Pathology Handbook The Pathology Partnership at the Lister Hospital, Stevenage

Effective from July 2015 This document is reviewed every two years – next review due June 2017

Pathology Handbook V13 |Monday 24 July 2015

Index Section

Heading

Page

1

Introduction

3

2

Contacts

4

3

Open hours

4

4

Identification of laboratory requests and specimens

5

5

Transportation of specimens

7

6

High risk specimens

8

7

Urgent requests and reporting of results

10

8

Pathology information for general practitioners

11

9

Clinical biochemistry

12

10

Specialist metabolic investigations

39

11

Haematology

41

12

Blood transfusion

45

13

Immunology

47

14

Microbiology

49

15

Histopathology

60

16

Diagnostic non-gynae cytology

64

Appendix 1

Requesting pathology tests and accessing results using Sunquest ICE

Appendix 2

Pathology specimen collection policy

Appendix 3

Blood sciences out-of-hours policy

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1. Introduction The Pathology services at East and North Hertfordshire NHS Trust are provided by the Pathology Partnership, a joint venture by six Trusts to modernise delivery of pathology services to hospitals, general practitioners (GPs) and patients. The six NHS Trusts are:  East and North Hertfordshire NHS Trust (ENH)  Cambridge University Hospitals NHS Foundation Trust (CUH)  Hinchingbrooke Healthcare NHS Trust  Colchester University Hospital NHS Foundation Trust  Ipswich NHS Trust  West Suffolk NHS Foundation Trust The Pathology Partnership offer a comprehensive range of accredited pathology services, Clinical Pathology Accreditation (CPA) or United Kingdom Accreditation Service (UKAS), fully supported and led by consultantgrade staff across the six Trusts. All pathology sections participate in external quality assurance schemes recognised by CPA/UKAS. The results from these schemes are sent to the various national panels for peer review of performance. Heads of Departments and their deputies inspect results of internal quality control and external quality assessment exercises regularly. The Pathology service operates within a quality management system which is regularly audited against standards as set by major UK regulatory bodies (CPA (UK) Ltd, UKAS, MHRA and HTA). For further information about the Pathology Partnership go to https://thepathologypartnership.info/ Immunology and microbiology services for the East and North Hertfordshire area are centralised at the Pathology Partnership’s Cambrridge Hub at CUH. Information on these disciplines can be located: 

Immunology - Click on link:- - http://thepathologypartnership.info/docs/our_services/2015-08-



26&Cambridge_Clinical_Immunology_Laboratory_Handbook_2015_v1.pdf Microbiology – Click on Link http://thepathologypartnership.info/docs/our_services/2015-0820&Cambridge_PHE_Clinical_Microbiology_Service_User_Handbook.pdf

This pathology handbook outlines the Pathology services offered at ENH provides information including interpretative data where relevant, specimen requirements and instructions for collecting specimens to comply with Health & Safety requirements. Further in-depth information can be found within the pathology pages of the Trust’s intranet (Knowledge Centre / Clinical Departments / Pathology). Additional information can be found on the following website www.labtestsonline.org.uk. This website offers education and information on blood, urine and other pathology tests to help users better understand this aspect of healthcare. For queries in connection with any aspect of the Pathology Partnership’s services, including amendments or suggestions to this handbook, please contact the pathology satellite manager Nazia Hussain - contact details below.

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2. Key contacts Clinical Director Dr Motez Al-Izzi E: [email protected] T: 01438 286 129 – internal extension 6129 Pathology Satellite Manager Nazia Hussain E: [email protected] T: 01438 284 089 – internal extension 4089 The Pathology Partnerhsip Helpdesk – for queries relating to tests carried out at Cambridge University Hospitals Open: Monday to Friday 08:00-20:00 E: [email protected] T: 0333 103 2220 Lister Pathology T: 01438 284690 For further discipline specific contacts please see appropriate section in this handbook.

