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Laboratory Guide to Services

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1. wnitehorse general hospital Laboratory Guide to Services April 2013 Table of Contents Section A Laboratory Information OCOnN DAR WDNDN gt 10 Hours OT SENICE eannan a ENUN EN NNa Contact Information ccccceeeeee eee eeeeeeeees WGH Laboratory Test Menu Our On site Services Referred Out Tests Our Support Team Sample Identification Criteria Labelling Proper Labelling of SAMples cccccece cece eee e eee eeeeeeeeeeeeeseaeeeeeengaees Sample Rejection Policy cccceeeeeeeeeeeees Sample Rejection Criteria cccceeee eee eeees Irreplaceable Sample Identification Policy Consent for Release Form ccceeeee eens Section B Ordering Tests amp Requisition Forms oBRWN List Of REQUISITIONS ccc cece eee eee eeee seen Acceptance Criteria for REQUISItIONS cccc ccc eee cece ee eee eee eeeeeeeeee eens Standing OFGSl Si cicnnstunersvdetcndanwibernteammeneeeaatins Add On Tests peerca cn ancataatiotonndtcbendoiseonees Examples of Requisition Forms 0000e0 Section C Collection Procedures 1a 1b 1c 1d 1e 1f NO O1 B W PD Blood Collection Procedure ccceeeeeee ees Tube Selection Order of Draw and Sample Mixing How to properly prepare a blood smear for CBC VS TION SS ree E N canes dese oead E E E idee senate eeene ai anveuceeev
2. Label your sample container with the following information e Your full first and last name e Your health care number and your date of birth e Your Doctor s name e The date and exact time of your collection 3 Warm the collection container in your hand before collecting your sample 4 Ejaculate directly into the container Do not use a condom 5 Put the lid on the container and close tightly 6 You must keep the sample warm while you are bringing it to Laboratory Keep the container inside your jacket or jeans pocket for example T Bring both your sample AND your Requisition to the WGH Laboratory WITHIN 30 MINUTES of collection Drop off Lab Hours Monday through Friday mornings 08 00 to 12 00 Please do not bring specimens after 12 00 noon Note The specimen will not be tested if the label or Requisition is missing information Implementation Date April 2013 Printed versions of this document are not controlled 84 We Whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions 8 Semen Analysis Post Vasectomy Please read these instructions carefully before you begin 1 Label your specimen container with the following information e Your full first and last name e Your date of birth OR health care STi TIGHTEN SECURELY ae OE xxx e Your doctor s name e The date and time of your collection 2 Ejaculate directly into the container Do not use a con
3. Legionella Bronchoalveolar lavage Sputum chial ate satiated diab CLINICAL INFORMATION Other specify GASTROINTESTINAL INFECTIONS OTHER TESTS Feces Sample Symptoms Consult with Bacteriology amp Mycology Culture and verotoxin Duration days Laboratory before ordering at Watery diarrhea Bloody diarrhea Fever Other 7 2 Verotoxin only 604 707 2617 Sample Type Urine Sample Culture for Salmonella Follow up for Salmonellosis Test Requested Contact with case ADDITIONAL CLINICAL TRAVEL INFORMATION CLINICAL TRAVEL INFORMATION Food poisoning Outbreak Post infection fallow up Antibiotic usage TRAVEL YES specify NO Immigration specify country of origin www bcquidelines ca qpac quideline_diarrhea htm Form DCBM 100 1001F Version 1 0 08 2009 00055689 BAM Current Requisition Form listed here http www phsa ca AgenciesAndServices Services PHSA Labs T esting Requisitions Diagnostic htm Implementation Date April 2013 Printed versions of this document are not controlled 36 Laboratory oe orms YY whitehorse general hospital Guide to Services Examples TE Section 1 Patient Information TE PHSA Laboratories Public Health Microbiology amp Reference Laboratory EC Centre for Disease Contro 655 West 12th Avenue Vancouver BEYSZ ARA wawphsa ca bced publichealthlah Mycobacteriology TB Requisition PERSONAL HEALTH NUMB Ebest of province Hea
4. Contact YCDC Contact YCDC peace Modified Amies Charcoal i Refrigerate Swab Sample must be received by the Lab within l AE 30 minutes of collection Must be kept Sterile container pink lid warm during transport room temperature body temperature 4 16 4 Sample must be received by the Lab within sterile container pink lid i 3 hours of collection Must be kept warm p during transport room temperature body temperature 2 1 1 2 2 Semen Analysis Infertility Semen Analysis Post Vasectomy Stool Clostridium sterile container with aia Refrigerate difficile spoon Stool Culture amp sterile container with ot pangs Sensitivity spoon Stool Occult Blood Hemoccult kit 3 sticks Samples remain stable for up to 14 days at plastic bag room temperature Stool Ova amp Parasites red top SAF container 1 Refrigerate Stool Viral sees alae oa Refrigerate Several sample types are accepted for TB testing consult the Mycobacteriology TB TB Mycobacteriology Reguisition yp p g y gy Urinalysis sterile container pink lid a vamp es musi De Heel e Wii 2NG DI collection TEN MENE Transport in a 10 mL red top vaccutainer Urine ACR sterile container pink lid oso Larger containers also accepted 24 hr urine container 3L Samples must be transferred from 3L Urine 24 Hour orange jug collection hat orange jugs to 10 mL sterile containers amp Collection food medicine restrictions pH must b
5. Encephalopathy NKH C Unverricht Lundborg Disease Name amp Relationship C HFE Related Hemochromatosis CO X linked ichthyosis STS Deficiency Hemoglobin Disorders Zygosity C Alpha Thalassemia O DNA Extraction Only C Beta Thalassemia Reason REQUIRED C Hemoglobin S E C Hemolytic Disease of the Newbom O RhD Rhe O Rhe Kel CO Hemophilia A C Hemophilia B C Hereditary Multiple Osteochondromatosis O Hereditary Neuropathy with Liability to Pressure Palsies O Heterotaxy X linked o o o o i Re Jeva nt o linle aE amily History Provide Na me Do8 PHN amp relationship of any individual s relevant to interpretation of requested tast s Huntington Disease Hyperkalemic periodic paralysis Hypokalemic periodic paralysis Hypochondroplasia Ordering Physician Signature REQUIRED Date Form CWMG_REQ 0000 Vorsion 3 2 Last Updated March 12 2012 Current Requisition Form listed here www genebc ca Implementation Date April 2013 Printed versions of this document are not controlled 42 Laboratory Pr Procedures whitehorse l d general hospital Guide to Services Section C Collection Procedures 1a Blood Collection Procedure The WGH Laboratory follows guidelines and procedures for venipuncture outlined by the Clinical and Laboratory Standards Institute CLSI 2007 Overview of Phlebotomy and Specimen Labelling Procedure The following table provides an over
6. Examples include blood samples that were not centrifuged in a timely manner and blood samples for LDH that were not transported at room temperature Note frozen samples that arrive thawed may not provide accurate results and are treated with caution based on the specific circumstances Sample Too Old to Process e Samples will be rejected when the sample has been in transit too long for obtaining valid results Time sensitivity varies for each test Contact the lab if you are uncertain about the viability of a sample Every effort should be made to transport samples to the Lab as soon as they are collected Implementation Date April 2013 Printed versions of this document are not controlled 7 whitehorse Laboratory Laboratory ZX general hospital Guide to Services Information Microbiology Sample Rejection Criteria Microbiology samples may be rejected for the following reasons x Unlabelled Samples x Incorrectly Labelled Mislabelled Samples x Incomplete information on the Requisition or Sample x Sub optimal sample leaking urine stool containers insufficient quantity x Duplicate microbiology samples received on the same day e g multiple ova amp parasite stool samples sputa samples x Sample delayed in transit Please refer to the Sample Collection Microbiology Section C 6 for further details Transfusion Medicine Sample Rejection Criteria Refer to Transfusion Service Manual T
7. MICROBIOLOGY LAB ON SITE TESTING Ph 867 393 8794 fax 867 393 8772 O Throat KO Group A strep Penicillin Allergy Yes L No L Treatment Failure Yes L No L O Eyesis D Left Eight _ Extemal conjunctiva O Other specify gJ Ers J Left Fight CJ Extemal cams Middle ear drainage tinid O Other specify J Month Gingiva Tongue R O Yeast O Fld Culture specify site SKIN WOUND ULCER ABSCESS CULTURE MUST peciy ammte siie Tp wami s gt dian deep O Wound L Trauma O Surgical O Diabetic Your information is protected under the WGH Privacy Policy Laboratory Requisition Guide to Services Forms Examples Laboratory Use Only Vagimitis Initial o to _ Ew and yeast Soumrte site hae ie LY Throat Rectal LlOther MUST indicate clinical information O l3 yeas 60 years J Toxic Shock Syndrome URINARY TRACT SPECIMENS O Midsteam Urine imou Catheter indwelling Catheter Se Clinical Information Q dyaria L frequency L pyumia C pregnant _ kidney transplant MESA Screen LJ Harms _ Penmanal Other VRE Screen 7 Rectal 1 Other STOOL SPECIMENS C C dificil 5 Hospital Road Whitehorse Yukon YA SH7 24 Requisition VY whitehorse Laboratory Forms general hospital Guide to Services Examples HOLTER MONITOR WHAT IS IT a E This is a machine that monitors your heart for a period of 24 hours You wear the monitor while you maintain your current lifestyle The
8. Modified Amies emer pa odens Clear swab and a smear oe Female Patients Vaginal Culture Modified Amies Trichomoniasis Vagina Trichomonas vaginalis SE sam a Modified Amies Clear swab Implementation Date February 2013 Printed versions of this document are not controlled 66 COLLECTION CEN PRO A A PTV A Urine Specimen Collection Guide PROCEDURE _ for Chlamydia trachomatis CT and Neisseria gonorrhoeae GC GUIDE Collection for Male and Female Urine Specimens Patient should not have urinated for at least 1 hour prior to specimen collection 1 Direct patient to provide first catch urine approximately 20 to 30 mL of initial urine stream into urine collection cup free of any preservatives Collection of larger volumes of urine may result in specimen dilution that may reduce test sensitivity Female patients should not cleanse labial area prior to providing specimen 2 Remove cap from urine specimen transport tube and transfer 2 mL of urine into urine specimen transport tube using disposable pipette provided The correct volume of urine has been added when fluid level is between black fill lines on urine specimen transport tube label 3 Re cap urine specimen transport tube tightly This is now known as the processed urine specimen Specimen Transport and Storage 1 After collection transport and store the processed urine specimens in the APTIMA urine specimen transport tube at 2 C to 30 C until test
9. Mycology Requisition form Available at http www phsa ca AgenciesAndServices Services PHSA Labs Testing Requisitions Diagnostic htm 6 Seal in biohazard bag refrigerate and ship as soon as possible in a cooler containing ice packs 2 Choice Postnasal specimens Label the container with the patient s full name and date of birth Incline the patient s head as required and insert the swab into the patient s mouth To avoid contamination from the oral cavity bend the wire to an angle of 135 about 1 cm from the tip 4 Rest the swab against the posterior wall of the pharynx and move the tip up and down a few times 5 Place the swab into the accompanying vial of Amies transport media 6 Fill out the PHSA Labs Bacteriology amp Mycology Requisition form 7 Seal in biohazard bag refrigerate and ship as soon as possible in a cooler containing ice packs U N e PHSA 305 Rev 2012 02 Implementation Date April 2013 Printed versions of this document are not controlled 75 Wm whnanone Laboratory Sample ZF general hospital Guide to Services Orero Miscellaneous 8 Miscellaneous Samples Requisition Storage Transport Instructions amp Sample Type Kit Contents General Comments labelled dark blue paper See BCCDC Guide to Services for Mycology Fungal 1 l l packet information on collections Outbreak Gastrointestinal GI Contact YCDC 6 Contact YCDC Outbreak Influenza See PHSA Like llIness ILI
10. Procedures 1b Tube Selection Order of Draw and Sample Mixing Gently Invert mix tubes 8 10 times immediately after collection to ensure the preservative is mixed completely with the sample Tube Top Colour Order of Draw Additives Label Code BLOOD l CULTURES Blood Culture bottles always collect first keep warm D eee C lation PT INR Tub tb oagulation l l ube must be Sodium citrate Citrate plasma PTT Dimer completely filled BLUE nee Th tic d 1 erapeutic drug ete Serum monitoring Product indicate on transfer tube labels Common Lab Tests Notes Black Cannot be shipped Sodium citrate Whole Blood ee to Lab sample only sedimentation rate BLK good 4 6 hrs Light Green Lithium heparin Plasma Most routine chemistry PST Lavendar or pink EDTA Whole Blood LAV or EDTA Hematology Transfusion Medicine as Gold Most chemistry A Se silica polymer gel Serum Infectious Disease i testing Cancer SST Screening Note Two blood smears must be made from blood collected for hematology testing For more information on collection tubes visit http www bd com ca Implementation Date April 2013 Printed versions of this document are not controlled 45 whitehorse l d general hospital Guide to Services Laboratory Pisa Procedures 1c How to properly prepare a blood smear for CBC A properly prepared blood smear is essential for accurate assessment of cellular morphology The wedge
11. Refer to the following websites for more information www transfusionmedicine ca http orbcon transfusionontario org bloodyeasy http www tragprogram ca http www blood ca Blood Components Available in stock at Whitehorse General Hospital 1 2 3 4 Red Blood Cell Units Packed Cells N B Phenotyped blood for patients with antibodies and special red cell requirements i e CMV seronegative or Irradiated will need to be ordered from Vancouver and will require additional time Frozen Plasma requires 15 minutes to prepare Cryoprecipitate Platelets must be ordered from Vancouver as the need arises Please allow a minimum of 24 hours for delivery Platelets are to be ordered in Adult Doses each dose should bring the platelet count up by approximately 20x10 L in the absence of ongoing lose consumption Blood Products Available in stock at Whitehorse General Hospital 1 2 3 4 Oo 01 8 9 10 11 Rh Immune Globulin WinRho 25 Albumin 5 Albumin Intravenous Immune Globulin IVIG for specific diseases IVIG Utilization Management Policy defines approval process Hepatitis B Immune Globulin for high risk neonates and Needlestick patients Varicella zoster Immune Globulin for high risk exposures Recombinant Factor VIII for specific hemophilia patients Phenotyped blood for patients with antibodies may require additional time Recombinant activated Factor VII NiaSta
12. Testing e Phone the Laboratory at 393 8739 to book appointments for patients Exception Spirometry tests are now booked by our staff e Fax completed Requisitions to the Laboratory 867 393 8772 A Electrocardiogram ECG EKG 1 Refer patients with acute chest pain directly to the WGH ED not to the Laboratory A requisition is not required 2 Appointments ensure the ordering physician is available in their clinic at the proposed time of the patient s ECG appointment The physician must review abnormal ECG reports before patients can leave the hospital 3 Pediatric patients will require longer appointment times so please indicate the age of the child when booking the appointment 4 Provide patient with a Patient Information Sheet see Section D if required 5 Verbally inform the patient of the following information e Arrive at least 10 minutes early for the appointment so there is time for check in If you are late there may be delays or your appointment may need to be rebooked e Be prepared to wait there can be delays if your doctor needs to review the ECG test results While the actual test is fast the entire appointment may last 30 minutes Implementation Date April 2013 Printed versions of this document are not controlled 12 whitehorse Laboratory Laboratory general hospital Guide to Services Information B Holter Monitor 1 Provide patients with a Patient Information Sheet see Section D 2 Verbally i
13. and offered but must be ordered by physician Early ultrasound is required to confirm dates if there is any doubt of gestational age Complete documentation of counseling acceptance refusal physician order is required http www bcprenatalscreening ca page130 htm Screening tests May be drawn during the initial visit or deferred to a later visit Note SIPS 1 is collected 10 13 wks If no ABO Rh typing is on file WGH Lab recommends drawing as early as possible due to the length of time it takes to get results Revised by Community Nursing August 2010 Revised March 2011 August 2012 Implementation Date April 2013 Printed versions of this document are not controlled 59 sample WZ whitehorse Laboratory P i Collection ZF general hospital Guide to Services Procedures 3 Body Fluid Collections All fluids are considered STAT and must be brought to the Laboratory within one hour of collection Synovial Fluid Orderable Tests Collection Tube Needed Notes Cell count with differential EDTA mauve topped Mucin clot test Plain Serum red topped Crystals Red or mauvetop Rheumatoid Arthritis Redtop Glucose actate dehydrogenase Room temp only otal Protein ic Aci Culture and Sensitivity Never freeze Peritoneal Dialysate All testing is initiated when upon inspection the collected bag of dialysate appears cloudy _ s Orderable tests TIGHTEN SECUR
14. apart e Endocarditis on antimicrobial therapy obtain 2 separate culture sets on each of 3 successive days Reference BioM rieux Inc 2008 Worksafe BacT ALERT Blood Culture Collection Procedure Instruction sheet available from www biom rieux usa com Implementation Date April 2013 Printed versions of this document are not controlled 53 sia Sample x whitehorse L ABOTA OTY Collection general hospital Guide to Services Proced r s 2 Blood Bank Transfusion Medicine Patient Identification Positive patient identification is of utmost importance for transfusion medicine errors can result in fatal outcomes Only specimens collected using the WGH Blood Bank Identification Card system will be used for crossmatching and transfusion purposes This card is normally only available within Whitehorse General Hospital You must follow this specialized patient identification procedure if you anticipate the patient may require blood components 1 Order a Group and Screen test Identify the patient using at least two unique identifiers Ask the patient their full name and date of birth check this information against the hospital admission wristband Compare other identifiers i e Healthcare Number Chart Number etc if available 3 Collect two 7 mL EDTA collection tubes tall pink topped tubes of blood 4 Label each collection tube with at least two identifiers use of an ID sticker is acceptable the date amp time of collec
15. apply an exception to sample rejection Upon receipt of samples that do not provide the information listed above an Irreplaceable Sample Identification Record Form see next page will be filled out and returned to the physician or your Clinic Implementation Date April 2013 Printed versions of this document are not controlled 9 w whitehorse Laboratory Laboratory ZF general hospital Guide to Services Information Irreplaceable Sample Identification Record Samples received on showed the following deficiencies Date and time of receipt in the Laboratory Patient Full Ordering Name Physician Date of YT Health Birth Care Please check the appropriate box Collection Tube or Container Requisition Unlabelled No patient information provided Illegible No requisition received No secondary identifier Illegible No date amp time of collection specify specify This record must be signed by the Ordering Physician and the sample and Requisition as indicated above must be corrected before testing will be performed Incorrect Notest s ordered verify that the sample from the above named patient cannot be recollected The information has been corrected and take full responsibility for the results and repercussions of testing on this sample Print name clearly Sig nature declaring corrected patient identity Date MLA or Tech Witness Implementation Date April 2013 Printed versions of this document are
16. endocervical canal 3 Gently rotate swab clockwise for 10 to 30 seconds in endocervical canal to ensure adequate sampling 4 Withdraw swab carefully avoid any contact with vaginal mucosa 5 Remove cap from swab specimen transport tube and immediately place specimen collection swab into specimen transport tube 6 Carefully break swab shaft at scoreline use care to avoid splashing contents 7 Re cap swab specimen transport tube tightly Collection for Male Urethral Swab Specimens Patient should not have urinated for at least 1 hour prior to specimen collection 1 Insert specimen collection swab blue shaft swab in package with green printing 2 to 4 cm into urethra 2 Gently rotate swab clockwise for 2 to 3 seconds in urethra to ensure adequate sampling 3 Withdraw swab carefully 4 Remove cap from swab specimen transport tube and immediately place specimen collection swab into specimen transport tube 5 Carefully break swab shaft at scoreline use care to avoid splashing contents 6 Re cap swab specimen transport tube tightly Specimen Transport and Storage After collection transport and store swab in swab specimen transport i tube at 2 C to 30 C until tested Specimens must be assayed with the gt APTIMA Assay for CT and or GC within 60 days of collection If longer storage is needed freeze at 20 C to 70 C for up to 90 days after collection 10210 Genetic Center Drive San Diego CA 9212
17. for medical indications example to determine if patient needs Rhlg after miscarriage and non medical example travel visas indications Non medical requests will require payment by the client Group and Antibody Screen This test is used to identify the patient s blood group and to establish if they have any unexpected red blood cell antibodies in preparation for a possible transfusion Red Blood Cell units will be crossmatched when a transfusion is ordered Positive Antibody Screens are sent to Canadian Blood Services in Vancouver for identification of the detected antibody This will delay the availability of red cells units for transfusion Contact the Laboratory for more information if this occurs Order Prenatal Screens blood group and antibody screen on the Canadian Blood Services Prenatal Screen requisition Do not order GROUP amp HOLD as this restricts inventory and causes unnecessary workload Should the need for blood arise after a Group and negative Antibody Screen is complete the crossmatching can be completed within 15 minutes Crossmatch This test is used to prove compatibility between the patient and the donor red cells and will be completed only when the blood is required for prompt transfusion Please see the Nursing Policy Manual BBK Guidelines for information on ordering retrieving and transfusing blood products Direct Antiglobulin Test DAT This test is used to determine if the patient s re
