MLA 1119 - Study Guide 1 PDF

Who may request laboratory testing? Request by a licensed physician Requisition is the first step in initiating testing, tracking laboratory requests and patient identification A College of Physicians and Surgeons member must authorize all laboratory requests. There are a few o...

Who may request laboratory testing? Request by a licensed physician Requisition is the first step in initiating testing, tracking laboratory requests and patient identification A College of Physicians and Surgeons member must authorize all laboratory requests. There are a few other healthcare practitioners who may request laboratory: a. A legally qualified medical practitioner or a dentist b. A midwife c. A registered nurse who holds an extended certificate of registration d. Naturopathic Doctors (must be registered provincial/national naturopathic college) e. Practitioners listed above are limited to certain test requests, whereas physicians may order any test/analysis that is performed by both public and private laboratories Who may fill out a requisition? A physician orders procedures on a patient’s chart and a nurse/unit clerk/receptionist checks off or writes the tests that the physician orders. It is also this individual who completes all the “required” information on the requisition Standing Orders - A Physician may request that a test be performed several times, or over a period of time (or both). If there are any noticed or suspected discrepancies or deficiencies on a test request, you must contact the ordering Physician to amend/correct the request. What is a lab requisition? Contains patient identification information, the requesting practitioner’s information as well as the specific tests requested and the details of when the sample was collected. What is the difference between a hard copy request (requisitions) and an electronic request (LIS- Laboratory Information System)? A hard copy request is a paper requisition that the patient takes with them to a collection site. These are typically used for an outpatient collection. “Downtown procedure” occurs when either the LIS system or an analyzer is down. In these cases, we perform the testing using manual methods and paper reporting  Electonic Requests are laboratory test requests that are submitted to the Lab Information System (LIS) by the ordering Physician. No paper copy accompanies this request. These are typically used in the hospital during a patient’s admittance to the facility, also called “inpatients”. The request is submitted to the LIS, the lab staff is notified, and specimen labels are printed that are then taken to the patient’s bedside for collection What are the different component of a requisition? This is the minimum amount of information needed to correctly identify and contact the patient and provider to proceed with the testing. at each checkpoint, we are not able to proceed if information is missing or incorrect. This would be considered Checkpoint #1, or as we refer to it, a “Clerical Check”. The complete list of required patient information is: a. Patient’s full name (first and last name) b. At least one of the following unique identifier is required: ULI (unique life identifier), PHN (personal health number), personal identification number (Federal, RCMP, Passport etc.), or facility-assigned number (MRN, hospital, clinic, unit, accession, account) c. Gender & Date of Birth - not considered a unique identifier as people will have the same date of birth but it can be used as an additional identifier or in verbal identification. Many reference ranges are determined by patient gender and/or age. Patients do have the opportunity to choose “non-binary” or “prefer not to disclose” on any requisition.  d. Confidential patient information - patient identity may be protected by assigning a code name and number that is unique to the patient. You will need to maintain a record of the assigned patient code and number. e. Patient Address and Phone Number - A patient phone number is required for community patients f. Chart number - if applicable, enter the chart #. This most often applies to frontline staff, as lab staff don’t often access the patient’s chart. The required provider information is: a. Referring (ordering) Physician - indicate the name and location of the ordering physician. Community physicians are provided with a stamp. When a stamp is not available for use, please provide the physician's first and last name and address for report delivery b. Copy to Physician - When requesting additional report copies please provide the first and last name and location of the 'copy to' physician. The ‘copy to” information allows the reports to be sent to more than one practitioner. The required collection information is: a. Date of Collection - documentation of the day that you performed the collection. Day/Month/Year (dd/mm/yyyy) b. Time of Collection - we use the 24-hour clock. It is written strictly as just the 4 numerical digits, e.g., 230 p.m. is written as “1430” c. Location of Collection - what facility was the sample collected at? For eg. if you are collecting at the Red Deer Regional Health Center, you would record “RDRHC.” d. Collector ID - When you are working in a lab, you are assigned a ‘collector ID.” This number is used to identify you in the LIS and is also sometimes handwritten on the tubes. This helps us to identify who performed the collection in case the testing staff needs to troubleshoot.  