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Patient Cycle

 

Patient Reception

Receptionist will receive patients and request information from patients using the correct request form (with the full approval of the patient, the request form is considered a contract and if finalized to start testing).

            

Patient will either:

·         Hand in an official request from physician.

·         Hand in an insurance form with the requested tests and the clinical history.

·         Or require verbally for tests to be performed, in this case a preliminary clinical history of why tests are done is registered on the request form.

·         Receptionist will fill in the Laboratory request rorm with all patient and test related     information.

 

   

Information required on orders or request forms to include at least the following:

 

1.       Patient Full name: first, middle and surname.

2.       Age and gender.

3.       Referring physician information (if applicable): name and fax number if required.

4.       Phone number: Home, office or mobile.

5.       Patient preparation (e.g. fasting, pregnant) if required.

6.       Other clinical history: diabetic, last dose of drug, supplements intake, smoker, date of birth, gestation, abstinence, medication, LMP, blood group, weight, etc ...

7.       Specimen type / source, amount, time of collection when appropriate.

8.       Collection instructions: preservative, anti-coagulant, refrigeration etc...

9.       Patient ID #, available for previous patients or assigned for new patients.

10.   Additional information required for selecting appropriate tests to ensure accurate test interpretation and reporting of results (for example; race, ethnicity, family history, pedigree).

 

Note: If the patient requires deviations and exclusions from the physician prescription, it is recorded on the patient request form and is reflected in the patient’s examination results.

 

Patient preparation

·         Positive identification: double check the patient’s name by asking for it again and matching it with the labels of blood withdrawal.

·         Position the patient properly on the phlebotomy chair with a stable armrest. The arm should be turned with the ventral surface up.

·         Tie or attach the tourniquet around the patient's arm approximately 3-4 inches above a potential veni-puncture site, usually a half loop is tied so as to allow for rapid release with one hand. Attach the tourniquet tightly but not in a way that is uncomfortable to the patient and not for more than 1-2 minutes as this may cause hemo-concentration (clarify if tests need a tourniquet or not.)

·         Ask the patient to form a fist in order to allow veins to become more prominent.

 

Specimen Collection

After all required information's has been recorded; specimen collection is performed as mentioned earlier. Each specimen has its own criteria and principle:

 

Blood collection

Procedures: 

a.    Adults/children

·         Select the needle/ vaccutainer.

·         Select a vein-puncture site.

·         Perform the vein-puncture.

·         Wear gloves and clean the veni-puncture site with an alcohol pad in a circular motion, from center to the periphery, then wipe it with a sterile dry gauze pad.

·         Stabilize the vein by pulling the skin 1-2 inches below the veni-puncture site with your index finger and thumb.

·         Turn the needle's bevel point upward and insert it gently to the skin and vein at approximately 15-30 degree angle, do not push the needle all through the vein as this may cause vein injury and blood leakage into tissues.

·         For syringes, pull back the plunger of the syringe smoothly and slowly, if the plunger is pulled back quickly and with force this might cause hemolysis.

·         Release the tourniquet, and then withdraw the needle gently while applying clean dry gauze to the vein-puncture site without pressing.

·         After making sure the needle is completely withdrawn ask the patient to press the site firmly and elevate his/her arm in order to enhance tissue thromboplastin to activate coagulation factors.

·         Ask the patient to remove gauze pad and apply a band-aid to the site.

·         Note: inform the patient to remove the band-aid after maximum one hour.

·         Evacuate withdrawn blood into appropriate tubes paying attention to the Order of draw: 

If tests with different blood specimen types are required, follow the proceeding order of blood draw and evacuation:

When using a vacutainer or syringe

1-       Blood culture tube and/or yellow top tube (only drawn by vacutainer)

2-       Sodium citrate tube (i.e. Blue top)

3-       Serum tube with or without clot activator and with or without gel separator (i.e. red, glass or plastic; SST, gold, red-gray marbled)

4-       Heparin tube with or without gel separator (i.e. green top)

5-       EDTA tube (i.e. lavender top)

6-       Oxalate/fluoride-antiglycolytic tube (i.e. gray top)

 

 After veni-puncture:

1. Do not recap the needle prior to disposal.

2. Dispose of the needle in the designated sharps container.

3. Immediately following blood collection, invert the tubes gently and completely 4-5 times at approximately 180 degrees.

