Directory of ServicesBestCare Laboratory Services, LLC
Table of ContentsPage 1 Introduction 2 Customer Service 2 Reporting 2 Specimens Collected by the Facility 3 Standing Orders 3 Timed Tests 3 Stat Orders 4 Stat Testing Menu 5 Routine Tests and Panels 6 Specimen Collection, Preparation, and Handling 6 Safety and Disposal Considerations in Specimen Collection 6 Preparation of the Patient 7 Order of Tube Draw 7 Specimen Containers 8 Test Requisitions/Laboratory Logs 8 Collecting of the Specimen 9 Processing the Specimen 9 Label requirements 9 Stat Collection 9 Routine Collection 10 Centrifugation of Gel Tubes 10 Storing and/or Transporting the Specimen 10 Specimen Transport 10 Acceptable Specimens 10 Unacceptable Specimens 11 Avoiding Common Problems 12 Specimen Collection 12 Serum Preparation 12 Plasma Preparation 12 Urine Collection 12 Hemolysis 13 Vacuum Tubes without Anticoagulants 13 Lipemic Serum or Plasma 14 Quantity Not Sufficient 14 Patient States 15 Times Specimens 16 Anticoagulants and Preservatives 16 Urinalysis and Culture and Susceptibility 16 Random Urine Collection for Routine Analysis 17 24-Hour Urine Collection 17 Recommended Patient Instructions for 24-Hour Urine Collections
Page 19 Microbiology Specimen Criteria: Collection and Handling 19 Unacceptable Specimens 20 Anaerobic Cultures 20 Acceptable Anaerobic Culture Sources 22 Unacceptable Sources for Anaerobic Culture 24 Clinical Hints Suggesting Possible Infection with Anaerobes 24 Body Fluids (CSF, Synovial, Peritoneal, Pleural, Thoracentesis, etc.) 24 Genital 25 Respiratory 26 Upper Respiratory Cultures 26 Nasopharyngeal 26 Influenza A & B 26 Sputum, Bronchial Wash, Tracheal Aspirate 27 Stool 27 Culture 27 Occult Blood 28 Fecal Leukocytes (WBCs) 28 C difficile Toxin A & B 28 Urines 28 Collection Methods 29 Miscellaneous 29 Bone 29 Catheter Tip 29 Ear 29 Eye 30 Skin and Superficial Wounds 30 Neisseria gonorrhea Specimens 30 Blood Cultures 30 Site Selection 31 Disinfection of the Vials 31 Venipuncture 31 Volume 31 Specimen Labeling 32 Ordering of Blood Cultures 32 Timing of Collection 33 Therapeutic Drug Monitoring Guide 34 Reference Range Guidelines 36 Critical Value Guidelines 38 Billing and Insurance Information 38 Client Billing 38 Medicare- Overview of Medical Necessity 38 Medicare Coverage 39 Medicaid Test/Panel Menu (test/panel; container; volume; storage; reference range; units; critical values, CPT codes, turn-around time; special requirements) Quick Guides (order of draw; container; common tests; storage; additive)
From Our CEO/PresidentMaking a difference, it is what we do. I am very proud of all the accomplishments we have achieved.There are many aspects and services, which distinguish BestCare from other laboratories:Recruiting most qualified healthcare professionalsQuality of our servicesDependability and quick responseCommunication with our clients providing accurate, reliable dataSame day routine test resultsModern state of the art laboratoryAt BLS, we make a difference by striving to deliver you the quality you need and the service yourpatients deserve. We are CLIA and COLA certified and Medicare approved. Founded in 2002, ourcompany has expanded substantially because of our hard work dedication and professionalism. Iam proud of our achievements in quality laboratory services, outstanding performance andexceptional customer service. It is an honor for us to be recognized in a national news magazine(Washington G-2) for three consecutive years and look continuously forward to serving you withexcellence. I take pride in our workmanship and professionalism in the healthcare industry and lookforward to providing you the BestCare in laboratory services – and thank you for placing yourconfidence in BLS.Sincerely,Karim Maghareh, Ph.D, MBA, MHA, MT (ASCP), CLSPresident/CEO
Preface:While every effort is made to create a publication that is up-to-date, technology often brings aboutchanges in methodology that can affect test availability and specimen requirements. If you have anyquestions, please contact the laboratory.Dedication to Excellence:At Bestcare, quality is never compromised. Test results from every section of the laboratoryare routinely monitored for reliability, precision, and accuracy by both internal and externalquality control programs.Customer ServiceThe customer service department at BestCare can provide you with information concerning: • Status of testing in progress • Specimen and special handling requirements • Test results • Billing • Availability of tests • Adding tests to specimens already in progressReportingMost frequently ordered tests are completed and usually reported within 24 hours followingreceipt of specimens in our laboratory. Those requiring longer testing time are reported assoon as results are available.BestCare’s computerized reporting system includes printouts with reference intervals forcomparison. For most procedures, abnormal quantitative, results are “flagged” orhighlighted.Specimens Collected by the Facility 1. Urine, stool, and cultures should be ordered when the specimen is collected by the facility. 2. If ordered in conjunction with other blood work, the phlebotomist will check the designated area, cooler, or refrigerator and transport to the laboratory. 3. All specimens must be labeled and must be accompanied by a copy of the order.Standing Orders
1. Standing orders are entered in the Laboratory Information System, pending collection, with their frequency. 2. Prior to each week, a list of standing orders, for that week, will be sent to your facility for review. 3. You may notify us of any changes, via fax, or written in the laboratory log.Timed Tests 1. Please order all timed test 24 hours in advance to assure scheduling of a phlebotomist or assure supplies are made available for you.Stat Orders 1. To insure adequate turnaround time, contact the laboratory for STAT collections. 2. Refer to the list of tests performed STAT. Tests not on this list can be drawn at the same time but will tested as routine. 3. All STAT results are faxed to the facility upon completion.HIPAABestCare Laboratory Services, Inc. (BLS) maintains compliance with the law known as “HIPAA”(Health Insurance Portability and Accountability Act of 1996). BLS protects the legal rights of thepatient and protects the patient from invasion of privacy as a result of indiscriminate andunauthorized access to and disclosure of confidential information.
STAT TESTING MENUThe following list comprises the tests or panels which are available for STAT testing. Upon therequest of STAT testing, we will dispatch the first available phlebotomist to your facility. The resultswill be available within one hour from the time the specimen is received in the laboratory. Individual Tests Albumin LDH Alkaline Phophatase Lithium ALT (SGPT) Lipase AST (SGOT) Magnesium Ammonia PT/INR Amylase PTT Blood Cultures Phosphorus Calcium Phenytoin (Dilantin) CK Phenobarbital CK-MB Potassium Chloride Protein Carbamezipine Sodium CO2 Total Billirubin Creatinine Theophylline D-Dimer Total Protein Digoxin Troponin I GGT Valproic Acid Glucose Vancomycin Iron Panels CBC with Differential Hgb & Hct (H&H) Electrolytes Basic Metabolic (BMP) Comprehensive Metabolic (CMP) Liver Function Test (LFT) Lipid Panel Renal Function Panel (RFP) Cardiac Panel Urinalysis with micrscopics
Routine Tests and PanelsCHEMISTRY Lipid Panel URINEElectrolytes Panel HDL UrinalysisSodium LDL (calculation) Urine Drug ScreensPotassium CholesterolChloride TriglyceridesCO2 HEMATOLOGY Other Chemistry CBC w/DiffBasic Metabolic Panel Ammonia CBC w/o DiffLytes + Amylase Hgb & Hct (H&H)Glucose B12 ReticBUN, Creatinine BNP Sedimentation RateCalcium CK (CPK) CRP COAGULATIONComprehensive Metabolic Panel Ferritin PT/INRBasic Metabolic + Folic Acid PTTAlbumin FT3 D-DimerAlkaline Phosphatase FT4ALT (SGPT) GGT MICROBIOLOGYAST (SGOT) hCG Qualitative S, U Occult Blood StoolTotal Bilirubin HgbA1C Blood CulturesTotal Protein Iron C. difficile Toxin A+B LDH Routine CulturesLiver (Hepatic) Function Panel Lipase WBC Feces SmearAlbumin Magnesium Flu A & BAlkaline Phophatase Prealbumin VRE ScreenALT (SGPT) PSA MRSA ScreenAST (SGOT) RPRDirect Bilirubin T3 UptakeTotal Bilirubin TIBCTotal Protein Total T4 TSHRenal (Kidney) Function Panel Uric AcidBasic Metabolic + Vitamin DAlbuminPhosphorus Therapeutic Drugs CarbamezipineCardiac Panel DigoxinCKMB LithiumTroponin I PhenobarbitalMyoglobin Phenytoin (Dilantin) Theophylline Valproic Acid VancomycinFor more testing information contact the laboratory.
