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Pathology Services
Handbook
Eastbourne District General Hospital
Conquest Hospital, Hastings
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Written/Produced by: Title/Department Date Ian Diton Pathology 02/03/
Person Responsible for Monitoring Compliance & Review
Charlotte Hendon-Dunn Pathology Quality Manager
Signature & Date 04/11/
Multi-disciplinary Evaluation/Approval
Title/Speciality Date Quality Manager Nov 2021 Principal BMS Nov 2021 Haematology Lead BMS Nov 2021 Microbiology Lead BMS Nov 2021 Cellular Pathology Lead BMS Nov 2021 Clinical Biochemistry Lead BMS Nov 2021 Lead for Central services Nov 2021 Laboratory Director Nov 2021
Ratification Committee
Date of Issue Version
Next Review Date
Date Ratified
Name of Committee/Board/Group
June 2010 v3 Jun 11 25/05/10 Pathology Management Team Sept 2011 v4 Sept 12 30/09/11 Pathology Management Team Nov 2012 v5 Sept 13 14/11/12 Pathology Management Team Jan 2014 v6 Sept 14 09/01/14 Pathology Management Team Sept 2014 v7 Sept 15 05/09/14 Pathology Management Team Feb 2015 v8 Feb 16 05/02/15 Pathology Management Team Aug 2015 v9 Feb 16 23/09/15 Pathology Management Team Mar 2017 v10 Mar 18 17/02/17 Pathology Management Team Mar 2018 v11 Mar 19 26/03/18 Pathology Management Team Feb 2019 v12 Feb 20 06/02/19 Pathology Management Team Jan 2020 v13 Jan 21 22/01/20 Pathology Management Team Nov 2020 v14 Nov 21 12/11/20 Pathology Management Team Nov 2021 v15 Nov 22 04/11/21 Pathology Management Team
- Contents..................................................................................................................................................
- Introduction
- Complaints and Plaudits .......................................................................................................................
- Consent ................................................................................................................................................
- Pathology Opening Hours .....................................................................................................................
- Services Provided .................................................................................................................................
- Phlebotomy Service ..............................................................................................................................
- Requests and Results
- Minimum labelling for specimens and request forms ............................................................................
- Hospital In-Patients and Out-Patients ...................................................................................................
- GP Patients
- Protection of personal information
- Additional Tests
- Ward order comms / ICE requests (electronic requesting)
- Handling and labelling danger of infection specimens
- Transportation of samples
- Urgent Requests (instructions for Trust requesters)
- Urgent Requests (instructions for non-Trust requesters e.g. GPs)
- Pathology out of hours service (Haematology and Clinical Biochemistry)
- Instructions for the air tube system
- Results................................................................................................................................................
- Appendices
- Clinical Biochemistry
- Availability of Clinical Advice
- Sample requirements
- Quality control
- Sample considerations........................................................................................................................
- Reporting results.................................................................................................................................
- Phoning policy
- Paediatric investigations
- Thyroid function testing
- Troponin testing
- Protein electrophoresis
- Investigation of suspected phaeochromocytoma and carcinoid
- Therapeutic drug monitoring
- Investigation of drug abuse (Drug Abuse Screen – Referral laboratory)
- Paracetamol poisoning
- Lipid analysis
- Guidance on the requesting of tumour markers
- Simple dynamic function tests.............................................................................................................
- Specimen requirements for Biochemistry............................................................................................
- Adult reference ranges and typical turnaround times
- Regularly used referral laboratories
- Point of Care Testing
- Haematology, Blood Transfusion & Immunology
- General information
- Availability of Clinical Advice
- Maximum Surgical Order Blood Schedule...........................................................................................
- Laboratory Services Provided
- Labelling Requirements
- Blood Donor Pack Compatibility Labelling...........................................................................................
