 - additional testing such as viral culture, Cytology, Oligoclonal Bands, additional Microbiology testing

The Lumbar Puncture Tray is equipped with four prelabelled specimen vials with screw caps. These specimen tubes are numbered 1, 2, 3 or 4 on one side and are marked for measurement in ml on the other. For accurate testing it is important to indicate the order in which the CSF tubes have been collected so that the appropriately numbered tube is used for each test as requested. This can be achieved by using the prelabelled tubes in the correct order or by writing the number on the adhesive labels from the requisition.

In addition to indicating the order of collection number on each tube, ensure the specimens are labelled with the patient’s first and last name and the MRN.

CSF specimens are to be accompanied by completed requisitions and a SDCL requisition is required for testing that is referred to the Saskatchewan Disease Control Laboratory.

For more information: Refer to RQHR Lab Specimen Requirements in the Laboratory Services Manual on the Intranet: http://www.rqhealth.ca/service-lines/master/files/rqhr_lab_specimen_requirements.pdf

CSF specimens are transported to the laboratory immediately and handed directly to laboratory personnel where they are processed STAT. Do not refrigerate the specimens.

LABAccnOP7027J1 CSF Labelling at the Time of Collection Page 1 of 1 Laboratory Services Regina Qu'Appelle Health Region Last printed 11/14/2018 8:53 AM TEST PRIORITY

STAT - refers to life threatening medical emergencies. Laboratory staff prioritizes STAT requests at the expense of other orders, therefore this priority should only be used when absolutely necessary.

□ MTP □ Code Blue □ Stroke □ MI □ Other Life Threatening

URGENT - refers to tests that are required as soon as possible but are not involved in life threatening medical emergencies.

□ Initial Workup □ Changed Condition □ Medication Change □ Missed or Lost Lab Work

ROUTINE – these specimens are handled after STATs and URGENT Collections.

TIMED - used when specimens are to be collected at specified times of the day.

Timed collections are ordered in the following instances only: - pre-op bloodwork - special procedures (eg: angioplasty, ACTH stimulation tests) - TPN bloodwork - timed drug levels - INR - timed due to medication adjustment - CK, Troponin ordered as per physician request for CCU protocol

REQUISITIONS

Requisitions for urgent, routine, and timed blood tests must be delivered to the laboratory well in advance of the required time of collection.

Requisitions should be in the laboratory no later than 2100 hours the day prior to collection to facilitate processing the AM blood work.

Requisitions received after 2100 hours may not be processed in time for collection on the first A.M. collection run. Occasional exceptions may be required for critical care areas.

STAT COLLECTIONS

1) First - FAX all STAT requisitions to the Lab (RGH 766-4307 / Pasqua 766-2223) for data entry into the LIS. 2) Second - Call the STAT phone number (RGH 766-1658 / Pasqua 766-8412) to notify the Phlebotomist of the STAT collection.

Phlebotomist will always confirm that the STAT requisition has been faxed to lab for data entry into the Lab Information System.

LABRegOP7900A3.1.3 Specimen Collection Process FAQ Page 1 of 3 Laboratory Services Regina Qu'Appelle Health Region Last printed 03/04/2018 6:29 PM TEST ORDER ENTRY

All laboratory test orders must be data entered (accessioned) into the Laboratory Information System (LIS) before patients can be positively identified using the SoftID electronic identification verification system prior to collection. The SoftID hand held will print labels for the pre-accessioned lab work.

REQUISITION TEST ADD-ONS OR CHANGES

CALL THE LABORATORY as indicated below, with any additions or changes to tests on a requisition previously delivered to the laboratory. These ADD-ON test requests will be data entered into the LIS. When required, additional vacutainer tubes or blood cultures will be collected.

RGH 1) ADD-ONS - BEFORE specimens have been collected - CALL Accession 766-4495 ADD-ONS - AFTER specimens have been collected - CALL Chemistry 766-4490 Select option 2 to add on orders. or Hematology 766-4477

PASQUA All ADD-ONS call Chemistry 766-2256 Select option 2 to add on orders. or Hematology 766-2631

COLLECTION OF ADD-ON TESTS

Coagulation tests (INR, APTT, D-Dimer) cannot be added onto an order already collected. Previously collected Coagulation tubes may have a D-Dimer added if collected within the last 4 hours for an open tube and 24 hours if the original Coagulation tube has not been opened.

Hematology tests may be added onto a previously collected hematology EDTA tube within the last 24 hours.

Chemistry tests are able to be added onto previous chemistry orders, in most circumstances. However, Ammonia, Blood Gases, ETOH, High Sensitivity Troponin I Lactate, BNP and certain drug levels cannot be added on.

Blood Cultures cannot be added onto previously collected test requests.

RQHR Lab Specimen Requirements – see link below http://www.rqhealth.ca/service-lines/master/files/rqhr_lab_specimen_requirements.pdf

Use the SEARCH button to quickly find the test you are requesting.

LABRegOP7900A3.1.3 Specimen Collection Process FAQ Page 2 of 3 Laboratory Services Regina Qu'Appelle Health Region Last printed 03/04/2018 6:29 PM NEW ADMISSIONS

New admission patient requisitions should be delivered to the lab. When this is not possible during the night shift due to work load, mark the requisition with “NEW ADMISSION” and fax to the lab to be data entered into the LIS for the AM Collection run (morning swarm).

POSITIVE PATIENT IDENTIFICATION

Utilizing a mechanical barrier system or an electronic identification verification system such as the SoftID ensures that the patient from whom the specimen was collected is the same patient reported on. This positive patient identification process is capable of reducing the risk of misidentification. The laboratory will be monitoring the effectiveness of the SoftID system implemented.

FAX PROBLEMS

Test your fax machine and provide training for your staff on the use and limitations of the fax machine. When a STAT requisitions is faxed appropriately, specimen collection will NOT be delayed.

Common problems associated with faxing requisitions:

1) Upside down requisitions – blank page 2) Cut off requisitions 3) Two requisitions cannot be faxed at once 4) Black page – due to the lid open on your scanner

LIS DAILY LOG

The requisitions that are brought to Lab Services for next day collections are accessioned into the LIS throughout the day, evening, and night. A daily log of patients entered into the LIS is printed each morning at 4:00 am to Phlebotomy. Phlebotomy faxes this daily log to the units, so unit staff are able to identify which requisitions have been sent to the lab for the AM Collection run (morning swarm). This is to avoid sending of duplicate requisitions for patient collection, thus avoiding patients being collected twice for the same physician order.

LABRegOP7900A3.1.3 Specimen Collection Process FAQ Page 3 of 3 Laboratory Services Regina Qu'Appelle Health Region Last printed 03/04/2018 6:29 PM Name of Activity: Lab Services for Inpatient Rehab and EC/VAC Program

Role performing: Inpatient Rehab and EC/VAC Program staff Location: WRC Department: All Document Owner: Region/Organization where this STANDARD Virginia Marsh/ Tara Standard Work originated: Griffiths/ Lisa RQHR WORK Chamberlain Date Last Revision: Date Approved: Prepared: July 16/2014 Nov 14/2017 Dec 22,/2014

Standard Work Summary:

(Mon – Fri) Daily Schedule for WRC Collection Centre Blood Collection/ ECG / X-ray services.

(Weekends – see Note below)

Task Sequence Task Definition Task Cycle Time (Order in which (Brief summary of task ) (Define unit of measure - tasks occur) seconds, minutes etc.) 1. Laboratory requisitions for same day morning AM collections need to be completed ASAP to be ready for Lab staff morning collection schedule. See below #4. Please deliver these same day morning requisitions to the Lab for data entry into the LIS prior to phlebotomy. 2. Lab staff to collect Fasting and Drug level collections 0745-0820 on all units. 3. Lab staff to Collect unit 3-2. 0820-0915 4. Lab staff to finish unit 3-2 if needed, then collect all 0930-1030 other units. 0930 3-3 0950 3-5 1000 3-6 1010 2-6 1020 2-5 1030 M6, M5 5. Same day lab specimens such as a urine, swab, or 1000 sputum, collected in the morning, will be picked up by the Lab staff during the morning collections. Ward collections after 1000 must be delivered by the ward staff to the lab fridge. Card access is required to access the Lab fridge. LABRegOP7900A4.1.2 Lab Services for Inpatient Rehab and EC/VAC Program Page 1 of 3 Laboratory Services, Regina Qu’Appelle Health Region 12/1/2017 1:25 PM 6. Specimen courier pick – up 1100 7. Lab Out-Patient Collection Hours: 1100 - 1130 1330 – 1415 1430 - 1530 8. If blood work is ordered for the patient/resident, the team leader/charge nurse is responsible to advise the patient/resident (caregiver of resident) to remain on the unit until the lab has completed the blood draw. 1100 - 1130 1330 – 1415 If a patient/resident is not on the unit when the lab 1430 - 1530 arrives to draw blood, the patient/resident will be required to go to the Lab. If assistance is required a team leader/charge nurse will ensure the patient/resident is taken to the lab for specimen collection. 9. Same day requisitions for blood work, ECG, and X-ray 1200 need to be delivered to Lab by ward staff before 1200 and placed in drop box beside the Lab entrance. 10. Lab staff will collect same day collections and perform 1300-1330 ECGs on all units. 11. X-rays will be performed from 1330-1530. 1330 - 1530 12. Same day lab specimens such as a urine, swab, or 1400 sputum collected after 1000 should be delivered by the unit staff to the Lab fridge before 1400 to catch the 1445 courier. If not collected before 1400, collect the specimen the next morning. Card access is required to access the Lab fridge. 13. Next day requisitions taken down by the unit 1500 clerk/designate will be placed in the drop box beside the Lab entrance. 14. Unit Clerk / Charge Nurse will call for STAT blood STATs collection, STAT ECG or STAT x-ray to the Lab STAT call line 5555. Otherwise, all requisitions are to be taken to the Lab by 1200 for same day testing and 1500 for next day testing. 15. Standing Order and future blood work requisitions must Standing Orders be taken to the Lab one week in advance. Future Blood Work 16. Do NOT call the lab to inform them of NON-STAT Routine Orders orders.

LABRegOP7900A4.1.2 Lab Services for Inpatient Rehab and EC/VAC Program Page 2 of 3 Laboratory Services, Regina Qu’Appelle Health Region 12/1/2017 1:25 PM Notes: 1) Weekends - STAT patient specimen collection requests  RCC Charge Nurse to call Phlebotomy at RGH 4527  STAT requisitions must be delivered to the drop box beside the Lab entrance by 1200 noon.  Requisitions must clearly be marked as STAT. This enables the phlebotomist to sort the routine requisitions from the STAT requests. 2) Do not use interoffice mail to transport requisitions to the lab, due to delays in delivery. 3) Patients that require x-rays (ECGs in Lab) must always be accompanied by nursing staff, who will remain with the resident throughout the procedure. 4) Ventilation patients must be accompanied by staff experienced in managing their condition, who will remain with the resident throughout the procedure. (Respiratory, nursing staff) 5) Card Access – For those WRC staff that require card access complete the Lab Safety Training checklist and send to Regulatory Affairs Laboratory Services, RGH.

LABRegOP7900A4.1.2 Lab Services for Inpatient Rehab and EC/VAC Program Page 3 of 3 Laboratory Services, Regina Qu’Appelle Health Region 12/1/2017 1:25 PM

Specimen Collection Information for Health Care Practitioners Offices

Specimen Collection Instructions

Collect the specimen tubes in the following order:  blood cultures (aerobic then anaerobic)  blue top tube(s) with citrate (completely fill the tube)  Serum tubes, with or without clot activator, with or without gel i.e. Yellow Serum Separator Tube (SST) with gel, or Red top tube  green top tubes with heparin  mauve top tube(s) with EDTA  tube(s) with other additives (e.g. grey top tube)

Gently invert all the tubes 5 times to mix the blood with the additives. To invert turn the filled tube upside-down and then return it to an upright position.

A. HEMATOLOGY and TRANSFUSIONS

1. CBC (with WBC differential), ESR, Retic For any combination of tests in this group: - draw one 4 mL EDTA tube (lavender top) - transport to the testing laboratory within 2 hours of collection - refrigerate at 4C until transport; specimens refrigerated for up to 24 hours after collection will be accepted

2. PTT, INR For any combination of tests in this group: - draw one 1.8 mL or 2.7 mL sodium citrate tube (blue top) ensuring that the tube fills completely - transport to the testing laboratory within 2 hours of collection - if greater than 4 hours time to testing is expected for PTT test only; centrifuge specimen for 10 minutes at 2500 RPM, separate plasma and freeze at -20C. Send specimen to RGH in frozen state.

3. Malaria - draw two 4 ml EDTA tubes (lavender top) - transport to the testing laboratory within 2 hours of collection - refrigerate at 4C until transport; specimens refrigerated for up to 24 hours after collection will be accepted

4. Monospot (serum), RBC folate For any combination of tests in this group: - draw one 4 mL EDTA (lavender top) tube and one 5 mL Serum Separator Tube (SST) with gel (yellow top tube) - transport specimens to the testing laboratory within 2 hours of collection

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- if greater than 4 hours is expected, allow SST specimen to clot (at least 30 minutes), centrifuge for 10 minutes at 2500 RPM and refrigerate EDTA and SST tubes at 4C until specimen is transported

5. Blood group & Rh, Blood Group & Rh & Screen, Direct Antiglobulin Test, Transfusion Reaction Investigation For any test in this group: - collect two - 4 mL EDTA (lavender top) tubes - label tubes with patient’s first and last name, health services number and the date of birth

6. Cold Agglutinin Testing - Collect 1-4ml EDTA (lavender top) tube and 1 red top tube (clot at 37 C, centrifuge and separate serum from cells immediately by aliquotting into a properly labeled container).

7. Synovial Fluid - collect 3-5 mL of specimen in EDTA tube (lavender top) - mix immediately by inverting tube at least five times and ensure that specimen is not clotted - transport to RGH laboratory within 4 hours of collection - specimens refrigerated for up to 24 hours after collection will be accepted but note that a differential may not be possible since there is cellular deterioration after 4 hours

B. CHEMISTRY Albumin Glucose ALP – alkaline phosphatase ßHCG ALT Iron / TIBC AST LDH B 12 Lipase Bilirubin Luteinizing Hormone Calcium Lipid panel (cholesterol, triglycerides, CA125 HDL, LDL) CEA Liver panel (ALP, ALT, bilirubin) CRP Magnesium CK Phosphorus Creatinine Prolactin Electrolytes (Na, K, Cl) TIBC Estradiol Total protein Ethanol Transferrin Ferritin PSA FSH Renal panel (Na, K, Cl, urea, creatinine) GGT TSH, FT4, FT3 Urea Uric Acid

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 2 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

For any combination of tests in the above table: - draw one 5 mL SST gold top tube (serum separator tube with gel) - transport specimen to testing laboratory within 2 hours of collection - if greater than 2 hours is expected, allow specimen to clot (at least 30 minutes) and centrifuge for 10 minutes at 2500 RPM - refrigerate at 4C until specimen is transported, but no more than 24 hrs.

ANA AMA Protein Electrophoresis (PE/IFE) also order Total Protein and Albumin Immunoglobulins alpha 1 Antitrypsin RA/RF IFE For any combination of tests in the above group: - draw one 5 mL SST gold top tube (serum separator tube with gel) - transport specimen to RGH for testing within 2 hours of collection - if greater than 2 hours is expected, allow specimen to clot (at least 30 minutes) and centrifuge for 10 minutes at 2500 RPM - refrigerate at 4C until specimen is transported, but no more than 24 hrs.

Carbamazapine/Tegretol Digoxin Dilantin Phenobarbitol Theophylline Valproic acid For tests in this group: - draw one EDTA mauve top tube - Transport specimen to RGH for testing within 2 hours of collection - If greater than 2 hours is expected, centrifuge for 10 minutes at 2500RPM and aliquot plasma (indicate on label EDTA plasma) - refer to the RQHR compendium for information regarding collection times - specify time and date of last dose

Creatinine Clearance (record patient’s height (cm.) and weight (kg.) on requisition) Bence Jones Protein For tests in this group: collect a 24 hour urine specimen

Microalbumin / Creatinine Ratio Collect a random urine specimen. Use a 5 – 10 mL plastic aliquot tube to send the specimen. Do not ship in a C and S container.

C. MICROBIOLOGY

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 3 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

THROAT Instruct the patient to breathe deeply, depress the tongue gently with a tongue depressor. Sample the posterior pharynx, tonsils, and inflamed areas with swab. Avoid touching the oral mucosa or tongue with the swab. Have the patient say "AH", this lifts the uvula and reduces the gag reflex. Place swab in transport media and send to the laboratory.

Please indicate if request is for treatment failure and susceptibility testing is required.

VAGINA Use a speculum without lubricant and swab mucosa high in the vaginal canal. Place the swab in transport media.

URINE NOTE : Duplicate urine specimens on the same patient for routine culture within a 3 day period will not be processed.

A "clean-catch" midstream specimen is adequate for culture provided the urine has been collected after adequate cleansing. The specimen should be sent in a special urine transport tube containing boric acid. If there is to be a delay of over 30 minutes in transporting the specimen, it should be refrigerated.

Collection of Clean-Catch Mid-stream Specimen . use sterile container . aseptically transfer to special urine transport tube containing boric acid.

For males (Midstream) While holding foreskin retracted, begin voiding. After several mL have passed, collect midstream portion without stopping flow of urine. Transfer more than 5 mL of specimen into a urine transport tube containing Boric Acid preservative (add urine up to fill line on Boric Acid container).

For females (Midstream) While holding labia apart, begin voiding. After several mL have passed, collect midstream portion without stopping flow of urine. Transfer more than 5 mL of specimen into a urine transport tube containing Boric Acid preservative (add urine up to fill line on Boric Acid container).

WOUNDS/SKIN Wound as a specimen source is inadequate. Always provide a specific anatomical site.

When collecting these specimens, attention to skin decontamination is critical.

a) Superficial wound – Clean wound surface with 70 % alcohol. Swab or aspirate the affected areas. Avoid touching surrounding skin.

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 4 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

b) Deep Wound – Clean and decontaminate wound. Swab or aspirate the affected areas. c) Burns – Swabs of superficial lesions are inappropriate. Clean wound surface with 70% alcohol. Obtain a 3 mm3 punch biopsy and place into a sterile container. d) Decubitus ulcers – Decubitus ulcers, such as coccyx, sacral or ischio rectal, are of limited value, and will not be processed. e) Sinus tract – Superficial swabs are unsuitable. Submit aspirated pus in an Aimes eSwab.

STOOLS Ova and Parasites For the detection of ova and parasites, specimens should be submitted in a special container with SAF preservative, and filled to the line marked on the container. A number of substances can interfere with stool examination: mineral oil, bismuth, barium (radiological), non-absorbable anti-diarrhoeal preparations, anti-malarials and antibiotics. After administration of these compounds, specimens should not be submitted for 1 - 2 weeks as they may not reveal parasites for a week to several weeks. The two most commonly used agents are barium and antibiotics which modify normal gut flora, and diminish the number of protozoa, since the growth and reproduction of protozoa are dependent on the presence of the intestinal bacteria.

Duplicate stool specimens on the same patient within a 5 day period will not be processed.

Culture and Sensitivity (C & S) Approximately 1 gram of stool freshly passed directly into clean, dry container. Transfer to a container containing Enteric Pathogen Transport Medium when being submitted for culture. There should be no contaminating material (e.g. urine, tissue paper) mixed with the specimen. Rectal swabs may be adequate for the detection of pathogens in acute infections but not in carriers.

H. Pylori Stool Antigen Test Collect 1g (~size of a hazelnut) of freshly passed stool into sterile container with no preservative. There should be no contaminating material. E.g. urine, tissue paper, water. Transport at room temperature, as soon as possible. If delay is anticipated, store and ship specimen at 4 C.

⁰

The following agents must be discontinued prior to testing: -Antibiotics: 28 days. -Bismuth preparations, e.g., -Pepto-Bismol: 14 days. -Proton pump inhibitors (H+, K+ - ATPase Inhibitor): 14 days.

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 5 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

NOTE: Histamine blockers or H2 antagonists ex. Pepcid, Tagamet, Axid and Zantac CAN be used during this time.

Testing is performed Mondays, Wednesdays, and Fridays. Turnaround time is 2-7 days.

This test can be used for H. pylori diagnosis as well as a test of cure 28 days after completion of treatment. Indeterminate results may require retesting with a new specimen if a patient’s symptoms persist.

MICROBIOLOGY SPECIMENS SUBMITTED TO SDCL Pertussis Nasopharyngeal specimens collected for Bordatella pertussis or “Whooping Cough” are collected in Regan-Lowe media. Ensure the wire of the collection swab is trimmed and contained in the media tube and the cap is screwed on. A SDCL Microbiology requisition must be included upon submission.

Specimens for Sexually Transmitted Infections Please consult the Saskatchewan Disease Control Laboratory Microbiology Requisition to determine the collection kit to be used for each specimen. A completed SDCL Microbiology requisition must be included upon submission. Please note: specimens must be collected in the media as described on the requisition or they will be rejected.

D. Histology

Routine Processing for Surgical Specimens

- Specimens removed during surgical excision must be placed immediately into 10% Neutral Buffered Formalin in a clean, leak-proof, screw-top plastic container. - Volume of formalin must be a minimum of ten times greater than the size of the tissue specimen. - Specimen containers must be of adequate size to freely accommodate the specimen and appropriate volume of formalin. - Label specimen container with patient’s first and last name, Health Services Number and the nature and location of the specimen. Unlabelled or improperly labelled specimens will be returned for correction. - Place specimen container and requisition into separate sealed zip-lock bags. - Place bags into mailing container or sturdy cardboard box. Use packing materials to cushion contents. - Seal container/box with packing tape. - Affix Return Address label. - Affix Address label for Histology Laboratory

- Ship to: Histology Laboratory Pasqua Hospital

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 6 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

4101 Dewdney Ave. Regina, SK S4T 1A5

E. Cytology

Pap Smear

The Pap smear is a highly effective tool for detecting cancerous and precancerous cervical lesions but it is considered a screening test only and has been demonstrated to produce false negative rates.

The objective of an adequate Pap smear is to provide a sampling of the Squamocolumnar junction between the ecotcervix and endocervix utilizing the one slide technique. Combinations of various types of sampling are possible and can vary. Both the spatula (ectocervix) and brush (endocervix) should be used. The cervical brush alone should not be used. A cervical smear should not be taken at the time of menstruation. The optimal time is mid-cycle. As well, the patient should be advised not to douche 48 hours prior to the examination. Use of cotton tipped applicators and lubricating jelly on the speculum are NOT recommended. a. Prepare slide by writing the patient’s first and last name and one additional identifier on the frosted end of the slide. b. Wooden Spatula Technique: Transformation Zone Scrape - Insert and rotate one full turn - Spread material over top-half of slide - Spray immediately with fixative, holding spray bottle 3-4 inches away from the slide - Pump 5-6 times or until slide is saturated - The spray will contact the bottom half of the slide. This will not jeopardize the remainder of the procedure

Cytobrush Technique: Endocervical sampling (inform patients that some spotting may occur with use of the Cytobrush) - Gently insert the Cytobrush into the endocervix - Rotate slowly one turn only - Remove the Cytobrush - Spread the material on the bottom-half of the slide by rolling and twisting the Cytobrush - Spray immediately as described above. There is no need to direct spray away from material already on the slide. Additional spray will not alter the specimen.

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 7 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

c. Place the slide in the blue plastic slide mailer, leaving open until the slides are dry. When the slides are completely dry, close the slide mailer. Wrap the requisition around the blue mailer and secure with a rubber band d. Mail or deliver to the Regina Qu’Appelle Health Region- Pasqua Hospital, Cytology Laboratory.

Non-Gynecological Specimens

The Thin Prep instrument has become the optimal choice for preparing cell samples for Cytology. Specimens include pleural, peritoneal, pericardial, urine, sputum, cyst contents, washings, brushings and needle aspirates collected for cytologic examination. The addition of 50% ethyl alcohol or cytolyt to the specimen will prefix cells during transport. The specimen can then be prepared in the Cytology lab.

1. Sputum - The first specimen of the morning is considered to be the most representative. - It is also recommended that the patient wait at least one hour after consuming food to produce a sputum sample, in order to avoid contamination of the sputum by food particles. - Specimen should be collected in a labelled, leak proof container. - The patient is to rinse his/her mouth, clean his/her throat with a gentle cough, and deep cough from the diaphragm and expectorate all sputum into an appropriate specimen container - A sputum series (i.e. repeated once a day for three days) is generally recommended. - Add an equal volume of 50% ethyl alcohol or cytolyt to the specimen. The addition of fixative should be noted on the requisition and specimen container

2. Urine Specimens - This includes voided urine, bladder washing and catheterized urine - Voided urine: patient should be hydrated. A midstream specimen is recommended. First morning specimen is not recommended. - All of the above specimens should be collected and submitted in an appropriately labelled, leak proof container with the addition of an equal volume of 50% ethyl alcohol

3. Synovial (Joint) Fluids - The specimen should be aspirated into a sterile leakproof tube - DO NOT ADD ANY TYPE OF FIXATIVE to the specimen - Indicate on the requisition if the test is for crystals - Transport immediately to the laboratory

4. Breast Secretions (Nipple Discharge) - Label slide with patient’s first and last name and one additional identifier

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 8 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

- Secretion is expressed by gently squeezing the areolar area between the thumb and forefinger - Secretion is smeared across a glass slide - The smear should be immediately sprayed with fixative - If the secretion is thick. Place another labeled glass slide on top and gently pull apart slide; fix with spray fixative - Prepare as many slides as there is secretion - Allow slides to dry, and place into a blue slide mailing container - Attach the requisition to the mailing container

5. Solid/Cyst Lesion Fine Needle Aspiration (Fine Needle Aspirate Biopsy) - Cellular material extracted by fine needle aspiration from any solid or cystic lesion - If the specimen is cystic, the fluid as well as the cyst wall should be aspirated. - After removing the needle from the lesion, detach the needle from the syringe, fill the syringe with air, reattach the needle and express the contents in a clearly labelled leak proof screw top tube (i.e. Falcon tube) that contains 50% ethyl alcohol or cytolyt. - A needle rinse should be performed as well. This is done by aspirating and expressing the fixative to remove any cells or tissue fragments from the syringe.

LABRegOP7900A5.1.0Specimen Collection Information for Health Care Practitioners Offices Page 9 of 9 Laboratory Services Regina Qu'Appelle Health Region Last printed 12/13/2017 5:29 PM

Laboratory Tests Quick The Laboratory Test Compendium lists tests and specimen requirements. It can be accessed on the RQHR INTRANET. Reference RQHR Home- Departments- Laboratory-RQHR Lab Specimen requirments RRPL: refers to Provincial Lab and requires a separate RR Provincial Lab requisition Tube Additive Common Tests Collection Instructions Blood culture (Draw the Aerobic bottle first) Green – aerobic – volume required 8 – 10 mL Orange – anaerobic – volume required 8 – 10 mL Yellow – Pediatric – volume required 1 – 3 mL Blood Red – TB culture bottle (special request only) Cultures Mix by inverting 8 - 10 times. Store at Room Temp. Blue Sodium Hematology: Used for coagulation tests Correct volume is critical (MUST be filled to fill line). Citrate PT/PTT D-Dimer Fibrinogen Collection of a discard tube before the blue top will prime the Hit assay 2(Blue) + 2(Red) tubing and ensure the correct anticoagulant to blood ratio. Mix by inverting 3 - 4 times to prevent clotting. Red Chemistry: Fluids Hematology: Hit assay 2(Blue) + 2(Red) RRPL: Drug Screen (2 tubes) Orange Contains a Chemistry: CO2 Ferritin Lipase Protein Mix 5 - 6 times Rapid thrombin Alcohol CEA FSH Lipid Panel PSA Serum coating on AST CK GGT Lithium Renal Panel Tube tube B12 Cortisol Glucose Liver Panel TSH, FrT3, FrT4 (RST) interior to BhCG CRP Iron Magnesium Uric Acid promote Bilirubin Electolytes Ketones Osmolality B12/Folate requires 1(Orange or yellow)+1(Mauve) or rapid CA125 (Na, K,Cl, CO2) LD Phosphorus clotting Calcium Estradiol LH Prolactin Yellow Clot Immunology: Quantitative Immunoglobulins RRPL: Serology tests, Hepatitis, HIV (SST) activator ANA RF Serum protein electrophoresis Green Heparin Chemistry: Ammonia (must be on ice and brought to lab immediately) Mix by inverting 8 - 10 times (Lithium) Fluid pH (must be on ice) VBG/VBG with Lactate (deliver to lab within 10 minutes) Tube must be full, mix sample thorughly Mauve Potassium Chemistry: BNP, hsTroponin,PTH, ** Therapeutic Drugs Separate tubes for each lab section EDTA Immunology: A1C HGB electrophoresis Mix by inverting 8 - 10 times to prevent clotting Hematology: CBC/Diff ESR Reticulocytes Transfusions: Group & Screen 2 - tubes Must have 3 identifiers Confirmatory 1-tube Grey Sodium Chemistry: Lactate/Lactic Acid Mix by inverting 8 - 10 times to prevent clotting Fluoride/ Potassium Other Syringe Chemistry: ABG/ABG with Lactate (deliver to lab within 10 minutes) Expel air bubbles immediately (Heparinized) VBG/VBG with Lactate (deliver to lab within 10 minutes) Mix sample thoroughly ** Therapeutic Drugs: Acetaminophen Digoxin Phenobarbital Salicylate Tobramycin Use corresponding Amikacin Gentamicin Phenytoin Theophylline Vancomycin NEVER attempt to share blood from one tube to another. tube color Carbamazepine Lithium (Dilantin) (Aminophylline) This can result in very serious errors in patient results. LABRegOP7900A6 Laboratory Common Tests Quick Reference Page 1 of 1 Laboratory Services, Regina Qu’Appelle Health Region Last Updated 6/25/2019 7:55 AM Pediatric Collection Room

If you think that your child will have difficulty handling blood tests please use the Regina General Main Lab where staff have experience with children and there is a special Pediatric collection room.

For families to book appointments in advance or to schedule a tour of the Pediatric collection room, contact either:

Angela McTaggart Sylvia Dmyterko Manager Procurement Services, Supervisor Procurement Services Laboratory Services-Regina Laboratory Services-Regina Saskatchewan Health Authority Saskatchewan Health Authority Regina, Saskatchewan Regina, Saskatchewan (Phone) 306-766-4259 (Phone)306-766-8560

saskhealthauthority.casaskhealthauthority.ca 8695-18-MMS-JP Req SCAN Label Do not use for Regina Qu’Appelle Health Region Community Microbiology or Chemistry/Hematology Transfusion See Reverse for Community Collection Sites and Hours of Operation Requesting Dr (Name / Initials): RQHR Dr LIS Code: ______Location: ______Date: ____(dd/mm/yyyy)_____

Clinic/Name, Address: *Patient Name:___(last)______(first)______

*HSN: ______DOB:____ (dd/mm/yyyy)____ Specify Province: ______ Fax report to: ( ) - MRN: ______Gender: M M F F Patient Address: **Copy for: Dr; (Name / Initials) RQHR Dr LIS Code: ______Clinic Name, Address

Patient Contact Number:  Fax report to: ( ) - **Copy for: Dr (Name / Initials) Requesting Dr and cc Dr(s): Diagnosis RQHR Dr LIS Code: ______Dr Name / Clinic / Address required Clinic Name, Address Do not use RQHR LIS Code alone Specimen type (if not serum) .**Copies for additional physicians, may not be sent if the mailing address Collected Date / Time / Initials  Fax report to: ( ) - cannot be determined. Hematology General Chemistry Therapeutic Drugs *The labeling information on the CBC Electrolytes (Na, K, Cl) Date and Time of Last Dose: specimens submitted must match the requisitions for the patient ______Potassium (only) Specimen containers must be labeled with PT/INR Renal Panel aPTT the patient name (last and first), date of Electrolytes ⁭ Carbamazepine (Tegretol) birth (day, month, year) and HSN Specify Anticoagulant: Urea ⁭ Digoxin Coumadin / Warfarin ⁭ Lithium Creatinine Microbiology: Heparin Liver Panel ⁭ Phenobarbital Separate Microbiology Requisition No Anticoagulant T Bili ⁭ ⁭ Theophylline Other:______ALK Phos ⁭ Phenytoin (Dilantin) must be completed by Physician to Monotest ALT ⁭ Valproic Acid (Depakene) ensure adequate information is Lipid Panel (Fasting) Vancomycin Pre ⁭ Post provided ⁭ Sirolimus Prenatal Lipid Panel (Non-fasting) Newborn Bilirubin ⁭ Tacrolimus Other:  Complete SHA Request for CK Albumin Prenatal Testing requisition Urine Tests for Prenatal Group & Screen Calcium Total Protein ⁭ Urinalysis (Random Only) or Paternal Group. Magnesium Uric acid Phosphorus B-HCG  Complete RRPL Fe / TIBC Ferritin Pregnancy Test (Random) Requisition for Prenatal Albumin / Creat Ratio

Panel (includes Rubella IgG, Syphilis, HBV, HCV, HIV). Tumor Markers

⁭ PSA ⁭ AFP 24 hour Urine Collections ⁭ CEA ⁭ CA-125 Start Date:______Transfusion

Thyroid Tests End Date: ______Complete RQHR Transfusion requisition if Group & Thyroid Screen Volume: ______mL Antibody Screen ordered. Follow up tests: ⁭ Total Protein (24h Urine) TSH ⁭ FT4 ⁭ Creatinine (24h Urine) Chemistry ⁭ Creatinine Clearance

Glucose Serology / Hepatitis ______height (cm) Fasting Random Testing ______weight (kg) 2 hr PC (RRPL requisition required)

Hemoglobin A1c Hepatitis A IgM Hepatitis B surface Antigen

Glucose Tolerance Tests Hepatitis B surface Antibody Maternal 50g 1 hr Hepatitis C Antibody LIS Patient Label Maternal 75g 2hr 2hr (non-pregnant) 75g LIS USE ONLY . RQHR 217 (01/20) RQHR Doctor code can be requested by calling (306) 766-8900

Albert Park 3984 Albert St. Monday to Friday 7 am to 8 pm Saturday 7 am to 3 pm Sunday 8 am to 3 pm Stat Holidays 8 am to 3 pm

Towers 2723 Avonhurst Dr. Monday to Friday 7 am to 6 pm Saturday 7:30 am to 3 pm Sunday 8 am to 3 pm Stat Holidays 8 am to 3 pm

Gardiner 372 University Park Dr. Monday to Friday 7 am to 4 pm Park

Broad St. 2162 Broad St. Monday to Friday 8 am to 4 pm

Normanview 344 McCarthy Blvd. N. Monday to Friday 7:30 am to 4 pm Crossing

 If you require a blood test to be taken, please register at the location at least 20 minutes prior to closing.  Please present your health card each time you visit the lab.  Requisitions must be completed in full including first and last name, hospitalization number, date of birth and ordering physician.

