ALL POTENTIALLY INFECTIOUS MATERIAL SHOULD BE HANDLED, LABELED AND TRANSPORTED ACCORDINGLY.

It is essential that the following instructions be followed exactly to assure delivery of a specimen that is adequate for testing. All specimens must be properly identified by indicating the patient's name on every tube or container. The test request form has to be completed and has to include the time and date of the specimen collection, as well as the signature of the Physician requesting the patient's tests.

Chemistry, Hematology and Miscellaneous

Blood:

When whole blood is requested, obtain the full amount into a vacuum tube as shown in the specimen requirement section of this Compendium.

Lavender, Gray, Green, and Blue Top tubes contain different anticoagulants that inhibit blood coagulation. When drawing these specimens, immediately invert the tube 10-12 times. Do not shake the tube as this can cause Hemolysis.

Serum:

Obtain sufficient blood to yield the required volume of Serum. A plain Red Top tube or Red/Mottled top Barrier tube (Corvac, SST, etc.) should be used.

When drawing these specimens, immediately invert the tube 5 times. Allow the blood to clot for about 30 minutes and centrifuge for 15 minutes to separate the serum. If a Barrier tube is used, no other manipulations are required. Make sure that the gel has formed a thick, solid, intact barrier between the serum and the clotted cells. If the gel trails into the bottom of the tube, recentrifuge the tube for another 10 minutes. If a plain Red Top tube is used, transfer the serum with a pipette to a Transfer tube. It is important to avoid hemolysis. Serum in contact with red cells will produce erroneously high Potassium, LDH, and SGOT results and erroneous low Glucose results. Red top tubes for blood banking specimens should not be centrifuged.

Plasma:

Treat the specimen as in blood (above).

Urine:

Urinalysis: To adequately test urine specimens the sample should be collected in a tube with a stabilizing chemical present. The tube provided contains a yellow "pop off" cap and a "Stabilur" tablet which preserves the formed elements such as red cells, white cells, casts and epithelial cells. For urinalysis, use a paper cup and transfer about 10 mL of urine to the stopped tube.

Urine Chemistry: Most assays require a 24 hour collection that should contain boric acid, hydrochloric acid, or sodium carbonate as a preservative. Some analysis require a urine specimen without any additive. Refer to the specific test in this Compendium for specific test details. Instruct the patient to discard the first urine voided upon arising in the morning and thereafter save all urine specimens in the 24 hour container, including the first morning voiding of the following day. Fluid intake during the 24 hour period should be restricted as much as possible. Measure the 24 hour volume and record it on the container and the test request form. Keep the specimen refrigerated until picked up by the laboratory.

Urine, Drugs of Abuse (DAU):

For routine DAU testing, submit a specimen in a blue "pop-off" capped tube.

Urine Culture:

Collect the urine into a yellow-label screw capped vial (Boricon). It is not necessary to urinate directly into the vial. It is satisfactory to urinate into a paper cup (non-sterile) and to immediately pour the specimen into the Boricon. Refrigerate the specimen as soon as possible.

Frozen Specimens:

Certain tests must be submitted frozen because of the lability of the analyte being tested. Keep all frozen specimens separate from the routine tests and submit a separate test request form. As soon as possible separate the serum or plasma and transfer to a plastic transfer tube. Place the specimen in the office freezer and keep until it is solid. Notify the laboratory Logistics Department as soon as possible that you have a frozen specimen for pick up.

PLEASE STORE YOUR SPECIMEN IN THE REFRIGERATOR OR FREEZER UNTIL PICK UP, UNLESS SPECIFICALLY INSTRUCTED TO DO OTHERWISE. Your driver will pick up specimens from the nurse or receptionist at your office or from a box outside your door if after hours.

Cytology

Use Cytology requisition form for all Cytology specimens. Relevant clinical information should be written down in the space provided.

Directions for making Direct Smears:

1. Write patient's name with lead pencil on frosted end of clean slide.
2. Spread material evenly over slide.
3. Fix immediately with cytology spray fixative from a distance of 10 - 12 inches until liquid droplets form.
4. Allow slides to dry before sending out in designated slide holders.

