Specimen Collection And Other Test Information x31667
The Test Tables portion of the Laboratory Manual provide information regarding the amount of specimen required for a test, the type of container in which it should be submitted, what preservative is needed, and how the sample should be handled. See "Urine Collection for Chemical Analysis" section for detailed information on urine preservatives and sample collection for various analytes.
Where a test is performed, the testing schedule, expected turnaround time, reference ranges, methodology and - where applicable - "critical" values, are also included in the Tables. Central Processing personnel can also provide information regarding when time tests sent to reference laboratories are picked up. Note that for many send-out tests, sample stability and transport issues may make it inadvisable to draw samples for testing after 12:00 noon on Thursday and they should not be collected Friday, weekends or holidays except when absolutely necessary. The "collection instructions" listed in the Laboratory Manual for each test will have this information when applicable. For tests not listed in the laboratory manual it is advisable to contact laboratory Send-out staff (x3-1349) before collecting samples to determine the requirements for the test, when it may be drawn and any special requiremnts for referring the test to another laboratory.
All this information is kept up-to-date and is accessible electronically at our website (http://labmed.ucsf.edu/labman) and via STOR/CDS and UCare terminals and PCs distributed throughout the Medical Center (see LABORATORY INQUIRIES & REPORTS).
An extensive section of "Synonyms" is included in the on-line Manual to facilitate the recognition of requests under variant names and abbreviations. If you have trouble finding a test using a "common" term or acronym, please contact the lab and request the term be added to the synonym list.
Additional details of test performance, e.g., reagent vendor, method, accuracy, precision (including Levey-Jennings plots and coefficients of variation), sensitivity and linearity are available on request from the performing laboratory section.
Laboratory Services For Ambulatory Patients, Including Phlebotomy
A. Patient Registration
Patients must be registered before their laboratory orders will be processed and their samples collected. Registration is performed as part of each clinic visit, or at the registration desks in the first floor lobby of the ACC, the first floor at 2330 Post St., and the first floor of the UCSF/Mount Zion Cancer Center. Registration is abbreviated when there has been no change in demographic information or insurance coverage. Prior hospitalization at UCSF does not eliminate the requirement for registration. Patients should bring the properly completed laboratory requisition bearing a current IDX registraton label affixed to ensure optimal service. A legible ordering physician first and last name, his or her UCSF physician number, signature and designation as attending, resident/fellow or allied health provider are required. If the ordering individual is a resident, fellow or allied health provider the name and UC number for the supervising attending physician is also required. Applicable ICD-9 diagnosis code(s) are required on all outpatient requisitions. Patients who present with requisitions which lack these items will be asked to call or return to the clinic and obtain them from the person ordering the tests. Samples will generally not be collected until this information is available.
To request that copies of reports be sent to another provider, enter the provider's full name and UC number on the requisition. To reduce the potential for HIPAA violations the laboratory will not generate reports to practitioners without a current, active UC provider number.
Reports for outpatients are directed to the address or UCSF Box number listed in the Medical Staff Office database for the ordering clinician and any 'Copy To' physicians indicated on the requisition. It is imprative that this information be kept up to date to avoid mis-directed reports. The laboratory receives this address information via a nightly update from the Medical Staff Office, any change to the information must be made in their database.
If a sample has been collected on an unregistered patient and delaying processing would jeopardize the sample the laboratory can enter the sample and patient information into the laboratory information system using a temporary ID number. The patient should be registered as soon as possible so that the temporary number can be replaced. Note that results on samples identified with a temporary number do not broadcast to UCare or the STOR clinical display system. To obtain results on patients who have not been registered, contact the laboratory at 3-1667 (415-353-1667) and provide the patient's full name and date of birth. Although a hard copy report may be generated for an unregistered patient, their results will not appear in STOR or UCare until they have been registered and their records merged.
B. Locations and Hours of Service
LOCATION |
HOURS |
PHONE |
|---|---|---|
| UCSF Ambulatory Care Center (ACC) | 0730-1830 |
415-353-2736 |
| UCSF Pediatric Clinic | 0845-1715 |
415-353-2652 |
| UCSF Hematology/Oncology Clinic | 0800-1700 |
415-353-8068 |
| 2330 Post St. (Mount Zion) | 0700-1730 |
415-885-7531 |
| UCSF Mount Zion Cancer Center | 0700-1700 |
415-885-7764 |
| UCSF Donor Center (Milburry Union MU09) | Sat 0900-1545 |
415-353-1809 |
The UCSF Clinical Laboratories offers limited outpatient phlebotomy
services at Parnassus on Saturday in The UCSF Blood Donor Center
(MIlburry Union, I level, see above). Due to limited staffing, however,
we ask that patients be drawn in clinics whenever possible and the
samples transported to the 5th floor receiving area of the clinical
laboratory.
Ambulatory patients sometimes appear at the 5th floor Moffitt main Clinical Laboratory for nonemergency blood drawing, particularly in the evening and on weekends. Laboratory personnel are not permitted to draw blood on the 5th floor, and the patient will be asked to return during the hours when routine services are provided.
C. Containers and Instructions
Ambulatory patients should be referred to the ACC or 2330 Post St. sites for containers, and for any special collection instructions (for some of the more common tests, these are available in Chinese, and Spanish as well as English).
D. Scheduling Special Tests
Bone marrow aspirations, Bleeding Time, Sweat Chloride, Glucose
Tolerance and/or other procedures which require timed or sequential
draws should be scheduled at least one day in advance (Mount Zion:
x57500; UCSF x32736 and for sweat Chloride, x31755). Tests
that require scheduling are listed in the Test Tables.
E. Who May Order Tests?
Under California Business and Professions Code section 1288:
- "Any person conducting or operating a clinical laboratory may accept assignments for tests only from and make reports only to persons licensed under the provisions of law relating to the healing arts or their representatives…"
In order to be "licensed under the provisions of law relating to the healing arts", the healthcare practitioner must be licensed in the state of California as a physician and surgeon, or licensed as a healthcare provider with a scope of practice that authorizes ordering clinical laboratory tests. If the test results can be lawfully used by the healthcare provider to diagnose, manage or treat the patient, then it would likely be appropriate for that healthcare provider to order the test.
In order to be considered a "representative" of the healthcare practitioner, that person must be an employee of a person authorized to order tests, such as the ordering practitioner's physician assistant or registered nurse. A patient cannot be made a 'representative' of a physician in order to directly receive his or her own laboratory test results. Please do not request that the laboratory provide results directly to patients or tell patients that they may contact the laboratory to obtain their results. It is standing policy for the UCSF Clinical Laboratories to not provide reports directly to patients in compliance with the above regulations and laboratory staff are instructed to deny such requests and refer the patient back to his or her physician for their test results.
Although in 2002, California state law (SB1131 ) allowed for patient self-ordering of certain laboratory tests, due to payment and reporting constraints the UCSF Clinical Laboratories do not accept patient self-orders. If patients wish to self-order testing they should be referred to a commercial laboratory that accepts such requests.
Furthermore, for reimbursement purposes, requests for outpatient testing must carry the name of an identifiable individual who is recognized as authorized to order tests in California. Unless charged to a budget/research account, outpatient orders cannot therefore be submitted in the name of a medical student, nurse practitioner, registered nurse or licensed vocational nurse, or anonymously as "Fellow" or "Resident 1", etc.; in each case the request slip must bear the name of an individual licensed physician who is taking responsibility for the orders, e.g., the supervising physician of nurse practitioner or the attending physician instructing the student.
F. Medical Necessity
Only tests which are considered "medically necessary," i.e., warranted by the medical condition of the patient, will be reimbursed by Medicare, MediCal and in general, most third-party carriers. Screening tests and general health examinations are typically not covered by most insurance and are specifically excluded form reimbursement (with minor exceptions) by both Medicare and MediCal.
Physicians are required by law to provide the laboratory with the ICD-9 (International Classification of Diseases [Clinical Modification], 9th edition) diagnostic code(s) which justifies the test(s) he or she has ordered. CMS and, increasingly, other carriers have developed guidelines for the use of many laboratory tests, and will not pay for these tests if an appropriate diagnostic code is not provided at the time the test is requested. All laboratory requistions have areas where the ICD-9 codes are to be entered.
G. Advance Beneficiary Notice (ABN)
If a test which is unlikely to be covered is ordered upon a Medicare patient, the patient will be informed of the reason WHY coverage is unlikely and will be asked to sign an Advenced Beneficiary Notice acknowledging personal financial responsibility for the cost of testing if, as expected, reimbursement is refused. If the patient refuses to sign the form the test(s) in question will not be performed and a note to this effect will be entered into the computer.
Reasons for lack of coverage include:
- lack of an ICD-9 diagnostic code consistent with "medical necessity" guidelines;
- the diagnostic test not having been approved for diagnostic use by the FDA and thus being deemed "experimental" by HCFA;
- prior refusal or announcement by Medicare of its unwillingness to cover the test.
- tests which have frequency limitations and for which the laboratory cannot determine the last time the patient had the test performed
In-Patient Services
A. Admission, Preoperative and Other In-Patient Blood Drawing
Blood may be drawn on preoperative patients in the Ambulatory Care Center (hours noted above under Ambulatory Patient Blood Drawing). In-patient phlebotomy is provided via laboratory phlebotomists on actue inpatient wards. Nursing staff perform collections on all intensive care and neonatal units.
