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BestCare LaboratoryServices, LLC

Table of ContentsPage

1 Introduction2 Customer Service2 Reporting2 Specimens Collected by the Facility3 Standing Orders3 Timed Tests3 Stat Orders4 Stat Testing Menu5 Routine Tests and Panels6 Specimen Collection, Preparation, and Handling6 Safety and Disposal Considerations in Specimen Collection6 Preparation of the Patient7 Order of Tube Draw7 Specimen Containers8 Test Requisitions/Laboratory Logs8 Collecting of the Specimen9 Processing the Specimen9 Label requirements9 Stat Collection9 Routine Collection10 Centrifugation of Gel Tubes10 Storing and/or Transporting the Specimen10 Specimen Transport10 Acceptable Specimens10 Unacceptable Specimens11 Avoiding Common Problems12 Specimen Collection12 Serum Preparation12 Plasma Preparation12 Urine Collection12 Hemolysis13 Vacuum Tubes without Anticoagulants13 Lipemic Serum or Plasma14 Quantity Not Sufficient14 Patient States15 Times Specimens16 Anticoagulants and Preservatives16 Urinalysis and Culture and Susceptibility16 Random Urine Collection for Routine Analysis17 24-Hour Urine Collection17 Recommended Patient Instructions for 24-Hour Urine Collections

Page19 Microbiology Specimen Criteria: Collection and Handling19 Unacceptable Specimens20 Anaerobic Cultures20 Acceptable Anaerobic Culture Sources22 Unacceptable Sources for Anaerobic Culture24 Clinical Hints Suggesting Possible Infection with Anaerobes24 Body Fluids (CSF, Synovial, Peritoneal, Pleural, Thoracentesis, etc.)24 Genital25 Respiratory26 Upper Respiratory Cultures26 Nasopharyngeal26 Influenza A & B26 Sputum, Bronchial Wash, Tracheal Aspirate27 Stool27 Culture27 Occult Blood28 Fecal Leukocytes (WBCs)28 C difficile Toxin A & B28 Urines28 Collection Methods29 Miscellaneous29 Bone29 Catheter Tip29 Ear29 Eye30 Skin and Superficial Wounds30 Neisseria gonorrhea Specimens30 Blood Cultures30 Site Selection31 Disinfection of the Vials31 Venipuncture31 Volume31 Specimen Labeling32 Ordering of Blood Cultures32 Timing of Collection33 Therapeutic Drug Monitoring Guide34 Reference Range Guidelines36 Critical Value Guidelines38 Billing and Insurance Information38 Client Billing38 Medicare- Overview of Medical Necessity38 Medicare Coverage39 Medicaid

Test/Panel Menu (test/panel; container; volume; storage; reference range; units; critical values, CPT codes, turn-around time; special requirements)

Quick Guides (order of draw; container; common tests; storage; additive)

From Our CEO/President

Making a difference, it is what we do. I am very proud of all the accomplishments we have achieved. There are many aspects and services, which distinguish BestCare from other laboratories:

Recruiting most qualified healthcare professionalsQuality of our services Dependability and quick responseCommunication with our clients providing accurate, reliable dataSame day routine test results Modern state of the art laboratory

At BLS, we make a difference by striving to deliver you the quality you need and the service your patients deserve. We are CLIA and COLA certified and Medicare approved. Founded in 2002, our company has expanded substantially because of our hard work dedication and professionalism. I am proud of our achievements in quality laboratory services, outstanding performance and exceptional customer service. It is an honor for us to be recognized in a national news magazine (Washington G-2) for three consecutive years and look continuously forward to serving you with excellence. I take pride in our workmanship and professionalism in the healthcare industry and look forward to providing you the BestCare in laboratory services – and thank you for placing your confidence in BLS.

Sincerely,

Karim Maghareh, Ph.D, MBA, MHA, MT (ASCP), CLSPresident/CEO

Preface:

While every effort is made to create a publication that is up-to-date, technology often brings about changes in methodology that can affect test availability and specimen requirements. If you have any questions, please contact the laboratory.

Dedication to Excellence:

At Bestcare, quality is never compromised. Test results from every section of the laboratory are routinely monitored for reliability, precision, and accuracy by both internal and external quality control programs.

Customer Service

The customer service department at BestCare can provide you with information concerning:

Status of testing in progress Specimen and special handling requirements Test results Billing Availability of tests Adding tests to specimens already in progress

Reporting

Most frequently ordered tests are completed and usually reported within 24 hours following receipt of specimens in our laboratory. Those requiring longer testing time are reported as soon as results are available.

BestCare’s computerized reporting system includes printouts with reference intervals for comparison. For most procedures, abnormal quantitative, results are “flagged” or highlighted.

Specimens Collected by the Facility

1. Urine, stool, and cultures should be ordered when the specimen is collected by the facility.

2. If ordered in conjunction with other blood work, the phlebotomist will check the designated area, cooler, or refrigerator and transport to the laboratory.

3. All specimens must be labeled and must be accompanied by a copy of the order.

Standing Orders

1. Standing orders are entered in the Laboratory Information System, pending collection, with their frequency.

2. Prior to each week, a list of standing orders, for that week, will be sent to your facility for review.

3. You may notify us of any changes, via fax, or written in the laboratory log.

Timed Tests

1. Please order all timed test 24 hours in advance to assure scheduling of a phlebotomist or assure supplies are made available for you.

Stat Orders

1. To insure adequate turnaround time, contact the laboratory for STAT collections.

2. Refer to the list of tests performed STAT. Tests not on this list can be drawn at the same time but will tested as routine.

3. All STAT results are faxed to the facility upon completion.

HIPAA

BestCare Laboratory Services, Inc. (BLS) maintains compliance with the law known as “HIPAA” (Health Insurance Portability and Accountability Act of 1996). BLS protects the legal rights of the patient and protects the patient from invasion of privacy as a result of indiscriminate and unauthorized access to and disclosure of confidential information.

STAT TESTING MENU

The following list comprises the tests or panels which are available for STAT testing. Upon the request of STAT testing, we will dispatch the first available phlebotomist to your facility. The results will be available within one hour from the time the specimen is received in the laboratory.

Individual TestsAlbumin LDHAlkaline Phophatase LithiumALT (SGPT) LipaseAST (SGOT) MagnesiumAmmonia PT/INRAmylase PTTBlood Cultures PhosphorusCalcium Phenytoin (Dilantin)CK PhenobarbitalCK-MB PotassiumChloride ProteinCarbamezipine SodiumCO2 Total BillirubinCreatinine TheophyllineD-Dimer Total ProteinDigoxin Troponin IGGT Valproic AcidGlucose VancomycinIron

PanelsCBC with DifferentialHgb & Hct (H&H)ElectrolytesBasic Metabolic (BMP)Comprehensive Metabolic (CMP)Liver Function Test (LFT)Lipid PanelRenal Function Panel (RFP)Cardiac PanelUrinalysis with micrscopics

Routine Tests and Panels

CHEMISTRY Lipid Panel URINEElectrolytes Panel HDL UrinalysisSodium LDL (calculation) Urine Drug ScreensPotassium CholesterolChloride TriglyceridesCO2 HEMATOLOGY

Other Chemistry CBC w/DiffBasic Metabolic Panel Ammonia CBC w/o DiffLytes + Amylase Hgb & Hct (H&H)Glucose B12 ReticBUN, Creatinine BNP Sedimentation RateCalcium CK (CPK)

CRP COAGULATIONComprehensive Metabolic Panel Ferritin PT/INRBasic Metabolic + Folic Acid PTTAlbumin FT3 D-DimerAlkaline Phosphatase FT4ALT (SGPT) GGT MICROBIOLOGYAST (SGOT) hCG Qualitative S, U Occult Blood StoolTotal Bilirubin HgbA1C Blood CulturesTotal Protein Iron C. difficile Toxin A+B

LDH Routine CulturesLiver (Hepatic) Function Panel Lipase WBC Feces SmearAlbumin Magnesium Flu A & BAlkaline Phophatase Prealbumin VRE ScreenALT (SGPT) PSA MRSA ScreenAST (SGOT) RPRDirect Bilirubin T3 UptakeTotal Bilirubin TIBCTotal Protein Total T4

TSHRenal (Kidney) Function Panel Uric AcidBasic Metabolic + Vitamin DAlbuminPhosphorus Therapeutic Drugs

CarbamezipineCardiac Panel DigoxinCKMB LithiumTroponin I PhenobarbitalMyoglobin Phenytoin (Dilantin)

TheophyllineValproic AcidVancomycin

For more testing information contact the laboratory.

SPECIMEN COLLECTION, PREPARATION, AND HANDLING

Introduction

Laboratory tests contribute vital information about a patient’s health. Correct diagnostic and therapeutic decisions rely, in part, on the accuracy of test results. Adequate patient preparation, specimen collection, and specimen handling are essential prerequisites for accurate test results. The accuracy of test results is dependent on the integrity of specimens.

Safety and Disposal Considerations in Specimen Collection

In all settings in which specimens are collected and prepared for testing, laboratory and health care professionals should follow current recommended sterile techniques, including precautions regarding the use of needles and other sterile equipment as well as guidelines for the responsible disposal of all biological material and contaminated specimen collection supplies. For all those who are involved in specimen collection and preparation, the responsibility to adhere to current recommendations designed to maintain the safety of both patients and health care workers does not end when the patient is dismissed.

There are four steps involved in obtaining a good quality specimen for testing:

1. Preparation of the patient2. Collection of the specimen3. Processing the specimen4. Storing and/or transporting the specimen

1. Preparation of the patient

Prior to each collection, review the appropriate test description, including the specimen type to be collected, volume, procedure, collection materials, and storage and handling instructions.

Verbally reassure patient prior to collection of blood and/or any body fluid that requires invasive procedures.

Verify the patient and the requisition match using at least 2 patient identifiers. Patients may be asked to state their name and date of birth. In a hospital setting, identity should be confirmed using the patient’s armband. (Phlebotomists should say “Please tell me your name” rather than “Are you Ms. Jones?” Some patients may be hard of hearing, in a phase of dementia, or on medications and not always give accurate or appropriate answers.) The phlebotomist may need to ask the patient’s caregiver for identity in some instances.

Have all supplies and equipment needed at patient’s bedside prior to collection.

Supplies: Gloves Labels Vacutainer tube holderTourniquet Vacutainer tubes Sharps containerAlcohol prep Adhesive strip Safety needle if neededButterfly apparatus if needed Gauze/cotton balls Syringe if needed

When more than one blood specimen is required, multisample needles and vacuum tubes make blood collection simpler and more efficient.

Order of tube draw

a. Blood cultureb. Bluec. Redd. Greene. Lavendarf. Gray

Place the sharps container within reach. Open the needle package in front of the patient; do not remove the needle sheath.

During venipuncture, do not have the patient clench and unclench the fist repeatedly (pumping). This will cause a shift in fluid between the vein and the surrounding tissue. This can lead to changes in concentration of certain analytes. To facilitate making the vein more prominent, the patient may be asked to clinch fist tightly. Also, never leave a tourniquet on the arm for more than 1 minute without releasing it. This can cause discomfort to the patient and may also cause hemoconcentration leading to erroneous results.

ANTICOAGULANT:

The proper anticoagulant must be used for a test (i.e., EDTA for CBC's, citrate for PT and aPTT's, serum or heparinized plasma for most chemistries, etc.). If the correct anticoagulant is not used (as stated below) the specimen must be recollected.

Specimen Containers:

Red-top tube:

Contain no anticoagulant or preservative

Mottled red/gray or cherry red-stopper tube:

Contains clot activator and gel for separating serum from cells, but not anticoagulant. Do not use serum-separator tubes to submit specimens for therapeutic drug monitoring. Always check the test description to determine whether a serum-separator tube is acceptable.

Lavender-top tube:Contains liquid K3 EDTA.

Gray-top tube:

Contains sodium fluoride.

Blue-top tube:

Contains sodium citrate. Be sure to use only tubes with a 3.2% sodium citrate concentration. These are easily identified by the yellow diagonal stripes on the label.

Green-top tube:

Contains sodium herapin or lithium heparin.

Yellow-top tube:

Contains 1 ml acid citrate dextrose (ACD) solution.

Royal blue-top tube:

Contains sodium EDTA for trace metal studies.

TEST REQUISITIONS/LABORATORY LOGS:

1. All specimens for testing must be ordered on a test requisition/laboratory log and must be legible.

a. Add-On Tests per Physician Orders - The laboratory may order add-on tests, when appropriate, only upon the order of a physician which must be in writing and faxed to the laboratory.

b. Any specimen received in the lab must be accompanied by a requisition with the patient's full name, other ID number, age and/or date of birth, gender, room number or location, physician’s name, other patient data as appropriate to the test ordered, test(s) requested, time and date ordered, time and date of collection, and initials of person ordering or collecting specimen.

2. Collecting of the Specimen

After securing the tourniquet and reaffirming your selection of the best vein, both by sight and palpation, proceed as follows.

Note: If a patient has intravenous (I.V.) solutions going into both arms, it is acceptable to puncture the vein 3-4 inches below the site of the I.V.

Draws from PICC lines must be drawn by nursing staff, following their facility protocol.

a. Cleanse the site with sterile alcohol wipe in a circular motion, inside to outside, to push contaminants away from the puncture site. Iodine may contaminate specimens for certain chemistry tests.

b. Allow the puncture site to air dry after cleansing. If alcohol is not allowed to dry, it may cause specimen hemolysis. If the arm is dry, you will avoid stinging the patient at venipuncture.

