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Laboratory Specimen Care and Handling in Perioperative Care Areas (2.3.11)

Laboratory Specimen Care and Handling in Perioperative Care Areas (2.3.11) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.11


UW HEALTH CLINICAL POLICY 1
Policy Title: Laboratory Specimen Care and Handling in Perioperative Care Areas
Policy Number: 2.3.11
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 8, 2016

I. PURPOSE

To assist Operating Room (OR) nursing personnel in the proper labeling and handling of OR Specimens.
Staff my also refer to Clinical Laboratories departmental policy #1502.5.06, Acceptance Policy for Specimen
Identification.

II. LABORATORY INFORMATION

Order test using Health Link or appropriate Lab Requisition Form. Transport to the lab immediately. Do not
let specimen sit at room temperature.

A. Surgical Pathology – Hours of operations
i. Normal laboratory hours are Monday through Friday, 7:30 am – 7:00 pm. Outside normal hours the
Surgical Pathology resident-on-call should be contacted. The call list is available in the OR call
schedule book, the UW Health Paging and Messaging center (608-262-2122), or online at the U-
Connect Web Paging Link.
ii. For clinicians requesting STAT services after hours, pathologist approval must be obtained before
testing will proceed.
a. To obtain pathology resident approval, the ordering provider should call UW Health
Paging and Messaging Center (608-262-2122) and ask for the Clinical Pathology resident-
on-call.
B. Clinical Service Department provides support for the users of UWHC Clinical Laboratories
i. The UWHC Clinical Laboratories Phone Center (608-263-7060, B4/225) provides telephone
response to questions from health care providers regarding laboratory testing availability, specimen
requirements, add-on orders, test results, result reporting, specimen transport, problem solving,
and general information about laboratory services at UWHC.

III. PROCEDURE

A. Labeling
i. The label must contain patient identification that is accurate, complete and legible and whenever
possible printed by a machine or device.
a. At a minimum the patient information on the specimen must include at least two patient
specific identifiers. Patient’s full name and medical record number. Trauma identification
name and trauma ID# may be used in lieu of name until an actual patient identity is
assigned.
ii. At least two of the patient identifiers on the request form must match two of the patient identifiers
on the specimen label.
iii. Two persons are required to verify the labeling of the specimen as well as matching labels with
requisition prior to the specimen leaving the room or area of collection.
iv. Label the specimen on the container (not on the lid) in the presence of the patient.
v. Each specimen must have its own label.
vi. Do not number the specimens unless numbering is necessary for mapping tumors, staging
laparotomies, or checking margins.
vii. Pathology, Cytopathology, Microbiology Labeling:
a. 2 patient identifiers (The medical record number is required for all Inpatient specimens)
b. Physician name
c. Type and source of tissue
d. Requested test
e. For Frozen: include the OR phone number on the Tissue Examination Request form
viii. Blood samples for Type and Screen and Crossmatch Labeling
a. The information on the label must match the information on the patient’s ID band
b. 2 patient identifiers
c. Employee identification number (preferred), or full name and title, or network login



UW HEALTH CLINICAL POLICY 2
Policy Title: Laboratory Specimen Care and Handling in Perioperative Care Areas
Policy Number: 2.3.11

identification (for physician) of specimen collector
d. Collection date and time on the tube label
ix. All specimens will be entered into the OR specimen log books prior to being sent to Pathology per
UWHC policy #7.01, Pathology Specimen Care and Handling.
B. Containers:
i. See the Laboratory Test Directory on U-Connect for identifying the appropriate container for a
specific test.
ii. Specimens that are too large to be transported in a standard leak-proof container must be securely
bagged in two biohazard (red) bags or placed in a basin inside a biohazard (red) bag.
iii. Specimens in Syringes:
a. Remove the needle
b. Insure that air has been expressed
c. Place cap or Luer lock cap
iv. Surgical Pathology: Refer to UWHC policy #7.01, Pathology Specimen Care and Handling; Related
document “Surgical Specimen Pocket Reference”
v. Microbiology Specimens:
a. Use sterile screw top containers or A.C.T. 1 tubes
b. Tissue or fluid should be submitted rather than swab when possible
c. Do not use A.C.T. 1 tube if the agar is blue, pink, lavender in color or outdated
vi. Cytopathology Specimens:
a. Cytology fluid specimens in a sterile screw cap container should be submitted fresh. Do
not add any type of fixative or anticoagulant. Do not collect fluid in blood collection tubes.
b. Fine Needle Aspiration (FNA) specimens: outside of routine hours should be submitted in
centrifuge tubes and Hanks Balanced Salt Solution (HBSS). Note: the UWHC Cytology
Lab prefers that the Cytopathology FNA team perform or assist in all FNA procedures.
FNA procedures are scheduled with Cytopathology at least 1 day in advance.
C. Transport:
i. If the exterior of the primary container is visibly contaminated, it must be decontaminated before
transport. If the primary container is leaking or the exterior of it cannot be decontaminated, transfer
the specimen to a new leak-proof container.
ii. When specimens are being transported via the pneumatic tube system, the specimen should be
bagged twice.
a. The primary specimen container must be placed within a sealed color-coded plastic bag
indicating the contents are biohazardous. The requisition should be placed in the outside
pocket of this biohazard bag.
b. This color-coded plastic biohazardous bag should then be placed into a thicker bag within
the pneumatic tube container and sealed.
iii. Since all tests are ordered as STAT, send a green “OR Priority Form” with the specimen and paper
work to the lab.
iv. Microbiology:
a. If Gram Stain is ordered STAT, call microbiology or write on form before transport.

IV. COORDINATION

Author: Director, Surgical Services Departments
Senior Management Sponsor: SVP Patient Care Services and CNO
Reviewers: Clinical Operations Manager; Director, Clinical Labs, Special Technical Services; Patient and
Resources Flow Coordinator
Approval committees: Surgical Services Policy and Procedure Committee; UW Health Clinical Policy
Committee
UW Health Clinical Policy Committee Approval: July 18, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.




UW HEALTH CLINICAL POLICY 3
Policy Title: Laboratory Specimen Care and Handling in Perioperative Care Areas
Policy Number: 2.3.11

V. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

Appendix: Clinical Labs Contact Information
U-Connect Laboratory Test Directory
U-Connect Client Services
U-Connect Surgical Pathology
UWHC Clinical Laboratories departmental policy #1502.5.06, Acceptance Policy for Specimen Identification
UW Health clinical policy #2.5.1, Use of Containers for Clinical Specimens
UWHC policy #7.01, Pathology Specimen Care and Handling
UWHC policy #8.12, Blood and Blood Component Transfusion (Requiring Pre-Transfusion Testing)

VII. REVIEW DETAILS
Version: Revision
Next Revision Due: August 2019
Formerly Known as: Surgical Services departmental policy #2.15