Hematology & Urinalysis Policies & Procedures
Contents
1. Coagulation 1 Two levels of Dade ci Trol Coagulation controls are run each 8 hour shift in use 2 Participation in a JCAHOICLIA CAP approved proficiency program Sedimentation Rates 1 Two levels of Polymedco Sed Chek Controls are run each day in use 2 Participation in Polymedco Quality Assurance Program 3 Participation in a JCAHO CLIA CAP approved proficiency program Reviewed 11 14 1 Revised 11 14 Cochise Regional Hospital Hematology and Urinalysis Policies and Procedures Urinalysis im Two levels of Kova Trol are run each day of use 2 Participation in a JCAHO CLIA CAP approved proficiency program Serology 1 Each kit has manufacturer supplied controls that are run as per manufacturer s recommendations 2 Participation in a JCAHO CLIAJCAP approved proficiency program Blood Bank 1 Ortho Confidence system is performed each day of use 2 Participation in a JCAHO CLIAJCAP approved proficiency program Microbiology l Gram Stains are done on slides with known organisms Rapid Strep kits are Qc d with each lot number change or on the first of each month Internal control results are documented on each test performed 3 Participation in a JCAHO CLIA CAP approved proficiency program Reviewed 11 14 Revised 11 14 Quality Control Troubleshooting Protocol for QC Out of Control Quality Control programs exist in all laboratory areas When Quality Control values fall outside the established limits the fol2. Protein This test is based on the protein error of indicators principle At a constant pH the development of any green color is due to the presence of protein Colors range from yellow for Negative through yellow green and green to green blue for Positive reactions Urobilinogen This test is based on a modified Ehrlich reaction in which p diethylaminobenzaldehyde in conjunction with a color enhancer reacts with urobilinogen in a strongly acid medium to produce a pink red color Nitrite This test depends upon the conversion of nitrate derived from the diet to nitrite by the action of Gram negative bacteria in the urine At the acid pH of the reagent area nitrite in the urine reacts with p arsanilic acid to form a diazonium compound This diazonium compound in turns couples with 1 2 3 4 tetra hydrobenz h quinolin 3 ol to produce a pink color 10 Leukocytes Granulocytic leukocytes contain esterases that catalyze the hydrolysis of the derivatized pyrrole amino acid ester to liberate 3 hydroxy 5 phenyl pyrrole This pyrole then reacts with a diazonium salt to produce a purple product Reviewed 11 14 27 Revised 11 14 Materials 1 MultiStix 10 SG as supplied in the laboratory Product is stable until the expiration date printed on the container label when stored at room temperature between 15 30 C Do not store the container in direct sunlight All unused strips must remain in the original container after open
3. Controls are tested once each day of use and patient results are not reported until quality control results are within published acceptable limits References Polymedco Sediplast user manual Cortland Manor New York Reviewed 11 14 14 Revised 11 14 cP Cell Count Principle Normal CSF is crystal clear with viscosity comparable to water There are many conditions which cause the CSF to change in turbidity and viscosity Cell counts are performed to provide the physician with the necessary information to diagnose these conditions Reagents and Equipment Hemocytometer Pasteur pipette saline Procedure 1 tube Chemistry 2 tube Hematology 3 tube Microbiology 4h tube Serology Cytology Mix the CSF in tube 3 well Fill both sides of the hemocytometer with undiluted CSF Allow the hemocytometer to settle for 10 minutes Count all red and white blood cells in the 9 large squares on each side of the chambers S Procedural Notes and Limitations If there are too many cells present to count dilute the CSF 1 1 with saline before filling chamber Additional serial dilutions may be needed If greater than 5 WBC cu mm are seen a differential must be done Calculations Number of cells counted x dilution cells cu mm 9 OR Number of cells counted x dilution x depth 10 cells cu mm Number of squares counted 9 Reviewed 11 14 15 Revised 11 14 cP Expected Values Adults 0
4. If the serum specimen is cloudy or highly viscous dilute it with equal parts of saline before testing Hemolyzed specimens may require a new sample for accurate results Lipemic specimens may be centrifuged for a short period of time Specimen Storage Specimens urine or serum may be stored at 2 8 C for up toP241 ours prior to testing If specimens are refrigerated they must be equilibrated to room temperature before testing Serum specimens can be frozen at 20 C for 3 months before testing Frozen samples must be thawed and mixed before testing Quality Control Internal Controls The appearance of a Control Line in the C region of the device is a positive procedural control Correct procedural technique specimen flow and device performance is confirmed when a colored line appears in the C control area of the membrane If the colored line fails to appear in the C control area the test result is invalid A clear background is an internal negative procedural control The Reviewed 11 14 38 Revised 11 14 cP background color should be white to light pink and should not interfere with the reading of the membrane If a more intensely red background color appears it may interfere with the ability to read the test result therefore the test should be repeated External Controls Urine Serum positive and negative quality control material is supplied in the laboratory External quality controls are tested with each new lot or s
5. 14 cP Examine slide under low power Observe distribution of white cells and choose the area near the thin end where red cells touch but do not overlap Performance of Differential 2 Shift to oil immersion objective and classify each WBC until 100 cells have been counted Note presence of nucleated RBC s and correct WBC count if necessary Corrected WBC count WBC x 100 100 of Nrbc s 3 Note RBC morphology estimate of platelet count adequate decreased increased etc When the platelet count is normal 8 20 platelets are noted per high power field Procedural Notes and Limitations A good differential depends on a good slide and proper staining technique Slides should not be counted if e there are ridges lines or holes e poor margination e bluish cast after staining All abnormalities should be brought to the attention of a supervisor or should be repeated for Pathologist review Result Reporting In order to result a manual differential the technologist must contact the primary or attending physician of the need for the review Upon receipt of the order the results may be entered into the 114MS WsreaP using the test code While reflexing the blood smear will still be policy reporting the results will not occur until the order has been received Manual differentials should not be made on blood tubes older than 24 hours old References 1 Clinical Diagnosis and Management by Laboratory Methods 16 edition
6. Procedure Choose 5 7 patient samples covering the ranges of low normal and high Run samples on HMX ACL 8000 and DXC600 Run samples on ACT 5 ACL 1000 and CX3 Compare results for any deviations Document any troubleshooting action Notify Lab Manager of any problems Results should be given to Lab Manager for evaluation LV for each analyte should be 90 acceptance ON tS Reviewed 11 14 Revised 11 14 cP Criteria for Manual Blood Smear Review A manual differential should be performed if any of the following conditions exist and remits entered into the system using the appropriate test code results are also recorded in the instrument result form Leukocyte count is Less than 2 500 cmm Greater than 15 000 cmm Granulocyte is greater than 85 Monocyte is greater than 12 Eosinophil is greater than 15 Reverse Differential lymph s gt grans except pediatric patients Flags on any cell line Review Ruby Cell Dyn flag messages and perform a manual slide for morphology if any of the Following conditions exist and remits entered into the system using the appropriate code Abnormal RBC distribution RDW greater than 16 MCH less than 27 MCV greater than 100 MCV less than 75 Platelet Count lt 50 000 or gt 600 000 Abnormal platelet distribution Flag for nucleated RBC Reviewed 11 14 9 Revised 11 14 cP Manual Blood Smear Policy It is the policy of Cochise Regional Hospital Laboratory to r