3. ENH pathology opening hours Core opening hours Monday to Friday

09:00 - 17:00

On-call hours

17:00 - 09:00 Monday - Friday All day Saturday, Sunday and Bank Holidays

Contacting the on-call Biomedical Scientist

For all urgent out of hours work you must contact the relevant Biomedical Scientist: Biochemistry: Bleep 14690 or call ext 4690 Haematology Bleep 1005 or call ext 4961 Blood Transfusion(BT): Bleep 1005 or call ext 5245 Microbiology: Contact Addenbrooke’s Switchboard Histology/Cytology: No service

Phlebotomy opening hours Monday to Friday

Saturday

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Lister: 08:00 - 17:30 QE2: 08:00 - 17:00 HCH: 08:00 - 15:45 Lister: 09:00 - 12:00 QE2: 09:00 - 12:00 HCH: No phlebotomy service

4. Identification of laboratory requests and specimens The ‘NHS number’ implementation guidance document was issued in December 2008 which proposed full acceptance of the NHS number as the primary patient identifier by December 2009. We would ask that this number is used as the primary laboratory identification of any patient/request. Request forms Pathology requests for blood transfusion, cytology and histology must be made using the appropriate request forms. Pathology requests for haematology, biochemistry, immunology and microbiology should be made using ENH’s Sunquest ICE order communication system (OCS) – See appendix 1. If ICE requesting is not available, requests can be made using the appropriate, legible, fully completed, paper request form, inadequately completed forms will lead to unesscesary delays. If request forms are not correctly and legibly completed then the laboratory reserves the right to cancel requests for the safety of patients. We attempt to inform and advise users of such problems as they arise but may not always be able to contact those concerned. It is essential that all patient details are completed and contain: • sufficient information to allow unique identification of the patient • identification, location and contact number of the requesting individual • date and time of specimen collection • type of specimen and, where appropriate, anatomical site of origin • investigations requested • relevant clinical information • identification of priority status • location to which results are to be sent If using addressograph labels on duplicate/triplicate forms, a label must be applied to each copy. The clinician signing the form is responsible for checking that the details are completed correctly. Specimens Specimens must be labelled immediately after the sample has been obtained verifying the information with the patient notes. The specimen label must contain a minimum of three points of identification to include:  NHS Number  surname  first name  date of birth As well as the labelling using the above ID information all samples must include the following:  date and time of specimen collection  initials of person collecting the sample Addressograph labels may be used for the majority of samples but must not be used for blood transfusion samples. For blood transfusion specimens all of the above points of identification are required, including the NHS number. All transfusion samples must be signed by the person performing the venepuncture.

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Please note: Blood Transfusion operates a zero tolerance of samples and request forms that are not labelled with the NHS number (where a patient has one). Samples and request forms without this information will not be processed unless the patient requires urgent blood product support. All specimens must be transported inside a clear marsupial sealed bag (for blood transfusion samples, this is integral to the request form. The laboratory cannot process specimens or interpret the result accurately without suitable and sufficient clinical information. The quality and integrity of the sample is the responsibility of the person collecting the sample. The sample may deteriorate if there is any delay in delivery to the laboratory or if the sample has not been stored correctly before delivery. The laboratory will endeavour to provide the best possible service but the quality of the results ultimately depends on the quality of the sample submitted for testing. To ensure valid results are obtained: 1. Avoid prolonged venous stasis when collecting blood - consult tube guide for order of drawing samples 2. Avoid contamination of sample with iv fluids 3. Do not mix blood from one specimen container with another 4. Ensure that urine collections are timed correctly and kept cool 5. Avoid sending samples outside the routine working hours unless they are urgent ones and the laboratory staff are expecting them 6. If more than one patient/sample have similar names please use the ‘special note, patients with similar names’ yellow stickers available 7. Send samples to the laboratory or specimen collection points without delay For blood gas analysis samples must be sent in syringes correctly sealed with special caps (never send syringes with needles still attached). Syringe samples must be labelled as above with the request form and transported the laboratory as soon as possible. Do not use the pneumatic tube for blood gas samples. Samples arriving in this manner will be rejected because results are seriously altered by the pressures in the pneumatic tube. Do not contaminate request forms with the sample. For minimum acceptance criteria for making pathology requests see Appendix 2 - Pathology Sample Collection policy. Specimen identification blood collection tubes Sarstedt Tube type

Colour

Serum Gel 4.9ml Serum 4.9ml Li Heparin Gel 4.9ml Li Heparin 4.9ml Glucose 2.7ml ESR 3.5ml

Brown Top Brown Top Orange Top Orange Top Yellow Top Purple Top

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EDTA K 2.6 ml EDTA K 2.7ml Citrate Coag 3.0ml EDTA (BT) 4.5ml EDTA (BT) 4.9ml Yellow urine monovettes

Red Top Red Top Green Top Blue Top Blue Top Yellow Top

Category II Category II work: Certain investigations will fall into this category, request forms must be clearly marked "CAT II". Usually the requesting doctor is invoiced. If the doctor requests that the patient be invoiced, this can be done if the patient's address is given; occasionally an invoice may be sent to an organisation. Private Work Private Patients: Specimens submitted from private patients are investigated by the same protocols as NHS patients. The private patient box on the request form must be ticked. The invoice address must be supplied on the request. Private Patients attending phlebotomy with their requests form will be asked to sign an ‘Agreement to pay’ form before being bled.

