ࡱ>  KI>?@ABCDEL` Wbjbjss 5Rwg. . . . ~ ~ ~  82| 7z~($h~ . . . 8~ ~f ~ r dʟ^RN2*07r)~  7 LVWP VW . . . . . .   INTRODUCTION The Pathology Directorate of Swansea NHS Trust includes all four major disciplines: Cellular Pathology, Chemical Pathology, Haematology and Microbiology, each with a Consultant Head of Department. Technical work is performed by teams of qualified, skilled and dedicated Biomedical Scientists, supported in some departments by Clinical Scientists. The department provides a comprehensive analytical and consultant advisory service both to hospital staff and to General Practice. The department is busy, performing over 2.6 million investigations annually and has an annual budget of approximately 8.5 million. Every effort should be made to restrict the demand for all pathology investigations to those essential to diagnosis and management, as the total budget for Pathology is finite. This handbook has been produced to help you make best use of laboratory services and while we hope it will answer many of your questions and provide a convenient source of reference, we would encourage you to contact the laboratory if in any doubt about particular investigations or tests. You will usually speak first to a Biomedical Scientist who will, if necessary, refer your query to medical (or clinical scientist) staff or to the Head of Department who can of course be contacted directly if you prefer. We also hope that, from time to time, you may be able to visit the laboratory and actually meet the staff here. Finally, we would encourage you to read this booklet. We believe it will prove useful to you during your time in Swansea and also after you have moved on. Pathology Executive Committee Swansea NHS Trust KEY PATHOLOGY PERSONNEL Telephone Clinical DirectorDr W Williams 5016Pathology Services Manager/Head BMSMr R Rooke5014 / 3048 Cellular Pathology Consultant Histopathologist (HoD)Dr C O'Brien3035Consultant HistopathologistDr A Dawson3016Consultant HistopathologistDr P Griffiths3319Consultant Histopathologist3041Consultant HistopathologistDr V Shah5015Consultant HistopathologistDr N Toffazal6323Consultant HistopathologistDr N Williams5017Consultant HistopathologistDr S Williams5013Consultant Histopathologist Consultant HistopathologistDr W Williams Dr H Thomas5016 6351Service Manager/Head BMSMrs C Davies5020Head MTOMr P Benson5063 Chemical Pathology Consultant Chemical Pathologist (HoD)Dr A Gunneberg3987Consultant Chemical Pathologist Consultant Clinical Chemist Dr R Still4909 Service Manager/Head BMSMr D Stockwell3773 Haematology Consultant Haematologist (HoD)Dr A Benton6364Consultant HaematologistDr S Al-Ismail5079Consultant HaematologistDr A Beddall6561Consultant Haematologist Consultant HaematologistDr A Salamat Dr H Sati6364 6360Service Manager/Head BMSDr R Munro4050 Microbiology (NPHS) Consultant MicrobiologistDr A Lewis5066Service Manager/Head BMSMr I Thomas5046Infection Control Morriston NursesD Davies 3690C Peacock  3690Singleton NursesJ Cutter 5045L Duffy 5045 Neath Port Talbot Nurses 2123 / 2233 LABORATORY TELEPHONE NUMBERS Cellular Pathology Morriston Hospital 3040 / 3044Singleton Hospital 5022 / 6357Cytology 5018Reception 5073 Chemical Pathology Morriston Hospital 3046Clinical Scientists' Office Duty Biochemist (to discuss Results/investigations) (Dr A Fielding/ Dr L Ward) 3994 3036Singleton Hospital 5037Neath Port Talbot Hospital 2226Haematology Morriston HospitalRoutine Laboratory3033Blood Bank3054Coagulation3034Singleton HospitalRoutine Laboratory5080Blood Bank5075Immunology5074Neath Port Talbot HospitalRoutine Laboratory2223Blood Bank2367 Microbiology Urine Laboratory5071Blood Culture5040Sputa / Fungi / Infertility5041Faeces / Genital Specimens5031Wounds/Sterile Fluids / CSF5048Virology5059Serology5060 Mortuary Morriston Hospital3250Singleton Hospital5063Neath Port Talbot Hospital2100 General Offices / Receptions Morriston HospitalGeneral Office3050 Fax:01792 703051Reception3825Singleton HospitalGeneral Office5023 Fax:01792 285537Reception5073Neath Port Talbot HospitalReception2219 Fax:01639 862436 The telephone system operates across the three main hospital sites: Morriston Hospital extensions begin with 3 or 4 Singleton Hospital extensions begin with 5 or 6 Neath Port Talbot Hospital extensions begin with 2 or 7 By placing 71 before the extension number you can contact extensions on other sites. Please see local telephone directories for information on paging. OPENING HOURS Weekdays 08:45 to 17:00 Saturdays 09:00 to 12:30 (urgent samples only) All other times are covered by an emergency service. A list of staff on call for emergencies is kept with the hospitals' telephonist. This is not a 24-hour service for routine investigations. There are distinct emergency numbers for each department: - Chemical Pathology Morriston Hospital24 hour / 7 days a week3052Singleton Hospital24 hour / 7 days a week5037Neath Port Talbot Hospital24 hour / 7 days a week2226 Both Singleton and Neath Port Talbot laboratories are open 7 days a week between 08:00and 23:30. Outside these times samples are transported to Morriston. Please contact your local laboratory telephone number as calls are automatically diverted. Haematology Morriston HospitalHaematology / TransfusionPage 3914CoagulationPage 3974Singleton HospitalPage 5716Neath Port Talbot HospitalVia Switchboard Microbiology Singleton HospitalBleep 5724 Virology Singleton HospitalBleep 5717 Cellular Pathology Contact Morriston and Singleton Hospitals' Switchboard. TEST REQUESTING To retrieve results, the pathology computer relies upon accurate information. It is therefore essential that each request form and sample container be clearly marked with the patient identity and location. PATIENT SAMPLE AND REQUEST FORM IDENTIFICATION CRITERIA. NB: The minimum statutory requirements for samples and request forms for blood grouping and compatibility testing are specifically detailed in the "Blood Transfusion Section", and the minimum requirement for Cervical Cytology is detailed in the Cellular Pathology section. Before accepting a clinical specimen, laboratory staff must ensure certain minimum criteria for sample identification are met. It is the responsibility of the requesting clinician to ensure that samples are correctly labelled and request forms completed to the agreed standard thereby ensuring the safety of the patient. Sample and request form information MUST be compatible. The ESSENTIAL data required on SAMPLES are: NHS NUMBER PATIENT'S FULL NAME DATE OF BIRTH AND/OR HOSPITAL NUMBER The ESSENTIAL data required on REQUEST FORMS are: NHS NUMBER PATIENT'S FULL NAME DATE OF BIRTH AND/OR HOSPITAL NUMBER DESTINATION FOR REPORT PATIENT'S CONSULTANT OR GP The clinical information, date and time the sample is collected (which sometimes becomes ESSENTIAL), patient's address, sex, signature of requesting Clinician and Clinician's bleep number are also desirable. Barcodes on the sample DO NOT replace full sample labelling and MUST be identical to barcodes on the request form Use only SMALL specimen labels on samples. Laboratory staff are instructed NOT to amend details on either the sample or request form. Where patients are sent to the hospital for phlebotomy it is the responsibility of the requesting clinician to ensure request forms provided by reception staff comply with the above criteria. Samples or request forms received without the minimum essential identification criteria outlined above WILL be referred back directly to the requesting Clinician immediately. Subsequent action must reflect the purpose for which the specimen was intended. This may include: Sealing the sample and storing it. Requesting a fresh sample and request form. Unlabelled samples will not usually be processed. In cases where an inadequately labeled request form or sample is received from a patient who is not easily accessible for a repeat sample, then, at the discretion of senior laboratory staff, the sample may be processed with a disclaimer, detailing the shortcomings of the sample and/or request, CLEARLY INDICATED ON THE REPORT. The disclaimer WILL alert the requesting Clinician to take responsibility for the results and for any action taken as a result of the report. Telephoned results obtained on samples falling into this category WILL be conveyed to the requesting Clinician who MUST accept responsibility. Confirmation of this acceptance, bearing the name of the Clinician WILL appear on the report form. The final laboratory report WILL clearly indicate any action consequent to the occurrence of inadequate labeling. SPECIMEN COLLECTION Phlebotomy A Phlebotomy service for inpatients is provided during the following periods: - Morriston HospitalMonday - Friday08:00 - 11:30Saturday08:00 - 11:30Sunday / Bank Holiday08:00 - 11:00 Singleton HospitalMonday - Friday08:00 - 12:00Saturday08:00 - 11:00Sunday / Bank Holiday08:00 - 10:30 Neath Port Talbot HospitalMonday - Friday08:30 - 11:00Saturday08:00 - 11:00Sunday / Bank Holiday08:00 - 11:00 Saturdays, Sundays and Bank Holidays are limited services. EVACUATED BLOOD COLLECTION SYSTEM  An evacuated plastic tube containing a pre-measured vacuum to provide a controlled pre-specified draw. A holder that is used to secure the needle during insertion into the vein and subsequent sample collection. A sterile single-use blood collection needle suitable for drawing either single or multiple samples. If samples are collected by needle and syringe DO NOT inject sample into the specimen container through the rubber stopper as this may lead to haemolysis. Remove the needle from the syringe using forceps, remove the stopper and gently add the blood to the required level. General Instructions for Evacuated Tube Use Wearing gloves during venepuncture and when handling blood collection tubes can minimise exposure to hazards. Open needle package but do not remove needle shield. Screw needle onto holder. Tubes that contain additives should be gently tapped to dislodge any additive that may be trapped around the stopper. Insert tube into holder. Push tube stopper onto needle until leading edge of stopper meets guideline of holder. Tubes will retract slightly. LEAVE IN THIS POSITION Perform venepuncture as normal. Push tube to end of holder, puncturing the diaphragm of the stopper. Remove tourniquet as soon as blood appears in the tube. Do not allow contents of tube to contact the stopper or the end of the needle during the procedure. When the first tube is full and blood flow ceases, remove it from holder. Place succeeding tubes in holder, puncturing diaphragm to initiate flow. Tubes without additives are drawn before tubes with additives. While each successive tube is filling, invert the previous tubes containing additive 8 - 10 times. Do not shake - vigorous mixing can cause haemolysis. DO NOT resheath needle , dispose of both the needle and holder into an appropriate sharps disposal container A tube colour guide is available from the laboratory. Order of Draw of Evacuated Tubes Blood culture bottles, sterile tubes Tubes without additives Tubes containing Gel Tubes for coagulation studies Tubes with additives:- Pink/lavender stoppers Black stoppers Grey stoppers NOTE that serum or plasma Zinc level will show misleading elevation due to the presence of Zinc in the stopper. Special tubes for Trace Element Studies (dark blue stopper) are available from the Chemical Pathology Department. HIGH RISK SAMPLES Anyone responsible for taking and/or dispatching specimens