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Lab Manual for UCSF Clinical Laboratories

Lab Manual for SFGH

Internal Resources

Consultation and Test Approval



Laboratory Medicine Residents are available for assistance and consultation 24 hours a day, seven days a week.


  1. CONTACTING LABORATORY MEDICINE RESIDENTS

Routine hours: Monday through Friday 8 am - 5 pm

Clinical Chemistry Resident:

Pager: (415) 443-2311

Hematology/Blood Bank Resident:

Pager: (415) 443-0179

Microbiology Resident:

Pager: (415) 443-1438


  1. ON-CALL HOURS

At all other times, page the on-call Lab Medicine Resident at pager 415-443-6969, or call Clinical Laboratory Inquiry Section, 206-8590, and ask them to contact the resident on call.



  1. CONSULTATION

The residents and faculty of the Department of Laboratory Medicine are pleased to consult on general or specific problems of test selection and interpretation, and to assist in resolving problems or obtaining unusual laboratory services. Call us if you have questions about the collection and handling of a specimen, the availability of a particular test, or the interpretation of a test result. The Laboratory Medicine Resident can also arrange for laboratory procedures that require advance approval, scheduling, or special handling of the specimens. Please be prepared to give the patient’s name, hospital number and location.


Contact the Laboratory Medicine Resident IMMEDIATELY if you have any questions about test results; for example, if you question whether or not a test result is clinically significant, or if a result is unexpected for the patient’s clinical condition.


  1. TEST APPROVAL

A number of laboratory tests, including all procedures not specifically listed in this manual, require advance approval by the Laboratory Medicine Resident (or, in some cases, the Resident or Fellow in a specialty such as Hematology or Endocrinology). Restricted tests (see below) require the approval of authorized attending physicians. It is the responsibility of the requesting physician to call the appropriate Resident or Attending for approval. For further information, refer to the Availability section under the ALPHABETICAL LIST OF TESTS, or to the list of Tests Requiring Approval.


This requirement for advance approval was instituted to assure that only medically appropriate tests are performed and to encourage the most effective utilization of the limited resources of the department. The approval procedure is supported by the SFGH&TC Chiefs of Service. Any questions, comments, or problems related to this policy should be addressed to the Director of the Clinical Laboratory.


Restricted Tests

Tests in this category require submission of the request from an approved location OR advance approval by an authorized SFGH provider (see table, below). Additionally, please note that send-out tests are not generally orderable from the Emergency Department. The rationale for this policy is that send-out test results will not be available for several days after submission of the sample. For more information, see archived memo Send-out tests no longer available from the Emergency Department (January 2009).

See the archived memo, Send-out Test Restriction, also from January 2009, for instructions on ordering restricted tests and other information about the approval process. Please note that the list of restricted tests and authorized providers may have changed since the original memo was distributed.

An up-to-date list of restricted tests and providers authorized to approve them is maintained in LCR/Invision (Restricted Tests), also accessible in LCR from the patient test menu by clicking on "Results," then "Lab," then "Restricted Labs Info."


  1. BLOOD PRODUCT APPROVAL

Transfusion Service (Blood Bank) Orders for Apheresis Platelets, Fresh Frozen Plasma, and Cryoprecipitate Needing Approval of the Laboratory Medicine Resident

All orders for Apheresis (Single-Donor) Platelets, Fresh Frozen Plasma and Cryoprecipitate will be screened by the Blood Bank technologists except for patients in Surgery and the Emergency Department.


A. Apheresis platelet orders will need approval:

1. If platelet count >20,000/µL

Exceptions: 1) Platelet count < 50,000/µL in bleeding patients or in patients pre-invasive procedure (surgery, biopsy, spinal tap, thoracentesis, paracentesis), 2) platelet count < 75,000/µL for patients receiving massive transfusion; i.e., transfusion of at least one blood volume/24 hours, and bleeding uremic patients, or 3) patients with a platelet count < 100,000/µL undergoing any neurosurgical or ophthalmological procedure (7 days before or after surgery).

