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<ul><li>Phlebotomy and the Biochemistry Dept </li></ul><ul><li>Felicity Dempsey </li></ul><ul><li>Senior Medical Scientist...
Role of Phlebotomist <ul><li>Inform patient of any test preparation </li></ul><ul><li>Ensure correct sampling & handling <...
Role of Phlebotomist <ul><li>Knowledge of test requirements (user manual) </li></ul><ul><li>Universal Blood Precautions (C...
CPA STANDARDS <ul><li>C3standard  – The facilities for the patient should provide privacy during reception and sampling </...
E3 Specimen collection and handling <ul><li>E3.1   Lab management should establish procedures for specimen collection and ...
Sampling Procedures <ul><li>Venepuncture </li></ul><ul><li>Finger prick </li></ul><ul><li>Heel prick </li></ul><ul><li>Cap...
Sample types <ul><li>Plasma (anticoagulated) </li></ul><ul><li>Serum (clotted) </li></ul><ul><li>Whole blood </li></ul>
Laboratory Process <ul><li>Preanalytical – Major Advances </li></ul><ul><li>Primary Sampling, Analysers </li></ul><ul><li>...
Preanalytical issues <ul><li>Diet </li></ul><ul><li>Diurnal variations </li></ul><ul><li>Drug Therapy </li></ul><ul><li>Pr...
Viruses Bacteria Foods Sunlight Stress Drugs Genes Menopause Pregnancy Post-pregnancy Preanalytical                       ...
Preanalytical issues <ul><li>Haemolysis </li></ul><ul><li>Lipaemia </li></ul><ul><li>Icterus </li></ul><ul><li>Partially f...
Problems with vacuutainers <ul><li>Loss of vacuum </li></ul><ul><li>Improper storage </li></ul><ul><li>Incorrect sampling ...
Blood containers <ul><li>Evacuated or syringe </li></ul><ul><li>Gel separators </li></ul><ul><li>Viscosity changes on cent...
 
Additives <ul><li>Liquid, spray dried or powder </li></ul><ul><li>Anticoagulants </li></ul><ul><li>Antiglycolytic </li></u...
Order of draw <ul><li>Blood Cultures </li></ul><ul><li>Citrate </li></ul><ul><li>Serum </li></ul><ul><li>Heparin </li></ul...
Essential precautions <ul><li>Invert gently to mix </li></ul><ul><li>Vigorous mixing - haemolysis </li></ul><ul><li>Cross ...
NCCLS H3-H5, Vol 23, No 23, 8.10.2
Anticoagulants <ul><li>Chelates/ precipitates calcium </li></ul><ul><li>Ca unavailable coagulation process </li></ul><ul><...
Commonly used in Biochemistry <ul><li>Colour coded tubes </li></ul><ul><li>Lithium Heparin (green/orange) </li></ul><ul><l...
Test requisition <ul><li>Electronic Patient Register (EPR) </li></ul><ul><li>Phlebotomy lists </li></ul><ul><li>Bar coded ...
Minimum Acceptance Criteria <ul><li>Form / EPR label </li></ul><ul><li>Patients Name </li></ul><ul><li>MRN </li></ul><ul><...
Transport to Laboratory <ul><li>Pneumatic transport tube system </li></ul><ul><li>Hospital porter </li></ul><ul><li>Intern...
Considerations for Phlebotomists <ul><li>Transport on ice  </li></ul><ul><li>Transport frozen </li></ul><ul><li>Light prot...
Analytical issues <ul><li>Routine biochemistry (daily) </li></ul><ul><li>Routine biochemistry (1-3 times weekly) </li></ul...
Routine – Organ Profiling <ul><li>Renal /Liver/Bone/Cardiac profiles </li></ul><ul><li>ICU profiles – ICU, HDU, BU, Oncolo...
Renal profile <ul><li>Urea </li></ul><ul><li>Creatinine </li></ul><ul><li>Sodium/Potassium (Na/K) </li></ul><ul><li>Bicarb...
Bone Profile <ul><li>Calcium (Ca) </li></ul><ul><li>Inorganic Phosphate (In P) </li></ul><ul><li>Alkaline Phosphate (ALP) ...
Liver profile <ul><li>Total Protein/Albumin </li></ul><ul><li>Total Bilirubin </li></ul><ul><li>Enzymes – GGT, ALP, </li><...
