Norfolk and Norwich University Hospital HAEMATOLOGY …

Eastern Pathology Alliance Haematology NNUH User Manual Page 1 of 38

Dept/Site : Haematology NNUH Doc Ref: EBN-HQP-001 Author: A. Macartney

Revision: 7 Issued: 16/04/2021 Authorised by: R. Pipkin Review interval: Annual

Norfolk and Norwich University

Hospital

HAEMATOLOGY DEPARTMENT

USER MANUAL

April 2021




Version control sheet: HAEMATOLOGY DEPARTMENT – USER MANUAL

Version Date Author Status Comment

4 16.10.18 KS Active UKAS accreditation notes added to tests

4 08.11.18 MW Active UKAS schedule added as embedded document

5 18.04.19 KW Active Removal of UKAS schedule PDF and addition of hyperlink

5 18.04.19 KW Active Addition of information regarding which tests are sent to referral laboratories

5 18.04.19 KW Active Statement regarding consent to share information

5 18.04.19 KW Active Complaints responsible person changed

5 18.04.19 KW Active Staff updates

5 18.04.19 KW Active Changes to analysers for FBC & Misc. Fluid Cell Count

5 18.04.19 KW Active Addition of reference to Massive blood loss in children doc

5 18.04.19 KW Active BT referral labs

6 04.02.20 KW Active CR7656 Contents page - says Molecular genetics is on p39,

should say p29; Section 5 refers to Trust Venepuncture Policy

v6, should say v7.

6 04.02.20 KW Active CR8123 Page 7, remove the Trust documents revision

numbers as the two quoted are out of date. Just use the

trust ID number

6 04.02.20 KW Active CR8395 harmonise telephone criteria to EPA-HAP-061

6 04.02.20 KW Active Add in reference to Introducing Pre-Labelling of Pathology

Samples Trust Doc ID 14472

6 04.02.20 KW Active Updated Trust draw order (Appendix 1)

7 17.03.21 DS Active Pg 4 Specific wording regarding laboratory accreditation

status changed

Pg 4 Clarification made regarding what is and is not included

within Accreditation schedule for UKAS.




Haematology User Manual INDEX

Section Page 1 2 3 4 5 6 6.1 6.2 6.3 6.4 6.5 7 8 8.1 8.2 9 10 11 12 13 14 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 15 16 17 18

Introduction Location Contact names and numbers Working hours Phlebotomy Samples General guidelines Rejection of unacceptable samples Packaging and transport of samples Sending samples via the pneumatic tube system Transport to Microbiology NNUH “High risk” samples Tests and sample requirements Routine Haematology tests Routine Coagulation tests Result enquiries/Telephoned results Clinical Liaison Complaints Non-NHS samples Haematology Reference Ranges / Turnaround times Transfusion Consultants and senior staff Sample labelling and request forms Component requesting Collection and administration of blood components Transfusion reactions Massive blood loss protocol Transfer/receipt of components with a patient between hospitals Transfusion Referral Laboratories Molecular Genetics Referral Laboratories Add-on Tests Key factors known to affect test performance and result interpretation Appendix 1: Advice on use of vacutainer tubes / Tube Guide Appendix 2: Storage, retention and disposal of clinical samples Appendix 3: Point Of Care Testing (POCT) Appendix 4: Supply of specimen containers and request forms

4 4 5 6 6 8 8 9 10 10 11 11 12 12 14 15 15 16 16 17 25 25 27 26 27 27 27 28 28 29 30 31 32




1. Introduction The Haematology Department based at the Norfolk and Norwich University Hospital (NNUH) is part of the Eastern Pathology Alliance (EPA), a managed Pathology network involving NNUH, the James Paget University Hospitals NHS Foundation Trust and the Queen Elizabeth Hospital Kings Lynn. The Laboratory’s services include Automated Haematology and Coagulation, Specialised Coagulation, Malaria, Morphology, Transfusion, Molecular Genetics and Andrology. In order to maintain high standards of analysis this Department participates in national external quality assessment schemes (EQA). The Haematology Department is a UKAS accredited medical laboratory No. 10295. The defined schedule of tests for which the laboratory is accredited can be found by clicking on the link below.

Haematology accreditation no. 10295

Please note that this schedule does not include Andrology, Molecular Genetics or Blood Transfusion which are not UKAS accredited. The Blood Transfusion section is compliant with the requirements of the Blood Safety and Quality Regulations 2005 as assessed by the Medicines and Healthcare Products Regulatory Agency (MHRA). This user manual provides information about how users can access our services, who to contact for advice, which tests we perform, sample requirements, normal ranges and turnaround times. The information within this manual is accurate at the time of issue and is reviewed and updated regularly to incorporate new developments. For patients using this manual, please note that any information provided should not be used for self-diagnosis and should you have any concerns about your health please consult your GP. If you find any errors within this document or would like to make any comments and/or suggestions for improvement, please contact David Stokely, EPA Quality Manager on 01603 286900 or email [email protected] NOTE: All information held by the laboratory regarding patients and their results is in accordance with the NNUH Trust policy on patient confidentiality: Confidentiality Protocol v5. Doc ID 8265.

2. Location

The Haematology Department is located on Level 1 in East Block at the Norfolk and Norwich University Hospital. Directions to Pathology, where the department is located, can be sought from the reception areas at the major entrances to the hospital.

https://www.ukas.com/wp-content/uploads/schedule_uploads/00007/10295%20Medical%20Single.pdf

mailto:[email protected]




3. Contact names and numbers

Consultants

Clinical Consultant Ext. 6744

Laboratory Consultant Bleep 0158

Specialist Registrar Bleep 0163

Medical Staff Secretary Ext. 6750, Fax 01603 286918

Dr. Hamish Lyall Clinical Lead, Haematology 01603 287865/Ext. 3865

Prof. Kris Bowles Consultant Haematologist 01603 289979/ Ext. 5979

Dr. Matt Lawes Consultant Haematologist 01603 289979/Ext. 3106

Dr. Nimish Shah Consultant Haematologist 01603 289942/Ext. 01603 286987/Ext. 2897

Dr. Angela Collins Consultant Haematologist 01603 286899/Ext. 01603 286984/Ext. 2894

Dr. Suzanne Docherty Consultant Haematologist 01603 286895

Dr. Cesar Gomez Consultant Haematologist 01603 287695/Ext. 2894

Dr Victoria Willimott Consultant Haematologist

Haematology Scientific staff

Dr. Gavin Willis Clinical Scientist, Molecular Genetics 01603 287068/Ext. 3068

Alistair Macartney Chief Biomedical Scientist 01603 286909/Ext. 2909

Carol Harvey Network Transfusion Manager 01603 287337/Ext. 3337

Diane Murley Network Transfusion Quality Lead 01603 287337/Ext. 3337

EPA Staff

Nigel Roberts EPA Service Operations Manager 01603 286936/Ext. 2936

Richard Pipkin EPA Network Blood Sciences Manager 01603 286901/Ext. 2901

David Stokely EPA Network Quality Manager 01603 286900/Ext. 2900

Ginny Marley EPA Network Assistant Quality Manager 01603 286903/Ext. 2900

Rebecca Cozens EPA Network Training Manager 01603 286963/Ext. 2963

Specialist Haematology Nurses – Ext. 6753 Amanda Hutchings – lead nurse Christine Havers Liz McClagish Rhodora Manville Catherine Stephenson

Pathology

(level 1)

Pharmacy is located

here

(level 1)

Phlebotomy Services

Level 3, East Outpatients

0830 – 1700 Monday to Friday

Level 3, West Outpatients

0830 – 1700 Monday to Friday

(Closed between 1300 – 1400 daily)

Appointments: 01603 286 921

Phlebotomy – Level 3

Pathology – Level 1




Specialist Anticoagulant Nurses – Ext 3809 Specialist Transfusion Practitioners – Bleep 0852 or 0663 Alison Rudd Kathy Ford

4. Working hours

The laboratory is open 24 hours a day, 7 days a week but operates core working hours of Monday to Friday 08.00 - 20.00hrs and 09.30 - 12.30hrs at the weekend (except Molecular Genetics). During these times we are routinely staffed and will be able to respond to most requests.

