Haematology & Blood Transfusion Handbook

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Haematology and Blood Transfusion

Haematology and Blood Transfusion Handbook

Version 18 Dec 2020

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Author : Laura Cowell Page 1 of 50

Haematology & Blood Transfusion Handbook

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Contents

General Information……………………………………………………………………………………………………..……..4 Service Overview ............................................................................................................ 4 Contact Information ....................................................................................................... 5

The Clinical Haematology Service ...................................................................... 5 Haematology Management Team - All Sites ...................................................... 6 Laboratory Locations .......................................................................................... 6

Accreditation Status ....................................................................................................... 7 Personal Information Policy ........................................................................................... 7 Complaints/Compliments .............................................................................................. 7

Hospital Blood Transfusion Practitioners……………………………………………………………………………..8 Blood Transfusion Tests and Procedures………………………………………………………………..............10

Group and Save ............................................................................................................ 10 Specimens for Investigation of a Positive Antibody Screen. ........................................ 10 Red blood cells ............................................................................................................. 10 Platelets ........................................................................................................................ 11 Fresh Frozen Plasma ..................................................................................................... 11 Investigation of Transfusion Reactions ........................................................................ 12 Plasma Fractions........................................................................................................... 12 Platelet and Granulocyte Immunology at NHSBT ........................................................ 12 HLA at NHSBT ............................................................................................................... 13 Foetal Typing at NHSBT ................................................................................................ 13 Antenatal Screening ..................................................................................................... 13 Emergency Blood .......................................................................................................... 14

Anticoagulant Service………………………………………………………………………………………….……………..15 Specimen Collection, Labelling and Transport……………………………………………………….…………..16

Specimen Collection ..................................................................................................... 16 Sample and Request Form Labelling ............................................................................ 17 Blood Transfusion test requests................................................................................... 17 Haematology test requests .......................................................................................... 17 Storage and Transport conditions ................................................................................ 19 Pneumatic Tube System (Not Rochdale Infirmary) ...................................................... 20 High Risk Samples ......................................................................................................... 20

Repertoire of Tests and Reference Ranges…………………………………………………..…………………….22 Blood Transfusion test repertoire ................................................................................ 22 Haematology in house test repertoire ......................................................................... 23 Reference Ranges ......................................................................................................... 24 Patient Consent ............................................................................................................ 26 Factors known to affect test performance .................................................................. 26 Additional tests ............................................................................................................ 27

Results…………………………………………..…………………………………………………………………….…………..…28 Specialist test information and procedures………………………………………………..………………..…. 29

Haemoglobinopathy Screening .................................................................................... 29

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Bone Marrow Testing ................................................................................................... 30 Blood Coagulation ........................................................................................................ 30 Major Blood Loss .......................................................................................................... 31 Suspected Bleeding Diathesis....................................................................................... 31 Suspected Disseminated Intravascular Coagulation (DIC) ........................................... 31 Screen for Liver Biopsy ................................................................................................. 31 Heparin Therapy ........................................................................................................... 31 Oral Anticoagulants ...................................................................................................... 31 Thrombophilia screen .................................................................................................. 32 Lupus Anticoagulant Screen ......................................................................................... 33 D Dimer ......................................................................................................................... 33 Factor Assays ................................................................................................................ 33 von Willebrand Screen ................................................................................................. 33 Haemolytic Disorders ................................................................................................... 34 Haematinics assays ....................................................................................................... 34 Erythropoietin Levels ................................................................................................... 34 Blood Film Morphology ................................................................................................ 34 Screening for Malaria and Other Blood Parasites. ....................................................... 35

Quality Control, Assurance and Measurement Uncertainty……………………………………………….35 Quality Control………………………………………………………………………………………………………..36

Quality Assurance ......................................................................................................... 36 Measurement Uncertainty (MU) ................................................................................. 36

Referred Tests.............………………………………………………………………………………………………………..37

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General Information

Service Overview

The Pennine Acute Hospitals NHS Trust (PAT) is one of the largest in the North West and the largest non-teaching hospital Trust in England. It employs over 9,000 staff and provides high quality general and specialist services to approximately 820,000 residents across the north east of Greater Manchester. The Trust currently provides services from three Care Organisations, Oldham (Oldham Royal Hospital), Bury (Fairfield General Hospital) and Rochdale (Rochdale Infirmary). The Trust also provides a range of community services. The Pennine Acute Hospitals NHS Trust and Salford Royal NHS Foundation Trust have recently joined together to create a new Group of hospitals to deliver a variety of local healthcare services; the Northern Care Alliance (NCA). Pathology at Pennine provides services to the Oldham, Bury and Rochdale Care Organisations and also to North Manchester General Hospital and to primary care in the surrounding areas. The Haematology and Blood Transfusion service is provided by a Central Facility located at the Royal Oldham Hospital (TROH) in conjunction with Essential Service Laboratories (ESL’s) located at the Fairfield General Hospital (FGH) and North Manchester General Hospital (NMGH). The service is provided 24 hours a day, 365 days a year by a team of HCPC Registered Biomedical Scientists, Associate Practitioners and Biomedical Support Workers. The laboratories provide a full service between 09:00 hours and 17:00 hours, Monday to Friday excluding public holidays. Outside these hours the service is primarily for urgent work. Samples originating from Rochdale Infirmary are transported and processed at the Central Facility at Oldham, although Point of care testing for full blood count (FBC), INR and D-Dimer is available at Rochdale Clinical Assessment Unit. The Haematology and Blood Transfusion Laboratories within PAT are IBMS (Institute of Biomedical Sciences) and HCPC (Health & Care Professions Council) approved for Training Biomedical scientists.

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Contact Information

The Clinical Haematology Service

The department of Haematology and Blood Transfusion provides a complete clinical referral service for all the hospitals within Pennine Acute Hospitals NHS Trust and an outpatient referral service for General Practitioners. The clinical team consists of the following consultants:

Name Position Telephone

Dr Allameddine Allameddine

Consultant Haematologist Clinical Lead Haematology/Transfusion. Clinical Director of Blood Sciences

0161 778 5033 Internal 75033

Dr David Osborne

Consultant Haematologist Clinical Chair for Pathology

0161 656 1914 Internal 71914

Dr Martin Rowlands

Consultant Haematologist 0161 656 1650 Internal 71650

Dr Hayley Greenfield


Dr Antonina Zhelyazkova

Consultant Haematologist 0161 778 5033 Internal 75033)

Dr Satarupa Choudhuri


Vacancy Consultant Haematologist 0161 627 8387 Internal 78387

Dr Jeyaprakash Ramachandran


All requests for Clinical Haematology advice can be made via switchboard who will contact an appropriate member of the Clinical Haematology team. This applies to all times of the day and not just outside of normal working hours.

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Haematology Management Team - All Sites

Name Position Telephone

Michael Heaton Haematology & Blood Transfusion Service Manager

0161 656 1678 (Internal 71678)

Laura Cowell Technical Manager Haematology (Quality, Coagulation, IT)

0161 656 1763 (Internal 71763)

Jane Nelson Technical Manager Haematology (Automation, Haematinics, Haemoglobinopathies, Health and Safety, Training)

0161 656 1762 (Internal 71762)

Jane Uttley Technical Manager (Blood Transfusion)

0161 656 1761 (Internal 71761)

Laboratory Locations

Hospital Site Address Telephone No - Haematology

Telephone No - Blood Transfusion

Royal Oldham Hospital

Postal Address: Rochdale Rd Oldham OL1 2JH

For Technical Queries: Haematology Lab: 0161 627 8370 or 8371 (Internal 78370/1)

Blood Transfusion lab: 0161 627 8372/3 (Internal 78372/3)

North Manchester General Hospital The ESL Laboratory is located on the main hospital corridor.

Postal Address: Delaunays Rd Crumpsall Manchester M8 5RB

For General Enquiries: 0161 604 5386 (Internal 45386) For Technical Queries: Haematology Lab 0161 604 5387 (Internal 45387)

Blood Transfusion lab: 0161 720 2100 (Internal 42100)

Fairfield General Hospital The Laboratory is located behind the Broadoak Suite adjacent to Fairfield House.

Postal Address: Rochdale Old Rd Bury BL9 7TD

For Technical Queries: Haematology Lab 0161 778 2597 (Internal 82597)

Blood Transfusion lab: 0161 778 2598 (Internal 82598)

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Accreditation Status

The laboratory is UKAS accredited to ISO 15189:2012 (Lab No 8146). An up to date schedule of accreditation is available on the UKAS website: Schedule of Accreditation . The Pennine Pathology Service has taken the decision not to make reference to accreditation on its reports at this time.

Personal Information Policy

Details of how the Trust uses and protects personal information can be found in the link below:http://www.pat.nhs.uk/patients-and-visitors/patient-privacy-notice-how-we-use-share-and-protect-your-personal-information.htm

The Haematology and Blood Transfusion Department adheres to The Pennine Acute Hospitals Trust’s policy on data protection and disclosure. For further details see the Trust’s Information Governance Policy EDI001. We hold personal data for the purposes of providing patients with appropriate care and treatment. This helps to ensure that patients receive the best possible care from us. All members of staff working in the NHS and other healthcare organisations have a legal duty of confidentiality to keep your information strictly confidential. Everyone working for this organisation is subject to the Common Law Duty of Confidence. Information provided in confidence will only be used for the purposes advised and consented to by the patient.