5. Transportation of specimens to the pathology department All acute work from the Trust is processed within ENHT pathology department with the exception of Immunology and Microbiology which is transported to CUHFT. Specimens should be sent to the laboratory by either the pneumatic tube system or by arranging collection by a hospital porter. High-risk samples, blood gas samples, blood culture samples and Histology samples must not be sent through the pneumatic tube system. Specimens from other hospital sites, Queen Elizabeth II (QEII) and Hertford County Hospitals (HCH) are transported to pathology departments by citysprint logistic services. Specimens for tests which are referred to a diferent site are transported in different ways; CitySprint  Post  NBSBT

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General practitioner practices A single request is placed into a marsupial bag and the GP practices separate the specimens into either a large clear bag or a Green bag as outline in the table below. These specimens are then collected by Citysprint logistic services and delivered to the correct location. Clear bags contain all specimens which are tested at CUH and the Green bags goes to ENH for testing. Test Requests

Bag Type to place Individual sample requests in

Location of where samples are processed

Haematology/Biochemistry/Microbiology/ Immunology

Clear Bag

CUH

Urgent Haematology/Biochemistry/Microbiology/ Immunology samples in Red Bags

Clear Bag

CUH

Cervical Screening

Clear Bag

CUH

D-Dimer samples in Red Bag

Green Bag

ENH

ALL Antenatal Tests including grouping

Green Bag

ENH

Blood Transfusion Requests

Green Bag

ENH

Thyroglobulin, Trace metals

Green Bag

ENH

Histopathology, non gynae cytology outpatients, (All Consultant requests)

Green Bag

ENH

INR

Green Bag

ENH

Transport Times from Lister to CUHFT Citysprint Collect from Lister 07:45 10:30 12:30 13:00 14:00 14:50 16:05 18:00 19:30

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Arrive at CUHFT 08:30 11:15 13:15 13:45 14:45 15:35 16:50 18:45 20:15

6. High risk specimens Separate procedures are used in the laboratory for the safe handling and examination of samples from patients known or suspected to have infections caused by high risk (hazard group 3&4 pathogens - see below) that pose a risk to laboratory workers and others if handled incorrectly. It is the responsibility of the person making pathology requests, under the Health & Safety at Work etc Act 1974, to ensure that the laboratory is appropriately informed of the potential dangers of handling any high risk samples. Requests made via ICE should be flagged by ticking the high risk box within order entry screen on ICE. Paper/ICE requests must give sufficient clinical information to enable experienced laboratory staff to know what special precautions are necessary. In the interests of confidentiality ‘High Risk’ labels should be placed only on the sample. Specimens collected from a patient with a known or suspected infection due to Hazard group 3 or 4 category pathogens, must be labelled as HIGH RISK and placed in a sealed plastic bag before sending to any of the pathology laboratories. Hazard group 3 & 4 pathogens include the following: Alpha viruses Blastomyces Brucella sp. Claophialophora Coccidioides Duvenhage E.coli O-157 Flaviviruses Hanta viruses Histoplasma HIV 1 and 2 Hepatitis B virus Hepatitis C virus Hepatitis D virus Hepatitis E virus Hepatitis G virus Herpesvirus simiae HTLV 1 and 2 Leishmania Monkeypox Mycobacterium sp Naegleria Nipah Paracoccidioides Penicillium marneffei Phleboviruses Piry Plasmodium falciparum Rickettsia sp Salmonella paratyphi Salmonella typhi Simian Immunodeficiency virus (SIV)

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Hazard Group 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3

Trypanosoma Variola (minor & major)

3 4

and the causative agents of: Anthrax Bovine spongiform Encephalitis (BSE) Brucellosis Creutzfeldt-Jakob disease (CJD) Dengue Diphtheria Dog tapeworm Dysentry Fatal familial insomnia Glanders Hendra Kuru Mellioidosis Paratyphoid Plague Pork tape worm Q-fever Rabies SARS Smallpox Tick borne encephalitis Transmissible spongiform encephalopathies (TSE) Tularaemia Typhoid Variant Creutzfeldt-Jakob disease (vCJD) Viral Haemorrhagic Fever (Lassa Fever, Ebola Fever and Marburg Disease) Yellow Fever