Outside these hours Haematology operates a shift system and qualified Biomedical Scientists are available in the department to undertake emergency and certain routine tests. Special or unusual tests may have to be analysed in batches and may not be available outside the core times.

The laboratory does not need to be contacted if urgent routine investigations are required.

5. Phlebotomy The Phlebotomy Department is managed by Haematology. Our team of Phlebotomists is dedicated to providing a service of the highest standard to the Norfolk and Norwich University Hospital inpatients and outpatients. The main out-patient department is based in East Block on Level 3, opposite the Elsie Bertram Diabetes Centre. There is also a smaller clinic in the West OPD, also on level 3 next to the Early Pregnancy Unit. For further details please refer to appropriate section below. East Outpatients (located on level 3 East Block) Walk-in and appointment clinic Glucose Tolerance Tests (by appointment only) Babies and children To make an appointment please telephone 01603 286921 Normal opening times: Monday to Friday 08:30 - 16:55 Please note if there are more than 6 patients waiting for a blood test at 16:45 the door will be closed. Due to staff training the phlebotomy East OPD clinic will open at 9.05 am on the last Wednesday of every month. West Outpatients (located on level 3 West Block) Walk-in clinic Glucose Tolerance Tests (by appointment only) Babies and children (depending on phlebotomist availability) Normal opening times: Monday to Friday 08:30 - 16:55




Please note if there are more than 6 patients waiting for a blood test at 16:45 the door will be closed. Due to staff training the phlebotomy West OPD clinic will open at 9.15 am on the last Wednesday of every month. Weekends and Public / Bank Holidays The East and West OPD clinics are closed on weekends and public / bank holidays. The phlebotomy ward round operates 365 days a year. Ward Rounds Daily Ward rounds are carried out at the following times 365 days a year: Monday - Friday 07:30 - 12:30 Weekends and Public / Bank Holidays 07:15 - 10:45 (non- routine / essential bloods only) All wards are covered except Buxton Ward. The phlebotomy ward round service will be reduced to allow for staff training on the last Wednesday of every month. Request Forms Forms must be requested on Web Ice by 06:00 for that day’s round. Extra forms will not be accepted by the phlebotomists during the ward round. Requests marked 'URGENT' WILL NOT be taken by the Phlebotomist - these must be done by the requesting clinician. Request forms which have the incorrect location on the request form will be sent to the correct location (if identified) via the pneumatic air tube system. If the phlebotomist on the correct location has already completed their ward round the request form will become the responsibility of the ward staff to obtain blood sample collection for their patient. If the phlebotomist is unable to obtain blood sample collection the request form will be returned to the clinician.

Patient consent:

NOTE - All procedures carried out on a patient need the informed consent of the patient.

For most routine laboratory procedures, consent can be inferred when the patient presents himself or herself at a laboratory, or other suitable area, within a primary or secondary care setting, with a request form and willingly submits to the usual collecting procedure.

Patient preparation and all other procedures must be followed as detailed in the Trust phlebotomy documents. Venepuncture policy E3 Trust Doc ID 1114. 24 hour advance blood test request policy Trust Doc ID 5092.




6. Samples 6.1 General guidelines

All requests for pathology investigations must be made by, or on behalf of, a registered medical practitioner, a recognised nurse practitioner or similar, to whom the results will be sent (see below for patient detail requirements). Requests signed by an authorised person (e.g. practice nurse) on behalf of a practitioner are acceptable as long as the origin is stated clearly and the request is fully completed (including relevant clinical details). If possible requests should be made using ICE which limits errors in patient identification and speeds up workflow in the laboratory. When making a request please ensure that all the relevant patient identification, clinical details and locations are provided, including the name of the requesting physician. Contact information must be supplied when an urgent request is made. A request form must accompany all specimens sent to the laboratory. For high risk samples also attach a yellow biohazard/Danger of Infection label. All request forms should clearly state the following information:

Patient’s surname and forename

Patient’s address

Date of birth

NHS number

Gender

Location and Consultant where applicable

GP practice code where applicable

Requestor’s name and telephone/bleep number

Type of sample/specimen

Date and time sample/specimen taken and who collected it

Investigations/tests required

All relevant clinical details including any treatment (recent, current and intended) and foreign travel

Risk status - if applicable

Date of onset and duration of illness

Useful epidemiological information, e.g. date of contact if relevant Priority level

The best results are obtained when an appropriate, well taken sample, in the proper container, is delivered to the laboratory promptly and relevant clinical information is provided on the request form. General guidelines on sample collection are:

Please fill all sample bottles with the correct volume of blood.

Samples must be transported promptly to the laboratory. Delays can render the samples unusable.

Samples should be stored at room temperature until transported to the laboratory.

The laboratory does not check the expiry date of sample collection devices when the sample is received for testing. It is the responsibility of the person collecting and sending the sample to ensure that the device is in date when the sample is collected and with sufficient time remaining for the sample to reach the laboratory for processing.




Patient Preparation:

Verify the patient’s identity against the laboratory requisition, using a minimum of four points of identification (surname, forename, date of birth and hospital or NHS number), confirmed with the patient wristband if present and where possible with the patient themselves verbally.

Review the clinician’s request and the patient’s written or verbal consent and that any special requirements have been met.

Review the procedure with the patient. Inform him or her about the tests for which the samples are being collected and allow the patient to ask questions.

Please contact the laboratory if there is any doubt about the best sample to take or concerning the availability of a test.

NOTE: All procedures and investigations carried out on a patient need the informed

consent of the patient.

Please note that the laboratory infers informed consent has been obtained when samples are received. It is the responsibility of the clinician requesting the test to ensure that informed consent has been obtained.

This consent includes notification to third parties where required by law for example under the Health Protection (Notification) Regulations 2010: we are required to notify any infection of public health significance to local public health department as mandated by the regulation. Please ensure your patient is aware of this before submission of samples for testing.

6.2 Rejection of unacceptable samples

Samples may not be suitable for testing if they are so inadequately labelled that the patient's identification is in doubt, or if they have leaked or been contaminated. If samples are rejected every effort is made to inform the requesting doctor first. Samples and request forms are checked on receipt to confirm the patient identification (PID) information provided on the form and sample agree. A minimum of four points of PID, ie. Surname, Forename, Date of Birth and ID Number (Hospital or NHS) are required by the laboratory and these must match in order for the sample to be accepted. It is good practice for us to have location and




date and time of sample but is not absolutely necessary. If errors are found the laboratory will contact the requestor, explain the problem and request a repeat sample. For samples that are not easily repeated (such as CSF or paediatric samples) the problem will first be discussed with a BMS from the relevant section who will make a decision on whether testing may be allowed to proceed (usually after discussion with the clinician concerned). Usually the requestor will be given the opportunity to come to Pathology and complete patient information on the sample or request and sign a disclaimer. If the sample is tested the report will clearly state the nature of the problem as a comment. Alternatively, the requesting clinician will be asked to send a repeat sample. For full details regarding incompletely labelled samples or forms please contact the laboratory.