The Testing Information Section: a. In the top left of the Test Information section is the Priority indication. The options are ROUTINE or STAT b. Generally speaking, tests collected at PSCs are considered routine. c. STAT collections tend to be reserved for in-hospital collections, or in times of urgent blood product requests from smaller labs that require the Transfusion Medicine department to complete the testing quickly. d. priority assigned to each test guides how quickly we must provide the ordering physician with results. e. “turnaround time” this is a measure of the time from when the sample was collected, to the time the results are released from the testing staff. - STAT: 60 minutes. Tests are urgently needed for critical patients. Collect IMMEDIATELY. - Urgent: 8 hours - Routine: 24 hours - Timed: Collect at a specific time (as per physician’s orders). Used for tests in which timing is critical for accurate results. Collect these samples as close as possible to the requested time, and record the time of actual collection f. Requisition date - the date the testing is ordered g. Fasting requirements - Many tests may be instructed to follow some pre-collection steps. The most common example of this is “fasting.” This is where a patient must refrain from eating or drinking for a recommended period of time (usually 8-12 hours) before having their blood drawn. h. Testing Selection Section - The remaining portion of the testing section is a checklist of the tests that Physicians can order. The tests indicated will be checked off or marked with an “X” and you will need to scan the full section before collecting to ensure you haven’t missed any orders. Performing a Clerical Check on a requisition. Before proceeding with a collection, a thorough review of the requisition and labels must be performed. Avoids duplication of test orders and ensures that the sample is collected at the correct time, under the correct condition (eg. fasting requirements) it allows us to prepare any special equipment required. To properly review a requisition, the phlebotomist must: a. Check all required information has been recorded and is correct and complete b. Check that the information on the tube labels matches the requisition exactly. If there are any discrepancies noted, they must be rectified before collecting the sample. c. Verify the tests to be collected and review any collection requirements related to the sample requirements. d. Identify any diet restrictions or other special instructions before the collection e. Determine the test priority (STAT, Urgent, Routine, Timed) Workflow of tests through the lab We stick to a strict way of doing our work because it's important to follow each step of the testing process the same way every time. This helps us be sure that the test results are accurate. If we change things or make mistakes, we can't be confident that the results are correct. Workflow of tests through the lab, from request to reporting: 1. Test order - physician indicates on requisition which tests are to be collected/performed. (Physician) 2. Patient Registration - patient identification begins during the registration process. Registration is the entering of patient information in the computer system. Occurs at the front desk or the admitting/registration desk of a hospital and long-term care facility. *On occasion, lab staff may need to perform this step to register a patient in the system: Full Name, DOB & Gender, Full address, Proof of ID (gov't issued card) 3. The lab receives the request for testing, and collection labels/lists are generated by the LIS. This is the point at which you would perform the first Clerical Check of the requisition and label information. (MLA) * 4. The phlebotomist (MLA or Nurse) performs the specimen collection procedure and documents the collection date, time, location and the ID of the phlebotomist. The collected sample(s) are returned/sent to the lab for processing. (MLA)* 5. Receiving Specimen - the specimen is scanned into the LIS and the collection date and time, and collector ID are added to the test orders. This step, “receiving”  the specimen registers in the LIS that the sample is now “in the lab”, for tracking purposes. (MLA)* 6. Specimens are processed as per individual requirements and delivered to the testing department. Common processing requirements include sorting, centrifuging, aliquoting, delivery to testing departments and transport to the referral lab. 7. Sample analysis (testing) - performed by testing staff. If additional testing is required, it will be ordered in the LIS by the testing staff (reflex testing). (MLT)* 8. Results reviewed and verified by testing staff. Any critical results will be phoned to the ordering physician before the release of results. (MLT)* 9. Results were released to the ordering physician. (MLT)* 10. Sample retention and storage of records - each test has a different