B. Routine A.M. Phlebotomy
Inpatient blood drawing for routine laboratory blood studies is usually performed each morning between 0400 and 0800. Labels are generated by the laboratory from a list of orders sent the night before or the orders are transferred to CareFusion devices used by phlebotomists to print labels at the patients bedside. These labels prompt for the correct container type and greatly reduce labelling errors. Preentry also increases the speed with which specimens can be processed upon receipt, decreasing test turnaround time.
Point-of-Care Testing (POCT)
Point-of-Care Testing (POCT) is available at many inpatient and outpatient clinic locations in order to provide rapid testing in support of patient care. The Point of Care Committee maintains oversight of all POCT within the UCSF system. Each site performing POCT is audited monthly for compliance with POCT testing policies and laboratory regulations by clinical laboratory staff. The results of these audits are monitored for each location and reported quarterly to the committee which in turn reports annually to the Clinical Performance Improvement Committee (CPIC). Sites found to be out of compliance on repeat audits may have their authorization to perform POCT suspended until such time as they can demonstrate compliance.
In the inpatient setting only licensed individuals who have been properly trained and demonstrated competency may perform POCT. Physicians may perform POCT utilizing visual endpoint tests without formal a competency assessment, however, they must demonstrate annual competency for any test using a device. In the outpatient clinics non-licensed personnel may perform POCT classified as waived by the FDA provided they have received training and demonstrated annual competency for each test they perform.
Each location performing POCT classified by the FDA as "moderately complex" must enroll in and successfully perform proficiency testing (PT) for each such test. The results of all proficiency testing are reported to the Point of Care Committee. Sites that demonstrate unsuccessful PT performance will cease performing the unsuccessful test until they can demonstrate successful PT performance.
Provider Performed Microscopy (PPM; KOH preps, Wet mounts, Fern testing, Urine sediment exam, Pinworm exam) requires that each provider take and pass an annual on-line competency assessment in each area of PPM that they wish to perform. Further, after demonstrating initial competency, each provider must apply for privileges in PPM from the UCSF Credentials Committee. Providers who have not demonstrated competency via the annual examination or who have not been granted PPM privileges may not perform PPM examinations.
New sites that wish to perform POCT or requests for new POCT from existing sites must be made in writing to the Point of Care Committee. The committee will evaluate the request and determine if the request will be approved. If testing involves a new analyte the UCVSF Clinical Laboratories will assist in the evaluation of available tests and in the validation of any test kit or device that is selected. No site may initiate POCT or expand their menu of tests without approval of the committee. Each POCT site maintains a list of the tests they are authorized to perform signed by the Chair of the Point of Care Committee. POCT Request for Approval Form
Please visit the Point Of Care Testing Manual for specific test information.
Blood Drawing - Technical Issues
A. Collection Containers Available
| TOP | DRAW (mL) |
INTERIOR COATING |
TUBE CONTENTS |
|---|---|---|---|
| (Stoppers are silicone-coated unless otherwise specified) | |||
| Blue (BD# 363080) |
1.8 | none | 0.109 M (3.2%) buffered citrate, 0.2 mL |
| Blue (BD# 363083) |
2.7 | none | 0.109 M (3.2%) buffered citrate, 0.3 mL |
| Gray (BD# 367925) |
6.0 | none | sodium fluoride, 15.0 mg, potassium oxalate, 12.0 mg |
| Dark Green (BD# 367871) |
4.0 | none | sodium heparin, 60 USP units |
| Light Green (PST) (BD# 367962) |
4.5 | none | inert polymer gel, with lithium heparin sufficient for a 4.5 mL draw |
| Dark Green-Micro (BD# 365969) |
0.6 | none | inert polymer gel, with lithium heparin sufficient for a 0.6 mL draw |
| Gold (SST) (BD#367989) |
5.0 | silicone | Inert polymer gel and silica clot activator |
| Lavender (BD# 367863) |
6.0 | none | EDTA (K2), 10.8 mg - BLOOD BANK use only (13x100 mm tube) |
| Lavender (BD# 367856) |
3.0 | none | EDTA (K2), 5.4 mg |
| Lavender-Micro (BD# 365973) |
0.6 | none | EDTA (K2), 0.75 mg |
| Navy Blue (BD# 369736) |
7.0 | none | EDTA (Na2), 10.5 mg, trace metal-free (purple lettering) |
| Pink-Micro (BD# 365962) |
0.7 | none | no additive; for BLOOD BANK use or FOR CERTAIN DRUG OR ANTIBODY LEVELS ONLY |
| Red (BD#367815) |
6.0 | silicone | Silica clot activator. For drug and some antibody levels only. |
| Red-Micro [SST] (BD# 365960) |
0.6 | none | plastic tube with inert polymer gel - NOT FOR BLOOD BANK |
| Yellow (BD# 364606) |
8.5 | silicone | acid citrate dextrose solution (ACD A), 1.5 mL |
For certain tests, e.g., blood gases, plastic syringes containing 100U of heparin and drawing 3 mL, or 50 U of heparin and drawing 1 mL, are also available.
B. General
The laboratory makes a sincere effort to minimize the amount of specimen required for analysis. A certain amount of specimen is required to perform each test, but because technical problems can occur and a test may have to be rerun, it is a good idea to submit a sample large enough to provide at least twice this minimum. The laboratory staff recognize that this is not always possible, particularly in premature infants and will make every effort to provide an answer on the sample submitted.
The Test Tables lists the "Preferred" and "Minimum" volumes for each test as well as the sample type (whole blood, serum, plasma, urine, etc.). The volumes refer to the amounts needed to perform each specific test, the total volume needed for multiple tests is the total of the individual volumes required for each test. However, many common serum/plasma chemistry tests may be performed on a very small sample size, these tests are indicated in the Test tables with "Click here for Micro-determination info" which provides this information (also see 'Micro Determinations' below).
For tests performed on blood samples the Test Tables also list the "Amount to Collect", this is the volume of blood necessary to provide the 'Preferred' sample volume and varies by the sample 'type' neded for the test. Note that for tests that require serum or plasma the 'Amount to Collect' is 2x the 'Preferred volume'.
The Clinical Laboratories have a general policy for phlebotomists regarding the maximum amount of blood that can be collected during any single phlebotomization that is based on the patient’s weight. For children and small adults weighing < 45 kg (approx. 100 lbs) the maximum amount that will be collected without provider approval is 1 mL/Kg. For adult patients > 45 Kg the maximum volume that will be collected without provider approval is 50 mL. When test orders are placed that require these guidelines to be exceeded the phlebotomists have been instructed to contact the ordering provider to clarify the order. The provider, based on his/her knowledge of the patient, may adopt to have the full blood volume collected, delete one or more tests from the order or instruct the phlebotomist to collect the 'minimum' blood volume for one or more tests.
One should avoid submitting quantities of blood greatly in excess of analytical requirements, particularly in complex or severely ill patients who are subject to repeated phlebotomy. Submitting excess sample does the patient a disservice and can lead to an otherwise unexplained "anemia of hospitalization".
Routine daily laboratory
testing should be discouraged unless the results are necessary for
patient monitoring and care decisions. Many tests ordered as 'daily
labs' are unnecessary unless the patient's status is changing and they
merely contribute to the developement of iatrogenic anemia.
C. General Technique
1. Avoid hemolysis
-
A great many blood tests are affected by hemolysis, which can be avoided by careful technique:
-
- Avoid prolonged venous stasis prior to sample collection,
- Do not force blood from syringe through a needle into a vacutainer as the resultant jet may damage red cells, instead allow the sample to be pulled into the vacutainer,
- Mix specimens with the anticoagulant contained in the collection tubes by gentle inversion (x5), DO NOT shake.
2. Avoid a running IV line
-
Unless it cannot be avoided, DO NOT withdraw specimens from the arm proximal to a running IV, nor from the IV line itself as this may result in cantamination of the sample with the IV fluid. (see instructions below on "D. Drawing from Intravascular Catheters"). If it is necessary to draw proximal to an IV it is important that the IV be stopped and the vein allowed to clear (minimum 1 minute) before the sample is drawn.
3. Complete filling of vacutainers, especially coagulation testing:
Liquid-containing vacutainers (e.g. Citrate; Blue tops & ACD; Yellow tops) should always be filled to their full draw volume for chemical analysis; this is particularly critical for coagulation testing; short filling will alter dilution factors and may interfere with recalcification of samples during measurement of clotting parameters. Therefore if a winged blood collection set ("butterfly") is used and the coagulation tube is the first tube drawn, a discard blue top tube should be used to clear the deadspace volume of the line to assure adequate blood volume is collected.
Specimens for coagulation testing may also be affected by an abnormal hematocrit. If the the hematocrit is above 55%, contact the Hematology laboratory (x31747) and request a tube adjusted to contain the appropriately decreased amount of citrate anticoagulant. There is no standard at present for adjusting the amount of anticoagulant for specimens with low hematocrits. Finally, specimen(s) for coagulation testing should NOT be drawn from a heparinized line.