18. handled without gloves 3 Paperwork Requisitions etc accompanying the specimen must be protected from contamination and separate from the primary specimen 4 If specimens are held in cold storage prior to transport label refrigerators amp freezers containing biohazards with appropriate WHIMIS labels Ensure appliances are located in an area with restricted access Implementation Date April 2013 Printed versions of this document are not controlled 108 whitehorse Laboratory Packaging amp general hospital Guide to Services Transport 5 Place specimens in a third rigid container to better protect specimen integrity in transport and protect specimens from temperature fluctuations when a climate controlled environment is required Again biohazard labels are required Labels alert all workers to follow universal precautions Inpatient and Outpatient Samples Transport within WGH Transport specimens from inpatient units to the main Laboratory in a rigid plastic tray Transport larger numbers of samples in a secondary container Keep laboratory specimen paperwork separate from the primary specimens and free of contamination Contact the Laboratory immediately in the event of accidents or spills Where appropriate Laboratory personnel will take necessary action to contain the spill or notify the appropriate Officials Implementation Date April 2013 Printed versions of this document are not controlled 109 W whitehorse Labor
19. mL is about half full iv Remove the container from the stream of urine 4 Add an equal amount of 50 methanol from container 2 to the sample in container 1 5 Tightly seal the lid on the container and place it in a plastic bag seal the bag with a twist tie 6 Collect 1 sample Only one sample can be tested in a 24 hour period 7 Bring the sample to the Laboratory within 2 hours of collection If you live in a remote community you must refrigerate and transport the sample to the Laboratory within 24 hours Questions Concerns Please phone WGH Laboratory at 393 8739 Methanol Warning See other side of this sheet Return all containers to the Laboratory Implementation Date April 2013 Printed versions of this document are not controlled 101 whitehorse Laboratory Patient ZX general hospital Guide to Services Instructions CAUTION METHANOL is FLAMMABLE Keep away from sparks and flame METHANOL IS TOXIC Keep out of reach of children First Aid for Methanol Contact Skin 12 Flush skin with lukewarm running water for at least 15 minutes 13 Remove clothing with Methanol spill on it take care not to spread the spill 14 Discard or decontaminate clothing under running water 15 Unless contact has been very minor go to the Hospital Emergency Department Outside Whitehorse contact your Doctor or Nurse right away Eyes 1 Flush the eyes for at least 15 minutes with lukewarm running water Hold the eyelids
20. medium and make smear 1 Clean the ear canal with a disinfectant i e 70 alcohol or SOLU I V and rinse it with saline 2 Sample the canal several minutes after cleansing by swabbing briskly over any lesion present 3 Use a separate sterile swab to make a direct smear on a glass slide Label the frosted end of the slide Patient s full name and date of birth AND health care number site of collection date of collection Label the swab with the same information as above 5 If delay in transport is unavoidable refrigerate the sample at 4 C Eye Samples Collect using clear swab Amies transport medium and make smear 1 These instructions are not meant for skin areas around the eye see superficial wound samples for these types of swabs 2 Specify left or right eye and the site of the sample e Conjunctival e Lid margin e Corneal e Aqueous or e Vitreous sample Do not use the non specific term eye for identifying a sample 3 The method of sample collection depends on the site of the eye infection In bilateral conjunctivitis culture of one eye only is necessary 4 Please make a smear at time of collection Use a separate sterile swab to make a direct smear on a glass slide Label the frosted end of the slide patient s legal name site of collection date of collection 5 Label swab smear and Requisition with patient information 6 If delay in transport is unavoidable hold the sample at 4 C Im
21. monitor will record your heart s activity during this time period HOW TO PREPARE FOR THE TEST Wear a 2 piece outfit that is loose fitting and preferably buttons down the front Shower prior to coming for the test DO NOT use tale or powder The appointment will take about 30 mins You will need to return at the same time the following day with a diary of activities to have the recorder removed 5 Ifyou are not able to keep your appointment please call the Laboratory at 393 8739 TO BE COMPLETED BY PHYSICIAN i e pa n a a APPOINTMENT DATE WGHIDF NAME _ ee DOB PHONE h w SOSS PACEMAKER NO YES VVI__ DDD ___ AAI k CLINICAL PROBLEMS REASON FOR TEST eee Ten MEDICATIONS REFERRING PHYSICIAN E ooo E PLEASE PRINT First and Last SIGNATURE x e onmes oon ma a e a G Sr RECORDER TYPE OXFORD MARQUETTE Implementation Date April 2013 Printed versions of this document are not controlled 25 WS whitehorse Laboratory Requisition k4 general hospital Guide to Services ronne Examples L a First Name Submitting Doctor Clinic Comes of report to Amve 10 mins arty to check in Reason for testing For diagnos wihhold respiratory Medic at0ns see reves Physigan must provide specife wisructans fo patent Monitoring therapy continue respiratory medications Spirometry FVC FEV fow volume boop ne bonchodlaior Approx 30 mins Reversibility Testing Pre and Post bronchodil
22. of Service Main Laboratory 0630 1600 Regular Hours Monday Friday 1600 2400 Staffed by one Technologist Weekends amp Holidays 0800 2400 Staffed by one Technologist 2400 0800 One Technologist On call Microbiology Laboratory All testing processing of Everyday 0800 1600 Microbiology samples performed during Regular Hours STAT Requests After Hours Please contact Main Laboratory Technologist Outpatient Collection Centre 0700 1130 Monday Friday Regular Hours amp 1230 1600 Weekends amp Holidays Closed Timed blood work needed on weekends amp holidays must be pre arranged with Lab staff 2 Contact Information Phone Fax General Lab Inquiries m ans 867 393 8739 867 393 8772 Appointment Bookings Collection Instructions Microbiology Collection Instructions 867 393 8794 867 393 8772 Results Implementation Date April 2013 Printed versions of this document are not controlled 1 w whitehorse Laborato ry Laboratory general hospital Guide to Services Information 3 WGH Laboratory Test Menu Our On site Services Whitehorse General Hospital Laboratory Test Menu Our On site Services Hematology Tests available on whole blood CSF and bodyfluids Complete Blood Count CBC Malaria screen PTT WBC differential RBC morphology Reticulocytes D dimer Platelet count PT INR Fibrinogen C Chemistry Testing on plasma serum urine amp other body fluids for many analytes Glucose tests include Fasting Ra
23. page The ordering physician must sign the form in order for the request to be processed Notes Standing Orders are only valid for a maximum of 1 year Once expired a new request form will need to be completed If a patient is absent for 4 months or more their Standing Order will be cancelled A new request form will need to be completed to resume service Results will only be sent to the Ordering Physician s on the standing order Only tests listed on the Standing Order will be completed If additional tests are needed at a given time you must fill out a separate Requisition e Refer to Standing Order tests on the Requisition if both are to be done e Ask the patient to mention their Standing Order to Laboratory staff upon arrival Implementation Date April 2013 Printed versions of this document are not controlled 19 w whitehorse Laborato ry ZF Requisitions general hospital Guide to Services Request for Standing Orders for Laboratory Services Name of Patient Lastname Firstname Address amp Phone number Date of Birth dd mm yy Health Care Ordering Physician Physician s Signature Required Additional Copies to include fax s Test s Required amp Frequency of Tests Duration year Internal Lab Use Only Date Received Date Card Made Implementation Date April 2013 Printed versions of this document are not controlled 20 Laboratory 7 Whitehorse Re
24. smear technique is as follows 1 Use two high quality beveled edge microscope slides one serves as the blood smear slide and the other as the spreader slide Place a drop of EDTA anti coagulated blood about 3 mm in diameter at one end of the smear slide The size of the drop is important too large a drop creates very long or thick smears too small a drop often makes short or thin smears Place the spreader slide in front of the drop at a 30 45 degree angle to the smear slide Pull the spreader slide back into the drop of blood and hold it in that position while the blood spreads across the width of the slide Quickly and smoothly push forward to the end of the slide to create a wedge smear Moving the spreader slide too slowly accentuates poor leukocyte distribution by pushing larger cells monocytes granulocytes to the very end of the sides of the smear For higher than normal hematocrit the angle between the slides must be lowered so that the smear is not too short and thick For extremely low hematocrit the angle must be raised A well made peripheral blood smear has the following characteristics 1 2 About two thirds to three fourths of the length of the slide is covered by the smear The feather edge thin portion is very slightly rounded not bullet shaped Lateral edges of the smear should be visible The smear is smooth without irregularities holes or streaks When the slide is held up to light the feather e
25. the inside rim of the sample container Eliminate the last drops by holding the tip of the slide to a piece of paper towel or tissue Carefully return the slide to the plastic tube and close tightly Do not leave excess urine in the Bactube container Label the Bactube container with patients name date of birth or health care number date amp time of collection as well as type of collection i e MSU catheter Keep the Bactube at room temperature Submit labelled Bactube and completed Microbiology Requisition to the Laboratory for testing Peds bag neonatal bagged urine Note This method is used to collect urine from newborns and those without bladder control neonates and young toddlers but it is not a very effective method for ruling out UTI due to contamination P 2 3 Wash the external genitalia Place a collection bag over the external genitalia Transfer urine from the bag immediately to a clean sterile container Straight line Catheters In Out Catheters 1 Clean the patient s urethral opening and in females the vaginal vestibule with soap and carefully rinse the area with water Using sterile technique pass a catheter into the bladder Collect the initial 15 to 30 mL of urine and discard it from the mouth of the catheter Collect a sample from the mid or later flow of urine into a sterile container Implementation Date April 2013 Printed versions of this document are not controlled 72 Labora
26. tumor origin etc perform 2 additional aspirates and rinse all material directly into 10 neutral buffered formalin This will allow the laboratory to make a cell block for these studies To learn more about FNA technique go to http www papsociety org fna html Lung and GI Cytology Place all washing brushing and lavage samples directly into CytoLyt or 50 Washings Brushings ethyl or methyl alcohol Brush tips may be cut off and left in the solution Lavage Place sputum samples in 50 ethyl or methyl alcohol If possible deliver fresh unfixed to the lab within 24hrs refrigerate ship cool do not freeze Otherwise preserve by adding an equal volume of 50 ethyl or Cerebrospinal Fluid CSF methyl alcohol U Preserve urine sample by immediately adding an equal volume of 50 methyl rine or ethyl alcohol Nipple secretions Nipple secretions Thinly smear secretions directly onto a clean glass slide and allow to air dry Received from BCCA February 10 2012 Implementation Date April 2013 Printed versions of this document are not controlled 62 ZF whitehorse l d general hospital Guide to Services Laboratory Pinal Procedures 6 Microbiology Sample Collections General Sample Requirements 1 The quality of the laboratory result is dependent on the quality of the sample and the information given to the laboratory There are no normal values in Microbiology An improperly collected sample means inaccurate
27. types Influenza ILI Pertussis GI Outbreaks GC Chlamydia Implementation Date April 2013 Printed versions of this document are not controlled 3 w whitehorse Laboratory Laboratory g general hospital Guide to Services Information 5 Sample Identification Criteria Labelling Samples are labelled immediately after collection and in the presence of the patient Samples are labelled with the following minimal information e Patient s last and first name e Second identifier D O B and or healthcare number e Identity of individual collecting the sample where required e Time and date of collection It is acceptable to use the date format on a computer generated label provided it is accurate Collection time is recorded using the 24hr clock format e Sample source where applicable WGH Laboratory Quality Manual QP 07 01 p 1 6 Proper Labelling of Samples Affix labels to blood collection tubes as follows v Position labels such that the Patients name begins near the coloured cap of the collection tube v Cover the original label such that a portion of the blood sample is visible to verify quantity and quality v Mint green PST and Gold SST capped collection tubes ensure a small portion of the original tube label colour is visible once coloured caps are removed for analysis they are recapped with non specific generic caps tube label colour is necessary info for technologists v Ensure the label isn
28. 1 800 523 5001 WWW GEN PROBE COM L578 REV A 2006 Gen Probe Incorporated We Whitehorse Laboratory Sample i Collection ZF general hospital Guide to Services Procedures Pregnancy screen Refer to the Prenatal Checklist in Section X for full schedule of tests Common Pathogens Sought Test Performed Clinical Condition Site Vagino Anorectal remember Groupe o reniococtis Vagino anorectal culture at 35 to request Group B screen p p 37 weeks gestation clear swab Vagina Bacterial vaginosis Smear for Gram stain Solana acnOMmetts Combined Chlamydia GC PCR Cervix i Swab or Urine PCR Neisseria gonorrhoeae Infection Control Screening MRSA or VRE Samples submitted solely for the detection of MRSA Methicillin Resistant Staphylococcus aureus OR VRE Vancomycin Resistant Enterococcus Perianal preferred site or groin Nares left and right on ONE swab Previously positive sites FO Se ENEE All open wounds swab each one separately one of the following p p y Ostomy site if applicable Invasive device site if applicable Open wounds if applicable For VRE screening collect Rectal swab Swabbing sites for MRSA or VRE Collect using clear swab Amies transport medium Pre moisten a swab with Sterile Saline One swab per site except for Nares 1 swab for both right and left nares Roll the swab at the site for 2 3 seconds lS a Label appropriately with e patient s legal name date of bi
29. 13 Printed versions of this document are not controlled 16 W hnanere Laboratory List of FG general hospital Guide to Services Requisitions Section B Ordering Tests amp Requisition Forms 1 List of Requisitions Requisition Title Header Site of Testing Types of Tests Run WGH Laboratory On Site l Blood Urine Fluid Tests 1 Whiteh I H i eile MeN Okse Meche eee Booked Procedures Genital Smears amp Swabs C amp S Gram stain 2 WGH Microbiology Laboratory Whitehorse General Hospital Interpretation Cardiology Unit at iia St Paul s Hospital Spirometry QC The Lung Centre VCH UBC Spirometry testing WGH Laboratory Referred Out Testing Clik e Se PHSA Laboratories Tumor Mark Canadian Blood Services 7 Diagnostic Services Perinatal Screen Request Requisition Centre of British Columbia Screen SIPS PHSA Laboratories Electrocardiography 24 48 hrs Canadian Blood Services Perinatal Screening Vancouver Cervical Cancer Screening Cancer Screening Pap smear Laboratory Vancouver BC samples Gynecological Cytology Requisition Form ae Od ann ele Oe St Paul s Hospital Chlamydia GC PCR Laboratory 11 hoa S Seley BC Centre for Disease Control B eng wes Screening Requisition Syphilis Hepatitis 12 PHSA Laboratories Parasitology BC Centre for Disease Control Parasites as detected from Requisition various tissue samples 13 PHSA Laboratories Virolog
30. 3 Test s Requested PATIENT STATUS C Hospital inpatient C ER patient C History of contact with infection LJ Travel history RESPIRATORY VIRUSES C Nasopharyngealswab _ Nasal swab C Bronchoalveolar lavage _ Nasal wash C Other specify Tested by POC for Positive Negative influenzaB Positive Negative RSV Positive Negative Influenza A HEPATITIS VIRUSES Blood for C Qualitative HCV RNA diagnosis C Quantitative HCV RNA treatment only C Baseline 7 Week specify _ C HCV Genotyping hor other con stilt the Public He Tee Vil svailable tests and additional information robioloay amp Reterenci Programs a hsa ca bec dcpub ichealthlab ADDITIONAL COPIES TO Acsress M5Ca SIGNS SYMPTOMS Date of Onset oO Asymptomatic _ Fever C Upper Respiratory Infection DD MMM YYYY C Other specify HERPES VIRUSES C Genital lesion for HSV C Skin swab for Varicella Zoster C Other specify Urine for _ Cytomegalovirus ENCEPHALITIS MENINGITIS Cerebrospinal Fluid for C Encephalitis e g HSV 1 West Nile Virus C Meningitis HSV 2 Enterovirus g Other specify MUMPS VIRUSES C Buccal swab C Urine For information on sample collection please call Virus Isolation Lab at 604 707 2623 vi C Non genital lesion for HSV Virology Requisition SAMPLE REF NO DATE COLLECTED DO MMMYYYYY TIME COLLECTED HH MIAS C Co
31. A restrictions total volume in mls random sample L Lead special collection container LJ Mercury special collection container LJ VMA requires diet restrictions 0 Zinc special collection container Preservative added Y N Name of preservative Volume mls Lab Req FORM 8400270 2009 09 5 Hospital Road Whitehorse Yukon Y1A 3H7 Implementation Date April 2013 Printed versions of this document are not controlled 27 W ZF Laboratory Requisition whitehorse Forms eneral hospital j j i g p Guide to Services Examples PHSA t boratories SAMPLE TYPE PATIENT INFORMATION SERUM O USE ADDRESSOGAAPH OR PRINT A service ican Health Services Authority PLASMA 0 a a So tain Av Yi AC V SURNAME GIVEN WAME ta Cuslomer Si ETIA ine Bex Cone SS TE CJ eo iini a TUMOUR MARKER LAB REQUISITION SS DATE LO BOARS on SEX PRIORITY Phiebotomists Routine C Stat 0 Initials a BEARER oa rome ASAP C results within 4 hours SAMPLE TIME _ Sample must be received in TML by 1300 BOA EN en ii hrs not available for PAP SCC ee eet eee l DIAGNOSIS SYMPTOMS PHYSICIAN REFERRING LAB INFORMATION __ HISTORY AND RELEVANT DATA caer Pipin Man e CURRENT TREATMENT itiona icians E Aa ysicians x EF lt i SROGRAM Pe Referring Lab Hospital A Address _ PARE ar MENT l WHITEHORSE FT aT RADIOTHERAPY g YIA 3H7 CHEMOTHERAPY and or HORMONES ben W Ser
32. Acceptance Criteria for Requisition Forms Ensure the following information is provided Complete Name Surname amp Given Name Health Care Number Date of Birth DD MM YYYY ml eee SSS a componen SSS EA Fax Number if Outside Yukon Doctor or Facility Name Patient Information Billing Number or Facility Number ax Number if Outside Yukon Date and Time K M K M ice Sample Type Tests Ordered ice Test Requested wom e Relevant Clinical Travel History If Patient collects sample remind them to fill out Blood if decanted from original tube specify serum heparanized plasma citrated plasma whole blood etc Indicate if frozen Sample Type Current Requisition used by the WGH Laboratory Though updates will be provided through WGH Laboratory Memos we strongly encourage you to visit Referred Out Laboratory websites periodically to ensure you are using the current Requisition Infrequently ordered tests may require other Requisition not displayed here Phone the Laboratory 867 393 8739 to discuss requirements Implementation Date April 2013 Printed versions of this document are not controlled 18 Laboratory whitehorse Requisitions R4 general hospital Guide to Services 3 Standing Orders Purpose To eliminate the need for Requisitions for each visit when patients require blood work on a regular basis Procedure Complete a Standing Orders Request for Laboratory Services Form see next
33. C before transport with ice pack Do not freeze sample For information on sample collection please call Environmental Microbiology Lab at 604 707 2611 Form DCFP_102_1001F2 Version 1 0 09 2009 GIOB GIOB Current Requisition Form listed here http www phsa ca AgenciesAndServices Services PHSA Labs T esting Requisitions Diagnostic htm Implementation Date April 2013 Printed versions of this document are not controlled 38 ZF whitehorse general hospital Guide to Services Laboratory a Examples wy rovidence HEALTH CARE C Mount Saint Joseph Hospital O St Paul s Hospital DEPARTMENT OF PATHOLOGY SURGICAL REQUISITION Date of Surgery Bill to CXMSP JWCB RCMP Self pay C Other EXACT SOURCE OF THE SPECIMEN Time into Blank space for drawing orientation of specimen fixative Clinical diagnosis history and additional information including any previous relevant surgery Lack of clinical history may result in sub optimal interpretation an J bag M DEPARTMENT USE ONLY Number of Frozen Sections GROSS DIAGNOSIS RUSH DIAGNOSIS Pathologist Surgeon printed name Signature Copies to Dr billing number OCIA ATA TA As s s Current Requisition Form available from the WGH Laboratory Please provide Implementation Date April 2013 Printed versions of this document are not controlled 39 Wy Laboratory Requisition ZF whitehorse Forms eneral hospital i i i g p G