FASTING – means you should not have anything to eat or drink except plain water for 10 to 12 hours before your lab test. Questions for fasting test(s). Answers May I drink water? Yes, small amounts of plain water. Should I take my medications? Yes, unless your doctor tells you not to. May I drink juice? No. May I drink coffee? No, not even black without sugar, and the same goes for tea. May I chew gum? No, sorry, not even sugarless. May I smoke? No, smoking can affect the test results, so it is recommended you do not smoke. May I do my exercise routine? No, exercise can also affect test results.

Req Scan Label RQHR Microbiology Location: ______Date: dd/mm/yyyy)__ Community Requisition. General Inquiries: (306) 766-8900 Patient Name:___(last)______(first)______

Requesting Physician (full name required) HSN: ______DOB:______RQHR Dr LIS Code______Specify Province: ______(dd/mm/yyyy) Last First Initial

Location/Facility/Clinic Name: MRN: ______Gender: M F

Additional Copy for: (full name and location required) Patient Address: Physician Name: ______RQHR Dr LIS Code: ______Last First Initial

Location/Facility/Clinic Name: Patient Contact Number:

DIAGNOSIS: ______ANTIBIOTICS: ______Collected by: ______Date:______Time: ______ALLERGIES: ______BLOOD & STERILE FLUIDS URINE RESPIRATORY/UPPER GI TRACT Blood culture  *C&S only if positive urinalysis  C&S  Influenza & RSV (NP swab, inpatients only)  Venipuncture, specify site:  Midstream urine  Pediatric auger suction (bacterial C&S)  Peripheral line, specify site:  Catheter – in/out, straight  Sinus aspirate:  bacterial/yeast  fungal  Central line, specify site:  Catheter – indwelling  Nasal (S. aureus carriage screen)  other, specify:______ Cystoscopy  Mouth swab (yeast only) CSF  other, specify: ______ Esophageal brush or biopsy (yeast only)  bacterial/yeast  fungal+Cryptococcal Ag Clinical Info (check all that apply): Throat swab  Lumbar puncture  symptomatic  pregnant  prostatitis  Group A Streptococcus (GAS) screen  Extraventricular drain  suspect poly-microbial infection  Other, specify: ______ Indwelling shunt  chronic catheter  kidney transplant Lower Respiratory  bacterial/yeast  fungal  other, specify:______ recent/pending GU surgery  stents  Sputum Sterile Fluids  bacterial/yeast  fungal STOOL  ETT suction  Pleural fluid  Bacterial C&S  Bronchial wash  Peritoneal fluid ⁭ dialysis  Clostridium difficile  Brochoalveolar lavage  Synovial fluid  Giardia/Cryptosporidium  Protected Brush Specimen  Bone marrow  Pinworm exam  Lung Biopsy, specify:  other, specify:  Parasite identification  Transbronchial  Transthoracic  Open  Catheter tip, specify: ______ Full Ova & Parasite exam EARS/EYES Relevant history required: WOUNDS/SURGICAL  Travel/immigration Eyes  left  right (check affected eye) Must specify site: Country: Dates:  bacterial/yeast  fungal  Gonorrhea ______ immunosuppressed  <13 yrs  Conjunctiva (submit swab from each eye) ⁭ bacterial/yeast ⁭ fungal  unsafe food/water  case contact  Cornea ⁭ Superficial wound swab (<1cm deep)  prior parasite:  Vitreous/Aqueous fluid ⁭ Deep wound swab (>1cm deep)  other, specify: ______ other, specify: ______⁭ Aspirate/fluid/drainage GENITAL TRACT Ears  left  right ⁭ Tissue/biopsy  Gonorrhea  cervical  urethral  rectal  bacterial/yeast  fungal ⁭ Bone chip  Group B Streptococcus (GBS) screen  External canal ⁭ Foreign body/implant, specify:  Bacterial Vaginosis & Candida  Tympanocentesis or surgical  Vaginal Culture  other, specify: ______Clinical Info (check all that apply): Upper Genital Tract  swab  tissue  aspirate OTHER/SPECIAL REQUESTS  abscess  surgical site  trauma  bite  Endometrial/Uterine  diabetic  immunocompromised  Tubo-Ovarian  osteomyelitis  foreign material in situ  other, specify:  chronic infection  sinus tract  External Genitalia, specify: ______ARO SCREENS DERMATOPHYTES MRSA: ⁭ nose ⁭ groin ⁭ other: Fungal microscopy & culture LIS Patient Label VRE: ⁭ rectal ⁭ stool ⁭ other:  skin  hair  nails Lab Use Only    ESBL/CRE: ⁭ rectal ⁭ stool ⁭ other: *Urinalysis (U/A) is included and will be used to screen urine. C&S will be performed only if U/A is positive for Nitrites or Leukocyte Esterase.

Note: Physician must complete SDCL requisitions for viral or Mycobacterial culture, GC/CT, or viral NAAT, hepatitis & other serologies

RQHR 1275 (05/18) RQHR Doctor code can be requested by calling (306) 766-8900

Albert Park 3984 Albert St. Monday to Friday 7 am to 8 pm Saturday 7 am to 3 pm Sunday 8 am to 3 pm Stat Holidays 8 am to 3 pm

Towers 2723 Avonhurst Dr. Monday to Friday 7 am to 6 pm Saturday 7:30 am to 3 pm Sunday 8 am to 3 pm Stat Holidays 8 am to 3 pm

Gardiner 372 University Park Dr. Monday to Friday 7 am to 4 pm Park

Broad St. 2162 Broad St. Monday to Friday 8 am to 4 pm

Normanview 344 McCarthy Blvd. N. Monday to Friday 7:30 am to 4 pm Crossing

All specimens must be labeled and submitted with a completed requisition. Specimens may be rejected if:

 they are improperly labeled or not accompanied by a completed requisition  submitted in an inappropriate container, received in leaking or otherwise compromised container  insufficient quantity of specimen, inappropriate specimen type for test requested, duplicate specimens, or if integrity of specimen has been compromised (e.g. lack of temperature control, delays in transit)

Whenever possible, specimens for microbiologic detection should be collected before antibiotics are given.

Care must be taken to avoid contamination of specimens with organisms of the normal flora or environment.

Specimens should be delivered to the laboratory soon after they are collected. Delays in transport can lead to incorrect, invalid, or misleading results.

The date and time of specimen collection should be recorded on the requisition in order to identify these delays and aid in results interpretation.

Providing relevant clinical information will ensure specimens are processed and reported appropriately.

Please refer to the RQHR Microbiology Compendium (http://www.rqhealth.ca/clinical-support/other-lab- services-resources) for descriptions of testing performed, specimen collection and transport instructions, and expected turnaround times. For special requests or additional information, please contact the Microbiology laboratory at (306)766-4481.

RQHR 1275 (05/18) RQHR Doctor code can be requested by calling (306) 766-8900

Rural/Referred-in Testing Requests Department of Laboratory Medicine Regina General Hospital, 1440 14th Ave Regina, SK S4P 0W5 phone: (306) 766-8900

Requesting Facility / Clinic: Location:______Date: ____(dd/mm/yyyy)_____

 Printed copy of report not required. Requesting Dr: RQHR LIS Dr Code: ______*Patient Name:___(last)______(first)______Dr Name / Initials) *HSN: ______DOB:____ (dd/mm/yyyy)____ Dr / Clinic Address: Specify Province: ______M F *MRN: ______Gender: M F

 Fax report to: ( ) - Patient Address: **Additional Copy for: RQHR LIS Dr Code: ______Dr Name / clinic / address Patient Contact Number:

Requesting Dr and cc Dr(s): Relevant Diagnosis:  Fax report to: ( ) - Dr Name / Clinic / Address required Do not use RQHR LIS Code alone. **Additional Copy for: RQHR LIS Dr Code: ______Do not use non-RQHR Dr Codes. Specimen Type (if not serum) Dr Name / clinic / address **Copies for additional physician(s), may not be sent if the mailing address cannot Collected by: Date / Time  Fax report to: ( ) - be determined.

Hematology General Chemistry Therapeutic Drugs Microbiology: CBC Electrolytes (Na, K, Cl) Date and Time of Last Dose: Separate Microbiology Requisition Potassium (only) ______be completed by Physician to PT/INR must Renal Panel ensure adequate information is aPTT Carbamazepine (Tegretol) Electrolytes provided. Specify Anticoagulant: Digoxin Urea Coumadin / Warfarin Creatinine Lithium Heparin *The labeling information on the Liver Panel Phenobarbital specimens submitted must match the No Anticoagulant T Bili Theophylline requisitions for the patient. Other:______ALK Phos Phenytoin (Dilantin) Specimen containers must be labeled with

ALT Valproic Acid (Depakene) the patient name (last and first), date of Prenatal Lipid Panel (Fasting) Vancomycin Pre ⁭ Post birth (day, month, year) and HSN or MRN Lipid Panel (Non-fasting) Sirolimus  Complete SHA Request for Tacrolimus Prenatal Testing requisition for Newborn Bilirubin OTHER Testing - Refer to the RQHR Test Prenatal Group & Screen or CK Albumin Compendium for available testing and Paternal Group. Urine Tests sample / shipping requirements. Calcium Total Protein Urinalysis (Random only) Magnesium Uric acid  Complete RRPL Requisition http://www.rqhealth.ca/department/laborato for Prenatal Panel (includes Phosphorus B-HCG Pregnancy Test (Random) ry-services/rqhr-lab-specimen-requirements Rubella IgG, Syphilis, HBV, Fe / TIBC Ferritin Albumin / Creat Ratio

HCV, HIV). ECG Tumor Markers 24 hour Urine Collections Other: Transfusion ⁭ PSA AFP Start Date:______⁭ CEA CA-125 Complete RQHR Transfusion End Date: ______requisition if Group & Thyroid Tests Volume: ______mL Antibody Screen ordered. Thyroid Screen Total Protein (24h Urine) Follow up tests: Chemistry Creatinine (24h Urine) TSH FT4 Glucose Creatinine Clearance

Fasting Random ______height (cm) 2 hr PC Collect on Ice / Ship Frozen

Hemoglobin A1c Lactate Ammonia ______weight (kg)

H. Pylori Glucose Tolerance Tests LIS Patient Label Maternal 50g 1 hr

Maternal 75g 2hr 2hr (non-pregnant) 75g RQHR Doctor code can be requested by calling (306) 766-8900

RQHR 1284 (03/20)

Regina Qu’Appelle Health Region Rural/Referred-in Testing Requests Department of Laboratory Medicine Regina General Hospital, 1440 14th Ave Regina, SK S4P 0W5 phone (306) 766-8900

 Please present your health card each time you visit the lab.

 Requisitions must be completed in full including first and last name, hospitalization number, date of birth and ordering physician.

RQHR Rural Collection Locations

South East Integrated Care Centre – Moosomin Montmartre Health Centre (306) 435-3303 (306) 424-2222 Tuesday, Wednesday, Thursday only Whitewood Health Centre All Nations Healing Hospital - Fort Qu’Appelle (306) 735-2010 (306) 332-3627 Broadview Union Hospital Balcarres Integrated Care Centre (306) 696-5504 (306) 334-6260 Grenfell Health Centre St. Joseph’s Integrated Care Centre – Lestock (306) 697-4035 (306) 274-2311 Wolseley Memorial Union Hospital Cupar Health Centre (306) 698-4440 (306) 723-4646 Tuesday and Friday only Indian Head Union Hospital Long Lake Valley Integrated Facility – Imperial (306) 695-4021 (306) 963-2122

RQHR 1284 (09/15) Specimen Collection for FERTILITY (SEMEN)

SPECIMEN DROP-OFF MUST BE BOOKED PLEASE CALL 306-766-4852 between 7:30 am and 4:00 pm(Mon – Fri) to book a time. TIMES AVAILABLE ARE 8:00 AM – 2:45 PM MON-FRI at Regina General Hospital Main Laboratory (1E on the first floor; please see over for map). Testing is NOT available after 2:45 pm weekdays or on weekends or statutory holidays. Note: Specimens dropped off without a booked appointment will be rejected.

APPOINTMENT TIME BOOKED BY PATIENT: ______SPECIMEN COLLECTION  Pick up a STERILE container with this REQUISITION from your physician’s office.  DO NOT ejaculate 2-5 days prior to the testing.  DO NOT use lubricants during the collection.  DO NOT use condoms during the collection.  Please submit the ENTIRE EJACULATE by masturbation.  Label the container with: NAME, DATE OF BIRTH,HOSPITALIZATION NUMBER,COLLECTION TIME.  Deliver sample to the laboratory within 30 MINUTES of collection.  Keep the sample as close to BODY TEMPERATURE as possible (e.g., place in an inside pocket until it is delivered to Regina General Hospital).

FILL IN THE INFORMATION COMPLETELY (Incomplete information may result in cancellation of testing) NAME (As it appears on your health card): ______HOSPITALIZATION NUMBER: ______DATE OF BIRTH (DD/MM/YYYY): ______ADDRESS: ______CITY: ______POSTAL CODE: ______PATIENT’S PARTNER: ______HOSPITALIZATION NUMBER: ______(if applicable) DATE OF COLLECTION (DD/MM/YYYY): ______TIME OF COLLECTION: ______am/pm METHOD OF COLLECTION:  Masturbation  Other NUMBER OF DAYS OF ABSTINENCE FROM SEXUAL INTERCOURSE/MASTURBATION_____ COLLECTION OF EJACULATION:  Complete  Incomplete TRANSPORT PROBLEMS (e.g., delay more than 30 minutes, exposure to hot or cold temperatures):  Yes  No PHYSICIAN’S FULL NAME: ______PHYSICIAN’S ADDRESS/LOCATION: ______

*I certify that the person named above has provided this sample*

NAME: ______

SIGNATURE: ______DATE (DD/MM/YYYY): ______

RQHR 196 (06/19)

Specimen Collection for POST VASECTOMY

IMPORTANT NOTES FOR THE TESTING Semen analysis should only be done 12 WEEKS or 20 EJACULATIONS or more after the procedure date. Any sample received BEFORE 12 weeks from the date of surgery will be CANCELLED by the laboratory. Note: Specimens dropped off without a booked appointment will be rejected.

APPOINTMENT TIME BOOKED BY PATIENT: ______

SPECIMEN COLLECTION  Pick up a STERILE CONTAINER with this REQUISITION from your physician’s office.  DO NOT ejaculate 2-5 days prior to the testing.  DO NOT use lubricants during the collection.  DO NOT use condoms during the collection.  Please submit the ENTIRE EJACULATE by masturbation.  Label the container with: NAME, DATE OF BIRTH,HOSPITALIZATION NUMBER,COLLECTION TIME.  Deliver sample to the laboratory within 30 MINUTES of collection.  Keep the sample as close to BODY TEMPERATURE as possible (e.g., place in an inside pocket until it is delivered to Regina General Hospital).

FILL IN THE INFORMATION COMPLETELY (Incomplete information may result in cancellation of testing) NAME (As it appears on your health card): ______HOSPITALIZATION NUMBER: ______DATE OF BIRTH (DD/MM/YYYY): ______ADDRESS: ______CITY: ______POSTAL CODE: ______DATE OF COLLECTION (DD/MM/YYYY): ______TIME OF COLLECTION: ______am/pm METHOD OF COLLECTION:  Masturbation  Other COLLECTION OF EJACULATION:  Complete  Incomplete TRANSPORT PROBLEMS (e.g., delay more than 30 minutes, exposure to hot or cold temperatures):  Yes  No PHYSICIAN’S FULL NAME: ______PHYSICIAN’S ADDRESS/LOCATION: ______DATE OF SURGERY (DD/MM/YYYY): ______

*I certify that the person named above has provided this sample*

NAME: ______

SIGNATURE: ______DATE (DD/MM/YYYY)______

RQHR 197 (06/19)

CHEMISTRY CRITICAL VALUES

TEST (Blood) LOW HIGH UNITS Sodium  120 155 mmol/L Potassium  2.8  6.0 mmol/L Potassium (newborn)  2.5  7.0 mmol/L Bicarbonate  10 mmol/L Calcium (total – check  1.8  3.0 mmol/L corrected value) Neonatal Bilirubin ≥300.00 umol/L Glucose  2.2  25 mmol/L Glucose (newborn)  1.7  17 mmol/L Magnesium <0.50 > 2.10 mmol/L Phosphorus  0.30 mmol/L Iron (< 14 years) > 50.0 umol/L pH  7.20  7.60 pCO2  20  70 mmHg pO2  40 mmHg Acetaminophen  600 umol/L Amikacin >10 mg/L (Pre) mg/L >30 mg/L (Post) Carbamazepine  63 umol/L Digoxin ≥ 3.0 nmol/L Gentamicin ≥ 2.0 (Pre) mg/L ≥ 15.0 (Post) Lithium ≥ 2.0 mmol/L Phenytoin ≥ 119 umol/L Phenobarbital ≥ 200 umol/L Salicylate  2.3 mmol/L Theophylline >110 umol/L Tobramycin ≥ 2.0 (Pre) mg/L ≥ 15.0 (Post) Vancomycin ≥ 21.0 (Pre) mg/L ≥ 60.0 (Post) HIV Reactive* Hepatitis C Antibody Reactive* Hepatitis B Surface Reactive* Antigen HTLV Reactive*

*Indicate to ward that sample is being referred to RRPL for confirmation

LABChemOP8200T1 Chemistry Critical Results Page 1 of 1 Laboratory Services, Regina Qu’Appelle Health Region Last printed 6/24/2019 2:46 PM JOB AID LABHemaOP7019T1 HEMATOLOGY CRITICAL VALUES Any critical/ urgent value where the Physician can not be notified must be paged to the Hematologist on call and an occurrence report initiated. (Refer to the time notification for paging Hematologist) Any new critical finding must have a HEMR ordered and a slide sent to the Hematologist on a separate tray Test Name Critical Value Alert/Urgent Value (called to the Physician immediately) (Physician notified within 24 hours) Platelet ≤ 20 x 109 /L New Case ≤ 50 x 109 /L Outpatient & ER Pateint ≤ 70 x 109 /L Patient Bleeding ≤ 100 x 109 /L PAC, DS, DAS ≤ 100 x 109 /L Neonate ≥ 1000 109/L New Case Hemoglobin ≤ 60 g/L New Case ≤ 90 g /L PAC, DS, DAS ≤ 70 g/L OutPatient ≥ 220 g/L Newborn ≥ 190 g/L Adult Male-New Case ≥ 180 g/L Adult Female-New Case Malaria Positive WBC ≥ 50 x 109 /L (inpatients-new case) ≥ 50 x 109 /L outpatients ≤ 1.5 x 109 /L (new case) Monotest Positive: if reflexed from lab PT INR > 6.0 ASAP INR ≥ 1.5 pre-op patients or first time on none PTT ≥ 100 sec. ASAP ≥ 39 sec pre-op patients or first time on none Fibrinogen ≤ 1.0 g/L D-Dimer ≥ 5000 μg/L CSF TNC ≥ 10 Kleihauer Positive with an actual ml bleed (Called to ward or physician)

Any test result that the technologist feels is significant should be called

Test Name Critical Value Urgent Value (Notify the Hematopathologist on call immediately) (Hematopathologist notified within 24 hrs) Abnormal 1. New Leukemia/Lymphoma-Blasts 1. Marked Rouleaux (2+ or greater)- new or blood films Immature cells from Promyelocytes to Blasts-New cases significant change. or significant change from previous. 2. 3+ Agglutination - new. 2. Schistocytes-Any with platelets ≤ 100 x 109 /L and/or 3. ANEUT ≤ 0.5 x 109 /L -first time hgb drop ≥ 30 g/L (except hemodialysis patients) 3. Spherocytes- 2 + with anemia-new case 4. Sickle cells-Any new case 5. Positive Malaria or any Questionable malaria requiring immediate review. Brown Plasma When plasma sample has severe hemolysis (not from difficult poke) Order: CBC, Scan, HEMR, renal & liver panel, LD, PT, PTT, Fib, D-Dimer and DAT-if not done in the past 6 hr. *Give sample to Chemistry to follow up with a plasma HGB &/or methemalbumin if ordered by the Hematologist. Kleihauer Positive with an actual ml bleed (Blood Bank notified ASAP)

LABHemaOP7019T1 Hematology Critical Values Page 1 of 1 Laboratory Services Regina QuAppelle Health Region Last printed 9/18/2018 2:52 PM LABMicOP8000.A.8.2MicrobiologyCriticalValues

Microbiology Critical and Significant Values

When results fall within "Critical" ranges, results should be verified, and then within 1 hour the Ward, or Physician concerned must be notified. This notification may be a phone call, with read back, followed by a hard copy of the report sent to their printer, or it may be a phone call notifying them you are sending a report, followed by confirmation that they have received the report. All calls must be documented.

The following are considered Critical Values in Microbiology:

Test Critical Value Notification to: Any new positive on In Patients or Emergency Patients.

If Gram Positive Cocci in Clusters seen in Gram Immediate call & send report to appropriate Blood Culture smear and new positive patient, ward. Do MRSA/SA GeneXpert test. Call Gram smear results at the same time you call GeneXpert results.

Immediate call & send report to appropriate CSF Any positive Gram smear. ward. Gram Smears

Sterile body fluids and tissue

specimens

Immediate call & send report to appropriate STAT All Gram smear results if marked STAT ward.

Eye If morphologies consistent with Bacillus or Immediate call to ward & MOC. Pseudomonas are pure or ≥ to normal flora on Send report to appropriate ward. Gram smear

LABMicOP8000.A.1 Microbiology Critical Values Page 1 of 4 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 23 July 2019 LABMicOP8000.A.8.2MicrobiologyCriticalValues

Test Critical Value Notification to: Immediate call & send report to appropriate CSF culture Any new positive result. ward. Call Gram smear results first, then when Positive Blood Culture Direct identification on Vitek MS available, call MS direct identification. Immediate. On weekdays: Group A Streptococcus isolated - Send report to Public Health from sterile sites, patients with - Send report and call Infection control. Any new positive result. Cultures history of necrotising fasciitis On weekends: - Call MHO on call. Regina 766-7773. Other Health Regions – refer to call list. Send report to

Pseudomonas aeruginosa or Immediate call to ward & MOC. Any new positive result. Bacillus species isolated from Send report to appropriate ward.

Eye

LABMicOP8000.A.1 Microbiology Critical Values Page 2 of 4 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 23 July 2019 LABMicOP8000.A.8.2MicrobiologyCriticalValues

When results fall within “Significant” ranges, the Ward, Clinic, or Physician concerned should be notified. Depending on the specimen and the result, notification may require a phone call or it may just be the electronic sending of the report. Notification should occur within that day. All calls must be documented.

The following are considered Significant Values in Microbiology: Test Protocol Call & send report for any new positive on patients from Referred In or Blood Culture Clinics. Gram Smears Sterile body fluids and tissues Positive Gram smears – Call results & send to appropriate ward. (including OR but NOT STAT) Negative Gram smears - Just send results, no call required. PJP PCR Pneumocystis Positive Just send results to ward, no call required. Call & send report of new positives to Ward / Clinic. Immediate call & send report to Infection Control MTB PCR MTB PCR positive Electronic report will be sent to Public Health.

Stool PCR Call & send report of new positives to Ward / Clinic. Enteric Pathogens If In patient notify Infection Control. (Campylobacter sp., Salmonella, Shigella, Electronic report will be sent to Public Health. Shiga-toxin producing E. coli).

Toxin Positive (regardless of method) In Patient (including Rural), Emerg., Nursing Home, - Call & send report to Ward, & Infection Control. Clostridium difficile New positives Out Patient or Clinic: Just send results to location. No calls required. Public Health does not need to be notified. Non-culture Call & send report of new positives to Ward. Influenza Screen Positive If In patient notify Infection Control. Electronic report will be sent to Public Health.

Gram smear is suspicious of dimorphic Mycology Notify MOC immediately and a MLT 2/MLT 3 supervisor. fungus.

LABMicOP8000.A.1 Microbiology Critical Values Page 3 of 4 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 23 July 2019 LABMicOP8000.A.8.2MicrobiologyCriticalValues

Test Protocol Call all confirmed or highly suspicious organisms to Ward or Clinic, RRPL, & Bioterrorism Agent Infection Control & Notify Microbiologist. Blood culture growth report Just send results, no call required unless a new organism is recovered. Body fluid, & Tissues Just send results, no call required.

Listeria Just send results, no call required. Interim reports on new RQHR In patient positive – Call & send report to Ward. MRSA Screen Positive If In patient notify Infection Control. If Out Patient no notification required. VRE Screen Positive Final reports - Just send results, no calls required. ESBL Positive Organism Electronic report will be sent to Public Health. (Only notify Public Health of ESBL from sterile sites) Cultures Send report of new positives to Ward / Clinic if isolate is from non-genital source. If genital culture, no call required. Neisseria gonorrhoeae Electronic report will be sent to Public Health. NEVER notify Infection Control Immediate call & send report to Public Health (Regina 766-7789). After Hours call MHO on call. Regina 766-7773 Other Health Regions – refer to call list. Neisseria meningitidis (sterile site)

Immediate call & send report to Infection Control for isolates from In Patients, Nursing Homes, and WRC. Electronic report will be sent to Public Health. Streptococcus agalactiae (Group B) Isolated from children <4weeks of age Immediate call & send report to Infection Control for isolates from In Patients, Nursing Homes, and WRC.

LABMicOP8000.A.1 Microbiology Critical Values Page 4 of 4 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 23 July 2019

LABTranOP7001W3 Transfusions Critical Values

When tests or results fall within "Critical" ranges, the Ward/ Physician concerned and Hematopathologist on call must be notified. This notification may be a phone call which should be documented on the Transfusions report. To do this, a tech call test is ordered and any relevant information recorded as a comment in the tech call test.

The following are considered “Critical Circumstances” in Transfusions:

“Test/Result” Critical circumstance Alert Hematopathologist/Ward Within relevant time Within 24 hrs frame based on testing Positive antibody Unmatched blood may be issued upon request before antibody √ - ward must be notified screen after screen testing is completed. If the antibody screen appears to immediately, then unmatched packed be positive, the transfusion of any unmatched units should be Hematopathologist on call cells are issued stopped immediately and the units returned to Transfusions. is notified Delay in ability to 1. Due to shortage of product at CBS (i.e. platelet shortage) √- Hematopathologist supply blood 2. Due to unknown or multiple antibodies, or antibodies to √ -Hematopathlogist on call √ - make “on call products for high incidence antigens is notified if need for Hematopathologist transfusion 3. Compatible units unavailable due to patient’s condition or packed cells is immediate ” aware of patient disease (i.e. presence of a WAA in a CLL pt) √ - Hematopathologist/ and history ward Suspect transfusion Appearance of grossly icteric or hemolyzed plasma NOT due √ - if serious transfusion √ - make “on call reaction due to to a difficult draw. Patient’s transfusion history and diagnosis reaction is suspected and Hematopathologist colour of patient should be reviewed with the ward to rule out the possibility of patient requires blood ” aware of patient plasma a hemolytic/serious transfusion reaction. transfusion and history WinRho Pregnant/ bleeding Rh D negative patients in Emerg may √ - follow up with ward and √ - if patient has required/not leave prior to receiving WinRho. The ward is notified when Hematopathologist on been discharged required for Rh testing is complete if patient requires WinRho. weekends if patient is prior to receiving negative Patient should be given product within 72 hours of bleeding discharged prior to recommended dose pregnant/bleeding episode. receiving WinRho of WinRho women

LABTranOP7001W3 Transfusion Critical Values Page 1 of 2 Laboratory Services Regina Qu'Appelle Health Region Last printed 8/21/2018 12:56 PM

Positive blood For best practice, Transfusions is to notify the ward or Ward/Physician to be cultures on issued “Physician if patient is discharged” when a blood culture notified when report has bone bank comes back positive on a bone bank product issued from been received in products, interim Transfusions. Transfusions and calls/faxes and final reports documented on paper report Any test result or issue that the technologist feels is significant should discussed with the Hematopathologist on call

LABTranOP7001W3 Transfusion Critical Values Page 2 of 2 Laboratory Services Regina Qu'Appelle Health Region Last printed 8/21/2018 12:56 PM

Subject/Title: LABHistOP1003.1.6 Anatomic Pathology Critical Results Last Updated Time: 10/24/2018 Revision: 1.60 Approving Authority: Medical Pathologist Contact for Interpretation: Histology Phone: (306) 766-2075 Current Version on Print Date

ANATOMIC PATHOLOGY CRITICAL RESULTS

Significant or unexpected pathology findings are to be promptly communicated to the patient’s clinician or appropriate health care provider. Documentation of the date and time of notification and name of the recipient of the notification are to be included in the pathology report.

A) Surgical Pathology - significant or unexpected findings include but are not limited to the following:

1. Malignancy in an uncommon location or specimen type (e.g. hernia sac, intervertebral disk material, tonsil, etc.).

2. Absence of chorionic villi when clinically expected (potential ectopic pregnancy).

3. Change of a frozen section diagnosis after review of permanent sections

4. Mycobacterial, fungal or other significant organisms identified on special stains.

The pathologist will document the name of the clinician notified and the date and time of the call on the surgical report.

B) Amendments to Surgical Pathology reports that would significantly affect patient care are reported promptly to the responsible clinician(s).

The pathologist will document the name of the clinician notified and the date and time of the call on the Amended surgical report.

C) Correlation of Results - There is a process to correlate the results of specialized studies (e.g. immunohistochemistry, flow cytometry) with the morphologic diagnosis. It is not in the best interests of the patient to have potentially conflicting diagnoses or interpretations rendered by different sections of the laboratory. The pathologist should issue a report reconciling potentially conflicting data, when appropriate.

D) Autopsy - significant or unexpected pathology findings may include, but are not limited to the following:

1. Unexpected fatal malignancy.

2. Heritable genetic abnormalities. LABHistOP1003.1.6 Anatomic Pathology Critical Results Laboratory Services Regina QuAppelle Health Region Page 1 of 1 Last Printed: March 19, 2019

3. Procedural complications.

4. Reportable infectious diseases.

The pathologist will document the name of the clinician or coroner notified and the date and time of the call on the autopsy report.

LABHistOP1003.1.6 Anatomic Pathology Critical Results Laboratory Services Regina QuAppelle Health Region

Subject/Title: LABCytoOP7047 Communication and Documentation of Cytopathology Critical Results Last Approved Time: Angeles, Ronald(Head of

Cyto Pathology) (06/10/2018) Revision: 1.10 Approving Authority: Cytopathologist Contact for Interpretation: Cytology Phone: (306) 766-2641 Current Version on Print Date

Policy

Process Control

Purpose

There are certain cytopathology diagnoses that may be considered particularly significant and unexpected. There are no consensus guidelines developed on Critical Values in cytology, so we will address the type of cases that the RQHR Cytopathology Department has designated as Critical Results. It is important to have prompt communication and documentation of these particular diagnoses.

Procedure

Cytology Critical Value (CV) cases: . Bacteria or fungi in cerebrospinal fluid . Pneumocystis, fungi, or viral cytopathic changes in BAL, wash, or brush . Bacteria in FNA . Fungi in FNA . Acid-fast bacilli in any specimen . Completely unexpected malignancy (malignancy in a fluid with a negative history and no clinical suspicion) . Malignancy (suspected or not) in critical places (sup.vena cava synd., risk of spinal cord injury)

1. The Cytotechnologist screening the case, will identify the Critical Result and will take it immediately to the pathologist reporting the case. 2. The pathologist will promptly communicate the significant or unexpected findings to the patient’s physician or other clinical personnel responsible for patient care by telephone. 3. The pathologist will document the date and time of notification and name of the recipient of the notification on the cytology report. 4. If after 3 tries, a physician cannot be reached by telephone, the report will be

LABCytoOP7047 Communication and Documentation of Cytopathology Critical Results Laboratory Services Regina QuAppelle Health Region

Page 1 of 2 Last printed 3/27/2019 3:05 PM

faxed to the physician / ward within 24 hours.

Procedure notes

 Any amendments to reports that would significantly affect patient care are reported promptly to the responsible clinical personnel in the same manner.

References

Diagnostic Cytopathology, Vol 34, No 6, “Critical Values in Cytology”

Related documents

RQHR Quality Manual, LABRegOP8101 Timely Communication of Critical Values and New Diagnosis LABRegOP7900 Laboratory Services Manual General Information

Appendixes (charts, form, job aids, labels, logs, tables, tags, worksheets)

Revision History

Found in SoftTech Health Lab QMS™ Document Management System

Author

Ronald Angeles, MD, FRCPC, PATHOLOGIST, L. Kozak, MLT

LABCytoOP7047 Communication and Documentation of Cytopathology Critical Results Laboratory Services Regina QuAppelle Health Region

Page 2 of 2 Last printed 3/27/2019 3:05 PM

RURAL LAB CRITICAL RESULTS

IMPORTANT: Please provide a contact number on the requisition to enable critical results to be phoned to the requesting practitioner or designate after normal office hours.

