HEMATOLOGY / URINALYSIS / BODY FLUIDS

GENERAL INFORMATION

1. Routine Tests:

Tests ordered as "routine" will be performed the same day or the next regular day if the requisition is received no later than the times given for the respective section performing the test. If there are problems, please contact the LSS supervisor (686-6230), or the CP Resident (pager 688-2820).

2. Stat or Emergency Requests:

STAT means immediately and the testing will be done promptly. Any test indicated as STAT, the name of the physician must be on the requisition.

An authorized phone call from the physician may institute a STAT order when the physician's name has been omitted or the need for a "STAT" becomes apparent after the specimen reaches the laboratory. If the proper procedure is not followed, the laboratory cannot honor a STAT request. Medical students, nurses and ward clerks may not order STAT work on their own initiative.

"STAT" requests must be immediately delivered to the laboratory, time stamped and placed in the STAT window at Central Processing.

                    Please Note: Use a STAT request only when absolutely necessary.

3. Emergency Room Requests:

Emergency Room requests will be routinely processed on an as soon as possible basis. If needed "STAT", please follow the procedure delineated in #2 above. A quick phone call by a physician to the LSS supervisor (686-6230) will be helpful in expediting the situations.

Consultation with the CP Resident (pager 688-2820) or the attending clinical pathologist is encouraged.

4. Phone Reports:

All patient results that fall within the guidelines for critical (panic) values are called to the patient's primary care nurse. The name of the individual taking the result, the date, and time are recorded. All results from the ED "Trauma" section are called.

GENERAL GUIDELINES

1. Critical Laboratory Values:

The following laboratory values have been designated to be "life threatening" unless therapy is instituted quickly. All critical values are called to the patient's primary care nurse. The name of the individual taking the result, the date, and time are recorded.

HEMATOLOGY CRITICAL LABORATORY VALUES

Hematology & Coag*	Less Than	Greater Than
PT-INR	N/A	4.0
PTT	18	90 seconds
Fibrinogen	100 mg/dL	N/A
Platelets	20,000/µL	1,000,000/µL
Hgb	7 gm/dL	18 gm/dL (Adult)
HCT	21%	55% (Adult)
RBC	2.0 x 106/µL	7.0 x 106/µL
WBC	1,500 /µL**	30,000/µL
Blasts	N/A	ANY new occurrence (If confirmed by manual review)
Plasma Cells	N/A	20% (BONC)

*Once a baseline critical value has been established, the result is called only once a day.
Exception: Prominent change in abnormal result.

**The low panic value has been removed from the WBC parameter on all ONC patients at the request of the ONC physicians.
ONC patients are considered in-patients for all other critical value purposes.

Urinalysis:    Glucose:  Any level in Neonate**
                            **When confirmed by reducing substances test.

                    Myoglobin:  Positive
                       
Body Fluids:      CSF: ≥10  WBC count or if ≥ 50% PMNs -- Adult
                        CSF Neonates: ≥30 WBC count or if ≥ 50% PMNs
                        Pleural fluid: ≥1,000 WBC count or if ≥ 50% PMNs
                        Peritoneal fluid: ≥500 WBC count or if ≥ 50% PMNs
                        Joint fluid ≥1000 WBC count or if ≥ 50% PMNs

    The presence of crystals or organisms in any body fluid should be called.

2. Delta Checks:

When a patient's current result differs significantly from the immediate previous result, it may be due to (1) clerical error, (2) analytical error (3) specimen mix-up or (4) due to a change in patient's physiologic state. When delta checks differ for hematology or coagulation results, the physician or primary nurses will be notified. Delta check variations are as follows:

                    Hgb: + 3gm/dL
                    Hct:  + 9%
                    Platelets: + 100 K/µl
                    WBC:  + 10 K/µl
                    FBG: 100 mg/dL down
                    MCV:  +6 fl
                    MCH:  + 5 pg
                    MCHC:  +5.0 g/dL
                    RBC:  + 1.5 million/µl

3. Hematology:

A.    CBC includes Hemoglobin, Hematocrit, RBC indices, RBC, WBC, Platelet Count and an automated 6 part White Cell differential. CBC's and differentials are performed on purple top tubes. The following tests can be ordered separately: CBC without differential, RBC, WBC, HGB, HCT, and PLAT. A manual 100-cell count is not performed routinely unless specific criteria are exceeded (see #4, Automated/6 Part Differential). A manual differential will be performed upon specific physician request.

