CHESHIRE PATHOLOGY SERVICES

Transcription

1 CHESHIRE PATHOLOGY SERVICES Laboratory Department Handbook January 2016 Clinical Lead / Laboratory Director Pathology Service Manager Dr R Rajendran Vikki Sandland Tel No: Tel No: (3453) Leighton Hospital Middlewich Road Crewe CW1 4QJ Tel: (01270) Fax: (01270) Pathology Handbook Page 1 of 94 Version 7

2 TABLE OF CONTENTS Page Contacts List 4 General Information 6 Laboratory and Mortuary Location and Hours, Leighton Hospital laboratory 6 Transport of Samples 7 Completion of request forms and specimen labelling 7 Urgent samples 8 Danger of infection specimens 8 Accessing results 8 Tests sent to other Laboratories 8 Additional tests on samples already submitted for examination 8 Ordering laboratory consumables/request forms 8 Research 8 Emergency out of hour s Laboratory services 9 Range of investigations 10 Laboratory s policy on protection of personal information and complaint procedure 11 Phlebotomy Services 12 Clinical Chemistry 14 Opening hours 15 Urgent requests 15 Reporting times 15 Requests 15 High risk cases 16 Sample containers 16 Reference ranges 16 General test information 17 Drug assays 17 Lipids 18 Blood gases 18 Urine 18 Patient Instructions for 24hour urine collection 19 Faeces 19 Cerebrospinal & other fluids 19 Diabetes diagnosis & monitoring 20 Thyroid function tests 21 Adrenal function 21 Specialised endocrine tests 21 Sex hormone investigations 22 PSA (prostate specific antigen) 23 Renal disease 23 Sweat tests 24 Troponin I 24 Alphabetical list of biochemistry tests 24 Clinically significant changes in results 29 Graph to assess severity of paracetamol overdose 30 Critical abnormal results 31 Sample collection notes 32 Iron studies and ferritin 32 Haematology and Blood Transfusion 33 Specimen requirements for Haematology 34 Normal ranges 35 Turnaround times 36 Telephone results 37 Thrombophilia (Prothrombic) screening 37 Referred test requirements 38 Anticoagulation 43 Pathology Handbook Page 2 of 94 Version 7

3 Blood Transfusion 45 Procedure for requesting Blood and Blood products 45 Specimen requirements 45 Prescribing Blood products 48 Transfusion reactions 48 Management of Severe/Acute Transfusion Reaction 49 Guidelines for Adult Transfusion (non Oncology patients) 50 Maximum blood order schedules 51 Referred Tests 54 Histopathology/Cytology/Morbid Anatomy 57 Histopathology 57 Request forms 57 Tissues for routine Histopathology 57 Formalin spillages 58 Transport of Histology specimens 58 Verbal Reports 58 Accessing reports 59 Frozen section service 59 Immunofluorescence service 59 Muscle biopsies for potential Myopathy 59 Alopecia Biopsies 60 MDT (Multi-Disciplinary Team) Meetings 60 Turnaround times 60 Referral Sites 60 Cytology 64 Diagnostic Cytology 64 Semen Analysis 65 Turnaround times 66 Morbid Anatomy 67 Transfer of deceased persons to the Mortuary 67 Viewing of deceased persons 67 Hospital Post-Mortems 67 Coroners Post-Mortems 68 Common misconceptions and difficulties 68 Cremation Forms 69 Medical Microbiology 70 Test requesting 71 Urgent specimens 72 Urgent investigations available on call 72 Collection and transport of specimens 73 Lumbar Puncture (LP, CSF) 73 MRSA screens 73 Nose, throat and pernasal swabs 74 Respiratory specimens 75 Aspirates (pleural, joint, peritoneal, pelvic) 75 Tissues/biopsies 76 Pus/wound swabs 76 High vaginal, cervical and urethral swabs 77 Specimens for Chlamydia antigen tests 78 Semen analysis 78 Eye specimens 79 Investigation of keratitis/corneal ulcers 80 Cutaneous specimens (hair, skin, nail) for fungal isolation 80 Urine specimens 81 Faecal specimens 83 Collection of enterobius vermicularis eggs 84 Blood cultures 85 Antibiotic assay of blood 86 Therapeutic drug level monitoring reference ranges 86 Serological and immunological investigations 87 Disposal of materials used in specimen collection 88 Turnaround times 89 Appendix 1 List of non-biochemistry tests sent to other laboratories 90 Pathology Handbook Page 3 of 94 Version 7

4 CONTACTS LIST ENQUIRY CONTACT EXTENSION NUMBER Pathology Service Manager Vikki Sandland 3453 Pathology Information Technology Manager Jason Peters 3886 Pathology Service Lead Governance Carol Tonge 3913 Pathology Help Desk General enquiries/routine results 2345 BIOCHEMISTRY Consultant Clinical Scientist Sarah Robinson 2376 Principal Clinical Scientist Sam King 3885 Service Lead Ian Johnson 3454 HAEMATOLOGY/BLOOD TRANSFUSION Consultant Haematologist (Clinical Advice) Dr G Tarkovacs 8019 Secretary Clinical Nurse Specialists Tonia Ward Tracy Howe Karen Bowyer Laboratory (including Senior Biomedical 2645 / Scientists) Service Lead Jack Flevill Blood Transfusion Manager Diane Benson 2647/3726 Transfusion Practitioner Lesley Adams 3217 Oral Anticoagulation Service Julie Salisbury 2781/3285 Anticoagulation Coordinator Ann Jones 3285 MICROBIOLOGY Clinical Advice Line 3370 Consultant Microbiologists Dr M A T O Donoghue 3683 Dr V Panagea 3713 Secretary Claire Norbury 2236 Microbiology enquiries HISTOLOGY/CYTOLOGY Clinical Advice (Consultant Histopathologists) Dr D Butterworth 2642 Dr N Nasir 2624 Dr A Nicol 3762 Dr J Stafford 2627 Histology Laboratory 2629 Diagnostic Cytology Preparation Room 8143 Service Lead Julie Crawford 3730 Histology and Diagnostic Cytology Results and enquires Histology Secretaries Joanne Lauszkin (PA to Dr Stafford, Dr Nasir and Dr Nicol) Wendy Parry (PA to Histopathology Consultant Team) Cheryl Senior (PA to Dr Butterworth) Pathology Handbook Page 4 of 94 Version 7

5 MORTUARY General Enquiries 2250 Coroner s Office Warrington Town Hall Coroner s Officers PHLEBOTOMY Phlebotomy GP appointments (27)3568 Phlebotomy Manager Donna George (27)3592 SUNDRIES ORDERING Non-routine blood tubes, specimen bottles, report forms, etc Path Lab Stores (11am-1pm) Fax number Formalin pots/buckets Histology Lab MCHFT Internet site Information for users can be found using the following link, including; user surveys, newsletters and an additional link for GPs. Pathology Handbook Page 5 of 94 Version 7

6 GENERAL INFORMATION Laboratory and Mortuary Location and Hours, Leighton Hospital Laboratory All Pathology departments are accredited by United Kingdom Accreditation Service (UKAS) against standards for Medical Laboratories Requirements for quality and competency (ISO 15189:2012). Current schedules of tests accredited for each department within Pathology are available on the UKAS web site using the following link: Enter the Accreditation number from the box below for the Department required and press Search. Select Medical Laboratories if given an option. UKAS Accreditation Numbers MCHFT ECHT Haematology 8056 Haematology 8075 Biochemistry 8083 Biochemistry 8047 Cellular Pathology 8039 Microbiology 8064 The laboratory is located on the first floor of the hospital. From the main entrance take the stairs ahead, Pathology is to the left and the route is signposted. The Mortuary is located on the ground floor of the hospital. From the main entrance, walk to the left of the stairs then at the entrance to the corridor turn right. At the crossroads turn left. The Mortuary is on the left hand side half way down the corridor. Microbiology is now provided from a combined Department at Macclesfield District General Hospital. Phlebotomy is located in the main outpatient hall and is signposted with Pathology (Blood Tests) signs. The Laboratory at Leighton is open from 9.00 am to 5.00 pm Monday to Friday for all routine Haematology, Blood Transfusion and Biochemistry services and a reduced service from 9.00am to noon on Saturday morning and Bank Holidays. The Microbiology laboratory at Macclesfield is open from 9.00am to 8.00pm Monday to Friday and 9.00am to 5.30pm at weekends and Bank Holidays. Outside of these hours Haematology, Blood Transfusion and Biochemistry departments are staffed 24 hours per day and Microbiology has an emergency on call service. Haematology, Blood Transfusion and Biochemistry can be contacted via the bleep system; Microbiology staff may be contacted via switchboard. Histopathology and Cytology departments are open 9.00am to 5.00pm from Monday to Friday. No routine service is available outside these hours or Bank Holidays. The Mortuary is open 8.30am to 4.30pm Monday to Friday. Porter access to Mortuary is 24 hours. A Mortuary Technician is on call at all times contactable via switchboard. A Consultant is available for each department to provide clinical advice outside routine hours. They are contactable via switchboard. A clinical advice line for Microbiology is available 9am to 5pm Monday Friday (excluding Bank Holidays). The clinical advice line number is Pathology Handbook Page 6 of 94 Version 7

7 TRANSPORT OF SAMPLES From within the Hospital Specimens should be brought to the pathology specimen reception. They must be transported in sealed plastic bags with the request card placed in the secondary compartment. When the entrance is closed specimens can be posted into a collection box through a letterbox. Please note that histology specimens from main and minor theatres should be brought directly through to Histology lab rather than Pathology specimen reception, and must only be delivered from Monday to Friday, 9am to 5pm. From outside the hospital Specimens are collected daily Monday to Friday from General Practitioners and outlying hospitals by a courier service. All samples are transported in accordance with the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009, which requires that all specimens in biohazard bags are transported appropriately to the laboratory in the approved containers provided. Please ensure the lids are fastened. Times of collection are available from the Pathology Office. Spillages of samples during Transportation In the unlikely event of a spillage during transportation please contact the laboratory immediately for advice on (2345). COMPLETION OF REQUEST FORMS AND SPECIMEN LABELLING NB: Blood samples for cross matching and group/screen MUST be labelled by hand, by the person collecting them computerised labels are NOT accepted. Request forms for all blood and blood products must be handwritten, ICE request forms or computerised labelled request forms will not be accepted. Computerised forms for Group and Save tests, however, will be accepted but the blood samples must still be hand labelled. It is essential that all specimens received in the laboratory have sufficient, clearly legible information to allow positive identification and correct interpretation. All samples must be labelled with: - (a) (b) (c) (d) (e) SURNAME FORENAME Date of birth NHS number (the MCHFT hospital number will only be used if the NHS number is not available) All Blood Transfusion samples must be labelled with the MCHFT hospital number due to the Electronic blood tracking system. NB: Specimens with insufficient data will be rejected except under extenuating circumstances. For Transfusion all identifiers must be provided in hand-written format. Clinicians should usually make requests via the Anglia ICE electronic requesting system. Where this is not available, manually completed paper request forms may be used. STANDARD ADDRESSOGRAPH LABELS MUST NOT BE USED to label blood samples as these labels will get caught up in the analysers. Please use ICE stickers or label the samples manually. All samples must be accompanied by an appropriate request form bearing the following information: - (a) Patient details i.e. first and last name, date of birth, NHS number, Hospital Number and address (b) Ward/location, Consultant/GP for return of report (c) For manual requests, the legible signature/name stamp of the person making the request (please use ID stamp) (d) Appropriate/relevant clinical information as outlined in the Health and Safety Executive Safety Notice HID all staff requesting diagnostic testing must ensure that clinical details supplied on Pathology request forms contain clear information regarding the nature of test being requested and sufficient detail to inform laboratory staff upon the safety precautions they need to take in order to process the specimen without risk of infection. Pathology Handbook Page 7 of 94 Version 7

8 (e) Sample type and date and time of collection (f) If computerised labels are used for patient identification one must be attached to each part of the form The above details are required to protect patients, reduce errors and conform to: - National Patient Safety Agency Guidance Medical laboratories Requirements for quality and competence - ISO 15189:2012 standard Institute of Biomedical Science guidance for specimen acceptance criteria MCHFT Patient Identification Policy HANDWRITTEN AMENDMENTS TO ELECTRONIC REQUESTS WILL NOT BE PROCESSED Urgent Samples If a sample is urgent please ensure that this is marked clearly on the request form and that the laboratory is contacted in advance of the specimen being sent. If the lab is not contacted, samples marked urgent will be prioritised according to workload pressures. Danger of Infection Specimens When a specimen is collected for a patient who may have a disease that could be a hazard to laboratory staff for example, Hepatitis, HIV or TB the request form and specimen MUST carry a yellow Danger of Infection sticker. Such samples must be contained within approved sealed specimen request bags. Please ensure all relevant clinical information (including foreign travel) is included on the request so potential high risk samples can be identified and effective Health and Safety procedures initiated. Please refer to HSE Safety Notice HID ( ACCESSING RESULTS Results can be viewed on the wards via the Clinisys Web Browser; there is a link on the Intranet homepage labelled Pathology. GP results are usually ed, but they can also be accessed using the ICE system which also includes results requested by the hospital. Please refer to specific departmental sections for a guide as to what will be telephoned. TESTS SENT TO OTHER LABORATORIES A list of referred tests and laboratories is available in Appendix 1, but most externally referred biochemistry tests are listed separately in biochemistry section 24. These reports should be filed in the patient s notes and can be viewed within hospital locations using Therefore (previously ADOS). Instructions are available on request. ADDITIONAL TESTS ON SAMPLES ALREADY SUBMITTED FOR EXAMINATION Additional tests on blood samples will only be performed on receipt of an add-on test request form available on the intranet site/frequently used forms/pathology. Samples for Biochemistry examinations are kept for a maximum of 1 week. Haematology samples can only be kept for 24 hours. For blood transfusion tests and all non-blood samples contact the individual laboratories concerned to seek advice on the possibility of performing further tests on specimens already submitted. Incomplete forms may delay processing. D Dimer requests need to be performed within 4 hours of collection. ORDERING LABORATORY CONSUMABLES/REQUEST FORMS Orders for routine blood bottles must be placed with NHS Supplies along with your other ward orders. Non routine bottles can be ordered using the Sundries Order Form for Ward Supply found in Frequently Used Forms on the Intranet. Please do not contact on-call staff. Certain consumables are only issued by individual departments. Formalin pots and Bouin s fixative from Histology, transport medium for FNA samples from Cytology, Corneal scrape kits from Microbiology. Contact the individual department for further supplies. RESEARCH If research projects are undertaken that result in additional work for the laboratory, funding will be required. Please seek advice from the appropriate Consultant Pathologist. Evidence of ethical approval will be required. Pathology Handbook Page 8 of 94 Version 7

9 EMERGENCY OUT OF HOURS LABORATORY SERVICES The service is for URGENT investigations only and must be used only when tests are necessary for the immediate treatment of patients. Specimens that are not urgent should be sent to the laboratory in normal working hours. For Biochemistry and Haematology the out of hours service operates from hrs to hrs on weekdays, from hrs on Friday to hrs on Monday and the whole of bank holidays. Contact during these times is by bleep only. For Microbiology the out of hours service operates from Macclesfield from hrs to hrs on weekdays, from 17:30 to 0900 hours on weekends and bank holidays. Results from Microbiology on-call investigations will be telephoned on completion. Please note that the out of hours Microbiology Service is an emergency on call service and staff are not on site outside routine working hours. Please see Microbiology section for details on how to access the service. Results of routine tests are NOT available by telephone out of hours. Authorised reports can be viewed via the Clinisys Web Browser or ICE Requesting / Reporting system. To contact a Biomedical Scientist (BMS) out of normal hours: - Biochemistry bleep 2920 Haematology bleep 2647 Please see Microbiology section NB: B-hCG please contact the Biochemistry BMS You MUST notify the laboratory before sending Blood Gases, urgent work, Cross Matches or any requests where tests are needed in life-threatening situations. IMPORTANT please observe Do not send urgent samples without first contacting the on-call BMS. If Biochemistry/Haematology samples are semi-urgent (i.e. require analysis soon but not immediately) it is not necessary to bleep staff based on site. Please be aware that the bleep may not be answered immediately as the on-call staff may be busy with tests that cannot be interrupted. Your call will be returned. Pathology Handbook Page 9 of 94 Version 7

10 RANGE OF INVESTIGATIONS Please remember that the fewer tests you request the more quickly the result will be available. By asking for only the absolute minimum of investigations, you will help us to respond more quickly to life-threatening emergencies. Your help in this regard is much appreciated. The following tests can be carried out outside normal laboratory working hours when required for the immediate treatment of the patient. See Appendix 1 for non-biochemistry Referral Tests (for biochemistry, these are listed in section 24). Haematology/Blood Transfusion Blood Groups and antibody screens Issue of red cells Issue of blood products, including fresh frozen plasma, platelets and cryoprecipitate. Issue of batch products (i.e. Albumin, Anti-D, PCC) Direct Coombs Test Full Blood Count (FBC) Reticulocytes ESR Blood Film Prothrombin time Activated Partial Thromboplastin time Fibrinogen (must be requested separately as it is not part of the routine coagulation screen) D-Dimer ** Coagulation samples must be filled to the frosted line. Underfilled/Overfilled samples are unsuitable as they give inaccurate results** Sickle cell screening I.M. Screen Malarial parasites Factor VIII/IX Biochemistry CSF Glucose and Protein Renal, liver, bone and protein profiles Bilirubin neo-natal Glucose Amylase Creatine Kinase (CK) Lactate Dehydrogenase (LDH) Blood gases Salicylate Paracetamol Troponin I hcg CRP Urate Gentamicin Theophylline Digoxin Lithium Ammonia Lactate Iron (for overdose only) Microbiology (at Macclesfield) CSF Ascitic fluids (only for diagnosis of SBP) Joint aspirates Pus from deep head and neck collections (e.g. orbital abscess, retropharyngeal collections) Please note that antibiotic assays other than Gentamicin (now undertaken in Biochemistry) are not available unless agreed with Consultant Microbiologist. Exceptionally other investigations may be carried out if clinical indications justify them and doctors will be asked to discuss the need with the appropriate Consultant Pathologist. Pathology Handbook Page 10 of 94 Version 7

11 COMPLAINT PROCEDURE We realise that there may be times when we do not always get things right. On these occasions we welcome your feedback as this helps us to improve the services we provide. If you have any problems with any aspect of the Pathology Services, please tell us by contacting a member of Pathology staff (refer to contacts list on page 4). If you wish to make a complaint, the Customer Care Team will advise you on what you need to do and who to contact. If you feel that you have made every effort to try and resolve your concerns directly with the staff or through the Customer Care Team, but this has not been successful you may decide to make a formal complaint. If this is what you decide to do then it is important to do this as soon as possible; this should be normally within twelve months of the event. You can make a formal complaint by letter, telephone or by Write to: The Customer Care Manager Leighton Hospital Middlewich Road Crewe, Cheshire CW1 4QJ Telephone: Fax: [email protected] Visit the MCHFT website for further information on the customer care team and complaints procedure PROTECTION OF PERSONAL INFORMATION MCHFT takes the security of personal information very seriously. Everyone working for the NHS has a legal duty to keep information about patients confidential. Patients health information is protected through a number of measures; all Trust staff are required to: a. Record patient information accurately and consistently b. Keep patient information private c. Keep patient information physically secure d. Disclose and use information with appropriate care Any breaches of security or incidents relating to Information Governance are investigated, actioned and reported via the Trust s Governance Structure. In order to support our staff in ensuring personal information is kept securely the Trust have a number of policies which set out the requirements staff must fulfil when accessing or sharing personal information. Furthermore, all staff receive Information Governance Training which includes topics such as information security, confidentiality and data protection. Information Governance leaflets are available on the MCHFT website at the following address: You can also contact our Information Governance Department: Information Governance Manager Leighton Hospital Middlewich Road Crewe, Cheshire CW1 4QJ Telephone: [email protected] Pathology Handbook Page 11 of 94 Version 7

12 PHLEBOTOMY SERVICES Phlebotomy Manager Donna George Tel (3592) GP Appointments Tel (3568) Pathology Handbook Page 12 of 94 Version 7

13 PHLEBOTOMY SERVICES GPs should, in the first instance, use the phlebotomist at their premises, if they have them. After that, the Northwich area GPs may send patients to VIN. Other GPs may send their patients to Leighton but appointments must be made here as there are a limited number of slots available. Appointment telephone number between pm Services at Victoria Infirmary, Northwich A blood collecting room staffed by Phlebotomists is open during the following hours: Monday to Friday 8.30 am to 4.30 pm Services at Leighton Hospital (i) Ward Service The daily ward phlebotomy service is managed by the relevant Divisions. They MUST NOT collect Blood Cultures (must be collected by the Doctor) When patient identification is in doubt (wrist bands obviate this problem) Blood for tests required at times other than those when the ward phlebotomists are on duty must be collected by the Doctors and sent to the laboratory. (ii) Outpatient Service This is located in the main outpatient hall and is signposted with Pathology (Blood Tests) signs. The outpatient service is mainly for patients attending OPD clinics. However as mentioned above there is an appointment system in operation for GP patients. The Phlebotomy Manager manages this service. Opening hours are Monday to Friday Ideally patients on wards should be bled on the ward. Patients should only be sent to outpatients as a last resort. This MUST be by prior arrangement and the patients dress must not compromise their dignity. A phlebotomy service is also provided at many GP practices; this is through a contract with the local CCG. Any enquiries about this service should be directed to the Phlebotomy Manager. Children from GP s under the age of 8 should be referred to the Krishnan Chandran Centre. Pathology Handbook Page 13 of 94 Version 7

14 CLINICAL CHEMISTRY Consultant Clinical Scientist Sarah Robinson Ext 2376 Site Service Lead Ian Johnson Ext 3454 Pathology Handbook Page 14 of 94 Version 7

15 BIOCHEMISTRY DEPARTMENT: THE SERVICE The Biochemistry Department provides a comprehensive service covering a wide range of biochemical estimations including diabetic monitoring, endocrine testing, lipid profiling, therapeutic drug monitoring and screening for drugs of abuse. Arrangements are also in place to refer tests which cannot be performed on site to regional laboratories. The department is led by a consultant chemical pathologist and a consultant clinical scientist, supported by a principal clinical scientist; they are available to discuss clinical aspects of cases and to suggest further tests that may be of value. The department is staffed by a highly qualified and experienced team of biomedical scientists, assisted by medical laboratory assistants. 1. OPENING HOURS The department is open from 9:00 am to 5.00 pm from Monday to Friday. For all out of hours arrangements see the General Section. 2. URGENT REQUESTS For full information on the procedure for requesting urgent estimations see the General Section. Please note that ALL requests for blood gas analysis as well as urgent requests should be pre-notified to the laboratory. 3. REPORTING TIMES We aim to achieve the following turnaround times, from receipt in the laboratory to authorisation of results, on at least 90% of occasions: Urgent requests: Blood gases General biochemistry (U&E/glucose/LFT etc.) Drug assays (including gentamicin) hcg (serum) assays Troponin I assays Routine Inpatient requests: General biochemistry Drug assays (excluding anticonvulsants) Routine Outpatient and GP requests: General biochemistry Drug assays (excluding anticonvulsants) Non-urgent routine assays: Haematinics, PSA & other tumour markers, Thyroid function tests & other endocrine assays Lipids, Albumin/creatinine ratio (urine) HbA1c Anticonvulsants (unless urgent) Serum & Urine Protein Electrophoresis BNP 15 minutes 60 minutes 90 minutes (unless requires referral to Macclesfield) 60 minutes 60 minutes 3 hours by end of same working day unless referral required 1 working day 1 working day 1 working day unless weekend/bank holiday 2 working days unless weekend/bank holiday 1 working day unless weekend/bank holiday 2 working days unless weekend/bank holiday 1 week 1 week 2 weeks Tests referred to external laboratories: For most commonly requested tests such as Vitamin D, the turnaround time is approximately 2-3 weeks from receipt in the local laboratory to the reporting of results. This turnaround time includes the transit time for both samples and reports to/from the external laboratory as well as the analysis there. Results for immunosuppressant drugs (tacrolimus and ciclosporin A) are usually available within 1 week and for certain trace elements (chromium, cobalt, copper, selenium and zinc) within days. Results for some tests, including urine amino/organic acids, faecal elastase, porphyrins and very specialised tests, may take up to 4 weeks to be reported. Once a sample has been dispatched from the laboratory, the estimated due date can be viewed via the LabCentre Browser results enquiry. Results are available for remote enquiry via the Clinisys Web Browser in hospital locations immediately after they have been technically authorised. Hard copy reports for hospital requests are printed every weekday and Pathology Handbook Page 15 of 94 Version 7