- Blood Products Available
- Suspected Transfusion Reactions
- Emergency Transfusion
- Immunology
- Telephoning abnormal results
- Haematology Normal Ranges and turnaround times
- Haematology Referral Laboratories
- Factors affecting samples / tests
- Microbiology
- General information
- Laboratory Services
- Results which will be telephoned to doctors/wards
- Microbiology Samples
- Turnaround Times
- Microbiology Referral Laboratories
- Cellular Pathology
- General information
- Enquiries.............................................................................................................................................
- Histopathology
- Histopathology Referral Laboratories
- Cytopathology
- Mortuary
- Admission
- Death Certification
- Coroners Referrals
- Hospital Consented Post Mortem Examinations
- Paediatric and Perinatal Post Mortems
- Viewing
- Releases
- Appendix 1: Alphabetic test container guide
- Appendix 2: Unlabelled Specimen Policy
Introduction
The guidance in this handbook has been written for all users of Eastbourne DGH and Conquest Pathology services to enable clinical staff to make the best use of our Pathology services. Should you
have queries with regard to any aspect of the service, please use the e-mail address esh-
tr.ContactPathology@nhs.net. Please note that this e-mail account is not intended for blood
collection supplies enquiries or Phlebotomy issues.
The Pathology department consists of: UKAS accredited medical laboratory no. 8189 Clinical Biochemistry Conquest 8790 Cellular Pathology 8923 Clinical Biochemistry EDGH 9915 Microbiology 9988 Haematology EDGH 9989 Haematology Conquest
You are most welcome to visit the department with prior arrangement.
This handbook has been updated to provide information of both Eastbourne DGH and Conquest hospital Pathology departments and we have tried our best to make it user friendly. The authors would be grateful for comments as well as any suggestions for the next edition.
For the Pathology department to provide an accurate, complete and timely service, it is essential that you, the user of this service, provide the following:-
The right sample
In the right container (transported in the right conditions)
For the right test
At the right time.
The information contained in this document identifies these requirements.
Pathology Opening Hours
Patient Information The Pathology Reception on each site is open for receipt of specimens 9am – 5pm.
General enquiries can be made by phoning switchboard on: Conquest 0300 131 4500 (ext 734928) EDGH 0300 131 4500 (ext 134255) For details regarding tests requested please refer to the following website:- http://www.labtestsonline.org.uk/home
GP Information
The Pathology Department is open for receipt and processing of routine specimens during the following
hours. Please consult the Pathology telephone directory (page 6) for departmental telephone numbers.
Site / Department Monday - Friday Saturday / Sunday / Bank Holidays Phlebotomy Reception 8:30am – 4:30pm Closed Reception Conquest 9am - 5pm closed Reception EDGH 8am – 8pm (^) closed Haematology and Transfusion Conquest
8:45am - 5pm n/a
Haematology and Transfusion EDGH
9am - 5pm n/a
Clinical Biochemistry Conquest 9am - 5pm n/a Clinical Biochemistry EDGH 9am - 5pm n/a Microbiology Conquest 9.00am – 5.05pm (Conquest GP Consultant Microbiologist advice only)
n/a
Microbiology EDGH 8.30am – 16.30pm (all laboratory tests and Eastbourne GP advice only)
n/a
Histology Conquest 8.30am – 5pm n/a Histology EDGH 8am – 4.30pm (^) n/a Cytology Conquest 8.30am – 5pm n/a Cytology EDGH 8am – 4pm n/a
Information for hospital users
The Pathology Department is open for receipt of samples at the following times. Please note the conditions for processing of samples outside of normal office hours and for processing of urgent samples at any time:
Routine samples Urgent Samples Site / Dept Monday - Friday
Saturday / Sunday / Bank Holidays
Normal hours
Outside hours
Reception Conquest 9am – 5pm n/a Phone n/a Reception EDGH 8 am – 8 pm n/a Phone n/a Haematology and Blood Transfusions
Open access / On Call
Open access / On Call Phone Contact BMS through switchboard Clinical Biochemistry Open access / On Call
Open access / On Call Phone Contact BMS through switchboard Microbiology 8.30am – 6.00pm
n/a Phone Contact BMS through switchboard Histology 9am - 4pm n/a Phone n/a Cytology 9am – 4.30pm n/a Phone n/a
Services Provided
The Eastbourne DGH laboratory is located on the Ground floor adjacent to the restaurant. The following services are provided on-site at Eastbourne DGH.