or other potentially hazardous material for laboratory examination has duties under the Health and Safety at Work Act (HSWA) and the COSHH Regulations to conduct the work safely. One specific requirement (covered by section 3 of the HSWA) is to convey knowledge of known or suspected hazards to those who need to handle any material that is sent for examination. All samples in this category MUST be sent to the laboratory in one of the sealable, plastic transport bags. These are provided on the wards and departments. The request form should be placed in the separate pocket. Both the request and the specimen MUST be labelled DANGER OF INFECTION with the special yellow label provided. The medical officer taking the sample must ensure that a senior member of the department is informed of the impending arrival of the sample on which only the most appropriate tests will be performed. Prior consultation with the consultant pathologist concerned is advisable. VACUUM TUBE TRANSPORT SYSTEM Each hospital site has a vacuum tube transport system that can be used for sending samples to the Pathology Laboratories. Specific site instructions are available at each station. The tube system must NOT be used to send blood culture bottles , blood gas or CSF samples. High Risk Samples may be transported in the large diameter system at Singleton Hospital and Neath Port Talbot Hospital provided they are enclosed in a rigid secondary container in the pod. PATHOLOGY RESULTS ENQUIRY FOR WARD USERS Ward users can have access to the Pathology computer system for results enquiry, provided the following points are observed: Access only those pathology results as appropriate for the care of your patients. Preserve patient confidentiality. Log-off the system as soon as you have finished. Keep your password secret. New medical staff are usually provided with a username and password in their induction packs, or shortly thereafter. Otherwise, you can apply for a username at any time by completing an application form available from Medical Personnel or any Pathology office, or by contacting the number below. Passwords for existing accounts can be reset by contacting the number below. Training on how to use the system is given at the new doctors' induction, or as required. Full instructions are also sent with the username and password details. Some brief tips are shown below: The pathology computer is case sensitive and some functions only work in capitals, so put the keyboard into UPPER case by pressing the CAPS LOCK key on your keyboard. Patients can be searched for by Hospital or NHS numbers, or by invoking a name search by entering S in the Patient Number field. To choose a patient or specimen from a list, or access a result box on an area of the screen, type in the number displayed next to it. To move up or down lists of patients or specimens use the cursor keys or Enter or F2 to go down or up respectively. Results spanning more than one page show a confusing prompt at the bottom right of the screen, e.g. "Page 1 of 2: Multivalue Action". Use the following keys to navigate: Move forward one page: F Move to end of list if more than two pages: FF Move back one page: B Move to start of list: BB Cancel / Exit F1 F1 will quit from any screen, return you from the Multivalue Action prompt to the options, clear any messages, and also log-off your session if you press it repeatedly. Options are displayed when available at the foot of the screen. To choose an option, type the highlighted letter(s), e.g. type P for the PrevRes option - this will display previous results in a tabular format to view trends easily. Phil Morris, Pathology Computer Manager Morriston 4007  HYPERLINK "mailto:phil.morris@swansea-tr.wales.nhs.uk" phil.morris@swansea-tr.wales.nhs.uk ELECTRONIC RESULTS REPORTING TO GENERAL PRACTICE (Path Links) Most Pathology tests are reported electronically to the 60 practices that we serve in the Swansea, Neath Port Talbot, and Powys LHB areas. There may be differences according to primary care system, but most Chemical Pathology, Haematology, Bacteriology, and Virology results are sent electronically soon after they are available, often on the same day that we receive the specimen. We can only send reports to GPs when either the GP has requested the analyses, or a specific GP and surgery has been indicated as a copy-to location on the request form. The quality of the Pathology requesting and reporting process is greatly enhanced if GPs use their Pathology codes on the request forms. Your Practice Manager should have a copy of these, otherwise please use the contact details below to discuss this further. Additionally, we can supply blank A5 paper to those Practices wishing to use an approved template for self-printed request forms that are automatically populated with patient's details. Results are sent via the NHS Data Transfer Service (DTS), and are held in specific Practice mailboxes until collected by the Practice computer systems. Electronic results are generated daily at 07:00 and then hourly between 12:30 and 17:30, but the time that a Practice actually receives them depends on when their system collects them from their DTS mailbox. Troubleshooting and Error Reporting: The majority of errors are caused by the Practice system not collecting results from their DTS mailbox. If your Practice has not received any results and some were expected, please follow your local troubleshooting procedures or call your system supplier before contacting the Pathology. If there is a problem in the laboratory that will cause a significant delay in result transmission, all Practices will be notified by email when possible. For general Path Links enquiries, Read-coding issues, or requests for new GP codes, please email the address below. For misdirected reports, please email the specimen number (also called the Provider Ref. on some systems) of the erroneous report: no patient-identifiable information need be sent if the specimen number is correct. Phil Morris, Pathology Computer Manager  HYPERLINK "mailto:phil.morris@swansea-tr.wales.nhs.uk" phil.morris@swansea-tr.wales.nhs.uk CHEMICAL PATHOLOGY SERVICE The Chemical Pathology Service to all hospitals and clinics in West Glamorgan is provided from a central laboratory in Morriston Hospital. Small laboratories are maintained in the other major hospitals to carry out urgent work. Telephone Numbers Routine Enquiries 3046 Secretary 3988 Information, advice & interpretation: Duty Biochemist 3036 or 703036 (direct line) Consultant Chemical Pathologist 3987 or 703987 (direct line) Consultant Chemical Pathologist 4909 Clinical Scientists' Office 3994 Requesting To simplify requesting, a number of profiles are available. Most of them can be selected by using the tick-box part of the request form. Provision of full clinical information is extremely helpful. U&E Sodium, potassium, chloride, bicarbonate, urea and creatinine. N.B. Glucose - requires a separate Grey top vacutainer. Liver Function Tests. Total protein, albumin, bilirubin ,ALT, Alkaline Phosphatase and serum calcium. Lipids Cholesterol, triglyceride. HDL and LDL cholesterol. Thyroid function tests TSH and Free T4. Free T3 is provided as a second line test when necessary. Please state if the patient is on thyroxine, carbimazole, propylthiouracil, lithium or amiodarone. DAR (Diabetic Annual Review) profile Urine for microalbumin, EDTA (purple top) for HbA1c, fluoride oxalate (grey top) for glucose and clotted (gold top) sample for lipids and creatinine. Complete ONE request form for all Chemical Pathology tests that are required on the patient at any one time. Reports Reference values (normal ranges) appear on all reports. Reports are supplemented by general guidance on interpretation and by detailed comment when appropriate. Urgent Requests All work that needs to be given priority or where a report by telephone is required MUST be arranged with the laboratory by telephone. Instructions are on the reverse of the request form. At Singleton Hospital Tel 5037 At Morriston Hospital Tel 3052 At Neath General Hospital Tel 2226 Requests Out-of-Hours Chemical Pathology: Routine hours are 08.45 a.m. to 5.00 p.m. on weekdays. Outside these hours a reduced service operates. It is not necessary to ring to arrange analyses (except for blood gases and tests not normally offered out of hours). Work received will usually be processed and results available on the ward enquiry terminals within 2 hours (3 hours between 11.30 pm and 8.00 a.m.). More rapid analysis can be arranged if required for the immediate management of patients by ringing Morriston 3052, Singleton 5037 or Neath 2226. Even though the 11.30 p.m. to 08.00 a.m. service in Neath and Singleton is provided from Morriston with regular scheduled transport, these numbers apply 24 hours a day 365 days a year. In general, any investigation that is necessary will be provided, but if the test is complex or time consuming, the requesting doctor may be asked to discuss the request with the consultant or clinical scientist "on-call". Contact with "on-call" staff should be made through the hospital switchboard. Useful Information 1. SAMPLE COLLECTION Most tests and profiles can be done on a 5ml SST "gold top" vacutainer. If a large number of tests are needed ( i.e. more than 5 ), it is advisable to fill two vacutainers. There are a number of investigations that require special collection procedures or patient preparation, including those listed below. Investigations that require prior contact with the lab have been marked with (. A print-out of sample requirements for Paediatric patients can be provided upon request. If in doubt please ring Ext.3036 at Morriston. AlcoholFluoride oxalate (grey top) vacutainerAldosterone (& Renin) (2 lithium heparin (green top) vacutainers. Contact lab for collection protocol. Transport to lab immediately after collection. Please supply full drug history.AluminiumSodium heparin (navy blue top) vacutainer.Ammonia (Paediatric patients only. Lithium heparin (green top) paediatric tube. Transport to lab on ice.Bence-Jones proteinRandom urine. Plain (white top) universal container.Catecholamines24 hr acid urine collection. Acidified universal container for paediatric patients. Please supply full drug history.Carboxyhaemoglobin (carbon monoxide)Lithium heparin (green top) vacutainer.ComplementSST (gold top) vacutainer.Urinary free cortisol (UFC)24 hr urine (plain container).Creatinine Clearance24 hr urine collection, plain container, and a clotted (gold top) blood sample.Cryoglobulin (Please contact lab for detailsCyclosporinEDTA (purple top) vacutainer. Collect sample just before dose is given.Gastrin/gut hormone profile (Patient must be fasting. Special blood preservative required - please contact lab. Transport to lab immediately after collection. Please supply full drug history.GlucoseFluoride oxalate (grey top) vacutainers or yellow top paediatric tube.Haemoglobin A1cEDTA (purple top) vacutainer.5 Hydroxyindoleacetic acid (5HIAA)24 hour urine collection (plain container)Insulin (Lithium heparin (green top) or SST (gold top) sample. Hypoglycaemia must be documented. Please send additional fluoride oxalate (grey top) vacutainer for glucose analysis. Transport to lab immediately after collection (sample must be separated within 30 minutes).LactateFluoride oxalate (grey top) vacutainer or yellow top paediatric tube.LithiumGold top vacutainer. Sample should be collected 12 hrs post