6.3 Packaging and Transport of Samples Samples are a potential source of infection and should be treated accordingly. Please fill all sample bottles with the correct volume of blood to ensure correct anticoagulation, and all containers must be securely closed. Leaking samples with gross contamination of contents and containers are discarded. Pocket bags are available for sample transport. Samples should be placed in the appropriate container, which must be securely fastened. This must be placed in a clear plastic bag and sealed. Samples accompanied by forms without specimen bags must be put into marsupial bags with the request form being placed in the side pouch. Refer to local Trust policies. The transport of samples from GP surgeries or other primary care locations is carried out by the Logistics service staff who will collect all samples from dedicated collection points. Samples from within the hospital can be transported to Pathology either by the Pneumatic Tube System (PTS) if suitable or by a porter. For urgent samples ward staff are required to arrange delivery to the laboratory. Samples must first be placed in the plastic sample bags together with the completed request form. The safe transport of specimens to the laboratory is the responsibility of the requesting doctor or carrier. Laboratory responsibility for the sample begins when it has arrived at the laboratory. NOTE: Packaging, labelling and transportation of specimen’s policy Trust Doc ID 7808. Transportation of specimen’s policy Trust Doc ID 7806.

Introducing Pre-Labelling of Pathology Samples Trust Doc ID 14472

6.4 Sending samples via the pneumatic tube system:

All items MUST be sent in the carriers provided.

Samples MUST not be placed directly into the carriers. ALL Pathology samples MUST be placed in specimen bags and the lids of all items with the potential to leak (fluids etc.) tightly secured BEFORE placing them in the carriers.

Do not cram samples/items into the carrier as this may lead to breakage/leakage and system failure.

Only one carrier at a time should be placed in a delivery station.

Ensure that carriers are closed securely at both ends to avoid them jamming in the tube network.

If any defect is noticed with the operation of the air-tube systems please notify the laboratory at the earliest opportunity.




The system must not be used for sending consumables and other “forbidden items” around the hospital.

The air tube systems are for the transport of Blood Sciences specimens to the laboratories only. The air-tube system should NOT to be used for:

Danger of Infection samples

Blood gases

Blood cultures

Unrepeatable samples

CSFs (for culture, protein, glucose or xanthochromia) SEE INDIVIDUAL TRUST POLICIES.

6.5 Transport to Microbiology NNUH During normal working hours:

Non-urgent specimens from NNUH should be taken/sent to Pathology Reception, East Block, Level 1, Norfolk and Norwich University Hospital; these will be delivered by routine van runs to the EPA Microbiology Department.

Urgent specimens from NNUH should be taken to the Security desk at the West Atrium for delivery to the EPA Microbiology Department. The EPA Microbiology Department must be contacted to ensure that the specimen is dealt with immediately.

Outside normal working hours:

Non urgent specimens from NNUH should be taken/sent to Pathology Reception, East Block, Level 1, Norfolk and Norwich University Hospital, for delivery the following day to the EPA Microbiology Department.

Urgent specimens from NNUH should be sent to the Security desk at the West Atrium NOT Pathology and instructions given to send the specimen to the Microbiology Laboratory. Remember the Microbiology service is provided from the Norwich Research Park, Colney. The specimen will be sent to the Microbiology Department via the most appropriate available transport.

7. “High Risk” samples Medical officers responsible for the care of patients have a duty of care towards other members of staff - therefore all samples from patients who are known to have, or strongly suspected of having the conditions noted below must be identified. Creutzfeldt - Jakob disease Viral haemorrhagic fever (VHF) of any type Microorganisms, (biological agents) in Hazard Group 3 or 4. Pyrexia of unknown origin (PUO) recently returned from Africa. Medical staff should ensure that appropriate information, including relevant travel history, is provided in order to alert laboratory staff of potential dangers. Clinical details supplied on sample request forms must contain clear information regarding the nature of the test being requested and sufficient detail to inform laboratory staff upon the safety precautions they need to take in order to process the sample without risk of infection. If, during patient intervention, further information becomes available that has implications for the safety of laboratory staff this must be communicated immediately to the laboratory so that




appropriate steps regarding containment can be taken. NOTE: Patient suspected of having VHF (guidelines) v3. Doc ID 10584

Contact details for the Infection Protection and Control Nurses: 09:00 - 17:00 Mon-Fri Tel: 01603 289847 (Ext: 5847) Email: IP&[email protected] Out of hours: First contact the relevant site practitioner. See flow chart: Infection prevention and Control On-call Service Flow Chart IP&C guidelines and policies can be found on the IP&C Manual on the Intranet or by using the “Hands” shortcut on the desktop.

8. Tests and sample requirements

8.1 Routine Haematology Tests Full Blood Count (FBC): Abbott Alinity H analysers produce a complete automated blood count result with a differential and platelet count - individual parameters need not be requested. Reticulocytes and Nucleated Red Blood Cell Analysis can also be undertaken where appropriate. Blood films are made and examined if requested or if the parameters suggest that a manual film and/or differential will be helpful. Sample Requirements: 3 ml ETDA or Paediatric EDTA. Erythrocyte Sedimentation Rate (ESR) : The ESR is an indirect measure of the degree of inflammation present in the body. It is a non-specific test and has to be interpreted within the clinical context in which it is requested. It may be helpful in diagnosing inflammatory disorders such as temporal arteritis/polymyalgia rheumatica and may also be used to monitor disease activity and response to therapy in these and other inflammatory disorders. It is affected by age, gender and anaemia. Analysed on request. Sample requirements: 3ml EDTA – can use the same sample as FBC. Detection of Epstein Barr Virus (Paul Bunnell): A test for the presence of heterophile antibodies in the serum produced in infectious mononucleosis. Sample requirements: 3 ml EDTA - can use the same sample as FBC.