Cardiac Profiles/Markers <ul><li>Enzymes </li></ul><ul><li>LDH, AST, CK </li></ul><ul><li>Markers </li></ul><ul><li>CKMBM ...
Routine Biochemistry <ul><li>Lipid profiles </li></ul><ul><li>Therapeutic Drug Monitoring   (TDM) </li></ul><ul><li>anti e...
Endocrinology <ul><li>Thyroid function tests </li></ul><ul><li>Infertility testing </li></ul><ul><li>Adrenal testing </li>...
 
Specialities <ul><li>Porphyria </li></ul><ul><li>Haemochromotosis typing </li></ul><ul><li>Tumour Markers </li></ul><ul><l...
Irish Neonatal Metabolic Screening Programme <ul><li>Phenylketonuria (PKU) </li></ul><ul><li>Maple Syrup Urine Disease (MS...
Guthrie Cards <ul><li>Preanalytical Considerations </li></ul><ul><li>Adequate sample application </li></ul><ul><li>Air dry...
Commonly encountered sample problems <ul><li>Delay in separation (GP) </li></ul><ul><li>Haemolysis </li></ul><ul><li>Incor...
Timing of samples <ul><li>Fasting samples </li></ul><ul><li>TDM requirements </li></ul><ul><li>Digoxin - +6 hrs </li></ul>...
TDM requirements <ul><li>Efficacy Dose </li></ul><ul><li>Avoid Toxicity </li></ul><ul><li>Compliance </li></ul><ul><li>Lit...
Chain of Custody Protocols <ul><li>Samples unsuitable medico-legal purposes </li></ul><ul><li>Legal samples </li></ul><ul>...
Glucose Testing <ul><li>Random </li></ul><ul><li>Fasting </li></ul><ul><li>2hr PP </li></ul><ul><li>GTT </li></ul><ul><li>...
Take home message <ul><li>Reference ranges not consensus </li></ul><ul><li>Method/ Instrument variation </li></ul><ul><li>...
Therapeutic Phlebotomy <ul><li>Haemochromatosis (Fe) </li></ul><ul><li>Porphyria Cutanea Tarda (Fe) </li></ul><ul><li>Poly...
Common aims   <ul><li>Know & Comply Hospital/Dept Quality Policy </li></ul><ul><li>Reduce Turnaround Time (TAT) </li></ul>...
Post analytical <ul><li>Data Review </li></ul><ul><li>Delta checking </li></ul><ul><li>Phone urgent results </li></ul><ul>...
Post analytical <ul><li>Electronic reports - Wards Healthlink, Medibridge </li></ul><ul><li>Computer generated results </l...
Changing face of Pathology <ul><li>Pathology review – just published </li></ul><ul><li>3 cold labs (GP work) ??S,W,E </li>...
Changing face of Pathology <ul><li>Preanalytical analysers </li></ul><ul><li>Blood Sciences </li></ul><ul><li>Combined Bio...
 
 
Why Don’t You…… <ul><li>Visit your hospital laboratory </li></ul><ul><li>Befriend the Lab Staff </li></ul>
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Phlebotomist &amp; Biochemistry

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Transcript of "Phlebotomist &amp; Biochemistry"

  1. 1. <ul><li>Phlebotomy and the Biochemistry Dept </li></ul><ul><li>Felicity Dempsey </li></ul><ul><li>Senior Medical Scientist </li></ul><ul><li>Biochemistry Laboratory </li></ul><ul><li>St James’s Hospital </li></ul>
  2. 2. Role of Phlebotomist <ul><li>Inform patient of any test preparation </li></ul><ul><li>Ensure correct sampling & handling </li></ul><ul><li>Properly identify the patient </li></ul><ul><li>Label sample with 2 unique identifiers </li></ul><ul><li>Adherence Hospital Quality System </li></ul><ul><li>Adherence Health & Safety Codes </li></ul><ul><li>Minimise risk management </li></ul>
  3. 3. Role of Phlebotomist <ul><li>Knowledge of test requirements (user manual) </li></ul><ul><li>Universal Blood Precautions (CJD) </li></ul><ul><li>Ensure quality of sample </li></ul><ul><li>Ensure patient details stated correctly </li></ul><ul><li>Avoid haemolysis & microclotting </li></ul><ul><li>Prioritise STAT samples </li></ul><ul><li>Prompt dispatch </li></ul><ul><li>LIS/EPR operation </li></ul>