dose.Oligoclonal BandsCSF sample in white capped universal and blood in a Gold topped vacutainer.Porphyrins (Depending on clinical details, samples may include EDTA (purple top) blood, random urine (plain container) and faecal sample. Samples should be protected from light (e.g. wrap tubes in foil). Phone lab for advice on appropriate tests.Parathyroid Hormone (PTH)SST (gold top) vacutainer. Transport to lab immediately after collection (sample must be separated within 2 hours).Renin (& Aldosterone) ( 2 lithium heparin (green top) vacutainers. Contact lab for collection protocol. Transport to lab immediately after collection. Please supply full drug history.XanthochromiaCSF sample in brown glass vial, and blood in Gold topped vacutainer.ZincSodium heparin (navy blue top) vacutainer. DYNAMIC FUNCTION TESTS (e.g. Synacthen test, insulin stress test) Send samples (apart from glucoses) to lab together. Samples should all be clearly labelled with the time of collection. Please notify lab (ext 3052) before performing dynamic function test. Please contact lab at least 3 days before performing water deprivation test so appropriate arrangements can be made. If a glucose tolerance test is performed on the ward or in the surgery, it is essential that the type of sample (capillary or venous) is stated on the request form as this will affect interpretation. TOXICOLOGY & DRUGS OF ABUSE There are a small number of drugs for which the concentration after overdose is a guide to specific therapy, e.g. paracetamol, salicylate, iron and lithium. Information is available in the BNF (emergency treatment of poisoning). Please notify lab of the time since overdose. Biochemical confirmation of overdose is additionally available for digoxin, theophylline and some anticonvulsants. Treatment with "Digibind" in cases of digoxin toxicity interferes with digoxin assays. Urine testing for drugs of abuse is performed for clinical management only. If drugs testing is required for any other reason, e.g. employment screening, then please contact the lab for advice before sample collection. CELLULAR PATHOLOGY SERVICE. The department provides the histopathology and cytopathology service to Morriston, Singleton and Neath General Hospitals, to their associated hospitals and to the general practitioners in the respective catchment areas. Opening times. The department is open Monday to Friday 08.45 to 17.00. The departments work consists of three main areas: (I) The processing and reporting of histology specimens (25,000 p.a.), including intraoperative frozen sections, from the wide range of surgical specialties represented on the three main hospital sites together with a large volume of endoscopic biopsies and many samples from GPs. (ii) A comprehensive cytology service (30,000 specimens p.a.) including fine needle aspiration cytology and cervical screening. (iii) Autopsies performed at the request of clinicians with relatives consent = permission cases (approx. 55 p.a.) and those requested by HM Coroners (approx. 550 p.a.). The service is provided on the two main sites at Morriston and Singleton Hospital where all processing is carried out and 9 consultant pathologists are based between the two sites. A satellite service is provided at Neath General Hospital where a consultant pathologist is present each week day morning for clinical consultation, to report urgent fine needle aspiration cytology and frozen sections and to perform autopsies. Request Forms The request form must contain full patient details and as much clinical information as possible. The laboratory should be notified of any potential risk of infection i.e. T.B., hepatitis B and C, HIV, CJD and specimens and forms labelled with biohazard stickers. Specimens and request forms should be placed in the plastic bags provided. Histopathology Gross specimens and biopsies are usually received in 10% buffered formalin , which must be about 20, times the volume of the tissue. The bottles and buckets used to transport the specimens must have well fitting lids to prevent leakage, and be properly labelled. Containers of various sizes are available from the Singleton and Morriston histology departments. Formalin is a moderately flammable liquid when exposed to heat or naked flame. It is a known carcinogen, a strong eye, skin and mucous membrane irritant and a skin sensitiser and may be fatal if swallowed. Full health and safety data is available from the laboratories. Spillage absorption granules should be present in any department using formalin together with instructions for their correct use; again information is available from the laboratories. Most cases will be processed and reported on within 36hrs of receipt. Cases labelled urgent will be reported by phone, other reports will be delivered by mail. Frozen Sections The specimen must be sent dry. In general at least 24hrs notice should be given to ensure that the pathologist will be available, and any unusual requests can be discussed with the surgeon performing the operation. Muscle Biopsy These usually require specialised processing. These are not processed at Swansea and should be sent to UHW in Cardiff by the requesting clinician. Lymph Node Biopsy The following advice applies to cases where lymphoma is in the differential diagnosis. Molecular diagnostic methods are increasingly important in the diagnosis of lymphoma. These methods are facilitated by the availability of snap frozen, fresh, unfixed biopsy material. Therefore these specimens should be sent as quickly as possible to the laboratory unfixed, in a dry container. The request form should make it clear that lymphoma is suspected, and some advance warning to the laboratory would be helpful. The following exceptions to this procedure should apply: ( i ) Very small biopsies i.e. needle biopsy samples, should be fixed in formalin in the usual way. ( ii ) Any procedures carried out at night or on holidays or weekends, where delay in handling the specimen is inevitable, should also be fixed in formalin in the traditional manner. Renal Biopsy Should be sent immediately to the laboratory. Any delay may compromise the quality of the investigation. Unusual Specimen Any special requests please discuss with laboratory. Wales Cancer Bank. Tissues are received fresh from theatre after the Pathology Nurse receives consent from the patient. Cytology Most fluids, urines, pleural fluids, etc should be collected in white capped universals and sent to the laboratory without delay. There is no great advantage in sending vast quantities of an effusion for cytological examination, generally four universals is considered to be a representative sample. Any non gynae fluids should be delivered to the laboratory before 4,30 p.m. on a Friday as there is no on call service therefore the sample would not be processed until Monday and the diagnostic viability of the sample would be compromised. Sputum Examination These should be early morning deep cough specimens sent on the day of production and collected into plain universal bottles. Fine Needle Aspiration Cytology Specimens should be sent to the department via the portering service as soon as possible. If a member of Cytology staff is required to assist in the collection please telephone the Cytology department to arrange. Cervical Cytology. Liquid Based Cytology. (LBC) Rotate the Cervex ( brush 360( five times in a clockwise direction. Detach the head of the brush and immediately place into a vial containing special preservative. In certain situations an endocervical sampler may be used. As with the brush head, detach head of endocervical sampler and place immediately into the vial. Secure lid to avoid spillage. Ensure cap is closed tightly. Place completed label (included in LBC kit) with patients details onto the vial. Put vial into clear plastic bag attached to HMR form and seal. Transport specimens to the laboratory in supplied transport bag (maximum 5 samples per bag). Request forms must be fully and accurately completed .The information supplied must be legible and comply with the following minimum data requirements: Full Name Date of Birth Patients full address (including post code) NHS number. Name and address of smear taker. Smear taker ID code. Name and address of General Practitioner. LBC supplies are obtained via Welsh Health Supplies ( Bridgend Stores 01656 641236) Autopsies Hospital Consent Cases If a consent post-mortem is required by the clinical team the following steps should be taken:- Provide relatives with the death certificate (N.B. if the cause of death is known the case should be referred to the coroner). Following the certification of death and completion of appropriate death certificate where a hospital post mortem is indicated, the following procedure must be adhered to for the completion of the new Consent to Post Mortem Forms: Adults. A Consent to a hospital post mortem examination on an adult form must be completed. (The new Consent forms can be found at ward level or obtained from the Patient Affairs Officer) As the procedure will require the consent of the next of kin, arrangements must be made to discuss completion of the Consent form with the deceaseds family as soon as possible. The next of kin must be given time to discuss this matter with other family members. The family / next of kin must be issued with the guide to the post mortem examination procedure information leaflet. A member of the medical team requesting the Post Mortem should be available to discuss the consent form and procedure with the relatives of the deceased. The family / next of kin should be taken, step-by-step, through each page of the consent form (pages 1 4). On completion of the form, you must ensure that the Consent form is appropriately signed by the next of kin and witnessed accordingly (page 5). The Consent form must then be signed by the member of staff seeking consent (page 6). Baby or Child: A Consent to a hospital post mortem examination on a baby or child form must be completed. (The new Consent forms can be found at ward level or obtained from the Patient Affairs Officer) Consent for the Post Mortem must be sought from those with parental responsibility. If the child was in care, the local authority may have parental responsibility. Wherever possible, discussion should be with both parents and both should sign the Consent form. If either parent is known to object, a post mortem examination should not be carried out. Written Consent from the Mother must be obtained for the examination of babies and fetuses delivered dead, regardless of gestational age. Those with parental responsibility must be issued with the guide to the post mortem examination procedure involving a baby or child information leaflet. A member of the medical team requesting the Post Mortem should be available to discuss the consent form and procedure with the parents or legal guardians. The parents or legal guardians should be taken, step-by-step, through each page of the consent form (pages 1 5). On completion of the form, you must ensure that the Consent form is appropriately signed by the parents or legal guardian and witnessed accordingly (page 6). The Consent form must then be signed by the member of staff seeking consent (page 7). General information for both Adult and Child consent. Once the Consent form has been signed, the copies must be distributed as follows: Blue top copy of each page to be given to the parent or legal guardian Pink duplicate copy of