MGH Pathology Service Laboratory Reflex Test Protocols 2016 Reflex Test Protocols Reflex tests fall into 2 categories: standard industry practice (example: sensitivities, interpretations, and confirmations) and institutional practice based on staff clinical practice Tests that are reflexed should be reasonable and medically necessary. The medical community should approve reflex protocols. The physician must have the option of selecting a reflex protocol or a single test. Blood Transfusion Services Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Antibody Screen Antibody Screen Positive screen Antibody identification Cold agglutinin screen Cold agglutinin screen Positive (>1+) Cold agglutinin titer Direct antiglobulin test Direct antiglobulin test IgG positive and transfused w/in 3 Eluate mo Fetal Screen Fetal screen Positive Kleihauer-Betke Core Lab - Chemistry Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Thyroid Screen TSH TSH>5.00 Free T4 TSH<0.40 Free T4. T3 Monitoring L-T4 Therapy TSH TSH<0.05 Free T4 Thyroglobulin Thyroglobulin Specimen received and test Thyroglobulin Antibodies requested Direct LDL Lipid Panel with calculated LDL Triglycerides >399 Direct (measured LDL) Free testosterone Total testosterone, sex hormone Albumin <3.5 Free testosterone measured by binding globulin (SHBG), albumin, equilibrium dialysis free testosterone (calculated), % free testosterone (calculated). Notes: The albumin is needed for the calculation but will not be reported. All other values will be reported. If the total testosterone is outside of the measurement range, free testosterone and % free testosterone will not be reported. Core Lab - Emergency Department Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Urinalysis Macroscopic urinalysis 1+, 2+, 3+ for blood protein, Microscopic leukocytes Troponin-l Troponin-l Borderline or positive Troponin-T Rapid Influenza screen Rapid flu screen Admission samples Confirmation in main Microbiology Rapid Influenza screen Rapid flu screen Negative on Pediatric case and at Viral Panel in main Microbiology request of MD Rapid Strep A Antigen Strep screen Presumptive negative Confirmation on second swab in main Microbiology Cytology Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Pap Smear Liquid-based PAP Atypical cytology HPV test Anal Pap Smear Liquid-based PAP Atypical cytology HPV test Diabetes Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Hemoglobin A1C Hemoglobin A1C >4.50% or <14.50% Calculated mean blood glucose MGH Laboratory Reflex Test Protocols 2016 – Approved by Medical Policy 2016 MGH Pathology Service Laboratory Reflex Test Protocols 2016 Health Centers – Chelsea and Revere Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Urinalysis UA-Macroscopic Any of the following Urine Sediment Protein:1+ or more Blood: Trace or more Leukocyte esterase: Positive CBC MCHC>38.0 Manual hematocrit Differential – Manual Differential – Manual - Clinical requests pathologist review - Blasts seen - Unusual abnormal white cells Rapid Influenza screen Rapid flu screen Admission samples Confirmation in main Microbiology Rapid Influenza screen Rapid flu screen Negative on Pediatric case and at Viral Panel in main Microbiology request of MD Rapid Strep A Antigen Strep screen Presumptive negative Confirmation on second swab in main Microbiology Core Lab - Hematology Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Hemoglobin electrophoresis Hemoglobin fractionation Test performed Pathologist review of results. Pathologist review of peripheral blood smear if abnormal findings seen on hemoglobin electrophoresis. No concurrent CBC CBC Sickle screen Sickle screen Previous positive Test result Hemoglobin electrophoresis Urinalysis Macroscopic urinalysis Positive WBC screen occult blood Microscopic or >TRACE albumin (i.e., 1+ or more) CBC CBC Instrument flag PLT review on smear Manual PLT first time <50,000 Platelet Instrument flag Manual hematocrit; other RBC RBC > 7.0 million/uL parameters not reported MCHC > 38.0 Manual hematocrit Differential Differential-automated Instrument flag Differential or automated differential with manual review Differential-manual Differential-manual Clinician request Pathologist review Blasts seen for first time on the patient Unusual abnormal white cells PT PT >138 and/or reason to Manual PT (and fibrinogen when query accuracy of result e.g. initial PT >138) low fibrinogen interfering substance (lipemia, gross hemolysis) Instrument flag MGH Laboratory Reflex Test Protocols 2016 – Approved by Medical Policy 2016 MGH Pathology Service Laboratory