Directions for sending Fluids (Collected or Aspirated):

1. Write patient's name on container.
2. All fluids including gastric washings, pleural and peritoneal (ascitic) fluids, have to be placed in a container with an equal volume of 50% ethyl alcohol.
3. Send fluid immediately in securely closed containers.

NOTE: A sputum specimen will be considered unsatisfactory for diagnosis if no pigmented macrophages (dust cells) are present.

Aspiration Biopsy by Fine Needle (FNA):

1. Use the form for Non-Gyn Cytology for all FNA requests. Relevant information and clinical data should be written down as requested, in the space provided.
2. Solid masses: Do direct smears and spray with Cytology spray fixative immediately.
3. Fluids: Add directly to fixative supplied in special container.

Method For Obtaining An Optimum Fine Needle Aspiration Specimen:

A high percentage of smears are difficult, and sometimes impossible, to accurately diagnose. This difficulty is primarily due to poorly preserved cellular material or a lack of adequate cellular material. Poorly preserved material is usually due to a delay in fixing the smears or spraying them too closely with the fixative and freezing the material. A lack of adequate cells is generally the result of a hypocellular cystic fluid spread too thinly over the slide.

Bio-Reference recommends the following procedure:

Fine needle Aspiration Technique

Local anesthesia is not necessary.

1. Clean the skin overlaying the mass with an antiseptic.
2. After the needle has entered the mass, retract the plunger to create a vacuum in the syringe.
3. Move the needle back and forth several times in the lesion as the material is being sucked into the needle by negative pressure.
4. The cell sample should remain in the needle and should not be visible in the syringe barrel.
5. Before withdrawing the needle from the lesion, the suction must be released to avoid aspiration of the material into the syringe barrel.

Slide Preparation

6. The needle is quickly detached from the syringe and the plunger is retracted to allow air to fill the syringe.
7. Reattach the needle and eject its contents forcefully onto the slides by pushing down on the plunger.
8. With the two slide method, place the slides together and gently pull the slides apart with one continuous motion.
9. IMMEDIATELY PLACE THE SLIDE(S) IN 50 ML TUBE CONTAINING 95% ALCOHOL to achieve preservation of material.
10. After slides are prepared, the syringe is thoroughly rinsed in a separate 50 mL tube of 95% alcohol (obtained from Bio-Reference Laboratories). Both tubes are then sent along with slides and/or cyst fluid to the laboratory where the specimen is processed using the cytocentrifuge. Using this procedure, even the most hypocellular specimens will generally show a yield of cells which is adequate for diagnosis.

ThinPrep Pap Test Broom-Like Device Protocol

1. Obtain an adequate sampling from the cervix using a broom-like device. Insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix. Push gently, and rotate the broom in a clockwise direction five times.

2. Rinse the broom into the PreservCyt Solution vial by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. As a final step, swirl the broom vigorously to further release material. Discard the collection device.

3. Tighten the cap so that the torque line on the cap passes the torque line on the vial.

4. Record the patient’s name and ID number on the vial. Record the patient information and medical history on the cytology requisition form.

5. Place the vial and requisition in a specimen bag for transport to the laboratory.

Directions for Obtaining a Routine Cervical Smear:

1. Do not use lubricating gel.
2. Do not use Q-tip to obtain endocervical cells; consider using endocervical brush.
3. Do not obtain during menstruation.
4. Obtain a direct scrape of the cervix, preferably at the junction between exocervix and endocervix; consider adding a vaginal pool sample to the cervical sample in women over 40 years of age.
5. Follow directions for making Direct Smears.

NOTE: In order to comply with the standards established by the Bethesda System, the following guidelines will be followed.

The pap smear will be reported as unsatisfactory with the following conditions:

1. Smears unlabeled
2. Scant cellularity
3. Poor fixation or preservation. Cells are obscured by inflammation, foreign material or blood.
4. Not representative of anatomic site.
5. Slides broken beyond repair.

A Gyn pap smear will be considered less than optimal when there is no endocervical component present.