CHEMISTRY TEST (Blood) LOW HIGH UNITS Sodium  120 155 mmol/L Sodium: Piccolo Instrument Only  120 150 mmol/L Potassium  2.8  6.0 mmol/L Potassium (newborn)  2.5  7.0 mmol/L Bicarbonate  10 mmol/L Bilirubin (neonatal)  300 umol/L Calcium (total – check corrected  1.8  3.0 mmol/L value) Glucose  2.2  25 mmol/L Glucose (newborn)  1.7  17 mmol/L Magnesium <0.50 > 2.10 mmol/L Phosphorus  0.30 mmol/L PH < 7.20 > 7.60 PCO2 ≤ 20 ≥ 70 mmHg PO2 ≤ 40 mmHg Acetaminophen  600 umol/L Digoxin ≥ 3.0 nmol/L Salicylate  2.3 mmol/L Phenytoin  119 umol/L

HEMATOLOGY Any new critical finding must have a HEMR (Hematologist Review) ordered. Send 2 unstained slides and CBC report to RGH hematology. Test Name Critical Value Alert/Urgent Value (called to the Physician immediately) (Physician notified within 24 hours) Platelet ≤ 20 x 109 /L (new case) ≤ 50 x 109 /L (out-patient/community) ≤ 70 x 109 /L (patient bleeding) ≤ 100 x 109 /L Pre-Op ≤ 100 x 109 /L (neo) Hemoglobin ≤ 60 g/L (new case) ≥ 200 g/L adult male ≥ 220 g/L (new born) ≥ 180 g/L adult female

LABRlabOP7900A2.1.3 Rural Lab Critical Result Appendix Page 1 of 2 Laboratory Services Regina Qu’Appelle Health Region Last printed 12/06/2017

RURAL LAB CRITICAL RESULTS ≤ 90 g /L Pre-Op Malaria Positive WBC ≥ 30 x 109 /L (inpatients-new case) ≥ 30 x 109 /L outpatients ≤ 1.5 x 109 /L (new case) Monotest Positive: if reflexed from lab PT INR > 5.0 ASAP INR ≥ 1.5 pre-op patients or first time on none PTT ≥ 100 sec. ASAP ≥ 39 sec pre-op patients or first time on none Any test result that the technologist feels is significant should be called

Test Name Critical Value Urgent Value (Notify the Hematopathologist on call immediately) Send unstained slides (2) (Hematopathologist notified within 24 hrs) along with CBC report to RGH for HEMR) Abnormal 1. New Leukemia 1. Marked Rouleaux- new or significant change. blood films 2. Schistocytes-Any with platelets ≤ 50 x 109 /L and/or hgb drop ≥ 30 g/L 2. 3+ Agglutination - new. (except hemodialysis patients) 3. Absolute Neutrophil < 0.5 x 109 /L-first time 3. Spherocytes- 2 + with anemia-new case 4. Sickle cells-Any new case 5. Positive Malaria Brown Plasma When plasma sample has severe hemolysis (not from difficult poke) Order: CBC, Scan, HEMR, renal, & liver panel, LD, PT, PTT, Fib, D-Dimer and DAT-if not done in the past 6 hours (some tests may not be available on site. Refer those tests to RGH for testing.) *Give sample to Chemistry to follow up with a plasma HGB &/or methemalbumin if ordered by the Hematologist Note:  New Leukemias-First time Blasts(add comment: refer to Hematologist’s review for verification)

TRANSFUSION The laboratory will call whenever there will be a delay in filling the crossmatch request – detailing the reason for the delay. MICROBIOLOGY All POSITIVE blood culture results will be phoned. NOTES 1. Any result that the technologist feels is significant should be phoned, especially if there is a change from a previous result. 2. Critical results telephoned from the testing facility should be telephoned to the inpatient ward, office/clinic or directly to the ordering physician. 3. Any critical / urgent values where the Physician cannot be notified refer to LABRlabOP7900J1 Rural Lab Critical Result Calling Results Job Aid.

LABRlabOP7900A2.1.3 Rural Lab Critical Result Appendix Page 2 of 2 Laboratory Services Regina Qu’Appelle Health Region Last printed 12/06/2017

Subject/Title: LABChemOP8202C1.3.7 Chemistry Tests Last Approved Time: Mali, Bahera(Medical Biochemist) (01/04/2019) Revision: 3.70 Approving Authority: Medical Biochemist Contact for Information: Chemistry Phone: (306) 766-4490 Current Version on Print Date

TEST STAT TAT 24 hr Test Site (in minutes) Availability RGH / PH Acetaminophen 70 * * * AFP (alpha fetoprotein) * Albumin (serum/fluid) 70 * * * Alcohol (Ethanol) 70 * * * Alkaline Phosphatase 70 * * * ALT 70 * * * Amikacin 70 * * Ammonia (plasma) 70 * * * AST 70 * * * B12 * BhCG - Quantitative 70 * * * Bilirubin-total and direct 70 * * * (serum/fluid) Blood and Body Fluid Exposure 2.5 hours * * * Blood Gases 10 * * * BNP (plasma) 70 * * * CA125 * Calcium 70 * * * Calcium (urine) * * Carbamazepine 70 * * Carbon Dioxide (CO2) 70 * * * Carboxyhemoglobin/ 30 * * * Methemoglobin (whole blood) CA15-3 * CA19-9 * CEA * * Chloride 70 * * * Chloride (urine) * * Cholesterol (serum/fluid) * * * CK 70 * * * Cortisol 70 * * Creatinine (serum/urine/fluid) 70 * * * CRP 70 * * * CSF Glucose 70 * * *

LABChemOP8202C1.3.7 Chemistry Tests Laboratory Services Regina QuAppelle Health Region

CHEMISTRY TESTS

CSF Protein 70 * * * Cyclosporine (whole blood) 4 hours * Digoxin 70 * * * Estradiol 70 * Ferritin * Folates (RBC) * Free PSA * Free T3 * Free T4 * FSH * Gentamicin 70 * * GGT 70 * * * Glucose 70 * * * Glucose Tolerances * * HDL / LDL Cholesterol * * * Hemoglobin – fetal (APT test) 70 * * Iron 70 * * * Ketones 60 * * * Lactate 70 - plasma * * * 30 – whole blood Lipase 70 * * * LD 70 * * * LH * Lithium 70 * * Magnesium 70 * * * Magnesium (urine) * * Methotrexate 2 hours * * Microalbumin (urine) * Occult Blood (feces/gastric) * * Osmolality (serum/urine) 70 * * * Phenobarbital 70 * * Phenytoin 70 * * * Phosphorus 70 * * * Phosphorus (urine) * * Potassium 70 * * * Potassium (urine) * * Pregnancy test (urine) 60 * * * Prolactin * Protein (serum/urine/fluid) 70 * * * PSA * PTH 70 * * Salicylate 70 * * * Sirolimus (whole blood) 4 hours * Sodium 70 * * * LABChemOP8202C1.3.7 Chemistry Tests Laboratory Services Regina QuAppelle Health Region

LABChemOP8202C1.3.5 Chemistry Tests Page 2 of 5 Laboratory Services, Regina Qu’Appelle Health Region Last printed 3/22/2019 11:09 PM

CHEMISTRY TESTS

Sodium (urine) * * Tacrolimus (whole blood) 4 hours * Theophylline 70 * * TIBC * * * Tobramycin 70 * Triage (urine) 60 * * * Triglyceride (serum/fluid) * * * High Sensitivity Troponin I 70 * * * TSH 70 * Urea (serum/urine/fluid) 70 * * * Uric Acid (serum/ fluid) 70 * * * Uric Acid (urine) * * Urinalysis 60 * * * Urine Albumin * Valproic Acid 70 * * Vancomycin 70 * *

Wards will be notified if testing delayed due to uncontrolled circumstances.

LABChemOP8202C1.3.7 Chemistry Tests Laboratory Services Regina QuAppelle Health Region

LABChemOP8202C1.3.5 Chemistry Tests Page 3 of 5 Laboratory Services, Regina Qu’Appelle Health Region Last printed 3/22/2019 11:09 PM

CHEMISTRY TESTS

Chemistry Specialized Testing

Chemistry Specialized Testing is staffed Monday to Friday 0730 – 1600 @ RGH. Testing is unavailable on the weekend. Call back may be required for some stat tests.

TEST STAT ROUTINE TAT TAT α-1 antitrypsin 5 days AGBMA 5 days Alkaline Phosphatase Isoenzymes 5 days AMA 14 days ANA Screen 14 days Anti-dsDNA 21 days Anti-RNP 21 days Anti-Scl 70 21 days Anti-Smith 21 days Anti-SSA (Ro 60) 21 days Anti-SSB 21 days ASMA 14 days Bence Jones Protein – Urine 10 days B2 Microglobulin 5 days C3 – C4 2 hours 5 days Cryoglobulin / Cryofibrinogen 14 days Free Light Chains 14 days Glucose 6 Phosphate Dehydrogenase 5 days Haptoglobin 2 hours 5 days Hemoglobin A1C 5 days Hemoglobin A2 2 weeks Hemoglobin F 2 weeks Hemoglobin Electrophoresis 2 weeks Hemoglobin in Plasma 2 hours 2 days IFE with Quant Immunoglobulins 10 days Oligoclonal Bands in CSF 1 week PE with IFE – Quant Immunoglobulins 10 days Porphyrin Screen, Urine 2 hours 1 week Protein Electrophoresis – Serum 10 days Protein Electrophoresis – Urine 10 days Pyrogens 5 days Quant Immunoglobulins 2 hours 5 days RF 5 days Sweat Chloride 3 days

LABChemOP8202C1.3.7 Chemistry Tests Laboratory Services Regina QuAppelle Health Region

LABChemOP8202C1.3.5 Chemistry Tests Page 4 of 5 Laboratory Services, Regina Qu’Appelle Health Region Last printed 3/22/2019 11:09 PM

CHEMISTRY TESTS

All testing performed is approved by Health Canada regulations.

LABChemOP8202C1.3.7 Chemistry Tests Laboratory Services Regina QuAppelle Health Region

LABChemOP8202C1.3.5 Chemistry Tests Page 5 of 5 Laboratory Services, Regina Qu’Appelle Health Region Last printed 3/22/2019 11:09 PM

GUIDELINES FOR EXPECTED TURN AROUND TIMES IN HEMATOLOGY

STAT “ TAT” 24 HR TEST PERFORMED TEST AVAILABILITY RGH PASQUA CBC * * 1 HR * CBC * * 90 MINS * DIFFERENTIAL * MALARIA SCREEN 90 MINS * APTT * * 1 HR * PT * * 1 HR * FIBRINOGEN * * 1 HR * D-DIMER * * 3 HR * CSF * * 1 HR * * * CSF DIFFERENTIAL 2 HR * PERITONEAL * * FLUID & 2 HR * DIFFERENTIAL ESR * * 2 HR * MONOTEST * * 90 MINS * KLEIHAUER * 90 MINS NOTIFICATION * BONE MARROWS SAME DAY 12HRS-(VERBAL * FLOWCYTOMETRY RESULT BY PHONE)

LABHemaOP7031C1.1.3 Guidelines for Expected Turn Around Times in Hematology Page 1 of 4 Laboratory Services, Regina Qu’Appelle Health Region Last printed 6/7/2017 10:59 AM

GUIDELINES FOR EXPECTED TURN AROUND TIMES IN HEMATOLOGY

TEST ROUTINE TEST PERFORMED RGH PASQUA CBC 6 HRS * *

DIFFERENTIALS 24 HRS * *

APTT 4 HRS * *

PT 4 HRS * *

FIBRINOGEN 4 HRS * *

OTHER FLUIDS 4 HRS * *

ESR 6 HRS * *

RETICS 24 HRS * *

MONOTEST 6 HRS * *

KLEIHAUER 24 HRS *

SEMEN ANALYSIS 48 HRS *

BONE MARROWS 72 HRS * *

FLOWCYTOMETRY 48 HRS *

CD4/CD8 24 HRS *

LABHemaOP7031C1.1.3 Guidelines for Expected Turn Around Times in Hematology Page 2 of 4 Laboratory Services, Regina Qu’Appelle Health Region Last printed 6/7/2017 10:59 AM

GUIDELINES FOR EXPECTED TURN AROUND TIMES IN HEMATOLOGY

The following tests are available but they are to be approved by the hematologist mainly because: a) These tests are time consuming. b) These tests are difficult to interpret.

TEST RGH

SERUM VISCOSITY *

SICKLE CELL TEST *

HEINZ BODY TEST *

MYELOPEROXIDASE STAIN *

COMBINED ESTERASE * STAIN

IRON STAIN *

MALARIA IDENTIFICATION *

LABHemaOP7031C1.1.3 Guidelines for Expected Turn Around Times in Hematology Page 3 of 4 Laboratory Services, Regina Qu’Appelle Health Region Last printed 6/7/2017 10:59 AM

GUIDELINES FOR EXPECTED TURN AROUND TIMES IN HEMATOLOGY

The following special coagulation tests have to be approved by the Hematologist. These tests are time consuming and difficult to interpret. The TAT for these tests is 4-6 weeks.

TEST RGH FACTOR ASSAYS * RISTOCETIN * FACTOR VIII RELATED ANTIGEN * PLATELET AGGREGATION STUDY * PROTEIN S * PROTEIN C * ANTITHROMBIN III * APC RESISTANCE RATIO * ANTICARDIOLIPIN ANTIBODIES * DRVVT * THROMBIN TIME * FACTOR XIII * HEPARIN ASSAY * INHIBITOR STUDIES * HIT TEST * PFA *

LABHemaOP7031C1.1.3 Guidelines for Expected Turn Around Times in Hematology Page 4 of 4 Laboratory Services, Regina Qu’Appelle Health Region Last printed 6/7/2017 10:59 AM

Subject/Title: LABMicOP8000.A.2 Anticipated Turn Around Times for Microbiology Tests Last Approved Time: 07/25/2019 Revision: 6.10 Approving Authority:Medical Microbiologist Contact for Interpretation: Microbiology Phone: (306) 766-4481 Current Version on Print Date

Turn-around time (TAT) for Microbiology specimens is from the time of receipt of specimen in the laboratory to the time of generation of the final report. Specimen Initial Processing Final culture Comments Negative Positive Abscess Microscopy 72 hours. 24 – 48 hours Mixed cultures, with Aspirate performed and Sterile fluids received in after isolation of anaerobic organisms Sterile fluids reported. blood culture bottles that organism. may require longer time. CSF Specimen cultured. are negative will have Deep Wound preliminary results issued after 24 hours incubation, and a final results after 5 days. Blood Cultures Bottles are placed 5 days 24 – 48 hours Mixed cultures may in an automated after isolation of require longer time. system for organism. continuous If Gram Positive **Fungal blood cultures monitoring. Cocci in clusters are incubated for 5 days. Bottles that are are seen in the flagged as positive Gram smear, a **If extended incubation are subcultured GeneXpert is requested, & approved immediately, and MRSA / SA test by MOC: microscopy results is performed to Blood culture bottles and/or organism ID determine if will be monitored on the (whenever specimen is automated system for 5 available) are called positive for days. If negative after 5 STAT. MRSA, days, terminal Positive blood Staph.aureus, or subculture will be cultures on new Coagulase performed. patients will have a Negative Staph. direct identification Acceptable TAT performed same for this test ≤3hrs. day and if results acceptable identification will be reported. C. difficile Toxin ≤ 24 hours ≤ 24 hours Appropriate ward and Test the Infection Control department are notified of all positive results. Eyes / Ears Microscopy 48 – 72 hours 24 – 48 hours performed and reported. LABMicOP8000.A.2 Anticipated Turn Around Times for Microbiology Tests Laboratory Services Regina QuAppelle Health Region

Anticipated Turn Around Times (TATs) for Microbiology Tests Specimen cultured

LABMicOP8000.A.2 Anticipated Turn Around Times for Microbiology Tests Laboratory Services Regina QuAppelle Health Region

LABMicOP8000.A.6.1 Anticipated Turn Around Times For Microbiology Tests Page 2 of 5 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 25 July 2019

Anticipated Turn Around Times (TATs) for Microbiology Tests

Specimen Initial Processing Final culture Comments Negative Positive ESBL / CRE Specimen cultured. ≤ 24 hours 48 – 72 hours Ward and Infection Screen control notified immediately when isolated on new patients. Suspect CRE isolates are sent to NML for confirmation. Results may take up to a week. FLU Test In house testing only ≤ 24 hours ≤ 24 hours *STAT test results (Rapid) performed on In Patients available within 4 hours. during flu season. Specimens All specimens are sent to from out patients are referred Reference Lab. for to Reference Laboratory for confirmation. testing. Genital Microscopy performed and 48 hours for 24 – 72 hours reported. Candida Specimen cultured. 72 hours for bacterial pathogens including N. gonorrhoeae Group B Strep Specimen is placed into a 16 - 24 hours. Susceptibility testing is Screen broth culture and incubated. not routinely performed.

MRSA Screen PCR negative test results are ≤24 hours ≤72 hours Ward and Infection reported directly. PCR control notified positive test results are immediately when confirmed by culture. Interim MRSA is isolated on positive results should be new patients.. reported as soon as presumptive testing confirms identification MTB PCR ≤24 hours ≤24 hours *STAT test results available within 4 hours.

LABMicOP8000.A.2 Anticipated Turn Around Times for Microbiology Tests Laboratory Services Regina QuAppelle Health Region

LABMicOP8000.A.6.1 Anticipated Turn Around Times For Microbiology Tests Page 3 of 5 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 25 July 2019

Anticipated Turn Around Times (TATs) for Microbiology Tests

Specimen Initial Processing Final culture Comments Negative Positive Skin (superficial) Microscopy performed and 48 hours 48 – 72 hours reported. Specimen cultured Oral swabs Microscopy performed and 24 hours 24 hours reported. Specimen cultured only upon request Sputum Microscopy performed and 48 hours 48 – 72 hours **If salivary specimen, reported. ward will be notified and Only non-salivary asked to recollect. specimens are cultured from non-Cystic Fibrosis patients. Lower Microscopy performed and 48 hours 48 – 72 hours Respiratory Tract reported. Specimen Cultured PJP (BD Max PCR) ≤ 24 hours 24-72 hours Positive PCR results are confirmed by fluorescent staining. Throat culture Specimen cultured 18 - 24 hours 18 - 24 hours Antimicrobial susceptibility testing performed only upon request. Stool Bacterial (BD Max PCR) ≤ 24 hours ≤ 24 hours Specimens with positive Enteric PCR: PCR results are sent to Reference Lab. for confirmation. Urine 18 - 24 hours 48 – 72 hours VRE Screen Specimen cultured ≤ 72 hours ≤ 96 hours Ward and Infection control notified immediately when VRE is confirmed.

LABMicOP8000.A.2 Anticipated Turn Around Times for Microbiology Tests Laboratory Services Regina QuAppelle Health Region

LABMicOP8000.A.6.1 Anticipated Turn Around Times For Microbiology Tests Page 4 of 5 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 25 July 2019

Anticipated Turn Around Times (TATs) for Microbiology Tests

Microscopy Results Turn-around time (TAT) for Microbiology specimens is from the time of receipt of specimen in the laboratory to the time of generation of the final report. Test STAT Routine

1 hour *Positive Gram smears from blood, CSF, sterile Gram Stain Same day fluids, tissues, or biopsies are critical values and must be called as soon as results are available.

Notes: 1. Additional interim reports are sent when delays in identification and / or susceptibility testing occur, as with fastidious organisms and mixed cultures. All positive cultures will have interim reports issued within 48 hours. Prompt and updated reports aid the physician in appropriate clinical interventions and proper patient management.

2. If these TAT limits cannot be met because of problems within the laboratory such as equipment, media, or reagents, the client will be notified (physician / ward), and if necessary, testing at an alternate site will be arranged.

3. Audits of TAT’s for interim and final reports are performed on a quarterly basis, evaluating different specimen types each quarter.

LABMicOP8000.A.2 Anticipated Turn Around Times for Microbiology Tests Laboratory Services Regina QuAppelle Health Region

LABMicOP8000.A.6.1 Anticipated Turn Around Times For Microbiology Tests Page 5 of 5 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 25 July 2019

LABTranQP7000W1 Turn Around Times (TAT) for Requested Blood Products

Product Requested TAT Group O Uncrossmatched Packed cells 10 minutes Group-specific Uncrossmatched Packed 15 minutes from sample receipt in Lab Cells Fully Crossmatched Packed Cells 45 minutes from sample receipt in Lab (assuming no serological problems) Frozen Plasma – need a current admission 25 minutes (product must be thawed) blood group or issue universal donor group Platelets (if available on site) - need a 10 minutes current admission blood group Cryoprecipitate - need a current admission 25 minutes (product must be thawed and blood group or issue universal donor group pooled)

NOTE: The Pasqua Hospital does not do serological testing. All serological testing is completed at the Regina General Hospital. The time that group-specific uncrossmatched packed cells and fully crossmatched packed cells are available is dependent on the time the sample is received at the Regina General Hospital.

LABTranQP7000W1 Turn Around Times for Requested Blood Products Page 1 of 1 Laboratory Services, Regina Qu’Appelle Health Region Last printed 6/17/2019 2:53 PM

LABTranQP7000W2 Turn Around Times for Transfusion Tests

Test Requested TAT Blood Group – Stat 15 minutes from sample receipt in Lab Blood Group - Routine 4 hours Group and Screen – Stat 45 minutes Group and Screen – Routine 4 hours Cold Agglutinin test 24 hours Direct Antiglobulin Test – Stat 30 minutes Direct Antiglobulin Test - Routine 8 hours

NOTE: The Pasqua Hospital does not do serological testing. All serological testing is completed at the Regina General Hospital. The time that testing results are available is dependent on the time the sample is received at the Regina General Hospital.

LABTranQP7000W2 Turn Around Times for Transfusion Testing Page 1 of 1 Laboratory Services, Regina Qu’Appelle Health Region Last printed 6/17/2019 2:53 PM Laboratory Test Menu-Rural Facilities STAT Testing ** On Call Sites testing Available 24 hours Turn Around Time: 70 minutes l l a l l C

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Carbon Dioxide (C02) √ √ √ √ √ √ √ √ Creatinine √ √ √ √ √ √ √ √ Chloride √ √ √ √ √ √ √ √ Sodium √ √ √ √ √ √ √ √ Potassium √ √ √ √ √ √ √ √ Glucose √ √ √ √ √ √ √ √ Glucose Tolerance Collection √ √ √ √ √ √ √ √ √ √ √ Magnesium √ √ √ Phosphorus √ √ √ Protein, Total - Serum √ √ Triglyceride √ √ Urea √ √ √ √ √ √ √ √ Uric Acid √ √ Alkaline Phosphatase √ √ √ √ √ √ Alanine Transaminase √ √ √ √ √ √ Amylase √ √ √ √ √ √ Aspartate Transaminase √ √ Creatine Kinase √ √ TROPONIN T √ √ √ √ √ √ Gamma Glutamyl Transferase (GGT) √ √

LABRlabOP7900A3.1.6 Laboratory Services Regina Qu'Appelle Health Region 3/1/2019 1 l l a l l C

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LABRlabOP7900A3.1.6 Laboratory Services Regina Qu'Appelle Health Region 3/1/2019 2

REGIONAL POLICY

Subject/Title: Manual:

Reference Number: Identification of Client/Patient/Resident 612 Effective Date: July 27, 2010 Approving Authority: CEO and President Revision Dates: Recommended by: CQI Team/Required Organization Practice (ROP) Working Group Originated July 2010. Classification: Contact for Interpretation: Executive Director, Diagnostic Imaging, Laboratory, and

Nuclear Medicine Source

See related procedure

1. Policy Client identification will be confirmed using two (2) client identifiers prior to the provision of any health service.

All physicians and staff will follow client identification procedures in effect in their area of service and procedure delivery to ensure care to the correct client at each health service interaction.

2. Purpose • To ensure accurate identification of clients/patients/residents prior to performing any health service or procedure. • To reduce/eliminate the risk of clients receiving unintended services or procedures. • To provide a positive method of linking each health service or procedure to the correct medical record. • To comply with Accreditation Canada Required Organizational Practice for the reassurance and confidence of all our stakeholders.

3. Responsibilities All physicians and staff are expected to follow applicable client/patient/resident identification procedures in effect in their area of service and procedure delivery using two (2) client identifiers which may include: observation, documentation, and/or verbal identification.

4. Definitions • “Client” may refer to clients, patients, or residents in any area of care within the RQHR. • Health services examples include, but are not limited to: admission, transfer, discharge, IVs, injections, venipunctures, other specimen collection, drug administration, anesthesia, respiratory procedures, surgical procedures, blood transfusion, diagnostic procedures, and therapies.

• Two client identifiers include: o First and last names o Unique identifying numbers o Photographs o Witnesses o Other individual specific identifiers. • Unique identifying numbers include: a. Health Services Number (HSN) b. Medical Record Number (MRN) c. Stay number (visit number) d. Date of Birth (DOB) e. Address Note: location or room numbers are never acceptable client specific identifiers. • Verbal identification is confirmed by asking the client to state his/her own first and last name and date of birth, rather than the staff member stating the first and last name and date of birth then asking for confirmation. • Witnesses include family, advocate, or staff member familiar with the client and who are able to confirm the identity of the client including first and last names.

5. Revision History • This is a new regional policy.

REGIONAL PROCEDURE Subject/Title Manual:

Reference Number: Identification of Client/Patient/Resident 612-1 Effective Date: July 27, 2010 Approving Authority: CEO and President Revision Dates: Recommended by: CQI Team/Required Organization Practice (ROP) Working Group Originated July 2010. Classification: Contact for Interpretation: Executive Director, Diagnostic Imaging, Laboratory, and

Nuclear Medicine Source

See policy

Client identification processes are intended to improve effectiveness and coordination of communication among care/service providers and with the recipients of care/service across the continuum. The client identification procedure is intended to reliably identify the individual for whom a health service is intended

1) Procedure: • Every program or service area within the RQHR shall have a client identification procedure that will reliably identify the individual by using 2 client identifiers on each individual for whom a health service is intended • Client identification procedures shall include confirmation of at least two client identifiers through observation, documentation and/or verbal verification • Identification procedures should include program or service specific instructions for client identification and include the following information:

a) Identification Documents: o Identification Band o Health Services Number (HSN) card o Medical Record Number (MRN) o Birth Certificate o Immigration Documentation o Photo Identification (examples: Driver’s license, Student ID card) o Client Photograph – current and recognizable o RCMP/Department of Veterans Affairs o Other identification documents such as pink sheets, addressographs, requisitions, medical administration record (MAR), pharmacy information program (PIP), etc

b) Other Identification (no documents available): Interview the client, family member, or advocate requesting the following minimum identification information: o First and Last Name AND o Health Services Number (HSN) OR o Date of Birth (DOB) OR

o Address

c) Unconscious, Too Young, Cognitively Impaired or Communication Challenged, Unknown or Unidentified Clients o Clients who are unable to provide identifying information and whose condition requires emergency care and treatment necessary to stabilize the client's condition, must be registered following the RQHR Unidentified Emergency Client procedure (ED 045 rev. Jan 26, 2010) o Each program or service area must have a specific procedure for verifying unknown or unidentified clients. o Where possible ask a family member, advocate or staff member familiar with the client to provide the client identifiers and where possible compare verbal identifiers with available documented identifiers.

d) Same or similar names o Clients with the same name or similar last names, located in the same service area, should be identified using a name alert process such as: Name Alert process ♦ The nurse or designate will use a red permanent marker and clearly write “Name Alert” on the following applicable documentation: ◊ Clients identification plate ◊ Clients health record ◊ Clients identification band ◊ Medication administration record (MAR) ◊ Unit census ◊ Requisitions that are sent to other departments

♦ If applicable, same or similar names will be flagged in the Sunrise Clinical Manager (SCM) facility board and verbally communicated with the care team.

e) Discrepancies in Client Identifiers o Any discrepancy in the information or concerns that the client has been identified incorrectly should be reported immediately and program and service area specific procedures should identify next steps for staff and physicians.

2) Responsibilities: a) Level of risk o Each program or service area is responsible for assessing the level of risk of each health service interaction and must ensure it has appropriate procedures. b) All staff and physicians are responsible for following regional, departmental, and other client identification policies and procedures specific to the program or service areas in which they are delivering a health service and interacting with clients.

3) Definitions • “Client” may refer to clients, patients, or residents in any area of care within the RQHR.

• Health services examples include, but are not limited to: admission, transfer, discharge, IVs, injections, venipunctures, other specimen collection, drug administration, anaesthesia, respiratory procedures, surgical procedures, blood transfusion, diagnostic procedures, and therapies.

4) Revision History • This is a new regional procedure.

Roy Romanow Provincial Laboratory Test Request & Sample Requirements

The quality and accuracy of laboratory results can only be assured when samples and test requests meet specific criteria for collection, labeling and sample integrity. The following are Roy Romanow Provincial Laboratory’s requirements:

Test Requests - The laboratory requires a written or an electronic request for all patient tests requests from an authorized person. An oral request can be accepted, but requires that a written authorization follow before the results are released by the laboratory.

The requisition must include the following information:-

• Ordering Provider’s Full Name (Last Name, First Name & Initials) & Address (include MSB# & Clinic#) • Patient’s Full Name (Last Name, First Name & Initials) & Address • Unique Patient Identifiers (i.e. HSN, Sex and date of birth) • Sample Information including source (or type), date and time of collection, and additional relevant information as necessary for specific test to ensure accurate and timely testing and reporting of results (e.g. antibiotic therapy, clinical history)

If the laboratory transcribes or enters test requisition or authorization information, the laboratory needs to ensure that the information is transcribed or entered accurately.

Samples – Refer to the collection information as given in the RRPL Compendium of Tests and the pictorial Sample Transport Containers Available at the RRPL on the website at http://RRPL-testviewer.ehealthsask.ca/

Label the sample with the following information:

• Patient’s Full Name (Last Name, First Name & Initials) • Unique Patient Identifiers (i.e. HSN, date of birth) • Collection Information (e.g. date and time of collection, initials of person who collected the sample)

Doc 25200-00 QM153 v2.0 Test Request Sample Requirements v2.0 Page 1 of 2 Current Effective Date: August 29, 2018

Sample Rejection Criteria - Samples will be rejected for the following reasons:

• Samples that cannot be safely processed by RRPL staff (e.g. container is cracked or broken or has leaked in transit) • Samples that have been improperly transported or packaged • Samples that have improper collection or handling (e.g. incorrect container or transport medium) • Missing information as required to identify the patient and provider accurately

In the event that rejecting the sample could compromise patient care or the recollection of the sample causes the patient undue hardship, the laboratory will attempt to resolve any discrepancy within a reasonable confidence level. The laboratory would then require a signed waiver verifying the correct information be faxed to RRPL by the submitter.

Doc 25200-00 QM153 v2.0 Test Request Sample Requirements v2.0 Page 2 of 2 Current Effective Date: August 29, 2018

Roy Romanow Provincial Laboratory Chemistry & Immunoserology Requisition

Patient’s Name & Address (Print Clearly) Patient HSN Provider (Include First Name and Middle Initials) Provider MSB#

Birthdate Return Address (Provider/Clinic/Hospital) Clinic # ______D / M / Y Gender Male Female Sending Location Phone # Provider or Lab Phone Number ______HIV Only: Confidential Patient ID Code (see reverse) Travel History If Additional Copy is Required: Fax to Ordering Provider - Fax #

Symptoms Onset Date Provider Fax # First 2 letters First 2 letters of D / M / Y Last Name First Name Initial of first name last name Address Hospital ID, Ward or Room #  In Patient Outbreak #  Out Patient City/Prov. Postal Code Diagnosis Medication All tests indicated with a pink selection box can be performed on a single Collection Date Sample Type 13 x 100mm x 5.0 mL gold top SST provided the tube is full and the D / M / Y Serum Plasma (Heparin) Urine sample is not hemolyzed. Place tube for pink highlighted tests in pink foam rack unless patient has non-pink tests ordered then place all tubes Collection Time Blood Plasma (EDTA) CSF (except frozen*) in blue foam rack for transport to SDCL. H / M Plasma (K2EDTA – Royal Blue) CHEMISTRY IMMUNOSEROLOGY On thyroid medication or previous abnormal result Thyroid Screen (TSH) Needle Exposure Work-Up: Source Staff If approved: Free T3 Free T4 Cross Reference of Exposure: Indicate corresponding source or staff ______Estradiol DHEA-SO4 Lipase Progesterone Cortisol B12 Contact Person: ______Phone #: ______

Prolactin Magnesium Ferritin HIV Serology: Please fill in HIV Epidemiology Data on reverse

LH/FSH Cholinesterase Iron Studies (Iron, HIV Screen Testosterone Ceruloplasmin Transferrin, Ferritin) HIV Viral Load (Frozen EDTA plasma) SHBG/FAI Phenylalanine FIT (FOBT) (Stool) Hepatitis A IgG (immune) HBV Viral Load RBC Folate Hematocrit ______Neurological Condition Hepatitis A IgM (EDTA whole blood) (Frozen EDTA plasma) Required - Please attach CBC result Hepatitis B surface antibody 25-OH Vitamin D Status HCV Viral Load Hepatitis B surface antigen (Frozen EDTA plasma) Fecal Calprotectin HBV/HAV vaccination in last 4 weeks HCV Genotype *Samples must be received frozen for the following tests: Hepatitis C antibody (Frozen EDTA plasma) Gastrin* ACTH* 17-OH Progesterone* Prenatal Panel (Rubella IgG, Syphilis, HBV, HCV, HIV) Insulin* C-Peptide* Free/Total Carnitine* Prenatal HIV not required on this patient HGH* Homocysteine* Methylmalonic Acid* Syphilis (serum only) VDRL (CSF only)

iPTH* Androstenedione* Thyroglobulin Level* H. pylori ANA C1 Esterase Inhibitor Heavy Metals: Rheumatoid Factor ANCA (Vasculitis) C3 Complement Lead (Whole Blood) Copper Zinc Anti-CCP Celiac Panel C4 Complement Other ______C Reactive Protein Antistreptolysin (ASO) CH100* (Frozen serum) 24 Hour Urine Tests: CRP High Sensitivity 24 hr volume: ______(mL) Start Date/Time: ______IgA IgG IgM IgE Body weight if child 10 or under: ______(kg) End Date/Time: ______Thyroid Antibodies (Thyroglobulin Antibody & Microsomal TPO Antibody) Catecholamines Oxalate UFC Metanephrines Porphyrins Viral Serology Tests: Immune Status/IgG IgM HVA, VMA, 5HIAA Citrate Other ______Measles Cytomegalovirus Toxoplasmosis Drugs of Abuse (URINE only): Mumps Epstein-Barr Virus Lyme Disease Standard screen (includes 40 common drugs of abuse) Rubella Varicella Zoster C. pneumoniae (IgM only) Alcohol Barbiturates Other ______Parvovirus HSV 1&2 (IgG only) M. pneumoniae Toxicology (Special: West Nile Virus ToRC screen (CMV, Toxo, Rubella) (IgM only) Ethanol (whole blood) Methanol Ethylene Glycol Other Tests: Carboxyhemoglobin (CO) Specify drug(s) required: ______

Doc 1400-55 SDCL003R v10 Chemistry & Immunoserology Requisition Effective Date: January 2019 Roy Romanow Provincial Laboratory Chemistry & Immunoserology Requisition GENERAL INFORMATION

To ensure the integrity of the laboratory information management system (LIMS), the patient’s health services number (HSN) and birth date are required. Both the health services number and the date of birth are used to identify specimens.