NOTE: Never blow or fan the puncture site with your hand. You will introduce contaminates.

c. Remove the needle cap. d. Anchor the vein. Enter the vein at an angle of approximately 45 degrees.e. If only a single collection tube is required, when the vacuum is exhausted and the tube

completely filled, release the tourniquet, and remove the tube from the needle assembly. Place a piece of dry gauze over the needle and withdraw the needle carefully.

f. When multiple specimens are required, remove the first collection tube from the holder as soon as the blood flow ceases, invert the first tube to prevent clotting, and gently insert the second tube into the holder. Puncture the diaphragm of the stopper by pushing the tube forward and initiating vacuum suction. Remove and invert each successive tube after it is filled. When all samples have been drawn, remove the entire assembly from the arm.

g. Firmly lock the safety shield on the needle, discard the needle and holder into the sharps container. Do not recap or reuse needles.

h. Apply direct pressure to the puncture site.

See Microbiology Specimen Collection for microbiology studies.

3. Processing the specimen

All specimens must be labeled in the presence of the patient.

Label requirements:a. Full nameb. Unique identifier (date of birth acceptable)c. Date, including the yeard. Time of collectione. Initials of collectorf. Cultures must include sight and source

STAT Collection

Provider or Nurse orders the tests by entering all information on the requisition/Laboratory log.For clients that draw their own STAT specimens, call for transportation of specimen to the laboratory.For clients that require BestCare Laboratory Services, Inc. (BLS) to draw a STAT call BLS.Results for in-house testing will be provided in within one hour from the time the specimen is received into the lab.

Routine Collection

Provider or Nurse orders the tests by entering all information on the requisition/Laboratory log.BestCare Laboratory Services, Inc. will draw routines and pick-up specimens at the times designated by contract. Line draws are performed by licensed nursing personnel. Results for in-house testing will be provided in 24 hours or less except for Microbiology.Centrifugation of Gel (Gold-or-speckled top) tubes:

Gel-barrier tubes contain clot activator and gel for separating serum from cells but include no anticoagulant. Adhere to the following steps when using a gel-barrier tube. Do not use gel-barrier tubes to submit specimens for therapeutic drug monitoring, direct Coombs’, blood group, and blood types.

a. Let the specimen stand for a minimum of 15-30 minutes and (preferably) not longer than 60 minutes prior to centrifugation. This allows time for the clot to form. If the specimen is allowed to stand for longer than 2 hours, chemical activity degeneration of the cells within the tube will take place, and test results will be affected.

b. After allowing the clot to form, insert the tube in the centrifuge, stopper end up. Operate the centrifuge for 10 minutes at the speed recommended. Employ a balance tube of the same type containing an equivalent volume of water.

c. When the centrifuge comes to a complete stop, remove tubes carefully without disturbing the contents. Inspect the barrier gel to ensure that it has formed a solid seal between the serum and packed cells.

d. Make sure the tube is clearly labeled with all pertinent information.e. Serum specimens may be sent at room temperature unless otherwise indicated. See charts

below.

4. Storing and/or transporting the specimen

Appropriate storage and handling are necessary to maintain the integrity of the specimen and, consequently, the test results. See guidelines and test index.

Specimen transport:

a. Laboratory Specimens are sent directly to the laboratory via phlebotomist/courier:b. Specimens must be accompanied by a proper requisition/laboratory log.c. Date, time of collection, and initials of collector will be documented on the specimen.d. Specimens which must be kept cold must arrive in the laboratory on ice. e. Specimens are submitted in a leak proof container.f. Specimens are placed in plastic bags for transport.g. Couriers transporting lab specimens are trained to handle and deliver specimens

appropriately.

ACCEPTABLE SPECIMENS:

1. Specimens must be properly ordered, collected, labeled, accompanied by the correct requisition. If any of these criteria are not met, the specimen may be rejected for testing.

2. Condition of Specimen - Any specimen received in the laboratory must be collected correctly as to the container, quantity (volume), anticoagulant or not, condition (i.e., iced, protected from light, preservatives, etc.).

3. Specimen Preservation – Specimen’s received in the laboratory must be preserved according to the requirements of the ordered test.

UNACCEPTABLE SPECIMENS:

1. Hemolysis - If a specimen is hemolyzed, it should be recollected, if appropriate. If it is not possible or practical to recollect a hemolyzed specimen, the physician must be notified of the condition of the specimen and it will be noted on the test results that the specimen was hemolyzed and the care giver notified.

2. Clotted whole blood specimens – If a specimen is clotted, i.e. complete blood count (CBC) or coagulation studies, it will be rejected.

3. Expired collection device.4. Inappropriate collection device/specimen type.5. Unlabeled specimens.6. Leaking/broken specimen container.7. Gross bacterial contamination of specimen.8. Quantity of specimen not sufficient for testing.9. Specimen not submitted at the proper temperature.10. Rejected Specimen - The laboratory must use judgment in accepting or rejecting a

specimen. There may be occasions when some answer is better than no answer. Communication with Nursing Services, the physician, or possibly even the patient may be necessary to determine the acceptability of a specimen. If the decision is made to do testing on less than optimal specimen, the following notation on the report must be made: 1) why the specimen was not acceptable, and 2) why the specimen was tested.

11. When a specimen is rejected, the following protocol is followed:a. Discard specimen.b. Notify caregiver.c. In laboratory information system enter test(s) rejected, describe situation completely

in the comments section, documenting the first and last name and title of the person that is notified of the rejected specimen.

d. If the specimen is recollected, the correct date, time, and initials of recollection will be documented by collector on the properly labeled recollected specimen.

12. When a test is reported from a less than optimal specimen, then later another more suitable specimen is received, the new results are substituted. An amended report is printed to the client. Documentation is kept of these proceedings.

13. A comment will be generated in the LIS for the collector that mislabels a specimen that causes the laboratory to document results on a wrong patient.

14. Any discrepancy related to patient name or client will follow the guidelines below:a. There will be no re-labeling of specimen.b. Specimen (when feasible) will be recollected, properly label, and transported to the

laboratory.15. Exceptions to the policy on rejecting specimens:

a. CSF and other body fluids and surgical specimens – Invasive procedures that are performed on patients to obtain body fluids and/or tissues for testing purposes should be handled with care by collector, nurse, and laboratory. Clients and laboratory personnel will openly communicate so that all specimens collected will be labeled according to proper collection.

Avoiding Common Problems

Careful attention to routine procedures can eliminate most of the problems outlined in this section. Materials provided by the laboratory for specimen collection can maintain the quality of the specimen only when they are used in strict accordance with the instructions provided. To ensure a sufficient quantity of each type of specimen indicated for the procedures to be performed, please consult the volume requirements. Some of the problem areas listed will only become apparent when the physician ordering the test interprets the results in conjunction with other diagnostic information related to the patient.

Specimen Collection – Some of the common oversights affecting all types of specimens include:

Failure to label a specimen correctly and to provide all pertinent information required on the test request form.

Insufficient quantity of specimen to run test or QNS (quantity not sufficient). Failure to use correct container/tube for appropriate specimen preservation. Inaccurate and incomplete patient instructions prior to collection. Failure to tighten specimen container lids, resulting in leakage and/or contamination of

specimen. Failure to maintain the specimen at the appropriate temperature requirement.

Serum Preparation – The most common serum preparation considerations include:

Failure to separate serum from red cells within 30-60 minutes of venipuncture. Failure to allow clot specimens to clot before centrifugation. Hemolysis: red blood cells broken down and components spilled into serum. Lipemia: cloudy or milky serum sometimes due to the patient’s diet.

Plasma Preparation – The most common lapses in the preparation of plasma include:

Failure to collect specimen in correct additive. Failure to mix specimen with additive immediately after collection. Hemolysis or damage to red blood cells. Incomplete filling of the tube, thereby creating a dilution factor excessive for total specimen

volume (QNS). Failure to separate plasma from cells within 15-30 minutes of venipuncture for those

specimens requiring this step.

Urine Collection – The most common urine collection oversights include:

Failure to obtain a clean-catch, midstream specimen. Failure to refrigerate specimen or store in a cool place. Failure to provide a complete 24-hour collection/aliquot or other timed specimen.

Failure to add the proper preservative to the urine collection container prior to collection of the specimen.

Failure to provide an appropriate collection container and to refrigerate specimen when bacteriological examination of the specimen is required.

Failure to tighten specimen container lid, resulting in leakage of specimen. Failure to provide patients with adequate instructions for 24-hour urine collection.

Hemolysis

In general, grossly or even moderately hemolyzed blood specimens may not be acceptable for testing. Hemolysis occurs when the red cells rupture and hemoglobin and other intracellular components spill into the serum. Hemolyzed serum or plasma is pink or red, rather than the normal clear straw or pale yellow color.

Most cases of hemolysis can be avoided by observing the steps listed.

1. For routine collections, use a 20 to 22 gauge needle. (It may be necessary to use a 23 gauge needle for patients from elderly populations with small or difficult veins.)

2. If there is air leakage around the needle or loss of vacuum in the tube, replace the vacuum tube.

3. Collect blood in room temperature containers unless the specimen requirement specifies otherwise.

4. When there is difficulty accessing a vein or when a vacuum tube fills too slowly due to a difficult venipuncture, damage to the red blood cells may result. Correct by collecting a fresh tube when blood flow is established or select another puncture site and, using sterile/unused equipment, collect a second specimen. Also, a blood pressure cuff will reduce trauma to fragile red blood cells.

5. Do not remove the needle from the vein with the vacuum tube engaged. This applies to both the last tube collected during a routine venipuncture and to tubes collected during a difficult procedure.

6. Premature removal of the tube causes a rush of air to enter the tube, which may result in damage to the red cells.

7. Be as gentle as possible, drawing the blood evenly. Too much pressure in drawing blood into a syringe or forcefully ejecting blood into a collection tube from a syringe may damage red cells.

8. Allow collection site to dry after cleaning. Alcohol used to clean the puncture site may cause contamination in a tube.

9. Do not collect a specimen in a hematoma.10. Allow specimen to clot completely before centrifuging.11. Do not centrifuge the specimen for a prolonged period of time.

Vacuum Tubes Without Anticoagulants – When using vacuum tubes containing no additives:

1. Permit the tube to fill completely.2. Let the specimen stand for a minimum of 15-30 minutes and (preferably) not longer

than 60 minutes prior to centrifugation. This allows time for the clot to form. If the specimen is allowed to stand for longer than 60 minutes, chemical activity degeneration of the cells within the tube will take place, and test results may be affected.

3. Centrifuge the specimen at the end of the waiting period for 10 minutes and in accordance with the manufacturer’s instructions for speed.

Lipemic Serum or Plasma (Turbidity)

Normal serum or plasma is a clear and light yellow to straw in color. Turbid serum or plasma appears cloudy or milky.

Serum or plasma may be cloudy due to bacterial contamination or chronic or transient high lipid levels in the patient’s blood.

The primary dietary sources of lipids (fatty substances) are meats, butter, cream, and cheese. Patients who consume these foods within the 24-hour period immediately preceding collection of a blood specimen may have temporarily elevated lipid levels, which may be manifested by cloudy lipemic serum. Lipemic serum or plasma may not be a true indicator of the patient’s physiologic state. Regardless of diet and length of fast, some patients may produce cloudy specimens.

To avoid dietary-induced high lipid levels prior to testing, many physicians require to exclude the high-fat foods from their diets or to fast for 12-14 hours prior to specimen collection. For morning specimen collection, the laboratory recommends that the patient be required to fast from 6 PM on the previous evening.

Quantity Not Sufficient (QNS)

One of the most common problems in specimen collection is the submission of an insufficient volume of specimen for testing. The laboratory sends out a report marked QNS, and calls for a repeat collection. To ensure an adequate specimen volume:

1. Always draw whole blood in an amount 2 ½ times the required volume of serum required for a particular test.

2. For example, if 4ml serum is required, draw at least 10ml whole blood. If there is difficulty in performing venipuncture, minimum volume may be submitted. Indicated “difficult draw” on the test requisition.

3. Provide patients with adequate containers and instructions for 24-hour and stool collections.4. For most serum and plasma tests, check to be certain that the tube is half full. Note: Certain

tests (eg, prothrombin time) require a 90% to 100% accurate draw in order to achieve the proper blood-to-anticoagulant ratio; otherwise, the specimen may be found to be QNS.

Patient States

In general, specimens for determining the concentration of body constituents should be collected when the patient is in a basal state (ie, in the early morning after awakening and about 12-14 hours after the last ingestion of food). Reference intervals are most frequently based on specimens from this collection period.

The composition of blood is altered after meals by nutrients being absorbed into the bloodstream. Consequently, postprandial blood (blood drawn after a meal) is not suitable for some chemistry tests. An overnight fast is preferable to ensure that the patient is in the basal state. This minimizes the effects of ingested substances on the test results. Before you collect the specimen, ask the patient when he/she last ate or drank anything. If the patient has eaten recently and the physician wants the test to be performed anyway, you should indicate “nonfasting” on the test request form. In the clinical information/comment section of the test request form, indicate the time the patient ate. Fasting does include abstaining from coffee, tea, or sugar-free products.