34. Collection Laboratory Clinical Information Please answer all questions to receive the most accurate report DATE ANG TIRE OF COLLEGION 1 Amniocentesis or CVS for chromosome testing already done in this pregnancy C NO Wi YES GOLLEGTION GENIE FAGLITY GODE i 2 Complete first trimester screen E bloodwork NT done at private centre O NO B YES COLLECTOR S INITIALS 3 Nuchal translucency NT ultrasound done planned NO C YES Collect SmL SST tuba centrifuge transport to the C amp W Lab within 6 hours 4 C if yes date and location cof NT US For altomate instructions contact lab 4 Type 1 or Type 2 diabetes mellitus Note not gestational diabetes LJ NO L YES 5 Racial origin LI Caucasian C East Asian LJ South Asian L First Nations Black _ Other specify EAST ASIAM pg CHINESE JAPANESE FILIPING VIETNAMESE KOREAN SOUTH ASIAN og INDIAN PAKISTANI SARI LANKAN FOR COMPLETION BY C amp W LABORATORY Screen Requested Choose One Only 6 Most recent maternal weight Ibs or kg Sorum integrated Pronatal Screen BIPS Smoking in this pregnancy NO YES C Pati 10 136 wks 8 Taking oral or IV steroid medication s in this pregnancy E NO ia YES C Pat 15 2066 wks 9 In vitro fertilization IVF pregnancy Iwo D ves Quad Screen 15 206 wks a If donor agg used birth date of agg donor Y M Peports chance of neural tube defect MSY a ae Or Se eee but not Down sy
35. Drawn From Newly Placed IV Sites in the Emergency Department Journal of Emergency Nursing 31 4 338 345 Implementation Date April 2013 Printed versions of this document are not controlled 49 YY Sample YX whitehorse L any Collection general hospital Guide to Services Proced r s 1e Sample Handling amp Storage prior to Transportation Analytes in blood samples can be affected by delayed or improper handling prior to transport Centrifugation time temperature light exposure and storage conditions can affect some test results sometimes with severe consequences to patient health and safety Centrifuge samples within 30 minutes of collection Samples that have not been centrifuged will be rejected if they arrive more than 2 hours post collection Glycolysis the metabolism of glucose can occur when serum or plasma remains in contact with red blood cells during storage and transport Glycolysis can result in falsely lower glucose results The process is accelerated in higher temperatures or with elevated white blood cell counts lon Exchange can also occur when samples are not centrifuged in a timely fashion Potassium moves through red cell membranes when samples are cooled increasing potassium levels substantially in the plasma False readings of potassium are a potential threat to patient safety These are just two consequences of improper handling See the table below for other examples of analytes that change during seru
36. ELY STERILE BIEN RESSERREZ OO gg DOBMN e e i S h j gt y Cell Count and differential use WGH On Site requisition Culture and Sensitivity use WGH Microbiology requisition Amylase use WGH On Site requisition Collection notes e Mix dialysate bag well to ensure the contents are evenly distributed e Clean access port prior to collection of fluid using 70 isopropyl alcohol e Collect a 50 mL aliquot of fluid and place it into a sterile collection container e Collect one lavender top EDTA and one gold top SST vacutainer e Samples MUST be sent to the Laboratory immediately for processing cells disintegrate rapidly and results will be inaccurate if processing is delayed e DO NOT send the entire bag Implementation Date April 2013 Printed versions of this document are not controlled 60 We Whitehorse Laboratory Sample Collection ZF general hospital Guide to Services Proced res 4 Pathology Sample Collections All Pathology Samples are sent to Providence Health Care SPH Special Requests for fresh tissue Duration of Fixation Type of Specimen Type of Fixative ROUNE Aca 10 Buffered Neutral specimens moles Paman overnight lumps amp bumps Cone Biopsies Core 10 Buffered Neutral slice the cone through l ae l i i overnight Biopsies Formalin its largest diameter Cervical and endometrial 10 Buffered Neutral o l 1 2 hours biopsies Formalin For all samples the Volume of Fixative
37. L R PEC Previous Malignancy CLINICAL DATA Radiation Therapy _ Yes DATE Chemotherapy YES DATE CLINICAL INFORMATION Adequate clinical information is essential for accurate cytological interpretation THYROID LR Isthmus G OTHER E L E R SPECIFY SITE Other NIPPLE DISCHARGE L R OTHER SPECIFY PAP os MGs i E mi l a E REOUSITION LABEL m total aa Printkormii i Current Requisition Form listed here http www bccancer bc ca NR rdonlyres 299F69DD 84C0 4856 9026 OD0D31B78F74 52600 DiagnosticC ytologyrequisition3 pdf Implementation Date April 2013 Printed versions of this document are not controlled 40 Laborator Requisition R4 n a ital Guid S 4 Porn g p uide to Services Examples af BCBiomedical Dr C J Coady Associates LABORATORIES LTD 6 Tel 604 507 5000 Consultants in Laboratory Medicine Fax 604 507 5200 SPECIFIC ALLERGEN IgE REQUEST FORM a S amp ss of amp itderingi Phy yp ESC YY Patient s Last Name First N ing Physician Fi A Date Billing The following information must be supplied MSP guidelines require that generally no more than 5 allergens be tested as an insured benefit within a 12 month period and patients must be in one of the following categories for serum testing Please indicate by checking the appropriate box and include Clinical History Diagnosis O 1 Ahistory of life thre
38. LungAssociationSk depicts the test we perform at the WGH Laboratory http www youtube com watch v 7JORNHWVrY amp list UUo02i4ilvca 7JpewgqD9xY5GVA amp index 2 amp feature plc Implementation Date April 2013 Printed versions of this document are not controlled 15 w whitehorse Laboratory Laboratory g general hospital Guide to Services Information D Oral Glucose Tolerance Testing OGTT or GTT and Gestational Diabetes Screen GDS 1 Includes Non Gestational and Gestational GTT tests The Non Gestational GTT has in most circumstances been replaced by the HbA C test 2 Provide patient with e Requisition e Patient Information Sheet see Section D 3 Verbally inform patient of the following information e Fast for 8 hours before the test e You can continue to take your medications Drinking water is permitted e Arrive 10 minutes early to get signed in You will be at the Hospital for just over 2 hours e Read the Patient Information Sheet before the test to prepare for the appointment Dose and Collection Procedures for OGTT Dose of Trutol 100 Blood Restrictions 1gm 3mL Collections 8 hr fast water permitted take medication s 2 hr OGTT Non Gestational Adult 225 mL Fasting 75 gm 2hr 8 hr fast water Adult 225 mL Fasting permitted take 75 gm 1 hr medication s 2hr 2 hr OGTT Gestational 50 gm GDS Gestational Diabetes Screen Adult 150 mL 50 gm Implementation Date April 20
39. NTPELLED FEBA TPR Le W hitia Laboratory Supplies for FG general hospital Supplies Order Form Clinics Instructions 1 Fax 867 393 8772 or drop off completed form to the WGH Laboratory 2 Orders will be filled within 1 week and delivered to the WGH doctors lounge for pick up Ordering Clinic Information Clinic Name Ordered by Order Date Requisitions Quantity Supplies Quantity Amies with Charcoal Swabs Starswab Referred Out Testing 7 Amies Clear Swabs Starswab E WGH Microbiology Uricult Trio BacTube for C amp S urine Viral Collection kits respiratory red top UTM Viral Collection kits non respiratory blue top Multitrans Chlamydia Gonorrhoeae Swab Collection kits Aptima BCCA Misc BCCA Cytology Canadian Blood Services Prenatal Screen Request Chlamydia Gonorrhoeae Urine Collection kits Aptima BC Biomedical RAST a Stool O amp P containers SAF fixative SIPS testing red top containers Stool C amp S containers white lid with spoon Starplex Molecular Diagnostics BC Children s Hospital Pertussis Collection kits Swabs Pathology St Paul s Hospital Amies with Charcoal Chlamydia GC testing Semen Analysis kits 24 hr Urine collection containers Hemoccult slides occult blood stool ProvLab BC amp PHSA req s download from their websites Laboratory Use Only Note PAP Smear requisitions and supplies must be orde
40. Prenatal Biochemistry Lab Req v2 pdf Implementation Date April 2013 Printed versions of this document are not controlled 30 Requisition WZ whitehorse Laboratory q Forms general hospital Guide to Services Examples ec cancer agency Gynecological Cytology Services Authority Requisition Form Complete and proper labelling of the specimen and requisition ensures the most timely and quality patient care Sections in red are required information Patient First Name amp Initials Patient Previous Last Name Cytology Lab ID Smear Date dd mm yyyy MP Date dd mm HPV Vaccination No MEAR SITE CLINICAL INFORMATION UTERINE PROCEDURES ectocervix endocervix Bleeding Lesion Cervix Beek Bs eine C Using uD Colposcopy Bite Biopsy E n Cone Biopsy LEEP ost _ Lateral Vaginal Wall L Menopausal Post Partum Pregnant Cryotherapy Laser Hormonal Therapy Tick all that apply Pelvic Radiation Vagina vault _ Estrogen _ Progesterone Other Total Hysterectomy Uterus and Cervix removed Collection Method Date of Hysterectomy yyyy Brush _ Broom Device Spatula Hysterectomy Reason i Malignant Malignant Benign icen L Other DELIVER SAMPLES TO CONTACT Cervical Cancer Screening Laboratory Telephone 1 877 747 2522 1 877 PHSA LAB Central Processing and Receiving Fax 604 707 2601 655 West 12th Avenue Vancouver BC V5Z 4R4 Supplies fax 604 707 2606 Gynecological Cyt
41. Product Name amp Uses SAF Fixative red top vial Stool Ova amp Parasite Starplex sterile container with spoon Stool culture amp sensitivity C difficile virology Urine samples Semen analysis Sputum for AFB bacteriology amp fungal analysis cytology with methanol added 24 Hour Urine containers B350 Urisafe Simport Scientific For 24 Hour urine collection 3L containers Implementation Date February 2013 Laboratory Guide to Services Collection Containers continued N SECURELY Printed versions of this document are not controlled Visual Key to Kits W whitehorse Laboratory Visual Key ZF general hospital Guide to Services to Kits Collection Containers continued Product Name amp Requisition Uses ThinPrep CytoLyt Solution Contact Lab For some cytology specimens Product Name amp Requisition Uses Kit for Fungal specimens scrapings Teer Wiha batter Be Cabell Bacca Thiinig J Bike The World Lomder in Clecult Bioed Testing For occult blood screening Implementation Date February 2013 6 200 Hemoccutt I TEST FAA SOREENNG Pon FECAL GOUT Bo Phan HALE aa MPEET are a Sw Conon DAT PEM M Doueen EMOTE AF GOAT Ea EA L Printed versions of this document are not controlled OME AT CONTE A Eee TL Dr Hemoccult Il EERAL TEST FOR PEUTIE Soa POR FECA OCOULT BLOC A EMET a O e F BARE ONE HE PETTAN MALE TORN AT OO
42. R cr out of province Health Number and DOB CO MMMAYYY GENDER province FC UNK ADDRESS POSTAL CODE _ Ido not require a copy of the report CLINIC OR HOSPITAL Name and address ofreport delivery Section 3 Test s Requested OVA amp PARASITES BLOOD amp TISSUE PARASITES PARASITE IDENTIFICATION Sample Microscopic Examination Request For Sample C Feces C Urine Malaria Diagnosis C Confirmation C Worm C Proglottid Signs Symptoms C Other specify C Other specify C Asymptomatic Referring Lab Test Results For Malaria C Diarrhea _ Fever ther C Positive Thin and or Thick smear _ Negative Thin and or Thick smear Duration _ days C Tick Positive dipstick Rapid Test _ Negative dipstick Rapid Test _ High Risk Setting see reverse C Dipstick Rapid Test not done Sources Of Tick C Human L Dog Cat C Other specify C immigration specify below C Travel within past 12 months specify below Sample _ _ _ Thick amp Thin blood smear s _ Thick blood smear s C EDTA blood C Thin blood smear s _ Tissue Biopsy specify 9 02 SPECIAL TESTS Name of Pet Owner IF NOT noted as the C Body fluid specify patient above Consultation required 604 707 2629 C Other specify C Strongyloides Concentration Isolation C ELISA Amoebiasis Culture For Signs Symptoms C Schistosoma Hatch Test
43. T010 Patient Identification and Sample Labelling for correct labelling procedures All other samples will be rejected In all cases where samples have been rejected the appropriate patient care unit will be notified of the rejection and a request for recollection will be made Implementation Date April 2013 Printed versions of this document are not controlled 8 whitehorse Laboratory Laboratory ZX general hospital Guide to Services Information 9 Irreplaceable Sample Identification Policy Laboratory policy requires the following critical elements to ensure samples received are tested and reported on the correct individual e Patients must be positively identified using 2 identifiers e Samples are labelled immediately after collection and in the presence of the patient e Samples are labelled with the following information as a minimum Patient s last and first names Secondary identifier date of birth and or healthcare number that links directly to that patient identity of the individual collecting the samples where required Time and date of collection It is acceptable to use the date format on a computer generated label provided it is accurate Collection time is recorded using the 24hr clock format Sample source where applicable The WGH Laboratory recognizes that if the sample is less common involves an invasive procedure or could not otherwise be easily recollected it may be acceptable to
44. Via bility C Acanthamoeba species Cl Leishmania species _ Asymptomatic C Fever PINWORM C Other specify C Rash type Sample C Sticky paddle preferred C Anal swab Signs Symptoms C Asymptomatic Fever Skinlesion _ Eye C Other specify C immigration specify below _ Travel within 12 months C Travel within past 12 months specify below specify below C Other specify g Transparent scotch tape sitology Lab at 604 707 2625 PA_100_ Version 1 0 09 2009 PARA PARA Current Requisition Form listed here http www phsa ca AgenciesAndServices Services PHSA Labs Testing Requisitions Diagnostic htm Implementation Date April 2013 Printed versions of this document are not controlled 34 whitehorse general hospital W ZF PHSA Laboratories Laboratory Requisition Guide to S Forms uide to Services Examples vi Public Health Microbiology amp Reference Laboratory BC Centre for Disease Control 655 West 12th Avenue Vancouver BEYSZAR4 wyew phsa ca bocdcpublichealthlab Section 1 Patient Information PERSONAL HEALTH NUMBER ie ou province ADDRESS alth Nurniber and coymaawyyyy GENDER COM OF OUNK m e y TESI Ga e NI OAT TT Section 2 Healthcare Provider Information ORDERING PHYSICIAN Provide MSC Narne and address of report delivery g Ido not require a copy of the report CLINIC OR HOSPITAL Name and address of report delivery Section
45. YYY Section 4 Test Information TEST REQUESTED C Viral Bacterial Outbreak Test do not use SAF vial C Ova amp Parasitic Test use SAF vial C Other specify SAMPLE TYPE go Feces 0O Vomitus C Other specify SIGNS SYMPTOMS C Diarrhea C Watery C Bloody O Persistent C Vomiting C Abdominal cramps Fever CI Other specify ADDITIONAL INFORMATION C Initial sample L Follow up sample C Food handler C Staff member C Recent travel specify C Current antibiotics specify CI Other specify INSTRUCTIONS FOR SAMPLE COLLECTION SUBMISSION Label vial with patient name before collecting sample Pass feces or vomitus into a clean container avoiding contamination from urine or water from toilet Use a dry sterile vial and fill up to the line indicated Replace and tighten cap Place vial in the biohazard bag and completed requisition in the outside pocket Do not place the requisition inside the biohazard bag containing the specimens Ova and Parasite Testing Fill red capped vial with SAF with 2 3 spoonfuls of feces to the line indicated and mix well Red capped vial with SAF is not a suitable specimen for Viral Bacterial Outbreak Test Return to Health Unit or BCCDC Public Health Microbiology amp Reference Laboratory at 655 W 12th Avenue Vancouver BC V5Z 4R4 as soon as possible Keep specimens at 10 20 C for immediate same day delivery otherwise refrigerate at 4
46. aior Aporox 1hour Broncnodilaior dosage 4 x 100 mog puii of Salbutamol salf administerad by metered dose mhaler frouga aeochambe Refr io fhe 2005 ATSERS Standard for Spromety hin fwwectovacnconpsliatemertsresources PF TZ pat Contrandications for Spirometry Postpone if the patient Absolute Contraind ications 45 Experiencing an acute respiratory liness history of an aneurysm zs had a recent within one month heart attack uncontrolled hypertension zs had a recent stroke h s had recent eye abdominal thoracic surgery zs had a recent pneumothorax Referrals witout a physigan s sqnaiure wel mot be processed renia 212 ate recens in Lad Implementation Date April 2013 Printed versions of this document are not controlled 26 Laboratory a orms Examples whitehorse l i general hospital Guide to Services WF whiteh REFERRED OUT X general hospital TESTING REQUISITION Collection Date Ph 867 393 8739 fax 867 393 8772 Collection Time Collected by LAST NAME FIRST NAME MUO FO DATE OF BIRTH 42mm y HEALTH CARE Prov of samples sent DOCTOR CRNIC BURSIG ATIO Patient fasting E N COPY OF REPORT mer St Paul s Testing Vancouver Hospital 0462 1 Q AIA D ANA Ld Ionized Calcium LJ Anti Thrombin I LJ Lithium LJ Anti cardiolipin IgG amp IgM LJ Anti Thyroperoxidase date of last dose CO Anti DNA UL APO A Lipoprotei
47. ale and Female Midstream Urine culture Urine Cytology Sputum Samples Infant Ubag H pylori Urea Breath Test for H pylori Implementation Date April 2013 Printed versions of this document are not controlled 77 W ZF 1 whitehorse Laboratory Patient general hospital Guide to Services Instructions Your ECG Recording Your Heart s Rhythms Please follow these instructions before your appointment e Shower or bathe the morning of your appointment e Please do not use talcums lotions or perfumes e Wear a comfortable 2 piece outfit a shirt that you can easily remove e Men Be aware that we may need to shave off some chest hair where the sensors are attached e Women Do not wear panty hose sensors will be attached above your ankles e Please arrive at the hospital 10 minutes early to sign in e You will be asked to remove your shirt and lie down for the test Note While the test is very short you may need to wait in the hospital after the test Your Doctor may need to review your results before you can leave Appointments may last 30 minutes Electrodes Questions Concerns Unable to attend your booked appointment Implementation Date April 2013 Printed versions of this document are not controlled 78 WZ whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions 2 The Holter Monitor Tracking Your Heart s Rhythms for 24 Hours Please read and follow these instructions before your
48. alth lii rabialog y amp Relerence Laboratory s Side to Pr MOET NS nnd services al wii oh sa cay bcodcpublicheatthlab For information on sample collection please call Mycobacteriology TB Lab at 604 707 2620 Form PHTB_ 100 1001F Version 3 0 TE Current Requisition Form listed here http www phsa ca AgenciesAndServices Services PHSA Labs Testing Requisitions Diagnostic htm Implementation Date April 2013 Printed versions of this document are not controlled 37 YY whitehorse general hospital PHSA Laboratories Public Health Microbiology amp Reference Laboratory Laboratory Requisition Guide to S Forms uide to Services Examples GIOB Gastrointestinal Disease Outbreak Requisition BC Centre for Disease Control 655 West 12th Avenue Vancouver BCY57 ARA www abe ichealthlab Section 1 Patient Information province gk ADDRESS op Section 2 Healthcare Provider Information ORDERING PHYSICIAN M ovide MSCs Name and address of report defivery _ Ido not require a copy of the report CLINIC OR HOSPITAL Name and address of report delivery Section 3 Outbreak Information OUTBREAK IDENTIFICATION Outbreak ID Is specific to the event facility hospltal ward followed by the year e g Boardwalk Place 2009 as per instructions on page 2 of the G Outbreak Notification Form SUSPECTED ETIOLOGICAL AGENT SAAN ADDITIONAL COPIES TO Address M5C8 SAMPLE REF NO DATE COLLECTED DOVMAM Y
49. an s responsibility to provide their patients with specific instructions about withholding medications Recommended time for withholding medication prior to spirometry testing 7 Time to Medication withhold Short acting bronchodilators Salbutamol Ventolin Airomir Ratio Salbutimol Apo Salvent etc 4 hours ipratropium bromide Atrovent terbutaline Bricany Long acting bronchodilators salmeterol Serevent formoterol Oxeze 12 hours Combination Medications Advair salmeterol fluticasone Symbicort budesonide formoterol Theophylline 24 hours Theo Dur Once a day medications 24 hours tiotropium Spiriva motelukast sodium Singulair Corticosteroids Inhaled fluticasone Flovent budesonide Pulmicort ciclesonide Do not stop Alvesco beclomethasone Qvar Oral Prednisone source SpiroTrec The Lung Association of Saskatchewan 2010 The Spirometry Training and Educator Course Participant s manual Implementation Date April 2013 Printed versions of this document are not controlled 14 whitehorse Laboratory Laboratory general hospital Guide to Services Information Contraindications for Spirometry Postpone if the patient Absolute Contraindications is experiencing an acute respiratory illness history of an aneurysm has had a recent within one month heart attack uncontrolled hypertension has had a recent stroke has had recent eye abdominal thoracic surgery has had a recen
50. appointment Shower or bathe the morning of your appointment Please do not use talcums lotions or perfumes Wear a comfortable 2 piece outfit a E Best choice a shirt that opens in the front with higher neckline amp pants with a belt 5 Men Be aware that we may need to shave off some chest hair where the sensors are attached 6 Please arrive at the hospital 10 minutes early to sign in Questions Concerns Unable to attend your booked appointment Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 79 Z whitehorse Laboratory Patient general hospital Guide to Services Instructions 3 Spirometry How is your breathing Laboratory staff will contact you by phone to book an appointment These tests are only done on certain days Please follow these instructions before your appointment 1 Postpone your appointment if you ve had e A heart attack in the last month e A stroke in the last month e Eye surgery in the last month e Surgery in your chest or stomach in the last month e Pneumothorax in the last month 2 You cannot take this test if you ve ever had an aneurysm or if you have uncontrolled hypertension 3 Do you take medicines i e puffers for breathing If yes bring them with you to the appointment You may need to stop taking these medicines for a short time before the test your doctor will provide you wi