4. As soon as possible, set the blood upright in a test tube rack.

 

Note: availability of the vein viewer facilitates veni-puncture by visually aiding vein locations.

b.    Neonates

·         Puncture site: lateral to midline surface of the heel.

·         Procedures:

1. Warm the heel for 3 minutes prior to puncture by rubbing the site gently.

2. Clean the veni-puncture site with an alcohol pad in a circular motion then wipe it with a sterile dry gauze pad.

3. Hold the baby's foot firmly to avoid sudden movement.

4. Using a sterile blood lancet, puncture the site of the heel gently in the appropriate regions.

5. Using a clean, dry cotton pad, wipe away the first drop of blood.

6. Gently and progressively squeeze the heel to let blood out.

7. Collect the blood using capillary tube/s as needed (See Fig.5). Tests run using capillary tubes are total serum bilirubin and packed cell volume only.

8. When finished, elevate the heel, place a piece of dry cotton over the puncture site and hold it in place until the bleeding has stopped.

 

Important notes for phlebotomy:

·      Do not insert the needle in the patient's arm before making sure the veni-puncture site is completely dry.

·         Never draw blood from patients improperly positioned.

·         Never remove the needle before removing the tourniquet, as the pressure caused by the tourniquet may cause vein breakage and blood leakage to other tissues.

·         Do not draw blood from an arm that contains a fistula used for dialysis patients.

·     In neonates and children under 1 year of age, the depth of heel puncture should not exceed 2 mm depending on the skin condition.

·         Never collect blood in expired test tubes.

·         Prior to withdrawal, make sure that the tip of the needle is free of hooks, burrs or any small particles that could obstruct the flow of blood or get into the patient's blood stream.

·         No food, liquid, gum or thermometer should be in the patient's mouth, especially children, at the time the specimen is drawn.

·         Do not recap, bend, break or remove needles form disposable syringes.

 

Note: It is preferable not to redraw blood twice from the same patient, if the first time failed to succeed (unless obligated), always call a colleague. (KPI assigned to help reduce double pricking from occurring).

 

Urine collection (spot/24 hour/cytology)

a.    Spot Urine:

1.       Stick the pre-printed Label on a plastic urine cup with the patient’s name and technician initials.

2.       Ask the patient to void the urine into the urine cup, mid stream.

3.       Testing by strip screening and microscopic examination must be performed within one hour of collection to avoid bacterial and fungal growth, cast decomposition, RBC-lysis and pH changes.

4.       For microbiological examination urine may be stored up to 24 hr at 2 to 8°C.

5.       For determination and differentiation of proteins, urine may be stored up to 1 week at 4 to 8 degrees; but it must not be deep-frozen or stabilized by any chemical additives.

6.       Urine is discarded in the sink when results are released and the cups in the garbage leave water running after urine disposal in the sink.

 

b.    24hr Urine Collections:

1.       Give the patient the 24 hr urine container.

2.       Explain the method of collection as follows; empty the bladder and discard the first sample in the morning of collection (note the time of starting collection). All following urine samples are to be collected in the container provided. In the meantime keep the container in the fridge (or cool place 2-8 degrees Celsius) to avoid bacterial contamination. The next day, collection ends with the first morning urine sample collected in the container (note the time of ending collection).

3.       In addition, give patients the instruction cards if available, and be aware of test requirements.

         

c.    Urine for Cytology:

 Direct the patient to the following (give the 24 hr collection container):

1.    Empty bladder.

2.       Drink one large cup of water every 15 minutes for 2 hours; refrain from going to the toiled during these two hours (be as mobile as possible since it helps collect the cells in urine).

3.       Empty bladder again.

4.       Refrain from going to the toiled for another hour.

5.       Collect the whole sample even if it exceeds the container size (use more than one container).

6.       In addition, give patients the instruction cards if available.

 

Semen collection

       Semen should be collected after a minimum of 72 hours but no longer than 7 days

       of sexual abstinence.

1.       Stick the pre-printed Label on a plastic urine cup with the patient's name and technician’s initials.

2.       Advise the patient to urinate and then wash and dry hands and genitals thoroughly prior to ejaculation to avoid bacterial contamination of semen, plus record ejaculation time.