each page to be placed in the medical records Yellow duplicate copy of each page must be sent to the Mortuary Please be aware of familys wishes should the family indicate any particular wishes in connection with the Post Mortem Procedure, this should be indicated on the Consent form (section 6). Should Consent be subsequently withdrawn each page of each copy of the Consent form (or relevant section) must be clearly struck through. the person recording the withdrawal should sign and date the Consent form and note the action taken to inform the Mortuary. i.e. date, time and name of member of Mortuary staff Please contact the laboratory to speak to the consultant pathologist involved if further information regarding the extent of PM and the possible need to retain organs are required. Inform the mortuary. Singleton extension 5063, Morriston extension 3250 and Neath extension 2100. Dispatch the notes, completed request forms and completed permission form to the mortuary. If you require any further assistance / guidance on the completion of the new Consent forms, please contact the appropriate Patient Affairs Officer: Singleton - Ext: 5128 (Bleep 5638) Morriston Ext: 3114 (Bleep 3578) 2. Coroners Cases. If the cause of death is not known or the death is thought to be unnatural please inform the relevant coroner's officer phone #6 243 and ask for relevant coroner's officer i.e. Neath/Port Talbot/Swansea. If in doubt, discuss the case with your senior colleagues or contact one of the histopathologists. If the coroner requires an autopsy to be done, his officer will make the necessary arrangements. Preparation of a short clinical summary is of great assistance to the pathologist. The clinical notes should be dispatched to the Mortuary as seen as requested. Clinical staff involved will usually be contacted to discuss the findings with the pathologist. Post Mortem reports are dispatched to the relevant consultants and general practitioners subject of course to the coroner's agreement, in coroners cases. Death Certification and Cremation Forms The cause of death should be formulated in a logical sequence, proceeding from the immediate cause of death in I (a) to the underlying pathology in I (b) and I (c). If a cremation forms is required the doctor completing part B should ensure that they are available to discuss the case with the doctor completing form C and should arrange with the mortuary staff to view the body. A fee is payable and should be collected promptly from the mortuary when available. Please endeavour to complete death certificates and cremation forms as promptly as possible in order to facilitate bereaved relatives. Please discuss any problematic cases with the Consultants in cellular pathology who will be pleased to help you. Telephone numbers. MorristonMain Laboratory3044Main Office3050Consultant PathologistDr C J O`Brien3043Dr A Dawson3016DR P Griffiths 3319Mortuary3250SingletonCytology Laboratory5018Histology Laboratory5022Main Office5023Service Manager/ Head BMSChristine Davies5020Consultant PathologistDr S Williams5013Dr N Williams5016Dr W Williams5015Dr N Toffazal6323Dr V Shah5017Dr H Thomas6351Mortuary5063Neath/Port TalbotPathologists Office2217Mortuary2100 HAEMATOLOGY SERVICE The work of the Haematology department in West Glamorgan is shared between the three laboratories based at Morriston, Neath and Singleton Hospitals. Although each laboratory performs routine investigations for its base hospital, those of a specialised nature are referred to a laboratory in the district where special equipment and expertise relevant to the field of work is concentrated e.g. Morriston Specialised coagulation investigations Investigation of haemoglobinopathies Antenatal serology Singleton Vit B12, Folate, Ferritin Red Cell Mass. Rheumatoid investigation, ANF Anti-ds DNA organ antibodies Cell surface markers. HAEMATOLOGY DEPARTMENTS Morriston (71) 3033 Singleton (71) 5080 Neath (71) 2223 Full Blood Count (FBC) Specimens for FBC are processed on technologically advanced analysers, which produce a haematology profile including a five-population differential white cell count. Those with normal results or where clinical details do not indicate further investigations will usually be reported within 3-4 hours of receipt. Where indicated, film examinations will be reported without a specific request. Most urgent requests can be completed within 15 minutes of receipt of the specimens in the laboratory. Grossly abnormal and life threatening results will be telephoned regardless of a request to do so. The development of ward terminal links allows access to authorised pathology reports. PHONING RESULTS IS VERY TIME CONSUMING - PLEASE DO NOT ASK FOR THIS SERVICE UNLESS IT IS REALLY NECESSARY. E.S.R ESR estimations are available. Bone Marrow Aspirates and Trephine. Bone marrow aspirations should be performed by a medical officer. A member of the Haematology staff will attend to spread films of the marrow specimens. Please telephone the department in advance to arrange a suitable time. If you are unable to keep the arranged time please inform the laboratory as soon as possible. Advise ward and ensure trolley is set up with B M aspiration set available. Reference Ranges Erythrocytes HaemoglobinRBCHaematocritMCVMCHUnitsg/dlx1012/11/1flpgChildren (3-12yrs)11.0 15.03.8 - 5.50.36 0.4581 9125 32Male13.7 - 17.24.5 - 5.60.40 0.5083 9828 33Female12.0 - 15.23.9 5.10.37 0.4685 9828 33 Leucocytes (x109/l) Adults3.6 9.2Full term infants10.0 25.0Infants (1 Year)6.0 18.0Children (4 7 years)6.0 15.0Children (8 12 years)4.5 13.0 Differential Leucocyte Count (x109/l) AdultChildren(6Yrs)Neutrophils1.7 6.22.0 - 6.0Lymphocytes1.0 3.45.5 - 8.5Monocytes0.2 - 0.80.7 - 1.5Eosinophils0.00 - 0.40.3 - 0.8Basophils0.00 - 0.1<0.01 - 0.1 Platelets (x109/l) Cord Blood & Infants140 450Adults Male140 320Adults Female 180 - 380MPV (fl) Male9.4 12.2MPV (fl) Female9.2 12.9PDW15.5 17.5 Reticulocytes % of erythrocytesabsolute (x109/l)Adults & Children0.2 2.020 - 80Infants (Cord Blood)2.0 6.0100 - 250 ESR Age (Yrs)MaleFemale0 171 101 1018 501 103 1251 603 124 19 61 - 982 145 - 20 HAEMATINIC ASSAYS. Singleton (71) 5081 Samples required 1 clotted (yellow top) and 1 EDTA (purple top). Serum Vitamin B12 and Folate. Normal Ranges: Vitamin B12 Male 113 - 567 pg/ml Female 136 - 600 pg/ml Folate Male 2.1 - 14.7 ng/ml Female 2.7 - 18.1 ng/ml Parietal cell and intrinsic factor antibodies are done on all vitamin B12 results that are less than 145 pg/ml Red Cell Folate Only done if serum folate is <2.5 ng/ml Normal Range: >165 ng/ml Serum Ferritin Normal Ranges: Male 11 - 215 ng/ml Female 5 - 119 ng/ml IN-VIVO ISOTOPE TESTS Singleton (71) 5074 In-vivo isotope tests are only performed after consultation with a Consultant Haematologist. Blood Volume Studies. Measurement of Red Cell Mass from which Plasma Volume and Total Blood Volume are calculated. LYMPHOCYTE MARKERS / IMMUNOPHENOTYPING Singleton (71) 5074 These tests are only performed following discussion with a Consultant Haematologist. Appointments should then be made via the laboratory on extension 5074. CD4/CD8 counts. Lymphocyte sub-sets Lympho-proliferative disorders Acute leukaemia and other haematological neoplasms Singleton (71) 5074 Sample required 1 clotted (yellow top) bottle for each test. When requesting these tests please specify which antibody is required and include clinical details. Requests for Autoantibodies will only have rheumatoid and anti-nuclear antibodies done. Rheumatoid antibodies. IgG Particle agglutination. Reported as Positive (with titre) or Negative. Anti-Nuclear Antibodies (ANA). IgG Indirect Immunofluorescence. Reported as Positive (with titre) or Negative. Specific ANA patterns will be identified, which include: Homogenous Speckled Nucleolar Centromere All positive ANA results, ( 1: 80 have anti ds-DNA antibodies and ENA screen performed automatically. Anti dsDNA Antibodies. IgG ELISA test. Normal range 0 20 IU/ml Liver Antibodies. IgG Indirect Immunofluorescence. Anti Mitochondrial Antibodies (AMA). Reported as Positive (with titre) or Negative. Anti Smooth Muscle Antibodies (ASMA). Reported as Positive or Negative. Anti Neutrophil Cytoplasmic Antibody (ANCA) IgG Indirect Immunofluorescence. Reported as Positive (with titre) or Negative. Specific ANCA patterns will be identified: c-ANCA p-ANCA Atypical ANCA All positive ANCA results are further tested for MPO and PR3 antibodies. Gastric Antibodies. Parietal Cell Antibodies. IgG ELISA. Reported as Positive or Negative. Intrinsic Factor Antibodies. IgG ELISA. Reported as Positive or Negative. Anti Cardiolipin Antibodies (ACA). IgG and IgM ELISA test. Normal Range: IgG 0 10 GPLU/ml IgM 0 7 MPLU/ml Thyroid Peroxidase Antibodies. IgG ELISA test. Normal Range: 0 75 IU/ml Coeliac Serology. Tissue transglutaminase antibodies (TTG). IgA ELISA test. Normal Range: 0 15 U/ml TTG is thought to be the best screen for coeliac disease. Negative results may occur in IgA deficiency. Active coeliac disease can occasionally occur without positive antibody tests. Equivocal and positive TTG results are checked by IgA endomysial antibodies. Anti Centromere Antibodies. See Anti Nuclear Antibodies. Antibodies to Extractable Nuclear Antigens (ENA) IgG ELISA screening test. Reported as Positive or Negative. Positive screening tests are further tested for the 6 ENAs: Ro (SSA) La (SSB) RNP Sm Scl-70 Jo-1 A service is provided for the following specialist autoantibody tests, where serum is forwarded to the appropriate accredited reference laboratory: Glomerular Basement Membrane (GBM) Liver/kidney/microsomal (LKM) Cardiac/striated muscle Adrenal cortex Pancreatic Islets Neuronal (Hu/Yo/Ri) Ganglioside (GM1/GQ1b) Glutamic acid decarboxylase (GAD) Myelin associated glycoprotein (MAG) Voltage gated Ca2+ or K+ channel Beta 2 Glycoprotein 1 Histone Pemphigus Bacterial (HIB, Pneumococcus, Tetanus) Meningococcal Neutrophil (Please contact laboratory before requesting) Platelet (Please contact laboratory before requesting) If autoantibodies not listed above are required please indicate which laboratory performs the required test. COAGULATION Morriston (71) 3034 Singleton (71) 5080 Neath (71) 2223 Basic coagulation tests (PT, APTT, Coag Screen) are available on each site, with more specialised work being carried out on the Morriston site. Requesting Requests should be made on the red Haematology forms. It is vital that relevant clinical details are provided. This includes whether the patient is on any anticoagulants. This is essential to reduce the amount of unnecessary follow-up testing. Reports Reports are printed and despatched daily. Normal ranges are quoted on reports. Enquiries Please use the pathology computer to make result enquiries. Urgent requests If results are required urgently, telephone the laboratory in advance. Do not use the daily phlebotomy service for urgent requests. Please make other arrangements to get the sample to the laboratory urgently. Out-of-hours requests All urgent requests arriving between 17.00 and 08.45 will be processed. There is only a need to contact the on-call biomedical scientist if there is a particular urgency. Requests after midnight should be kept to an absolute minimum. Haemophilia Centre This is based in Singleton Hospital. There is a haemophilia clinical nurse specialist available Mon-Fri 09.00 17.00 hrs. Telephone ext. 5648 or bleep 5563. Coagulation Sample Collection Coagulation tests are sensitive to pre-analytical