3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 4 4 3/4 3 3 3 3 4 3

In cases indicated in red do NOT send specimens until the case has been discussed with a Consultant Microbiologist. For a full list see www.dh.gov.uk – ACDP Approved list of biological agents 10/02/2004 (4th update)

7. Urgent requests and reporting of results Urgent requests During core and out of hours all urgent requests must be arranged with the laboratory. Request will not be treated as urgent unless the requesting doctor has informed the laboratory, providing patient details, reason for urgency. The samples must be sent to the laboratory immediately with a clearly completed request form marked as urgent and must contain both name and bleep number of the requesting clinician. Results will be available on the ICE System as soon as they are ready or will be telephoned to the requesting clinical team in the case of locations where Ward reporting is not available. Critical results will always be telephoned to the requesting clinician.

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Patients requiring phlebotomy for tests with ‘special’ requirements, see individual discipline section. Electronic reporting of results Access to completed pathology results is available throughout the Trust sites (e.g. wards and departments), CCG sites (e.g. health centres) Hertfordshire Partnership units and a number of GP surgeries via ICE OCS (order communications system). Critical results reporting Critical results as outlined by the critical reporting protocol will always be telephoned to the requesting clinician, ward or clinica team. In line with the Trust’s policy ‘Acting on Diagnostic Investigations’ it is the requesting clinician responsibility to review all pathology results from tests requested and to act on these results appropriately. the receiving clinician (who must be a qualified member of nursing, midwifery or medical staff; or a Clinical Support Worker who has undertaken specific training) documents the results within the patients notes at the earliest opportunity; bringing it to the attention of a senior member of staff where necessary.

Laboratory supplies Blood collection tubes supplies can be collected from the laboratory. Point of care testing The laboratory is responsible for providing advice and support for Point-of-Care testing (POCT) (e.g. urine testing, blood gas, blood glucose etc.). The current East and North Hertfordshire NHS Trust Policy on POCT must be followed. Ward-based tests may only be performed by authorised users after adequate training. Users who perform tests as part of their clinical practice are advised to contact the laboratory with any queries about maintenance, quality control, operation problems or health and safety aspects. The laboratory point of care co-ordinators lead on all training, audits and support issues. Before purchase of any extra-Laboratory instruments, the Trust POCT Committee must be consulted about suitability. Installation may only take place after approval by the POCT committee and relevant Pathology Consultant. Please note that there are MHRA Hazard Notices regarding the use of Ward-based instruments, of which users must be aware. Other services and complaints Pathology is able to provide a range of services and information to wards, departments and GP practices. If you wish to discuss any service developments or require information relating to or derived from the pathology service then please direct your enquiry as follows: To discuss service developments – please speak to the pathology satellite manager, Nazia Hussain: See contact details in section 2. To make a complaint email: [email protected] To log an incidents email: [email protected]

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8. Pathology information for general practitioners The Pathology Partnership provides the pathology services for the general practitioners (GPs) within the ENH area. All the GP requests are tested at the Cambridge Hub, located at CUH. GP requests are collected by CitySprint logistics services at regular intervals and are transported to the Hub for processing. For enquires please contact the Pathology Partnership helpdesk – (08:00-20:00 Monday-Friday), E: [email protected], T: 0333 103 2220 Urgent requests:- Place the request into a small Red marsupial bag and then place the bag into its corresponding bag according to where the sample will be tested (Sample Sorting - see Page 8) For requests going to CUH, please call the helpdesk and inform them that you are sending an urgent request, providng patient details, the test requested and your contact details. For requests going to the Lister Hospital, please contact pathology department at Lister inform them that you are sending an urgent request, providng patient details, the test requested and your contact details. (Lister Pathology - 01438 284690) For detailed pathology information please select the corresponding link below: Haematology - Click on link :- http://10.154.5.9/index.cfm?articleid=4957 Biochemistry- Click on link - http://thepathologypartnership.info/docs/our_services/2015-08-

26&Cambridge_Clinical_Biochemistry_Laboratory_Handbook_2015_v3.6.pdf Immunology - Click on link:- - http://thepathologypartnership.info/docs/our_services/2015-08-

26&Cambridge_Clinical_Immunology_Laboratory_Handbook_2015_v1.pdf Microbiology – Click on Link http://thepathologypartnership.info/docs/our_services/2015-08-

20&Cambridge_PHE_Clinical_Microbiology_Service_User_Handbook.pdf Critical result Communications for GP requests:- these results are reported within 2 hours as per our contractual agreement. For further details please select the elevant link above.