SPECIMEN COLLECTION, PREPARATION, AND HANDLINGIntroductionLaboratory tests contribute vital information about a patient’s health. Correct diagnostic andtherapeutic decisions rely, in part, on the accuracy of test results. Adequate patient preparation,specimen collection, and specimen handling are essential prerequisites for accurate test results. Theaccuracy of test results is dependent on the integrity of specimens.Safety and Disposal Considerations in Specimen CollectionIn all settings in which specimens are collected and prepared for testing, laboratory and health careprofessionals should follow current recommended sterile techniques, including precautions regardingthe use of needles and other sterile equipment as well as guidelines for the responsible disposal ofall biological material and contaminated specimen collection supplies. For all those who are involvedin specimen collection and preparation, the responsibility to adhere to current recommendationsdesigned to maintain the safety of both patients and health care workers does not end when thepatient is dismissed.There are four steps involved in obtaining a good quality specimen for testing: 1. Preparation of the patient 2. Collection of the specimen 3. Processing the specimen 4. Storing and/or transporting the specimen1. Preparation of the patientPrior to each collection, review the appropriate test description, including the specimen type to becollected, volume, procedure, collection materials, and storage and handling instructions.Verbally reassure patient prior to collection of blood and/or any body fluid that requires invasiveprocedures.Verify the patient and the requisition match using at least 2 patient identifiers. Patients may beasked to state their name and date of birth. In a hospital setting, identity should be confirmed usingthe patient’s armband. (Phlebotomists should say “Please tell me your name” rather than “Are youMs. Jones?” Some patients may be hard of hearing, in a phase of dementia, or on medications andnot always give accurate or appropriate answers.) The phlebotomist may need to ask the patient’scaregiver for identity in some instances.Have all supplies and equipment needed at patient’s bedside prior to collection.Supplies:Gloves Labels Vacutainer tube holderTourniquet Vacutainer tubes Sharps containerAlcohol prep Adhesive strip Safety needle if neededButterfly apparatus if needed Gauze/cotton balls Syringe if needed
When more than one blood specimen is required, multisample needles and vacuum tubes makeblood collection simpler and more efficient.Order of tube draw a. Blood culture b. Blue c. Red d. Green e. Lavendar f. GrayPlace the sharps container within reach. Open the needle package in front of the patient; do notremove the needle sheath.During venipuncture, do not have the patient clench and unclench the fist repeatedly (pumping).This will cause a shift in fluid between the vein and the surrounding tissue. This can lead to changesin concentration of certain analytes. To facilitate making the vein more prominent, the patient may beasked to clinch fist tightly. Also, never leave a tourniquet on the arm for more than 1 minute withoutreleasing it. This can cause discomfort to the patient and may also cause hemoconcentration leadingto erroneous results.ANTICOAGULANT:The proper anticoagulant must be used for a test (i.e., EDTA for CBCs, citrate for PT and aPTTs,serum or heparinized plasma for most chemistries, etc.). If the correct anticoagulant is not used (asstated below) the specimen must be recollected.Specimen Containers:Red-top tube:Contain no anticoagulant or preservativeMottled red/gray or cherry red-stopper tube:Contains clot activator and gel for separating serum from cells, but not anticoagulant. Do not useserum-separator tubes to submit specimens for therapeutic drug monitoring. Always check the testdescription to determine whether a serum-separator tube is acceptable.Lavender-top tube:Contains liquid K3 EDTA.Gray-top tube:Contains sodium fluoride.Blue-top tube:Contains sodium citrate. Be sure to use only tubes with a 3.2% sodium citrate concentration. Theseare easily identified by the yellow diagonal stripes on the label.Green-top tube:
Contains sodium herapin or lithium heparin.Yellow-top tube:Contains 1 ml acid citrate dextrose (ACD) solution.Royal blue-top tube:Contains sodium EDTA for trace metal studies.TEST REQUISITIONS/LABORATORY LOGS: 1. All specimens for testing must be ordered on a test requisition/laboratory log and must be legible. a. Add-On Tests per Physician Orders - The laboratory may order add-on tests, when appropriate, only upon the order of a physician which must be in writing and faxed to the laboratory. b. Any specimen received in the lab must be accompanied by a requisition with the patients full name, other ID number, age and/or date of birth, gender, room number or location, physician’s name, other patient data as appropriate to the test ordered, test(s) requested, time and date ordered, time and date of collection, and initials of person ordering or collecting specimen.2. Collecting of the SpecimenAfter securing the tourniquet and reaffirming your selection of the best vein, both by sight andpalpation, proceed as follows.Note: If a patient has intravenous (I.V.) solutions going into both arms, it is acceptable to puncturethe vein 3-4 inches below the site of the I.V.Draws from PICC lines must be drawn by nursing staff, following their facility protocol. a. Cleanse the site with sterile alcohol wipe in a circular motion, inside to outside, to push contaminants away from the puncture site. Iodine may contaminate specimens for certain chemistry tests. b. Allow the puncture site to air dry after cleansing. If alcohol is not allowed to dry, it may cause specimen hemolysis. If the arm is dry, you will avoid stinging the patient at venipuncture. NOTE: Never blow or fan the puncture site with your hand. You will introduce contaminates. c. Remove the needle cap. d. Anchor the vein. Enter the vein at an angle of approximately 45 degrees. e. If only a single collection tube is required, when the vacuum is exhausted and the tube completely filled, release the tourniquet, and remove the tube from the needle assembly. Place a piece of dry gauze over the needle and withdraw the needle carefully. f. When multiple specimens are required, remove the first collection tube from the holder as soon as the blood flow ceases, invert the first tube to prevent clotting, and gently insert the second tube into the holder. Puncture the diaphragm of the stopper by pushing the tube forward and initiating vacuum suction. Remove and invert each successive tube after it is filled. When all samples have been drawn, remove the entire assembly from the arm. g. Firmly lock the safety shield on the needle, discard the needle and holder into the sharps container. Do not recap or reuse needles.
h. Apply direct pressure to the puncture site. See Microbiology Specimen Collection for microbiology studies.3. Processing the specimenAll specimens must be labeled in the presence of the patient.Label requirements: a. Full name b. Unique identifier (date of birth acceptable) c. Date, including the year d. Time of collection e. Initials of collector f. Cultures must include sight and sourceSTAT CollectionProvider or Nurse orders the tests by entering all information on the requisition/Laboratory log.For clients that draw their own STAT specimens, call for transportation of specimen to thelaboratory.For clients that require BestCare Laboratory Services, Inc. (BLS) to draw a STAT call BLS.Results for in-house testing will be provided in within one hour from the time the specimen isreceived into the lab.Routine CollectionProvider or Nurse orders the tests by entering all information on the requisition/Laboratory log.BestCare Laboratory Services, Inc. will draw routines and pick-up specimens at the timesdesignated by contract. Line draws are performed by licensed nursing personnel.Results for in-house testing will be provided in 24 hours or less except for Microbiology.Centrifugation of Gel (Gold-or-speckled top) tubes:Gel-barrier tubes contain clot activator and gel for separating serum from cells but include noanticoagulant. Adhere to the following steps when using a gel-barrier tube. Do not use gel-barriertubes to submit specimens for therapeutic drug monitoring, direct Coombs’, blood group, and bloodtypes. a. Let the specimen stand for a minimum of 15-30 minutes and (preferably) not longer than 60 minutes prior to centrifugation. This allows time for the clot to form. If the specimen is allowed to stand for longer than 2 hours, chemical activity degeneration of the cells within the tube will take place, and test results will be affected. b. After allowing the clot to form, insert the tube in the centrifuge, stopper end up. Operate the centrifuge for 10 minutes at the speed recommended. Employ a balance tube of the same type containing an equivalent volume of water. c. When the centrifuge comes to a complete stop, remove tubes carefully without disturbing the contents. Inspect the barrier gel to ensure that it has formed a solid seal between the serum and packed cells. d. Make sure the tube is clearly labeled with all pertinent information. e. Serum specimens may be sent at room temperature unless otherwise indicated. See charts below.4. Storing and/or transporting the specimenAppropriate storage and handling are necessary to maintain the integrity of the specimen and,consequently, the test results. See guidelines and test index.