16 dispatched the same day to wards and consultants secretaries. Reports for general practitioner requests are currently transmitted electronically thrice daily (at 1215, 2000 and 2345). 4. REQUESTS Clinicians should usually make requests via the Anglia ICE electronic requesting system. Where this is not available, please use the standard combined Haematology/Biochemistry/Serology request form for biochemistry requests. It is essential that all details are clear and legible. Please remember to add the clinic/ward location, consultant and name of the requesting medical officer and date and time of collection, even if an addressograph label is affixed. A label must be attached to all copies of the form. Requesting Additional Tests on Existing Samples Samples are retained for 1 week and in most instances tests can be added after the initial sample has been sent, providing sufficient sample is left. However, certain analytes are less stable; requests for these tests, including ammonia, bicarbonate, ethanol, lactate and PTH, cannot be added to existing samples. Additional requests can only be made by sending a completed update form. Verbal requests will not be accepted unless this form is sent subsequently. The requesting clinician will be notified if the test(s) cannot be done. 5. HIGH RISK CASES Specimens and request forms from patients suspected to be suffering from blood borne diseases must be sent to the laboratory suitably identified with Danger of Infection stickers with a single sample per transport bag. 6. SAMPLE CONTAINERS Gold top plain containers containing gel (SST) are used for most routine serum Biochemistry requests in adults. One sample will usually suffice, but an additional sample is helpful when requesting several externally referred tests at the same time (see alphabetical test list in biochemistry section 24). Requests for glucose, lactate and ethanol must be sent in a fluoride oxalate (grey top) container. HbA1c requests should be sent in an EDTA (lavender top) container. Fill these tubes last to avoid contamination of other tubes. The tube types used for infants differ, but the preservative requirements are as for adults. Gently mix blood samples by 2-3 inversions to ensure contact with the anticoagulant or clot activators. Requests for certain less frequent or specialised investigations and tests not done on blood require special tubes or handling arrangements. Please consult the alphabetical test list (biochemistry section 24) for specific details of sample requirements. Contact the Pathology Help Desk (ext. 2345) if in any doubt. Fasting tests Certain blood tests are preferably done on fasting samples, including calcium/phosphate, glucose and lipids, and other tests as specified in the list in Section 24. For a fasting sample, the patient should be instructed to fast overnight for at least 12 hours and have nothing to eat or drink (except for water) until blood has been collected. Specimen handling and storage prior to receipt in the laboratory Wherever possible, all samples should be sent to the laboratory on the same day as collection to ensure sample integrity is maintained. If a delay in receipt of the sample is anticipated, please contact the laboratory to discuss storage requirements. Refrigeration may not be appropriate, in particular for some general biochemistry tests such as potassium and phosphate. See section 27 for details of other factors that may affect test results. 7. REFERENCE RANGES Adult reference ranges for most tests analysed at Crewe or Macclesfield are shown in the alphabetical test list (biochemistry section 24). Reference ranges are included with reports (paper and electronic) and displayed with results on the Clinisys LabCentre Browser. Unexpected critically abnormal results will be telephoned to the requesting clinician/location as appropriate (see section 26). Pathology Handbook Page 16 of 94 Version 7

17 8. GENERAL TEST INFORMATION One clotted blood sample (SST) will suffice for any combination of the following tests or test groups: Profiles U&E: Bone: LFTs: Proteins: Lipids: Iron studies: Thyroid: Individual Tests General: sodium, potassium, urea, creatinine; estimated GFR in adults over 18y (unless pregnant) calcium, phosphate, alkaline phosphatase, albumin; adjusted calcium also reported if albumin below 40 g/l albumin, bilirubin (total), alkaline phosphatase, ALT (alanine transaminase) total protein, albumin, calculated globulin total cholesterol, HDL cholesterol, triglycerides (fasting sample preferred); calculated LDL cholesterol reported if sample fasting and triglycerides <= 4.0 mmol/l iron, transferrin, calculated transferrin saturation free T4 and TSH; freet3 measured at laboratory s discretion; TPO antibody also available amylase, aspartate transaminase (AST), bicarbonate, bile acids, chloride, creatine kinase (CK), differential bilirubin (conjugated and unconjugated), γ-glutamyl transferase (GGT), lactate dehydrogenase (LDH), magnesium, osmolality, troponin I, urate Drugs: carbamazepine, digoxin, gentamicin, lamotrigine, lithium, paracetamol, phenobarbital, phenytoin, salicylate, theophylline, tobramycin, valproate, vancomycin Endocrine: Haematinics: Proteins: cortisol, FSH, hcg, LH, oestradiol, PTH, prolactin, testosterone and SHBG ferritin, folate, vitamin B12 Beta-2 microglobulin, CRP (C-reactive protein), immunoglobulins, protein electrophoresis Tumour Markers: AFP, CA-125, CA-19-9, CEA, PSA (total) Glucose Please send a separate fluoride oxalate (grey top) tube } but please use the same request HbA1c Please send a separate EDTA (lavender top) tube } form as for the above tests. 9. DRUG ASSAYS Therapeutic Drug Monitoring (TDM) Please give details of dosage, time of last dose and time of sample collection (mandatory for antibiotics) with ALL requests for therapeutic drug monitoring. Generally samples taken pre-dose or at least 6h post dose give optimal information see test list in biochemistry section 24. Therapeutic (target) ranges given are for guidance only. Gentamicin, tobramycin and vancomycin results should be discussed with the Microbiologist. See also the Mid Cheshire Hospitals NHS Foundation Trust Antibiotic Policy and the Microbiology section of the handbook on page 81. Sample Requirements: Drugs listed in biochemistry section 8 SST (gel) tube Ciclosporin A, sirolimus and tacrolimus EDTA blood taken immediately pre-dose Other drugs analysed at external laboratories Plain red top tube (without gel) Paracetamol Samples should be collected at least 4 hours after ingestion, as results obtained before 4 hours may be misleading. Repeated measurements are unnecessary. Results above the following levels are potentially toxic and merit treatment: 100 mg/l at 4 hours, 50 mg/l at 8 hours, 25 mg/l at 12 hours. See graph in biochemistry section 25 for assessing the severity of paracetamol overdose. Salicylate Serum therapeutic range (adults): Concern level associated with toxicity: Severe poisoning occurs at: mg/l 350 mg/l (280 mg/l if <5y) over 700 mg/l Pathology Handbook Page 17 of 94 Version 7

18 10. LIPIDS A fasting sample (taken after a fast of at least 12 hours) is preferred, where practicable. LDL cholesterol will not be reported on random samples and cannot be calculated if triglycerides exceed 4.0 mmol/l. The triglyceride reference range of mmol/l strictly applies to fasting samples only. If the random triglyceride level exceeds 1.7 mmol/l, a repeat fasting sample is recommended. HDL cholesterol reference ranges are as follows: Female mmol/l, Male mmol/l. Low levels are associated with increased cardiovascular risk. Targets For secondary prevention (patients with pre-existing cardiovascular disease or diabetes mellitus), the aim of cholesterol lowering should be to decrease LDL cholesterol to less than 2 mmol/l or by more than 30% from baseline, whichever gives the lower value. The equivalent figures for total cholesterol are a decrease to less than 4 mmol/l or by more than 25% from baseline, whichever gives the lower value. Intervention with lipid-lowering drug therapy may be needed to achieve such cholesterol concentrations, where not attained with dietary measures. For primary prevention, refer to the Joint British Societies Coronary Risk Prediction Chart in the BNF (issues 49 or later for current version). The total/hdl cholesterol ratio will be reported to facilitate risk estimation, unless the patient is known to have pre-existing cardiovascular disease or diabetes mellitus or is coded as already being on statin therapy. A reference range of is quoted for the total/hdl cholesterol ratio; values over 6.0 indicate increased cardiovascular risk per se. Guidance ranges are quoted on reports for total and LDL cholesterol for adults of mmol/l and mmol/l respectively. These are not reference ranges as such, but provided solely to enable high and low cholesterol results to be flagged on reports. Decisions regarding treatment of dyslipidaemia should be based on a full risk assessment of the patient, not just the cholesterol level. 11. BLOOD GASES Please telephone the laboratory before collection to ensure that sample receipt does not coincide with machine maintenance. Blood gas syringes must be sent to the laboratory with the needle removed from the syringe and replaced with a blind hub before despatch. Do not send through the air tube. The standard profile comprises ph, pco2, po2, bicarbonate and base excess. Oxygen saturation, carboxyhaemoglobin and methaemoglobin can be measured on the same sample if requested. Test Reference Range Units Test Ref. Range Units ph Oxygen Saturation % pco kpa Carboxyhaemoglobin % po kpa Methaemoglobin % Bicarbonate (standard) mmol/l Base Excess -2.5 to +2.5 mmol/l 12. URINE Random urine samples For quantitative assays, including albumin/creatinine ratio, protein/creatinine ratio and U&E, a 10 ml Sarstedt Monovette tube, with an incorporated syringe to aspirate urine into the tube, is strongly preferred. For qualitative assays (e.g. protein electrophoresis), please send a plain white top Universal container. Red top bottles containing boric acid are unsuitable for biochemistry tests. 24 hour urine samples Use plain 5 Litre bottles, except for some tests which require a bottle containing an acid preservative. Please contact the laboratory (ext 2345) to obtain bottles and patient instructions for collecting the 24 hour urine sample. Test U&E, Creatinine, Cortisol, Protein, Urate, Trace Elements (e.g. copper) 5-HIAA, Calcium, Citrate, Oxalate, Metadrenalines Preservative in Bottle NONE (plain container) 20 ml 50% HCl Pathology Handbook Page 18 of 94 Version 7

19 PATIENT INSTRUCTIONS FOR COLLECTION OF 24 HOUR URINE SAMPLES PLEASE READ PRIOR TO START OF COLLECTION 1. Collect the container suitable for your particular test from the laboratory. 2. The collection can be started at any convenient hour (say 7am) on one day and finishes at the same time the following day. 3. Container may contain acid or other preservative, do not throw out and avoid contact with this preservative. Read carefully the information stickers on the bottle. Procedure: 1. Supposing you start collecting at 7am on Sunday morning. The 7am Sunday morning specimen must be passed into the toilet, NOT INTO THE BOTTLE, so that at 7am you have an empty bladder. 2. All urine you pass after this, should go into the bottle provided, including the 7am Monday specimen, which is the last. Please ensure you catch, in a suitable clean container (e.g, clean jam jar), any urine passed whilst having your bowels open, and add this to the collection bottle(s) that you have been provided with. If you are likely to require more than one bottle (3 litres), please request an additional bottle before you commence the collection. The laboratory will only accept samples in the bottles that you are provided with. 3. Bring the bottle(s) and request form into the Pathology laboratory between 9 am and 5 pm on the day the test finishes, Monday to Friday (but not Saturday or Sunday). 4. Should you forget to collect any part of a 24 hour urine collection, inform the laboratory personnel. The test may need to be repeated. If the test is done on an incomplete specimen, you will be cheating yourself and the Doctor, and may receive inappropriate treatment, based on the faulty test. 5. If for any reason the test is incomplete, the specimen should still be returned to the laboratory for proper disposal and the laboratory advised. Notes You may be required to have a blood test when you return this container. If you are not intending to return this container yourself, please enquire at your GP Surgery if blood will be required in your case. If blood does need collecting it should be within the 24 hour period or immediately after it. Please ensure that your name, date of birth and the date/time of collection is on every bottle that you have used and that you also return the bottle with a completed request form. Failure to do this may result in the laboratory not being able to process or delay the processing of your sample. Please ensure the cap is tightened on the bottle, on completion of collection. 13. FAECES Please use a sterile collection pot or Universal container for all faecal tests. Occult blood testing is no longer done. 14. CEREBROSPINAL & OTHER FLUIDS CSF Collect samples in a plain white top Universal container, and also a fluoride oxalate tube if glucose is required. Please remember to contact Microbiology on call staff out of hours for CSF microbiology testing. Samples should be sent to the laboratory via a porter. The air tube system must not be used. Xanthochromia determination by spectrophotometry needs an additional sample of at least 1 ml CSF (protected from light) which should be the last sample collected. This test is only available Monday to Friday 09:00 16:00. Samples should be collected at least 12 hours after the suspected subarachnoid haemorrhage and sent to the laboratory (protected from light) within 30 minutes of collection. OTHER FLUIDS Samples for Biochemistry (except ph) should be sent in Vacutainers, which should be filled as far as the top of the label on the tube by attaching a green (21 gauge) needle to the syringe used for fluid aspiration and inserting the needle through the rubber cap so that the tubes will fill using the vacuum. Pathology Handbook Page 19 of 94 Version 7

20 For most biochemistry tests (e.g. protein, LDH), send a gold top SST. For glucose, send a separate grey top Vacutainer (fluoride oxalate preservative). For ph, please send a separate sample in blood gas syringe (ensuring that it contains no air) and process as for blood gases (biochemistry section 11). Pleural fluid samples for general biochemistry tests (except ph) should preferably be sent in SST Vacutainers (Gold Top). It may not be possible to analyse fluids that are especially turbid or viscous. 15. DIABETES DIAGNOSIS AND MONITORING Diagnosis The preferred screening test is fasting venous plasma glucose the patient should fast for at least 12 hours. Fasting Glucose Action <= 6.0 mmol/l Normal. Repeat test may be appropriate if result borderline ( ) & there are symptoms or other features (e.g. high triglycerides) suggesting diabetes mmol/l Repeat. If repeat also raised (>6.0 mmol/l), do an oral glucose tolerance test. >= 7.0 mmol/l Suggests diabetes. If patient asymptomatic, need repeat test for confirmation. Random Glucose Action <= 6.0 mmol/l Normal. No further action mmol/l Probably normal, but consider checking fasting plasma glucose mmol/l Check fasting plasma glucose. If this is raised (>6.0 mmol/l), do an OGTT. >= 11.1 mmol/l Suggests diabetes. If patient asymptomatic, check fasting glucose to confirm. Oral Glucose Tolerance Test (OGTT): Please send a request form to the biochemistry secretary (ext 3405) if you wish to book a test. Procedure: Three days of an unrestricted carbohydrate diet should be allowed before the test. The test should be done in the morning following an overnight fast (at least 12 hours). The patient should have nothing to eat or drink (except for water) until the test is complete. Obtain a fasting blood sample in a grey top Fluoride Oxalate Vacutainer tube and include the time of the specimen on the label and request form. For tests done by Phlebotomy at Leighton Hospital, the patient is required to wait 60 minutes for the initial blood test to be processed. Confirmation of the result is sent to Phlebotomy with the decision to either proceed with the test or to discharge the patient. Give the patient a drink containing 75g of glucose (e.g. 410 ml Lucozade) - chilled to reduce nausea. The drink should be consumed within 10 minutes and the time noted. During the test the patient should rest and should not eat, drink (other than glasses of water) or smoke. Take the second venous blood sample in a grey top Vacutainer tube exactly 2 hours after the patient finished the glucose drink. Label the bottle and request form with the time of the sample. The test is now complete and the patient may eat as normal. Send the 2 blood samples together with a single request form to the laboratory for analysis. Glucose meters are not sufficiently accurate for diagnostic purposes. For glucose tolerance tests arranged via the laboratory, the patient will be sent an information sheet, including instructions about pre-test preparation. This leaflet can be obtained from the laboratory on request. Interpretation of plasma glucose concentrations (mmol/l): Normal Diabetes Impaired Glucose Tolerance Impaired Fasting Glycaemia Fasting <6.1 >=7.0 < and and/or and and 2h Post Load <7.8 >= <7.8 HbA1c (Glycated Haemoglobin) The primary use of HbA1c is for assessing glycaemic control, but it can also be used for diagnosis. Measurements more frequently than every 2 months are of minimal value due to the red cell lifetime of approximately 120 days. Pathology Handbook Page 20 of 94 Version 7

21 While fasting glucose is still recommended as the initial screening test for suspected diabetes, WHO (2011) has now recommended that HbA1c can be used as a diagnostic test for diabetes in most situations. The main exceptions are rapid onset diabetes (as HbA1c reflects glycaemia over the preceding 2 3 months) and some genetic, haematological and other disorders; in particular haemoglobinopathies, anaemia and other diseases associated with changes in red cell turnover (e.g. malaria, drug-induced haemolysis) or glycation rates (e.g. chronic renal disease). In these situations, HbA1c is not recommended as the sole test to diagnose diabetes. An HbA1c of 48 mmol/mol is recommended as the cut point for diagnosing diabetes, and can therefore be used to confirm a diagnosis of diabetes in an asymptomatic individual with a fasting glucose 7.0 mmol/l or random glucose 11.1 mmol/l, precluding the need for a repeat glucose measurement or glucose tolerance test. However, an HbA1c value <48 mmol/mol does not exclude diabetes diagnosed using glucose tests. Criteria for Glycaemic Control using HbA1c in Patients with Type 1 and Type 2 Diabetes Good Borderline Sub-optimal Type 1 < 48 mmol/mol mmol/mol > 58 mmol/mol Low risk Arterial risk Microvascular risk Type 2 < 48 mmol/mol >= 48 mmol/mol > 58 mmol/mol 16. THYROID FUNCTION TESTS (TFTs) Please give full details of drug treatment and also gestation if applicable. Free T4 and TSH are the front line thyroid function tests. Free T3 is assayed at the laboratory s discretion (it is only useful in borderline hyperthyroidism or if the patient is on liothyronine therapy). Thyroid peroxidase antibody will be assayed if the TSH is persistently borderline raised. Thyroid hormone levels change slowly and there is little point in repeating TFTs within 1 month. Test Reference Range Units Free T4 (thyroxine) pmol/l ( in 2 nd & 3 rd trimesters) TSH (thyroid stimulating hormone) mu/l ( in children <5y) Free T3 (tri-iodothyronine) pmol/l TPO (thyroid peroxidase) antibody 0-9 kiu/l 17. ADRENAL FUNCTION Adrenal Cortex Random or midnight serum cortisol levels are generally of minimal value, and measurement of 9 am cortisol has poor sensitivity for adrenal dysfunction. If there is significant clinical suspicion of adrenal disease, it is preferable to do one of the following dynamic function tests. Short Synacthen (Tetracosactide) Test for suspected Hypoadrenalism Take 3.5 ml clotted blood (SST) for serum cortisol between 09:00h and 10:00h. Give 250 ug tetracosactide (Synacthen) by intramuscular injection. Take a further SST sample for cortisol at 30 minutes post tetracosactide injection. A 60 minute sample is not required. Following Synacthen, a response of 475nmol/L at 30 minutes indicates an adequate response Overnight Dexamethasone Suppression Test for suspected Cushing s Syndrome 1 mg dexamethasone should be taken orally at 11 pm (± 1 hour). Take 3.5 ml clotted blood (SST) for serum cortisol at 9 am (± 1 hour) the following morning. This test is preferred to measurement of 24 hour urine free cortisol. Adrenal Medulla Measurement of 24 hour urine metadrenalines is the preferred test for investigating suspected phaeochromocytoma. The sample must be collected into a bottle containing hydrochloric acid preservative, which is available from the laboratory on request. Pathology Handbook Page 21 of 94 Version 7

22 18. SPECIALISED ENDOCRINE TESTS Please phone extension 2376/3885 to discuss requests for the following specialised/dynamic function tests and obtain protocols before collecting samples. Interpretation will be provided with the report. Dexamethasone Suppression Tests (low and high dose) Glucose Tolerance Test with Growth Hormone measurements Growth Hormone stimulation tests (arginine, glucagon) Gut Hormone profile (gastrin, glucagon, PP, somatostatin, VIP) Insulin and C-Peptide measurements Metoclopramide test Pituitary Stimulation tests: Gn-RH (gonadorelin), TRH (pro-tirelin) and Insulin PTH-related Peptide measurement Renin and Aldosterone measurements Water Deprivation test This list is not comprehensive and other tests may be available on request. 19. SEX HORMONE INVESTIGATIONS Adult Reference Ranges Females Males Units FSH* ( post-menopause) iu/l LH* (20-60 post-menopause) iu/l Progesterone 30 indicates ovulation not applicable nmol/l Prolactin** ( if >=50y) mu/l hcg 0-5 (non-pregnant) 0-5 (as tumour marker) iu/l Testosterone*** (lower if >=40y) nmol/l SHBG*** nmol/l Free Androgen Index (FAI)**** 0-7 Not applicable**** Oestradiol follicular , luteal mid-cycle post-menopausal < pmol/l * In menstruating women, ranges apply to follicular & luteal phases; levels are higher mid-cycle. For female patients 55 years, a comment will be appended stating post-menopausal reference ranges are being quoted. ** Samples with a significantly raised prolactin (>700 mu/l) will be tested for presence of macroprolactin. *** Testosterone values >3 nmol/l and/or raised FAI in female patients >11 years will be referred to an external laboratory for testosterone measurement by tandem mass spectrometry. In men, testosterone ranges apply to blood taken between 0800h & 1000h; ranges (nmol/l) for men 40 years are (40-49y), (50-59y), (60-69y), ( 70y). **** In males >11 years, FAI not reported as not clinically valid. Please refer to in order to calculate free testosterone in these patients. PREGNANCY TESTING Urine hcg is the first-line test for confirming pregnancy and is done by Microbiology at Leighton Hospital, Crewe. Serum hcg measurement is useful for investigating/monitoring a suspected non-viable pregnancy (e.g. ectopic). Please include the date of the last menstrual period (LMP) with all requests. INFERTILITY INVESTIGATIONS Mid-luteal phase serum progesterone is useful to define ovulation. In women with a regular 28 day cycle, a day 21 serum progesterone of at least 30 nmol/l indicates an ovulatory cycle (for ovulation, median 60 nmol/l, range nmol/l). In some cases, several samples for serum progesterone during luteal phase may be helpful, particularly in those with irregular cycles. Progesterone measurement is only indicated for investigating infertility and is inappropriate in the follicular phase or if there is amenorrhoea. In women without clear evidence of ovulation, measurement of FSH at day 2-5 of the cycle is the most helpful investigation available locally for assessing ovarian reserve. Pathology Handbook Page 22 of 94 Version 7