7. buffered or alkaline urines Contamination or the urine specimen with quaternary ammonium compounds e g from some antiseptics and detergents or with skin cleansers containing chlorhexidine may also produce false positive results The reagent area is more sensitive to albumin than to globulins hemoglobin Bence Jones proteins and mucoprotein a negative result does not rule out these other proteins 10 Urobilinogen The reagent area may react with interfering substances known to react with Ehrlich s reagent such as p amino salicylic acid and sulfonamides Atypical color reactions may be obtained in the presence of high concentrations of p amino benzoic acid Strip reactivity increases with temperature the optimum temperature is 22 26 C The test is not a reliable method for the detection of porphobilinogen The absence of urobilinogen cannot be determined with this test 11 Nitrite Pink spots or pink edges should not be interpreted as a positive result Any degree of uniform pink color development should be interpreted as a positive result suggesting the presence of 100 000 or more organisms per mL but color development is not proportional to the number of organisms present A negative result does not in itself prove that there is no significant bacteriuria Negative results may occur when urinary tract infections are caused by organisms that do not contain reductase to convert nitrate to nitrite when urine has not been retained in the bla
8. controls and reagents 2 Repeat test with new control 3 If still not expected results repeat with new dipstick or reagent 4 Record corrective action on worksheet Reviewed 11 14 19 Revised 11 14 Clintek Status Principle Clinitek status Urine chemistry analyzer is a portable instrument for reading traditional Bayer Reagent Strips for Urinalysis Refer to the bottle label or carton for the tests that are included with each product The analyzer can also report the color of the urine sample No special training is needed to use the instrument Materials 1 Multistix Pro 2 Paper Towel for blotting Specimen Random Urine Quality control Positive and Negative control solutions should be tested on a regular basis This provides a check to ensure that the test strips are reacting properly and the instrument is reading strips properly Testing controls also helps detect errors caused by incorrect user technique Prepare the control solutions as instructed in the package insert that comes with control product Then test the control solution using the same procedure as you use when testing patient urines Record the controls results If any results are not within the expected range notify the lab supervisor or physician Refer to the bottle label and or package insert for storage information and expiration date You should test controls 1 At the start of the day 2 When you open a new bottle of test strips 3 Whe
9. reaction One enzyme glucose oxidase catalyzes the formation of gluconic acid and hydrogen peroxide from the oxidation of glucose A second enzyme peroxidase catalyzes the reaction of hydrogen peroxide with a potassium iodide chromogen to oxidize the chromogen to colors ranging from green to brown Bilirubin This test is based on the coupling of bilirubin with diazotized dichloroaniline in a strongly acid medium The color ranges through various shades of tan Ketone This test is based on the development of colors ranging from buff pink for a negative reading to purple when acetoacetic acid reacts with nitroprusside Specific Gravity This test is based on the apparent pKa change of certain pretreated polyelectrolytes in relation to ionic concentration In the presence of an indicator colors range from deep blue green in urine of low ionic concentration through green and yellow green in urines of increasing ionic concentration Blood this test is based on the peroxidase like activity of hemoglobin which catalyzes the reaction of diisopropylbenzene dihydroperoxide and 3 3 5 5 tetramethylbenzidine The resulting color ranges from orange through green very high levels of blood may cause color development to continue to blue pH The test is based on the double indicator principle that gives a broad range of colors covering the entire urinary pH range Colors range from orange through yellow and green to blue
10. 0 1 Calibrations are to be run 2 Calibrations are to be run 3 Calibrations are to be run Architect C400 1 Calibrations are to be run 2 Calibrations are to be run 3 Calibrations are to be run Architect i1000 1 Calibrations are to be run 2 Calibrations are to be run 3 Calibrations are to be run Reviewed 11 14 Revised 11 14 every 6 months when any instrumentation has been replaced when drifts and trends in quality control correlations appear every 6 months with each new lot number of control for DDIMER when drifts and trends in quality control correlations appear according to manufacturer s instructions for each new lot number of reagent when drifts or trends appear in quality control correlations According to manufacturer s instructions for each new lot number of reagent when drifts or trends appear in quality control cP Calibration Verification Principle Calibration verifications are performed in order to validate calibrations and quality control Policy It is the policy of Cochise Regional Hospital Laboratory to run calibration verification testing every six months Materials Chemistry Immunology Maine Standards Validate Kits Glucometers RNA Medical Glucose Calibration Verification Control Hematology Streak CVA for cell Dyn Procedure Run linearity kits for each analyte according to manufacturer s instructions Fill out appropriate paperwork per kit Include i
11. 1 14 36 Acetest Test for Ketone or Acetone Urine or Serum Principle This test is based on the nitroprusside reaction with Ketone bodies to give a purple color The presence of Ketone bodies is important in the evaluation of carbohydrate metabolism Reagents and Equipment White paper Acetest tablet Quality Control Normal and Abnormal KOVA trol should be performed when confirmatory testing is needed Procedure 1 Remove tablet from bottle and recap promptly Place tablet on clean dry white paper 2 Put one drop of urine or serum directly on top of tablet 3 For urine testing compare color tablet to charts 30 seconds after application of specimen 4 For serum testing compare color of tablet to color chart two minutes after application of serum Expected Values Ketones are not found in blood or urine in normal patients or normal carbohydrate metabolism Result Reporting Log on urinalysis log Serum Acetone should be reported as positive or negative in the computer system References Acetest Package insert August 2010 Reviewed 11 14 37 Revised 11 14 Ep Sure Vue Serum Urine Pregnancy Test Principle The Sure Vue Serum Urine Pregnancy Test utilizes a combination of monoclonal and polyclonal antibody reagents to selectively detect elevated levels of hCG in serum or urine The assay is conducted by the addition of a serum or urine specimen into the test device sample well and observing for
12. 5 cells cu mm Neonates 0 20 cells cu mm Result Reporting In the HMS system the technologist will enter the results for both white and red blood cells using the test code CSFCELLS References Clinical Diagnosis and Management by Laboratory Methods 17 Edition p 463 464Spinal Fluid Procedure http www pathguy com lectures csf htm Reviewed 11 14 Revised 11 14 16 cP Operation of the SYSMEX CA 500 Coagulation Analyzer The Sysmex CA 500 is an automated Blood Coagulation analyzer fully automated capable of 5 parameter random analysis for in vitro analysis This instrument has the capability to analyze 10 regular samples and also one Stat giving us the opportunity of running everything at the same time Moreover it allows analyzed data to be display and printed out together with reaction curves thus making it possible to obtain highly reliable results MAINTENENCE Daily Daily maintenance must be started at the beginning of every day before quality control and patient analysis It must be done on the following order 1 Turn off and on the Sysmex CA 500 2 Empty tube trash box located at the right side Also empty the waste container 3 Replenish water container with Deionized water 4 Check all supplies and refill everything with fresh reagents CA CLEAN must be changed every 24 hrs Buffer every 8 hour shift 5 Perform probe rinse If visible residue wipe probe with 70 alcohol 6 Wipe condensation f
13. Fan of slender prisms G urate Yellow 80 C Cystine 1 Colorless Flat hexagonal plates with rare 2 Highly re well defined edges tractile Singly or in clusters Cholesterol 1 Colorless Broken window panes with Ether rare notched corners Chloro Flat plates form Leucine 1 Yellow or Spheroids with striations Slightly rare Brown Pure form hexagonal 7i nhot 2 Highly re f H20 tractile Tyrosine Colorless or Fine silky needles in sheaves m rare Yellow or rosettes Bilirubin Reddish Cubes Acetone Brown Rhombic plates 80 C Chloro Amorphous needles form ACID NEUTRAL OR SLIGHTLY ALKALINE URINE Calcium Colorless Octahedral r Dilute oxalate Dumbells Often small use h p HCI Hi ippuric Colorless Hot l1 0 acid ALKALINE NEUTRAL OR SLIGHTLY ACID URINE Triple Colorless Coffin lids Dilute phosphate 3 6 sided prism Acetic Occ fern leaf Acid ALKALINE URINE Calcium Colorless Needles carbonate Rhombic plates Spheres Four sided prisms Acetic Dumbells Acid Ammonium Yellow Thorn apple spheres 60 C Writes Opaque Dumbells with Brown Sheaves of needles Acetic Acid Calcium Colorless Prisms Dilute phosphate Plates Acetic Needles Acid Reviewed 11 14 Revised 11 14 24 cP Bacteria Normal urine contains no bacteria If proper and careful technique was used to obtain the sample and if the specimen was protected from contaminants before examination the presence of bacteria in signi