stability window and is held in the lab for a specific time frame (*) This icon indicates the workflow points where a Clerical Check is performed by lab staff. Tracking of Specimen from collection to reporting/information required to track specimens (MRN, PHN/ULI, Accession Numbers) a. Tracking ensures that each specimen is meeting the proper turnaround times, that no tests are missed and that timely intervention can be made if needed. b. Medical Record Number (MRN) - a site-specific number assigned by the facility (hospital) that helps identify patients and is not relevant outside of that particular health authority. *Entering an MRN into the LIS will bring up every encounter the patient has had at one particular facility* c. Personal Health Number (PHN)- Identifier issued to Albertans who are eligible for basic coverage with the Alberta Health Care Insurance Plan. The terms “PHN” and “ULI” are often used interchangeably but note that a PHN is only assigned to patients who have qualified for Alberta Health Insurance. *Entering a PHN into the LIS will bring up all orders, tests and treatments performed (in Alberta) under a patient’s profile. d. Unique lifetime identifiers (ULI) - a unique and permanent number assigned to all persons who receive health services in Alberta. This number functions like a PHN but also includes patients who do not qualify for, or who have not yet received Alberta Health Insurance. *Entering a ULI into the LIS will yield the same search results as a PHN e. Accession Numbers - these numbers are used by the laboratory staff to identify a specific specimen. Each individual tube collected is assigned an accession number. This allows the laboratory to track the specimens through the lab at all times. An accession number is specific to the tube and tests associated with it.  f. Hematology/Chemistry/Coagulation/microbiology (Routine Laboratory Requests) have a CONNECTCARE assigned accession number that is structured the same. Anatomical Pathology and Cytology (Histo/Cyto) specimens have their own unique accession number system. Finally, Transfusion Medicine has a Connectcare accession number AND a unique TSIN (Transfusion Service Identification Number). How else do we track specimens in the lab? Information that must be documented to track a specimen from test request to reporting includes: 1. Patient information- Initiation of test request (test order and accessioning) 2. Collection lists (draw lists)- For outpatients, this is a paper req. For inpatients, you will receive the tube labels required for the draw 3. Priority (sometimes called “schedules”) -routine, urgent, timed, STAT 4. Preparation of labels- (If receiving a paper req instead of labels) 5. Accession records/log sheets 6. Site Batches - tracks specimens that are being sent from one facility to another 7. Work lists (listing specimens by test/instrument) 8. Test results - verifying and releasing results 9. Storage of test results - in the LIS 10. Dissemination of test results (reporting) Collection (Draw) Lists - A collection or draw list is a list of patients that require blood specimen collection and the tests that are requested for those patients. Information on the collection list may also include the collection tube(s) required, volume of sample and specimen handling requirements (e.g., “keep on ice,” “keep in the dark,” “keep warm”). Once specimens have been collected from a particular patient, the phlebotomist must record the collection date/time/initials on the collection list, (most often this info is entered into the LIS). Worklist/Pending Specimens Log - This is a real-time tracking list in the LIS that contains all the specimens that have been received in the lab but have not yet been received/reported. The ConnectCare LIS system allows users to customize their workstations to suit numerous workflows. Once a test has been completed and the results have been verified and released in the LIS by the testing staff, the patient/test information is automatically removed from the worklist. Accession Logs - Manual logs may be required if the LIS is down. The LIS tracks all the accession numbers assigned as tests are ordered on individual patients, which eliminates the need to maintain manual accession logs Site Batches - samples being sent off-site also need to be tracked so they don’t get lost in transit. They are put on a “batch” list in the LIS, and this moves their location from one facility to another.  