4. Order in which multiple samples should be drawn:
Blood samples should be collected directly into vacutainer(s) in the following order to prevent cross contamination of one tube with the additive of another which could produce spurious lab results.
-
- Blood Culture*
- Trace metal free tube with EDTA (NAVY BLUE TOP W/
PURPLE LETTERING)
... STOP!! If other tests are requested draw these from a separate venipuncture. - Citrate tubes for coagulation tests (LIGHT BLUE TOP)
- Gel (SST) tube with clot activator (GOLD TOP)
- Activated clot tube without gel (RED TOP)
- Sodium-heparin tube without gel (GREEN TOP)
- Lithium-heparin tube with gel (LIME GREEN TOP)
- EDTA tube (PURPLE TOP)
- Oxalate/fluoride tube (GRAY TOP)
- Acid-Citrate Dextrose tube (YELLOW TOP)
* In general, because of the risk of bacterial contamination, if blood cultures are needed they should always be drawn first (see the MICROBIOLOGY section in the following pages). The only exception is if trace metal determination(s) (Navy blue top) are requested along with blood culture. In this circumstance, draw the Navy blue top first from one venipuncture, and proceed to perform the remaining collections from a second venipuncture.
5. When drawing ONLY a (light) blue top tube for coagulation studies:
If the draw of blood is promptly successful with a good flow of blood directly into the vacutainer, that single, filled tube may be submitted for coagulation studies. If, by contrast, the draw is difficult with much searching for the vein, the blood flow slow, or the collection is made into a large syringe, the coagulation cascade may become activated; in that case the initial tube should be discarded and a second filled tube should be collected and submitted.
When a second tube appears to be needed:
-
- If the patient is 6 years old or more, 5 mL of blood should be drawn and discarded before the blue top tube is filled.
- If the patient is <6 years old, one (1) mL of blood should be drawn and discarded before the blue top tube is filled, whether a syringe or a vacutainer is used.
- If using a syringe, draw the amount of blood to be discarded into one syringe, then use a second syringe to draw the sample which will be transferred to a blue top tube.
- If using a vacutainer, draw the amount of blood to be discarded into one tube, then change to and fill the blue top tube
6. DO NOT Transfer samples between vacutainer types:
Transferring blood from a one tube type when short of sample for other tube types should NEVER be done. The anticoagulants and clotting activators in each tube are specific for the type of sample necessary for testing. Transferring sample between tubes results in adulteration of the sample and will produce spurious test results.
D. Drawing from Intravascular Catheters
Note: Blood is preferrably obtained by venipuncture and not from catheters. If blood is to be obtained from a catheter, it must be collected by nursing staff.
If blood is obtained from an intravascular line, it is important to clear the line of the fluid which has been infused through it or is "keeping it open" (e.g. heparin or saline). If this is not done, spurious results are likely to be obtained, e.g., an elevated PTT from residual heparin or an unrepresentative elevated glucose or potassium from the remnants of an intravenous solution.
To obtain a representative specimen uncontaminated by the initial contents of the line, a volume of blood at least six times (6x) greater than the catheter dead space should be removed and discarded prior to collecting the sample to be sent to the laboratory.
E. 'Micro' Determinations
Micro determinations are available for the following tests:
| Group A (200 µL of serum/plasma minimum, 350 µL of serum/plasma for all) |
Group B | |
|---|---|---|
| Albumin | Creatinine | Ionized calcium (300 µL) |
| Alkaline phosphatase | GGT | Osmolality (100 µL) |
| ALT | Glucose | Salicylate (300 µL) |
| Amylase | Lactic Dehydrogenase | |
| AST | Magnesium | |
| Bilirubin, Total | Phosphorus | |
| Bilirubin, Direct | Protein, Total | |
| Calcium | Potassium | |
| Chloride | Sodium | |
| Cholesterol | Triglycerides | |
| CK, Total | Urea Nitrogen | |
| CO2, Total | Uric Acid | |
Any test in Group A requires a minimum of 200 µL of serum or plasma. If tests are ordered from Group A and from Group B, the serum/plasma requirements are additive. The minimum volumes for many other tests, including many drug levels, are now routinely in the "micro" range; see the entries in the Test Tables section of the Manual. Microtainer capillary collectors for blood collection are available in the nurseries, the 6th floor Pediatrics wards, and the Emergency Department. These containers hold a maximum of 600 µL blood (approximately 300 µL serum).
Urine Collection For Chemical Analyses
The collection requirements may differ for many substances (see table below), highlighted tests require a preservative be used during collectioin. Tests which use the same preservative may be collected together unless required collection times are in conflict (i.e., 12-hour collection mandatory, spot collection mandatory, etc).
Collection containers containing the additives specified in the test tables are not stocked on the floors; they can be obtained from the Specimen Desk at the 5th floor Clinical Laboratories in Moffitt Hospital or at the blood drawing station on the 1st floor of the Ambulatory Care Center.
- Tests that do not specify a preservative should not be collected simultaneously with tests requiring a preservative.
- It is preferable to keep all urines refrigerated during timed collections.
- Acid washed container - supplied by reference laboratory or made in the clinical laboratory by washing container using 1:1 mix of 6N HNO3 & de-ionized water.
| Test name | Test code | Sample type | Container type | No Preserv | Acid wash | 30 mL 6N HCl | 10g Boric acid |
|---|---|---|---|---|---|---|---|
| 5-Hydroxyindoleacetic acid, 24 hour urine | 5HQT | 24 hour urine collection | 24 hour urine collection container with 30 mL 6 N HCl | X | X | ||
| Albumin (Microalbumin), 24 hour urine | AU24 | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | |
| Aldosterone, urine | ALDU | 24 hour urine collection | 24 hour urine collection container with 10g boric acid | OK | X | ||
| Arsenic, 24 hour urine | ASU | 24 hour urine collection | 24 hour specimen collected in acid-washed plastic container w/o preservative | X | X | ||
| Calcium, total, urine | CAU | 24 hour urine collection | 24 hour urine collection container containing 30 mL of 6N HCl | OK | X | OK | |
| Chloride, urine | CLU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | |
| Chromium, urine | MOLT | 24 hour urine collection | Acid washed 24 hour urine collection container without preservative | X | X | ||
| Citrate, 24 hour urine | CITU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | OK |
| Copper, 24 hour urine | COPU | 24 hour urine collection | Acid washed 24 hour urine collection container without preservative. | X | X | ||
| Cortisol, Unconjugated, urine | CRTF | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | OK |
| Creatine, urine | CRTU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | OK |
| Creatinine Clearance | CRCL | 24 hour urine collection or timed urine | 24 hour urine collection container | X | OK | OK | OK |
| Creatinine, urine | CRU | 24 hour urine collection or timed urine | 24 hour urine collection container | X | OK | OK | OK |
| Delta-Aminolevulinic Acid Quantitative, 24 hour urine | ALAQ | 24 hour urine collection | 24 hour urine collection container covered with aluminum foil | X | OK | ||
| D-Xylose Absorption, urine | MOLT | 5 hour urine | 24 hour urine collection container | X | OK | ||
| Free Catecholamines, Fractionated, Urine | UCAF | 24 hour urine collection | 24 hour w/30 mL 6N HCl | X | OK | ||
| Free Hydroxyproline | FHPR | 24 hour urine collection | 24 hour urine collection container with 30 mL 6N HCl | X | OK | ||
| Free Kappa & Lambda light chains, urine | FRULC | 24 hour | 24 hour urine container without preservative | X | OK | ||
| Glucose, urine | GLUU | 24 hour urine collection | 24 hour urine collection with 10 g Boric acid as a preservative | OK | X | ||
| Histamine, urine | HISTU | 24 hour urine collection | Lightsafe 24 hour urine collection container with 10 mL 6N HCl | OK | 10 mL | ||
| Homovanillic Acid, 24 hour urine | HVA | 24 hour urine collection | 24 hour urine collection container with 30 mL 6N HCl | OK | X | ||
| Hydroxycorticosteroids, 17- | 17HS | 24 hour urine collection | 24 hour urine collection container w/10 g Boric acid | X | |||
| Hydroxyproline, Total | HPRT | 24 hour urine collection | 24 hour urine collection container with 30 mL 6N HCl | X | OK | ||
| Immunofixation Electrophoresis, urine | IFEU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | |
| Iron, urine | FEU | 24 hour urine collection | 24 hour urine collection container, acid washed, without preservative | X | X | ||
| Ketosteroids, 17- | 17KS | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | OK |
| Lead, 24 hour urine | PBU | 24 hour urine collection | 24 hour urine collection container, acid washed | X | X | OK | |
| Magnesium, 24 hour urine | MGU | 24 hour urine collection | 24 hour urine collection container with 30 mL 6N HCl | X | OK | ||
| Manganese, urine | MOLT | 24 hour urine collection | 24 hour urine collection container collected, acid-washed, w/o preservative | X | X | ||
| Mercury, 24 hour urine | HGU | 24 hour urine collection | 24 hour urine collection container, acid washed w/o preservative | X | X | ||
| Metanephrines, urine | METN | 24 hour urine collection | 24 hour urine collection container w/ 30 mL 6N HCl | X | OK | ||
| N-Telopeptide, urine | MOLT | 24 hour urine collection | 24 hour collection container w/out preservative | X | OK | ||
| Oxalic Acid, Urine | OXAU or MOLT (See processing Instructions) | 24 hour urine collection | 24 hour urine collection container w/ 25 mL 6N HCl | 25 mL | OK | ||
| Para-Aminobenzoic Acid | MOLT | 6 hour urine | 24 hour urine collection container w/out preservative | X | OK | ||
| Phosphorus, urine | PO4U | 24 hour urine collection | 24 hour urine collection container with 30 mL 6N HCl | OK | X | ||
| Porphobilinogen, Quantitative, 24 hour urine | PBQT | 24 hour urine collection | 24 hour urine collection container w/out preservative (collection w/ 5g sodium carbonate as preservative acceptable) Cover container with aluminum foil | X | |||
| Porphyrins, Fractionated, Urine | PORFU | 24 hour urine collection | 24 hour urine collection container w/out preservative (collection w/ 5g sodium carbonate as preservative acceptable) Cover container with aluminum foil | X | |||
| Potassium, Urine | KUR | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | |
| Pregnanetriol | PRTL | 24 hour urine collection | 24 hour urine collection container without preservative. | X | OK | ||
| Protein Electrophoresis, urine | PEU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | |
| Protein, Total, Urine | TPU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | |
| Sodium, urine | NAUR | 24 hour urine collection or random urine | 24 hour urine collection container | X | OK | OK | |
| Thallium, urine | MOLT | 24 hour urine collection | 24 hour acid washed urine collection container without preservative | X | X | ||
| Urea Clearance | URCL | 24 hour urine AND serum | 24 hour urine container AND Gold top vacutainer | X | OK | OK | |
| Urea Nitrogen, Urine | UNU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | OK |
| Uric Acid, urine | UCAU | 24 hour urine collection | 24 hour urine collection container | X | OK | OK | |
| Vanillylmandelic Acid, urine | VMA | 24 hour urine collection | 24 hour urine collection container wtih 30 mL 6N HCl | X | OK | ||
| Zinc, 24 hour urine | ZINU | 24 hour urine collection | 24 hour urine collection container acid washed | X | X | OK |
Yellow shading = test that requires acid preservative
Cerebrospinal Fluid (CSF) Collection
CSF should be collected and transported to the laboratory in the special vials provided in the lumbar puncture kit. Each vial should be labeled with patient information (full name and medical record number are minimum requirements) and also list the name of the person who collected the specimen and the date it was collected.
