LEARNING OUTCOMES Dehydrated patient

 Describe the steps involved in processing and
handling different types of specimens
 List the criteria for specimen rejection
 Perform routine and special specimen
processing and handling procedures
 Explain time constraints and exceptions for
delivery and processing of specimens
 Identify Occupational Safety and Health
standards act (RA 11058) required protective
equipment worn when processing specimens
SPECIMEN HANDLING
 The quality of results depends on proper
handling of the specimen in the preanalytical
phase.
Preanalytical Phase
 all the steps taken before the actual testing of
the sample.
 Estimated that 46% to 68% of all laboratory
errors occur prior to analysis.
 Specimen handling is a critical part of this
phase.
 Proper handling from the time a specimen is
collected until the test is performed helps
ensure that results obtained on the specimen
accurately reflect the status of the patient.
 The phlebotomist in-charge should be
responsible enough to follow all appropriate
steps required for each steps
Improper handling
 A preanalytical error that can render the most
skillfully obtained specimen useless or affect
the analyte (Substance undergoing analysis) in a
way that causes erroneous (invalid) or
misleading test results, which in turn cause
delayed or incorrect care for the patient
PREANALYTICAL ERRORS
 Factors that alter test results that are
introduced into the specimen before testing,
including before, and during collection, and
during transport, processing, and storage.
POSSIBLE SOURCES OF PREANALYTICAL ERROR
 The result of a test is compromised when the
proper collection procedures, storage,
processing, and transporting protocol were not
followed in the preanalytical phase
 The specimen is rejected if it did not meet a
specific criteria
BEFORE COLLECTION
Age of patient
 Different age groups have different normal
values or reference ranges.
Altitude
 People who tend to live in high areas have
slightly elevated normal values as compared to
those who are living in low areas,
 Usually reflects the blood chemistry, specifically
the electrolytes
Duplicate test orders
 Multiple test request done on a single patient
can also lead to erroneous results
Strenuous Exercise
 Too much exercise can cause RBC destruction
which can alter test results
 Usually athletes
Gender of patient
 Male patients have normally higher values
compared to females
Inadequate fast
 If the patients is required to fast for at least 8
hrs, but the specimen is collected earlier than
the required time (kulang ng minutes/hours)
causes result alteration
Incomplete requisition
 Incomplete requests = incompete tests —
incomplete results
Medications
 Intravenous medications can also alter the
results
Patient stress
Pregnancy
 Have different normal set of values compares to
those who are not
Smoking
 Alters the WBC count, specifically neutrophils
Treatments
 the intravenous medications, radioisotopes
Wrong test ordered
 Yields to wrong results
AT THE TIME OF COLLECTION
 Misidentified patient
 Always ask the basic information of the patient
(name, age. gender) to avoid mislabeling and
exchange of results
 There are rare cases in which patients share the
same name
Antiseptic not dry
 Leads to contamination of specimen
Expired tube
 Different anticoagulated tubes requires/have
different expiration dates
 Red top tubes do not have anticoagulant but
still has an expiration date
 Can still be use beyond expiration date.
The expiration date refers to the vacuum, if using a
vacutainer technique, the specimen collected may not
reach the minimum required amount.
Failure to invert additive tubes properly
 Different anticoagulated tubes require different
number of inventions
Faulty technique
 Application of tourniquet or withdrawal of
needle
Improper vein selection
 Instead of the vein, the artery was hit
Inadequate volume of blood
 Insufficient amount of sample taken
Inappropriate use of plasma separator tube (PST) or
serum separator tube (SST)
 Ex. did not centrifuge sample
Incorrect collection tube
 Ex. instead of EDTA tube, sample was placed in
red top
Incorrect needle position
 Wrong angle of insertion
Incorrect needle size
 Ex. Large needle is used in small vein causing
rupture of the vein
Mislabeled tube
 Results will be provided to the wrong person
Mixing tubes too vigorously
 Too much force will induce hemolysis
 Always invert to mix, NOT shake
Nonsterile site preparation
 Induces bacterial infection
Patient position
 Patient should be in a comfortable position
 Not standing patient
Prolonged tourniquet application
 Induce hemolysis
Underfilled tube
 Inappropriate ratio of sample to anticoagulant
due to insufficient sample collected
Wrong collection time
 Ex. Instead Of morning, the test was collected in
the aftemoon
