Pre-analytical:
The pre-analytical phase includes the steps that are performed prior to actual testing. These include the following:
- Test orders (making sure they are correct and ordered on the correct tube-type, not duplicates, not part of a larger panel, something that is performed at your lab or needs to be redirected to another site or sent out to a specialty lab)
- A test order is also called a requisition
- Tests are also called assays
- The LIS is the laboratory information system (computer software) that the orders will show up in once the doctor or nurse puts it in
- The LAS is the laboratory automation system that the orders will enter into for the instrumentation/analyzers
- Where IS the sample? The status shows you the tracking of the sample:
- Dispatched: ordered, but not collected yet
- Collected: may or may not truly be collected yet, but not sent to the laboratory yet or to be processed yet; will show date and time of collection
- In-Transit: coming from another location
- Received or In-Lab: received in specimen processing and is being prepared (tracked, received, spun, labeled, etc...)
- Tracked to Specific Area: (Ex: Chemistry, Immunology, Hematology, Etc...) Ready to be processed by your department
- NOTE: The date and time of collection should be monitored on pending logs and turnaround time boards to make sure that your department has the sample and if there are any hold-ups or problems with the sample so that you can resolve them as soon as possible.
- Collection of the Sample:
- Patient prep (fasting, non-fasting, supplements, hydration, dehydration, tourniquet, etc...)
- IV's and infusion pumps must be turned off 15 minutes prior to collection to prevent contamination
- Order of the draw must be followed by the phlebotomist in order to prevent contamination
- A discard tube should be drawn if the patient has a line prior to drawing samples for testing in order to prevent contamination
- Verification of order and patient information and that it is entered under the correction patient identifier numbers
- Proper tube-type (cap color, anticoagulant, additive type for the test)
- Sample amount (full tube, sometimes more than 1 full tube)
- Labels on the tube (barcodes, no writing or smears on the barcode, label facing straight, not crooked, label right-side up not upside-down, no tears, testing label versus chart label, not stuck to the cap, has date and time of collection and collector's information)
- Collection time
- Samples without additives must be allowed to sit and clot for 30 to 60 minutes prior to centrifuging in order to prevent problems with the gel separator
- If urine, was it routine or timed? Was it a 24-hour urine? If so, must be collected in a jug with preservative and total time of collection in minutes (1440 for 24 hours) and total volume listed
- Transport and Temperature:
- Room temp., if required, upright (in foam if transported), parafilmed, etc...
- Refrigerated (cold packs in coolers from couriers or for send-out)
- Frozen (dry ice in coolers from couriers or for send-out)
- On ice slurry (Fractionated ALK-Phos, following pre-heating in 56 degree Celsius water bath)
- Water bath is filled and at proper temp. (56 degrees Celsius)
- Protected from light
- Protected from heat
- Protected from moisture
- Capped or sealed properly (CO2 and pH can change if not properly capped)
- Not leaking
- In Biohazard bag for protection when transported through a courier or tube system
- Specimen has actually arrived to your section of the lab
- Check specimen processing, tube system, other areas, courier, etc.. if specimen is missing or if delayed or if it says it has been collected or has arrived (investigate it)
- Receipt:
- Received and tracked by specimen processing
- Make sure that outreach and specimen processing have allowed 1 hour clot time for red-top tubes and 30 minutes for gold-top tubes
- Received by proper laboratory section and tracked
- Gently invert tubes containing whole blood, especially EDTA, 8x to mix cells will the anticoagulant thoroughly
- Visually inspect whether the specimen has been spun or unspun
- Put unspun specimens in correct centrifuge or on automated track for automated centrifuge
- Aliquot any short samples or samples that need to be poured off into other types of tubes from the original and document on label
- Reprint upside-down labels, unreadable barcodes, smeared barcodes, etc...