Please ensure that the ordering provider’s name, clinic, or hospital address and phone number are on the requisition. Results are sent directly back to the address on the requisition. Sample tube and requisition require two common identifiers or the test request will be rejected.

PATIENT IDENTIFICATION CODE: For all tests requested, if the name is provided, it will appear on the report. However, for HIV testing there is the option of providing a code, first two letters of the first name and first two letters of the last name instead of the full name. This report will contain only the patient’s HSN and the code provided. * See Test in compendium for special handling (https://rrpl-testviewer.ehealthsask.ca)

CHEMISTRY IMMUNOSEROLOGY SUBMISSION OF SPECIMENS: IgM: These are diagnostic tests for a patient with symptoms of acute infection, not for immune status Serum Separator Tubes (SST) should be avoided in therapeutic drug testing. IgG: These tests determine immune status or previous exposure to a specific infectious agent. URINE CHEMISTRY REQUIREMENTS: SUBMISSION OF SPECIMENS:

1. Record 24hr volume and body weight on requisition. Send required 1. HIV/HCV/HBV Viral load testing†: 4-5mL of frozen EDTA plasma aliquot for testing. Infants born to HIV positive mothers should be tested by HIV viral 2. Please submit 25mL of urine for the following tests: catecholamines, load. Refer to compendium for details.

5-HIAA, VMA, MET, HVA, Oxalates. Please ensure the pH is between Add 6N HCl if necessary. 2. VDRL: CSF specimens only. 3. Please submit 8mL of random urine, aliquoted into 2 (12 x 75 mm) plastic tubes for the “drugs of abuse” screen. 3. Hepatitis B Core Total testing is included in the “acute” panel.

4. Alcohol(s)……………………..3mL whole blood ToRC: IgM tests in this panel will only be done if the patient is Barbiturates…………………..2mL serum symptomatic or an infant. Carbon monoxide…………….2mL whole blood Clobazam……………………..4mL serum For interpretation of results, please phone: Ibuprofen………………………2mL serum 306-591-0020 Immunoserology “On Call” Tricyclic antidepressants…….4mL serum 306-787-4948 Section Manager, Immunoserology Other specific drugs………….4mL serum 306-787-8316 Medical Director Lead……………………………2mL whole blood

Needle Exposure Work-up: Please indicate which sample is “source” For further information, please phone: and which one is the health care worker (staff) on both requisitions. (306) 787-3197 Toxicology (If applicable)

For after hours STAT testing, please phone: For further information, please phone: (306) 536-4653 On-call cell phone 306-787-3055 Core Lab

For interpretation of results, please phone: For STAT testing of an exposure, please call Core Lab 306-787-3055 for instructions prior to sending the specimen and requisition. (306) 787-3284 Director, Screening & Reference Testing Fax requisition to: 306-787-0766.

For weekend needle stick exposure testing, please phone: Regina General Hospital Chemistry Lab 306-766-4490

HIV HIV POC was performed. Result: Positive Negative Indeterminate Invalid NOTE: HIV POC is only a preliminary screening test, all reactive results require confirmation.

Check all applicable risk factor(s):

Needle Stick Injection Drug User Sex trade worker From endemic area Multiple sex partners Hepatitis C infected Sharing injection drug equipment Sex partner of high-risk person(s) Men who have sex with men (MSM) Recent history of STI (e.g. Syphilis) History of incarceration Sexual partner of patient with AIDS or HIV History of unprotected sexual intercourse Roy Romanow Provincial Laboratory Microbiology Requisition

Patient Name & Address (Print Clearly) Patient HSN Provider (Include First Name and Middle Initial) Provider MSB #

Date of Birth Return Address (Provider/Clinic/Hospital) D / M / Y

Male Female

Submitter Phone # Provider or Lab Phone Number Hospital ID, Ward or Room # IN Patient Outbreak # If Additional Copy is Required: OUT Patient Fax to Ordering Provider - Fax # Symptoms Symptom Onset Date Provider Fax # D / M / Y Last Name First Name Initial Diagnosis Collection Date Address D / M / Y City/Prov. Postal Code Medication Collection Time H / M Reason for Request CHOOSE ONE TEST PER SPECIMEN Prenatal High Risk USE ONE REQUISITION PER SPECIMEN Occupational Immigration/Travel Sexual Assault/Abuse Other Details ______Respiratory Sexually Transmitted Infections Dermatophytes Respiratory Screen (NAAT) Chlamydia & Gonorrhoea Screen Hair Nails Use UTM for respiratory viruses and Pertussis Urine Use APTIMA Urine Collection Kit [YELLOW] Skin scraping: Site ______Nasopharyngeal Swab Throat Swab Vagina Rectum Throat Travel/Animal Contact ______Source ______Use APTIMA Multitest Swab Specimen Collection Kit [ORANGE] Mycology Bacterial Studies (Culture ) Cervix Urethra Eye Use APTIMA Unisex Swab Collection Kit [WHITE] Sputum Bronchial wash Pertussis Culture [Nasopharyngeal swab in Regan-Lowe Medium] Trichomonas Use APTIMA Multitest Swab Specimen Collection Ear Eye Left Right Diphtheria Vagina Kit [ORANGE] Specimen Source ______Fluid, tissue, biopsy, aspirate, specify: Legionella Ureaplasma/Mycoplasma Culture Cervix Urethra Other: ______TB & Mycobacteriology Stool Other, specify ______Sputum [Optimal Volume is 5 to 10 mL ] Use Stool Container [No Preservative] CLINICAL INFORMATION (Immunosuppressed, etc.): C. difficile reference Bronchial (Specify) ______Viral Studies Norovirus testing Blood [Myco/F-Lytic Blood Culture bottles ONLY] Culture (reference testing): organism______CSF Urine H. Pylori antigen [Store at 2-8C, frozen if >72 hours] Organisms/Reference Testing Tissue (Specify)______Food Borne Illness Outbreak Bacteria Yeast Fungus Sterile fluid (Specify) ______Parasites Other (Specify) ______Confirm ID Subtype Susceptibility Giardia and Cryptosporidium antigen Specimen Source ______CSF [Optimal Volume is 2 mL] screen (stool in SAF) HSV PCR- preapproved [Freeze and Ship Frozen ] Pinworm Exam (paddle preferred) Suspected ID: VZV PCR- preapproved [Freeze and Ship Frozen ] Parasite ID (worms, arthropods, etc.) Gram/other stains: Growth conditions: WNV PCR - preapproved [Freeze and Ship Frozen ] Scabies (skin scrapings) O2 CO2 Anaerobic Viral Culture [Refrigerate] Schistosoma haematobium (urine) Comments ______Viral Exanthemata Ova & Parasite Exam (stool in SAF) Oxidase: Catalase: Haemolysis: Mumps Urine (50 ml min) Buccal Swab Relevant History Required, check all that apply Resistance confirmation (ESBL, CRE etc.): Measles Nasopharynx Throat Travel/immigration Age <13 years Urine (50ml min) Country ______Symptoms >2 weeks Comments ______Dates ______Herpes Simplex/Varicella Zoster Unsafe food/water Other/Special requests Immunosuppressed Swab for Lesion Screen [Use UTM] Prior parasite: Suspected helminth Specimen ______other than Enterobius ______vermicularis Urine Case contact CMV (Cytomegalovirus) [Minimum volume 50 ml] Eosinophilia Legionella Antigen Detection Other ______

Doc. 1400-55 RRPL 001R V8 Microbiology Requisition RRPL-TestViewer.eHealthSask.ca Effective Date: November 5, 2018 Roy Romanow Provincial Laboratory Microbiology Requisition GENERAL INFORMATION Unique Patient Identifiers: Patient Name, Health Services Number (HSN/PHN), and Date of Birth (DOB) are used to identify specimens. To assist testing and reporting, HSN and DOB must be clearly printed on both the Requisition and Specimen. Reporting: Test results are reported directly to the Return Address listed on the Requisition. To ensure accurate reporting, the Provider’s Full Name, Clinic/Hospital Address, and Phone/Fax Number must be clearly printed on the Requisition. All results are sent to the Saskatchewan Laboratory Results Repository and are available electronically via the eHS Viewer. If additional paper (Fax or Mail) copies are required, complete the ‘Additional Copy’ section of the Requisition. Fax Machines must be in a secure location accessible ONLY to persons requiring reports. STAT Testing, Outbreak Samples, and Outbreak Numbers: STAT testing requests must be pre-arranged. Call 306-787-3131 to request approval from the appropriate RRPL section. To assist with identification and testing of STAT and Outbreak Specimens, flag the shipping tote with a Yellow Closure Tie and identify STAT sample within the tote. Upon declaring an Outbreak, the Medical Health Officer or designate should assign an Outbreak Number, as follows: Health Region [3 – 4 letter acronym] – Calendar Year [4 digits] – Sequential Number [3 digits] e.g. RQHR-2015-001. Include the Outbreak Number on the Requisition.

TESTING & SPECIMEN COLLECTION: For comprehensive information about RRPL Testing and Specimen Collection protocols, see the RRPL Compendium of Tests. The RRPL Compendium of Tests is now available on-line at: RRPL-testviewer.ehealthsask.ca/

Stool Specimens For Enteric Pathogens Only submit fresh, loose stools. Formed stools and rectal swabs are NOT acceptable specimen types and will not be tested. Bacterial Studies or Parasites should not be requested for IN Patients who have been hospitalized for longer than 3 days. Some medicines can interfere with testing. If submitting stool for Bacterial Studies or Parasites, do not take antibiotics or any medicines containing mineral oil, barium, bismuth, magnesium, or kaolin for at least 6 days prior to collection.

Chlamydia & Gonorrhoea

The Chlamydia & Gonorrhoea Screen is a nucleic acid amplification-based test that has become the standard method of detecting infection with Chlamydia trachomatis and/or Neisseria gonorrhoeae. Indicate on requisition if testing for LGV is required. Contact the RRPL to request APTIMA Collection Kits that are compatible with Chlamydia & Gonorrhoea Screen. Chlamydia Culture is no longer performed at the RRPL. A separate specimen is to be submitted for Trichomonas testing. Pertussis (Whooping Cough) RRPL offers two options based upon the type of specimen transport medium. 1. Swabs in UTM will be tested for Pertussis by NAAT as part of the Respiratory Screen. 2. Nasopharyngeal swabs in Regan-Lowe medium are required for Pertussis Culture to isolate strains for surveillance activities. Fungal Culture (Mycology) Submit Skin, Hair and Nail specimens using the Mycopak Collection Kit. To order Mycopaks, contact the RRPL. Mouth/Throat swabs and Stool specimens are NOT acceptable specimen types for Fungal Culture and will not be tested.

Drug Resistant Organisms To submit a MRSA, VRE or ESBL isolate for Provincial Surveillance activities, use the RRPL Surveillance Strain Submission Form.

CONTACT INFORMATION:

Roy Romanow Provincial Laboratory (RRPL) RRPL Customer Services: 5 Research Drive Phone: 306-787-3131 Regina, SK, Canada Fax: 306-787-9122 S4S 0A4 Email: [email protected] Web: RRPL-testviewer.ehealthsask.ca/

Subject/Title: LABChemOP7269 Chemistry Lab Services Last Approved Time: Mali, Bahera(Medical Biochemist) (05/17/2019) Revision: 5.30 Approving Authority: Medical Biochemist Contact for Information: Chemistry Phone: (306) 766-4490 Current Version on Print Date

Policy

Process Control

Purpose

The purpose of this procedure is to provide information about the services provided by the Chemistry department at the Regina General Hospital and the Pasqua Hospital. The department is operational 24 hours a day to provide essential diagnostic testing. Routine and specialized testing is performed Monday to Friday from 0730 – 1600. Evening and night shifts are staffed to handle essential coverage only. A Biochemist is always on call to handle any unusual issues or problems that may arise.

Procedure

The Chemistry department has two sections, Routine Chemistry (RGH and Pasqua) and the Specialized Testing section at the RGH. The testing profile of the Chemistry department is quite extensive. Requirements for all tests are listed on the RQHR Intranet – Department / Laboratory / RQHR Lab Specimen Requirements.

Critical result list is found in an appendix in the General Lab Services procedure. Test availability and turn-around-time is found in an appendix in the General Lab Services procedure.

The following tables provide extra information regarding specimen collection that may be needed by the nursing unit. The tables are separated by specimen type. There are two additional tables regarding toxicology and therapeutic drug monitoring.

LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

Page 1 of 11 Last printed 5/18/2019 8:41 PM

Blood Specimens Rapid ACTH Test  This test is used as a screening test for (Cortrosyn) adrenocortical function  Cortrosyn is a synthetic 1-24 ACTH.  Baseline Cortisol is collected 250 ug of cortrosyn is injected intravenously by the ward  30 min Cortisol is collected  60 min Cortisol is collected  See attached Appendix for specific ordering and collection instructions Blood Ethanol  Chemistry only tests ethanol for medical purposes  The legal driving limit of 0.08 is equal to 17.4 mmol/L  Plasma ethanol results are about 7% higher than whole blood Blood Gases Capillary  Ward notifies the Chemistry department that a capillary blood gas is needed  Chemistry staff will inform ward to warm the foot or the hand (this depends on the size and age of the patient)  The site is usually warmed with a wet cloth and then wrapped up with something to hold the heat in (for example wrapping a diaper around the cloth). The temperature should not exceed 45° C  The site is ideally warmed for 3 – 4 minutes prior to the collection

Arterial  Arterial samples are drawn by a Respiratory Therapist or may be collected from an arterial line by a RN  It is of utmost importance that the sample be correctly labeled (2 identifiers)  The time of collection should also be indicated on the requisition. If the time is not stated, the technologist will default the entry to the time received in the laboratory.  When dropping off specimens in Chemistry or when sending them through the pneumatic tube

LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

Page 2 of 11 Last printed 5/18/2019 8:41 PM system, it is EXTREMELY important the staff know that there is a sample to run  Staff should be paged or phoned if no one was present in the department when the sample was dropped off  Blood gas samples should not be left in the porthole at the RGH but should be brought directly to the department  Blood gases are always analyzed STAT  Report will print to ward immediately Dexamethasone Suppression  Screen for Cushing’s syndrome Test  Baseline Cortisol levels are drawn at 0800 and 2000 hrs  1.0 mg of dexamethasone is given at 2300 hr  A 0800 (post dose) Cortisol is drawn the next morning Glucose Tolerance  Patient should have been on a diet that contained adequate carbohydrates (150 g) for three days prior to testing  Patient must fast for 10 hours prior to test (not required for gestational screen – see below)  The commercially prepared glucose drink is obtained from the Chemistry department  For patients that may be allergic to the dye in the orange drink, an alternative drink is available but the lab must be notified by the physician’s office so alternative drink can be ordered.

Non-Pregnant Adult Glucose Tolerance (75 g)  Fasting glucose sample is collected  75 g drink (296 ml) is given  Patient should consume drink within 5 minutes  2 hour glucose sample is collected

Gestational Diabetes Screen (50 g)  Women are tested between their 24th and 28th weeks of gestation  Patient does not have to be fasting  50 g drink (296 ml) is given  1 hour glucose sample is collected

Gestational Diabetes Tolerance (75 g)  Test is done when woman has an elevated LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

Page 3 of 11 Last printed 5/18/2019 8:41 PM result with the screening test  Fasting glucose sample is collected  75 g drink (296 ml) is given  Patient should consume drink within 5 minutes  1 and 2 hour glucose samples are collected  See attached Appendix for specific ordering and collection instructions

Children  Dosage of drink must be calculated based on patient’s weight (not to exceed 75g of glucose)  Calculation will be performed by a Chemistry technologist  Fasting glucose sample is collected  Drink is given  Patient should consume drink within 5 minutes  2 hour glucose sample is collected

Calculation of drink volume  patient’s weight (kg) X 1.75 = #gm of drink  #gm X 3.95 = # mLs of drink  LIS test code GLMLS will calculate # mLs when patient weight (kg) is entered

Hypoglycemic Screen ( 5hr GTT)  Approval by Medical Biochemist/Clinical Chemist should be sought prior to ordering this test as poor correlation with symptoms are typically seen  Fasting glucose sample is collected  75 g drink is given  Blood samples are drawn at 0.5, 1, 1.5, 2, 3, 4, 5 hour times Growth Hormone  Patient fasts overnight Suppression Test  Fasting blood sample drawn for Growth Hormone  75 g glucose drink (296 mL) given  Blood samples are drawn for Growth Hormone at the intervals requested by the physician Insulin  Insulinoma is a rare condition that can cause organic hypoglycemia  Measure blood glucose when symptoms of hypoglycemia are exhibited (glucose should be <2.5 mmol/L) LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

Page 4 of 11 Last printed 5/18/2019 8:41 PM  Insulin levels should then be requested  Measurement of glucose, insulin and C-peptide may be indicated if administration of exogenous insulin is suspected Toxicology  See separate section Therapeutic Drug Monitoring  See separate section

Urine Specimens Specimen Collection  All specimens received must be labeled following standard laboratory labeling practice (2 identifiers)  All specimens are accessioned into the LIS

1st morning urine specimen  ideal specimen for testing as most concentrated  patient voids first morning sample into a clean 80 mL sterile container or a graduated urine tube, specimen is labeled and sent to lab

Random urine specimen  specimen collected at any time of day  patient voids into a clean 80 mL sterile container or a graduated urine tube, specimen is labeled and sent to laboratory 24 hour urine specimen  Disposable 24 hour urine container are used for collection  It is important to have a complete and accurate specimen collected for valid results  Patient empties bladder in a.m. (do not save this sample)  Record start time and date  For the next 24 hour collect all urine specimens that are voided during the day and night  Last sample should be when patient empties bladder the next morning at the same time as start time  Record stop time and date  Label specimen and send to laboratory  If possible specimen should be kept cool during collection Urine Testing Notes  The testing requirements can all be found on the Intranet LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

Page 5 of 11 Last printed 5/18/2019 8:41 PM  Specimens should NOT be collected in containers containing boric acid for tests performed by the Chemistry department  The collection for metals requires a special acid washed container – Obtain from the Chemistry department prior to beginning the 24 hour collection  Required preservatives are added by the Chemistry staff after the 24 hour collection is completed

Feces Specimens Feces Tests Occult Blood  Tests for the presence of blood  Label specimens with two identifiers  Specimen to be collected in sterile plastic container (be careful not to contaminate the outside of the container with specimen) Fecal Fat  Test requires the approval of SDCL prior to testing (contact Jeff Eichhorst 787-3284)  Test requires a 72 hour stool collection  Pre-weighed containers, instruction for collection and shipping are provided by SDCL  Start test after bowel movement. Discard this sample.  Record start time and date  Collect all stool passed in the next 72 hours  Record stop time and date  Specimen should be kept cold and entire specimen delivered to lab when complete  Patient should not have any procedures that could alter the stool specimen (ie enema)

CSF Specimens Routine Chemistry  Protein, Glucose, LD, Lactic Acid

Oligoclonal Bands  Requires at least 2 mL CSF specimen  If possible a serum sample is collected and run simultaneously with the CSF sample

LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

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Toxicology Specimens  Quantitative measurement is available on a 24 hour basis for: Acetaminophen, Ethanol, Salicylate on blood samples  Stat Qualitative testing for Drugs of Abuse is available on urine specimens on a 24 hour basis by ordering a Urine Triage – Acetaminophen/Paracetamol, Amphetamines, Methamphetamines, Barbiturates, Benzodiazepines, Cocaine, Methadone, Opiates, Phencyclidine, THC, Tricyclic Antidepressants  Methanol and Isopropanol levels are measured by SDCL – call back required if after normal business day  Routine urine drug screens are sent to SDCL for testing  Suspected overdose of Therapeutic Drugs can be tested on a 24 hour basis for those drugs that are performed by the Chemistry department

Fluid Specimens Specimen Collection  Specimens are collected by ward  Specimens must be labeled with 2 identifiers  Specimens for pH must be collected in a syringe or a green top tube – Specimen must be on ice and brought down immediately or pH will be rejected  All other Chemistry tests should be collected in a red top tube or in a sterile C&S container Tests Performed Pleural Fluid  Protein, Lipase, LD, Cholesterol, Triglyceride, pH, Glucose, Chylomicrons Peritoneal Fluid (ascites fluid)  Protein, Creatinine, Bilirubin, pH, Albumin Synovial Fluid  Glucose, Uric Acid, Cholesterol, Triglyceride Pericardial Fluid  pH, LD, Protein Dialysate  Glucose, Creatinine, Protein, Urea Pancreatic Cyst Fluid

LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

Page 7 of 11 Last printed 5/18/2019 8:41 PM  CEA, Lipase Fluid Notes  The matrix of fluids is different than serum samples and therefore may affect results  The testing of fluids for many tests is not indicated as there are no reference values for comparison  Testing is often done to determine if specimen is a transudate or an exudate  Transudate – low protein, no cells present  Exudate – high protein, cells present

Therapeutic Drug Testing

For TDM to be effective, it is essential that the requisition is completed with the drug dosage regimen and administration time Separate requisitions are required for pre and post samples Ideal sampling times are indicated below – guidelines from the Pharmacy and Therapeutics Committee

Test Ideal sampling time Test notes Amikacin Pre level – 30 minutes before dose Just before 3rd regular dose or as ordered by pharmacy Post level – 30-60 minutes after dose After 3rd regular dose or as ordered by pharmacy Once daily – 6-14 hours after dose After 3rd dose Carbamazepine Pre level – Steady state reached on day 7 of 0 – 1 hour before dose dosing regime Digoxin Pre level – Post load dose – done on day 2 0 – 1 hour before dose Maintenance dose – done on day 5

(do not collect if less than 6 hours after dose) Ethosuximide Pre level – Steady state reached on day 7 of 0 – 1 hour before dose dosing regime Gentamicin Pre dose - 0 – 30 minutes before dose Just before 3rd regular dose or as ordered by pharmacy Post dose - 30 minutes after dose After 3rd regular dose or as ordered by pharmacy

LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

Page 8 of 11 Last printed 5/18/2019 8:41 PM Once daily Gentamicin – After 1st or 2nd dose 6 – 14 hours after dose Pre level not recommended Lidocaine 12 hours should elapse Indication for collection before collecting level - when toxicity is suspected - when ventricular arrhythmias occur despite lidocaine administration

Lithium Post level – Steady state reached on day 4 of Collect 12 hours after dosing regime evening dose (do not collect before 8 hours post dose) Phenobarbital Pre level – IV loading – no restrictions 0 – 1 hour before dose Maintenance – day 3 Steady state – Children/Infant – day 8 Adult/Adolescent – day 10 Phenytoin (Dilantin) Pre level – Maintenance – day 3 0 – 1 hour before dose Steady state – day 7 Primidone Pre level – Steady state reached on day 3 of 0 – 1 hour before dose dosing regime Procainamide / N- IV Loading levels Acetylprocainamide 1) Immediately after loading infusion 2) 2 hours post infusion 3) 24 hours post infusion

Maintenance levels Maintenance – 24 hours Pre level – 0 – 60 minutes before dose Post level – Peak level may not occur until 2-4 75 minutes after oral dose hrs following dose in some patients Quinidine Pre level – Steady state reached on day 2 of 0 – 1 hour before dose dosing regime Salicylate Post level – Steady state reached on day 3 of (therapeutic) 1 – 3 hours after dose dosing regime Theophylline Infusion Steady state – 24 – 48 hours (Aminophylline) Collect level any time

Intermittent (IV or po) Steady state – day 2 Pre level – (do not collect pre dose greater than 0 – 30 minutes before dose 60 minutes before dose) Post level – regular release – 2 hours slow release – 3 – 5 hours LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

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Tobramycin Pre level – Just before 3rd regular dose or as 0 – 30 minutes before dose ordered by pharmacy

Post level – After 3rd regular dose or as ordered 30 – 60 minutes after dose by pharmacy (collections times must be followed for accurate interpretation of result)

Vancomycin Pre level – Just before 3rd regular dose or as 0 – 30 minutes before dose ordered by pharmacy

Post level – After 3rd regular dose or as ordered 60 - 90 minutes after dose by pharmacy

(collections times must be followed for accurate interpretation of result)

References

A Handbook of Routine Urinalysis, Sister Laurine Graff Saskatchewan Disease Control Laboratory Test Compendium Pharmacy and Therapeutics Committee

Related documents

Lab Services Manual General Information LABRegOP7900

Revision History

Found in Softtech Health Lab QMS™ Document Management System

Author

Tammy Ottenbreit, MLT, ART Revised Tiffany Munns MLT Revised Cathy Sarty, MLT

LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

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LABChemOP7269 Chemistry Lab Services Laboratory Services Regina QuAppelle Health Region

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Appendix LABChemOP7352A1 ACTH Stimulation Test

ACTH Stimulation Test can be performed Monday – Friday AM Only (not available on Stat Holidays). Baseline must be performed between 0800 – 1000.

All ACTH Stimulation Tests must be pre-booked with the accession department. Please call the Lab Accession Department at 4495 the day before the test is to be done.

PROCEDURE A

ACTH Stimulation Test Requiring Phlebotomy Drawing Blood

Ward - stamp one In-House requisition with patient addressograph - complete requisition – write ACTH Stimulation Test (this test includes a BASELINE cortisol, a 30 MINUTE cortisol and a 60 MINUTE cortisol). State required time for baseline collection ie 0800 hrs.

Note: ACTH Stimulation Test does not include an ACTH level. If an ACTH baseline level is also required, stamp a blue RRPL requisition, check the ACTH box and send to Laboratory with the In-House requisition request for ACTH Stimulation Test

- Pre-book testing with lab. Call 4495 the day before testing is to be done. - the requisition must be in the Laboratory before 2100 hrs the day prior to the test being performed to ensure that the test is ordered in the LIS and phlebotomy is prepared for collection in am. - ACTH Stimulation Test (baseline collection or injection) should not be started before 0700 hrs. - phlebotomy will collect the baseline sample - DO NOT give injection until phlebotomy informs you that baseline sample has been collected - immediately after patient has been given the injection, phone phlebotomy at 4527 (RGH) or 8412 (PH) and say “patient name” has been given injection for ACTH Stimulation Test

Accession - Ward will call the Accession Department the day before to book the ACTH Stimulation Test for both the Pasqua and RGH Hospitals. Refer to ACTH

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Stimulation Booking Calendar regarding questions the Ward should be asked and what information is required. - test is accessioned with LIS code – RACTH - it will ask for date and collection time - time marked is for the baseline collection - collection times for 30 minute and 60 minute collections will automatically fill in

Phlebotomy - PDA will display collection for the ACTH stimulation test - patient order will have 3 labels with timed collections - collect baseline sample and print label - mark other 2 collections as “no” so labels are not printed - inform the ward that the baseline sample has been collected and that the injection can be given - the ward will call 4527 (RGH) or 8412 (PH) and say when the injection has been given - phlebotomist that receives the call will go into patient order in the LIS and modify the collection times

EXAMPLE 1. ward will say injection has been given at 0900 hrs 2. 30 minute will be 0930 hrs and 60 minute will be 1000 hrs 3. go into patient order 4. specimen tab 5. place cursor on collection to be modified (ie B30 for 30 minute) 6. select “Specimen” from top tool bar 7. select “Modify Specimen” 8. enter in the correct time for collection (ie 0930 hrs) 9. repeat for 60 minute specimen 10. save order

- collections will now appear in the PDA’s with the proper collection time and all phlebotomists will be aware

PROCEDURE B

ACTH Stimulation Test for Ward/Arterial Line Draw

Ward - stamp 3 In-House requisitions with patient addressograph - Requisition 1 – write ACTH Stimulation Test – BASELINE CORTISOL. State required time for baseline collection. ie 0800 hrs - Requisition 2 – write ACTH Stimulation Test – 30 MINUTE CORTISOL LABChemOP7352A1 ACTH Stimulation Test Lab Services Regina Qu’Appelle Health Region Page 2 of 3 Last printed 6/24/2019 11:59 AM

- Requisition 3 – write ACTH Stimulation Test – 60 MINUTE CORTISOL

- Pre-book testing with lab. Call the Accession Department at 4495 the day before testing is to be done. Inform lab that an ACTH Stimulation test is being performed by Ward/Arterial Line Draw.

Note: ACTH Stimulation Test does not include an ACTH level. If an ACTH baseline level is also required, stamp a blue RRPL requisition, check the ACTH box and send the sample to Laboratory with the baseline Cortisol level once drawn.

For Ward /Arterial line draw - ward is responsible for following protocol - 1 SST (yellow top tube) is required for cortisol level - If a baseline ACTH level is also required, a chilled purple (EDTA) top tube is required. Specimen must be delivered to lab immediately after collection. - Each timed specimens must be labeled using the corresponding green requisition label (from the bottom of the requisition) with the patients first and last name and MRN. The type of collection (ie baseline/ 30 minute/60 minute) must also be written on each corresponding tube and matched to the requisition to ensure specimens are processed correctly - exact collection time must be noted on each requisition

Accession

- Ward will call the Accession department the day before to book the ACTH Stimulation Test for both the Pasqua and RGH Hospitals. Refer to ACTH Stimulation Booking Calendar regarding questions the Ward should be asked and what information is required. - the Ward will deliver the baseline (cortisol) specimen for the ACTH Stimulation Test to the main desk in the Accessioning department - test is accessioned with LIS code – RACTH - enter ORDER COMMENT #42 “Ward will draw all specimens for ACTH Stimulation Test” - it will ask for date and collection time, leave as current date and enter time as 00:00 - Collect and receive the baseline specimen only with the collection time provided on the requisition. - label specimen (00S label) and deliver to Chemistry for analysis - leave the original requisition at the main Accessioning desk with a note attached “ACTH Stimulation Test in Progress” - 30 minute and 60 minute specimens will arrive once collected by ward. Use existing order number provided to properly label sample with 30 minute (B30 label) and 60 minute (60S label).

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Appendix LABChemOP7317A1 75 gm Maternal Glucose Tolerance To be tested between 24 and 28 weeks gestation

Ward - stamp a green requisition with patient’s addressograph - order MAT 75gm 2 hr only (do not mark fasting glucose) - enter collection time for fasting sample (ie 0700) - ensure requisition is received in laboratory the day before test is required - phlebotomy will collect fasting sample - DO NOT give drink until phlebotomist informs you that fasting sample has been collected - when patient has finished drink, call 4527 and say “patient name” has finished drink at _____ time. - phlebotomy will return at the 1 and 2 hour interval to collect glucose sample

Accession - requisition is accession with LIS code - GTTGE - it will ask for date and collection time - time marked is for the fasting collection - collection times for 1 and 2 hour will automatically fill in

Phlebotomy - PDA will display collection for the tolerance - patient order will have 3 labels with timed collections - collect fasting sample and print this label - mark other 2 collection as ‘no’ so labels are not printed - inform the ward that the fasting sample has been collected and that the drink can be given - the ward will call 4527 and will say when patient has finished the drink (or they will leave message) - phlebotomist that receives call will go into patient order in the LIS and modify the collection times EXAMPLE 1. ward says drink complete at 0830 2. 1 hr will be at 0930 and 2 hr will be at 1030 3. go into patient order 4. Specimen tab 5. place curser on collection to be modified (ie CHEM1 CH1 for 1 hr) 6. select ‘Specimen’ from top tool bar 7. select ‘Modify Specimen’ 8. enter in the correct time for collection (ie 0930) 9. repeat for 2 hr specimen 10. save order

LABChemOP7317A1 Page 1 of 2 Lab Services Regina Qu’Appelle Health Region Last printed 10/19/2015 10:42 AM

- collections will now appear in the PDAs with the proper collection time and all phlebotomists will be aware

LABChemOP7317A1 Page 2 of 2 Lab Services Regina Qu’Appelle Health Region Last printed 10/19/2015 10:42 AM

Subject/Title: LABAccnOP7200.1.2 Cytogenetics Last Approved Time:11/15/2018 Revision:1.20 Approving Authority Manager of Support Services Contact for Interpretation: Accession Phone: (306) 766-4495 Current Version on Print Date

CYTOGENETICS

I GENERAL INFORMATION

Specimens for cytogenetic (chromosome) and DNA studies are sent to a referral laboratory for testing. Specimens are to be collected MONDAY THROUGH THURSDAY ONLY AND MUST BE RECEIVED IN THE LABORATORY BEFORE NOON ON THE DAY OF COLLECTION. NOTE: Specimens are NOT to be collected or sent on a statutory holiday or on Thursday when Friday is a statutory holiday.