B. Body fluids and CSF: Cell counts are performed on hemacytometers or automated cell counter and differentials are interpreted on a cytocentrifuged slide.  Cell counts are NOT performed on clotted body fluids.

C. Unacceptable specimens: The following listed conditions are not acceptable for analysis. The patient's doctor or nurse will be notified, and a new specimen requested. 

Purple Top tube - clotted, Quantity Not Sufficient (QNS), overfilled or underfilled, hemolyzed or diluted with IV fluid.

Blue Top tube - clotted, QNS, overfilled or underfilled, hemolyzed or unsatisfactory due to low or high Hct

Other: Wrong tube, mislabeled or inappropriately labeled specimen.

4. Automated/6 Part Differential:

The Sysmex automated 6 part white cell differential is based on an 20,000 cell count and classifies leukocytes as either granulocytes, lymphocytes, monocytes, eosinophils, basophils, or immature granulocytes. An automated Nucleated Red Blood Cell is also reported.

A manual review of the automated differential is performed only when guidelines for certain automated criteria are met. In cases where the differential was not initially ordered, the physician can contact the laboratory and specifically request a differential.

5. Tests Performed - Hematology Section: For specific details and availability see the alphabetical listing of procedures.

Body Fluid Counts	Kleihauer-Betke (Fetal Hemoglobin)
Bone Marrow Aspirate (staining and differential count)	Pregnancy Test, Urine
CBC / Differential	PT/PTT
CBC without differential	Protein C
CSF Counts & Diff	Protein S
D-Dimer	Activated Protein C resistance
Eosinophil Count, Urine	Antithrombin III
Fibrinogen	Platelet Function Screen
G6PD-Screen	Reticulocyte Count
Hemosiderin, Urine	Thrombin Time
Mixing Study Screen	Urinalysis
Myoglobin, Urine	Westergren Sedimentation Rate

 6. Urinalysis:

All urine specimen containers (not lids) must be labeled with full name, unit number of patient, and time and date of collection. A separate sterile specimen is required for Microbiology.

All requisitions must have full name, unit number, location of patient, attending physician, diagnosis, and date and time of collection.

Urine specimens must be received in the laboratory within 2 hours of collection to obtain valid results.

 If the total protein, blood, leukocyte esterase or nitrite are negative, no microscopic examination will be performed.  Urine microscopics will be performed upon specific physician request.

7. Special Hematology:

Special Hematology encompasses the bone marrow aspirate staining and differential and specialized procedures. During routine hours, the Clinical Pathology resident on the Hematology rotation is available for consultation to review slides. After hours (M-F/4:30pm or Sat, Sun, Holidays) contact the Clinical Pathology resident on call at pager 688-2820. Cytochemical stains: chemical analysis is available and will be performed as indicated. This includes dual esterase for myeloid/monocytoid differentation, and myeloperoxidase for identification of myeloid differentiation.

Bone Marrow Aspirate and Biopsy Requests

Bone marrow aspirates and biopsies are performed by experienced Bone Marrow Procurement Technicians Monday - Friday.  Outpatient bone marrows should be scheduled through PHS.  Inpatient bone marrows are scheduled through Bone Marrow Procurement at (501) 686-7027, Monday-Friday from 7AM-3:30PM. From 3:30PM-7AM call Hematology at (501) 686-6193 to schedule. On weekends and holidays, urgent requests require pathologist's approval. Nursing personnel are responsible for filling out the Bone Marrow requisition to include:
1)    Patient diagnosis
2)    Physician
3)    Test requested
  a)    Aspiration for:
                1.    Flow cytometry
                2.    Cytogenetic
                3.    Research labs (Epstein, Shaughnessey, Moore)
                4.    Microbiology cultures
  b)    Biopsy

Bone marrow slides are usually stained within 2 hours following the procedure.  Bone marrow biopsy material, if received by 2 pm (Mon-Fri), will be available for sign-out out by 10 am the next day. Since marrow biopsies are not processed on weekends, biopsy specimens received on or just before holidays will not be available until the day after the holiday. Weekend or holiday aspirate specimens are always available within 2-4 hours after the procedure for review. In emergency cases where a diagnosis is urgent, special flow cytometry or cytochemical evaluation may be performed on holidays, after pathologist approval.

Initial bone marrow aspirates and biopsy reports may be given verbally to the requesting physician by a pathologist, with a written report to follow. All slides are kept in the Clinical Laboratory and are available for review.