variables. It is vital that samples are collected by non-traumatic venepuncture. The sample tubes are designed to be used by the evacuated tube technique, and must be filled to the correct level: this is determined by the vacuum in the tube. Underfilled and overfilled tubes can lead to erroneous results. TestSample(s) requiredAverage TurnaroundPT/INR1 BlueSame DayAPTT ratio1 BlueSame DayCoagulation Screen1 BlueSame DayLupus Anticoagulant2 Blue + 1 Yellow1 MonthD - Dimer1 Blue24 HoursFactor Assays1 Blue1week(Heparin-Platelet Factor 4 antibodies (1 Blue + 1 Yellow24 hours Thrombophilia Screen((4 Blue, 2 Mauve, 1 Yellow1 MonthAnti Xa Assay ( Low MW Heparin )(((1 blueSame day Other Investigations Bleeding Times, and Platelet Function Tests are arranged via a Consultant Haematologist only * Factor assays- turnround time 1 week, unless required urgently. ** Thrombophilia screens comprise the following: Protein C, Protein S, Antithrombin III, Lupus Anticoagulant, Prothrombin G20210A mutation and Activated Protein C Resistance (APCR). Only those samples with APCR value below the cut off value are specifically tested for the Factor V Leiden mutation. *** Anti- Xa assays are available for selected patients to monitor Low Molecular Weight Heparin, Unfractionated Heparin and Danaparoid. Please specify which type of heparin the patient is receiving, as this affects how the test is calibrated. ( Screening for Heparin-Platelet Factor 4 Antibodies- found in Heparin Induced Thrombocytopaenia. Requests for this test must be discussed with a consultant haematologist. Samples must be in the laboratory by 9:00 am. Thrombophilia Thrombophilia screens should not be requested immediately after a thrombotic event, when haemostasis is deranged. Coagulation factors may be raised or reduced as a result of a thromboembolitic event. It is preferable to test during a more stable period, and at least two weeks after discontinuation of anticoagulant therapy. Which patient to refer for thrombophilia screen The following patients should be considered for referral to the haematology department for full assessment and thrombophilia screen First episode or previous episode before age 40 45 years Recurrent venous thrombosis or thrombophlebitis Thrombosis in an unusual site e.g. Mesenteric vein, cerebral vein etc Unexplained neonatal thrombosis Skin necrosis, particularly if on oral anticoagulants Arterial thrombosis before age 30 years Relatives of patients with thrombophilic abnormality Patients with a clear family history of venous thrombosis Unexplained prolonged APTT Patients with recurrent foetal loss, idiopathic thrombocytopaenia or SLE THE ANTICOAGULANT CLINIC (Singleton & Morriston) The anticoagulant control clinic is held daily between 8:30 am and 11:30am. There is a specialist nurse in attendance at each session offering advice and guidance to patients with warfarin related problems. (Anticoagulant nurse specialist Morriston Bleep 3970, Singleton Bleep 5563. ) New anticoagulant referrals are seen daily between 9:00am and 11:30am at Singleton hospital and Tuesday and Thursday mornings at Morriston hospital. These new patients should on the first and subsequent visits present an anticoagulant record book, which bears all the relevant information, requested on each page. A copy of the discharge summary addressed to the clinic is essential. This must provide full clinical details, the indication for treatment and the duration of the treatment. The anticoagulant clinic should be notified of any medication likely to influence anticoagulant treatment. Please notify Morriston Anticoagulant Clinic on Ext 3079 of all new patients that are to be referred to the clinic. The Anticoagulant clinic at Neath hospital is a pharmacy led service under the auspices of the Consultant medical staff. Contact Ext (71) 2223 for details of these clinics. It is vital that particular attention is paid to discharge and follow-up arrangements for patients on anticoagulant therapy. Therapeutic Range for INR (Recommended in the Guide Lines on Oral Anticoagulation, British Society for Haematology - 1998). INDICATIONS FOR ANTICOAGULATIONINDICATIONTARGET INRPulmonary embolism2.5Proximal deep vein thrombosis2.5Calf vein thrombosis2.5Recurrence of venous thromboembolism when no longer on Warfarin Therapy2.5Recurrence of venous thromboembolism whilst on Warfarin therapy3.5Symptomatic inherited thrombophilia2.5Antiphospholipid syndrome3.5Non Rheumatic Atrial Fibrillation2.5Atrial fibrillation due to Rheumatic Heart disease congenital Heart disease Thyrotoxicosis2.5Cardioversion2.5Mural Thrombus2.5Cardiomyopathy2.5Mechanical Prosthetic heart valve3.5Bioprosthetic valvenot indicatedIschaemic stroke without Atrial fibrillationnot indicatedretinal vessel occlusionnot indicatedperipheral arterial thrombosis & graftsnot indicatedcoronary artery thrombosisnot indicatedcoronary artery graft thrombosisnot indicatedCoronary angiopathy and stentsnot indicated ANTICOAGULANT SCHEME Day 1-5 Heparin Infusion Day 3 onward Warfarin DAY 1 Check baseline APTT and INR. Heparin loading doses 5000 units. Then infuse 1400 units/hr. Check APTT after 4-6 hrs of infusion and daily thereafter. Adjust infusion rate to keep the APTT to 1.5-2.5 times the control (APTT ratio). N.B. LOW MOLECULAR WEIGHT HEPARIN is controlled by Factor Xa Assay by arrangement with laboratory (Morriston) DAYS 2-5 (9-10am) Check APTT and adjust Heparin infusion. DAY 3 (9-10am) Check APTT and INR. (4.00pm) Loading dose of Warfarin (10mg). DAYS 4 AND (9-10am) Check APTT and INR. (4.00pm) Warfarin as per schedule. DAY 6 (9-10am) Check INR ONWARD Warfarin as per schedule HEPARIN SCHEDULE APTT Patient = APTT Ratio APTT Control Therapeutic Range of APTT Ratio is 1.5 - 2.5 Loading Dose = 5000 units over 5 minutes Start at 1400 units/hour e.g. 8400 units in 100ml over six hours. Check APTT after six hours and adjust rate of infusion according to APTT ratio Check APTT thereafter at 4 6 hours after ratio change. APTT RatioInfusion Rate Change>7Stop for 30 mins to 1 hour and reduce by 500iu/hr.5.1 - 7.0Reduce by 500 iu/hr. 4.1 - 5.0Reduce by 300 iu/hr.3.1 - 4.0Reduce by 100 iu/hr.2.6 - 3.0Reduce by 50 iu/hr.1.5 - 2.5No change. *THERAPEUTIC RANGE1.2 - 1.4Increase by 200 iu/hr.<1.2Increase by 400 iu/hr WARFARIN SCHEDULE WARFARIN INDUCTIONDAYINRWARFARIN DOSE(mg) given at 5 7pmPRE-DOSE<1.410.>1.451st<1.8101.81 >1.80.5 2nd<2.010 2.0-2.15 2.2-2.34.5 2.4-2.54 2.6-2.73.5 2.8-2.933.0-3.12.5 3.2-3.323.41.53.513.6-4.00.5 <4.00 Predicted Maintenance Dose3rd<1.4> 8 1.481.57.51.6-1.771.86.51.962.0-2.15.52.2-2.352.4-2.64.52.7-3.043.1-3.53.53.6-4.034.1-4.5miss out next days dose then give 2mgs>4.5miss out 2 days doses then give 1 mg Reference Ranges Coagulation Prothrombin Time (PT)9.0 11.5 secsAPTT24.7 31.7 secsThrombin Clotting Time (TCT)13.8 17.4 secsFibrinogen (Clauss)1.6 4.2 g/lFibrinogen (Derived)2.1 4.9 g/lBleeding time (Simplate)2.0 9.0 minutesFactor II82 133%Factor V70 150%Factor VII60 164%Factor VIII48 - 204%Factor IX65 142%Factor X75 147%Factor XI61 142%Factor XII59 133% Lupus Anticoagulant Screen Kaolin Clotting Time Ratio (KCTTR)<1.2Kaolin Clotting Time Mix Ratio (KCTMR)<1.2Dilute Russell's Viper Venom Time Ratio(DRVVTR)0.9 1.10Anti-Thrombin III86 128%Protein C75 160%Protein S (Free)21 53%Protein S (Total)55 125%Activated Protein C Resistance (APCR)>2.0 BLOOD TRANSFUSION DEPARTMENT Morriston (71) 3054 Singleton (71) 5075 Neath (71) 2367 Blood samples for "Group and Save" are retained for 5 days and then discarded. If more than 48 hrs elapse between the previous transfusion and another being required, then a new sample must be taken to screen for antibodies that may have developed after the previous transfusion. There is a recommended blood-ordering schedule in operation, details of which are printed in the blood transfusion protocols, which are available on every ward. Blood for transfusion may only be ordered by Medical Staff, or specially trained registered nurses. 2. The person requesting the blood must complete the request form and sample tube. Addressographs can only be used on request forms. The sample tube must be hand written and signed by the person taking the specimen. Discrepancies between the form and blood samples will invalidate the request and both form and specimen will be returned to the person concerned to correct minor discrepancies, if the discrepancies are major the sample will be discarded. The patient should be identified by asking their full name, DOB and address. This should be confirmed by checking the information on the patients wristband. 3. The minimum requirements for identification for forms and samples for group and save/compatibility testing are as follows:-, Full Name, Address,Date of Birth and Hospital Number if available. Only in exceptional circumstances will samples be accepted that do not conform to these requirements. 4. The Blood Bank requires 1-day notice for all Cold Work" and half a working day notice for all theatre work. 5. It is advisable that all possible candidates for surgery should be grouped and screened on admission to the ward as this will allow time to provide blood for theatre should antibody problems be encountered. EMERGENCY CASES The Doctor should telephone the Blood Bank to explain the situation and that blood samples are being despatched. The sample and request form must be delivered directly to the Blood Bank so that they can be processed immediately. LOCATION OF COLLECTING FRIDGES Morriston Only On the day that the patients are in theatre, blood is kept in a fridge in the recovery room and is kept there until 9.00am the following morning when it us returned to the laboratory stock. (b) All units of cross-matched blood (other than for use in theatre) may be collected from the laboratory issue fridge, which is located adjacent to the Department of Pathology .There is a Blood Tracking system in place which records the time the units are removed from the issue refrigerator and by whom. Staff are only able to collect blood from the refrigerator after they have been trained by the transfusion co-ordinator and issued with an individual user ID by the blood bank staff. Singleton & Neath Hospitals All units of crossmatched blood are available from the blood issue fridge which is located in the department of pathology. Collection of Blood Blood should only be removed from the issue refrigerator when it will be transfused immediately. Ensure the patient is available, has been prescribed transfusion therapy and IV access is in place. Any blood left unrefrigerated for more than 30 minutes cannot be returned to the refrigerator and will be wasted. PRE-TRANSFUSION CHECK Before a unit is transfused there must be an identity check by any two persons (medical or nursing) who must acknowledge identification of the recipient by signing the printed report of cross-matched donor numbers, which is always attached to the first unit of blood or blood product to be transfused. This check should be performed at the bedside. TRANSFUSION REACTION INVESTIGATIONS If it is suspected that a patient has had a 'non allergic' reaction to donor blood, then the Blood Bank Staff should be informed. All the donor blood bags should be returned as part of the investigations. Blood should be collected from a vein other than the one used for transfusion. BLOOD TRANSFUSION PROTOCOLS These are available on each ward/ department and cover all transfusion issues. Telephone Numbers Dr Ann Benton Consultant Haematologist