VA NORTHERN INDIANA HEALTH CARE SYSTEM

January 2011 POLICY NO. 113-06-

STAT AND ROUTINE LABORATORY PROCEDURES

1. PURPOSE: To define and establish policy for the use, ordering, turnaround time,
and reporting of STAT and Routine laboratory tests.

2. POLICY: It is the policy of VANIHCS that STAT testing will take precedence;
however, all testing will be done in an expedient and timely manner to aid the medical
staff in their diagnosis and treatment of the patient.

3. DEFINITIONS:

a. STAT Lab Orders: To be utilized when a patient’s condition is deemed to be life

threatening or a critical medical decision is pending outcome of the test. Specimen
collection and testing are the highest priority. A list of STAT eligible tests is included
as Attachment A.

b. ASAP Lab Orders: To be utilized when the patient’s condition is not life
threatening or critical, but results are needed in a timely manner. Specimen collection
and testing are prioritized after STAT orders, but before Routine orders.

c. Routine Lab Orders: To be utilized when the results are not time sensitive.
Specimen collection and testing will be prioritized after STAT and ASAP orders.

d. Lab Collection: This collection type is utilized when the specimen is to be

drawn as part of the routine inpatient unit collections. It is automatically scheduled for
the next morning collection unless a specific date is selected.

e. Ward Collection: This collection type is utilized for specimens collected by the
inpatient unit staff. For example, urine specimens or culture swabs.

f. Send Patient to Lab: This collection type is utilized when the patient will be
sent to the Outpatient lab area for specimen collection.

g. Immediate Collect: This collection type is utilized when the specimen needs to
be collected by the laboratory or designated nursing staff the same day it is ordered.

4. PROCEDURE: Orders for laboratory testing entered with the appropriate priority
and collection type designation ensures testing is completed as needed for patient
care. Testing available on a STAT basis is listed on the attached STAT list and is the
same for both campuses, however, there are some procedures that must be sent out
at each campus due to on site testing availability.
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a. Fort Wayne Campus.

(1) Tests requested to be collected during routine morning inpatient collections

must be entered into the computer by 4:00am the day they are to be
collected to insure they appear on the laboratory’s collection list. They are
entered with the collection type “Lab Collect”.

(2) The laboratory will check for routine collections daily at 11am and 2pm.
Orders to be drawn should be entered as a Routine priority with the collection
type “Immediate Collect”.

(3) Timed collections are entered as a Routine priority with the date and time of
collection specified and the collection type “Immediate Collect”. The
laboratory must be called with the order number and the desired time of
collection.

(4) STAT/ASAP orders are entered with the appropriate priority and a collection
type of “Immediate Collect”. The laboratory must be called with the order
number to initiate the collection.

(5) Outpatient laboratory services are available during administrative hours.

b. Marion Campus

(1) Tests requested to be collected during routine morning inpatient collections

must be entered into the computer by 4:00am the day they are to be
collected to insure they appear on the laboratory’s collection list. They are
entered with the collection type “Lab Collect”.

(2) The laboratory is available for routine inpatient specimen collections during
administrative hours. Requests for collections must be entered with the
collection type of “Immediate Collect” and the order number called to the
laboratory staff.

(3) Timed collections are entered as a Routine priority with the date and time of
collection specified and the collection type “Immediate Collect”. The
laboratory must be called with the order number and the desired time of
collection.

(4) STAT/ASAP orders are entered with the appropriate priority and a collection
type of “Immediate Collect”. The laboratory must be called with the order
number to initiate the collection.

(5) Outpatient laboratory services are available during administrative hours.

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(6) During non-administrative hours, STAT tests, selected from the STAT list,
are performed as ordered by the provider. Orders are entered with a priority
of “STAT” and the collection type “Immediate Collect”. Tests not on the
STAT list may be run STAT; however, the provider must first contact the
Chief, Pathology and Laboratory Medicine Service (PALMS), or designee,
with special requests. Non-administrative hours laboratory collections are
performed by trained nursing personnel and sent to Marion General Hospital
for testing. Nursing personnel phlebotomist can be contacted through the
Nurse Coordinator. Laboratory results are faxed from Marion General
Hospital directly back to VANIHCS Marion Triage and given to the provider
for review.

(7) During non-administrative hours, designated nursing personnel have the

capability of performing select ancillary testing on site. Test available for
ancillary testing are Troponin, Myoglobin, BNP, Emergency Panel (Sodium,
Potassium, Chloride, CO2, BUN, Creatinine, Glucose, Hct), Urine Pregnancy
Test and dipstick only urinalysis.

c. Result Reporting

(1) All laboratory test results are reported via the computer, and any critical
(panic) values are called per the Critical Value Policy.