Malarial Parasites: Thick and thin blood films are stained with Giemsa stain and examined for the presence of malarial parasites. A rapid immunological test is also performed as a complementary test to the standard blood film examination. Blood films for malarial parasites will be made on request if clinical indications suggest the patient is at risk of malaria. Positive blood films are sent to the London School of Hygiene and Tropical Medicine for confirmation. Sample requirements: 3ml EDTA. SAMPLE SHOULD ARRIVE IN THE LABORATORY NO LATER THAN 4 HOURS AFTER BEING TAKEN.

mailto:IP&[email protected]

http://nnvmwebapps01/TrustDocs/ViewDoc.aspx?id=9313




Haemoglobinopathy Screening: Haemoglobinopathy screens can be requested for any patient who might be considered to be at risk of having a haemoglobin variant or thalassaemia. A haemoglobinopathy screen consists of a Full Blood Count and Hb HPLC analysis. If haemoglobin variants are detected by HPLC, confirmation will be performed by electrophoresis and the Sickle Solubility Test. Rare haemoglobin variants that cannot be identified by our laboratory are referred to the Special Haematology Laboratory at Guy’s Hospital (Viapath). These tests should be requested by the patient’s clinician with prior consent. The laboratory does not take telephone requests for add-on haemoglobinopathy screening unless made by a Consultant Haematologist. Sample requirements: 3ml EDTA – can use the same sample as FBC. Sickle Cell Solubility Screen: This is a rapid test to detect the presence of sickle haemoglobin, eg. HbS but in itself doesn’t distinguish between sickle cell trait and sickle cell disease. Positive screen results will be referred for further confirmatory tests. This test is performed when Hb HPLC indicates the presence of a haemoglobin variant or if a rapid result on sickle status is required. Sample requirements: 3ml EDTA – can use the same sample as FBC. Antenatal Sickle Cell and Thalassaemia screening: NNUH participates in the National Screening Programme as a “low prevalence area”. Screening is performed according to the National Screening Programme guidelines using FBC, family of origin questionnaire and, when indicated, HPLC. Sample requirements: 3ml EDTA – can use the same sample as FBC. Glucose-6-phosphate dehydrogenase (G-6-PD) Screening Test: G-6-PD deficiency is the most common inherited genetic enzyme deficiency. Most individuals are asymptomatic, but devastating haemolysis can occur when susceptible patients are exposed to oxidative drugs or infection. It is important to identify individuals at risk as certain drugs may then be avoided. The screening test is based on a qualitative visual fluorescence screening procedure. This test is not performed by the NNUH laboratory – Please note - samples are sent away. Sample requirements: 3ml EDTA – can use the same sample as FBC. Urinary Haemosiderin: Haemosiderin is a pigment formed during the breakdown of haemoglobin and indicates chronic intravascular haemolysis. The test may be used to evaluate and manage disorders involving the destruction of red blood cells. Centrifuged urine deposits can be stained and examined for the presence of urinary haemosiderin. The test is normally only performed at the request of Haematology clinicians. Sample requirement: Urine in Universal Container -not Boric Acid. Cerebrospinal Fluid (CSF) Analysis: CSF is centrifuged, the resulting preparation stained and a manual count made of any cells present. Usually only performed if requested by Haematology Registrar/Consultant if there is a suspicion of CNS involvement in haematological neoplasms. Any other reasons for cell counting should be referred to Microbiology or Cytology. Sample requirement: 1ml CSF. Bone Marrow Sample Analysis: Bone Marrow samples are only taken by a Haematology medical staff. All diagnostic samples (morphology, cytogenetics, molecular genetics) are sent to Addenbrookes Haematopathology and Oncology Diagnostic Service (HODS) for analysis. Depending on the clinical




indication some bone marrow aspirate slides are also processed in duplicate at NNUH to allow for a provisional result and assist with patient management. Turn-around times depend on the assays required. Discuss with haematologist. Peripheral blood Leucocyte Immunophenotyping: Samples are sent to Addenbrookes HODS. See above Sample Requirements: 3mlEDTA Miscellaneous Fluid Cell Counts: Samples are assayed using the Abbott celldyn Ruby analysers and the total White Cell Count reported. Some samples may not be appropriate for analysis if they contain clots or other particulate matter. Sample requirements: Fluid preferably in an EDTA container.

8.2 Routine Coagulation Tests Coagulation Screening: Prothrombin Time/International Normalised Ratio (PT/INR) and Activated Partial Thromboplastin Time (APTT) are our standard coagulation tests. Prolonged clotting times are an indication of abnormal clotting which could lead to an increased risk of bleeding. Further coagulation investigations may be reflexed by the laboratory depending on the nature of the coagulation results and previous test results to aid interpretation. Clauss fibrinogen is reflex tested if the coagulation analyser indicates that the fibrinogen level is likely to be low (derived fibrinogen). Fibrinogen can also be requested by the requesting clinician. When requesting coagulation screening tests it is important to include relevant clinical information as to why the test was requested to enable laboratory staff to determine the best course of action in the event of an abnormal result. It is not appropriate to request a coagulation screen for patients receiving warfarin or heparin as the reference ranges will not be valid. If monitoring of anticoagulants required select the appropriate test on ICE (warfarin monitoring or heparin monitoring) Anticoagulant monitoring: Always ensure the request form contains details of any anticoagulants given, follow prompts on ICE and ensure accurate information is given regarding type of anticoagulant and correct tests are requested. All INR results >5.0 will be telephoned to the GP practice. No other INR results are routinely telephoned. Coagulation results are accessible on ICE For queries related to the anticoagulant monitoring service contact the anticoagulation service on 01603 646515. VTE (venous thromboembolism) screening: D-dimer is used to help venous thromboembolism. It is a restricted test and should only be used in conjunction with a clinical probability score e.g. Wells score and when the result will affect patient management (e.g. allow VTE to be excluded without radiology tests). D-dimer results are generally raised in in-patients and should not be requested. WebICE does not permit D-dimer requests from inpatient locations. D-dimer requests which are not permitted by webICE can only be made after discussion with the duty haematologist who can sanction adding on the request to a coagulation screen if indicated. Specimen Requirements:




3ml Citrate bottle (ensure it is filled appropriately). Specialist Coagulation Tests: Discuss with a Consultant Haematologist.

9. Result enquiries/Telephoned results

Authorised results are available on the ICE system, which is updated regularly throughout the day. If a result is needed urgently and/or cannot be found via the ICE system the laboratory may be contacted 01603 286929/286931. Results of urgent requests, if ICE access or electronic delivery is not available, and unexpected results, which may aid immediate patient management, will be telephoned. In the event that the laboratory is unable to deliver the required service due to equipment failure we will endeavour to contact all relevant users. Haematology telephone criteria: It is the requestor’s responsibility to review laboratory results and act on any abnormal findings. Users must not expect that they will be contacted directly by the laboratory to inform them of any abnormal results. However, the laboratory will always telephone abnormal results if they satisfy the criteria in the table below, unless it is clear to the laboratory scientist authorising the result that the finding is to be expected (for example repeated samples showing the same abnormality). Other abnormal results not fulfilling the criteria below may also be telephoned according to the local laboratory telephone policy. A copy of the laboratory telephone policy can be obtained on request.

Test EPA-wide criteria

Hb Hb < 70 (any MCV) No requirement to telephone high Hb/Hct

Hct Hct >0.6 During working hours or next day

Neutropenia/Neutrophilia

Inpatients:

ED/acute admissions area – telephone if <1.0

Haematology /oncology ward or day unit – not required

All other inpatient locations < 0.5

No requirement to telephone where previous day was also low and telephoned

Outpatients: <0.5

(no requirement to telephone if requesting doctor is a haematology or oncology consultant)

GP samples <0.5 No requirement to telephone high neutrophils

Thrombocytopenia /Platelets (ensure blood film is reviewed before telephoning)

< 20

No requirement to telephone where previous days result telephoned and <20

No requirement to telephone to haematology ward or day




Test EPA-wide criteria

unit No requirement to telephone high platelets

Blood film

Suspected acute leukaemia

TTP

1st presentation Platelet <20

1st presentation CML with WBC >100

1st presentation Haemolytic Anaemia Hb <80g/l

discuss immediately with haematologist

Coagulation/Clotting studies

PT/APTT only if prolonged and clinical details state bleeding/major haemorrhage protocol

PT/APTT unobtainable results, telephone requester for repeat sample urgently.