Reflex Test Protocols 2016 Hematology Pathology Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Bone Marrow Exam Specimen received and test Pathologist review of blood smear request (from CBC ordered <24 hours prior to bone marrow sample or slide from CBC with manual differential/special slide ordered < 7 days prior to bone marrow) Flow cytometry for hematologic Specimen received and test CBC with differential, special slide malignancy request and pathologist review. CSF Flow Cytometry Ordered CSF Total Nucleated TNC> 5/µL or history of CSF flow cytometry Cell Count (TNC) hematologic malignancy Chart review for history Clinician requests policy (If reflex criteria not met, flow of hematologic override cytometry will not be performed by malignancy default, but clinician may request override) Lymphoma staging bone marrow Morphologic Pancytopenia or Routine cytogenetics examination by a question of MDS hematopathologist Flow, morphology and Cytogenetics with stimulation Flow cytometry or IHC positive for IHC as needed lymphoma No evidence of marrow Cytogenetics not performed (test involvement by cancelled by Hematopathology). lymphoma based on flow, morphology or IHC Bone marrow examination for Morphologic Diagnosis Molecular Add-on tests suspected acute leukemia examination by a hematopathologist AML SNaPshot, FLT3, NPM1, CEBPA Flow cytometry IHC as needed APML SNaPshot, FLT3, PML-RARA B-ALL BCR-ABL qualitative MDS SNaPshot MPN or MDS/MPN overlap JAK2 V617F and SNaPshot CMML SNaPshot, NPM1, FLT3 Other Discuss with clinician MGH Laboratory Reflex Test Protocols 2016 – Approved by Medical Policy 2016 MGH Pathology Service Laboratory Reflex Test Protocols 2016 Immunology Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Protein electrophoresis on serum Protein electrophoresis on Presence of 1 or more abnormal Immunofixation to characterize or CSF agarose gel bands in the gamma globulin zone abnormal bands with physician review Protein electrophoresis on serum Protein electrophoresis on Presence of abnormal banding Immunofixation to characterize or CSF agarose gel and altered immunoglobulin profile abnormal bands and, as needed, free kappa and lambda light chains by nephelometry with physician review Protein electrophoresis on serum, Protein electrophoresis on Test performed Physician review urine, CSF agarose gel Urine Bence Jones proteins Agarose gel electrophoresis and Abnormal band on agarose gel Immunofixation to characterize immunoelectrophoresis not identified by abnormal bands and, as needed, immunoelectrophoresis free kappa and lambda light chains by nephelometry with physician review Antinuclear antibody ANA screen Presence of staining of substrate ANA Titre and pattern Physician nuclei or cytoplasm review Quantitation of serum IgG, IgA, IgM by nephelometry If lgG>7 g/dL, lgA >3 g/dL, or lgM Viscosity immunoglobulins >5 g/dL Quantitation of serum lgG lgG by nephelometry <500 mg/dL and adult patient Immunofixation electrophoresis, and, as needed, free kappa and lambda light chains by nephelometry and physician review of findings Cryocrit Cryoprecipitable protein Cryoprecipitable protein present If not previously tested within 6 months to 1 year, cryoprecipitable protein is identified by immunodiffusion, immunofixation, and physician review ENA panel ELISA If ELISA positive for any antigens Perform ANA test on Hep2 cells if (Ro/La/Sm/RNP/Jo/Sci-70) in ENA panel not already performed within last 2 months MGH Laboratory Reflex Test Protocols 2016 – Approved by Medical Policy 2016 MGH Pathology Service Laboratory Reflex Test Protocols 2016 Microbiology Test ordered on Requisition Initial Test Performed Criteria for Reflex Test Ordered by Reflex Routine culture on CSF Culture Cloudy fluid Gram stain Lower respiratory culture Culture Evaluation of specimen quality Gram stain Lower female tract culture Culture Diagnosis of bacterial vaginosis Gram stain made by gram stain not culture. Culture performed for yeast and GC Gram stain Gram stain Presence of potential pathogens TB, fungal or anaerobic cultures observed and/or smears Brain abscess Routine culture Specimen site Anaerobic culture Gram stain routine culture Bacterial cultures Routine Culture Isolation of clinically significant Susceptibility testing organisms requiring Vancomycin MIC to check for susceptibility VISA or VRSA Isolation of methicillin resistant Confirmatory test for the Staph aureus from blood, body presence or absence of the fluid, or wound MecA gene or the gene product Staphylococci from blood, body PBP 2a for certain fluid, or wound