Fasting or diet restrictions, such as low-fat diets, should be explained in detail, particularly to aged or overanxious patients or their caregivers. Inform patients that fasting does not include abstaining from water. Dehydration resulting from water abstinence can alter test results.

When specimens are not collected in the basal state, the following additional effects should be considered when interpreting test results.

Exercise – Moderate exercise can cause an increase in blood glucose, lactic acid, serum protein, and creatine kinase (CK).

Emotional or Physical Stress – The clinical status of the patient can cause variations in test results.

Time of Day Collection – Diurnal variations and variations in circadian rhythm can also affect test results. For example, growth hormone peaks in the morning before waking and decreases throughout the day. Serum iron levels may change as much as 30% to 50%, depending on individual variation, from morning until evening.

Note: For profile testing, 12-14 hour fasting specimens are recommended.

Timed Specimens

There are two types of timed blood specimens: One is for a single blood specimen ordered to be drawn at a specific time. The other is for a test that may require multiple blood specimens to be collected at several specific times.

Single Specimens – Here are some instances in which timed single specimens may be required.

Fasting plasma glucose alone or in conjunction with a random glucose determination, as recommended by the American Diabetes Association, to diagnose diabetes. Fasting here is defined as no caloric intake for at least 8 hours.

Postprandial glucose may be performed 2 hours after a meal for a timed test that is helpful in diabetes detection.

Blood glucose determinations may be ordered at a specific time to check the effect of insulin treatment.

Blood cultures may be ordered for a specific time if a bloodstream bacterial infection is suspected.

Therapeutic monitoring of patients on medication.

Multiple Specimens – Here are some instances in which timed multispecimen tests may be ordered.

The most common timed procedure is a glucose tolerance test. First, a blood specimen is drawn from a fasting patient. Then, the patient is given glucose orally and blood specimens are drawn at fixed intervals, beginning with a 30 minute specimen.

To test the effects of a certain medication, a physician may order the same tests to be obtained on consecutive days, before, during, and after the patient has received a medication.

Collection of an acute and convalescent serum to aid in the diagnosis of a viral infection when culturing is not feasible.

Other examples include such tests as occult blood, ova and parasites, and blood cultures.

Blood Collection

The accuracy of any result depends upon the quality of the specimen. Following the collection, preparation, and instructions suggested by the laboratory helps to ensure the best possible test results. The laboratory supplies materials for proper specimen collection.

Proper identification of specimens is extremely important. Label each specimen. Information on labels must be verified before the specimen is submitted to the laboratory. The name on the test request form must exactly match the patient’s name on the specimen submitted.

Anticoagulants and Preservatives – To ensure accurate test results, all tubes containing an anticoagulant or preservative must be allowed to fill completely. Attempts to force more blood into the tube by exerting pressure, as in collection with a syringe, will result in damage to the red cells (hemolysis). If the vacuum tube is not filling properly, and you are certain that you have entered the vein properly, substitute another tube.

Urinalysis and Culture and Susceptibility

Submit a sterile container or urinalysis preservative tube and culture and susceptibility preservative tube. Label both filled tubes with patient’s full name and date and time of specimen collection.

Urinalysis Only

Submit a sterile container or urinalysis preservative tube. Label filled tube with patient’s full name and date and time of specimen collection.

Culture and Susceptibility Only

Submit a culture and susceptibility preservative tube. Label the filled tube with the patient’s name and date and time of specimen collection. Enter the source in the Laboratory Log. i.e., catheter, clean catch, etc.

Random Urine Collections for Routine Analysis

Patients should be provided with both written and spoken “clean-catch” instructions. The collected urine should be added to the appropriate urine preservative tube or refrigerated immediately to retard growth of bacteria until the test is performed.

The time of collection is critical because urine values vary considerably during a 24-hour period, and most testing methods are based on normal values for first morning samples. The first urine voided in the morning is preferred because it has a more uniform volume and concentration and a lower pH, which helps preserve the formed elements.

24-Hour Urine Collection

For many urine chemistry, it is necessary to analyze a sample taken from an entire 24-hour excretion. Incorrect collection and preservation of 24-hour urine collections are two of the most frequent lapses in urine collections.

The 24-hour urine specimen should be submitted in a chemically clean, properly labeled urine container provided by BestCare Laboratory Services. (Patients should not be allowed to submit urine specimens in their own “clean” jars. The laboratory will add required preservatives or supplies the proper preservative with the container.

Written instructions should clearly explain the following points:

1. The collection of the 24-hour urine starts with the patient voiding (completely emptying bladder) and discarding the first urine passed in the morning.

2. Except for this first discarded urine, all of the urine passed during the day and night, up to and including the first voiding of the following day, must be collected. Urine passed during bowel movements must also be collected.

3. If possible, the entire specimen should be refrigerated at 2oC to 8oC during collection, or kept in a cool place, since urine is an excellent culture medium for organisms, and its components decompose quickly.

4. The 24-hour urine container may contain a preservative of acetic acid, boric acid, or hydrochloric acid, which may cause burns if touched. If ingested, a physician should be notified immediately.

The patient should be informed a normal intake of fluids during the collection period is desirable unless otherwise indicated by the physician or test specimen requirements.

Recommended Patient Instructions for 24-Hour Urine Collections

This section includes written instructions to be provided to the patient with the specified laboratory collection container. Supplement these instructions by discussing them with the patient and explaining why the test and collection procedures are necessary. Collection containers that include acids should be clearly marked. Contact the laboratory for the collection container(s).

To the care giver: You may wish to photocopy these instructions so you can provide your patients with written instructions.

To the patient: Follow these instructions in collecting your 24-hour urine specimen.

You will find it more convenient to void (urinate) into the smaller container provided and transfer the urine into the larger collection container. Do not add anything but urine to the container and do not pour out any liquid, tablets, or powder that may already be in the larger collection container. These substances may cause burns if touched. The collection container should be kept tightly closed and refrigerated throughout the collection period.

1. Upon rising in the morning, urinate into the toilet, emptying your bladder completely. Do not collect this sample. Note the exact time and print it on the container label.

2. Collect all urine voided for 24 hours after this time in the container provided by the care giver. All urine passed during the 24-hour time period (day or night) must be saved. Urine passed during bowel movements must also be collected.

3. Refrigerate the collected urine between all voidings or keep it in a cool place.4. At exactly the same time the following morning, void completely again (first time after

awakening), and add this sample to the collection container. This completes your 24-hour collection.

5. A BestCare Laboratory representative will transport the specimen to the laboratory.

Microbiology Specimen Criteria: Collection and Handling

Introduction

The quality of microbiology results is heavily dependent on receipt of adequate, representative specimen material, properly collected, and promptly delivered to the laboratory. Specimens should be collected early after onset of symptoms and before antimicrobial therapy is instituted. Tests are ordered by the physicians and entered into the lab log by nurses, ward clerks, or other personnel as designated by the facility. The specimen is labeled and sent to the Laboratory accompanied by the laboratory log.

1. All specimens for microbiological examination are collected in sterile containers in asufficient quantity to permit a complete examination. Whenever possible, specimensshould be obtained before antibiotics are administered.

2. All specimens are sent to the laboratory promptly, in a sterile container when required, of sufficient quantity for complete examination, and the container is to be closed tightly and have NO leakage.

3. Each specimen should be labeled with patient's name, collection location, date and time of collection, and specimen source. The initials of the person collecting the specimen should be included next to the time and date.

4. All specimens must be transported to the laboratory in a biohazard bag.6. In the case of unacceptable specimens, if re-collection is not possible, the state of the specimen

will be documented on the laboratory report including the person notified.

Unacceptable Specimens:

Specimens that fall into any of the following categories should be considered unacceptable for processing:

1. Specimens not submitted in a sterile container when required.2. Improper label, order slip and/or specimen container as to the source of specimen, patient's

full name, location, collection time and date (where applicable).3. Name on order or label and the specimen is mismatched.4. Urine specimen not submitted immediately if not in preservative tube or refrigerated.5. Stool specimen contaminated with barium (white area, chalky, heavy) or oil for the

examination of ova and parasites.6. Sputum consisting of saliva, only.7. Specimen received after prolonged delay.8. Specimen in a leaking container or specimen evident on the outside of the container.9. Specimen in fixatives.10. Dried-out swabs.11. Requests for anaerobic cultures on expectorated sputum, superficial wounds, urine, feces,

throat, vaginal swabs, or urethral discharge.12. Insufficient amount of specimen.13. Specimen left in the refrigerator is not acceptable if the organism is to be isolated is

fastidious or cold sensitive, such as gonococci.14. Pooled (24-hour) specimens. 15. Specimens not received in transport media or system when required.

Handling Unacceptable Specimen’s

1. Upon receipt of an unacceptable specimen in the Laboratory, the nursing unit is immediately notified. BestCare Laboratory Services, Inc. informs the nurse or physician that the specimen

will not be processed and request a freshly, properly collected specimen be sent to the laboratory. And, explains the reason for the rejection. In the "Comments" area of the LIS, the reason for the rejection is documented, the name of the person receiving the explanation, the date and time of the rejection.

2. If a specimen cannot be re-collected (ex: specimen collected in O.R. and patient is no longer in O.R., patient already started on antibiotics, etc.) the laboratory will note the condition of the specimen so that it will be a permanent record along with the culture results.

Procedure for Collection and Handling:

Caution: Pathogenic microorganisms, including Hepatitis B Virus and Human Immunodeficiency Virus, may be present in specimens. Universal Precautions and guidelines established by the laboratory should be followed in handling all items contaminated with blood or body fluids. Wear gloves at all times. Properly dispose of all contaminated materials.

1. ANAEROBIC CULTURES

Special precautions must be taken in the collection of specimens from certain sites. Most of the anaerobes found associated with infections in humans are also present on mucous membranes as normal flora. These anaerobes are so numerous at these sites that if clinical material comes into contact with a minute portion of normal flora, false positive or misleading culture results will be obtained. Any specimens collected should be transported as rapidly as possible. The specimen should not come in contact with air or oxygen.

ACCEPTABLE ANAEROBIC CULTURE SOURCES:Site designations on culture orders must come from this list, or will be considered unacceptable by Microbiology at BestCare Laboratory Services, Inc. for anaerobic workup.

BODY FLUIDS Amniotic fluidAscitic fluidBileBloodBone marrowPericardial fluidPeritoneal fluidPeritoneal dialysatePleural fluidSynovial fluidThoracentisis

CENTRAL NERVOUS SYSTEMBrain abscessIntracranial surgery wound

HEAD AND NECKChronic sinusitisMaxillary sinus Middle ear fluid Chronic otitis mediaNeck woundsScalp wounds

DENTAL, ORAL, FACIALOrofacial, of dental originRoot canal infection

Periodontal abscessDental abscess (endodontic origin)Mandibular areaBite woundsSublingual spacesPertonsiilar abscess

LOWER RESPIRATORY TRACT - PLEUROPULMONARYAspiration pneumoniaLung tissueLung abscessBranch brushingsBronchoscopy specimens obtained via double lumen catheterEmpyema (accumulation of pus in thorax)Trans-tracheal aspirate

ABDOMINALAbdominal cavityAbdominal fluidAppendixAppendix with peritonitisLiver abscessOther intra-abdominal infections (post surgery)Biliary tractPerirectal abscessPeritoniumPeritoneal fluidRetroperitoneal abscess

OBSTETRIC - GYNECOLOGICEndometriumEndocervicPelvic AbscessVulvovaginal abscessSeptic abortionBartholin ascessOvaryPlacenta - fetal or maternal sideUterineFallopian tubeCuldoscopy aspiratesEndometrial aspirates

MALE REPRODUCTIVEProstatic fluid Testicular abscess

SOFT TISSUE AND MISCELLANEOUSEndocarditisCatheter exit site other than foley catheterPilonidal sinusBite wound sitesInfected diabetic gangreneDeep decubitus ulcersOsteomyelitisCellulitisGangrene (myonecrosis)

Breast abscessAll tissuesAll biopsiesAspirated pusAll surgical woundsBoneAll deep wounds

Routine Specimens for Culture of Anaerobes:a. Necrotic or debrided tissue from suspected gas gangrene, gas forming or

necrotizing infections.b. Pus or aspirate from deep wound or abscess.c. Amniotic fluid, bile, bloods. d. Endometrium, uterine material from septic abortions, uterus, placenta, Bartholin glands.e. Biopsies or surgical specimens.f. Pericardial, peritoneal, pleural, or synovial fluid, bone marrow.g. Peritoneal dialysate. h. Drain, prosthesis, CVP i. Trans-tracheal aspirate.

Specimens for Cultures of Anaerobes by Request:a. Eye, earb. Vaginal cuffc. Material from infected bitesd. Supra-pubic bladder aspiratee. Bronchoscopic specimensf. Rectal swab in cases of suspected pseudomembraneous enterocolitisg. CSF

UNACCEPTABLE SOURCES FOR ANAEROBIC CULTURESpecimens collected from the following sources will not be processed.a. Sputumb. Nasotracheal suction aspiratec. Throat swabd. Nasal swab e. Oropharyngeal swabf. Gastric contentsg. Small bowel contents or fecesh. Cervical, vaginal, rectal, or urethral swabsI. Clean-catch or catheterized urinesj. Superficial wounds

Abscesses: Post-operative wounds, in most cases, it is necessary to obtain an aspiration sample with a

sterile needle or intravenous catheter attached to sterile syringe. A swab is not regarded as an acceptable method of collection for anaerobic bacteriology

cultures. Instead, an aspirate should be obtained whenever possible. If swabs have to be obtained, use a culturette approved for anaerobic collection such as Becton Dickinson’s Max V+ system.

