Medical Technologist Exam Secrets PDF

ProductID: MedicalTech Medical Technologist Exam MT Test Review for the Medical Technologist Examination Dear Future Exam Success Story: Congratulations on your purchase of our study guide. Our goal in writing our study guide was to cover the content on the test, as well as provide insight into typical test taking mistakes and how to overcome them. Standardized tests are a key component of being successful, which only increases the importance of doing well in the high-pressure high-stakes environment of test day. How well you do on this test will have a significant impact on your future- and we have the research and practical advice to help you execute on test day. The product you’re reading now is designed to exploit weaknesses in the test itself, and help you avoid the most common errors test takers frequently make. How to use this study guide We don’t want to waste your time. Our study guide is fast-paced and fluff-free. We suggest going through it a number of times, as repetition is an important part of learning new information and concepts. First, read through the study guide completely to get a feel for the content and organization. Read the general success strategies first, and then proceed to the content sections. Each tip has been carefully selected for its effectiveness. Second, read through the study guide again, and take notes in the margins and highlight those sections where you may have a particular weakness. Finally, bring the manual with you on test day and study it before the exam begins. Your success is our success We would be delighted to hear about your success. Send us an email and tell us your story. Thanks for your business and we wish you continued success- Sincerely, Mometrix Test Preparation Team Need more help? Check out our flashcards at: http://MometrixFlashcards.com/MedicalTech Copyright © 2014 by Mometrix Media LLC. All rights reserved. Written and edited by the Mometrix Exam Secrets Test Prep Team Printed in the United States of America TABLE OF CONTENTS Top 20 Test Taking Tips..................................................................................................................................... 4 Blood Bank............................................................................................................................................................... 5 Laboratory Practice........................................................................................................................................... 18 Chemistry and Urinalysis Tests.................................................................................................................... 48 Chemistry......................................................................................................................................................... 48 Urinalysis.......................................................................................................................................................... 58 Hematology.......................................................................................................................................................... 65 Immunohematology.......................................................................................................................................... 80 Microbiology........................................................................................................................................................ 91 Bacteriology..................................................................................................................................................... 91 Mycology......................................................................................................................................................... 101 Parasitology................................................................................................................................................... 102 Virology........................................................................................................................................................... 103 Immunology.................................................................................................................................................. 104 Practice Test....................................................................................................................................................... 109 Practice Questions...................................................................................................................................... 109 Answers and Explanations...................................................................................................................... 117 Secret Key #1 - Time is Your Greatest Enemy...................................................................................... 128 Pace Yourself................................................................................................................................................. 128 Secret Key #2 - Guessing is not Guesswork........................................................................................... 129 Monkeys Take the Test............................................................................................................................. 129 $5 Challenge.................................................................................................................................................. 130 Secret Key #3 - Practice Smarter, Not Harder...................................................................................... 131 Success Strategy........................................................................................................................................... 131 Secret Key #4 - Prepare, Don’t Procrastinate....................................................................................... 132 Secret Key #5 - Test Yourself...................................................................................................................... 133 General Strategies............................................................................................................................................ 134 Special Report: Additional Bonus Material............................................................................................ 140 -3- Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Top 20 Test Taking Tips 1. Carefully follow all the test registration procedures 2. Know the test directions, duration, topics, question types, how many questions 3. Setup a flexible study schedule at least 3-4 weeks before test day 4. Study during the time of day you are most alert, relaxed, and stress free 5. Maximize your learning style; visual learner use visual study aids, auditory learner use auditory study aids 6. Focus on your weakest knowledge base 7. Find a study partner to review with and help clarify questions 8. Practice, practice, practice 9. Get a good night’s sleep; don’t try to cram the night before the test 10. Eat a well balanced meal 11. Know the exact physical location of the testing site; drive the route to the site prior to test day 12. Bring a set of ear plugs; the testing center could be noisy 13. Wear comfortable, loose fitting, layered clothing to the testing center; prepare for it to be either cold or hot during the test 14. Bring at least 2 current forms of ID to the testing center 15. Arrive to the test early; be prepared to wait and be patient 16. Eliminate the obviously wrong answer choices, then guess the first remaining choice 17. Pace yourself; don’t rush, but keep working and move on if you get stuck 18. Maintain a positive attitude even if the test is going poorly 19. Keep your first answer unless you are positive it is wrong 20. Check your work, don’t make a careless mistake -4- Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Blood Bank Determining donor eligibility The following are explanations for determining if certain individuals would be able to donate whole blood at the present time:  21-year old woman who received a tattoo 14 months ago: She can donate whole blood at present; prospective donors are disqualified from giving blood within 12 months of receiving a tattoo because of hepatitis concerns  35-year old man who went on a trip to Nigeria 3 months ago: He cannot donate blood for one year because malaria is prevalent in Nigeria. If he was also born or lived in Nigeria, or had close contact with West Africans, then he is banned from ever donating because of Type O HIV.  33-year old woman with a hematocrit of 38%: She is allowed to donate whole blood because her hematocrit is within the normal range for an adult female of 38% to 46%; female anemia is a hematocrit of 36% or below. Also, her hemoglobin must be at least 12.5 g/dL to qualify.  48-year old man who received a blood transfusion 5 months ago: He must defer donation for one year after his transfusion in the USA, due to the possibility of hepatitis B, which can incubate six months. He cannot donate at all if he was transfused in the UK or West Africa. Blood donor requirements and basic examinations Basic examinations and requirements of blood donors are:  Temperature: lower than 99.5°F  Blood pressure: at least 80/50 mm/Hg and no higher than 180/100 mm/Hg  Pulse: between 50 and 100 bpm, and if you are paced, few irregular beats  Body weight: at least 110 lbs  Hematocrit: at least 39% for males and 36% for females  Hemoglobin: at least 12.5 g/dL Donor exclusion periods The following are exclusion periods for donors:  Malaria: Wait three years after receiving antimalarials or living in a malaria-endemic country, and one year after travelling in a malaria-endemic country.  Aspirin: 48 hours from last ingestion for platelet apheresis, but no deferral for whole blood donation  Viral hepatitis: permanent exclusion  Accutane use: one month after last use  Body fluid exposure: one year following exposure, especially after jail detention, sex with a hepatitis carrier, blood transfusion, or a human bite -5- Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved.  