No need to telephone high APTTR results for patients on unfractionated heparin.

Fibrinogen < 2.0g/L

INR > 5

Malaria screen Any positive

Sickle screen Not required

ESR Not required

Direct Coombs Not required

10. Clinical Liaison

Consultation about investigation and management of conditions is welcomed. For advice on diagnosis and the interpretation of Haematology results or advice on treatment contact a Consultant Haematologist. Outside normal hours of service they may be contacted through the hospital switchboard.

11. Complaints We strive to ensure a high quality service, but if you wish to make a comment or complaint please contact: Mr Nigel Roberts, EPA Service Operations Manager Laboratory Medicine, Norfolk and Norwich University Hospital, Norwich. NR4 7UY Tel: 01603 286936 Email: [email protected]

12. Non-NHS samples Category 2 and private samples must be clearly indicated on the request form.





All work on prospective students of universities or other institutions of further education (except rubella screening in females), is classified as Fee Paying Services and will therefore be charged at Category 2 rates. Testing will only be performed where it is indicated to whom the bill should be sent. Please ensure that your patients are aware that they will be charged for these tests before the sample is taken. Prices are available on request.




13. Haematology Reference Ranges / Turnaround times

Test (A) indicates that test is UKAS Accredited

Reference range

Units Sample Comments/ Precautions

Turnaround Time (TAT) From arrival in lab to result available on WebICE

Ideal sample age for accurate results / Maximum acceptable sample age (at the time of analysis)

Activated partial thromboplastin time: (A) Infant (full term - 15 days) Infant (15 days to 28 days) Infant (1 month to 5 months) Infant (6 months-11 months) Child (1 to 5 years) Child (6 to 10 years) Child (11-17 years) Adult (17 + years

35-53 27.6 - 45.6 24.8-40.7 25.1-40.7 24-39.2 26.9-38.7 24.6-38.4 24.1-38

seconds Sodium Citrate

Routine coagulation test

Urgent: 1hr Inpatient routine: 4hrs GP/OPD routine: 8hrs

Within 8 hours / 24 hours

Prothrombin time: (A) Infant (full term - 15 days) Infant (15 days to 28 days) Infant (1 month to 5 months) Infant (6 months-11 months) Child (1 to 5 years) Child (6 to 10 years) Child (11-17 years) Adult (17 + years

12.0-23.5 9.5-12.6 9.7-12.8 9.8-13.0 9.9-13.4 10.0-14.6 10.0-14.1 9.8-13.1

seconds Sodium Citrate








Reference range




Fibrinogen: (A) Infant (full term - 15 days) Infant (15 days to 28 days) Infant (1 month to 5 months) Infant (6 months-11 months) Child (1 to 5 years) Child (6 to 10 years) Child (11-17 years) Adult (17 + years

0.95-2.45 1.36-3.00 1.41-4.37 1.48-3.67 1.64-4.97 1.71-5.37 1.68-5.29 2.00-3.93

g/L

Sodium Citrate




D Dimer (A) <500 g/L Sodium Citrate




Specialist coagulation - - Sodium Citrate

Discuss with consultant haematologist. ASAP, within 1 hour / 8 hours

Factor assays (A) II,V,VII,VIII,IX,X,Xa,XI,XII

Contact laboratory

- Sodium Citrate

Urgent requests must be discussed with haematology consultant and/or the laboratory

Routine: 1 week

ASAP, within 1 hour / 8 hours

Thrombophilia screen N/A -

Sodium Citrate

Routine: 3 weeks ASAP, within 1 hour / 8 hours

Lupus anticoagulant (A) - -

Sodium Citrate

Routine: 3 weeks ASAP, within 1 hour / 8 hours

Haematocrit 0 - 3 days

0.45 – 0.75

% EDTA FBC Urgent: 1hr Inpatient routine: 4hrs






Reference range




4 - 6 days 7 - 13 days 14d – 1m 1m – 2m 2m – 3m 3m – 1yr 1 year 2 – 5 yr 5 – 11yr 12+ yr (Male) 12+ yr (Female)

0.45 – 0.67 0.42 – 0.66 0.39 – 0.63 0.33 – 0.53 0.28 – 0.42 0.30 – 0.40 0.30 – 0.38 0.34 – 0.40 0.35 – 0.45 0.40 – 0.50 0.36 – 0.46

GP/OPD routine: 8hrs

Haemoglobin 0-3 days 4-6 days 7-13 days 14d – 1m 1m – 2m 2m – 3m 3m – 1yr 2 – 5yr 6 – 11yr 12+ yr (Male) 12+ yr (Female)

140 – 220 150 – 210 135 – 215 125 – 205 115 – 165 94 – 130 111 – 141 110 – 140 115 – 155 130 – 170 120 - 150

g/L EDTA FBC



MCH 0d – 1m 1 – 2m

31-37 30-36

pg EDTA FBC Urgent: 1hr Inpatient routine: 4hrs GP/OPD routine: 8hrs






Reference range




2 – 3m 3m – 1yr 1year 2 – 5yr 6 – 12 yr 12+ yr M/F

27-33 24-30 25-29 24-30 25-33 27-32

MCHC 0-3 days 4-6 days 7-13 days 14d – 1m 1m – 2m 2m – 3m 3m – 1yr 1year 2 – 5yr 6 – 11yr 12+ yr M/F

300 – 360 290 – 370 280 - 380 280 - 380 290 - 370 285 - 355 300 - 360 320 - 360 310 - 370 310 - 370 315 - 345

g/L EDTA FBC



MCV 0-3 days 4-6 days 7-13 days 14d – 1m 1m – 2m 2m – 3m 3m – 1yr

100 – 120 92 – 118 88 – 126 86 – 124 92 – 116 87 – 103 68 – 84

fl EDTA FBC







Reference range




1year 2 – 5yr 6 – 11yr 12+ yr M/F

72 – 84 75 – 87 77 – 95 83 – 101

Platelets: 0-3 days 4-6 days 7-13 days 14d – 1m 1m – 2m 2m – 3m 3m – 1yr 2 – 5yr 6 – 11yr 12 = yr M/F

100 – 450 210 – 500 160 – 500 170 – 500 200 – 500 210 – 650 200 – 550 200 – 490 170 – 450 150 – 410

109/L

EDTA

FBC



Red blood count (RBC) 0-3 days 4-6 days 7-13 days 14d – 1m 1m – 2m 2m – 3m 3m – 1yr 1 year 2 – 11 yr 12+ yr (Male)

5.0 – 7.0 4.0 – 6.6 3.9 – 6.3 3.6 – 6.2 3.0 – 5.4 3.1 – 4.3 4.1 – 5.3 3.9 – 5.1 4.0 – 5.2 4.5 – 5.5

1012/L EDTA FBC







Reference range




12+ yr (Female) 3.8 – 4.8

Reticulocytes 0 - 3 days 4 - 6 days 7d – 1m 1m – 2m 2m – 3m 3m – 1yr 1 -11 yr 12+ yr M/F

120 – 400 50 – 350 50 – 100 20 – 60 30 – 50 40 – 100 30 – 100 50 – 100

% EDTA FBC



White blood count (WBC) 0-3 days 4-6 days 7d – 1m 1m – 2m 2m – 3m 3m – 1yr 1 year 2 – 5yr 6 – 11yr 12+ yr M/F

10 – 26 7 – 23 6 – 22 5 – 15 5 – 19 6 – 18 6 – 16 5 - 15 5 - 13 4 - 10

109/L EDTA

FBC



Detection of Epstein Barr Virus (Paul Bunnell) (A)

N/A - EDTA One working day 24 hours / 24 hours

Malaria parasites (A) N/A - EDTA

Processed on arrival

Within 2 hours ASAP, within 1 hour / 4 hours





Reference range




Urinary haemosiderin N/A -

URINE – NOT in boric acid

Same day Within 8 hours / 24 hours

CSF analysis N/A - CSF Same day Within 4 hours / 8 hours

Leucocyte immunophenotyping N/A - EDTA

Verbal report available within one day. Requests send to Addenbrookes, Cambridge.