Complaints/Compliments

Complaints or compliments can be raised by contacting a member of the Haematology Management Team. Users are encouraged to use the DATIX systems where possible, to register non-conformances. Complaints are received in the Pathology department either via the Trust complaints department, Patient advice and liaison service (PALS), DATIX incident reporting or individually by letter, telephone or email to a member of staff. The department follows the Trust Complaints Handling Policy NCAG005(19)

https://www.ukas.com/wp-content/uploads/schedule_uploads/00007/8146%20Medical%20Multiple.pdf

http://www.pat.nhs.uk/patients-and-visitors/patient-privacy-notice-how-we-use-share-and-protect-your-personal-information.htm

http://www.pat.nhs.uk/patients-and-visitors/patient-privacy-notice-how-we-use-share-and-protect-your-personal-information.htm

http://nm-ashanti.pat.nhs.uk:86/DMS/DesktopModules/WroxDocs/ViewDocument.aspx?ItemID=524&mid=9000&key=524

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Hospital Blood Transfusion Practitioners The Trust has a team of Blood Transfusion practitioners, an assistant transfusion practitioner, cell salvage coordinator and admin support. Contact details for the team are in the following table.

Name Position Site Telephone

Sue Andrews Transfusion Practitioner Royal Oldham Hospital

07870692823 Internal 78790

Christopher Porada

Transfusion Practitioner Fairfield General and Rochdale Infirmary

07870693110 Internal 83825

Kaiser Mushtaq

Transfusion Practitioner North Manchester General

07970603681 Internal 42797

Deborah Curley

Assistant Transfusion Practitioner

All Sites 07854764557

Jo Ann Bayliss

Cell Salvage Coordinator All Sites Bleep #7755

Margaret Hardy

Blood Transfusion Secretary

All Sites 0161 6561260 Internal 71260

The Trust has a Trust Transfusion Committee (TTC) that aims to achieve better co-operation, communication and closer working relationships between the Blood Transfusion Department and the users of the service to improve Transfusion practice and improve patient safety. Each of the Trust Clinical Divisions are represented to ensure that relevant transfusion related issues are raised, discussed and where appropriate policies amended or produced to maintain and improve quality standards and patient safety. The role of the Transfusion Practitioner is to educate and train trust staff in Transfusion practice and promote a safe and effective service for all patients who require the transfusion of blood and blood products. Duties include: - Provision of education, competency assessment and practical support to all staff

involved in the transfusion chain. Act as the key person relating to the Trusts Risk Management Strategy. Identifying areas suitable for research and audit and taking appropriate action in

accordance with the findings of the audit. Development and implementation of policies following national and local guidelines that

are designed to ensure the delivery of a safe and effective transfusion service.

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The policies that have been produced are available on the Trust Intranet Documents in the Blood Transfusion folder and are as follows - list not exhaustive:

Indications for red cell transfusion - the green policy: EDC007

Requesting, collecting and labelling of a blood sample for transfusion tests, which generate a blood group. EDC012

The Administration of Blood Components Policy: EDC006

Management of Massive Blood Loss: EDC 009

Guidelines for the Use of Platelet Transfusions in adults & children/neonates: CPDI011

Policy for the use of Fresh Frozen Plasma Components CPDI 012

Guideline for special requirements for blood components CPDI036

Policy - Management of Transfusion Reactions: EDC 005

Policy for the use of Blood and Blood Components on the Neonatal Unit CPDI026

Protocol for the use of Human Albumin 5% & 20%. CPDI 137

Policy – Transfer of Blood and blood components between hospitals within the Trust and other hospitals: CPDI043

Guideline – Bleeding in patients receiving antithrombotic agents or who require emergency/elective anticoagulant reversal – CPDI 201

Policy - The Management of all Patients Who Decline Blood Components, including Jehovah’s Witnesses: CPDI064

Collection of Blood Components, EDC011 Cell Salvage Intra operative cell salvage services are available within the Trust. For further information please contact Jo-Ann Bayliss, Cell Salvage Coordinator via Trust switchboard on bleep #7755.

http://nm-ashanti:86/DMS/Default.aspx?tabid=8466&pnode=1&cnode=28&snode=1&seltype=2

http://nm-ashanti:86/DMS/Default.aspx?tabid=8466&pnode=1&cnode=28&snode=1&seltype=2

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Blood Transfusion Tests and Procedures

Group and Save

Samples sent for Group and Save are processed for a blood group and antibody screen and then retained for seven days for identification and record keeping purposes. However, validity of retained samples for blood product issue is dependent upon blood transfusion history and obstetric status. Please see document Requesting, collecting and labelling of a blood sample for transfusion tests, which generate a blood group EDC012 on Trust Intranet Documents for further information. Pre-operative samples needed for scheduled procedures must have the date of operation clearly indicated on the request card. Samples are kept for 7 days, day one being the day taken.

Specimens for Investigation of a Positive Antibody Screen.

Occasionally when a patient develops an antibody it may be necessary to send further samples to NHSBT for evaluation and confirmation. The samples are requested by the laboratory staff, who then arrange the transportation to the appropriate centre. The availability of results depends on the complexity of the testing. NHSBT normally issues 95% of reports for all red cell investigation (RCI) tests within 5 working days of receipt of sample except in cases where more complex antibody investigations are encountered or where extensive testing is required. In these cases the Transfusion laboratory will be notified. RCI will prioritise investigations according to the clinical requirements of the case. In the case of an antenatal patient, paternal samples may be requested and a regime of follow up testing for the mother may be implemented.

Red blood cells

Allocated blood is kept in the Blood bank issue fridges at various locations. The blood is reserved until the morning of the second day post stated date required, then returned to the laboratory and returned to stock. If the operation is cancelled or delayed, please inform the Blood Transfusion department in order to facilitate any change. Once a blood transfusion has commenced the total crossmatched blood MUST be used within 48 hours. Timings of samples suitable for crossmatching must comply with BSH Guidelines 2012.

Patients transfused within 90 days or pregnant - the sample must be taken no more than 3 days before transfusion.

Patient’s transfusion more than 90 days-the sample must be taken no more than 7 days before transfusion. This enables the laboratory to assess the antibody status of the patient.

Blood is collected from the Blood bank issue fridges by trained nursing staff and porters who must bring the appropriate patient identification documentation. Refer to document Policy

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for the collection of red cells from the blood bank fridge, EDC011 on Trust Intranet for further information. NB: For the issue of any group specific blood product two blood groups are required from two separate samples taken at two different bleeds. Take one sample initially and if a further sample is required the laboratory will contact the ward to request another group and save sample

Platelets

Two blood group results from two different group and save samples will be required to be on record before platelets can be issued.

Pooled platelet concentrate, leucocyte depleted (random donor) ABO and Rh specific, supplied by NHSBT already pooled from 4 donors, approximate volume 300ml, content of platelets >240 x 109 per donation.

Platelet apheresis, leucocyte depleted (single donor) ABO and Rh group specific, supplied as one pack collected by cytophoresis from a single donor. Volume 200-300ml, content of platelets >240 x 10 9 approximately equivalent to 4 single donations. These are also available as HLA/HPA antigen matched donors, which may be effective in patients who do not respond to platelets due to HLA or HPA antibodies. Crossmatched platelets may be indicated in certain instances – donors are selected by a test for reaction with recipients’ plasma. HLA/HPA matched and crossmatched platelets will need at least 24 hours’ notice to order as they are ordered in specifically from NHSBT.

Refer to document Guidelines for the Use of Platelet Transfusions in adults & children/neonates: CPDI011 on Trust Intranet Documents for further information.

All platelet packs must be stored at room temperature 20-24oC with constant agitation and must not be refrigerated. Platelet packs should be infused over a period of 30 minutes. A fresh standard giving set should be used and will be issued with the platelet pack by the laboratory.

Fresh Frozen Plasma

Two blood group results from two different group and save samples will be required to be on record before FFP can be issued.

Fresh frozen plasma, leucocyte depleted (random donor) ABO and Rh group specific, approximate volume 150-300ml plasma containing CPDA, which contains normal plasma levels of stable clotting factors, albumin and immunoglobulin. They do not contain platelets. Stored in the Blood bank at –25oC and 40 minutes is required to defrost each request. Must then be used within 4 hours if stored at 20-24 oC or 24 hrs if stored at 4 oC in a designated Blood bank refrigerator.




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Refer to document Policy for the use of Fresh Frozen Plasma Components CPDI 012 on Trust Intranet Documents for further information.

Octaplas ( Solvent Detergent Treated Human Plasma ) Octaplas is also suitable for patients born after 01/01/1996. It is also indicated for use in plasma exchange in patients with thrombotic thrombocytopenic pupura (TTP). Octaplas is allocated on each site for emergency use.

Cryoprecipitate, leucocyte depleted A cryoglobulin fraction of plasma containing concentrated FVIII:C and VW factor, fibrinogen, FXIII and fibronectin. Stored in the Blood Bank at -25oC. Must be kept at 20-24oC and transfused within 4 hours of thawing.

Granulocytes

Pooled granulocytes from 10 single packs used for supportive therapy in patients with neutropenia – 24hr shelf life stored at 22 ± 2°C.

Investigation of Transfusion Reactions

In the event or suspicion of a transfusion reaction, please contact the department. A transfusion investigation form must be completed and the relevant sample taken to investigate further and the unit returned to the laboratory. Refer to document Management of Transfusion Reactions: EDC 005 on Trust Intranet Documents for further information

Plasma Fractions

Human Prothrombin Complex, Fibryga, Recombinant factor VIIa and other coagulation factor concentrates Requests for these products should be made via a Consultant Haematologist. Consultant not required in cases of suspected Intracranial haemorrhage. C1 Esterase Inhibitor These products are not kept in stock but can be made available through the Transfusion Laboratory at the Royal Oldham site. All requests for these products should be made via a Consultant Haematologist.

Platelet and Granulocyte Immunology at NHSBT

Various platelet and granulocyte immunology investigations are available from Bristol NHSBT. Details of sample type and request form are available from the laboratory; please contact us if you need assistance. Turnaround time from reference laboratory - In 90% of cases the NHSBT aim to issue reports within 14 working days from receipt of samples. If further investigations are required the turnaround time may extend to 21 working days.