51. ase make sure you bring the Requisition form with your sample kit Cards must be labelled Label each card with your first and last name Label each card with your date of birth and your Doctor s name Label each card with collection date and time Implementation Date April 2013 Printed versions of this document are not controlled 92 Wy Z whitehorse Laboratory Patient general hospital Guide to Services Instructions 13 Stool Collection for Culture amp Sensitivity or C difficile tests Note You must bring your Requisition with your sample to the Laboratory If you do not collect or label your stool p00 sample properly it will not be tested Please read all instructions before collecting your stool sample Day of collection O Collect your stool between Monday and Thursday You must bring the collection container and Requisition to the Laboratory on the same day you collect Label the white topped container with Name Nom Your full name Vs pos Your date of birth or health care number Date and time of collection Your Doctor s name Record Date and time of collection on your Requisition forms Empty your bladder pee completely Do not let urine touch the stool sample Collect stool onto a clean disposable container example a paper plate Or Put plastic wrap between the toilet seat and the bowl and collect the stool onto the wrap Do not let water touch the stoo
52. ate April 2013 Printed versions of this document are not controlled 106 YY whitehorse Laboratory Test Directory general hospital Guide to Services Time Sensitive Testing While all samples should be delivered to the Lab as soon as possible some tests are very time sensitive and cannot be processed on Fridays Samples for the following tests must be received at the WGH Lab by Thursday Blood Tests that cannot be processed on Fridays or the day before statutory holidays Test Comments Always a STAT test must be done within 24 48 hours CD4 CD8 amp HIV Viral Load Monday to Thursday Cold Agglutinins Cryoglobulins Ammonia HLA Typing Immune Cell Markers Immunophenotyping Karyotyping Molecular Genetics of any kind Notes Additional information may be found in the Collection amp Reference Manuals for St Paul s BCCH When in doubt phone the WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 107 whitehorse Laboratory Packaging amp general hospital Guide to Services Transport Section F Packaging amp Transport of Patient Samples The transport of Patient samples is regulated by the Canadian Transportation of Dangerous Goods Regulations TDGR All staff responsible for packaging samples for transport to the WGH Laboratory should have completed TDG training All specimens must be handled in a manner in which the safety of the handler and
53. atening or severe allergic reactions 2 Generalized skin diseases Clinical History Diagnosis Please indicate the required allergens from the list below Grass Food Food cont d Insects O G3 Orchard Cocks Foot O F1 Egg white DO F84 Kiwi O i1 Honey bee O G4 Meadow Feascure O F2 Mik O F85 Celery C 12 White faced homet O G5 Rye O F3 Codfish O F87 Melon O 13 Yellow jacket O G6 Timothy O F4 Wheat O F91 Mango O 4 Paper wasp O G8 Meadow grass Kentucky blue O F5 Rye O F92 Banana O 15 Yellow hornet O G11 Broome grass O F6 Barley O F93 Cocoa O i Cockroach O GX1 Grass mix meadow Rye M OF Oat O F94 Pear Feascue Orchard Timothy O F8 Com O F95 Peach Mi i O F9 Rice O F96 Avocado Mucus O F13 Peanut O FXI Nutmix Peanut Hazelnut Sa le O wa Plaintain English O F17 Hazelnut O FX2 Seafood mix Cod Blue mussel M3 Aspergillus fumigatus O Fi8 Brazil Nut Shrimp Tuna Salmon O M5 Candida albicans Trees C F20 Almond O FX5 Children s food mix Egg white O M Altemaria altemata O T1 Maple Box Elder O F23 Crab Milk Wheat Peanut Soybean O MX1 M1 M2 M3 M5 M6 O T2 Gray Alder oon O F25 Tomato O 10F Sesame Seed O TE3 Bir h O F26 Pork D 12F Green Pea OIN M O F27 Beef O 201 Pecannut a O T6 Mountain Juniper Cedar O F3i Carrot O 202 Cashew O C01 Penicilloyl G Benzylpenicilloyl O TE Oak O F33 Orange O 203 Pistachio O C02 Penicilloyi V O T8 American Eim C F36 Coconut Phenoxymethy penicilloyl O 235 Lentil C T11 Map
54. atory Visual Key ZF general hospital Guide to Services to Kits Visual Key to Collection Kits Swabs and Collection Containers Swabs Product Name amp Requisition Uses Universal Transport Medium UTM Kit Copan red top For Respiratory Viruses ONLY H1N1 Influenza severe respiratory illness ILI Modified Amies Clear medium Starswab II For detecting a variety of bacteria multiple collection sites Multitrans System i Starplex blue eemititrans Sys SS top 13 For non respiratory Viruses all sample types except stool samples 110 Implementation Date February 2013 Printed versions of this document are not controlled We whitehorse Laboratory Visual Key FG general hospital Guide to Services to Kits Swabs continued Product Name amp Requisition Uses pe Fee x ih a n i a ETa oe PA i Modified Amies with Charcoal medium Starswab II or Copan For detecting Neisseria gonorrhoeae Bordetella pertussis Whooping cough Antibiotic susceptibility testing GenProbe Aptima Assay Collection Kit Swab or Urine Kits for detecting Chlamydia trachomatis amp GC nucleic acid testing NAT Collection Containers Uricult Trio For Urine culture amp sensitivity testing detection of bacteriuria Implementation Date February 2013 Printed versions of this document are not controlled oa Wy ZF whitehorse general hospital
55. ct it Start Collection Mark down the date amp time on the pink label start date amp start time Collect ALL your urine for the next 24 hours Put the orange container in the refrigerator when not in use Urinate pee into the white hat During Collection Transfer urine from white hat into orange container Be careful not to splash If the test is for trace metals do not rinse the white hat After 24 hours empty your bladder completely and put urine into the container Finish Collection Mark down the date amp time on the pink label finish date amp finish time Bring your filled orange container and Requisition to the Lab as soon as you can Container Label white hat on toilet Do not allow feces poo to get into your container Caution Ma Women do not collect during your menstrual cycle period have acid in it Questions Concerns Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 97 Vv WZ whitehorse Laboratory Patient general hospital Guide to Services Instructions 24 Hour Urine Test Diet and Medication Restrictions Please consult with your doctor before you stop taking any medications Doctors If your patient must continue to take one of the medications listed below please record this on the Requisition Type of 24 Hour Urine Test Diet and or Medication Restrictions Stop taking the follo
56. cy Policy 5 Hospital Road Whitehorse Yukon 14 3H Implementation Date April 2013 Printed versions of this document are not controlled 22 ZF whitehorse l general hospital Guide to Services Laboratory a orms Examples LABORATORY HOURS MONDAY through FRIDAY excluding HOLIDAYS 07 00 a m To 11 30 a m and 12 30 p m To 04 00 p m Children after 08 00 a m PATIENT INSTRUCTIONS FASTING 8 HOURS Do not eat or drink for 8 hours prior to the test Water and prescription drugs are permitted Alkaline Phosphatase Gastrin Phosphorus BI2 Glucose fasting Quantitative Amino Acid Carotene Growth Hormone Serum Folate C peptide Insulin Thyroglobulin Cryoglobulins Parathyroid Hormone FASTING 12 HOURS Do not eat or drink for 12 hours prior to the test Water is permitted Cholesterol Other lipid tests Triglycerides Abstain from alcohol for 48 hours prior DRUK LEVELS Take drug regularly the week before the test Blood should be collected PRIOR to the next dose If there are any problems check with the laboratory or your doctor TIMED TESTS e Testosterone prior to 10 00 hrs cl l l e am cortisol prior to 09 00 hrs pm cortisol must be done at 16 00 hrs 50gm loads not after 14 00 hrs reverse side of WGH Req Implementation Date April 2013 Printed versions of this document are not controlled 23 Wy NZ whitehorse general hospital Ww Whitehorse ganaral hospital
57. d blood cells are abnormally coated with immune proteins Antibodies and or Complement It is ordered by a physician to rule out certain autoimmune problems transfusion reactions or incompatibility between mother and newborn Cord Blood Investigation e Must be done on all infants born to Rh Negative mothers or mothers of unknown blood group e Itincludes a determination of ABO Rh and a DAT e Collection requirements One 7 mL EDTA tube lavender or pink stopper Implementation Date April 2013 Printed versions of this document are not controlled 55 ZF whitehorse l d general hospital Guide to Services Laboratory Pisa Procedures Transfusion Reaction Investigation Used to determine the cause of a suspected transfusion related adverse event It must be initiated as soon as a reaction is suspected to determine the possible severity and therefore morbidity mortality for the patient It will also determine if the transfusion can continue and identify future transfusion requirements Please see the Nursing Policy Manual BBK Guidelines for more information on recognizing and managing a Transfusion Reaction Always order as STAT Blood Component Uses The Circular of Information for the Use of Human Blood and Blood Components from Canadian Blood Services describes various blood components and their intended use Each patient area within the hospital has a copy and it is also available on line at www transfusionmedicine ca
58. d copy 7 PROTOCOL NAME o ADDITIONAL INFORMATION FOR BCCA PATIENTS Gens CURRENT STATUS BCCA SITE LJ vcc Fvce I vice O ccs g NED NO EVIDENCE OF DISEASE i ae g STABLE _ Outpatient Clinic 10 IMPROVEMENT O Inpatient Hosp Unit ot LPPOGRESRIGH o l 12 NYD NOT YET DIAGNOSED O Consultative Clinic bp METASTATIC SITE a Outreach RECURRENCE RESULTS DISPOSITION IS PATIENT ASMOKER _ PPD C Phone _ Fax Results to Has patient received diagnostic or therapeutic LJ Mail Results to Dr _ 7 7 monoclonal antibodies Address If so indicate Dose _ Date Additional Information if any C Send Copies to Dr Address Drs _ Address NORMAL NORMAL RESULT METHOD S UNITS _ Abbott Abb car lt 28 KU L ian lt 35 kU L Abbott Abbott TT mee ts m Tae PSA FREE VS TOTAL RATIO 40 80 um L Form AT 1 Revised Jan 06 60851 DATE REPORTED AAS FARA Implementation Date April 2013 Printed versions of this document are not controlled 28 l Laborator Requisition ZX Ail Roi ital Guid S 4 ronne g p uide to Services Examples Canadian Blood Services CANADIAN BLOOD SERVICES DIAGNOSTIC SERVICES es PERINATAL SCREEN REQUEST Lanadian blood Services iff ul wi fa giki PLEASE NOTE Blood samples are not collected at Canadian Blood Services CBS All information must be complete or testing will not be performed Maternal Information Matemal Label optional To be C
59. d for quality assurance management and disclosed to healtieare practioner involved in providing care or when required by law Personal information is protected fram unauthorized use and disclosure in accordance with the Personal information Protection Act and when applicable the Freedom of Informedon and Protectan of Povacy Act and may be used and disclosed only as Current Requisition Form listed here http www blood ca CentreApps Internet uw_v502 mainengine nsf page PerinatalServices OpenDocument Implementation Date April 2013 Printed versions of this document are not controlled 29 WW whitehorse Laboratory Requisition Forms MZ general hospital Guide to Services Examples Prenatal Biochemistry Laboratory 1m ie at Children s amp Women s Health Centre of British Columbia Pre natal Bioc hem istry in partnership with the BC Prenatal Genetic Screening Program Laboratory Requisition 4480 Oak Street Vancouver B C V6H 3V4 T 604 875 2331 F 604 875 3008 sia Please visit www bopranataiscreening ca for additional copies of the requisition Patient Information ohor ritat Patient Instructions Each blood sample must be accompanied by a completed requisition Bloca DATE OF BATH Y M D 5 can be collected at any blood collection facility No appointment is necessary SIPS PART 1 10 13 6 wks DATE BLOOD TO BE DRAWN SIPS PART 2 QUAD 15 20 wks DATE BLOOD TO BE DRAWN For Completion by
60. dge of the smear should have a rainbow appearance The whole drop is picked up and spread See illustrations Figures 1 1 to 1 3 on the following pages From Carr J H and B F Rodak 1999 Clinical Hematology Atlas W B Saunders Company Toronto 217 pp Implementation Date April 2013 Printed versions of this document are not controlled 46 Laboratory Sample 0 QZ combing i Guide to S Collection general nospita uide to services Procedures Figure 1 1 Wedge technique of making a peripheral blood smear A Correct angle to hold spreader slide B Blood spread across width of slide C Completed wedge smear From Rodak BF Diagnostic Hematology Philadelphia WB Saunders 1995 From Carr J H and B F Rodak 1999 Clinical Hematology Atlas W B Saunders Company Toronto 217 pp Implementation Date April 2013 Printed versions of this document are not controlled 47 Laborator samp YY Aerator m Guide to S y Collection general nospita ulae to services Procedures Figure 1 2 Well made peripheral blood smear From Rodak BF Diagnostic Hematology Philadelphia WB Saunders 1995 E 5 G H Figure 1 3 Examples of unacceptable smears From Rodak BF Diagnostic Hematology Philadelphia WB Saunders 1995 From Carr J H and B F Rodak 1999 Clinical Hematology Atlas W B Saunders Company Toronto 217 pp Implementation Date April 2013 Printed versions of this document are not controlled 48 Labo
61. dicated draw 7 mL min 3 mL amp ship at room temperature C Chorionic Vili CVS Gestational age _ COLLECTION LAB LABEL ONLY si ky estec Sec w ator lest Nain guid eline 5 j d tab policy Achondroplasia Alloimmune Thrombocytopenia Hpa 1 Angelman Syndrome Ashkenazi Carrier Screening C Myotonic Dystrophy Type 1 C Oculopharyngeal Muscular Dystrophy Periodic Fever Syndromes Carrier Testing Testing of minors see MGL policy Prenatal Diagnosis a ata o ona f Brugada Syndrome C Familial Mediterranean Fever May require genetic counselling C Hyper IgD Syndrome Charcot Marie Tooth Type 1A Chimerism Cystic Fibrosis Dystonia early onset primary DYT1 Dystrophinopathies DMD BMD O TRAPS Prader Willi Syndrome Sensorineural Hearing Loss GJB2 6 Spinal Muscular Atrophy SMA Spinobulbar Muscular Atrophy SBMA see o o o o o O CADASIL o 0 o B o OO 00000 Partner PHN FMR1 Related Disorders Spinocerebellar Ataxia Panel g Fragile x Syndrome SCA1 2 3 6 7 Will this testing alter the management of an C Premature Ovarian Insufficiency Thanatophoric Dysplasia ongoing smear fe s TONo O FXTAS Transthyretin Amyloidosis _If yes provide the follow C0 Friedreich Ataxia Uniparental Disomy C Glucose Transporter Deficiency Type 1 C che ch7 chi4 Chis CO Glycine
62. dom 3 Put the lid on the container and close tightly 4 Put the specimen container in the bag provided Wash your hands with soap and water 5 Bring both your sample AND your Requisition to the WGH Laboratory as soon as possible Keep the specimen warm between room temperature amp body temperature Drop off Lab Hours Monday through Friday mornings Please do not bring specimens after 12 00 noon Note The specimen will not be tested if the label or Requisition is missing information Implementation Date April 2013 Printed versions of this document are not controlled 85 We Whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions 9 Sputum Collection for Bacteriology or Fungal Study Please read these instructions carefully before you begin 1 Label your collection container with TIGHTEN SECURE BIEN RESSERREZ e Your full first and last name RESSE e Your date of birth OR health care number e The date and time of your collection e Write Sputum 2 Collect in the early morning before eating 3 Cough deeply to bring up sputum from deep down and spit it into the container See drawing on reverse side of this page for more details 4 Do not spit clear saliva into the container sputum should look thick and green or yellow green 5 Collect more than 2mL 72 teaspoon where possible 6 Tightly seal the lid on the container and place it in a plastic bag seal
63. e backing in place until the collection bag has been fitted over the aenital area When pressing adhesive to the skin be sure to start at the narrow bridge of skin between the anus and the base of the scrotum and work Outward from this point Ee sure skin is dry before applying the collection bag Printed versions of this document are not controlled Press adhesive firmly against the skin avoiding wrinkles When the bottom section is in Place remove the paper backing from the upper por tion of the adhesive patch Work upward to complete application 104 WI Z whitehorse Laboratory Patient general hospital Guide to Services Instructions 20 Helicobacter pylori Urea Breath Test UBT Your doctor has requested an H pylori Urea Breath Test The test will take approximately 50 minutes to complete You must remain at the hospital Lab for the entire test Please follow these instructions 1 Before the test avoid these medicines J Time to Avoid Medicine Examples before Test Amoxicillin Clarithromycin Aveek Metronidazole Tetracycline en Losec Prevacid Pantaloc H2 receptor antagonists Tagamet Zantac Pepcid Bismuth salts Pepcid Pepto Bismol Talk to your doctor before doing the test if you are taking any of these medicines 2 Fast for 4 hours before the test e Do not smoke e Do not eat anything e Do not drink anything except small sips of water Note You may chew gum and brush te
64. e buffered Contact the lab for as required details Dip BacTube within 2 hours Store amp transport at room temperature Urine C amp S midstream sterile container pink lid a TO Aptima Urine Transfer Transport to WGH Lab as soon as Urine Cytology sterile container pink lid a8 aie amount of 50 methanol to Urine Pediatric from U sterile container pink lid See Paientinstucions tordetaiis bag U bag Several sample types are accepted for viral studies consult the Virology Requisition 13 All kits should contain Patient Instructions P 1 Requisitions must accompany samples See Section G for images j 5 1 2 0 18 Viral Samples of kit contents Implementation Date February 2013 Printed versions of this document are not controlled 76 Wm Whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions Section D Patient Instructions List of Patient Instructions Patient Instructions for ECG Electrocardiogram ECG EKG 1 Spirometry Glucose Non Gestational 2 Hr Glucose Tolerance testing 4 Tolerance Gestational 2 Hr Glucose Tolerance testing Testing 50gm Oral Glucose Load semen Infertility Testing Analysis Post Vas Testing Bacteriology amp Fungal Cytology Standard amp TB Stool Occult Blood Test OO Samples Culture amp Sensitivity C amp S Ova amp Parasites O amp P 24 Hour Urine Test 12 Hour Urine Test Jane 12 Hour Urine Test S Samples M
65. e the hospital and you cannot smoke eat or drink during the 2 hours 11 You may wish to bring a book or a craft You may wish to bring a warm sweater 12 Bring a snack to eat you may eat it once the test is done Questions Concerns Unable to attend your booked appointment Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 82 WZ whitehorse Laboratory Honea general hospital Guide to Services Instructions 6 50 gm Oral Glucose Load Test Please follow these instructions before your test 1 You may eat normally before you come to the Lab for the test no fasting needed 2 If you have had surgery you must wait at least 2 weeks before doing this test 3 If you are sick on the day of the test cold flu infections you must rebook your appointment 4 You will be at the hospital for at least 1 hour You cannot leave the building and you cannot smoke eat or drink during that 1 hour Questions Concerns Unable to attend your booked appointment Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 83 W F whitehorse Laboratory Patient general hospital Guide to Services Instructions 7 Semen Analysis Infertility Testing Please read these instructions carefully before you begin 1 To prepare for collecting do not ejaculate for at least 24 hours preferably 3 days 2
66. ecateaeaeie Sample Handling amp Storage prior to Transportation How to Collect Blood Cultures 008 Blood Bank Transfusion Medicine 66 Body FIUIG CONCCHONS sic cecciccstdesainncteoenencecnesinvedwinslvetnncuaonesieatesennninedead Pathology Sample Collections ccceeeees Cytology Sample Collections cccceeee eee Microbiology Sample Collections 65 Miscellaneous Samples ccceeeeeeeeeeeeeeees Section D Patient Instructions OCOnNDODAARWDNDN O List of Patient InStructions cccee ween ees Your ECG Recording Your Heart s Rhythms The Holter Monitor Tracking Your Hearts Rhythms for 24 Hours Spirometry How is your breathing cccccecccsececeseeeeeeseeeeeeeseeeseeeeseeessneess Non Gestational Oral Glucose Tolerance Test Gestational Oral Glucose Tolerance Test 50 gm Oral Glucose Load Test 0ee eee semen Analysis Infertility Testing 68 Semen Analysis Post Vasectomy 00608 Sputum Collection for Bacteriology or Fungal Study ceeeeee es Sputum Collection for Cytology Testing ooan r BWD _ 17 17 18 19 21 21 43 43 45 46 49 50 51 54 60 61 62 63 76 TT TT 18 19 80 81 82 83 84 85 86 87 TE Sputum Collection tor B Te
67. ed Processed urine specimens should be assayed with the APTIMA Assay for CT and or GC within 30 days of collection If longer storage is needed freeze at 20 C to 70 C for up to 90 days after collection 2 Urine samples that are still in the primary collection container must be transported to the lab at 2 C to 30 C Transfer urine sample into APTIMA urine specimen transport tube within 24 hours of collection Store at 2 C to 30 C and test within 30 days of collection 10210 Genetic Center Drive San Diego CA 92121 800 523 5001 WWW GEN PROBE COM L579 REVA 2006 Gen Probe Incorporated COLLECTION SITE Py p Q Say al BS GUIDE Overfilling or Under filling Sample y Tubes Results In Sample Rejection Transfer urine into Collection Tube and fill between the black lines only 2006 Gen Probe Incorporated COLLECTION GEN PROBE ERR A PTM A Swab Specimen Collection Guide for Chlamydia trachomatis CT and Neisseria gonorrhoeae GC GUIDE Collection for Endocervical Swab Specimens 1 Remove excess mucus from cervical os and surrounding mucosa using cleaning swab white shaft swab in package with red printing Discard this swab A large tipped cleaning swab not provided may be used to remMOVE EXCESS MUCUS White Swab Blue Swab 2 Insert specimen collection swab blue shaft swab in package with cleaning then specimen Tee i i discard collection green printing into