14. Todd Sanford and Davidson 2 Wright Giemsa Stain label Reviewed 11 14 11 Revised 11 14 cP Criteria for Referral of Blood Smear to Pathologist 1 Evidence of hemoglobinopathy 2 Sickle cells or hemoglobin C crystals 3 Evidence of metabolic disease systemic disease or deficiency state a Teardrops b Howell Jolly bodies unless patient has had splenectomy c Cabot rings d Greater than moderate burr cells 4 Differential count abnormalities a Atypical lymphocytes gt 20 b Metamyelocytes and myelocytes gt 10 c Lymphocytes gt 60 if gt 10 years gt 80 if lt 10 years d Monocytes gt 20 e Eosinophil gt 15 f Basophil gt 8 g Promyelocyte and blasts any 5 Plasma cells in peripheral blood 6 Any unidentified cells 7 Any physician request for pathologist evaluation Send 2 3 unstained slides with a copy of the CBC report to the pathologist Reviewed 11 14 12 Revised 11 14 cP Autozero Westergren Erythrocyte Sedimentation Rate ESR by Sediplast Principle A pipette tube is filled with 1 0 mL of anticoagulated EDTA blood and allowed to stand for a period of one hour After one hour a reading is taken at the plasma meniscus This reading represents the distance in mm from the zero mark on the tube and is equal to the Erythrocyte Sedimentation Rate Materials 1 2 3 Fixed bore pipettes with self zeroing cap Vials Timer Test Procedure 1 Assemble and check for inte
15. ate up to expose the measuring prism Clean the prism and bottom surface of cover plate if necessary B Place a drop or two of sample on the prism Close cover plate immediately NOTE Do not use glass or metal applicators as they may scratch prism surface Or Close cover plate and place drop on exposed portion of prism Drop will be drawn into space between cover plate and prism Avoid lifting C Hold instrument by placing your finger on the cover plate and press gently but firmly This will spread the specimen in a thin layer over prism D Point instrument towards a light source Tilt until the contrast between light and dark is obtained Reviewed 11 14 42 Revised 11 14 cP E The reading should be taken at the point where the dividing line between light and dark fields crosses the scale See diagram below Values can be taken directly from the scale Expected Values Urine specific gravity ranges are 1 005 to 1 030 Normal Values Normal values for urine specific gravity ranges are 1 010 to 1 025 Quality Control Quality control will be run daily Maintenance A Clean with soft cloth or tissue paper moistened with distilled water B Wipe the prism and bottom surface of cover plate C Dry with a soft cloth or tissue paper Erroneous results may occur if surfaces are not cleaned properly NOTE Do not immerse eyepiece in water Never use gritty cleaning compounds or very hot water Do not expose instrume
16. ately before testing 2 Remove one strip from the container and replace cap 3 Completely immerse the reagent areas of the strip in the urine sample and remove immediately to avoid dissolving out reagents Note An alternate method of applying the sample is to use a clean disposable pippet to dispense the urine specimen onto the reagent pads one drop to a pad 4 While removing the strip from the specimen run the edge of the entire length of the strip against the rim of the urine container to remove excess urine 5 Hold the strip in a horizontal position to prevent possible mixing of chemicals from adjacent reagent areas and or contaminating the hands with urine and touch one side to a clean paper towel to remove excess urine Note If the sample has been applied with a pippet turn the strip on one side against a clean paper towel to remove excess urine 6 Compare the reagent areas to the corresponding Color Chart on the container at the times specified Hold the strip close to the color blocks and match carefully Avoid laying the strip directly on the Color Chart as this will result in the urine soiling the chart Proper read time is critical for optimal results Read the glucose and bilirubin tests at 30 seconds after dipping Read the ketone test at 40 seconds the specific gravity test at 45 seconds pH protein urobilinogen blood and nitrite at 60 seconds and leukocytes at 2 minutes The pH and protein areas may also be read imm
17. cells are conventionally reported in terms of cells per high power field casts are counted per low power field For each determination the number of elements seen in at least 10 fields should be counted and the average number used for the reported value Other elements ih as bacteria parasites crystals and spermatozoa are usually reported as well Urine is reflex to culture if microscopic examination reflects WBC is grater than 5 cells HPF Bacteria gt 2 Epithelial Cells gt 2 Yeast gt 1 Positive nitrites in dipstick In this laboratory results are reported as one of the following for each category Appearance Color Formed Elements CLEAR STRAW TRACE SLT HAZY LT YELLOW 1 HAZY YELLOW 2 TURBID DK YELLOW 3 CLOUDY ORANGE 4 RED RARE BROWN FEW 2 4 5 10 10 20 20 50 gt 50 NEGATIVE POSITIVE Reviewed 11 14 22 Revised 11 14 EXPECTED RESULTS e Red Blood Cells The finding of more than one or two red blood cells per high power field is an abnormal condition It can indicate a variety of renal and systemic diseases including trauma to the kidney It may also be found following violent exercise It may follow traumatic catheterization the passage of stones or contamination from menstrual blood Hematuria occurs with pyelonephritis tuberculosis of the genitourinary tract cystitis prostatitis renal calculi renal tumors and other malignancies of the urinary tract and hemorrhagic diseases such hem
18. cimen collection device as supplied in the laboratory 2 Urine centrifuge tubes as supplied in the laboratory 3 Bayer 10 SG Urine Dipsticks as supplied in the laboratory 4 Microscope as supplied in the laboratory 5 Slides and cover slips as supplied in the laboratory 6 Centrifuge as supplied in the laboratory Specimen The specimen of choice for this procedure is a fresh mid stream or clean catch specimen early morning samples are recommended collected into a clean dry container Samples may be stored for 1 hour before testing at room temperature then must be refrigerated at 2 8 C for up to 24 hours Quality Control Quality control testing for this procedure is outlined in the UA dipstick procedure for biochemical dipstick testing found elsewhere in this manual Proficiency testing supplied to prove competency for identification of formed elements found in a urine specimen are supplied on a quarterly basis Remedial Action In the event that a member of the laboratory staff cannot prove his competency with proficiency testing that staff member will take part in an educational in service meant to increase his her skills in identifying the formed elements of the urine specimen Procedure 1 Obtain a properly labeled urine specimen 2 Pour off 12 ml of urine into a separate centrifuge tube 3 Perform a dipstick examination as described in the UA Dipstick procedure found elsewhere in this manual 4 If blood leuk
19. cp Cochise Regional Hospital Hematology and Urinalysis Policies and Procedures Quality Control POLICY It is the policy of Southeast Arizona Medical Center Laboratory to follow all current federal state and manufacturer s requirements for quality control for all lab testing PROCEDURE Below is a quality control program for each clinical lab area Quality Control data in each area is printed and reviewed at least monthly by the supervisor Chemistry Architect c400 l Two levels of chemistry control are run each day of use Standards or calibrations are run as outlined by each procedure Assays are calibrated as needed by the manufacturer s recommendations each new lot number change or as needed per the QC Troubleshooting procedure 2 Participation in a JCAHO CLIA CAP approved proficiency program Immunochemistry Architect i1000 l Two levels of chemistry control are run each day of use 2 Calibrations are run as outlined by each procedure Assays are calibrated as needed by the manufacturer s recommendations each new lot number change or as needed per the QC Troubleshooting procedure 3 Participation in a JCAHO CLIA CAP approved proficiency program Hematology Ruby Cell Dyn l Two levels of Ruby Cell Dyn are run each 8 hour shift in use 2 If a manual differential is performed it is evaluated by the technologist for agreement with the Ruby results 3 Participation in a JCAHO CLIA CAP approved proficiency program