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HLA at NHSBT

HLA typing is sent to Barnsley NHSBT. A request card can be obtained from the Blood Transfusion department. Once completed, please return to the laboratory who will forward to Sheffield. In 90% of cases reports are issued within 5 working days from receipt of the samples in the lab, for example HLA and other immune polymorphism typing. A longer turnaround time may apply to investigations of other immune polymorphisms. HLA specific antibody test reports for patient’s refractory to platelet transfusion will normally be issued within 7 days. Drug dependent antibody screens (other than HIT) will be issued within 20 working days. Urgent HIT test results can be faxed within approximately 3 hours of receipt of samples.

Foetal Typing at NHSBT

Testing of foetal samples may be required when Haemolytic Disease of Foetus and New-born or Neonatal Alloimmune Thrombocytopenia is suspected. For this specific testing please contact the laboratory in advance to discuss samples required and timing of samples. In some cases of suspected HDFN, maternal samples can be used to test for cell free foetal DNA in order to predict the genotype of the foetus.

Antenatal Screening

The Antenatal protocol is as follows: Booking Bloods at 12 weeks for blood grouping and antibody screening, follow up bloods at 28 weeks for all patients. If antibodies are detected at either screening a regime of follow up testing may be implemented. The samples will be referred to Liverpool NHSBT (NHS Blood and Transplant Service) for confirmation and monitoring. Depending on the antibody specificity it may be necessary for paternal samples to be requested. All RhD Negative women and RhD Positive women with antibodies present require cord and maternal samples to be sent to the laboratory at the time of delivery. Routine Antenatal Anti D Prophylaxis (RAADP) In accordance with NICE guidance issued in 2002, Pennine offers routine Anti D prophylaxis to pregnant RhD Negative women. The Obstetricians have taken the decision to use a single dose of 1500iu anti-D at 28 weeks. All RhD Negative mothers are identified from the initial blood grouping and booked into a dedicated weekly clinic at each site where the Anti D is administered after the 28 week follow up bloods have been taken. Potentially Sensitising Events In addition to RAADP, Anti D immunoglobulin should be administered to pregnant RhD Negative women following any potentially sensitising event.

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500iu Anti D is required as a standard initial dose and a Kleihauer should be performed after 20 weeks gestation to assess the size of any bleeds. Anti-D must be given as soon as possible and always within 72 hours. For bleeds of >4mls red cells, extra Anti-D must be given (dose will be advised according to the result) and a repeat Kleihauer required 48 hours after the initial anti-D injection in order to assess whether further anti-D is required .

Emergency Blood

Around the 4 hospital sites there are satellite Blood bank fridges that hold emergency O RhD negative blood for emergency use only. As per policy EDC009 Management of Massive Blood Loss emergency blood is available on request from the Blood Transfusion laboratory. In cases of major haemorrhage blood samples should be taken at the earliest opportunity for: - Group, Antibody screen and crossmatch, Full Blood Count, Coagulation screen (PT & APTT) including fibrinogen estimation and Biochemistry - U&E Parameters should be checked frequently, at least four hourly or after each therapeutic intervention.


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Anticoagulant Service The Anticoagulant service offered varies across the hospital sites. The anticoagulant services for Royal Oldham Hospital and Fairfield General Hospital are provided by IntraHealth and are not provided on site. The contact details are: Intrahealth: Tel 0191 5181656 Fax 0191 518 1656 North Manchester General Hospital and Rochdale Infirmary have nurse led Anticoagulant services. The clinics, some of which are community based, use Roche Coagucheck Xs handheld near patient testing devices (capillary samples). The contact details are: North Manchester General Hospital Anticoagulant Service: Tel: 0161 720 4772 Fax: 0161 720 2274 Rochdale Anticoagulant Service: Tel: 01706 517446 Fax: 01706 517363

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Specimen Collection, Labelling and Transport

Specimen Collection

Please see the trusts venepuncture policies NCAIC001(19) Venepuncture in Adults and CPWC181 Neonatal cannulation and Venepuncture for information on the venepuncture procedure. The trust uses the Monovette blood collecting system comprising a combined syringe/container and a needle with valve for multiple samples instead of the conventional syringe and needle. Details of how to use the system can be found in the policies above. The trust recommends either of the following orders of draw. This is essential to avoid sample contamination and erroneous results. It is recommended to draw a discard tube first when a citrate sample is required.



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Sample and Request Form Labelling

Blood Transfusion test requests

Please note there is a separate policy for labelling blood transfusion samples. For all Blood Transfusion requests please refer to the following policy - Requesting, Collecting and Labelling of Blood Samples for Transfusion Tests which generate a Blood Group, available here: EDC012 - Requesting, Collecting and Labelling of Blood samples for Transfusion Tests which generate a Blood Group

Haematology test requests

Haematology requests are made using the Healthviews electronic ward ordering application or manually by using one of the red Haematology/Biochemistry/Immunology request cards. GP requesting is almost exclusively on the TQuest electronic GP ordering system or, as a back-up, by the Haematology/Biochemistry/Immunology request cards. In the event of any of the electronic systems being unavailable the request card should be used as a contingency. Electronic requests are encouraged where possible.

All requests must conform to the Pathology Labelling and Safe Handling of Samples and Request Forms Policy available here: CPDI061 - Policy for Labelling and Safe Handling of Pathology Samples and Request forms. Adherence to the labelling policy is crucial to ensure patient safety. Failure to follow the policies can lead to the incorrect diagnosis, the wrong treatment and patient harm.

On the Haematology request card a mark should be made clearly in the box opposite the required test. There is space for writing any additional tests which are not listed. To permit processing on the departmental computer system and facilitate enquiry for results on ward terminals, the patient's date of birth, hospital number (including any prefix letter with a total of 8 numeric characters) and name must be printed clearly. For HealthViews or TQuest ordering, labels printed in the presence of the patient containing the barcode must be used. When using the request card independent of an electronic ordering system, addressograph labels can be used for the card but the sample bottle MUST be completed by hand. In addition to ensuring that the patient identifiers are correct it is essential that the name of the healthcare professional requesting the examination is clearly identified on the request card. In a large organisation there can be a number of requestors with the same or similar names and the person making the request is the person responsible for accessing and acting upon the results of that examination. Labels generated whilst in the presence of the patient using a unique label printer are acceptable; these must contain all of the required information for sample labelling and must only cover the tube manufacturer’s primary label. If you are considering introducing a system please inform the Pathology department. ** In certain circumstances Unique Coded





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identifiers might be used e.g. GUM patients, major incidents and when a name is unobtainable. Please ensure any barcode labels applied to samples, such as those generated via T quest or Healthviews labels, are placed on the samples in a way that clearly identifies the sample and is readable by our analysers (see below for examples). Problem barcodes as indicated by the red crosses below will be delayed or maybe rejected.

Specimen and request cards not meeting the minimum required criteria for identification will not be processed, these samples will be retained for an appropriate period. It is not always possible to inform the requestor by telephone of this outcome. If the request is marked urgent the requestor will be informed. Routine Hospital Specimens A limited Phlebotomy Service is available for complex patients who meet a specific criteria at the Oldham site. Please discuss via the hospital switchboard if required. Only staff that have undertaken a venepuncture-training programme or have been assessed as competent should collect blood samples. If a needle-stick injury is sustained, it is essential to follow the Trust Accidental Inoculation Policy CPDI018 without delay. The Trust Accidental Inoculation Policy CPDI018which can be found on the Trust intranet.



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Storage and Transport conditions

Pennine GP work is tested at the Oldham Laboratory. The Trusts own internal transport system is in place to transport samples regularly from Rochdale Infirmary, Fairfield and North Manchester Hospital to the centralised lab at the Oldham site. In addition, the Trust provides a GP collection system for samples from GP surgeries within the North Manchester, Heywood Middleton and Rochdale and Bury CCG. SRCL services provide GP sample collection for GP surgeries within Oldham CCG.

All specimens whilst awaiting transportation must be stored in a safe manner ensuring patient and sample confidentiality and minimising the risk of sample deterioration. Containers should comply with a recognised British Standard, be robust and leak proof in normal use. Following collection and labelling, specimens should be placed in an individual transparent plastic bag and sealed. Staples, pins and metal clips must not be used for this purpose.

The container must have been closed securely and not be contaminated on the outside. Under no circumstances should anyone transport specimens in their hands or pockets.

Carriers should:

Not be used for any other purpose than carrying specimens.

Not be over filled.

Be cleaned and disinfected regularly and always following contamination.

The outside of the carrier should be marked with appropriate Biohazard information,

Arrangements should be in-place to ensure that samples are transported to the laboratory as soon as possible to avoid deterioration. Routine scheduled sample collections times or instructions for urgent collection should be in place.

Each Clinic and GP surgery must identify a collection point for specimens. The collection point should ensure confidentiality of patient and sample details and be of ambient temperature. Specimens must not be stored in extreme temperatures. Each collection point should have a Transport Collection Box.

Extremes of temperature can affect the results received from patient samples, and specimen deterioration by heat or cold conditions should be avoided.

Refer to your local policy for safe disposal of materials used in the collection of specimens. The laboratory follows the policy for Treatment and Disposal of laboratory waste where all infectious clinical waste, chemically contaminated waste and anatomical waste follows the ‘Yellow Waste Stream’ using the yellow clinical waste sacks.