  4. 4. CPA STANDARDS <ul><li>C3standard – The facilities for the patient should provide privacy during reception and sampling </li></ul><ul><li>C3.1 Waiting/Reception area with disabled access </li></ul><ul><li>Phlebotomy Area for privacy & recovery </li></ul><ul><li>Toilet facilities separate to staff </li></ul><ul><li>C3.2 Notices advising patients of Health & Safety precautions </li></ul>
  5. 5. E3 Specimen collection and handling <ul><li>E3.1 Lab management should establish procedures for specimen collection and handling </li></ul><ul><li>E3.2 Procedures available to service users & those responsible for specimen collection and handling </li></ul><ul><li>E3.3 Lab periodically reviews its sample volume requirements to ensure that neither insufficient nor excessive amounts are collected. </li></ul>
  6. 6. Sampling Procedures <ul><li>Venepuncture </li></ul><ul><li>Finger prick </li></ul><ul><li>Heel prick </li></ul><ul><li>Capillary </li></ul>
  7. 7. Sample types <ul><li>Plasma (anticoagulated) </li></ul><ul><li>Serum (clotted) </li></ul><ul><li>Whole blood </li></ul>
  8. 8. Laboratory Process <ul><li>Preanalytical – Major Advances </li></ul><ul><li>Primary Sampling, Analysers </li></ul><ul><li>Analytical – Instrumentation/Analyses </li></ul><ul><li>Postanalytical – Final result </li></ul>
  9. 9. Preanalytical issues <ul><li>Diet </li></ul><ul><li>Diurnal variations </li></ul><ul><li>Drug Therapy </li></ul><ul><li>Pregnancy </li></ul><ul><li>Dehydration </li></ul><ul><li>Patient’s current condition </li></ul>
  10. 10. Viruses Bacteria Foods Sunlight Stress Drugs Genes Menopause Pregnancy Post-pregnancy Preanalytical                                                                                                                                                     Gender
  11. 11. Preanalytical issues <ul><li>Haemolysis </li></ul><ul><li>Lipaemia </li></ul><ul><li>Icterus </li></ul><ul><li>Partially filled tubes </li></ul><ul><li>Cross contamination </li></ul><ul><li>Incorrect sample type </li></ul><ul><li>Incorrect/inadequate labelling/unlabelled </li></ul>
  12. 12. Problems with vacuutainers <ul><li>Loss of vacuum </li></ul><ul><li>Improper storage </li></ul><ul><li>Incorrect sampling technique </li></ul><ul><li>Incorrect blood/additive ratio </li></ul><ul><li>Expired tubes </li></ul>
  13. 13. Blood containers <ul><li>Evacuated or syringe </li></ul><ul><li>Gel separators </li></ul><ul><li>Viscosity changes on centrifugation </li></ul><ul><li>Inhibits cell metabolism </li></ul><ul><li>Change of tube system validated by lab </li></ul>
  14. 15. Additives <ul><li>Liquid, spray dried or powder </li></ul><ul><li>Anticoagulants </li></ul><ul><li>Antiglycolytic </li></ul><ul><li>Clot activators </li></ul><ul><li>Trace element </li></ul>
  15. 16. Order of draw <ul><li>Blood Cultures </li></ul><ul><li>Citrate </li></ul><ul><li>Serum </li></ul><ul><li>Heparin </li></ul><ul><li>EDTA </li></ul><ul><li>Oxalate </li></ul>
  16. 17. Essential precautions <ul><li>Invert gently to mix </li></ul><ul><li>Vigorous mixing - haemolysis </li></ul><ul><li>Cross contamination </li></ul><ul><li>Never transfer between tubes </li></ul>
  17. 18. NCCLS H3-H5, Vol 23, No 23, 8.10.2
  18. 19. Anticoagulants <ul><li>Chelates/ precipitates calcium </li></ul><ul><li>Ca unavailable coagulation process </li></ul><ul><li>Inhibits thrombin formation </li></ul><ul><li>Prevents Fibrinogen to Fibrin process </li></ul>