If there is only a very small amount of drainage or exudate present for study, the lesions can be injected with sterile water or saline and the specimen obtained from the edge of the lesions by aspiration. After aspirating the specimens, air bubbles must be expelled from the syringe; otherwise, the trapped oxygen alters the transport conditions.

The syringe can be immediately submitted to the laboratory after plugging with a sterile rubber stopper. If the specimen cannot be transported to the laboratory immediately, the

specimen in the syringe can be inoculated into a blood culture bottle (clean the top with 70% alcohol before inoculating the specimen). Anaerobic(gel) or MAX V +swabs must be used.

Lung Abscess, Pneumonia, and other Pulmonary Infections: In-patients with pulmonary infections believed to be due to anaerobes, trans-tracheal needle

aspiration or direct lung punctures are the optimal methods. Pleural effusions, empyema fluid and surgically removed tissue are other reliable sources for anaerobic cultures. (Bronchoscopically obtained specimens are not suitable, as the instrument itself becomes contaminated during insertion.)

The same transport methods are used as for abscesses. Tissue should be placed in a sterile container and submitted to the laboratory immediately.

Uterine Infection:

Anaerobic cultures are routinely performed from the uterine cavity by syringe or swab, using great care to avoid contamination. Anaerobic cultures are routinely performed on material from placenta, Bartholin glands, endometrial cavity, and fallopian tubes.Transport methods are the same as for abscesses.

Urinary Tract Infection: Anaerobic bacteria rarely cause urinary tract infections. The ONLY way their presence can

be documented is by supra-pubic aspiration since anaerobic bacteria normally colonize the distal urethra. Transport methods are the same as for abscesses. Label the specimen as supra-pubic aspiration.

Body Fluids: Blood, ascetic fluid, synovial, prostatic, pericardial and pleural fluid is routinely cultured for

anaerobes and should be collected and transported as described in "Anaerobes".

***** CLINICAL HINTS SUGGESTING POSSIBLE INFECTION WITH ANAEROBES **

1) Foul-smelling discharge.2) Location of infection in proximity to a mucosal surface.3) Necrotic tissue, gangrene, pseudomembrane formation.4) Gas in tissues or discharges.5) Endocarditis with negative routine blood cultures.6) Infection associated with malignancy or other process producing tissue destruction.7) Infection related to the use of aminoglycosides (oral, parenteral or topical).8) Septic thrombophlebitis.9) Bacteremic picture with jaundice.10) Infection following human or other bites.11) Black discoloration of blood-containing exudates.12) Presence of "sulfur granules" in discharges (Actinomycosis).13) Classical clinical features of gas gangrene.14) Clinical setting suggestive for anaerobic infection (septic abortion, infection following

gastrointestinal surgery, etc.)

2. BODY FLUIDS (CSF, Synovial, Peritoneal, Pleural, Thoracentesis, etc.)

CSF: Physicians are provided with sterile, flat-bottom centrifuge tubes in order to reduce

specimen handling. Label each tube with patient name and information. The specimen tubes are numbered in the order in which they were obtained. Collection of the specimen is under aseptic or sterile conditions and transported to the lab immediately, properly labeled. Prompt transport of the specimen to the laboratory is mandatory since fastidious organisms

such as Haemophilus influenzae and Neisseria meningitidis may not survive storage or variations in temperature. A CSF order is processed immediately and on a priority basis. Gram stains are performed on all CSF specimens with bacterial cultures.

Fluids: Specimen material may be sent in sterile flat bottom centrifuge tubes or sterile container (if

fluid is collected with sterile syringe, the needle must be removed prior to transportation to lab). Protect the specimen from oxidation because anaerobes may be present (see Anaerobe section above). Expel any accumulated air from syringes. Label specimen with patient name and information. Transport to the lab immediately. In addition to a routine aerobic culture, an anaerobic culture and gram stain are performed on all body fluid sources except CSF.

NOTE: Fluids or pus collected with a sterile syringe and needle can be transported to the lab in the syringe after plugging the syringe with a sterile rubber stopper. Any air bubbles should be expelled from the syringe before transport.

3. GENITAL

The lining of the normal human genital tract is a mucosal layer made up of epithelial cells. A variety of species of commensal bacteria colonize these surfaces, causing no harm to the host and helping to prevent the adherence of pathogenic organisms. The flora of the female genital tract varies with the pH and estrogen concentration of the mucosa, which is dependent on the age of the host. Microbiological cultures are performed to identify the microorganisms, which may be the etiological agent.

Clinical Specimen from Suspected Site of Infection:a. Urethral Discharge - collected with a flexible aluminum wire and small rayon-tipped swab. The

swab is inserted approximately 2 cm into the urethra and rotated gently before withdrawing. Remove the swab and insert it into the sleeve containing aimes gel medium. Push the cap to bring swab into contact with the gel at the bottom. Label specimen with patient name and information and LIS label containing orders. Transport to the lab immediately.

b. Cervix - collected with a swab inserted into the cervical canal, rotated and moved from side to side for 30 seconds before removal. Swabs are handled same as above but a culturette swab is routinely used.

c. Vaginal - same as cervix except specimen is collected from vagina.d. Endocervix - collected after the vagina has been exposed by insertion of a speculum.

NOTE: Urethral, penile, cervical, and vaginal discharge may be directly inoculated on a Martin-Lewis plate.

Organisms such as Neisseria gonorrhoreae will not survive on a dry swab. If a smear for Gram stain is prepared, roll (do not drag) the swab over a slide. Label specimen(s) with patient name and information. Transport to the lab immediately. The orders should be entered into the lab log and the log must accompany the specimen to the laboratory.

WET PREP test: For Trichomonas vaginalis, place a specimen swab in 0.5 ml of sterile physiological saline. Label specimen with patient name and information. Transport to the lab immediately. The orders should be entered into the lab log and the log must accompany the specimen to the laboratory.

4. RESPIRATORY

The respiratory tract begins with the nasal or oral passages and extends past the nasopharynx and oropharynx to the trachea and then into the lungs.

The upper respiratory tract is the upper airway from the larynx through the nasopharynx and neighboring oropharynx to the nose, to its communicating cavities, the sinuses, and middle ear.

A number of microorganisms can cause infections of the upper and lower respiratory tract. Respiratory tract cultures are performed to establish the etiology of such infections.

Upper Respiratory Cultures:

Throat:-Throat cultures are performed for the diagnosis of pharyngitis. Bacterial agents recognized to cause pharyngitis include beta hemolytic streptococci, C. diptheriae, N. gonorrhoreae, N. meningitidis, Staphylococcus aureus, Mycoplasma pneumoniae, and H. influenzae (in children). Of these organisms, beta hemolytic streptococci occur most frequently and are the usual concern. Therefore, most throat cultures are done to rule out pharyngitis due to beta hemolytic streptococci, although, on selected occasions other organisms might be of concern.

Collection:1. Use culturette to collect the specimen.2. Use tongue blade to depress tongue to minimize contamination.3. Swab vigorously tonsillary area, posterior pharynx, any area of inflammation, ulceration, or

capsule formation.4. Put the swab back in the tube and transport it to the lab with appropriate label.

Nasopharyngeal:

Collection:1. Use calcium alginate swab on a flexible wire (minitip) to obtain the culture.2. Pass the swab gently through the nose into nasopharynx, rotate and remove the swab.3. Place the swab in a plastic tube provided with the culturette.4. Transport the culture to the lab, correctly labeled.

Influenza A & B:It is recommended that specimens be obtained early in the course of the illness and be tested as soon as possible. 1. Acceptable specimens for evaluation with the Xpect® Flu A&B test include nasal washes, nasal

swabs, and throat swabs.2. Use a rayon or polyester- tipped swab with aluminum or plastic shafts to collect the specimen.

Calcium alginate should not be used.3. Samples may be placed in a viral transport medium or 0.5ml of sterile saline in a sterile

containaer. Contact BestCare Laboratory Services for appropriate collection container.4. Refrigerate the sample after collection.

NOTE: For RSV and/or Bordetella Pertussis please refer to individual proceduresfor these sendout tests.

Sputum, Bronchial Wash, Tracheal Aspirate:Pneumonia remains a leading cause of death in the U.S. in spite of effective antibiotics. Accurate etiologic diagnosis of lower respiratory infections is essential for proper management of such infections.

Collection:

Expectorated Sputum: These specimens are adequate for the detection of aerobic and facultative organisms, but not for anaerobes. Sputum screening by gram stain is essential to ensure that the specimen consists of lower respiratory secretions.

Collect specimens in sterile container that can be sealed to prevent leakage. Collect sputum under supervision to ensure that the specimen is a cough specimen.

Transport the specimen to laboratory immediately to ensure organism viability.

Screening of expectorated sputum for the number of epithelial cells present is performed routinely on expectorated sputum submitted for "routine culture". This is done in an effort to make sputum cultures more diagnostic. If a specimen has more than 25 epithelial cells and no wbc's or very few wbc's, the sputum will be rejected for culture since the screen shows that the specimen is more saliva than expectorated sputum.

Microbiology lab will notify the Nursing service immediately if a new specimen is needed.Nursing service will either recollect or notify Respiratory Therapy immediately for recollection.

Sputums aspirated by Respiratory Therapy do not need to be screened with a gram stain since the integrity of the sputum is assured.

5. STOOL

Culture specimen:1. Stools for best recovery of Salmonella and Shigella should be obtained in the acute (first 3 days)

of diarrheal disease.2. Rectal swabs are permissible when stool specimens are not readily obtained. However,

maximum recovery of organisms is not likely when swabs are used.3. Multiple stool samples should be submitted to increase chances of recovery of organisms (3

samples/admission).4. Stool specimen containers have to be sterile when submitting for culture.5. Label container correctly.6. Complete appropriate information in the laboratory log/requisition including date and time of

collection. Order the tests requested by the physician.7. Special requests should be put into "comments" and/or called to Micro Laboratory. The special

request must also be clearly marked on the label of the container, (i.e. look esp. for Yersinia, etc.).

8. Deliver specimen and request to laboratory immediately. Pathogenic stool organisms are very fragile and specimen requires immediate processing to ensure best possibility of recovery. Refrigerate specimen and transport on ice pack. Stool specimens stored at room temperature greater than 2 hours will be rejected.

Occult Blood:

Patient Preparation:Diet: It is recommended that the patient be placed on a high residue diet starting 2 days before and continuing through the test period.The diet may include: 1. Meats - Only small amount of well-cooked chicken, turkey, and tuna. NO red or raw meat should

be included in the diet.2. Vegetables - Generous amounts of both raw and cooked vegetables including lettuce, corn,

spinach, carrots, and celery. Avoid raw vegetables with high peroxidase activity such as turnips, cauliflower, red radishes, broccoli, cantaloupe, horseradish, and parsnip.

3. Fruits - Plenty of fruits, especially prunes and apples. 4. Cereals - Bran and bran-containing cereals. 5. Peanuts and popcorn in moderate amount daily.

If any of the above foods are known to cause discomfort, contact the physician.

Medications:For 7 days prior to and during the testing, no aspirin or any other anti-inflammatory medicines should be

taken.For 2 days prior to and during the testing, no rectal medicine should be used.For 2 days prior to and during the testing, no tonics or vitamin preparations containing Vitamin C in excess

of 250 mg/day should be taken.

Collection:1. Collect specimen in a plastic or waxed container. Container does not have to be sterile.2. Specimen may be collected and applied to a Hemoccult slide:

a. Open the front flap of the Hemoccult slide. Apply a very thin smear of stool specimen to one window of the slide, using an applicator.

b. Use an applicator to obtain a second sample from the same specimen, but from a different area. Apply similarly.

c. Allow the specimen on the slide to air dry and close the cover.

Transport the specimen or Hemoccult slide to the laboratory promptly and correctly labeled.

Fecal Leukocytes (WBC's):Collect stool specimen in a clean or non-sterile container. The container must contain NO preservatives and must be leak proof. Transport the specimen to the lab promptly, correctly labeled, and with the appropriate requisition.

Clostridium difficile:Collect stool specimen in a clean or non-sterile container. The container must contain NO preservatives and must be leak proof. Store specimens between 2 and 8C (Refrigerate).

6. URINES:

To ensure the most accurate results from urine cultures, proper instruction and techniques should be employed during collection. Always place specimens in a sterile container, preferably the Becton Dickinson Transport Tube with preservative. The urine should always be collected before any antibiotic therapy is begun, unless the physician orders the culture in the midst of antibiotic therapy.

The first voided morning specimen should be collected whenever possible. If this is not possible, urine should be allowed to incubate in the bladder for as long as possible before the collection to increase the number of organisms per milliliter.

The orders should be entered into the lab log and the log must accompany the specimen to the laboratory.

A urine specimen for culture may be used for routine urinalysis if it collected in a sterile container that does not contain preservatives and the urinalysis has been ordered. Urine received in a gray top Urine Transport Tube is not suitable for urinalysis.

Urine collected in a sterile container without preservative must be refrigerated immediately. Deliver to the laboratory within 2 hours of collection, no greater than 24 hours to ensure quality of testing.