20. dder long enough four hours or more for reduction of nitrate to nitrite to occur or when dietary nitrate is absent even if organisms containing reductase are present and bladder incubation is ample Sensitivity of the nitrite test is reduced for urines with high specific gravity Ascorbic acid concentrations of 25 mg dL or greater may cause false negative results with specimens containing small amounts of nitrite ion 0 06 mg dL or less Reviewed 11 14 30 Revised 11 14 cP 12 Leukocytes Elevated glucose concentrations gt 3 g dL or high specific gravity may cause decreased test results The presence of cephalexin Keflex cephalothin Keflin or high concentrations of oxalic acid may also cause decreased test results Tetracycline may cause decreased reactivity and high levels of the drug may cause false negative reaction Expected Values Expected values for the typical normal healthy population and the abnormal population are listed below for each reagent 1 w oa NO o Glucose Small amounts of glucose are normally excreted by the kidney These amounts are usually below the sensitivity of this test Results at the first positive level may be significantly abnormal if found consistently Bilirubin Normally no bilirubin is detectable in urine by even the most sensitive of methods Even trace amounts of bilirubin are sufficiently abnormal to require further investigation Atypical colors colors unli
21. e however Trace results observed repeatedly may be clinically significant Positive and repeated Trace results indicate the need for further testing of the patient and or urine specimen according to medically accepted procedures for pyuria Positive results may occasionally be found with random specimens from females due to contamination of the specimen by vaginal discharge Reporting of Patient Results Dipstick urine results are reported by means of the LIS Reporting is performed by the input of the levels obtained from the reagent strip Inoperable Test Conditions In the event that Reagent Strips are unavailable for testing the sample will be spun down and a microscopic examination will be made Clinitest tablets IctoTest AceTest and a Refractometer are available for use as backup biochemical testing Clinical Significance The benefit of reagent strip testing as aid to provide information regarding the status of carbohydrate metabolism kidney and liver function acid base balance and urinary tract infection is well documented References Bayer Multisix 10 SG package insert 4 99 Bayer Corporation Elkhardt IN Reviewed 11 14 32 Revised 11 14 cP Sulfosalicylic Acid Confirmatory Test for Protein Principle Sulfosalicylic acid tests for both albumin and globulin It is a simple precipitation test that in the presence of protein turns a clear urine specimen to turbid Changes in urinary solute concentrate effect the Chem
22. e containing glucose may decrease in pH as organisms metabolize the glucose Bacterial growth from contaminating organism may cause false positive blood reactions from the peroxidases produced In random urine urine specimens from females a positive result for leukocytes may be due to a source external to the urinary tract Contamination of the urine specimen with skin cleansers containing chlorhexidine may affect protein and to a lesser extent specific gravity and bilirubin test results The user should determine whether the use pf such skin cleansers is warranted Quality Control Known positive and negative specimens are supplied in the laboratory for quality control testing Known positive and negative specimens are tested once each day of use in the same manner as patient samples are tested Water should not be used as a negative control Patient results are never reported until acceptable results are obtained form quality control testing Remedial Action In the event that quality control testing does not produce acceptable results the following procedure may be used to correct any deficiencies 1 Repeat the testing being careful to follow incubation times exactly 2 Reconstitute new control material and repeat testing 3 Obtain a new vial of test strips and repeat testing 4 Contact the Laboratory Manager Reviewed 11 14 28 Revised 11 14 Procedure 1 Collect a fresh urine specimen in a clean dry container Mix well immedi
23. e intended use for qualitative hCG tests Approximately one third of all conceptions end in natural termination This may produce positive results when testing early in the pregnancy followed by negative results after the natural termination Low positive results may be confirmed by retesting with a fresh serum or first morning urine specimen collected 48 hours later This test provides a presumptive diagnosis for pregnancy Physicians should evaluate all clinical and laboratory findings before making a definitive diagnosis A viscous specimen high specific gravity may exhibit a slower flow rate therefore requiring more time for the test to be completed Ahigh dose hook effect may occur where the intensity of sample line decreases as the concentration of hCG increases If a hook effect is suspected dilution of specimens may increase color intensity of the sample line This test is designed to be a qualitative test only and does not correlate directly to quantitative hCG tests The intensity of color in a positive line should not be evaluated as quantitative or semi quantitative 10 Sensitive immunoassays may demonstrate false positive results with specimens containing heterophile antibodies Assays may also exhibit false positive or false negative results with specimens containing human anti mouse antibodies These specimens may come from patients receiving preparations of mouse monoclonal antibodies for diagnosis or therapy or
24. e loader and press F12 Ruby has a cap piercing system that will allow running closed tubes 3 If open mode is to be run input the patient s information in the next open tube entry either manually or using the hand held bar code reader 4 Mix the specimen according to the manufacturer s recommendation 5 Place the specimen under the aspiration probe raise the tube until the end of the probe is deeply immersed in the sample 6 Press the touch plate behind the probe to start the run cycle and take out the specimen while the rinsing probe pushes the specimen down 7 Results are displayed on the run view screen and printed automatically if auto print is on Reviewed 11 14 6 Revised 11 14 cP QUALITY CONTROL OUT OF CONTROL Department Month Year Problem Rev By Date Corrective Action Reviewed 11 14 Revised 11 14 cP Correlation of Back Up Instrumentation with Primary Systems Principle Correlation of patient samples between analyzers is performed to check the accuracy and precision of each analyzer Policy It is the policy of Southeast Arizona Medical Center Laboratory to run correlations between each primary analyzer and its corresponding back up system twice a year The following is a list of those analyzers Primary Back Up HMX ACT 5 ACL 8000 ACL 1000 DXC600 CX3 Polyme deo Sedimat 15 Excyte 10
25. ediately or at any time up to 2 minutes after dipping After dipping the strip check the pH area If the color on the pad is not uniform read the reagent area immediately comparing the darkest color to the appropriate Color Chart All reagent areas except leukocyte may be read between 1 and 2 minutes for identifying negative specimens and for determination of the pH and SG A positive reaction Small or greater at less than 2 minutes on the leukocyte test may be regarded as a positive indication of leukocytes in urine Color changes that occur after 2 minutes are of no diagnostic value Interpretation of Results Results with Bayer Reagent strips are obtained in clinically meaningful Units directly from the Color Chart comparison Limitations 1 As with all laboratory tests definitive diagnostic or therapeutic decisions should not be based on any single result or method 2 Substances that cause abnormal urine color such as drugs containing azo dyes e g Pyridium Azo Gantrisin Azo Gantanol nitrofurantoin Macrodantin Furadantin and riboflavin may affect the readability of the reagent areas on urinalysis reagent strips The color development on the reagent pad may be masked or a color reaction may be produced on the pad that could be interpreted visually as a false positive 3 Glucose Ascorbic acid concentrations of 50 mg dL or greater may cause false negatives for specimens containing small amounts of glucose 75 125 mg dL K