  19. 20. Commonly used in Biochemistry <ul><li>Colour coded tubes </li></ul><ul><li>Lithium Heparin (green/orange) </li></ul><ul><li>Fluoride Oxalate (grey) </li></ul><ul><li>Clotted (red) </li></ul><ul><li>Trace metal (royal blue) </li></ul><ul><li>System to system variation </li></ul>
  20. 21. Test requisition <ul><li>Electronic Patient Register (EPR) </li></ul><ul><li>Phlebotomy lists </li></ul><ul><li>Bar coded labels </li></ul><ul><li>Hospital Forms </li></ul><ul><li>GP multidisciplinary forms </li></ul>
  21. 22. Minimum Acceptance Criteria <ul><li>Form / EPR label </li></ul><ul><li>Patients Name </li></ul><ul><li>MRN </li></ul><ul><li>Hospital /Ward </li></ul><ul><li>DOB </li></ul><ul><li>Referring Consultant </li></ul><ul><li>Date/Time collected (desirable) </li></ul><ul><li>Clinical Details (noted if not supplied) </li></ul>
  22. 23. Transport to Laboratory <ul><li>Pneumatic transport tube system </li></ul><ul><li>Hospital porter </li></ul><ul><li>Internal Couriers </li></ul><ul><li>External Couriers </li></ul><ul><li>Train </li></ul><ul><li>Post </li></ul>
  23. 24. Considerations for Phlebotomists <ul><li>Transport on ice </li></ul><ul><li>Transport frozen </li></ul><ul><li>Light protected </li></ul><ul><li>Requires immediate separation </li></ul><ul><li>Refridgerated centrifuge </li></ul><ul><li>Inform lab of impending arrival </li></ul>
  24. 25. Analytical issues <ul><li>Routine biochemistry (daily) </li></ul><ul><li>Routine biochemistry (1-3 times weekly) </li></ul><ul><li>STAT biochemistry </li></ul><ul><li>Endocrinology </li></ul><ul><li>POCT </li></ul><ul><li>Discipline specific specialities </li></ul><ul><li>Neonatal/Paediatric Biochemistry </li></ul>
  25. 26. Routine – Organ Profiling <ul><li>Renal /Liver/Bone/Cardiac profiles </li></ul><ul><li>ICU profiles – ICU, HDU, BU, Oncology </li></ul><ul><li>Overlap in some tests </li></ul><ul><li>Glucose – random, fasting, post prandial </li></ul><ul><li>Amylase </li></ul><ul><li>Magnesium </li></ul>
  26. 27. Renal profile <ul><li>Urea </li></ul><ul><li>Creatinine </li></ul><ul><li>Sodium/Potassium (Na/K) </li></ul><ul><li>Bicarbonate </li></ul>
  27. 28. Bone Profile <ul><li>Calcium (Ca) </li></ul><ul><li>Inorganic Phosphate (In P) </li></ul><ul><li>Alkaline Phosphate (ALP) </li></ul><ul><li>Albumin </li></ul>
  28. 29. Liver profile <ul><li>Total Protein/Albumin </li></ul><ul><li>Total Bilirubin </li></ul><ul><li>Enzymes – GGT, ALP, </li></ul><ul><li>Transaminases - AST, ALT </li></ul>
  29. 30. Cardiac Profiles/Markers <ul><li>Enzymes </li></ul><ul><li>LDH, AST, CK </li></ul><ul><li>Markers </li></ul><ul><li>CKMBM (mass measurement) </li></ul><ul><li>Troponin T or I </li></ul><ul><li>Pro BNP </li></ul>
  30. 31. Routine Biochemistry <ul><li>Lipid profiles </li></ul><ul><li>Therapeutic Drug Monitoring (TDM) </li></ul><ul><li>anti epileptic, anti asthmatic, lithium, digoxin </li></ul><ul><li>Diabetes monitoring </li></ul><ul><li>HbA1c, urinary microalbumen </li></ul><ul><li>Toxicology </li></ul><ul><li>Non blood biochemistry </li></ul>
  31. 32. Endocrinology <ul><li>Thyroid function tests </li></ul><ul><li>Infertility testing </li></ul><ul><li>Adrenal testing </li></ul><ul><li>Growth & Development </li></ul><ul><li>DM & Obesity </li></ul>
  32. 34. Specialities <ul><li>Porphyria </li></ul><ul><li>Haemochromotosis typing </li></ul><ul><li>Tumour Markers </li></ul><ul><li>Bone Markers </li></ul><ul><li>DNA analysis </li></ul><ul><li>Metabolic disorders </li></ul><ul><li>Neonatal screening </li></ul>
  33. 35. Irish Neonatal Metabolic Screening Programme <ul><li>Phenylketonuria (PKU) </li></ul><ul><li>Maple Syrup Urine Disease (MSUD) </li></ul><ul><li>Congenital Hypothyroidism (CHT) </li></ul><ul><li>Galactosaemia </li></ul><ul><li>Homocystinuria </li></ul>