Singleton 5804 (Secretary: Jan Ace 6359) Morriston 4051 (Secretary: Jayne Gambold 3055) Dr S.Al-Ismail Consultant Haematologist Singleton 5079 (Secretary: Sharon Jeffreys 5024) Morriston (Secretary: Jayne Gambold 3055) Dr A Beddal Consultant Haematologist Singleton 6561 (Secretary: Sally Collis 5078) Morriston 3057 (Secretary: Jayne Gambold 3055) Dr A Salamat Consultant Haematologist Singleton 6364 (Secretary:) Morriston (Secretary: Jayne Gambold 3055) Dr H Sati Consultant Haematologist Singleton 6360 (Secretary:) Morriston (Secretary: Jayne Gambold 3055) Neath/Port Talbot 2213 Dr Salamat and Dr Sati Neath /Port Talbot- Haematology Secretary: Gaynor Mizon 2445 Dr R Munro Service Manager, Senior Chief BMS Singleton 5080 Morriston 4050 Mr C Russell Chief BMS Haematology Morriston 3032 Neath /Port Talbot 2214 Mrs B.Sullivan Chief BMS Blood Transfusion Morriston 3997 Ms S John Chief BMS Haematology Singleton 5076 Mrs W Kennedy Transfusion Co-ordinator Morriston 3996 Mrs K Shreeve Transfusion Co-ordinator (NBTS) Morriston 4005 Mrs W Abdullah CNS Anticoagulant Clinic Mrs L Evans CNS Anticoagulant Clinic Morriston 4047 Bleep 970 Mrs P Hayward Haemophilia and Anticoagulant Clinic Singleton 5563 MEDICAL MICROBIOLOGY SERVICE. Microbiology Services are provided to Swansea NHS Trust by the National Public Health Service based at Singleton Hospital. Specimens are transported to Singleton from all areas of the Trust several times a day during the normal working week. Normal Hours of Working. Monday-Friday 08.45 to 17.00hrs The laboratory requests that specimens are sent as early as possible during the day. A limited service is available on Saturdays, Sundays and Bank Holidays as follows; Saturday and Bank Holidays (0800 1200 noon) - Urgent work only Sundays all day Emergencies (on-call service) only Emergency on-call service An emergency service is available for urgent investigation only. The on call staff are not routinely present on site and can only respond to contact via the hospital switchboard. The hours when the on call service is in operation are:- Monday to Friday 17.00 08.45 a.m. Saturday/Bank holidays after 12.00 noon Sunday all day On call BMS staff can be contacted via the Singleton Hospital switchboard The Consultant Microbiologist is also available on call for urgent clinical advice and can be contacted via Morriston or Singleton switchboard Telephone Contact Numbers ( 08.45 a.m- 17.00 p.m.) NPHS Office - (01792) 285055 Microbiology - (01792) 285048 Virology - (01792) 285059 Fax No - (01792) 202320 Microbiology. If you are unsure about which specimen is required for a particular investigation, then please contact the department. When submitting particularly urgent specimens , please notify the department that an urgent result is required; this will ensure that the specimen is processed as soon as possible and the result telephoned. All positive intestinal pathogen isolates, hepatitis positive results, mycobacterial microscopy and culture, and positive blood culture results are telephoned immediately as a routine. Request Forms: The correct forms MUST be used. The blue BACTERIOLOGY form must be used for all bacteriological specimens (including pregnancy tests) and the appropriate VIROLOGY forms used for virus culture and serology. A separate request form is available for antenatal serology. All request forms must be completed fully, using ballpoint pen or addressograph label, including details of exact nature of specimen and relevant clinical information, so that the appropriate tests are carried out. Because microbiology reports are computer generated, patient data and other request form details have to be transferred to the data bank. It is therefore IMPERATIVE that such details are LEGIBLE (using block capitals for name and address where addressograph labels are unavailable) and ACCURATE, especially with regard to first names, the spelling of surname, the date of birth and clinicians name and location so that the report will return to the requesting doctor. If possible, the patients NHS number should also be included. Please note that, in line with the Trusts clinical governance agenda, unlabelled or mislabelled samples will be discarded according to the laboratorys specimen acceptance protocol. Specimen containers should be labelled with full name of patient, type of specimen and the date collected (again, failure to comply could result in the sample not being processed). Specimen containers and request forms must be transported to the laboratory in the purpose-designed double pocket pathology specimen plastic bag. DANGER OF INFECTION stickers must be attached to request form and specimen container bag if specimens are from cases of known or suspected communicable diseases. (See also Hepatitis and HIV). A. General Information on the transmission and storage of bacteriological specimens. All bacteriological specimens should be taken with the greatest care in order to avoid contamination. They should reach the laboratory as soon as possible after collection. All swabs used must be of the appropriate TRANSWAB variety, which contain different transport medium tubes. When, for any reason, a specimen cannot reach the laboratory on the day it is taken, it should be kept overnight in a refrigerator at 4(C (excepting Genital swabs and Blood cultures which should be kept at room temperature). B.Collection of Bacteriological Specimens (with notes on specific infection investigations). NOTE: Because of the wide variety of culture techniques now being used in the laboratory, clinical information must be adequate and the organ/site from which a specimen has been taken must be indicated on the request form. This ensures that the most appropriate laboratory techniques are used and meaningful interpretation of results. Please inform the laboratory in advance if a specimen is required to be processed urgently by telephoning the appropriate department and informing the laboratory of the sample type, the investigation required, the means by which it will arrive at the laboratory and to whom the urgent result must be telephoned to. Antimicrobial Therapy. It is impractical for the laboratory to test all isolates against every possible antibiotic. The following information attempts to explain how and why we report antibiotic sensitivities the way we do. Many agents are members of classes of antimicrobials, each of which has a broadly similar spectrum of activity. The laboratory therefore will test a representative member of a class (usually an antibiotic that is used widely). The results obtained are usually applicable to all other members of the class. For example: - First generation cephalosporins - Cephalexin tested, but others include cefaclor Quinolones - ciprofloxacin tested, others include moxifloxacin, levofloxacin, ofloxacin, norfloxacin. Broad spectrum penicillins Amoxycillin tested, others include ampicillin. Macrolides - erythromycin tested, others include clarithromycin and azithromycin Gram-positive organisms (eg Staphylococcus aureus, and streptococci) are routinely tested against the following: - penicillin, erythromycin and amoxycillin. (Also, flucloxacillin for staphylococci). Gram negative organisms (eg Escherichia coli, Proteus species etc) are routinely tested against the following:- amoxycillin, cefuroxime, gentamicin (not applicable to General Practice), coamoxiclav and ciprofloxacin. Urinary isolates are tested against the following: - amoxycillin, cefalexin, trimethoprim, nitrofurantoin, and ciprofloxacin. The range of antibacterial agents tested is continually reviewed in the light of current knowledge and experience. The Consultant Microbiologists will be pleased to give advice on such matters. Telephone Extensions:- Dr Ann Lewis- Morriston 4400 - Singleton 5066 Dr Khaled El -Bouri- Singleton 5044 Dr Nidhika Berry Singleton 5043 Control of Infection. For advice on control of infection phone Dr A Lewis - as above Dr K El- Bouri - as above Control of Infection Nurse - Morriston 3690 - Singleton 5045 Antibiotic Assays. (Please refer to Swansea NHS Trust Antibiotic Policy) The department monitors gentamicin and vancomycin levels at Singleton. Blood should be taken as follows (for b.d. or t.d.s. regimens):- Pre-dose Expected Post-dose Expected level level Gentamicin Before dose <2 mg/L 1 hour post-dose 5-10mg/L Vancomycin Before infusion<10mg/L 1 hour after end 20-40mg/L of infusion Gentamicin monitoring for Single dose regimes must reach the laboratory before 14:00 p.m. Only a pre-dose level is required Where investigation for antibiotic assays other than those listed above is necessary, the laboratory must be informed within sufficient time to organise transport to a reference laboratory. Please note that these requests are not usually processed by the reference laboratories on the weekends. Blood Cultures. All blood cultures must be taken according the advice and procedures distributed with each set of blood cultures issued. Blood cultures are monitored continuously for 5 days by an automated system. Microscopy results are telephoned immediately to the ward if blood cultures become positive. Blood cultures taken out of hours at Baglan and Morriston hospitals are incubated on site and transported to Singleton hospital for testing the following day. Chlamydia. An ELISA antigen test is used for the demonstration of the organism. The chlamydia transport medium (pink) is stable at room temperature for 12 months. Place a plastic stemmed swab into labelled Chlamydia transport medium. DO NOT USE wooden stemmed, calcium alginate or agar - or charcoal-containing swabs. Use cotton or Dacron tipped swabs with metal or plastic stems. The Chlamydia Specimen Collection Kit is recommended for the collection of urethral, endocervical and ophthalmic specimens. Specimens may be transported for up to 48 hours at room temperature (15-30C) before storage at 2-8C for a further 5 days before testing. Serology for Chlamydia may be useful in the investigation of female infertility. (Clotted sample 10ml). Urethral specimen Chlamydia Swab urethra using an appropriate swab by inserting the swab 2-4cm into the urethra, rotating the swab and withdrawing. Place the swab in Chlamydia transport medium. Specimens may be stored at 2-8C for no longer than 7 days before testing. Endocervical specimen Chlamydia. Clean cervix with sterile gauze before sampling. Swab cervix with an a appropriate swab by inserting the swab into the cervical canal and rotating the swab at the columnar-epithelial junction. Withdraw the swab without touching the vaginal surface and place in Chlamydia transport medium. Specimens may be stored at 2-8C for no longer than 7 days before testing. Vaginal specimens Chlamydia. Endocervical swabs are greatly preferred as vaginal swabs often give false negative results. Ophthalmic specimens Chlamydia. Carefully remove excess exudate from the surface of the eye before sampling. Vigorously apply an appropriate swab to the lower lid conjunctiva of the affected eye. Place the swab in Chlamydia transport medium. Specimens may be stored at 2-8C for no longer than 7 days before testing. Note: Rectal, anorectal or specimens contaminated with faecal material MUST NOT be tested. Urine Specimen (males) Chlamydia. Approximately 20ml of first catch urine should be collected in a boric acid sterile container. Specimens may be stored for 3 days at 2-8C before testing. Note: Patient should not have urinated for at least 1 hour