  1. If no platelet count has been obtained within the last 24 hours.

B. Fresh frozen plasma orders will need approval if:

  1. The PT/PTT are normal or have not been obtained within the last 24 hours.

  2. The INR is < 1.5 and the patient has not been transfused with at least 4 red cell or whole blood units in the last 24 hours.

  3. The PTT is < 55 seconds.

  4. Exceptions: Patients with a diagnosis of TTP do not require approval.

C. Cryoprecipitate orders will need approval:

If fibrinogen is over 100 mg/dL or not done within last 24 hours.

Exception: Patients with known afibrinogenemia.

  1. TESTS REQUIRING APPROVAL

The list below contains frequently requested laboratory tests that must be approved before they are performed. Consult the entry in the Alphabetical List of Tests section for specific instructions for obtaining approval for each test. Obtain approval before the specimen is drawn. Any test not otherwise listed in the Clinical Laboratory Manual requires approval.


Clinical Chemistry Resident:

Pager (415) 443-2311

Endocrinology Service:

206-8239

Endocrinology Fellow:

Long Range Pager 719-9535

Microbiology Resident:

Pager (415) 443-1438

Hematology/Blood Bank Resident

Pager (415) 443-0179

  • After hours call 206-8590 or pager (415) 443-6969

Tests Requiring Residents Approval

TEST

APPROVAL SOURCE

Adrenocorticotrophic Hormone (ACTH)

Endocrinology / Clinical Chemistry

Amebiasis Serology

Microbiology Resident

Amino Acids, Fractionated

Clinical Chemistry Resident

Anti-ENA (Extractable Nuclear Antigen)

Rheumatology / Clinical Chemistry

Anti-Glomerular Basement Membrane Antibodies

Clinical Chemistry Resident

Anti-Sjogren's Antibodies (SSA=RO,SSB=LA)

Rheumatology / Clinical Chemistry

Antithrombin III

Hematology / Blood Bank Resident

Anti-Yo

Clinical Chemistry Resident

Arsenic (Quantitative)

Clinical Chemistry Resident

Arsenic, Urine

Clinical Chemistry Resident

BCR/ABL Gene Rearrangement Study

Hematology / Blood Bank Resident

Bile Acids, Fractionated AND Total (Bile Acids, Total does not require approval)

Restricted Test

Blood Components

Hematology / Blood Bank Resident

Bone Marrow Aspiration

(Includes bone marrow hemosiderin and H & E sections. Bone marrow biopsy is performed when indicated.)

Hematology Fellow


(Consult Clinical Hematology Service)

Bordetella pertussis PCR

Microbiology Resident

Cancer Antigen (CA 19-9)

Restricted Test

Cardiolipin Antibodies

Hematology / Blood Bank Resident

Catecholamines (Epinephrine, Norepinephrine)

Endocrinology / Clinical Chemistry

Chromosome analysis:
Requires these forms, pre-approved:
ARUP Patient History Form
UCSF Marker Study Request

Hematology / Blood Bank Resident

Cyanide, Blood

Clinical Chemistry Resident

Cytogenetics, Subtelomeric Probes

Restricted Test

Cytomegalovirus, Blood

Microbiology Resident

Cytomegalovirus, Bone marrow

Microbiology Resident

Cytomegalovirus IgM Antibody

Microbiology Resident

Cytomegalovirus PCR on CSF

Microbiology Resident

Darkfield Exam for Treponema pallidum

Microbiology Resident

Epstein Barr Virus Antibody Panel

Microbiology Resident

Epstein Barr Virus PCR on CSF

Microbiology Resident

Erythropoietin

Hematology / Blood Bank Resident

Erythrocyte Enzymes (other than G6PD)

Hematology / Blood Bank Resident

Estriol, Estrone

Clinical Chemistry Resident

Factor Assays (Coagulation)