23 For interpretation of serum FSH, LH, progesterone and oestradiol results in menstruating women, please supply the date of the last menstrual period (LMP), due to the cyclicity of these hormones. INVESTIGATION FOR MENOPAUSE Diagnosis of the menopause is primarily clinical, but if laboratory confirmation is required, the preferred biochemical test is serum FSH measurement, at cycle day 2-5 if the woman is menstruating. Please supply the date of the LMP or other relevant menstrual details. The post-menopausal state is usually clearly indicated by high FSH and LH levels. Less pronounced increases, particularly of follicular phase FSH, are characteristic of the peri-menopause. Oestradiol measurement rarely provides extra information, but may be added occasionally at the discretion of laboratory staff. MONITORING HORMONE REPLACEMENT THERAPY (HRT) Before initiating treatment, measure FSH and oestradiol to increase the diagnostic certainty of menopausal transition if the woman is not clearly menopausal. Serum oestradiol measurement is useful to assess the adequacy of oestradiol HRT implants, but with patch or oral therapy it is only useful for testing for non-absorption and non-compliance respectively. Measurement is not appropriate if taking HRT other than oestradiol, as the assay is specific for this steroid and will not measure ethinyloestradiol, oestriol, oestrone or tibolone. Oral conjugated equine oestrogens undergo first pass metabolism in the liver to oestrone as the major circulating oestrogen. HRT reduces FSH & LH levels (by %), but they are not restored to basal pre-menopausal levels and their measurement is not useful for monitoring HRT. Please supply the HRT preparation used and the route of administration with the request. 20. PSA (PROSTATE SPECIFIC ANTIGEN) The following age-related reference ranges are in use for total PSA (ug/l): up to 49y to 59y to 69y over 70y Total PSA levels greater than 15 ug/l indicate a high probability of prostatic cancer. Total PSA levels greater than 75 ug/l strongly suggest metastatic disease. In addition to prostatic cancer, elevated serum total PSA levels may be found in patients: With benign prostatic hypertrophy (BPH), prostatitis or prostatic infarction. Undergoing prostate manipulation (prostate massage/rectal examination/prostatectomy/biopsy). With acute retention or constipation. Undergoing catheterisation. 21. RENAL DISEASE egfr: Estimated GFR calculated in adults over 18 y (unless pregnant); a value below 60 ml/min/1.73m 2 chronic kidney disease (CKD) stage 3 or worse, providing this persists for at least 3 months. indicates Stage/Category of CKD egfr (ml/min/1.73m 2 ) Recommended Frequency of Testing 1 Normal* >90 annually* 2 Mild impairment* annually* 3 Moderate impairment [CKD stage 3A] 6-monthly [CKD stage 3B] 6-monthly 4 Severe impairment monthly 5 Established renal failure <15 3-monthly * Stages 1 & 2 are only considered as CKD, needing yearly creatinine with egfr, if there is other laboratory or clinical evidence of kidney disease Pathology Handbook Page 23 of 94 Version 7

24 Urine Albumin/Creatinine Ratio ( Microalbumin ) This test is recommended as part of the diabetic annual review, along with serum creatinine/egfr. Non-diabetic subjects who are dipstick negative for protein but found to have CKD stage 3 or worse should also be tested once, with the test repeated again only if there is a significant deterioration in renal function (e.g. progression from CKD stage 3 to 4). In subjects who are dipstick positive for protein, the protein/creatinine ratio is the preferred test. For both albumin/creatinine and protein/creatinine ratios, send 5-10 ml of first morning urine in a container without preservative, preferably a plain 10 ml Sarstedt Monovette tube. Red top bottles containing boric acid are unsuitable. Guidelines for interpretation of Urine Albumin/Creatinine ratio (mg/mmol): Up to 2.5 (male) or 3.5 (female): Normal - rescreen annually. Raised but less than 30.0 indicates microalbuminuria. If this finding is new, suggest repeat within 3 months to confirm. To establish microalbuminuria, at least 2 out of 3 samples over 3-6 months should test positive or above indicates macroalbuminuria. Urine Protein/Creatinine Ratio This will be determined if the urine microalbumin concentration is greater than 1000 mg/l. It is also preferred to a 24 hour urine collection for protein as the initial test for suspected proteinuria. Values over 100 mg/mmol (equivalent to 1.0 g/24h) indicate significant proteinuria and a nephrology referral may be appropriate. 22. SWEAT TESTS Used to aid in the diagnosis of Cystic Fibrosis. Sample collection is done by Paediatrics, with analysis performed in the laboratory. Interpretation will be provided with the report. 23. TROPONIN I This is now the first-line test for investigating possible acute coronary syndrome or myocardial infarction. Please state the time of the suspected event on the request form. New reference range/units introduced 12 th October For rule-out purposes, samples should be collected at least 12 hours after the event, as the Troponin I level may not increase until then. A raised level over 40 ng/l indicates myocardial injury and supports the diagnosis of acute myocardial infarction, providing there are consistent symptoms or ECG changes. If the Troponin I level has been significantly raised (at least 200 ng/l) in the last week, repeat testing is of minimal value due to its long half-life and is only warranted if myocardial re-infarction is suspected. 24. ALPHABETICAL LIST OF BIOCHEMISTRY TESTS The list is not exhaustive; other tests are available on request. Please contact the laboratory about tests that are not listed (extension 2345 for information about tubes, 2638/3885 for more detailed advice). Analyses are done on blood samples collected in gold top (SST) containers except where indicated; tube types are different for infants. Certain tests are referred to external laboratories, mainly in Birmingham, Liverpool, Manchester, Salford and Sheffield, for analysis. However, requests should be referred via the Leighton Hospital laboratory and not sent directly to the external laboratory. Reference ranges will be issued with reports of these tests where appropriate. TEST SAMPLE ADULT REF.RANGE / COMMENT / EXTERNAL LAB ACE (Angiotensin Converting Enzyme) Separate SST Referred to Wythenshawe Hospital, Manchester Acetylcholine Receptor Ab Separate SST Immunology test. Referred to Manchester Royal Infirmary ACTH (Adrenocorticotrophin) EDTA, on ice AFP (Alpha-Fetoprotein) SST 0-10 ku/l (non-pregnant). Phone lab 2345 before collection & send immediately to lab after taken. Referred to Royal Liverpool Hospital Pathology Handbook Page 24 of 94 Version 7

25 TEST SAMPLE ADULT REF.RANGE / COMMENT / EXTERNAL LAB Albumin SST g/l Albumin/Creatinine: urine Plain Monovette Female 3.5; Male 2.5 mg/mmol.. See section 21 Alcohol [Ethanol] Fl. Ox. [grey] Units mg/l in line with National Guidelines Aldosterone Li Hep [green] Done with renin. Referred to Royal Liverpool Hospital Alkaline Phosphatase SST iu/l; levels higher in children and in pregnancy Alk. Phos. Isoenzymes Separate SST Only done if total high. Referred to King s College Hosp, London Alpha-1-Antitrypsin & Phenotype Separate SST Please specify if phenotyping also required. Referred to Sheffield Immunology Laboratory ALT (Alanine Trans.) SST Female iu/l; Male iu/l Aluminium Li Hep (green) Phone lab 2345 before collection to obtain tube Referred to Royal Liverpool Hospital Amiodarone Plain red top Referred to Llandough Hospital, Penarth, South Wales Amino Acids: urine Plain Universal Referred to Willink Laboratory, Manchester Ammonia Li Hep [green], on ice 0-40 umol/l; higher in children <2y. Phone lab 2345 before collection; send immediately to lab after taken Amphetamines: urine Plain Universal Part of drugs of abuse screen Amylase: serum SST iu/l. Amylase/Creatinine: urine Plain Monovette 0-9 iu/mmol; values up to 13 are borderline Androstenedione Separate SST Referred to Salford Royal NHS Foundation Trust Apolipoprotein E 2x EDTA Genotype. Referred to Christie Hospital, Manchester AST (Aspartate Trans.) SST Female 5-35 iu/l, Male 5-50 iu/l Barbiturates: urine Plain Universal Full container required. Referred to Salford Royal Hospital Bence Jones Protein: urine Plain Universal Qualitative screen by electrophoresis Benzodiazepines: urine Plain Universal Part of drugs of abuse screen Beta-2 Microglobulin SST <60 yr mg/l, 60 yr mg/l Bicarbonate: serum SST mmol/l Bile Acids SST 0-14 umol/l. Only for use in pregnancy. Done at Macclesfield. Bilirubin: Total SST 0-21 umol/l. Much higher in neonates Bilirubin: Direct SST 0-10 umol/l Blood Gases profile See section 11 ph, pco2, bicarbonate, base excess & po2 BNP: primary care only Separate EDTA 0-99 ng/l. To lab within 4h. Done at Macclesfield. Bone profile SST Calcium, phosphate, alkaline phosphatase, albumin Buprenorphine: urine Plain Universal Referred to Salford Royal Hospital C1 Esterase Inhibitor Separate SST Immunology test. Referred to Manchester Royal Infirmary CA-125 SST 0-34 ku/l. Females only CA-15-3 Separate SST Referred to Sheffield Immunology Laboratory CA-19-9 SST 0-35 ku/l. Caeruloplasmin Separate SST Referred to Royal Liverpool Hospital Calcitonin (fasting) Plain red top, on ice Phone lab 2345 before collection & send immediately to lab after taken. Referred to Christie Hospital, Manchester Calcium: serum SST mmol/l. Adjusted value reported if Alb <40 g/l Calcium: 24h urine Bottle with acid mmol/24h. Phone lab 2345 to obtain container Calcium/Creatinine: urine Plain Monovette mmol/mmol. Higher in children <18 months Calculi (renal stones) Plain Universal Referred to Birmingham City Hospital Cannabinoids: urine Plain Universal Qualitative screen Carbamazepine SST 4-12 mg/l. Collect sample >6h post dose. Done at Macclesfield Carboxyhaemoglobin Li Hep (green) %. Can use heparinised blood gas sample Carnitine profile Lithium Heparin Referred to Willink Laboratory, Manchester Catecholamines: urine (metadrenalines done) 24h urine in acid bottle Phone lab 2345 to obtain bottle with acid preservative Referred to Salford Royal Hospital Pathology Handbook Page 25 of 94 Version 7

26 TEST SAMPLE ADULT REF.RANGE / COMMENT / EXTERNAL LAB CCP Antibody Separate SST Immunology test. Referred to Manchester Royal Infirmary CEA SST 0-7 ug/l Chloride SST mmol/l Cholesterol: total, HDL SST See biochemistry section 10 Cholinesterase Separate SST Referred to Manchester Royal Infirmary Chromogranin A SST Referred to Sheffield Immunology Laboratory Ciclosporin A EDTA Collect pre-dose. Referred to external laboratory Citrate: 24h urine Bottle with acid Phone lab 2345 to obtain bottle with acid preservative Referred to Wythenshawe Hospital Cocaine: urine Plain Universal Part of drugs of abuse screen Complement C3 & C4 Separate SST Immunology test. Referred to Manchester Royal Infirmary Copper: serum Separate SST Referred to Royal Liverpool Hospital Copper: 24h urine Plain bottle Referred to Royal Liverpool Hospital Cortisol: serum SST nmol/l at 9am. Random samples are of limited value. Dynamic tests are preferred: see biochemistry section 17 Cortisol: 24h urine Plain bottle Referred to Royal Liverpool Hospital C-Reactive Protein SST 0-7 mg/l Creatine Kinase (CK) SST Female iu/l; Male iu/l Creatinine: serum SST Female umol/l; Male umol/l; lower if <18y Creatinine Clearance: serum AND 24h urine 24h urine (plain bottle) and SST Female ml/min, Male ml/min. Generally replaced by estimated GFR derived from serum creatinine Cystine: random urine Not available Qualitative screen no longer done; please send 24h urine. Cystine: 24h urine Plain bottle Quantitative assay. Referred to Wythenshawe Hospital DHEA Sulphate Separate SST Referred to Salford Royal NHS Foundation Trust Digoxin SST ug/l. Collect sample >6h post dose Drugs of abuse: urine Plain Universal Qualitative screen; sent to Salford Royal Hospital for confirmation Elastase: faeces Plain pot Referred to Wythenshawe Hospital, Manchester Erythropoietin Separate SST Referred to King s College Hospital, London Ferritin SST Female <50y 5-85 ug/l, 50y ug/l; Male: ug/l Folate SST µg/l Measured with vitamin B12 Free Androgen Index (FAI) SST 0-7 for females. Not reported in males - please refer to to calculate free testosterone Free Fatty Acids Li Hep (green) To lab within 1h. Sent to Alder Hey Hospital, Liverpool Free T3 (FT3) SST pmol/l. Only measured at laboratory s discretion Free Thyroxine (FT4) SST pmol/l. Part of Thyroid Function Test Profile FSH SST See section 19. State LMP if cycle; day 2-5 sample preferred Gal-1-Phos. Uridyl Tr: galactosaemia screen Lithium Heparin Don t take on Fridays. Invalid if recent blood transfusion. Referred to Willink Laboratory, Manchester Gamma GT (GGT) SST Female iu/l; Male iu/l Gastrin (fasting) 2x 6 ml EDTA tubes, on ice Phone lab 3885 before collection & send immediately to lab after taken. Referred to Charing Cross Hospital, London Gentamicin SST Range depends on dosing regime; state time of last dose GFR - Estimated SST >=60 ml/min; not reported if age <18y. See section 21 Globulin (calculated) SST g/l. Calculated from total protein and albumin Glucose: plasma Fl. Ox. [grey] Fasting mmol/l; Random mmol/l. Glucose: CSF Fl. Ox. [grey] mmol/l Interpret result against contemporaneous plasma glucose Glucose: other fluid Fl. Ox. [grey] Interpret result against contemporaneous plasma glucose Glucose tolerance test 2x Fl.Ox. [grey] Collect at 0 & 2 hours. Separate form. See section 15 Glycosaminoglycans Plain Universal Urine sample. Referred to Willink Laboratory, Manchester Gonadotrophins SST FSH & LH. State LMP if cycle; day 2-5 sample preferred Pathology Handbook Page 26 of 94 Version 7

27 TEST SAMPLE ADULT REF.RANGE / COMMENT / EXTERNAL LAB Growth Hormone Separate SST Only as part of DFT. Referred to Royal Liverpool Hospital Gut Hormone profile (fasting):gastrin,glucagon somatostatin, PP, VIP 4x 6 ml pink EDTA tubes, on ice Phone lab 3885 to discuss request before collection. Send immediately to laboratory after collected. Referred to Charing Cross Hospital, London Haptoglobin Separate SST Referred to Royal Liverpool Hospital HbA1c [glycated Hb] Separate EDTA See section 15. Fluoride oxalate tube (grey top) also acceptable HCG: serum SST 0-5 iu/l (non-pregnant). State LMP if applicable HCG: urine Plain Universal Done by Microbiology. Qualitative pregnancy test. State LMP HDL Cholesterol SST Female mmol/l, Male mmol/l. See section 10 Homocysteine (fasting) Separate EDTA on ice Phone lab 2345 before collection & send immediately to lab after taken. Referred to Royal Liverpool Hospital 3-Hydroxybutyrate Fl. Ox. [grey] To lab within 1h. Sent to Alder Hey Hospital, Liverpool 5-Hydroxyindole Acetic Acid (5-HIAA): urine 24h urine in acid bottle Phone lab 2345 to obtain bottle with acid preservative Referred to Wythenshawe Hospital 17-Hydroxy-progesterone Separate SST Referred to Royal Liverpool Hospital (sent to RMCH for children) IgE & specific IgE Separate SST Immunology test. Referred to Manchester Royal Infirmary IGF-1 Separate SST Referred to Royal Liverpool Hospital IgA Immunoglobulins: IgG IgM Insulin & C-peptide (preferably fasting); also request glucose SST Plain red top, on ice AND Fl. Ox. [grey] g/l; g/l if 12-45y, lower in children <12y g/l; lower in children <15y g/l; g/l if 12-45y, lower in children <12y Phone lab 2345 before collection Send immediately to laboratory after taken. Referred to Royal Liverpool Hospital Intrinsic Factor Antibody Separate SST Immunology test. Referred to Manchester Royal Infirmary Iron SST Female 9-30 umol/l; Male umol/l Iron Studies SST Iron, transferrin, calculated transferrin saturation Lactate: plasma, CSF Lamotrigine Fl. Ox. [grey], on ice Separate SST Plasma mmol/l, CSF mmol/l. Phone in advance & send immediately to lab after taken; CSF done at Macclesf d 3-15 mg/l. Collect sample >6h post dose. Referred to Manchester Royal Infirmary LDH: serum SST iu/l (higher in children) LDH: fluid SST Normally less than 2/3 rd of contemporaneous serum level LDL Cholesterol SST See section 10. Only reported if sample fasting Lead EDTA Referred to Royal Liverpool Hospital LH SST See section 19. State LMP if cycle; day 2-5 sample preferred Lipid profile (preferably fasting) SST Total & HDL cholesterol, triglycerides, LDL cholesterol if fasting & total/hdl ratio if primary prevention. See Section 10 Lithium SST mmol/l. Collect sample at 12h post dose. Liver Function (LFT) SST Albumin, bilirubin (total), alkaline phosphatase, ALT Lysosomal Enzymes 2x EDTA Not Fridays. Referred to Willink Laboratory, Manchester Magnesium: serum SST mmol/l Magnesium: 24h urine Bottle with acid mmol/24h. Phone lab 2345 to obtain container Manganese EDTA Referred to Birmingham City Hospital Mercury: blood EDTA Organic exposure. Referred to Birmingham City Hospital Mercury: urine Plain Universal Inorganic exposure. Referred to Birmingham City Hospital Metadrenalines: urine (Catecholamines) 24h urine in acid bottle Phone lab 2345 to obtain bottle with acid preservative Referred to Salford Royal Hospital Methadone: urine Plain Universal Part of drugs of abuse screen Methaemoglobin Li Hep (green) %. Can use heparinised blood gas sample Microalbumin : urine Plain Monovette Female 3.5; Male 2.5 mg/mmol creatinine. See section 21 Pathology Handbook Page 27 of 94 Version 7

28 TEST SAMPLE ADULT REF.RANGE / COMMENT / EXTERNAL LAB Mucopolysaccharides Plain Universal Urine sample. Referred to Willink Laboratory, Manchester Myoglobin: urine No longer done Please measure serum creatine kinase (CK) instead Oestradiol SST See Section 19 Oligoclonal bands & CSF Immunoglobulins CSF AND blood [SST] Need serum as well as CSF. Referred to Sheffield Immunology Laboratory Oligosaccharides Plain Universal Urine sample. Referred to Willink Laboratory, Manchester Opiates: urine Plain Universal If screen positive, referred to Salford Royal Hospital to confirm Organic Acids: urine Plain Universal State drugs. Referred to Willink Laboratory, Manchester Osmolality: serum SST mmol/l. Osmolality: urine Plain Monovette Oxalate: 24h urine Bottle with acid Phone lab 2345 to obtain bottle with acid preservative Referred to Wythenshawe Hospital Oxygen Saturation See section %. COHb & MetHb also reported P3NP Plain red top Not SST. Referred to Sheffield Immunology Laboratory Paracetamol SST See sections 9 and 25. State time after alleged ingestion. Do not collect sample before 4h after suspected overdose Paraprotein testing SST AND urine See protein electrophoresis (serum and urine) Paraquat: urine Plain Universal Qualitative screen ph: fluid Bl. Gas syringe See sections 11/14 for sample collection procedure Phenobarbital SST mg/l. Collect sample >6h post dose. Done at Macclesfield Phenylalanine separate SST or blood spot Referred to Alder Hey Hospital, Liverpool Phenytoin SST 5-20 mg/l. Collect sample >6h post dose. Done at Macclesfield Phosphate SST mmol/l. Higher in children less than 16y Phytanic Acid 2x EDTA Not Fridays. Referred to Willink Laboratory, Manchester Porphobilinogen (PBG) & Porphyrins: blood, urine & faeces Blood: EDTA Urine & Faeces each Plain pot Send blood, urine & faeces for full screen Protect from light in transit to laboratory. Referred to Salford Royal Hospital Potassium: serum SST mmol/l Pregnancy test: urine Plain Universal Done by Microbiology. Qualitative pregnancy test. State LMP Progesterone Prolactin Plain red top [not SST] SST Females only. Collect in luteal phase only & state LMP. Luteal Phase values 30 nmol/l indicates ovulation Female mu/l if 11-50y, mu/l if >=50y Male mu/l. Protein: 24h urine Plain bottle Up to 0.15 g/24h. Acidified samples cannot be analysed. Protein/Creatinine: urine Plain Monovette Up to 10 mg/mmol Protein electrophoresis (serum) Protein electrophoresis (urine Bence Jones) SST Plain Universal [full container] Samples with paraproteins quantitated, and also confirmed by immunofixation if paraprotein not previously known Qualitative screen by electrophoresis; positive samples confirmed by immunofixation if not previously known Protein (Total): serum SST g/l Protein (Total): CSF Plain Universal g/l Protein (Total): fluid SST Transudate <25 g/l; Exudate >30 g/l; g/l borderline Protein profile: serum SST Total protein, albumin, calculated globulin PSA (Total) SST Males only. Age-related ranges quoted: see section 20 PTH (parathyroid horm.) SST pmol/l PTH-related Peptide (PTHrP) Reducing Substances: urine, faeces Renin Special tube, on ice Plain container (e.g. Universal) EDTA NOT on ice Not routinely available; phone lab 3885 to discuss and obtain special tube; send immediately to laboratory after collection Sample must reach laboratory on day collected. Qualitative report. Faeces samples sent to Alder Hey Hospital. Phone lab 3885 before collection & send immediately to lab after taken. Referred to Royal Liverpool Hospital Pathology Handbook Page 28 of 94 Version 7

29 TEST SAMPLE ADULT REF.RANGE / COMMENT / EXTERNAL LAB Rheumatoid Factor SST 0-14 kiu/l; values between borderline Salicylate SST Concern level >350 mg/l (>280 mg/l if <5y). Section 1.9 Selenium Separate SST Referred to Royal Liverpool Hospital SHBG SST Female nmol/l (used to derive FAI), Male nmol/l Sirolimus EDTA Collect pre-dose. Referred to external laboratory Sodium: serum SST mmol/l Sweat Test (Conductivity) Special For suspected cystic fibrosis. Tacrolimus EDTA Collect pre-dose. Referred to external laboratory Teicoplanin Separate SST Collect pre-dose. Microbiology test. Sent to Southmead Hospital Testosterone SST See section 19. SHBG also done on adult female requests Theophylline SST mg/l. Collect sample 4-6h post dose (slow release tablets) Thyroglobulin Separate SST Referred to Sheffield Immunology Laboratory Thyroid Function (TFT) SST free T4 & TSH; free T3 analysed at laboratory s discretion Thyroid Peroxidase Ab SST 0-9 kiu/l. Thyroxine (Free T4) SST pmol/l. Part of Thyroid Function Test Profile Tobramycin SST Trough <2 Peak 8-12 mg/l. State dose times. Done at Maccl d TPMT EDTA Referred to Birmingham City Hospital Transferrin SST g/l Transferrin Saturation SST %. Calculated from iron & transferrin levels Triglyceride SST mmol/l (applies if fasting). See section 10 Tri-iodothyronine (Free T3) SST pmol/l. Only measured at laboratory s discretion Troponin I SST >40 ng/l; only valid for excluding myocardial infarction if collected >12h post event Tryptase (mast cell) Separate SST Immunology test. Referred to Manchester Royal Infirmary TSH SST mu/l. Part of Thyroid Function Test profile TSH Receptor Antibody Separate SST Referred to Royal Liverpool Hospital TTG Antibody (IgA) SST Referred to Manchester Royal Infirmary Urate: serum SST Fem umol/l; Male umol/l; lower if <12y Urate: 24h urine Plain bottle mmol/24h. Acidified samples cannot be analysed. Urea: serum SST mmol/l U&E: random urine Plain Monovette sodium, potassium, urea, creatinine U&E: 24h urine Plain bottle sodium, potassium, urea, creatinine Valproate SST mg/l (poorly defined); measurement only useful to assess compliance. Collect 2 4h post dose. Done at Macclesfield. Vancomycin SST mg/l (trough). Collect pre-dose. Done at Macclesfield. Very Long Chain Fatty Acids (VLCFA) 2x EDTA Do not collect on Fridays. Referred to Willink Laboratory, Manchester Vitamins A & E separate SST Protect from light. Referred to Wythenshawe Hospital Vitamin B12 SST ng/l; values between borderline Vitamin D (25OH-D2/D3) separate SST Referred to Wythenshawe Hospital, Manchester Xanthochromia: CSF Plain Universal Need 1 ml. Protect from light. Do not send by air tube Zinc Special blue top Vacutainer Phone lab 2345 before collection to obtain tube Referred to Salford Royal Hospital Pathology Handbook Page 29 of 94 Version 7