DURING SPECIMEN TRANSPORT
Agitation-induced hemolysis
 Rough handling and agitation can hemolyzed
specimen, they may activate the platelets and
affect coagulation tests and it may break the
tubes
Delay in transporting
 Samples may only be valid to certain test for a
certain period of time
Exposure to light
 Some specimens required in specific tests are
not allowed to be exposed to light
 Exposure will affect the result value
Failure to follow temperature requirements
 Refrigerated
Transport method
 By hand or pneumatic method
DURING SPECIMEN PROCESSING
Contamination
 Dust or glove powder
Delay in processing or testing
Delay in fluid separation from cells
Evaporation
 Did not maintain the temperature requirement
Incomplete centrifugation
 Prolonged or shortcut
Mislabeled aliquot
Multiple centrifugations
 Stimulated hemolysis
Rimming of clots
 Clots are ringed out after centrifugation, if not
done properly it will induce hemolysis
Failure to centrifuge specimen according to test
requirements
 Ex. Nakalimutan
DURING SPECIMEN STORAGE
Exposure to light
 Light sensitive specimens should not be
exposed, the tube should be wrapped by
 aluminium foil, and use the light blocking
hamper
 Ex bilirubin
Temperature change outside defined limits
 Affects specimen integrity
ROUTINE HANDLING
Mixing tubes by inversion
 Additive tubes require 3-10 gentle inversions
Transporting specimens
 Stopper should be up to avoid spillage of
leakage
 Should be in plastic bags with biohazard logo,
liquid-tight closure, & a slip pocket for paper
work
 All specimens are considered biohazard
 Paperwork - ensures/contain information of the
specimen and test to be performed
DELIVERY TIME LIMITS AND EXCEPTIONS FOR
DELIVERY AND PROCESSING SPECIMENS
DELIVERY TIME LIMITS
 Routine blood specimens should arrive at the
lab within 45 mins.
 Centrifugation, if required, should occur within
1 hr of arrival.
 Clinical and Laboratory Science Institute (CLSI)
set the maximum time limit for separating
serum and plasma at 2 hrs from time of
collection, unless evidence indicates that longer
contact time will not affect the accuracy of
results
 Less time is required for some tests, such as
cortisol and potassium
 Prompt delivery and separation minimizes the
effects of metabolic process such as glycolysis
unless chemically prevented by additives such
as sodium fluoride
 GlycolysiS continue in the blood specimen,
lowering glucose levels until the serum is
physically separated from cells
PROPER TUBE INVERSION
 Number of inversion depends on the
anticoagulant in the tube and manufacturer
instruction.
 Gentle inversion help distributes additives
equally while minimizing the chances of
hemolysis
 Usually between 3-10 inversions
SPECIMEN PREPARED FOR PNEUMATIC TRANSPORT
 System usually seen in tertiary hospitals
 Specimen if placed in a capsule and being
transported from one station to the laboratory
 Specimen should be transported with stopper
to avoid contacts between contents
 The stopper minimizes agitation of the
specimen and aid clot formation for serum
tubes
 Specimens are placed in liquid-tight closure
plastic bags with a visible biohazard logo and a
slip pocket for the appropriate paperwork
SERUM GEL TUBES
 Contain gel
 Right: before centrifugation; Left: after
centrifugation
 After centrifugation, the gel serves as a barrier
between the solid and liquid (serum) layer
SPECIMEN HANDLING TIME
LIMIT EXCEPTIONS
"STAT" or "medical emergency" specimens
 take priority over all other specimens and
should be transported, processed, and tested
immediately
Blood smears made from EDTA specimens
 prepared within 1 hour of collection to preserve
the integrity Of the blood cells and prevent
artifact formation due to prolonged contact
with the anticoagulant,
EDTA specimens for CBCs
 should be analyzed within 6 hours, but are
generally stable for 24 hours at room
temperature. CBC specimens collected in
microcollection containers should be analyzed
within 4 hrs.
EDTA specimens for erythrocyte sedimentation rate
(ESR) determinations
 must be tested within 4 hours if left at room
temperature or within 12 hours if refrigerated.
 ESR determines how quickly erythrocytes settle
at the bottom of the tube that contains the
sample. It is for infection, pregnancy, aging.
EDTA specimens for reticulocyte counts
 are stable up to 6 hours at room temperature
and up to 72 hours if refrigerated.
 Reticulocyte counts measure the number of
new red cell in the body
 In cases like hemolytic anemia where RBCs are
destroyed faster than they are made
Glucose test specimens drawn in sodium fluoride tubes
(grey top)
 are stable for 24 hours at room temperature
and
 up to 48 hours when refrigerated at 2C to 8C.
Prothrombin time (PT) results on unrefrigerated and
uncentrifuged specimens
 are reliable for up to 24 hours after collection.