Clotting factor injections: The health historian excludes all “bleeders” except Factor V deficiency (parahemophilia or Owren's disease) who do not take anticoagulants  Male prospective donor who had even one homosexual contact since 1977: permanent exclusion Autologous donation Autologous blood donation means the Blood Bank saves units of the patient's own blood for his/her exclusive personal use. Allogeneic blood donation means the patient receives blood from a donor. Providing no clerical error or freezer failure occurs, it is safer to receive an autologous transfusion than an allogeneic transfusion. A proper autologous donation means there is no delay for cross-matching, no possibility of transfusion reaction, and no disease transmission. However, autologous donation is expensive, time-consuming, and sometimes results in hypovolemia or anemia. Unnecessary autologous transfusion causes volume overload. The five kinds of autologous donation are: (1) preoperative autologous blood donation (PABD); (2) intraoperative blood salvage; (3) intraoperative hemodilution; (4) postoperative blood salvage; and (5) autologous self-stored blood banking. Transfusion procedure and reactions Always double-check the tag on the blood bag against the Blood Bank requisition before you release the unit to the nurse for transfusion. During the blood transfusion, check all of your patient's vital signs every 15 minutes, including body temperature, pulse, blood pressure, and respiration. If you observe any of these signs, then stop the transfusion immediately: hives; trembling (rigors); vomiting; flushed face; clammy skin; difficulty breathing (dyspnea); bloody urine (hematuria); fever; weak and rapid pulse; low blood pressure; or yellow jaundice. Ask the patient if he/she feels itching, lower back pain, nausea, anxiety, or chills. Keep the vein open with normal saline. Notify the attending physician, the patient's nurse, and the Blood Bank manager. Take the blood bag back to the lab for investigation. Do not transfuse another unit until the Charge Technologist confirms the cause of the reaction and rectifies it. If your patient is hemorrhaging, the doctor can safely order O- blood (universal donor). Ensure the patient has an IV in place with saline running to keep the vein open before you release blood for transfusion. Confirm that the doctor’s order and patient’s or guardian’s signed consent form are on file. Match the patient’s arm band to the requisition and firmly attached blood unit label. Visually inspect the unit for hemolysis, lipemia, and foreign bodies. Release only one unit at a time, unless it is a severe trauma. Storage and transportation Store red blood cells that have never been frozen between 1°C and 6°C (34°F to 46°F). Set an alarm on the refrigerator to sound if this temperature range is exceeded. Log the temperature at least once every four hours. If CPD (citrate-phosphate-dextrose) or CP2D -6- Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. (citrate-phosphate-2-dextrose) is the anticoagulant, then the expiration date for the red blood cells is three weeks after collection. However, if the anticoagulant is CPDA-1 (citrate- phosphate-dextrose-adenine-one), red blood cells can last five weeks. If the anticoagulants AS-1, AS-2, or AS-3 were used, then the red blood cells will last six weeks after collection. Flush expired or incorrectly stored blood down the Dirty Utility sink or latrine, and discard the bag in a biohazard garbage. Transport platelets at room temperature and avoid hemolysis by jostling. Transport red blood cells between 1°C and 10°C; place red blood cells in a Styrofoam box, resting on an ice bag, inside a cardboard box. Ship frozen blood components wrapped well on dry ice. The ideal storage conditions and usual shelf life of blood products are:  Frozen red blood cells: -65°C or less; 10 years from collection date  Platelets: between 20°C and 24°C; five days from collection date  Cryoprecipitate: -18°C or less; one year after collection date  Pooled platelets: between 20°C and 24°C; four hours after pooling  Thawed red blood cells: between 1°C and 6°C; 24 hours after thawing Blood product use Transfusing whole blood is wasteful. Usually, whole blood is only necessary for massive traumas where the patient loses 25% of his/her blood supply. Lab technicians in the developed world separate whole blood into red blood cells, platelets, and plasma with a centrifuge. One unit of whole blood can be split into blood products to conserve blood for these common situations:  Washed red blood cells: infant and intrauterine transfusions; IgA deficiency with anti-IgA antibodies; previous anaphylaxis, allergic, or febrile reactions to donated plasma proteins  Leukocyte-reduced red blood cells: frequently transfused chronic patients  Irradiated red blood cells: bone marrow and progenitor cell transplants; cancer chemotherapy or radiation therapy; intrauterine transfusions; occasionally given to immunodeficient individuals or premature infants Blood components The methods for removing components from the patient's whole blood are:  Plasmapheresis: a form of hemapheresis that removes only plasma from the donor's blood, and the nurse returns the remaining blood products to the donor, who may undergo this process once every eight weeks  Plateletpheresis: only platelets are removed from the donor's blood with an electronic apheresis instrument; donors may undergo this process once every 48 hours  Leukapheresis: only white blood cells are removed from the donor's blood with an electronic apheresis instrument; donors may undergo this process no more than twice a week or 24 times in one year -7- Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Blood separation process Centrifuge one 450 mL bag of whole blood at slow speed for separation into packed red blood cells (PRBCs) and platelet rich/concentrated plasma. Bag the PRBCs and mix with additives. Bag the platelet rich plasma separately in a platelet pack. Repeat centrifugation of the platelet rich plasma only at high speed to obtain one unit of random donor platelets and one unit of fresh frozen plasma (FFP). Put the plasma into a fresh frozen plasma bag; leave the platelets in their original container. Indications  Red blood cells: use after massive trauma; before surgery when the patient is anemic; preradiation or prechemotherapy; for sickle cell anemia; for premature infants  Platelets: use to treat excessive post-operative bleeding; during chemotherapy; after a bone marrow transplant  Plasma: use for liver disease coupled with bleeding; abnormal coagulation reaction after transfusion; before surgery for those already taking anticoagulant drugs  Whole blood: use when a trauma patient loses 25% or more of the entire blood volume; exchange transfusions Erythroblastosis fetalis Erythroblastosis fetalis is a potentially lethal condition, also known as hemolytic disease of the newborn (HDN). The pregnant mother has a different blood type than her unborn infant. The problem may be either Rh or ABO incompatibility. The mother's IgG antibodies travel through the placenta and attack the red blood cells of her fetus. The fetus may become anemic, leading to heart failure. Alternatively, hemoglobin from destroyed red blood cells is converted into indirect bilirubin, leading to jaundice, retardation, brain damage, deafness, and sometimes perinatal death. The baby is edematous, with hydrops and a swollen liver or spleen. The most severe, but least common, form of HDN is Rh incompatibility. A D- mother develops D antibodies in response to a D+ baby. If the same mother subsequently has another D+ fetus, then the D antibodies from her first pregnancy attack the red blood cells of the second fetus. The delivery team performs an exchange transfusion, aggressive hydration, and phototherapy to reduce the complications of HDN, which are neurological syndrome, kernicterus, hydrops fetalis, and hypotonia. Rh incompatibility HDN is preventable if the mother receives injections of RhoGAM immune globulins. ABO hemolytic disease is a less severe, but more common, form of HDN. A type A mother reacts to a type B or AB fetus; or a type B mother reacts to a type A or AB fetus; or a type O mother reacts to an A, B, or AB fetus. ABO hemolytic disease is treated with phototherapy, to remove excess bilirubin. -8- Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. To prevent HDN, the obstetrician treats the mother with RhoGAM, not the fetus or father. The standard dosage is as follows:  A pregnant D- mother receives 300 micrograms (1,500 IU) of RhoGAM IgG anti-D (anti-Rh immune globulin) intramuscularly between 26 and 28 weeks of gestation, and another 300 micrograms within 72 hours after delivery  A D- woman who had an abortion, amniocentesis, percutaneous umbilical blood sampling, abdominal trauma, intrauterine transfusion, or ectopic pregnancy receives 50 micrograms (250 IU) of MICRhoGAM within 72 hours of the procedure Kleihauer-Betke acid elution test Perform a Kleihauer-Betke (KB) test after a birth to determine the percentage of sensitizing fetal cells mixed with the mother's blood, so the doctor can calculate the correct dosage of RhoGAM. First, take a blood smear from the mother. Dip it in an acid buffer. Apply a counterstain. The mother's blood cells are bleached pale. The fetal cells stain bright pink and are 1.22 times the size of the mother's cells. A normal adult has less than 0.01% of fetal hemoglobin (Hb F) present. A normal, full-term newborn has more than 90% Hb F present. The percentage of fetal cells is equal to the number of fetal cells counted, divided by the total number of cells counted; multiply the percent of fetal cells by 50 to derive the milliliters of fetal blood present in the mother's circulation. DAT The direct antiglobulin test (DAT) is also called the Direct Coombs test. DAT detects hemolytic disease of the newborn, mismatched organ transplants, autoimmune hemolytic anemia, or transfusion reaction. DAT tells the doctor if the patient's red blood cells are coated with IgG antibodies or complement proteins. Obtain a heel prick from the infant, or a lavender or red stoppered venipuncture tube from the adult. Put two drops of blood in a clean test tube. Wash the red blood cells three times with isotonic saline solution. Make a 3% suspension of washed cells. Put one drop of washed cells into a tube marked POLY IS and a tube marked POLY 5”. Wash the tubes again with the cell button on top. Wipe dry with a tissue. Add one drop of Coombs serum (polyspecific antihuman globulin) to each tube. Mix well. Incubate the POLY 5” tube at room temperature for five minutes. Centrifuge the POLY IS tube. Resuspend its contents. Observe for agglutination, which indicates either complement proteins or IgG antibodies are present. If the POLY IS tube is negative, look at the blood for microscopic agglutination. If the blood is not agglutinated, add one drop of IgG-coated Coombs Control Cells to the POLY IS tube and centrifuge it. If the POLY IS tube still did not agglutinate, then the test is invalid. Test the POLY 5” tube. If the POLY IS tube is positive, do not test the POLY 5” tube. -9- Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. D-L test The Donath-Landsteiner test diagnoses a rare autoimmune hemolytic anemia, paroxysmal cold hemoglobinuria (PCH), also called Donath-Landsteiner syndrome (DLHA). Three people in 100,000 are affected. Usually, syphilis precedes PCH, but it also occurs a week after a viral upper respiratory infection or bacterial pneumonia. PCH can be idiopathic, or associated with non-Hodgkin lymphoma, or oat cell carcinoma. PCH is most common in male children. D-L autoantibody is a cold-reacting polyclonal IgG antibody that attacks P antigen on red blood cells. A PCH patient must avoid moving from warm to cold. Temperatures less than 30°C trigger D-L autoantibody to activate complement, which hemolyzes blood. PCH damages the patient's kidneys, hands, and feet. PCH causes anemia, and