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Pneumatic Tube System (Not Rochdale Infirmary)

This system allows the rapid transport of specimens from wards and units to the Pathology Department. Wherever possible urgent specimens should be sent via the pneumatic tube system. Precious samples, such as Bone Marrow/CSF, and suspected or confirmed category 4 pathogens must not be transported via the pneumatic tube. It is important when using this system for the rapid transport of specimens to ensure that all specimen containers provided are used in the correct manner and that the lids are fastened securely. Any leaking specimen leads to a delay in processing the sample and creates a hazard to the laboratory staff that has to handle the specimen. Incorrectly closed canisters jam the system, as does inserting two canisters at a time. If you receive canisters from other stations, you must return them to their parent station immediately. Please note that in the event of pod system breakdowns there is a Trust Contingency Plan. Estates are responsible for the pod system – please contact estates on 44646 or report via the portal

High Risk Samples

To conform to the guidelines issued by the Advisory Committee on Dangerous Pathogens to prevent infection in clinical laboratories and post mortem rooms the co-operation of all staff involved in ordering requests and taking blood is essential. Micro-organisms, viruses, materials etc., are classified into four groups according to the level of hazard they present and the minimum safety conditions for handling them. The four groups are described below. Categorisation of Biological Agents according to Hazard and Categories of Containment - 4th edition 1995): Group 1 A biological agent unlikely to cause human disease. Group 2 A biological agent that can cause human disease and may be a hazard to employees; it is unlikely to spread in the community and there is usually effective prophylaxis or effective treatment available. Group 3 A biological agent that can cause severe human disease and presents a serious hazard to employees. It may present a risk of spreading to the community but there is usually effective treatment or prophylaxis available Group 4 A biological agent that causes severe human disease and is a serious hazard to employees. It is likely to spread to the community and there is usually no effective prophylaxis or treatment;

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Group 4 Pathogens

Arena viruses: Junin, Lassa, Machupo and Mopeia viruses

Bunya viruses: Congo, Crimean haemorrhagic fever, Hazara

Filo viruses: Ebola, Marburg viruses

Tick-borne viruses: Kyasanur Forest Disease, Omsk haemorrhagic fever, Absettarov, Hanzalova, Hypr, Russian spring-summer encephalitis.

Clinical advice regarding high risk specimens

Group 4 Pathogens

Dr Joel Paul Consultant Virologist and/or the Microbiology Department should be consulted regarding such specimens, as should the Infectious Disease Physicians. There are no facilities within the Pennine Acute Hospital Laboratories for the handling of specimens suspected of containing Group 4 pathogens.

Patients suspected of having a Viral Haemorrhagic Fever (VHF), as a consequence of virus’s such as Ebola, may present themselves at any of the hospitals within Pennine Acute Trust and in particular at NMGH where the Infectious Diseases (ID) unit is based. The Haematology dept. is responsible for baseline testing of samples for the presence of Malarial Parasites and a Full Blood Count. They are also responsible for packaging samples for VHF testing at the Rare and Imported Pathogens Laboratories (RIPL) at Porton Down or Colindale. The laboratory has its own policy for the management of VHF samples. If VHF is suspected contact the ID team and refer to the Trust Policy:- Integrated Care Pathway for Patients Assessed as Being at Risk of Viral Haemorrhagic Fever

MERS-CoV – All suspected cases are to be discussed with the Infectious disease registrar and the laboratory must be informed.

Group 3 Pathogens

All specimens containing, or suspected of containing, organisms or viruses in Group 3, or from patients in the categories listed, must be labelled using the yellow BIOHAZARD labels both on the specimen container and request form by the person requesting the investigation. The nature of the BIOHAZARD must be specified on the request form.



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Repertoire of Tests and Reference Ranges

Blood Transfusion test repertoire

Request Specimen Container

Required volume (mls)

Routine Turnaround Time

Group & Save EDTA 7.5 24 hours

Crossmatch EDTA 7.5 4 hours

Fresh Frozen Plasma If patients group unknown

EDTA 7.5 45 minutes

Platelets If patients group unknown

EDTA 7.5 6 hours

Direct Antiglobulin Test

EDTA 2.7 24 hours

Ante Natal Screen EDTA 7.5 24 hours

Kleihauer EDTA 2.7 24 hours

Paternal Testing EDTA 7.5 8 days

NAIT- Foetal Genotyping EDTA/ Clotted

Maternal 6ml EDTA plus 6ml clotted sample Paternal 6ml EDTA Neonatal 1ml EDTA

8 days

Specimens For Investigation Of Positive Antibody Screen

EDTA 7.5 x 2 8 days

HLA Typing EDTA 7.5 8 days

HLA Antibody Investigation

Clotted 5.0 10 days

Cord and Maternal Investigation EDTA Maternal EDTA Cord

7.5 x 2 4.9

24 hours

Transfusion Reaction Investigation EDTA 7.5 24 hours

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Haematology in house test repertoire

Request Specimen Container

Required Volume

Paediatric Bottle

Available

Routine Turnaround

Time

FBC with Differential Red Top EDTA 2.7ml Yes <24 hours

Manual Differential Red Top EDTA 2.7ml Yes Urgent MD within 24hrs

Reticulocyte Count Red Top EDTA 2.7ml Yes <24 hours

Malarial Parasite Screen Red Top EDTA 2.7ml Yes <24 hours

Haemoglobinopathy Screen Red Top EDTA 2.7ml Yes 3 days

Paul Bunnell/Glandular Fever Screen Red Top EDTA 2.7ml Yes <48hours

G6PD Screen Red Top EDTA 2.7ml Yes <72 hours

Sickle Cell Screen Red Top EDTA 2.7ml Yes <24 hours

Plasma Viscosity Red Top EDTA 2.7ml No <72 hours

ESR Red Top EDTA 2.7ml No <24 hours

Serum B12 and Folate Brown Top Gel 7.5ml Yes 3 days

Intrinsic Factor Antibodies Brown Top Gel 7.5ml Yes 3 days

Serum Ferritin Brown Top Gel 7.5ml Yes 3 days

Erythropoietin levels Brown Top Gel 7.5ml Yes <21 days

Prothrombin Time and INR Green top Citrate 3ml Yes <24 hours

APTT/Thrombin Time Green top Citrate 3ml Yes <6 hours

D-Dimer Green top Citrate 3ml Yes < 4 hours

Thrombophilia Screen, includes:- Functional Antithrombin activity, Functional Protein C, Activated Protein C resistance ratio, Free protein S

Green top Citrate 3 x 3ml Yes <14 days

Lupus anticoagulant test Green top Citrate 2 x 3ml Yes <14 days

Individual Factor Assays ( F2 to F13) Green top Citrate 2 x 3ml Yes <7 days

Factor V (five) Leiden and Prothrombin Gene Variant

Citrate or EDTA 3ml or 2.7ml EDTA

Yes <3 days

Heparin assay or Anti XA assay Green top Citrate 3ml Yes <3 days

von Willibrand Screen, Includes:- von Willibrand Factor Antigen, Ristocetin Cofactor & Factor VIII

Green top Citrate 3 x 3ml Yes < 4 weeks

A/E routine tests are processed in less than 60 minutes. This is in line with our Key Performance Indicator (KPI’s) 6.8 A&E blood sciences turnaround times. KPIs have been developed to assist laboratories in demonstrating their contribution to patient management pathways. The KPIs should provide evidence of conformity with standards of accreditation and, through discussion with users of the service, will facilitate demand management and support a clinically effective service.

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Reference Ranges

FBC and White Cell Differential

Test/Age 0-24hrs

1 day- 1 Week

1 Wk – 2 Wks

2 Wks -2 Mths

2 Mths - 6 Mths

6 Mths - 1 Year

1-2 Years 2-6 Years

6-12 Years

12-18 Years Female

12-18 Years Male

18-120 Years Female

18-120 Years Male

Hb g/L

140- 220

130- 210

125-205 90- 135

100- 141

100- 141

100- 148

110- 148

111- 147

121- 151

121- 166

115 – 165

130 – 180

WBC X10

9/L

10-26 6-21

6-21

5-18

5-17

5-17

5-17

6-17

4.5-14.5 4.0-11.0

4.0-11.0

4.0-11.0

4.0-11.0

PLT X 10

9/L

150-450

150-450

150-450

150- 450

150- 450

150-450

150-450

150-450

150- 450

150- 450

150- 450

150-450

150-450

RBC X10

12/L

3.8- 6.5

3.2-6.4

3.2- 6.4

2.6 4.3

3.6- 5.0

4.1- 5.3

4.0- 5.0

3.9- 5.0

3.9- 5.2

4.1- 5.1

4.2- 5.6

3.8-4.8

4.5-5.5

Hct l/l

0.45- 0.67

0.42-0.66 0.39- 0.63

0.28- 0.42

0.30- 0.41

0.30-0.41 0.31-0.43 0.32-0.40 0.32-0.43 0.35-0.44

0.35-0.49

0.37–0.47

0.40-0.50

MCV fL

98- 130

88-120

88- 120

77- 115

72- 95

73- 92

73- 90

72- 87

76- 90

77- 95

77- 95

80-100

80-100

MCH pg

31.0- 39.0

28.0- 37.0

27.0- 36.0

29.0- 34.0

25.0- 33.0

24.0- 32.0

23.0- 32.0

24.0- 32.0

24.0- 32.0

27.0- 33.0

27.0-33.0

27-32

27-32

MCHC g/L

300- 360

280- 360

280- 360

280- 360

300- 360

300- 360

300- 360

300- 360

310- 360

315- 350

315- 350

315 – 350

315 – 350

Neutrophils X 10

9/L

4.8- 17.1

1.8- 8.0

1.5- 6.0

1.0- 9.0

1.0- 8.5

1.5- 8.5

1.5- 8.5

1.5- 8.5

1.5- 8.0

1.5- 7.5

1.5- 7.5

2.0-7.5

2.0-7.5

Lymphocytes X 10

9/L

2.0- 7.3

2.8- 9.1

2.8- 9.1

3.3- 10.3

3.3- 11.5

3.4- 10.5

3.0- 9.5

1.8- 8.4

1.5- 7.6

1.5- 4.5

1.5- 4.5

1.0-4.0

1.0-4.0

Monocytes X 10

9/L

0.1- 1.9

0.1- 1.7

0.1- 1.7

0.1- 1.7

0.2- 1.3

0.2- 1.3

0.2- 1.3

0.2- 1.3

0.2- 1.3

0.2- 1.3

0.2- 1.3

0.2-0.8

0.2-0.8

Eosinophils X 10

9/L

0.0- 0.9

0.0- 0.9

0.0- 0.9

0.0- 0.9

0.0- 0.9

0.0- 0.9

0.0- 0.9

0.0- 0.9

0.0- 0.9

0.0- 0.4

0.0- 0.4

0.0-0.4

0.0-0.4

Basophils X 10

9/L

0.0-0.2

0.0-0.2

0.0- 0.2

0.0- 0.2

0.0- 0.2

0.0- 0.2

0.0- 0.2

0.0- 0.2

0.0- 0.2

0.0- 0.2

0.0- 0.2

0.0-0.2

0.0-0.2

RETICS X 10

9/L

110- 450

10- 80

10- 80

45- 210

30- 120

40- 100

40- 100

40- 100

40- 100

40- 100

40- 100

40-100

40-100

RETICS %

3.0- 7.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2- 2.0

0.2-2

0.2-2

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Test Reference Range

PV (Plasma Viscosity) 1.50 – 1.72 mPas

*ESR Male 2-10 mm/hour Female 5-15 mm/hour

HbA2 1.9 – 3.5%

HbF 0.5 – 1.5%

INR Dependent upon reason for Anticoagulation Low level target Higher level target