Blood Transfusion Clinical Biochemistry Haematology Immunology Histology (cut up, reporting, frozen and skin immunofluorescence) Cytology (for receipt of specimens only, Cytology based at Conquest site) Microbiology (Consultant Microbiologist advice (via secretary) Routine specimen processing and test requests 08.00am-16.30pm, out of hours specimen processing Eastbourne Hospital only 18.00pm-08.00am Monday-Friday, Weekends and Bank holidays 16.00pm-08.30am) Mortuary Reception Point of Care Testing Department Phlebotomy (Level 2 Pink zone, Outpatients area, adjacent to hospital main entrance)
The Conquest laboratory is located on Level 4, Departmental Block, opposite the staff restaurant. The following services are provided on-site at Conquest.
Blood Transfusion Clinical Biochemistry Cytology Haematology Histology Microbiology (out of hours on call for sterile site cultures only) (Consultant Microbiologist advice (via secretary) out of hours specimen processing Conquest hospital requests only 18.00pm- 08.00am only. Weekends and bank holidays 16:30pm to 08:00am ) Mortuary Reception Point of Care Testing Department Phlebotomy (Adjacent to Pathology specimen reception)
Phlebotomy Service
The Trust’s phlebotomy team provide a 7day/week ward service (mornings only) and an outpatient clinic Monday – Friday. There is one clinic at each acute site providing a service for the Trust and local GP practices that are not able to bleed their own patients.
The clinics are by appointment only, contact phlebotomy reception on: Conquest: 0300 131 4826 (external) EDGH: 0300 131 4778 (external) Clinic opening hours Conquest: 08:30 – 16:30 (Mon-Fri only) EDGH: 08:30 – 16:30 (Mon-Fri only)
The following information is ESSENTIAL to aid the accurate and efficient processing of the sample and issue of the sample report. This information is also ESSENTIAL to identify the report destination for accurate activity monitoring:
Ward/Location To ensure the reports can be sent to the correct locations the appropriate ward must be written on the request form. Consultant name To ensure the reports are sent to the correct consultant, the name of the consultant responsible for the patient must be included on the request form. This is key information if the ward or location of the patient changes. Requesting doctor’s name and bleep number
This enables the laboratory to contact the requesting doctor if there are problems with the specimen or the results.
Clinical Details When available, these should be brief and relevant to the tests requested. Clinical details help the laboratory to check the relevance of the tests requested and to suggest other more appropriate tests if necessary. It is also helpful when interpreting abnormal results. Any drug or IV therapy should be particularly noted as these can cause result anomalies.
Test Requests Please remember to indicate which tests are required. If there is not a ‘tick’ box provided, the test request can be written on the form in the relevant section. Date of Specimen Collection Please state the date and time of specimen collection. It is helpful when interpreting abnormal results.
GP Patients
Minimum label requirements for specimens Patient Name This must consist of the full name of the patient. There is the added complication in GP practices that entire families may be registered with the same GP. The use of a title (Mr, Master) will assist with correct identification.
….. and at least one of the following two items (with the exception of BT samples which require all items – as below) Date of Birth The date of birth should clearly identify day, month and year, and must be verified with the patient at the time of specimen collection.
Unit Number or NHS number The PAS number or NHS number written in full.
Blood transfusion specimens (including all HLA tests inc HLA B27, HFE gene and Platelet antibody tests)
For patients registered with the hospital the PAS number (X number) must be included on the specimen label and the request form. For patients not registered with the hospital (PAS number not assigned), the NHS number of the patient must be included on the specimen label and the request form. Patient details must be handwritten on all specimens.
Minimum label requirements for request forms Patient Name The full forename and surname of the patient must be written. ….. and at least two of the following three items Date of Birth The date of birth should clearly identify day, month and year, and must be verified with the patient at the time of specimen collection. Unit Number or NHS number If available, the PAS number or NHS number must be included. Patient’s Address The current address of the patient must be included. This assists the laboratory and the practice in identifying patients correctly.
