LABORATORY TRAINING MODULE

1. LABORATORY TRAINING MODULE Linda Hastings, MT (ASCP) Clinical Pathology Augusta University Medical Center Augusta, GA 30912 May 2009 Revised 10.26.18

2. Objectives of Training Module At the end of this module users should be able to: • Locate and use the On-line Pathology Lab Manual • Identify frequently used test codes • Properly complete a Laboratory Requisition • Identify phlebotomy problems • Properly identify Blood Bank’s special specimen & labeling requirements • Have general knowledge of the laboratory process and causes of Patient Safety Net incident reports • Identify properly and improperly labeled specimen containers • Identify CPOE labeling problems • Identify properly and improperly labeled specimen containers • Better understand the Why’s of new labeling requirements

3. CPOE vs REQUISITIONS What is CPOE and do we need requisitions any longer? • CPOE or Computerized Physician Order Entry is the computerized ordering program being used by the physician to place orders for lab testing. • Requisitions will be replaced by CPOE orders but still needed for operation during computer downtime, rarely ordered tests, RRT, or Code Blue.

4. AUMC Laboratory Catalog Online Where is it? • The link to AUMC Laboratory Catalog is available on the PAWS web page: https://augustahealth.testcatalog.org/ and may be accessed by clicking on Lab Catalogas shown: Lab Catalog

5. On-line AUMC Laboratory CatalogWhat does it tell you? • Names of tests, common names and abbreviations (Complete Blood Count – CBC) • Type of Tube & Volume of specimen required for testing (Lavender tube, 1.5 mL for venipuncture, 300mcL for capillary specimen) • Special requirements for transporting specimen to lab • Reference or “normal” ranges for result interpretation & any notes pertaining to patient care (Age dependent. See report in PowerChart or refer to Reference Range table on intranet) • Causes for rejection (clotted specimen; insufficient quantity; wrong tube; improper labeling) • Turnaround time or approximately when results should be expected (2 hours) • CPT/HCPCS Codes (85027) • Which lab performs the test and special notes (This procedure is available continuously from the Hematology & SCC labs. Pediatric Teaching Lab and Family Medicine Lab operate from 8:30AM-5:00PM Mon-Fri)

6. Clicking on the Lab Catalog link takes you to search page of the catalog. Tests are listed alphabetically. You can search two ways: 1. Entering the name of the test into the search box and clicking the search button or 2. Clicking on C to bring up all test beginning with the letter C.

7. Click on “C” for a CBC Click Search

8. After clicking the “C”, you may have to scroll down to find the test you are searching for such as our example: CBC

9. "CBC" test may also be found using Synonyms

10. Clicking on CBC will bring up the following screen:

11. Completing Requisitions:Why is so much information needed? • Clear communication to the lab. • Getting the correct tests ordered and performed. • JOINT COMMISSION, CAP & GDHR regulations satisfied. • Information regarding results gets to the correct persons. • Allows for the successful completion of testing with least amount of delay.

12. Physician contact information, Order Taken Off is who is completing form Requisitions Patient Name, eMRN, CPI, DOB are required. IDX labels are sufficient Priority Who collected specimen & when CHECK APPROPRIATE SAMPLE TYPE FOR BLOOD GASES, NOTE FIO2 AND TYPE SAMPLE, (arterial venous, mixed venous) Check ALL boxes of desired tests

13. PhlebotomyDetails make a difference • Patient ID-patients should be identified using two identifiers. Patient should be asked to state their full name and birth date and this should be confirmed with the ID Band. • Confirm physician orders-multiple samples may be needed. • Prolonged tourniquet application may cause stasis, localized acidemia and hemoconcentration affecting results. • If using the syringe to transfer blood to tubes, avoid forcing blood into tubes as this may cause hemolysis of red blood cells. • Gently rotate back and forth 8 – 10 times tubes with additives in them to provide for adequate mixing. Inadequate mixing can cause clotting. Shaking can cause hemolysis of red blood cells and produce inaccurate results. • Specimens MUST be labeled at the patient bedside. Incorrect identification of specimens could result in diagnostic or therapeutic errors. All mislabeled & unlabeled samples are Safety and Intelligence incidents. • Transport specimens to lab immediately to ensure accurate results. Some tests are time sensitive.

14. DEFINITION & EFFECTS Hemolysis is the breakdown of red cell membranes during blood collection. It is the direct result of the collection process and DOES NOT happen upon standing or centrifugation of the specimen. Hemolysis causes the plasma or serum to turn pink to red. Hemolysis can effect many analytes causing the specimen to be rejected and the patient recollected. CAUSES OF HEMOLYSIS Using a small bore (25G) needle to collect a full tube can cause hemolysis due to vacuum pressure. Catheter collection can cause hemolysis due to several different internal diameters causing turbulence and rupturing cell membranes. Needle occlusion causing a slow flow. Vigorous mixing or shaking of sample. Metabolic disorders such as liver disease, hemolytic anemias. Hemolysis

15. Three Phases of the Laboratory Process

16. Tubes & Anticoagulant/Additives

17. Tubes of Today & Special Notes • The tubes of today are almost always plastic. They have specific additives in them and are NOT INTERCHANGEABGLE. • NEVER POUR BLOOD FROM ONE TYPE TUBE INTO ANOTHER. 3. Refer to the AUMC Laboratory Catolog ONLINE or contact the laboratory if unsure of type tube or transportation requirements for tests ordered.

18. SPECIMEN LABELING DO’s AND DON’T’s

19. Why this module is necessary? • New automation in the laboratory will utilize the latest technology to identify patient samples and perform testing on each sample.