2.5 3.5

*Prothrombin Time 9.7-14.1 secs

*APTT 25.1-36.5 secs

*Clauss Fibrinogen 2.0-3.9g/l

D-Dimer 0-230 ng/ml

Protein S Female 54.7-123.7 iu/dl Male 74.1-146.1 iu/dl

Protein C 70 – 140 iu/dl

Antithrombin 83–128 iu/dl

Factor Assays II, V, VII, VIII, IX, X, XI, XII

Female and Male 50-150 iu/dl for Factors II, V, VII, VIII, IX, X Female and Male 55-155 iu/dl for Factor XI Female and Male 50-150 u/dl for FXII For referred Factor assays, please see individual referral report

von Willibrand Factor Antigen VWF: Ag 42.0 – 176.3 iu/dl

Ristocetin Cofactor VWF: RiCo 48.2 -239.8 iu/dl

APCR (Screening test for FVL mutation) >2.0

Serum B12 150 – 620 ng/l

Serum Folate 3.1 – 19.9 ug/l

Serum Ferritin Note: These reference ranges relate to non-pregnant females. In pregnancy the suggested ferritin reference range is 30-200ug/L.

10 - 100 ug/l <10yrs 15 - 200 ug/l (F)10-50yrs 20 - 300 ug/l (F) >50yrs 20 - 300 ug/l (M) >10yrs

Erythropoietin levels 2.59-18.50 mIU/ml

* See electronic or paper copy of the report for age/sex specific reference ranges

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Patient Consent

The laboratory staff have no involvement in direct collection of samples from patients. This is carried out by the clinicians and HealthCare workers requesting the tests. It is assumed that arrival of a sample at the laboratory only occurs once the patient has consented to be tested for the investigations requested.

Factors known to affect test performance

It is essential, due to the dilution effect of the anticoagulant, that the citrate (green top) tubes are filled to the fill mark.

All tubes containing an anticoagulant, EDTA (red top) and Citrate (green top) must be mixed gently after filling to prevent the sample clotting. If these samples are laid to one side without gentle inversion they will clot and be unsuitable for analysis.

Do not overfill tubes.

Do not tip blood from one container into another this can adversely affect results. If blood ever has to be taken with a conventional needle and syringe do not force blood into the sample containers through the needle, always remove the needle first.

Taking samples from a drip arm should be avoided as this can lead to a massive dilution effect.

Difficulty with the venepuncture can cause problems. These may include haemolysis or a partially clotted sample which may lead to a falsely low platelet count, altered blood coagulation values or false positive DAT’s.

Avoid storing the samples prior to dispatch to the laboratory at extremes of temperature. (Avoid sample storage areas in direct sunlight or next to heat sources such as radiators)

ESR samples can be processed from the same 2.7ml EDTA as the FBC as long as it is completely filled to the 2.7ml mark, any less will be insufficient.

Samples for Plasma Viscosity should not be refrigerated overnight

Factor V Leiden PCR Testing Interferences - Rare Factor V mutations (A1696G, G1689A, and A1692C) and any additional single nucleotide polymorphisms (SNPs) in the probe binding region may interfere with the target detection and yield an invalid result. Patients on heparin therapy and blood transfusion patients may have blood specimens that potentially interfere with the PCR results and lead to invalid or erroneous results.

Lipaemic samples can be processed however if a result cannot be obtained then PT/APTT tests should be processed manually. The FBC is affected by lipaemia and the results would be appended with an appropriate comment to the result in LabCentre making reference to the lipaemia (e.g. Sample processed as a 1:7 dilution due to Lipaemia)

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For von Willebrand factor antigen and Ristocetin testing, the presence of Rheumatoid Factor may produce an overestimation of the test results which could potentially mask an abnormally low result.

High serum levels of free vitamin B12 may give false positive results for intrinsic factor antibody. Sample should not be collected from a patient who has received vitamin B12 injection therapy within the past week. Conversely, high titre levels of Intrinsic Factor Antibodies may give falsely raised Vitamin B12 results.

Coagulation assays may be affected by many commonly administered drugs and further studies should be made to determine the source of unexpected abnormal results. In patients taking HEMLIBRA, the APTT and APTT based assays give unreliable results and must not be used for clinical decisions.

FBC samples which cannot be sent to the laboratory and are kept overnight by the service user, should be refrigerated. If in any doubt then contact the lab on ext. 78370.

Additional tests

Due to the limited viability of Haematology samples some additional tests may not be possible (see below). Please send a request for additional tests form (P-FORM-3) found here: http://nww.pat.nhs.uk/clinical-departments/Pathology/forms.htm to the laboratory if additional testing on an existing sample is required. Please contact the laboratory for further information if required. Due to the limitations of cold storage space FBC samples will be disposed of after 48hrs:

Coagulation tests may be added to samples already in the laboratory but users must be aware that some coagulation tests may require a fresh sample.

Addition of a blood film to an FBC request should be done within 12 hours.

Addition of a Glandular fever screen may be done at any time providing the sample is still held.

Addition of a Malaria antigen screen may be done at any time providing the sample is still held. For microscopy we recommend the sample to be <12hrs old.

Haemoglobinopathy screen may be added to samples any time prior to disposal

DAT is suitable for testing up to 3 days after collection.

http://nww.pat.nhs.uk/clinical-departments/Pathology/forms.htm

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Results Results are either transmitted electronically or via paper report format depending on the location of the requestor. Trust staff are able to review Pathology results on-line through Healthviews, Review or via the Pathology Results Enquiry portal on the Interactive link on the Pennine Intranet homepage. GP surgeries receive reports electronically. Due to the high volume of work received in the laboratory, service users are encouraged to use on line services to check the status of diagnostic tests before the laboratory is contacted. Please note that currently Blood Transfusion results are only available on the Pathology Results enquiry portal/web browser. Results, which are markedly abnormal and / or require urgent attention, will be communicated via telephone. Warning: Results may be viewable before they have been technically validated. A disclaimer will be viewable to inform the user when this is the case.

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Specialist test information and procedures

Haemoglobinopathy Screening

Disorders of globin chain synthesis; both thalassemia and structurally abnormal haemoglobin such as haemoglobin S, which gives rise to sickle cell anaemia, are common in the UK and constitute a significant public health problem. One EDTA (2.7 ml) and a brown Gel tube (7.5ml) are required for each Haemoglobinopathy request. The initial screen for common abnormal variants and thalassemia includes full blood count, differential, a haemoglobinopathy screen by HPLC and ferritin. If an abnormality is detected, further samples may be required for identification by DNA analysis or Mass Spectrometry analysis. In an emergency, e.g. pre-anaesthetic, a sickle solubility test can be performed for the presence of haemoglobin S. All requests will be followed by a full Haemoglobinopathy screen. Counselling should be offered to the patient before the test request is made and if a clinically significant abnormality is detected the patient should be referred for genetic counselling and family studies should be considered. It is assumed by the laboratory that the patient has given informed verbal consent for Haemoglobinopathy screening to be performed. If the screen shows an abnormality that requires further investigation and DNA screening then informed written consent may be required. A consent form will be faxed to the requestor in such cases or it can be obtained from the laboratory on 0161 627 8370 (internal ext. 78370). For the more common haemoglobinopathy's, if an abnormality is detected a letter and an information booklet will be issued. Haemoglobinopathy screening of pregnant women is one of our Key Performance Indicators. We meet the 72 hour turnaround by 100%. This is standard 4 in the NHS Sickle Cell and Thalassemia Screening Programme Standards for the linked Antenatal and Newborn Screening Programme. This is also cross referenced in the minimum criteria (standards) for laboratories undertaking antenatal screening outlined in the Sickle Cell and Thalassemia Handbook for Laboratories. At risk couples where both partners are found to have an abnormal Haemoglobinopathy screen and women with an abnormal Haemoglobinopathy screen whose partner is unavailable for screening, are referred by Ante Natal to the Manchester Sickle Cell and Thalassemia Centre for further counselling and the offer of Pre Natal Diagnosis testing.