- Visual inspection:
- Noted for hemolysis, icterus or lipemia, color, composition
- Clots removed with sticks
- Fibrin or goobers removed with sticks and respun if needed
- Bubbles removed with sticks or fine pipettes
- Enough sample for tests needed
- Poured off or aliquoted if necessary or if short
- Good sample quality
- Label not upside-down (reprint label if necessary)
- Label without ink markings
- Label barcode is readable
- Label has the time of collection and person who collected or aliquoted it
- Checked for time or any delays to the section
- Spun or unspun
- Cap on and not crooked
- Not leaking
- Gel not slanted
- Information on label looks correct
- Centrifuge if needed:
- Centrifuge is operating correctly
- Set on correct time and speed and within performance test timeframe (usually performed by clinical engineering)
- Tested monthly
- Cleaned
- Pretreat or filter sample if needed
- Put on tube rocker or shaker if needed or vortexed
- Labels reprinted if needed
- Priority checked: (Shown on Label)
- Crisis
- STAT
- ASAP
- Timed
- Routine
- Add-on
- Errors are investigated and corrected and sample retested, recollected, cancelled, credited if necessary
- Samples that come off the track to be pre-treated or sent to other areas are taken care of
- Integrity is checked again prior to releasing results
- Specimens held for check prior to resulting are checked
- Specimens held while analyzer maintenance is being performed are followed up and resent to analyzer if needed
- Calibration on analyzer was successful
- QC on analyzer was successful and not held up
- Tests enabled
- Analyzers enabled/on
- Maintenance on analyzer and track were successful
- Sample is loaded correctly on analyzer or track
- Sample in correct rack (STAT, unspun, spun, capped, uncapped, send-out refrigerated, send-out frozen, from an outlying/outreach clinic)
- Racks are distributed where needed
- Laboratory cleaning, disinfecting, removal of trash and sharps
- Dry ice available for frozen specimens
- Ice packs available with coolers for refrigerated specimens
- Making or reconstituting solutions, reagents, calibrators and loading them on the analyzer
- Restocking the analyzer with needed supplies
- Putting away supplies and inventory tracking
- Preparing the work area by replenishing supplies needed
- Looking at the Plan My Day and Pending Log to have a map of what to expect that day
- Checking emails for any instructions or communication
- Checking the assignments to see where you are benched or re-benched
- Moving samples from a pending log in one location to a pending log in your own location
- Monitoring the pending tests
- Monitoring patient samples in-transit from other locations
- Monitoring samples collected until the time they arrive in specimen processing and to your section of the lab; Note any delays and reasons why
- Taking and monitoring temperatures throughout the laboratory
- Making sure that cleaners, solutions, detergents, reagents, calibrators, and QC materials and AMR materials, etc..., are stored properly
- Checking expiration dates
Analytical:
Analytical steps are the actual testing steps. The sample is now on or routed to the analyzer(s). These things include:
- Sample is on the automated track being taken to the analyzer/instrument or on the analyzer/instrument
- Sample is actually running and barcode has been read/picked up
- Barcode reader functioning and clean
- Track and storage and all its parts are running and functional
- You are troubleshooting problems that come up with the sample or the instrumentation or the orders
- HIL reference has run
- Calibrations have been performed in a timely manner and are active, not expired, current, and set points are correct
- Monitoring the test turnaround time (TAT)
- The barcode is being read
- Orders are correct
- The sample has been correctly received
- The sample is on your pending log and tracked to your section
- The instrument and tests are enabled and functioning properly
- Checked for interferences by analyzer after visual inspection:
- Bubbles (check for "aspiration errors" and reset the analyzer)
- Clots (analyzer will send back to track for tech to remove and put back on)
- Microclots (analyzer will send back to track for tech to remove and put back on)
- Fibrin (analyzer will send back to track for tech to remove and put back on)
- Goobers (analyzer will send back to track for tech to remove and put back on)
- Amount of sample (analyzer will send back to track for tech to remove and aliquot or cancel/credit/reorder)
- Turbidity (analyzer will send back to track for tech to order an auto or manual dilution )
- HIL reference:
- Hemolysis
- Icterus
- Lipemia
- There are enough reagents and solutions and supplies onboard the analyzer to perform testing (pipette tips, cuvettes, solutions, detergents, etc...)
- Dilutions may be needed (automatic, manual) and may need to be scheduled on the LIS or at the analyzer
- Filtering may be needed
- Pretreatment may be needed
- Specimens may be contaminated with IV fluid or EDTA and need to be called, canceled or credited
- Monitor for DELTA checks (reject/rerun sample)
- Monitor for errors
- Visually check < samples
- Visually check samples that seem like that have not been spun as you see results beginning to come across during testing
- Monitor for QC; will be held up if it is out of range
- QC is being run and accepted and troubleshooted on the instrument
- Precisions run if needed
- QC is being run and accepted and troubleshooted on the instrument
- Monitor for short samples and aspiration errors and reset the analyzer if one occurs
- Clear exceptions
- Monitor for critical values that need to be called and call them
- Monitor for results that need to be released and verified by you in order to be released
- You may need to verify part of a test panel before the other tests will run
- Monitor for any paperwork you may need to fill out for things like public health, corrections, instrument failures, QC failures, etc...
- If you have an automated track system, watch all parts to make sure everything is functioning properly, and troubleshoot any errors that may occur (track itself, racks, storage unit, decapper, recapper, resealer, aliquoter, divert gates, barcode readers; jams)
Post-analytical:
Post-analytical steps involve the things that occur right after testing. These include:
- Releasing results
- Canceling duplicate results or unnecessary results
- Manually entering results that need to be manually entered
- Calling critical values and documenting this information as required
- Calling to cancel/credit/reorder/recollect
- Calling corrections and filling out any needed paperwork
- Reporting certain results as required to your state (paperwork, calls, etc...)
- Filling out paperwork for possible blind samples
- Filling out any Quality Management Reports
- Verifying results
- Looking for add-on tests and monitoring the pending test logs for any specimens that are missing, not tracked, in other sections, not here yet from outreach clinics, need manual results or calculations, etc...
- Generating and analyzing reports
- E-mail notifications
- Finding samples
- Store samples
- Rack samples
- Delays and incomplete samples are discovered and investigated
- Taking samples to other departments
- Giving or receiving further directions regarding testing
- Preparing samples for send-out to other clinics or for reference testing
- Always communicating well with your coworkers