3.       In case of collecting sample at lab: whole ejaculate should be collected by masturbation into a clean urine cup.

4.       In case of collecting sample at home: whole ejaculate should be collected by masturbation into a clean urine cup. Sample should be delivered to the lab within 15 minutes during which the sample should remain close to body temperature (contain in hands or close to the body).

5.       In addition, give patients the instruction cards if available. 

6.       Semen upon arrival is placed in the incubator at 37°C for analysis.

7.       Semen is discarded in the autoclaved garbage when results are released.

 

Sputum collection

For best results, a series of early morning specimens should be obtained over a period of three consecutive days, submitting one specimen each morning for three days.

1.       Instruct patient to cough deeply (from the diaphragm/ stress to avoid saliva and give sputum).

2.       Collect all sputum in a urine cup that has the pre-printed label of the patient’s name and the technician initials.

3.       Describe how the material should be (watery, mucoid).

 

Stool collection

Stool testing by microscopy examination should be performed within maximum one hour of passing of the stool, since amoebic trophozoites die and become unrecognizable after that.

1.       Stick the pre-printed Label on a plastic stool cup with the patient’s name and technician initials.

2.       Ask the patient to give the sample in the container provided (either at the lab or at home provided the sample given at home is delivered to the lab within half an hour).

3.       Reject samples if:

·         Not in appropriate transport containers.

·         Diapers.

·          Old samples (more than half an hour from collection).

·         Insufficient samples.

4.       For occult blood: ensure patients acknowledge the following:                  

                             ·            Refrain from taking vitamin C three days prior to testing (might lead to a false positive result).

                             ·            Refrain from taking therapeutic iron for the day of collection (might lead to a false positive result).

                              ·            Avoid alcohol, aspirin and gastric irritants intake for the day of collection.

                              ·            Antacids should be avoided (might lead to a false negative result).

5.        Stool is discarded in the garbage when results are released.

 

Blood Culture samples

·      Specific bottles are used for collecting blood by a closed system using vacutainer needles specifically; (iodine and ethanol are used to disinfect area).

·      Place bottles in incubators at 37 degrees until processed.

 

Throat swab collection

Procedure:

1.      In good light, using a tongue depression, examine the throat and mouth.

2.      Look for inflammation, and the presence of any membrane, exudates or pus:   

3.       Swab the affected area using a sterile cotton or alginate wool swab. Take care not to contaminate the swab with saliva. Keep swab in its sterile container.

4.       For 8 hrs before swabbing, the patient must not be treated with antibiotics or antiseptic mouth washes.

5.        Within 2 hours of collection, deliver the swab with a request form to the laboratory. If the collected swab has to be transported from the health center to the laboratory, a suitable transport media is used. When these swabs reach the laboratory they are moistened in sterile nutrient both before being cultured.

 

Histopathology and Cytology Samples

Histopathological examination of tissues starts with surgery, biopsy, or autopsy. The tissue is removed from the body or plant, and then placed in a fixative which stabilizes the tissues to prevent decay. The most common fixative is formalin (10% formaldehyde in water) sometimes in case of cytological slides 96% Ethanol is used for fixation after proper air drying.

         ·            Specimen Reception

Specimens referred to laboratory should be properly handled following the proceeding steps:

 

a)     Copy doctor’s prescription and attach to worksheet.

b)     Upon sample reception, compare name written on request sheet with the sample received:

 

1) Slides

              In case of Pap Smear Slides:

·         Check Last Menstrual Period (LMP) date (Make sure patient is not giving the sample during menses), marital status, number of kids, abortion times (if any) and clinical history, hormonal therapy, (if any).

·         Record number of slides and send asap to the specialized department or

·         perform the following steps if sample is delayed on site:                     

·         Label slides with the patient's name using a diamond pencil, or use a regular pencil in case of frosted end slides.

·         Place all slides in 96% ethanol until staining.

 

            2) Fluid in Syringes/ Containers

               Record volume, color, appearance and clot presence (if any) and send

               immediately for analysis, otherwise need to place specimen in fridge.

                                                                                                         

3) Bacterial Cultures

Make sure the culture plates received are tightly sealed to avoid contamination. 

 

 

Note: Patient consent is needed for drug of abuse related-tests.



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