prior to collection for all urethral and urine (male) specimens. For optimal detection of Chlamydia antigen in urine, a first catch early morning urine is recommended. Cryptosporidium. The Cryptosporidium Reference Unit is based in the NPHS Microbiology Laboratory Swansea. Expert advice can be obtained by telephoning (01792) 285341. Enteric Fever. (Typhoid and Paratyphoid) Please send blood cultures, faeces and urine for culture. Give details of duration of present illness and history of foreign travel. Eye Infections Unless there is a profuse discharge, eye swabs are likely to be unsatisfactory for bacterial isolation. If swabs have to be used they must be of the charcoal TRANSWAB type. See also under Chlamydia. Faeces. Should be passed into a clean vessel and a small portion transferred to the screw-cap faeces container using the spoon provided. Faecal swabs (ie swab dipped into faeces) may also be sent. Rectal swabs or dried up faecal swabs are NOT suitable. The labelled container should be sent to the laboratory accompanied by the request form, stating the purpose of the examination, as processing methods in the laboratory vary according to the organism requested. Ordinary faecal specimens are suitable for cysts and ova examination provided that liquid paraffin has not been given to the patient in the preceding few days. Three samples will be required for parasitology investigations Threadworm eggs are most suitably collected by pressing the sticky side of a piece of Sellotape against the perianal area. This Sellotape is then stuck to a slide. If Cryptosporidium, Staphylococcal enterocolitis, Clostridium difficile or haemorrhagic colitis is suspected, then this should be clearly indicated on the request form so that the specific tests may be performed. (See also Food Poisoning). If the patient has diarrhoea, the request form must indicate relevant epidemiological information including date and time of onset, the name(s) and dates of foreign countries recently visited, other family members affected and name of hospital/ ward/department/shop etc. where employed if the patient is a health care worker or a food handler. Amoebae - In the acute stage of infection, consult the Microbiologist before sending the specimen. The Virology laboratory also examines faeces for Clostridium difficile toxin. Specimens for gastroenteritis viruses are referred to another laboratory for examination. These should be collected within 2 days of onset of symptoms. Faeces from food poisoning outbreaks are encouraged. Food Poisoning. Faeces, vomit and suspected foods may be submitted. Following infection with an enteric pathogen, patients may excrete the organisms continually or intermittently. It is recommended that at least 3 consecutive negative faecal specimen results be obtained before the patient is pronounced clear of infection, if required. Contact the Consultant Microbiologist or the Consultant in Communicable Disease Control, (Tel No. 01792 458066), regarding clearance specimens, especially if patient is a health care worker, or is a food handler. Faecal cultures are incubated for 2 days before the final report is issued. However, positive results in the interim period are telephoned immediately. In an outbreak or special circumstances, preliminary reports can be issued. Fungal Infections. Most mycological specimens are from cases of suspected ringworm; they usually consist of skin, nail or hair from infected areas. Each sample should be wrapped in a small piece of, preferably, black paper and enclosed in a labelled screw-capped container. As an alternative, Dermapak type 3 kits are available from the laboratory. For other specimens, such as sputum, pus, urine, blood, serum or biopsy material, standard transport systems are suitable. When a delay in transmission of the specimen is inevitable, the Microbiologist should be consulted about methods for the prevention of bacterial overgrowth. Gonorrhoea (including ophthalmia neonatorum). Swabs must be of the charcoal Transwab type and sent immediately to the laboratory. Viral Hepatitis. 7ml clotted blood should be collected and labelled with a DANGER OF INFECTION sticker. Use warning labels for blood from patients with acute hepatitis, abnormal LFTs, jaundice, chronic carriers, intravenous drug abuse and close contacts of cases. Pre vaccination screening is NOT carried out for Hepatitis B. Post vaccination screening. Please state Hepatitis B vaccination history, including date of last vaccine, number of booster doses. HIV. If HIV test is required contact the Consultant Microbiologist. However, if GP collects sample, take 7ml clotted blood, labelled ANGER OF INFECTION. The patient should be counselled before venepuncture. If infection is suspected or the patient is very anxious, consider referral to Department of Genito Urinary Medicine at Singleton Hospital. Notifiable Diseases. The following diseases must be notified, as soon as diagnosed, to the Consultant in Communicable Disease Control (Tel 01792 458066). Forms of notification are available, but an immediate telephone message should be sent in the case of the rarer and more infectious diseases (eg typhoid fever, meningococcal disease and outbreaks of food poisoning): - Acute Encephalitis Paratyphoid Fever Acute Meningitis Plague Acute Poliomyelitis Rabies Anthrax Relapsing Fever Cholera Rubella Diphtheria Scarlet Fever Dysentery (Amoebic Smallpox or Bacillary) Tetanus Food Poisoning Tuberculosis (all sources) Typhoid Fever Infectious Jaundice Typhus Lassa Fever Viral Haemorrhagic Legionnaires Disease Fever Leprosy Viral Hepatitis Leptospirosis Whooping Cough Malaria Yellow Fever Marburg Disease Measles Meningococcal septicaemia Pertussis. Pale blue topped per nasal swabs, (charcoal transwab, wire - NOT wooden-stemmed) should be used as these yield more positive results than nasal swabs. The swab must reach into the naso-pharynx. An incorrectly taken swab is a common cause of failure to isolate the causative organism. Specimens should be taken as early as possible in the course of the disease, since by the time the whoop has developed, cultures are usually unsuccessful. Pregnancy Testing. A FIRST morning urine specimen is recommended. The method of testing currently available within the department is monoclonal strip. Specimens sent for testing before 2.00pm will have results available after 4.00pm on the same day. Pregnancy tests will only be performed on receipt of the urine together with a request form signed by the GP (ie pp signatures not acceptable). The results will be communicated only to the GP. Specimens should be sent in plain universal containers. Sensitivity: - 25 mIU/ml hCG. Pus Swabs. Many pus swabs received in Bacteriology are dry, badly taken specimens. In many clinical situations, a collection of pus is seen but only a swab is taken. Bacteriological investigations will yield more significant results if the pus itself is sent in a dry sterile universal container. This is particularly important where abscess cavities are drained or actinomycosis or anaerobic organisms are suspected. The site from which pus is obtained must be indicated on the request form so that appropriate culture can be performed. See also SWABS FROM DRY AREA Rapid Virology A rapid diagnosis service for respiratory viruses and rotavirus is currently available. Rubella Serological Tests. a) Screening Tests: Rubella status eg in pregnancy, preconception, etc, Clotted blood (7ml) b) Rash or rubella contact in pregnancy Clotted blood (7ml). If positive, we will report Rubella antibody as >10 IU and ask for a follow up specimen usually immediately. These paired sera are then tested together, when both titres, an IgM result and an interpretation of rubella status will be given. Please give date of contact. Serological Tests in Virology. Paired Sera. It is always desirable, and frequently essential for diagnosis, to demonstrate a significant rise (usually at least 4-fold) in antibody titre. At least two 7ml specimens of clotted blood (paired sera) are therefore necessary. In general, individual viruses or groups of viruses cause illnesses having characteristic clinical features. The GP submitting specimens for virological examinations should give as full a list of relevant symptoms as possible and a date of onset of symptoms. This knowledge allows the correct specimen to be collected at the optimum time and the appropriate virological investigation to be performed. The Microbiologist will be pleased to advise in individual cases. See also virus isolation. Serological specimens should be taken:- a) as early as possible in the illness and certainly within five days of onset; b) in the third week of illness; sometimes an additional specimen taken later in convalescence is of value. A FULL clinical history should be supplied, including date of onset of illness, details of animal contacts, residence or recent visits abroad, etc. The following serological tests are currently available on a routine basis (some tests are referred). Adenovirus Leptospira Anti-streptolysin or ASOT Measles Chlamydia Myocoplasma pneumoniae Cytomegalovirus Q-fever Respiratory syncytial virus Glandular Fever Hepatitis A, B & C Rubella Herpes Simplex Staphylococcus aureus (chronic inf. ) HIV Influenza A & B Toxoplasma gondii Legionella Varicella zoster As methods are developed other serological tests may become available; contact Microbiologist for current advice. Semen Analysis. Please Note this service will NOT be available from the NPHS from April 1st 2006 Monday to Friday 08.45-12.00 Instructions for patients for Fertility Testing. 1. Do Not Ejaculate For 3 Days Before Passing Specimen. 2. Warm the outside of the container provided, pass the semen straight into the container in the morning. 3. Write the DATE and TIME on the label, also your NAME, AGE and ADDRESS. Bring the specimen as soon as possible (but in any case within 2 hours of production), to the Pathology Reception, Pathology Department, Singleton Hospital. Post Vasectomy. Please Note this service will NOT be available from the NPHS from April 1st 2006. At least 2 consecutive azoospermic samples are required to confirm success of operation. Culture of Semen. Patients should be requested to void urine and wash penis prior to producing ejaculate. Transfer the specimen to the laboratory immediately. Sputum. Patients should be instructed that sputum, and not saliva, is required (ie collected by a deep cough, preferably collected in the morning before drinking, eating or teeth cleaning has taken place). Salivary samples will be rejected. Routine sputum cultures include only screening tests for aerobic organisms. If full comprehensive anaerobic cultures are requested this must be clearly indicated on the request form, and the case should be discussed with the Microbiologist who will advise if further specimens are required. When sputum is sent from a case of atypical pneumonia, this diagnosis must be indicated on the request form since methods are now developed for culture of organisms such as Legionella. In these cases it is advisable to submit a urine sample as well for legionellosis. Staphylococcal Carriers (including MRSA). Take moistened swabs initially from anterior nares, throat and any skin lesion and, in infants, the umbilicus. The Microbiologist will advise if additional sites, such as perineum, hair or hands, are to be swabbed. The status Staphylococcus carrier or, if relevant, MRSA carrier must be indicated on the request form so that the appropriate epidemiological typing of isolated strains may be performed. Streptococcal Carriers. Swab anterior nares as well as throat. Swabs from dry areas. eg skin, are not satisfactory unless the swab is first moistened with the transport medium in the swab pack. Serological Tests for Syphilis. An ELISA test is routinely used for screening serum for syphilis antibodies. The Rapid Plasma Reagin (RPR) slide test and the Treponema pallidum haemagglutination (TPHA) tests are used for confirmation of positive ELISA results and for follow-up treatment. Both these tests are done quantitatively. In addition, the Fluorescent Treponemal Antibody (FTA-ABS) test is routinely used for GUM patients and also as a confirmatory test. False positive reactions may occur with the RPR test, especially in association with febrile infections, in auto-immune diseases. Such false positive reactions are rarely associated with the TPHA and FTA-ABS. They may also occur in apparently normal persons and in pregnancy. In the absence of definite clinical evidence of Syphilis, the test should be repeated. Toxoplasma. The Toxoplasma Reference Laboratory is based in the NPHS Microbiology Laboratory Swansea. Expert advice can be obtained by telephoning (01792) 285058/56. Tuberculosis. 