Directory of Laboratory Services 2013-2014 1 st edition Contact Information

Palomar Health Laboratory Services Palomar Medical Center Pomerado Hospital Palomar Health Downtown Campus 2185 West Citracado Pkwy, 15615 Pomerado Road, 555 E. Valley Pkwy, Escondido, CA 92029 Poway CA, 92064 Escondido, CA 92025 Phone: 442-281-1571 Phone: 858-613-4358 Phone: 760-739-3030 Fax 760-233-7840 Fax 858-613-4789 Fax 760-739-2864 Directory of Laboratory Services 2013-2014 1 st edition Contact Information Client Services Phone numbers 760-739-2867 858-613-4282 Fax number 760-739-2864 After hours number (5 pm 8 am) Phone number: 442-281-1503 (PMC) 858-613-4358 (POM) 760-613 4667 (SNF call for PMC) Infection Control Numbers 442-281-1699 858 583 8554 (Emergency) 1

Overview of Palomar Health Laboratories Palomar Health Laboratories are full-service facilities offering comprehensive clinical and anatomic pathology testing to the community we serve. We have 30,000 square feet of laboratory space equipped with state-of- the-art instrumentation, positive patient identification, and patient centric culture providing high quality and most efficient services. Our laboratories at Palomar Medical Center, Pomerado Hospital, and Palomar Health Downtown Campus, are accredited by the College of American Pathologist, Joint Commission on Accreditation of Health Care Organizations, Centers for Medicare and Medicaid Services, and State of California Department of Health Services. 2

Table of Contents I. Laboratory Certification 4 II. Laboratory Leadership 5 III. Client Services Information 6 IV. Testing Policies 7 V. Physician Client Service 8-13 a. Summary of Services 8 b. Clinical Lab, Cytology Test Requisitions 9 c. Pathology Lab Requisitions 10 d. Examples of Different Requisitions 11-13 VI. Skilled Nursing Facilities 14-18 a. Summary of Services 14 b. Weekday and Weekend Services 15 c. Holiday Schedule Services 16 d. Test Requisition Information 17 e. Standing Order procedure 18 f. Change Order Procedure 18 V. Appendix A Specimen Requirements 19-22 VI. Appendix B Stat Test List 23-25 VII. Appendix C SNF Stat Test List 26-27 VIII. Appendix D Critical Values 28-29 IX. Appendix E Specimen Collection Guide 30-32 3

Laboratory Certification Fully Accredited Laboratories Palomar Health Laboratory Services is acknowledged as a high quality laboratory and is accredited by the following: College of American Pathologists (CAP) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Centers for Medicare and Medicaid Services (CLIA) State of California Department of Health Services (DHS) Palomar Medical Center CLIA. 05D2044832 CAP 8044198 Medicare Provider.. 05-0115 Medical Provider..1457321317 California State Department of Health. CLF 342634 NPI (Lab).. 1639427685 Pomerado Hospital CLIA. 05D0668540 CAP. 23184-01 Medicare Provider.. 050636 Medical Provider ZZT40636F California State Department of Health.. CLF3150 NPI (Lab) 1811245863 Palomar Health Downtown Campus CLIA 05D0671677 CAP 2314901 Medicare Provider..05-0115 Medical Provider..1457321317 California State Department of Health. CLF 1006 NPI (Lab) 1639427677 4

Blesilda Singh, M.D. Lachlan Macleay, M.D. Pamela Danque, M.D. Linda Petroff, M.D. Laboratory Leadership Valley Pathology Medical Associates, Inc. Jerry Kolins, M.D. Medical Director Bradley Harward, M. D. Saskia Boisot, M.D. Pamela Price, M.D. Keith Lopes, PA Palomar Health Laboratory Services: Mark Reyes, MT (ASCP) MBA District Director, Lab Operations Tim Barlow, MT (ASCP) Manager, Laboratory Services PMC Blood Bank Supervisor Ted Drescher Office/Phlebotomy Manager Joane Barriteau, MBA/HCM, MT (ASCP) Hematology Supervisor Susan DeWindt, MT (ASCP) Microbiology Supervisor MaryAnn Snoke Phlebotomy Supervisor - PMC Sandy Lajeunesse, MLT (ASCP) Central Processing Supervisor - PMC Evelyn Chua, MT (ASCP) Evening Shift Supervisor PMC Robert Sharpell, MT (ASCP) Laboratory Info System Analyst PMC Gloria Austria, MBA/HCM, CLS Manager, Laboratory Services Pomerado Debra Mason, MT (ASCP) POCT Supervisor Judy Cavallo, MT (ASCP) Chemistry Supervisor Rebecca Anderson, MT (ASCP) Night Shift Supervisor PMC Susan David Phlebotomy Supervisor - Pomerado Brian Bakerink Pathology Supervisor Rose Pfliger Anatomic Pathology Transcription Supervisor Jim Peters, MT (ASCP) Laboratory Info System Analyst Pomerado 5