Collection methods for Urine Culture:1. Suprapubic aspiration of the bladder is performed by the physician and involves direct puncture of

the bladder through the lower abdominal wall using a sterile needle and syringe. This is the

preferred method for collecting urine from infants. Transfer to a sterile container.2. Straight catheter- Obtaining urine by single straight catheterization of the bladder is not routinely

recommended, as there is a variable risk of introducing bacteria into the bladder.3. The physician performs cystoscopy or bilateral ureteral catheterization. A sample is collected in a

sterile tube and labeled as CB (catheterized bladder urine), LK (left kidney urine), or RK (right kidney urine).

4. Indwelling catheter- For collection of a specimen from an indwelling catheter, clean the catheter with Betadine followed by 70% isopropanol, puncture directly with a needle and syringe, and withdraw several cc’s of urine. Place urine in a sterile container. Obtaining urine that has collected in a Foley bag is not recommended since urine from this site may be overgrown with bacterial flora from outside the urinary tract.

5. Clean catch, midstream urine-Patient must thoroughly wash their hands with soap and water and then dry their hands, A male patient should retract the foreskin and cleanse the glans with an antiseptic towelette.

Instruct the patient to void the first portion of the urine into the toilet bowl and then void a portion of the midstream urine into a sterile container.

A female patient should spread the labia with one hand and wash the vulva 2 or 3 times, using an antiseptic towelette. The towelette should be used in front to back movements only and be followed by rinsing with warm sterile water. The patient should void the first portion of urine into the toilet bowl and then void urine directly into the sterile container, without stopping the stream. The container should be held in such a way as to avoid contact with the vulva, leg, or clothing.

NOTE: If the patient is not capable of cleansing himself/herself, especially in the case of a bedridden patient, the nursing attendant should follow the above procedure for cleansing the patient before specimen collection.

7. Miscellaneous:

Bone:Specimens from orthopedic procedures or post-op complications must be transported to the laboratory immediately in a sterile container properly labeled. Indicate the specific site when ordering the culture on the lab log.

Catheter Tip:Collect the tip aseptically and transport to the laboratory quickly in a sterile container properly labeled. Indicate the specific site when ordering the culture on the lab log.

Ear:Culture of an infected ear is obtained by swabbing the infected area with the flexible mini tip swab/culturette. Refer to the section on Nasopharyngeal culture for use, labeling, ordering, and transporting the specimen to the laboratory.

Eye:Culture must be taken before topical anesthetics or antibiotics are applied.

1. Swab the infected area and replace the swab in the plastic tube provided with the culturette.2. Label the specimen, order the culture on the laboratory log/requisition, and transport to the

laboratory as soon as possible.3. Gram stains should be prepared at the bedside. Label the slides and transport the slides to

the microbiology department.4. Corneal scrapings need to be taken after the application of topical anesthetics. Material

should be directly plated on blood and chocolate agar plates and into thioglycollate broth. The media can be obtained from the microbiology department.

Skin and Superficial Wounds:1. Disinfect the lesion area with 70% alcohol. Allow to dry.2. Swab the infected area with the swab from the culturette.

3. Return the swab to the plastic tube of the culturette.4. When dealing with productive lesions, discard the surface material. Use the exudate from the

interior of the lesion for the microbiological analysis.5. Properly label the culturette including stating the specific site from which the culture material was

obtained.6. Order the test on the laboratory log and transport the specimen to the laboratory.

Neisseria gonorrhea Specimens:Genital specimen:

1. A culture may be collected with a culturette.2. Order the culture on the laboratory log/requisition and label the swab. Transport to the

laboratory immediately.

Note: If the physician orders a smear, make a thin smear of the specimen and allow to air dry. Label the frosted (or white) end of the slide in pencil with the patient’s name, date of birth, source, and date. Place the slide in a cardboard slide box and transport to the laboratory with the appropriate orders.

Throat, Rectal, Anal Swabs for N. gonorrhea:1. Collect specimens with swabs provided in the culturette system. Follow proper procedures

for labeling, ordering, and transporting to the lab.2. In addition to labeling the specimen, also note on the specimen that the culture is for “GC”.

8. Blood Cultures:

Because blood culture media have been developed as enrichment broths to encourage the multiplication of even one bacterium, it follows that these media will enhance the growth of any stray contaminating bacteria, such as a normal inhabitant of human skin. Therefore, careful skin preparation before collecting the blood sample is of paramount importance to reduce the risk of introducing contaminates into blood culture media.

Site selection:

1. Select a different body site for each culture set (aerobic and anaerobic vial) drawn.2. Avoid drawing blood through indwelling intravascular catheters unless blood can not be

obtained by venipuncture. Blood collected from intravascular catheters should be done with the knowledge that contamination may be an issue. If the patient has an existing IV line, the blood should be drawn below the existing line; blood drawn above the line will be diluted with the fluid being infused.

Site preparation:

1. Clean the intended venipuncture site with alcohol prep.2. Open the ChloraPrep package. Apply ChloraPrep disinfectant by beginning at the intended

venipuncture site, working in a circular motion with friction, covering an area of 2-3 inches in diameter. Do not return to the center of the site once swab has moved outward to the periphery. ChloraPrep or Iodine should be applied with friction and the site prepped 30 seconds to 1 minute.

3. Allow disinfectant solution to air-dry.4. DO NOT touch or palpate the area after cleansing.

Disinfection blood culture bottles:1. Remove the flip-off caps from BACTEC culture vials.2. Wipe top of each vial with a separate 70% isopropyl alcohol pad and allow drying3. Do not use ChloraPrep to disinfect tops of vials.

Venipuncture:1. Avoid touching the venipuncture site. If it is necessary to touch the site after it has been

cleaned, wipe your fingers with the iodine prep before touching the site.2. When using the Blood Collection Set (“butterfly”) the phlebotomist MUST carefully monitor

the volume collected by using the 5 mL graduation marks on the vial label. If the volume is not monitored, the stated maximum amount collected may be exceeded. This condition may adversely create a ‘false’ positive result, due to high blood background.

3. If using a needle and syringe, typically a 20 mL syringe is used for adults. Draw 16 to 20 mL of blood for one blood culture set (aerobic and anaerobic). Aseptically inject 8 to 10 mL of specimen into each vial

4. For pediatric patients, a 3 mL syringe is frequently used. Draw 1 to 3 mL of blood and transfer the entire amount into BACTEC™ PEDS PLUS/F vial.

5. After all specimens have been collected from the individual, use a sterile alcohol pad to remove the iodine solution from the venipuncture site.

6. Continue to care for the venipuncture site following guidelines recommended by BestCare Laboratory Policy.

7. The inoculated BACTEC vials should be transported as quickly as possible to the laboratory.

Volume: The volume of blood cultured is critical because the number of organisms per mL of blood in most cases of bacteremia is low, especially if the patient is on antimicrobial therapy. Because there is a direct relationship between the volume of blood and the yield, it follows that the more blood that is cultured, the greater the chance of isolating the organism. In infants and children, the number of organisms per mL of blood during bacteremia is higher than adults, so less blood is required for culture.

1. Children: 1 to 5 mL of blood per venipuncture. Transfer the entire amount to a BACTEC™ PEDS PLUS/F vial.

2. Adult: 16 to 20 mL of blood per venipuncture. If it is impossible to draw the required amount, aliquot as follows:

Amount per VenipunctureAmount in BACTECPlus Aerobic Vial

Amount in BACTECPlus Anaerobic Vial

16 - 20 mL Split equally between aerobic and anaerobic vials13 -16 mL 8 mL 5 - 8 mL10 -12 mL 5 - 7 mL 5 mL5 - 9 mL entire blood amount 0

NOTE: Optimum recovery of isolates will be achieved by adding 8 to 10 mL of blood (BACTEC PEDS PLUS/F: 1 - 3 mL). The use of lower or higher volumes may adversely affect recovery and/or detection times.

Specimen labeling-Each vial should be labeled with the appropriate patient information:• Patient’s name• Patient ID number Patient’s Date of Birth• Ordering Physician• Date and time of collection• Collector’s initials• Site of venipuncture• Or other information as per facility

Ordering of Blood Cultures:Each set of Blood cultures should be ordered on the laboratory log/requisition and a site of collection must be noted on both the log and the bottle. The test can then be ordered in the laboratory by laboratory personnel.

Timing of Collection:

The timing of cultures is not as important as other factors in patients with intravascular infections because organisms are released into the bloodstream at a fairly constant rate. Because the timing of intermittent bacteremia is unpredictable, it is generally accepted the two or three blood cultures be spaced about an hour apart. However, a study found no significant difference in the yield between multiple blood cultures obtained simultaneously or those obtained at intervals. The authors concluded that the overall volume of blood cultures was more critical to increasing organism yield than was timing. When a patient’s condition requires initiating antibiotic therapy as soon as possible, there is little time to collect cultures over a timed interval. An acceptable compromise is to collect 40 mL of blood at one time, 20 mL from each of two separate venipuncture sites, using two separate needles and syringes before the patient is given antimicrobial therapy. Blood cultures are transported to the laboratory.

THERAPEUTIC DRUG MONITORING

DIGOXIN specify time of last dose and dosage

LITHIUM specify time of last dose and dosage

DILANTIN specify time of last dose and dosageTrough: 30 minutes prior to next dose. Peak: 4 to 6 hours last dose

THEOPHYLLINE specify time of last dose and dosage

TOBRAMYCIN specify time of last dose and dosageTrough: Immediately before subsequent dosing

Peak: IV – 30 minutes after end of 30 minutes infusion or within 15 minutes after a 60-minute infusion

IM – 60 minutes post injection

GENTAMICIN specify time of last dose and dosageTrough: Immediately before next dose Peak: 60 minutes post IM injection

30 minutes after end of 30-minute IV infusionDirectly after 60-minute infusion

AMIKACIN specify time of last dose and dosageTrough: Immediately before subsequent dose Peak: 60 minutes post IM injection or

30 minutes after end of 30-minute IV infusion orDirectly after 60-minute IM infusion

CARBAMEZEPINE specify time of last dose and dosage(Tegretol)

Peak: 3 hours after an oral dose (patients on chronic therapy)

PHENOBARBITAL specify time of last dose and dosageTrough: Immediately before next oral dose

VALPROIC ACID specify time of last dose and dosage(Depakote) Trough: Immediately prior to next dose.

Peak: 1 to 4 hours after dose.

VANCOMYCIN specify time of last dose and dosageTrough: Immediately before next dosePeak: 90 minutes after end of a 60-minute IV infusion

Factors that may affect sampling times for TDM:Patient age, weight, sexAll drugs patient is receivingDosage regimen and dosage form of each drugClinical status of patient (e.g., renal and hepatic function, etc.)

Reason for drug measurementTime of sampling relative to dose

Reference Range Guidelines

Chemistry MicrobiologyTest Reference

RangesTest Reference Ranges

Albumin 3.5-5.0 g/dL C. difficile toxin NegativeAlkaline Phosphatase 30-126 U/L Occult Blood Stool NegativeALT (SGPT) 9-52 U/L WBC Smear None SeenAmmonia 9-30 umol/L Routine Cultures NegativeAmylase 30-110 U/LAST (SGOT) 14-36 U/LBNP 0-100 pg/mLBUN 7-17 mg/dLCalcium 8.4-10.2 mg/dLChloride 98-107 mEql/LCK 55-170 U/LCO2 22-34 mEql/LCholesterol <200 mg/dLCreatinine Female 0.5-1.0

Male 0.7-1.3mg/dLmg/dL

Digoxin 0.9-2.0 ng/mLDirect Bilirubin 0-0.6 mg/dLGlucose 65-99 mg/dLHDL 40-100 mg/dLHgbA1C% 4.3-6.1%Iron (Fe) Female 37-170 ug/dL

Male 49-181 ug/dLLDH 313-618 U/LLDL 0-40 mg/dLMagnesium 1.6-2.3 mg/dLPhenytonin 10-20 ug/dLPhosphorus 2.5-4.5 mg/dLPrealbumin 17.6-36 mg/dLPotassium 3.6-5.2 mEql/LSodium 134-145 mmol/LTIBC 250-450 ug/dLTotal Bilirubin 0.2-1.2 mg/dLTotal Protein 6.3-8.2 g/dLTriglycerides 40-149 mg/dLUric Acid 2.5-8.5 mg/dL

CoagulationTest Reference

RangesPT 10.4-13.8 secondsINR 0.8-1.2aPTT 25-40 seconds

Hematology

CBC Parameter Abbreviation Female Reference Range Male Reference RangeWhite Blood Cell Count WBC 4.0-10.8 K/uL 4.0-10.8 K/uLRed Blood Cell Count RBC 3.8-.5.0 M/uL 4.1-5.7 M/uLHemoglobin Hgb 11.0-15.8 g/dL 11.8-17.0 g/dLHematocrit Hct 33.0-47.4% 35.4-51.0%MCV MCV 82.0-99.0 fl 82.0-99.0 flMCH MCH 27.0-33.0 pg 27.0-33.0 pgMCHC MCHC 31.0-36.0% 31.0-36.0%Platelet PLT 150-450 K/uL 150-450 K/uLRDW RDW 12.0-15.0% 12.0-15.0%MPV MPV 8.0-12.0 fL 8.0-12.0 fLNeutrophil % NE% 37-80% 37-.0-80.0%Lymphocyte % LY% 10.0-50.0% 10.0-50.0%Monocyte % MO% 0-12% 0-12%Eosinophil % EO% 0-6% 0-6%Basophil % BA% 0-2% 0-2%Absolute Neutrophil Count NE# 1.9-5.0 K/uL 2.0-6.6 K/uLAbsolute Lymphocyte CountLY# 1.3-3.6 K/uL 1.5-3.6 K/uLAbsolute Monocyte Count MO# 0.1-1.0 K/uL 0.1-1.0 K/uLAbsolute Eosinophil Count EO# 0.0-0.4 K.uL 0.0-0.64 K/uLAbsolute Basophil Count BA# 0.0-0.02 K/uL 0.0-0.06 K/uL

TestSedimentation Rate ESR Male 0 – 10 mm/hr

Female 0 – 20 mm/hr

Critical Value Guidelines

For procedures performed at BestCare Laboratory, the following values are considered critical values:

Once a value has exceeded the established limits outlined above, the technologist may verify it by repeat testing.