Unless otherwise specified, requested tests will be done on selected tubes as follows:
Tube #1 Chemistry & Immunology tests
Tube #2 Microbiology cultures/tests
Tube #3 Cell counts and differentials
Tube #4 Cytologic examination (done by pathology)
Cell counts are preferably performed on Tube #3 to reduce the impact
of blood contamination secondary to the procedure itself. Counts on
multiple tubes are rarely required unless Tube #3 is visibly bloody at
which point a cell count on Tube #1 may be requested. A decrease in
counts between Tube #1 and Tube #3 suggests a traumatic tap. In this
circumstance cell counts should be interpreted with caution. Note: cell counts will not be performed on tube #1 if that sample is grossly more bloody than tube #3.
Supplies For Specimen Collection
A. In-Patient Nursing Units
Material Services, (Parnassus: 3-1837, Mt. Zion 5-7255), provides
procurement supplies for collection of clinical laboratory specimens.
These supplies are furnished only to the nursing stations in Moffitt
and Long Hospitals and are delivered daily.
Laboratory requisitions
Although written requests for laboratory tests can be made on
virtually any form (so long as the necessary information is provided)
we prefer the use of the standard UCSF laboratory requisitions. These
forms contain test codes, collection information and special
instructions for most commonly ordered tests and greatly improve both
the speed and accuracy of our staff's ability to enter test orders into
our computer system.
Routine laboratory
requisition (white): This form lists the most commonly ordered
laboratory tests and is the form that should be used for ordering most
hematology, chemistry and immunology tests on blood samples. The back
of the form lists many other tests of interest. DO NOT use this form
for ordering stat tests, tests on body fluids, microbiology tests or
blood products.
Urine & Body Fluids
(goldenrod): This form is used for ordering routine tests on
urine, and body fluid samples (CSF, pleural, peritoneal. joint,
amniotic fluid, etc.)
Emergency (Stat) (pink):
This form is used to request emergency testing on blood and body
fluids. It lists the tests that are available on an emergency basis
without approval. While additional tests could be performed on an
emergency basis these are generally not necessary for immediate patient
care and require approval of a laboratory medicine resident or
director. Order ONLY emergency tests on this form. Routine tests on
samples drawn together with the stat samples should be ordered on a
routine (white) requisition.
Microbiology (white):
This form is for ordering microbiologic tests and requires the specimen
type and tests desired be entered. Use a separate form for each sample
submitted for testing. Include clinical information whenever possible
as this greatly aids the laboratory in the appropriate handling of the
specimen.
Blood Bank (white):
This form is used for ordering blood products.
ID Serology & Molecular Testing (white): This form
contains the most commonly ordered Infectious Disease tests. Some tests
are duplicated on the Routine requisition. This form also has an area
for provider attestation of informed consent for HIV testing. The
ordering care provider should sign in this area when
requestiing tests used to diagnose HIV toprovide
documentation that consent was obtained. If unsigned the laboratory
will perform the requested testing, however, the provider is then
responsible for documenting consent in the patient record.
Molecular Genetics requisition
(white): This form contains the curently avaialble in house
genetic tests for inherited and neoplastic disorders and should be used
for ordering these studies. There is an area for the provider to
document that genetic counseling was offered to the patient for
non-neoplastic genetic tests. Note that for presymptomatic Huntingtons
and BRCA-1 or BRCA-2 testing, genetic counseling is REQUIRED before
testing will be performed and the name of the genetic counselor who
provided it must be listed. Requests for these two tests received
without this information will be held until it is provided.
To ensure that laboratory results on your patient are returned to the proper location, provide the following information on all Clinical Laboratory requisitions:
- Medical Record Number (MRN)
- Patient's Name
- Patient's Date of Birth
- Clinic (ward, clinic name, or full address if private practitioner)
- Date of Service
- Physician's Name and 5-digit UC Provider Number (required for outpatients)
- ICD-9 Code(s) (required for outpatients)*
- Test(s) Desired
- *Exceptions may be made in instances where the Medical Center bills the ordering practice rather than the patient
If for some reason a specimen must be/has been collected before the patient has been registered, the patient's name and date of birth should be written on the sample and the patient's name, address, and referring physician's name and address should be supplied as well. The patient identification should also be verified from a current California driver's license or other picture ID, if possible.
Specimen Identification And Labeling
Whoever obtains a specimen should label it. Do NOT give an unlabeled specimen to another individual to be labeled as this greatly increases the chance for mis-labeling.
THE LABEL ON A SPECIMEN FOR BLOOD TYPING OR CROSSMATCHING, ON A TISSUE BIOPSY OR ON AN INVASIVELY-COLLECTED SPECIMEN FROM A NORMALLY STERILE AREA (e.g., CSF, joint fluid, amniotic fluid, bone marrow) MUST DISPLAY THE LEGIBLE NAME OF THE INDIVIDUAL COLLECTING THE SPECIMEN AND THE DATE ON WHICH THE SPECIMEN WAS DRAWN. This rigorous labeling is desirable for all other specimens, particularly those which are invasively collected and not readily recollected, but is not required.
Addressograph-stamped or pre-printed labels are preferred, but the specimen must in any case be clearly labeled with the patient's first and last names and the correct full unit number including the visit number. If adhesive labels are not available, use white tape. Do NOT use gummed paper labels which must be moistened to adhere; they dry out and fall off, resulting in an unlabeled specimen.
When multiple samples of the same type are collected at intervals (e.g. glucose tolerance test, provocative testing) or when multiple samples are collected from multiple sites (e.g. tumor localization) it is imperative to label each sample with a sample identification number or letter, the time it was drawn or the location from which it was taken. This avoids problems with sample mix-up in these situations.
Fetal sample labels must show the mother's first and last name and the mother's unit number. The label and requisition must have "FETAL" clearly written on it. In addition, the date and time the specimen is collected and the initials of the person doing the collection should be included on the label.
Donor Sample labels must show the donor's first and last name labeled "DONOR" and the recipient's first and last name and unit number labeled "RECIPIENT." In addition, the date and time the specimen is collected and the initials for the person doing the collection should be on the specimen.
- Example:
- DONOR: Jones, Tom RECIPIENT: Smith, John 23456183 9/15/01 14:30 LR
Processing Of Mislabeled And Unlabeled Specimens
A. Specimen Labels
All labels must show at least the patient's first and last names and the correct unit number. Specimens with less information are inadequately identified, and will not be processed until the deficiencies are corrected. If an inadequately labeled specimen is brought to the laboratory by someone from the nursing unit or office, that individual will be asked to supply the missing information.
B. Specimens Received Without A Requisition
Specimen Desk personnel will not accept a specimen without a requisition. If a specimen is received without a requisition, one will be requested.