Client Services Telephone Inquiries Our Customer Service Representatives will gladly help you with your requests for test results, telephone orders, specimen requirements, and turnaround times. After hours, please call the PHLS Client Services Department and follow the steps to be transferred to Palomar Medical Center or Pomerado Hospital. PHLS Client Services Department: Phone: (760) 739-2867 or (858) 613-4282 Fax: (760) 739-2864 Hours of Operation: Monday Friday 8:00 A.M. 5:00 P.M. Result Reporting Specimens are processed and test results are reported to the client as soon as possible. Since reporting times vary, a testing schedule is available from the Outreach Laboratory office. STAT Results available within one (1) hour after specimen is received in the laboratory. ASAP Results are available within four (4) hours after specimen is received in laboratory. Routine Results are available within 24 hours. Lab Result Calling After Hours The CLS performing the test will call critical results with no time restrictions NOTE: The front office personnel will check the requisition for complete physician information including after hours contact number. In the event that the information is not available the laboratory personnel will: Call the client to get the physician information. If information is not available or the physician cannot be reached, the CLS will call the pathologist on call. Result Faxing: All laboratory results will be automatically faxed to your office. This includes clinical, cytology and anatomic pathology reports. Critical Value Handling The laboratory will immediately call results that fall within a range, which has been determined to be Critical or may have an effect in delaying surgery or need to be brought to the attention of the physician. A complete list of Palomar Health Critical Values can be found in Appendix D of this manual. 6

Testing Policies STAT Test List: A complete list of Outpatient STAT tests can be found in the Appendix B of this manual. Repeat Determinations We will repeat a test without charge whenever the result does not correlate, in the physician s opinion or with the clinical picture presented by the patient. Contact the Outreach Laboratory office with any requests for repeats. Follow-up or confirmatory testing is not considered a repeat determination, and such specimens will therefore be processed as a new request. Cancellation of Tests Cancellations received prior to test setup will be honored at no charge. Requests received following test setup or resulting cannot be honored. Referred Tests Palomar Health Laboratory Services is a full service laboratory. Most tests are performed in our laboratories; however, a few highly esoteric tests are referred to reliable reference laboratories. We use the services of ARUP Clinical Laboratories as our primary reference laboratory. The fees for referred tests are subject to change. Professional Courtesy California State and Federal Laws prohibits the offering of professional courtesy testing ; therefore we cannot honor requests for this service. Billing Palomar Health will bill all insurance PPO, Medicare, Medical, and HMO insurance. However, it is the responsibility of the patient to check with his/her insurance company prior to using our laboratory services if Palomar Health Laboratories is a network provider of his/her insurance carrier. Valley Pathology Medical Associates will bill for professional services provided by the pathologists. The pathologist s fee is normally covered by most health insurance providers. A separate bill will be sent to the patient if the insurance does not cover the professional fee. If you have any VPMA billing questions, please contact patient representative at 888 307 6064. Reportable Disease All reportable diseases are reported to the County of San Diego, Public Health Department as outlined by Title 17 California Code of Regulations (17CCR). Within 24 hours of identifying a reportable organism, a Confidentiality Morbidity Report (CMR) is completed and faxed to San Diego County Public Health. Specimen Collection Information A complete list of tests performed at Palomar Health Laboratories, specimen requirements, and special handling can be found in Appendix A of this manual. Specimen Size/Sample Size Without adequate sample size, testing cannot be performed. This inadequate specimen collection is detrimental to patient and patient care. Computer generated labels/ requisitions contain recommended sample sizes, tube type and recommended handling; consult specific departments for questions regarding sample size, minimum sample volumes, and specimen handling guidelines for tests not contained in this section. Unacceptable Specimens Improperly labeled/unlabeled Specimens: Palomar Health Laboratory Services will not accept specimens submitted without patient identification (patient name and date of birth). o Note: In the event the specimen is identified as irreplaceable, Palomar Health Laboratory Services will process the specimen only if authorized by the physician or client. The report will have documentation that the specimen was received as improperly labeled or unlabeled. Needles: Palomar Health Laboratory Services will not accept, transport or test any specimen with a needle attached. In cases where syringes must be submitted, the syringe must be plastic and have Lauer Lock securely attached. Glass Tubes: Glass tubes should be avoided due to the increased risk of broken glass and biological contamination. 7

A. Physician Client Services Summary of Services Palomar Health Laboratories provide STAT and Routine Laboratory services for physicians, medical groups, and reference laboratories. These services include: Client Service Department is available Monday to Friday from 8 am 5:00 pm Laboratory service 7 days a week STAT turn-around-time in 60-90 minutes after specimen is received in the laboratory Most routine results available the next day All critical values are called to the attending physician during normal business hours or on call physician after hours. Laboratory reports are distributed via fax, courier, or web-based. 8

Test Requisition Information Palomar Health Laboratory Services provide four types of personalized requisition forms for your convenience. They include: Clinical Laboratory testing - Blue/White form Cytology testing Purple Tissue/Surgical testing Green Skilled Nursing Facility testing- Yellow A requisition form or physician s order must accompany each laboratory order or specimen you submit. I. Clinical Laboratory Testing (Blue/White Requisition) used by physicians and other laboratories when sending specimens to Palomar Health Laboratories Filling Out the Clinical Laboratory Testing Requisitions: 1. Patient s full name (last, first, middle initial) 2. Current address 3. Phone number 4. Date of Birth 5. SSN, if possible 6. Check appropriate billing category and attach a copy of insurance card 7. Provide ICD-9 code(s) or chief complaint. This is a federal requirement and failure to provide may result in insurance denial. 8. Clearly mark tests to be performed. If not listed, use the Write-In area. 9. Clearly label each specimen being submitted with patient s name, date and time of collection. Use the identification labels provided. 10. Microbiology testing please indicate the source of the specimen being submitted for culture. The back of the requisition contains a complete list of panel components, specimen collection tube codes and reflexive tests. II. Cytology Testing Requisition (Purple/White Requisition) Filling Out the Test Requisition: All fields in bold red print on the requisition slip are required fields and must be filled out prior to specimen processing. Failure to do so may result in a delay of diagnosis. 1. Patient s full name (last, first, middle initial) 2. Current address 3. Phone number 4. Date of Birth 5. SSN, if possible 6. Ordering physician 7. Date and time of procedure 8. Check appropriate billing category and attach a copy of insurance card 9. Provide the Clinical History, prior history or clinical symptoms of the patient. 10. Provide ICD-9 code(s) or chief complaint. This is a federal requirement and failure to provide may result in insurance denial. 11. Provide the Clinical History, prior history or clinical symptoms of the patient. 12. Clearly mark site of specimen and laterality. 13. Clearly label each specimen being submitted with patient s name, date and time of collection. **Note: All Rush cases MUST have a direct physician contact number (preferably cell phone or pager) provided on the submission requisition to ensure timely communication by the pathologist to the treating physician. 9