sometimes cardiac failure. Signs and symptoms are: bloody urine; back, abdominal, leg, and head pain; chills; fever; cyanosis; pallor; jaundice; tachycardia; dyspnea; hives; nausea; vomiting; and malaise. If it does not resolve spontaneously, PCH requires a blood transfusion. To perform a Donath-Landsteiner test: Warm two red stoppered venipuncture tubes to 37°C. Draw blood from your patient. Allow one tube to clot at 37°C; this is the control. Place the other tube on ice (4°C) for one hour, then warm it to 37°C for 30 minutes. Centrifuge both tubes at 37°C. Observe the serum for hemolysis. The control serum should be clear. Pink serum in the previously chilled tube is a positive D-L result. Donor reactions Very few blood donors experience an adverse reaction (0.28% to 0.6%). However, your donor may develop nausea, dizziness, or syncope, especially if you are collecting whole blood or he/she is sensitive to citrate for apheresis. Observe your patient for agitation, pallor, bruising, sweating, and hyperpnea. The change in blood pressure during collection may trigger a seizure, heart trouble, or incontinence in susceptible patients. Stop the collection immediately. Remove the tourniquet. Seal the blood collection bag. Place the patient in recovery position. Ensure his/her airway is open. Check his/her pulse rate. If your patient faints, try smelling salts. If your patient is alert, give a sugary drink. Apply a cold compress to your patient's forehead if he/she wishes. Keep your patient reclining for at least 20 minutes, and assist him/her to stand. - 10 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Agglutination reactions The six grades of agglutination reaction for red blood cells are:  Zero: lowest grade; no agglutinative red blood cells are present  +w: red blood cell button divides into almost invisible or invisible clumps  1+: red blood cell button divides into a number of small and medium-sized clumps  2+: red blood cell button divides into numerous medium-sized clumps  3+: red blood cell button divides into large clumps  4+: red blood cell button does not break into clumps; free red blood cells cannot be seen in the background Transfusion reactions Only 0.004 blood recipients per 1,000 have an adverse transfusion reaction. The types of transfusion reaction are: acute; delayed; immune-mediated nonhemolytic; anaphylactic; nonhemolytic febrile reaction; transfusion-related acute lung injury; graft-versus-host disease; massive transfusion complications; and acquired diseases. Acute A recipient experiences an acute hemolytic transfusion reaction immediately after a blood transfusion. Signs and symptoms are: fever; chills; fast heart beat (tachycardia); blood clotting (DIC); hemoglobinemia; bloody urine (hemoglobinuria); low blood pressure (hypotension); kidney failure; and cardiac collapse. Acute hemolytic transfusion reaction results from an incompatible transfusion, with potentially deadly reactions between antibodies and antigens, and is usually traced to a clerical error. The laboratory indications that your patient has an acute transfusion reaction are decreased haptoglobin, elevated bilirubin, and elevated plasma free hemoglobin. Delayed The recipient typically experiences a delayed hemolytic transfusion reaction five to seven days after a transfusion. Signs are fever or mild jaundice. Delayed transfusion reaction is slightly more common than acute hemolytic transfusion reaction. However, delayed reaction does not usually pose a threat to survival. The following laboratory tests indicate a possible delayed hemolytic transfusion reaction: positive antibody screen post-transfusion; positive direct antiglobulin test; decreased hematocrit and hemoglobin. Immune-mediated nonhemolytic transfusion reaction Immune-mediated nonhemolytic transfusion reaction means the recipient has HLA antibodies that react to the donor’s antigens and cytokines. It is especially common in multigravida women (multiple pregnancies) or recipients of multiple transfusions. Signs and symptoms are back pain, headache, nausea, vomiting, and a fever beginning up to 24 hours after the transfusion. It is the most common type of transfusion reaction. - 11 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Anaphylactic transfusion reaction Life-threatening anaphylaxis begins almost immediately after a transfusion is initiated, from a severe allergic reaction. Signs are bronchospasms, wheezing, and cough, but not fever. Anaphylactic transfusion reaction is fatal if not treated immediately. Usually, the problem is that your patient inherited an immunoglobulin A (IgA) deficiency. Complement- binding anti-IgA antibodies form when your patient is exposed to the donor's IgA. However, proteins in the donor's plasma could also trigger a minor allergic reaction, and this is especially likely with fresh frozen plasma (FFP), pooled platelets, and whole blood. Nonhemolytic febrile reaction Cytokines form when blood is stored. Your patient may develop a fever as a reaction to the donor's cytokines, but it is unlikely that he/she will go on to develop breathing problems (respiratory distress) or low blood pressure (hypotension). The fever will probably be self- limiting, but you must still notify the doctor, nurse, and lab manager, as a precaution. Transfusion-related acute lung injury (TRALI) Any transfused blood product that contains plasma can harm your patient's lungs. The usual suspects are fresh frozen plasma (FFP), whole blood, and packed red blood cells (pRBCs). Rarely, cryoprecipitate, granulocytes, concentrated platelets, and apheresis platelets trigger TRALI. The donor's antileukocyte antibodies attack the recipient's white blood cells, which activates complement. (The culprits may be granulocyte or HLA class I or HLA class II antibodies in the plasma of female donors who had multiple pregnancies.) Mild symptoms start in one or two hours and are full-blown by four to six hours. Blood vessels in your patient's lungs become more permeable and leak, so your patient develops pulmonary edema, cyanosis, hypoxia, and dyspnea. Look for fever, chills, and hypotension. Your patient needs supplementary oxygen and perhaps mechanical ventilation. The doctor will order arterial blood gases and a chest x-ray. The radiologist will report bilateral pulmonary infiltrates. TRALI is the third most common cause of death by transfusion reaction. Graft-versus-host disease (GVHD) Normally, the recipient's immune system recognizes the donor's lymphocytes are foreign, and destroys them. However, if the donor is immunocompromised, or if the recipient's HLA haplotype is heterozygous and the donor's is homozygous, then the donor's lymphocytes are not killed and GVHD results. Graft-versus-host disease means the recipient's lymphatic tissue is attacked by the donor's lymphocytes. GVHD affects mostly babies, elderly, and cancer and transplant patients. Consider giving them irradiated blood to prevent GVHD. The mildest form of GVHD is Grade I and the most severe is Grade IV. Symptoms typically emerge three to 30 days after transfusion or organ transplant, but can take more than 100 days to appear. Watch for: hives; fever; diarrhea; sloughing skin; chronic cough; irritated mouth and eyes; muscle cramps; and abnormal liver function. Treatment is cyclosporin, methotrexate, prednisone, and removal of the transplanted organ (graft). Untreated Grade IV GVHD results in death from sepsis. - 12 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Massive transfusion complications When your trauma patient has more than half of his/her blood supply replaced in one day, or receives 10 units of blood in a few hours, expect massive transfusion complications. Your patient will likely develop volume overload, hypothermia, coagulopathy, and calcium and potassium fluctuations. Complications may progress to metabolic alkalosis, heart and liver failure. Acquired diseases Many bacterial, viral, and prion diseases are transmitted through blood transfusion, including: hepatitis; HIV; HTLV-1; babesiosis; CJD; TTV; anaplasmosis; cryoglobulinemia; Leishmaniasis; Chagas disease; Lyme disease; and toxoplasmosis. Compatibility Five million Americans receive blood transfusions annually. After disease and medication screening, the technician performs Landsteiner tests for group and type to prevent agglutination reactions. The Landsteiner system has been in use since 1901, and looks for inherited antigen proteins on red blood cells, and antibodies in blood plasma:  AB+ donates to AB+, but is the universal receiver who tolerates AB+, AB-, A+, A-, B+, B-, O+, and O-.  AB- donates to AB- or AB+, but receives AB-, A-, B-, or O-.  A+ donates to A+ or AB+, but receives A+, A-, O+ or O-.  A- donates to A-, A+, AB-, or AB+, but receives from A- or O-.  B+ donates to B+ or AB+, but receives from B+, B-, O+ or O-.  B- donates to B-, B+, AB-, or AB+, but receives from B- or O-.  O+ donates to O+, A+, B+, or AB+, but receives from O+ or O-.  O- is the universal donor who donates to AB+, AB-, A+, A-, B+, B-, O+, or O-, but receives O-. - 13 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Ethnicity and genotype If the recipient is frail, then the donor's ethnicity may be important. For example, to reduce the likelihood of a transfusion reaction in a fragile child recipient with sickle cell anemia, the hematologist may prefer a donation from an African-American, if one is readily available. According to the American Red Cross, the blood type frequencies for Americans by ethnicity are as follows: Blood White Black Latino Asian Type O+ 37% 47% 53% 39% O- 8% 4% 4% 1% A+ 33% 24% 29% 27% A- 7% 2% 2% 0.5% B+ 9% 18% 9% 25% B- 2% 1% 1% 0.4% AB+ 3% 4% 2% 7% AB- 1% 0.3% 0.2% 0.1% ABO alone provides insufficient evidence to prove a child's parentage. Generally, the child inherits his/her blood genotype from the parents in the pattern below. A black square indicates an impossible result, and an x indicates a possible result: Child's Parents' Landsteiner Blood Group Combinations Possible Blood AB AB AB AB B A A O O O Inheritance AB B A O B B A B A O O x x x x x x A x x x x x x x B x x x x x x x AB x x x x The University of Arizona's Biology Project offers a very handy, free blood genotype calculator for you to practice with online, at http://www.biology.arizona.edu/human_bio/problem_sets/blood_types/inherited.html However, remember that ABO and Rh factor (D antigen) are not the only tests required for paternity suits. The MT also tests the mother, child, and suspected father for C, c, E, and e, and H antigens. (About 1 in 10,000 people of East Indian or Taiwanese descent have the - 14 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. potentially misleading Bombay phenotype, also known as Oh or h/h blood type.) The attending physician and the genetics counselor are the appropriate staff members to discuss paternity with the patient, rather than the MT. Alternative systems The International Society of Blood Transfusion (ISBT) recognizes 26 blood classification systems and eight antigen collections. Landsteiner's ABO and Rh is the most prevalent blood classification system, but the MT must also be conversant with at least the following systems and their abbreviations:  Diego: antigens Dia, Dib, and Wra are the most significant, but there are 21 in all, with either IgG or IgM antibodies. Implicated in moderate to severe delayed transfusion reactions and mild to severe hemolytic disease of the newborn.  