The results will immediately be conveyed to the staff nurse (working under the direction of the physician). If the staff nurse is not available the Charge nurse will be notified.

All notifications will be documented in the Laboratory Information System (LIS) with the name of the person called, date, time, and initials of Technologist calling results. The Technologist will document that the critical value regarding the patient is read back correctly.

TEST LOW HIGHChemistryAmmonia NA >/= 100 umol/LSodium </= 125mmo/L >/= 155 mEq/LPotassium </= 3.0mEq/L >/= 5.8mEq/LChloride </= 80mEq/L >/= 120mEq/LCarbon Dioxide </= 11mEq/L >/= 40mEq/LBUN NA >/= 80mg/dL Calcium </= 7.0mg/dL >/= 13.0mg/dLGlucose </= 40mg/dL >/= 400mg/dLCK NA >/= 170U/LCKMB NA >/= 4.4 ng/mLMagnesium <1.0 mg/dLTroponin I NA >/= 0.40 ng/mL

HematologyWBC </= 2.0k/uL >/= 20.0K/uLHGB </= 8.0g/dL >/= 20.0g/dLHCT </= 24.0 % >/= 60.0 %Platelets </= 50,000 uL >/= 900,000 uL

CoagulationPT >/= 30 secondsINR >/= 3.6APTT >/= 45 secondsD-Dimer >/= 400 ng/mL

Therapeutic DrugsDrug levels noted to be in the Toxic RangeCarbamezapine NA >/= 20 ug/mLDigoxin NA >/= 2.5 ng/dLLithium NA >/= 2.0 mmol/LPhenobarbital NA >/= 20 ug/mLPhenytoin (Dilantin) NA >/= 30.0 ug/dLTheophylline NA >/= 30.0 ug/dL.Valproic Acid NA >/= 120 ug/mLVancomycin Peak NA >/= 40 ug/mL Vancomycin Trough NA >/= 20 ug/mL

TEST LOW HIGH

SerologyVDRL or RPR Positive/ReactiveHIV Positive

MircrobiologyBlood Culture PositiveCSF gram stain PositiveCSF culture PositiveAcid Fast Smear PositiveCulture s Positive for mycobacteriaC. difficile Toxin PositiveClostridium in wound PositiveSalmonella or Shigella PositiveMRSA PositiveVRE PositiveAcinetobacter Positive

< means Less Than </= means Less Than or Equal To> means Greater Than >/= means Greater Than or Equal To

Billing and Insurance Information

Client Billing

Clients will be billed monthly by an itemized invoice. Please note that these invoices are payable upon receipt. If you have any questions pertaining to your account, please notify us immediately in writing so that we may resolve them in a timely manner.

Medicare- Overview of Medical Necessity

Advance Beneficiary Notice:

If reimbursement is denied due to lack of medical necessity documentation, Medicare rules prohibit the laboratory or health care provider from billing the patient unless an Advance Beneficiary Notice (ABN) has been signed and dated by the patient prior to the service. As applicable, an ABN must be completed each time services are ordered. A blanket ABN is not acceptable to the Medicare program.

The centers for Medicare and Medicaid Services has established a standardized ABN that ensures the patient understands that he/she may be responsible for payment if the test is considered to be medically unnecessary by Medicare. The ABN identifies the limited coverage laboratory test and gives the reason the test is likely to be denied. In order for the patient to make an informed decision whether or not to receive the service, the ABN provided two options. Option 1 states that the patient chooses to have the service performed and understand that he/she is personally responsible for payment in the event Medicare denies payment. Option 2 states that the patient refuses to have the service performed and will notify his/her doctor of that decision.

Compliance

To comply with these new guidelines, physicians should (1) only order tests that are medically necessary in diagnosing or treating their patients; (2) be certain to enter the appropriate and correct ICD-9 code in both their patient files and on the test request forms; and (3) always have their patients sign and date an ABN if they believe that the service is likely to be denied.

Medicare Coverage

Bestcare agrees to accept the Medicare-allowed amount as payment in full for covered services. It is important to understand that assignment does not preclude billing of the patient for services denied by Medicare. The following situations may result in a bill to the patient.

Non-covered services. These services include test, visits, and procedures that are not reasonable or necessary by accepted medical standards, i.e., the services are found to be inappropriate or in excess of those required for diagnosis or treatment of the enrollee’s condition. CMS has determined that it is your responsibility to inform patients in writing if a service may not be covered. The Medicare does not cover tests that require, but do no have FDA approval. These procedures are referred to as “Investigational use only” and “Research use only” procedures and will be billed to the patient provided the beneficiary has signed and BestCare has on file a “Medicare Advance Beneficiary Notice”.

Medicare Coverage of Laboratory Testing

When ordering laboratory tests that are billed to Medicare/Medicaid, or other federally-funded programs, the following requirements may apply:

Only tests that are medically necessary for the diagnosis or treatment of the patient should be ordered. Medicare does not pay for screening tests, except for certain specifically approved procedures, and may not pay for non-FDA approved tests or for those tests considered experimental.

If there is reason to believe that Medicare will not pay for a test, the patient should be informed. The patient should sign an Advance Beneficiary Notice (ABN) to indicate that he or she is responsible for the cost of the test is Medicare denies payment.

Medicare requires the ordering physician provide an ICD-9 diagnosis code.Panels should be billed only when all components of the panel are medically necessary.

Medicare National Limitation Amounts for CPT codes are available. Medicaid reimbursement will be equal to or less than the amount of Medicare reimbursement. The CPT codes for the tests are profiled in this guide.

Medicaid

Medicaid is medical assistance for those people who cannot afford their own health care. It is important to note that Medicaid claims can only be filed after all other third-party resources have been exhausted. Patients should be asked at the time of service if there is other coverage, such as Medicare, Medicaid HMO, or private insurance. When applicable, any Medicare or private insurance information should also be provided.

CHEMISTRY                        

TESTS/PANELS SEXNORMAL

LOWNORMAL

HIGH UNITSCRITICAL

LOWCRITICAL

HIGH CONTAINER VOLUME STORAGESPECIAL

REQUIREMENTS

Turn Around

TimeCPT

CODES

ACUTE HEPATITIS PANEL             Gel 10mL Refrigerate     80074

HAAb, IgM Negative  

HBcAb, IgM Negative  

HbsAg Negative  

Hep C Ab Negative  

BASIC METABOLIC PANEL (BMP)             Gel 7mL Ambient   1 Day 80048

BUN M 9 20 mg/dL N/A >80  

  F 7 17 mg/dL N/A >80  

CALCIUM 8.4 10.2 mg/dL <7.0 >13.0  

CHLORIDE 98 107 mmol/L <80 >120  

CO2 22 34 mmol/L <11 >40  

CREATININE M 0.7 1.3 mg/dL >5.0  

  F 0.5 1.0 mg/dL >5.0  

GLUCOSE 65 99 mg/dL <50 >400  

POTASSIUM 3.6 5.2 mmol/L <3.0 >5.5  

SODIUM 134 145 mmol/L <125 >155  

CARDIAC PANEL             Lavender 4mL Ambient   1 Day  

CKMB 0.0 4.3 ng/mL >4.4   82553

TROPONIN I 0.0 0.40 ng/mL >0.41   84484

MYOGLOGIN 9.0 96.5 ng/mL >100   83874

COMPREHENSIVE METABOLIC PANEL (CMP)           Gel 7mL Ambient   1 Day 80053

A/G RATIO 0.9 2.5 Ratio  

Albumin 3.5 5.0 g/dL  

ALKALINE PHOSPHATASE 38 126 U/L  

ALT (SGPT) 13 69 U/L  

AST (SGOT) 15 46 U/L  

BUN M 9 20 mg/dL N/A >80  

  F 7 17 mg/dL N/A >80  

BUN CREATININE RATIO 6 28 Ratio  

CALCIUM 8.4 10.2 mg/dL <7.0 >13.0  

CHLORIDE 98 107 mmol/L <80 >120  

CO2 22-34 34 mmol/L <11 >40  

CREATININE M 0.7 1.3 mg/dL >5.0  

  F 0.5 1.0 mg/dL >5.0  

GLOBULIN 2.0 4.0 g/dL  

GLUCOSE 65 99 mg/dL <40 >400  

POTASSIUM 3.6 5.2 mmol/L <3.0 >5.5  

SODIUM 134 145 mmol/L <125 >155  

TOTAL BILIRUBIN 0.2 1.2 mg/dL  

TOTAL PROTEIN 6.3 8.2 g/dL  

ELECTROLYTES (Lytes)             Gel 7mL Ambient   1 Day 80051

POTASSIUM 3.6 5.2 mmol/L <3.0 >5.5  

SODIUM 134 145 mmol/L <125 >155  

CHLORIDE 98 107 mmol/L <80 >120  

CO2   22 34 mmol/L <11 >40            

TESTS/PANELS SEXNORMAL

LOWNORMAL

HIGH UNITSCRITICAL

LOWCRITICAL

HIGH CONTAINER VOLUME STORAGESPECIAL

REQUIREMENTS

Turn Around

TimeCPT

CODES

IRON BINDING CAPACITY (IBC)             Gel 7mL Ambient   1 Day  

IRON M 49 181 ug/dL   83540

  F 37 170 ug/dL   83540

TIBC 250 450 ug/dL   83550

UIBC 150 375 ug/dL   83550

% SATURATION 20 55 %  

LIPID             Gel 7mL Ambient FASTING 1 Day 82465

CHOLESTEROL 50 199 mg/dL  

HDL 40 100 mg/dL  

LDL 0 99 mg/dL  

TRIGLYCERIDES 40 149 mg/dL  

VLDL 0 0-40 mg/dL  

LIVER FUNCTION TEST (LFT)             Gel 7mL Ambient   1 Day 80076

A/G RATIO 0.9 2.5 Ratio  

ALBUMIN 3.5 5.0 g/dL  

ALKALINE PHOSPHATASE 38 126 U/L  

ALT (SGPT) 13 69 U/L  

AST (SGOT) 15 46 U/L  

DIRECT BILIRUBIN 0.0 0.6 mg/dL  

GLOBULIN 6.3 8.2 g/dL  

INDIRECT BILIRUBIN 0.0 1.1 mg/dL  

TOTAL BILIRUBIN 0.2 1.2 mg/dL  

TOTAL PROTEIN 6.3 8.2 g/dL  

RENAL FUNCTION PANEL (RFP)             Gel 7mL Ambient FASTING 1 Day  

ALBUMIN 3.5 5.0 g/dL   80069

BUN M 9 20 mg/dL N/A >80  

  F 7 17 mg/dL N/A >80  

BUN CREATININE RATIO 6 28 Ratio  

CALCIUM 8.4 10.2 mg/dL <7.0 >13.0  

CHLORIDE 98 107 mmol/L <80 >120  

CO2 22-34 34 mmol/L <11 >40  

CREATININE M 0.7 1.3 mg/dL >5.0  

  F 0.5 1.0 mg/dL >5.0  

GLUCOSE 65 99 mg/dL <50 >400  

PHOSPHORUS 2.5 4.5 mg/dL Gel 7mL Ambient   1 Day

POTASSIUM 3.6 5.2 mmol/L <3.0 >5.5  

SODIUM 134 145 mmol/L <125 >155  

THYROID PANEL             Gel 7mL Ambient   1 Day  

THYROXINE (T4) 5.53 11.0   84436

T3-UPTAKE 23.5 40.5   84479

FTI (FT4 INDEX)  