III. Pathology Testing Requisition (Green/White Requisition) Filling out the Test Requisition: All fields in bold red print on the requisition slip are required fields and must be filled out prior to specimen processing. Failure to do so may result in a delay of diagnosis 1. Patient s full name (last, first, middle initial) 2. Current address 3. Phone number 4. Date of Birth 5. SSN, if possible 6. Ordering physician 7. Date and time of procedure 8. Check appropriate billing category and attach a copy of insurance card 9. Provide the Clinical History, prior history or clinical symptoms of the patient. 10. Provide ICD-9 code(s) or chief complaint. This is a federal requirement and failure to provide may result in insurance denial. 11. Provide the Clinical History, prior history or clinical symptoms of the patient. 12. Clearly mark site of specimen and laterality. 13. Clearly label each specimen being submitted with patient s name, date and time of collection. **Note: All Rush cases MUST have a direct physician contact number (preferably cell phone or pager) provided on the submission requisition to ensure timely communication by the pathologist to the treating physician. 10

Palomar Health Clinical Laboratory Test Requisition 11

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B. Skilled Nursing Facility Client Services 1. Summary of Services Palomar Health Laboratories provide mobile phlebotomy services across more than 800 square miles in North San Diego County and La Jolla. Advantages of using Palomar Health include: Fast turn-around times Prothrombin Time results between 10 a.m. 12 p.m. STAT testing results in 2 4 hours from your call. Most routine results before 3 p.m. All STAT testing performed in-house 7 days a week on most tests High quality results. Specimens are tested shortly after collection to minimize hemolysis and ensure accuracy. All critical values are communicated to the facility by a telephone call and fax. Extremely competitive rates Infection Prevention Nurses available for consultation Serving Skilled Nursing Facilities for more than 21 years 14

2. Weekday and Weekend Services Weekdays Routine Testing: All routine test requests fulfilled the same day on contracted phlebotomy days. * STAT Testing: Standard Service STAT Test Menu available 24 hours a day Standing Orders: All routine (standing) orders are fulfilled Note: Clearly mark on the requisition write in section Standing Order, Expiration date: ) Time Draws: Peak and trough therapeutic drug level requests fulfilled as routine service on weekdays with 24-hour prior arrangement for the following therapeutic drugs: Amikacin, Gentamicin, Tobramycin, and Vancomycin Facility collected specimens will be picked up at the next scheduled phlebotomy visit Weekdays are defined as the period between Monday at 4:30 am through Friday at 11:30 P.M Weekends Routine Testing: Routine test requests fulfilled the day for any test on Appendix A when requests are phoned by 7:00 p.m. STAT Testing: Standard Service STAT Test Menu available 24 hours a day Standing Orders: Routine (standing) orders on file are fulfilled on Saturdays** and Sundays ** on limited tests Note: Clearly mark on the requisition write in section Standing Order, Expiration date: ) Time Draws: Peak and trough therapeutic drug level requests fulfilled as routine service on weekdays with 24-hour prior arrangement for the following therapeutic drugs: Amikacin, Gentamicin, Tobramycin, and Vancomycin Facility collected specimens will be picked up at the next scheduled phlebotomy visit. Unless the specimen integrity will be compromised, pick up will be done on the same day. Weekends are defined as the period between Friday at 11:31 P.M. through Monday 4:31 A.M. 15

3. Skilled Nursing Facility Services Holiday Schedule February President s Day Open for regular business May Memorial Day Closed: STAT service only July Fourth of July Closed: STAT service only September Labor day Closed: STAT service only November Thanksgiving Closed: STAT service only December Christmas Closed: STAT service only January New year s Day Closed: STAT service only PLEASE NOTE OUR HOLIDAY POLICY 1. Palomar Health will accept STAT orders for tests that appear on the SNF STAT Test menu only. (Refer to Appendix C) 2. Call all routine orders before 7:00 PM the day before the holiday. 3. Daily standing orders that fall on the holiday will be performed as scheduled. 4. All other standing orders will be rescheduled for the business day prior to, or the first business day following the holiday. 5. No peaks and troughs will be scheduled on the holiday. 16

1. Test Requisitions Filling Out the Skilled Nursing Facility Testing Requisitions: a. Patient s full name (last, first, middle initial) b. Room # and Bed # c. Date of Birth d. SSN, if possible e. Check appropriate billing category and attach a copy of insurance card f. Provide ICD-9 code(s) or chief complaint. This is a federal requirement and failure to provide may result in insurance denial. g. Clearly mark tests to be performed. If not listed, use the Write-In area. h. Clearly label each specimen being submitted with patient s name, date and time of collection. Use the identification labels provided. i. Microbiology testing please indicate the source of the specimen being submitted for culture. j. For Standing Orders: Write Standing Order in the Write order/special Instruction area and the expiration date of the standing order. 17