Kell: antigens K (Kell), k (Cellano), Kpa and Kpb, usually with IgG antibodies; IgM is uncommon. Kell immunization causes severe fetal anemia by suppressing the baby's red cell production. K0 is the null phenotype, associated with chronic granulomatous disease. Anti-Ku produces a potentially fatal transfusion reaction, so if your patient is K0, only transfuse K0 blood products.  Kidd: antigens Jk1, Jk2, and Jk3; usually IgG antibodies, but occasionally IgM antibodies. Kidd antibodies are difficult to detect when performing a routine cross-match. Implicated in severe, delayed hemolytic transfusion reactions and mild hemolytic disease of the newborn.  Duffy: antigens Fya, Fyb, Fy3, Fy4, Fy5, and Fy6, with almost exclusively IgG antibodies. IgM is uncommon. Associated with mild hemolytic disease of the newborn, mild to severe transfusion reactions, and sickle cell anemia. Absence of Duffy antigens confers some resistance to malaria, and is most common among people of West African descent.  Lutheran: antigens Lua and Lub with IgG antibodies. Use a Western Blot or Flow Cytometry. Lutheran antibodies are not implicated in transfusion reactions, and rarely cause mild hemolytic disease of the newborn.  Lewis: antigens Le a and Le b are formed in plasma and absorbed by RBCs. Almost exclusively IgM antibodies activate complement. Perform the Indirect Antiglobulin Test to detect them. Lewis antibodies are implicated in mild (subclinical) hemolytic disease of the newborn.  MNS: antigens M, N, S, and s (43 antigens in all), with IgM antibodies; anti-S and anti-s are IgG antibodies from pregnancy or blood transfusions. Implicated in delayed transfusion reactions, very rare hemolytic disease of the newborn, and antigen receptors of malarial parasites.  P: P, P1, and LKE with almost exclusively IgM antibodies. Anti-P antibody is detected via a Donath-Landsteiner test for paroxysmal cold hemoglobinuria. ISBT promotes a worldwide numeric blood nomenclature system to reduce confusion in Blood Bank. In March 2011, ISBT updated its standard terminology, which is available for free download at http://iccbba.org/home. - 15 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Indirect Antiglobulin Test The IAT looks for a weak expression of D antigen in blood. The MT performs an IAT for these patients only: (1) a D- baby born to a D- mother; (2) a BMT donor; (3) a father, when the obstetrician wants to avoid unnecessary RhIG injections. Prepare a 2% to 4% suspension of washed red cells from the patient, and suspends them in saline. Label one test tube “D CONTROL” and the patient's surname, and inserts one drop of control sera into it. Label another test tube “IAT-D” and the patient's surname, and inserts one drop of Novaclone anti-D into it. Add one drop of the patient's cell suspension into each of the tubes. Check that the volume is correct. Mix both tubes. Incubate them at body temperature (37°C) for 15 minutes. Wash the cells with saline. Add two drops of anti-IgG into each tube. Mix to resuspend the red cell buttons. Centrifuge. Resuspend the buttons. Observe for agglutination with the naked eye only; do not look for microscopic agglutination. Grade and record the reactions as follows: Anti-D IAT Control Report No agglutination No agglutination D- Agglutination No agglutination D+ Agglutination Agglutination Unable to interpret Mixed field agglutination No agglutination or agglutination If the result is negative, confirm by adding one drop of control cells, mix, resuspend, and observing for agglutination. Antibody enhancer An antibody enhancer is the chemical that stimulates the formation of antigen/antibody complexes. For instance, the proteolytic enzymes papain, ficin, and bromelain are frequently used as antibody enhancers, because they increase red blood cell agglutination. By contrast, bovine albumin encourages sensitized red blood cells to form agglutination lattices. Low ionic strength solution (LISS) is often used to stimulate the formation of antigen-antibody complexes. Sensitization Many in vitro antigen/antibody reactions start with sensitization, the point at which the antibody attaches to the antigen, but has not yet produced any agglutination or hemolysis. The optimal pH for sensitization is 7. The degree of sensitization depends on the incubation time, defined as the amount of time in which the antibody has to attach to the antigens. Also, antibodies react most strongly at body temperature (37°C). Finally, sensitization increases in proportion to the ratio of serum to cells; more serum means more available antibodies. - 16 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Limitations of cross-matching If the screening for disease, medication, and ABO Rh were satisfactory, then the MT proceeds with a cross-match. Remember that in vitro reactions (in the test tube) do not exactly predict in vivo reactions (in the body). Cross-matching does not detect viruses, bacteria, or parasites in donated blood. Patients can suffer delayed transfusion reactions or allergic reactions to proteins in the donor's plasma, neither of which can be predicted with cross-matching. Also, cross-matching has no effect on antibody formation in response to any foreign antigens in the red blood cells of the donor. For these reasons, cross-matching is not a foolproof way to make transfusion safe. The types of cross-matching are:  Major cross match: required test before a transfusion; donor cells are tested with the serum of the potential recipient; antibodies come from serum, antigens come from donor cells.  Compatible cross match: the MT ensures the mixture of potential recipient’s and potential donor's blood produced neither hemolysis nor agglutination of cells in vitro.  Incompatible cross match: the MT excludes potential donor blood that produced hemolysis or agglutination when mixed with the potential recipient's blood in vitro. Bacterial contamination of blood Occasionally, blood products in storage suffer bacterial contamination, usually with Yersinia enterocolitica or Pseudomonas fluorescens. Blood cultures are not part of a cross- match. Suspect contamination if your patient develops diarrhea, fever, respiratory distress, and sepsis. The CDC usually traces contamination to the donor's skin or to poor bagging technique. - 17 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Laboratory Practice Safety acronyms The following acronyms regarding safety:  CAP: College of American Pathologists.  CBRN: Chemical, biological, radiation, nuclear; part of emergency preparedness training in case of bioterrorism.  CDC: Centers for Disease Control and Prevention in Atlanta encourages lab safety, monitors emerging diseases, and publishes reliable health information.  CLIA: Clinical Laboratory Improvement Amendments (1988) ensures “accuracy, reliability, and timeliness of patient test results”. The U.S. Food and Drug Administration oversee CLIA.  DOT: U.S. Department of Transportation  EEOC: U.S. Equal Employment Opportunity Commission deals with discrimination and harassment.  HHS: United States Department of Health and Human Services  HIPAA: Health Insurance Portability and Accountability Act (1996) protects workers when they change or lose jobs by providing health insurance and privacy standards.  IATA: International Air Transport Association sets shipping standards for road, rail, air, and water.  IMS: Incident Management System controls CBRN events and how local authorities interact with labs.  JCAHO: Joint Commission on Accreditation of Healthcare Organizations offers accreditation, certification, education, standards, and reports on patient safety.  OSHA: U.S. Department of Labor’s Occupational Safety & Health Administration  PPE: Personal Protective equipment Just-in-time inventory Just-in-time inventory is an idea adopted from big car manufacturers, where supplies are not stockpiled, but are ordered from the vendor for delivery just a day or two before they are needed. This means your employer does not have to pay for expensive warehouse space – the vendor does – which helps with the lab’s cash flow. The Chemical Hygiene Officer will have no trouble listing what chemicals are kept on the premises, which OSHA requires. However, just-in-time makes it hard to figure out how much of a chemical your lab uses on a monthly basis, and often the danger depends on the level of exposure. OSHA does not require you to keep data on solutions with less than 1% of a harmful chemical or pre-packaged kit containing harmful chemicals. A useful chemical safety data sheet (MSDS) contains this information: Chemical name, trade name, hazard class; where and how it - 18 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. should be stored; storage quantity; vendor’s contact information; and vendor’s catalog number. Chemical grades Chemical grades, from highest to lowest purity:  ACS: Highest purity grade. The only universal standard. Meets American Chemical Society benchmarks.  USB: For reference materials because they have smaller amounts of contaminants or higher assay limits than reagent grade.  MB: Low levels of trace metals and genetic material for molecular biology.  AR: Analytical reagent grade for in-house lab work. Usually as pure as ACS, but lost certification because it was repackaged.  USP: Meets United States Pharmacopeia potency standards for drug use, suitable for most lab work.  Lab grade: Intermediate purity and low cost for teaching.  NF: Meets National Formulary requirements, and contains moderate amounts of impurities.  Practical grade: No official standards. Good quality for general use.  Pure: Low-intermediate grade inorganic chemicals with no standards. Used for teaching because of impurities.  Chemically Pure (CP): For industrial use, not intended for use in food, but more pure than technical grade.  Technical or commercial grade: Good quality, but impure. Industrial use only, not experimental or lab work.  