Directions for Obtaining a Vaginal Smear for Hormonal Evaluation (Maturation Index):

1. Do not use lubricating gel.
2. Obtain a lateral vaginal wall scrape.
3. Follow directions for making Direct Smears.

Directions for Obtaining Gastrointestinal Tract Washings:

1. Collect fasting specimen and put in labeled container.
2. Inject 300 mL of normal saline rapidly
3. Aspirate as much as possible of the injected saline and place in labelled container.
4. If possible, repeat steps 2. and 3. with patient in different positions.
5. Specimens may be pooled or collected separately in containers of 95% alcohol.
6. Send immediately to lab.

Directions for Obtaining Urine for Cytology:

1. Specimen can be randomly collected anytime.
2. Female patients should be instructed to wash their genitalia with soap and water prior to collection.
3. Void directly into container with 50% alcohol.
4. Send immediately to the laboratory in securely closed container.

Note:

INCLUDE PATIENT AGE AND PERTINENT CLINICAL DATA ON THE REQUEST FORM.

If there are any questions about specimen collection or if you need to order the container of fixative, call the Laboratory's Cytology Department.

Pathology, Anatomic
(Biopsies and Surgical Specimens)

General Instructions:

1. Use Surgical Pathology requisition form for all biopsies and surgical specimens. Relevant clinical information should be written down in the space provided.

2. Write patient's name on specimen container.

3. Place all tissues immediately in 10% buffered formalin at ten times the volume of the specimen. Specimen containers with 10% formalin are provided by the laboratory.

4. Send immediately to the laboratory in securely closed container. For additional information, please contact the laboratory.

Collection and Transport of Microbiology Specimens

Correct specimen collection and transport of clinical specimens to the laboratory are extremely important for rapid and accurate identification of significant microorganisms from patient samples.

Please send separate test requisitions for each culture.

General Consideration for Collection and Transport:

• Use sterile technique and transport to the laboratory as soon as possible.
  
• Close collection containers securely to prevent leaking of sample during transport. These specimens are biohazards.
  
• Whenever possible obtain specimens prior to the administration of antibiotics.
  
• Do not use expired tubes or media for specimen collection.
  
• Please write the patient's name on each specimen container.
  
• Send specimens in one of the following transport systems:
  
  1. Swabs with transport media (culturettes): eye, ear, nose, stool, strep screen, throat, wounds- give site. (Hold at room temperature or refrigerate).
  2. Non sterile containers: sputum
  3. Sterile containers: body fluids (except blood and urine, see below).
  4. Special transport systems:
  
  Blood- 2, 20 mL vacutainer tubes with Supplemented Peptone Broth.
  G.C. Specimens- Urethral discharge or any source: JEMBEC plates with bag.
  Urine- Container with preservative (boric acid) "Boricon"
  Parasitology- Special collection kits with Formalin and PVA
  

Body Fluid Culture (For PD fluid see Peritoneal Fluid):

Pleural, pericardial, and synovial fluids must be aspirated aseptically. The body site should be disinfected with an iodophor prior to aspiration. Use sterile technique. Inoculate into sterile tube or container or blood culture media.

Blood Culture:

Disinfect body site with iodophor prior to venipuncture. Use sterile technique. Inoculate 2 vacutainer tubes containing 18 mL Supplemented Peptone Broth (SPB) - 2 mL draw. disinfect top of tubes with alcohol prior to inoculation. Two sets from separate venipuncture sites recommended.

Eye, Ear:

Collect specimen with a culturette swab. After collection, place swab back into plastic tube. REFRIGERATE OR LEAVE AT ROOM TEMPERATURE.

Fluid:

See Body Fluid or Peritoneal Fluid

Fungi:

See Mycology

Environmental (Water and Dialysate) Cultures:

See separate instructions for use of Millipore Sampler

Genital Culture:

Collect these specimens using a Culturette swab. The swab may be used to culture urethral exudate or inflammation of the vaginal area. While these specimens are not optimal for gonococcal isolation, the diagnosis of vaginitis or urethritis may be made by the recovery of other pathogens. Swabs must be stored at room temperature until transported to the laboratory. If Gonorrhoeae is suspected, use Test No. 0075, Gonorrhea Culture.