Specimen transport: a. Laboratory Specimens are sent directly to the laboratory via phlebotomist/courier: b. Specimens must be accompanied by a proper requisition/laboratory log. c. Date, time of collection, and initials of collector will be documented on the specimen. d. Specimens which must be kept cold must arrive in the laboratory on ice. e. Specimens are submitted in a leak proof container. f. Specimens are placed in plastic bags for transport. g. Couriers transporting lab specimens are trained to handle and deliver specimens appropriately.ACCEPTABLE SPECIMENS: 1. Specimens must be properly ordered, collected, labeled, accompanied by the correct requisition. If any of these criteria are not met, the specimen may be rejected for testing. 2. Condition of Specimen - Any specimen received in the laboratory must be collected correctly as to the container, quantity (volume), anticoagulant or not, condition (i.e., iced, protected from light, preservatives, etc.). 3. Specimen Preservation – Specimen’s received in the laboratory must be preserved according to the requirements of the ordered test.UNACCEPTABLE SPECIMENS: 1. Hemolysis - If a specimen is hemolyzed, it should be recollected, if appropriate. If it is not possible or practical to recollect a hemolyzed specimen, the physician must be notified of the condition of the specimen and it will be noted on the test results that the specimen was hemolyzed and the care giver notified. 2. Clotted whole blood specimens – If a specimen is clotted, i.e. complete blood count (CBC) or coagulation studies, it will be rejected. 3. Expired collection device. 4. Inappropriate collection device/specimen type. 5. Unlabeled specimens. 6. Leaking/broken specimen container. 7. Gross bacterial contamination of specimen. 8. Quantity of specimen not sufficient for testing. 9. Specimen not submitted at the proper temperature. 10. Rejected Specimen - The laboratory must use judgment in accepting or rejecting a specimen. There may be occasions when some answer is better than no answer. Communication with Nursing Services, the physician, or possibly even the patient may be necessary to determine the acceptability of a specimen. If the decision is made to do testing on less than optimal specimen, the following notation on the report must be made: 1) why the specimen was not acceptable, and 2) why the specimen was tested. 11. When a specimen is rejected, the following protocol is followed: a. Discard specimen. b. Notify caregiver. c. In laboratory information system enter test(s) rejected, describe situation completely in the comments section, documenting the first and last name and title of the person that is notified of the rejected specimen. d. If the specimen is recollected, the correct date, time, and initials of recollection will be documented by collector on the properly labeled recollected specimen. 12. When a test is reported from a less than optimal specimen, then later another more suitable specimen is received, the new results are substituted. An amended report is printed to the client. Documentation is kept of these proceedings.
13. A comment will be generated in the LIS for the collector that mislabels a specimen that causes the laboratory to document results on a wrong patient. 14. Any discrepancy related to patient name or client will follow the guidelines below: a. There will be no re-labeling of specimen. b. Specimen (when feasible) will be recollected, properly label, and transported to the laboratory. 15. Exceptions to the policy on rejecting specimens: a. CSF and other body fluids and surgical specimens – Invasive procedures that are performed on patients to obtain body fluids and/or tissues for testing purposes should be handled with care by collector, nurse, and laboratory. Clients and laboratory personnel will openly communicate so that all specimens collected will be labeled according to proper collection.Avoiding Common ProblemsCareful attention to routine procedures can eliminate most of the problems outlined in this section.Materials provided by the laboratory for specimen collection can maintain the quality of the specimenonly when they are used in strict accordance with the instructions provided. To ensure a sufficientquantity of each type of specimen indicated for the procedures to be performed, please consult thevolume requirements. Some of the problem areas listed will only become apparent when thephysician ordering the test interprets the results in conjunction with other diagnostic informationrelated to the patient.Specimen Collection – Some of the common oversights affecting all types of specimens include: • Failure to label a specimen correctly and to provide all pertinent information required on the test request form. • Insufficient quantity of specimen to run test or QNS (quantity not sufficient). • Failure to use correct container/tube for appropriate specimen preservation. • Inaccurate and incomplete patient instructions prior to collection. • Failure to tighten specimen container lids, resulting in leakage and/or contamination of specimen. • Failure to maintain the specimen at the appropriate temperature requirement.Serum Preparation – The most common serum preparation considerations include: • Failure to separate serum from red cells within 30-60 minutes of venipuncture. • Failure to allow clot specimens to clot before centrifugation. • Hemolysis: red blood cells broken down and components spilled into serum. • Lipemia: cloudy or milky serum sometimes due to the patient’s diet.Plasma Preparation – The most common lapses in the preparation of plasma include: • Failure to collect specimen in correct additive. • Failure to mix specimen with additive immediately after collection. • Hemolysis or damage to red blood cells. • Incomplete filling of the tube, thereby creating a dilution factor excessive for total specimen volume (QNS). • Failure to separate plasma from cells within 15-30 minutes of venipuncture for those specimens requiring this step.Urine Collection – The most common urine collection oversights include: • Failure to obtain a clean-catch, midstream specimen.
• Failure to refrigerate specimen or store in a cool place. • Failure to provide a complete 24-hour collection/aliquot or other timed specimen. • Failure to add the proper preservative to the urine collection container prior to collection of the specimen. • Failure to provide an appropriate collection container and to refrigerate specimen when bacteriological examination of the specimen is required. • Failure to tighten specimen container lid, resulting in leakage of specimen. • Failure to provide patients with adequate instructions for 24-hour urine collection.HemolysisIn general, grossly or even moderately hemolyzed blood specimens may not be acceptable fortesting. Hemolysis occurs when the red cells rupture and hemoglobin and other intracellularcomponents spill into the serum. Hemolyzed serum or plasma is pink or red, rather than the normalclear straw or pale yellow color.Most cases of hemolysis can be avoided by observing the steps listed. 1. For routine collections, use a 20 to 22 gauge needle. (It may be necessary to use a 23 gauge needle for patients from elderly populations with small or difficult veins.) 2. If there is air leakage around the needle or loss of vacuum in the tube, replace the vacuum tube. 3. Collect blood in room temperature containers unless the specimen requirement specifies otherwise. 4. When there is difficulty accessing a vein or when a vacuum tube fills too slowly due to a difficult venipuncture, damage to the red blood cells may result. Correct by collecting a fresh tube when blood flow is established or select another puncture site and, using sterile/unused equipment, collect a second specimen. Also, a blood pressure cuff will reduce trauma to fragile red blood cells. 5. Do not remove the needle from the vein with the vacuum tube engaged. This applies to both the last tube collected during a routine venipuncture and to tubes collected during a difficult procedure. 6. Premature removal of the tube causes a rush of air to enter the tube, which may result in damage to the red cells. 7. Be as gentle as possible, drawing the blood evenly. Too much pressure in drawing blood into a syringe or forcefully ejecting blood into a collection tube from a syringe may damage red cells. 8. Allow collection site to dry after cleaning. Alcohol used to clean the puncture site may cause contamination in a tube. 9. Do not collect a specimen in a hematoma. 10. Allow specimen to clot completely before centrifuging. 11. Do not centrifuge the specimen for a prolonged period of time.Vacuum Tubes Without Anticoagulants – When using vacuum tubes containing no additives: 1. Permit the tube to fill completely. 2. Let the specimen stand for a minimum of 15-30 minutes and (preferably) not longer than 60 minutes prior to centrifugation. This allows time for the clot to form. If the specimen is allowed to stand for longer than 60 minutes, chemical activity degeneration of the cells within the tube will take place, and test results may be affected. 3. Centrifuge the specimen at the end of the waiting period for 10 minutes and in accordance with the manufacturer’s instructions for speed.Lipemic Serum or Plasma (Turbidity)
Normal serum or plasma is a clear and light yellow to straw in color. Turbid serum or plasmaappears cloudy or milky.Serum or plasma may be cloudy due to bacterial contamination or chronic or transient high lipidlevels in the patient’s blood.The primary dietary sources of lipids (fatty substances) are meats, butter, cream, and cheese.Patients who consume these foods within the 24-hour period immediately preceding collection of ablood specimen may have temporarily elevated lipid levels, which may be manifested by cloudylipemic serum. Lipemic serum or plasma may not be a true indicator of the patient’s physiologicstate. Regardless of diet and length of fast, some patients may produce cloudy specimens.To avoid dietary-induced high lipid levels prior to testing, many physicians require to exclude thehigh-fat foods from their diets or to fast for 12-14 hours prior to specimen collection. For morningspecimen collection, the laboratory recommends that the patient be required to fast from 6 PM onthe previous evening.Quantity Not Sufficient (QNS)One of the most common problems in specimen collection is the submission of an insufficientvolume of specimen for testing. The laboratory sends out a report marked QNS, and calls for arepeat collection. To ensure an adequate specimen volume: 1. Always draw whole blood in an amount 2 ½ times the required volume of serum required for a particular test. 2. For example, if 4ml serum is required, draw at least 10ml whole blood. If there is difficulty in performing venipuncture, minimum volume may be submitted. Indicated “difficult draw” on the test requisition. 3. Provide patients with adequate containers and instructions for 24-hour and stool collections. 4. For most serum and plasma tests, check to be certain that the tube is half full. Note: Certain tests (eg, prothrombin time) require a 90% to 100% accurate draw in order to achieve the proper blood-to-anticoagulant ratio; otherwise, the specimen may be found to be QNS.Patient StatesIn general, specimens for determining the concentration of body constituents should be collectedwhen the patient is in a basal state (ie, in the early morning after awakening and about 12-14 hoursafter the last ingestion of food). Reference intervals are most frequently based on specimens fromthis collection period.The composition of blood is altered after meals by nutrients being absorbed into the bloodstream.Consequently, postprandial blood (blood drawn after a meal) is not suitable for some chemistrytests. An overnight fast is preferable to ensure that the patient is in the basal state. This minimizesthe effects of ingested substances on the test results. Before you collect the specimen, ask thepatient when he/she last ate or drank anything. If the patient has eaten recently and the physicianwants the test to be performed anyway, you should indicate “nonfasting” on the test request form. Inthe clinical information/comment section of the test request form, indicate the time the patient ate.Fasting does include abstaining from coffee, tea, or sugar-free products.Fasting or diet restrictions, such as low-fat diets, should be explained in detail, particularly to aged oroveranxious patients or their caregivers. Inform patients that fasting does not include abstaining fromwater. Dehydration resulting from water abstinence can alter test results.When specimens are not collected in the basal state, the following additional effects should beconsidered when interpreting test results.