26. eflex any manual blood smear that exceeds the criteria for manual blood smear review According to Medicare reimbursement clinical reflexing will not be reimbursed without an order from a doctor It will be the policy of this laboratory to notify the doctor that a blood smear is indicated Lab results will then be entered upon receipt of the order for blood smear Results will also be recorded on the instrument printout Principle The examination of the blood smear is an important part of the hematologic evaluation Procedure Preparation of smear I Place a drop of blood 2 to 3 mm in diameter about 1 cm from the end of a clean dust free slide Place the slide on a flat surface 2 With the thumb and forefinger of the right hand hold the end of a second spreader slide against the surface of the first at an angle of 30 to 45 degrees and draw it back against the drop of blood until contact is established Allow the blood to run completely across the end filling the angle between the two slides 3 Push the spreader slide at a moderate speed forward so that the blood spreads evenly on the other side behind the edge of the spread keeping contact between the two until all the blood has been spread into a moderately thin film 4 Air dries the smear Staining the smear 1 Dip slide in stain for 10 seconds 2 Dip slide in distilled water ph 6 7 for 20 seconds or more for darker staining 3 Air dry Reviewed 11 14 10 Revised 11
27. etone bodies reduce the sensitivity of the test moderately high ketone levels 40 mg dL may cause false negatives for specimens containing small amounts of glucose 75 125 mg dL but the combination of such ketone levels and low glucose levels is metabolically improbable in screening The reactivity of the glucose test decreases as the SG of the urine increases Reactivity may also vary with temperature This test is specific for glucose no substance excreted in urine other than glucose is known to give a positive test The reagent area does not react with lactose galactose fructose nor reducing metabolites of drugs e g salicylates and nalidixic acid Reviewed 11 14 29 Revised 11 14 cP 4 Bilirubin Indican indoxyl sulfate can produce a yellow orange to red color response that may interfere with the interpretation of a negative or a positive bilirubin reading Metabolites of Lodine etodolac may cause false positive or atypical results ascorbic acid concentrations of 25 mg dL or greater may cause false negatives Since very small amounts of bilirubin may be found in the earliest stages of liver disease the user must consider whether the sensitivity of the reagent strip to bilirubin is sufficient for the intended use When very small amounts of bilirubin in urine are sought e g earliest phase of hepatitis ICTOTEST reagent tablets should be the method of choice 5 Ketone False positive results Trace or less may occur with high
28. ficant numbers may indicate urinary tract infection The presence of leukocytes helps to differentiate between contamination and a true Infection Yeast and Parasites Yeast cells Candida albicans may be indicative of urinary moniliasis especially in patients with diabetes mellitus Frequently yeast appears as a contaminant in the urine of female patients with vaginal moniliasis The majority of parasites observed in urine are contaminants from fecal or vaginal material A urinary tract parasite infestation may be associated with the presence of red blood cells as in Schistosoma haematobium Spermatozoa Spermatazoa are frequently seen in urine following nocturnal emissions or sexual intercourse Casts Cast formation occurs usually in the distal convoluted tubule of the nephron Casts may also occur in the ascending loop of Henle or the collecting duct Requirements for cast formation are an acid condition high salt concentration reduced urine flow and protein Casts are named according to the matrix of the inclusions contained in them e g red blood cell cast white blood cell cast etc Red Blood Cell Casts indicate the presence of an acute inflammatory or vascula disorder in the glomerulus causing renal hematuria They should always be regarded as pathological and may be the only manifestation of acute glomerulonephritis renal infarction collagen disease or kidney involvement in subacute bacterial endocarditis White B
29. gents and Equipment absorbent test mat Ictotest reagent tablet transfer pipette DI water Quality Control Normal and Abnormal KOVA trol should be performed when confirmatory testing is needed Procedure l Place a square of the absorbent test mat supplied onto a paper towel Place 10 drops of urine onto the center of the test mat 2 Shake one ICTOTEST Reagent Tablet into the bottle cap and transfer the tablet to the center of the moistened mat Do not handle tablet with the fingers Recap the bottle promptly 3 Place one drop of water onto the tablet Wait 5 seconds and then place a second drop of water onto the tablet so that the water runs off tablet onto the mat Expected Values Negative for normal urine Procedural Notes and Limitations The presence of a blue or purple color on the mat indicates that bilirubin is present A slight pink or red color should be ignored Metabolites of Phridium give bright red orange colors which may mask the reaction of small amounts of bilirubin Elevated concentrations of urobilinogen do not mask the reaction of small amounts of bilirubin but atypical orange colors are produced Chlorpromazine in large amounts may give a false positive result and metabolites of Lodine etodolac may cause false positive or atypical results Reviewed 11 14 35 Revised 11 14 cP Result Reporting Log on urinalysis log Referenced Icotest package insert September 2009 Reviewed 11 14 Revised 1
30. grity of supplies Remove the pink stopper on the prefilled vial 0 2 ml of 3 8 Sodium Citrate is used as diluent Using a transfer pipette fill the vial to the bottom of the indicated fill line with 0 8 ml of blood to make the required dilution ratio Replace pink pierceable stopper and gently invert several times to obtain homogeneous mixing Place vial in its rack on a level counter surface free from vibration The diaphragm of the pink stopper is calibrated to break under the light pressure made by inserting the pipette Carefully insert the pipette through the pierceable stopper and gently push downwards until the pipette comes into contact with the blood sample Next while holding the middle of the pipette gently twist the pipette and push downwards until the pipette rests on the bottom of the vial The pipette will autozero the blood and any reasonable excess will flow into the reservoir compartment To ensure proper results it is essential that the pipette makes firm contact with the bottom of the vial Let sample stand for exactly one hour and then read the numerical results of the erythrocyte sedimentation rate in millimeters Dispose of properly after use Interpretation of Results MALE under 50 0 15 mm hr over 50 0 20 mm hr FEMALE under 50 0 20 mm hr over 50 0 30 mm hr Reviewed 11 14 13 Revised 11 14 Quality Control Normal and Abnormal reacting quality control material is available in the laboratory
31. have been exposed to mice If the qualitative interpretation is inconsistent with the clinical evaluation results should be confirmed by an alternate hCG method Reporting of Patient Results Patient results are reported as either Positive or Negative in the LIS Inoperable Test System In the event that the Sure Vue Serum Urine hCG test kit is unavailable Quantitative BhCG may be performed using the Access Chemistry Instrument supplied in the laboratory w a co N Q Ko Reviewed 11 14 40 Revised 11 14 Clinical Significance The detection of hCG human chorionic gonadotropin in serum and urine has proven valuable in the presumptive diagnosis of pregnancy References Sure Vue Urine Serum hCG Test Kit insert 3 03 Fisher Scientific Co Houston Texas Reviewed 11 14 Revised 11 14 41 cP Refractometer Principle The Reichert Refractometer is designed for simple and rapid microanalysis of body fluids The three scale reticle provides read out for urine specific gravity while the remaining scale is calibrated for protein calibration of plasma or serum The instrument is temperature compensated for temperatures between 60 degrees F 16C and 100 degrees F 38C There is no need to adjust reading for either temperature of sample or ambient temperatures Materials Plastic disposable pipette distilled water refractometer sample Sapp Procedure A Hold instrument horizontally and swing cover pl
32. hipment of kits received every 30 days and as a means of troubleshooting procedural problems Remedial Action In the event that unacceptable quality control or patient results are obtained the following procedure is suggested 1 Obtain a new testing device and repeat the testing carefully following procedural steps Repeat the testing including quality control material 3 Obtain a new patient specimen and repeat the testing 4 Obtain a new package or lot number of testing devices and repeat the testing Contact the Laboratory Manager Patient results are not reported until acceptable quality control results are obtained Procedure The pouch must be at room temperature before opening to avoid condensation of moisture on the membrane Allow specimen and or controls to reach room temperature prior to testing 1 Remove enough test devices from their protective pouches to perform the necessary testing Place the devices on a flat surface Label the devices as necessary with patient or control identification Dispense 4 drops approximately 0 15 mL of specimen into the round sample well Wait for the colored lines to appear Read results at 4 minutes Positive results may be observed in as short as 30 seconds depending on the concentration of hCG The presence of the Control Line is not indicative of the test being completed Wait the entire 4 minutes for completion of the test Read under direct light to avoid interference of shado