Miscellaneous fluid cell counts N/A - Method not validated Same day Within 4 hours / 8 hours

Haemoglobinopathy screen HbF HbA2 Please note these are adult ranges, ranges for babies and children change with age. Please discuss with laboratory for further advice regarding references ranges in children

<1 1.5-3.4

% %

EDTA

Haemoglobinopathy Screen: 1 working day Antenatal Sickle Cell and thalassaemia screening: 3 days





White Cell Differential

Comments / Precautions


Neutrophils Lymphocytes Monocytes Eosinophils Basophils

X 109/l


0 - 3 days 4.0 -14.0 3.0 – 8.0 0.5 – 2.0 0.1 – 1.0 0.0 – 0.1

4 - 6 days 1.5 – 6.9 2.0 – 8.0 0.5 – 1.0 0.1 – 2.0 0.0 – 0.1

7 - 13 days 1.5 -6.9 3.0 – 9.0 0.1 – 1.7 0.1 – 0.8 0.0 – 0.1

14 days – 1 month

1.5 – 6.9 3.0 – 9.0 0.1 – 1.7 0.1 – 0.9 0.0 – 0.1

1 - 2 months

1.5 – 6.9 3.0 – 16.0 0.3 – 1.0 0.2 – 1.0 0.0 – 0.1

2 – 3 months

1.0 – 5.0 4.0 – 10.0 0.4 – 1.2 0.1 – 1.0 0.0 – 0.1

3 months – 1 year

1.0 – 6.0 4.0 – 12.0 0.2 – 1.2 0.1 – 1.0 0.0 – 0.1

1 year 1.0 – 7.0 3.5 – 11.0 0.2 - 1.0 0.1 – 1.0 0.0 – 0.1

2 - 5 years 1.5 – 8.0 1.8 – 8.5 0.2 - 1.0 0.1 – 1.0 0.0 – 0.1

6-11 years 2.0 – 8.0 1.0 - 5.0 0.2 – 1.0 0.1 – 1.0 0.0 – 0.1

12+ years 2.0 – 7.0 1.0 – 3.0 0.2 – 1.0 0.02 – 0.5 0.0 – 0.1


Dept/Site : Haematology NNUH Doc Ref: EBN-HQP-001 Author: A. Macartney/K. Smith

Revision: 3 Issued: Authorised by: R. Pipkin Review interval: Annual

14. Transfusion

The Transfusion Laboratory within Eastern Pathology Alliance (EPA) at the Norfolk and Norwich

University Hospital provides blood components for transfusion at the Norfolk and Norwich

University Hospital, Cromer Hospital, Priscilla Bacon Lodge (NCHC) and Spire Norwich.

They are also responsible for the supply of routine and prophylactic Anti-D, Prothrombin Complex

Concentrate (Beriplex) and clotting factors.

The Transfusion Lab is available 24 hours a day and can be contacted on Ext 2905/2906.

The lab is located in East Block on level one.

The turnaround time for blood groups and the sample requirements for Blood Transfusion are stated

on ICE in the test requesting screen.

All samples should be taken to the specimen reception hatch located on the main corridor or sent

through the pneumatic tube system (Numbers 302, 402, 502 & 602).

14.1 Consultants and senior staff

To contact the on call haematologist please contact the NNUH hospital switchboard.

Dr Suzanne Docherty Consultant Haematologist – Lead Consultant for Transfusion

(Secretary) Ext. 3866

Transfusion Practitioners:

Kathy Ford Transfusion Specialist Nurse Ext. 3863 Or

Bleep 0852/0663 Janet Pring Transfusion Practitioner

Alison Rudd Transfusion Specialist Nurse

Blood Transfusion Lab staff:

Carol Harvey EPA Network Transfusion Manager

Transfusion lab Ext. 2905/2906

Sandy Ellis Senior Biomedical Scientist in Transfusion

Tracey McConnell Senior Biomedical Scientist in Transfusion

Rosie Lynskey Transfusion IT Lead

The Hospital Transfusion Committee (HTC) is a multi-disciplinary team which meets 4 times a year

and is made up of a variety of specialities with an interest in transfusion.

The Hospital Transfusion Team (HTT) meets more frequently and is comprised of representatives

from the Medical staff, BMS staff and the Transfusion Practitioner team. The HTT is a subcommittee

of the HTC and issues can be feedback to the full committee when required.

If you have a matter you would like discussed please contact the Transfusion Practitioners at

[email protected] who will ensure that it is taken to the appropriate group.





14.2 Sample labelling and request forms Accurate patient identification and sample labelling is critical and the lab operates a zero tolerance

policy for samples that are incorrectly labelled or are missing the minimum patient identifiers.

The minimum information required on a sample is the patient’s full name, date of birth and hospital

number. These details must be the same on documentation used at any stage of the transfusion

(Wristband, sample, and prescription). The sample should be signed, dated and timed.

It is the responsibility of the person taking the blood sample to label it correctly at the patient’s side.

Incorrect or missing information can lead to the sample being rejected and therefore there will be a

delay in blood components being available.

All samples must be accompanied by an appropriate request form generated via the ICE system. If

the blood components are required in an emergency due to active bleeding then please phone the

lab to discuss the patient’s requirements.

For further information regarding requesting via ICE please see the Blood Transfusion ICE Requesting

User Guide (Trust Docs ID: 13770)

14.3 Component requesting In order to issue blood components for a patient the laboratory must have a valid sample for the

patient. A sample is suitable for issuing components for up to 7 days after the sample was taken

unless the patient has received a transfusion within the previous 3 months when a sample must be

taken and sent for testing within 72 hours of the planned transfusion.

The check group: in line with national guidelines a check group sample may be required. If the

patient has no previous transfusion records at the NNUH then a second sample will be needed to

confirm that the correct patient has been bled. If this sample is required then it should be taken by a

different person to the initial sample and must be taken from a separate venepuncture.

Requests for red cells must be made through ICE which has been designed to guide appropriate

requesting. All urgent requests must be phoned to the laboratory. Once a unit of red cells is issued

for a patient it will be available for 24 hours after the date and time required.

If platelets are required then these may need to be requested from NHSBT specifically for the

patient. In order to allow for delivery on the routine transport please contact the transfusion lab

before the order cut off time.

Order cut-off time Expected time of delivery

08.00 11.00

13.00 17.00

Out of hours deliveries are only available for emergency/urgent requests as there may be additional

costs associated with ad hoc deliveries.

Platelets will be returned to stock 8 hours after the date and time requested has passed.