2. New Routine Standing Order Procedure *A standing order is valid until its expiration date, but no longer than 12 months a. To initiate a routine (standing) Order, use the Palomar Health (triplicate) requisition form. b. Write in Standing Order, Expiration Date once a week or every Monday as an example. c. Complete all required information, patient name, date of birth, room #, bed#, billing information, tests ordered File the completed requisition in the card file by the first letter of the last name. 3. Change Order Form for Pre-Existing Routine (standing) Order a. Palomar Health requires written authorization to change pre-existing routine (standing) orders to be in compliance with the State law and the Office of the Inspector General of the Department of Health and Human Services. b. Please write the appropriate change/s below. c. Authorized person must sign and date the form. d. Fax the form to the appropriate location marked on the form (Palomar or Pomerado) e. For new orders, a new requisition must be filled out. SNF Change Order Form Palomar Medical Center Pomerado Hospital 2185 W. Citracado Pkwy., 1 5615 Pomerado Road, Escondido, CA 92029 Poway, CA 92064 Phone:442 281 1571 Phone: 858 613 4358 Fax: 760 233 7840 Fax: 858 613 4789 DO NOT USE FOR NEW ORDERS Attention: Director of Nurses/Medical Director Palomar Health requires written authorization to change pre-existing routine (standing) orders to be in compliance with the State law and the Office of the Inspector General of the Department of Health and Human Services. Please write the appropriate change/s below. Sign, date, and fax the form to the marked location (Palomar or Pomerado) Orders MUST be received before 3:30 P.M. Monday Friday in order to be processed Please check action/s that applies: Add on Test Cancel Test Change Order Note: For Change Order please fill out a new requisition FACILITY: Resident s Name: Sex: Room #: Date of Birth: Diagnosis Code: Physician: Physician Phone: ( Last, First name) Test(s) Added-on: Test(s) Canceled: Authorized by: Date: Time: Print Signature: For Palomar Health Use only: Patient s MRN: Original Accession #: Date and Time Collected: Completed by : Date: 18

Appendix A Specimen Requirements Test Submission Requirements / Tube Color Special Handling ABG (Arterial Blood Gas) 1 ml Li Heparin syringe ABG kit on Ice ABO typing 7 ml/lavender ABORh 7 ml/lavender Acetaminophen (Tylenol) Albumin 5 ml/pst /SST Alcohol, Ethyl (Ethanol) 5 ml/sst/pst Do not prep site with alcohol; Alkaline Phosphatase 5 ml/pst /SST ALT (SGPT) Ammonia (NH4) 5 ml/pst Deliver on ice - STAT. Amylase Antibody Screen 7 ml/lavender Anti-HAV IgM(Hep A virus AB, IgM) 6.5 ml/sst Anti-HBC IgM (Hep B virus AB, IgM) 6.5 ml/sst Anti-HCV (Hep C virus AB) 6.5 ml/sst APTT 3 ml/lt blue (4.5 ml/lt blue preferred) Return to lab ASAP. Arthritis Profile 5 ml/sst & 3 ml/lavender ASO Screen (Anti-Streptolysin) 6.5 ml/sst AST (SGOT) B12, Vitamin Bicarb (arterial) 3 ml/green Do not spin. Bilirubin, Direct Avoid hemolysis. Bilirubin, Total Avoid hemolysis. Blood Culture Blood Culture Peds Blood Culture BUN (Blood Urea Nitrogen) Calcium Calcium, Ionized Carbamazepine(Tegretol) Carboxyhemoglobin 8-10 ml/bactec (aer grey bottle) 8-10 ml/bactec (anaer purple bottle) 1-3 ml/bactec (Peds aer pink bottle) Special instruct: If 10-20 ml, split evenly between aer & anaer: 3-9ml add to aer; <3ml add all to peds 3 ml/green lithium heparin NON GEL 7 ml/green or a heparinized syringe 3 ml/lavender 3 ml/lavender 5 ml/sst Consult Departmental Procedure for additional instructions. Deliver on ice ASAP (NON-GEL tube) Deliver ASAP CBC (Complete blood count) CBC w/differential CEA (Carcinoembryonic Antigen) Chem 12(Na, K, Cl, Glucose, BUN, Creat, Calcium, T. Prot, Alb, AST, Alk Phos, T. Bili Chem + HDL Fasting required. Cholesterol 19

Test Submission Requirements / Tube Color Special Handling CK (CPK, Creatine Kinase) Cl (Chloride) Coombs, Direct 7 ml/lavender Coombs, Indirect 7 ml/lavender C-Reactive Protein, Acute C-Reactive Protein, Cardiac Creatinine Cross-Match (Type and Cross) 7 ml/lavender Patient must be BB banded. D-Dimer 3 ml/lt blue (4.5 ml/lt blue preferred) Digoxin Collect >5hr post dose. Dilantin(Phenytoin, PTN) Electrolytes (Na, K, Cl, CO2) ESR (Erythrocyte Sedimentation Rate; Sed Rate) 3 ml/lavender Estradiol 5 ml/sst FDP 2 ml/special DK Blue tube w/yellow label Ferritin Fibrinogen 3 ml/lt blue (4.5 ml/lt blue preferred) Folate/Vitamine B12 5 ml/sst/pst Folic Acid Free T4 (Free Thyroxine, FT4) FSH (Follicle Stimulating Hormone) 5 ml/sst Gentamicin (tr or pk) (Garamycin) GGT (Gamma-Glutamyl Transferase) Glucose (Blood sugar) / Gray Glucose, PG 50(post 50 gms Glucola) / Gray Consult PG 50 collect procedures Glucose, 2 hr PP / Gray Collect 2 hrs post meal. Glucose Tolerance test (Specify 3,4,5,6 hr) (GTT) 5 ml/gray each hour Consult GTT collection procedure Glycohemoglobin (Glycosylated Hemaglobin A1C) 3 or 7 ml/lavender Do not spin. HBSAg 5 ml/sst Must be drawn in separate tube. Send original tube HCG (Qual or Quant) 5 ml/sst (Urine for Qual) HDL(High Density Lipoprotein) Fasting required. HDL/LDL Fasting required. Hematocrit (CBC) 3 ml/lavender Hematology tests (CBC, sed rate, retic count) 3 ml/lavender Hemogram (CBC) 3 ml/lavender Hepatic Panel (Liver panel) Hepatitis Evaluation (or any Hepatitis testing) 5 ml/sst all = 7 ml/sst Hgb A1C (Hemoglobin A1C) 3 or 7 ml/lavender Do not spin. Homocysteine 4.5 ml lavender Must be drawn in separate tube. Send original tube 20