Hematology / Blood Bank Resident

Fecal Fat (24, 48 or 72 hours, total)

Clinical Chemistry Resident

Fibrinogen - Immunological

Hematology / Blood Bank Resident

Flow Cytometry (not CD4/CD8)

Hematology / Blood Bank Resident

Folate (RBC or Serum)

Restricted Test

Free Cortisol, Urine

Endocrinology / Clinical Chemistry

Fungal Susceptibility Testing

Microbiology Resident

Glucagon

Endocrinology / Clinical Chemistry

H. pylori Antigen (Stool)

Restricted Test

Hemochromatosis Mutation, PCR

Restricted Test

Hemoglobin, Plasma

Hematology / Blood Bank Resident

Hepatitis B E-Antibody

Clinical Chemistry Resident

Hepatitis B E-Antigen

Clinical Chemistry Resident

Hepatitis C Viral RNA, Genotype

Microbiology Resident

Hepatitis C Viral RNA, High Resolution Genotype

Microbiology Resident

Herpes Simplex Virus PCR on CSF

Microbiology Resident

Histoplasma Antigen

Microbiology Resident

HLA-B27

Rheumatology / Clinical Chemistry

Homocysteine

Restricted Test

Homovanillic Acid, Urine

Clinical Chemistry Resident

Human Placental Lactogen

Clinical Chemistry Resident

Hydroxyproline, Total (Urine)

Clinical Chemistry Resident

Insulin Antibody

Endocrinology / Clinical Chemistry

JAK2 Gene Mutation

Restricted Test

JC Virus PCR

Restricted Test

Keppra (Levetiracetam)

Restricted Test

Legionella Antigen, Urine

Microbiology Resident

Lupus Anticoagulant

Hematology / Blood Bank Resident

Lyme Disease Serology

Microbiology Resident

Methylmalonic acid, Urine

Clinical Chemistry Resident

Mixing Studies (inhibitor screen)

Hematology / Blood Bank Resident

Mycobacteria Susceptibility Testing (non-tuberculous mycobacteria)

Microbiology Resident

Organic Acids, Qualitative, Urine

Clinical Chemistry Resident

Phenylalanine > 10 yrs old

<10 yrs old - no approval required

Clinical Chemistry Resident

Plasminogen

Hematology / Blood Bank Resident

Platelet Aggregation

Hematology / Blood Bank Resident

PTH-related Peptide

Restricted Test

Pregnanediol or Pregnanetriol

Endocrinology Service

Protein C

Hematology / Blood Bank Resident

Protein S

Hematology / Blood Bank Resident

Reptilase Time

Hematology / Blood Bank Resident

Ristocetin Cofactor

Hematology / Blood Bank Resident

Rotavirus Enzyme Linked Assay

Microbiology Resident

Rubella Culture

Microbiology Resident

Russell’s Viper Venom Test, Dilute

Hematology / Blood Bank Resident

Somatomedin-C

Endocrinology / Clinical Chemistry

Syphilis (Treponema pallidum) Darkfield

Microbiology Resident

Thrombin Time

Hematology / Blood Bank Resident

Thrombosis Risk Factors Mutations

Hematology / Blood Bank Resident

Thyroglobulin

Restricted Test

Toxoplasma IgM

Microbiology Resident

Urine Hemosiderin

Hematology / Blood Bank Resident

Urobilinogen (quantitiative)

Clinical Chemistry Resident

Vanillylmandelic Acid (VMA)

Endocrinology / Clinical Chemistry

Varicella Virus PCR on CSF

Microbiology Resident

Viral Susceptibility Testing

Microbiology Resident

Vitamin B6

Clinical Chemistry Resident

Vitamin D 1,25 Dihydroxy

Restricted Test

Von Willebrand Antigen

Hematology / Blood Bank Resident

Von Willebrand Multimers

Hematology / Blood Bank Resident


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