The following information is ESSENTIAL to aid the accurate and efficient processing of the sample and issue of the sample report. This information is also ESSENTIAL to identify the report destination for accurate activity monitoring: GP name and Practice Practices must include the GP and practice name to ensure that reports can be sent to the correct location. The Pathology laboratory will not issue any results either verbally or in writing direct to patients. All results to GPs will be sent directly to the GPs concerned. Clinical Details These should be brief and relevant to the tests requested. Clinical details help the laboratory to check the relevance of the tests requested and to suggest other more appropriate tests if necessary. It is also helpful when interpreting abnormal results. Any drug therapy should be particularly noted as these can cause result anomalies. Test Requests Please remember to indicate which tests are required. If there is not a ‘tick’ box provided, the test request can be written on the form in the relevant section. Date and time of Specimen Collection
Please state the date and time of specimen collection. It is helpful when interpreting abnormal results.
UNLABELLED OR INADEQUATELY LABELLED SPECIMENS WILL NOT BE TESTED.
REPEATABLE SPECIMENS WILL BE DISCARDED.
Repeatable Specimens Non-Repeatable Specimens (including specimens collected by a surgical procedure) Hospital Patients Unlabelled or inadequately labelled repeatable specimens will not be tested and will be discarded. The requesting doctor / ward will be informed of the rejection in an appropriate manner.
Laboratory staff will ensure that unlabelled or inadequately labelled non repeatable specimens are corrected by the Doctor/Ward before testing commences (except in the case of Blood Transfusion specimens which will be discarded without exception).
GP Patients Repeatable unlabelled specimens will be discarded and the surgery informed. The minimum acceptable information on the specimen label is the full name of the patient and the date of birth (for transfusion specimens, the specimen must also include the PAS or NHS number). This will only be accepted if the request form is completed in full. If this is not the case the specimen will be discarded and the surgery
For unlabelled or inadequately labelled non repeatable specimens, the relevant GP surgery will be contacted by the applicable laboratory staff to correct the discrepancy.
the lab will aim to activate your account for requesting within 24 hours. There is a simple user guide in the Order Tests section that can be printed out.
Handling and labelling danger of infection specimens
Specimens and request forms from patients known to be at ‘risk of infection’ should be labelled with the Danger of infection warning label.
Specimens from the following will require “Danger of Infection” labelling: Patients with proven infection with a Hazard Group 3 (HG3) pathogen, (see Appendix B), tuberculosis and other mycobacteria, typhoid, brucella, Escherichia coli O157 and anthrax. Patients suspected of having a HG3 pathogen (see Appendix B), (information from clinical history and examination e.g. injecting drug user, haemophiliac, vCJD), a patient who is part of an ongoing outbreak caused by a HG pathogen.
Patients with MRSA do not require “Danger of Infection” labels. Patients with blood borne viruses HIV and Hepatitis B, C do not require “Danger of Infection” labels as standard universal precautions are sufficient to protect laboratory staff.
If there is doubt as to whether a specimen is “high risk”, please contact the microbiology laboratory.
Transportation of samples
Hospital collected samples Ensure that the request form is placed in the separate compartment of the specimen bag to the samples. Swabs and blood samples can be supplied to the laboratory either via the pneumatic tube system (except blood cultures) or hand delivery at the reception desk. Histology samples are to be delivered by hand in all cases. Samples for some tests will require special pre and post collection requirements (e.g. fasting, keep sample on ice, keep sample warm, etc). Details for any requirements are listed by the test in Appendix 1 of this handbook.