C. Mislabeled and Unlabeled Specimens
- When the identification of a sample submitted for analysis is in any way questionable, the laboratory will recommend that, if feasible, a new specimen should be obtained.
- If the laboratory is unable to determine from whom a sample has been collected with a reasonable degree of certainty, a new sample must be obtained. For example, if two unlabeled samples accompanying two requisitions arrive from the same nursing unit at the same time, or if neither sample nor requisition bears any identification, the samples must be recollected.
- All specimens submitted to the Transfusion Service (for blood typing, crossmatch, etc.) must be properly labeled. Mislabeled, unlabeled or unsigned samples will not be accepted.
- When a sample is received with a properly completed requisition but the specimen is unlabeled AND the sample can be identified with a reasonable degree of certainty we will allow the sample to be labeled by the person who obtained the specimen and the test to be run. The patient's physician must acknowledge that the sample identity was questioned in writing and the test result in the patient's chart will carry the notation that the sample was "REC'D MIS(UN)LABELED-RUN AT MD'S REQUEST"
- When there is a mismatch between the name on the requisition and on the sample (Mislabel) the sample should, in virtually all circumstances, be recollected. In cases where a mislabeled sample is irretrievable or where re-collection would jeopardize patient care (e.g. invasively collected samples, intra-operative samples, timed samples, etc.) AND the sample itself can be identified with reasonable certainly exceptions to the above policy may be made. These decisions will be the responsibility of the Laboratory Medicine resident on duty or a laboratory director. In cases where the sample is approved for testing the patient's physician must accept responsibility in writing for the specimen being processed. The test result in the patient's chart will carry the notation the sample was "REC'D MIS(UN)LABELED-RUN AT MD'S REQUEST and under some circumstances an entry may be made in the progress notes by laboratory staff further describing the relevant circumstances. A copy of the waiver may be sent to the patient's Attending Physician and, if a pattern of recurrent problems is apparent, to the Chief of Service as well.
Reporting Results on tests ordered in error
If a test is ordered and performed in error the charge for the test will be credited. A comment indicating that the test was ordered in error will be appended to each test result. The patient's physician will be contacted, appraised of the error and informed that the results will be released to the patient's record but not charged for. If the patient's physician has an issue with this or the test required prior patient consent the Laboratory Director or designee will be involved in the discussion and final decision.
Note that only in extreme circumstances will the results of a mis-identified sample be transferred to the record of the patient from whom the sample was actually obtained. Since there was a mis-labeling event the true identity of the patient from whom the blood was collected is in question, and moving the results may simply compund the error. Requests to move results are reviewed on a case-by-case basis and require the authorization of the CLIA Laboratory Director, or Acting CLIA Director.
Test cancellation
The UCSF Clinical Laboratory will try to honor requests from the ordering physician to cancel a test(s) up to the point that one or more results have been released to the patient record. After that point a test cannot be cancelled or the result removed from the patient record.
If a test is cancelled the patient will not be charged for the cost of the test, although there may be a specimen collection and processing charge for the sample. If the test was referred to an outside laboratory and cancelled before a result was generated, any charges incurred by UCSF for shipping the sample or charged by the outside laboratory will be passed on to the patient.
Charging Tests To Another Patient's Account
Under exceptional circumstances, we will perform a test on, e.g., a relative and charge the patient. These situations will be evaluated on a case-by-case basis, but can occur:
- when HLA Typing a related prospective renal or marrow transplant donor (third-party payers apparently accept such charges).
- when the sample is from an unborn fetus
- when the patient's diagnosis can be made only by testing someone else, and is likely to alter management. A patient with partially-treated bacterial diarrhea, from whom a pathogen is not isolated, could have an untreated, mildly symptomatic relative who still may have a positive culture, permitting better management of the culture-negative case.
Tests will NOT be charged to another patient's account when it will not be reimbursed by insurance carriers or other third parties, such as:
- for typing the blood of a potential designated donor who is unwilling to donate at a community blood bank and thereby be typed without charge.
- for the convenience of other ill members of a group or family who do not want to go to the trouble of registering.
A specimen should NEVER be intentionally labeled with the wrong name, even when it is proper to charge another patient's account; the risk that action could be taken or that treatment could be given for a condition the patient does not have is unacceptable.
Donor samples:
Tests will be ordered on the recipients medical record number/account and will appear both on STOR/CDS and laboratory reports under that number. The result field for donor samples will contain" PERFORMED ON DONOR SAMPLE, SEE COMMENT" with the actual results listed in a comment following the result line. This clearly identifies the results as belonging to a donor and not the recipient.
Fetal samples:
Tests will be ordered on the mother's medical record number /account
and will appear both in STOR/CDS and on paper laboratory reports under
the mother's medical record number. The result field for fetal samples
will contain" PERFORMED ON FETAL SAMPLE, SEE COMMENT" with the actual
results listed in a comment following the result line. This clearly
identifies the results as belonging to a fetus and not the mother.
Samples from Another Individual:
When a diagnosis requires testing another person: The individual on whom the test is to be performed must be registered and given a distinct unit number separate from that of the patient, or given a temporary unit #. This prevents the result of the test from being posted to the patient's record and accidentally mistaken for their result . The test will be billed to the patient's account.
Needle-Bearing And Other Hazardous Specimen Containers And Requisitions
A. Needle-Bearing Syringes
Because needlestick injuries are a major source of serious
infections, the Clinical Laboratories will NOT
accept specimens in syringes with needles attached. If a specimen is
submitted in a needle-bearing syringe, it will not be processed
until the individual submitting the specimen or their agent removes the
needle and seals the syringe with a suitable cap (the latter are
available from Materiel Services, along with plastic clamps for needle
removal). An exception will be made only for specimens which have been
obtained by Fine Needle Aspiration and are so small in volume
that the entire specimen is contained within the needle cavity. These
specimens, typically submitted for culture, should be brought directly
to the Microbiology processing
area on the 5th floor of Long Hospital.
B. Externally Contaminated Specimen Containers and Requisitions
Hospital employees who handle laboratory specimens have relatively high risks of acquiring work-related infections, particularly hepatitis. Loosely-capped containers and soiled requisitions pose a significant hazard to all who come in contact with these contaminated materials. Therefore, messengers, clerks and laboratory staff are instructed to refuse soiled laboratory requisitions and/or leaking specimen containers. If a messenger finds a leaking container and/or soiled requisition at the pickup station on the floor, the messenger will leave the contaminated materials there, inform the personnel at the nursing station of the problem, and request a new specimen.
Specimen Transport And Messenger Service
A. Automated Transport to the Laboratory
A suitable pneumatic tube delivery system is available in some units for STAT sample transport. Additionally, the southernmost of the three dumbwaiters near the Moffitt nursing station is dedicated to the delivery of laboratory specimens, and is highly recommended for bulk or multiple specimen delivery. When in working order and not already in use it usually takes less than one minute to arrive when called. Place the bagged specimen with its accompanying requisition in the box provided to minimize the very small likelihood of the sample falling off into the dumbwaiter shaft.
Pneumatic Tube Stations at Parnassus
| Station Location | Station Number | Phone Number |
|---|---|---|
| M BSMT PHARMACY | 100 AND 200 | 3-1154 |
| M 1ST EMERGENCY DEPT | 210 | 31238 |
| M 4th PACU | 241 | 3-1292 |
| M/L 4th OR | 240 | 3-1545 |
| M 5TH Clin. Labs - CENTRAL PROCESSING | 150 AND 250 | 8-4930 |
| L 568 Clin. Labs - CHEMISTRY | 151 | 3-1501 |
| M 524 Clin. Labs - HEMATOLOGY | 251 | 3-1747 |
| M 5TH BLOOD BANK | 252 | 3-1313 |
| M 6TH PICU | 160 | 3-1352 |
| M 7TH ICU | 270 | 3-1955 |
| M 8TH ICU | 180 | 3-8534 |
| M 9TH ICU | 190 | 3-1621 |
| M 10TH ICU CARDIAC | 910 | 3-1007 |
| M 11TH ICU NEURO | 911 | 3-1873 |
| M 13TH ICU | 913 | 3-8113 |
| M 13TH SOUTH SAT PHARMACY | 813 | 3-8151 |
| M 15TH ICN | 915 | 3-1565 |
| M 15TH NCPL - BLOOD GAS LAB | 916 | 3-1755 |
| ACC 1ST LAB | 211 | 3-2736 |
| ACC 5TH HEME/ONC CLINIC | 253 | 3-2068 |
Pneumatic Tube Stations at Mt. Zion
| Station Location | Floor & Bldg. | Station Type | Station Number | Phone Number |
|---|---|---|---|---|
| HS046 Radiology | Basement CC building | Recessed (1 inlet/outlet) | Sub Station 1 | 3-9966 |
| H1044 CC Draw Station | 1st floor CC draw station | Recessed (1 inlet/outlet) | Sub Station 2 | 5-1664 |
| Clinical Labs & Central (Specimen) Processing | 2nd Floor MZ B212 | Recessed (1 inlet/outlet) | Clin Lab B212 | 5-7845 |
| H2508 Breast CC | 2nd CC building | Recessed (1 inlet/outlet) | Sub Station 3 | 3-7070 |
| H3508 GYN-Oncology | 3rd floor CC building | Recessed (1 inlet/outlet) | Sub Station 4 | 3-7172 |
| H4508 General ONC | 4th floor CC building | Recessed (1 inlet/outlet) | Sub Station 5 | 3-7105 |
| H5310 Infusion Center | 5th floor CC building | Recessed (1 inlet/outlet) | Sub Station 6 | 3-7108 |
B. Laboratory Messengers
During the day shift, laboratory messengers pick up in-patient specimens every 1-2 hours from the laboratory refrigerators in Moffitt and Long Hospitals, and (on weekdays) every 15-30 minutes from the ACC labs. A laboratory messenger also makes inpatient rounds from 4:00 p.m. until midnight each evening.