• Exercise – Moderate exercise can cause an increase in blood glucose, lactic acid, serum protein, and creatine kinase (CK). • Emotional or Physical Stress – The clinical status of the patient can cause variations in test results. • Time of Day Collection – Diurnal variations and variations in circadian rhythm can also affect test results. For example, growth hormone peaks in the morning before waking and decreases throughout the day. Serum iron levels may change as much as 30% to 50%, depending on individual variation, from morning until evening.Note: For profile testing, 12-14 hour fasting specimens are recommended.Timed SpecimensThere are two types of timed blood specimens: One is for a single blood specimen ordered to bedrawn at a specific time. The other is for a test that may require multiple blood specimens to becollected at several specific times.Single Specimens – Here are some instances in which timed single specimens may be required. • Fasting plasma glucose alone or in conjunction with a random glucose determination, as recommended by the American Diabetes Association, to diagnose diabetes. Fasting here is defined as no caloric intake for at least 8 hours. • Postprandial glucose may be performed 2 hours after a meal for a timed test that is helpful in diabetes detection. • Blood glucose determinations may be ordered at a specific time to check the effect of insulin treatment. • Blood cultures may be ordered for a specific time if a bloodstream bacterial infection is suspected. • Therapeutic monitoring of patients on medication.Multiple Specimens – Here are some instances in which timed multispecimen tests may beordered. • The most common timed procedure is a glucose tolerance test. First, a blood specimen is drawn from a fasting patient. Then, the patient is given glucose orally and blood specimens are drawn at fixed intervals, beginning with a 30 minute specimen. • To test the effects of a certain medication, a physician may order the same tests to be obtained on consecutive days, before, during, and after the patient has received a medication. • Collection of an acute and convalescent serum to aid in the diagnosis of a viral infection when culturing is not feasible. • Other examples include such tests as occult blood, ova and parasites, and blood cultures.Blood CollectionThe accuracy of any result depends upon the quality of the specimen. Following the collection,preparation, and instructions suggested by the laboratory helps to ensure the best possible testresults. The laboratory supplies materials for proper specimen collection.Proper identification of specimens is extremely important. Label each specimen. Information onlabels must be verified before the specimen is submitted to the laboratory. The name on the testrequest form must exactly match the patient’s name on the specimen submitted.
Anticoagulants and Preservatives – To ensure accurate test results, all tubes containing ananticoagulant or preservative must be allowed to fill completely. Attempts to force more blood intothe tube by exerting pressure, as in collection with a syringe, will result in damage to the red cells(hemolysis). If the vacuum tube is not filling properly, and you are certain that you have entered thevein properly, substitute another tube.Urinalysis and Culture and SusceptibilitySubmit a sterile container or urinalysis preservative tube and culture and susceptibility preservativetube. Label both filled tubes with patient’s full name and date and time of specimen collection.Urinalysis OnlySubmit a sterile container or urinalysis preservative tube. Label filled tube with patient’s full nameand date and time of specimen collection.Culture and Susceptibility OnlySubmit a culture and susceptibility preservative tube. Label the filled tube with the patient’s nameand date and time of specimen collection. Enter the source in the Laboratory Log. i.e., catheter,clean catch, etc.Random Urine Collections for Routine AnalysisPatients should be provided with both written and spoken “clean-catch” instructions. The collectedurine should be added to the appropriate urine preservative tube or refrigerated immediately toretard growth of bacteria until the test is performed.The time of collection is critical because urine values vary considerably during a 24-hour period, andmost testing methods are based on normal values for first morning samples. The first urine voided inthe morning is preferred because it has a more uniform volume and concentration and a lower pH,which helps preserve the formed elements.24-Hour Urine CollectionFor many urine chemistry, it is necessary to analyze a sample taken from an entire 24-hourexcretion. Incorrect collection and preservation of 24-hour urine collections are two of the mostfrequent lapses in urine collections.
The 24-hour urine specimen should be submitted in a chemically clean, properly labeled urinecontainer provided by BestCare Laboratory Services. (Patients should not be allowed to submiturine specimens in their own “clean” jars. The laboratory will add required preservatives or suppliesthe proper preservative with the container.Written instructions should clearly explain the following points: 1. The collection of the 24-hour urine starts with the patient voiding (completely emptying bladder) and discarding the first urine passed in the morning. 2. Except for this first discarded urine, all of the urine passed during the day and night, up to and including the first voiding of the following day, must be collected. Urine passed during bowel movements must also be collected. 3. If possible, the entire specimen should be refrigerated at 2oC to 8oC during collection, or kept in a cool place, since urine is an excellent culture medium for organisms, and its components decompose quickly. 4. The 24-hour urine container may contain a preservative of acetic acid, boric acid, or hydrochloric acid, which may cause burns if touched. If ingested, a physician should be notified immediately. The patient should be informed a normal intake of fluids during the collection period is desirable unless otherwise indicated by the physician or test specimen requirements.Recommended Patient Instructions for 24-Hour Urine CollectionsThis section includes written instructions to be provided to the patient with the specified laboratorycollection container. Supplement these instructions by discussing them with the patient andexplaining why the test and collection procedures are necessary. Collection containers that includeacids should be clearly marked. Contact the laboratory for the collection container(s).To the care giver: You may wish to photocopy these instructions so you can provide your patientswith written instructions.To the patient: Follow these instructions in collecting your 24-hour urine specimen.You will find it more convenient to void (urinate) into the smaller container provided and transfer theurine into the larger collection container. Do not add anything but urine to the container and do notpour out any liquid, tablets, or powder that may already be in the larger collection container. Thesesubstances may cause burns if touched. The collection container should be kept tightly closedand refrigerated throughout the collection period. 1. Upon rising in the morning, urinate into the toilet, emptying your bladder completely. Do not collect this sample. Note the exact time and print it on the container label. 2. Collect all urine voided for 24 hours after this time in the container provided by the care giver. All urine passed during the 24-hour time period (day or night) must be saved. Urine passed during bowel movements must also be collected. 3. Refrigerate the collected urine between all voidings or keep it in a cool place. 4. At exactly the same time the following morning, void completely again (first time after awakening), and add this sample to the collection container. This completes your 24- hour collection. 5. A BestCare Laboratory representative will transport the specimen to the laboratory.