33. ing Do not remove the desiccant s from the container Do not remove the strip from the container until immediately before it is to be used for testing Replace the cap immediately and tightly after removing the reagent strip Do not touch the test areas of the reagent strip Work areas and specimen containers should be free of detergents and other contaminating substances 2 Specimen collection device as supplied in the laboratory 3 Cleansing wipes as supplied in the laboratory for performing a Clean Catch collection Specimen The specimen of choice for this procedure is urine collected in a clean container and tested as soon as possible Do not centrifuge The use of urine preservatives is not recommended If testing cannot be performed within an hour after voiding the specimen may be refrigerated for up to 24 hours before testing Allow the specimen to warm to room temperature if refrigerated Nitrite test results are optimized by using a first morning specimen or one that has incubated in the bladder for four 4 hours or more It is especially important to use fresh urine to obtain optimal results with tests for bilirubin or urobilinogen as these compounds are very unstable when exposed to room temperature and light Prolonged exposure of urine to room temperature may result in microbial proliferation with resultant changes in pH A shift to alkaline pH may cause false positive results with the protein with the protein test area Urin
34. ke the negative or positive color blocks shown on the Color Chart may indicate that bilirubin derived bile pigments are present in the urine sample and may be masking the bilirubin reaction These colors may indicate bile pigment abnormalities and the urine specimen must be tested further with a confirmative test such as the ICTOTEST Ketone Normal urine specimens ordinarily yield negative results with this reagent Detectable levels of ketone may occur in urine during physiological stress conditions such as fasting pregnancy and frequent strenuous exercise In ketoacidosis starvation or with other abnormalities of carbohydrate or lipid metabolism ketones may appear in urine in large amounts before serum ketone concentrations are elevated Specific Gravity Random urines may vary in specific gravity from 1 001 1 035 Twenty four hour urines from normal adults with normal diets and normal fluid intake will have specific gravity of 1 016 1 022 Blood The significance of the Trace reaction may vary among patients and clinical judgment is required for assessment in an individual case Development of green spots intact erythrocytes or green color free hemoglobin myoglobin on the reagent area within 60 seconds indicates the need for further investigation Blood is often but not always found in urine of menstruating females The test is highly sensitive to hemoglobin and thus complements the microscopic examination pH Bo
35. lood Cell Casts may be found in the urine from patients with acute glomerulonephritis nephrotic syndrome or pyelonephritis Since pyelonephritis may remain completely asymptomatic even though it is progressively destroying renal tissue careful examination of the urinary sediment for leukocyte casts is important In some cases it may be the only significant laboratory finding in an asymptomatic situation Epithelial Cell Casts are formed by fused desquamated tubular cells Since the tubule is a living membrane it is always replacing itself Thus the finding of an occasional renal epithelial cell or clump is not remarkable However in any disease producing damage to tubular epithelium the appearance of many casts may indicate excessive Reviewed 11 14 25 Revised 11 14 cP desquamation such as may occur in nephrosis eclampsia amyloidosis and in the presence of poisoning with heavy metals and a variety of other toxins e Hyaline Casts are formed of the gel of Tamm Horsfall protein The presence of hyaline casts imply damage to the glomerular capillary membrane permitting leakage of proteins through the glomerular filter Such damage may be permanent or transient as a result of fever or the effects of posture orthostatic iordotic emotional stress or strenuous exercise e Granular Casts The terms coarsely granular and finely granular are merely descriptive indicating the degree of degeneration that has occurred in the cell
36. lowing steps shall be followed 1 2 6 T Do not report patient results Review procedures and analytic system for identifiable errors Pour or reconstitute fresh control s Run both prior control s and fresh control s a If fresh control s is are within limits repeat the patient run and report Include a fresh control with the repeat patient run b If fresh control s and repeat control s remain unacceptable make or change reagent Rerun control s using new reagent a If control s is are now within limits repeat patient run including a control and report results b If control s remain unacceptable troubleshoot procedure or instrument in conjunction with the primary operator hotline personnel or lab manager Discard any control material reagents which yield unacceptable results Do not report any patient results until you have an acceptable control run Document all action taken in the work troubleshooting log Plot all control values including those out of range Reviewed 11 14 3 Revised 11 14 cP Principle CALIBRATIONS Calibrations provide a standard of analysis using preset determinations in order to establish continuity of quality control Policy It is the policy of Cochise Regional Hospital Laboratory to perform calibrations on the following instruments Ruby Cell Dyn 1 Calibrations are to be run 2 Calibrations are to be run 3 Calibrations are to be run CA 50
37. ly pigmented urine specimens or those containing large amounts of levodopa metabolites Compounds such as mesna 2 mercaptoethane sulfonic acid that contain sulfhydryl groups may cause false positive results or an atypical color reaction This test reacts with acetoacetic acid in urine it does not react with acetone or 8 hydroxbutyric acid 6 Specific Gravity The chemical nature of the reagent test strips may cause slightly different results from those obtained with other specific gravity methods when elevated amounts of certain urine constituents are present Highly buffered alkaline urines may cause low readings relative to other methods Elevated specific gravity readings may be obtained in the presence of moderate quantities of protein 100 750 mg dL 7 Blood Elevated specific gravity may reduce the reactivity of the blood test Capoten may also cause decreased reactivity Certain oxidizing contaminants such as hypochlorite may produce false positive results Microbial peroxidase associated with urinary tract infections may cause false positive reactions Levels of ascorbic acid normally found in urine do not interfere with this test 8 pH If proper procedure is not followed and excess urine remains on the strip a phenomenon known as run over may occur in which the acid buffer from the protein reagent will run onto the pH area causing a false lowering of the pH result 9 Protein False positive results may be obtained with highly
38. never test results are in doubt 4 When training instrument operators Procedure Routine Urines The urine specimen should be fresh well mixed and uncentrifuged If the urine depth is less than about 3 inches pour the specimen into a narrow tube such as a URIN TEK Specimen tube 1 DIP A BAYER REAGENT STRIP into the urine Be sure ALL the test pads are wet 2 Immediately Remove the reagent strip from the urine dragging the edge of the strip against the side of the container as you remove the strip At the Same Time press either green Start key You now have 10 seconds to complete Steps 3 and 4 3 Blot the strip to remove excess urine by touching the edge to a paper towel Do not drag the strip across the towel touch the edge only 4 Place the Reagent Strip With the test pads facing up into the middle trough of the test strip table until it touches the end of the trough 5 The table is automatically pulled into the instrument for reading Results are available in one minute Be sure not to move or bump the table Reviewed 11 14 20 Revised 11 14 cP Complete Urinalysis Principle The examination of urine is performed in three steps The first step involves evaluation of the physiochemical characteristics of the urine sample The second step involves the chemical examination of the urine specimen and the third step is the microscopic examination of the urine sediment by trained laboratory personnel Materials 1 Spe