C. Night and Emergency Messenger Service
Between midnight and 7:00 a.m., laboratory messenger service is generally unavailable except through the use of a nursing unit's own Patient Service or Patient Care Assistants.
D. Laboratory Refrigerators
Refrigerators designated specifically for storage and pickup of laboratory specimens are located in the utility area of each major nursing unit. Laboratory messengers are instructed to bring to the 5th floor laboratory any (non-leaking) specimens found in the laboratory refrigerators. Food as well as specimens which cannot be identified will be discarded. Please do not store partially complete urine collections, food, medications, or other materials not intended for laboratory analysis in the laboratory refrigerators.
E. Laboratory Messenger Schedules
The messenger schedules which follow are posted on the laboratory refrigerators:
WEEKDAY INPATIENT SPECIMEN PICKUP
Approximate Schedule for Clinical Laboratory Messengers
| R T E |
RUN NO. |
LV MAIN |
15-6 M/L |
HEM A510A, GYN A95D |
PED A220 |
M,Th Only TCL A333 |
ACC LAB A122 |
Prepare M170 |
ARR MAIN |
|---|---|---|---|---|---|---|---|---|---|
| A | 1 | 700 | 705 | 730 | |||||
| A | 2 | 800 | 805 | 830 | 835 | 840 | |||
| A | 3 | 925 | 930 | 955 | |||||
| A | 4 | 955 | 1000 | 1005 | |||||
| A | 5 | 1015 | 1020 | 1045 | |||||
| A | 1100-1145 | Lunch | |||||||
| A | 6 | 1200 | 1205 | 1210 | 1215 | 1220 | |||
| A | 7 | 1225 | 1230 | 1255 | |||||
| A | 8 | 1300 | 1305 | 1315 | |||||
| A | 9 | 1400 | 1405 | 1430 | |||||
| A | 10 | 1445 | 1455 | 1500 | 1510 | ||||
| D | 1 | 1530 | 1535 | 1600 | |||||
| D | 2 | 1610 | 1620 | 1625 | 1630 | 1635 | |||
| D | 3 | 1635 | 1640 | 1655 | 1655 | ||||
| D | 4 | 1655 | 1705 | 1710 | 1715 | 1725 | |||
| D | 5 | 1725 | 1730 | 1735 | 1740 | ||||
| D | 6 | 1740 | 1745 | 1810 | |||||
| D | 7 | 1810 | 1810 | ||||||
| D | 8 | 1815 | 1825 | 1840 | |||||
| 1845 | Lunch | Break | 1945 | ||||||
| D | 9 | 1945 | 2000 | ||||||
| D | 10 | 2000 | 2005 | 2035 | |||||
| D | 11 | 2035 | 2100 | ||||||
| D | 12 | 2145 | 2150 | 2215 | |||||
| D | 13 | 2215 | 2300 | ||||||
| D | 14 | 2300 | 2330 | ||||||
| Holiday | Pickup | ACC | 830 | ||||||
| 1005 | |||||||||
| 1100 | |||||||||
| 1210 | |||||||||
| 1320 | |||||||||
| 1440 | |||||||||
| 1510 |
WEEKDAY ACC SPECIMEN PICKUP
Approximate Schedule for Clinical Laboratory Messengers
A pickup box is situated to the left of the accession window outside the ACC phlebotomy station at A 122 for dropoff of specimens collected on site in the clinics. Specimens in this box will be picked up and transported to the Main 5th floor laboratory as part of the regular messenger runs from 0750-1825 Monday-Friday.
| R T E |
PEDS LAB A2463 A2201 |
Arrive ACC LAB A122 |
Leave ACC LAB A122 |
PSEP L170 |
Main LAB M521 |
OB/GYN Plaza Level |
Cyto 350 Parn. Rm. 800 |
|---|---|---|---|---|---|---|---|
| A | 8:00 | 8:05 | 8:15 | ||||
| A | 12:00 | 12:05 | 12:10 | 12:20 | |||
| A | 15:00 | 15:05 | 15:10 | 15:20 | 15:25 | ||
| A | |||||||
| B | 9:00 | ||||||
| B | 9:10 | ||||||
| B | 9:20 | 9:25 | 9:30 | 9:40 | 9:45 | ||
| B | 10:00 | 10:05 | 10:10 | 10:20 | 10:25 | ||
| B | 10:50 | 10:55 | 11:00 | 11:10 | 11:15 | ||
| B | 11:30 | 11:35 | 11:40 | 11:50 | 11:55 | 12:00 | |
| B | 12:00 to 13:00 | LUNCH | BREAK | ||||
| B | 13:00 | 13:05 | 13:10 | 13:20 | 13:25 | ||
| B | 14:30 | 14:35 | 14:40 | 14:50 | 14:55 | ||
| B | 15:10 | 15:15 | 15:20 | 15:30 | 15:35 | ||
| B | 15:50 | 15:55 | 16:00 | 16:00(M-Th) 16:30 (Fri) |
|||
| B | 16:58 | ||||||
| B | 16:30 | 16:35 | 16:40 | 16:50 | 16:55 | ||
| B | 17:10 | 17:15 | 17:20 | 17:25 | 17:30 | ||
| D | 16:25 | 16:30 | 16:35 | ||||
| D | 16:40 | 16:50 | |||||
| D | 17:00 | 17:05 | 17:10 | 17:20 | |||
| D | 17:30 | ||||||
| D | 17:45 | 18:00 | |||||
| D | 18:05 | 18:10 | 18:15 | ||||
| D | 18:20 | 18:25 | 18:30 | ||||
| A | 8:30 a.m | ||||||
| A | 10:05 a.m | ||||||
| A | 11:00 a.m | ||||||
| A | 12:10 p.m | ||||||
| A | 13:20 p.m | ||||||
| A | 14:40 p.m | ||||||
| A | 15:10 p.m | ||||||
A-Day Shift Messenger 7-15:30 P.M (In patient Courier)* Holiday Run.
*Last run on Holiday @ 16:30 p.m will be done by ACC staff.
B-ACC Day Shift Messenger 9:00 to 17:30 P.M
D-Evening Shift Messenger 15:30 to 24:00 In house and ACC (until 18:30 P.M)
WEEKEND IN-PATIENT SPECIMEN PICKUP
Approximate Schedule for Clinical Laboratory Messengers
| R T E |
RUN NO. |
LV MAIN |
15-6 M/L |
ACC SAC |
ARR MAIN |
|---|---|---|---|---|---|
| A | 1 | 700 | 705 | 730 | |
| A | 2 | 800 | 805 | 840 | |
| A | 3 | 925 | 930 | 955 | |
| A | 4 | 1015 | 1020 | 1045 | |
| A | 5 | 1140 | 1145 | 1210 | |
| A | 6 | 1225 | 1230 | 1255 | |
| A | 7 | 1400 | 1405 | 1430 | |
| A | 8 | 1435 | 1440 | 1505 |
a. Breaks between 0955-1015
b. Lunch between 1045-1140
Add-On Requests And Retention Of Specimens
Federal regulations require that verbal requests for additional tests be supported by written documentation. The Clinical Laboratories will request that a new laboratory requisition be submitted whenever we are asked to perform additional tests upon a specimen already in the laboratory. Complete the specimen collection information using the date and time of the specimen given to you by the laboratory when you made your telephone request. Check the appropriate box or write in the name of the additional test and write the words "ADD-ON TO SAMPLE ALREADY IN LAB" in the space in the lower right hand corner of the form. Where it is not expedient to wait for the receipt of the written confirmation, the additional tests will be processed in a timely manner to ensure that specimen integrity and quality of patient care are not jeopardized; note that the written request must match the verbal orders.
The laboratory will try to honor requests for STAT add-on tests, however, due to the additional steps required to locate a single specimen and get it to the correct section for testing we cannot guarantee the actual turn-around-time for such an test result. If the clinical situation is critical we suggest that a new sample be obtained and sent to the laboratory for testing.
Blood gas, culture specimens, and tests that depend upon intact cellular function or morphology cannot usually be saved. Many hematologic parameters (e.g., coagulation tests and sedimentation rate) are unstable after a few hours. Many chemical assays also cannot be performed on residual specimens because of instability of the analyte(s) (acid phosphatase, ionized calcium, intact parathormone (PTH) and many enzymes). If the leftover specimen has been uncapped or its volume is less than 1 mL, the specimen is unsuitable for quantitative assay because of evaporation.