Test Submission Requirements /Tube Color Special Handling Ionized Calcium 3 ml/green(non gel tube ) /Heparin Deliver on ice ASAP.(Non gel tube) Iron LA (Lactic Acid) 3 ml/green/heparin Deliver on ice ASAP. LD (Lactate Dehydrogenase; LDH) Avoid hemolysis. LH (Luteinizing Hormone) 5 ml/sst Lipase Lipid Profile / Panel (includes: Cholesterol, Trig, HDL, LDL, Risk Fasting required. Ratios) Lithium 5 ml/sst Liver Function / Panel (ALB, ALK PHOS, AST, ALT, T Bili, LD, T Prot) Magnesium Methemoglobin 7 ml/green Deliver on ice. Mini Panel (Na, K, Cl, CO2, BUN, Creatinine, Glucose, Calcium) Mono Spot 5 ml/sst Na (Sodium) O2 Saturation (Oxygen % Saturation) 2 ml/heparinized syringe OB Profile (Includes: HBsAg, CBC, Rubella, RPR, ABORh, Antibody 3ml lavender & 2-6 ml SST Screen) Partial Thromboplastin Time (PTT, APTT) 3 ml/lt blue (4.5 ml/lt blue preferred) ph-arterial 2 ml/heparinized syringe ph-venous 7 ml/green Phenobarbital (Luminal) Phenytoin (Dilantin; Diphenylhydantoin) Phosphorus (PO4) Potassium (K+) Avoid hemolysis. Stable for 4 hours after collection, room Platelet Function Epinephrine 4.5 ml /blue/glass only temperature only, DO NOT SPIN, DO (PFA) NOT Refrigerate Prealbumin Pregnancy (Qual) 5 ml/sst or urine Prenatal HbsAg 5 ml/sst Progesterone 7 ml/sst Prostate Specific Antigen (PSA) 5 ml/sst Protein, Total Prothrombin Time (PT; Protime) 3 ml/lt blue (4.5 ml/lt blue preferred) Deliver to lab ASAP. PSA (Prostate Specific Antigen) 5 ml/sst PTH 5 ml/sst RF (Rheumatoid Arthritis) Rapid Plasma Reagin (RPR) 5 ml/sst Renal Panel (Na, K, Cl, CO2, Glucose, Creat, Uric Acid, Calcium, Phos) Reticulocyte Count (Retic) 3 ml/lavender RPR (Rapid Plasma Reagin) 5 ml/sst 21

Test Submission Requirements /Tube Color Special Handling Salicylate Sed Rate 3 ml/lavender SGOT (AST) SGPT (ALT) Sodium (Na+) T-4, Free (FT4, Free Thyroxine) T-4, Total (Thyroxine) Tegretol (Carbamazepine) Theophylline (Aminophylline) 5 ml/pst /SST Document time last dose. Thyroid Stimulating Hormone Thyroxine (T4) TIBC (Total Iron Binding Capacity) Tobramycin (Nebcin) Peak/trough collection; consult policy. Total Bilirubin Avoid hemolysis. Total Iron Binding Capacity (TIBC) Total Protein Transferrin TSH Uric Acid Urinalysis 3 ml/urine (minimum) Urine Culture 1 ml/urine (minimum) Valproic Acid (Depakene; Depakote) Vancomycin (Vancocin) Peak/trough collection; consult policy; contact nursing staff prior to collection. Vitamin B12 Vitamin B12/Folate Vitamin D (Vit D 25 DH ) Pathology Test Requirements: Routine Histology Formalin 5% Zinc Formalin Routine pickup Frozen section Fresh tissue Call for Stat pickup Chromosome analysis (POC) Fresh tissue Call for Stat pickup Flow Cytometry Fresh tissue Call for Stat pickup Cytology Test Requirements: Body cavity fluid (includes sputum) Fresh fluid- refigerated Routine pickup Fine needle aspiration/biopsy Cytorich fixative Routine pickup Smears/Slides 95% Alcohol fixative Routine pickup CSF Cytorich fixative Routine pickup 22