TSH   0.465 4.680                 84443

HEMATOLOGY/COAG                        

TESTS/PANELS SEXNORMAL

LOWNORMAL

HIGH UNITSCRITICAL

LOWCRITICAL

HIGH CONTAINER VOLUME STORAGESPECIAL

REQUIREMENTSTurn

Around CPT

CODES

Time

Complete Blood Count (CBC) w Diff             Lavender 4mL Ambient   1 Day 85025

WBC M 4.0 10.8 10*3/uL <2.0 >20.0  

  F 4.0 10.5 10*3/uL <2.0 >20.0  

RBC M 4.10 5.70 10*6/uL  

  F 4.0 5.20 10*6/uL  

HGB M 11.8 17.0 g/dL <8.0 >20.0  

  F 11.5 17.0 g/dL <8.0 >20.0  

HCT M 35.4 51.0 % <24.0 >60.0  

  F 34.0 50.0 % <24.0 >60.0  

MCV M 82.0 99.0 fL  

  F 80.0 99.0 fL  

MCH M 27.0 33.0 pg  

  F 27.0 34.0 pg  

MCHC M 31.0 36.0 g/dL  

  F 32.0 36.0 g/dL  

RDW M 12.0 15.0 %  

  F 11.5 14.5 %  

MPV M 8.0 12.0 fL  

  F 7.4 10.4 fL  

PLATELETS M 150 450 10*3/uL <50 >900  

  F 150 450 10*3/uL  

NEUTROPHILS% M 37 80 %  

  F 37 80 %  

LYMPHOCYTES% M 10 50 %  

  F 10 50 %  

MONOCYTES% M 0 12 %  

  F 0 12 %  

EOSINOPHILS% M 0 6 %  

  F 0 6 %  

BASOPHILS% M 0 2 %  

  F 0 2 %  

NEUTROPHILS# M 2.0 6.6 K/uL  

  F 1.9 5.0 K/uL  

LYMPHOCYTES# M 1.5 3.6 K/uL  

  F 1.3 3.6 K/uL  

MONOCYTES# M 0.1 1.0 K/uL  

  F 0.1 1.0 K/uL  

EOSINOPHILS# M 0.0 0.4 K/uL  

  F 0.0 0.4 K/uL  

BASOPHILS# M 0.0 0.2 K/uL  

HCT & HGB (H&H)                        

HGB M 11.8 17.0 g/dL <8.0 >20.0  

  F 11.5 17.0 g/dL <8.0 >20.0  

HCT M 35.4 51.0 % <24.0 >60.0  

  F 34.0 50.0 % <24.0 >60.0  

PT   10.4 13.8 sec N/A >30 Blue 4mL Ambient   1 Day 85610

INR 0.8 1.2 RATIO >3.6 Included with PT 1 Day 85610

PARTIAL THROMBOPLASTIN TIME (PTT)   25 40 sec   >45 Blue 4mL Ambient   1 Day 85730

URINE                        

TESTS/PANELS SEXNORMAL

LOWNORMAL

HIGH UNITSCRITICAL

LOWCRITICAL

HIGH CONTAINER VOLUME STORAGESPECIAL

REQUIREMENTSTurn

Around CPT

CODES

Time

URINALYSIS             Urine 15mL Refrigerated   1 Day 81003

COLOR Yellow  

CLARITY Clear  

SPECIFIC GRAVITY 1.005 1.035  

pH 4-5 8.0  

PROTEIN Negative  

GLUCOSE Negative  

KETONES Negative  

OCCULT BLOOD Negative  

UROBILINOGEN <2.0 mg/dL  

BILIRUBIN Negative  

LEUKOESTERASE Negative  

NITRITES Negative  

UA MICROSCOPY                        

URINE DRUG SCREEN (8 panel)             Urine 10mL Refrigerate   1 Day  

AMPHETAMINES Negative ng/mL   80100

BARBITURATE Negative ng/mL   80100

BENZODIAZEPINES Negative ng/mL   80100

CANNBINOID Negative ng/mL   80100

COCAINE (METABOLLITE) Negative ng/mL   80100

METHADONE Negative ng/mL   80100

OPIATES Negative ng/mL   80100

PHENCYCLIDINE (PCP)   Negative   ng/mL               80100

All routine tests should be collected in order listed. Always label specimens at bedside using 2 identifiers. Initial and write the time on all specimens.

Tube Common TestsAdditional information/storage

Additive

Blood Culture Special bottles (vials)

Must draw before routine orders.Use Sterile techniques; Monitor VolumeInvert tube gently x 10 to mixStorage: Room Temperature

Media

Blue

Do Not over- or under-fill

PT

PTT

D-Dimer (Blue on ice + Lavender)Fibrinogen (x1)FDP (x1)Platelets (only if previous results for CBC note clumping)

Must fill to proper level; invert gently x 10Note: discard tube “no additive” must be used if ONLY drawing citrate (blue) tube with a tube holder and butterfly needle. Used only to remove air from tubing for proper fill.Storage: Refrigerate

Sodium Citrate

Red

ANAB12CEACK

Ferritin Folate HIT TIBC

Therapeutic drugs (eg.,Dig,Keppra, Phenytoin,Vanco, Crbm,Theo,Gent, Amik)

Storage: Refrigerate None

GEL

ALTAST AmylaseAlbuminBMPCMPCaCRP

HepatitisHIVIronLipaseLIPIDLiver Panel Lytes

PrealbuminPSARenalRPRUric AcidT3, T4, TSH

Storage: Refrigerate after centrifuging

Centrifugation: After allowing the clot to form (15-30 minutes), insert the tube in the centrifuge. Centrifuge for 10 minutes. Employ a balance tube of the same type containing an equivalent volume of water.

Gel

Green Ammonia (on ice) invert gently x 10 place on ice

Lithium Heparin

Lavender

Ammonia (x1 on ice)B-NP (x1)

CBC ClozarilD-Dimer (HOU/CON)

H&HHgbA1C (x1)

Platelet CntPTH-intact (x1)Prograf

Retic Count RBC Folate (x2)

ESR (Sed rate)CARDIAC (CKMB, Trop I, Myoglobin)

invert gently x 10; Storage: RefrigerateAmmonia: on ice - STAT delivery

EDTA

Gray Alcohol level FBS/Glucose

Lactic Acid(on ice)

invert gently x 10; Storage: Lactic Acid - on ice - STAT delivery

Sodium Fluoride

53

Any questions, please contact BestCare Laboratory Services, LLC

Always label specimens at bedside using 2 identifiers. Initial and write the time on all specimens.

Specimen container Tests/usesAdditional information/storage Additive

Cherry-red/Yellow Marbled Top

UrinalysisMinimum fill line is 7 mL; Max fill line is 8mLStorage: Refrigerate (up to 72 hrs)

Chlorhexadine, Ethyl Paraben, Sodium Propionate

Gray Rubber Topper

Urine Culture & SensitivityMinimum fill line is 3 mLStorage: Room Temperature (up to 72 hrs)

Boric Acid, Sodium Formate, Sodium Borate

Urine Collection Cup

Random Urine Chemistries, Urine Osmolality, Urinalysis, Urine Drug Screen, Urine Microalbumin

Storage: Refrigerate (up to 24 hrs)None

Specimen ContainerC-diff (Stool) Refrigerate immediately Storage: Refrigerate immediately None

Occult Blood (Guiac)Storage: Room Temperature or Refrigerate

None

Sterile containers Stool, sputum, tissue, body fluid, cath tips Storage: Room Temperature None

Culture Swab Collection & Transport System

Anaerobic and aerobic, wounds, MRSA screen, VRE screen, throat

Storage: Room Temperature (up to 72 hrs) Aimes media

Flu screens and viral culturesStorage: Room Temperature; transport to laboratory after collection

UTM-RTUniversal Transport Media

Any questions, please contact BestCare Laboratory Services, LLC

54

TESTSCONTAIN

ERVOLUM

ESTORA

GESEX

NORMAL LOW

NORMAL

HIGHUNIT

SCRITIC

AL LOW

CRITICAL

HIGHCPT

CODES

Turn Around

Time SPECIAL REQUIREMENTS

ACETAMINOPHEN Red 7mL Ambient   10 30 ug/mL     82003 1-2 Day NO Gel!!

ACID FAST BACILLUS CULTURE (AFB) Sterile  Refrigerate            

87015,87116, 87206

6-7 Weeks  

ALPHA-FETOPROTEIN (AFP) TUMOR MARKER Gel 7mL

Refrigerate   0.0 6.0 U/mL     82105 2 Days  

ALBUMIN Gel 7mL Ambient   3.5 5.0 g/dL     82040 1 Day  

ALCOHOL, BLOOD GRAY 7mLRefrigerate   <10   mg/dL     82055 1-3 Day DO NOT OPEN

ALCOHOL, Urine Urine 5mLRefrigerate             82055 1 Day DO NOT OPEN

ALDOLASE Gel 7mLRefrigerate             82085 1 Day  

ALDOSTERONE Gel 7mLRefrigerate             82088 1-2 Days  

ALKALINE PHOSPHATASE Gel 7mL Ambient   38 126 U/L     84075 1 Day  

ALT (SGPT) Gel 7mL Ambient   13 69 U/L     84460 1 Day  

ALT (SGPT) Gel 7mL Ambient             84460 1 Day  

AMIKACIN PEAK Red 7mLRefrigerate   20.0 30.0 ug/Ml     80150 2 Days NO GEL!!

AMIKACIN TROUGH Red 7mLRefrigerate   1.0 8.0 ug/Ml     80150 2 Days NO GEL!!

AMMONIA Lavender 4mL Freeze             82140 1 Day ON ICE!!

ANAEROBIC CULTURE Sterile   Ambient             87075 3-5 Days  

ANGIOTENSIN CONVERTING ENZYME Gel 7mLRefrigerate   12 68 U/L     82164 1 Week  

ANTIDIURETIC HORMONE (ADH)Gel & Lavender 7mL

Refrigerate   0.0 4.7 pg/mL     83930,84588 1 Week  

ANTINUCLEAR ANTIBODIES (ANA) Gel 7mL Ambient   0 99AU/mL     86038 1 Week  

ANTISTREPTOLYSIN Gel 7mLRefrigerate   0.0 200.0 IU/Ml     86060 2 Days  

AST (SGOT) Gel 7mL Ambient   15 46 U/L     84450 1 Day  

AST (SGOT) Gel 7mL Ambient             84450 1 Day  

BLOOD CULTUREBD BACTEC 5-10mL Ambient             87040 5-7 Days  

BODY FLUID CULTURE Sterile 1mLRefrigerate            

87070,87075, 87205 3-5 Days  

BONE/TISSUE CULTURE Sterile  Refrigerate            

87070,87075, 87205 3-5 Days  

BNP Lavender 4mL Ambient   0.0 100 pg/Ml     83880 1 Day  

BRONCHIAL BRUSHINGS CULTURE Sterile  Refrigerate             87070 3-5 Days  

BUN Gel 7mL Ambient M 9 20 mg/dL N/A >80 84520 1 Day  

        F 7 17 mg/dL N/A >80      

BUN CREATININE RATIO Gel 7mL Ambient   6 28 Ratio       1 Day  

CA 125 Gel 7mLRefrigerate             86304 2-3 Days  

CA 19-9 Gel 7mLRefrigerate             86301 2-3 Days  

CA 27.29 Gel 7mLRefrigerate             86300 2-3 Days  

CALCIUM Gel 7mL Ambient   8.4 10.2 mg/dL <7.0 >13.0 82310 1 Day  

CARBAMEZAPINE/TEGRETOL Red 7mLRefrigerate   4.0 12.0 ug/mL   >20 80156 1 Day  

CARCINOEMBRYONIC ANTIGEN (CEA) Gel 7mLRefrigerate             82378 1 Day  

CATHETER TIP CULTURE Sterile1-2 inches Ambient             87070 3-5 Days  

CEREBRIAL SPINAL FLUID (CSF) CULTURE Sterile 1mL

Refrigerate             87070 3-5 Days  

CERULOPLASMIN Gel 7mLRefrigerate             82390 2-3 Days  

CHLORIDE Gel 7mL Ambient   98 107 mmol/L <80 >120 82435 1 Day  

CHLORIDE, 24 HR Urine Urine  Refrigerate             82436 1-2 Days  

CHOLESTEROL Gel 7mL Ambient   50 199 mg/dL     82465 1 Day FASTING

CLOSTRIDIUM DIFFICILE, Stool Stool  Refrigerate   Negative     Positive   87324 1 Day  

CO2 Gel 7mL Ambient   22 34 mmol/L <11 >40 82374 1 Day  

COMPLEMENT C3, SERUM Gel 7mL Ambient             86160 2 Days  

COMPLEMENT C4, SERUM Gel 7mL Ambient             86160 2 Days  

CORTISOL Gel 7mLRefrigerate             82533 1-2 Days  

CORTISOL, AM Gel 7mLRefrigerate             82533 1-2 Days  

CORTISOL, PM Gel 7mLRefrigerate             82533 1-2 Days  

CK-MB Lavender 3mLRefrigerate   0.0 0.43 ngmL   >4.4 82550 1 Day  

CREATINE KINASE (CK) Gel 7mL Ambient   30 170 ug/mL   >170 82550 1 Day  

CREATININE Gel 7mL Ambient M 0.7 1.3 mg/dL   >5.0 82565 1 Day  

CREATININE       F 0.5 1.0 mg/dL   >5.0 82565 1 Day  

CREATININE CLEARANCE Gel/Urine   Ambient             82575 1-2 Days  

CREATININE, 24HR Urine Urine 10mL Ambient             82570 1-2 Days  

CREATININE, Urine Urine 10mL Ambient             82570 1-2 Days  

CRP Gel 7mLRefrigerate     <10.0 mg/L     86140 1-2 Days  

CRP, hs (HIGH SENSITIVITY) Gel 7mLRefrigerate             86141 1 Day  

CYCLOSPORINE Lavender 3mLRefrigerate             80158 1-2 Days  

D-DIMER Blue 4mL Ambient   0.0 0.4 ug/mL   >0.4 85379 1 Day  

D-DIMER (Houston/Conroe only) Lavender 3 mLRefrigerate     <400 ng/mL   >400 85379 1 Day  

DHEA Gel 7mLRefrigerate             82626 1-3 Days  

DHEA-SULFATE Gel 7mL Refrigera             82627 1-3 Days  

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DIGOXIN Gel 7mLRefrigerate   0.8 2.0 ng/Ml   >2.5 80162 1 Day  

EAR CULTURE Swab   Ambient             87070 3-5 Days  

ENVIRONMENTAL CULTURE Sterile   Ambient             87070 3-5 Days  

EOSINOPHIL, Urine Urine 5mLRefrigerate             87205 1 Day  

ERYTHROCYTE SEDIMENTATION RATE (ESR) Lavender 4mL Ambient M 0 10 mm/hr     85652 1 Day  

ERYTHROCYTE SEDIMENTATION RATE (ESR) Lavender 4mL Ambient F 0 20 mm/hr     85652 1 Day  

ERYTHROPOIETIN Gel 7mLRefrigerate             82668 2-3 Days  

ESTRADIOL Gel 7mLRefrigerate             82670 1-3 Days  

ESTROGEN, TOTAL Gel 7mLRefrigerate             82672 1-3 Days  

ETHOSUXIMIDE (ZARONTIN) Red 7mLRefrigerate   40 100 ug/mL     80168 2 Days NO Gel!!