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Bone Marrow Testing

Bone Marrow examination may be needed for diagnosis of primary bone marrow diseases and haematological malignancy such as leukaemia and myelodysplasia or as an addition to a staging procedure in solid tumours such as lymphoma or in some cases to investigate the cause of anaemia. All Bone Marrow requests should be made by Clinical Haematology or under the guidance of a Consultant Haematologist. Please contact Clinical Haematology for further information. Examination of bone marrow aspirate films allows morphological assessment of the cellular composition of the bone marrow allowing the identification of abnormal cells which may indicate a haematological malignancy. Special stains can be made to differentiate between types of acute leukaemia or in suspected cases of metabolic storage diseases. Iron stores may also be assessed by performing a Perl’s stain. Bone marrow trephine biopsies produce cores of bone and marrow that are decalcified and are processed for histological assessment. The trephine provides an excellent sample for examination of marrow architecture and cellularity and is the most reliable method for detecting marrow infiltration with non-haemopoietic malignancies. Immunophenotyping is a technique by which antigens are detected on the cell surface and can be used to help differentiate types of acute leukaemia or subtypes of lymphoproliferative disorders. In the diagnosis of haematological malignancy, it is usually performed on bone marrow aspirate samples but may be carried out on peripheral blood or other fluids if advised by a Consultant Haematologist. Blood and bone marrow Immunophenotyping and associated haematological malignancy investigations should only be requested by a Consultant Haematologist who would assess the patient and arrange further specialist diagnostic investigation as required.

Blood Coagulation

All the laboratories carry out blood coagulation testing using Werfen Instrumentation Laboratory analysers. Routine testing is performed on a single citrated sample which must be less than six hours old (for APTT) and filled to the 3ml level. Results for Prothrombin Time (PT), International Normalised Ratio (INR), Activated Partial Thromboplastin Time (APTT), Thrombin Time (TT) and Fibrinogen are available the same day.

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Major Blood Loss

As described in EDC009: Management of Massive Blood Loss Plasma fibrinogen, PT and APTT should be monitored as a guide to additional replacement therapy. If the fibrinogen level is <3.0g /litre (derived fibrinogen), then cryoprecipitate is indicated. If either the APTT is prolonged to more than one-and-a-half times the normal control and the INR is >1.5 or both, but the fibrinogen level is >2.0g /litre, then significant deficiency of factors V and VIII are likely to be present. In this instance, FFP is recommended (12-15ml FFP /Kg body weight). If circulatory overload is a risk i.e. in the treatment of neonates or patients with a compromised cardio-vascular system then cryoprecipitate should be used.

Suspected Bleeding Diathesis

It is important to take a full history of present and past bleeding incidents and to enquire about family history and drug ingestion. For screening purposes the following tests are usually sufficient: PT and INR Activated Partial Thromboplastin Time (APTT) Platelet Count

Suspected Disseminated Intravascular Coagulation (DIC)

Fibrinogen, D-Dimer, platelet count and blood film should be requested.

Screen for Liver Biopsy

PT, APTT, and platelet count should be requested (FBC)

Heparin Therapy

Intravenous unfractionated Heparin should be given by continuous infusion and monitored by the APTT. Monitoring is not usually necessary if subcutaneous Heparin prophylaxis is used for surgery. Therapeutic as opposed to low dose subcutaneous Heparin should be monitored by the APTT taken 4 hours after the last injection. Low molecular weight Heparin (LMWH) is now the parenteral anticoagulant of choice and does not cause prolongation of the APTT. LMWH given prophylactically or therapeutically does not usually need to be monitored. If monitoring is necessary e.g. renal failure or pregnancy then the anti-factor Xa assay should be used.

Oral Anticoagulants

These should be monitored by the INR (International Normalized Ratio). The therapeutic level lies between 2.0 and 4.5 and depends upon the condition being treated. The following targets are those recommended by the British Society for Haematology (1998) Target INR


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INR Target Condition

2.5

Atrial Fibrillation

Treatment of deep vein thrombosis

Pulmonary embolus

Transient ischaemic attacks

3.5

Recurrent deep vein thrombosis and pulmonary embolism

Mechanical Prosthetic Heart Valve

Antiphospholipid Syndrome

Thrombophilia screen

The laboratory is able to offer Thrombophilia Screening in order to investigate the possibility of hypercoagulable states that can lead to an increased tendency for thrombosis. Screening tests include measurement of Protein C, Protein S, Antithrombin and activated Protein C Resistance to Factor V. The addition of a Homocysteine level may also be appropriate depending on the clinical findings. Please note Homocysteine samples must reach the laboratory within 30minutes of venepuncture and are sent away to a referral lab for analysis. 3 citrated green top samples are required for Thrombophilia screening to be carried out and an EDTA if Homocysteine is required.

Genetic screening tests for Factor V Leiden Mutation and Prothrombin Gene Variant are processed at the Royal Oldham Hospital. A single citrated or EDTA (2.7ml) sample is required. Not all patients with thrombosis need a thrombophilia screen. In the majority of patients with an inherited thrombotic tendency the thrombosis is venous and not arterial. Requests for screens may be appropriate where there is evidence of:

Venous thromboembolism under the age of 45 years

A family history of early venous thrombosis

Recurrent thromboembolism

Venous thrombosis at unusual sites

Recurrent superficial thrombophlebitis

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A single venous thrombosis in an elderly patient is not an indication for a thrombophilia screen. Warfarin reduces levels of Protein C and S and can interfere with other thrombophilia tests. Thrombophilia screens should be done only when patients have been off Warfarin for at least 6 weeks. Protein C and S levels can also be affected by pregnancy. Please contact one of the Consultant Haematologists for specialist advice in the investigation of Haemostasis or thrombosis

Lupus Anticoagulant Screen

Lupus Anticoagulant screening requires the collection of 2 citrated samples. Positive screening tests will be confirmed using a reagent high in phospholipid. Anti Phospholipid syndrome is an autoimmune disease associated with a high risk of thrombosis, recurrent spontaneous miscarriages and thrombocytopenia.

D Dimer

D Dimer is used specifically to aid in the diagnosis of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Raised levels of D Dimer are indicative of a thrombotic event and the lysis of the thrombi, they may however be raised in infection, trauma, pregnancy and inflammation. D Dimer cannot therefore be used to diagnose DVT but forms part of an analysis based strategy using clinical information to form part of a negative predictive value. A normal D Dimer makes clinically significant DVT or PE less likely. It is advisable to perform a Wells score prior to sending a D-Dimer test.

Factor Assays

Clotting factor assays require 3 (where possible) citrated samples and are used to diagnose factor deficiencies, Haemophilia A, Haemophilia B and Von Willebrands disease. Factor assays for both the intrinsic and extrinsic pathways can be performed, usually after discussion with a Consultant Haematologist.

Von Willebrand Screen

The screening test for von Willebrand disease - a von Willebrand Factor Assay, Ristocetin Cofactor and Factor VIII assay is also performed in house. Clinical guidelines suggest that the measurement and comparison of von Willebrand Factor Antigen (VWF:Ag), VWF Activity and Factor VIII (FVIII) levels in plasma allow for the differentiation of quantitative defects (Type 1 or Type 3) or qualitative defects (Type 2) of VWF. All Clinical Interpretation is performed by the Consultant Haematologist.

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Haemolytic Disorders

For screening purposes an FBC, blood film, reticulocyte count and direct antiglobulin (Coombs) test should be requested from the Haematology/Blood Transfusion Department. A serum bilirubin, LDH and haptoglobin test can be requested from the Biochemistry Department. The results of the screening tests may lead to the need for further tests which the laboratory will undertake as appropriate.

Haematinics assays

Serum B12, Folate & Ferritin levels are performed in Haematology. All tests can be done on one Brown Gel sample but this must be a separate sample to any Biochemistry test requested. Haematology is unable to use/access the brown Gel tube that Biochemistry may have.

Erythropoietin Levels

Erythropoietin is not a routine test. Samples are centrifuged, aliquoted and stored at -20°C until the test can be performed. It is requested either to help differentiate between polycythaemia vera and secondary polycythaemia or to help differentiate between different types of anaemia. It also shows whether the amount of erythropoietin being produced is appropriate for the level of anaemia present. In patients with chronic kidney disease it may be used at intervals to monitor the kidneys' continued ability to produce sufficient erythropoietin but it is not used as a monitoring tool for anaemia. Occasionally, an erythropoietin assay may be used to help determine if a disease that is causing an excess production of RBCs is due to an overproduction of erythropoietin. https://labtestsonline.org.uk/tests/erythropoietin

Blood Film Morphology

If the presence of abnormal WBCs, RBCs or platelets is suspected, a blood film, examined by a trained eye, is performed for identifying immature and abnormal cells. There are many diseases, disorders and deficiencies that can have an effect on the number and type of blood cells produced, their function and their lifespan. Blood films are examined systematically, starting with macroscopic observation of the obtained film and then progressing from low-power to high-power microscopic examination. As the diagnosis of the type of anaemia or other abnormality present usually depends upon a comprehension of the whole picture which the film presents, the leucocytes, red cells, and platelets are all systematically examined. The film examination also serves to validate the automated blood count indices.

https://labtestsonline.org.uk/tests/erythropoietin

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Findings from the blood film test do not always give a diagnosis but can provide information indicating the presence of an underlying condition and its severity and the need for further diagnostic testing.

Screening for Malaria and Other Blood Parasites.

The laboratory provides Rapid Diagnostic Test screening (RDT) and microscopy for the presence of the following malarial parasites:

P. falciparum P. vivax P.ovale P.malariae P.knowlesi

The laboratory should be contacted prior to urgent screens being sent to the laboratory. The laboratory is able to provide a RDT result within 1 hour of receiving a sample in the laboratory. Full clinical details must be given including travel history and any prophylaxis taken. Ideally the samples should be taken at the height of fever and should be repeated up to 3 times if the screen is negative to fully exclude the presence of malarial parasites. This is reflected as a disclaimer in the laboratory report. Rarely malarial antibodies can be requested and sent to a reference laboratory.

If the malaria screen is positive samples are referred to the Malaria Reference Laboratory (MRL) in London for confirmation of the species

All samples that are positive for malarial parasites are currently tested for G6PD deficiency as certain treatments can give rise to a haemolytic crisis in patients that are found to be G6PD deficient.