Appendix B STAT List Orderable Section Turn Around Time FACILITY ABORh Blood Bank 1 hour PMC, POM, PHDC Acetaminophen Level Chemistry 1 hour PMC, POM, PHDC Albumin Level Blood Chemistry 1 hour PMC, POM, PHDC Alcohol Level Blood Chemistry 1 hour PMC, POM, PHDC Alkaline Phosphatase Chemistry 1 hour PMC, POM, PHDC ALT Chemistry 1 hour PMC, POM, PHDC Ammonia Level Chemistry 1 hour PMC, POM, PHDC Amylase Blood Chemistry 1 hour PMC, POM Antibody Screen Blood Bank 1 hour PMC, POM, PHDC AST Chemistry 1 hour PMC, POM, PHDC Beta-Hydroxybutyrate Chemistry 1 hour PMC, POM, PHDC Bilirubin Direct Chemistry 1 hour PMC, POM, PHDC Bilirubin Indirect Chemistry 1 hour PMC, POM, PHDC Bilirubin Total Chemistry 1 hour PMC, POM, PHDC Blood Gas Arterial Chemistry 1 hour PMC, POM, PHDC Blood Gas Arterial Cord Chemistry 1 hour PMC, POM, PHDC Blood Gas Capillary Chemistry 1 hour PMC, POM, PHDC Blood Gas Venous Chemistry 1 hour PMC, POM, PHDC Blood Gas Venous Cord Chemistry 1 hour PMC, POM, PHDC BMP-Mini Panel Chemistry 1 hour PMC, POM, PHDC BNP Chemistry 1 hour PMC, POM Body Fluid Albumin Chemistry 1 hour PMC, POM, PHDC Body Fluid Amylase Chemistry 1 hour PMC, POM Body Fluid Cell Count Hematology 1 hour PMC, POM, PHDC Body Fluid Chloride Level Chemistry 1 hour PMC, POM, PHDC Body Fluid Creatinine Chemistry 1 hour PMC, POM, PHDC Body Fluid Crystal Exam Hematology 1 hour PMC, POM, PHDC Body Fluid Glucose Chemistry 1 hour PMC, POM, PHDC Body Fluid LD Chemistry 1 hour PMC, POM Body Fluid Osmolality Chemistry 1 hour* PMC Body Fluid ph Chemistry 1 hour PMC, POM, PHDC Body Fluid Potassium Level Chemistry 1 hour PMC, POM, PHDC Body Fluid Protein Chemistry 1 hour PMC, POM, PHDC Body Fluid Sodium Level Chemistry 1 hour PMC, POM, PHDC Body Fluid Specific Gravity Hematology 1 hour PMC, POM, PHDC BUN Chemistry 1 hour PMC, POM, PHDC Calcium Level Blood Chemistry 1 hour PMC, POM, PHDC Calcium Level Ionized Chemistry 1 hour PMC, POM, PHDC Carbamazepine Level Chemistry 1 hour PMC, POM Carbon Dioxide Blood Chemistry 1 hour PMC, POM, PHDC Carboxyhemoglobin Blood Chemistry 1 hour PMC, POM, PHDC CBC Hematology 1 hour PMC, POM, PHDC CBC w/ Differential Hematology 1 hour PMC, POM, PHDC Chem Panel Chemistry 1 hour PMC, POM, PHDC Chloride Level Blood Chemistry 1 hour PMC, POM, PHDC 23

Orderable Section Turn Around Time FACILITY CK Chemistry 1 hour PMC, POM, PHDC CKMB Chemistry 1 hour PMC, POM, PHDC Clost difficile tox A/B Ag by EIA Microbiology 1 hour PMC, POM, PHDC Cooximetry Chemistry 1 hour PMC, POM, PHDC Creatinine Blood Chemistry 1 hour PMC, POM, PHDC CSF Cell Count Hematology 1 hour PMC, POM, PHDC CSF Chloride Level Chemistry 1 hour PMC, POM, PHDC CSF Glucose Chemistry 1 hour PMC, POM, PHDC CSF Lactic Acid Chemistry 1 hour PMC, POM, PHDC CSF LD Chemistry 1 hour PMC, POM CSF Protein Chemistry 1 hour PMC, POM, PHDC D-Dimer Coagulation 1 hour PMC, POM, PHDC Digoxin Level Chemistry 1 hour PMC, POM, PHDC Du test Blood Bank 1 hour PMC, POM, PHDC Electrolyte Panel Chemistry 1 hour PMC, POM, PHDC Eosinophil Count Total Hematology 1 hour PMC, POM, PHDC Fibrin Degradation Products Coagulation 1 hour PMC, POM, PHDC Fibrinogen Coagulation 1 hour PMC, POM, PHDC Fibronectin Chemistry 1 hour * PHDC Gentamicin Level Peak Chemistry 1 hour PMC, POM Gentamicin Level Random Chemistry 1 hour PMC, POM Gentamicin Level Trough Chemistry 1 hour PMC, POM GGT Chemistry 1 hour PMC, POM Glucose Blood Chemistry 1 hour PMC, POM, PHDC Gram Stain Microbiology 1 hour PMC, POM, PHDC HCG Qualitative Hematology 1 hour PMC, POM, PHDC HCG Quantitative Chemistry 1 hour PMC, POM, PHDC Hepatitis B Surface Antigen Chemistry 1 hour* POM HIV Rapid 1 & 2 Chemistry 1 hour PMC, POM, PHDC India Ink Microbiology 1 hour* PHDC Influenza A & B by PCR Microbiology 4 hours *PHDC Iron Level Chemistry 1 hour PMC KOH Microbiology 1 hour PMC, POM, PHDC Lactic Acid Blood Chemistry 1 hour PMC, POM LD Blood Chemistry 1 hour PMC, POM Lipase Level Chemistry 1 hour PMC, POM Lithium Level Chemistry 1 hour* PMC Liver Panel Chemistry 1 hour PMC, POM, PHDC Magnesium Level Blood Chemistry 1 hour PMC, POM, PHDC Malaria Smear Hematology 1 hour* PMC Methemoglobin Chemistry 1 hour PMC, POM, PHDC Mono Screen Serology 1 hour PMC, POM, PHDC Osmolality Blood Chemistry 1 hour* PMC Ova and Parasites (Direct Mount Only) Microbiology 1 hour* PHDC ph Blood Venous Chemistry 1 hour PMC, POM, PHDC Phenobarbital Level Chemistry 1 hour PMC, POM Phenytoin Level Chemistry 1 hour PMC, POM Phosphorus Level Blood Chemistry 1 hour PMC, POM, PHDC Platelet Count Automated Hematology 1 hour PMC, POM, PHDC Platelet Function Aspirin Coagulation 1 hour* PMC 24