Chemistry assays which require specimens collected in blue, gray, dark green, lavender or navy top tubes are often unsatisfactory, and will not be performed on leftover specimens unless approved by a Chemistry supervisor or a laboratory physician; approval by a supervisor or the resident on call is required for any tests requested on an unrefrigerated specimen or if more than 48 hours have elapsed since a specimen was received (24 hours for carbon dioxide [CO2]). With the exceptions noted, tests requested on at least 1 mL of separated, capped and refrigerated serum can be added-on without approval.
Because of limited facilities for storage, the laboratories are unable to save specimens for as long as we would like, for the uncommon occasion when it would be useful to repeat a test on the original sample. Specimens are retained according to the following schedule:
| Blood Bank | 2 weeks (cord blood-1 week) |
| Chemistry | 4 days |
| Hematology | 24 hours (smears-2 weeks, factors/inhibitors-1 month) |
| Immunogenetics | 6 months |
| Immunology | 1 month |
| Microbiology | 1 week (isolated pathogens) |
| Neonatal Clinical Physiology Laboratory (NCPL) | Not applicable |
| Reference Laboratories | variable (Nichols: 30 days, SKBL: 2 weeks) |
| San Francisco Health Dept. | 6 months |
Samples are generally destroyed after the above retention period. Occasionally the lab receives requests to release samples for other uses. In general there are two instances in which the laboratory may release samples:
- When requested to do so by the medical examiner for forensic testing purposes. In such cases the sample to be released are collected, information on the samples (patient name, MR#, type and date of collection of each sample to be released) is documented and the medical examiner staff will be asked to sign the this document for our records.
- When the UCSF CHR has approved the release of specified types of samples for research purposes. If such samples are to be released before the end of our stated retention time then there must be contact information provided to the laboratory on how to retrieve such samples should additional clinical testing or forensic testing be required.
Laboratory Inquiries & Reports x3-1667
A. Electronic Inquiries
The majority of inquiries about patient results are made electronically from UCare & STOR/CDS via PCs which are widely available throughout the Medical Center and at physician offices on both Parnassus and Mount Zion campuses.
Information about test availability, methods, sample collection-handling-storage requirements, reference ranges, testing schedules, expected turnaround time, etc., is given in the Test Tables of this Manual, the electronic version of which is up-to-date and always accessible on-line from campus PC's (Icon on UCare screens or selection 21 on the STOR main menu). Users with internet access can browse a web-based version at http://labmed.ucsf.edu/labman/. (NOTE: carefully observe the use of upper and lower case in entering this web address).
Dialup access to UCare and STOR/CDS is also available to authorized staff. For additional information about electronic access, contact the Medical Staff Office, your supervisor, or STOR (x32189); for problems which appear to represent failure of campus equipment, call the "Help" desk (x33600).
B. Telephone Inquiries
Phone inquiries may interfere with staff performing testing and should therefore only be made when there is an urgent need for test results. Test results may be obtained by telephoning x3-1667 (x3-1313 for Blood Bank, x3-1268 for Microbiology). Inquiries concerning specimen collection and processing, validity of laboratory results, discrepancies in the data, and other problems will be referred to the appropriate section or to a laboratory physician.
Laboratory results are stored in the computer by the patient's unit number and by most recent date and time of collection. To ensure that the correct patient is selected when laboratory data are requested, please provide the patient's unit number. If the unit number is not available, please give the patient's first and last names and date of birth. At present our laboratory computer stores results in an immediately accessible fashion for about 180 days after an inpatient has been discharged or after the last test has been completed for an outpatient episode of care, and for about one year for samples from outside our institution.
C. STAT Results, Critical Tests and Critical ('Panic') Values
1. STAT Results:
For practices or units that
do not have access to electronic reports (STOR, UCare) the UCSF
Clinical Laboratories will make every attempt to relay the results of
STAT tests by phone if a request to phone the results and an
appropriate number are indicated on the STAT requisition. However, as
this involves manual processes by the lab staff we cannot guarantee
that all results will be phoned when requested.
2. Critical ('Panic') Values:
Results of certain routinely requested tests may suggest an immediate threat to life. Chemistry results which exceed defined critical limits, which we have established in concert with SFGH and VAMC, are automatically called to the physician's office or nursing unit whenever found.
Critical results for some Hematology tests (e.g WBC, ANC, Platelet counts, PTT) generally result from more chronic conditions or therapy and are not as susceptible to immediate correction; a Hematology critical value for these tests will automatically be telephoned if a new finding within the previous 24 hours (however, all Platelet counts <10,000 and PTT results ≥ 80 seconds will be phoned).
Due to the potentially critical nature of these reports, critical results for hospital units will only be given to a licensed individual (e.g. MD, RN, NP, PA). For ambulatory clinics (including the ED), critical values will preferably be provided to a licensed individual, however, if none is immediately available the result may be reported to other clinic staff.
In all cases, the person receiving the critical value will record the value in the patient's record. If the recipient is not a physician or nurse, he/she assumes responsibility to notify the patient's nurse or a physician who can immediately respond to the result. The clinical laboratory staff will ask the recipient to read back and confirm the result(s) we provide and will document this in the computer. (Critical values listed below were approved by UCSF EMB on 12/18/07)
If a critical result is obtained for a clinic patient after the clinic has closed, we will notify the individual on-call for the clinic, usually reached via an answering service or delegated to the resident or fellow on call for the service involved.
If the UCSF Clinical Laboratory receives a critical result from a reference laboratory it will be handled in the same way as an in-house critical result and immediately relayed to an appropriate care provider even though the test may not have a critical value approved by the UCSF EMB.
Certain other test results that are deemed to have significant clinical import may be phoned to an appropriate care provider (e.g. Positive HIV Ab, Triglyceride > 2000 mg/dL) when resulted during the day shift Monay-Friday. As these do not reflect immediately life threatening conditions they will be phoned the next working day when identified evenings, nights, weekends or holidays. The test(s) to which this applies are determined by the Laboratory Director in consultation with laboratory and medical staff and do not require EMB approval.
CHEMISTRY CRITICAL VALUES
| Acetaminophen | >50 mg/L | pCO2, Arterial | <25 or >65 mmHg | |
| Calcium, Ionized | <0.80 or >1.55 mmol/L | pCO2, Venous | >75 mmHg | |
| Calcium, Total | <6.5 or >13.5 mg/dL | pH, Arterial | <7.20 or >7.55 | |
| Carbamazepine | >15 mg/L | pH, Venous | <7.20 | |
| Carboxyhemoglobin | ≥5.0% | Phenobarbital | >50 mg/L | |
| CO2, Total | <15 or >40 mmol/L | Phenytoin | >35 mg/L | |
| Digoxin | >2.0 µg/L | Phosphorus | <1.0 mg/dL | |
| Ethosuximide | >200 mg/L | pO2, Arterial |
<40 mmHg | |
| Glucose, CSF | <30 mg/dL | -for neonates |
<40 or >100 mmHg | |
| Glucose, serum | <50 or >500 mg/dL | Potassium | <3.0 or >6.0 mmol/L | |
|
-for neonates
|
<30 or >170 mg/dL | Primidone | >15 mg/L | |
| Glucose, POCT | <60 or >400 mg/dL | Procainamide | >15 mg/L | |
|
-for neonates
|
<40 or >150 mg/dL | -or NAPA |
>30 mg/L | |
| Lidocaine | >7.0 mg/L | Quinidine | >5 µg/mL | |
| Lithium | >2.0 mmol/L | Salicylate | >35 mg/dL | |
| Magnesium | <1.0 or >4.5 mg/dL | Sodium | <125 or >155 mmol/L | |
|
-for Birth Center
|
<1.0 or >8.0 mg/dL | Theophylline | >30 mg/L | |
| Methemoglobin | ≥2.0% | Troponin I | ≥0.05 µg/L* | |
| Osmolality | <240 or >320 mOsm/Kg | Valproic Acid | >150 mg/L |
* The first elevated troponin for a patient will be called. Subsequent elevated Troponin levels for the same patient in the next 72 hrs after the initial report will not be called.
HEMATOLOGY CRITICAL VALUES
| ANC | see PMN's |
| Fibrinogen | ≤75 mg/dl or >50% from any prior level |
| Fondaparinux | >1.26 µg/mL |
| Hematocrit, Spun | < 25% or > 65% |
| Hemoglobin | ≤7.0 g/dL |
| Heparin, Unfractionated | > 0.7 Anti-Xa U/mL |
| Heparin, Low Molecular Weight | > 1.50 U/mL |
| INR | ≥5.0 |
| Peripheral Smear | Blasts (first time) |
| Platelets | ≤25,000 /µL (25 x109/L)** |
| PMNs (ANC) | ≤1,000 /µL (1.0 x109/L)*** |
| PTT | ≥60 sec* (does not apply to infants < 6 days old, ie. 0-5 days) |
| WBC | ≤1,500 or ≥100,000 /µL (<1.5 or >100 x109/L)*** |
(See the Test Tables for the relevant assay units)
* PTT results from 60.0-79.9 seconds are phoned only if no previous critical value in last 24 hours; PTT ≥ 80.0 seconds are always called
** Platelet results from 11-25 x109/L are phoned only if no previous critical value in the last 24 hours. Platelet counts <10 x109/L are always called.