  34. 36. Guthrie Cards <ul><li>Preanalytical Considerations </li></ul><ul><li>Adequate sample application </li></ul><ul><li>Air dry elevated / horizontal </li></ul><ul><li>No stacking - Cross Contamination </li></ul><ul><li>Other Contaminants: </li></ul><ul><li>Powder / Lotions </li></ul><ul><li>Alcohol wipes </li></ul><ul><li>Urine, Faeces & Sweat </li></ul>
  35. 37. Commonly encountered sample problems <ul><li>Delay in separation (GP) </li></ul><ul><li>Haemolysis </li></ul><ul><li>Incorrect sample type </li></ul><ul><li>Cross contamination </li></ul><ul><li>Drip arm sample </li></ul><ul><li>Incorrect patient </li></ul><ul><li>Lipaemia </li></ul><ul><li>Icterus </li></ul><ul><li>Alcohol/Trace Metal Contamination </li></ul>
  36. 38. Timing of samples <ul><li>Fasting samples </li></ul><ul><li>TDM requirements </li></ul><ul><li>Digoxin - +6 hrs </li></ul><ul><li>Stimulation tests </li></ul>
  37. 39. TDM requirements <ul><li>Efficacy Dose </li></ul><ul><li>Avoid Toxicity </li></ul><ul><li>Compliance </li></ul><ul><li>Lithium – serum required </li></ul>
  38. 40. Chain of Custody Protocols <ul><li>Samples unsuitable medico-legal purposes </li></ul><ul><li>Legal samples </li></ul><ul><li>Coroner’s requests </li></ul><ul><li>Industry </li></ul><ul><li>Work related injury </li></ul><ul><li>Employee insurance schemes </li></ul><ul><li>Drug screening </li></ul>
  39. 41. Glucose Testing <ul><li>Random </li></ul><ul><li>Fasting </li></ul><ul><li>2hr PP </li></ul><ul><li>GTT </li></ul><ul><li>Incorrect Timing - misinterpretation </li></ul>
  40. 42. Take home message <ul><li>Reference ranges not consensus </li></ul><ul><li>Method/ Instrument variation </li></ul><ul><li>Possible sample type variation </li></ul><ul><li>Protocols may differ </li></ul><ul><li>Contact lab if unsure </li></ul>
  41. 43. Therapeutic Phlebotomy <ul><li>Haemochromatosis (Fe) </li></ul><ul><li>Porphyria Cutanea Tarda (Fe) </li></ul><ul><li>Polycytaemia (RBC) </li></ul>
  42. 44. Common aims <ul><li>Know & Comply Hospital/Dept Quality Policy </li></ul><ul><li>Reduce Turnaround Time (TAT) </li></ul><ul><li>Inform lab if urgent </li></ul><ul><li>Efficient transport </li></ul><ul><li>Efficient Reporting </li></ul><ul><li>Prioritise wards (ICU/CCU/BU/AE/HDU/Oncology </li></ul><ul><li>POCT </li></ul>
  43. 45. Post analytical <ul><li>Data Review </li></ul><ul><li>Delta checking </li></ul><ul><li>Phone urgent results </li></ul><ul><li>Additional testing </li></ul><ul><li>Gender based reference ranges </li></ul>
  44. 46. Post analytical <ul><li>Electronic reports - Wards Healthlink, Medibridge </li></ul><ul><li>Computer generated results </li></ul><ul><li>OPD / Clinic lists </li></ul><ul><li>Follow up letters/phonecalls </li></ul>
  45. 47. Changing face of Pathology <ul><li>Pathology review – just published </li></ul><ul><li>3 cold labs (GP work) ??S,W,E </li></ul><ul><li>14 hot labs (i.e. 14 A/E) </li></ul><ul><li>Reduced from 48 </li></ul><ul><li>Country wide/combine hospitals </li></ul><ul><li>Smaller hospitals – community hospitals </li></ul><ul><li>Tenders – public/private interests </li></ul>
  46. 48. Changing face of Pathology <ul><li>Preanalytical analysers </li></ul><ul><li>Blood Sciences </li></ul><ul><li>Combined Biochemistry, Haematology, Immunology analysers </li></ul><ul><li>Increased POCT </li></ul>
  47. 51. Why Don’t You…… <ul><li>Visit your hospital laboratory </li></ul><ul><li>Befriend the Lab Staff </li></ul>
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