Microbiology Specimen Criteria: Collection and HandlingIntroductionThe quality of microbiology results is heavily dependent on receipt of adequate, representativespecimen material, properly collected, and promptly delivered to the laboratory. Specimens shouldbe collected early after onset of symptoms and before antimicrobial therapy is instituted. Tests areordered by the physicians and entered into the lab log by nurses, ward clerks, or other personnel asdesignated by the facility. The specimen is labeled and sent to the Laboratory accompanied by thelaboratory log.1. All specimens for microbiological examination are collected in sterile containers in a sufficient quantity to permit a complete examination. Whenever possible, specimens should be obtained before antibiotics are administered.2. All specimens are sent to the laboratory promptly, in a sterile container when required, of sufficient quantity for complete examination, and the container is to be closed tightly and have NO leakage.3. Each specimen should be labeled with patients name, collection location, date and time of collection, and specimen source. The initials of the person collecting the specimen should be included next to the time and date.4. All specimens must be transported to the laboratory in a biohazard bag.6. In the case of unacceptable specimens, if re-collection is not possible, the state of the specimen will be documented on the laboratory report including the person notified.Unacceptable Specimens:Specimens that fall into any of the following categories should be considered unacceptable forprocessing: 1. Specimens not submitted in a sterile container when required. 2. Improper label, order slip and/or specimen container as to the source of specimen, patients full name, location, collection time and date (where applicable). 3. Name on order or label and the specimen is mismatched. 4. Urine specimen not submitted immediately if not in preservative tube or refrigerated. 5. Stool specimen contaminated with barium (white area, chalky, heavy) or oil for the examination of ova and parasites. 6. Sputum consisting of saliva, only. 7. Specimen received after prolonged delay. 8. Specimen in a leaking container or specimen evident on the outside of the container. 9. Specimen in fixatives. 10. Dried-out swabs. 11. Requests for anaerobic cultures on expectorated sputum, superficial wounds, urine, feces, throat, vaginal swabs, or urethral discharge. 12. Insufficient amount of specimen. 13. Specimen left in the refrigerator is not acceptable if the organism is to be isolated is fastidious or cold sensitive, such as gonococci. 14. Pooled (24-hour) specimens. 15. Specimens not received in transport media or system when required.Handling Unacceptable Specimen’s 1. Upon receipt of an unacceptable specimen in the Laboratory, the nursing unit is immediately notified. BestCare Laboratory Services, Inc. informs the nurse or physician that the specimen
will not be processed and request a freshly, properly collected specimen be sent to the laboratory. And, explains the reason for the rejection. In the "Comments" area of the LIS, the reason for the rejection is documented, the name of the person receiving the explanation, the date and time of the rejection. 2. If a specimen cannot be re-collected (ex: specimen collected in O.R. and patient is no longer in O.R., patient already started on antibiotics, etc.) the laboratory will note the condition of the specimen so that it will be a permanent record along with the culture results.Procedure for Collection and Handling:Caution: Pathogenic microorganisms, including Hepatitis B Virus and Human ImmunodeficiencyVirus, may be present in specimens. Universal Precautions and guidelines established by thelaboratory should be followed in handling all items contaminated with blood or body fluids. Weargloves at all times. Properly dispose of all contaminated materials.1. ANAEROBIC CULTURESSpecial precautions must be taken in the collection of specimens from certain sites. Most of the anaerobesfound associated with infections in humans are also present on mucous membranes as normal flora. Theseanaerobes are so numerous at these sites that if clinical material comes into contact with a minute portion ofnormal flora, false positive or misleading culture results will be obtained. Any specimens collected should betransported as rapidly as possible. The specimen should not come in contact with air or oxygen.ACCEPTABLE ANAEROBIC CULTURE SOURCES:Site designations on culture orders must come from this list, or will be considered unacceptable byMicrobiology at BestCare Laboratory Services, Inc. for anaerobic workup.BODY FLUIDSAmniotic fluidAscitic fluidBileBloodBone marrowPericardial fluidPeritoneal fluidPeritoneal dialysatePleural fluidSynovial fluidThoracentisisCENTRAL NERVOUS SYSTEMBrain abscessIntracranial surgery woundHEAD AND NECKChronic sinusitisMaxillary sinusMiddle ear fluidChronic otitis mediaNeck woundsScalp woundsDENTAL, ORAL, FACIALOrofacial, of dental originRoot canal infection
Periodontal abscessDental abscess (endodontic origin)Mandibular areaBite woundsSublingual spacesPertonsiilar abscessLOWER RESPIRATORY TRACT - PLEUROPULMONARYAspiration pneumoniaLung tissueLung abscessBranch brushingsBronchoscopy specimens obtained via double lumen catheterEmpyema (accumulation of pus in thorax)Trans-tracheal aspirateABDOMINALAbdominal cavityAbdominal fluidAppendixAppendix with peritonitisLiver abscessOther intra-abdominal infections (post surgery)Biliary tractPerirectal abscessPeritoniumPeritoneal fluidRetroperitoneal abscessOBSTETRIC - GYNECOLOGICEndometriumEndocervicPelvic AbscessVulvovaginal abscessSeptic abortionBartholin ascessOvaryPlacenta - fetal or maternal sideUterineFallopian tubeCuldoscopy aspiratesEndometrial aspiratesMALE REPRODUCTIVEProstatic fluid Testicular abscessSOFT TISSUE AND MISCELLANEOUSEndocarditisCatheter exit site other than foley catheterPilonidal sinusBite wound sitesInfected diabetic gangreneDeep decubitus ulcersOsteomyelitisCellulitisGangrene (myonecrosis)
Breast abscessAll tissuesAll biopsiesAspirated pusAll surgical woundsBoneAll deep woundsRoutine Specimens for Culture of Anaerobes:a. Necrotic or debrided tissue from suspected gas gangrene, gas forming or necrotizing infections.b. Pus or aspirate from deep wound or abscess.c. Amniotic fluid, bile, bloods.d. Endometrium, uterine material from septic abortions, uterus, placenta, Bartholin glands.e. Biopsies or surgical specimens.f. Pericardial, peritoneal, pleural, or synovial fluid, bone marrow.g. Peritoneal dialysate.h. Drain, prosthesis, CVPi. Trans-tracheal aspirate.Specimens for Cultures of Anaerobes by Request:a. Eye, earb. Vaginal cuffc. Material from infected bitesd. Supra-pubic bladder aspiratee. Bronchoscopic specimensf. Rectal swab in cases of suspected pseudomembraneous enterocolitisg. CSFUNACCEPTABLE SOURCES FOR ANAEROBIC CULTURESpecimens collected from the following sources will not be processed.a. Sputumb. Nasotracheal suction aspiratec. Throat swabd. Nasal swabe. Oropharyngeal swabf. Gastric contentsg. Small bowel contents or fecesh. Cervical, vaginal, rectal, or urethral swabsI. Clean-catch or catheterized urinesj. Superficial woundsAbscesses: • Post-operative wounds, in most cases, it is necessary to obtain an aspiration sample with a sterile needle or intravenous catheter attached to sterile syringe. • A swab is not regarded as an acceptable method of collection for anaerobic bacteriology cultures. Instead, an aspirate should be obtained whenever possible. If swabs have to be obtained, use a culturette approved for anaerobic collection such as Becton Dickinson’s Max V+ system. • If there is only a very small amount of drainage or exudate present for study, the lesions can be injected with sterile water or saline and the specimen obtained from the edge of the lesions by aspiration. After aspirating the specimens, air bubbles must be expelled from the syringe; otherwise, the trapped oxygen alters the transport conditions. • The syringe can be immediately submitted to the laboratory after plugging with a sterile rubber stopper. If the specimen cannot be transported to the laboratory immediately, the
specimen in the syringe can be inoculated into a blood culture bottle (clean the top with 70% alcohol before inoculating the specimen). Anaerobic(gel) or MAX V +swabs must be used.Lung Abscess, Pneumonia, and other Pulmonary Infections: • In-patients with pulmonary infections believed to be due to anaerobes, trans-tracheal needle aspiration or direct lung punctures are the optimal methods. Pleural effusions, empyema fluid and surgically removed tissue are other reliable sources for anaerobic cultures. (Bronchoscopically obtained specimens are not suitable, as the instrument itself becomes contaminated during insertion.) • The same transport methods are used as for abscesses. Tissue should be placed in a sterile container and submitted to the laboratory immediately.Uterine Infection: • Anaerobic cultures are routinely performed from the uterine cavity by syringe or swab, using great care to avoid contamination. Anaerobic cultures are routinely performed on material from placenta, Bartholin glands, endometrial cavity, and fallopian tubes.Transport methods are the same as for abscesses.Urinary Tract Infection: • Anaerobic bacteria rarely cause urinary tract infections. The ONLY way their presence can be documented is by supra-pubic aspiration since anaerobic bacteria normally colonize the distal urethra. Transport methods are the same as for abscesses. Label the specimen as supra-pubic aspiration.Body Fluids: • Blood, ascetic fluid, synovial, prostatic, pericardial and pleural fluid is routinely cultured for anaerobes and should be collected and transported as described in "Anaerobes".***** CLINICAL HINTS SUGGESTING POSSIBLE INFECTION WITH ANAEROBES ** 1) Foul-smelling discharge. 2) Location of infection in proximity to a mucosal surface. 3) Necrotic tissue, gangrene, pseudomembrane formation. 4) Gas in tissues or discharges. 5) Endocarditis with negative routine blood cultures. 6) Infection associated with malignancy or other process producing tissue destruction. 7) Infection related to the use of aminoglycosides (oral, parenteral or topical). 8) Septic thrombophlebitis. 9) Bacteremic picture with jaundice. 10) Infection following human or other bites. 11) Black discoloration of blood-containing exudates. 12) Presence of "sulfur granules" in discharges (Actinomycosis). 13) Classical clinical features of gas gangrene. 14) Clinical setting suggestive for anaerobic infection (septic abortion, infection following gastrointestinal surgery, etc.)2. BODY FLUIDS (CSF, Synovial, Peritoneal, Pleural, Thoracentesis, etc.)CSF: • Physicians are provided with sterile, flat-bottom centrifuge tubes in order to reduce specimen handling. Label each tube with patient name and information. The specimen tubes are numbered in the order in which they were obtained. Collection of the specimen is under aseptic or sterile conditions and transported to the lab immediately, properly labeled. Prompt transport of the specimen to the laboratory is mandatory since fastidious organisms