GP surgeries and private hospitals Blue Versapak travel bags are supplied to transport samples collected in GP surgeries and private hospitals. These bags meet the regulations regarding the transportation of diagnostic substances. Each Versapak travel bag contains a liner bag, a clip and an absorbent material pouch (contained within the liner bag). Samples are to be packaged for transport as follows:- Ensure that samples are placed in the specimen bag with the request form Place the specimen bag and request form inside the liner bag. Once all of the samples are inside the liner bag the top of the bag is sealed using the clip. The Versapak bag is then zipped close and a security tag placed in through the zip tab and into the bag. This secures the zip to identify if the bag has been opened whilst in transit. The bag is now ready for collection by the Trust courier, who will replace the collected bag with an empty one. All transport bag accessories and consumables are available to order via the Pathology Stores. Samples for some tests will require special pre and post collection requirements (e.g. fasting, keep sample on ice, keep sample warm, etc). Details for any requirements are listed by the test in Appendix 1 of this handbook.
For further information regarding the transportation of Pathology specimens, please refer to the Procedure entitled ‘ Procedure for the transportation of clinical samples to the pathology laboratory’. This is available on the internet website ( http://www.esh.nhs.uk/pathology/ ) and the Extranet by clicking on departments and divisions or via a document search.
Pathology out of hours service (Haematology and Clinical Biochemistry)
Eastbourne DGH and Conquest sites
7 day, 24-hour open access service for Haematology, Clinical Biochemistry and Transfusion
For Microbiology see Microbiology Laboratory Services Section of this handbook
Instructions for the air tube system
The air tube systems are for the transport of Pathology specimens to the laboratories. Ports are situated in various areas on each site. A full description of the use and maintenance of the pneumatic tube system is available from the extranet and also on the internet website.
The air tube system is NOT to be used for Danger of Infection samples, Blood cultures, CSF’s or any unrepeatable samples - please send all these samples by Porter instead.
Ensure that all samples and accompanying forms are sealed in transparent plastic bags. Place the sealed bag(s) containing sample & form in a pod having checked that the lid is properly closed and that the pod is in good condition (no cracks or breaks). Open the carrier door and input the number of the target destination onto the keypad. Place the pod into the carrier and close the door. The carrier mechanism will move the pod through 90º and send the pod on its way.
If this process does not take place within a few minutes or if an audible alarm is heard, please contact the Estates department.
Results
Printed reports are available electronically via the hospital computer system (E-Searcher at Conquest and E-Searcher at EDGH) for all wards and outpatients. GP practice results are either sent electronically via the GP links or via paper copies on a daily basis.
Significantly abnormal results will be telephoned to the requesting doctor, out of hours GP service (seadoc), nurse or consultant’s secretary as appropriate.
Appendices
For: Which specimen container, volume of specimen and any special storage requirements - see Appendix 1
For: Unlabelled specimen policy - see Appendix 2
Clinical Biochemistry
Availability of Clinical Advice
For clinical Biochemistry advice there is a Consultant available at the DGH (09.00 – 17.30h) or at the Conquest (08.00 – 15.30h), Mon-Fri. Telephones have answering machines in the event of annual leave etc. and there is a duty Biochemist email esh-tr.dutybiochemist@nhs.net
Sample requirements
A comprehensive list of available tests, with reference ranges, sample requirements and expected turnaround times is provided at the end of the Clinical Biochemistry section of this Handbook. The vast majority of Clinical Biochemistry tests are performed using Greiner Ochre (Gold) Top blood tubes.
Quality control
In order to maintain high standards of analysis the Pathology Department at both Conquest and EDGH participates in national quality assurance schemes and maintains its own internal system of quality control checks. However, additional errors can arise as a result of poor specimens (such as arise by poor bleeding technique, delays in transport, poor identification etc.), and also as a result of errors in recording results transmitted by telephone.
Sample considerations
Do not use large tubes for small blood samples as this greatly reduces the volume of serum/plasma which can be obtained. Blood taken for estimation of potassium, phosphate and bicarbonate must not be left unseparated overnight.
When using the Greiner vacutainer system, tubes must be filled in the following order to minimise contamination from tube additives:
Blood cultures Trisodium Citrate (Blue top) Plain (red top) Plain (Ochre) Li Heparin (Green top) EDTA (Lavender top) EDTA blood bank (Pink top) Sodium Fluoride (Grey top) Sodium Heparin trace elements (Royal blue top)
Never tip blood from one tube into another, or swap tube lids. Contact the department if any difficulties in interpretation occur, and do not just ignore results which cannot be explained or are thought to be erroneous.