P. knowlesi: - a very rare malaria which should be considered if the patient has travelled to South East Asia. The parasites are morphologically similar to P.malariae, however the clinical course is similar to that of P. falciparum malaria and patients can deteriorate rapidly. This is a medical emergency. Please contact the laboratory if you suspect P.knowlesi to avoid possible misdiagnosis and delay.

Please contact the laboratory if screening for other blood parasites such as Trypanosomes and Microfilaria are required.

All requests for Microfilaria screening should be discussed with Infectious Diseases first to ensure they are appropriate. A 2.7ml EDTA red top sample is required for thick and thin blood films and FBC. Microfiltration is always recommended in addition to blood films as it is a more sensitive method. 3 x green top citrate samples (10-20ml venous blood) are required for microfiltration.

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Quality Control, Assurance and Measurement Uncertainty

Quality Control

The department participates in all relevant National External Quality Assurance Schemes. Within batch accuracy and precision is monitored using commercially available quality control preparations and statistical methods incorporated into instrumentation.

Quality Assurance

This is relevant to all aspects of patient care and is increasingly subject to scrutiny by the processes of medical audit and accreditation. All laboratories will now be assessed by UKAS against the ISO 15189 Standard – “Medical Laboratories – Requirements for quality and competence”. The Haematology and Blood Transfusion laboratories within The Pennine Acute Hospitals NHS Trust are ISO 15189 accredited.

Measurement Uncertainty (MU)

It is now widely recognised that, when all of the known or suspected components of error have been evaluated and the appropriate corrections have been applied, there still remains an uncertainty about the correctness of the value of the quantity being measured for any test result. No measurement or test is perfect and imperfections give rise to “measurement uncertainty” (MU) which in essence means that if the same test is performed on the same sample several times, the results will differ slightly each time. The Haematology and Blood Transfusion Laboratory has undertaken a statistical analysis to assess the degree of uncertainty for the results we produce. This is not routinely reported, however, we will provide this information to our service users upon request.

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Referred Tests The tests listed below are not currently carried out within the Haematology laboratories at Pennine Acute Hospitals NHS Trust. They are received into our department and we arrange transport & send them to the referral lab. When the reports come back they are recoded in our laboratory computer system and the reports are forwarded to the requesting clinician. Reference ranges for these tests are stated on the paper and electronic reports provided. Criteria used to assess the suitability of referral laboratories include:-

UKAS ISO 15189 accreditation status www.ukas.com

Satisfactory EQA participation

Ability to meet expected turnaround times The above are reviewed annually.

http://www.ukas.com/

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ADAM TS13 - Sheffield

For suspected TTP SPECIMEN: 2 x 3ml citrated samples. ADDRESS: FAO Rebekah Fretwell

Sheffield Haemophilia and Thrombosis Centre Coagulation Laboratory, Floor H Royal Hallamshire Hospital Glossop Rd SHEFFIELD S10 2JF

ENQUIRES: Tel. No. 0114 2712955 Fax:01142712149

ADAM TS13 – Liverpool

(For known TTP patients upon request of Haematology Consultant ONLY)

SPECIMEN: At least 3ml citrated samples. ADDRESS: Coagulation Department 2nd Floor Duncan Building Royal Liverpool University Hospital Prescott Street Liverpool L7 8XP ENQUIRES: Tel. No. 0151 7064967

FOR HMDS LEEDS

BCR-ABL, JAK2, Calreticulin, JAK2 Exon 12,

Rare BCR-ABL variants, APML, & NPM1, Other rare mutations

GENERAL INFO: For all BCR-ABL, JAK2 & Calreticulin requests unless otherwise stated.

Includes BCR-ABL monitoring and mutation plus rare variants; JAK2 Exon12, Philadelphia Chromosome; APML; PCR for APML Monitoring & NPM1 marker for AML. Calreticulin For patients with essential thrombocythemia or primary myelofibrosis not associated with a JAK2 or MPL alteration, the test will detect a somatic mutation in CALR. This test is now performed automatically when a JAK2 test is requested. NPM1-Marker for AML This may be requested if the BCR/ABL is found to be negative

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JAK2 Exon 12 Mutation This is a rare mutation of JAK2 & should be sent on request by Haematology medics only.

SPECIMEN: 10mls EDTA required, 5ml minimum for each test (2-3ml EDTA sample for Bone Marrow).

ADDRESS: HMDS Level 3 Bexley Wing St James’s University Hospital Beckett Street. Leeds LS9 7TF

ENQUIRES: Tel: 0113 206 7851, Fax: 0113 206 7883

FOR MRI – ONLY WHEN SPECIFICALLY REQUESTED BY MEDICS – SEE HMDS

ABOVE FOR ROUTINE REQUESTS

BCR-ABL, JAK2, JAK2 EXON 12 & APML For MRI

GENERAL INFO: Includes BCR-ABL monitoring and mutation & rare variants; Jak2 Exon

12 mutation; Philadelphia Chromosome; APML; PCR for APML Monitoring only when specifically requested for testing at MRI by medics, normally sent to HMDS Leeds.

SPECIMEN: 10mls EDTA required, 5ml minimum for each test (2-3ml EDTA sample

for Bone Marrow). Blood may be refrigerated overnight; Bone Marrow samples must go the same day.

ADDRESS: Dr Abida Awan Senior Clinical Scientist Molecular Diagnostics Centre MRI Oxford Road Manchester M13 9WL ENQUIRES: 0161 276 8766 Results Line Enquiries

0161 276 4137 Direct line 0161 276 4809 Laboratory

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JAK2 Exon 12 Mutation (Usually sent to HMDS see above) This is a rare mutation of JAK2 & should be sent on request by Haematology medics only. The test is performed at Cambridge but can be sent via MRI at the address above. Please ensure the request card states clearly, sample for JAK2 Exon 12 testing at Cambridge to avoid duplicate testing of JAK2 at MRI.

Rare BCR-ABL Variants (Usually sent to HMDS see above)

For rare BCR-ABL variants for Hammersmith Hospital on request of Haematologist only Send with Hammersmith BCR-ABL PCR request form. The form can be downloaded directly from the Hammersmith Hospital website. www.imperial.nhs.uk/pathology-molecular-diagnostics-services/molecular-diagnostic/index.htm

ADDRESS: Dr Letizia FORONI

Imperial Molecular Pathology Laboratory G Block, 2nd Floor Hammersmith Hospital Du Cane Road London W12 OHS

ENQUIRES: Tel: 0208 383 2179 Fax: 0203 313 1507 email: [email protected]

B-RAF MUTATION ANALYSIS for Hairy Cell Leukaemia

SPECIMEN: 2 x 2.7ml EDTA ADDRESS: HMDS

Level 3 Bexley Wing St James’s University Hospital Beckett Street. Leeds LS9 7TF

ENQUIRES: Tel: 0113 206 7851, Fax: 0113 206 7883

CELL MARKERS FOR MRI (NON HAEMATOLOGY PATIENTS) SPECIMEN: EDTA 5mls OR 20mls blood and 400iµ heparin or 5mls marrow and

100iµ heparin and transport medium (Preferably in special Transport medium bottles supplied by Immunology at MRI)

http://www.imperial.nhs.uk/pathology-molecular-diagnostics-services/molecular-diagnostic/index.htm

http://www.imperial.nhs.uk/pathology-molecular-diagnostics-services/molecular-diagnostic/index.htm

mailto:[email protected]

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ADDRESS: Department of Immunology Clinical Sciences Building Directorate of Laboratory Medicine Manchester Royal Infirmary Oxford Road Manchester M13 9WL

ENQUIRES: Results Line: 0161 276 8766 Lab: 0161 276 6007 Fax: 01612766439

CELL MARKERS FOR HMDS, LEEDS (HAEMATOLOGY PATIENTS)

SPECIMEN: EDTA 5mls ADDRESS: HMDS

Level 3, Bexley Wing St James’s University Hospital Beckett Street. Leeds LS9 7TF

ENQUIRES: Tel: 0113 206 7851 Fax: 0113 206 7883

CELL MARKERS ON CSF - HMDS, LEEDS (HAEMATOLOGY PATIENTS)

SPECIMEN: CSF min 0.5ml ADDRESS: HMDS

Level 3, Bexley Wing St James’s University Hospital Beckett Street. Leeds LS9 7TF

ENQUIRES: Tel: 0113 206 7851 Fax: 0113 206 7883

CYTOGENETICS

SPECIMEN: Bone Marrow - 1ml in pink medium bottle, accompanied by a

completed oncology card. Be aware of expiry date on bottles. In emergency if pink medium is unavailable, bone marrow can be sent in lithium heparin. Blood samples - Lithium Heparin NB Pink media bottles are ordered and stored by HF11/HHDC. However, more can be ordered by telephoning 0161 446 3165.

ADDRESS: Oncology Cytogenetics Pathology Department Christie Hospital

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Wilmslow Road Manchester M20 4BX ENQUIRIES: Telephone: 0161 446 3165 Fax: 0161 446 3051

CD 4

SPECIMEN: 1 x 2.7ml EDTA ADDRESS: Department of Immunology

Clinical Sciences Building Directorate of Laboratory Medicine Manchester Royal Infirmary Oxford Road Manchester M13 9WL

ENQUIRIES: 0161 276 8766 (Results Line) 0161-276-6440

CD 20

SPECIMEN: 1 x 2.7ml EDTA ADDRESS: Department of Immunology


ENQUIRIES: 0161 276 8766 (Results Line) 0161-276-6440

CHROMOSOME ANALYSIS (ST MARY'S) KARYOTYPING

SPECIMEN: Lithium Heparin ADDRESS: GENETIC MEDICINE

6TH FLOOR St Mary's Hospital Oxford Road Manchester M13 9WL

ENQUIRIES: Laboratory: 0161 276 6118

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DHR TEST – NEUTROPHIL STIMULATION TEST

SPECIMEN: 1 x Lithium Heparin sample ADDRESS: Department of Immunology


ENQUIRIES: 0161 276 8766 (Results Line) Telephone: 0161 276 6007 Fax: 0161 2766439

EMA SCREEN FOR RED CELL MEMBRANE ABNORMALITIES. - (Spherocytosis screen)

SPECIMEN: 2.7ml EDTA sample ADDRESS: Department of Immunology, Clinical Sciences Building, M.R.I.