 Chromosome studies may be performed on blood, amniotic fluid, bone marrow or skin/tissue. No prior approval is required.

 Different specimens require different treatment and methodology. Therefore it is important to check the Test Compendium for type of vacutainer to use when collecting blood samples for chromosome studies.

Specialized genetic testing should be preapproved prior to sample collection. All genetic testing has been centralized at the Genetic Resource Centre at the Roy Romanow Provincial Laboratory. Questions regarding genetic testing can be forwarded to the GRC Laboratory Genetic Counsellor, Rachel Vanneste at [email protected] or by phone at (306) 655-6450.

Specimen(s) for Molecular Genetics (DNA studies) must be kept at room temperature at all times. Specimen(s) must be received at RGH by noon.

Appropriate requisitions for cytogenetic testing must be carefully completed with particular emphasis on relevant cytogenetic information ie: suspected chromosome abnormality or indication for request.

Testing for specific abnormalities (e.g. Fragile X) must be specifically requested as they are not part of routine testing.

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II BLOOD CHROMOSOME STUDIES

1. Routine – determines constitutional karyotype. Check test compendium for type of specimen container required for collection.

2. For Hematological Disorders

For patients who have a high WBC count and more than 10 percent circulating immature myeloid cells (myelocytes or younger), peripheral blood may be examined for acquired chromosome abnormalities.

III BONE MARROW STUDIES

(i) Marrow is the tissue of choice for the detection of chromosome abnormalities in hematological malignancies. (ii) Can be set up mornings only Monday to Thursday. (iii) Please notify the Hematology lab well before the marrow tap is begun so that the necessary preparations may be made.

IV AMNIOTIC FLUID

Fluid should be collected at 13+ weeks gestation. (a) Use plastic syringes and sterile tubes Approximately 20 - 30 ml of fluid is required. Withdraw 2 - 3 ml and DISCARD. This minimizes contamination with maternal macrophages. (b) The next 10-12 ml of fluid drawn is gently inserted into a sterile tube. (c) Using a NEW SYRINGE withdraw another 10-12 ml of fluid and insert into a second sterile tube. (d) Approximately 5ml in a third tube are required for Alpha -fetoprotein.

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V PRODUCTS OF CONCEPTION

Products-of-conception tissue is not routinely submitted for cytogenetic studies. However if the testing is requested be sure to:

1. Collect spontaneous abortion material in its entirety into sterile containers. To keep specimen from drying out, cover with sterile saline-soaked gauze and deliver to the lab as soon as possible. The sample should be kept at room temperature if it is delivered the same working day. Samples that cannot be delivered the same day should be refrigerated.

2. Therapeutic abortion material (larger fetuses) should be kept from drying out by covering with sterile saline/water-soaked gauze or adding a small amount of sterile water or saline to the container and bring to the lab as soon as possible.

VI CORD BLOOD

1. Collect into heparinized tube (green top), mix thoroughly and bring to laboratory. 2. May be kept refrigerated if necessary until morning.

VII BUCCAL SMEARS FOR SEX CHROMATIN STUDIES

This test is no longer performed.

VIII OUT-PATIENT SERVICE

Patient reports to the Specimen Collection Laboratory before Noon Monday to Thursday except statutory holidays. Physician’s Name, Address and Telephone number must be clearly marked on the requisition. Specimens must be delivered to the RGH Laboratory by NOON on day of collection with the appropriate cytogenetic requisition.

Note: Specimens are not collected or shipped on a Thursday when Friday is a statutory holiday.

Related Documents

LABAccnOP7005J1 Packaging Genetic Specimens for Transport to RRPL LABAccnOP7101 Shipping General Information Including Equipment and Supplies

LABAccnOP7200.1.2 Cytogenetics Laboratory Services Regina QuAppelle Health Region

Page 3 of 4 Last printed 6/18/2019 2:44 PM LABAccnOP7102 Shipping Specimens to Saskatoon LABAccnOP7103 Shipping Specimens by FedEx within Canada LABAccnOP7104 International Shipping using FedEx

Revision History

Found in SoftTech Health Lab QMS™ Document Management System

Author

Paula Hamelin, MLT (revised)

LABAccnOP7200.1.2 Cytogenetics Laboratory Services Regina QuAppelle Health Region

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Subject/Title: LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Last Approved Time: Angeles, Ronald(Head of

Cyto Pathology) (06/10/2018) Revision: 2.40 Approving Authority: Cytopathologist Contact for Interpretation: Cytology Phone: (306) 766-2641 Current Version on Print Date

Diagnostic Cytology Laboratory Services Manual and Testing Compendium

I. PURPOSE The primary purpose of this manual is to provide a guideline for proper collection and handling of clinical specimens that are submitted for cytological diagnosis.

II. SPECIMEN

A. Types: 1. Endocervix 2. Exocervix 3. Vaginal wall 4. Vulva 5. Cerebrospinal fluids 6. Joint fluids (synovial) 7. Ocular fluids 8. Serous effusions - pleural, pericardial, peritoneal 9. Urine 10.Respiratory 11.Skin 12.Various lesions - superficial, deep-seated

B. Collection Methods: 1. Scrapings 2. Brushings 3. Lavages 4. Drainage 5. Washings 6. Fine needle aspiration biopsies 7. Aspirations 8. Secretions

C. Specimen Identification and Labeling:

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Inadequately identified specimens will not be accepted. 1. Primary specimen containers must be labeled with at least two patient-specific identifiers at the time of collection. Examples of acceptable identifiers are: patient name, date of birth, HSN (Health Services Number), MRN (Medical Record Number).

2. Specimen slides must also be labelled with two patient-specific identifiers. Please use a lead pencil to write on the frosted end of the slide. Do not use pen-type inks as the ink tends to fade and wash off during cytology processing.

3. If more than one site is sampled on the same patient, the specific source/site must be indicated on each specimen submitted, as well as, indicated on individual cytology requisitions.

III. SPECIMEN SUBMISSION & TRANSPORTATION

A. Prepared Slide Submission:  all slides must be labeled with two unique patient identifiers  a completed cytology requisition must accompany the slide(s)  slides are packaged within a blue plastic slide mailer to prevent slide breakage  all prefixed smears/slides are allowed to dry prior to closing them up in the mailer  wrap the requisition around the mailer and secure with a rubber band (NOTE: Patient identification on the blue mailer is not acceptable; must be on specimen slides. The Regina Qu’Appelle Health Region Cytology Laboratory will supply mailers upon request)

B. Fresh (Liquid) Specimen Submission:  fresh specimens are submitted in a properly labeled, secure, leakproof container. Do not transport specimen in a syringe or other collectable device.  The labeled specimen container may be placed within a secondary container. Examples are a sealable plastic bag or a secondary leakproof container.  cytology requisitions must accompany the specimen, and should not be placed within the secondary container

IV. CYTOLOGY REQUISITION FORM:

1. The requisition form must accompany the properly labeled cytology specimen.

2. The requisition must provide identifying information:  patient’s full name  provincial hospitalization number  date of birth and/or age  ordering physician’s name and address (copy to physician’s name and address) LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

Page 2 of 12 Last printed 3/21/2019 1:46 PM  date of specimen collection  source and site of specimen  type of collection method  relevant clinical information and history

(NOTE: The RQHR Cytology Laboratory will supply requisitions upon request)

V. SPECIMEN REJECTION CRITERIA

1. Specimen Container/Slide mislabeled or unlabeled

2. Discrepancy of information between specimen and requisition form

3. Slide(s) broken beyond repair

4. Specimen received without accompanying requisition or vise versa

5. Inadequate preservation of specimen

6. Specimen container broken or leaking

7. Specimen received from an unauthorized source

8. Exact same specimen site received after 3 previous positive results in a 4 week period

9. Requisition lacking pertinent information on:  patient’s full name  patient demographics  ordering physician  source/site of specimen

VI. RQHR CYTOLOGY LABORATORY ADDRESS & HOURS of OPERATION

RQHR Diagnostic Cytology Division, Anatomical Pathology Laboratory Pasqua Hospital 4101 Dewdney Avenue Regina, SK S4T 1A5 1-306-766-2641 - Cytology Supervisor 1-306-766-2642 - Microscopy Area 1-306-766-2519 - Cytopreparatory Area 1-306-766-2752 - Fax

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

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The Satellite Cytology service is located at the:

RQHR Regina General Hospital Satellite Cytology Laboratory 1440 14th Avenue Regina, SK 1-306-766-4488 - Cytotechnologist 1-306-766-4772 - FAX

Hours of operation: 0730-1530 Monday-Friday

The Fine Needle Aspiration Clinic is located at the: RQHR Pasqua Hospital Ambulatory Clinic 4101 Dewdney Avenue Bookings: Regina, SK S4T 1A5 1-306-766-2240

Hours of Operation: Wednesday: 0900-1200

NOTE: The Cytology laboratories are not staffed on Saturdays, Sunday or Statuary Holidays.

VII. GENERAL TECHNIQUES

A. PAP SMEAR PROCEDURE

The objective of an adequate Pap smear is to provide a sampling of the squamocolumnar junction between the ectocervix and endocervix (Transformation Zone). Combinations of various types of sampling are possible and can vary. Please note that use of cotton-tip applicator is NOT recommended. Sampling devices are available from the RQHR Cytology laboratory and can be ordered directly on the requisition. The Pap smear is considered a screening test only and has been demonstrated to produce false negative rates however it is still considered to be a highly effective tool for detecting cancerous and precancerous cervical lesions

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

Page 4 of 12 Last printed 3/21/2019 1:46 PM 1. Complete cytology requisition. Include all pertinent information, including the clinical information section, the reason for the Pap smear, age, LMP date, hormone replacement therapy, post menopause history, and the sampling tools used. 2. Prepare slide by writing two patient-specific identifiers on the frosted end of the slide. 3. Wooden Spatula: Transformation Zone Scrape (and vaginal pool sample, if indicated)  insert and rotate one full turn  spread material over top-half of slide  spray immediately with fixative, holding spray bottle 3-4 inches away from slide  pump 5-6 times or until saturated  the spray will contact the bottom half of the slide. This will not jeopardize the remainder of the procedure Cytobrush: endocervix sampling  gently insert cytobrush into the endocervix  rotate slowly one turn  remove cytobrush  spread material on the bottom-half of the slide by rolling and twisting the cytobrush  spray immediately as described above. There is no need to direct spray away from material already on the slide. Additional spray will not alter the specimen. 4. Place slide in slide holder, leaving open until dry 5. When completely dry, close folder. Wrap the requisition around the holder and secure with rubber band 6. Mail or deliver to the RQHR Pasqua Hospital Cytology Lab.

PRECAUTIONS: USE OF CYTOBRUSH

Manufacturers of cytobrush suggest these precautions:

You may want to inform your patients that due to thorough sampling of the endocervical canal by the Cytobrush, there may be minor painless spotting for a day or two following the Pap test.

B. SPUTUM 1. Specimen  the first morning sputum is generally considered to be the most representative for cytological examination 2. Specimen Collection  the patient receives a labeled specimen container the night before, and is instructed how to expectorate sputum  upon awakening the next morning, the patient is to rinse his/her mouth, clean his/her throat with a gentle cough, and deep cough from the diaphragm and expectorate all sputum into an appropriate seal proof specimen container LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

Page 5 of 12 Last printed 3/21/2019 1:46 PM  the procedure should be repeated once a day for three days 3. Submission  the cup should be collected by early morning and immediately taken to the laboratory  specimens collected after hours or on the weekend should be refrigerated.  An equal volume of CytoLyt or 50% ethyl alcohol should be added to the specimen if there will be a delay in reaching the laboratory (more than one day). The addition of preservative should be noted on the requisition and specimen container 4. Limitations  If pulmonary macrophages are not seen, the specimen will be reported as unsatisfactory

C. BRONCHIAL BRUSHING 1. Specimen  bronchial brushing is a selective brushing of the bronchial tree, and is performed by the physician during fiberoptic bronchoscopy  brushings are usually taken and immersed in a balanced salt solution 2. Specimen Collection  bronchial brushing is performed by the physician  the brush is immersed in a seal proof specimen collection tube that contains saline or Cytolyt (preservative) 3. Submission  the specimen is to be immediately taken to the laboratory  the specimen collected after hours or on the weekend should be refrigerated, making sure preservative of CytoLyt or 50% ethyl alcohol has been added

D. BRONCHIAL WASHING 1. Specimen  bronchial washing selectively washes a specific area of the bronchial tree, and is performed by the physician during fiberoptic bronchoscopy  washings are usually taken using a balanced salt solution 2. Specimen Collection  the distal airways are rinsed with normal saline  the fluid is collected via suction  the specimen is collected within an appropriate seal proof container 3. Submission  the specimen is to be immediately taken to the laboratory  specimens collected after hours or on the weekend should be refrigerated  an equal volume of CytoLyt or 50% ethyl alcohol should be added to the specimen if there will be a delay in reaching the laboratory (more than one day). The addition of alcohol should be noted on the requisition and specimen container.

E. URINE SPECIMENS/BLADDER WASHINGS 1. Specimen  voided or catheterized urine specimens; bladder washings

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

Page 6 of 12 Last printed 3/21/2019 1:46 PM 2. Specimen Collection  voided urine: the patient is hydrated and the subsequent midstream voided urine is collected in a labeled container  bladder washing: is usually done at cystoscopy by irrigating the bladder with normal saline  catheterized urine: is collected through the catheter and is transferred into a labeled container  renal pelvis and ureters: hydrate patient one glass water every 15 minutes for 2 hours. Patient should void and discard urine. Catheterize ureter below level of suspected lesion and collect urine for ½ hour. Other ureter catheterized as control. Same for renal pelvis with or without saline irrigation. 3. Submission  the specimen is immediately taken to the laboratory  specimens collected after hours or on the weekend should be refrigerated.  if the specimen cannot be refrigerated, the addition of equal volume of CytoLyt or 50% alcohol should be added. This addition should be noted on the requisition form, and on the specimen container 4. Limitations  Low grade papillary urethelial carcinoma may not be diagnosed by cytologic examination alone as recent instrumentation or calculi may produce similar atypical changes in the urothelial cells

F. SEROUS EFFUSIONS 1. Specimen  pleural (thoracic) fluids, peritoneal (ascites) fluids, pericardial fluids 2. Specimen Collection  serous effusions collections are performed by a physician  fluid is withdrawn from the serous body cavity  fluid is collected in a clearly labeled, screw-top leakproof container  if possible patient should be moved into several positions in order to well suspend the cellular material prior to collection 3. Submission  the specimen is immediately taken to the laboratory  fluids should be submitted fresh  the size of the fluid sample should not exceed 200 ml. If the amount is greater than 200 ml., the fluid should be well mixed and the specimen should be centrifuged in a few tubes to obtain a button of cells. Decant the supernatant and add CytoLyt or 50% ethyl alcohol to the button. Resuspend the cells. Place the entire resuspended specimen (with added preservative) into a leakproof container  the practice of salvaging large amounts of fluids is not recommended  fluids collected after hours or on the weekend should be refrigerated  the addition of an equal volume of CytoLyt or 50% ethyl alcohol should be added if the specimen will be delayed in reaching the laboratory (more than one day). This addition must be noted on the requisition and the specimen container

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G. CEREBROSPINAL FLUID 1. Specimen  cerebrospinal fluid specimens 2. Specimen Collection  the specimen is obtained by the physician while performing a lumbar puncture  fluid is collected in a clearly labeled, leakproof tube 3. Submission  the specimen is to be immediately taken to the laboratory  specimens collected after hours or on the weekend should be refrigerated.  if the specimen cannot be refrigerated, the addition of equal volume of CytoLyt or 50% alcohol should be added. This addition must be noted on the requisition form, and on the specimen container

*NOTE: Please indicate on the requisition if lymphoma/leukemia is suspected so RPMI can be added to the specimen for Flow Cytometry analysis.

H. ABDOMINAL and PELVIC WASHINGS 1. Specimen  abdominal and pelvic washings 2. Specimen Collection  abdominal and pelvic washings are performed by a physician  washings are usually collected in balanced salt solution  washings are collected in a clearly labeled, screw-top leak proof container 3. Submission  the specimen is immediately taken to the laboratory  fluids should be sent fresh and unfixed if at all possible  fluids collected after hours or on the weekend should be refrigerated  if the specimen cannot be refrigerated, the addition of equal volume of CytoLyt or 50% alcohol should be added. This addition must be noted on the requisition form, and on the specimen container

I. GASTROINTESTINAL, ESOPHAGEAL, and GASTROESOPHAGEAL BRUSHINGS 1. Specimen  brushings from the gastrointestinal, esophageal, and gastroesophageal sites 2. Specimen Collection  the gastroenterologist performs the brushing  after the brushing technique is completed, the brush is cut with wire cutters from the flexible wire leaving approximately 1 inch of wire  the brush is dropped immediately into a test tube filled with CytoLyt or 50% alcohol 3. Submission  the specimen is to be immediately taken to the laboratory  specimens collected after hours or on the weekend should be refrigerated.

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

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J. BREAST SECRETIONS (NIPPLE DISCHARGES) 1. Specimen  nipple discharges 2. Specimen Collection  slide is labeled with two patient identifiers  secretion is expressed by gently squeezing the areolar area between the thumb and index finger  the secretion is smeared across a glass slide  the smear is immediately sprayed with fixative  if secretion is thick, place another labeled glass slide on top and gently pull apart slide; fix with spray fixative  prepare as many slides as there is secretion 3. Submission  allow slides to dry and place in slide mailer  requisition is attached to slide mailing container  specimen is immediately delivered to the laboratory

K. JOINT FLUIDS (SYNOVIAL FLUIDS) 1. Specimen  synovial fluids, joint fluids 2. Specimen Collection  the physician aspirates the fluid from the joint  the synovial fluid is aspirated into a sterile test tube  do not add any type of fixative 3. Submission  the synovial fluid is transported immediately to the cytology laboratory  the requisition must indicate if the test is for the presence of crystals

L. CYST FLUIDS 1. Specimen  cellular material extracted from suspected cysts 2. Specimen Collection  the clinician aspirates the contents of the cyst, and samples the wall and adjacent tissue by means of fine needle aspiration  the aspirated material may be submitted in a clean leak proof container 3. Submission  the specimen is immediately taken to the laboratory  specimens collected after hours or on the weekend should be refrigerated  if the specimen cannot be refrigerated, the addition of equal volume of CytoLyt or 50% alcohol should be added. This addition must be noted on the requisition form, and the specimen container 4. Limitations

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

Page 9 of 12 Last printed 3/21/2019 1:46 PM  improper fixation, failure to include pertinent history  specimens lacking representative cyst lining will be considered unsatisfactory

M. OCULAR SPECIMENS 1. Specimen  ocular discharges, secretions, conjunctival lesion, corneal lesions 2. Specimen Collection  mucoid discharges are collected with a sterile cotton swab pre-moistened with sterile saline  conjunctiva scrapings are collected with a rounded spatula or instrument to avoid abrasion  material is gently smeared on a glass slide and is immediately immersed in 95% alcohol or is sprayed with fixative  the scraping tool may be rinsed in a sterile saline and the solution is submitted for cytology  intra-ocular aspiration for fluid cytology should be treated like a FNAB 3. Submission  any fluid, secretion or scraping is immediately transported to the laboratory  fresh specimens collected after hours or on the weekend should be refrigerated  specimens are fixed immediately in 95% alcohol or sprayed with fixative

N. GUIDED FINE NEEDLE ASPIRATION BIOPSIES ( CT SCAN, ULTRASOUND, ETC): ADEQUACY CHECK

Introduction: The Cytotechnologist will assist the clinician in the fine needle aspiration biopsy procedure of deep-seated lesions. You may contact the cytology lab at one of the following numbers: Pasqua site……………..ext. 2519 or 2642 Regina General site……ext. 4488

 the cytology lab is notified at the hospital site where the procedure is being performed  adequacy check will be provided on all aspirated specimens by the cytotechnologist, and a pathologist can be contacted if necessary

1. Specimen . radiologically guided fine needle aspiration of a deep-seated lesion 2. Collection & Procedure . the cytotechnologist prepares an area for FNAB preparation upon arrival. He confirms the patient and site with the radiology staff. He labels slides and a preservative- filled falcon tube with at least two patient identifiers . following the aspiration technique, the cytotechnologist assists the clinician in the preparation of the specimen. Adequacy of specimen and difficulty of biopsy being performed determine the number of direct smears  the clinician expels material on the slide

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

Page 10 of 12 Last printed 3/21/2019 1:46 PM  the cytotechnologist makes pull-apart smears. Both air-dried and spray fixed smears are made. Air-dried smears are stained for adequacy using Diff Quick stain  if at any time during the aspiration, the needle appears to be a dry tap, draw up a little preservative into the hub of the needle and then expel material on a slide  the cytotechnologist views the stained smears (Diff Quick) with a light microscope, and indicates whether the sample contains representative cellular material of the aspirated lesion *this preliminary assessment of adequacy is documented on the back of the requisition and in the cytopathology report  after an adequate number of smears are prepared, the needle is rinsed in the appropriate preservative tube for further testing  the cytotechnologist makes sure that each prepared slide is labeled separately and that patient identifiers are placed on any specimen container with collected material (including different sites, if warranted)  NOTE: It is very important that the cytology requisition is properly filled-out, including relevant clinical history, clinical suspicions, and if STAT diagnosis is required 3. Transportation . the cytotechnologist transports the specimen to the cytology laboratory and the specimen is immediately processed

O. FINE NEEDLE ASPIRATION CLINIC, PASQUA HOSPITAL

Introduction: The Regina Qu’Appelle Health Region has a Fine Needle Aspiration Clinic within the Pasqua Hospital, Ambulatory Care, Level 1. The Aspiration Clinic is run by the Pasqua Hospital Pathology Department. A Pathologist performs the aspiration and interprets the specimen for adequate sampling. A Cytotechnologist is also present to assist the Pathologist.

Address and Bookings:

Regina Qu’Appelle Health Region- Pathology Department Fine Needle Aspiration Clinic Pasqua Hospital, 5’th level 4101 Dewdney Avenue Regina, Sask S4T 1A5

Appointment Booking: (306) 766-2240 or 2245 Fax number: (306) 766-2752 Hours of Operation: Wednesday 0900-1200

1. Specimen  head and neck lesions (thyroid, lymph nodes, salivary glands)  breast lesions

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

Page 11 of 12 Last printed 3/21/2019 1:46 PM  miscellaneous (superficial soft tissue) 2. Collection and Procedure  the cytotechnologist prepares the area for fine needle aspiration upon the patient’s arrival. He checks the name band on the patient to make sure it matches the name on the requisition  the pathologist discusses the fine needle aspiration procedure with the patient, including FNA site and any relevant clinical history. The patient is asked to provide written consent before the procedure begins  upon patient consent, the patient is then prepared for the procedure. The cytotechnologist labels slides and a preservative-filled falcon tube with at least two patient identifiers  the pathologist performs the fine needle aspiration. The number of direct smears will be determined by the adequacy of the specimen and difficulty of the biopsy being performed  the pathologist expels material onto glass slides  pull- apart smears are made. Both air-dried and spray fixed smears are made. Air dried smears are stained for adequacy using Diff Quik stain  the pathologist views the Diff Quik smears using a light microscope and indicates whether the sample contains representative cellular material of the aspirated lesion  after an adequate number of smears are prepared, the needle is rinsed in the appropriate preservative tube for further processing *the cytotechnologist makes sure that each prepared slide is labeled separately and that patient identifiers are placed on any specimen container with collected material (including different sites, if warranted) 3. Transportation . the cytotechnologist makes sure the specimen is transported to the cytology laboratory for immediate processing and reporting

Revision History

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Y. Shelley Taylor, ART (CSMLS) / H. Budinski, MLT / L. Kozak, MLT

LABCytoOP7000 Diagnostic Cytology Lab Services Manual and Testing Compendium Laboratory Services Regina QuAppelle Health Region

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Subject/Title: LABHemaOP7001.2.9 Hematology Last Approved Time: 04/25/2018 Revision: 3.00 Approving Authority: Medical Hematopathologist Contact for Interpretation:Hematology Phone: (306) 766-4477 Current Version on Print Date

HEMATOLOGY

I GENERAL INFORMATION

The laboratory provides a comprehensive series of hematology tests, and processes hundreds of specimens per day. A department with such a large volume of work requires a degree of organization and rostering of procedures to achieve maximal efficiency. This means that certain tests are not constantly available. Whenever investigations are urgently required for medical reasons, the laboratory staff will be pleased to be of service as quickly and as completely as possible. Out-of-hours tests are restricted to those on the STAT list unless authorization is obtained by the physician of record from the hematologist.

The laboratory hematologist will be pleased to discuss problems at any time.

II REQUISITION FORMS

These should be accompanied by relevant information like anticoagulant therapy or diagnosis, particularly in those tests outside the routine work of the laboratory.

All test requests for PT and APTT must have specific anticoagulant therapy, if any, stated on the requisition. If information is incomplete, laboratory staff will phone the ward for this information before the test results will be released.

1. BIOCHEMISTRY/HEMATOLOGY Form (green): for CBC, PT/INR, APTT, MONO and other tests not listed. This form is used for requests from the hospital wards.

2. COMMUNITY LAB REQUISITION Form (blue): for CBC, PT/INR, APTT, MONO and other tests ordered from the physician offices.

3. RQHR SEMEN COLLECTION REQUISITION: Available on EMR or from the Print Shop. The requisition print number is RQHR 1167.

LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 1 of 10 Laboratory Services Regina Qu'Appelle Health Region

III COLLECTION OF SPECIMENS

Usually a phlebotomist or technologist is available to take blood specimens, but medical staff may need to take blood in emergencies, or when the laboratory staff find it impossible to obtain blood.

The following vacutainer specimen tubes are used:

Mauve top (EDTA) - CBC, platelets, ESR, Malaria Blue top (citrate) - Coagulation tests Red top (clotted blood) – Monotest, H.I.T.

For coagulation tests it is essential that an unhemolyzed specimen without frothing is taken as rapidly as possible. Therefore, choose a large vein and aspirate with a large bore needle without undue delay. The collection of a frothy, hemolyzed and slowly taken specimen will initiate the early stages of the coagulation system and invalidate results. It is always worth remembering that a syringe is often more useful in taking blood from "difficult" patients. Also, a full tube of blood is required for all coagulation testing.

IV BONE MARROW EXAMINATIONS

A. Requests

These should be booked (Monday – Friday) 24 hours in advance whenever possible and will normally be done only before 1300 hours in order to facilitate histology processing.

Marrows with chromosome studies (or other genetic testing) must be collected Monday – Thursday to facilitate shipping procedures and referral laboratories.

When a marrow examination is urgently required outside normal hours, this may be arranged on consultation with the laboratory hematologist. All requests for bone marrow examination must be accompanied by relevant clinical information.

B. Collection of Specimen

A good marrow specimen needs a meticulous method of aspiration.

Only the first 0.5 ml of aspirate contains a good concentration of particles and this should be drawn out as rapidly as possible since marrow, being rich in thromboplastic substances, clots rapidly. If more marrow is required, i.e. chromosome analysis, flow cytometry, culture, etc., use a second syringe.

If the first aspiration fails, use a new needle at a different site.

LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 2 of 10 Last printed 8/15/2019 1:26 PM V LIST OF TESTS PROVIDED IN HEMATOLOGY

A. General Hematology:

1. CBC: This gives print out of Hemoglobin, Hematocrit, WBC, RBC, platelets, MCV, MCHC, MCH, MPV, RDW and five-part differential count. ACT DIFF 2: This back-up analyzer provides hemoglobin, hematocrit, WBC, RBC, platelets, MCV, MCH, MCHC and a three part differential count. 2. Reticulocyte count 3. Erythrocyte sedimentation rate (ESR). 4. Monotest 5. Serum Viscosity 6. Kleihauer test 7. Malaria Identification

B. The following tests are available but they are to be approved by the hematologist mainly because:

(i) these tests are time consuming and (ii) they are difficult to interpret

1. Sickle cell test 2. Heinz body test 3. Hb electrophoresis 4. Test for Hb 'H' 5. Plasma Hb 6. Methemalbumin 7. Urinary hemosiderin 8. Myeloperoxidase Stain 9. Combined Esterase Stain 10. Iron stain 11. PNH-referred to Calgary

C. Coagulation Tests: Coagulation Screen includes the following tests:

1. Prothrombin Time 2. Activated partial thromboplastin time 3. Fibrinogen 4. D-Dimer

LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 3 of 10 Last printed 8/15/2019 1:26 PM The following special coagulation tests must have Special Coagulation requisition completely filled out including diagnosis and history:

1. Factor Assays 2. Ristocetin Cofactor 3. von Willebrand Factor Antigen 4. Platelet Aggregation Study 5. Protein C 6. Protein S 7. Antithrombin 8. APC Resistance Ratio 9. Anticardiolipin Antibodies 10. DRVVT/KCT 11. Thrombin Time 12. Factor XIII 13. Heparin/Anti Xa Assay 14. Inhibitor Studies 15. HIT test 16. PFA

D. Body Fluids:

Cell counts are done on CSF, pleural, peritoneal, synovial fluid, dialysate and bronchial washings.

E. Semen Analysis:

1. Sperm count is done on post vasectomy. 2. Semen Analysis is done on specimens for fertility studies. (Semen analysis for fertility study or post vasectomy are done weekdays only from 08:00 – 14:45 except statuary holidays.)

LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 4 of 10 Last printed 8/15/2019 1:26 PM VI BLOOD REQUIRED FOR LABORATORY TESTS

TEST TYPE VOL. OF BLOOD ANTICOAGULANT VACUTAINER

CBC (hemoglobin Min. 2 mL EDTA mauve WBC, RBC)

Fibrinogen 2.7 mL 3.2% Na Citrate adult blue 1.8 mL 3.2% Na Citrate pediatric blue

Partial Thrombo- 2.7 mL 3.2% Na Citrate adult blue plastin Time 1.8 mL 3.2% Na Citrate pediatric blue

Prothrombin Time 2.7 mL 3.2% Na Citrate adult blue 1.8 mL 3.2% Na Citrate pediatric blue

Sedimentation Rate Min. 2 mL EDTA mauve

Monotest Min. 2 mL EDTA mauve Min. 2 mL (preferred) none (serum) red

Kleihauer Min. 2 mL EDTA mauve

Viscosity Min. 5 mL none (serum) red

CSF none red

Pleural, peritoneal, EDTA mauve synovial, dialysate fluids, and bronchial washings

Semen(Fertility or C&S Post Vasectomy) container

Malaria Min. 2 mL EDTA mauve 4 Thick & 4 Thin slides

NOTE: When an analysis is required for which capillary blood is required, the Laboratory Technologist will obtain the specimen.