20. New advances in the lab • Part of the laboratories new instrumentation includes a specimen track system

21. So what does this have to do with the nursing unit? • Specimens sent to the lab must be labeled properly to avoid delays and problems with new instrumentation being able to process your specimens in a timely manner. • The specimen collector will be required to properly label all specimens to avoid delays in patient care and obtaining patient results.

22. Labeling patient specimens • It is hospital policy that all specimens obtained from the patient will be labeled at the bedside. • http://www.waynesburg.edu/files/Nursing_0.jpg

23. The Ten Commandments of Phlebotomy • 1 Thou shalt protect thyself from injury. • 2 Thou shalt identify thy patients. • 3 Thou shalt puncture the skin at about a 15 degree angle. • 4 Thou shalt glorify the medial vein. • 5 Thou shalt invert tubes containing anticoagulants immediately after collection. • 6 Thou shalt attempt to collect specimens only from an acceptable site. • 7 Thou shalt label specimens at the bedside. • 8 Thou shalt stretch the skin at the puncture site. • 9 Thou shalt know when to quit. • 10 Thou shalt treat all patients as if they are family. http://laboratory-manager.advanceweb.com/Editorial/Content/Editorial.aspx?CC=6203

24. How to read and complete a laboratory specimen label Patient name & MRN 1st Tube Type 2nd Tube Type Laboratory Specimen label sets are divided into 3 areas: Demographic Label Large label on top of the label set Specimen Tube Barcodes – 1 tube type per label set. 1 label set consists of 1 large barcode label and 2 aliquot. Aliquot Labels - 2 aliquot labels for each large lab label for lab use or for Microtainers. Tests Ordered Ordering Physician Collection Tube Label Accession Number Aliquot Labels

25. How to read and complete a laboratory specimen label (continued) • All laboratory tests generate at least one specimen label. More than one tube type may be printed on each large lab label. Please read the left and right barcoded labels for the tube requirements. Be sure to send all labels with the specimens when submitting to the laboratory for testing. ALL labs must be signed off in the computer via the collection list before sending to lab. • Specimen Demographic Labels used during a Downtime must include : • Collection date • Collection time (Military Time) • Cerner Username of the person who collected the specimen(s) • Print all information clearly. • Use only the collector’s Cerner Username – not the name and not the initials. • Avoid the use of gel pens as the ink from gel pens will smear and become unreadable during transport. • If any of this information is not on the label, the laboratory staff will not be able to accept the specimen into the lab system for testing. If the lab cannot read any of the collection information, the tests cannot be performed. • When labeling the specimen tubes, make sure that the barcode label is placed correctly. Hold the tube with the top of the tube to the left. Place the left side of the barcode label on the tube so that the label lies horizontally on the tube and the name and accession number can be clearly read. Make sure that the label is even, smooth and without any folds or wrinkles. Do not make any marks on the barcode itself.

26. What you need to know! • Out with the OLD and IN with the NEW!!!! • Best dressed tubes are the latest and greatest!!!! Best dressed tubes are dressed for SUCCESS!!!! The Hospital Gown look is IN. • Worst dressed tubes are OLD and SLOW and NOT THE WAY TO GO. They increase the wait. Best Dressed Tubes Chart from Beckman Coulter TOP Training CD

27. Best Dressed Tubes Qualities are: • Label placed directly under the cap. • Name at the TOP • Barcode Straight • Hospital Gown Look…leave visible window by placing CPOE label directly over the tube manufacturer’s original label. Best Dressed Tubes Chart from Beckman Coulter TOP Training CD

28. Examples of Properly labeled tubes:

29. More examples of properly labeled tubes and syringes

30. Multiple labels on one tube The following slides will show examples of incorrectly labeled specimens Best Dressed Tubes Chart from Beckman Coulter TOP Training CD

31. The Twisted Shirts Best Dressed Tubes Chart from Beckman Coulter TOP Training CD

32. The Turtlenecks Best Dressed Tubes Chart from Beckman Coulter TOP Training CD

33. Multiple labels on one tube • The new system will NOT read more than one barcode label on a single sample. EACH SAMPLE MUST HAVE A UNIQUE ACCESSION NUMBER.

34. The Wrap Around & The Topsy Turvy Best Dressed Tubes Chart from Beckman Coulter TOP Training CD

35. The Cinched Belt & Wrinkled Best Dressed Tubes Chart from Beckman Coulter TOP Training CD

36. Cancellation Process • Laboratory specimens are cancelled for a variety of reasons: Suboptimal specimens: • hemolyzed, • quantity not sufficient (QNS), • improper transport (i.e. Ammonia or Lactic Acid not on ice, Methotrexate not wrapped in foil), • incorrect specimen container. • specimen not signed off in the computer via the Specimen Collect list. • Labeling issues: • name on labels sent with specimen and label on specimen do not match, • unlabeled specimens. • Paper Requisitions lacking information: • contact information (for critical values), • medical record numbers to enter tests into Cerner PathNet/PowerChart.

37. Cancellation Process • Test cancellation can take place at any phase, but occurs primarily in the Pre-analytical phase. This begins when the technologist notices a problem with the requisition or specimen and notifies the unit/clinic. This usually leads to recollection or determination to recollect at a later time. The technologist will cancel the requested test in the Cerner PathNet/PowerChart system noting who was notified of the cancellation and the time of notification.

38. References • http://images.dotmed.com/cgi-bin/size.pl?t=2&a=3&i=592809.jpg • Best Dressed Tubes Chart Beckman Coulter TOP TRAINING CD • http://www.waynesburg.edu/files/Nursing_0.jpg • http://laboratory-manager.advanceweb.com/Editorial/Content/Editorial.aspx?CC=6203