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9. Clinical biochemistry Clinical Biochemistry is part of Blood Sciences department at ENHT, this information is related to all acute work performed with ENHT Opening hours Monday to Friday: 09:00-17:00 At all other times contact the Biomedical Scientist on call for urgent work only. Bleep 4690 General queries: 01438 284690

Key contacts Consultant chemical pathologist and head of department for blood sciences Dr Adie Viljoen E: [email protected] T: 01438 285972 (Ext 5972) Consultant biochemist and point of care committee chair Mrs Angela Woods E: [email protected] T: 01438 286145 (Ext 6145) Pathology satellite manager Nazia Hussain E: [email protected] T: 01438 284089 (Ext 4089) Blood sciences manager Karen Hutchinson E: [email protected] T: 01438 285225 (Ext 5225) Point of Care Testing co-ordinators Jay Vaid E: [email protected] T: 01438 288018 (Ext 8018) and Sarah Church E: [email protected] T: 01438 284439 (Ext 4439) POCT admin/BT admin Zuzana Bales E: [email protected] T: 01438 288009 (Ext 8009) Results Pathology results are available on Sunquest ICE system, if results are not available please contact the laboratory on Ext 5461

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Tests and specimens Results are reported with reference ranges and/or an interpretative comment. Advice on appropriate requesting and interpretation of results is available at all times from the consultant staff by telephone, mobile telephone. Out of core hours the consultant on-call should be accessed through switchboard. Add on requests will only be accepted for tests performed within ENHT pathology, these must be made within 24hours and must be accompanied by a request form. Dynamic function tests – please discuss with the consultant chemical pathologist or the consultant biochemist.

Critical results - these apply to acute work only, for GP requests refer to biochemistry handbook page 12. Results outside the limits below will be telephoned urgently to the requesting clinician. Test name Units Critical low Critical high Albumin g/L 15 Amylase U/L 500 Ammonia μmol/L 100 Bilirubin (newborn) µmol/L 250 Calcium – adjusted mmol/L 1.8 3.50 Carbamazepine mg/L 15.00 Creatine Kinase U/L 5000 Creatinine µmol/L 500 Digoxin µg/L 2.4 Gentamicin,predose (adults) mg/L >1 Gentamicin,predose mg/L >2 (neonates) Gentamicin post dose mg/L >10 Fasting Glucose (unless mmol/L 3.0 15.0 known DM) Glucose mmol/L 3.0 20.0 Iron µmol/L 55 Lithium mmol/L 1.0 Magnesium mmol/L 0.40 2.00 Paracetamol mg/L 100 Phenytoin mg/L 25 Phosphate – inorganic mmol/L 0.40 3.00 Potassium mmol/l 2.5 6.5 Salicylate mg/L 350 Sodium mmol/L 120 160 Theophylline mg/L 25.0 Triglycerides mmol/L 20.0 Urate umol/L 1000 Urea mmol/L 30.0

In addition

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Troponin T >14 ng/L in outpatient or GP patient Biochemistry blood tests – if the assay required is NOT listed then please contact the department directly. All results are reported with reference ranges and/or an interpretative comment. Advice on appropriate requesting and interpretation of results is available at all times from the Chemical Pathologists and Clinical Biochemists. Sample volumes: Most routine tests can be performed on 5ml clotted (BROWN) serum sample, unless otherwise stated below (For paediatric samples a minimum of 1ml of blood is required). Indicative turnround times are given for non-urgent situations. It may be possible to expedite results by discussing the clinical situation with the laboratory consultant staff. If a required test is not listed here, please discuss with the laboratory consultant staff. *For full referral address refer to Appendix 1 (Blood sciences) Test

Sample

Acylcarnitines

4 dried blood spots (Guthrie card)

ACTH Adrenocorticotr ophin

EDTA (Red)

Adrenaline [part of Plasma catecholamines] Albumin

Lithium Heparin [Orange]

Alcohol (ethanol) Aldosterone ALP (alkaline phosphatase) ALP isoenzymes

ALP Bone Specific [bone ALP]

Adult Reference range Interpretation with report

*If referred site code

Turnaround time

GOS