Orderable Section Turn Around Time FACILITY Platelet Function Epinephrine Coagulation 1 hour PMC, POM Platelet Function P2Y12 (Plavix Inhibitor) Coagulation 1 hour* PMC Potassium Level Blood Chemistry 1 hour PMC, POM, PHDC Procainamide Level Chemistry 1 hour* PMC Protein Blood Total Chemistry 1 hour PMC, POM, PHDC Protime Coagulation 1 hour PMC, POM, PHDC PTT Coagulation 1 hour PMC, POM, PHDC Renal Panel Chemistry 1 hour PMC, POM, PHDC Respiratory Syncytial Virus by EIA Microbiology 1 hour PMC, POM, PHDC Retic Count Hematology 1 hour* PMC,PHDC Rh Typing Blood Bank 1 hour PMC, POM, PHDC Rhogam Workup Blood Bank 1 hour POM, PHDC Rotavirus by EIA Microbiology 1 hour* PHDC Salicylate Level Chemistry 1 hour PMC, POM, PHDC Sed Rate Hematology 1 hour PMC, POM, PHDC Sodium Level Blood Chemistry 1 hour PMC, POM, PHDC Strep Gr A Rapid Immunoassay Microbiology 1 hour PMC, POM, PHDC Theophylline Level Chemistry 1 hour PMC, POM Tobramycin Level Peak Chemistry 1 hour PMC, POM Tobramycin Level Random Chemistry 1 hour PMC, POM Tobramycin Level Trough Chemistry 1 hour PMC, POM Troponin I Chemistry 1 hour PMC, POM, PHDC TSH Chemistry 1 hour PMC, POM, PHDC Type and Cross Blood Bank 1 hour PMC, POM, PHDC Type and Screen Blood Bank 1 hour PMC, POM, PHDC Uric Acid Blood Chemistry 1 hour PMC, POM Urinalysis Screen Dipstick Urinalysis 1 hour PMC, POM, PHDC Urinalysis Sedimentation Microscopic Urinalysis 1 hour PMC, POM, PHDC Urine Drug Screen (In House Test) Chemistry 1 hour PMC, POM, PHDC Valproic Acid Level Chemistry 1 hour PMC, POM Vancomycin Level Peak Chemistry 1 hour PMC, POM Vancomycin Level Random Chemistry 1 hour PMC, POM Vancomycin Level Trough Chemistry 1 hour PMC, POM WBC Smear Microbiology 1 hour PMC, POM, PHDC Wet Mount Microbiology 1 hour PMC, POM, PHDC *1 hour turn-around time if specimen is delivered directly to the performing facility 25

Acetaminophen Level Acetone Albumin Level Blood Alcohol Level Blood Alkaline Phosphatase ALT AST Bilirubin Direct Bilirubin Indirect Bilirubin Total Blood Gas Arterial Blood Gas Venous BMP-Mini Panel BNP BUN Calcium Level Blood Calcium Level Ionized Carbamazepine Level Carbon Dioxide Blood Carboxyhemoglobin Blood CBC CBC w/ Differential Chem Panel Chloride Level Blood CK CKMB Cooximetry Creatinine Blood D-Dimer Digoxin Level Electrolyte Panel Fibrin Degradation Products Fibrinogen Gentamicin Level Peak Gentamicin Level Random Gentamicin Level Trough GGT Glucose Blood Gram Stain HCG Qualitative HCG Quantitative KOH Lactic Acid Blood LD Blood Lipase Level Liver Panel Magnesium Level Blood Appendix C Skilled Nursing Facility Client STAT Services 26

Methemoglobin Mono Screen ph Blood Venous Phenobarbital Level Phenytoin Level Phosphorus Level Blood Platelet Count Automated Potassium Level Blood Procainamide Level Protein Blood Total Protime PTT Renal Panel Respiratory Syncytial Virus by EIA Retic Count Salicylate Level Sed Rate Sodium Level Blood Strep Gr A Rapid Immunoassay Theophylline Level Tobramycin Level Peak Tobramycin Level Random Tobramycin Level Trough Troponin I Uric Acid Blood Urinalysis Screen Dipstick Urinalysis Sedimentation Microscopic Urine Drug Screen (In House Test) Valproic Acid Level Vancomycin Level Peak Vancomycin Level Random Vancomycin Level Trough WBC Smear Wet Mount 27