(2) Test results for testing performed during non-administrative hours at the
Marion Campus, either as ancillary testing or at Marion General Hospital, are
entered into the VANIHCS computer system as soon as possible by
laboratory staff during administrative hours.

(3) STAT turnaround time for in house testing has been defined as one hour
after the blood is received in the Laboratory. Do not call the Laboratory for
results unless there has been more than a reasonable delay. Unnecessary
calls interrupt procedures and delay testing.

(4) ASAP turnaround time for in house testing has been defined as two hours
after the blood is received in the laboratory. Do not call the Laboratory for
results unless there has been more than a reasonable delay. Unnecessary
calls interrupt procedures and delay testing.

(5) Routine turnaround time for in house testing has been defined as less than
or equal to one day. This may be extended in the event of instrument
malfunctions that cannot be resolved within one day.

(6) Tests offered by the Laboratory will not be sent out to a fee basis laboratory,
except in an emergency situation. Authority for such must come from the
Chief, PALMS, or designee.

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(7) Tests not performed in house and sent to reference laboratories have had
turnaround times defined in the bidding process.

5. RESPONSIBILITY:

a. The Chief, PALMS or designee is responsible for:

(1) Education of providers on proper Laboratory order priorities and collection

types.

(2) Education of laboratory staff on expectations for each priority and collection
type.

(3) Insuring the STAT list is appropriate for the VANIHCS population.

(4) Insuring turnaround times meet the expectations set forth in this policy.

b. Laboratory Staff are responsible for:

(1) Utilizing collection types to identify orders requiring collection.

(2) Utilizing order priorities to manage workload.

(3) Organizing workload to assure turnaround time expectations are met.

c. Primary Care Services is responsible for:

(1) Entering orders for laboratory services utilizing the appropriate collection
type and priority.

(2) Arranging for laboratory notification when indicated.

d. Patient Care Services is responsible for:

(1) Notifying laboratory of provider lab orders when indicated.

(2) Collecting non-blood specimens.

(3) Providing laboratory collection and ancillary testing services to the Marion
Campus during non-administrative hours.

6. REFERENCES:

a. College of American Pathologists General Checklist, revised 2010

b. Joint Commission: Accreditation Process Guide for Laboratories, 2009

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7. RESCISSION: VANIHCS Policy Memorandum No. 113-06, STAT and Routine

Laboratory Procedures, dated December 6, 2005, is rescinded.

8. RECISSION DATE: January 2014

9. FOLLOW-UP RESPONSIBILITY: Chief, Pathology and Laboratory Medicine

Service

SUSAN SORENSEN, M.D.

Chief, Pathology and Laboratory Medicine Service

HELEN RHODES, MPA, RN

Associate Director for Operations, Marion Campus

CYNTHIA GOODMAN, MBA/HCM, ACSW, LCSW

Acting, Associate Director for Operations, Fort Wayne Campus

AUDREY L. FRISON, MHA, BSN, RN

Associate Director for Patient Care Services

RAHMAT LEGHARI, M.D.

Chief of Staff

DANIEL HENDEE, FACHE

Director

Attachments: A

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Attachment A

VA NORTHERN INDIANA HEALTH CARE SYSTEM

STAT LIST

Glucose Amylase

BUN Lipase

Creatinine PT with INR

Sodium PTT

Potassium Fibrinogen (sent out in Fort Wayne and

Electrolytes (Sodium, Potassium, CO2, Chlorides)
Basis Metabolic Panel (Glucose, BUN,
Creatinine, Sodium, Potassium, Chlorides, CO2, Calcium)
Marion)
D-Dimer (sent out in Fort Wayne and Marion)
Type and Crossmatch (sent out in Marion)

CBC (Hemoglobin, Hematocrit, WBC, Differential count, Gram Stain (Sent out in Marion)
Platelet count)

Hepatic Function Profile (Total Protein, Blood Cultures

Albumin, Bilirubin (Total, Conjugated & Unconjugated),
Alkaline Phosphatase, ALT, AST)
Ethanol
Calcium
Phenobarbital (sent out in Fort Wayne and
Marion)
Phosphorous
Fluids (Glucose, Cell Count, Gram Stain) (sent out in
Magnesium Fort Wayne and Marion)

Urinalysis India Ink (Sent out in Marion)

Urine Drug Screens

Troponin

Myoglobin

NT-proBNP

Dilantin

Digoxin