Pyrotechnic: Low quality for fireworks and industrial use. Sustaining a corrosive burn Flooding corrosive powder burns with water will activate the chemical and deepen the burn. Take a piece of paper and gently brush off as much of the dry chemical as possible into a garbage can before diluting it with water. If it is liquid corrosive or in the eye, flood with cool, running water immediately for at least 15 minutes at an eyewash station or sink. Immerse if skin is sloughing. Visit a doctor immediately. If you cannot immediately consult a doctor, use the neutralizing agent supplied by your Chemical Hygiene Officer. If clothing is melted into the flesh, do not remove it. Recognize the severity to complete the incident report in 24 hours: First degree burns involve the top layer of skin and are red. Second degree burns are red, blistered, and swollen, with severe pain and involve the first two layers of skin. Third degree burns are charred black, red, yellow, or white and are leathery, with destroyed nerves and blood vessels and minimal pain. - 19 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Safety concerns Waste disposal Disposing of concentrated, infected human waste incorrectly infects the water and food supplies with diseases like cholera, dysentery, polio, and typhoid. Segregate contaminated solid waste (e.g., bandages, gloves) from regular waste in a red plastic bag sitting on absorbent material (corn cobs) in a lidded, leak-proof outer container with a biohazard symbol on it. Ensure the location is convenient to your workbench. Incinerate it. Add non- corrosive disinfectant to a plastic carboy and pour concentrated liquid waste into it before disposal down a sanitary sewer system. Sanitize and autoclave contaminated instruments before reuse, or discard them in sharps containers before sealing, autoclaving and sanitary landfill. Place heavy waste (specimens, corpses, animal bedding) in burst-proof, rigid containers with sturdy handles before incineration. Before changing a HEPA filter in a safety cabinet, seal it with plastic sheets and tape, and steam the filter with paraformaldehyde flakes. Wear personal protective equipment (PPE) and wash your hands frequently when handling lab waste. Follow your Safety Officer’s instructions for mixed waste (radiation, infectivity, and chemical contaminants). Hazardous chemicals Hazardous chemicals are carcinogens (cancer-causing), corrosives (burning), irritants, mutagen (damages DNA), sensitizers, teratogens (cause fetal damage) or toxins of the bone marrow, eyes, kidney, liver, lungs, mucous membranes, nerves, and skin. They must be statistically proven in at least one properly conducted scientific study to cause significant adverse health effects in laboratory employees to be classified as hazardous. The U.S. Department of Labor’s Occupational Safety & Health Administration requires the employer to write a Chemical Hygiene Plan and update it monthly for safety. It lists the lab equipment that must be used, specific procedures that must be followed, Personal Protective Equipment (PPE) that must be worn, and general safe work practices that must be observed for protection from hazardous chemicals. A Chemical Hygiene Officer is an employee with special training or experience the employer chooses to design and maintain the Chemical Hygiene Plan, for protection and expert advice. Soiled laundry Contaminated laundry should be bagged near where it was used. Place it in red plastic bags with an orange biohazard symbol firmly attached if the laundry is being washed off- site at a commercial laundry. If your facility adheres strictly to standard (universal) precautions and does its own laundry, it can use other bag colors, providing all staff are trained on what they mean. Wear gloves and a plastic apron, and handle contaminated laundry minimally. Do not shake, sort, or rinse out the stain where the contamination occurred. If laundry was contaminated with HIV or Hepatitis B, then it must be incinerated. If laundry was just used in an HIV or Hepatitis B area, but not visibly contaminated, then it must be decontaminated first, before laundering. - 20 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Sharps containers A sharps safe can be any container that is red with an orange biohazard label firmly affixed to it. It must resist punctures, have a leak-proof bottom and sides, and be placed inside another biohazard container if its outside is contaminated or punctured. A satisfactory sharps safe can at least be closed, or preferably, locked to prevent theft of used syringes by drug addicts. The safe must never be reopened or reused after it has once been closed. It must be kept upright and replaced regularly, before overflowing. One of the most common causes of needle stick injuries is trying to cram one more sharp into an overflowing safe. Sharp safes must be easily accessible, and located where one would expect to find sharps, such as a laundry, operating room, examination room, neonatal intensive care unit, medication cabinet, or bleeding station. They must be autoclaved before final disposal in sanitary landfill. Safety training requirements Your employer must keep for three years a record of the date you received safety training, a summary of what was covered in the session, the name and credentials of your teacher, and a class list of student names and job titles. You are entitled to free Hepatitis B vaccine within10 days after you start work, given at a reasonable time and place, free HIV and HBV blood screening an at an accredited lab, and free HBV booster shots. Your employer must record your needle stick injury in the Sharps Injury Log, including the device brand involved, the department, incident details, and identification of the source patient. You are entitled to a free medical exam, disclosure of the source’s HIV and HBV status, prophylaxis, counseling, a follow-up of subsequent illness you report, and a written report in 15 days. Cleaning schedule The employer is responsible for keeping the workplace sanitary. This means writing a schedule that states when and how each lab surface will be cleaned. The decontamination method depends on the type of surface material, where it is located in the facility, the type of spills, and the procedures underway in the area. Whenever any surface is in contact with blood or other material suspected to be infectious, it needs to be cleaned immediately. If protective equipment coverings are contaminated, they need to be replaced by shift’s end. Garbage cans, pails, and reusable bins must be cleaned regularly and as soon as possible after they are contaminated. A brush, dustpan, tongs, forceps, gloves, disinfectant, sharps container, and paper towels need to be handy to clear away broken glass immediately. Lab coats, plastic aprons, or isolation gowns are worn for cleaning – never street clothes or unprotected uniform. If there is any possibility for splashes by body fluids, goggles and a mask, or a face shield, a cap, and shoe covers should be worn. Extra precautions The extra precautions need when the laboratory is involved in HIV or HBV research or vaccine production (not just diagnostic testing):  Allow authorized persons only into the lab.  Post policies and procedures outlining lab dangers and entry requirements, and update them annually.  Observe strict entry and exit procedures for animal rooms and work stations. - 21 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved.  Autoclave or incinerate all waste.  Close all doors while HIV or HBV is handled in the lab, or infected animals are present.  Post biohazard signs on all doors.  Place contaminated material in a leakproof, puncture-proof, labeled or color-coded biohazard container; close it before removal from the workstation.  Work only in annually certified biological safety cabinets; do not perform open bench work.  Wear PPE at all times; remove it before leaving the area; autoclave it before laundering and reuse.  Know how to use the eyewash station.  Protect vacuum lines with disinfectant traps and HEPA filters.  Use hypodermic syringes only on diaphragm bottles and lab animals, and locked needle syringes for other uses; do not bend, shear or recap needles.  Trained staff cleans spills immediately. Preventing infection The following terms regarding the prevention of infection:  Asepsis prevents infection during surgical procedures by reducing pathogens. It requires sterile instruments and sterile gloves, and a strong disinfectant that can kill both gram-positive and gram-negative bacteria and their resistant spores, like 70% povidone-iodine.  Antisepsis is reducing the flora and transient microorganisms on the skin for minor procedures like venipuncture. Clean gloves are worn. It requires a short-acting antiseptic like 70% isopropyl alcohol that can denature proteins.  Strict isolation segregates infectious patients to one room, and visitors are restricted. Modified isolation attempts to limit infection with protective techniques, like donning gloves, gowns, and masks when handling the patient’s body fluids. Reverse isolation protects a patient from others in a clean room, as after kidney transplant.  Standard or universal precautions means healthcare workers control the spread of disease by assuming every patient’s samples are infectious, and following the U.S. Occupational Safety and Health Administration (OSHA) standards for proper hand washing, wearing gloves, bagging specimens in biohazard bags, and disposing of needles and lancets in a sharps safe. Workplace injuries for phlebotomists About 43% of phlebotomists suffer annual needle stick injuries from: Improper needle withdrawal; struggling patients; transferring blood from one container to another; carrying needles in a lab coat pocket; recapping a needle after use; used needles left in a patient’s bedclothes by another caregiver; trying to force a needle into an overflowing sharps safe; emptying a sharp safe to reuse it instead of sealing it for disposal; handling garbage bags containing carelessly discarded sharps. The risks are for accidentally injecting toxic material or occupational blood-borne infection. There is a 30% chance the phlebotomist - 22 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. will develop Hepatitis B following a needle stick injury; a 10% chance of Hepatitis C, and a 0.3% chance of HIV infection. The phlebotomist may rarely get other bacterial, viral, or fungal infections, such as: Brucellosis; cutaneous gonorrhea; diphtheria; herpes; malaria; mycoplasma caviae; Rocky Mountain spotted fever; staphylococcus; streptococcus; syphilis; toxoplasmosis; tuberculosis. Needle stick first aid Phlebotomists must follow the OSHA bloodborne pathogens standards and keep all immunizations up-to-date. Most occupational health nurses administer free Hepatitis B vaccine as prophylaxis for at-risk staff. When a needle stick injury occurs:  Let it bleed freely and wash the wound immediately, ideally with povidone-iodine.  Report it within 24 hours to your employer.  Fill out any workers’ compensation forms and keep copies.  If you are breastfeeding, stop until your doctor advises you otherwise.  Request prophylactic Hepatitis B immune globulin (HBIG) to boost your antibodies. This may help even if your immunization did not include Hepatitis B.  If you know which patient contacted the particular sharp that cut you, you may request disclosure of his/her disease status.  