Test Results - Once testing results have been reviewed, verified and released by the testing staff, Physicians can access the results through the LIS or via Netcare (a provincial system that requires special access). Different reporting formats include: i) Event report – results of one event or test. e.g. STAT ii) Interim/preliminary report – results are delivered as they become available rather than delaying the report until all tests have been completed. iii) Cumulative report – summary of all test results on a patient over a given time period. Storage of Test Results in the LIS - Once entered and verified, test results are stored in the LIS computer database and can be retrieved at any time. Other information that a laboratory may document for management purposes may include: 1. Billing - The LIS database can be customized to include any type of billing that may be required, such as Alberta Health Care, Out–of–province, Company Bill, etc. 2. Work unit tabulation - Collection of statistics (i.e. number of tests performed and types of patients) for phlebotomy and test work units can be done via the LIS. 3. Laboratory management - The LIS can produce detailed and accurate accounts of laboratory activities including turnaround time, workload distribution, variations in day-to-day activity, etc. 4. Quality control- Quality control samples are processed using the same protocol as the patient specimens and results are entered and verified in the LIS. Apply criteria to determine proper specimen identification/suitability Once a specimen is received in the laboratory, staff in the Specimen Collection and Control area are responsible for checking to ensure that the specimen is correctly labelled, that all the required information has been received/entered and that it is the correct specimen type, volume, fixative, etc. All specimen information must be complete and correct and must match exactly with the requisition: a. Patient Information: Check that the requisition and specimen match EXACTLY and that there are no errors regarding patient information: full name (last, first), PHN #, birthdate, and gender. b. Type of Specimen: Check that you are processing the correct type of specimen for the test ordered, including: type of tube collected (e.g. anticoagulant, plain, siliconized, etc.) type of specimen (e.g. venous vs capillary blood, CSF, etc.) volume of specimen is correct/adequate Special instructions followed regarding specimen handling after collection (i.e., on ice, room temperature, keep in dark)  proper preservative/fixative used (e.g., acid preservative for 24 urines) c. Collection Date and Time: The date and time of collection must be recorded on the label of the specimen and the collection list or requisition. This is especially crucial for timed collections and may include information such as the start and stop time of a 24-hour urine specimen. d. Other information which may be required: particularly infectious specimens, i.e. HIV or HBV positive priority of testing, i.e. STAT name and location of ordering physician clinical data as required (i.e. diagnosis, medications) pertinent patient history or clinical information, i.e. patient on a particular antibiotic. Criteria for specimen suitability/rejection for testing (APL Rejection policy) Before delivering samples to the appropriate testing departments, each specimen must be carefully examined to determine if it is indeed suitable for testing; that is, it will provide valid results. a. Unlabeled Specimens: - Considered to be major deficiencies - Common specimen types (blood, urine, swabs, sputum, stool, etc) can be easily recollected and cannot with certainty be identified, which will require recollection. - Specimens which are less common and more difficult to recollect (CSF, fluids, tissues, etc) will require the person who collected them to identify the specimen and sign a waiver assuming responsibility for the identification - If the person responsible for collecting the specimen is unable with certainty to identify the specimen, the appropriate clinical leader or designated and ordering physician will be notified b. Incorrectly Labelled Specimens: - May be major or minor deficiencies - Specimens labelled with the wrong patient’s name compared to the requisition - Minor deficiencies may be accepted and procedures ordered will be performed (the exception is requests for blood products for transfusion, which must be recollected) however major deficiencies may be rejected. c. Incorrect container or Preservative:  - Specimens received in an incorrect container, or without appropriate preservatives, which would invalidate the results, will require recollection. d. Insufficient Specimen for Procedures: - If insufficient specimen is received for all procedures requested and the specimen is easily able to be recollected (urine, stool, sputum, blood, etc.), a repeat collection will be requested. - Also referred to as “NSQ”, meaning Not Sufficient Quantity. e. Unsuitable Specimen for Procedures: - unsuitable for the procedure requested (saliva for sputum test, urine for blood tests) or if the specimen has been in transit too long for a valid result, the specimen will be rejected. f. Anatomical Pathology samples must be labelled with the following information: - Exact anatomical site of tissue origin. - Multiple specimens on the same patient with the same collection date must have an alpha designation (A, B, C, etc.) - Specimens from patients with known or suspected infectious diseases should be marked as infectious g. Microbiology samples must be labelled with the following information: - When multiple samples are submitted to the laboratory at the same time for the same patient, include the exact site (source/type) of the sample, Date and time of collection - Multiple specimens requiring individual diagnosis should be placed in separate collection containers What is “NOD” and why do we do