68. edure Laboratory Collection Instructions PHSA Laboratories for Pertussis Testing ai a sae Public Health Microbiology amp Reference Laboratory Specimens e Optimal samples are pernasal swabs but postnasal swabs are also accepted though less sensitive DO NOT SUBMIT THROAT SWABS e Only Dacron tipped swabs with aluminum wire shafts should be used COPAN swabs below are ideal EVY I A SS E E E ENA A COPAN 125C Amies Charcoal soft aluminum wire green tip Collection Collect specimens from patients presenting with cough within 72 hours of onset of symptoms Personal protection during specimen collection Minimize self exposure by minimizing the amount of time spent in taking a sample wearing personal protection and following infection control practices Hands should be washed and fresh gloves used for each new patient Procedure 1 Choice Pernasal specimens 1 Label the container with the patient s full name and date of birth 2 Gently insert swab into one nostril straight back not upwards until it reaches the posterior wall The distance from the nose to the ear gives an estimate of how far back the swab should be inserted Do not force the swab If an obstruction is encountered try the other side 3 Rotate swab a few times loosening the cells in the mucus cavity and then remove 4 Place the swab into the accompanying vial of Amies transport media 5 Fill out the PHSA Labs Bacteriology amp
69. esting req TSH Random Glucose 1 gold top tube spin down send serum in WGH Lab On Site Testing req plastic tube Urine for C amp S MSU Uricult WGH Lab Microbiology req CC Cr Cervical Os Swab Chlamydia Amplicor Invitro Chlamydia GC swab PCR St Paul s Hospital Virology and amp Gonorrhea Reference Laboratory Chlamydia amp GC PCR Vaginal Swab amp Smear Swab Clear Medium amp Smear WGH Lab Microbiology Yeast amp Bacterial Vaginosis As per Clinical Practice Guideline BCCA Gynecological Cytology 1 10ml plain red top tube spin down send Children s and Women s Health Centre of serum in smaller plain red top tube Time BC sensitive may need to ship frozen Prenatal Genetic Screens All 50 Gm Oral Glucose Load See lab manual WGH Lab On Site Testing 1 gold top tube spin down send serum in plastic tube Vaginal Rectal Swab for Swab Clear Medium WGH Lab Microbiology Group B Strep Introduction of Period of Purpl Community Nurse Whitehorse Health Crying i Centre Nurse during Prenatal Classes Note All referred out testing is sent via the lab at Whitehorse General Hospital All specimens must be accompanied by the appropriate requisition i e the frozen sample must have the req in the same container if previous Hx gestational diabetes obesity fetal macrosomia or glycosuria All prenatal women are to be counseled
70. eth during the fasting period 3 Laboratory Hours for this test Tuesday Friday between 12 30 p m 2 p m You do not need to make an appointment 4 Bring your Requisition from your doctor 5 The Test Breath Samples before amp after a test drink e Give a breath sample take a normal breath then blow through a straw into a collection tube for 4 8 seconds e Drink a lemon lime flavoured drink e Wait 30 minutes do not smoke eat chew gum or drink during this time e Give a second breath sample Questions Concerns Unable to attend your booked appointment Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 105 whitehorse Laboratory Test Directory general hospital Guide to Services Section E Test Directory amp Time Sensitive Testing Test Directory The WGH Laboratory is developing a lab test directory at this time Thank you for your patience while it is developed The St Paul s Hospital Accessioning Reference Manual distributed as a digital file can provide guidelines for tests that are processed by their labs The BCCDC Public Health Microbiology amp Reference Laboratory PHSA Laboratories Guide to Services is available online at http www phsa ca NR rdonlyres D632D356 8E8F 491 7 BC3D 463EB5F8A14B 0 GuidetoProgramServices pdf When in doubt contact the WGH Laboratory directly at 393 8739 Implementation D
71. f birth FOR FECAL OCCULT BLOOD Your Doctor s name PATIENT NAME STREET 7 ax Collecti n Date Day 1 m A Di TM SP Ni ame BEA SICIAN MAME STORE AT CONTROLLED ADOM TEMPERATURE 2 Lift up the tab on the front of card 1 only Implementation Date April 2013 Printed versions of this document are not controlled 91 Day 1 ee ee Ce 1 When ready to begin collecting write the date on the first card Do not tear sections apart We Whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions 3 You will see 2 windows labeled A and B 4 Collect stool onto a clean disposable container For example a paper plate 5 Or put plastic wrap between the toilet seat and the bowl and collect the stool onto the wrap Do not let water touch the stool 6 Using a wooden stick take a small piece of stool smaller than a pea Make a very thin smear of stool from edge to edge in window A 7 Using the same wooden stick collect another small sample from a different part of the stool Make a very thin smear of stool from edge to edge in window B SS 8 Close the tab and let the sample air dry in a paper bag EEE Repeat these steps on 2 other days to fill the other 2 cards Be sure to write down the date you collected each sample Once complete put the cards in a plastic bag and seal it with a twist tie Bring your samples to the WGH Laboratory as soon as possible Ple
72. fection present at time of collection and can perform appropriate testing Submit labelled sample smear and completed Requisition to the Laboratory for testing in a timely manner If a delay in transport is unavoidable refrigerate the sample at 4 C Please include useful information on the Requisition 1 Wound Type l YP e g left knee rash right arm abscess diabetic ulcer 2 Location left leg 3 Condition 4 Signs of Infection e g presence of pain inflammation exudate pyrexia 6 Testing Requested i e C amp S anaerobic culture 7 Indicate if Wound Deep or Superficial Deep gt 2 cm deep Implementation Date April 2013 Printed versions of this document are not controlled 73 Laboratory Sample We whitehorse ecleeon SS General hospiti Guide to Services Procedures Superficial Wounds lt 2 cm deep Includes drainage surface wounds ulcers boils 1 Syringe aspiration is preferable to swab collection e Disinfect the surface of the wound with SOLU I V and allow to dry e Using a 3 to 5 ml syringe with a 22 to 23 gauge needle a Physician will aspirate the deepest portion at the advancing margin of the lesion not just the pus e From a closed wound collect exudates and a sample of the abscess wall e Place aspirate into a sterile container e Using a sterile swab make a smear of the aspirate ensuring that you roll the swab as you streak on a clear glass slide Label the smear at the frosted end of slide with t
73. he patient s legal last name date of collection and collection site 2 If syringe aspiration is not possible a swab may be collected e For open wounds cleanse wound with sterile non bacteriostatic saline using gauze Do not irrigate wound e Place swab deep at the leading edge of the wound e Label sample patient s name date of birth or health care number site type of collection and date time of collection 3 Use separate sterile swab to make a smear label the frosted end of the slide Deep Wounds Includes deep abscess aspirates implanted devices bites Repeat instructions as for superficial wound If an anaerobic infection is suspected obtain an anaerobic swab from the Microbiology Laboratory Burns 1 Debride the area and disinfect the surface of the burn with SOLU I V Allow to dry 2 As exudate appears sample it firmly with a swab 3 Submit the swab sample for aerobic culture C amp S 4 Try to collect biopsies from deeper tissues The surfaces of burn wounds will become colonized by the patient s normal flora or by environmental organisms cultures of the surface alone are therefore misleading 5 Sample different areas of the burn Organisms may not be distributed evenly in burn wounds Implementation Date April 2013 Printed versions of this document are not controlled 74 Laborator samp YY Alerter m Guid S y Collection general hospita uide to Services Procedures Pertussis Collection Proc
74. kers Varicella IgG Qvz HTLV 1 1 CIJAHTLV SYPHILIS Non Prenatal Anti hepatitis A Total CJHAVT HSV IgG CJ Hsvg H pylori IgG CIHPGS Ommune Status Syphilis Screen CTPS Anti hepatitis A IgM Cavin Mycoplasma IgM CJMPem Syphilis Confiirmatory CJ resc Acute Infection OTHER TESTS Specify Anti HBs _JHBVSAB History Required for confirmatory testing immune Status Anti HBc Total JHBCT Natural Infection Anti HBc IgM CJHeciM HIV Non Prenatal vienna Note Patient has legal right to choose EAG nominal or non nominal reporting of Posi jc Monitoring CHEBEAC tive HIV toMHO i j Anti HBe CIHEBEAB HIV Nominal Reporting IHN Therapeutic Monitoring HIV Non Nominal HIV j Rajorting Anti HCV LJHEPC For information on sample collection please call the Central Processing amp Receiving Lab at 1 877 PHSALAB Form CPSE_100_1001F Version 1 1 09 2009 Current Requisition Form listed here Forms Examples http www phsa ca AgenciesAndServices Services PHSA Labs T esting Requisitions Diagnostic htm Implementation Date April 2013 Printed versions of this document are not controlled 33 VY whitehorse Laboratory Requisition Forms general hospital Guide to Services Examples penne PARA PHSA Laboratories Public Health Microbiology amp Reference Laboratory Parasitology Requisition BC Centre for Disease Control 655 West 12th Avenue Vancouver BCV57 ARA www abe chealthlab Section 1 Patient information PERSONAL HEALTH NUMBE
75. l Add stool to the container using spoon inside the jar until the liquid is at the fill line Take from parts of the stool that look bloody slimy or watery Please do not overfill Be careful not to spill the liquid Make sure nothing else is in the collection container i e no toilet paper no plastic wrap Tightly close the container with the lid and shake until the stool specimen and liquid are well mixed continued on next page Implementation Date April 2013 Printed versions of this document are not controlled 93 7 Laborato ry Patient whitehorse general hospital Guide to Services Instructions O For small children Fasten plastic wrap inside a diaper with childproof safety pins then remove the stool from the plastic and put it into the collection container Do not bring used diapers to the Laboratory O Put the container in the plastic bag and seal the bag with a twist tie Container lids tightly closed O Wash your hands with soap and water Remember You must bring your collection container and Requisition to the Laboratory on the same day you collect Questions Concerns Unable to attend your booked appointment Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 94 V WZ whitehorse Laboratory Patient general hospital Guide to Services Instructions 14 Stool Collection for Ova amp Parasite Exam Note Y
76. le Leaf Sycamore O F37 Blue mussel O 256 Walnut ahi ones TE E ee Occupational O T14 Cotto O F41 Samon O 309 Chick Pea O TX1 Tree Mix Gray Alder Hazel C F44 Shrimp O K82 Latex Em Cottonwood Willow O F45 Yeast C K84 Sunflower seed Mites Dust C F49 Apple O F54 Sweet Potato OE1 Cat dander O D1 Dematophagoides ptenoyssinus C FTS Eoo yok OE5 Dog dander For further information O 02 Demmatophagoides farinae OF Rect globulin O E70 Goose feathers please contact the supervisor or O Hi House dust Greer C E86 Duck feathers Dr Arun K Garg at 604 507 5000 O F79 Gluten O H2 House dust Hollister Stier Fy Fee keke 2 r O HX1 Mite Mix 1 01 02 H1 16 Gta di Revised February 2011 FRM062 Current Requisition Form listed here http www bcbio com company forms specific allergen ige request form Implementation Date April 2013 Printed versions of this document are not controlled 41 Requisition YY whitehorse Laboratory lt a general hospital Guide to Services Examples MOLECULAR GENETICS LABORATORY Requisiti ino abiapeiiinnamtatcings aaa ee a LIA Facility L1050 Sarnouner Bes Wee and abd neem ONLY ONLY a A A fe MNWwWw genep a moie APUCTICUCS Ww CW DC CcCa nrar ER SO aaa a NEER Last Name First and Middle Names Date of Birth DD MMM Y Y EM GF Gn Personal Health Number PHN Referring Hospital ID Clinic 1D Patient Phone Number mj EDTA Blood Unless otherwise in
77. les themselves see instructions below An attempt should be made to collect the first voided sample in the morning Otherwise advise patient to hold urine as long as possible before collection for culture and sensitivity testing Avoid forcing the patient to increase fluid intake to void urine Collect urine directly into a sterile container pink lid do not use a urinal or bedpan or paper cup for collection Immediately after collection dip Bactube Uricult slide in the container Do not send urine to the Laboratory for dipping See instructions below regarding proper dipping technique Implementation Date April 2013 Printed versions of this document are not controlled 71 Laborator Sample WY meore Laboratory kard general hospita uide to Services Procedures Proper Method for Use of Bactube Uricult Trio Dip the Bactube before contaminating the urine with urinalysis dipstick If urine cannot be dipped within 2 hours of collection refrigerate up to a maximum of 24 hours Inspect agar surfaces of the unopened Bactube they should not be dried out or falling off Check expiry date Unscrew the cap remove the slide from the plastic tube do not touch the agar surfaces Dip the slide three times into the freshly voided urine so that the agar surfaces are completely immersed If there is insufficient urine carefully pour the urine over the agar surfaces Let excess urine drip off by holding the tip of the slide against
78. lth Number and provincal ON PATIENT SURNAME PHSA LABORATORIES Ore i Section 2 Healthcare Provider Information USE ONLY ORDERING PHYSICIAN E ovide MSCu Marne and adina o Trepa t daniy E SAMPLE REF NO do not requires copy of the report CLINIC OR HOSPITAL E Name and address ofreport delivery iota TIME COLLECTED PHSA CLIENT HO Section 3 Testis Requested SAMPLES FOR AFB SMEAR AND MYCOBACTERIUM CULTURE INTER LABORATORY SAMPLES INDICATE SAMPLE TYPE SAMPLES FOR MYCOBACTERIUM NUCLEIC ACID TESTING Has sample been digested CI Yes LI Neo Hassample been concentrated Yes No tissue specify source o Acid fast smear result Body fluid specify source _ _ Specify source Gastric wash buffered Sputum Bronchial wash a CULTURES OF MYCOBACTERIUM Urine Blood Date culture became positive Specify source Feces Clinical history is mandatory a N a A e a a Other sample specify Special Test Requests _ Special Test Requests _ Consultatian required please call Program Head at 604 707 2616 Consultation required please call Program Head at 604 707 2616 EXPOSURE TREATMENT HISTORY CLINICAL HISTORY Exposure to active TB case Exposure to MOR or XDR TB Specify country of exposure Member of high risk group Specify Positive TE skin test or interferon gamma release assay For other available tests and additional information consult the Public He
79. m cell exposure Examples of Analytes That Change During Serum Cell Exposure Increased Decreased Lactate Dehydrogenase LD Glucose Phosphorus lonized Calcium Ammonia Bicarbonate Potassium Folate Creatinine B12 ALT AST Care of Samples Affects Patient Care Disregarding time temperature and light specifications for blood samples can lead to pre analytical errors Results could be dramatically altered and medical errors made Implementation Date April 2013 Printed versions of this document are not controlled 50 edd whitehorse Laboratory Collection eneral hospital Guide to Services g Procedures 1f How to Collect Blood Cultures Order using the WGH Microbiology Laboratory requisition The rapid accurate isolation and identification susceptibility testing of organisms found in the blood is vitally important Left undetected and untreated septicemia can be fatal within 24 hours Blood cultures are obtained whenever there is reason to suspect bacteremia This includes patients with 1 pneumonia meningitis and pyelonephritis 2 suspected intravascular infection i e endocarditis infection of the graft 3 prolonged fever 4 fever accompanied by rigor 5 afebrile but known or suspected of having endocarditis treated or untreated 6 certain multisystem infections i e enteric fever typhoid or paratyphoid leptospirosis brucellosis etc 7 immunosuppression with significantly decreased amount of neutro
80. mdrome or trisomy 18 10 Previous pregnancy with Ordering Doctor Midwife Nurse Practitioner L Down syndrome _ Tisomy18 _ Trisomy 13 _ None 11 Twin pregnancy C NO H YES NAME SRST S tyes _ Monochorionic C Dichorionic GE SEER Gestational Age Information gestational age MUST be indicated EDD v Ma Di SIGNATURE DATE c Results to LMP y__ m m C UNSURE Cycle langth days Cycle is LJ PEGULAR _ IRREGULAR MAME MSP PRACTITIONER Date of first ultrasound Y M a li ai Gestational age weeks days NAME MSP PRACTITONER Crown rump length CRL rm ADDRESS TELEPHONE Biparietal diameter BPD mm Tht BC Pronatal Genetic Screening Program is part of the Provincial Health Services Authorin s Ponnatal Services BC The personal infonmalion collected here and a part of any future prenatal diagnostic wating you may undergo in BG la used to provide safen more accurate teats Measure ouinomes and evaluate and digseminate new evidence knowledge The Program collects and protects personal information under the authority af Section 26 2 of the Freedom of infomation and Protection ol Privacy Act Should you have any Questions regarding te collection use or decir of your personal miomalon please conte the BO Prenatal Genetic Somening Program at 604 B7S 277 2 Additional infomation is aso avallahie on our website at were bopeenatalscraening ca Current Requisition Form listed here http www bcprenatalscreening ca sites prenatal2 files
81. mp finish time Collection Do not allow feces poo to get into your container Women do not collect during your menstrual cycle period Questions Concerns Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 99 whitehorse Laboratory Patient ZX general hospital Guide to Services Instructions 17 Midstream Urine Collection 1 Wash your hands with soap and water Pull back your foreskin if present Completely wash your glans penis head of penis using the towelette provided Wipe away from the urethra opening of the penis Remove lid from container Urinate pee into the toilet a small amount then stop Place the container a few inches from your penis and then begin urinating in the container Do not touch the container to your penis Fill the container about half full If needed continue urinating in the toilet Close the lid tightly to the container 9 Wash your hands again Do not touch the inside of the container with your fingers Women Wash your hands with soap amp water Sit as far back on the toilet as possible and spread your legs Remove lid from container Hold your labia folds of skin apart with your fingers and keep apart for the rest of the collection Completely wash your entire inner genital area using the towelette provided Wipe from front to back While continuing to hold your labia apar
82. mples that are not clearly labelled in accordance with the sample identification criteria 8 Sample Rejection Criteria Samples may be rejected for the following reasons x Unlabelled Samples x Incorrectly Labelled Mislabelled Samples x Incorrect Container or Preservative x Insufficient Sample for Procedure s x Unsuitable Sample for Procedure s x Blood Sample Hemolyzed x Improper Transport Conditions x Sample Too Old to Process Implementation Date April 2013 Printed versions of this document are not controlled 5 v whitehorse Laboratory Laboratory general hospital Guide to Services Information Unlabelled Samples e Common sample types blood urine swabs sputum stool etc which cannot with certainty be identified will require recollection e Less common samples that are more difficult to recollect CSF fluids tissues etc require the Physician who collected them to come to the Laboratory to identify the sample and complete the Irreplaceable Sample Identification Record Form ACCO10F They assume responsibility for the identification of the sample e If the person responsible for collecting the sample is unable with certainty to identify the sample the appropriate Clinical Care Manager designate and Ordering Physician will be notified Incorrectly Labelled Mislabelled Samples e If the patient s name date of birth or health care number conflic
83. n 12h fast RS OR Maan LJ Anti smooth muscle Antibody O APOB Lipoprotein 12h fast l Lipase ee RENCE gestae Oper fasting i OLH LJ Anti tissue transglutaminase c Cl Phenobarbitol LL ENA Oca date of last dose LJ Factor V Leiden LJ Cortisol a m 0800 0830hr __ time of last dose LJ HLA B27 need patient history 1600hr E Prog esterone LJ Prolactin L Protein 3 a Ja wi A date of last dose F cases Hlectropheresis time of last dose l rotem 5 LJ CRE LJ PTH intact U DHEA S LJ RBC Folate EDTA O DRVVT Russel Viper Venom H a F m Lupus Anticoagulant Ristocetin co factor LY Estradiol L Tacrolimus LJ Lead blood LJ Sirolimus date of last dose time of last dose O Cortisol p m 1530 o Tartisol random LJ Cyclosporin BC Children s C00631 LJ Amino Acids Q Ik LJ Ammonia CJ Mercury blood LJ Vitamin D 25 Hydroxy date of last dose tume of last dose L Folate serum fasting OTHER TESTING ron LJ Testosterone iT a pror to 10 00 a m O FT4 LJ Transferin Panel iron transferrin saturation LJ Immunoglobulins IgA LJ Thyroglobulin fasting IgG Q valproic Acid Q ig date of last dose LJ Homocysteine tune of last dose Urine testing O Albumin creatinine ratio J Catecholam ines medication restrictions start date end date sat LJ Cortisol start time ss end time 0 5 Hydroxyindole acetic acid 5 HLA
84. ndom and Tolerance GTT Acetaminophen Creatinine eGFR LDH Albumin Creatinine clearance Magnesium Alkaline Phosphatase Creatine Phosphokinase Osmolality Digoxin Phosphorus Ethyl Alcohol Phenytoin Sodium Salicylate Potassium Triglycerides Arterial Blood Gases Chloride Total Protein Cord pH and Base Excess Bicarbonate Troponin Lactate Ferritin TSH Venous Blood Gases Gentamicin Urea Bilirubin GGT Uric Acid Calcium Glucose Vancomycin Carbamazepine Hgb A1C Cholesterol HDL profile Urinalysis and Miscellaneous Testing Urine macroscopic amp microscopic Pregnancy Test Monotest if indicated Fecal Occult Blood Screen Fetal Fibronectin semen Analysis Urine drugs of abuse Rheumatoid Factor Screen amp Titre Transfusion Medicine Limited Red Cell inventory Blood Components on site Red Cells Plasma Aloumin 5 and 25 IVIG Rhlg Factor VIII Factor IX Prothrombin Complex concentrate Activated Factor VII recombinant ABO amp Rh Typing Compatibility test cross match Rh typing Antibody Screen Direct Antiglobulin Test DAT Transfusion reaction investigation Microbiology Tests on blood urine sterile fluids sputa and swabs from various body sites Culture and sensitivities Infection control screening for C difficile antigen and toxin assay Gram stain Antibiotic Resistant Organisms Point of Care Testing Record test results in Nursing notes Include time date and tester identification Glucometer outreach Procurement amp Acces