*** WBC and ANC criticals are not called if a prior critical value was reported in the preceding 24 hours.
MICROBIOLOGY CRITICAL VALUES
The Microbiology and Virology Laboratories will call initial results for life-threatening infections and those that are of public health concern. All results are promptly entered into the computer and are available in STOR and UCare.
All STAT gram stains requests on specimens from the OR will be called.
In addition, the following results will be called:
BACTERIOLOGY
| Positive Gram stains of samples from normally sterile sites |
| Blood cultures: Only gram stain results from the first positive blood culture for each patient (call again if a different organism is isolated on same or subsequent culture or if >7 days since last call) |
| Positive CSF cultures |
| Positive CSF cryptococcal antigen |
| Stool cultures positive with E coli O157:H7, Vibrio cholerae, or Salmonellae that cause enteric fevers (e.g., S. typhi) |
| Shiga toxin producing E. coli |
| Positive USP cultures |
| Bacillus anthracis |
| Bordetella pertussis DNA detected by PCR |
| Brucella spp. |
| First Burkholderia cepacia isolate on a CF patient |
| Burkholderia mallei and pseudomallei |
| Corynebacterium diphtheriae |
| Franciscella tularensis |
| Group A streptococci only from sterile sites |
| Group B streptococci from patients in Labor and Delivery and the Nursery |
| Legionella spp. |
| Neisseria gonorrhoeae from all sites |
| Neisseria meningitidis from sterile sites |
| Yersinia pestis |
MYCOBACTERIOLOGY
| First positive AFB smear; first positive AFB culture if smear negative or no smear; first isolate of M. tuberculosis; positive M. tuberculosis PCR on a respiratory specimen; first isolate of Nocardia (call again if subsequent positive specimen is from a different site or if >2 months since last call) |
| Positive AFB culture on CSF |
MYCOLOGY
| Biphasic fungi (e.g., Coccidioides immitis) |
| Zygomycetes (e.g., mucormycosis) |
| KOH if C. immitis spherules present or non-septate hyphae suggestive of Zygomycetes |
| CSF cultures that yield a fungus |
PARASITOLOGY
| Blood parasites (e.g., malaria) |
| Parasites from CSF |
| Entamoeba histolytica from invasively collected specimens |
VIROLOGY
| Positive Clostridium difficile toxin assay |
| Positive HSV or VZV DFA from inpatients |
| HSV DNA detected by PCR |
| VZV DNA detected by PCR |
| Influenza A and B from inpatients |
| Parvovirus B19 DNA detected by PCR |
| RSV from inpatients |
D. Printed Reports
Results for most procedures are reported by computer; an effort is being made to incorporate those results which currently are not. Problems involving delayed, missing or incorrectly addressed reports should be directed to x3-1667.
1. Inpatient Ward Reports:
Because laboratory results are routinely obtained via the UCare and STOR/CDS, printed reports are no longer routinely generated.
Whenever Clinical Laboratories has been notified by Hospital Information Technology that the UCare or STOR/CDS system is out of commission for at least 3 hours, printed reports are distributed to units every hour. Production of these reports will continue until the CDS is again operational. The reports are posted at each nursing station, and contain all computer-processed results since approximately 0600 of that day. STAT results for the OR and ED will be phoned during these periods as well as all critical values.
In the event of a UCare or STOR/CDS breakdown, PLEASE CONSULT THESE REPORTS BEFORE CALLING THE LABORATORY.
2. Cumulative Summaries:
Cumulative Summary reports of all results for the hospital admission are not routinely printed for all nursing stations. If for any reason a cumulative summary is wanted for a particular patient, contact the laboratory at x3-1667 and request that one be produced and tubed to the nursing station, which can be done within several minutes.
3. Discharge Summaries:
When all tests have been completed on the discharged patient, a Final Cumulative Report is printed and sent to any Referring Physician identified during the Admitting process for their records.
4. Ambulatory Patient Reports:
For ambulatory patients, reports showing New Activity only are printed Sunday-Thursday evenings for distribution the following day. These reports are sent to the ordering location, sorted by ordering physician. Additional New Activity reports are generated whenever additional results for a particular episode of care become available; results of previously reported tests are not reprinted. Final Reports, containing the results of all tests ordered during a patient encounter, are printed when all testing for the particular outpatient visit has been completed.
If additional copies of results are required for "Copy to:" UCSF physicians, this should be indicated on the laboratory requisition by entering the full name and UC number for the UCSF physician in the area provided for this at the top of the requisition.
E. Fax Requests
The UCSF Clinical Laboratories are often requested by patients to fax copies of laboratory reports to physicians other than the one ordering the test(s). As we have limited automatic faxing capabilities in the laboratory computer system it is very problematic for us to honor such requests.
Generally, there are three methods to handle getting test information to other physician(s) who did not order the test(s):
- If the other physician is a UCSF provider, he or she will have a 5-digit physician ID number that the lab staff can enter into our computer system. The patient should get the ID number from the other physician and ask that the lab staff enter he or she as a 'Copy to'. A printed report will then be forwarded to that physician.
- The patient can request that the 'copy to' physician contact the physician who ordered the test and request a copy of the results.
- Contact UCSF Medical Records and request a copy of the test results be forwarded to the other physician(s).
F. Computer Crashes
The laboratory is served by two linked computers, providing us with partial "fault-tolerance". When one of these devices fails ("crashes"), the nursing units are notified and interim reporting arrangements are implemented.
If the breakdown is likely to last longer than 2-3 hours, we will prepare and deliver handwritten reports to the nursing stations (for Microbiology, only handwritten antimicrobial susceptibility reports are generated). These handwritten reports are difficult to duplicate; please retain them in the chart until after the computer is again in operation, and the results in the UCare and STOR/CDS systems are again up-to-date. Most crashes are resolved within 6-8 hours; on the rare occasions when they are more prolonged we usually are able to partially restore function.
Critical (panic) values and stat results are telephoned to the floors during a crash. Routine telephoning policies for microbiology results are observed: all positive cultures from normally sterile sites are called, as well as isolates of beta-streptococci, gonococci, enteric pathogens, and acid-fast bacilli.
The impact of a computer breakdown varies with the time of day at which it occurs. Although our instrumentation can operate independent of the computer, the large volume of data, the need to manually assign and record specimen numbers, and the slowness of manual filing and retrieval of results combine to significantly decrease the speed with which we can turn out reports during a crash. Our ability to look up the results of previously completed tests is severely impaired, and medical and nursing staff must depend heavily upon the UCare and STOR/CDS and its content of results generated prior to the breakdown. Except in emergencies, it generally is not practical for us to look up results which have already been reported; if such results are required obtaining them will be a very slow process. Tests which were completed but not reported prior to the crash may have to be rerun, which may require collection of additional samples.
Please do not come to the laboratory to obtain routine results. Avoid calling the laboratory except for those results needed to implement current patient care decisions; record these results carefully in the patient's chart because it is difficult to recover them in the laboratory.
G. Prohibition regarding direct release of test results to patients
Section 1288 of the California Business and Professions Code forbids Clinical Laboratories from directly releasing results to patients. Results MUST pass through the hands of the person authorized to order the test before they can be given to a patient. This prevents patients from misinterpreting test results and potentially taking unnecessary actions (or failing to take necessary actions) because of misinterpretation.
Please do not request that the laboratory provide results directly to patients or tell patients that they may contact the laboratory to obtain their results. It is standing policy for the UCSF Clinical Laboratories to not provide reports directly to patients in compliance with California regulations and laboratory staff are instructed to deny such requests and refer the patient back to his or her physician for their test results.
H. Other Delays in Reporting
Expected turn-around times are listed for each test in the table section of this Manual. In general, because of redundant equipment for the high volume routine tests required for most operational needs, only a mild-to-moderate slowdown in the availability of important test results is ever seen. Problems judged to affect a wide variety of users are announced to the clinical staff by our requesting that a message be posted at login to the Clinical Display System (STOR), the primary route of access to laboratory results at this institution at the present time and/or distribution of written memos to the nursing units.
If prolonged equipment or methods failure appears to delay results which are needed within hours to several days, we will arrange for testing to be performed at the laboratories of our sister institutions (e.g., UCSF/Mount Zion or SFGH) or - for tests not offered - one of our contract commercial vendors. Notification in the latter case will depend upon whether the test is of special interest to some subgroup of physicians, of universal interest, or of little or no interest.
In all cases, the report will carry the name of the performing laboratory and call attention to any temporary changes in reference ranges (ranges at Mount Zion are already set in parallel with our own).
Comments or Complaints About Service x26128
Comments or complaints about laboratory services can be sent via e-mail from th following web-link: http://labmed.ucsf.edu/labmanual/mftlng-mtzn/feedback/feedback.html
If the complaint involves a specific instance or patient issue pleas provide as much inforamation about it so that apropriate follow-up can occur. The location, date and time, patient information (Name, MR#, DOB) and if known, the names of any involved laboratory staff should be included.
If you feel your problem is urgent and has not been resolved by laboratory personnel or their supervisors, please promptly bring it to the attention of the Laboratory Director or Manager (x3-1723). Do not accumulate complaints; we can best serve you if any difficulties are reported promptly. When the "trail" is still fresh, the cause of trouble can usually be identified and often remedied.