39. nstrument printouts and give results to Lab Manager Notify Lab Manager of any problems hw nN Reviewed 11 14 Revised 11 14 cP Operation of the Cell Dyn Ruby Hematology Analyzer PRINCIPLE The cell dyn Ruby is a multi parameter automated hematology analyzer for in vitro diagnostic use in counting and characterizing blood cells with the capability of a five part leukocyte differential by flow cytometry which uses a laser beam to intersect cells light is scatter at different angles that are measure to give the data about cells Ruby is capable of running in both modes open and closed with the purpose of identify patient results with normal system generating parameters and to flag patient s data that require additional studies Ruby also has an automated reticulocyte mode START UP At the beginning of the day the system shall be on standby but if the system is idle for 4 hours it automatically goes into standby then F12 prime key must be pressed to run a background count which is used to confirm that the system s baseline performance meets stated criteria if results are within acceptable ranges proceed to run QC DAILY QUALITY CONTROL 1 Two controls shall be run every 8 hours 2 Controls shall be run following a background count Prime OPERATION CBC 1 From the main screen press F11 to select the mode desirable to be run 2 If closed mode is to be run load the specimen with the barcode on the rack and place it on th
40. nt to temperatures above 150 degrees F 60C Reviewed 11 14 43 Revised 11 14 Calibration The Reichert Refractometer rarely needs adjustment according to manufacturer documentation however if readjustment is warranted take the following steps A Temperature of instrument should be between 70 degrees F 21C and 85 degrees F 29C B Using distilled water apply sample to prism C Take reading If reading departs from 1 000 an adjustment may be made by adjusting the screw at the bottom of instrument Turning screw first counterclockwise will move the dividing line below 1 000 Turn clockwise to bring back to 1 000 Final adjustment is always clockwise Do not remove screw from instrument Reviewed 11 14 Revised 11 14 cP Semi quantitative Confirmatory Testing for Albumin in Urine Using Cargille Kingsbury Clark Standards and Sulfosalicylic Acid Method PRINCIPLE The Kingsbury Clark standards consist of eight 8 standards which are turbidity suspensions in a gel to represent 5 10 20 30 40 50 75 and 100 mg of albumin as part of a total protein precipitation in 100 ml or urine Albumin and other proteins precipitate from urine with a 3 solution of sulfosalicylic acid in a graduated albumin tube The solution is mixed and compared to the standards after 10 minutes The Cargille Kingsbury Clark standards were developed in order to provide a set of stable standards for visual comparison with urine treated with sulfo
41. ocyte esterase protein greater than a trace or nitrites are positive a microscopic examination is required If the listed tests are negative even though other tests are positive a microscopic examination need not be performed or performed upon physician request 5 Centrifuge the 12 ml sample of urine for two 2 minutes in the urine centrifuge 6 Decant all but 1 ml of the sample 7 Mix the 1 ml sample well and place one 1 drop of the concentrated urine onto a clean dry slide Cover with a cover slip as supplied in the laboratory 8 Perform a microscopic examination of the urine sample Reviewed 11 14 21 Revised 11 14 cP Interpretation of Results The slide is first examined under low power magnification to locate casts and elements that are present in only a few fields Casts tend to congregate near the edges of the cover slip After the entire slide has been scanned a further examination is made under high power magnification in order to identify specific types of cells crystals elements and objects present in the urine and to delineate the various types of casts A minimum of 10 to 15 high power fields should be scanned for this examination Good technique requires varying the intensity of the light source of the microscope in order to correctly identify the various components of the sediment Some elements are more easily recognized in subdued light others in brighter light Red blood cells leukocytes and epithelial
42. ophila etc Red blood cells will tend to lyse or dissolve if allowed to stand in urine which is alkaline or dilute e White Blood Cells The presence of large numbers of white blood cells leukocytes usually indicates bacterial infection in the urinary tract Pyuria may also be seen in acute glomerulonephritis The cells are segmented neutrophils or polys Large amounts of mononuclear cells Lymphs in a patient with a kidney transplant may indicate early tissue rejection phenomena Epithelial Cells Large numbers of renal epithelial cells may indicate active tubular degeneration These cells are noted in the urine of patients with acute tubular necrosis and necrotizing papillitis squamous epithelial cells appear frequently in normal urine e Crystals The type and quantity of crystalline precipitate vary with the pH of the urine Amorphous material is of little importance Crystals in normal urine are formed as the specimen cool Crystals of abnormal urine cystine leucine tyrosine and cholesterol The following table lists some crystals found in urine sediment and the physical chemical characteristics associated with them Reviewed 11 14 23 Revised 11 14 INORGANIC SEDIMENT ACID URINE SOLUBILITY NAME COLOR SHAPE ALK ACID ALCOHOL C OTHER Amorphous Brick Red Granules 80 C is Acetic urates Acid Uric Acid Yellow Brown Polymorphous whetstones rosettes of prisms rhom bohedral prisms hexagonal plate Sodium Colorless to
43. rom reagent cooler 7 Check the trap chamber and drain if needed 8 Check temperatures Monthly Maintenance 1 Replace reagent Bottles Quarterly Maintenance 1 Clean diH2O Rinse bottle with alcohol 2 Perform LED calibration Yearly Maintenance 1 Replace Rinse Filter Rinse and prepare As needed Maintenance 1 Replace fuse 2 Perform Rinse and Prepare 3 Perform maintenance rinse 4 Clean instrument surface Reviewed 11 14 17 Revised 11 14 DAILY QUALITY CONTROLS Two levels of ci Trol should be run every 8 hours shift for PT and aPTT tests Two levels of Innovance D dimer should be run every 8 hours when there are specimens to be run OPERATION OF SYSMEX CA 500 l Go to the main menu 2 Place sample in the rack with the barcode facing outward if the specimen does not have barcode input the specimen id by pressing the ID No Entry icon which gives the numeric keyboard then select the test desire to be run and press START then press continue to start running the specimen 3 When the analyzer finishes the run automatically the result is printed Reviewed 11 14 18 Revised 11 14 cP Urinalysis Quality Control A General KOVA trol Normal and Abnormal urine controls should be used each day for the urine dipsticks Controls need to be run for confirmatory tests when the tests are performed Expected values are posted in the laboratory B Out of Control QC li Check expiration date of
44. salicylic acid The standards have stepped degrees of turbidity which are compared with the turbidity of the specimen which is caused by the precipitation of protein by the sulfosalicylic acid SUMMARY The Kingsbury Clark standards rack holds eight 8 standards alternately placed in order to accommodate the urine albumin tube The black background shows the presence of faint traces of turbidity under opaque back lighting Critical comparisons are made using the black and white comparison strip PROCEDURE Recommended 1 Fill a 6 ml albumin comparison tube to the lower graduated mark 4 5ml with distilled water 2 Add specimen to the 6 ml mark 3 Add one 1 135mg sulfosalicylic acid tablet and invert until dissolved 4 Let stand for 10 minutes after addition of the tablet and then shake to suspend precipitate 5 Compare tube to standard tube to determine semi quantitative value for albumin Reviewed 11 14 45 Revised 11 14 cP Alternate Procedure 1 Fill 6 ml albumin comparison tube to the lower graduated mark 4 5m1 with 3 sulfosalicylic acid solution Add specimen to the 6 ml mark Invert the tube several times to mix thoroughly Let stand 10 minutes and then shake to suspend precipitate Compare tube to standard tube to determine quantitative albumin wk wh e To make 3 solution make 30gm of sulfosalicylic acid up to 1 liter with distilled water A red or blue color indicates the presence of iron dis