If the patient is a known carrier of HIV, you may consider taking AZT and getting antibody tests at baseline, three months, and six months after exposure. There are health and insurance risks associated with this decision, so consult your doctor first. Quality control ISO quality management system The International Organization for Standardization (ISO 9001 – 2000) set the current quality management system used by medical laboratories, car manufacturers, and aviation. Subsections that apply to medical labs are 17025 (reference laboratory testing and calibration) and 15189 (clinical laboratory quality and competence). Quality management makes it easy to do the right thing and hard to do the wrong thing. A quality management system means all staff are trained and follow safe, accurate processes consistently. Problems arise from incorrect processes, not people. Quality management involves asking yourself if the service you provide is appropriate, efficient, effective, and high-quality. ISO standards require your lab manager to have a policy and procedure manual that defines all your activities, monitors and measures their effectiveness, and encourages continuous improvement. Your lab processes must match exactly the documented procedures. You must know exactly how to do a job, where to find information, who is responsible, and how your job is linked to others’. Your goal is to reduce 98,000 annual U.S. deaths from medical errors. - 23 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Correcting faulty lab processes When a faulty lab process is found as part of an audit:  Bring it to the attention of the quality manager.  Gather proof (requisitions, results, incident reports, quality control records)  Map the process now used.  Review the OSHA and CLIA requirements pertaining to the problem.  Find gaps in the process.  Find gaps in the documentation. The quality manager will prioritize the problem, plan and document the new process. Verify that the new process works, determine if it affects any other processes, and give the quality manager feedback. The quality manager surveys co-workers and patients, trains the staff, and sets a time to implement the new process. Help the quality manager measure how effective the new process is, and to modify it if required. The quality manager will update the manual. ASCLS quality controls ASCLS suggests:  U.S. Department of Health and Human Services to collect standardized reports of all adverse and sentinel events and allow the public access to them  Error management education for all staff  Review of medical errors during accreditation, certification, or licensing  Raised standards for all healthcare professionals  Patient identification system to be used from the patient’s first visit  Specimen bar coding for identification  Raised awareness of medical errors (iatrogenic disease)  Tools to reduce errors using evidence-based information and personal anecdotes  Laboratories “provide adequate space and instrumentation, sufficient supplies and support staff, ergonomically sound design, and personal protective equipment”  Each lab appoints a Patient Safety Manager OSHA The U.S. Department of Labor’s Occupational Health and Safety Administration has a Web site at http://www.osha.gov that provides important updates you are required to adopt as part of your standards of practice. Your Safety Officer must check the site regularly, and will notify you of any pertinent changes, and arrange for your training at your employer’s expense. You need to check the site:  Whenever you need a refresher about established safe practice, like bloodborne pathogens.  Whenever a serious new threat develops, like an influenza pandemic.  When equipment or supplies change in your laboratory, to make sure your current best practice for infection control and hazardous chemicals covers the change. - 24 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved.  When contemplating a grievance against your employer for allowing unsafe practices, to make sure you know exactly what the correct standards are before registering a complaint. Hygiene standards Your employer measures, cleans, repairs, and disposes of your personal protective equipment at company expense. You must remove PPE before leaving the laboratory. OSHA forbids you to apply make-up, lip balm, or other cosmetics (e.g., nail polish, sun screen) in your laboratory workplace because they could become contaminated. OSHA does not allow you to handle your contact lenses in the laboratory. You are not permitted to put beverages or food on lab countertops, shelves, or in supply cabinets, or specimen or reagent refrigerators and freezers. You are not allowed to bring food and drink into the lab or consume them there, or into the reception area where patients drop off specimens. If you are performing tolerance tests that require you to administer drinks (e.g., glucose, lactose, and lactulose), then you must keep them in a separate refrigerator, away from specimens. You must not smoke in the laboratory, as it could not only affect results and annoy the other staff members, but could infect you. Hand washing technique To wash your hands correctly, first remove your jewelry. Use clean, dry paper towels to turn on the taps. Use warm water to avoid skin damage. Wet your hands and apply disinfectant soap (povidone scrub or bar soap rinsed and stored in a drainer). Count to 30 while scrubbing the backs and palms of your hands with the lather, and interlace your fingers while rubbing them together. Brush gently under your nails. Note any cuts, rashes, broken or long nails that need treatment before resuming work. Rinse well and dry your hands with paper towels, not a blow dryer. Use clean paper towel to turn off the taps and to open the exit door. If there is no sink nearby, use 70% to 80% alcohol cleanser (Cutan, Florafree, Manorapid, Purell) for 15 seconds, followed by disposable antiseptic towelettes (benzalkonium chloride). Change gloves frequently by turning them inside out from the wrists. Wash your hands as soon as possible. Gloving before blood collection OSHA requires phlebotomists to glove before every venipuncture as part of standard (universal) precautions for bloodborne pathogens. Only if your employer runs a volunteer blood donation center does OSHA allow for ungloved venipunctures, providing:  The phlebotomist is experienced. Trainee phlebotomists must glove.  The phlebotomist agrees not to glove. The employer must provide gloves if an employee requests them, and if the employee is allergic to latex or powdered gloves, the employer must provide hypoallergenic or unpowdered gloves, liners, or barrier cream.  The phlebotomist’s skin is intact, i.e., it does not have any visible burns, rashes, cuts, or scratches.  The patient is co-operative. If the patient is likely to struggle or have a reaction, then the phlebotomist must glove. - 25 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Your employer cannot discourage you from using gloves for blood collection. Your employer must reevaluate the no-glove policy periodically to see if it continues to be a low- risk option. In circumstances where there will almost always be contact with blood, like infant heel pricks, gloves are required. CBRN event versus OSHA emergency A CBRN event is bioterrorism or an industrial accident that releases chemicals, biologicals, radiation, or nuclear waste and requires the assistance of local officials (police, fire, ambulance, Public Health, and the IMS Team) and your help with decontamination. An OSHA emergency is whenever any physical hazard is released into your workplace in an uncontrolled way. This could be because its container breaks or leaks, or if control, storage, or testing equipment malfunctions (e.g., filters, refrigerator, Coulter Counter). Physical hazards are combustible liquids, compressed gases, explosives, flammables, pyrophoric chemicals that ignite above 130°F, chemicals or metals that react in air or water, organic peroxides and oxidizers. Fume hoods, HEPA filters and OSHA’s formaldehyde gas regulations A fume hood, or BSC, is a workplace for toxic chemicals, tissue grinding, or infectious body fluids that is shut in on five sides, and partially enclosed on the sixth side to allow the technician access with covered hands and arms. The fume hood draws air from the lab and prevents as much aerosol as possible from returning to the lab. Fume hoods are equipped with High Efficiency Particulate Absorbing (HEPA) air filters that absorb 99.97% of particles 0.3 microns or larger from the air, including allergens, bacteria, dander, dirt, dust, fungi, pollen, and some viruses, and have ultraviolet light shining on them to speed killing by dehydration. N100 respirator masks are the equivalent of a HEPA filter on your face. You must wear a respirator if you will be exposed to more than 0.5 parts per million of formaldehyde in the air during an eight-hour shift. Your plant operations manager ensures lab air is exchanged 6 to 12 times every hour wherever carcinogenic formaldehyde is used. HIPAA Title II of HIPAA The intent of Administration Simplification (Title II) of HIPAA was to reduce healthcare costs by stopping healthcare fraud, ensure patients have privacy, and secure patients’ personal information. The Department of Health and Human Services standardized the way healthcare providers, billing services, and community health information systems perform electronic transactions, the type of information they can keep, and how they can use it. Each employer, insurer, and healthcare provider now has a national identifier. The Privacy Rule for Protected Health Information outlines what your provider, insurer, or billing company can disclose from your medical record. This includes how you pay, payment history, provider’s name, or what your health status is. The disclosure must be minimal, has to be documented for a legitimate purpose, and the patient must be told about it within 30 days. Every patient has the right to have errors corrected on his/her file, and to complain to the Privacy Officer and the Department of Health and Human Services for Civil Rights. - 26 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Security Rule HIPAA’s Security Rule requires that you have Administrative, Physical and Technical safeguards in place at your facility to protect patients’ rights. That means you must have clear policies and procedures in place (P&P) that state:  A management person oversees them  The workers agree to follow them as a condition of employment  The classes of workers who have access to confidential information  Security controls in detail  Routine audits will be performed  Adverse event audits will be performed  Emergency back-up plans in case of a breach, with detailed instructions for follow- up You must monitor data access and protect it by allowing only properly trained and authorized persons to access it. You must control access to your computer system and protect it from intrusions, like viruses and spyware. CMS and CLIA Ten regional offices of the Centers for Medicare and Medicaid (CMS) throughout the U.S. provide health insurance for about 74 million vulnerable Americans through fee-for- service. The Social Security Act of 1965 governs Medicare, Medicaid, and Child Health. The CMS controls American labs through the Clinical Laboratory Improvements Amendment (CLIA). The only exception to this control is private research labs, which are exempt.  