Oxford Road Manchester M13 9WL ENQUIRIES: 0161 276 8766 (Results Line)

0161 276 6440. Fax: 0161276 6439 (Ring lab before faxing)

FACTOR VIII INHIBITOR SPECIMEN: 3ml Tri - Sodium Citrate sample required

Always check previous results before sending. If the FVIII assay is still pending or is normal and a mixing study corrects, it is unlikely to be a FVIII inhibitor. Suggest discuss with Haematology Consultant before sending.

ADDRESS: Coagulation Laboratory Manchester Royal Infirmary Oxford Road Manchester M13 9WL

ENQUIRES: 0161 276 8766 (Results Line) Tel: 0161 701 2123 Coagulation

Fax: 0161 276 4654

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FACTOR XIII (FACTOR 13) SPECIMEN: 3ml Tri - Sodium Citrate sample required. ADDRESS: Coagulation Laboratory

Manchester Royal Infirmary Oxford Road Manchester M13 9WL

ENQUIRES:

0161 276 8766 (Results Line) Tel: 0161 701 2123 Coagulation 0161 276 4695/4428 Spec. Reception Fax: 0161 276 4654

FIP1L1 - PDGFRA SPECIMEN: 1 x 10-20 ml peripheral blood in EDTA ADDRESS: Professor Nick Cross

Wessex Regional Genetics Laboratory Salisbury District Hospital Salisbury Wiltshire, UK SP2 8BJ

ENQUIRIES: Tel: 01722 429080 Fax: 01722 338095 e‐mail: [email protected]

G6PD Assay

SPECIMEN: 2.7ml EDTA ADDRESS: Red cell Dept

Manchester Royal Infirmary Oxford Road Manchester

M13 9WL ENQUIRIES: 0161 276 4689 Fax: 01614654

HAEMOCHROMATOSIS GENE TESTING SPECIMEN: 1 x EDTA min 1ml ADDRESS: Haematological Analysis Section

Genomic Diagnostics Laboratory The Manchester Centre for Genomic Medicine St Mary’s Hospital

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Oxford Road Manchester M13 9WL

ENQUIRIES: 0161 276 8766 (Results Line) Tel: 0161 2764809 Fax: 0161 2765989

HAEMOGLOBINOPATHIES (Non Ante Natal)

SPECIMEN: 1 x EDTA ADDRESS: The National Haemoglobinopathy Reference Laboratory

Molecular Haematology Level 4 John Radcliffe Hospital Oxford OX3 9DU

ENQUIRES: Telephone: 01865 572769 Fax: 01865 572826 Email: [email protected]

HEPARIN INDUCED THROMBOCYTOPENIA

HIT TESTING SPECIMEN: 1 x Brown gel tube or 1 x Citrate tube. Min 400µl ADDRESS: FAO Kevin Horner

Coagulation Laboratory Floor H Royal Hallamshire Hospital Glossop Rd SHEFFIELD

S10 2JF ENQUIRES: Tel no 0114 2712955 Fax: 0114 2712149

HOLO TRANSCOBALAMIN/ACTIVE B12 and SERUM METHYLMALONIC ACID SPECIMEN: 7.5ml Serum Brown Gel. ADDRESS: Nutristasis Unit

Haemostasis and Thrombosis Viapath Pathology 5th Floor, North Wing St. Thomas’ Hospital London SE1 7EH

ENQUIRES: Telephone: 02071888008 (Results) 02071886815 Fax: 02071882726

mailto:[email protected]

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HOMOCYSTEINE

SPECIMEN: Homocysteine levels at Cardiff are to be performed on Plasma. An

EDTA is required, the plasma of which MUST be separated from the red cells within 30 minutes of venepuncture.

ADDRESS: Medical Biochemistry Department University Hospital of Wales Cardiff CF14 4XW ENQUIRIES: 029 2074 7747 029 2074 2805-Reception 029 2074 2637-Biochemistry 029 2074 3560-Special Biochemistry

029 2074 8383 (Fax)

MALARIA PCR SPECIMEN: EDTA from Positive Malaria. ADDRESS: Malaria Reference Laboratory London School of Tropical Medicine Keppel Street (Gower Street) London WC1E 7HT ENQUIRIES: Tel: 020 7927 2427

Fax: 020 7637 0248

MALARIA ANTIBODIES SPECIMEN: A minimum of 0.5ml of serum from Brown Gel Tube

or 0.5ml EDTA plasma is required. ADDRESS: The Department of Clinical Parasitology

The Hospital for Tropical Diseases 3rd Floor Mortimer Market Centre Mortimer Market London WC1E 6JB

ENQUIRIES: Tel Lab: 020 3447 5413 General enquiries: 020 3447 5418

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MICROFILARIA MICROFILTRATION AND CONFIRMATION SPECIMEN: 3 x citrate (10-20ml blood)

If sending slides to DPL for confirmation: 4 x unfixed unstained thick films 2 x thin films fixed in methanol. High risk samples All high risk samples must be clearly labelled. Patients with confirmed or ? Hazard Group 4 organisms (such as VHF) must not be sent to DPL for microfiltration. Requesting clinicians must ring the Fever Service on 0844 7788990 for advice. See the following handbook for more information: https://www.lshtm.ac.uk/files/dpl-handbook.pdf

ADDRESS: HPA - Diagnostic Parasitology Laboratory London School of Hygiene & Tropical Medicine Keppel St / Gower St London WC1E 7HT ENQUIRIES: Tel: 020 79272427 Fax: 020 7637 0248 or http://www.parasite-referencelab.co.uk

PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA (PNH)

SPECIMEN: 4mls EDTA ADDRESS: HMDS

Level 3 Bexley Wing St James’s University Hospital Beckett Street. Leeds LS9 7TF

ENQUIRIES: Tel: 0113 206 7851 Fax: 0113 206 7883

Telephone Leeds to inform them samples have been sent.

PLATELET FUNCTION ASSAY - PFA 100 SPECIMEN: Sample 5mls Citrate. Needs to be <4hrs old from time sample taken to

time of processing at MRI. Please phone MRI when patient booked in clinic so they can plan for the sample arriving. This request must be vetted by a Haematology Consultant

ADDRESS: Coagulation Laboratory

https://www.lshtm.ac.uk/files/dpl-handbook.pdf

http://www.parasite-referencelab.co.uk/

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Manchester Royal Infirmary Oxford Road Manchester M13 9WL ENQUIRIES: Tel: 0161 276 8766 (Results Line)

0161 701 2123 Coagulation 0161 276 4695/4428 Specimen Reception Fax: 0161 27604654

PLATELET FLOW CYTOMETRY (GLYCOPROTEINS) SPECIMEN: 4 x 3ml Citrate samples <24hrs old. ADDRESS: Immunology Dept

Manchester Royal Infirmary Oxford Road Manchester M13 9WL ENQUIRIES: Tel: 0161 276 8766 (Results Line)

0161 276 6440 (Contact Andy Moran) Fax: 0161 2766349

PYRUVATE KINASE DEFICIENCY

RED BLOOD CELL ENZYME DEFICIENCIES SPECIMEN: 1ml EDTA. Declare any information regarding Transfusion on form Raised reticulocyte levels and/or WBC may affect assay. ADDRESS: FAO Chris Lambert

Red Cell Laboratory Department of Haematological Medicine

King's College Hospital Demark Hill London SE5 9RS ENQUIRIES: Laboratory: Chris Lambert 020-3299-9000

FAX: 0203 2991267

T CELL RECEPTOR GENE REARRANGEMENT STUDIES (TCR) SPECIMEN: 4 EDTA samples or Bone Marrow ADDRESS: HMDS

Level 3 Bexley Wing

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St James’s University Hospital Beckett Street. Leeds LS9 7TF

ENQUIRIES: Tel: 0113 206 7851 Fax: 0113 206 7883

TRANSPLANTATION LABORATORY (MRI) - FOR RENAL DONOR/RECIPIENT SAMPLES ONLY (Including cytotoxic antibodies)

SPECIMEN: EDTA's, heparin, heparin/saline. Depending whether testing is on donor or recipient. ADDRESS: The Transplantation Laboratory 2nd Floor, Purple Zone Manchester Royal Infirmary Oxford Road Manchester M13 9WL ENQUIRIES: Telephone: 0161 276 6397 Fax: 0161 276 614

ZINC PROTOPORPHYRIN (Z.P.P)

SPECIMEN: 0.5 – 1.0ml EDTA ADDRESS: Block 46 St James’s University Hospital Beckett Street Leeds LS9 7TF ENQUIRIES: TEL: 0113 206 4760 or 0113 206 6063 Fax: 0113 206 597

APIXABAN LEVELS SPECIMEN: 3ml Tri - Sodium Citrate sample required ADDRESS: Coagulation Laboratory

Manchester Royal Infirmary Oxford Road Manchester M13 9WL

ENQUIRIES: 0161 276 8766 (Results Line) Tel: 0161 701 2123 Coagulation Fax: 0161 276 4654

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SOLUBLE CD25 LEVELS

SPECIMEN: 1ml Brown gel/serum

ADDRESS: Clinical Immunology Laboratory Level 4 Camelia Botnar Laboratories Great Ormond Street Hospital London WC1N 3JH

ENQUIRES: Tel: 020 782 98835