30 24A. CLINICALLY SIGNIFICANT CHANGES IN RESULTS Many of the laboratory tests requested each year are used to monitor patients rather than for diagnosis. Sequential changes in cumulative results, when placed in a clinical context, can be as important as the absolute value of the result. The laboratory undertakes regular quality assurance activities to ensure the reliability of the results, but it must be noted that there will always be some degree of uncertainty associated with all results. When a single specimen from a patient is assayed several times identical results are not found every time. This is due to analytical imprecision. IQC programmes allow the laboratory to calculate and to know the analytical imprecision for each analyte measured. In addition, the concentration of an analyte from any individual subject varies from day to day. This may be termed biological, intra-individual or within subject variation. Biological variation may itself be inherent in nature or dependent on variables such as timing (e.g. cyclical rhythms, which may be daily, monthly or seasonal), diet, stress, and posture. Changes in results may therefore be caused by a combination of: analytical imprecision plus biological variation in addition to deterioration or amelioration of the patient's condition under assessment. The "critical difference" between results, i.e. the change that must occur before significance can be claimed, can be calculated. The critical differences for specific tests are available from the laboratory on request. 25. GRAPH TO ASSESS SEVERITY OF PARACETAMOL OVERDOSE Patients whose serum paracetamol concentration related to time from ingestion is above the line require specific treatment. This line was revised by the Commission on Human Medicines (MHRA) on 3 rd September Pathology Handbook Page 30 of 94 Version 7

31 26. CRITICAL ABNORMAL RESULTS Biochemistry results outside the following limits will be telephoned immediately to the requesting clinician/location as soon as the results are confirmed to be analytically correct. Test (serum/blood if not otherwise stated) Lower Limit Upper Limit Ammonia 100 µmol/l Alcohol ALT AST Amylase Anticonvulsants: Carbamazepine Lamotrigine Phenobarbital Phenytoin Bilirubin (neonates) Bile Acids (in pregnancy only) 3000 mg/l 900 iu/l } (GP/OP only, 500 iu/l } if new/increasing) 250 iu/l 25.0 mg/l 30.0 mg/l 75.0 mg/l 25.0 mg/l 280 µmol/l (35 cord blood) 14 µmol/l Bicarbonate 10 mmol/l 45 mmol/l Calcium (adjusted if albumin <40 g/l) 1.80 mmol/l 3.00 mmo/l Carboxyhaemoglobin 20 % C-Reactive Protein Creatine Kinase (CK) Creatinine Digoxin 300 mg/l (GP/OP only) 2000 IU/L 350 µmol/l (only if a new finding) 2.0 µg/l Gases: ph Glucose: plasma (fasting or random) 2.5 mmol/l 20.0 mmol/l Glucose: CSF 1.7 mmol/l 15.0 mmol/l Lithium Lactate 1.2 mmol/l 5.0 mmol/l Magnesium 0.40 mmol/l 2.0 mmol/l Paracetamol 40 mg/l Phosphate 0.35 mmol/l Potassium 2.5 mmol/l 6.5 mmol/l Protein: 24 hour urine Protein/Creatinine ratio: random urine Salicylate 2 g/24h (pregnancy) 200 mg/mmol (pregnancy) 350 mg/l Sodium 120 mmol/l 155 mmol/l Theophylline 20.0 mg/l (neonates 15.0) Troponin I Urea 40 ng/l (GP/OP Only) 30.0 mmol/l (only if a new finding) Xanthochromia: CSF Any Positive Result Pathology Handbook Page 31 of 94 Version 7

32 27. SAMPLE COLLECTION NOTES Certain substances, drugs and procedures can affect the results of some laboratory tests. 1. Haemolysis Can increase serum levels of potassium, magnesium, phosphate, zinc, folate and many enzymes, and cause analytical interference with other assays, including lithium. 2. Delayed separation As with haemolysis, this may increase serum levels of potassium, magnesium, phosphate, PTH, zinc, folate and many enzymes. 3. EDTA contamination Occurs if samples are tipped from an EDTA tube into another tube - will increase potassium and decrease calcium, magnesium and alkaline phosphatase levels. 4. Intravenous infusions Samples collected from a drip arm into which an intravenous infusion is running will give artefactually high results for analytes in the infusion and artefactually low results for any other analytes. 5. Lipaemia Can interfere with many assays - results should be interpreted with caution. 6. Proteins/Calcium Posture and/or prolonged venous stasis can increase concentrations. 7. Uric acid Thiazide diuretics and paracetamol can affect levels. 8. Glucose/Triglycerides Time of food intake should be taken into account. 9. CK (creatine kinase) Injections, trauma, surgery and hypothermia can increase levels. 10. Cortisol Stress, time of day and steroids (e.g. prednisolone) affect levels. In all cases, a repeat sample should be collected if doubt exists regarding the validity of the results. 28. IRON STUDIES AND FERRITIN Acute or chronic disease can affect measurements used to assess iron status. In particular, a low serum iron level, which is especially common in hospital inpatients, does not necessarily indicate iron deficiency. A low serum iron with a low transferrin saturation (below 15%) is suggestive of iron deficiency if the transferrin is raised or high normal ( 3.0 g/l). However, a low serum iron with a low or low normal transferrin (typically < 2.5 g/l) usually suggests disease due to a cause other than iron deficiency, such as a chronic inflammatory disorder. Therefore, the preferred biochemical test for suspected iron deficiency is serum ferritin. A ferritin value below the lower limit of the reference range supports the diagnosis of iron deficiency. However, as serum ferritin is increased by the acute phase response, an apparently normal value in the lower part of the reference range (< 75 µg/l) does not exclude iron deficiency. If a patient is unwell, it is therefore desirable to request a marker of the acute phase response (such as CRP) at the same time as requesting serum ferritin. In addition, a high ferritin value above the reference range does not necessarily indicate iron overload, due to the effect of the acute phase response. Serum ferritin may also exceed the reference range in liver disease not due to haemochromatosis. Therefore, the preferred test for screening for haemochromatosis is serum iron studies. The serum iron and transferrin results are used to calculate the transferrin saturation - a value above 45% is suggestive of this diagnosis, provided that the patient is not on iron therapy, but clinical haemochromatosis is unlikely if the transferrin saturation does not exceed 40%. Please do not directly request haemochromatosis (HFE) genotyping without seeking specialist haematology advice unless the transferrin saturation is above 45% (preferably on at least 2 occasions). Please note that age and sex-related reference ranges are used for both iron and ferritin results. Where appropriate, senior biochemistry laboratory staff may add additional tests (including CRP) in order to assist with the interpretation of equivocal serum ferritin and iron/transferrin results. Pathology Handbook Page 32 of 94 Version 7

33 HAEMATOLOGY, BLOOD TRANSFUSION & ANTICOAGULATION Consultant Haematologist Dr G Tarkovacs Ext 8019 (or contact via Switchboard) (Covering Haematologist from North Staffs Ext 2644) Clinical Nurse Specialists Tracy Howe and Karen Bowyer Ext: 8017 Service Lead Jack Flevill Blood Transfusion Manager/Deputy Service Lead Diane Benson Ext / 3726 Oral Anticoagulation Service Manager Julie Salisbury Ext / 3285 Pathology Handbook Page 33 of 94 Version 7

34 HAEMATOLOGY SAMPLE REQUIREMENTS Full Blood Count Reticulocytes Blood film ESR IM Screen Malaria parasites Haemoglobinopathy screen Sickle solubility test G6PD Coagulation: Prothrombin Time (PT)/INR Activated Partial Thromboplastin Time (APTT) Coagulation Screen Fibrinogen D-Dimer Factor V Leiden Prothrombin G20210A Thrombophilia studies: Antithrombin Protein C Protein S APC Resistance Lupus anticoagulant (as individual test) Factor VIII Factor IX 4 ml EDTA (lavender top) 2.7 ml citrate (blue top) minimum fill frosted line, do not overfill 1 x 2.7 ml citrated (blue top) AND 2 x 9 ml (blue top) fill to black mark 2.7 ml citrated (blue top) AND 9 ml citrated (blue top) *Cold Agglutinins 1 x 6ml serum (red top) Must be maintained at 37 C *Cryoglobulins Outpatients: patient to attend phlebotomy in the morning Inpatients: contact Haematology on ext during office hours *these tests are not accredited by UKAS as no suitable control material is available All samples must be mixed after collection with 10 inversions. ADD-ON TESTS Requests for additional tests should be received as soon as possible because sample degradation will occur. In particular D-dimer request must be received within 4 hours of sample collection. If another result is required to support the interpretation of any requested test this will be automatically added. E.g. FBCs are added to haemoglobinopathy screen results to exclude thalassaemia. The laboratory staff may add on the following tests if the initial results are abnormal, to improve diagnostic value, prevent patients being rebled, reduce medical staff time and to aid early diagnosis: Blood film Malaria parasites Reticulocytes IM screen Iron studies Vitamin B12 and folate Total protein, immunoglobulins and protein electrophoresis Pathology Handbook Page 34 of 94 Version 7

35 ADULT NORMAL RANGES Wherever possible use the age and sex specific reference ranges on the report Test / Parameter Generic Male Female Hb g/l g/L WBC 4 11 x 10 9 /L PLTS x 10 6 /L MCV fl MCH pg RBC x /L X /L HCT L/L L/L Reticulocytes x10 9 /L x10 9 /L Neutrophils x 10 9 /L Lymphocytes x 10 9 /L Monocytes x 10 9/L Eosinophils x 10 9 /L Basophils x 10 9 /L ESR 0 14mm/Hr 0 20mm/Hr HbA % HbF < 1.0% PT 9-13 s INR APTT s APTR Clauss Fibrinogen g/l D-dimer <500 FEU Antithrombin iu/dl Protein C iu/dl Free Protein S iu/dl iu/dl Protein S Activity iu/dl DRVVT Screen ratio Factor VIII iu/dl Factor IX iu/dl APCr Thrombin Time s Cold Agglutinins < 1 in 64 G6PD Normal Activity Tests that do not have a numerical value will be reported with interpretative comments dependant on the result. Other tests may also have comments to qualify the result or provide further information relating to that test. Pathology Handbook Page 35 of 94 Version 7

36 TURNAROUND TIMES TEST ROUTINE URGENT FBC 4 hours from receipt 1 hour from receipt ESR 4 hours from receipt 1 hour from receipt FACTORS AFFECTING TEST* H, L, C C, U Reticulocyte 4 hours from receipt 1 hour from receipt IM screen Same day 1.5 hours from receipt Malaria parasites Same day 1.5 hours from receipt PT/INR 4 hours from receipt 1 hour from receipt APTT 4 hours from receipt 1 hour from receipt Thrombophilia screening Up to 6 weeks depending on results and send away aspects of screen. Not applicable Sickle solubility test 3 working days 1.5 hours from receipt Haemoglobinopathy screening Initial report within 3 working days. Final identification within 4 weeks. Sickle screen 1.5 hour from receipt See Sickle Solubility Test R Immunological test only H, U, L, O H, U, L, O H, U, L, O Pt on anticoagulants. H, U, O A Cryoglobulins 7 days Not applicable G6PD Within 3 working day Same working day D-Dimer Not applicable 1 hour from receipt Raised Reticulocyte level H, U, L, O * H = Haemolysis L = Lipaemia C = Cold Agglutinins U = Underfilled Sample O = Overfilled Sample R = Increased level of Rheumatoid factor A = Aged Sample (> 3 days old) Pathology Handbook Page 36 of 94 Version 7

37 CRITICAL RESULTS TO BE TELEPHONED This may be omitted if urgent treatment is unlikely to be required, e.g. patient has a history of abnormal results or the given clinical information suggests such a result is expected. GP / Outpatients Hb. < 80 g/l or > 200 g/l PLTS. < 50 x 10 9 /L. or >1000 x 10 9 / L Neutrophil count < 1.0 or > 20.0 x 10 9 /L INR. > 1.5 (patients not on Warfarin) INR. > 5.0 (patients on Warfarin) APTT. ratio >1.5 Inpatients Hb. < 70 g/l or > 200 g/l Neutrophil count < 1.0 or > 30.0 x 10 9 /L PLTS. < 30 x 10 9 /L INR. > 2.5 (patients not on Warfarin). INR. > 5.0 (patients on Warfarin) APTT. ratio >5.0 (patients on unfractionated Heparin) APTT. ratio >1.5 (patients not on Heparin) THROMBOPHILIA (PROTHROMBOTIC) SCREENING Involves a set of assays to measure the level of coagulation inhibitors present in the body. The risk of VTE increases if patent presents with the following thrombophilia results: 1. The presence of Lupus Anticoagulant. 2. Deficiency of coagulation inhibitors: Antithrombin III, Protein C and Protein S. 3. The presence of genetic mutation of Factor V Leiden as measured by the Activated Protein C Resistance screen or the Prothrombin G20210A mutation. Patients must not be on anticoagulation therapy when thrombophilia screening is requested. In addition, sampling should be avoided during acute episodes, intercurrent illness, pregnancy and use of COCP, HRT. Pathology Handbook Page 37 of 94 Version 7

38 SEND-AWAY TESTS Test Name(s) Anti Factor Xa. Sample & Request Form 1 x 2.7ml and 1x 9ml sodium citrate (blue) Pre dose and 2 hrs post dose Contact Coagulation, MRI Lab Results Max Rindl / Clair Gair TAT / Cost 14 days Tested Mondays and Fridays Additional Comments Used to monitor LMW heparin dose in selected patients BCR/ABL Fusion Gene Product. 1 x EDTA (more if WBC low) New cases will need 1 x gel free lithium heparin (green top) too. Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x days CML investigation Kerry Wall ABL1 AKD mutation analysis (ABL1 kinase domain) 1 x EDTA Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x weeks For patients not responding to Imatinib and other drugs used in treatment for CML Bone Marrow Trephine Trephine in formalin aspirate films MIRHO form Histology Laboratory Queen Elizabeth Hospital Birmingham Kim O Leary 7 days Ensure sufficient absorbent material in bag to contain leak Calreticulin (CALR) CD4 (includes CD8) 1 x EDTA (more if WBC very low) 1 x EDTA Preferably <24 hrs old Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x 4333 Immunology, MRI days Mutations cause myeloproliferative neoplasms. Found in majority of JAK2 /MPL negative patients with essential thrombocytosis and primary myelofibrosis, 8 days Treat samples as High Risk Pathology Handbook Page 38 of 94 Version 7

39 Test Name(s) Cell Markers. Cytogenetics EMA binding for Hereditary Spherocytosis Factor V Leiden FIP1L1- PDGFRA/PDGF RB/ FGFR1 (platelet derived growth factor receptor) FISH ATM p53 Prognosis of CLL or 17P 11Q For CLL FMH Feto-maternal haemorrhage G 6PD Deficiency Screening Haemochromatosis Genetic Screen (HFE Gene). Sample & Request Form 1 x EDTA blood or bone marrow Minimum volumes Blood adult 4ml, Blood paed 0.5ml Bone marrow 2mL 1 x gel-free lithium heparin (green top) bone marrow or blood MIHRO form 1 x EDTA sample. 1 x 2.7mL sodium citrated (blue top) 1 x 6ml gel free lithium heparin (green top) 1 xl 6mL gel free lithium heparin (green top) Blood or Bone Marrow MIRHO form 6ml EDTA with 3 points of matching ID on sample and request form 1 EDTA 1 EDTA Contact Immunology University of Birmingham Results Consultant Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x 4333 Haematology, MRI Tel: Manchester Molecular diagnostics, MRI Tel. No /4880 Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x 4333 Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x 4333 Red cell lab, Liverpool / 7148 OOH Haematology Macclesfield Tel (Prof. Worwood), Ext Tel for results TAT / Cost 12 days. Urgent requests shorter Urgent: up to 5 days Routine: 28 days 9 days 21 days. 3 weeks days 7 working days from receipt. Macclesfield will enter result directly onto LabCentre 15 working days Additional Comments Rituximab (usually rheumatology): CD20 required. Put On Rituximab on request Send 2 unfixed/unstained BM slides if available Always performed in tandem with prothrombin Gene G20210A Variant Eosinophil Markers/ Eosinophil Leukaemia to see if will respond to Imatinib For Prader Willi investigations Call Haemato-oncology about other FISH tests Call Liverpool to arrange delivery and telephoning/faxing of results Will not appear on send-away list. Record in lab comments: Sent to Macclesfield for G6PD testing on <date> Cardiff do not test patients under 18 years old unless consultant confirms that it is required eg unexplained iron overload / hyperferritnaemia Sample must be accompanied by signed form indicating parent fully informed by GP/consultant and have given consent because disease is late onset Pathology Handbook Page 39 of 94 Version 7

40 Test Name(s) Haemoglobinopathy DNA analysis for thalassaemia / variant haemoglobin Sample & Request Form 10mL EDTA blood. 2mL minimum Requesting midwife/doctor must complete consent form (signed by patient) and request form see notes Contact Red cell lab, MRI Tel Fax Steve Keeney Genetics TAT / Cost 8 weeks, longer for complex cases Free if within algorithm. Basic alpha thal 105, moderately complex 240, gene cluster deletions/ml PA 480 Additional Comments Google Manchester Haemoglobinopathy Diagnostic Service for forms and algorithm / guidelines Prenatal diagnosis use the specific request form. For all other tests use the genotype request form. Enter onto Lab Centre as HDNA. Haemoglobin Variants LabCentre code HBVR Ig Gene Rearrangement 1 EDTA 1x EDTA Bone Marrow or Blood Red Cell Lab, MRI Tel Fax Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x 4333 Kim O leary 21 working days Unidentified variants should usually undergo phenotypic testing initially. 20 days B-cell or plasma cell differentiation JAK 2 mutation 1 x EDTA Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham 15 working days Tel x 4333 Haemato-oncology at Birmingham extract DNA and forward to Addenbrooks : JAK 2 Exon 12 1 x Lithium Heparin gel-free (green top) MIRHO form Dr Anthony Bench Molecular Genetic Testing Addenbrooks Hospital Hills Rc Cambridge CB2 2QQ 40 working days Malarial parasite referral See right Tel Diagnostics lab Liverpool School of Tropical Medicine Tel: / 3290 Results are telephoned on day of receipt of sample. Confirmation of species if initial screen positive / equivocal Malaria is a notifiable disease and the LSOTM will notify the correct body. Add the request item MPR (Malaria Parasite Referral) to the LabCentre request MPL Exon 10 Leeds HMDS Mutation 2 x EDTA 2/52 Jak 2 Investigations (Mipple) Tel Pathology Handbook Page 40 of 94 Version 7

41 Test Name(s) Sample & Request Form Always contact Birmingham to arrange date before collection Contact Haematology, City Hospital, Birmingham Tel TAT / Cost Additional Comments Oxygen Dissociation p50 1 X EDTA Sample from another patient collected at similar time to act as a travel control Ward must contact us so we can check MRI have cartridges Fax sukhjinder.marwah@s wbh.nhs.uk Not stated PFA 100 Collect at 12 midday and hand deliver to lab Put on courier specialist coagulation, MRI Tel days 2 x 2.7mL sodium citrate (blue) 2 x EDTA samples Plasma Viscosity. Minimum 1 half full Tel <5 days. 1 x EDTA Immunology University of Birmingham 12 days. PNH Protein C and S Gene Mutation Can manage with 100ul - minimum 1 EDTA or red cells from sodium citrate Results Consultant Jacky Cutler Molecular Haemostasis Lab St Thomas Hospital Not Stated Now tested using cell markers For patients seen by Dr Chandra at Haemostasis Clinic Prothrombin Gene G20210A Variant Pyruvate Kinase Deficiency Schilling Test see factor V Leiden 1 x EDTA Min 0.5ml travel control (normal sample collected the same time) 24-hour urine sample. Tel Red Cell Laboratory Kings College Hospital Tel e ext 2455 Nuclear Medicine Group, Christie Hospital Not stated 2/52 Jane Bryon T-Cell Receptor Gene Rearrangement. TcR (For MRD assessment). 2 x EDTA Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x /52 Pathology Handbook Page 41 of 94 Version 7

42 Test Name(s) Von Hippel Landau Genetic Test vhl Sample & Request Form 1 x EDTA Contact Haemato-oncology Lab West Midlands Regional Cytogenetics Laboratory Birmingham Tel x 4333 Coagulation, MRI TAT / Cost 8 weeks Additional Comments No further consent required Investigation for erythrocytosis (? High Affinity Hb) VWF, RICOF, Antithrombin, Protein C or S requiring antigen confirmation & any other coagulation assays & inhibitor screens. 1 x 2.7mL sodium citrate & 1 x 9mL sodium citrate (blue top) Tel. No. #6178 ( ) or Special coag for copies of results 35 days. Pathology Handbook Page 42 of 94 Version 7

43 ANTICOAGULATION Contact Phone No: internal ext: 3285 Answer phone service for out of hours. Fax No: Routine Working Hours: Monday Friday Low Molecular Weight Heparin Enoxaparin (Clexane) is used: Therapeutic dose: Prophylactic dose: 1.5mg/kg bodyweight o.d. s/c 40mg o.d s/c is suitable for most patients. The dose should be reduced in patients with chronic renal impairment (creatinine clearance <30ml/min). Patients on Clexane should have their platelet count measured at the beginning of treatment. If platelet count falls by >50% from first count contact Haematologist urgently for advice regarding possibility of HITT (heparin induced thrombocytopenia and thrombosis). Monitoring of LMWH is not usually necessary except for the following groups of patients: Pregnant Women Renal and liver failure patients Extreme bodyweight ie: obese/underweight Children Long term patients Patients with either active of treated malignancy. Contact Haematology Dept: ext 2645 for advice about anti-factor Xa assays. For prophylactic cases U/ml, for therapeutic cases U/ml (approx depending on LMWH formulation in use). Warfarin Therapy - before commencing anticoagulant therapy check: FBC, coag screen, liver and renal function. Contact Haematologist if platelet count <100 X 10 9 /L or INR 1.4 or above. Cases of impaired renal/liver function Loading regimes: Rapid loading schedule (Fennerty Regimen) Refer to yellow anticoagulant referral form Page 1. Give Warfarin daily at 6pm Check INR daily day 1 4, take blood sample between 9 11am, dose accordingly to INR result. Slow induction 3mg daily for 1 week then check INR. Patients already taking warfarin prior to admission DO NOT USE EITHER LOADING REGIMEN if Warfarin is stopped temporarily. RESTART normal dose and check INR day 3. Referral to Outpatient/GP Monitoring Service Complete the Anticoagulation Referral Form (available on Intranet) Form must be signed by a medic with name printed. All relevant sections must be completed; otherwise patient appointment will be delayed. For in-patients (Page 1 of referral) should be used until discharge, then file it in patient notes. For all patients complete Page 2 of referral and fax it to Office staff will phone back to arrange appointment for patients. Pathology Handbook Page 43 of 94 Version 7

44 In-patients will be seen at next available new patient clinic slot at Leighton Hospital; initial appointment will be minutes for education. GP/outpatients non urgent cases will be seen within 1 weeks of date of referral for the vast majority. For urgent GP/OP referrals patients will be given next available new clinic slot as above. All patients will then be monitored routinely at their local outreach clinic. Anticoagulant Clinics are held in each town within CECCG. Please note: IVDA/s and most patients with active cancer should not be started on Warfarin, but treated instead with LMWH (therapeutic dose). Alternative oral Vitamin K antagonists anticoagulants used for patients who cannot tolerate Warfarin (adverse side effects) include Sinthrome and Phenindione. Please phone office for advice. New oral anticoagulants (NOACs) are now also available These include: Dabigatran Rivaroxaban Apixaban Edoxaban Information about the use of these anticoagulants can be found on the Trust Intranet, Policies + Procedures, search Anticoagulation. GPs can access the Pathology Handbook via the Anglia ICE system. There are currently no antidotes for NOACs. Refer to Management of bleeding in patients on Dabigatran, Rivaroxaban or Apixaban at MCHFT. In cases of severe blood loss refer to the Massive Haemorrhage Protocol, page 70 of the Transfusion Policy for blood and blood products. Tests to perform if an overdose of NOAC is suspected Dabigatran Thrombin Time is the most sensitive Rivaroxaban, Apixaban, Edoxaban Prothrombin Time is the most sensitive Seek advice from the Consultant Haematologist Pathology Handbook Page 44 of 94 Version 7