85. ner and place it in a plastic bag seal the bag with a twist tie 7 Collect 1 sample per day for 3 days 8 Collect soutum again 2 weeks after your treatment begins 9 Ensure your Requisition form is filled out including the Patient History section 10 You must bring the sample to the Laboratory within 2 hours of collection Remote collections you must refrigerate and transport the sample to the Laboratory within 24 hours Questions Concerns Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 89 V GF whitehorse Laboratory Patient general hospital Guide to Services Instructions How to collect Soutum 1 Gargle or rinse with the water you are given Do not use antiseptic mouthwash 2 Hold the sample container to your mouth with your lips inside it Take as deep a breath as you can and cough then spit into the container do NOT just spit saliva 3 The sample you cough should look thick and yellow or green The sample should be bigger than 1 teaspoon 5 Give the sample to your caregiver right 4 Close the container lid away tightly 5 ai lf you are at home Seal your sample in the plastic bag you were given Put the bag in the fridge right away Return your sample to your caregiver within 24 hours Implementation Date April 2013 Printed versions of this document are not controlled 90 We Whiteh
86. nform the patient of the following information e You must come to the WGH Laboratory to have your Holter Monitor fitted the fitting appointment will take approximately 20 30 minutes e You must wear the Holter Monitor for a 24 hour period e You must return to the lab the next day to have the monitor removed 10 minutes e Read the Patient Instructions thoroughly to prepare for the appointment e You will complete a diary of your activities for 24 hours Implementation Date April 2013 Printed versions of this document are not controlled 13 w whitehorse Laboratory Laboratory ZF general hospital Guide to Services Information C Spirometry and Reversibility Testing at WGH Laboratory These tests were formerly referred to as Pulmonary Function Tests PFT s The Laboratory performs both Spirometry testing one session no bronchodilator administered and Reversibility testing Pre amp Post bronchodilator Spirometry We have created a separate requisition see Section B to reflect new requirements Please note the following guidelines for determining patient suitability before submitting a requisition Patients must be 26 years old to be eligible Indications for spirometry as listed on requisition Reason for testing For confirmation of diagnosis patient must withhold respiratory medications Physician must provide specific instructions to patient Monitoring therapy continue respiratory medications It is the physici
87. ning water Hold the eyelids open Take care not to rinse contaminated water into the other eye 6 Go to the Hospital Emergency Department Outside Whitehorse call your Doctor or Nurse right away If Swallowed 7 Rinse mouth thoroughly with water Induce vomiting Drink 1 2 cups of water Call 911 Outside Whitehorse call your Doctor or Nurse right away 8 If another person swallowed Methanol and 9 collapses or is unconscious or convulsing do not give anything by mouth Call 911 10 stops breathing begin CPR if you have been trained Call 911 Implementation Date April 2013 Printed versions of this document are not controlled 88 We Whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions 11 Sputum Collection for TB Testing Please read these instructions carefully before you begin 11 Label your collection container with the following information e Your full first and last name e Your date of birth OR health care number STERLE TIEN REECURELY e The date and time of your collection e Write Sputum 2 Collect in the early morning before eating 3 Cough deeply to bring up sputum from deep down and spit it into the container See drawing on reverse side of this page for more details 4 Do not spit clear saliva into the container sputum should look thick and green or yellow green 5 Collect more than 2mL 1 2 teaspoon where possible 6 Tightly seal the lid on the contai
88. not controlled 10 whitehorse Laboratory Laboratory ZX general hospital Guide to Services Information 10 Consent for Release Form This form must be completed for the release of laboratory information from Whitehorse General Hospital Laboratory l D O B Health Care Patient Name Please Print DD MM YY Yukon Health Insurance consent to the release of my test results from sample s collected Date sample collected tO if release to person other than stated above provide contact phone number to confirm authorization Name of Person Organization to whom information will be released for the following purpose Access is restricted to the above named person No other persons shall have access to my health information without my written consent Patient Signature Date Witness Signature Laboratory Use Only Confirming identification picture ID Meditech comment by Release date time Tech ID Implementation Date April 2013 Printed versions of this document are not controlled 11 w whitehorse Laboratory Laboratory ZF general hospital Guide to Services Information 11 Booking Procedures Tests Requiring Appointments The following procedures and tests require appointments Procedure or Test Requisition A Electrocardiogram ECG EKG WGH Lab On Site Testing B Holter Monitor Holter Monitor Spirometry and Reversibility Testing WGH Lab Spirometry D Oral Glucose Tolerance Test OGTT WGH Lab On Site
89. o less blood is required for culture Blood Volumes needed are based on the age of the patient Age Bottle colour Amount 1 0 mL 3 4 mL orange Anaerobic 8 10 mL blue Aerobic 10 mL orange Anaerobic 10ml 34ml blue Aerobic 8 10 mL 10ml Number of sets and timing The optimal number and frequency of blood cultures will depend on the disease suspected and can only be determined by the physician Most cases of bacteremia are detected by using 3 sets of separately collected blood cultures More than 3 sets of cultures yield little additional information Conversely a single blood culture may miss intermittently occurring bacteremia and make it difficult to interpret the clinical significance of certain isolated organisms These guidelines apply for both adult and pediatric patients e Fever of unknown origin obtain 2 separate culture sets from 2 separately prepared sites initially After 24 36 hours obtain 2 more before patients temperature rises e Acute sepsis meningitis osteomyelitis arthritis acute untreated bacterial pneumonia or pyelonephritis obtain 2 separate culture sets from 2 separately prepared sites prior to starting therapy e Endocarditis Acute obtain 3 culture sets with 3 separate venipunctures over 1 2 hours and begin therapy e Endocarditis Subacute obtain 3 culture sets on day 1 at least 15 min apart If all are negative at 24 hours obtain 3 more sets at least 15 min
90. ology Requisition 00050902 Rev November 2011 Electronic Version available on http www becancer bcca HPIAabservices PathologyRequestForms htm Current Requisition Form listed here http www bccancer bc ca HPI labservices PathologyRequestForms htm Implementation Date April 2013 Printed versions of this document are not controlled 31 Laborator Requisition T gh Sse i art Forms g p uide to Services Examples VIROLOGY and REFERENCE LABORATORY St Paul s Hospital 6 Floor Burrard Bld 1081 Burrard St Vancouver B C V Z 1 Ph 604 806 8470 Healthcare Date of Collection Chlamydia GC PCR cl Cervi ania J Un Ph Billing O0 Endocervix Copies to O Urethral Shipper Clinical Data Whitehorse General Hospital Laboratory Pregnancy weeks gestation 5 Hospital Rd Date of onset of disease Whitehorse YT Y1A 3H Diagnosis provisional S none Borne Precautions i Current Requisition Form listed here http www phsa ca AgenciesAndServices Services PHSA Labs T esting Requisitions Diagnostic htm Implementation Date April 2013 Printed versions of this document are not controlled 32 VY whitehorse i general hospital Guide to Services Laboratory Requisition PHSA Laboratories Public Health Microbiology amp Reference Laboratory BC Centre for Disease Control 655 West 12th Avenue Vancouver BEVSZ ARA www phsa ca bcedqpublichealthlab Serology Screening Requisition Section 1 Patient Informati
91. om the blue tab 6 Remove the blue tab from the bag and pour the urine into the sterile container Do not touch the inside of the container T Discard the U bag and wash your hands 8 Label your collection container with the following information Your full first and last name Your health care number OR your date of birth The date and time of your collection 9 You must bring the sample and Requisition to the Laboratory immediately Remote collections you must refrigerate and transport the sample to the Laboratory within 24 hours Questions Concerns Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 103 We Whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions Attaching an Infant Urine Sample Collection Bag U bag The skin area must be clean and dry Avoid oils baby powders and lotion soaps that may leave a residue on the skin and interfere with the adhesive s ability to stick Begin application on the tiny area of skin between the anus and genitals The narrow bridge on the adhesive patch prevents feces from contaminating the urine sample and helps position the collection bag Female Lay infant on her back and wash each skinfold in the genital area A gentle bath soap is preferred Avoid using a lotion soap solution as it can leave a residue that may interfere with adhesion Wash anus las
92. ompleted by Physician Sumame of Mother Hospital for Delivery in full CBS Reference mo RhIG given this pregnancy Specimen collected before injection L wo L ves Date L wo L ves Paternal Information Mother s information must be complete when submitting Father s specimen Personal Health Number PHN or Unique number if no PHN All information must be complete Please indicate clinic name Results faxed within 72 hours of sample receipt Billing nurniber Billing number f Physscan name Midwie Name CLINIC NAME CLINIC NAME Label tubes with full name PHN or other unique number and date of collection Ensure that information on specimens EXACTLY matches information on requisition Mother Routine or Infertility Mother Clinically Significant Antibody Father When requested Initial amp 26 weeks E When requested by CBS Diagnostic Services E by CBS Diagnostic Services Draw one 6 of Tml EDTA Draw three 6 or Tml EDTA Draw one 6 or 7mL EDTA Date of Collection Collection Facility YYY narmi Canadian Blood Services Diagnostic Services Fax 604 874 6582 Phone 604 T07 3527 BC amp Yukon Centre 4750 Oak Street Vancouver BC V6H 2N9 FYa583 2011 06 25 C390 o10y The personal information collected on this tom is collected under the authority of the Personal information Protection Act The personal information is used to provide medical Services requested on fis requisition The information collected is use
93. on and Physician Information PERSONAL HEALTH NUMBER cr outofpronince Health DATE COLLECTED TIME COLLECTED ORDERING PHYSICIAN Provide M5ce Number shd peovince DOAMMSYYYY HAM Nameand address of report definvery DOB GENDER Om Or Du O ioangneamesenma CITY TOWN POSTAL COD 1 PRA n Fain RIU u a Section 2 Clinical Information Clinical Information C Asymptomatic C Gastrointestinal symptoms C Therapeutic monitoring NEEDLESTICK C Headache Stiff neck _ Respiratory symptoms C Immigration _ Acute C Convalescent C Rash symptoms C STD contact C STO symptoms C Prenatal C Outbreak Cluster Event C Fever C Other specify C Follow up C Other specify ee lll Section 3 Test s Requested Note Codes for PHSA Labs Use Only PRENATAL SCREENING HEPATITIS OTHER SEROLOGY HIV Nominal Reporting CHIV Acute undefined etiology Immunity Acute HIV Non Nominal Reporting _ Hiv HBsAg Anti HBc Total HEPS Measles IgG Omis Measles IgM Omm Anti HBs Anti HCV Rubeola Rubeola CJHeve Anti HAV IgM q Mumps IgG LIMUIG Mumps IgM CJMUIM RUBIG p e3 Chronic undefined etiology Parvo B19 IgG C paave Parvo B19 IgM Clearv Syphilis Screen TPS oe HBsAg Anti HBc Total O HEPCH_ Rubella igG Crusis Rubella IgM RUBIM Hepatitis B Screen EBV IgG LJEBGS EBV IgM ERMS HB Anti HB HBYSAG pps Total 0 CMV IgG LICMVIG CMV IgM CICMVIM EDC Hospital of Delivery Specific Hepatitis Mar
94. open Take care not to rinse contaminated water into the other eye 2 Go to the Hospital Emergency Department Outside Whitehorse call your Doctor or Nurse right away lf Swallowed 1 Rinse mouth thoroughly with water Induce vomiting Drink 1 2 cups of water Call 911 Outside Whitehorse call your Doctor or Nurse right away 2 If another person swallowed Methanol and collapses or is unconscious or convulsing do not give anything by mouth Call 911 stops breathing begin CPR if you have been trained Call 911 Implementation Date April 2013 Printed versions of this document are not controlled 102 Wm Whitehorse Laboratory Patient ZF general hospital Guide to Services Instructions 19 Infant Urine Collection Using a U Bag Your collection kit contains Towelettes wipes to clean your baby s skin U bags urine sample collection bags A sterile sample container Please read these instructions carefully before you begin 1 Wash your hands with soap and water 2 Carefully wash around your baby s urethra with the wipes provided and allow to air dry 3 Attach a U bag to your baby s genital area See page 2 for detailed instructions for cleaning and attaching the U bag 4 Put a diaper on your baby covering the bag Check your baby often 5 Once your baby has urinated peed into the bag gently peel off the bag s sticky tape from the skin and remove the bag Tilt the bag so the pee is away fr
95. ore the test no food or drink for 8 hours You can drink water and take your prescription medicines On the day of your test 4 At the hospital you will be asked to drink a sweet drink then to sit and rest You will be at the hospital for at least 2 hours Your blood will be drawn before and after the 2 hours You cannot leave the building and you cannot smoke eat or drink during the 2 hours 5 You may wish to bring a book or a craft You may wish to bring a warm sweater 6 Bring a snack to eat you may eat it once the test is done Questions Concerns Unable to attend your booked appointment Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 81 whitehorse Laboratory Patient general hospital Guide to Services Instructions 5 Gestational Oral Glucose Tolerance Test Please follow these instructions before your test 7 lf you have had surgery you must wait at least 2 weeks before doing this test 8 If you are sick cold flu infection on the day of the test you must rebook your appointment 9 You must fast for 8 hours before the test no food or drink for 8 hours You can drink water and take your prescription medicines On the day of your test 10 At the hospital you will be asked to drink a sweet drink then to sit and rest You will be at the hospital for at least 2 hours Your blood will be drawn after 1 and 2 hours You cannot leav
96. orse Laboratory Patient ZF general hospital Guide to Services Instructions 12 Occult Blood Testing for Abnormal Blood in Stool This is a common way to test for cancer in the colon Please follow these instructions carefully for good test results Getting ready Medicines For 7 days before amp during Avoid using lbuprophen Naproxen Aspirin amp other collection days NSAIDs non steroidal anti inflammatory drugs Acetaminophen Tylenol may be taken as needed For 3 days before amp during Avoid taking Vitamin C pills you don t want more than collection days 250 mg per day from pills citrus fruits or juices Food For 3 days before amp during f Avoid red meats beef lamb liver wild game collection days Eat a healthy diet of fruits and vegetables including bran or fibre products The World Leader in Occult Blood Testing The World Leader in Occult Blood Testing The Workd Leader In Occult Blood Testing BUDAN BUON CouuE R You should collect stool p00 samples from 3 different days HON Oe t Hemoccult If Hemoccult If Hemoccutt If Do not collect samples if you can see blood in your stool or urine pee Example from menstruation period active cee seckt i REN haemorrhoids urinary tract infection Call your Doctor La bel all 3 ca rds with The World Leader In Ocen Blood Testing BECKMAN a COLTER Your full name Hemoccult J SERIAL TEST FOR ROUTINE SCREENING vourdate o
97. ou must bring your Requisition with your sample to the Laboratory Please read all instructions before collecting your stool sample D gt lt POISON The fluid in the red topped collection container is poisonous If il 2 swallowed drink lots of milk or water Phone 911 Outside Whitehorse contact your Doctor or Nurse immediately Day of collection Collect your stool between Monday and Thursday You must bring the collection containers to the Laboratory on the same day you collect You must bring your Requisition with your containers Label the red and white topped containers with Your full name Your date of birth OR health care number Date and time of collection Your Doctor s name Record Date and time of collection on your Requisition forms Empty your bladder pee completely Please do not let urine touch the stool sample Collect stool onto a clean disposable container example a paper plate Or Put plastic wrap between the toilet seat and the bowl and collect the stool onto the wrap Do not let water touch the stool Add stool to the container using spoon inside the container until the liquid is at the fill line Take from parts of the stool that look bloody slimy or watery Please do not overfill Be careful not to spill the liquid Make sure nothing else gets in the container i e no toilet paper no plastic wrap Implementation Date April 2013 Printed versions of this documen
98. phils Remember To avoid contamination Blood Culture samples must be drawn first before any other blood samples 1 Assemble needed supplies e Computer generated labels preferred e blood culture bottles e butterfly needle attached to blood culture collection adapter cap e alcohol swabs amp antiseptic swabs e tourniquet e gauze pads adhesive tape bandaids e protective gloves e Sharps container 2 Locate the vein and cleanse the site with both a 70 alcohol swab and then an antiseptic swab Use a radiating circular motion from vein site outwards Allow to air dry Do not re palpate the vein before venipuncture 3 Prepare the blood culture bottles e Adults you must collect 1 blue capped aerobic bottle and 1 orange capped anaerobic bottle Pediatrics collect 1 yellow capped bottle e Ensure integrity of each bottle sensor on the bottom should be grayish green yellow coloured sensor indicates the broth is contaminated amp bottle must be discarded Check the expiry date amp discard if necessary e Remove protective overcap on bottles sterilize rubber septum with 70 alcohol Implementation Date April 2013 Printed versions of this document are not controlled 51 NY Sample ZF whitehorse Laboratory Collection general hospital Guide to Services Procedures e Mark the desired fill volume level on each bottle see Blood Volumes table on page x 10 mL of blood per bottle is optimal for adults bottles a
99. plementation Date April 2013 Printed versions of this document are not controlled 64 WA whitehorse Laboratory WGH Microbiology ZF general hospital Guide to Services Sample Collection Genital Samples Note Our Microbiology Lab has changed its processing amp reporting protocols as of August 2012 Collection protocols have been streamlined Collect smears for patients of all ages Collect swabs using a Modified Amies Clear Medium swab as warranted see table below This protocol includes routine genital testing for urethritis cervicitis bacterial vaginosis vulvovaginitis trichomoniasis and candidiasis pregnancy and patients at risk of STIs 1 Include any relevant information on the Requisition such as routine screen possible STI contact pregnancy etc 2 Complete separate Requisition for Chlamydia amp GC PCR testing as these are referred out tests Virology and Reference Laboratory requisition see Section B Transport immediately to Laboratory If delay in transport is unavoidable keep sample at 4 C For Chlamydia testing freezing no longer required When doing a slide for Micro and a PAP Smear please use two separate blue slide holders We do not want to receive two slides in one slide holder Label each slide with site one PAP the other VAG as well as other common descriptors Vag gram stains are processed on site do not spray with fixative PAP smears are sent out and do require
100. quisitions R4 general hospital Guide to Services 4 Add On Tests Purpose When another blood test needs to be added to an existing order Chemistry samples processed in the WGH Laboratory are kept for one week to ensure add on tests can be performed Due to sample stability and storage requirements temperature light etc not all Add On tests can be performed e g bilirubin troponin Procedure 1 Phone the lab to verbally indicate the need for additional tests 2 Fax the Add On test Requisition to the Laboratory at 867 393 8772 The Requisition should be clearly marked Add on to sample drawn on date 5 Examples of Requisition Forms Following pages Implementation Date April 2013 Printed versions of this document are not controlled 21 W ZF Laboratory Requisition whitehorse Forms general hospital Guide to Services Examples w whitehorse 7 general hospital ON SITE TESTING REQUISITION Ph 867 393 8739 _ fax 867 393 8772 SUBMITTING DOCTOR COPY OF REPORT TO HEMATOLOGY L cac LJ AA LJ MALARIAL SMEARS LJ ABORAN Blood Type QC ancasc LJ mono COUNTRY VISITED Reason CJ ina Pt LJ esr DATE Prenatals require CBS Reg PATIENT ON COUMADIN N IS PATIENT SYMPTOMATIC Y N O Pre Op Group amp Sereen U er O Aenc OF Date ranenTonwHeranin Y N LJ OTHER O Ou Pi Transfusion PATIENT ON LMWH Y N of Unite O DIMEA TEST WGH Pharmacy requires pre chemo patient height and weight Tx Da
101. ratory Sample YW whitehorse Collection general hospital Guide to Services Procedires 1d Hemolysis Hemolysis or the rupture of red blood cells usually occurs during sample collection and can result in rejection of a sample Possible causes of hemolysis include e unsecure line connections e contamination e prolonged tourniquet application e incorrect needle size excessive suction can cause red blood cells to be smashed on their way through a hypodermic needle e excessive suction from use of vacuum syringe veins may collapse e Vigorous shaking of filled tubes e difficult collections e g veins that are difficult to find small fragile veins in elderly patients Experience and proper technique are essential for any phlebotomist or nurse to prevent hemolysis Loudoun Hospital Center Leesburg VA 20176 Specimen Integrity Chart for Hemolysis Hemolysis can interfere with a variety of tests that can include CK LDH potassium blood bank testing coagulation testing iron digoxin ALT AST B HCG The laboratory may have to reject a specimen based on the test and the degree of hemolysis The laboratory will use the color chart below to grade hemolysis Slight Moderate Gross Hemolysis Hemolysis Hemolysis 800 3 madLl a g L SI units 400 4 If hemolysis 200 mg dl then reject As in Dugan et al 2005 Dugan L L Leech K G Speroni J Corriher 2005 Factors Affecting Hemolysis Rates in Blood Samples