Appendix D Palomar Health Laboratories Critical Values Table Table 1. Blood Gas, Coagulation, Chemistry, and Hematology Test Unit Critical Values Low High Blood Gases ph, Arterial or Venous N/A <7.20 >7.60 pco2, Arterial or Venous mm Hg n/a >60 po2, Arterial mm Hg <50 N/A Chemistry Calcium, Total mg/dl <6.0 >13.5 CO2 mmol/l <10 >50 Glucose mg/dl <40 >500 Magnesium mg/dl <1.0 >6.9 Phosphorus mg/dl <1.0 > 12.0 Potassium mmol/l < 2.8 > 6.2 Sodium mmol/l <120 >160 Urea Nitrogen (BUN) mg.dl N/A N/A Coagulation Prothrombin Time INR N/A N/A >4.0 Partial Thromboplastin Time (PTT) seconds N/A > 150 Hematology Absolute Neutrophil Count (ANC) X1000 mm3 < 0.5 N/A Hematocrit % <19.8 >70 Hemoglobin g/dl < 6.6 > 23 Platelet X1000 mm3 <20 >1000 White Blood Cells X1000 mm3 < 1.0 N/A Table 2. Therapeutic Drugs Test Unit Therapeutic Drugs Through Peak Gentamicin mcg/ml >2.0 >25 Tobramycin mcg/ml >2.0 >25 Vancomycin mcg/ml >25 >50 Test Unit Potentially Toxic Values Carbamezapine mcg/ml >15 Digoxin mcg/ml >2.2 Lithium mcg/ml >1.5 Phenobarbital mcg/ml >50 Phenytoin mcg/ml >25 Theophylline mcg/ml >20 Valproic Acid mcg/ml >200 28

Table 3. Microbiology Malarial smears - Any positive Blood Culture - Any positive CSF Gram Stain or Culture Any positive Gram Stain or Culture from any sterile body fluid Any positive CSF Latex antigens Any positive India Ink Any positive Gram Stain or culture on tissue abscess or aspirate from a visceral organ (ex. lung, liver, or brain - Any positive Carbapenem resistant Enterobacteriaceae Extended spectrum Beta lactamase producing organism Methicillin Resistant Staphylococcus aureus (MRSA) with a MIC as caused of an infection Vancomycin Resistant Enterococci (VRE) with a MIC as caused of an infection Stool Positive for Clostridium difficile Toxin A and/or B Table 4. Anatomic Pathology All first time malignant diagnoses (with the exception of carcinoma of the skin). Absence of chorionic villi when clinically expected (potential ectopic pregnancy) Change of a frozen section diagnosis after review of permanent sections. Significant unexpected findings and/or significant discordant pre-op and post-op diagnoses. Mycobacterial, fungal or other significant infectious organisms identified on special stains. 29

Palomar Health Specimen Collection Guide Transport Container Test(s) Transport Container Test(s) E Swab Sterile Container Aerobic wound Anaerobic wound Cervical Culture Throat Culture (not rapid Group A screen) Yeast Screen Strep A or B Culture Screen MRSA or VRE Culture Screen NOTE: DO NOT collect body fluid and tissue with a swab, send in sterile container Room Temperature Urine Culture Stool Culture Stool for WBC C.Diff toxin Rapid Rotavirus Ova and Parasites Tissue Culture* Body Fluid* Sputum Nasopharyngeal wash for a. Rapid RSV b. Rapid Influenza A/B Catheter tip* *Room Temperature, all others refrigerate BBL Red Top Double Swab or White Top Single Swab Rapid Group A Strep Vaginal Wet Mount KOH NOTE: DO NOT use for tissue, body fluid or anaerobic wound Room Temperature UTM w/ Flocked Swab Viral culture (DFA or PCR) Mycoplasma culture Ureaplasma culture Chlamydia culture Rapid Influenza A/B Rapid RSV Refrigerate BBL Green Top-Mini Tip Pertussis Culture/DFA/PCR [nasopharyngeal( NP) swab] Eye Culture Urethral Culture NOTE: Collect 1 NP swab for each test method Copan Red Capped Swab with RED Lettering on Plastic Tube Group B Strep Screen by PCR MRSA Nasal Screen by PCR Room Temperature Room Temperature 30

Transport Container Test(s) Transport Container Test(s) Urine C&S Preservative Hemosure Tube Urine for Culture and Sensitivity, not acceptable for urinalysis Note: Fill the tube with urine up to fill line (minimum of 4 ml) Fecal Occult Blood Room Temperature GC/Chlamydia Aptima Collection Kit Nucleic Acid Amplification Test (NAAT) Endocervical or Male urethral swab Urine collect in sterile urine container Refrigerate Rapid Clearview Chlamydia Red Top Copan Swab NO SPONGE in the bottom of container Female Endocervical Specimens ONLY < 24 hours Room Temperature 24 hours Refrigerate Blood Culture Room Temperature Amount per Venipuncture Amount in BACTEC Plus Aerobic Vial Amount in BACTEC Plus Anaerobic Vial 16 20 ml Split equally between aerobic and anaerobic vials 13 16 ml 8 ml 5 8 ml 10 12 ml 5 7 ml 5 ml 3 9 ml entire blood amount 0 Amount in BACTEC Ped Plus < 3 ml entire blood amount Vial 31

Transport Container Test(s) Transport Container Test(s) UA Screen and Culture & Sensitivity Transport Urinalysis w/ culture Urinalysis w/ Culture if indicated Note: Submit both urine cup and urine tube with boric acid (UBOR) to the lab) QuantiFERON-TB Gold Tubes Shake tubes 10 times Refrigerate Urine Cup only Platelet Function Assay (PFA-EPI) AKA Platelet Function Epinephrine NOTE: 4.5 ml GLASS tube only. DO NOT use plastic tubes. DO NOT SPIN Room Temperature Room Temperature Platelet Function PF P2Y12 (Plavix Inhibition) PF Aspirin NOTE: 2.0 ml Special partial fill Blue Top tube DO NOT send platelet function test tubes via pneumatic tube system DO NOT Spin Room Temperature 32