45 BLOOD TRANSFUSION THE SAFEST TRANSFUSION IS THE ONE YOU DON T GIVE Please see the blood transfusion policy which is held on all wards and available on the intranet for greater detail relating to blood transfusion. Blood is a valuable commodity and should be used appropriately with much consideration. Blood is a living tissue and its transfusion from one individual to another is not without risk. Sample requirements Blood group/antibody screen Cross match Direct antiglobulin test HLA B 27 typing HLA typing other groups Kleihauer test 6 ml specific transfusion bottle (pink) 4 ml EDTA (lavender) 3 x 4ml EDTA (lavender) Contact blood transfusion laboratory for requirements 4 ml EDTA (lavender) All blood transfusion samples and forms including HLA typing MUST be labelled by hand and contain all the identifying criteria as listed on page 6 Please note alternative size samples are available for paediatrics. Grossly haemolysed samples cannot be processed. Samples containing cold agglutinins may require warming and take longer to process. Procedure for Requesting Blood and Blood Products Transfusions of blood and blood products must be requested from the blood transfusion laboratory on an individual named patient basis. Medical staff will normally complete the request form for blood and blood products, but it may be appropriate for non-medical staff to make the request in emergency situations, these staff groups are as follows: Authorised Nurse Specialist Authorised Midwife Authorised Emergency Nurse Practitioner All requests forms must be handwritten using capital letters and black pen and include the following (It is mandatory to complete all shaded areas of the form): Surname First name (initial is not sufficient) Date of birth Unique hospital patient identification number Gender Location Diagnosis/indication for transfusion Pathology Handbook Page 45 of 94 Version 7

46 Type/quantity of blood product required Previous transfusion history Any special requirements e.g. irradiated Date and time required (ASAP is not sufficient) Requesting person to print and sign their name Contact number (extension or bleep number) of requesting person Telephone requests are accepted in emergency situations only, and will be followed up by a written request. Blood will not be issued from the blood transfusion laboratory until a request form has been received. Non-urgent transfusion requests should be received at least one clear working day before the blood is required. Longer notice is required for large transfusions (more than four units) or if cross-matching difficulties are likely e.g. known abnormal antibodies. MCHFT is working to the updated BCSH pre-compatibility guidelines for blood transfusions (2012) which include the following: a) Two samples, taken at separate times, are required on a patient with no historic blood group prior to issuing blood. This is to ensure that wrong blood in tube errors are detected prior to a patient being transfused. In an emergency situation if this is not possible, then Group O red cells will be issued until the second sample is received. b) Sample timings for patients who have received a transfusion or have been pregnant within the last three months samples will be valid for 72 hours (3 days). For patients not transfused or pregnant within the last 3 months samples will be valid for 7 days. TRANSFUSION OF BLOOD PRODUCTS YOUR RESPONSIBILITIES Documentation in Patient Notes Explain risks, benefits and alternatives in a timely manner to patients prior to obtaining verbal consent to transfusion and document in patient notes Check notes and/or computer for previous transfusion history or any special requirements Document Indications for transfusion Number of units transfused Effectiveness of transfusion Sampling/Requests Positively identify your patient prior to venepuncture All samples must be handwritten at the patient s bedside All shaded areas on request form are mandatory (in capital letters, black biro) Transfusion Duration (for each unit) Red Blood Cells 2-3hrly (max 4 hrs) Platelets 30mins (not in stock, order in advance) Pathology Handbook Page 46 of 94 Version 7

47 Fresh Frozen 30mins (advanced notice required, defrost time Plasma (FFP) approx 30mins, use within 24hrs of thawing) Transfer to another Hospital with Blood Products If your patient is to be transferred to another hospital with blood products you must inform the blood bank (they will do the necessary paperwork for you). It is recommended that no more than two units of red cells are transferred with a patient, to avoid unnecessary wastage. Transfusion Reactions You must report these to blood bank. The Trust has a legal responsibility to report all reactions to the external agencies SHOT and SABRE. Dosage of Blood Products Fresh Frozen Plasma 12-15ml/kg (usually 4 packs) Platelets 1 unit of platelets contains 4 adult therapeutic doses one adult therapeutic dose raises platelet count by x 10 9 L Urgent Requests You must inform the lab via telephone prior to sending the request card. Telephone Requests Telephone requests are accepted e.g. in an emergency but must be followed up by a written request. Blood will not be issued from the lab until a written request form has been received. For all FFP and Plasma requests you must telephone the lab prior to sending your request Should the Massive Haemorrhage Protocol be activated a protocol can be found in all clinical areas and also in the Transfusion policy. It is imperative that an audit proforma is completed for each massive haemorrhage incident, and the paperwork returned to the blood transfusion department as soon as possible. We are more than happy to answer any questions or queries you may have, please contact the lab or the following contacts. Diane Benson Blood Bank Manager Ext 2647/3726 Sister Lesley Adams Transfusion Practitioner Ext 3217 Pathology Handbook Page 47 of 94 Version 7

48 PRESCRIBING BLOOD PRODUCTS To comply with EU regulations and the Blood Safety and Quality Regulations 2005 all blood and blood products must be prescribed using the Trusts transfusion record sheet available on all wards. Blood and Blood Products Availability Adult Red Cells: Platelets: Fresh Frozen Plasma: Cryoprecipitate: Albumin (4.5/20.0%): Anti D immunoglobulin: Ante natal Anti D: Whole Blood: Available from stock (if compatible) Advance order required, not held as stock Available from stock Available from stock Available from stock Available from stock Prophylaxis available by arrangement with blood transfusion department Very rarely used by arrangement only Reservation Period Cross matched blood will be reserved for 24 hours after the time requested and if not used will be returned to stock for use for other patients. Please inform blood transfusion department if the blood will be required later than the original time or if surgery is postponed. Flying Squad Two units of O Negative blood for adult emergency use and two paediatric units of O Negative blood for neonatal/paediatric emergency use are available on the top shelf of the blood fridge. Inform the blood transfusion laboratory staff immediately if these are used. Two units for 0 Negative blood for adult emergency use is also available in the Main theatre fridge. Again inform the blood transfusion laboratory staff immediately if they are used. The great majority of transfusion disasters are due to clerical and administrative errors, therefore always check that the name and details on each unit label are correct before starting the transfusion. Staff coming to collect blood must be competency trained in the blood collection process and their competencies be up-to-date. TRANSFUSION REACTIONS The transfusion should be stopped immediately if adverse symptoms occur. The blood being transfused, the giving set and the remains of any previous units of blood should be returned to the laboratory together with 10ml clotted blood and 6ml pink top blood transfusion samples. Detailed instructions on what to do in the event of a transfusion reaction is contained within the blood transfusion policy. Pathology Handbook Page 48 of 94 Version 7

49 MANAGEMENT OF SEVERE/ACUTE TRANSFUSION REACTION Symptoms/signs of Acute Transfusion reaction Fever, chills, Tachycardia, hyper or hypotension, collapse, rigors, flushing, urticaria, bone, muscle, chest and/or abdominal pain, shortness of breath, nausea, generally feeling unwell, i t di t Stop the Transfusion and Call A Doctor Measure temperature, pulse, blood pressure, respirations and pulse saturation. Check the identity of recipient, the details on the unit and compatibility form. Febrile non-haemolytic transfusion reaction If temp rise <1.5 C, the observations are stable and the patient is otherwise well administer Paracetamol 1g (PR/PO) max 4g/24hour. Reduce infusion rate and observe every 15 minutes Mild fever Reaction involves Mild fever or Urticarial Urticaria Mild allergic reaction Administer Chlorpheniramine 10mg slowly I.V reduce the transfusion rate and observe more frequently ABO incompatibility Take down unit and giving set and return both intact to blood bank. Commence IV saline to maintain IV access. Monitor urine output/catheterise. Maintain urine output at >100mls per hour. Administer Frusemide 20-80mg IV (no faster than 4mg/min) if urine output falls/absent. Treat any DIC with appropriate blood components. Inform blood bank immediately Haemolytic reaction/bacterial infection of unit Take down unit and giving set and return both intact to blood bank. Take blood cultures; repeat blood group/crossmatch/fbcx, Coag screen, Biochemistry, and urinalysis. Monitor urine output. Commence broad-spectrum antibiotics if suspected bacterial infection. Commence oxygen and fluid support. Seek Haematology advice. Yes Yes Suspected ABO incompatibility? Recheck pack and patient ID Severe allergic reaction? No Other Haemolytic reaction/bacterial contamination? Yes Consider Involving Outreach Team if EWS >4 Severe Allergic Reaction Bronchospasm, angiodema, abdominal pain, and/or hypotension. Discontinue transfusion. Return unit and giving set intact to blood bank. Administer Chlorpheniramine 10mg slowly IV. Commence Oxygen Administer Salbutamol nebuliser. If hypotension severe, administer adrenaline 0.5ml of 1 in 1000 (i.e. 0.5 mg) IM. Clotted sample to blood bank. Saline wash future components. No Fluid overload STOP INFUSION Administer oxygen and Frusemide40 80mg IV (no faster than 4mg/min) Raised CVP Acute dyspnoea/hypotension Monitor blood gases, perform CXR, measure CVP/pulmonary capillary pressure Normal CVP TRALI Dyspnoea, CXR whiteout Discontinue transfusion administer oxygen Treat as ARDS-ventilate if hypoxia indicates Pathology Handbook Page 49 of 94 Version 7

50 GUIDELINES FOR ADULT TRANSFUSION (NON ONCOLOGY PATIENTS) Acute Blood Loss Over 20% Volume Patient Anaemic (Hb below 100g/L) Consider Immediate Transfusion Surgical Medical Pre-op Investigate Post-op Hb below 80g/L No Acute MI Hb g/L Acute MI Signs Or Symptoms Transfuse to Hb of 100g/L Yes No Do Not Transfuse unless Hb below 70g/L No Signs or Symptoms Signs or Symptoms Or Hb below 70g/L Hb below 70g/L Transfuse, but Evaluate after each unit Transfuse, but Evaluate after each unit Do Not Transfuse Transfuse, but Evaluate after each unit Pathology Handbook Page 50 of 94 Version 7

51 MAXIMUM BLOOD ORDER SCHEDULES These have been agreed by the Blood Transfusion Committee as a guide for Medical Staff. Note: G & S = Group and antibody screen (sample saved for 7 days) At least one clear working day s notice is required for non-urgent blood transfusions. Longer notice is required for larger transfusions e.g. > four units or if cross-matching difficulties are expected, for example due to the presence of abnormal antibodies. PROCEDURE No. of UNITS MEDICINE E.R.C.P. G & S GENERAL SURGERY Cholecystecomy and exploration of common ducts 2 Cholecystecomy G & S Splenectomy 2 Laparotomy planned exploration Liver biopsy Vagotomy +/- drainage G & S G & S G & S Gastrostomy Oesophagectomy 6 Hiatus hernia G & S Partial gastrectomy 2 Oesophago-gastrectomy 4 Hepatectomy 6 Mastectomy (simple) Endocrine Thyroidectomy partial/total Parathyroidectomy Adrenalectomy G & S G & S G & S G & S Pancreatectomy partial Whipple 4 COLO-RECTAL SURGERY Rectum pouch: resection/excision etc 2 Intra-abdominal colectomy etc 2 Pathology Handbook Page 51 of 94 Version 7

52 Rectopexy 2 A.P. Resection 3 VASCULAR SURGERY Amputation of leg Sympathectomy Femoral endarterectomy Carotid endarterectomy Femoro-popliteal bypass G & S G & S G & S G & S G & S Bifemoral bypass 6 Aorto-iliac bypass 6 Aorto-iliac endarterectomy 6 Intra-renal aortic aneurysm 6 Thoracic or thoraco-abdominal aneurysm 10 Ruptured aneurysms 10 ORTHOPAEDIC Removal hip pin or femoral nail G & S Osteotomy / upper femur 2 Bone graft from iliac crest 1 side Nailing fractured neck of femur Spinal fusion Lumbar spine recalibration G & S G & S G & S G & S Internal fixation of femur 2 Internal fixation fibia or ankle Arthroplasty total knee Total hip Total elbow Shoulder G & S 2 or G & S 2 or G & S G & S G & S Changing hip prosthesis 2 Dynamic hip screw / hemi-arthroplasty G & S UROLOGY Cystectomy 6 Cystectomy and Urethrectomy 6 Pathology Handbook Page 52 of 94 Version 7

53 Nephrectomy 2 or 4 Nephrectomy and exploration of vena cava 6 Open Nephrolithotomy 2 Open Prostatectomy (RRP) 4 TURP TUR Bladder tumour (large tumour) G & S G & S Percutaneous Nephrolithotomy 2 Ureterolithotomy Cystotomy Reimplantation of Ureter G & S G & S G & S OBSTETRICS & GYNAECOLOGY LSCS (Hb < 100g/l) x match 2 units ERPC/D & C G & S G & S Hydatidiform mole 2 Placenta praevia (variable) APH/PPH 2 Hysterectomy abdominal or vaginal Simple Extended (variable) G & S 2 Wertheim s hysterectomy 4 Myomectomy 2 Oophorectomy (radical) 2 Termination of pregnancy G & S Pathology Handbook Page 53 of 94 Version 7

54 BLOOD TRANSFUSION REFERRED TESTS Test Sample Testing Laboratory TAT Request Form Storage Additional Comments Red Cell Immunohaematology: Alloantibody ID ABL ABO/Rh grouping Compatibility Testing Anti D/c quantitation Paternal phenotyping 2 x 6ml EDTA FAO: Red Cell Immunohaematology NHS Blood & Transplant 14 Estuary Banks Speke Liverpool L24 8RB Upto 21 days White Form 1A Blue writing 2 8 o C Send via: Manchester Blood Centre Plymouth Grove Manchester M13 9LL (Diagnostic) HLA B27 HLA typing HLA Ab screening 6ml EDTA H&I Diagnostic Reference Lab Longley Lane Sheffield S5 7JN Upto 21 days White Form 3A Purple Header 2 8 o C Send via: Manchester Blood Centre Plymouth Grove Manchester M13 9LL (Haematopoietic Stem Cell Transplantation) Patients HLA type Donor HLA type HLA-specific antibodies 6-80ml EDTA 6ml EDTA 6ml clot NHS Blood and Transplant 500 North Bristol Park Northway Filton Bristol. BS34 7QH Upto 21 days White Form 3B Blue Header 4 o C Samples should be transported at ambient temp and delivered to the lab in a timely manner preferably within 24hrs of collection. Prior to transportation store at 4 o C Foetal Typing Maternal Blood 16ml EDTA from mother 3ml from partner Send to: Mr Peter Martin NHS Blood and Transplant North Bristol Park Northway Filton Bristol BS34 7 QG 5-7 working days White Form F014 Room Temp to reach Filton within 48 hours Mother should be at least 16 weeks pregnant for foetal typing Foetal Sex Typing Maternal Blood 16ml EDTA maternal blood White Form F071 Pathology Handbook Page 54 of 94 Version 7

55 Test Sample Testing Laboratory TAT Request Form Storage Additional Comments Foetal/Neonatal alloimmune thrombocytopenia Maternal 1 x 6ml EDTA & 6ml clotted Paternal 1 x 6ml EDTA NHS Blood and Transplant North Bristol Park Northway Filton Bristol BS34 7 QG 7-10 working days Form 3D Orange Header Room temp sample age maximum 3 days. Neonate or cord blood 1ml HITT 6ml clotted (red topped) Blood Transfusion Pathology Department University Hospital North Midlands NHS Trust Royal Stoke Hospital Newcastle Road Stoke on Trent ST4 6QG Upto 7 working days UHNS form BTF020 Room Temp sample age maximum 3 days Patients Doctor needs to complete the BTF020 form which can be faxed to North Staffs or sent with sample. Send a copy of our request form together with the BTF020 form requesting the HIT screen. Granulocyte Immunology See form 3E NHS Blood and Transplant North Bristol Park Northway Filton Bristol BS34 7QH 7-10 working days Form 3E Green Header Room temp to reach Filton within 24 hours Pathology Handbook Page 55 of 94 Version 7

56 HISTOPATHOLOGY / CYTOLOGY AND MORBID ANATOMY Consultant Histopathologists Dr D M Butterworth Ext 2642 Dr N Nasir Ext 2624 Dr A Nicol Ext 3762 Dr J S Stafford Ext 2627 Service Lead Julie Crawford Ext 3730 Pathology Handbook Page 56 of 94 Version 7

57 HISTOPATHOLOGY The department provides a routine diagnostic Histopathology service to inpatients, outpatients and GP patients. Routine Histopathology is available on all tissue samples. For Muscle Histochemistry to diagnose myopathies, frozen section service and Immunofluorescence service see relevant section below. REQUEST FORMS All specimens must be received with a request form. For GP practices these are available from the general Pathology Laboratory Office. For all wards and departments these are available to order from Regional Stores. The request form should bear the following clearly legible information, please also note that the use of abbreviations should be avoided, e.g., for right and left: (a) Patient details i.e. full name, date of birth, address and hospital number. (b) Ward/location, Consultant/GP for return of report. (This is essential, as copy reports will not be issued). If an extra copy is required to be sent out to an individual, please ensure this is to be noted in the same field on the request form. (c) The signature and printed name of the person making the request. (d) Appropriate clinical information e.g. any known previous malignancies, any relevant clinical data regarding the patient s physical state. Please ensure that any relevant clinical information is also available to the Radiologists so that the card can be completed fully, especially for liver biopsies and pleural effusions. (e) Date and time of collection. (f) Patient category i.e. NHS, Private Patient, Cat 11 etc. (g) Investigations requested. (h) Specimen type and site of biopsy. (i) Accurate labelling of multipart specimens as A, B and C rather than 1, 2, 3 and ensuring labelling of the pots correlates with the form. In addition, where appropriate, clearly labelled as - (a) Urgent (b) Danger of Infection (c) Radioactive (d) EGFR Mutation Screening NOTE: Please ensure that if you need any additional tests that you complete and send in the correct request form and it MUST be completed and signed. Products of Conception (POC) (up to and including 12 weeks and 6 days gestation) require a completed consent form for Examination of Foetal Material following Miscarriage. This form can be found on the Trust Intranet. We WILL NOT accept a POC specimen without this form being completed, in addition to the routine request form. The specimens will be returned if there are any discrepancies in the name demographics on the request form and the specimen pot or an appropriate consent form is not received. POCs of 13 weeks gestation and above should be sent to the mortuary for examination. See the Morbid Anatomy Section below for details. TISSUES FOR ROUTINE HISTOPATHOLOGY All specimen containers MUST bear the following clearly legible information: (a) Surname in full (b) Forename, first name in full and initials of any other (c) Date of birth (d) Hospital number and date of collection. NOTE: Labelling of pots in multipart specimens must correlate with the site information given on the form exactly. Pathology Handbook Page 57 of 94 Version 7

58 In addition, where appropriate, pots must be clearly labelled as (a) Danger of Infection (b) Radioactive On removal, tissues should be immediately placed into a suitably sized container of 10% buffered formalin. It is important to select a container of adequate size; tissue must never be crammed into a container. Ideally the volume of fixative should be at least five times that of the specimen. Failure to place the tissue in a suitably sized container with adequate Formalin may compromise the diagnostic properties of the sample and further tests required. Formalin is available from the laboratory. No other fluid (e.g. alcohol) is suitable. Do not send the specimens dry. Please note that once in formalin, the tissue is unsuitable for bacteriological examination. NB: Formalin is hazardous; take appropriate precautions. Safety data sheets are available from the laboratory on request. FORMALIN SPILLAGES For a small spillage of Formalin i.e. no more than 2 litres the following action is recommended: 1. Evacuate the room and prevent others from entering. 2. Wear Personal Protective Equipment, gloves and goggles. 3. Ensure adequate ventilation when mopping up the spillage. 4. Use a dishcloth or mop and bucket, which must be washed out well in running water afterwards. 5. Wash formaldehyde down the sink with copious amounts of water. For a larger spillage of Formalin evacuate the room and prevent others entering. Contact the laboratory for further advice.. TRANSPORT OF HISTOLOGY SPECIMENS Ensure that lids are the correct size and securely placed on the pot, the pot is not leaking and that the specimen is double-bagged to contain any leakage. Hazardous specimens MUST be clearly labelled. Theatres should deliver specimens to the laboratory immediately after each theatre session. This enables the laboratory to part-dissect large specimens to ensure proper penetration of fixative. Part dissection should not be performed prior to arrival at the laboratory. * Specimens for Frozen Section, Immunofluorescence and Muscle Histochemistry should be communicated through to the laboratory, by phoning extension 2630 at least 24 hours in advance of the procedure occurring. These specimens must be packaged and labelled accordingly, then brought to the laboratory immediately. See below for further instructions. Urgent specimens should be labelled and brought personally to the laboratory to avoid delay. If an urgent result is required telephone (2630) and ask to speak to a Consultant Histopathologist. VERBAL REPORTS Giving verbal reports on histopathology specimens is discouraged because of risk of misinterpretation when such reports are given to non-medical personnel. Anyone asking for results will be encouraged to look on the Intranet where they can print them off themselves. On request of a verbal report, the Histology secretaries will pass the call on to the reporting Consultant Histopathologist. Pathology Handbook Page 58 of 94 Version 7

59 ACCESSING REPORTS Histopathology reports are available electronically within the hospital via the LabCentre computer system in all areas where terminals are situated. GPs can access patient results via their desktops. Hard copy reports are sent out to the requesting GP/Consultant. It is the departmental policy not to issue extra copies of reports except in exceptional circumstances. FROZEN SECTION SERVICE Frozen sections are available by arrangement. At least 24 hours notice should be given when booking this service. The cut off time for receiving frozen sections is 16.00hrs. To arrange this service contact the Histology secretaries on extension Details of the date of frozen section, time of procedure, theatre number and telephone extension, requesting Consultant, specimen type and any relevant clinical information will be requested. Specimens for frozen section must NOT be put in fixative, instead they MUST be immediately transferred to the Histology laboratory fresh and dry with a completed request form, stating frozen section as the investigation required. Frozen sections cannot be cut on material from patients infected or thought to be infected with any category 3 or 4 pathogens or TB. NB: Please do not abuse this service. Frozen section is indicated only when the result will lead to an immediate change in clinical management. IMMUNOFLUORESCENCE SERVICE Where possible 24 hours notice should be given when requiring this service. The Histology laboratory MUST BE notified by telephone on x2630 prior to each specimen being taken. At this point the patient s name, hospital number and estimated time of specimen arrival into the lab will be required. Two skin biopsies must be taken from the bulla and/or the skin adjacent to the bulla depending on the nature of the disease suspected. Take two 5mm punch biopsies at these areas. Biopsy 1 Biopsy 2 Place the biopsy into a pot of 10% buffered formalin. Label the specimen container with the patient s full name, date of birth and date specimen taken. Place the biopsy into a specimen pot containing Michel s Medium. Label the specimen container with the patient s full name, date of birth and date specimen taken. A histology specimen card should be completed and the specimen type should read Biopsy 1 - Punch biopsy from (area) for histological examination. Biopsy 2 - Punch biopsy from (area) for Immunofluorescence. Both specimens and the specimen card should be immediately transported, by hand, or specialist courier, directly to the Histology lab. MUSCLE BIOPSIES FOR POTENTIAL MYOPATHY Muscle biopsies that are taken for suspected myopathies require specialist examination in the form of enzyme histochemistry in order to type the muscle fibres and accurately diagnose any pathology. Enzyme histochemistry has to be carried out on fresh frozen tissue that is sent to a reference laboratory in Liverpool on the same day that it is taken. Special procedures are therefore required when performing the clinical procedure: Pathology Handbook Page 59 of 94 Version 7