102. rc en ap Sa 5 hospital Road IOD MMM YYYY i Whitehorse YT Y1A3H7 TIME COLLECTED PHSA CLIENT NO iii Section 3 Test s Requested USE REVERSE SIDE TO SUBMIT ISOLATES FOR IDENTIFICATION AND OR TYPING SEXUALLY TRANSMITTED INFECTIONS Samples for Chlamydia Plus Gonorrhea NAT Swab Urine Urethra Cervix Rectal Throat Swabs for N gonorrhoeae Culture Urethra Cervix Rectal Throat Eye Vagina Hysterectomy Direct Smears Examined For Vagina 1 Bacterial vaginosis and yeast Slide 1 Vagina 2 Trichomonas Slide 2 Urethra Gonorrhea and pus cells Rectal Gonorrhea Eye Gonorrhea Chlamydia DFA Eye swab Nasopharyngeal aspirate OR swab Neonates only Tracheobronchial aspirate Neonates only For other available tests and additional information consult the Public Health Microbiology amp Reference Laboratory s Guide to Programs and Services at www phsa ca bccdepublichealthlab For information on sample collection please call Bacteriology amp Mycology Lab at 604 707 2617 BAM Guideline for Ordering Stool Specimens RESPIRATORY INFECTIONS MYCOLOGY Pertussis Sputum Nasopharyngeal Pernasal swab Bronchial wash Nasopharyngeal wash Body fluid specify Group A Strep Clinical case Contact with case Tissue Biopsy Abscess specify Throat swab Diptheria Clinical case Contact with case Other specify Throat swab Nose swab TRAVEL YES specify NO
103. re pre marked with 5mL increments 4 Perform venipuncture 5 Attach the aerobic blue bottle to the collection adapter cap and hold the cap down on the bottle 6 Using the fill indicator line you marked obtain the needed volume of blood Then remove the adapter cap from the bottle and attach it to the anaerobic orange bottle Obtain the needed volume of blood 7 If additional blood is required for other tests draw them after the blood culture bottles are filled 8 Terminate the venipuncture and dispose of butterfly needle in the Sharps container Retain the adapter cap for cleaning 9 Label the specimen bottles with prepared labels Do not cover any portion of the peel off section of the barcode labels or lot numbers on the bottles 10 Repeat this collection process from another vein site You must collect two sets of aerobic amp anaerobic bottles from two different vein sites 11 Place labelled specimens in plastic biohazard bags and prepare for transport using TDG protocols Implementation Date April 2013 Printed versions of this document are not controlled 52 Laboratory Sample We whitehorse ecleeon SS General hospiti Guide to Services Procedures Volume of Blood This is critical because the concentration of organisms in most cases of bacteremia is low especially if the patient is on antimicrobial therapy In infants and children the concentration of organisms during bacteremia is higher than in adults s
104. red directly from BC Cancer Agency Implementation Date June 2013
105. results 2 Ensure that samples are labelled with Patient s legal name last first Patient s health care number Date of Birth microbiology important for interpretation of results Date and Time of collection The site or type of collection 3 Complete the WGH Microbiology Requisition including the same information as above 4 List any antibiotics presently in use or intended to be used on the Requisition as well as a tentative diagnosis e g R O UTI This will enable the lab to set up special plates techniques etc as needed 5 Transport to the Laboratory within 24 hours of collection see specific sample requirements Sample Rejection Criteria Rejection criteria are designed to prevent inaccurate data and to ensure the safety of laboratory personnel Microbiology samples may be rejected for the following reasons Unlabelled Samples Incorrectly Labelled Mislabelled Samples Incomplete information on the Requisition Sub optimal sample leaking urine stool containers insufficient quantity Duplicate microbiology samples received on the same day e g multiple ova amp parasite stool samples sputa samples Sample delayed in transit Implementation Date April 2013 Printed versions of this document are not controlled 63 sia Sample ZF whitehorse Laboratory eatin eneral hospital Guide to Services g Procedures Ear Samples Otitis Externa External Ear Collect using clear swab Amies transport
106. rth health care number MRSA screening site of swab date time of collection Implementation Date April 2013 Printed versions of this document are not controlled 67 sample W gt whitehorse Laboratory P Collection ZF general hospital Guide to Services Procedures 6 Send sample and completed Microbiology Requisition to the Laboratory ASAP Implementation Date April 2013 Printed versions of this document are not controlled 68 Ay whitehorse Laboratory Collection eneral hospital Guide to Services g Procedures Nasal Swabs 1 Submit for detecting Staphylococcus aureus carriers 2 Collect using clear swab Amies transport medium Insert swab into the nose until resistance is met at the level of the turbinates approx 1 inch into the nose 4 Rotate the swab against the nasal mucosa 5 Repeat the process on the other side both nares on one swab 6 Label swab with patient s legal name date of birth health care number site of swab nasal S aureus screen date time of collection 7 Send sample and completed Microbiology Requisition to the Laboratory ASAP Implementation Date April 2013 Printed versions of this document are not controlled 69 Laboratory Sample WZ whitehorse c i ollection ZF general hospital Guide to Services Proced res Sputum Samples 1 Collect using a sterile container clear disposable amp leak proof 2 Early morning deep cough sample or samples after ches
107. sample 4 C e Refrigeration prevents oropharyngeal bacteria from multiplying and overwhelming pathogenic bacteria Too long at room temperature can kill pathogenic bacteria 7 Only one satisfactory sample is required for C amp S 8 Please do not send sputum samples for C amp S in series as only one will be cultured Implementation Date April 2013 Printed versions of this document are not controlled 70 ZF whitehorse l d general hospital Guide to Services Laboratory Pisa Procedures Throat Samples 1 2 Submit for the detection of Group A Streptococcal infections Collect using clear swab Amies transport medium Exception if N gonorrhoeae is suspected use a charcoal swab Clearly state methodology on the Requisition Depress tongue gently with a tongue depressor Extend sterile swab between the tonsillar pillars and behind the uvula Avoid touching the cheeks tongue uvula or lips Sweep the swab back and forth across the posterior pharynx tonsillar areas and any inflamed or ulcerated areas to obtain sample Label swab with patient s name date of birth or health care number collection site throat and date of collection Submit swab and Microbiology Requisition to the Laboratory for testing Urine Samples Submitted to rule out urinary tract infections UTI s 1 Provide patients with Patient Instructions for Midstream Urine collection see Section D For patients unable to collect samp
108. se Prothrombin Complex Concentrate BeriPlex for the immediate reversal of oral anticoagulants in specific circumstances C1Esterase Inhibitor for a specific patient condition Antihemophillic Factor von Willebrand Factor for a specific patient condition All other products must be ordered from Vancouver as the need arises Please allow a minimum of 24 hours for delivery Implementation Date April 2013 Printed versions of this document are not controlled 56 Laboratory Pinal ZF whitehorse general hospital Guide to Services Proced res Rh Immune Globulin Standard 300u g 1500 IU dose is to be administered Used for Rh Negative mothers to prevent immune Anti D sensitization It is given At 28 weeks Postpartum as indicated by Cord Investigation After a Therapeutic Abortion Post amniocentesis Threatened Abortion Other trauma etc See product insert or Quick Reference Sheet in the Nursing Policy Manual for administration procedures Follow the Prenatal Checklist provided by Yukon Health and Social Services Available Units NOTE Issue Transfuse cards are issued with each unit by the lab and must by fully completed and returned to the Lab Empty blood product containers are to be retained on the ward for a minimum of four hours after the transfusion is complete in case a Transfusion Reaction develops They are not to be returned to the lab unless a Transfusion Reaction is
109. should be 10X the Volume of Tissue Routine Surgical specimens e fa rush diagnosis is required please state on the accompanying patient surgical requisition in bold letters e Label the sample and accompanying surgical requisition with patient s demographics The requisition must also include patient history e Sample type description on the container must exactly match the sample type on the Requisition e g Rt thyroid nodule e List 1 the time the sample was collected and 2 the time the sample was subsequently placed in formalin on the Requisition Sample Rejection Criteria Doctor s signature missing on Requisition Samples or Requisition not labelled with patient demographics and or history Pathology description on container does not exactly match description on the Requisition Time of collection and time sample added to formalin are not listed on Requisition Implementation Date April 2013 Printed versions of this document are not controlled 61 sample W whitehorse Laboratory P Collection ZF general hospital Guide to Services Procedures 5 Cytology Sample Collections All cytology samples from health care facilities outside of the Whitehorse General Hospital are sent to the BC Cancer Agency Vancouver Centre s Diagnostic Cytology Laboratory phone 604 877 6000 fax 604 873 5384 The following table provides a summary of collection instructions from their lab Type of Sample Sample Me
110. sioning Electrocardiograms Spirometry amp Reversibility Testing 24 Hour Urine preparation Holter Monitoring NO Implementation Date April 2013 Printed versions of this document are not controlled w whitehorse Laboratory Laboratory ZF general hospital Guide to Services Information 4 Referred Out Tests Our Support Team The following is a listing of laboratories outside Yukon to which we send samples for testing Depending on requests samples may be sent to the following referral laboratories Facility Webpage Providence Health Care PHC http www providencehealthcare org Within PHC we have contracts with St Paul s Hospital E eg ane Provincial Health Services Authority PHSA http www phsa ca Within PHSA we have contracts with BC Communicable Diseases Control BCCDC http www bccdc ca BC Children s Hospital http www bcchildrens ca BC Women s Hospital amp Health Centre Canadian Blood Services CBS BC amp Yukon Vancouver Coastal Health http www vch ca Within VCH we have contracts with Vancouver General Hospital http www vch ca 402 7678 site_id 470 Note Other Canadian Laboratories are periodically used for tests that are less frequently requested Samples for the following are sent to referral microbiology laboratories for testing Microbiology Referred Out Testing Stool samples all tests Viral Cultures all sample types tests TB testing all sample
111. sting ennaa 89 12 Occult Blood Testing for Abnormal Blood in Stool c ccece eee eee ees 91 13 Stool Collection for Culture amp Sensitivity or C difficile tests 00 93 14 Stool Collection for Ova amp Parasite Exam cccceccee cece eee eee seat eeeenees 95 15 24 HOUr Urine TeSUNG akuista EE E E E 97 16 AZ OU Unne Testing orerirniens teriateeeeeahnwsstatieeind 99 17 Midstream Urine Collection ccccccc cece cece cee e ee eee seats eneeenaeeenaeenes 100 18 Urine Collection for Cytology Testing ccccccceceee sees eee eneeeneeeeenes 101 19 Infant Urine Collection Using a U BaQ ccccee cece eee eee eee eeaeeeeenenes 103 20 Helicobacter pylori Urea Breath Test UBT ccccceceeae eee eeeeeaeeaees 105 Section E Test Directory amp Time Sensitive Testing 106 TeSt WCCO seis scree net Leet 5 ala bare accra da siig tad ie ns E vance reuse weenie 106 Time Sensitive RESTING sachicaritede ict ictatotcand a chi deeseatsacbseceeates 107 Section F Packaging amp Transport of Patient Samples 108 Section G Ordering Supplies 110 Visual Key to Collection Kits 00 ccccc cee ce cece eee eeeenseeeeeeaeeeeeeaeneeas 110 Laboratory Supplies Order FOrm ccccecece cece eee eee eee eeeneeteeeeeenaaeees 114 w whitehorse Laboratory Laboratory g general hospital Guide to Services Information Section A Laboratory Information 1 Hours
112. suspected After hours please sign out the crossmatched unit according to established protocol and ensure you leave the ticket from the bottom of the Issue Transfuse card on the bench If units are not issued within 72 hours or the patient is discharged any remaining units will be cancelled and returned to the blood bank inventory Blood Products will only be picked up from the Lab by healthcare workers who have been oriented to the process If the units are unmatched or full testing is not yet complete the doctor ordering the transfusion must acknowledge the assumption of increased risk This can be done by a signed notation in the patient chart This document is intended to provide general information only Please see the Nursing Policy Manual BBK Guidelines and the Clinical Transfusion Resource Guide for specific information about Transfusion Medicine procedures Prenatal Patients Refer to Community Nursing s Prenatal Checklist next page for collection schedule Implementation Date April 2013 Printed versions of this document are not controlled 57 W ZF whitehorse Counseling prenatal vitamins folic acid life style choices alcohol smoking f Review list of Screening tests to be offered Er the BC Prenatal Genetic Screening fur unsure of sesietonal age LMP an early ultrasound should be done especially if doing List of screening tests to be offered I ABO Rh Typing RBC Antibody Screen Results ma
113. t Rinse and dry Cleanse entire area again using the towelette pro vided Allow to air dry Remove protective backing from the bottom half of the adhesive patch It is easier to leave the top half of the adhesive covered until the botom section has been applied to the skin Ensure that the skin surface is dry before applying collection bag Stretch perineum to separate skin folds and expose vagina When applying adhesive to the skin be sure to start at the narrow bridge of skin that separates the vagina from the anus and work outward from this point Press adhesive firmly against the skin avoiding wrinkles When the bottom section is in place remove the paper backing from the upper por tion of the adhesive patch Work upward to complete application securing adhes ive around the vagina Male Step 2 Step 1 Lay infant on his back and wash entire genital area A gentle bath soap is preferred Avoid using a lotion soap solution as it can leave a residue that may interfere with adhesion Wash scrotum first then penis and anus last Rinse and dry Cleanse entire area again using the towelette provided Allow to air dry Implementation Date April 2013 Remove protective backing from the bottom half of the adhesive patch It is easier to leave the top half of the adhesive covered until the bottom section Aas besn applied to the skin However with an active boy it may be easier to leave all th
114. t urinate pee into the toilet a small amount and then stop Position the container and then begin urinating in the container Do not touch the container to your body Fill the container about half full If needed continue urinating in the toilet Close the lid tightly to the container 10 Wash your hands again Do not touch the inside of the container with your fingers Implementation Date April 2013 Printed versions of this document are not controlled 100 WI Z whitehorse Laboratory Patient general hospital Guide to Services Instructions 18 Urine Collection for Cytology Testing Please read these instructions carefully before you begin 1 Label your collection container 1 with 13 Your full first and last name 14 Your health care number OR your date of birth Vy 2 g bara tT ou 15 The date and time of your collection we ii ADD EQUAL Voi 30 METHANOL TO SAMPLE PRO Keep out of reach of children I Men wipe clean the head of your penis M METHANOL a Do not collect your first morning urine pee b Collect a midstream sample of urine li Women wash your entire genital area with soapy water and rinse well iii As you start to pee allow a small amount to fall into the toilet this cleans the opening of your urethra where the pee is coming out Then catch about 50 mL into the empty container you were given 1 see the side of the container 50
115. t are not controlled 95 Vv GF Laboratory Patient whitehorse general hospital Guide to Services Instructions 10 Tightly close the container s lid and shake until the stool specimen and liquid are well 11 12 13 mixed Be careful not to spill the liquid From the same stool sample add stool to the second collection container white lid using the spoon inside the container Take from parts of the stool that look bloody slimy or watery Please do not overfill Name Nom For small children Fasten plastic wrap inside the diaper with childproof safety pins then remove the stool from the plastic and put it into the collection container Do not bring used diapers to the Laboratory Put the containers in the bag and seal the bag with a twist tie Wash your hands with soap and water Remember e You must bring the labelled collection containers to the Laboratory on the same day you collect e You must bring your Requisition with your containers Questions Concerns Unable to attend your booked appointment Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 96 w whitehorse Laboratory Patient g general hospital Guide to Services Instructions 15 24 Hour Urine Testing Please follow these instructions Before Collecting Follow your doctor s orders about food and medicine Empty your bladder pee in the toilet Do not colle
116. t crooked amp doesn t surpass the tube s length our analyzers may reject the sample or labels may be ripped off when placed in racks In the lab coloured caps are removed for analysis amp recapped with non specific caps Remember Never affix labels to collection tubes prior to collection Always affix labels in the presence of the patient These golden rules reduce the chances of improper labeling Implementation Date April 2013 Printed versions of this document are not controlled 4 v whitehorse Laboratory Laboratory general hospital Guide to Services Information References Clinical and Laboratory Standards Institute CLSI 2007 Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture Approved Standard Sixth Edition CLSI document H3 A6 ISBN 1 56238 650 6 Clinical and Laboratory Standards Institute 940 West Valley Road Suite 1400 Wayne Pennsylvania 19087 1898 USA Vancouver Coastal Health 2010 Phlebotomy amp Specimen Labelling Procedure Version 2 3 March 16 2010 7 Sample Rejection Policy The WGH Laboratory reserves the right to delay or cancel testing on samples that have been improperly collected labelled processed stored or transported The laboratory shall take measures to maintain sample integrity while following up on the receipt of an inadequate sample Please note that the large number of samples received by the laboratory makes it impossible to positively identify sa
117. t physiotherapy are best Morning samples are the most concentrated sample of disease causing organisms Food or saliva contamination ruins samples 3 Give the patient a sample container and the Patient Instruction Sheet for sputum collection see Section D e Gargle rinse with water and discard prior to sample collection no mouthwash Remove lid from sample container and hold container to open mouth with lips inside the container opening e Take as deep a breath as is comfortable and cough do not spit into the container Screw container lid tightly in place Clean the outside of the container with a paper towel soaked in disinfectant if it is soiled 4 Samples that appear like saliva spit or postnasal samples are not appropriate collections 5 Create a slide at the time of sample collection For proper slide preparation e Use a sterile swab and aggressively stir the sputum focusing on the purulent chunks bacteria are harboured in these chunks e Distribute sample from swab onto glass slide and air dry 5 Label the frosted end of the slide using a pencil patient s legal name date of birth health care number date of collection sputum 6 Submit labelled sample smear and Microbiology Requisition to the Laboratory for testing in a timely manner preferably within 2 hours of collection e Samples should be sent to the laboratory within 24 hours of collection e If immediate transport is not possible please refrigerate
118. t pneumothorax Appointments for Spirometry and Reversibility testing are now booked by WGH Laboratory staff 1 Obtain the patient s current phone number s where they can be reached during business hours so Laboratory staff can phone to book the appointment Fax the Requisition and contact phone numbers to the Laboratory 867 393 8772 Patients will be contacted in the order in which Requisitions are received Provide patient with a Patient Information Sheet see Section D Verbally inform the patient of the following You will be contacted by a Laboratory staff member to book your appointment These tests are performed on select days Avoid smoking for at least 4 hours prior to the test Avoid eating a large meal 2 hours prior to the test Avoid exercising heavily 30 minutes prior to the test Avoid drinking alcohol 4 hours prior to the test Avoid wearing tight clothing that might restrict full deep breaths Do not wear fragranced products perfume cologne shower gels etc Bring your medication puffers with you to the appointment You must follow your doctor s instructions about using these medicines before the test Arrive 10 minutes early to check in You will be at the hospital for approximately 1 hour because the test will be done twice before and after you are given a medicine You cannot smoke during the test The following YouTube video Title Spirometry Technique Review uploaded by