such as Haemophilus influenzae and Neisseria meningitidis may not survive storage or variations in temperature. A CSF order is processed immediately and on a priority basis. Gram stains are performed on all CSF specimens with bacterial cultures.Fluids: • Specimen material may be sent in sterile flat bottom centrifuge tubes or sterile container (if fluid is collected with sterile syringe, the needle must be removed prior to transportation to lab). Protect the specimen from oxidation because anaerobes may be present (see Anaerobe section above). Expel any accumulated air from syringes. Label specimen with patient name and information. Transport to the lab immediately. In addition to a routine aerobic culture, an anaerobic culture and gram stain are performed on all body fluid sources except CSF.NOTE: Fluids or pus collected with a sterile syringe and needle can be transported to the lab in the syringe after plugging the syringe with a sterile rubber stopper. Any air bubbles should be expelled from the syringe before transport.3. GENITALThe lining of the normal human genital tract is a mucosal layer made up of epithelial cells. A varietyof species of commensal bacteria colonize these surfaces, causing no harm to the host and helpingto prevent the adherence of pathogenic organisms. The flora of the female genital tract varies withthe pH and estrogen concentration of the mucosa, which is dependent on the age of the host.Microbiological cultures are performed to identify the microorganisms, which may be the etiologicalagent.Clinical Specimen from Suspected Site of Infection:a. Urethral Discharge - collected with a flexible aluminum wire and small rayon-tipped swab. The swab is inserted approximately 2 cm into the urethra and rotated gently before withdrawing. Remove the swab and insert it into the sleeve containing aimes gel medium. Push the cap to bring swab into contact with the gel at the bottom. Label specimen with patient name and information and LIS label containing orders. Transport to the lab immediately.b. Cervix - collected with a swab inserted into the cervical canal, rotated and moved from side to side for 30 seconds before removal. Swabs are handled same as above but a culturette swab is routinely used.c. Vaginal - same as cervix except specimen is collected from vagina.d. Endocervix - collected after the vagina has been exposed by insertion of a speculum.NOTE: Urethral, penile, cervical, and vaginal discharge may be directly inoculated on a Martin-Lewisplate. • Organisms such as Neisseria gonorrhoreae will not survive on a dry swab. If a smear for Gram stain is prepared, roll (do not drag) the swab over a slide. Label specimen(s) with patient name and information. Transport to the lab immediately. The orders should be entered into the lab log and the log must accompany the specimen to the laboratory.WET PREP test: For Trichomonas vaginalis, place a specimen swab in 0.5 ml of sterile physiologicalsaline. Label specimen with patient name and information. Transport to the lab immediately. Theorders should be entered into the lab log and the log must accompany the specimen to thelaboratory.4. RESPIRATORY
The respiratory tract begins with the nasal or oral passages and extends past the nasopharynx andoropharynx to the trachea and then into the lungs.The upper respiratory tract is the upper airway from the larynx through the nasopharynx andneighboring oropharynx to the nose, to its communicating cavities, the sinuses, and middle ear.A number of microorganisms can cause infections of the upper and lower respiratory tract.Respiratory tract cultures are performed to establish the etiology of such infections.Upper Respiratory Cultures: • Throat:-Throat cultures are performed for the diagnosis of pharyngitis. Bacterial agents recognized to cause pharyngitis include beta hemolytic streptococci, C. diptheriae, N. gonorrhoreae, N. meningitidis, Staphylococcus aureus, Mycoplasma pneumoniae, and H. influenzae (in children). Of these organisms, beta hemolytic streptococci occur most frequently and are the usual concern. Therefore, most throat cultures are done to rule out pharyngitis due to beta hemolytic streptococci, although, on selected occasions other organisms might be of concern.Collection:1. Use culturette to collect the specimen.2. Use tongue blade to depress tongue to minimize contamination.3. Swab vigorously tonsillary area, posterior pharynx, any area of inflammation, ulceration, or capsule formation.4. Put the swab back in the tube and transport it to the lab with appropriate label.Nasopharyngeal:Collection:1. Use calcium alginate swab on a flexible wire (minitip) to obtain the culture.2. Pass the swab gently through the nose into nasopharynx, rotate and remove the swab.3. Place the swab in a plastic tube provided with the culturette.4. Transport the culture to the lab, correctly labeled.Influenza A & B:It is recommended that specimens be obtained early in the course of the illness and be tested assoon as possible.1. Acceptable specimens for evaluation with the Xpect® Flu A&B test include nasal washes, nasal swabs, and throat swabs.2. Use a rayon or polyester- tipped swab with aluminum or plastic shafts to collect the specimen. Calcium alginate should not be used.3. Samples may be placed in a viral transport medium or 0.5ml of sterile saline in a sterile containaer. Contact BestCare Laboratory Services for appropriate collection container.4. Refrigerate the sample after collection.NOTE: For RSV and/or Bordetella Pertussis please refer to individual proceduresfor these sendout tests.Sputum, Bronchial Wash, Tracheal Aspirate:Pneumonia remains a leading cause of death in the U.S. in spite of effective antibiotics. Accurateetiologic diagnosis of lower respiratory infections is essential for proper management of suchinfections.Collection:
Expectorated Sputum: These specimens are adequate for the detection of aerobic and facultativeorganisms, but not for anaerobes. Sputum screening by gram stain is essential to ensure that thespecimen consists of lower respiratory secretions. • Collect specimens in sterile container that can be sealed to prevent leakage. Collect sputum under supervision to ensure that the specimen is a cough specimen. • Transport the specimen to laboratory immediately to ensure organism viability.Screening of expectorated sputum for the number of epithelial cells present is performed routinely onexpectorated sputum submitted for "routine culture". This is done in an effort to make sputumcultures more diagnostic. If a specimen has more than 25 epithelial cells and no wbcs or very fewwbcs, the sputum will be rejected for culture since the screen shows that the specimen is moresaliva than expectorated sputum.Microbiology lab will notify the Nursing service immediately if a new specimen is needed.Nursing service will either recollect or notify Respiratory Therapy immediately for recollection.Sputums aspirated by Respiratory Therapy do not need to be screened with a gram stain since theintegrity of the sputum is assured.5. STOOLCulture specimen:1. Stools for best recovery of Salmonella and Shigella should be obtained in the acute (first 3 days) of diarrheal disease.2. Rectal swabs are permissible when stool specimens are not readily obtained. However, maximum recovery of organisms is not likely when swabs are used.3. Multiple stool samples should be submitted to increase chances of recovery of organisms (3 samples/admission).4. Stool specimen containers have to be sterile when submitting for culture.5. Label container correctly.6. Complete appropriate information in the laboratory log/requisition including date and time of collection. Order the tests requested by the physician.7. Special requests should be put into "comments" and/or called to Micro Laboratory. The special request must also be clearly marked on the label of the container, (i.e. look esp. for Yersinia, etc.).8. Deliver specimen and request to laboratory immediately. Pathogenic stool organisms are very fragile and specimen requires immediate processing to ensure best possibility of recovery. Refrigerate specimen and transport on ice pack. Stool specimens stored at room temperature greater than 2 hours will be rejected.Occult Blood:Patient Preparation:Diet: It is recommended that the patient be placed on a high residue diet starting 2 days before andcontinuing through the test period.The diet may include:1. Meats - Only small amount of well-cooked chicken, turkey, and tuna. NO red or raw meat should be included in the diet.2. Vegetables - Generous amounts of both raw and cooked vegetables including lettuce, corn, spinach, carrots, and celery. Avoid raw vegetables with high peroxidase activity such as turnips, cauliflower, red radishes, broccoli, cantaloupe, horseradish, and parsnip.3. Fruits - Plenty of fruits, especially prunes and apples.4. Cereals - Bran and bran-containing cereals.5. Peanuts and popcorn in moderate amount daily.