60 Contact a Consultant Pathologist to confirm that a muscle biopsy needing enzyme histochemistry is planned giving at least 24 hours notice. The specimen must arrive in the laboratory before 2.00pm to ensure that it reaches the referral laboratory in normal working hours. The specimen must be fresh and wrapped in saline soaked gauze, placed in an empty labelled sterile container and accompanied by a completed request form with as much clinical information as possible. NB: Muscle biopsies for suspected myositis can be submitted to the lab in formalin in the usual way. If you require further information or need to plan such a biopsy then please contact the Histology Laboratory on extension 2630 and ask to speak to a Consultant Histopathologist. ALOPECIA BIOPSIES The clinical appearance and differential diagnosis must be listed on the request card to permit correct specimen handling. If scarring alopecia is suspected: two 4mm punch biopsies including subcutaneous tissue are required from the active edge of alopecia. If non-scarring alopecia is suspected: two 4mm punch biopsies including subcutaneous tissue are required. One should be from the active edge of the alopecia and the other from an uninvolved area, e.g., mid occiput with both being clearly labelled as such. MDT (MULTI DISCIPLINARY TEAM) MEETINGS Please note that the cut off for acceptance for the cases due on an MDT meeting is at least 48 hours prior to the meeting. Any cases received after this time will not be prepared for the MDT. HISTOLOGY TURNAROUND TIMES The department works to current Royal College of Pathologists Key Performance Indicators for Cellular Pathology reporting turnaround times: 80% of cases reported within seven calendar days of the procedure. 90% of cases reported within ten calendar days of the procedure. For cases requiring prolonged decalcification and cases sent for external opinion, it will take longer to produce the final report. SECOND AND EXPERT OPINION REFERRAL SITES BONE and JOINT BREAST Dr D C Mangham Department of Musculoskeletal Pathology Royal Orthopaedic Hospital 111 Dale Road Sellyoak Birmingham West Midlands B29 6AY Dr I Ellis Department of Pathology City Hospital Hucknall Road Nottingham NG5 1PB Pathology Handbook Page 60 of 94 Version 7

61 BRAIN CARDIOVASCULAR Dr Duplessis Consultant Neuropathologist Department of Histopathology Hope Hospital Stott Lane Salford Manchester M6 8HD Dr J R Gosney University Department of Pathology Duncan Building Royal Liverpool University Hospital Daulby Street Liverpool Merseyside L69 3GA Dr M Burke Department of Pathology Harefield Hospital Hill End Road Harefield Uxbridge Middlesex UB9 6JH Dr M Shepherd Department of Histopathology National Heart & Lung Institute Royal Brompton Hospital Sydney Street London SW3 6NP CYTOLOGY ENDOCRINE Dr D Rana Department of Histopathology & Cytopathology Clinical Sciences Building Manchester Royal Infirmary Oxford Road Manchester M13 9WL Dr Nonaka / Dr Menasce Department of Histopathology Christie Hospital Wilmslow Road Manchester M20 9BX Dr T Stephenson Department of Histopathology E Floor Royal Hallamshire Hospital Glossop Road Sheffield S10 2JF ENT EYE Dr T Helliwell Department of Pathology University of Liverpool Duncan Building Daulby Street Liverpool Merseyside L69 3GA Dr R E Bonshek Department of Histopathology Clinical Sciences Building Central Manchester Health Care NHS Trust Oxford Road Manchester M13 9WH Pathology Handbook Page 61 of 94 Version 7

62 GASTROINTESTINAL TRACT Dr F Campbell University Department of Pathology Duncan Building Royal Liverpool University Hospital Daulby Street Liverpool Merseyside L69 3GA Prof N A Shepherd Department of Histopathology Cheltenham General Hospital Sandford Road Cheltenham Gloucestershire GL53 7AN GYNAECOLOGICAL Dr S Ismail Department of Histopathology The Christie NHS Foundation Trust 550 Wilmslow Road Manchester M20 4BX Dr G E Wilson Department of Histopathology & Cytopathology Clinical Sciences Building Manchester Royal Infirmary Oxford Road Manchester M13 9WL KIDNEY / URETER Dr Shanks Department of Histopathology The Christie NHS Foundation Trust 550 Wilmslow Road Manchester M20 4BX University Department of Pathology Duncan Building Royal Liverpool University Hospital Daulby Street Liverpool Merseyside L69 3GA LIVER Dr F Campbell University Department of Pathology Duncan Building Royal Liverpool University Hospital Daulby Street Liverpool Merseyside L69 3GA Dr S G Hubscher University Hospital Birmingham Queen Elizabeth Medical Centre Birmingham B15 2TH Dr F Charlton University Department of Pathology Royal Victoria Infirmary Queen Victoria Road Newcastle Upon Tyne Tyne and Wear NE1 4LP Pathology Handbook Page 62 of 94 Version 7

63 LYMPH NODE / SPLEEN Dr M Stephens Department of Histopathology University Hospitals North Midlands NHS Trust Royal Stoke University Hospital Newcastle Road Stoke on Trent ST4 6QG Dr Menasce Department of Histopathology The Christie NHS Foundation Trust 550 Wilmslow Road Manchester M20 4BX PAEDIATRIC / FOETAL RESPIRATORY SKIN Dr G Kokai Liverpool Children s Hospital Alder Hey Eaton Road West Derby Liverpool, L12 2AP Dr P Bishop Department of Pathology Wythenshawe Hospital Southmoor Road Manchester M23 9LT Dr Slater Department of Histopathology Royal Hallamshire Hospital Floor E Glossop Road Sheffield South Yorkshire S10 2JF Dr Eduardo Calonje Director of Diagnostic Dermatopathology Department of Dermato-Histopathology St John s Institute of Dermatology St Thomas s Hospital London Dr Lynne Jamieson / Dr Louisa Motta Department of Histopathology Salford Royal NHS Foundation Trust Stott Lane Salford M6 8HD Dr P Shenjere Department of Histopathology The Christie NHS Foundation Trust 550 Wilmslow Road Manchester M20 4BX SOFT TISSUE Dr D C Mangham Department of Musculoskeletal Pathology Royal Orthopaedic Hospital 111 Dale Road Sellyoak Birmingham West Midlands B29 6AY Dr P Shenjere Department of Histopathology The Christie NHS Foundation Trust 550 Wilmslow Road Manchester M20 4BX Pathology Handbook Page 63 of 94 Version 7

64 EYE SPECIMENS FRESH MUSCLE FIXED MUSCLE Ophthalmic Specimens Specimen Reception Department of Pathology Royal Liverpool University Hospital 5 th Floor Duncan Building Daulby Street Liverpool L7 8XP Dr Daniel Crooks Consultant Neuropathologist Department of Neuropathology The Walton Centre for Neurosurgery Lower Lane Fazakerly Liverpool L9 7LJ Dr Daniel Crooks Consultant Neuropathologist Department of Neuropathology The Walton Centre for Neurosurgery Lower Lane Fazakerly Liverpool L9 7lJ CYTOLOGY The department provides a diagnostic non-gynaecological cytology service and a post vasectomy semen analysis service to inpatients, outpatients and GP patients. DIAGNOSTIC NON-GYNAECOLOGICAL CYTOLOGY The Diagnostic Cytology service is available for bronchial washings, bronchial brushings, sputum, serous effusions, urine and fine needle aspirates. Specimens should be received in a sealed container within a sealed plastic bag accompanied by a fully completed request form (identical to the Histopathology request form). Please state the specimen types clearly and provide full clinical details. If both Histology and Cytology specimens are being sent from the same patient (e.g. biopsy and bronchial brush), each specimen must be placed in a separate bag, but with the bags attached to each other. Specimens must reach the laboratory by 4.30pm. Otherwise please refrigerate and send the following morning. NB High risk/hazardous specimens must be clearly labelled before sending to the laboratory. Specimens cannot be processed on material from patients infected or thought to be infected with any category 3 or 4 pathogens or TB. Bronchial Washings A minimum of 5ml of specimen in a clean dry container is required. Please send separate specimens and request cards when bacteriological investigation is required as well as cytology. Bronchial Brushings A transport medium is available for bronchial brush specimens. Please contact the laboratory for supplies and advice. Please detach the brush and remove the plastic outer sleeve before placing the brush in transport medium for sending to the laboratory. Pathology Handbook Page 64 of 94 Version 7

65 Sputum Sputum cytology has been shown to give very poor diagnostic results. Sputum samples should not be sent for cytology unless the patient is unsuitable for bronchoscopy. If the samples are sent they should be early morning deep cough specimens collected before the patient eats or drinks. The sputum should be sent to the laboratory as soon as possible after expectoration. Urine Urine should be a mid-morning clean catch specimen into a dry container not boric acid container. Samples should arrive in the laboratory without delay (preferably within two hours of voiding). If there is unavoidable delay the urine may be refrigerated for up to 48 hours. This is however not ideal. Serous Effusions All pleural and ascitic fluids for cytology should be sent in a clean dry container, NOT in transport medium. Samples should be sent to the laboratory as quickly as possible. If cell blocks are required as part of the analysis, then we require at least 100mls of fluid. Fine Needle Aspiration A transport medium is available for fine needle aspiration specimens. Please contact the laboratory for supplies and advice. For Health and Safety reasons the Cytology Department advises that following fine needle aspiration the syringe needle is NOT sent to the laboratory. However to maximise cellular yield, please ensure that before disposal the needle is thoroughly flushed out into the specimen pot, using the attached syringe and the transport medium provided in the pot. Joint aspirates/synovial fluids The laboratory no longer processes joint aspirates. These should now be sent directly to the University of Manchester, School of Medicine for processing using their own lithium/heparin specimen bottles and Synovial Fluid analysis request form. PREPARED SLIDES Cytology staff are no longer able to support requests for clinic attendance as a matter of routine but it is recognised there will be rare occasions when the assistance of trained Cytology staff would be considered essential to the patient management. Please note that if the clinician prepares a nipple discharge smear it MUST be air dried. Prepared slides are not recommended for FNAs from other sites but if this is unavoidable, fix the spread as soon as possible and write on the request form that this has been done. NB: Separate specimens and request cards are required when bacteriological or chemical investigations are needed as well as cytology. SEMEN ANALYSIS Semen analysis is only carried out, in-house for post vasectomy patients. For fertility testing the patient should be referred to the Patrick Murphy Unit at Leighton Hospital. The British Andrology Society recommendations are for a first specimen to be collected at 16 weeks after the operation and the second specimen two to four weeks later. Pathology Handbook Page 65 of 94 Version 7

66 Specimens should be collected into the 60ml plastic containers and should arrive in the laboratory as soon as possible after collection between the hours of 09:00 and 15:00, Monday to Friday. These specimens are not accepted on weekends or Bank Holidays. The specimen should be kept as near to body temperature as possible until arrival in the laboratory. It is essential that collection time is written down on the sample and the request form. This laboratory offers post vasectomy screening of semen samples. If spermatozoa are seen, the result will be issued with the comment Please note; non-motile spermatozoa seen using British Andrology Society (2002) methods. Screening test only. Unable to gauge viability of spermatozoa. If further investigations are required please refer patient to the Patrick Murphy Unit in Leighton Hospital. Method of Collection The essentials are that a whole, fresh specimen is collected without contact with any chemical, to arrive for analysis very quickly at the right temperature. There must be at least 48 hours and no more than 7 days abstinence before collection of the specimen. The specimen must be collected by masturbation into the small sterilised container provided but the container must be at body temperature. No rubber contraceptives must be used in the collection. The container is kept at body temperature e.g. in trouser pocket or under the clothing and brought to the laboratory immediately. Note the time of collection and please make sure that a completed request form accompanies the specimen. Please label all specimens with full name and address, date and time of collection and the name of the doctor or surgeon. When delivering the specimen to the laboratory, patients will be asked about the period of abstinence before production of the specimen and to confirm the date of the operation and verify that the complete sample has been collected. Rejection of Semen Specimens Samples will be rejected if there are signs of obvious contamination or if the patient indicates that the sample is incomplete or inappropriately collected (condom or other secondary receptacle that may be spermicidal). Most samples for post-vasectomy checks are processed as they are delivered in person and checked by central specimen reception staff to ensure that they are labelled on receipt. If samples are received via GP transport, there is no potential to check details and specimens may be rejected if they are not labelled correctly or the sample has leaked in transit. Post vasectomy samples are only received Monday Friday inclusive. There is no provision for processing outside these designated hours unless in exceptional circumstances by prior arrangement with the laboratory. If a sample is received outside these times without prior consultation then it may not always be possible to process samples. Every effort will be made to process the sample but decreased staffing levels on weekends and bank holidays may mean that this can t be done. Information to Patients We do not supply information directly to the patient so we would be grateful if you would include this information as you counsel the patient who is undergoing a vasectomy. TURNAROUND TIMES The department works to current Royal College of Pathologists Key Performance Indicators for Cellular Pathology reporting turnaround times: 80% of cases reported within seven calendar days of the procedure. 90% of all cases reported within ten calendar days of the procedure. For cases sent for external opinion, it will take longer to produce the final report. Pathology Handbook Page 66 of 94 Version 7

67 MORBID ANATOMY TRANSFER OF DECEASED PERSONS TO THE MORTUARY Deceased persons should be transferred to the mortuary as soon as possible after death. Contact the Porters desk (extension 2356). They will transfer the body appropriately. Part A of the Mortuary Body Acceptance Form should be completed by the nursing staff and given to the Porters. The patient details on the form must match those on the body/shroud. Particular attention should be paid to the accurate recording of the presence of valuables on the body. Unless this form is fully completed, Porters cannot accept the body for removal. Part B of the form is to be completed by the Porters when transfer to the Mortuary has been carried out. VIEWING OF DECEASED PERSONS Requests to view a deceased person must be made by appointment with the Anatomical Pathology Technologists (APTs) on (2250). Apart from exceptional circumstances, viewing should take place between 9.00am and 4.30pm Monday- Friday. Please contact the APT on-call for advice if a viewing is requested outside of these hours. HOSPITAL POST-MORTEMS The following are some practical points in connection with requests for hospital post-mortems: 1. The senior clinician concerned should see the relatives and obtain a written consent on the appropriate form as soon as possible. It is not desirable for this to be delegated. It is important to point out to relatives the clause in the PM consent form regarding removal and/or retention of organs. The consent form, the Clinical Summary Sheet should be brought to the Mortuary, with the notes, as soon as possible. Neither the Pathologist nor the Hospital has any power to retain a body once a death certificate has been signed. The Clinical Summary Sheet can be found on the MCHFT intranet under frequently used forms/pathology/clinical Summary Sheet for Post Mortems. 2. Signing or issuing of a death certificate must not be held up pending the result of a post-mortem. To do so, is in fact illegal. If the doctor involved is not prepared to offer a death certificate without the results of a post-mortem examination, then the case must be referred to the Coroner. Please telephone the Consultant Histopathologist for advice on death certification should a problem arise. PAEDIATRIC POST MORTEM EXAMINATION AND PAEDIATRIC DECEASED THAT DO NOT REQUIRE POST MORTEM. Foetuses and stillbirths of 13 weeks gestation and above should be sent to the mortuary. Foetuses and stillbirths requiring examination will be transferred to Alder Hey Hospital. Full and informed consent is necessary for the examination and a copy of the completed consent form must accompany the baby to the mortuary along with a Maternity Body Acceptance Form and a copy of the mother s notes covering the pregnancy. If the Paediatric deceased does not require a post mortem, when transferring the deceased from the ward to the mortuary it must be accompanied by Maternity Body Acceptance Form. If cytogenetic investigations are required, the specimen should be taken to Pathology Central Specimen Reception, for transfer to Liverpool Women s Hospital. Pathology Handbook Page 67 of 94 Version 7

68 CORONER S POST-MORTEMS Any death which may possibly come into the list below must be reported to the Coroner through the Coroner s Officer, telephone or #6 242 from the hospital. If in doubt ask the Coroner s Officer for advice or ask one of the Consultant Pathologists. Please note that all hospital Coroners deaths MUST be accompanied by a completed clinical summary sheet. If a Clinician wishes to view the post mortem, they can indicate their wish on this form. Post-mortems are usually performed between the hours of 9.00 a.m. and 1.00 p.m. Monday to Friday. All clinicians are welcome to attend whether the case is a hospital or Coroner s post-mortem. The technicians will inform the clinical team of the approximate date and time of the post-mortem by to the appropriate hospital Consultant. REPORTABLE DEATHS IN CHESHIRE Deaths are to be reported in the following circumstances: 1. The cause of death is unknown. Remember, you must know the CAUSE of the death, rather than the mode of dying (heart failure for instance, is not considered a cause of death but a mode of dying). 2. You did not attend the deceased in his or her last illness and to your knowledge, no other doctor attended or if they did attend, they are not currently available. 3. The Registration Regulations cannot be satisfied for some other reason (e.g. the name of the deceased is not known). 4. The deceased has not been seen by you for treatment within the 14 days before death. 5. The death was violent, unnatural, suspicious or unexpected. 6. The death may be linked to poison or drugs. 7. The death may be due in whole or in part to an accident, no matter when the accident occurred. 8. The death may be due to self-neglect or neglect by others, including poor care in a residential or nursing home. 9. The death may be due to an industrial disease or related to the deceased s employment or the deceased was in receipt of industrial injury or disablement pension or war pension, even if the death does not appear to be related to the condition for which the pension has been awarded. 10. The death may be due to an abortion. 11. The death occurred during an operation or before recovering from the effects of an anaesthetic. 12. The death occurred within 12 months of an operation. 13. The death occurred within 24 hours of admission to hospital. 14. The death may be linked to an operation or any other medical procedure or drug (medicinal or otherwise and whether or not prescribed). 15. The death may be due to lack of medical care or allegations of medical mismanagement have been made. 16. The death may be due to the actions of the deceased, including suspected suicide or solvent abuse, etc. 17. The death (whether natural or not) occurred during or shortly after detention in police or prison custody. Remember that although a prisoner may die in hospital he is still in custody for these purposes. 18. The patient has had a fall even though this may not have contributed to the death. Common misconceptions and difficulties The year and a day rule no longer apply. If a death is related to an unlawful, accidental or intentional injury or non-natural cause, it is reportable, no matter how long ago the original event occurred. Industrial diseases and employment deaths often have their counterpart in natural disease processes. Always consider very carefully the possibility of an employment connection, particularly with a respiratory illness or cancer. Refer to the death certificate book for a list of many of the industrial diseases. Do not deprive a family of a legitimate claim for compensation by failure to report. Pathology Handbook Page 68 of 94 Version 7

69 It is inappropriate to rely on viewing the body after death to overcome the fact that the deceased was not seen within 14 days of death. At best this may help to rule out a violent death but will not assist in establishing the cause of death. Death due to alcoholism or smoking or sexually transmitted AIDS is not considered unnatural but please note that death due to the acute effects of alcohol is reportable. It is not a legal requirement for the certifying doctor to view the body before issuing a death certificate, but good practice nevertheless. Old age alone as the cause of death should be avoided unless entirely appropriate and only if the person is over 80, otherwise it should be reported. Some doctors confuse unnatural with unlawful; a death following a fall, choking on food or through the transfusion of infected blood is as unnatural as a death due to hanging, stabbing or gun shot wounds. Do not guess, you have a duty to report on the cause of death to the best of your knowledge, information and belief. Do not use myocardial infarction or bronchopneumonia or stroke, based on statistical likelihood rather than diagnosis. Important If the doctor is in any doubt whether the death of a patient under his care should be notified to the Coroner or not, please contact the Coroner s Officer or Consultant Histopathologist for advice. This in the long term is very much in the interest of the doctor concerned. The Coroner regards wilful failure to notify appropriate deaths as a serious matter. CREMATION FORMS Currently, cremation forms are completed in the mortuary. It is the responsibility of the Bereavement Manager to inform a doctor who was responsible for the care of the deceased to collect notes from the bereavement office and take to the mortuary to complete Part 1 (Cremation 4) of the cremation form. Cremation forms must be completed as follows: Do not use stickers with patient details hand write all information requested Please read questions and understand what is being asked All questions must be completed legibly in black ink Whilst most questions are straight forward some of the following may be helpful: Question 5 Were you the deceased s usual medical practitioner? This relates to the patient s GP therefore answer will generally be no. Question 8 Examination: Full external examination including pacemaker NOTE ensure that you do a thorough examination when looking for a pacemaker. Question 14 When giving the full name and address of any person who nursed the deceased please ensure that you complete as follows: example: staff nurse Ward ---- Leighton Hospital, Middlewich Road, Crewe, CW1 4QJ. Question 20 Has a Corner been informed about the death? This is generally no as you would normally speak to one of the Coroner s Officers. Question 21 Has there been any discussion with a coroner s officer about the death of the deceased? If you have contacted the Coroner s office the response to this is generally yes. Once part 1 of the cremation form has been completed leave with the medical notes in the mortuary. This is in preparation for a second doctor to complete Part 2 (Cremation 5). The doctor completing Cremation 5 must be a medical practitioner of at least five years standing who is not a relative of the deceased, the medical practitioner who issued the medical certificate (form Cremation 4) or a relative or partner or a colleague in the same practice or clinical team as the medical practitioner who issued that certificate. Five years standing means a medical practitioner who has been a fully registered person within the meaning of the Medical Act 1983 for at least 5 years and, if paragraph 10 of Schedule 1 to the medical Act 1983 (Amended) Order 2002 (S.I. 2002/3135) has come into force, has held a licence to practice for at least five years of since the coming into force of the paragraph. Pathology Handbook Page 69 of 94 Version 7

70 MEDICAL MICROBIOLOGY On-site Consultant Medical Microbiologists Dr M A T O Donoghue Ext 3683 Dr V Panagea Ext 3713 Microbiology Clinical Advice Line (Mon-Fri 9am 5pm) 3370 Service Lead Kevin Wright Macclesfield Pathology Handbook Page 70 of 94 Version 7

71 MEDICAL MICROBIOLOGY The Department provides both an emergency and non-urgent diagnostic service for inpatients and outpatients as well as a service to G.P. patients. Biomedical Scientists examine specimens for the presence and effects of bacteria, fungi, viruses and parasites, and carry out appropriate antimicrobial sensitivity tests. The Consultant Medical Microbiologists will advise on the therapy of patients with infection. Clinical advice is offered on 9-5pm Monday to Friday, by a Consultant Medical Microbiologist on a dedicated advice line: From Macclesfield, use extension 3644 (outside line ). From Leighton, use extension 3370 (outside line ) Both numbers link to the Consultant Microbiologist on duty for clinical calls for both sites, on that day. Outside routine laboratory opening hours, clinical advice can be obtained from a Consultant via the hospital switchboard Please note: During normal working hours (Monday to Friday 9am to 5pm) calls are only accepted from junior doctors of grade CT1 and above. During out of hours, on call, calls are only accepted from doctors of grades ST3 and Specialty doctors and above for urgent matters only. This does not affect the full advice service provided to Primary Care. Scientific and technical enquiries should be directed towards the Biomedical Scientists of the Department. The Department aims to provide a high quality, comprehensive service to hospital and community users. Full quality control is carried out and the Department strives to achieve and maintain UKAS accreditation status. Tests not available on site are referred to specialist laboratories. In addition, the Department manages a small serology repertoire at the Macclesfield site, which examines blood specimens for the presence of antigens and antibodies produced against a wide range of infectious agents, for example, Rubella, Syphilis, Hepatitis, HIV, and Varicella Zoster. Please note that some specimens for virological and serological examination, and all blood samples for immunological investigations are referred to specialist laboratories for testing (please see list in appendix 1) In collaboration with the local Infection Control Team and Public Health England, the Department contributes to the surveillance, control and prevention of nosocomial infection and cross infection in the Trust hospitals, the local community and nationally. TEST REQUESTING The decision to initiate a microbiological investigation on a patient is primarily a clinical one and is usually made by a Medical Practitioner as an aid to diagnosis and/or to monitor a patient s response to treatment. It is important to supply relevant clinical information as the range of investigations performed on a specimen often depends on the clinical information stated. It is important also to specify any additional investigations required such as staining and culture for AAFB (TB and other Mycobacterium species), or examination for fungi. Information about antibiotic treatment is also important. The laboratory should always be contacted in advance and informed of any urgent samples being sent. CSF specimens for culture are always deemed urgent and the laboratory should always be informed when such samples are being taken Pathology Handbook Page 71 of 94 Version 7