119. t with those recorded on the Requisition the Unlabelled Samples criteria apply e Samples with patient names misspelled but with correct health care number and D O B will have a notation accompany the patient report Procedures ordered may be performed after every effort is made to confirm spelling These errors cause delays in sample processing Incorrect Container or Preservative e Recollection is required for samples received in an incorrect container or with without the appropriate preservative e g a blood collection in the wrong collection tube These errors can lead to invalid results Insufficient Sample for Procedure s e Repeat collections will be requested when there is insufficient sample to provide results for all tests ordered Procedure s for which there is sufficient sample will be performed Unsuitable Sample for Procedure s e Samples will be rejected if samples collected are unsuitable for the test requested saliva for sputum tests urine for blood tests Blood Sample Hemolyzed e Hemolyzed blood samples will be rejected Free hemoglobin in hemolyzed blood samples interferes with the accuracy of most test results Implementation Date April 2013 Printed versions of this document are not controlled 6 whitehorse Laboratory Laboratory general hospital Guide to Services Information Improper Transport Conditions e Samples will be rejected if the samples were subjected to improper transport conditions
120. te URINE URINALYSIS STOOL REDUCING SUBSTANCES LJ occult econ CHLORIDE HCG pen PHEG AESULTS _ AMYLASE BICARBONATE ASON FOR SEALIM HCG CREATININE a __ GLUCOSE fasting i _ FERAITIN PROTEIN andom Hgb AIG URIC ACID 50 gm LOAD Gestational Screen ORAL GLUCOSE TOLERANCE please boo please book PRESERVATIVE UREA and p 2 r GTT VOLUME CREATININE 2 hr GTT GESTATIONAL TSALCIUN cx 7 THERAPEUTIC DRUGS PRESERVATIVE TROPONIN DATE TIME OF LAST DOSE TOTAL PROTEIN CARBAMEZAPINE TEGRETOL ALBUMIN PHENYTOIN DILANTIN gt ine must have BILIRUBIN eer i SALICYLATE CREATININE CLEARANCE sarum crealining ALP fasting ACETAMINOPHEN LOH room kenpamiure anspor GENTAMICIN rough AST SGOT pa ALT SGPT DIGOXIN GT VANCOMYCIN trough GALCIUM o o THYROID FUNCTION Pra Posi BRONCHODILATOR PHOSPHORUS _ Tesling follows B C Health Services algorihm Soirometry Bronchodilatar Standing Order MAGNESIUM En Thyroid replacement therapy i mee reverse will be used unless URIC ACID ihyraid disease mot yet diagnosed olarwiine spaced reno at above pec cori FLUIDS SEMEN Monday Thursday 0800 1200 only PLEURAL PERITONEAL O oTHER LJ POST vas J INFERTILITY LJ SELL COUNT Ol vric acio TIME OF COL LJ PROTEIN LDH PAATNER OF GLUCOSE L POST REVERSAL MINU COANE OTT Your iWormation amp protected under ihe WOH Priva
121. th more information 4 If you are sick have a cold or flu on the day of the test please rebook your appointment If you have been severely sick or have had ear infections postpone the appointment for 3 weeks 5 Avoid e Smoking for at least 1 hour before the test e Drinking alcohol within 4 hours of the test e Exercising heavily within 30 minutes of the test e Wearing tight clothing that might restrict full deep breaths e Eating a large meal within 2 hours of the test 6 Do not wear fragranced products perfume cologne shower gels etc 7 Please arrive 10 minutes early to sign in lf you want to see how the test is done watch this YouTube video Title Spirometry Technique Review produced uploaded by LungAssociationSk http www youtube com watch v 7ORNHWVrY amp list UU02i4iUca7JpewgD9xY5GVA amp index 2 amp feature plc Questions Unable to come to your booked appointment Please phone the WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 80 whitehorse Laboratory Patient general hospital Guide to Services Instructions 4 Non Gestational Oral Glucose Tolerance Test Please follow these instructions before your test 1 lf you have had surgery you must wait at least 2 weeks before doing this test 2 If you are sick cold flu infection on the day of the test you must rebook your appointment 3 You must fast for 8 hours bef
122. the bag with a twist tie 7 Collect 1 good sample Only 1 sample can be tested in a 24 hour period 8 If you are unable to get a good sample after 3 attempts talk to your doctor 9 Bring the sample to the Laboratory within 2 hours of collection If you live in a remote community you must refrigerate and transport the sample to the Laboratory within 24 hours Questions Concerns Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 86 Laboratory Patient YY whitehorse general hospital Guide to Services Instructions 10 Sputum Collection for Cytology Testing Please read these instructions carefully before you begin 1 Label your collection container 1 with the following information e Your full first and last name Q 2 I There HI Your date of birth OR your health care number e The date and time of your collection Dis 1 ji HF He pr gg 3 A METHANOL Warnings on int tag a contin ca aee e Write Sputum ADD EQUAL Voll W METHANOL 10 SAMPLE PROP s s MF seam Keep out of reach of children E K lt ban Collect early in the morning before eating Rinse your mouth with water Hold the container 1 to your mouth with your lips inside it Take a deep breath and cough deeply Spit the sputum from deep down into the empty container Do not spit clear sali
123. the environment are protected while preserving the integrity of the specimens Note The information contained in this document is meant as a guide to certain parts of the Transportation of Dangerous Goods Regulations and is not meant to be a substitute for them It is the responsibility of those handling shipping or transporting dangerous goods to consult the Regulations for exact requirements A copy of the TDGR can be found on Transport Canada s website http www tc gc ca eng tdg clear menu 497 htm Information on packing material is found on the Saf T Pak website http www saftpak com StpPack stpackaging aspx Packaging 1 Place specimen in a primary container and label with at least two patient identifiers Primary containers include e blood collection tubes e formalin containers e urine containers e blood culture bottles e any other suitable sealed container which safely contains the specimen for testing 2 Place primary container s into a secondary leak proof container labelled biohazard The secondary container prevents the specimen from leaking if the primary container breaks or leaks in transit to the Laboratory Secondary containers include e small biohazard specimen bags e large red hospital designated biohazard bags e any other suitable leak proof container with a biohazard label on it no requirement for biohazard labelling wnen secondary containers are clear Once sealed in a secondary container it may be
124. the spray fixative 6 For Trichomonas Antigen Testing collect a second vaginal sample Modified Amies Clear swab Send within 24 hours if delayed refrigerate specimen at 4 C The Lab will not process swabs gt 36 hours old This test is performed only when patients are exhibiting clinical symptoms Contact the Microbiology Lab for more details Implementation Date February 2013 Printed versions of this document are not controlled 65 w whitehorse Laboratory WGH Microbiology ZF general hospital Guide to Services Sample Collection Genital Samples continued Site of sample collection for genital pathogens is dependent upon Clinical conditions Clinical Common Pathogens Req Condition Hie Sought TRS A N Page Urethralurine Neisseria gonorrhoeae re Chlamydia GG aon oo oe gonorrhoeae Combined Chlamydia GC PCR Swab oe Cervix Chlamydia trachomatis Combined Chlamydia GC PCR Swab oe Neisseria a Combined Chlamydia GC PCR a males collect a urine specimen Urethra Urine Sranmvdiatrachomalis Combined Chlamydia GC PCR y males collect a urine specimen STI Risk Other Throat STI Risk Genital Neisseria gonorrhoeae Modified Amies Charcoal Swab e Bacterial vaginosis Smear for Gram stain oe Vulvovaginitis Initial Vagi i agina presentation mT Trichomonas vaginalis See below Bacterial vaginosis Smear for Gram stain E Candida Candida Culture Modified Amies Clear swab Vulvovaginitis l Vaginal Culture
125. their decision making Appropriate documentation of i f i 1 i a a rt a yp a te counseling acceptance of or declining the screening is to be made 18 20 20 WEEKS G GESTATION RBC S RAENOR screen amp or repeat ABO Rh as recommended by Canadian Blood Services 28 Weeks Gestation _Winkho if Rh negative order from WGH Laboratory Services _ 50Gm Oral Glucose Load lt Hemoglobin 35 37 WEEKS GESTATION Vaginal Rectal Swab for Group B Strep _ 36 38 Weeks Gestation wp Ne DIRES E Machi ae ravel Documents f iniii a a aana pee on mee Sn a ee ep eee eee l Fax prenatal Record to WGH Maternity Ward Travel to Whitehorse eoe ee ee eee eee i 1 M ii iii i iM i IMi IM i mm Prenatal Visits every 4 weeks until 28 weeks every 2 weeks until 34 weeks every week until 38 weeks Revised by Community Nursing August 2010 Revised March 2011 August 2012 Continued on next page Implementation Date April 2013 Printed versions of this document are not controlled 58 Laborator Zampe QZ Alerter m Guide to S y Collection general nospita uide to services Procedures Yukon Health and Social Services PRENATAL CHECKLIST Collection Method Requisition amp Destination _ 1 X 7ml pink top EDTA tube Canadian Blood Services 2 X 7ml gold SST top tubes No need to PHSA BCCDC spin or separate 1 X 3ml lavender top EDTA tube smear WGH Lab On Site T
126. thod Provide at least 50 100 mL of fluid in an equal volume of 10 neutral buffered Body Cavity Fluids pleural formalin peritoneal pericardial Pelvic Washings Pap smears Add 3 units of heparin per mL of fluid to prevent clotting of very bloody fluids Option 1 From 2 aspirates prepare 2 separate smears directly onto slides one air dried and one immediately spray fixed with an alcohol based fixative Cytofix or immediately immersed in 95 methyl or ethyl alcohol If the slide is directly immersed it should be allowed to fix for a minimum of 2 minutes and Thyroid Fine Needle then allowed to air dry prior to packaging Then rinse needles from each Aspirates aspirate into CytoLyt Option 2 Rinse all aspirated material directly into CytoLyt To learn more about FNA technique go to _http www papsociety org fna html Prepare at least 2 separate smears directly onto slides with half of the slides air dried and half immediately spray fixed with an alcohol based fixative Cytofix or immediately immersed in 95 methyl or ethyl alcohol If the slide is Immersed in alcohol it should be allowed to fix for a minimum of 2 minutes and then allowed to air dry prior to packaging Then rinse needles from each aspirate into CytoLyt or 50 ethyl or methyl alcohol Fine Needle Aspirates other than Thyroid i ye If special stains or genetic studies are likely to be required e g for tumor classification identification of primary
127. tion and your initials Affix a Blood Bank Identification Number sticker from the card on each tube collected 5 Write the date time and your initials on the wristband strip from the bottom of the Blood Bank Identification Card Insert it into a pink wristband and affix to the patient at the time of specimen collection Label the Identification Card with the patient s identifiers your initials and the date amp time of collection to verify you have confirmed identification of the patient with the samples Note The pink numbered identification band must be on the patient s wrist before a Transfusion can be performed WGH Blood Bank Identification Card Label with a Patient info date time amp initials of collector SPECIMEN TUBE Terai eciplen Syslem San Faranda CA gig FORM 6310 i SPECIMEN TUBE Attach ID stickers to blood collection tubes The idoni A Blood A L kat bat i E r E f LF GEJ 1 GY ci a F ni Record date time amp your initials Detach amp insert into pink wristband Affix to patient 02006 Prcision Dyramics Com FOR EASY REMOVAL OF LABELS BEND SHEET VERTICALLY AT LABEL ENDS Implementation Date April 2013 Printed versions of this document are not controlled 54 Laboratory Sample WZ whitehorse c i ollection ZF general hospital Guide to Services Proced res ABO Blood Group This test is used to identify a patient s blood group
128. tory Sample WZ whitehorse Collection ZF general hospital Guide to Services Procedures Indwelling Catheter iP 2 Clean the catheter collection port with 70 alcohol wipe Using sterile technique puncture the collection port with a needle attached to a syringe Note do not collect urine from collection bag Aspirate the urine and place it in a sterile container Wound Samples Wound is a broad term used by microbiology technologists to describe abscesses bites burns carbuncles cuts incision lines lacerations lesions rashes ulcers etc This protocol includes routine C amp S testing for many miscellaneous body sites Samples can generally be divided into 3 main groups Superficial Deep amp Burns See specific instructions below for each wound type All wounds 1 Clinical suspicion of infection must be present before a sample is collected to avoid misleading results Swabs of serous fluids are not recommended as this is part of normal healing For dry encrusted lesions culture is not recommended unless an exudate is present Collect using syringe clear swab or anaerobic collection kit as required then make a smear Prepare a smear slide at the same time the sample is collected Label smear with patient s name site of collection and date of collection on frosted end of slide using a pencil Submit this smear for Gram stain so that Microbiology is able to assess the amount of in
129. ugh LC Rash C Lower Respiratory Infection GASTROINTESTINAL VIRUSES Feces for C Rotavirus Adenovirus C Norovirus C Other specify Guideline for Ordering Stool Specimens www bcquidelines ca qpac quideline_diarrhea html MEASLES RUBELLA VIRUSES C Measles C Rubella C Urine C Nasal Nasopharyngeal swab C Other specify _ BIOPSY AUTOPSY OTHER TESTS Form DCVI_100_1001F Version 1 0 09 2009 VI Current Requisition Form listed here http www phsa ca AgenciesAndServices Services PHSA Labs T esting Requisitions Diagnostic htm Implementation Date April 2013 Printed versions of this document are not controlled 35 whitehorse general hospital W ZF Requisition Forms Examples Laboratory Guide to Services BAM BAM PHSA Laboratories Public Health Microbiology amp Reference Laboratory Bacteriology amp Mycology Requisition BC Centre for Disease Control 655 West 12th Avenue Vancouver BCVSZ 484 www phsa ca becdcpublichealthlab Section 1 Patient In PERSONAL HEALTH NU DoyMMMYYYYL GEND UNK DATE RECEIVED province PATIENT SURNAME oe NER E ADDRESS L CODE PHSA LABORATORIES USE ONLY Section 2 Healthcare Provider Information ORDERING PHYSICIAN Provide M5C ADDITIONAL COPIES TO Address M5C Name and address of report delivery OUTBREAK ID SAMPLE REF NO I do not require a copy of the report F Whitehorse General 5
130. uide to Services Examples ke D 600 West 10th Avenue TIENT DEMOGRAPHICS ravinert aa Vancouver BC Canada V5Z 4E6 Enter data manually addressograph or affix label Health Services we enmesraganey Tel 604 877 6000 x 2101 Vancouver Cancer Canine Fax 604 873 5384 DIAGNOSTIC CYTOLOGY REQUISITION NOTVE Each specinen part type must have a separate fully completed BIRTHDATE OPA yey requisition All specimens requisitions and slides must be labelled Lack offor unclear information will result in a delay or failure of processing PHSA Labs are not responsible for unlabelled specimens aaa Number O Specimen Collection Date Slide s FIXED EA Number Of Send Re orts To oo Sf Slide s P Doctor MSC UNFIXED Doctors Name and Address Office Clinic or Hospital RIRA RAE A z MAME LASI E SENTSI Specific Lobe BRONCHIAL WASH DL OR WHI EE oa OSPITAL BRONCHIAL BRUSH 3L R 5 HOSPITAL ROAD 7 BRONCHOALVEOLARLAVAGE L 7 R WHITEHORSE YT a I YIA 3H7 EBUS Lymph Node specify site Urinary Send Copy To URINE VOIDED ILEAL CONDUIT MSCE URINE CATHETERIZED URETER L R URINE CYSTOSCOPY f RENALPELVIS L UR MSN OTHER speciry SITE m YES M No DATE TYPE luids CEREBROSPINAL FLUID C PLEURALFLUID L R PERITONEAL FLUID 7 WASH T PERICARDIAL FLUID 7 JOINT FLUID 7 LR ee Fine Needle Aspirate SPECIFY C BREAST
131. va into the container sputum should look thick and green yellow green More than 2mL 2 teaspoon where possible Add an equal amount of 50 Methanol from container 2 into your sample in container 1 Tightly seal the lid on the container and place it in a plastic bag seal the bag with a twist tie Collect just 1 sample Only one sample can be tested in a 24 hour period Bring the sample to the Laboratory within 2 hours of collection If you live in a remote community you must refrigerate and transport the sample to the Laboratory within 24 hours Questions Concerns Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 87 whitehorse Laboratory Patient ZX general hospital Guide to Services Instructions Methanol Warning See other side of this sheet Return all containers to the Laboratory CAUTION METHANOL is FLAMMABLE Keep away from sparks and flame METHANOL IS TOXIC Keep out of reach of children First Aid Contact with Methanol Skin 1 Flush skin with lukewarm running water for at least 15 minutes 2 Remove clothing with Methanol spill on it take care not to spread the spill 3 Discard or decontaminate clothing under running water 4 Unless contact has been very minor go to the Hospital Emergency Department Outside Whitehorse contact your Doctor or Nurse right away 5 Flush the eyes for at least 15 minutes with lukewarm run
132. view of the phlebotomy and specimen labelling procedure Detailed descriptions of each step are provided after the table A a 2 6 Applythe Toumiguet Phlebotomy Perom Veninte win Cored erty o mams o oot 6 Prepare samples erpor cone separate eigeae eie Implementation Date April 2013 Printed versions of this document are not controlled 43 vY Sample ZF whitehorse Laboratory Collection general hospital Guide to Services Procedures Supplies for Venipuncture needles of various gauges Sharps container for waste butterfly needles isopropyl alcohol wipes disposable tourniquets needle adapter gauze pads or cotton balls non latex gloves ee Vacutainer collection tubes adhesive tape For more detailed information on phlebotomy consult the references provided below References Clinical and Laboratory Standards Institute CLSI 2007 Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture Approved Standard Sixth Edition CLSI document H3 A6 ISBN 1 56238 650 6 Clinical and Laboratory Standards Institute 940 West Valley Road Suite 1400 Wayne Pennsylvania 19087 1898 USA Vancouver Coastal Health 2010 Phlebotomy amp Specimen Labelling Procedure VCH Regional Laboratory Medicine Version 2 3 March 16 2010 Implementation Date April 2013 Printed versions of this document are not controlled 44 Laborator samp theming sai Guide to S y Collection general nospita ulae to services
133. wing for 2 weeks prior to collection Methyldopa Bromocriptine Amphetamines 1 Dopa Hydralazine Beta blockers Clonidine Catecholamines amp VMA s Tricyclic antidepressants Mixnoxidil Alcohol Avoid for a minimum of 2 weeks prior to collection Porphyrins Alcohol Chloropromazine Sedatives Coporphyrins Uroporphyrins Antipyretics Phenylhydrazine Sulfonamides Barbiturates Avoid for 72 hours prior to collection 9 hydroxyindoleacetic Avocados Pectin Phenothiazines acid Bananas Salicylates Cough medicines Nuts Pineapple Avoid for 48 hours prior to collection Oxalate Vitamin C Rhubarb Cola Spinach Chocolate Questions Concerns Please phone WGH Laboratory at 393 8739 Implementation Date April 2013 Printed versions of this document are not controlled 98 Laboratory Patient WZ whitehorse general hospital Guide to Services Instructions 16 12 Hour Urine Testing Please follow these instructions Before Follow your doctor s orders about food and medicine Collecting Empty your bladder pee in the toilet Do not collect it Start Collection Mark down the date amp time on the pink label start date amp start time During Collection Urinate pee into the white hat Transfer urine from white hat into orange container Be careful not to splash After 24 hours empty your bladder completely and put urine into the container ellen Mark down the date amp time on the pink label finish date a
134. y BC Centre tor Disease Control Viruses as detected from Requisition various tissue samples A Respiratory Infections 14 POR zaROTLONGS PacIGroiogy BC Centre for Disease Control Gastrointestinal Infections amp Mycology Requisition Mycology 15 PHSA Laboratories E BG Genie T TEREE TOE Mycobacteria as detected from Mycobateriology TB Requisition various tissue samples POR EOE Viral Bacterial Ova amp Parasite 16 Gastrointestinal Disease BC Centre for Disease Control a tests on Feces and Vomitus Outbreak Requisition Providence Health Care 17 Department of Pathology Surgical St Paul s Hospital Pathology samples Requisition Diagnostic Cytology Requisition PHSA amp BCCA Cytology samples various BCBiomedical Specific Allergen BCBiomedical Laboratories Ltd Allerg tesih IgE Request Form Surrey BC vy J Molecular Genetics Laboratory C amp W Health Centre of BC Molecular Genetics testing ia Requisitions needed for Prenatal tests see Community Nursing s Prenatal Checklist Co Implementation Date April 2013 Printed versions of this document are not controlled 17 W gt whitehorse Laboratory Requisitions ZF general hospital Guide to Services 2 Acceptance Criteria for Requisitions It is the submitting client s responsibility to ensure that requisitions are filled out completely accurately and legibly Failure to do so could mean delays in processing and testing of Patient samples
135. y take 17 days or longer to return Repeats may be requested by Canadian Blood Services at 24 26 weeks ervical Os Swab GC amp Chlamydia same swab BS i Pap Smear See BC Cancer Aiea Office Manual NO tobrush ere pregnanc i i Serum Integrated Prenatal Screen SIPS 1 10 13 wks SIPS 2 15 26 wks i Quad Marker Screen Quad 15 20 wks Maternal alpha fetoprotein AFP 15 Laboratory Sample general hospital Guide to Services Lapa 4 Name HG kon YHIS LER eee EDC by Dates PRENATAL CHECKLIST EDC by Ultrasound INITIAL VISIT g N ea _ Date DUE DATE Don Done genetic screening if done early lt 16 weeks will need to be repeated as below Antenatal Record History and Physical Examination including risk score i SEAC DA NEAS N E a a E eee i Syphilis Hepatitis B Varicella Rubella _ HIV Hepatitis C 0 CBC Random Glucose cei TSH if on Levothyroxin _ If multiple risk factors for GDM exist screen duit first trimester and reassess canted sabeaquent tinmester consult physician re their preferred screening tests to offer i e FBS and or 50 or 75 Gm OGTT _ Urine Dip Urine for C amp S AE CIERNA S vaginal Smear Yeast LEN 20 wks Integrated Prenatal Screen IPS currently referrals to out of Yukon facilities are required http Mwww bcprenatalscreening ca page130 htm It s your choice is a pamphlet available for clients to assist in

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