it? a. Name, Occupation, Duty b. How we will greet and introduce ourselves to our patients every time. Once NOD is performed, we must obtain “informed consent” before continuing. What does “Informed Consent” mean? a. Practitioners cannot perform procedures, treatments or medical interventions without obtaing informed consent from the patient or legal guardian b. Informed consent means that the appropriate person understands the medical treatment required and is aware of its consequences. c. Consent may be written, spoken, or implied d. Where informed consent is not possible: unconscious, a minor(under the age of 18), mentally incapable og making decisions. How do we properly obtain consent? a. 5 elements of consent that must be included: 1. The nature of the procedure 2. The risks and benefits of the procedure 3. Reasonable alternatives 4. Risks and benefits of the alternate procedures 5. Assessment of the person’s understanding of elements 1 through 4 Different Types of Consent? a. Implied Consent - a patient passively cooperates in a process without discussion or formal consent. An example would be in blood collection is when a patient rolls up their sleeve, and/or extends their arm for you without you having to ask. b. Verbal Consent - where a patient states their consent to a procedure verbally but does not sign with any written form. c. Written Consent - necessary in case of extensive intervention involving risks where anesthesia or sedation is used, restorative procedures, surgical procedures, and medications with known high risks. A patient has the absolute right to refuse any medical procedures/treatments/interventions. We always respect this right and documentation of refusal may be required. In this situation, we must refer to and follow the facility’s policy/procedure What criteria must be met for a proper patient ID? Verification of a person is important to meet Canada’s Organizational Practices standard for patient identification. Two or more identifiers shall be used to confirm the patient’s identity before a health service is provided. Preferred identifiers are the patient’s full name and PHN. Approved identifiers: confirm patient by using at least 2 identifiers a. First and last name b. Full DOB c. Unique lifetime Identifier (ULI) d. Personal health number (PHN) e. Medical Record Number (MRN) f. Patient Identification Barcode g. Patient address if the address is provided by the patient How do I properly ID a patient in an OUTPATIENT setting? A clerical check has been completed and all information is correct, the phlebotomist will then perform a second patient ID before collecting the samples. This is considered “confirmation of identity”. To do this you will ask the patient to state and spell their first and last name and state their DOB. You do not need to ask for the PHN because a clerical check has been performed already. How do I properly ID a patient in an INPATIENT setting? Criteria for patient ID are the same in any setting- 2 or more approved identifiers. Inpatients should have an armband with their identifying information. This band should be worn at all times. In some instances, patients may be wearing this band around an ankle, and that is acceptable. Armbands that are not worn on a patient’s body are not valid for identification. In these cases ask the nurse to confirm the patient's identity. To confirm identity, perform NOD and obtain consent to collect the specimen. Locate the armband and ask the patient to state and spell their first and last name, and DOB, confirm this information by looking at the armband. If there are any discrepancies noted, resolve them before you proceed with collection, as per the facility-specific protocol/policy. What if a patient is unable to provide confirmation of identity In an emergency situation patient’s identity cannot be immediately identified: a. AHS shall not refuse or delay a health service b. A patient shall be assigned an anonymous name and unique identity number until the patient’s identity can be verified Pre-phlebotomy criteria the collector must verify before the collection of blood Diet restriction or instructions - most common, involves overnight fasting Medication restrictions - eg. aspirin Timed collection - specimen must be drawn as close to the desired time as possible Discuss what the term “whole blood” refers to. Blood is made up of different components, each serving a different purpose or function within our body Identify all the components: plasma, leukocytes, platelets and red cells The figure below represents the different components and their normal ratios/proportions. These components will separate, by either centrifugation or by simply sitting upright and undisturbed based on their individual densities. What does “whole blood” refer to? Consists of red blood cells, white blood cells, and platelets suspended in a protective yellow fluid known as plasma. Whole blood samples are collected into tubes that contain an anticoagulant An anticoagulant is an additive used in some blood collection tubes that prevents the activation of the coagulation cascade (a process that creates a clot). Whole blood refers to a sample whose components have not been altered in any way. No longer an accurate representation of the original component ratios. Identify and discuss the different components of blood. Erythrocytes: a. Red blood cells, also known as erythrocytes b. Deliver oxygen to the tissues in your body. Oxygen turns into energy and your tissues release carbon dioxide. Transport carbon dioxide to your lungs for you to exhale. c. Mad in our body’s soft bone tissue (bone marrow) is released into your bloodstream after they fully mature, which takes about seven days. 90-day life cycle.  