72 URGENT SPECIMENS Definition of Out Of Hours: After 5 pm transport Mon to Friday After 2.30 transport weekends and BH NB Sample must be in Pathology in time for these transport times or the ward will be responsible for arranging the transport as described below. Samples The only samples accepted by Microbiology during on call periods are: CSF (send samples 2 and 3 for Microbiology, and sample 1 to Biochemistry at Leighton, If Xanthachromia is requested please sent the last specimen to Biochemistry. If only one specimen is available, please send to Microbiology) Ascitic fluids (only for diagnosis of SBP) Joint fluids Pus from deep head and neck collections (e.g. orbital abscess/retropharyngeal collections), All other samples collected out of hours should be sent to pathology to be transported to the lab the following morning. Collect the sample do not call the Microbiology on call staff before the sample is collected. Pack the specimen - Only the provided packaging can be used. Pack the specimen in the rigid inner screw cap container with the form on the outside, between this container and the cardboard outer box. Packaging is available from the following points in Leighton Hospital: Surgical assessment, Medical assessment, Childrens assessment, NICU Emergency Department (A&E). Telephone switchboard 1. Ask for the Biomedical Scientist for Microbiology. Inform the Biomedical Scientist of the nature of the specimen. 2. Telephone switchboard again and ask them to put you through to Abbey taxis tell them there is a sample to pick up from A&E at Leighton 3. Close the cardboard box. Arrange for it to be taken to A&E immediately and handed to reception staff. NB: Blood cultures do not require the attendance of the BMS. Out of hours take the samples to Pathology as quickly as possible, where the on-site Pathology staff will transfer them to the blood culture incubator located in central specimen reception. Other non-urgent specimens can be left overnight in a fridge until the next day e.g. urine, sputum, but if in doubt please contact the on-call Biomedical Scientist. Pathology Handbook Page 72 of 94 Version 7

73 COLLECTION & TRANSPORT OF SPECIMENS Please ensure all relevant clinical information is provided on the request form (including foreign travel) and ensure a High Risk sticker is attached to the request form to identify high Risk patients. Please refer to HSE Safety Notice HID regarding the provision of key information on laboratory request forms( LUMBAR PUNCTURE (LP, CSF) Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected. NB: IT IS VERY IMPORTANT TO SPEAK WITH THE CONSULTANT MICROBIOLOGIST BEFORE ANY SPECIMENS ARE TAKEN FROM PATIENTS SUSPECTED OF TSE/CJD. Please send as large a volume as possible. CSF is normally collected sequentially into three or more separate containers, which should be numbered consecutively. Ideally a minimum volume of 1 ml should be sent for culture for Mycobacterium species. If examination for Xanthochromia is required, please collect an extra sample (at least 1 ml) and send this sample, which should be the last of those collected in a plain white Universal container, to Biochemistry. Collection of an additional sample in a container with fluoride for glucose estimation is also recommended, although such tubes should be filled last because they may contain environmental bacteria which might otherwise contaminate samples for culture. This specimen is sent to Biochemistry. Equipment: Skin preparation Method: As provided by C.S.S.D. 70% alcohol + povidone-iodine As demonstrated by senior colleague Collect the CSF in sterile 20ml universal screw topped containers, without preservative, label the containers 1-3 in the order in which they are collected. Send specimens 2 and 3 to Microbiology and specimen 1 to Biochemistry. If examination for Xanthochromia is required please send the last sample taken to Biochemistry. If only one specimen is available, please send to Microbiology where it will be forwarded as required. Meningococcal disease Where Meningococcal meningitis or septicaemia is suspected blood specimens can be referred for PCR (molecular techniques). Please send 2.7 mls EDTA blood sample. Please discuss any problems with diagnosis, or treatment of meningitis with the Consultant Microbiologist. MRSA SCREENS Please complete the MRSA request form and label the form and all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Please refer to Control of Infection guidelines for information for MRSA screens or telephone Infection Control, Ext 2190, or Consultant Microbiologists for advice. For collection of samples see the relevant sections for individual specimens. Pathology Handbook Page 73 of 94 Version 7

74 NOSE, THROAT AND PERNASAL SWABS Swabs should be taken before antimicrobial therapy where possible. Specimens should be transported and processed as soon as possible. If processing is delayed, refrigeration is preferable to storage at ambient temperature. Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Nasal swab Equipment: Method: Charcoal transport swab Sterile Normal Saline 0.9% sachet Waste container Moisten the swab with the sterile Saline and gently rotate around the anterior nares. Replace the swab stick into the transport medium. Throat swab Equipment: Method: Charcoal transport swab or Sterile cotton tipped swab stick Spatula Light source Waste container Position the patient comfortably and arrange for the throat to be properly illuminated. Depress the patients tongue with the spatula. Use the swab to obtain material from both fauces. Transfer the swab into the required transport medium. Pernasal swab NB: If whooping cough is suspected please use this type of swab to allow recovery of Bordetella pertussis. Equipment: Method: Flexible pernasal swab Position the patient comfortably Introduce the pernasal swab below the inferior turbinate and into the post nasal space and gently rotate the swab to collect the sample. Transfer the swab into the transport medium. Please ring the laboratory and inform staff that this sample is being sent.. Pathology Handbook Page 74 of 94 Version 7

75 RESPIRATORY SPECIMENS Sputum If the patient is suspected of having T.B. follow instructions identified by local risk assessment during collection and discard any waste material into clinical waste bags. Specimens should be taken before anti-microbial therapy where possible. Specimens should be transported and processed as soon as possible. Sputum may be refrigerated for up to 2-3 hr without an appreciable loss of pathogens. Any delay beyond this time may allow overgrowth of certain pathogens. Early morning freshly expectorated sputum is recommended for Mycobacterium species. Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time of collection and the specimen type. Equipment: Method: Wide necked screw capped sterile container Tissues Bag for waste disposal Care should be taken to ensure the specimens sent for examination is SPUTUM and NOT SALIVA. The material required is sputum from the lower respiratory tract expectorated by deep coughing. When the cough is dry, physiotherapy, postural drainage or inhalation of an aerosol before expectoration may be helpful. Saliva and postnasal secretions are not suitable. Early morning specimens for examination of Mycobacterium species should be collected on at least 3 consecutive days. Note samples for TB investigations are forwarded to the University Hospital of North Midlands for analysis. Bronchoalveolar Lavage BAL and associated specimens should be collected according to local protocol. Please send as large a volume as possible. Please note that BAL are examined for AAFB (TB and other Mycobacterium species) only on request. Respiratory Syncitial Virus (RSV) Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time of collection and the specimen type. A nasal wash sample should be collected in a manner that is suitable for the age of the patient and transported to the laboratory without delay. Samples may be stored at room temp for 4 hours or refrigerated for up to 24 hours. ASPIRATES (PLEURAL, JOINT, PERITONEAL, PELVIC) Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Specimens should be collected according to specialist local protocols into a sterile container. Aspirates requiring microbiological examination are to be placed in sterile screw capped containers WITHOUT ADDED FIXATIVES OR PRESERVATIVES. Please note that pleural fluids are examined for AAFB (TB and other Mycobacterium species) only on request. Notes on transport: Specimens should be transported and processed as soon as possible. The volume of specimen influences the transport time that is acceptable. Large volumes of purulent material maintain the viability of anaerobes for longer; however the recovery of anaerobes is compromised if the transport time exceeds 3 hours. If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 48 hours will not produce optimum results and are strongly discouraged. Pathology Handbook Page 75 of 94 Version 7

76 TISSUES/BIOPSIES Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. SPECIMENS RECEIVED IN FORMOL-SALINE ARE NOT SUITABLE FOR CULTURE. Biopsies for H. pylori: Please request special transport medium from the Microbiology laboratory. Other tissues and biopsies: Place in a sterile container for transport as soon as possible. The volume of the specimen influences the transport time that is acceptable. Larger pieces of tissue maintain the viability of anaerobes for longer. Tissue or biopsy material in a sterile container has an optimal time for transport to the laboratory of up to 30 mins. If the specimen is small, cover with sufficient sterile water or saline to prevent desiccation. If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 48 hrs are undesirable PUS / WOUND SWABS FOR HEALTH & SAFETY REASONS DO NOT SEND PUS IN SYRINGES WITH NEEDLE ATTACHED. Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Samples of pus are preferred to swabs. Ideally, a minimum volume of 1 ml of pus should be sent. If swabs are used, sample the deepest part of the wound and soak well in pus. Specimens should be transported and processed as soon as possible. The volume of specimen influences the transport time that is acceptable. Large volumes of purulent material maintain the viability of anaerobes for longer. Equipment: Charcoal transport swab Sterile syringe and needle Sterile screw capped container Method: Place the sterile swab deep into the wound and collect specimen. Aspirated material may be placed directly into the screw-capped container; alternatively pus may be transferred directly to the container from a sterile receiver. Do not place the container in contact with the lesion, to avoid contaminating the outside of the container. If the patient is suspected of having T.B. or other Mycobacterial infection please request this investigation on the request form. Pathology Handbook Page 76 of 94 Version 7

77 HIGH VAGINAL, CERVICAL AND URETHRAL SWABS Please note that HVS samples are no longer examined for N. gonorrhoeae, as endocervical swabs have been shown to be the most appropriate sample for isolation of this microorganism Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Cervical and high vaginal swabs should be taken with the aid of a speculum. It is important to avoid vulval contamination of the swab. For Trichomonas vaginalis, the posterior fornix, including any obvious candidal plaques should be swabbed. If pelvic infection, including gonorrhoea, is suspected, the cervical os should be swabbed. Separate samples should be collected into the appropriate medium for the detection of viruses, or C.trachomatis (see below). Equipment: Vaginal speculum Charcoal transport swab Good light source Sterile gauze swab Container for waste disposal HVS & cervical swabs Put on gloves. Place patient in dorsal position (lying on the back, knees flexed and widely separated). With gloved hand part labia and introduce the speculum into the vagina and under good vision collect material from:- a) Posterior fornix b) Cervical os Carefully withdraw the swab, avoid contamination with lower vaginal and perineal flora. The swab should then be placed in transport medium. Cervical swabs After introduction of the speculum to the vagina, the swab should be rotated inside the endocervix. The swab should then be placed in transport medium. Coils Coils should be removed with care to avoid vaginal contamination and placed directly into a sterile 60ml container. Urethral swabs Contamination with micro-organisms from the vulva or the foreskin should be avoided. Thin swabs are available for collection of specimens. The patient should not have passed urine for at least 1 hour. For males, if a discharge is not apparent, attempts should be made to milk exudates from the penis. The swab is gently passed through the urethral meatus and rotated. Pathology Handbook Page 77 of 94 Version 7

78 SPECIMENS FOR CHLAMYDIA PCR Specimens for Chlamydia PCR are referred. CORRECT SPECIMEN COLLECTION IS VITAL TO THE QUALITY OF YOUR PATIENT S RESULTS. Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Equipment: Vaginal speculum Good light source Container for waste disposal Plain urine container or Chlamydia collection kit NB: It is important that no other types of swab are used, as this may cause problems during testing. It is also important that Chlamydia swabs and transport media are used only for Chlamydia tests. The only acceptable specimens are: Urine specimens from males, or females collected and transported as explained below. Do not send specimens collected in urine containers with preservatives such as boric acid. Endocervical & urethral swabs collected and transported as explained below. Collection of urine It is most important that patients have not urinated during the previous 2 hours prior to collection of the sample ml of first catch urine should be collected into a sterile urine polypropylene container without preservatives. Seal the container and label with the patient s name and date of birth and place in the plastic bag provided with the completed request form. Transport to the laboratory as normal. Urine specimens are stable for 24 hrs at room temperature ( C) however urine specimens that cannot be processed within 24 hrs must be refrigerated at C and must then be processed within 7 days of collection. Collection of swabs Endocervical swabs remove cervical mucous and sample columnar and squamo-columnar cells. Collect urethral swabs in the usual fashion. Leave swabs in the transport medium. Seal the specimen container and label with the patient s name and date of birth and place in the plastic bag provided with the completed request form. Transport to the laboratory as normal, but if transport is delayed for more than 1 hour from the time of collection, please refrigerate swab specimens at C until transport is available. Swabs must be processed however within 7 days of collection. SEMEN ANALYSIS Semen samples for infertility screening are now examined by prior arrangement with embryologist (located in the Patrick Murphy Unit). An appointment will have to be made for the patient at the unit. Please use the form supplied by them. Telephone Ext 2212 for further information. Vasectomy samples are currently examined by the Cellular Pathology Department in Leighton Hospital. Please see the appropriate section for more information. Pathology Handbook Page 78 of 94 Version 7

79 EYE SPECIMENS Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Conjunctivitis: Swabs should always be taken for culture of bacteria and viruses. In certain situations chlamydial infections should also be considered. Separate samples must be collected into appropriate transport media for detection of viruses or Chlamydia. Notes on transport: If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 48hr are undesirable. Conjunctival swab for bacterial and viral cultures Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Equipment: Cotton tipped swab stick Viral transport media (available direct from Microbiology laboratory) Transwab for bacterial isolation Method: Eye swabs should always be taken before local anaesthetics are applied to the eye. Any pus should be sampled as well as any lesion(s) of interest. Hold the swab parallel to the eye with your free had, part the patient s eyelids and gently rub the conjunctiva of the lower eyelid with the swab, transfer this swab into the viral transport medium. Then repeat using the transwab, transferring it into the accompanying transport medium. A throat swab for the isolation of adenoviruses should always be taken when viral conjunctivitis is suspected Conjunctival swabs for the isolation and identification of Chlamydia Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Equipment: Method: Chlamydia kit (swab and transport media). These are available direct from the laboratory. Any purulent discharges must be wiped off prior to taking the sample for Chlamydial investigation. Hold the swab parallel to the eye with your free hand part the patient s eyelids and rub the conjunctiva of the lower eyelid with the swab. Place the swab into the Chlamydial transport media Ensure that the specimen reaches the laboratory as soon as possible. Pathology Handbook Page 79 of 94 Version 7

80 INVESTIGATION OF KERATITIS/CORNEAL ULCERS Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Specimens should always be taken before treatment is commenced. If infection with Acanthamoeba is suspected please contact the Microbiology Department (Ext 2712) so that arrangements can be made for referral to the reference laboratory. Equipment: Method: Sterile scalpel blade Corneal scrape kit (obtainable from the lab at Macclesfield). The kit includes a microscope slide and a bottle with nutrient broth. Please ensure the location of material on the slide is indicated). If Acanthamoeba infection is suspected, scrapings should be placed in 200 µl sterile normal saline (available on request from the lab).. Concomitant conjunctival and eyelid swabs should also be taken. Endophthalmitis Conjunctival cultures are generally regarded as being inadequate. All cases of traumatic and post surgical endophthalmitis should have aqueous and vitreous aspiration for cultures and smears. The material obtained from these taps should be inoculated into a sterile container which should be transported to the laboratory immediately. Two sets of blood cultures must be taken when endophthalmitis is suspected. CUTANEOUS SPECIMENS (HAIR, SKIN, NAIL) FOR FUNGAL ISOLATION Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Equipment: Method: HAIR: SKIN: NAIL: Alcohol wipe Forceps Paper towel Scalpel Gloves Screw capped container or Dermapack (available from the lab) Wash hands Put on gloves Remove distorted or fractured hairs with forceps. Pluck hair from scalp. DO NOT USE CUT HAIR Cleanse with alcohol wipe, before a specimen is collected, to reduce the level of contaminating skin flora. Take shavings of epidermal scales at the active border of the lesion onto a paper towel using a scalpel. Cleanse nail with alcohol wipe The outermost layer of the nail is than removed by scraping with a scalpel onto a paper towel. Deeper scrapings, debris from under the edge of the infected nail, and nail clippings from the infected areas, are also suitable for culture. Put all specimens either into a Dermapack or a sterile laboratory screw-capped container. Pathology Handbook Page 80 of 94 Version 7

81 URINE SPECIMENS MSU, CSU, Suprapubic aspirate (SPA) Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. For bacterial culture, sample containers with Boric acid preservative should be used where delays are likely to occur, however it should be noted that boric acid may be inhibitory to some organisms especially where a small volume of urine only is collected and it may inhibit tests for leucocyte esterase. Equipment: Method: Bed pan/toilet/urinal/receiver Warm saline or soap and water for cleaning Sterile gallipot Cotton wool balls Gloves Specimen container Receptacle for soiled disposals Wash hands and put on gloves Males: retract the foreskin and clean the glans penis and urethral meatus with soap and water/warm saline. Females: clean the urethral meatus and vulva with soap and water/warm saline; swab with cotton wool balls from front to back. Ask the patient to micturate into bedpan/toilet.urinal and then collect the mid stream of the urine (20-30mls) into the specimen container (men) receiver (women). Infants- Boric acid may inhibit bacterial growth in small volume samples. Please use white top bottles in such instances. Note however that any delay in transport to the laboratory may affect culture results. Boys After preliminary cleansing, a sterile tube is strapped to the penis to serve as a collecting vessel. Girls A polythene bag with adhesive fitting is placed over the previously cleansed perineum. (Alternatively a sterile latex glove may be used as a collecting vessel). MIDSTREAM URINE (MSU) Please label all samples clearly with the patient s name, DOB or Hospital number, date and time collected and the specimen site. The first part of voided urine is discarded and without interrupting the flow, approximately 10 ml is collected into a sterile container. The remaining urine is discarded. If boric acid preservative is used, ensure the container is filled up to the mark in the same manner and the contents mixed well. Clean-catch urine: This is a reasonable alternative to MSU. Thorough peri-urethral cleaning is recommended. The whole specimen is collected into a sterile container and then an aliquot sent for examination. Please do not overfill urine containers as this may result in leakage. Pathology Handbook Page 81 of 94 Version 7

82 CATHETER SPECIMEN OF URINE (CSU) Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Equipment: Method: Alcohol swab Sterile syringe and needle Catheter clamp Sterile specimen container Receptacle for soiled disposables Clamp the drainage bag tubing below the rubber self-sealing sampling port. Wash your hands Cleanse the sleeve/port with alcohol swab. Insert the assembled needle and syringe at a 45 0 angle into the rubber sleeve and 90 0 angle into the protected sampling port. (All sampling sleeves are designed to occlude puncture holes when needle is withdrawn). Aspirate catheter urine into the syringe. Withdraw the needle and syringe from the catheter. Re-swab the sampling sleeve/port with alcohol swab. Transfer urine sample into container. REMOVE CLAMP from the drainage bag tubing. The specimen should not be obtained from the collection bag SUPRAPUBIC ASPIRATE (SPA) Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen site. Please ensure SPA is stated clearly on the request form. Urine is obtained aseptically, directly from the bladder by aspiration with a needle and syringe. The use of this invasive procedure is usually reserved for clarification of equivocal results from voided urine (e.g. in infants and small children). URINE SPECIMEN FOR AAFB EXAMINATION: (TB & OTHER MYCOBACTERIUM SPECIES) Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen type. Collect 3 total early morning urine specimens into 30 ml white-topped sterile universal containers URINE FOR PREGNANCY TESTS This test is now carried out by the Biochemistry Department at Macclesfield DGH. Pathology Handbook Page 82 of 94 Version 7

83 FAECAL SPECIMENS The laboratory undertakes bacterial culture, examination for C difficile toxin, tests for Rotavirus and microscopy for Ova Cysts & Parasites. Routine samples are examined for parasites associated with acute diarrhoea. If there is clinical evidence of chronic intestinal parasitic infection, send stool samples from 3 consecutive days with a single request for OCP and clinical details including foreign travel. Samples for virology for Enterovirus are referred to Manchester. Faeces for viral enteritis are only referred in the investigation of an outbreak. Faeces are also examined for Helicobacterpylori antigen at Macclesfield if appropriate request is received. Please label all samples clearly with the patient s name, DOB, NHS or Hospital number, date and time collected and the specimen type. Clinical details including foreign travel are also required to ensure samples are managed appropriately. Where AMOEBIC infection is suspected, please inform the laboratory and send a specimen without delay Specimens may be passed into a clean, dry, disposable bedpan or similar container and transferred into a leakproof container. The specimen is unsatisfactory if any residual soap, detergent or disinfectant remains in the pan. 1-2g is sufficient for routine culture. Specimens of faeces should be transported to the laboratory and processed as soon as possible, as a number of important pathogens such as Shigella species may not survive the ph changes that occur in stool specimens, which are not promptly delivered to the laboratory, even if refrigerated. Equipment: Method: Bedpan Spatula Screw capped container Toilet tissue Receptacle for soiled disposables Adults: The stool is passed into the bedpan without urinating. Using a spatula select (when possible) a suitable portion containing blood and mucus and place in container. Please wash your hands! Outpatients Adults Infants: - Where possible a spatula should be used to collect material from soiled napkins and the specimen transferred to the container as above. In other cases a transwab inserted at least ½ above the anal margin may be used. The patient is issued with a screw capped container and spatula and advised to proceed as follows:- Method: Place in the W.C. pan a few loosely packed toilet papers Defaecate onto the paper in the W.C. pan. Collect a faecal sample from the paper using the spatula and transfer to the screw capped container avoiding contaminating the outside of the container. Screw down the lid tightly; discard the spatula wrapped in paper/polythene bag into the household dustbin. Wash hands with soap and water. Outpatients Infants Instruct mothers to collect a specimen from the napkin as above. Alternatively a doctor or nurse may collect a rectal swab. Pathology Handbook Page 83 of 94 Version 7

84 FAECES SAMPLES FOR CLOSTRIDIUM DIFFICILE Please label all samples clearly with the patient s name, DOB, NHS or Hospital Number, LOCATION and date taken. IMPORTANT NOTE: ONLY LIQUID STOOLS WILL BE EXAMINED FOR C DIFFICILE, AS FORMED STOOLS ARE NOT SUITABLE FOR TESTING. Note - C.difficile testing is carried out by a two step protocol as recommended in the Department of Health guidelines. Specimens are initially screened for the presence of C.difficile (by testing for GDH) those found to be positive in the initial screen are then tested for the presence of toxin. It is not necessary to retest previous GDH positive patients. If diarrhoea persists in these patients please contact IPCS. Please send specimens as soon as possible after onset of symptoms. Routine specimens should be received in the laboratory by 12.30pm to ensure results are available that day. Tests can be undertaken on the same specimen sent for culture. A liquid specimen of 1-2ml is sufficient for culture and C. difficile detection/toxin detection. Repeat testing of positive samples is not indicated within a 28 day period. If a negative result is obtained and symptoms persist, a further specimen should be retested as it is known that a one-off negative may occur. COLLECTION OF ENTEROBIUS VERMICULARIS EGGS Please label all samples clearly with the patient s name, DOB or Hospital number, date and time collected. We now recommend using the Pinworm Egg Collector (available from the laboratory) as follows: - Method: Unscrew the egg collector cap from its container. Holding the cap, roll the adhesive-ended stick around the patient s perianal skin to collect the eggs. Return the stick to the container, screw lid securely. Label clearly with patients details and send to the laboratory. NB: For best results take specimens 2-3 hours after patient has retired for the night (e.g pm). Do not take specimens immediately after defecation and/or after washing the perianal region. Submit 3 specimens before considering patient free from threadworm infection. LEGIONELLA ANTIGEN TEST Please label all samples clearly with the patient s name, DOB or Hospital number, date and time collected. Method: Collect a urine sample as described in the urine section of this handbook. White top containers are preferred although boric acid can be used. If a positive urinary antigen result is obtained submit a standard Sputum sample and 10 ml clotted blood sample to the laboratory. These will be sent to a specialised reference laboratory for confirmatory testing. Pathology Handbook Page 84 of 94 Version 7