Medicare A is no-cost insurance for Social Security recipients over 65 years old, and patients with renal failure (dialysis patients) in these facilities: Critical access hospitals; home care; in-patient hospitals; hospices; skilled nursing facilities.  Medicare B insurance covers out-patients for $88.50 per month for: Blood transfusion; diagnostic tests like glaucoma, Pap smears, mammograms, and prostate exams; doctors’ office visits; durable assistive devices, like beds, oxygen, walkers, wheelchairs; laboratory tests; one physical exam in the first 6 months; out-patient clinics for mental health, occupational therapy, and physiotherapy; out-patient surgery; vaccines, like Hepatitis B and Pneumococcus. Peer assessment JCAHO peer assessment visit at accreditation renewal time and required duties are following. A peer assessment is conducted to make sure the lab:  Conforms to ISO and CLIA standards, state and federal legislation.  Hires competent people who follow quality requirements.  Conforms to the scope of tests on its license.  Stays current and meets any special challenges.  Has a quality manual that explains how to collect, store, ship, and test specimens.  Continuously looks for problems and corrects them quickly.  Gets accredited and remains open for business. - 27 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. As part of the accreditation review, you might be asked to:  Fill out questionnaires for the assessors.  Help prepare an agenda.  Book conference rooms and audio/visual equipment.  Arrange lunches.  Book briefing and debriefing sessions.  Get visitor passes and lab coats for the assessors.  Arrange for the assessors to interview doctors and nurses associated with your lab.  Review OSHA standards and your quality manual.  Produce conformance evidence (log sheets, medical records, inventory records).  Help find solutions to non-conformance issues in 90 days. Risk factors yielding errors The risk factors your patients could have that would predispose their test results to errors or to the patient having complications after testing:  Allergies: Patients may forget to tell you about allergies to latex gloves, tape adhesive, medication, or contrast dyes.  Age: Very young and very old patients are fragile and susceptible. They do not control internal temperatures well. Their normal values may be different than young adults’.  Central Nervous System disorders: Unsteady gait, convulsions, weak or spastic muscles, and tiredness all contribute to falls. Patients with canes, walkers and other assistive devices can be slow-moving.  Drug use: Patients who mix over-the-counter (OTC) medicines or herbs with prescription drugs, abuse alcohol or street drugs, or who take sedatives or strong analgesics that cause drowsiness are at-risk.  Immunosuppression: Patients with AIDS, cancer patients receiving chemotherapy or radiation, chronically ill patients, and organ recipients who are taking Cyclosporin to prevent organ rejection all have weakened immune systems and are infection- prone.  Psychological problems: Aggressive patients, those who take hallucinogens or phencyclidine, have uncontrolled pain, are restrained, or have psychiatric problems are a challenge.  Sensory impairments: Blindness, deafness, imbalance, or paresthesia can make tests difficult. Disease incidence Disease incidence measures how prevalent a disease is among a given population in a specific place, over a specific time. Incidence predicts how probable it is a patient will develop a disease, and its etiology (likely cause). Predicted values estimate how likely a test result is to be right or wrong, given certain variables, like the patient’s age, occupation, race, income, how long the symptoms have lasted, and if there is fever. Positive predictive - 28 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. value is the likelihood that a patient with a positive test result really has the condition. Negative predictive value is the likelihood that a patient with a negative test really does not have the condition. Sensitivity and specificity Sensitivity is also known as the recall rate. It measures how many times a test produces true-positive results, indicating patients probably have a disease, compared to the gold standard test for that particular illness. Sensitivity is important for early detection of disease, or to stop an epidemic. To calculate the percentage of sensitivity, divide the number of patients who really have the disease and test positive by the total patients tested who have the disease (including those who tested false-negative), and multiply by 100. Specificity measures how many times a test produces true-negative results, indicating patients probably do not have a disease, compared to the gold standard test for that particular illness. Specificity is important when treatment is toxic and could harm a patient, like chemotherapy. To calculate the percentage of specificity, divide the number of patients who really do not have the disease and test negative by the total patients tested who do not have the disease (including those who tested false-positive), and multiply by 100. Retesting When a sample result is abnormal, it is better to alert the doctor and let him/her decide whether to call the patient back for a repeat test. The sample may, in fact, be a “panic value” (critical result) where the patient needs to be called back STAT for resampling. However, check the margin of error. For example, the lab test is accurate to the 95th percentile, and the first result is abnormal. This patient happens to be among the 5 in 100 who tests abnormally even when healthy. The technologist repeats the test on the same specimen. You can calculate the probability that the second result will also be abnormal with this formula: 0.95 × 0.95 = 90.25% 100% - 90.25% = 9.75% The healthy patient now has an even greater chance of abnormal test results second time around: 9.75% probability of a second mistake, instead of 5% on the first test. Each time the specimen is retested increases the chance that the result will be falsely abnormal. Mean, median, and standard deviation Mean is the value obtained by dividing the sum of a set of quantities by the number of quantities in the set. It is also called average. Median is the midpoint of the range numbers that are arranged in order of value. Standard Deviation, in statistics, is the average amount a number varies from the average number in a series of numbers. - 29 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Mode and coefficient of variation Mode is the most frequent score. For example, your kidney transplant patient has hemoglobin levels taken for a week following the surgery. Hemoglobin in g/dL 15.0 12.0 12.0 12.0 10.0 8.0 7.0 The most frequent hemoglobin test result is 12.0 g/dL, so 12.0 is the mode. Coefficient of variation is the standard deviation divided by the mean, multiplied by 100. Its short form is %CV. It tells you how precise a test is. The lower the percentage, the more likely it is that there was no variation in the way a test was performed from sample to sample. Ideally, there should be no more than 4% coefficient of variation. Remember that your lab can have a low coefficient of variation, but can still be making the same testing mistakes over and over again because of poor quality control. Coefficient of variation also allows you to compare the differences (inequalities) between two populations. Managing test results The steps for a phlebotomist to effectively manage test results and avoid malpractice charges: 1. Log all tests collected and send-out lab name 2. Track send-out tests until all results are received back 3. Call the reference lab to find out reasons for delays 4. Call back patients for repeat testing if the sample was lost, broken, insufficient, untestable, or gave equivocal results 5. Flag abnormal results 6. Ensure the doctor reviews all results 7. Inform the patient of normal results in a timely manner, if authorized by the doctor 8. Give numerical results to well-regulated patients with chronic conditions, where the doctor has discussed disease management and the meaning of the results with the patient beforehand (e.g., diabetics, dialysis, and anticoagulant patients) 9. Document that the patient was informed of results by a staff member 10. Ensure the doctor’s recommended follow-up occurred (e.g., inform patient of prescription order) 11. Book a return appointment for the patient to meet with the doctor to discuss abnormal results 12. Mail a copy of the results to the patient - 30 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Confidentiality practices When training a temporary replacement, the following need to be communicated regarding confidentiality practices:  Never carry on a conversation with an unidentified caller, or directly tell a caller if the patient is in the office. Reporters, lawyers, and domestic violence perpetrators use this tactic to track people. Always get the name of the caller. Say you will look to see if the patient is there. Ask the patient if he/she wants to take the call.  Turn over confidential papers and schedules and turn off your computer screen when you leave your desk. Angle screens and papers so that visitors cannot read them while you work.  Use low background music to help blur conversations for eavesdroppers.  When talking about a patient in a crowded area, try to use only one name, e.g., Mrs. Bartleson or Jane, not both.  Get a signed consent to disclosure form before releasing confidential information.  You’re a Business Associate under HIPAA, so you must protect patient information and report unintentional disclosure. You can be dismissed and charged if you fail to do so. Three instances when law overrides the patient’s right to confidentiality are:  The doctor must report some infectious diseases to Public Health to prevent an epidemic. These include sexually transmitted diseases and tuberculosis.  Caregivers’ have the right to know the patient’s diagnosis if it poses a risk to them (infection, likely to assault).  