 Detects bleeding and clotting disorders
Partial Thromboplastin Time (PTT) test specimens (blue
top)
 require analysis within 4 hours Of collection
regardless of storage conditions.
 Measures the time it take for blood to clot
SPECIAL HANDLING
Body temperature specimens
 36.4 C - 37.6 C ; average of 37 C
 Room temp 15 - 30 C
 Refrigerated temp 2-10 C
 Frozen temp -20 C or lower; some specimens
require -70 C or lower
 Should be collected in a pre-warmed tube
 Should be transported at or near normal body
temp. of 37 C
 Specimens that precipitate or agglutinate if
allowed to cool below the body temp, should be
transported with 37 C
 Use portable heat blocks to maintain temp-
during transport
 Heat blocks are kept in an incubator at 37 C
until needed and are available for transporting
body temp specimen
 Heat blocks can hold the temperature for
approx. 15 mins after removal from the
incubator
 Cold agglutinin, cryofibrinogen, and
cryoglobulins
 Chilled specimens
 Should be immersed in a slurry Of crushed ice &
water
 Can't use ice cubes as large chunks of ice
without water do not allow adequate
cooling of the entire specimen
 Contact with solid piece of ice can freeze
parts of the specimen, resulting to
hemolysis and possible analyte breakdown
 Should be tested immediately or refrigerated
 Chilling of specimens slows the metabolic
process which could affect the result for some
specimens
 Adrenocorticotropic hormone acetone, enzyme
(ACE), angiotensin-converting ammonia,
catecholamines, free fatty acids, gastrin,
glucagon, homocysteine, lactic acid, parathyroid
hormone (PTH), ph/blood gas (if indicated),
pyruvate. and renin.
Specimen processing
 Central processing area in large labs for triage
 Screening and prioritizing area
 Here, specimens are:
 Identified
 Logged/accessioned
 Sorted by department & type processing
required
 Evaluated for suitability for testing
Specimen suitability
 Specimens are rejected for:
 Hemolysis
 Destruction of RBC
 Insufficient amount of specimen
 Quality not sufficient (QNS)
 Clotting
 Wrong or outdated tube
 Improper handling
 Wrong collection time
 Exposure to light
 Delay in testing
 Delay or error in processing
 Inadequate, inaccurate, or specimen ID missing
CENTRIFUGATION
Centrifuge
 An apparatus that is used to separate cells,
plasma, or serum of blood specimens,
 a machine that spins blood tubes at high rpm
 Centrifugal force separates cells & plasma or
serum
Tubes awaiting centrifugation
 Stoppers should remain on to prevent
inaccurate results, evaporation, &  Pouring of serum or plasma in the aliquot tube
contamination
 Removal of stoppers can cause loss of C02 and
increase pH
 Sources of contamination can be as simples as a
drop of sweat which interferes with electrolyte
results or glove powder which can interfere
with calcium determination
Centrifuge operation
 Tubes must be balanced (equal-size tubes with
equal volumes of specimen must be placed
opposite one another)
 Different manufacturers have diff models, sizes
and capacity.
Centrifuging plasma specimens
 Must be centrifuged immediately and without
delay
Centrifuging serum specimens
 Serum specimens must be completely clotted
before centrifugation
 Complete clotting takes 30 to 60 min. at room
temp.
Stopper removal
 Some testing machines sample specimens
directly through the stopper.
 Most require stopper removal
 Certain machines don't require the removal of
stopper, the machine puncture the cap of the
test tube
 Stoppers may be removed by removal devices
or robotics,
 If removing manually:
 Face shield or splash shield should be used
 Gauze or tissue should cover the stopper
 Stoppers should be pulled straight up and off.
ALIQUOT PREPARATION
Aliquot
 a portion Of specimens used for testing.
 used when
 Multiple tests are ordered.
 Tests are performed on different a instruments
or in different areas.
 Prepared by transferring a portion of specimen
into one or more tubes labeled with the same
ID info as a specimen tube.
 Each aliquot tube should be covered or capped
as soon as it is filled.
 Specimens with different anticoagulants should
not be put in the same aliquot tube
 Specimen being transferred to aliquot tube
is not recommended as it increases the
possibility of aerosol formation or splashing.
Pipette
 Device used to transfer liquid specimens
OSHA ACT (RA 11058)
Required Protective Equipment Worn When
Processing Specimens
 The healthcare institution should comply with
the appropriate protective equipment set by
the Occupational Safety and Health Standards
Act (RA 11058)
 Protective equipment includes gloves,
laboratory gowns/coats, and masks,