Gonorrhea Cultures:

JEMBEC plates are provided for the isolation of Neisseria gonorrhoeae from rectal, pharyngeal, and genital sites. JEMBEC plates contain antibiotics to allow the isolation of N. gonorrhoeae from these heavily contaminated areas and must be stored at refrigerated temperatures before use. However, it is important that they be at room temperature at the time of inoculation because cold temperatures inhibit growth of gonococci. Exudate is obtained with a sterile swab and immediately inoculated on the JEMBEC agar. Urethral discharge may be collected with a swab which is then immediately streaked onto the agar surface. A CO2 atmosphere is necessary to recover neisseria gonorrhoeae. This may be performed by placing a CO2 generating tablet in the small well present in the plate. The plate is then sealed in a plastic bag. No water is needed to activate the tablet. ONCE SEALED, THE BAG SHOULD BE STORED AT ROOM TEMPERATURE UNTIL TRANSPORTED TO THE LABORATORY.

Gonorrhea/Chlamydia DNA Probe:

1. Specimen collection swabs and transport media are supplied by the laboratory. Remove excess mucus from the cervical os and surrounding mucosa using one of the swabs provided; discard this swab.
2. Insert the second swab from the collection kit 1.0 - 1.5 cm into the endocervical canal.
3. Rotate the swab 30 seconds in the endocervical canal to ensure adequate sampling.
4. Withdraw the swab, avoiding any contact with the vaginal mucosa.
5. Insert this swab into the Gen-Probe transport tube, snap off the shaft at the score-line, cap the tube, and store at 2 - 25°C until tested.

Mycology (Yeast):

Cultures for yeast can be submitted on a Culturette. For fluids and sputum, best results are obtained by submitting the entire specimen. If dermatophytes are suspected, the specimen should be submitted in a dry sterile tube.

Nasal Culture:

A Culturette swab is gently inserted through the nose to the posterior nasopharynx where it is gently rotated. It should remain in this position for several seconds. The withdrawal should be slow to minimize irritation. Place the inoculated swab into the sterile plastic tube and crush the ampule.

Parasitology Specimens:

Stools for Ova and Parasites should be shipped in Ova and Parasite kits- 5 gm minimum of stool in EACH of the paired vials. CLEAR tape preparation or pinworm paddle is appropriate for submission of specimens for pinworm examination. Submit intact parasites (insects or worms) in 70% alcohol.

Peritoneal Fluid or Dialysate Culture:

Disinfect bag's injection sampling port. Use sterile collection technique. Inoculate 3 mL each into four vacutainer tubes with SPB (Supplemented Peptone Broth). Disinfect top of tubes with alcohol prior to inoculation.

Sputum Culture:

Instruct the patient to obtain material from a deep cough which is expectorated into a sterile container. Sputum containers are best suited for this collection. The volume of specimen need not be large (3 mL). Once collected, sputum should be refrigerated until transport. Be sure that the cap is tightly sealed on the container once the specimen is collected. A leaky container is a biohazard.

Stool Culture:

Use Culturette swab. Obtain pea-size feces on swab and place in culturette.

Throat Culture:

Use Culturette swab to obtain all types of throat specimens. Rub the sterile swab firmly over the back of the throat (posterior pharynx), both tonsils or tonsillar fossa, and any area of inflammation. Once the specimen is collected, the swab should be replaced in the plastic tube and the ampule at the base crushed to wet the swab.

Throat, Group A Strep Screen:

Use Culturette to obtain specimen for Group A Strep only. Results take one day versus 2 - 3 days for complete culture.

Urine Culture Screen:

Collect a "clean-catch" mid stream urine into a paper cup. Immediately transfer to Boricon tube with Bacteriostatic preservative. A first morning specimen is preferable and should be refrigerated until pick-up.

Note: It is not necessary to collect a specimen for culture in a sterile cup if the urine is immediately transferred to the Boricon tube.

Wound Culture:
A superficial wound culture should be collected with a Culturette swab. After collection, place swab back into plastic tube, and refrigerate or leave at room temperature until transport. If the lesion is not open, a sterile needle and syringe should be employed to remove material. the culturette may be inoculated with this sample.

Important

Please note that to comply with new Federal requirements (C.L.I.A. 88). All test requests are to be signed by the ordering physician and the time and date of the specimen collection are to be clearly added to the request form.

Note

Reference Ranges are method dependent and may change if a methodology changes. Check the final report for all reference ranges.