If you require blood components for a patient with a known special requirement it is important to

ensure that the transfusion lab is aware of that patient’s needs. If the requirement is new or if the




patient has not been treated at the hospital before then the appropriate special requirements

request form must be completed and sent to the lab to allow an alert to be created for previous

attendances (Trust Docs ID: 1286).

14.4 Collection and administration of blood components To collect blood components from the transfusion lab an EBTS pick up slip must be used. This should

be taken to the transfusion issue hatch (East Block, Level One) and given to the Lab staff who will

issue the required components.

For areas that have a satellite blood fridge only staff who have been appropriately trained can put

units in or remove them as per the Trust Guideline for the Storage of Blood Components in and

Maintenance of Satellite Blood Fridges ( Trust Docs ID: 1074)

For further information on collection and administering blood components please see

Trust Policy for the Collection and Return of Blood Components/Products from the Norfolk and

Norwich University Hospital Transfusion Laboratory (Trust docs id 1077)

Trust Clinical Policy for Checking Blood Components/Products prior to Administration (Trust docs ID

No: 1094)

14.5 Transfusion reactions If you suspect a transfusion reaction stop the infusion and assess the patient.

If a transfusion reaction is suspected then Appendix 1: Investigation/reporting of transfusion

reaction form should be completed and the transfusion lab informed.

For full advice on the management of a transfusion reaction please see the Trust Guideline for the

Management of Reactions to Blood and Blood Products (Trust docs ID 1281).

14.6 Massive blood loss protocol Massive blood loss is defined as ≥40% loss of total blood volume, blood loss of 4000mls within a

24hr period, blood loss of 2000mls in a 3hr period, or blood loss at a rate of >150mls/min. In recent

years a more practical approach is that patients suspected of bleeding (especially if it is internal) will

demonstrate a pulse of >110 bpm and a systolic blood pressure of < 90 mmHg.

The NNUH uses the treatment algorithm developed by the East of England Trauma Network and

agreed by the East of England Transfusion Committee.

To activate the protocol phone the transfusion lab on ext. 2905/2906 and state “I want to trigger the

massive blood loss protocol”.

All subsequent communications between the clinical area and the lab staff should be started with

“This call relates to the massive blood loss protocol”. A specific member of the clinical team should

be nominated to co-ordinate communication with the transfusion lab.

Full details can be found in the Guideline for the Management of: Massive Blood Loss in Adults

(MBL) (Trust Docs ID: 1175) and Massive blood loss in children (Document ID 9960 and Flow chart ID

10828)




14.7 Transfer/receipt of components with a patient between

hospitals Blood components should only be transferred between hospitals if it is felt that there is likely to be a

need to administer them during the transfer or if they have been requested for the individual

patient due to antibodies and that the receiving hospital will not have appropriate units available.

Any units being transferred must be packed in a suitable transfer box by the Lab and the necessary

documentation completed.

All transfer boxes will be sealed by the lab staff. This seal must not be broken unless units are being

administered.

If receiving a transfer box from another hospital the box should be taken to the transfusion lab with

the seal intact to allow the blood units to be correctly stored and recorded.

14.8 Referral Laboratories The transfusion laboratory uses the reference laboratories of NHS Blood and Transplant for

investigations and consultancy.

Red cell immunohaematology: red cell antibody investigations that cannot be resolved in the NNUH

laboratory are sent to Colindale, North London.

Histocompatiblity and Immunogenetics: e.g. Investigation of platelet refractoriness, TRALI, are also

sent to Colindale, North London

Platelet immunology: e.g. HIT and NAIT cases are sent to Filton, Bristol

Cell-free fetal DNA (cffDNA) - A 6ml EDTA sample is required. A small amount of the unborn baby’s

DNA is present in the mother’s blood. By detecting the baby’s DNA in the mother’s blood it is

possible to determine the unborn baby’s D group. This test is known as the fetal RHD screening test

and is used to guide antenatal anti-D prophylaxis. These tests are sent to the International Blood

Group Reference Laboratory (IBGRL), Bristol.




15. Molecular Genetics

CONSTITUTIONAL GENETICS

Condition Test Offered Sample type and Transport Medium

Sending Samples and Turnaround Times

Hereditary Haemochromatosis (HH)

HFE gene Mutations Most HH patients are homozygous for a point mutation at codon 282 of the gene. A small number of patients are compound heterozygotes with a mutation at codon 282 in combination with a mutation at codon 63 on the other chromosome

3 ml of peripheral blood in EDTA

Mark samples “Molecular Genetics” and send immediately to Pathology Reception at NNUH. Turnaround time 10 days.

Inherited Thrombophilia Screening

Factor V Leiden and Prothrombin 20210 mutation

3 ml of peripheral blood in EDTA (the full thrombophilia screen also requires 3 citrate tubes and one clotted tube for coagulation tests)

Turnaround time 3 weeks

DNA Extraction and storage

Long term storage of DNA for future investigations. DNA can be extracted from many tissue types, quantitated and archived at -20oC for future diagnostic investigations and clinical trials etc.

For constitutional genetic studies please send 3ml of peripheral blood in EDTA. Fresh tissue biopsies should be transported in saline.

Mark samples “Molecular Genetics” and send immediately to Pathology Reception at NNUH. Turnaround time N/A.




16. Referral Laboratories

Some specialised or low volume assays are referred to external laboratories for analysis; these may take up to 4 weeks for a result to become available. Please contact the laboratory if there is any urgency for these investigations. Information regarding specimen type for referred tests can be obtained by contacting the laboratory. In line with accreditation requirements we endeavour to use UKAS accredited laboratories whenever possible. Further information on the reference laboratories we use can be obtained from the Individual Head of Section or from the Quality Manager if required. Below is a list of tests which are sent to referral laboratories: Test Name

ACUTE LEUKAEMIA PANEL

ADAMTS13

APL MOLECULAR TESTING

B CELL PANEL

B-ALL FISH PANEL

BONE MARROW

CD34 (PERIPHERAL CD34)

CD62L SHEDDING

CHIMERISM ASSAY: BLOOD (TWO CELL FRACTIONS)

CHIMERISM ASSAY: BONE MARROW

CHIMERISM ASSAY: PERIPHERAL BLOOD CHIM.

ERYTHROPOIETIN (EPO) LEVEL

FACTOR IX INHIBITOR ANTIBODY

FACTOR VIII ASSAY: CHROMOGENIC

FACTOR VIII ASSAY (INHIBITOR AB)

FACTOR XIII ALPHA SUBUNIT

FACTOR XIII ASSAY

G6PD *

GENOTYPING OF HAEMOGLOBIN DISORDERS

HAEMATOLOGICAL MALIGNANCY DIAGNOSTIC SERVICE (TREPHINE BIOPSY)

HAEMATOLOGY WORK UP CLASS 1 & 11 + SCREEN

HAEMATO-MOLECULAR DIAGNOSTIC SERVICES

HAEMOGLOBINOPATHY SCREEN

JAK2 EXON 12 MUTATION

JAK2 V617F MUTATION

MALARIAL PARASITE REPORT

PCR BCR ABL

PCR BCR ABL (BONE MARROW)

PCR FOR WHIPPLES

PIPECOLATE

PLATELET AGGREGATION [PFA100]

PLATELET FUNCTION TEST (PFA100 [COLLAGEN/ADP])

PLATELET NUCLEOTIDES

PML: RARA PCR (TRANSLOCATION 15:17 MRD, BM)




PNH SCREEN

PYRUVATE KINASE

RETROGRADE SEMEN ANALYSIS

SEZARY CELLS

STEM CELL

T CELL PANEL

THALASSAEMIA SCREENING (BAND 3)

VACUOLATED LYMPHOCYTES

WHITE CELL CYSTEINE

G6PD * Urgent requests must be discussed with haematology consultant and/or the laboratory. Turnaround times for urgent testing – 1 day, routine testing – 1 week. For references ranges please see report.