If any of the above foods are known to cause discomfort, contact the physician.Medications:For 7 days prior to and during the testing, no aspirin or any other anti-inflammatory medicines should be taken.For 2 days prior to and during the testing, no rectal medicine should be used.For 2 days prior to and during the testing, no tonics or vitamin preparations containing Vitamin C in excess of 250 mg/day should be taken.Collection:1. Collect specimen in a plastic or waxed container. Container does not have to be sterile.2. Specimen may be collected and applied to a Hemoccult slide: a. Open the front flap of the Hemoccult slide. Apply a very thin smear of stool specimen to one window of the slide, using an applicator. b. Use an applicator to obtain a second sample from the same specimen, but from a different area. Apply similarly. c. Allow the specimen on the slide to air dry and close the cover.Transport the specimen or Hemoccult slide to the laboratory promptly and correctly labeled.Fecal Leukocytes (WBCs):Collect stool specimen in a clean or non-sterile container. The container must contain NO preservativesand must be leak proof. Transport the specimen to the lab promptly, correctly labeled, and with theappropriate requisition.Clostridium difficile:Collect stool specimen in a clean or non-sterile container. The container must contain NO preservativesand must be leak proof. Store specimens between 2° and 8°C (Refrigerate).6. URINES:To ensure the most accurate results from urine cultures, proper instruction and techniques should beemployed during collection. Always place specimens in a sterile container, preferably the BectonDickinson Transport Tube with preservative. The urine should always be collected before any antibiotictherapy is begun, unless the physician orders the culture in the midst of antibiotic therapy.The first voided morning specimen should be collected whenever possible. If this is not possible, urineshould be allowed to incubate in the bladder for as long as possible before the collection to increasethe number of organisms per milliliter.The orders should be entered into the lab log and the log must accompany the specimen to thelaboratory.A urine specimen for culture may be used for routine urinalysis if it collected in a sterile container thatdoes not contain preservatives and the urinalysis has been ordered. Urine received in a gray top UrineTransport Tube is not suitable for urinalysis.Urine collected in a sterile container without preservative must be refrigerated immediately. Deliver tothe laboratory within 2 hours of collection, no greater than 24 hours to ensure quality of testing.Collection methods for Urine Culture:1. Suprapubic aspiration of the bladder is performed by the physician and involves direct puncture of
the bladder through the lower abdominal wall using a sterile needle and syringe. This is the preferred method for collecting urine from infants. Transfer to a sterile container.2. Straight catheter- Obtaining urine by single straight catheterization of the bladder is not routinely recommended, as there is a variable risk of introducing bacteria into the bladder.3. The physician performs cystoscopy or bilateral ureteral catheterization. A sample is collected in a sterile tube and labeled as CB (catheterized bladder urine), LK (left kidney urine), or RK (right kidney urine).4. Indwelling catheter- For collection of a specimen from an indwelling catheter, clean the catheter with Betadine followed by 70% isopropanol, puncture directly with a needle and syringe, and withdraw several cc’s of urine. Place urine in a sterile container. Obtaining urine that has collected in a Foley bag is not recommended since urine from this site may be overgrown with bacterial flora from outside the urinary tract.5. Clean catch, midstream urine-Patient must thoroughly wash their hands with soap and water and then dry their hands, • A male patient should retract the foreskin and cleanse the glans with an antiseptic towelette. Instruct the patient to void the first portion of the urine into the toilet bowl and then void a portion of the midstream urine into a sterile container. • A female patient should spread the labia with one hand and wash the vulva 2 or 3 times, using an antiseptic towelette. The towelette should be used in front to back movements only and be followed by rinsing with warm sterile water. The patient should void the first portion of urine into the toilet bowl and then void urine directly into the sterile container, without stopping the stream. The container should be held in such a way as to avoid contact with the vulva, leg, or clothing.NOTE: If the patient is not capable of cleansing himself/herself, especially in the case of abedridden patient, the nursing attendant should follow the above procedure for cleansing the patientbefore specimen collection.7. Miscellaneous:Bone:Specimens from orthopedic procedures or post-op complications must be transported to thelaboratory immediately in a sterile container properly labeled. Indicate the specific site when orderingthe culture on the lab log.Catheter Tip:Collect the tip aseptically and transport to the laboratory quickly in a sterile container properlylabeled. Indicate the specific site when ordering the culture on the lab log.Ear:Culture of an infected ear is obtained by swabbing the infected area with the flexible mini tipswab/culturette. Refer to the section on Nasopharyngeal culture for use, labeling, ordering, andtransporting the specimen to the laboratory.Eye:Culture must be taken before topical anesthetics or antibiotics are applied. 1. Swab the infected area and replace the swab in the plastic tube provided with the culturette. 2. Label the specimen, order the culture on the laboratory log/requisition, and transport to the laboratory as soon as possible. 3. Gram stains should be prepared at the bedside. Label the slides and transport the slides to the microbiology department. 4. Corneal scrapings need to be taken after the application of topical anesthetics. Material should be directly plated on blood and chocolate agar plates and into thioglycollate broth. The media can be obtained from the microbiology department.Skin and Superficial Wounds:1. Disinfect the lesion area with 70% alcohol. Allow to dry.
2. Swab the infected area with the swab from the culturette.3. Return the swab to the plastic tube of the culturette.4. When dealing with productive lesions, discard the surface material. Use the exudate from the interior of the lesion for the microbiological analysis.5. Properly label the culturette including stating the specific site from which the culture material was obtained.6. Order the test on the laboratory log and transport the specimen to the laboratory.Neisseria gonorrhea Specimens:Genital specimen: 1. A culture may be collected with a culturette. 2. Order the culture on the laboratory log/requisition and label the swab. Transport to the laboratory immediately.Note: If the physician orders a smear, make a thin smear of the specimen and allow to air dry. Labelthe frosted (or white) end of the slide in pencil with the patient’s name, date of birth, source, anddate. Place the slide in a cardboard slide box and transport to the laboratory with the appropriateorders.Throat, Rectal, Anal Swabs for N. gonorrhea: 1. Collect specimens with swabs provided in the culturette system. Follow proper procedures for labeling, ordering, and transporting to the lab. 2. In addition to labeling the specimen, also note on the specimen that the culture is for “GC”.8. Blood Cultures:Because blood culture media have been developed as enrichment broths to encourage themultiplication of even one bacterium, it follows that these media will enhance the growth of any straycontaminating bacteria, such as a normal inhabitant of human skin. Therefore, careful skinpreparation before collecting the blood sample is of paramount importance to reduce the risk ofintroducing contaminates into blood culture media.Site selection: 1. Select a different body site for each culture set (aerobic and anaerobic vial) drawn. 2. Avoid drawing blood through indwelling intravascular catheters unless blood can not be obtained by venipuncture. Blood collected from intravascular catheters should be done with the knowledge that contamination may be an issue. If the patient has an existing IV line, the blood should be drawn below the existing line; blood drawn above the line will be diluted with the fluid being infused.Site preparation: 1. Clean the intended venipuncture site with alcohol prep. 2. Open the ChloraPrep package. Apply ChloraPrep disinfectant by beginning at the intended venipuncture site, working in a circular motion with friction, covering an area of 2-3 inches in diameter. Do not return to the center of the site once swab has moved outward to the periphery. ChloraPrep or Iodine should be applied with friction and the site prepped 30 seconds to 1 minute. 3. Allow disinfectant solution to air-dry. 4. DO NOT touch or palpate the area after cleansing.Disinfection blood culture bottles: 1. Remove the flip-off caps from BACTEC culture vials. 2. Wipe top of each vial with a separate 70% isopropyl alcohol pad and allow drying 3. Do not use ChloraPrep to disinfect tops of vials.Venipuncture: 1. Avoid touching the venipuncture site. If it is necessary to touch the site after it has been cleaned, wipe your fingers with the iodine prep before touching the site.
2. When using the Blood Collection Set (“butterfly”) the phlebotomist MUST carefully monitor the volume collected by using the 5 mL graduation marks on the vial label. If the volume is not monitored, the stated maximum amount collected may be exceeded. This condition may adversely create a ‘false’ positive result, due to high blood background. 3. If using a needle and syringe, typically a 20 mL syringe is used for adults. Draw 16 to 20 mL of blood for one blood culture set (aerobic and anaerobic). Aseptically inject 8 to 10 mL of specimen into each vial 4. For pediatric patients, a 3 mL syringe is frequently used. Draw 1 to 3 mL of blood and transfer the entire amount into BACTEC™ PEDS PLUS/F vial. 5. After all specimens have been collected from the individual, use a sterile alcohol pad to remove the iodine solution from the venipuncture site. 6. Continue to care for the venipuncture site following guidelines recommended by BestCare Laboratory Policy. 7. The inoculated BACTEC vials should be transported as quickly as possible to the laboratory.Volume: The volume of blood cultured is critical because the number of organisms per mL of blood in most cases of bacteremia is low, especially if the patient is on antimicrobial therapy. Because there is a direct relationship between the volume of blood and the yield, it follows that the more blood that is cultured, the greater the chance of isolating the organism. In infants and children, the number of organisms per mL of blood during bacteremia is higher than adults, so less blood is required for culture. 1. Children: 1 to 5 mL of blood per venipuncture. Transfer the entire amount to a BACTEC™ PEDS PLUS/F vial. 2. Adult: 16 to 20 mL of blood per venipuncture. If it is impossible to draw the required amount, aliquot as follows: Amount in BACTEC Amount in BACTECAmount per Venipuncture Plus Aerobic Vial Plus Anaerobic Vial16 - 20 mL Split equally between aerobic and anaerobic vials13 -16 mL 8 mL 5 - 8 mL10 -12 mL 5 - 7 mL 5 mL5 - 9 mL entire blood amount 0NOTE: Optimum recovery of isolates will be achieved by adding 8 to 10 mL of blood (BACTEC PEDS PLUS/F: 1 - 3 mL). The use of lower or higher volumes may adversely affect recovery and/or detection times.Specimen labeling-Each vial should be labeled with the appropriate patient information: • Patient’s name • Patient ID number • Patient’s Date of Birth • Ordering Physician • Date and time of collection • Collector’s initials • Site of venipuncture • Or other information as per facilityOrdering of Blood Cultures: Each set of Blood cultures should be ordered on the laboratory log/requisition and a site of collection must be noted on both the log and the bottle. The test can then be ordered in the laboratory by laboratory personnel.Timing of Collection:
The timing of cultures is not as important as other factors in patients with intravascular infectionsbecause organisms are released into the bloodstream at a fairly constant rate. Because thetiming of intermittent bacteremia is unpredictable, it is generally accepted the two or three bloodcultures be spaced about an hour apart. However, a study found no significant difference in theyield between multiple blood cultures obtained simultaneously or those obtained at intervals. Theauthors concluded that the overall volume of blood cultures was more critical to increasingorganism yield than was timing.When a patient’s condition requires initiating antibiotic therapy as soon as possible, there is littletime to collect cultures over a timed interval. An acceptable compromise is to collect 40 mL ofblood at one time, 20 mL from each of two separate venipuncture sites, using two separateneedles and syringes before the patient is given antimicrobial therapy. Blood cultures aretransported to the laboratory.