Suspicion of child abuse: Since 1996, all states require doctors, nurses, chiropractors, psychologists, social workers, law officers, daycare staff, clergy, and teachers to alert local authorities if they suspect child abuse or neglect under the Child Abuse Prevention and Treatment Act (CAPTA). Abuse and neglect occur when a person who is responsible for a child under 18 commits or omits an act that may cause death, serious emotional or physical harm, sexual abuse or exploitation. Each state has an abuse hotline. Many states require anybody who has reasonable cause, in good faith, to believe a child or elder is being abused to report it or face civil liability. Spectrophotometry A spectrophotometer (Spec-20) compares the intensity of light entering a sample and exiting from it (percent transmittance) to find the concentration of the sample. Visible spectrum light ranges from 440 nm to 700 nm. Different substances absorb different light wavelengths. Beer’s law states absorbance is proportional to the concentration of a solution. A completely transparent sample has 100% transmittance. A completely opaque sample has 0% transmittance. Beer’s law only applies if absorbance is between 0.1 and 1.0. Grind your sample with 25 mL of 6M HCl in a 250 mL beaker. Cover and boil gently in a fume hood for 15 minutes. If volume falls below 15 mL, add distilled water up to 25 mL. - 31 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Let cool. Filter out any solids into a 100 mL flask. Pipette 1 mL into a 50 mL flask. Add hydroxylamine hydrochloride, sodium acetate, 1,10-phenanthroline and distilled water to the line and place in the spectrometer on a clean cuvette. If you need to correct the solution because the sample contained dye, omit the 1,10-phenanthroline. How to use a spectrophotometer The Biomate 3 is typical; all spectrophotomers work similarly. Use quartz cuvettes when measuring DNA and stock solutions. Use disposable plastic cuvettes when measuring bacteria. Wipe the windows on the quartz cuvettes with 95% ethanol and a Kimwipe. Do not use Kleenex or acetone, as they will damage the $700 quartz cuvettes. Measure your stock solutions first. Choose Smart Start. Choose Oligo. Refer to your oligo sheet and enter the conversion factor in mcg/OD. Place 995 mcL of MQ water on a 1 mL cuvette. Load it into the cuvette holder. Choose Run Test, then Measure Blank. Add a 5 mcL sample or media to the cuvette. Mix by inverting and replace it in the cuvette holder. Choose Measure Sample or Cell Growth. If the oligo is diluted, use a microcuvette. Add 90 mcL, choose Measure Blank, add 10 mcL diluted solution, and vortex. A260 should be above 0.1. Choose Esc. Save test results. Wash out the cuvettes with MQ water and 95% ethanol and blow dry. Microscopes Main parts of the microscope and why they are needed:  Aperture: Hole in the middle of the stage. Light shines through it onto the slide.  Arm: Joins the eyepiece, stage and base. Used to carry the microscope securely.  Base: Weighted stand below the stage to keep the microscope upright.  Knobs: Coarse adjustment knob moves objectives up and down. Fine adjustment knob clarifies the view. Stage knobs move the slide around to change the field in view.  Lighting: The base illuminator dome light is below the stage. Behind the base illuminator is an on/off switch. Above the base illuminator, on the bottom of the stage, is a light adjustment lever for low, medium and high lighting.  Objectives: Low power, high power, and oil immersion objectives hang down from the revolving nosepiece.  Ocular: Eyepiece(s) at the top of the microscope (monocular or binocular).  Revolving Nosepiece: Under the ocular, above the stage, the revolving nosepiece holds the objectives steady.  Slide Clip: Holds the glass slide in position on the stage.  Stage: Flat surface under the objectives on which the slide rests. Cleaning and storing a microscope There are five glass areas on the microscope made of soft, optically ground glass. Kleenex and paper towels are too rough to safely clean this expensive type of glass because they will scratch it. Lightly dip lens paper in xylene or another oil solvent. Clean the ocular first, then the low, high, and oil immersion objectives, and lastly the stage aperture. Wipe the entire stage. Polish the glass and stage with a fresh, clean, dry piece of lens paper. Rotate - 32 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. the low power objective clockwise into place with the revolving nosepiece, and raise it to the highest position with the coarse adjustment knob to avoid scratching the lens. Wrap the power cord around the base. Drape the microscope with a plastic cover or put it in a microscope box. Keep it away from temperature extremes and moisture. Carry it only by the arm and avoid and bumps or falls. Calculating magnification The ocular(s) are usually marked 10x magnification. (Small office models are sometimes 5x magnification.) The low power objective is marked 10x magnification. If you use a 10x ocular with a low power objective, then 10 × 10 = 100, so you are looking at an object at 100 times its actual size. The field you see is actually around the size of three pin heads. The high power objective is marked 43x or 44x, depending on the model. If you use the 10x ocular and the high power objective, then 10 × 43 = 430, and 10 × 44 = 440, so you are viewing an object at 430 or 440 times its actual size. The oil immersion objective requires special oil on the slide in order to focus properly. It is marked 100x magnification. If you use a 10x ocular and the oil immersion objective, then 10 × 100 = 1,000, so you are viewing an object at 1,000 times its actual size. The field is pinpoint size. When a smear cannot be identified If you find something on a smear you cannot read or that is very significant, use the vernier scales on the right and bottom sides of the stage to mark your place. Center the item that you cannot identify in the middle of the field by using the stage knobs. One knob moves the slide horizontally and one moves it closer or farther from your eyes. Carefully note the readings on the two vernier scales, e.g., Bottom 24, Side 40. Then you can safely resume reading the slide, and still return to the unusual item easily. Avoid jiggling the slide or allowing it to dry out, because movement or evaporation may change the location of the item. Inform the charge technologist or doctor that you need assistance to identify the item, or that you have found a significant structure and want it confirmed. Focusing a slide clearly Use the correct stain, and a cover slip on top to prevent evaporation if it is a wet mount. Place the slide on the stage. Clip it down to secure it. Plug the microscope into an electrical outlet. Turn on the base illuminator with the light switch. Turn the light to low by moving the lever to the far right. Make sure the low power 10x objective is locked into position with the silver knobs on the revolving nosepiece. Turn the coarse adjustment knob away from you to lower the objective towards the slide. Watch from the side so you do not grind the soft lens into the slide and damage both – keep the objective just above the slide. Rotate the fine adjustment knob away from you. Look into the ocular with both eyes to avoid eye strain. Turn the coarse adjustment knob towards you very slowly to focus the slide. Stop when an object can be seen. Turn the fine adjustment knob towards you to bring it into sharp focus. - 33 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Viewing fine details with an oil immersion lens Center the object you want in the middle of the field by using the stage knobs. The oil immersion lens is the longest, so use the coarse adjustment knob to raise the lower power objective and allow enough room for the longer lens. Turn the objectives clockwise to oil immersion. Place a drop of immersion oil on the slide below the lens. Use the coarse adjustment knob to lower the long objective near the oil drop. Watch from the side as you turn the fine adjustment knob away from you to slowly lower the lens into the oil. Look through the ocular and focus the object with the fine adjustment knob. Move the light adjustment knob left to brighten the field. Once the object is focused, do not move the lens in and out of the oil, but keep them in contact as you move through the fields. Clean the immersion oil from the lens with xylene and lens paper before using the microscope for another specimen, or storing it. Operating a centrifuge If you do not balance your centrifuge before using it, the blood may hemolyze because of motor vibrations. An unbalanced centrifuge “walks” across the workbench and may fall. Glass tubes may break in an unbalanced centrifuge, requiring lengthy cleanup and disinfection. Place sealed tubes containing approximately equal volumes opposite each other in the centrifuge cups. If you have only two tubes with very unequal amounts of blood (e.g., 3 mL and 10 mL), or an unequal number of tubes, then match them across from counterweight tubes filled with water of the corresponding volume. Never open a centrifuge while it is still spinning, as broken glass and dangerous aerosols may fly out. Wait until the centrifuge stops completely before opening it. Do not jiggle the tube as you remove it, because the solids will resuspend in the liquid. Each day, wipe down the outside with a damp cloth. Remove broken glass with forceps. Clean spills with alcohol on a cloth and air dry the parts. Lab refrigerators Lab refrigerators are used to store highly volatile, flammable liquids. They must have no sources of ignition that would be in a domestic fridge, such as heater strips, inner thermostats, light switches, and compressors and circuits at the base where flammables can accumulate. They must be explosion-proof, have self-closing doors, thresholds, friction latches, magnetic door gaskets, and a compressor and circuits at the top. They must be manually defrosted, and have continuous recording thermometers, set between 0°C to +6°. Blood bank requires +4°C. Class IA, IB, and IC are flammables. Class II, IIIA, and IIIB are combustibles. No more than 120 gallons of Class I, II, and IIIA liquids can be stored in a lab fridge, and of those, no more than 60 gallons may be Class I and II. Do not locate more than three storage cabinets in one fire area. No more than 50% of the flammables can be stored for teaching. Use DOT approved glass, metal or polyethylene containers no larger than 1.1 gallons (4 liters). - 34 - Copyright © Mometrix Media. You have been licensed one copy of this document for personal use only. Any other reproduction or redistribution is strictly prohibited. All rights reserved. Biochemistry laboratory machines Johnson and Johnson’s Vitros DT60 II is good for point-of-care (bedside or clinic) routine chemistry testing or as a small backup machine in case the main analyzer fails. Randox Daytona is a benchtop system for large labs because it can test up to 40 specimens at a time and it automatically barcodes specimens and refrigerates the reagents. The Roche/Hitachi Analyzer performs 26 routine chemistry tests, like electrolytes and proteins, on CSF, plasma, serum, and urine, and is good for small labs with low patient volume. The Roche Cobas Integra tests 36 routine tests, like protein, and common drug levels like lithium. Cobas is good for labs with limited space and staffing, because the reagents inventory is automated and it is very sparing when it uses reagents. The Abbott ARCHITECT Analyzer is used for chemiluminescent immunoassay (CMIA), to perform tests like AFP and Beta HCG. The Abbott AxSYM is used performs microparticle enzyme immunoassay (MEIA) for CEA. Aliquot Aliquot is dividing a chemistry solution into equal parts. It is used for very expensive reagents, which are measured out into smaller solutions as needed, instead of using the whole bottle. Aliquot is also used to make adjustments to blood samples or drugs that are below scale. For example, a chemistry machine can test blood samples as small as 15 cc, but you have many tests ordered and not enough blood in separate tubes. You

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