17. Add-on Tests There are occasions when extra tests are required to be added to existing samples for patient management. Add-on investigations from within Trust NOTE – Only Add-On requests from the following locations will be accepted, unless the sample cannot be repeated. Emergency Medicine A&E, AMUL/M, EAUS

Critical Care NICU CCC

The clinician must phone into the laboratory if add-on investigation(s) required. Only those on the agreed list are added on. If other investigations are required they

will have to be discussed with the Haematology Consultant who is contactable via switchboard.

With D-Dimer Add-Ons please request clinical reason If Add-On test is accepted then transfer information relating to patient and sample

to Add-on Request Slip and send to the laboratory. If samples are insufficient or inappropriate it is the responsibility of the laboratory to

inform the requesting clinician of the problem.

Outside normal laboratory hours the following procedure will be followed:

The BMS will take the telephone call from the requesting clinician and use the add-on sheet available.

While requester is on the phone the following message will be read out to the requesting clinician: “If we can find the sample it will be processed but this may take a while. Also if you are intending to take another sample at any time in the near future this may be the quicker route.”




If there is any doubt regarding the request the BMS may refer the call to either the

on-call Consultant or the Duty Manager, whichever is felt more appropriate. Sample is then assayed as appropriate. If insufficient or inappropriate sample then it is the responsibility of the relevant

section to inform requesting clinician of problem. Procedure for requesting add-on investigation(s) from outside the Trust

The clinician must phone into the laboratory if add-on investigation(s) required. Only those on the agreed list are added on. If other investigations are required they

will have to be discussed with the Haematology Consultant who is contactable via switchboard.

While requester is on the phone the following message will be read out to the requesting clinician: “If we can find the sample it will be processed but this may take a while. Also if you are intending to take another sample at any time in the near future this may be the quicker route.”

If insufficient or inappropriate sample then it is the responsibility of the relevant section to inform requesting clinician of problem.

Add-On Request Slip Agreed list of add-on tests: Blood Film (only available if FBC requested) Full Blood Count (Only available if EDTA sample received) Detection of Epstein Barr Virus (Paul Bunnell), D-Dimer (VTE – AE, AMU L/M only unless approved by Haematology Consultant) Sickle Cell Screen and ESR

Date:

Time:

Patients Name:

Hospital No.:

Ward / Surgery

Medic’s Bleep No:

Accession No.:

Lab Section:

Call taken by:

Tests:

Investigation(s) added (Please Tick)

Check in AMS

Sample Found (Please Tick)

Results Reported (Please Tick)




18. Key factors known to affect test performance and result interpretation

There are several key factors known to affect the performance of tests or the interpretation of results and although some like jaundice cannot be avoided, others like sample volume and exposure to sunlight, can. It is therefore very important that samples are taken in the correct containers and any specific sampling or transporting instructions adhered to. Some of these key factors are listed below. If any of these are found appropriate comments will be attached to the report and repeat specimens maybe requested.

Cold Agglutinins/Cryoglobulins

Delay in testing which can affect tests which are prone to sample lability e.g. serum potassium

Interfering substances (e.g. heparin, bacteria)

Jaundice

Haemolysis

Lipaemia

High protein level

Poor sample taking leading to mechanical haemolysis

Wrong sample container/wrong anticoagulant

Temperature extremes

Sample volume – especially where liquid anticoagulants are used

Exposure to sunlight Uncertainty of Measurement The Laboratory is required to determine uncertainty of measurement for all reportable parameters. Uncertainty of Measurement details are available from the Laboratory on request. However, any UoM details which impact clinically will be communicated directly to users.




Appendix 1: Advice on use of Vacutainer tubes The Becton Dickinson (BD) Vacutainer system is designed to be used as a vacuum draw system and is therefore calibrated to withdraw the required volume of venous blood providing it is used as specified by BD. However, there may be occasions when it is not appropriate to use it as designed and venous blood will need to be added to the tubes manually via transfer devices. This process will ensure the correct ratio of blood to anticoagulant. Do not use large tubes for small blood samples as this greatly reduces the volume of serum/plasma which can be obtained, and may increase the ratio blood: anticoagulant, which may adversely influence some results. Never tip blood from one tube into another







Appendix 2: Storage, retention and disposal of clinical samples Under the Human Tissue Act, neither consent nor a licence is required for the storage of material for diagnostic purposes for the benefit of the person from whom the tissue was removed during life. This exemption includes genetic testing. Plasma and serum: Kept for a minimum of 48 hours after the final report has been issued by the laboratory. If there is a requirement to store for longer, specimens that have been centrifuged but not separated should be separated to prolong stability. Ref: The retention and storage of pathological records and specimens, 5th edition, April 2015 -guidance from the Royal College of Pathologists and Institute of Biomedical Science.

Appendix 3: Point of Care Testing (POCT)

POCT is defined by the MHRA (Medicines and Healthcare products Regulatory Agency) as any analytical test performed for a patient by a healthcare professional outside the conventional laboratory setting.

Governing bodies, including the MHRA, the Royal College of Pathologists and the International Organisation for Standardisation (ISO) have all produced guidelines and standards in relation to POCT. To protect patients and staff, use of POCT devices must therefore comply with these regulations and standards.

POCT devices currently in use within the Trust include:

Blood Gas analysers Blood Glucose & Ketone meters Haemoglobin meters INR meters Urine Pregnancy test readers Urinalysis HbA1c analysers Activated Clotting Time (ACT) analysers Bilirubinometers




Responsibility for the management of these devices rests with the Directorate where they operate, with support and advice from Laboratory Medicine. For details of respective responsibilities, please see Trust Point of Care Policy.

Procurement of replacement or new devices must comply with Trust procurement procedures and include discussion with the POCT Co-ordinator, Clinical Engineering and, if required, the Trust IT Department.

A clinical need for a POCT device must be established and a business case prepared and presented to the Pathology Users and POCT Committee prior to acquisition of the device.

All Directorates using POCT at NNUH will be required to sign up and pay for membership of the

appropriate national External Quality Assessment (EQA) scheme. EQA participation is an MHRA

directive and ensures the safe use of POCT, analysing the whole process from user analysis through

to patient record keeping.

Contact Us:

Theresa Hornsby POCT Co-ordinator Ext: 2934

Elaine Mitchell POCT Healthcare Scientist Ext: 2969

Maria Hall POCT Administrator Ext: 3710

NOTE: Point of care testing policy Trust Doc ID 8679.

Appendix 4: Supply of sample containers and request forms Supplies of sample containers and request forms can be obtained from the Pathology Stores Manager, Mr Paul Buckingham on 01603 286286 ext. 6027.

http://nnvmwebapps01/TrustDocs/Doc.aspx?id=8679

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