KEY TO VACUTAINERS

RED No anticoagulant for clotted blood

GREY Potassium oxalate for chemistry

GREY T.S.Thymol/Sodium Fluoride for chemistry (lactic acid)

MAUVE EDTA for Hematology LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

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GREEN Heparin for pH, Carboxyhemoglobin, "Stat" Electrolytes only, Flowcytometry

BLUE Liquid Sodium Citrate for Prothrombin Time, P.T.T. and other coagulation tests

VII ESTABLISHED NORMAL (REFERENCE) RANGES

A. CBC (12 years or older)

WBC 4 - 10 x 109/L

RBC Men 4.3 - 5.4 x 1012/L Women 3.7 - 5.1 x 1012/L

Hb Men 140 - 180 g/L Women 120 - 160 g/L

Hct Men 0.400 - 0.500 L/L Women 0.370 - 0.470 L/L

MCV 82 - 97 fL

MCH 27 - 32 pg

MCHC 320 - 360 G/L

RDW 11.5 - 14.5

Platelet 150 - 400 x 109/L

MPV 7.4 - 10.4 fl

LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 6 of 10 Last printed 8/15/2019 1:26 PM CBC reference ranges (under 12 years old)

Test 0 - 3 Day 4 Day-3 Mo 3 – 12 Mo 12 Mo-3 Yr 3 - 6 Yr 6 - 12 Yr

WBC 10.0 - 30.0 10.0 - 26.0 6.0 – 18.0 6.0 - 18.0 5.0 - 15.0 4.5 - 13.5 x 109/L

RBC 4.00 - 6.00 4.00 - 6.00 3.20 - 4.80 3.60 - 5.20 4.10 - 5.50 4.00 - 5.40 x 1012/L

Hgb 135 – 195 135 - 195 96 – 126 110 – 130 120 - 140 115 - 145 g/L

Hct .440 - .640 .440 - .640 .320 - .440 .360 - .440 .370 - .450 .370 - .450 L/L

MCV 98.0 - 114.0 98.0 - 114.0 87.0 - 103.0 70.0 - 86.0 77.0 - 91.0 77.0 - 91.0 fL

MCH 24.0 - 34.0 24.0 - 34.0 24.0 - 34.0 23.0 - 31.0 24.0 - 30.0 24.0 - 30.0 pg

MCHC 320 – 360 320 - 360 320 - 360 320 – 360 320 - 360 320 - 360 g/L

RDW 11.5 - 14.5 11.5 - 14.5 11.5 - 14.5 11.5 - 14.5 11.5 - 14.5 11.5 - 14.5

Platelet 150 – 400 150 - 400 150 - 400 150 – 400 150 - 400 150 - 400 x 109/L

MPV 7.4 – 10.4 7.4 - 10.4 7.4 – 10.4 7.4 – 10.4 7.4 - 10.4 7.4 - 10.4

Neutrophil 5.0 – 13.0 5.0 - 13.0 2.0 – 6.0 2.0 – 6.0 2.0 - 6.0 2.0 - 6.0 x 109/L

Lymph 3.5 - 8.3 3.5 - 8.3 5.5 – 8.5 5.5 – 8.5 5.5 - 8.5 5.5 - 8.5 x 109/L

Monocyte 0.5 - 1.5 0.5 - 1.5 0.7 – 1.5 0.7 – 1.5 0.7 - 1.5 0.7 - 1.5 x 109/L

Eosinophil 0.1 - 2.5 0.1 - 2.5 0.3 – 0.8 0.3 – 0.8 0.3 - 0.8 0.3 - 0.8 x 109/L

Basophil 0.0 - 0.1 0.0 - 0.1 0.0 – 0.1 0.0 – 0.1 0.0 - 0.1 0.0 - 0.1 x 109/L

B. WBC Differential Counts (12 years or older)

Absolute Neutrophils: 1.5 - 6.5 x 109/L

Absolute Lymphocytes: 1.2 - 3.4 x 109/L

Absolute Monocytes Count: 0.2 - 0.8 x 10 9/L

Absolute Eosinophil Count: 0.0 - 0.4 x 109/L

Absolute Basophil Count: 0.0 - 0.2 x 109/L

Neutrophil % - 42.2 - 75.2% Lymphocytes % - 20.5 - 51.1% Monocytes % - 1.7 - 7.6% Eosinophils % - 0.0 - 5.0% Basophils % - 0.0 - 0.8% LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 7 of 10 Last printed 8/15/2019 1:26 PM C. Coagulation

1. INR: 0.9 – 1.3 Therapeutic Range INR: DVT 2.0 - 3.0 Recurrent P.E. 2.5 - 3.5

2. Activated Partial Thromboplastin Time: 25 - 38 sec. Therapeutic Range: 55 - 80 seconds.

3. Fibrinogen: 1.8 – 3.5 g/L

4. D-Dimer: less than 500 ug/L FEU

D. Chromogenic Assays and Special Coagulation Tests

1. Anti-Thrombin: 80% - 120%

2. Protein C: 70% - 130% of normal

Women Men 3. Protein S Free 50 - 130% 70 -150% Functional Protein S 64 – 149%

4. APC Resistance 2.0 – 5.0

5. Anticardiolipin IgM 0 – 10 MPL/ml Anticardiolipin IgG 0 – 22 GPL/ml Anticardiolipin IgA 0 – 21 APL/ml

6. DRVVT Ratio 0.0 – 1.3

KCT Ratio 0.0 – 1.2

7. VW Factor Antigen 50-200% of normal Lower Limit of normal is 40% for blood Group O individuals

8. Ristocetin CoFactor 50-200% of normal

9. Factor XII Assay 0.45 – 1.50 units/mL

10. Factor Assays 0.50 – 1.50 units/mL (V,VII,VIII,IX,X,XI)

E. Erythrocyte Sedimentation Rate (ESR) 0 - 20 mm/hr

LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 8 of 10 Last printed 8/15/2019 1:26 PM F. Body Fluids

CSF: Clear, colorless RBC - 0 WBC - adults 0 - 5 x 106/L neonates 0 - 30 x 106/L

Differential Adults Neonates Lymphocytes 60% + 20% 20% + 15% Monocytes 30% + 15% 70% + 20% Neutrophils 2% + 4% 4% + 4% Eosinophils less than 1% less than 1%

Pleural, synovial fluids Clear, pale yellow WBC: Pleural 0 - 1.0 x 109/L Synovial 0 - 0.2 x 109/L RBC: 0 x 1012/L Differential - less than 25% neutrophils

Peritoneal fluids Clear, pale yellow WBC: 0 - 300 per mm3

Dialysate fluids Clear, colorless WBC: 0.0 – 0.10 x 109/L RBC: 0 x 1012/L

G. Semen Fertility Analysis  Liquefaction- complete after one hour  Volume- ≥ 1.5 mL  Viscosity- Does form small discrete drops  Motility- ≥ 32%(progressive)  Total Motility- 40 to 100%  Sperm Concentration- > 15 x 10^6/mL  Sperm Number- ≥ 39 x 10^6  Vitality- ≥ 58% normal  Morphology- ≥ 4% normal

Revision History

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LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

Page 9 of 10 Last printed 8/15/2019 1:26 PM Author Revised by Joan Isaak Revised by Cathy Christopherson, MLT (revised April 25/18) Revised by Sheri McCorriston, MLT

LABHemaOP7001.2.9 Hematology Laboratory Services Regina QuAppelle Health Region

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Subject/Title: LABHemaOP7037.1.1 Flowcytometry Last Approved Time: 08/09/2018 Revision: 2.10 Approving Authority: Pathologist Contact for Interpretation:Flowcytometry Phone: (306) 766-6191 Current Version on Print Date

Policy

General Information Technical staff is available weekdays 0730 to 1600 hours (except statutory holidays). Specimens should be received at Pasqua laboratory by 1400 hours to facilitate processing. Out of hours tests are restricted unless authorization is obtained by physician of record from the Pathologist.

Collection of Specimens

Specimen Requirement Additional Information Whole Blood for Adults-1 ACD-A(full draw) Store and transport at 2-8˚C. Specimen Flowcytometry Pediatrics-1 sodium citrate(full must be processed within 48 hrs of draw) collection. If lymphocyte subsets are required a CBC must also be ordered at the same time.

Whole Blood for 1 EDTA (mauve). Keep at room temperature. Optimum CD4/CD8 1 microtainer EDTA (minimum of specimen result is 24 hrs from time of 250ul) collection. Samples >24hrs are tested and a disclaimer is noted about age of sample. Bone Marrow 1-3 ml in Sodium Heparin Store and transport at 2-8˚C. Specimens must be processed within 24-48 hrs of collection. Body Fluids Minimum of 20 ml in C&S Freshly collected and sent immediately. container with equal amount of Store and transport at 2-8°C. Must be RPMI preservative and without processed within 24-48 hrs of any anticoagulant. collection. Tissue specimen Place in 10ml RPMI Store and transport at 2-8°C. Specimens preservation media. must be processed within 24-48 hrs of collection. DO NOT FREEZE. Fine Needle Aspirates Place in 10ml RPMI Store and transport at 2-8°C. Must be (FNA) preservation media. processed within 24-48 hrs of collection. LABHemaOP7037.1.1 Flowcytometry Laboratory Services Regina QuAppelle Health Region

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LABHemaOP7037.1.1 Flowcytometry Laboratory Services Regina QuAppelle Health Region

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List of Tests provided in Flowcytometry

1. CD4/CD8 2. Leukemia Immunophenotyping 3. Lymphocyte/Lymphoma Phenotyping

Revision History

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Revised Faye Gorrill, MLT

LABHemaOP7037.1.1 Flowcytometry Laboratory Services Regina QuAppelle Health Region

Page 3 of 3 Last printed 4/16/2019 10:32 AM

Subject/Title: LABHistOP1000 Histopathology Clinical Support Services Man Last Updated Time: 06/13/2017 Revision: 3.30 Approving Authority: Medical Pathologist Contact for Interpretation: Histology Phone: (306) 766-2075 Current Version on Print Date

HISTOPATHOLOGY CLINICAL SUPPORT SERVICES MANUAL

Hours of Operation:

Technical Staff are available Monday to Friday, 0600 to 1530 hours. Non-technical staff are available Monday to Friday, until 1700 hours. Saturdays, Sundays and Statutory Holidays are not worked.

I. SUBMISSION OF TISSUES FOR PATHOLOGICAL EXAMINATION

1. For routine pathological examination, the requirements are: - Tissues should be immersed in 10% neutral buffered formalin immediately after removal. - Volume of the 10% neutral buffered formalin should be at least 10 times the volume of the specimen. - Tissues should not be squashed into small containers. - 10% neutral buffered formalin for the nursing units and operating room is available from Histopathology at the Pasqua Hospital or the laboratory at the Regina General Hospital. - affix gummed label to each specimen jar clearly indicating name of patient, HIN, HSN, surgeon, nursing unit, nature of specimen and date of surgery. - the attending physician must complete and legibly sign the Histopathology request form and provide relevant clinical history, nature of specimen and date of surgery (include operative findings and details of previous surgery with dates). Where relevant provide obstetrical and gynaecological history. THIS IS A STATUTORY REQUIREMENT.

2. URGENT or over-night reports on tissue - These tissues must be submitted to Histopathology no later than 1500 hours; only small biopsies can be processed this quickly. If it is considered that fixation is not complete; the specimen will not be processed: every effort will be made to notify the clinician.

3. Tissues for Microbiological Culture and subsequent Pathological Examination. - These tissues should be submitted in a sterile container and should be sent immediately to Microbiology at the RGH in the fresh state with no formalin added.

LABHistOP1000 Histopathology Clinical Support Services Man Laboratory Services Regina QuAppelle Health Region

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- The requisition should state clearly that a culture is required and, wherever possible, what organism is suspected. - If pathologic examination is also required, a pathology requisition must also be completed.

4. Tissues for Quick Section - This is routinely available Monday through Friday (except statutory holidays) and available at other times by direct arrangement between the physician of record and the pathologist on call. - The equipment to perform Quick Sections is kept in the Histopathology laboratory and specimens should be sent by pneumatic tube or special messenger to Histopathology without delay. - A pathologist should be informed before the specimen leaves the operating room. Call local 2228 at PH or use Phillips intercom system to call the Histology Lab. At RGH, call the pathologist at 4466 or page on pathologist’s pager 6290. - The tissue should be fresh with no added formalin.

5. Tissue for Electron Microscopy - If electron microscopy on tissue is required, Histopathology should be notified a day in advance so the proper solutions can be made. Phone local 2228 at PH. - Dispatch the tissue immediately to the Histopathology laboratory in the fresh state with NO added solution. - The requisition should state clearly that ELECTRON MICROSCOPY is required. - A full clinical history must be supplied. - For specimens originating from the RGH, notify the onsite pathologist at local 4466. - Tests for Electron Microscopy are referred outside the region.

6. Tissues requiring photography with subsequent pathological examination. - These should be sent immediately to the laboratory in the fresh state with no formalin added (Monday to Friday only). - The requisition should state clearly that a photograph is required and also indicate what features are to be demonstrated. - The pathologist on call must be notified for specimens procured out of normal working hours.

7. Immunofluorescence for bound immunoglobulin - Tests ordered on renal biopsies are referred to Saskatoon City Hospital Pathology Department for testing. Pediatric (0-16 yr) renal biopsies are referred to Winnipeg Health Sciences Centre for testing. - Testing of skin and oral mucosa biopsies is performed by Histopathology on a weekly basis. - Tissues should be placed in Michel's fixative without refrigeration or freezing. Michel's fixative is available from Histopathology (local 2228).

LABHistOP1000 Histopathology Clinical Support Services Man Laboratory Services Regina QuAppelle Health Region

LABHistOP1000.3.3 Histopathology Clinical Support Services Manual Page 2 of 7 Last printed 4/1/2019 8:02 AM

- Tissue for conventional light microscopy should be submitted at the same time.

8. Lymph Nodes and Open Lung Biopsies - At PH - Notify the Histology department (local 2228). - Send immediately by special messenger to Histopathology, in the fresh state with NO added formalin. - After 1700 h, special arrangements must be made with the pathologist on call.

- At RGH - Notify the on-site pathologist (local 4466). - Send immediately by special messenger to the Laboratory, in the fresh state with NO added formalin. - After 1700 h, special arrangements must be made with the pathologist on call.

9. Testicular Biopsies: - Bouin's fixative is available from Histopathology upon request (local 2228). - Notify a day in advance.

10. Amputated limbs - Limbs which do not require pathological examination should be accompanied by a requisition clearly marked FOR DISPOSAL and should be placed in a vault in the Autopsy suite for later disposal.

11. After 1630 hours - Specimens without fixative (i.e. fresh specimens) must not be left in the Histopathology Laboratory. - For lymph node biopsies, kidney biopsies, thoracic biopsies, flow cytometry and other urgent specimens, contact the on call pathologist.

12. Muscle Biopsies: - Processing and reporting of all muscle biopsies is performed by an external reference laboratory. - The Histology laboratory requires 48 hours notice of the intent to perform a muscle biopsy. It is essential that the on-call pathologist receives notification of intent to do a muscle biopsy. - Liquid nitrogen is not stored in the laboratory and can only be delivered Tuesdays and Thursdays, effectively restricting our ability to offer the service to Wednesday, Thursday and Friday.

13. Nerve biopsies: - Processing and reporting of all nerve biopsies is performed by an external reference laboratory. - It is essential that the Histopathology Laboratory (local 2228), receive 24 hour notification of the intent to perform a nerve biopsy so that the proper solutions can be made. LABHistOP1000 Histopathology Clinical Support Services Man Laboratory Services Regina QuAppelle Health Region

LABHistOP1000.3.3 Histopathology Clinical Support Services Manual Page 3 of 7 Last printed 4/1/2019 8:02 AM

- Prior to commencement of the procedure, the pathologist on call must be notified so that they may ensure that proper protocol is followed.

14. Flow Cytometry: - This is routinely available Monday through Friday (except statutory holidays) and available at other times by direct arrangement between the physician of record and the pathologist on call. - Tissue submitted for Flow Cytometry must be submitted in RPMI medium and delivered immediately to the laboratory.

15. Chromosome Studies: - Tissues submitted for chromosome studies are sent to an external reference laboratory for testing. - Tissues submitted should be fresh with no added formalin and delivered immediately to the laboratory. - The pathologist on call should be notified that a specimen has been sent for chromosome studies

16. Kidney Biopsies: - Notify the pathologist on call prior to performing the biopsy. - Ideal specimen: two kidney needle core biopsies each measuring 1-1.5 cm in length. These biopsies are placed between two pieces of filter paper that have been dampened with normal saline. Dispatch the tissue immediately to the Histopathology laboratory. - A full clinical history must be supplied Kidney Biopsies are sent to Saskatoon City Hospital for testing. Pediatric (0-16 yr) cases are sent to Winnipeg Health Sciences Centre for testing.

II. AUTOPSIES

1. CORONER'S AUTOPSIES:

 “Warrant for Post-Mortem or Other Examination” (Form C) must be completed by the coroner. This form is provided by the coroner.

 A coroner’s autopsy differs from a hospital autopsy in that the coroner’s order to perform an autopsy constitutes a legal consent and does not require the consent of the decedent’s family.

The coroner should be notified in all cases of death due to:  Homicide  Suicide  Accident  Unusual circumstances which require investigation falling under the general category of “misadventure”

NOTE: A Coroner should be called in those cases in which death is due to so-called “natural conditions” such as infection, renal failure,

LABHistOP1000 Histopathology Clinical Support Services Man Laboratory Services Regina QuAppelle Health Region

LABHistOP1000.3.3 Histopathology Clinical Support Services Manual Page 4 of 7 Last printed 4/1/2019 8:02 AM

pneumonia, etc., when those conditions are thought to be a consequence of an injury even when death occurs months or years following the initial incident.

In doubtful cases it is advisable to discuss the case with the Coroner.

2. HOSPITAL AUTOPSIES:

 All hospital autopsies require a completed and signed “Consent for Autopsy” (Form RQHR 064) before an autopsy can be performed. For the order of those who may give legal consent for a hospital autopsy - see list below

 The request for autopsy shall be made by the attending or consulting physician or his designate. A resident or house physician may request an autopsy after consulting with the attending or consulting physician.

 Nursing or Admitting personnel may obtain and witness the consent signature. If consent/permission is sought by telephone, the person obtaining permission and a witness to the telephone conversation must both sign the “Consent for Autopsy” (RQHR 064) form.

 There are no legal requirements making a hospital autopsy mandatory.

3. COURTESY AUTOPSIES:

 A request must be made to the Director or pathologist on call. The following documentation is required:  Valid consent from the legal next of kin. It is acceptable to use their own form or the “Consent for Autopsy” (Form RQHR 064) will be provided.  Adequate legible or type-written clinical history (must not be photocopy of hospital chart)  Referring agency to pay for transportation  Courtesy autopsies are performed Monday through Friday subject to time constraints. They are not performed on weekends/holidays except in rare instances.

THE FOLLOWING MAY GIVE CONSENT FOR AUTOPSY:

 The Coroner  The legal next of kin (in certain circumstances the executor or person lawfully in possession of the body). See list below.  In the case of common-law relationship, the Pathologist must contact Risk Management (766-4979) for verification.  Please refer to the following procedure - RHD Procedure No: 1.1.7 (Page 13) 4.3 Consent to Autopsy.

4.3 Consent to Autopsy LABHistOP1000 Histopathology Clinical Support Services Man Laboratory Services Regina QuAppelle Health Region

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The attending physician is responsible for ensuring that the individual providing the consent is aware of the nature, purpose, and effect of the consent. A Medical Resident may be appointed by the attending physician to explain the nature, purpose, and effect of the autopsy to the substitute decision maker or person lawfully in possession of the body.

An autopsy requires a written consent using the Consent for Autopsy Form. When obtaining consent, the next-of-kin who may authorize autopsy are listed in order below. All except the spouse must be at least eighteen years of age:

 spouse (unless living separate immediately prior to the death or illness)  children of the person  either parent  brother or sister  any other next-of-kin  the person lawfully in possession of the body other than the RHD, the Minister of Justice, or a funeral director

When permission is obtained from a person other than the person or persons listed on the hierarchical list, the reasons should be documented on the health record.

When the extent of autopsy is not indicated on the consent form, authorization for the complete autopsy is assumed.

Under those circumstances which warrant a coroner’s investigation, no autopsy shall be performed unless and until authorized by the coroner.

The completed “Consent for Autopsy” form (both sides) and patient chart are to accompany the body to the Laboratory. The patient chart and “Consent for Autopsy” form must be left in the “Autopsy Permission Box” by the accession area at RGH or in the “Autopsy Permission Box” on the wall at Pasqua.

Note: Under no circumstances should the “Consent for Autopsy” form and patient chart be placed into the morgue vault along with the body.

Note: Under no circumstances should the “Consent for Autopsy” form and patient chart be sent to Health Records.

References

 4.3 Consent to Autopsy - Page 13 of RHD Procedure No: 1.1.7 (this can be found on the RQHR Intranet)

Revision History LABHistOP1000 Histopathology Clinical Support Services Man Laboratory Services Regina QuAppelle Health Region

LABHistOP1000.3.3 Histopathology Clinical Support Services Manual Page 6 of 7 Last printed 4/1/2019 8:02 AM

Found in SoftTech Health Lab QMS™ Document Management System

Author D. McHardy, MLT

LABHistOP1000 Histopathology Clinical Support Services Man Laboratory Services Regina QuAppelle Health Region

LABHistOP1000.3.3 Histopathology Clinical Support Services Manual Page 7 of 7 Last printed 4/1/2019 8:02 AM

Subject/Title: LABMicOP7204 MICROBIOLOGY LABORATORY SERVICES Last Approved Time: 07/18/2019 Revision: 2.20 Approving Authority:Medical Microbiologist Contact for Interpretation: Microbiology Phone: (306) 766-4481 Current Version on Print Date

Policy Process Control

Purpose This procedure provides information on the hours of operation and the scope of services provided by the Microbiology laboratory. It also provides guidelines for the collection and transportation of specimens for Microbiology.

Hours of Operation Technical staff is available Monday to Sunday providing 24 hour coverage.

Scope of Service Bacteriology: - Bacterial culture - Organism identification - Drug susceptibility testing Mycobacteriology (Microscopy only. Culture will be sent to the Provincial Laboratory (RRPL)) Virology (Limited viral screens are performed on In Patient specimens. All specimens are referred to RRPL for viral cultures) Clostridium difficile cytotoxin testing

LABMicOP7204 MICROBIOLOGY LABORATORY SERVICES Laboratory Services Regina QuAppelle Health Region

Page 1 of 3 Last printed 7/18/2019 3:47 PM LABMicOP7204.2.2 Microbiology Laboratory Services

Procedure Step Action Additional Information 1 Complete a Microbiology These are white or blue in colour. The white requisition. requisition is used by the Hospitals and Nursing Homes. The blue requisition is used by the community laboratories.

Each form has a set of perforated numbers at the bottom. Removal of the tape enables the numbers to be firmly affixed to each specimen submitted for bacteriological examination. In the case of swabs, the labels should be applied along the length of the tube. Each number sticker must have name, MRN/HSN, specimen type and date filled in.

The appropriate spaces at the top half of the requisition should be filled in by the Nursing Unit or Clinic, with all the pertinent information requested, including the diagnosis and antibiotic therapy. This information is important in the correct identification of the specimen, and also in determining the culture method to be used.

2 Collect specimen and Refer to Appendix 1 for Specimen Containers for transport specimens to Microbiology. laboratory. Refer to Appendix 2 for Microbiology Collection and Test Compendium.

Refer to Table 1 for the Criteria for Rejection of Microbiology Specimens.

Procedure notes All specimens and containers should be considered contaminated. Biohazard bags are not necessary for transport of specimens; however, personal protective equipment must be used. ie. Gloves. Gross contamination of specimen containers must be removed prior to transport (wipe visible contamination from specimen container with cotton ball soaked in 0.5% hypochloride solution or use an alcohol swab).

LABMicOP7204 MICROBIOLOGY LABORATORY SERVICES Laboratory Services Regina QuAppelle Health Region

Page 2 of 3 Last printed 7/18/2019 3:47 PM LABMicOP7204.2.2 Microbiology Laboratory Services

Reporting Results A direct gram smear will be performed and reported on all appropriate specimens. These results will be sent to the appropriate ward when results have been completed. STAT gram smears will be performed and results called within 30 minutes.

When a specimen culture yields a pathogenic organism, the organism will be reported along with a list of antibiotics to which the organism is susceptible with standard adult dosage. Dosage adjustments must be made for other age groups, and for patients with underlying disease. eg. renal failure.

Qualitative tests such as Clostridium difficile cytotoxin testing will be reported as “positive” or “negative”.

Each individual test on a Microbiology report will be flagged as an “interim” or a “final” report.

When results fall within ranges identified as “Critical”, Laboratory staff will telephone results to the nurse on the unit concerned or to the physician, or in the case of out-patient or referred in specimens to the clinic or physician’s office. Refer to Microbiology Critical Values.

Related documents LABMicOP7202.T.1 Criteria for Rejection of Microbiology Specimens LABMicOP8000.A.3 Microbiology Critical Values

Appendixes LABMicOP7204.A.1 Specimen Containers for Microbiology LABMicOP7204.A.2 Microbiology Collection and Testing Compendium LABMicOP7204.T.1 Criteria for Rejection of Microbiology Specimens

Revision History Found in Softtech Health Lab QMS™ Document Management System

Author Carol Barth, MLT.

LABMicOP7204 MICROBIOLOGY LABORATORY SERVICES Laboratory Services Regina QuAppelle Health Region

Page 3 of 3 Last printed 7/18/2019 3:47 PM Specimen Transport Containers for RGH Microbiology Laboratory

E-Swab Stool container For all routine specimens when Stool container with WITHOUT preservative aerobic and/or anaerobic Cary-Blair media or media organisms are suspected For the detection of including Neisseria gonorrhea bacterial stool For H. pylori stool (all sources) and Candida species pathogens antigen and C.diff toxin testing Use for C&S only Oxoid Cat# R21925 Alere Cat# CA-480C-ST VWR Cat# CA73240-137

Sterile Container Urine Transport with Boric Acid pre- For urine specimens, sterile fluids and/or tissues servative that can be rapidly transported (<2hrs) to the Preferred container for Urine C&S laboratory and therefore do not require transport media Minimum fill 5ml VWR Cat# CA73240-132L-Direct VWR Cat# CA73240-130

Blood Culture Vials Universal Transport Medium A) FA– Plus– Aerobic For recovery of Viruses, B) FN-Plus– Anaerobic Mycoplasma and Ureaplasma from all sources C) PF-Plus Pediatric

Order from RR Prov Lab BioMerieux Cat# 410851, 52, and 53

For complete instructions on specimen collection, transport and storage refer to the RGH Laboratory Microbiology Compendium RQHR Microbiology Test Compendium

The Regina Qu’Appelle Health Region (RQHR) Division of Microbiology, within the Department of Laboratory Medicine provides amalgamated service to all patients and providers within RQHR.

The laboratory is staffed 24 hours a day, 365 days per year, with medical consultation available 24/7.

Laboratory Services, Microbiology Regina General Hospital 1440 – 14 Ave Regina, SK S4P 0W5 Phone: 306-766-4481 Fax: 306-766-4640

The Medical Microbiologist on-call can be reached through the hospital switchboards at 306-766-4444 or 306-766-2222.

General Specimen Collection and Submission Requirements All specimens must be labeled and submitted with a completed requisition (see Laboratory Services Manual - General Information for further details). Specimens may be rejected if:

 they are improperly labeled or not accompanied by a completed requisition  submitted in inappropriate container, received in leaking or otherwise compromised container  Insufficient quantity of specimen, inappropriate specimen type for test requested, duplicate specimens, or if integrity of specimen has been compromised (e.g. lack of temperature control, delays in transit)

Whenever possible, specimens for microbiologic detection should be collected before antibiotics are given. Care must be taken to avoid contamination of specimens with organisms of the normal flora or environment.

Specimens should be delivered to the laboratory soon after they are collected. Delays in transport can lead to incorrect, invalid, or misleading results. The date and time of specimen collection should be recorded on the requisition in order to identify these delays and aid in results interpretation.

Providing relevant clinical information will ensure specimens are processed and reported appropriately.

This compendium describes routine testing performed. For special requests or additional information, please contact the Microbiology laboratory or Medical Microbiologist on-call.

Last revised June 2019

Last revised June 2019 Compendium of Tests

TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING

BLOOD & STERILE FLUIDS Blood Cultures [See LABMicOP7021 Bottles are incubated on an Positive gram stains are Adult blood culture bottles Collection of Blood Cultures automated instrument with considered CRITICAL RESULTS must be filled to the procedure for details] continuous monitoring until and are phoned to submitting appropriate volume in order growth is detected, or for 5 location immediately upon to achieve optimal dilution of Adults (≥16 years) set: days if negative. detection 24 hours per day. ingredients. Over-filling or 1 aerobic + 1 anaerobic under-filling bottles will bottle; 8 – 10 mL each Once growth is detected, Identification and reduce the sensitivity of Gram stain is performed STAT susceptibility results are detection. Child (1 – 15 years) set: and bottles are sub-cultured. usually available 24 – 48 Collect approximately 1mL hours after organism is Label bottles and provide per year of age total. Divide isolated. information on requisition to total volume into multiple identify the source of each bottles as indicated. Reports of no growth are sent blood culture set (e.g. sets 1 – 4 years: 1 pediatric bottle at 24 hours and 5 days, if labeled #1, #2; requisition 5 – 8 years: 2 pediatric bottles applicable. indicates #1 venipuncture, #2 9 – 15 years: 1 pediatric + 1 PICC line). aerobic adult bottle Pediatric blood cultures will Infant (0 – 12 months) set: be drawn as a single set 1 pediatric bottle (1 – 2 mL) unless specifically ordered as 2 sets. Pediatric blood For all adult collections, 2 sets cultures will not include collected from 2 separate anaerobic culture bottles sites will always be unless specifically requested. performed. One set should always be collected from a peripheral venipuncture. Label sites of collection.

Transport at room temperature, as soon as Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING possible and <24 hours. Do not freeze or refrigerate. CSF (Cerebrospinal fluid) Collect using sterile technique Gram stain and culture for Positive gram stains are Avoid sending first tube  Lumbar puncture into sterile screw capped bacteria and yeast is considered CRITICAL RESULTS collected for microbiology  Extraventricular drain containers. performed routinely. Cultures and are phoned to submitting testing due to increased risk  Indwelling shunt are incubated for 7 days. location immediately upon of specimen contamination. Minimum volumes: detection 24 hours per day. Bacterial/yeast culture ≥1 mL Filamentous fungal cultures If ordering additional testing Fungal culture ≥2 mL performed if ordered on Identification and from reference laboratory, requisition. Specimen will be susceptibility results are ensure adequate volume is Transport at room forwarded to RRPL for testing. usually available 24 – 48 submitted: ≥2 mL for temperature, as soon as hours after organism is Mycobacterial culture, ≥1mL possible and <2 hours. Do not All CSF specimens requesting isolated. for viral isolation, and freeze or refrigerate. filamentous fungal culture approximately 1mL per will have a qualitative Reports of no growth are sent additional special request Cryptococcal Antigen lateral at 24 and 72 hours, if flow assay (CrAg LFA) applicable. performed at RGH. Positive specimens will undergo semi- quantitative titration. Sterile Fluids Collect using sterile technique Gram stain and culture for Positive gram stains are Swabs of sterile fluid are  Pleural fluid into sterile screw capped aerobic and anaerobic considered CRITICAL RESULTS inappropriate specimens. This  Peritoneal fluid container. bacteria, and yeast is and are phoned to submitting significantly compromises the  Pericardial fluid performed routinely. Cultures location immediately upon sensitivity of organism  Synovial fluid Alternatively, collect 2 mL are incubated for 7 days. detection 24 hours per day. detection.  Bone marrow into a sterile screw capped container for Gram stain Filamentous fungal cultures Reports of no growth are sent preparation, then inoculate performed if ordered on at 24 and 72 hours, if aerobic and anaerobic blood requisition. Specimen will be applicable. Specimens culture bottles with 6 – 8 mL forwarded to RRPL for testing. submitted in blood culture each. bottles will have negative Specimens submitted in blood reports sent at 24 hours and 5 Transport at room culture bottles are incubated days. temperature, as soon as on an automated instrument possible and <24 hours. Do with continuous monitoring not freeze or refrigerate. until growth is detected, or

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING for 5 days if negative. Intravascular Catheter tip Disinfect surrounding skin Intravascular catheter tips are Identification and Submit intravascular catheter before removal. Aseptically processed by a semi- susceptibility results are tips only if there are signs of remove catheter and cut 1-2” quantitative roll method, and usually available 24 – 48 infection. of distal end into sterile incubated aerobically. hours after an organism is container. isolated. Tips from Foley catheters, Neonate or TPN, culture for chest tubes, and other drains If an intravascular line Malassezia spp. Will be Reports of no growth are sent are not accepted. infection is suspected, blood forwarded to RRPL for testing. at 24 and 96 hours, if cultures should be collected applicable. simultaneously. Collect 1 set CSF shunt and peritoneal from suspected intravascular dialysis catheter tips are line before removal, and flushed and vortexed with collect 1 set from a peripheral broth, which is then cultured venipuncture. Label sites of semi-quantitatively. collection. Cultures are incubated Transport at room aerobically for 4 days. temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. WOUNDS/SURGICAL Superficial wound swab Clean wound thoroughly Gram stain and culture for Identification and If aspiration of wound is before swabbing affected aerobic bacteria and yeast is susceptibility results are possible, this is preferred as it areas. Avoid touching performed routinely. Cultures usually available 24 – 48 will more accurately identify surrounding skin. are incubated for 48 hours. hours after an organism is pathogens and minimize isolated. isolation of colonizing Use liquid-based E-swab organisms. collection system (preferred) Reports of no growth are sent or M-40 Transystem swabs. at 24 and 48 hours, if Note: swabs from decubitus applicable. ulcers and pressure sores Transport at room cannot distinguish infecting temperature, as soon as pathogens from colonizing possible. If delay is organisms and are not anticipated, keep specimen at routinely processed. Please

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING 4°C. submit tissue or aspirate specimens.

Note: swabs are not appropriate for isolation of filamentous fungi Deep wound swab Clean wound thoroughly Gram stain and culture for Identification and If aspiration of wound or before swabbing affected aerobic and anaerobic susceptibility results are tissue biopsy is possible, this areas. Avoid touching bacteria, and yeast is usually available 24 – 48 will be preferred as it will surrounding skin. performed routinely. Cultures hours after an organism is more accurately identify are incubated for 72 hours. isolated. pathogens and minimize Use liquid-based E-swab isolation of colonizing collection system (preferred) Reports of no growth are sent organisms. or M-40 Transystem swabs. at 24 and 72 hours, if applicable. Note: swabs from decubitus Transport at room ulcers and pressure sores temperature, as soon as cannot distinguish infecting possible. If delay is pathogens from colonizing anticipated, keep specimen at organisms and are not 4°C. routinely processed. Please submit tissue or aspirate specimens.

Note: swabs are not appropriate for isolation of filamentous fungi Aspirate/fluid/drainage Clean and decontaminate Gram stain and culture for Identification and surface before collecting aerobic and anaerobic susceptibility results are specimen. Aspirate ≥1 mL of bacteria, and yeast is usually available 24 – 48 specimen using sterile performed routinely. Cultures hours after an organism is technique. are incubated for 72 hours. isolated.

Specimen can be submitted Filamentous fungal cultures Reports of no growth are sent to lab in a sterile screw performed if ordered on at 24 and 72 hours, if capped container, or in requisition. Specimen will be applicable. capped syringe with needle forwarded to RRPL for testing.

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING removed. If Actinomycosis is suspected, Transport at room please indicate under temperature, as soon as ‘Other/Special Requests’. possible. If delay is Cultures will be incubated for anticipated, keep specimen at 10 days. 4°C. Tissue/biopsy Collect using sterile Gram stain and culture for Positive gram stains are technique, into sterile screw aerobic and anaerobic considered CRITICAL RESULTS capped container. You may bacteria, and yeast is and are phoned to submitting add a small amount of sterile performed routinely. Cultures location immediately upon saline to keep tissue from are incubated for 7 days. detection 24 hours per day. drying out. Filamentous fungal cultures Identification and Transport at room performed if ordered on susceptibility results are temperature, as soon as requisition. Specimen will be usually available 24 – 48 possible. If delay is forwarded to RRPL for testing. hours after an organism is anticipated, keep specimen at isolated. 4°C. If Actinomycosis is suspected, please indicate under Reports of no growth are sent ‘Other/Special Requests’. at 24 hours and 7 days, if Cultures will be incubated for applicable. 10 days. Bone Chip Collect using sterile Gram stain and culture for Positive gram stains or technique, and place into aerobic and anaerobic detection of growth from sterile screw capped bacteria, and yeast is bone bank specimens are container. performed routinely. Cultures considered CRITICAL RESULTS are incubated for 7 days. and are phoned to submitting Bone bank products may be location immediately upon directly placed into tube of Bone bank products are detection 24 hours per day. Thioglycollate broth. incubated in submitted Thioglycollate broth for 7 Identification and Transport at room days. susceptibility results are temperature, as soon as usually available 24 – 48 possible. Do not freeze or hours after an organism is refrigerate. isolated.