d. Contain a protein called hemoglobin that is responsible for binding and carrying oxygen from your lungs to the rest of your tissues. e. Have a unique “biconcave disc” shape- round with an indentation in the center. Mature RBCs that are found in the peripheral circulation (outside the bone marrow) do not have a nucleus like WBCs do, allowing them to change shape and move through the body more easily. f. Make up approximately 45% of blood and will settle at the bottom of the blood collection tube. Buffy Coat: a. Refers to the layer of a separated blood sample that settles between the RBCs and the plasma (“supernatant”, or liquid portion). It contains Leukocytes (WBC) and the platelets. Leukocytes: a. Leukocytes, also known as white blood cells b. Part of the Immune system and protects the body against infection. Travels through the bloodstream and tissues, they locate the site of infection and act as an army general to notify other WBCs of the location. c. Made in the bone marrow and originate from stem cells. d. Make up less than 1% of your blood volume and settle in the bluffy coat layer of a separated sample. e. Have a round shape with a distinct centralized nucleus. There are 5 types of WBC and they serve different immune and infection-fighting function: 1. Neutrophils - fight bacteria, fungus and foreign debris. 2. Lymphocytes - consist of T cells, B cells and natural Killers cells to protect against viral infections. Also produces antibody proteins. 3. Eosinophils - identify and destroy parasites and cancer cells. Also, assist basophils with allergic responses. 4. Basophils - produce an allergic response like coughing, sneezing or runny nose 5. Monocytes - defend against infection by cleaning up damaged cells Platelets: a. Platelets, also known as thrombocytes b. Small cell fragments in our blood form clots and stop or prevent bleeding. It circulates in the blood and binds together when they recognize damaged blood vessels. c. Smallest of our blood cells, shaped like small plates in their non-active form. A blood vessel will send out a signal when it becomes damaged. When platelets  receive that signal, they’ll respond by travelling to the area and transforming into their “active” formation. Plasma: a. Liquid portion of our blood and makes up a little more than half of our blood volume. b. A yellow fluid that appears hazy. c. The main role is to deliver nutrients, hormones and proteins to the parts of the body that need them. d. Cells excrete their waste products into plasma. The plasma helps to take these waste products to the body’s elimination mechanisms e. Contains water (mostly), electrolytes and enzymes as well as: 1. Antibodies - immune responses 2. Clotting factors - needed for blood clotting processes 3. Protein - albumin, fibrinogen, fibrin f. The most important about plasma, it contains the component listed above, as this will be used as a differentiation between plasma and serum. g. Supernatant - refers to the liquid portion of a blood sample, you will find it is used in reference to both plasma and serum. Define and Discuss the difference between whole-blood vs clotted blood. a. Whole blood is the natural makeup of a person’s blood that has not been altered in its proportions and has been stabilized with an anticoagulant. b. Clotted/Serum samples - obtained using a clot-activator additive in the blood tube, standing time to allow a clot to form and centrifugation to separate the components. How does Blood Clot? a. Collected without the addition of an anticoagulant (in the blood collection tube). b. A clear, yellow fluid known as serum is squeezed out of the clot, and this serum then makes up the supernatant. c. The whole blood specimen (on the left side) contains 3 separate layers - plasma, buffy coat and red blood cells. This sample contains PLASMA as the supernatant. d. The clotted specimen (on the right side) contains only 2 layers - serum and a blood cell clot. Once a sample has clotted, the supernatant is serum as several of the components found in plasma are used up during the clotting process and no longer remain in the liquid portion. e. To form a clot, the following constituents are required: Coagulation factors (aka “clotting factors) - contained in plasma Tissue thromboplastin - contained in plasma Calcium (divalent ion) - contained in plasma Fibrinogen - contained in plasma Platelets - free-floating throughout blood components f. Either initiates by injury to a vessel (in the living body or in “vivo”), or by contact with a foreign surface (in a blood tube, or “in vitro”) g. When whole blood is put into a tube, the tube acts as a foreign surface and causes