1. Urine - Early morning mid-stream specimens (the first urine voided during the day) on 3 consecutive days should be sent to the laboratory in sterile universal containers (NOT Boric acid containers). Two bottles are preferred for each specimen. The usual aseptic method of collection is essential (see under urine sections). The samples should be taken immediately to the laboratory to avoid multiplication of contaminating organisms. ii. Sputum - Early morning specimens on 3 consecutive days should be sent. In cases of suspected pulmonary tuberculosis, when it is difficult to obtain sputum repeated gastric lavage specimens or laryngeal swabs should be collected. Warn the patient against providing saliva. iii. Initial isolates of mycobacteria are routinely identified and tested against Isoniazid, Rifampicin and Ethambutol. Further sensitivity tests are carried out, as necessary, if Atypical mycobacteria are isolated. Urine Specimens. Mid-stream specimens should be taken aseptically into sterile boric-acid containing universal containers. Mid-stream catheter specimens should also be taken directly into sterile boric-acid containers. All urine samples must be taken immediately to the laboratory. Urines are NOT routinely cultured for anaerobic organisms. Boric acid containers are suitable for Chlamydia tests though not for nucleic acid assays. The boric acid will, however, kill viruses. Please use plain containers if Mumps or Cytomegalovirus detection is required. Advice for collection of urine from females. 1. Using warm water, thoroughly wash hands and genital region including between the labia (lips) of the vagina. Dry with a clean towel, wiping from the front backwards. 2. Remove the cap from the sterile container and put it down rim uppermost, ensuring that the inside of the container or the cap is not touched. 3. Separate the labia of the vagina with two fingers of one hand and begin passing urine. 4. While continuing to urinate move the container into the stream of urine with the other hand. Remove the container before the stream of urine stops. If possible completely fill the container. 5. Replace the cap securely, again without touching the inside of the cap or the container. 6. Dry the outside of the container. Write the name, the date and the time at which the specimen was taken on the gummed tear-off label and stick it onto the container. Vaginal and Cervical Swab. Black topped transwabs should be used for bacteriology; pink Chlamydia transport medium for Chlamydia; and milky virus transport medium for herpes. THESE ARE NOT INTERCHANGEABLE. Varicella Zoster Immunity. Clotted blood (7ml) In antenatal patients in contact with chickenpox or shingles. Contact Consultant Microbiologist to discuss necessity for Varicella zoster immunoglobulin. Virus Isolation. For isolating viruses from the alimentary tract, faeces sufficient to fill 1/3 to 1/2 of a sterile universal container, are required. NO PRESERVATIVE must be added. From other sites, swabs broken off into a bottle of milky virus transport medium (obtainable from the laboratory) are suitable. When viral meningitis is suspected, specimens of faeces and throat swabs should be sent as many cases of viral meningitis are caused by the enterovirus group (eg Coxsackie, Polio, ECHO) which are excreted in large numbers in the faeces for up to three weeks following the attack. Virus survival at room temperature is usually short. Specimens should, therefore, reach the laboratory as rapidly as possible. If storage of specimens for longer than 24 hours is necessary, consult the laboratory. For the best diagnostic yield, specimens for virus culture should be taken within 2 days of onset of symptoms. Appropriate swabs are:- throat swabs from patients with influenza like symptoms eye swabs for adenovirus or herpes conjunctivitis genital lesion lesion swabs (with fluid for the rapid differential diagnosis of pox and herpes viruses by electron microscopy), best taken as early as possible since virus late in infection is non-cultivable. Specimen investigationContainer and commentsAntimicrobial assaysSpecimen of clotted blood (510 ml each)Antral washings Sterile universal containerAspirates and fluids from sterile sites Sterile universal containerBlood cultures Bactec bottles (Use special bottles for infants and patients receiving antibiotics)Bronchoalveolar lavageSterile containers e.g.: 120140 ml distributed in 3-4 sterile universal containers. Send for MC&S, virology, PCP, mycology, and TB as appropriateCerebrospinal fluid (CSF)For cell count, Gram staining and culture send 23ml in each of 3 universal containers. Send separate specimens for glucose and protein analysis to the appropriate departments, and a separate sample for Virology.CSF for molecular investigationDedicated sample required for meningococcal, HSV and enterovirus PCR For other assays please discussChlamydiaSwabs from conjunctiva, urethra or endocervix in Chlamydia transport medium, smears on glass slidesFaecesWith the spatula provided transfer a plum sized portion of faeces, or equivalent volume of fluid, into a sterile faeces containerIntrauterine contraceptive device (IUCD)Send the device in a sterile universal containerNasopharyngeal aspirateSealed traps containing specimenNon-directed bronchial lavagesterile universal containerPeritoneal fluidsterile universal containerPleural fluidsterile universal containerPus/ exudateAspirate into sterile universal containerPus swabUnsuitable specimen (see above)Seminal fluidsterile universal containerSkin, nail and hair for mycologyuse black card or DermapaksSputumsterile universal containerEndocervical swabFor the investigation of gonorrhoea use a bacteriology swab in Amies transport medium with charcoal. For the investigation of Chlamydia use a Chlamydia swab and Chlamydia transport mediumCough swabSend in Amies transport medium with charcoalEar swab Send in Amies transport medium with charcoalEye swabSend in Amies transport medium with charcoal. For the investigation of Chlamydia use a Chlamydia swab and Chlamydia transport mediumHigh vaginal swab (HVS)For the investigation of gonorrhoea, Candida, Trichomonas and vaginosis use a bacteriology swab in Amies transport medium with charcoal. For the investigation of Chlamydia use a Chlamydia swab and Chlamydia transport mediumMouth swab Send in Amies transport medium with charcoalNasal swabSend in Amies transport medium with charcoalPer nasal swab (for pertussis)Use wire shafted swabs. Transport to the laboratory IMMEDIATELYUrethral swabFor the investigation of gonorrhoea use a bacteriology swab in Amies transport medium with charcoal. For the investigation of Chlamydia use a Chlamydia swab and Chlamydia transport mediumWound and ulcer swabSend in Amies transport medium with charcoalViral swabs from skin and mucosal lesionsWith a sterile lancet or needle raise the cover of the vesicle; use a swab to collect the vesicle fluid and then gentle rub the base of the vesicle. Break swab stick and transport in viral transport medium. Follow the same procedure but use a clean glass slide to collect the vesicle fluid/cells from the base of the vesicle and transport slide in slide box, DO NOT forget to label slide on the correct sideThroat swabSend in Amies transport medium with charcoal. For virology send the swab in virus transport mediumTissues and biopsiessterile universal container. If biopsy is small add 0.5ml of Ringers or sterile saline to prevent it from drying out. Ensure there is NO preservativeTuberculosisBest specimens are sputum, urine, pus or tissue. For sputum and urine send 3 early morning specimens taken on consecutive days. Send specimen in a sterile universal containerUrine (including Legionella antigen)Sterile universal containerUrine for tuberculosisSterile universal container Two 30ml volumes of urine on three consecutive days Laboratory Tests including turn around times TestTurnaround timeCommentsAntibiotic assays24hrsSame day if received before 1400Blood Culture5 daysAll significant positive results are phoned CSF microscopy and culture 48hrsMicroscopy and positive 24hr culture results are phoned PD fluids, microscopy and culture72hrsPositive microscopy is phonedJoint fluids, microscopy and culture72hrs5 days if extended culture required.Faeces microscopy and culture48hrsFaeces C.difficile24hrsSame day if recd before 9.00amSputum culture48hrsLonger for CF samplesBronchaeolar lavage48hrs5 days for extended culture Pleural effusion/Chest fluids72hrsUrine, microscopy and culture 48hrsUrine pregnancy test24hrsSame day if received before 1400 Genital swab (GC only)48hrsPositive microscopy phoned 24hrsGenital swab microscopy and culture48hrsSkin/Nail/Hair for fungi7 - 21days Tissue/Bone microscopy and culture48hrs5 days if extended culture requiredWound swab48hrsEar/Nose and Throat swab48hrsMRSA Screen72hrsAFB microscopy and culture4-6 weeksPositive microscopy phoned 24hrs (2)AFB culture4-6 weeks Processed in Mtb reference unit. NPHS CardiffPer nasal swabs7 daysPositive Results phonedHepatitis A (immunity)24hrsHepatitis A (diagnostic)24hrsHepatitis B24hrsHepatitis C24hrsHIV24hrsHTLV7 daysAntinatal screen24hrsFaeces C.difficile24hrsSame day if recieved before 9.00amRubella (immunity)72 hrsRubella (diagnostic)72 hrsEBV acuteDailyParvovirus7 daysMumps (immunity)7 daysMumps (diagnostic)7 daysMeasles (immunity)7 daysMeasles (diagnostic)7 daysHSV7 daysCMV7-28 daysToxoplasma3 daysNPHS Swansea Reference LaboratoryMycoplasma24 hrsASO2 3 daysLegionella24hrsLegionella (antigen)24hrsHydatid7 daysNPHS Microbiology Cardiff Reference LaboratoryToxocara3 4 weeksNPHS Microbiology Cardiff Reference LaboratoryCFT 3 4 daysChlamydia Culture72 hrsNPHS Microbiology CardiffChlamydia Elisa48 hrsChlamydia DIF24hrsVirus Isolation1-21 daysElectron Microscopy7 daysHPA Bristol Reference LaboratoryAntigen Detection (DIF)24 hrs NOTES: In cases of exceptional urgent need, some investigations can be performed more quickly, if specific arrangements are made. For out-of-hours requests, the results of tests that can be performed immediately will be telephoned as soon as they are completed. 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