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING

Reports of no growth are sent at 24 hours and 7 days, if applicable. Foreign body/implant Collect using sterile Gram stain and culture for Identification and For unusual specimens or technique, and place into aerobic and anaerobic susceptibility results are special requests, contact the sterile screw capped bacteria, and yeast is usually available 24 – 48 Microbiologist on-call before container. performed routinely. Cultures hours after an organism is submitting to laboratory. are incubated for 7 days. isolated. Transport at room temperature, as soon as Reports of no growth are sent possible. Do not freeze or at 24 hours and 7 days, if refrigerate. applicable. ARO SCREENS MRSA Nares: insert into nostril 2-3 Real Time Polymerase Chain Turnaround time ≤24 hours. Submit screens from nares, (Methicillin-Resistant cm and roll swab 5 times. Reaction (RT-PCR) testing groins, invasive devices in Staphylococcus aureus) Insert same swab into second performed routinely. Newly Newly identified colonization place ≥1 month (e.g. nostril and repeat. identified colonization is confirmation available at 72 tracheostomy, catheters), and confirmed with culture. hours. open wounds. Only 1 Groin: roll swab from top to requisition per patient is bottom of inguinal area 5 Inpatient wards and Infection needed for all MRSA times. Repeat using same Control notified immediately screening specimens. swab on opposite side. of new positive results. New positive cases are reported to Repeat specimens received Use liquid-based E-swab Public Health. <7 days after a negative collection system (preferred) screen or <30 days after a or M-40 Transystem swabs. positive screen will not be processed. Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. VRE Rectal swab: insert into Chromogenic screening Turnaround time 48 – 72 Repeat specimens received (Vancomycin-Resistant rectum 2-3 cm and rotate 5 cultures are performed hours. <7 days after a negative Enterococcus) times routinely screen or <30 days after a

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING Inpatient wards and Infection positive screen will not be Use liquid-based E-swab Control notified immediately processed. collection system (preferred) of new positive results. New or M-40 Transystem swabs. positive cases are reported to Public Health. Stool: collect 1g (~size of a hazelnut) of freshly passed stool into sterile container with no preservative (White top).

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. ESBL/CRE Rectal swab: insert into Chromogenic screening Turnaround time 48 – 72 Repeat specimens received (Extended Spectrum Beta- rectum 2-3 cm and rotate 5 cultures are performed hours. <7 days after a negative Lactamase / Carbapenemase times routinely screen or <30 days after a Resistant Enterobacteriaceae) Inpatient wards and Infection positive screen will not be Use liquid-based E-swab Control notified immediately processed. collection system (preferred) of new positive results. New or M-40 Transystem swabs. positive cases are reported to Public Health. Stool: collect 1g (~size of a hazelnut) of freshly passed stool into sterile container with no preservative (White top).

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. URINE

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING C&S only if positive urinalysis Midstream: hold labia apart Urinalysis screening Urinalysis results will be If submitting urine for or (female) or retract foreskin performed. reported within 24 hours. diagnosis of urinary tract C&S (male), begin voiding and infection (UTI), please order discard first several mL urine. If urinalysis is positive for If specimen is cultured, “C&S only if positive Without stopping flow of leukocyte esterase (LE) or organism identification is urinalysis”. A negative urine, collect 5 – 10mL nitrites, specimen will usually available 24 – 48 urinalysis has high specificity midstream specimen into undergo quantitative culture hours after it is isolated. to rule out UTI. If urinalysis is wide-mouth sterile container. for uropathogenic bacteria. positive for nitrites or Cultures are incubated 24-48 Reports of no growth are sent leukocyte esterase culture Straight Catheter: thoroughly hours. at 24 hours, if applicable. will be performed routinely. clean urethral area with mild soap and water. Aseptically If urinalysis is negative, this Urine from pregnant women insert catheter into bladder. predicts the absence of a or individuals undergoing GU Discard initial several mL urinary tract infection. surgery/manipulation should urine, collect 5 – 10 mL. Specimen will not be order a regular urine C&S to cultured. ensure appropriate Indwelling Catheter: disinfect processing. catheter collection port with If C&S is ordered, urine will be 70% alcohol. Use needle and cultured without a urinalysis Urine collected or received in syringe to aseptically collect 5 performed. non-sterile containers is – 10 mL of urine. unacceptable for culture. Catheter bags are not suitable Supra-pubic aspirate or for culture. Specimens Cystoscopy collection: collect collected in pediatric urine 5 – 10 mL using aseptic bags should be aseptically technique. transferred into sterile container and tube containing Transfer urine into tube Boric acid preservative. containing Boric acid preservative and fill to Repeat specimens received indicator line. Sterile within 3 days will not be containers may be submitted processed. if processed <2 hours after collection.

If ordering “C&S only if

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING positive urinalysis”, submit urine in both sterile container and preservative.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. STOOL Enteric Bacterial Panel- PCR Collect freshly passed stool Real Time Polymerase Chain Turnaround time ≤24 hours Repeat specimens received into clean, dry container. Reaction (RT-PCR) testing within 5 days will not be Transfer to enteric transport performed routinely for the All positive PCR results are processed. media container (Cary Blair). detection of Salmonella sp., sent for confirmation at RRPL. Fill to line marked on Shigella sp., Camplybacter sp., Stool cultures are not container. There should be no and E. coli shiga- toxin Positive Reports are sent to performed on patients who contaminating material. E.g. producing (STEC). Public Health. have been in hospital >3 days. urine, tissue paper. Consider C.difficile testing in hospitalized patients with Transport at room new onset diarrhea. temperature, as soon as possible. If delay is Susceptibility testing is not anticipated, keep specimen at routinely performed on 4°C. enteric pathogens from patients without known risk factors. If antibiotic therapy is indicated, please contact the Microbiology lab at 766-4481. Clostridium difficile Collect 1g (~size of a All stools are initially tested Turnaround time 24 hours. The rate of asymptomatic hazelnut) of freshly passed for GDH and Toxin A/B using carriage of C.difficile in young stool into sterile container an enzyme immunoassay children is high (up to 50% <3 with no preservative. There (EIA). Specimens with years; up to 74% <1 year). should be no contaminating concordant results (i.e. Specimens from children <1 material. E.g. urine, tissue GDH+/Toxin+ or GDH-/Toxin-) year will not be processed. paper. are reported immediately. Positive results in children <3 Specimens with discordant years should be interpreted

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING Transport at room results (i.e. GDH+/Toxin-) with caution. temperature, as soon as undergo PCR testing, and possible. If delay is results of the PCR assay are Repeat specimens from anticipated, keep specimen at reported. patients with previously 4°C. positive C.difficile <2 weeks will not be tested.

Formed stools are not routinely processed. If patient is suspected of C.difficile- related ileus, please clearly indicate on requisition or contact the Microbiology lab at 766-4481. GENITAL TRACT Gonorrhea Cervical: use a speculum Culture for Neisseria Turnaround time 24 – 72 Culture to diagnose infection without lubricant to visualize gonorrhoeae performed hours. with N.gonorrhoeae from the the cervix. Wipe off any routinely. Gram stains are genital tract should generally mucus or secretions with first prepared for conjunctival and Positive cultures from be accompanied by swab and discard. Using male urethral specimens. conjunctival specimens or specimens sent for molecular second swab, insert into the Cultures are incubated for 72 from patients <13 years of detection of N.gonorrhoeae os and rotate. Do not touch hours. age are considered CRITICAL and C.trachomatis. Molecular the sides of the vaginal canal RESULTS and are phoned to detection has superior with the swab. submitting location sensitivity to culture and is immediately upon detection performed at the Urethral: insert small urethro- 24 hours per day. Saskatchewan Disease genital swab 2 – 4 cm into Control Laboratory. urethral lumen, rotate swab, Positive reports are sent to and leave in place for at least Public Health. 2 seconds.

Other acceptable specimens include: rectal, pharyngeal, conjunctival

Use liquid-based E-swab

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING collection system (preferred) or M-40 Transystem swabs.

Transport at room temperature, as soon as possible. Do not freeze or refrigerate. Group B Streptococcus (GBS) Collect a swab specimen of Specimen is screened for Turnaround time 24 – 48 Susceptibility testing is not screen the vaginal introitus and presence of Streptococcus hours. routinely performed as anorectum. agalactiae (Group B organism is universally Streptococcus; GBS). susceptible to first line Use liquid-based E-swab treatment/prophylaxis with collection system (preferred) beta-lactam antibiotics. If or M-40 Transystem swabs. susceptibility testing is required, please clearly Transport at room indicate on requisition or temperature, as soon as contact Microbiology possible. If delay is Laboratory at 766-4481. anticipated, keep specimen at 4°C. Bacterial Vaginosis & Candida Using a speculum without Direct examination using Nugent score (or N score) is Nugent score (or N score) is lubricant, swab vaginal microscopy is performed reported with interpretation not validated for the mucosa high in the vaginal routinely for bacterial vaginosis diagnosis of bacterial canal. diagnosis. Presence and vaginosis in pre-pubescent or quantity of yeast is reported. post-menopausal women. Use liquid-based E-swab collection system (preferred) Turnaround time 24 hours. or M-40 Transystem swabs.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Vaginal culture Using a speculum without Gram stain and culture for Identification and Vaginal cultures are not lubricant, swab vaginal Streptococcus pyogenes susceptibility results are indicated in the investigation

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING mucosa high in the vaginal (Group A Streptococcus, usually available 24 – 48 of vaginitis in estrogenized canal or at visibly affected GAS), Staphylococcus aureus, hours after an organism is women. Please send site. and yeast are performed isolated. specimens for Bacterial routinely. Vaginosis & Yeast, Use liquid-based E-swab Reports of no growth are sent Trichomonas and/or collection system (preferred) Specimens from children <13 at 24 and 48 hours, if Gonorrhea/Chlamydia or M-40 Transystem swabs. years will also be screened for applicable. (performed at SDCL). common enteric and Transport at room respiratory pathogens. Children <13 years can temperature, as soon as occasionally experience possible. If delay is Cultures are incubated for 48 vaginal infections due to anticipated, keep specimen at hours. Salmonella spp., Shigella spp., 4°C. S.pneumoniae, H.influenzae, and N.meningitidis Upper Genital Tract Collect specimens using Gram stain and culture for Identification and Aspirate or biopsy specimens sterile technique, avoiding aerobic and anaerobic susceptibility results are will yield more accurate lower genital tract bacteria, N.gonorrhoeae, and usually available 24 – 48 results compared with swabs. contamination. yeast are performed hours after an organism is routinely. Swabs and isolated. Place biopsies into sterile aspirates are incubated 72 screw capped container. You hours; biopsy specimens are Reports of no growth are sent may add a small amount of incubated up to 7 days. at 24 hours and at end of sterile saline to keep from incubation, if applicable. drying out. If Actinomycosis is suspected, please indicate under Aspirates can be submitted in ‘Other/Special Requests’. a sterile screw capped Cultures will be incubated for container, or in capped 10 days. syringe with needle removed.

If using a swab, liquid-based E-swab collection system (preferred) or M-40 Transystem swabs are acceptable.

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. External Genitalia Use liquid-based E-swab Gram stain and culture for Identification and Note: swabs are not collection system (preferred) aerobic bacteria and yeast are susceptibility results are appropriate for isolation of or M-40 Transystem swabs. performed routinely. Cultures usually available 24 – 48 filamentous fungi are incubated for 48 hours. hours after an organism is Transport at room isolated. temperature, as soon as possible. If delay is Reports of no growth are sent anticipated, keep specimen at at 24 and 48 hours, if 4°C. applicable. RESPIRATORY TRACT Nasopharyngeal Influenza A/B Using flocked swab, insert Nucleic acid amplification test Results reported as Positive This testing is routinely into nostril straight back (not (NAAT, or PCR) detecting or Negative available only for inpatients upwards) and into the Influenza A, Influenza B. during influenza season (as nasopharynx. The distance Routine testing will be determined by Public Health). from the patient’s nose to performed within 24 hours of Requests from outpatients or their ear gives an estimate of receipt in laboratory. STAT outside of influenza season the distance the swab should testing is available within 4 will be forwarded to the Roy be inserted. Leave in place for hours. Rowmanow Provincial a few seconds, then gently Laboratory (RRPL) for full rotate swab to collect Positive results are sent to NAAT respiratory panel epithelial cells and withdraw. Public Health. testing.

Repeating procedure for the All specimens tested at RGH second nostril will improve Microbiology will pathogen detection. subsequently be forwarded to RRPL for full NAAT respiratory Place swab in Universal panel testing. Transport Media (UTM). Break the shaft off at the breakpoint and close vial tightly.

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING

Transport at room temperature, as soon as possible. Pediatric Auger Suction Using a syringe and tubing, Gram stain and culture for Identification and push a small amount of sterile aerobic bacteria and yeast are susceptibility results are saline into the nose, then performed routinely. Cultures usually available 24 – 48 apply gentle suction to collect are incubated for 48 hours. hours after an organism is aspirate. isolated.

Submit specimen in sterile, Reports of no growth are sent screw-capped container. at 24 and 48 hours, if Small volumes may be left in applicable. tubing, with tubing submitted in sterile container.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Sinus Aspirate bacterial C&S Collect invasive specimen at Gram stain and culture for Identification and Nasal swabs, nasal secretions, time of nasal endoscopy or by aerobic and anaerobic susceptibility results are or swabs of secretions will not needle puncture and bacteria and yeast are usually available 24 – 48 be cultured. aspiration of sinuses. performed routinely. Cultures hours after an organism is are incubated for 72 hours. isolated. Submit specimen in sterile, screw-capped container. Filamentous fungal cultures Reports of no growth are sent performed if ordered on at 24 and 72 hours, if Transport at room requisition. Specimen will be applicable. temperature, as soon as forwarded to RRPL for testing. possible. If delay is anticipated, keep specimen at 4°C. Nasal Staphylococcus aureus Insert into nostril 2-3 cm and Culture for Staphylococcus Turnaround time 24 hours. carriage screen roll swab 5 times. Insert same aureus is performed Screening for MRSA reported

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING swab into second nostril and routinely. If positive, isolates at 48 hours. repeat. are screened for methicillin- resistance (MRSA). Use liquid-based E-swab Cultures are incubated for 24 collection system (preferred) hours. or M-40 Transystem swabs.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Mouth swabs (buccal mucosa, Scrape area with tongue Gram smear is performed. Turnaround time 24 hours. If Candida susceptibility tongue, or oropharynx) depressor to remove plaque, testing is required please then swab to collect clearly indicate on requisition specimen or contact Microbiology Laboratory at 766-4481. Use liquid-based E-swab collection system (preferred) or M-40 Transystem swabs.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Throat swab – GASS Depress tongue gently with a Specimen is cultured on Turnaround time 24-48 hours. Repeat specimens received tongue depressor. Sample the Chromogenic media for within a 24 hour period are posterior pharynx, tonsils, Streptococcus pyogenes Reports of no/non-significant not processed. and inflamed areas with (Group A Streptococcus, growth are sent at 24 and 48 swab. Avoid touching the oral GASS) is performed routinely. hours, if applicable. Susceptibility testing is not mucosa or tongue with the routinely performed as swab. organism is universally susceptible to first line Use liquid-based E-swab treatment with beta-lactam collection system (preferred) antibiotics. If susceptibility

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING or M-40 Transystem swabs. testing is required, please clearly indicate on requisition Transport at room or contact Microbiology temperature, as soon as Laboratory at 766-4481. possible. If delay is anticipated, keep specimen at 4°C. Throat swab – other Depress tongue gently with a Culture for aerobic bacteria is Identification and If patient has cystic fibrosis, tongue depressor. Sample the performed routinely. Cultures susceptibility results are indicate clearly on requisition posterior pharynx, tonsils, are incubated for 48 hours. usually available 24 – 48 Final report is issued after 5 and inflamed areas with hours after an organism is days. swab. Avoid touching the oral isolated. mucosa or tongue with the swab. Reports of no/non-significant growth are sent at 24 and 48 Use liquid-based E-swab hours, if applicable. collection system (preferred) or M-40 Transystem swabs.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Sputum Have patient rinse mouth or Gram stain and culture for Identification and Sputum specimens are gargle with water before aerobic bacteria and yeast is susceptibility results are screened to assess the specimen collection to performed routinely. Cultures usually available 24 – 48 amount of oropharyngeal remove contaminating are incubated for 48 hours. hours after an organism is contamination before material and organisms. isolated. culturing. Specimens grossly Filamentous fungal cultures contaminated by the upper Patient must cough deeply so performed if ordered on Reports of no/non-significant respiratory tract, including that exudative material is requisition. Specimen is sent growth are sent at 24 and 48 salivary specimens, are not obtained from the lung; saliva to RRPL for testing. hours, if applicable. cultured. and nasal drainage are inadequate specimens. Deep Repeat specimens for routine coughing may be induced by culture received within a 3

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING inhalation of an aerosol of day period are not routinely warm, hypertonic (5-15%) processed, unless originating saline (label as “Induced” if from an intensive care unit. collected this way).

Submit sample volume of 5 – 10mL in sterile, screw-capped container.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Endotracheal tube (ETT) Collect sputum samples from Gram stain and culture for Identification and suction patients with tracheostomies aerobic bacteria and yeast is susceptibility results are and endotracheal tubes using performed routinely. Cultures usually available 24 – 48 a suction device and a sterile are incubated for 48 hours. hours after an organism is sputum trap. isolated. Filamentous fungal cultures Transport at room performed if ordered on Reports of no growth are sent temperature, as soon as requisition. Specimen is sent at 24 and 48 hours, if possible. If delay is to RRPL for testing applicable. anticipated, keep specimen at 4°C. Bronchial wash During bronchoscopy, wash Gram stain and quantitative Identification and Bronchial washings submitted bronchus with sterile, normal culture for aerobic bacteria susceptibility results are from the same patient, from saline (or other physiologic and yeast is performed usually available 24 – 48 the same procedure are solution). Collect washing routinely. Cultures are hours after an organism is pooled for routine fluid into sterile screw-capped incubated for 48 hours. isolated. microbiologic processing. container. Filamentous fungal cultures Reports of no growth are sent Transport at room performed if ordered on at 24 and 48 hours, if temperature, as soon as requisition. Specimen is sent applicable. possible. If delay is to RRPL for testing. anticipated, keep specimen at

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING 4°C. Brochoalveolar lavage During bronchoscopy, lavage Gram stain and quantitative Identification and distal airways and alveoli with culture for aerobic bacteria susceptibility results are sterile, normal saline (or and yeast is performed usually available 24 – 48 other physiologic solution). routinely. Cultures are hours after an organism is Collect lavage fluid into sterile incubated for 48 hours. isolated. screw-capped container. Filamentous fungal cultures Reports of no growth are sent Transport at room performed if ordered on at 24 and 48 hours, if temperature, as soon as requisition. Specimen is sent applicable. possible. If delay is to RRPL for testing. anticipated, keep specimen at 4°C. Protected Brush Specimen During bronchoscopy, use Gram stain and quantitative Identification and Protected Brush Specimens protected brush to directly culture for aerobic bacteria susceptibility results are have the greatest yield sample respiratory tract. and yeast is performed usually available 24 – 48 isolating pathogens, Place protected brush- routinely. Cultures are hours after an organism is compared to other invasively- catheter into sterile screw- incubated for 48 hours. isolated. collected respiratory capped container. specimens (i.e. bronchial Filamentous fungal cultures Reports of no growth are sent wash, bronchoalveolar Transport at room performed if ordered on at 24 and 48 hours, if lavage) temperature, as soon as requisition. Specimen is sent applicable. possible. If delay is to RRPL for testing. anticipated, keep specimen at 4°C. Lung Biopsy Collect using sterile technique Gram stain and culture for Positive gram stains are (transthoracic) or minimize aerobic and anaerobic considered CRITICAL RESULTS contamination from upper bacteria, and yeast is and are phoned to submitting respiratory tract performed routinely. Cultures location immediately upon (transbronchial), into sterile are incubated for 7 days. detection 24 hours per day. screw capped container. You may add a small amount of Filamentous fungal cultures Identification and sterile saline to keep tissue performed if ordered on susceptibility results are from drying out. requisition. Specimen is sent usually available 24 – 48 to RRPL for testing. hours after an organism is Transport at room isolated.

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING temperature, as soon as If Actinomycosis is suspected, possible. If delay is please indicate under Reports of no growth are sent anticipated, keep specimen at ‘Other/Special Requests’. at 24 hours and 7 days, if 4°C. Cultures will be incubated for applicable. 10 days. EARS/EYES Eyes – conjunctiva Cleanse skin around eye. Gram stain and culture for Identification and Swabs from both the infected Make-up or ointment should aerobic bacteria and yeast is susceptibility results are and uninfected eye need to be removed with sterile performed routinely. Cultures usually available 24 – 48 be submitted. Clearly indicate cotton and saline. are incubated for 48 hours. hours after an organism is which eye is affected. isolated. Swab the conjunctiva around Culture for Neisseria the inner canthus or cul-de- gonorrhoeae will be Reports of no growth are sent sac. Lower the bottom eyelid performed if ordered on at 24 hours and 48 hours, if and apply the swab tip to the requisition. Specimens from applicable. lower bulbar conjunctiva for infants <2 months will about 5 seconds, without automatically be cultured for touching the eyelid margin. N.gonorrhoeae. Cultures are incubated for 72 hours. Use liquid-based E-swab collection system (preferred) or M-40 Transystem swabs.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Eyes – invasive Collect vitreous/aqueous fluid Gram stain and culture for Identification and If infection with amoeba and corneal specimens using aerobic and anaerobic susceptibility results are suspected, please consult sterile technique. bacteria. usually available 24 – 48 with the Medical hours after an organism is Microbiologist on-call. Specimen can be submitted Fluorescent stain and culture isolated. to lab in a sterile container, or for yeast and filamentous in capped syringe with needle fungi is performed routinely Reports of no growth are sent removed. Eye Packs are at RRPL and inoculate media at 24 hours and 72 hours, if

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING available for ophthalmology will be forwarded after applicable. to directly inoculate media at Bacterial culture is performed site of collection. at RGH.

Transport at room Bacterial cultures are temperature, as soon as incubated for 7 days. possible. If delay is anticipated, keep specimen at 4°C. Ears – external canal Cleanse external canal with Gram stain and culture for Identification and Samples from the external ear mild detergent prior to aerobic bacteria and yeast is susceptibility results are are appropriate for the swabbing affected area, performed routinely. Cultures usually available 24 – 48 diagnosis of otitis externa touching only the discharge are incubated for 48 hours. hours after an organism is only, and not recommended from deeper areas or active isolated. in the evaluation of otitis margin. media. Reports of no growth are sent Use liquid-based E-swab at 24 hours and 48 hours, if collection system (preferred) applicable. or M-40 Transystem swabs.

Transport at room temperature, as soon as possible. If delay is anticipated, keep specimen at 4°C. Ears – invasive Collect surgical or Gram stain and culture for Identification and tympanocentesis specimens aerobic and anaerobic susceptibility results are into sterile container. bacteria and yeast is usually available 24 – 48 performed routinely. Cultures hours after an organism is Transport at room are incubated for 72 hours. isolated. temperature, as soon as possible. If delay is Reports of no growth are sent anticipated, keep specimen at at 24 hours and 72 hours, if 4°C. applicable. OTHER/SPECIAL REQUESTS Mycobacterium tuberculosis Acceptable specimens include Nucleic acid amplification test Results will be reported as Testing is routinely available

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING (TB) PCR spontaneous or induced (NAAT, or PCR) performed Positive or Negative for for inpatient settings only. sputum, bronchoalveolar using Cepheid GeneXpert detection of M.tuberculosis. lavage, and bronchial wash. MTB/RIF® PCR testing is indicated on Routine testing will be one specimen per diagnostic Collect specimens as performed within 24 hours of evaluation, estimated by once described above; minimum receipt in laboratory. STAT per 6 months. Additional volume required 4 mL. testing is available within 4 specimens will be forwarded hours. to the Roy Rowmanow Transport at room Provincial Laboratory (RRPL) temperature, as soon as Positive results are sent to for acid fast bacilli (AFB) possible. If delay is Public Health and microscopy and anticipated, keep specimen at Saskatchewan TB Control. mycobacterial culture. 4°C. All specimens undergoing TB PCR testing will subsequently be forwarded to RRPL for AFB microscopy and mycobacterial culture.

This assay can be used to support discontinuation of airborne isolation precautions in hospitalized patients, as its sensitivity is comparable to 3 sputum smears. However, this assay does not replace culture-based diagnostics. Mycobacterial culture of 3 specimens is required to rule out the diagnosis of active TB. Cryptococcal Antigen CSF: collect using sterile Cryptococcal Antigen lateral Results will be reported as CSF specimens requesting technique, into sterile screw flow assay (CrAg LFA) is Positive or Negative for Cryptococcal Antigen testing capped container. Minimum performed. detection of Cryptococcal will also be forwarded to volume ≥2 mL antigen. RRPL for fungal cultures. Positive specimens will Transport at room undergo semi-quantitative Positive specimens will have CSF specimens requesting

Last revised June 2019 TEST ON REQUISITION SPECIMEN COLLECTION & TESTING PERFORMED TURNAROUND TIME & NOTES TRANSPORT REPORTING temperature, as soon as titration. titer reported. fungal culture will also have possible and <2 hours. Do not Cryptococcal Antigen testing freeze or refrigerate. performed first, then sent to RRPL for fungal cultures. Testing can also be performed on serum collected in SST. Transport at room temperature. Pneumocystis jirovecii Acceptable specimens include PCR testing is performed. Turnaround time 24 – 72 Repeat testing of sputa for (previously Pneumocystic spontaneous or induced hours Pneumocystis jirovecii does carinii pneumonia or PCP) sputum, bronchoalveolar All positive results are to be not significantly increase lavage, and bronchial wash. repeated and then examined diagnostic yield and delays under a fluorescent definitive diagnosis. In HIV Collect specimens as Microscopy. positive patients, a described above; minimum bronchoalveolar lavage is volume required 1 mL. indicated after the first negative sputum. In HIV Transport at room negative patients, sputa have temperature, as soon as very low sensitivity and possible. If delay is bronchoalveolar lavage anticipated, keep specimen at should be considered as a 4°C. primary diagnostic specimen. Person Under Investigation of Level 4 Infection, including DO NOT COLLECT ROUTINE SPECIMENS Ebola Virus Disease or novel CONTACT MICROBIOLOGIST ON-CALL THROUGH HOSPITAL SWITCHBOARD emerging pathogens

Last revised June 2019

TESTING PROVIDED THROUGH THE SASKATCHEWAN DISEASE CONTROL LABORATORY (SDCL)

Refer to Saskatchewan Disease Control on-line compendium http://sdcl-testviewer.ehealthsask.ca/

Mycobacterium culture/AFB culture Ab, e Ag Schistosoma urine exam Bedbugs identification Hepatitis B viral load Stool viral food borne illness outbreak BK virus Hepatitis C Antibody Syphilis IgG screen Mycoplasma/Ureaplasma genital culture Hepatitis C viral load Tick identification Blastomyces serology/Fungal Serology Hepatitis C genotyping ToRC screen-serology (IgM and IgG) for Borrelia burgdorferi serology (IgG/IgM) HSV type 1 and 2 serology (IgG) Toxoplasma, Rubella and CMV Borrelia burgdorferi PCR HSV PCR Toxoplasma serology (IgG/IgM) Chlamydophyla pneumonia serology (IgG/IgM) H pylori serology (IgG) Toxocariasis serology EBV viral load HIV Ag/Ab combo, HIV viral load Varicella zoster serology (IgG/M) Echinococcosis serology/Parasitology serology Rapid HIV test (chemistry) VDRL- CSF only Respiratory Screen by NAAT Lesion screen- HSV or VZV Stool- H. pylori Parvovirus serology (IgG/IgM) Malaria screen Stool- parasites and ID Filariasis serology/parasitology serology Measles IgG/M Stool- viral cultures Fleas- ectoparasite identification Norovirus NAAT CSF- viral culture Rash panel- serology Mumps IgG/M Tissue biopsy- viral cutlure Voriconazole level Mycology testing Trichomonas NAAT Food borne illness outbreak-food samples Rickettsial serology/Q fever Bacterial (S.pneumoniae, H. influenza, N. Gonorrhea and Chlamydia/ Trichomonas STD Rabies meningitides) PCR on CSF panel NAAT Legionella culture and Urine antigen West nile virus serology (IgM) Hantavirus- serology Rubella IgG/M West nile virus CSF- PCR Hepatitis A IgM/IgG Sacchromyces antibody Yersinia serology Hepatitis B surface Ab, surface Ag, core Ab, e Schistosoma serology (IgG)

Last revised June 2019

Patient Instructions for Sputum Specimen Collection A sputum specimen collected first thing in the morning is the best specimen. At least 5mL (1 teaspoon) of specimen is required. 1. Label the specimen container with: i. The patient’s full name (last and first) ii. The date of collection iii. The patient’s Provincial Health Number 2. Gargle and rinse your mouth with water. This helps to eliminate accumulated cells and normal bacteria that may interfere with your test results. 3. Inhale deeply several times and exhale with an explosive cough. This should produce mucus from the lungs. Saliva (spit) from the mouth is not an acceptable specimen. 4. Cough specimen into the specimen container. 5. Replace lid and tighten securely so sample will not leak. 6. Transport the specimen with the requisition to the laboratory or collection site as soon as possible. If there is a delay of more than 2 hours in transporting, the specimen should be refrigerated.

Notes:  An early morning specimen, collected before eating, drinking, or brushing teeth, is the preferred sample.  The specimen should be collected before starting antibiotics.  Saliva (spit) has a clear color. This is not a suitable specimen and will not be processed by the laboratory.  Specimen MUST be labeled with a first and last name, and a Provincial Health Number (HSN). If you do not have an HSN, please label specimen with patient’s first and last name, and date of birth.  Some tests require more than one specimen. If multiple specimens are requested, they must be collected first thing in the morning for 3 consecutive days.

LABMicOP7204.A.3 Sputum COLLECTION.doc Print date: 18 May 2016

Patient Instructions for Stool Specimen Collection

- Prior to collecting the samples (at least 48 hours), the patient should not take antacids (Rolaids, Tums), oily laxatives, or antidiarrheal medication (Kaopetate). - Radiology examinations using bismuth, or barium should also be avoided if ova & parasite testing is requested. - Collect one specimen for each test requested unless otherwise instructed. Collection of specimens from multiple days is usually not required.

1. Label the specimen container with: i. The patient’s full name (last and first) ii. The date of collection iii. The patient’s Provincial Health Number

2. Wash hands before beginning collection and after collection.

3. Urinate prior to stool collection, to avoid contaminating the specimen.

4. Pass stool directly into a clean, dry, wide mouth container, such as a plastic or Styrofoam cup or plate, or other plastic container, or plastic bag, or clean diaper.

5. Carefully open the specimen container and place on a table or counter. If it contains a fluid, do not discard it. This fluid is a preservative for the sample. These fluids are poisonous and must be kept away from children. If more than 1 specimen vial is required, fill only one vial at a time and replace the lid onto the same vial it came from.

6. Using the spoon attached to the lid of the specimen vial, add spoonfuls of stool to each vial so that the liquid reaches the “fill line” located on the label of the vial. If the vial does not have a “fill line”, then only add enough specimen to half fill the container. If the specimen is runny it may be poured directly into the specimen vial. It is important to take areas of the specimen which appear bloody, slimy, or watery. Hard stools are not acceptable for most testing.

7. Replace the lid and tighten securely so samples will not leak, and mix vial well. Proceed to the next container if more than 1 vial is requested.

8. Transport the specimen with the requisition to the laboratory or collection site as soon as possible. If there is a delay of more than 2 hours in transporting, the specimens must be refrigerated.

LABMicOP7204.A.4.2 Stool Collection Effective date: 2 June 2017

Mid-stream Urine Collection Instructions for ADULT Patients

Make sure the label has the correct information

Jo Smith

PHN: 123 456 789 June 5 Use the sterile container  9:50   provided to you for collection. Open the container. Set the lid • Full name (first and last) aside. Do not touch the inside of Wash hands with • Date and time of collection the rim of the container. soap and warm water • Personal Health Care Number for 20 seconds.

 Urinate a small amount of urine into the toilet. This washes FEMALES away some of the contaminating MALES bacteria that normally reside in Sit as far back on the toilet the urethra. Continue urinating. Retract the foreskin, exposing as possible and spread legs. Midway through, move the the head of the penis Spread and hold the labia apart container into the stream of urine until the end of urine collection. and fill 1/2 to 2/3 full.

   If specimen was collected, on site, give to Clinic staff.

If specimen was collected at home, take the specimen with the requisition to the laboratory or collection site as soon as possible.

Replace lid and Wash hands with If there is a delay of more than 2 hours in tighten firmly. soap and warm water transporting, refrigerate the specimen. for 20 seconds

MMS 7820-16-ddh-images supplied by Medical Media and Istock CEAC 1256 Approved January 2017 Mid-stream Urine Collection Instructions for PEDIATRIC Patients

Make sure the cup label has the correct information

Jo Smith

PHN: 123 456 789 June 5 Use the sterile screw-capped  9:50   container provided to you for collection. Open the container. • Full name (first and last) Wash hands with Set the lid aside. Do not touch • Date and time of collection soap and warm water the inside of the rim of the • Personal Health Care Number for 20 seconds. container. 