the blood to solidify, within 30 minutes. h. Clot retraction - the fibrin forms crosslinks and contracts into a smaller denser mass. i. The serum will not contain fibrinogen since the fibrinogen was converted to fibrin and the fibrin remains in the clot portion of the specimen. Serum will also not  contain the anticoagulation factors, as they were used up during the clotting process. Define and Discuss: Clot Retraction, Clotting Factors, Fibrinogen, Fibrin, Serum vs Plasma Clot Retraction: refers to actions of the platelets during the clotting process. Functions in 3 ways: a. Platelet adhesion - the process by which platelets bind to the vessel wall b. Platelets aggregation - the process by which platelets bind to each other, The first 2 steps form a “platelet plug” at the site of injury c. Clot retraction - the platelets form filaments that bring the edges of the damaged vessel closer together, further reducing bleeding. d. The elements responsible for these other processes are contained within the plasma and are referred to as “clotting factors” Clotting Factors: a. When there is an injury to a vessel, 4 things occur: 1. Constriction of the blood vessels - to reduce blood flow 2. Formation of a temporary platelet plug 3. Activation of the coagulation cascade 4. Formation of the “fibrin plug” or the final clot b. When injury to a vessel occurs, platelets release molecules into the blood that help activate the clotting factors and the coagulation cascade begins. During this process, tissue thromboplastin catalyzes the conversion of prothrombin to thrombin. The thrombin then cleaves fibrinogen to fibrin (a long, thin and sticky protein). When fibrin is activated, it forms a mesh-like matrix to hold the platelet plug in place-known as a fibrin clot. c. Ionized Calcium - calcium in your blood that isn’t attached to proteins and makes up about half of all the calcium in your blood. d. As collectors, understand the additives in our blood collection tubes. Many of the anticoagulants used function by chelating (binding) calcium, thereby making it unavailable for the clotting process. Hence, no clotting occurs in anticoagulant tubes.  Plasma Serum Yellow/hazy Yellow/Clear Contains WBCs and platelets NO WBCs/platelets (may contain trace amount) Contain clotting factors NO clotting factors (used up during clotting) Contains fibrinogen NO fibrinogen (used up during clotting) Whole Blood Sample Clotted sample Define and Explain how they affect a blood specimen concerning appearance and suitability for analysis: Hemolysis/hemolyzed, Lipemic, Icteric, Jaundice, Xantochromia Hemolyzed Specimens: a. The hemolyzed specimen is either the plasma or the serum appears to be clear red color rather than the usual yellow. b. Hemolysis usually occurs because the RBC have been traumatized and have burst (lysed), spilling their hemoglobin contents. c. There are some disease states that cause hemolysis, for example, auto-immune hemolytic anemia, whereby the body destroys its own red blood cells. In this case, a recollection of the sample would not yield a better sample. Lipemic Specimens: a. Serum or plasma occurs when there is an increase in the amount of lipids (fats) in the blood specimen. Lipemia is milky in appearance, this is usually avoided by collecting pre-breakfast (fasting) specimens. May be corrected by ultracentrifugation of the specimen. Resources Icteric Specimens: a. Synonyms with jaundice or yellow. Indicate increased bilirubin. These specimens may come from patients who have infectious hepatitis; specimens should be handled carefully. Define Listed Terms: Cyanosis - condition; skin turns bluish colour due to lack of oxygen in the blood Edema - interstitial fluid trapped in tissues resulting in swelling or a “puffy” appearance. Febrile - pertaining to fever Hematoma - localized collection of blood which has been trapped in the tissue (bruise) In vitro - occurring outside of the body (eg. blood collection tubes) In vivo - occurring inside the body Hemoconcentration - decrease in the fluid content of the blood, resulting in concentration of RBC (formed elements) and an increase in proteins (eg. prolonged application of the tourniquet) Palpation - feeling for a vein by application of light pressure to the skin surface with fingers Phlebitis - inflammation of a vein wall Sclerosed - veins or arteries that have become hardened due to a thickening and/or loss of elasticity of the vessel walls. Thrombophlebitis - inflammation of a vein associated with clot formation at the site. Venostasis - decrease of normal blood flow (pooling of blood) often as a result of a loss function of valves Supernatant - usually clear liquid overlying the material deposited by settling, precipitation, or centrifugation. Eg. plasma or serum CBC - complete blood count. This test is collected into a mauve top tube which contains EDTA and is delivered to the hematology department LYTES - Electrolytes consist of four individual tests: K+, Na+, Cl-, and CO2-. When ordered in Routine, collected into a gold top tube (SST) when ordered in STAT, collected into a green tube which contains Heparin (PST). Both STAT and routine are delivered to the chemistry department