THERAPEUTIC DRUG MONITORINGDIGOXIN Π specify time of last dose and dosageLITHIUM Π specify time of last dose and dosageDILANTIN Π specify time of last dose and dosage Trough: 30 minutes prior to next dose. Peak: 4 to 6 hours last doseTHEOPHYLLINE Π specify time of last dose and dosageTOBRAMYCIN Π specify time of last dose and dosage Trough: Immediately before subsequent dosing Peak: IV – 30 minutes after end of 30 minutes infusion or within 15 minutes after a 60-minute infusion IM – 60 minutes post injectionGENTAMICIN Π specify time of last dose and dosage Trough: Immediately before next dose Peak: 60 minutes post IM injection 30 minutes after end of 30-minute IV infusion Directly after 60-minute infusionAMIKACIN Π specify time of last dose and dosage Trough: Immediately before subsequent dose Peak: 60 minutes post IM injection or 30 minutes after end of 30-minute IV infusion or Directly after 60-minute IM infusionCARBAMEZEPINE Π specify time of last dose and dosage(Tegretol) Peak: 3 hours after an oral dose (patients on chronic therapy)PHENOBARBITAL Π specify time of last dose and dosage Trough: Immediately before next oral doseVALPROIC ACID Π specify time of last dose and dosage(Depakote) Trough: Immediately prior to next dose. Peak: 1 to 4 hours after dose.VANCOMYCIN Π specify time of last dose and dosage Trough: Immediately before next dose Peak: 90 minutes after end of a 60-minute IV infusionFactors that may affect sampling times for TDM: Patient age, weight, sex All drugs patient is receiving Dosage regimen and dosage form of each drug Clinical status of patient (e.g., renal and hepatic function, etc.)
Critical Value GuidelinesFor procedures performed at BestCare Laboratory, the following values are considered criticalvalues: • Once a value has exceeded the established limits outlined above, the technologist may verify it by repeat testing. • The results will immediately be conveyed to the staff nurse (working under the direction of the physician). If the staff nurse is not available the Charge nurse will be notified.All notifications will be documented in the Laboratory Information System (LIS) with the name of theperson called, date, time, and initials of Technologist calling results. The Technologist will documentthat the critical value regarding the patient is read back correctly.TEST LOW HIGHChemistryAmmonia NA >/= 100 umol/LSodium </= 125mmo/L >/= 155 mEq/LPotassium </= 3.0mEq/L >/= 5.8mEq/LChloride </= 80mEq/L >/= 120mEq/LCarbon Dioxide </= 11mEq/L >/= 40mEq/LBUN NA >/= 80mg/dLCalcium </= 7.0mg/dL >/= 13.0mg/dLGlucose </= 40mg/dL >/= 400mg/dLCK NA >/= 170U/LCKMB NA >/= 4.4 ng/mLMagnesium <1.0 mg/dLTroponin I NA >/= 0.40 ng/mLHematologyWBC </= 2.0k/uL >/= 20.0K/uLHGB </= 8.0g/dL >/= 20.0g/dLHCT </= 24.0 % >/= 60.0 %Platelets </= 50,000 uL >/= 900,000 uLCoagulationPT >/= 30 secondsINR >/= 3.6APTT >/= 45 secondsD-Dimer >/= 400 ng/mLTherapeutic DrugsDrug levels noted to be in the Toxic RangeCarbamezapine NA >/= 20 ug/mLDigoxin NA >/= 2.5 ng/dLLithium NA >/= 2.0 mmol/LPhenobarbital NA >/= 20 ug/mLPhenytoin (Dilantin) NA >/= 30.0 ug/dLTheophylline NA >/= 30.0 ug/dL.Valproic Acid NA >/= 120 ug/mLVancomycin Peak NA >/= 40 ug/mLVancomycin Trough NA >/= 20 ug/mL
TEST LOW HIGHSerologyVDRL or RPR Positive/ReactiveHIV PositiveMircrobiologyBlood Culture PositiveCSF gram stain PositiveCSF culture PositiveAcid Fast Smear PositiveCulture s Positive for mycobacteriaC. difficile Toxin PositiveClostridium in wound PositiveSalmonella or Shigella PositiveMRSA PositiveVRE PositiveAcinetobacter Positive< means Less Than </= means Less Than or Equal To> means Greater Than >/= means Greater Than or Equal To
Billing and Insurance InformationClient BillingClients will be billed monthly by an itemized invoice. Please note that these invoices are payableupon receipt. If you have any questions pertaining to your account, please notify us immediately inwriting so that we may resolve them in a timely manner.Medicare- Overview of Medical NecessityAdvance Beneficiary Notice:If reimbursement is denied due to lack of medical necessity documentation, Medicare rules prohibitthe laboratory or health care provider from billing the patient unless an Advance Beneficiary Notice(ABN) has been signed and dated by the patient prior to the service. As applicable, an ABN must becompleted each time services are ordered. A blanket ABN is not acceptable to the Medicareprogram.The centers for Medicare and Medicaid Services has established a standardized ABN that ensuresthe patient understands that he/she may be responsible for payment if the test is considered to bemedically unnecessary by Medicare. The ABN identifies the limited coverage laboratory test andgives the reason the test is likely to be denied. In order for the patient to make an informed decisionwhether or not to receive the service, the ABN provided two options. Option 1 states that the patientchooses to have the service performed and understand that he/she is personally responsible forpayment in the event Medicare denies payment. Option 2 states that the patient refuses to have theservice performed and will notify his/her doctor of that decision.ComplianceTo comply with these new guidelines, physicians should (1) only order tests that are medicallynecessary in diagnosing or treating their patients; (2) be certain to enter the appropriate and correctICD-9 code in both their patient files and on the test request forms; and (3) always have theirpatients sign and date an ABN if they believe that the service is likely to be denied.Medicare CoverageBestcare agrees to accept the Medicare-allowed amount as payment in full for covered services. It isimportant to understand that assignment does not preclude billing of the patient for services deniedby Medicare. The following situations may result in a bill to the patient.Non-covered services. These services include test, visits, and procedures that are not reasonable ornecessary by accepted medical standards, i.e., the services are found to be inappropriate or inexcess of those required for diagnosis or treatment of the enrollee’s condition. CMS has determinedthat it is your responsibility to inform patients in writing if a service may not be covered. TheMedicare does not cover tests that require, but do no have FDA approval. These procedures arereferred to as “Investigational use only” and “Research use only” procedures and will be billed to thepatient provided the beneficiary has signed and BestCare has on file a “Medicare AdvanceBeneficiary Notice”.
Medicare Coverage of Laboratory TestingWhen ordering laboratory tests that are billed to Medicare/Medicaid, or other federally-fundedprograms, the following requirements may apply:Only tests that are medically necessary for the diagnosis or treatment of the patient should beordered. Medicare does not pay for screening tests, except for certain specifically approvedprocedures, and may not pay for non-FDA approved tests or for those tests consideredexperimental.If there is reason to believe that Medicare will not pay for a test, the patient should be informed. Thepatient should sign an Advance Beneficiary Notice (ABN) to indicate that he or she is responsible forthe cost of the test is Medicare denies payment.Medicare requires the ordering physician provide an ICD-9 diagnosis code.Panels should be billed only when all components of the panel are medically necessary.Medicare National Limitation Amounts for CPT codes are available. Medicaid reimbursement will beequal to or less than the amount of Medicare reimbursement. The CPT codes for the tests areprofiled in this guide.MedicaidMedicaid is medical assistance for those people who cannot afford their own health care. It isimportant to note that Medicaid claims can only be filed after all other third-party resources havebeen exhausted. Patients should be asked at the time of service if there is other coverage, such asMedicare, Medicaid HMO, or private insurance. When applicable, any Medicare or private insuranceinformation should also be provided.