45. st be used to read the assay correctly Urine If no colored line appears in the C control window add 1 to 2 additional drops of urine and wait an additional 4 minutes If a colored line still does not appear in the C control window the test is invalid and should be repeated using another device Expected Values Negative results are expected in healthy non pregnant women and healthy men Healthy pregnant women have hCG present The amount will vary with gestational age and between patients Sure Vue Serum Urine hCG can detect hCG levels as low as 25 mlU mL Limitations 1 False negative results may occur when levels of hCG are below the sensitivity level of the test When pregnancy is still suspected a fresh serum or a first morning urine specimen should be collected 48 hours later and tested 2 Elevated levels of hCG may be found in trophoblastic disease choriocarcinoma and embryonal cell carcinoma Islet cell tumors may also produce hCG as well as other carcinomas Detectable levels of hCG may remain several weeks following normal pregnancy delivery by cesarean section or spontaneous or therapeutic abortion 4 Ectopic pregnancies may produce very low levels of hCG A negative test therefore does not exclude ectopic pregnancy If this condition is suspected further testing using a quantitative test may be desirable Abnormally high levels of hCG may be seen in molar pregnancies Samples form abnormal pregnancies are beyond th
46. strip results but not the sulfosalicylic acid method Quality Control Normal and Abnormal KOVA trol should be performed when confirmatory testing is needed Procedure A Using a 12 x 75 test tube add one part sulfosalicylic acid to one part centrifuged urine and observe for turbidity holding the tube against a white background with black print B Grade and report as follows 1 Neg no turbidity 2 trace slight distinct turbidity 3 1 definite turbidity print readable 4 2 light cloud print readable a 3 moderate cloud slight precipitate 6 4 heavy cloud flocculent Expected Values Negative for normal urine Result Reporting Log on urinalysis worksheet References Fundamentals of Clinical Chemistry 2nd Edition package insert Reviewed 11 14 33 Revised 11 14 Clinitest is not specific for glucose and will react with urine that contains sufficient quantities of other reducing substances An example would be galactose It is important that the physician be notified when the Clinitest is positive but the urine dipstick is negative Result Reporting Log on urinalysis worksheet Reference Clinitest Reagent tablet insert September 1995 Reviewed 11 14 34 Revised 11 14 cP Ictotest Confirmatory Test for Bilirubin Principle Ictotest reagent tablets are used to test for the presence of bilirubin in urine The presence of bilirubin is an important finding in the evaluation of liver function Rea
47. th the normal and abnormal urinary pH range is from 5 to 9 Protein Normally no protein is detectable in urine although a minute amount is excreted by the normal kidney A color matching any block greater than Trace indicated significant proteinuria For urine of high specific gravity the test area may most closely match the Trace color block even though only normal concentrations of protein are present Clinical judgment is needed to evaluate the significance of Trace results Urobilinogen The normal urobilinogen range obtained with this test is 0 2 1 0 mg dL 1 mg is approximately equal to 1 Ehrlich Unit dL A result of 2 0 mg dL represents the transition from normal to abnormal and the patient and or urine specimen should be evaluated further Nitrite Normally no nitrite is detectable in urine The proportion of positive nitrite tests in cases of significant infection depends on how long the urine specimens Reviewed 11 14 31 Revised 11 14 cP were retained in the bladder prior to collection Identification of known positive cases with the nitrite test ranges from as low as 40 when little bladder incubation occurred to as high as approximately 80 when a minimum of four hours of bladder incubation occurred Leukocytes Normal urine specimens generally yield negative results positive results Small or greater are clinically significant Individually observed Trace results may be of questionable clinical significanc
48. the formation of colored lines The specimen migrates via capillary action along the membrane and reacts with the colored conjugate A positive specimen reacts with the hCG specific antibody colored conjugate and forms a colored line in the T test window Absence of this colored line suggests a negative result To serve as a control for the procedure a colored line in the C control window will always appear regardless of the presence or absence of hCG Materials 1 Sure Vue Serum Pregnancy test device as supplied in the laboratory The device is stable until the expiration date printed on the package label when stored at room temperature 15 30 C The test device must remain sealed in the protective pouch until ready for use 2 Timer 3 Specimen collection container Specimen Urine The specimen of choice for this procedure is a fresh urine specimen collected into a clean dry container either plastic or glass Specimens collected at random may be used however the first morning urine generally contains the highest concentration of hormone A urine sample exhibiting visible precipitates should be centrifuged or allowed to settle before testing Gross hematuria may prevent an accurate reading of test results by masking the positive line Serum The specimen of choice for this procedure is blood collected by approved laboratory methods into a sterile tube without any anticoagulants and processed to produce a clear serum specimen
49. tilled water is best STORAGE Standards should be stored at ambient temperatures 4 40C away from heat and sunlight Cracking or crazed gelatin is a symptom of freezing RESULTS Compare turbidity of treated urine sample with the turbidity of the standard to match concentration This procedure will be used to confirm positive proteins on dipstick urinalysis If confirmatory testing matches the dipstick report out dipstick value If confirmatory testing is negative report out as negative Reviewed 11 14 46 Revised 11 14
50. ular inclusion the cells having been broken down into coarse or finer particles While an occasional granular cast may be found in normal individuals their presence beyond occasional cast may indicate pyelonephritis Granular casts are also found in chronic lead intoxication e Waxy and Fatty Casts are associated with tubular inflammation and degeneration The broad waxy cast is formed in the collecting tubules when the urine flow them is reduced Both waxy and fatty casts are found in chronic renal disease Reporting of Patient Results co ewe are entered into the LIS using the above table for reporting of results Inoperable Test System In the event that come et urinalysis testing cannot be performed samples will be sent to the Sierra Vista Regional Hospital Clinical Significance The benefit of performing complete urinalysis examination is well known as a means to assess kidney function References Modern Urine Chemistry 1982 Ames Company Elkhardt Indiana Reviewed 11 14 26 Revised 11 14 cP Urinalysis Multi Stix 10 SG Principle The Multi Stix SG Reagent strips for Urinalysis are firm plastic strips to which are affixed several separate reagent areas The reagent test areas on the Reagent Strips are ready to use upon removal from the bottle and the entire reagent strip is disposable The following are chemical principles of the reagent ares 1 Glucose This test is based on a double sequential enzyme
51. ws in the T and C windows Interpretation of Results Negative Results The test result is negative if a colored line appears only in the C control ark ON window Positive Results The test result is positive if one colored line appears in the T test window and one colored line appears in the C control window Any colored line in the T test window should be considered positive Colored lines may be lighter or darker than each other Specimens with HCG levels near the threshold of the test may develop color faint lines overtime after the 4 minutes reading In such cases another test should be performed with a new specimen in 48 72 hours A line that appears after 15 minutes should be ignored Invalid Results The test is invalid if no colored line appears in the C control window even if a colored line appears in the T test window Serum If no colored line appears in the C control window or the migration of the specimen is too slow or incomplete add 1 to 2 additional drops of serum or add 1 to 2 drops of deionized water or saline into the sample well and wait an additional 4 minutes Ifa colored line still does not appear in the C control window the serum could be too Reviewed 11 14 39 Revised 11 14 cP viscous Dilute the serum 1 1 with saline or deionized water and repeat the test using another device Dilution with saline or deionized water to specimens with low levels of hCG will dilute sample lines Care mu
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