EYE CULTURE Swab   Ambient             87070 3-5 Days  

FERRITIN Gel 7mLRefrigerate             82728 1 Day  

FIBRIN DEGRedATION PRODUCTS (FDP) Blue 4mL Ambient   <5         85362 1 Day  

FIBRINOGEN Blue 4mL Ambient             85384 1 Day  

FOLIC ACID Gel 7mL Ambient   2.8 >20 ng/Ml     82746 1 Day  FOLLICLE STIMULATING HORMONE (FSH) Gel 7mL

Refrigerate      

mIU/mL     83001 2-3 Days Contact lab for ranges

FUNGUS CULTURE Sterile   Ambient             871014-6 Weeks  

FUNGUS STAIN Sterile   Ambient             87206 1-3 Days  GAMMA GLUTAMYL TRANSPEPTIDASE (GGT) Gel 7mL Ambient   12 58 U/L     82977 1 Day FASTING

GENITAL CULTURE Swab   Ambient             87070 3-5 Days  

GENTAMICIN, PEAK Red 7mLRefrigerate   6.0 10.0 ug/mL   >10.0 80170 1 Day NO Gel!!

GENTAMICIN, TROUGH Red 7mLRefrigerate   0.5 1.5 ug/mL   >2.0 80170 1 Day NO Gel!!

GLOBULIN Gel 7mL Ambient   2.0 4.0 g/dL       1 Day NO Gel!!

GLUCOSE Gel 7mL Ambient   65 99 mg/dL <40 >400 82565 1 Day  

GLUCOSE BODY FLUID Sterile 1mL Ambient       mg/dL     82945 2 Days Fasting (synovial fluid only)

GC (Neisseria gonorrhoeae) CULTURE Swab   Ambient             87081 3-5 Days  

GRAM STAIN Sterile                 87025 1-3 Days  

hCG QUALITATIVE, SERUM Gel 7mLRefrigerate       U/L     84703 1 Day  

hCG QUALITATIVE, URINE Urine cup 1mLRefrigerate             81025 1 Day  

HCT Lavender 4 Ml Ambient   34 50 % <24.0 >60.0 85014 1 Day  

HDL Gel 7mL Ambient   40 100 mg/dL     83718 1 Day  

HEMOGLOBIN A1C% Lavender 4mL Ambient   4.3 6.1 %     83036 1 Day  

HEMOGLOBIN ELECTOPHORESIS Gel 7mLRefrigerate             83021 2-3 Days  

HEPARIN-INDUCED PLATELET AB Red 7mL Freeze             86022 1-2 DaysTransfer serum to plastic tube, Freeze

HEPATITIS A Ab Gel 7mLRefrigerate   Negative         86708 2 Days  

HEPATITIS B CORE Ab, IGM Gel 7mLRefrigerate   Negative         86705 2 Days  

HEPATITIS B SURFACE Ag Gel 7mL Refrigera   Negative         87340 2 Days  

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HEPATITIS C Ab Gel 7mLRefrigerate   Negative         86803 2 Days  

HGB Lavender 4mL Ambient   11.5 17.0 g/dL <8.0 >20.0 85018 1 Day  

HIV 1&2 SCREEN Gel 7mLRefrigerate             86703 2-3 Days  

HOMOCYSTINE, PLASMA Lavender 3mLRefrigerate             83090 1-2 Days  

IMMUNOFIXATION (IFE), SERUM Gel 7mLRefrigerate               2-3 Days Call Laboratory for CPTs

IMMUNOFIXATION (IFE), Urine Urine 10mLRefrigerate             86335 2-3 Days  

INFLUENZA A & B    Refrigerate             87804(2) 1 Day Call Laboratory

INSULIN Gel 7mL Frozen   0.0 24.9uIU/mL     83525 3-5 Days Fasting

IONIZED CALCIUM Gel 7mLRefrigerate   1.15 1.32

mmol/L     82330 1 Day DO NOT OPEN!!

IRON Gel 7mLRefrigerate M 49 181 ug/dL     83540 1 Day  

IRON Gel 7mLRefrigerate F 37 170 ug/dL     83540 1 Day  

LACTIC ACID DEHYDROGENASE (LDH) Gel 7mL Ambient   313 618 U/L     83615 1 Day  

LDH BODY FLUID Sterile 7mL Ambient       IU/L     83615 2-3 Days Ranges not established.

LACTIC ACID, PLASMA Gray 7mLRefrigerate   4.5 19.8 ug/dL     83605 1 Day  

LDL Gel 7mL Ambient   0 99 mg/dL     83721 1 Day  

LEVETIRACETAM (Keppra), SERUM Red 7mL Ambient             82541 2 Days  

LIPASE Gel 7mL Ambient   23 300 U/L     83690 1 Day  

LITHIUM Gel 7mLRefrigerate   0.5 1.5

mmol/L   >2.0 80178 1 Day  

LOWER RESPIRATORY CULTURE Sterile 1mL Ambient             87070,87205 3-5 Days  

MICROALBUMIN, 24HR Urine Urine  Refrigerate             82043 2-3 Days  

MONONUCLEOSIS QUALITATIVE Gel 7mL Ambient   Negative         86308 1 Day  

MRSA CULTURE Swab   Ambient             87081 2-3 Days  

MYOGLOBIN, PLASMA Lavender 4mLRefrigerate   0 107 >107     83874 1 Day  

MYOGLOBIN, SERUM Red 7mLRefrigerate             83874 1 Day  

MYOGLOBIN, Urine Urine 1mLRefrigerate             83874 1 Day  

NT-proBNP Lavender 4mL Ambient   0 450 pg/mL     83880 1 Day  

OCCULT BLOOD, Stool Stool   Ambient             82272 1 Day  

OSMOLALITY, SERUM Red 7mLRefrigerate             83930 1 Day  

OSMOLALITY, Urine Urine 2mLRefrigerate             83935 1-2 Days  

PARTIAL THROMBOPLASTIN TIME, ACTIVATED (APTT) Blue 4mL Ambient   20 40 sec   >80.0 85730 1 Day  

pH BODY FLUID Sterile 10mLRefrigerate             83986 2 Days  

PHENOBARBITAL Red 7mLRefrigerate   15 40 ug/mL   >20.0 80184 1 Day NO Gel!!

PHENYTOIN, FREE Red 7mLRefrigerate             80186 2-3 Days  

PHENYTOIN/DILANTIN Red 7mLRefrigerate   10 20 ug/mL   >30.0 80185 1 Day NO Gel!!

PHOSPHORUS Gel 7mL Ambient   2.5 4.5 mg/dL     84100 1 Day  

PLATELETS Lavender 4 mL Ambient   150 45010*3/uL <50 >900 85049 1 Day  

POTASSIUM Gel 7mL Ambient   3.6 5.2mmol/L <3.0 >5.5 84132 1 Day  

POTASSIUM, 24HR Urine Urine   Ambient             84133 1 Day  

PRIMIDONE (MYSOLINE) Red 7mLRefrigerate   5.0 12.0 ug/mL     80184/80488 2 Days NO Gel!!

PROGESTERONE Gel 7mLRefrigerate             84144 1-2 Days  

PROPOXYPHENE Red 7mLRefrigerate             83925 1-2 Days NO Gel!!

PROTEIN BODY FLUID Sterile 1mL Ambient   0.0 2.4 g/dL     84157 2 Days  

PROTEIN ELECTROPHORESIS, R Urine Urine 20mLRefrigerate             84156,84166 2-3 Days  

PSA Gel 7mL Ambient   0.0 4.0 ng/mL     84153 1 Day  

PT Blue 4mLRefrigerate   10.4 13.8 sec N/A >30.0 85610 1 Day  

INR Blue 4mL Ambient   0.8 1.2RATIO   >3.6 85610 1 Day Included with PT

PTH, INTACT Lavender 3mL Frozen             83970 2-3 Days  

PTT Blue 4mlRefrigerate   25 40 sec N/A >45      

QUANTITATIVE TISSUE CULTURE Sterile  Refrigerate            

87071,87073, 87205    

QUINIDINE Red 7mLRefrigerate             80194 2 Days NO Gel!!

RAPID STREP GRP A Swab   Ambient             87880-QW 1 Day  

RA FACTOR Gel 7mL Ambient             86431 1-2 Days  

RPR Gel 7mLRefrigerate  

Non-Reactive         86592 1 Day  

RUBELLA ABS, IGG Gel 7mL Ambient             86762 1-2 Days  

SICKLE CELL (HGB SOLUBILITY) Lavender 4mL Ambient             85660 1 Day  

SODIUM Gel 7mL Ambient   134 145mmol/L <125 >155 84295 1 Day  

SODIUM, 24 HR Urine Urine  Refrigerate             84300 1 Day  

STOOL CULTURE Stool 1mLRefrigerate             87045 3-5 Days  

STOOL WBC Stool 0.5mL Ambient             87205 1 Day  

STREP A CULTURE Swab   Ambient             87081 3-5 Days  

TRIIODOTHYRONINE (T3) FREE Gel 7mLRefrigerate   2.44 4.20 pg/mL     84481 1 Day  

T3, REVERSE Gel 7mLRefrigerate             84482 1-2 Days  

T3-UPTAKE Gel 7mL Ambient   23.5 40.5       84479 1 Day  

TESTOSTERONE TOTAL Gel 7mLRefrigerate             84403 1-2 Days  

THEOPHYLLINE Red 7mLRefrigerate   10 20 mg/dL   >30.0 80198 1 Day NO Gel!!

THYROXINE (T4) Gel 7mL Ambient   5.53 11.0       84436 1 Day  

THYROXINE (T4) FREE Gel 7mL Ambient   0.78 2.19 pg/mL     84439 2 Days  

TIBC Gel 7mL Ambient   250 450 ug/dL     83550 1 Day  

TOTAL BILIRUBIN Gel 7mL Ambient   0.2 1.2 mg/dL     82242 1 Day  

TOTAL PROTEIN Gel 7mL Ambient   6.3 8.2 g/dL     84155 1 Day  

TRIGLYCERIDES Gel 7mL Ambient   40 149 mg/dL     84478 1 Day FASTING

TROPONIN I Lavender 3mLRefrigerate   0.00 0.40 ng/mL   >0.40 84484 1 Day  

TSH Gel 7mL Ambient   0.465 4.680 mIU/L     84443 1 Day  

UIBC Gel 7mL Ambient   150 375 ug/dL     83550 1 Day  

UPPER RESPIRATORY CULTURE Swab   Ambient             87070 3-5 Days  

URIC ACID Gel 7mL Ambient   2.5 8.5 mg/dL     84550 1 Day  

URINE CULTURE Urine 1mLRefrigerate             87086 2-3 Days  

VALPROIC ACID/DEPAKOTE Red 7mLRefrigerate   50 120 ug/mL   >120 80164 1 Day NO Gel!!

VANCOMYCIN PEAK Red 7mL Ambient   18.0 40.0 ug/mL   >40 80202 1 Day NO Gel!!

VANCOMYCIN RANDOM Red 7mL Ambient   5.0 40.0 ug/mL   >20 80202 1 Day NO Gel!!

VANCOMYCIN TROUGH Red 7mL Ambient   5.0 10.0 ug/mL     80202 1 Day NO Gel!!

VITAMIN A Gel 7mLRefrigerate             84590 2-5 Days Chill tube, protect from light

VITAMIN B1 Lavender 4mL Freeze             84425 2-5 DaysFreeze whole blood, protect from light

VITAMIN B-12 Gel 7mLRefrigerate   239 931 pg/mL     82607 2-5 Days FASTING

VITAMIN B6 Lavender 4mL Freeze             84207 2-5 Days Freeze plasma, protect from light

VITAMIN C Gel 7mL Freeze             82180 2-5 DaysFreeze immediately, protect from light

VITAMIN D, 25-HYDROXY Gel 7mLRefrigerate             82306 2-5 Days  

VITAMIN D125, DIHYDROXY Gel 7mLRefrigerate             82652 2-5 Days  

VITAMIN E Gel 7mLRefrigerate             84446 2-5 Days protect from light

VRE CULTURE Swab                 87081 2-3 Days  

WET PREP Swab   Ambient             87210 1 Day NO GEL!!

WOUND CULTURE Swab   Ambient             87070 3-5 Days  

ZINC, SERUM Red 7mL Ambient             84630 2-3 Days