85 BLOOD CULTURES AND THE LABORATORY DIAGNOSIS OF BACTERAEMIA AND SEPTICAEMIA Please label all samples clearly with the patient s name, DOB, NHS or Hospital Number, LOCATION and date. Clinical details including foreign travel are also required to ensure the samples are managed appropriately. Blood Cultures In bacteraemic patients the number of viable bacteria in the blood varies from hour to hour and may frequently be as few as one or two organisms per ml., therefore, a relatively large volume of blood (5-10ml) must be used as the inoculum. Do not exceed the manufacturer s recommended maximum volume for each bottle. If blood for other tests such as blood gases or ESR is to be taken at the same venepuncture, the blood culture bottles should be inoculated first to avoid contamination. Optimal time of collection Before Antimicrobial therapy where possible and as soon as possible after a spike of fever, except in endocarditis where timing is less important. Notes on transport: Where there is a delay in transport to the laboratory and/or loading on to the automated system, blood cultures should be incubated at C as soon as possible after inoculation, pending processing. They must not be refrigerated. Out of hours take the samples to Pathology as quickly as possible, where the on-site Pathology staff will transfer them to the blood culture incubator located in central specimen reception. Method of collection Blood cultures should only be collected by staff who have received training in the aseptic technique. Contact the Nurse Practitioners for advice. The procedures vary dependent upon whether a winged needle or needle and syringe is used. The procedures are available on the Trust intranet site: IT IS IMPORTANT THAT THE patient details label IS NOT PLACED over the Bar Code on the blood culture bottle. PLEASE NOTE: Do not remove bottle barcode labels to place in patient s notes. Aseptically withdraw 16-20ml blood by venepuncture and, with a fresh sterile needle, carefully inoculate bottle with equal volumes of blood (8-10ml blood per bottle). For Paediatric patients, use one Paediatric bottle, inoculate with 1-3ml blood. Suspected bacterial endocarditis at least 30mls of blood in total is required. The blood should be collected into at least 2 sets of blood culture bottles at intervals of 15 minutes or more. Please do not contact the microbiology on-call BMS staff regarding newly positive blood cultures, as they will be unable to provide additional information. Clinical advice may be obtained from the on-call Consultant Microbiologist. Pathology Handbook Page 85 of 94 Version 7

86 ANTIBIOTIC ASSAY OF BLOOD ANTIBIOTIC MANAGEMENT GUIDELINES ARE AVAILABLE ON THE TRUST INTRANET SITE UNDER POLICIES & PROCEDURES, ANTIBIOTIC MANAGEMENT Please label all samples clearly with the patient s name, DOB or Hospital number, date and time of collection. A few antibiotics, e.g. Aminoglycosides, Chloramphenicol and Vancomycin, exhibit a narrow range between the therapeutic and toxic concentrations. Assays of antibiotic levels in the blood may be necessary to confirm that adequate concentrations of antibiotic are being achieved in blood e.g. in-patient with known defective intestinal absorption or in the C.S.F. for the treatment of meningitis, OR in order to avoid excessive blood concentrations when the drug is known to be toxic especially if the patient has impaired renal of hepatic function, or in neonates whose renal and hepatic handling of drugs is imperfectly developed. Sample required: A minimum of 1ml-clotted blood in a gold top bottle. IMPORTANT Gentamicin assays are now undertaken in the Biochemistry department at Leighton Hospital and are available 24/7. Please notify the Biochemistry department if the request is urgent. Vancomycin and Tobramycin assays are sent for testing to the Biochemistry department at Macclesfield District General Hospital. NB: There is no need to take a peak sample post-vancomycin. The transport leaves Leighton at 8.00am Monday-Friday and results will be available on LabCentre browser on the day of receipt at the Macclesfield laboratory. Urgent requests, or requests required outside routine hours (09:00-17:00 Mon-Fri) will be sent by taxi from the Leighton laboratory. Teicoplanin assays are referred to a specialist centre for testing which is performed on weekdays only. Trough sample only required. Blood should be collected immediately before a dose. This should not be collected until the patient has received treatment for 5-7 days. Treatment with Teicoplanin should be continued whilst awaiting the results of the pre-dose level. THERAPEUTIC DRUG LEVEL MONITORING REFERENCE RANGES Pre dose Post dose Trough Peak Tobramycin (multiple daily dosing for cystic fibrosis patients < 2 mg/l 8-12 mg/l only) Tobramycin (multiple daily dosing for NON cystic fibrosis patients) Vancomycin < 2 mg/l 6-10 mg/l On the advice of consultant microbiologist only mg/l Gentamicin See guideline on hospital intranet (Trust info/antibiotic Management/Once Daily Gentamicin) Teicoplanin mg/l For severe infections only (e.g. MRSA, osteomyelitis, septic arthritis) Pathology Handbook Page 86 of 94 Version 7

87 Serum level assays for itraconazole, 5-flucytosine, and voriconazole are performed at reference laboratories and should be booked with Microbiology staff in advance. Samples must reach the laboratory by 9am to allow transport to the appropriate laboratory. SEROLOGICAL/VIROLOGY INVESTIGATIONS Those tests which are analysed on the Macclesfield site are marked in bold and have a two day turnaround time SPECIMEN TYPE CONTAINER STORAGE Aspergillus pptns Gold top bottle Fridge Avian pptns Gold top bottle Fridge Blood for ASO 5-10ml Gold Top Bottle Fridge* Chlamydia (antibodies) Gold top bottle Fridge Functional antibodies (pneumococcal, Hib etc..) Gold top bottle Fridge Helicobacter (faecal sample) 60 ml plain container Fridge* Hepatitis A antibody (acute) Gold top bottle Fridge Hepatitis A antibody (immunity) Gold top bottle Fridge Hepatitis B antigen (acute) Gold top bottle Fridge Hepatitis B past infection (core antibody) Gold top bottle Fridge Hepatitis B immunity post vaccination Gold top bottle Fridge Hepatitis C antibody Gold top bottle Fridge Hepatitis B or C type/viral load EDTA bottle Fridge HIV Gold top bottle Fridge Hydatid Serology Gold top bottle Fridge Leptospira (Weils) Gold top bottles Fridge Lyme Disease Gold top bottle Fridge Measles Gold top bottle Fridge Meningococcal PCR EDTA Sample Fridge Mumps Gold top bottle Fridge Pathology Handbook Page 87 of 94 Version 7

88 SPECIMEN TYPE CONTAINER STORAGE Rubella Gold top bottle Fridge Syphilis Gold top bottle Fridge Toxoplasma Gold top bottle Fridge Varicella Zoster Immunity Gold top bottle Fridge Viral culture If swabs must be in transport medium Fridge Viral Titres Gold top tube Fridge * If a fridge for patient specimens is not available a cool dark place is preferred For viral titres please ensure clinical details or specific investigation required indicates type of virus suspected Varcella zoster contact in pregnancy Please contact the laboratory in advance if VZ status required. A positive IgG result indicates existing immunity. If acute VZ infection is suspected please inform laboratory to ensure specimen is tested for both IgG and IgM. All other serological and immunological tests are referred to external laboratories for testing. See appendix 2 for a list of commonly referred tests. For immunological investigations please send 5ml clotted blood accompanied by an immunology request form (pink card). The following tests are processed in the Biochemistry Department, and should be requested on a Biochemistry form where electronic requesting is not in use: immunoglobulins protein electrophoresis (serum and urine) rheumatoid factor thyroid autoantibodies (thyroid peroxidase antibody and TSH receptor antibody) tissue transglutaminase (TTG) antibody (coeliac disease screen) DISPOSAL OF MATERIALS USED IN SPECIMEN COLLECTION All disposable equipment used in the collection of Microbiological samples must be disposed of as clinical waste in accordance with current regulations. Particular care must be taken when disposing of sharps to ensure such articles are handled and disposed of in the correct designated containers in such a manner as to prevent injury to any individual. Re-usable equipment must be appropriately disinfected or sterilised after use in accordance with local policies. Pathology Handbook Page 88 of 94 Version 7

89 TURNAROUND TIMES These timescales are for guidance only and relate to samples received in the laboratory by 4.30 p.m. Turnaround times may be delayed occasionally if additional work or tests are required. Negative urinalysis results Positive urinalysis results same working day Within 2 working days Blood cultures positive Gram film telephoned on day of detection Blood cultures negative 5 days Routine bacteriology culture (negative result) Routine bacteriology culture (positive result) Chlamydia PCR TB culture Serology results urgent Serology results routine Within 2 working days Within 3 working days (may be provisional) Within 3 working days 10 weeks same working day Within 1-2 working days REQUESTING ADDITIONAL TESTS Bacteriology samples Due to the instability of bacteria over time and the processing undertaken for some samples, requesting additional tests on submitted samples is not advised, unless done on the day of receipt. Serology samples The time limit for requesting additional tests for blood samples tested in house is two weeks. Pathology Handbook Page 89 of 94 Version 7

90 APPENDIX 1 LIST OF TESTS SENT TO OTHER LABORATORIES Please refer to the biochemistry section for sendaway tests handled by the biochemistry department CHECK IN EACH DEPARTMENTAL SECTION SPECIMEN TYPE REQUIRED Test Department Address Acanthamoeba specimens Microbiology London school of Hygiene and Tropical Medicine, Keppel St, London Acetylcholine Receptors Antibody Immunology, MRI, Manchester Adrenal Cortex (Antibodies To) Immunology, MRI, Manchester Amikacin Microbiology Biochemistry Dept, Alder Hey Hospital, Liverpool Amoebiasis Microbiology London school of Hygiene and Tropical Medicine, Keppel St, London ANA (Antinuclear Ab) Immunology, MRI, Manchester ANCA (Neutrophil Cytopklasmic Ab) Immunology, MRI, Manchester Anti 68 KD Microbiology Cambridge Life Sciences Cambridge Business Park Angel Grove, Ely, Cambridgeshire CB7 4DT Antibodies To ENA Immunology, MRI, Manchester Anticardiolipin Antibodies Immunology, MRI, Manchester Anti GAD antibodies Immunology, Churchill Hospital, Oxford Anti Musk antibodies Immunology, Churchill Hospital, Oxford Anti-neuromyelitis optica abs Immunology, Churchill Hospital, Oxford Antennal Screening (Down s syndrome) Sent direct by Department of Obstetrics Wolfson Institute St Barts School Of Medicine & Dentistry Charterhouse Square London EC1M 6BQ Anti-Ds-DNA Microbiology Immunology, MRI, Manchester Antimitochondrial Antibodies Microbiology Immunology, MRI, Manchester Antiphospholipid Antibodies Microbiology Immunology, MRI, Manchester Anti-Sperm Antibodies Microbiology Immunology, MRI, Manchester Arthropathy Screen Microbiology Immunology, MRI, Manchester Aspergillus Precipitins Microbiology Immunology, MRI, Manchester Autoantibodies Microbiology Immunology, MRI, Manchester Avian Precipitins Microbiology Immunology, MRI, Manchester Atypical Pneumonia For Storage/Screen Microbiology Virology, Manchester Medical Microbiology Partnership (MMMP), Manchester Bcr Abl Fusion Gene Haematology Dr Abida Awan Molecular Diagnostics Centre Top Floor, Multipurpose Building York Place (Gate 3) Manchester Royal Infirmary Bilharzia Microbiology Department Of Parasitology Hospital For Tropical Diseases Liverpool Borrelia Titre/Antibodies Microbiology PHE General Hospital Southampton SO16 6yd Bordetella PCR (discuss with Consultant Microbiology RSIL, PHE, Colindale London microbiologist) Bordetella serology/antibodies Microbiology RSIL, PHE, Colindale London Burkholderia Cepacia (study) Microbiology PHE, Colindale, London C1 Esterase Inhibitor Immunology, MRI C3 and C4 (complement) Immunology, MRI Campylobacter serology Microbiology Laboratory of Gastrointestinal pathogens, PHE Colindale Pathology Handbook Page 90 of 94 Version 7

91 Test Department Address Candida Albicans If ID and sensitivities required Microbiology Mycology Reference Laboratory, Bristol Cardiac Muscle Antibodies Immunology, MRI, Manchester Cardiolipin Antibodies Immunology, MRI, Manchester CD4 & Viral Load Haematology Virology, Manchester Medical Microbiology Partnership, Manchester Cell Markers Haematology Department Of Haematology Royal Liverpool Hospital, Liverpool CH50, C3 Breakdown, C4, C3, C1 Immunology, MRI, Manchester Inhibitor Chikungunya virus Microbiology Special pathogens reference unit, PHE, Colindale, London Chlamydia antibodies Microbiology PHE, Bristol Cholinesterase Receptor Antibody Immunology, Sheffield Chromosomes Cytogenetics Liverpool Womens Hospital, Liverpool Heparinised Whole Blood (Not Gel) CMV Microbiology Virology, MMMP, Manchester Coeliac Marker (TTG IgA Ab) Biochemistry Immunology, MRI, Manchester Complement, C3, C4 Immunology, MRI, Manchester Complement Fixation Test Microbiology Virology, MMMP, Manchester Coxsackie B Microbiology Virology, MMMP, Manchester Cri Du Chat Syndrome Cytogenetics Liverpool Womens Hospital, Liverpool (Heparin Not Gel) Crystal analysis of joint fluids Diagnostic Cytology Cytology centre, Manchester. NB lithium heparin tube required and Manchester cytology centre request from CSF (? Meningococcus) for PCR Microbiology Meningococcal reference unit, MMMP, Manchester CTD Connective Tissue Disorder Immunology, MRI, Manchester Cyclic Citrullinated Peptide Ab (CCP) Immunology, MRI, Manchester Cystic Fibrosis (EDTA 5mls) Cytogenetics Liverpool Womens Hospital, Liverpool Cysticercosis Microbiology Liverpool School of Tropical Medicine, Liverpool Cytogenetics (For Bone Marrows) Haematology Oncology Cytogenetics Pathology Department Christies Hospital, Manchester Dengue fever serology Microbiology PHE SPRU, Porton Down, Salisbury Di George Syndrome (Heparin Not Gel) Cytogenetics Liverpool Women s Hospital, Liverpool Diptheria Antibodies Microbiology MMMP Manchester EBV Microbiology Virology, MMMP, Manchester Entamoeba histolytica serology Microbiology Dept Parasitology, Hospital for Tropical Diseases, London Factor V Leiden & Prothrombin Gene G20210A Variant Haematology Steve Keeney Manchester Molecular Diagnostic Centre Top Floor, Multipurpose Building Manchester Royal Infirmary Oxford Road, Manchester M13 9WL Tel: /4880 Factor Xa Assay Haematology Coagulation Laboratory Manchester Royal Infirmary Manchester (Must go via Courier) (FH) Familial Haemachromatosis Gene (EDTA) 4 Edta Samples HFE Gene Haematology Prof Mark Woodward Department Of Haematology University Hospital Of Wales Cardiff. CF14 4XW Or Dr Cummings, C/O Haematology Department Manchester Royal Hospital, Manchester Pathology Handbook Page 91 of 94 Version 7

92 Test Department Address Farmer s Lung Preciptins Immunology, MRI, Manchester Flucytosine (Serum) Microbiology PHE (Mycology Lab) Myrtle Road Kingsdown, Bristol Fragile X (Lithium Hep Blood) Cytogenetics Liverpool Womens Hospital, Liverpool Fungi For Identification Microbiology Mycology Reference Laboratory, Bristol Gastric Parietal Cell Antibody Immunology, MRI, Manchester Gliadin/Gluten Antibodies Biochemistry No longer done see TTG IgA Antibody Glomerular Basement Membrane Ab Immunology, MRI, Manchester Helicobacter Biopsy Samples Microbiology PHE Gloucester Gloucester Royal Hospital Great Western Road, Gloucester, CL1 3NN Hep C/Chlamydia with PCR for Varicella & Enterovirus Microbiology Virology, MMMP, Manchester Histoplasma serology Microbiology Mycology Reference Laboratory, Bristol Hydrotherapy pool waters Microbiology University Hospital of North Midlands, Stoke on Trent Hepatitis B markers, viral load Microbiology Virology, MMMP, Manchester Her2 Histology Histology, Royal Liverpool. Herpes serology, PCR Microbiology Virology, MMMP, Manchester Hep C PCR Microbiology Virology, MMMP, Manchester Hib (Haemophilus Influenza B) Microbiology Immunology, Churchill Hospital Headington, Oxford HIV/HTLV III Microbiology Virology, MMMP, Manchester HPV testing (cervical smear samples) Cytology Micropathology Ltd, University of Warwick Science Park, Coventry, CV4 7EZ Hydatid Disease (Cft) Microbiology Malaria Ref Lab London School of Hygiene & Tropical Medicine Keppel St, London, WC1E 7HT IgA / IgM / IgG Biochemistry In house test IgE & Specific IgE Immunology, MRI, Manchester IgG Subclasses Immunology, MRI, Manchester Influenza Antibodies Microbiology Virology, MMMP, Manchester Itraconazole Microbiology Regional Mycology Lab, Wythenshawe Hospital, Southmoor Rd, Manchester, M23 9LT Intrinsic Factor Antibody Microbiology Clinical Haematology MRI, Manchester Insulin Autoantibodies / PICA (pancreatic Immunology, MRI, Manchester islet cell antibodies) (Serum) Islet Cell Antibody Immunology, MRI, Manchester Karyotyping (Heparin Not Gel) Cytogenetics Liverpool Womens Hospital, Liverpool Lebers screen (6mls EDTA) Genetics Genetics Laboratory, MRI Legionella antibodies/ culture Microbiology RSIL Atypical pneumonia Unit PHEColindale Leishmaniasis Microbiology School Of Tropical Medicine, Liverpool Leptospirosis Antibodies (Weils Disease) Microbiology Virology, MMMP, Manchester Lupus screen Immunology MRI, Manchester Lyme Disease Microbiology Rare & Imported Pathogens, Microbiology Services, PHE, Porton Down, Salisbury, Wilts, SP4 0JG, DX Salisbury 92/SP Malarial Antibodies Haematology Dr. J W Bailey Diagnostics laboratory Liverpool School of Tropical Medicine Pembroke Place, Liverpool L3 5QA Measles Microbiology Virology, MMMP, Manchester Meningococcal Antibodies Microbiology Meningococcal reference unit, Manchester Medical Microbiology Partnership, Manchester Pathology Handbook Page 92 of 94 Version 7

93 Test Department Address Miller-Dieker Syndrome Cytogenetics Liverpool Womens Hospital, Liverpool (Heparin Not Gel) Mitrochondria (Antibodies To) Immunology, MRI, Manchester Muscle Biopsy for Myopathy Histology Walton Centre, Liverpool. Muscular Dystrophy (EDTA) Cytogenetics Liverpool Womens Hospital, Liverpool Mycoplasma serology Microbiology Virology, MMMP, Manchester Myositis specific antibody Immunology, MRI Myotonic Dystrophy (EDTA) Cytogenetics Liverpool Womens Hospital, Liverpool Oligoclonal Bands (CSF) & Igs Biochemistry Sheffield Immunology Laboratory Parietial Cell Antibodies Immunology, MRI, Manchester Parvo Virus Microbiology Virology, MMMP, Manchester PCR (Meningo), DNA, CSF Serology Microbiology Meningococcal reference unit, MMMP, Manchester PCR for Varicella 7 Enterovirus Herpes Microbiology Virology, MMMP Manchester & Chlamydia, Viraemla (Hep C) Pemphigoid & Pemphigus Antibodies Immunology, MRI, Manchester Pertussis Microbiology RSIL, PHE Colindale Ave, Bordetella Ref Unit, London Plasma Viscosity (Pv) 2x EDTA samples Haematology Department Of Haematology, Wythenshawe Hospital Pneumococcal For Typing Microbiology RSIL, PHE, Colindale Pneumococcus Antibodies Please mark card Leighton Hospital Microbiology Dr Ray Burrow, Meningocoaal Ref Unit, Manchester Medical Microbiology Partnership Pneumocystis carinii (PCP) Microbiology Virology, MMMP, Manchester PPT Asp Antigens Immunology, MRI, Manchester Prader-Willi Syndrome (EDTA) Cytogenetics Liverpool Womens Hospital, Liverpool Protein Electrophoresis (serum/urine) Biochemistry In house test Psittacosis (Farmers Lung) Microbiology Virology MMMP MRI, Manchester Quantiferon Immunology, MRI, Manchester Q.Fever (Coxiella) Microbiology Virology, MMMP, Manchester Rabies antibodies Microbiology Vetrinary Lab Agency, Addlestone, Surrey RAPA Immunology, MRI, Manchester RAST (Specific IgE) Immunology, MRI, Manchester Rheumatoid Factor Biochemistry In house test Rickettsia Microbiology Centre For Applied Microbiology & Research (Camb) Porton Down, Salisbury, Wilts, SP4 0JG Salivary Duct Antibody Immunology MRI, Manchester SCAT Immunology, MRI, Manchester Schistosomiasis Microbiology Dept Of Parasitology Hospital Of Tropical Disease Pembroke Place, Liverpool L3 5QA Skin Antibody Immunology MRI, Manchester SLE Markers Immunology, MRI, Manchester Smooth Muscle Antibody Immunology, MRI, Manchester Sperm Antibodies Immunology, MRI, Manchester Spinal Muscular Atrophy (EDTA) Cytogenetics Liverpool Womens Hospital, Liverpool Streptomycin Microbiology Regional Antimicrobial Ref Lab., Southmead Hospital, Bristol Striated Muscle Antibody Immunology, MRI, Manchester T.B specimens Microbiology Microbiology University Hospital of North Midlands Teicoplanin levels Microbiology Southmead Hospital, Bristol Tetanus Antibodies Microbiology Virology, MMMP, MRI, Manchester Thyroid Peroxidase (TPO) Antibody Biochemistry In house test Tissue Transglutaminase (ttg) serum Biochemistry Immunology, Manchester Royal Infirmary Pathology Handbook Page 93 of 94 Version 7

94 Test Department Address Tobramycin Biochemistry Biochemistry, Pathology, Macclesfield District General Hospital TORCH Microbiology Virology, MMMP Manchester Toxocariosis Microbiology HPA Clinical Parasitology, Hospital for Tropical Diseases, London Toxoplasmosis Serology Microbiology Virology MMMP, Manchester Tryptase Levels (Serum) Immunology, MRI, Manchester TSH Receptor Antibody Biochemistry Biochemistry, Royal Liverpool Hospital Ureaplasma Microbiology Microbiology, Birmingham Womens Healthcare NHS Trust, Birmingham Vancomycin Biochemistry Biochemistry, Macclesfield Hospital Varicella Zoster (Chicken Pox) IgM Microbiology Virology MMMP, Manchester Viral Load Microbiology Virology MMMP Manchester Virus and Virus Serology Microbiology Virology MMMP, Manchester Von Willebrand Factor / Ristocetin Co- Factor / Factor Assays or Thrombophilia Samples (Antithrombin, Protein C or S) Haematology Nigel Humble AutoLab/Coagulation Department Manchester Royal Infirmary Oxford Road, Manchester M13 9WL Tel: #6 178 or (Coagulation Dept) Whipples Disease (PCR) Microbiology Molecular Pathology, St James University Hospital, Leeds Williams Syndrome (Heparin not gel) Cytogenetics Liverpool Womens Hospital, Liverpool Yersinia antibodies Microbiology Lab. of Enteric pathogens PHE Colindale Ave, London Please note: for advice on immunology tests, all enquiries should be directed to the immunology department at Manchester Royal Infirmary Pathology Handbook Page 94 of 94 Version 7