FEMALES As the child begins to urinate, MALES Sit as far back on the toilet as allow a small amount of urine Gently retract the foreskin possible and spread legs or have into the toilet. This washes and wipe the tip of the penis child squat on the toilet seat. Wipe away some of the contaminating with a soapy paper towel. the genitals with a soapy paper towel. bacteria that normally reside in Hold the foreskin back until Spread and hold the labia apart until the urethra. Move the container the end of urine collection. the end of urine collection. into the stream of urine and fill 1/2 to 2/3 full.

   If specimen was collected, on site, give to Clinic staff.

If specimen was collected at home, take the specimen with the requisition to the laboratory or collection site as soon as possible. Wash hands with Replace lid and If there is a delay of more than 2 hours in soap and warm water tighten firmly. transporting, refrigerate the specimen. for 20 seconds.

MMS 7820-16-ddh - Images supplied by Medical Media and istock CEAC 1307 Approved January 2017

Table 1: Criteria for Rejection of Microbiology Specimens Specimen type Rule Exception Bronchial Washings - Washings are not processed for C&S, but are - C&S is done on washings processed for AFB and Fungus from ICU patients, or Dr. - Mini BAL will be processed only for tests Jones, Dr. Dewar patients. requested

MRSA Screens - Axilla swabs are not processd. - Duplicate specimens for MRSA screening from the same patient within a 5 day period should be approved before they are processed.

Sputum C&S - Sputum specimens for C&S from the same - ICU patients can have one patient within a 3 day period are not processed. sputum specimen for C&S daily.

Stool PCR - Stool specimens for PCR from the same - Additional testing may be patient within a 5 day period are not processed. required if clinical conditions - Stool specimens for PCR on patients after 3 indicate, but must be approved by days hospitalization are not processed. the Microbiologist.

Stool C. diff Toxin - More than two stool specimens for C. diff Toxin from the same patient within a 5 day period, if the first one is positive, are not processed. - Formed stool specimens are not processed.

Throat Grp A Screen - Throat swabs from the same patient within a - If susceptibility testing is 24 hour period are not processed. required culture will be performed on the repeat specimen.

Tips - All Central Venous Line tips are processed - All “other” tips must be approved before processing.

Urine C&S - Duplicate urine specimens on the same patient - Check previous culture result in a 3 day period will not be processed. before canceling.

VRE Screens - Only VRE screens from rectal swabs, or stool - All “other” sites must be will be processed. * Rectal swabs must be approved by Microbiologist stool stained to be acceptable. before processing.

LABMicOP7204.T.3.1 Criteria for Rejection of Microbiology Specimens Page 1 of 2 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 12 June 2017

Table 1: Criteria for Rejection of Microbiology Specimens

Specimen Problem Rule Exception Inappropriate - Saliva, breast milk, 24 hour urine specimens, (**Placenta tissue collected surgically specimens foley catheter tips, vomitus, gastric aspirate, is acceptable for culture.) and placenta swabs are all inappropriate specimens.

Swabs of decubitis - Specimens from these sites are of limited value - Swabs of rectal abscesses are ulcers, such as coccyx, as they are colonized by organisms which will acceptable for culture. sacral, or ischial rectal. grow on culture but may not be the infecting - A biopsy is the preferred agent. specimen.

Multiple Specimens - Multiple specimens from the same patient and - Exceptions: AFB requests, blood the same source collected on the same day will cultures, and specimens collected not be processed. (eg. Urine, stool, sputum) by invasive procedures. - If multiple specimens from similar sources (swabs) are received, consult Microbiologist.

LABMicOP7204.T.3.1 Criteria for Rejection of Microbiology Specimens Page 2 of 2 Laboratory Services Regina Qu'Appelle Health Region Effective Date: 12 June 2017

Subject/Title: LABMicOP7021 Collection of Blood Cultures Last Approved Time: Malejczyk, Kathy(Medical Microbiologist) (04/16/2019) Revision: 5.10 Approving Authority:Medical Microbiologist Contact for Interpretation: Microbiology Phone: (306) 766-4481 Current Version on Print Date

Purpose This procedure provides instruction for collecting blood culture specimens. Blood cultures are critical in the diagnosis of bacteraemias and fungaemias, which are life threatening conditions. Strict adherence to the accepted methods for collection of blood cultures ie. timing, volumes, and numbers, are essential in the detection of pathogenic organisms. Failure to recognize bacteraemia and fungaemia leads to delay or lack of treatment. Also of importance is the use of aseptic technique in blood culture collection. Failure to do so can result in a contaminated specimen, ie. false positive culture, resulting in the inappropriate use of antibiotics.

Collection and Timing 1. Collect blood aseptically by venipuncture. 2. Blood culture bottles taken during a single venipuncture or vascular access point defines a “set” of blood cultures. 3. Optimal collection of blood cultures is as follows: Bottles / Set Volume / Number Timing Bottle of sets Neonate – Pediatric blood culture will be 1 pediatric 1 – 2 mL 1 1 yr. drawn as a single set (1 >1 yr.- 4 yrs. 1 pediatric Collect 1 venipuncture) unless approx.. specifically ordered as 2 sets. 1mL of blood per Pediatric blood cultures will 5 – 8 yrs 2 pediatric year of 1 not include anaerobic bottles age, unless anaerobic culture is divided specifically ordered. into multiple 1 pediatric + 9 – 15 yrs bottles if 1 1 aerobic applicable Adult 1 aerobic + 8 – 10 mL 2 (>15 yrs) 1 anaerobic 8 – 10 mL

Reagents Supplies Blood Culture vials BD Push Button Blood Collection Set, alcohol swabs, cotton balls, Band-Aid, tourniquet, vacutainer holder, butterfly needle

LABMicOP7021 Collection of Blood Cultures Laboratory Services Regina QuAppelle Health Region

Page 1 of 3 Laboratory Services Regina Qu'Appelle Health Region LABMicOP7021.5.1 Collection of Blood Cultures~~000010019

Special Safety Precautions Universal body substance precautions. Refer to the Safety Manual for general safety requirements.

Procedure STEP ACTION 1 Place required equipment within easy reach 2 Remove flip caps from blood culture vials and clean vial tops with alcohol swab; do not use iodine or disinfectants to swab rubber caps on vials. 3 Select vein and prepare arm using a double application of 70% alcohol starting at the centre of the site and swabbing concentrically. 4 Allow the venipuncture site to dry. Do not touch the venipuncture site after preparation or prior to phlebotomy. Screw a vacutainer holder onto the needle farthest from the butterfly. 5 Remove sleeve from needle closest to butterfly. 6 Perform venipuncture 7 Hold the butterfly in place while filling the vials. If both hands are being used the butterfly can be taped to the arm. 8 Insert multi sample needle into blood culture bottle. The multi sample needle must be held in place in the vial. 9 Remove the needle from the aerobic vial and insert the needle into the anaerobic vial. Remember to hold the needle in place. 10 Fill vials with an adequate amount of blood.. 11 Proceed to collect required vacutainer tubes following the regular venipuncture procedure. 12 Release tourniquet and remove needle from vial. 13 Cover puncture site with gauze/cotton, then activate the safety device. 14 Remove needle from arm and apply pressure to cotton swab on venipuncture site. 15 Place butterfly needle unit into needle disposal container by placing sharp edge of both needles together and insert sharp edges first. 16 Time, date and initial requisition. Record the site of the venipuncture in the LIS. 17 Locate bar code on side of bottle. DO NOT mark it or cover it in any way. 18 Label vials with LIS sticker or write the patient’s name & MRN on the vials. 19 Blood cultures should not be refrigerated, but delivered to the Microbiology laboratory immediately. If collected at Pasqua, leave bottles at room temperature until they can be transported to RGH.

LABMicOP7021 Collection of Blood Cultures Laboratory Services Regina QuAppelle Health Region

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Procedure Notes 1. A solitary blood culture bottle is not acceptable except in children ≤ 4 years. Adult blood cultures from two separate venipunctures are required. If a blood culture is required and only one requisition is supplied, request a second requisition for the second collection. Two sets of cultures increase the chances of detecting bacteraemias, and aids in differentiating contamination from true episodes of bacteraemia. 2. Drawing blood through indwelling intravenous or intra-arterial catheters are associated with higher rates of contamination. This should only be done when a line infection is suspected and must be accompanied by a culture drawn from a peripheral venipuncture. 3. The volume of blood is critical because the concentration of organisms in the bloodstream is usually low. Culture of larger volumes of blood increases the recovery of pathogens and also decreases the time to detection. Culturing an insufficient volume of blood leads to a decrease in sensitivity for detecting infection, which will result in false negative results. 4. The recommended blood to broth ratio is 1:5 to 1:10. Adult blood culture bottles must be adequately filled to dilute potentially inhibiting substances. Pediatric blood culture bottles are able to accommodate low volumens and should be used when appropriate blood volumes for adult bottles cannot be met.. 5. Caution must be taken if you are using the BacT/Alert Blood Collection Adapter Caps in combination with a third-party blood collection set. Some blood collection sets have incompatible threads and the blood collection, even when the needle is screwed all the way down, the threads do not firmly connect, and the luer needle could back out of the adapter cap during use. To reduce the chance of this happening, maintain control of the luer connector by securing it between the thumb and forefinger during the venipuncture.

References 1) Isenberg, HD., Clinical Microbiology Procedure Handbook, ASM Press, 2010 2) Baron, EJ. et al, Blood Cultures IV, Cumitech, 1C, 2000. 3) Clinical and Laboratory Standards Institute (CLSI) M47-A. Principles and Procedures for Blood Cultures. 4) CPS Guidelines 5) Manual of Clinical Microbiology 6) IDSA / ASM Guidelines

Revision History Found in Softtech Health Lab QMS™ Document Management System

Author Carol Barth, MLT.

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Subject/Title: LABTranOP7001.6.1 Transfusions Laboratory Guidelines Last Approved Time: 09/14/2018 Revision: 6.60 Approving Authority : Medical Hematopathologist Contact for Interpretation: Transfusion Supervisor Phone: (306) 766-4412 Current Version on Print Date

TRANSFUSIONS LABORATORY GUIDELINES

I LEGAL RESPONSIBILITY

A. Most Responsible Physician (MRP) / Authorized Health Practitioner:

The ordering physician is responsible for using clinical judgement to determine that the benefits to be obtained from transfusion outweigh the risks. They are also responsible to obtain informed consent for the transfusion from the patient or substitute decision maker in a timely fashion and to ensure that the necessary clinical information is available to the laboratory.

B. Medical staff, nursing staff (Transfusionist) or Perfusionist:

The Medical staff, nursing staff (Transfusionist) or Perfusionist are responsible for ensuring that blood administered to the patient is the blood crossmatched for the patient, as identified by its labelling and it is administered in a safe manner. The Transfusionist should ensure that the consent is documented on the health record or that there is a clear directive from the MRP to proceed without consent.

C. Laboratory:

The laboratory is responsible for maintaining adequate blood product within the limits of the national supply, maintaining satisfactory blood storage conditions and using safe testing techniques.

II SUPPLY OF BLOOD

Every effort will be made to supply blood at the time requested. If sufficient advance notice is given, inability to fill an order will be unusual.

III ORDERING BLOOD TRANSFUSIONS

A. Blood Specimens:

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 1 of 12 Last printed 4/9/2019 1:55 PM The sample required for an ABO Group, Rh type and cross match (compatibility testing) is 2 x 4 mL mauve top Vacutainer tubes.

Ensure that the patient armband is legible and affixed to the patient. (Phlebotomy staff and technologists are instructed that a specimen must not be taken unless these conditions are met.) In the case of unconscious patients who have not yet been identified, an unidentified number is assigned; it is vital that the armband bearing this identification is not removed prematurely. Patients who are leaving the hospital and returning for transfusion (i.e. pre-surgical, outpatients and patient transfers) must be identified by a red armband with a unique red blood number attached at the time of collection. This armband must be affixed to the patient when they return for transfusion.

Confirm the patient's identity by checking the patient’s wristband against the requisition prior to drawing the sample for:

- first and last name - medical record number - date of birth - red blood band number if applicable

Label the specimen tubes with the patient's first and last name, hospital identification number, red blood band number if applicable, and date of birth. The date of collection will be on the printed LIS labels.

Technologists are instructed to reject specimens that are inadequately labelled or unsatisfactory in quality or amount.

Specimens are stored for 35 days and may be used up to 14 days for crossmatch providing the patient has not been pregnant or transfused in the last three months. Specimens from patients who have been pregnant or transfused within the last three months samples may be used up to 96 hours. Neonatal specimens may be used for up to 4 months from the date of birth, regardless of previous transfusions.

If more than 96 hours have elapsed since a transfusion, a new specimen must be sent for further crossmatching in case new clinically significant allo-antibodies have developed.

B. Blood Transfusion Requisition:

The information requested on the form is essential in aiding the laboratory staff. The following must be given: 1) The name and date of birth of the patient 2) Medical Record Number 3) Patient location 4) Date of order 5) Blood Product type and amount required 6) Diagnosis

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 2 of 12 Last printed 4/9/2019 1:55 PM 7) Date of surgery or transfusion if applicable 8) History of previous transfusions, blood group, antibodies and pregnancy 9) Ordering physician

Technologists are instructed not to accept incomplete or illegible requisitions.

C. Blood Products Transferred with Out of Town Patients:

All transported blood products that arrive in the hospital must be left in the sealed container, and delivered immediately to the Transfusions Department. Breaking the seal will result in wastage of transported products.

IV ISSUE OF BLOOD

When the testing has been completed a computer-generated report is printed to the patient’s ward. The report contains the patient's ABO and Rh type and results of the antibody screen. This is a record that must be added to the patient's chart.

When the blood is required, present a slip of paper indicating the patient's first and last name, hospital identification number, date of birth and the type of blood product required to the Transfusion technologist. If the patient’s has a red blood band, the unique identification number is required. In order to maintain the integrity of the blood product, only one unit of blood will be issued at a time except in circumstances where the product will be infused quickly.

A two part pink transfusion record is attached to the donor unit containing the patient name, donor unit number, patient and donor blood group and compatibility status. The technologist performs a verbal check with the portering personnel for transport to the ward. The porter name is recorded and the person receiving the product and the technologist sign the crossmatch tag.

V PATIENT NOTIFICATION

All patients who receive human blood products are given a “Notification of the Administration of Blood and Blood Products” form. This form is given with the first product transfused in each patient stay. Upon discharge the nurse must review this information with the patient and have the patient sign the form. The canary copy is given to the patient and the white copy retained on the chart.

VI BLOOD INFUSION

All transfused patients must have provided informed consent prior to transfusion. If consent hasn’t been given prior to the start of the transfusion there must be a

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 3 of 12 Last printed 4/9/2019 1:55 PM clear directive from the MRP to proceed without consent. This shall be documented on the patient Health Record chart.

The patient shall be informed with a description of the blood component, the associated and benefits, including life-threatening risks and alternatives to transfusion by the MRP/authorized practitioner.

1. Check the patient information on the Blood Bank Report i. e. patient's name, medical record number, date of birth and ABO Group and Rh.

2. Check that the donor ABO Group, Rh and unit number on the Transfusion Record pink tag matches the label of the blood pack.

3. Check the identity of the patient carefully on the wristband and compare it to the patient information on the Transfusion Record tag attached the blood pack. Check the patient's first name, last name, medical record number and date of birth. This must be done in full. Failure to do this is the major cause of transfusion accidents.

4. Sign, date and time the Transfusion Record tag to indicate that the information has been verified. Remove the pink copy of the Transfusion Record tag and attach to the chart. NOTE: Do not remove the white copy of the tag from the unit until the infusion is complete.

5. NOTE: It is not necessary to verify the unit numbers against the Blood Bank Report.

6. Check the patient vital signs as per the nursing protocol.

7. Transfusions must be started within 30 minutes of product issue. Return units to Transfusions if unable to hang immediately. Do not put blood in any nursing unit refrigerator.

8. Infusion rate is as prescribed by the MRP / authorized practitioner.

9. Infusion must be completed within 4 hours of blood issue.

10. Infuse blood slowly during the first 15 minutes as the signs of a severe transfusion reactions often appear early in the transfusion.

11. Blood must be warmed using approved blood warming apparatus only. Serious hemolysis may occur with over-warming.

12. Do not add any medication to the blood product.

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13. For additional information on the administration of blood and blood products, see the Circulars of Information found in on the Intranet.

14. The empty bag must be kept on the ward for 12 hours post transfusion prior to discard. Return the Transfusion Record white tags from each unit to Transfusions after the 12 hour post transfusion period has passed and the empty bag may be discarded in a suitable waste container on the ward.

15. If there is a transfusion reaction the bag must be returned with the tag. The Transfusion lab staff will instruct nursing on the proper procedure to be followed.

VII CANCELING BLOOD

To assist the Laboratory in making the most efficient use of the donor blood inventory, notify the Laboratory immediately when blood is no longer required for a patient.

VIII SHORTAGES OF BLOOD

Due to variation in supply and demand, shortages of blood occur from time to time. One consequence of this may be an acute shortage of a particular group (most commonly O Rh Negative). It may be necessary on occasion to issue blood of a different group than the patient. This will be done based on established protocols, or in consultation with the Transfusion Medicine Physician.

IX EMERGENT AND ROUTINE TRANSFUSIONS

A. EMERGENT Transfusions:

An emergent request for transfusion should be made when blood is required to preserve life.

In such situations, uncrossmatched O Negative blood, or uncrossmatched blood of the patient's group, may be issued on the responsibility of the ordering physician. Group-specific blood takes a short time (approximately 10 minutes) to obtain and is preferred to O Negative blood (due to limited supply).

“STAT” crossmatch requests will be processed as soon as possible.

Note: Refer to the General Lab section for a complete list of turnaround times

B. ROUTINE Transfusions: LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

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Requests for blood should, whenever possible, be made before 1400 hours on the day before the blood is needed. Elective transfusions should not be requested on evenings or nights to ensure adequate ward staff is available to properly observe the patient and manage any adverse reactions.

X CONFIRMATORY BLOOD GROUP

A second blood group test will be requested and collected on all non-emergent patients who do not have a historical blood group on file.

The confirmatory blood group protocol was implemented as a risk reduction system. Patient misidentification occurs at sample collection in approximately one out of every 1,000 samples.

XI CROSSMATCHES FOR SURGERY

Patients who are likely to need transfusion during surgery should have their blood group determined and screened for antibodies prior to surgery.

XII CORD BLOOD

All newly delivered infants have a specimen of umbilical cord blood taken as soon after delivery as possible from the placental end of the cut cord. Draw the specimen into 1 x 7 mL red top tube (clotted blood) and 1 x 4 mL mauve top tube (EDTA anticoagulant). Label the tubes clearly with the infant's surname and medical record number. If infant and mother’s surnames are different, label tubes with both names. Send the sample with a properly completed maternal requisition to the Transfusion Laboratory. Laboratory testing will be performed if required.

If the baby has a positive Direct Antiglobulin Test, additional testing will be performed as indicated.

XIII EXCHANGE TRANSFUSION

Exchange transfusion is used as a treatment for severe hyperbilirubinemia secondary to hemolytic disease of the newborn. Removing the infant's plasma both reduces the load of bilirubin and the amount of unbound antibody. Antibody-coated cells, whose destruction would further raise the bilirubin load, are removed and replaced with red cells compatible with the maternal antibody.

Specialized blood products are required for neonatal transfusions.

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XIV NEONATAL TRANSFUSION

The Transfusion Laboratory aliquots a unit of packed cells for small volume transfusions. This unit will be used until outdate for the assigned baby.

XV AUTOLOGOUS AND DIRECTED DONATIONS Canadian Blood Services will collect units of blood for a patient’s own use if requested by the attending physician. These units are specially labeled and can only be used for the donor. The patient will bring a portion of the autologous label and a letter for the ward explaining that autologous units are available along with a letter explaining the process to the ward on admission. Place the green tags on the Health Records chart along with the letter. The patient’s own blood must be used prior to any other units. Canadian Blood Service also operates a directed donation program for parents donating to children under the age of 17. Please contact the Transfusions Lab for information on this program.

XVI BLOOD REQUIRED FOR LABORATORY TESTS

Test requested Specimen required Group and Rh Only 1 x 4 mL mauve (including confirmatory blood group) Antibody Screen 2 x 4 mL mauve Cross match Direct Antiglobulin Test 1 x 4 mL mauve Cold Agglutinin testing 2 x 6 mL red top 2 x 4mL mauve top (must be clotted at 37°C then quickly separated from the clot) Cord Blood Testing 1 x 6mL red 1 x 4mL mauve

Vacutainer Key

RED No anticoagulant for clotted blood. Do not use the serum separator tubes (SST) MAUVE EDTA Anticoagulant

XVII ADVERSE EFFECTS OF TRANSFUSION

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 7 of 12 Last printed 4/9/2019 1:55 PM Notify the Physician and report all adverse reactions to the laboratory immediately. The Transfusion lab staff will instruct nursing on the proper procedure to be followed. Return the unit of blood to the Transfusion department as soon as possible accompanied by the tag. An Adverse Event Report Form should be completed with all pertinent information.

If it appears that the adverse event may have been caused by an attribute in the blood component such as bacterial contamination, notify the Hematopathologist immediately so a determination can be made on notification of Canadian Blood Services (CBS). It is important that available companion products be removed from inventory prior to transfusion. (i. e. a large increase in temperature without an underlying cause can be indicative of bacterially contaminated units).

If the adverse event resulted in a fatality notify the manufacturer (either CBS or the plasma protein manufacturer) immediately. See LABTranOP7135 Adverse Event Reporting.

1. Febrile Non-Hemolytic Reaction

A febrile reaction is suspected if the patient has one of more of the following; a fever (>38°C and a change of ≥ 1°C from pretransfusion value), chills, sensation of cold or rigors. These signs and symptoms may be observed during the transfusion or within 4-6 hours of its completion without any other apparent cause.

A fever can have many causes unrelated to blood transfusion; therefore, a blood transfusion is not necessarily discontinued if a fever develops. Most febrile transfusion reactions are mild and may be treated or prevented by the administration of antipyretics such as acetaminophen prior to the transfusion.

Severe febrile symptoms may indicate a more serious reaction, such as acute hemolytic reaction or bacterial contamination.

2. Allergic Reactions - Minor

Symptoms include transient urticarial or other skin rash with pruritus associated with the transfusion. This may be associated with fever.

The cause of urticaria is thought to be a reaction to a soluble antigen in the donor plasma. Mild urticaria is usually harmless and should be treated with antihistamines. It is not necessary to discontinue the transfusion as long as serious symptoms (below) are not present.

3. Allergic Reactions – Severe/Anaphylactic

Signs and symptoms of a severe allergic reaction can include rash greater than 2/3 BSA, respiratory symptoms (tightness in throat, cough, hoarseness, dyspnea, wheeze, hypoxemia) and unstable vital signs (hypotension, tachycardia). The reaction may progress to respiratory failure and circulatory collapse.

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 8 of 12 Last printed 4/9/2019 1:55 PM Anaphylactic reactions occur in individuals who are IgA deficient and who have developed antibodies to IgA. These antibodies react with IgA in transfused plasma. It should be noted that it is possible for reactions to occur even during the first transfusion.

Stop the transfusion immediately, keep the I.V. open with normal saline to allow for the administration of medications as ordered by the physician.

4. Hemolytic Transfusion Reactions

Signs and symptoms include fever, chills, nausea, hypotension, chest or back pain, shock, generalized bleeding, hemoglobinuria, oliguria or anuria within 24 hours of the receipt of the transfusion.

Hemolytic transfusion reactions are caused by the intravascular destruction of red blood cells. This usually follows the transfusion of ABO incompatible blood given to a patient that has been improperly identified. Hemolytic reactions may also occur following the transfusion of blood that has outdated, is bacterially contaminated or that has been damaged by freezing or heating.

Action to take if an Acute Hemolytic Transfusion Reaction is suspected:

a) Stop transfusion and maintain the IV line with normal saline. b) Check patient’s vital signs and commence oxygen if required. c) Notify physician and the laboratory immediately and request an investigation. d) Check patient identification against the tag on the unit of blood as a clerical check. e) Fill out the Adverse Event Report Form found on the Transfusions home page on the RQHR website. f) Send the remaining donor blood to the laboratory for investigation with the Adverse Event Report form as well as any post reaction samples requested by the Transfusions department. g) Collect the first urine passed following the reaction. Send to the laboratory for a routine urinalysis and free hemoglobin. h) Monitor the urine output. i) Have a post reaction serum bilirubin done.

Treatment of a hemolytic reaction is determined by the specific symptoms. Treat hypotension with fluid replacement. Induce and maintain urinary flow by fluid replacement and diuretics. Dialysis may be required. If the patient has symptoms of a hemostatic disorder laboratory tests will determine if platelets or specific coagulation factors should be given.

5. Delayed Hemolytic Transfusion Reaction

Delayed Hemolytic Transfusion reactions may occur 3 days to 2 weeks after transfusion. The patient typically presents with hemolytic anemia (low

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 9 of 12 Last printed 4/9/2019 1:55 PM haemoglobin, high bilirubin, reticulocytosis, spherocytosis, high LDH), a positive antibody screen, and a positive direct antiglobulin test (i.e., DAT, Coombs’ test).

Most are benign, but life-threatening hemolysis with severe anemia and renal failure may occur. Notify physician and Transfusion Laboratory immediately.

6. Bacterial Contamination- Acute reaction

Despite the observance of aseptic technique during collection and processing, the possibility of bacterial contamination (usually by normal skin flora) still exists.

This contamination does not usually cause clinical problems because the products are stored at temperatures that inhibit bacterial growth. However, when the storage or administration of a blood product does not meet accepted standards, proliferation of bacteria may occur and cause serious harm to the patient.

Symptoms of a reaction include high fever, hypotension, shock, hemoglobinuria, DIC and renal failure. Stop the transfusion immediately and notify the Transfusion Laboratory. Send the product to the laboratory for Gram stain and culture. Blood cultures on the patient are also recommended to help establish that the blood product was the cause of any infection.

Treatment includes supportive care, including appropriate antibiotics.

7. Disease Transmission – Delayed reaction Infectious diseases may be transmitted in spite of careful selection of donors and testing of blood. Donor selection criteria are designed to screen out individuals who are at high risk for viral infections, including HIV, hepatitis B and C, and HTLV. Testing is also performed on all units prior to release. For a complete listing of tests, see the Canadian Blood Services Circular of Information.

8. Circulatory Overload (TACO)

Pulmonary edema may develop rapidly in a patient who has received too much or too rapid an intravenous infusion, particularly in patients with renal failure, heart failure or severe chronic anemia. The symptoms include dyspnea, cyanosis, orthopnea, severe headache, hypertension or congestive heart failure during or soon after the receipt of a transfusion

Be circumspect in transfusing such patients. It is wise to limit the patient to no more than 2 units of packed cells per 24 hours, watching carefully for signs of heart failure.

If circulatory overload occurs, treat with elevation of head of the bed, diuretics, etc.

9. Transfusion Associated Graft Versus Host Disease (TA-GVHD)

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 10 of 12 Last printed 4/9/2019 1:55 PM Blood products are routinely irradiated to prevent GVHD for high risk populations. TA-GVHD is extremely rare and most commonly occurs in immunocompromised recipients who do not receive irradiated blood products.

Symptoms of TA-GVHD include fever, skin rash (which often starts on the palms, the soles of the feet and the ear lobes), elevated liver enzymes (ALT and AST, Alkaline phosphatase) and bilirubin, pancytopenia and diarrhea. The reaction is very severe and results in death in over 90% of the cases.

10. Transfusion Related Acute Lung Injury

TRALI is suspected if the recipient experiences acute pulmonary edema in the absence of cardiac failure within 6 hours of the receipt of a transfusion. It is most often related to transfusion of plasma/plasma products. Symptoms include dyspnea, cyanosis, chills, fever and hypotension. If a case of TRALI is proven by symptoms and follow up testing (x-rays), CBS should be notified. They may request that the TRALI Patient Data be filled out and the appropriate samples collected and sent to CBS Regina.

14. Other Complications Other rare adverse events such as iron overload, Post Transfusion Purpura, hypotensive reactions and Aseptic Meningitis have been associated with transfusion. The Transfusion Medicine Physician on call should be contacted if any of these are suspected.

XVIII PRODUCT INFORMATION

Information on blood and blood products can be found in References of this procedure. The latest versions of the Canadian Blood Services Circular of Information and the Clinical Guide to Transfusion are found online on the CBS website – blood.ca). The Clinical Guide to Transfusion supplied by Canadian Blood Services and the Bloody Easy book sponsored by Ontario are both excellent, informative books available for information on transfusion medicine. Additional information can be obtained from the technologists in the Transfusions Department, or the Transfusion Medicine physician on call.

References

1. American Association of Blood Banks, Technical Manual, 18th ed 2. Health Canada Guidance Document: Blood Regulations 2016-03-08 3. CSA Z902-15 Blood and blood components December 2015 4. Canadian Society for Transfusion Medicine Standards for Hospital Transfusion Services Version 4 April 2017

LABTranOP7001.6.1 Transfusions Laboratory Guidelines Laboratory Services Regina QuAppelle Health Region

Page 11 of 12 Last printed 4/9/2019 1:55 PM 5. Canadian Blood Services Circular of Information - on line link: https://www.blood.ca/en/hospitals/circular-information 6. Public Health Agency of Canada Adverse Event Definitions User’s Manual Version 3.0 November 2007 7. Clinical Guide to Transfusion - on line link: http://www.transfusionmedicine.ca/resources/clinical-guide-transfusion

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LABTranOP7001W1 Canadian Blood Services Circular of Information

The Circular of Information is an extension of the component label and provides information regarding component composition, packaging, storage and handling, indications, warnings and precautions, adverse events, dose and administration etc. The Circular conforms to the applicable regulations issued by Health Products and Food Branch, Health Canada.

The Circular of Information is available to facilities where health care professionals are involved in the preparation and transfusion of human blood and blood components.

Disclaimers This document can be printed. Please note that the contents of this document cannot be modified due to Copyright. This is a time-sensitive document and may be outdated. Please visit the Canadian Blood Services website regularly for the current version. The table below provides a list of the contents of the Circular of Information.

Note: These documents can be downloaded.

Current Version (English Versions)

Red blood cells Leukocytes reduced (LR) Pooled platelets LR CPD, apheresis platelets

Current Version (English Versions)

Plasma components (FFPA, FP CPD, Cryosupernatant CPD, Cryoprecipitate CPD)

Visit the Canadian Blood Services website for the current version of this document.

https://www.blood.ca/en/hospitals/circular-information

LABTranOP7001W1 CBS Circular of Information Page 1 of 1 Laboratory Services Regina Qu'Appelle Health Region August 21, 2018 JJOOBB AAIID LLABTrranOP7142A MMAASSSSIIVVEE TTRRAANNSSFFUUSSIIOONN PPRROOTTOCOL ALGORITHM UUppddaatteedd JJuunnee 220018 Criteria for Activation > 4 packed red cells transfused in < 1 hour with uncontrolled bleeding and/or request by Code Blue Captain, Trauma Team Leader Treatment Considerations or Anaesthesiologist when clinically · Use a blood warmer and consider other necessary. measures to warm the patient. Monitor core temperature. Goal temp > 36°C. Contact Physician determines MTP · Consider the use of tranexamic acid for activation is required. ALL trauma patients who are within 3 hours from time of injury. Dose – 1 g IV load in 100 mL NS over 10 min, then 1 g IV in 250 mL NS over 8 hr. · Consider use of a Cell-Saver (contact Team Contact (Charge RN) calls Perfusionist on call via switchboard). Transfusions to activate MTP. Transfusions will initiate the overhead page when required. (Refer to Massive Transfusion Protocol Nursing Guidelines in Code Blue Binder I am activating the Massive for other Team Contact duties). I am activating the Massive Transfusion Protocol at Transfusion Protocol at ______(location). ______(location). The patient’s name is Collect baseline bloodwork The patient’s name is ______. per MTP requisitions ______. The MRN is (sent by Transfusions with first box). The MRN is ______. ______. The gender is The gender is ______. ______. The requesting physician is The requesting physician is Transfuse blood products as provided ______. ______. Box 1A: 4 packed red cells (sent immediately) Box 1B: 4 thawed plasma + 1 adult platelet (sent in 20-25 minutes) Note: MTP boxes will be available from Transfusions every 30 minutes until the MTP Dedicated MTP Transport is discontinued. The physician can always Contact Numbers ask for more products in addition to the boxes. RGH Pasqua 0709 8488

TRANSFUSE Collect bloodwork Treatment Considerations Based CONTENTS OF MTP (MTP panel) on Lab Results BOXES every 30-60 minutes · If INR > 1.7 or aPTT > 40 seconds, and review results for consider an additional 4 units of plasma. Box 1: 4 red cells + additional treatment · If fibrinogen < 1.5 g/L (or < 2.0 g/L in 4 plasma + 1 adult considerations. obstetrical patients), consider an additional platelet dose Use MTP requisitions. 6 units of cryoprecipitate. MTP Panel · If platelets < 75 x 109/L, consider an Box 2: 4 red cells + Includes: additional adult dose of platelets. 4 plasma + 6 units CBC · If ionized Ca++ <1 mmol/L, give 1 g calcium cryoprecipitate INR/aPTT gluconate. Fibrinogen · Monitor pH closely, consider lactate to The se will alternate Arterial Blood monitor effect of resuscitation. every 30 minutes Gases · If patient is on anticoagulants or other until the MTP is Ionized Calcium transfusion advice is required, consult discontinued. Lactate Hematopathologist on call via switchboard.