Venous blood
Specimens of venous blood should preferably be taken with the patient sitting or lying down and without prolonged venous stasis. Do not collect specimens from a vein in a limb into which an intravenous infusion is being given. If there is anticoagulant in the tube, mix by repeated gentle inversion – do not shake the specimen.
If in doubt, contact the department.
Reporting results
Results will be reported as soon as possible but interim reports may be issued when any delay is expected because a more difficult or time-consuming analysis has been requested. Printed reports are no longer sent to the wards because they are no longer filed and the results can be viewed electronically, printed outpatient reports are sent to the consultants’ secretaries. Results on routine in- patient and out-patient samples are usually available on E-Searcher.
Some results (e.g. those that are grossly abnormal) may be telephoned to the requesting doctor as per the telephoning policy. Results of emergency analyses may also be telephoned, but results reported in this way are a frequent source of error, so please repeat the results back to the laboratory staff when they have been recorded. Please do not telephone the laboratory for results unless you cannot find them in any other way. Constant interruptions delay the flow of work.
Phoning policy
Results will be telephoned under the following circumstances:
If E-searcher is working: i) If we have been contacted by the Doctor who requests results to be phoned. ii) When the request is from a GP or Outpatients and marked “urgent” or “please phone”. iii) For SCBU and ITU: we will inform the units that the results are now available on E-searcher. Results will not normally be phoned unless we have been requested to do so by the doctor, or they are outside the Action Limits. iv) For all other wards and GPs/OPs results will be phoned if they are outside the laboratory set phoning criteria.
If E-searcher is not working: As above, but we will endeavour to telephone all A&E, ITU and SCBU results.
Paediatric investigations
Test priority
Because of the small sample volume available for measurement of blood constituents, test priority should be indicated in case there is insufficient sample to perform everything requested.
Sweat tests
Sweat tests are carried out by a biochemist trained and experienced in this technique, following a referral from Paediatrics. Arrangements for sweat tests can be made with the lab by telephone.
Suspected inborn errors of metabolism
In addition to general biochemistry, the majority of these patients will require some or all of the following investigations:
plasma amino acids 1 ml blood in paediatric lithium heparin tube (Green top) urine amino acids 5-10 ml urine in a plain (white top) universal urine organic acids 10 ml urine in a plain (white top) universal blood ammonia 2 ml blood in paediatric EDTA tube (Lavender top) Lab must have prior notice. Sample must reach Lab within 20 mins of collection). blood lactate 1 ml blood in fluoride oxalate tube. Lab must have prior notice. Take sample without stasis and ensure sample arrives in lab within 1 hour of collection). acyl carnitine profile 3-4 spots of blood on a Guthrie card
Where possible, samples should be collected during acute illness. Relevant clinical details must be provided, including drug and diet history.
Please contact senior biochemistry staff for advice and when urgent analyses are required.
Thyroid function testing
TSH is used as a first line approach to thyroid function testing.
If the serum TSH falls outside either the lower or upper reference range when screening a patient then a free T4 will also be assayed. All patients on anti-thyroid drugs or receiving treatment for thyrotoxicosis e.g. radioiodine, are pregnant or are under 18 years of age will also have a freeT4 measured. Patients who are taking thyroxine will only have a free T4 measured if the TSH is found to be suppressed.
Free T3 assay is also available for the confirmation of suspected T3 thyrotoxicosis in patients with suppressed TSH and normal levels of free T4. TSH, FT4 and FT3 will be measured if the patient is indicated as being on Amiodarone.
Please state the suspected diagnosis and give details of any recent thyroid related therapy when making a request – otherwise the test cascade will not operate properly.
Please do not request thyroid function tests on acutely ill patients unless there is reason to believe that thyroid disease is responsible for their acute condition. The results are difficult to interpret in the acutely ill.
