22. Molecular Diagnostics Services Request Form REQUEST FORMS
141
22. Molecular Diagnostics Services Request Form (continued)
HTAA, KUANTAN
142
22. Molecular Diagnostics Services Request Form (continued) REQUEST FORMS
143
23. Molecular Study for Thalassemia - DNA Ana for Thal Synd & Hbpa-
thy(s) REQform Version 3.0
HTAA, KUANTAN
144
24. Ujian Molecular Anaysis for Leukaemia Version 2.0 REQUEST FORMS
145
25. Ujian HIV Genotype Resistance Testing (IMR/Viro/HIV/24)
HTAA, KUANTAN
146
26. Ujian PCR HIV (Bayi) - IMR/Virus/NARL2 REQUEST FORMS
147
27. Leptospirosis Laboratory Request Form - IMR/IDRC/BACT/LEPTO/01
HTAA, KUANTAN
148
28. Primary Immunodeficiency (PID) Screening - IMR/AIRC/PID/RF REQUEST FORMS
149
28. Primary Immunodeficiency (PID) Screen-
ing - IMR/AIRC/PID/RF (continued)
HTAA, KUANTAN
150
29. Peripheral Blood Cytogenetic REQUEST FORMS
151
29. Peripheral Blood Cytogenetic (continued)
HTAA, KUANTAN
152
30. Permohonan Peminjaman/Pengambilan Bahan Diag-
nostik Unit Histopatologi - HKL/JP/HI-BP-01 (Appendix 6-C) REQUEST FORMS
153
31. Permohonan Pengambilan Spesimen/Tisu Unit Histopa-
tologi - HKL/JP/HI-BP-02 (Appendix 6-D)
HTAA, KUANTAN
154
31. Permohonan Pengambilan Spesimen/Tisu Unit Histopa-
tologi - HKL/JP/HI-BP-02 (Appendix 6-D) (continued) REQUEST FORMS
155
32. Permohonan Mendapatkan Gambar Histopatologi - HKL/
JP/HI-BP-03 (Appendix 6-E)
HTAA, KUANTAN
156
33. Haematology / Serology Test (Borang Pusat Darah Negara) - PDN/
HA/QP-01/01 REQUEST FORMS
157
34. Permohonan Rujukan Ujian Immunohematologi
PDN/IH/QP-01/04
HTAA, KUANTAN
158
35. Permohonan Rujukan Ujian Platelet Immunologi
PDN/IH/QP-03/03 REQUEST FORMS
159
36. Molecular Study For BCR-Abl / JAK2 V617F and other test
HTAA, KUANTAN
160
37. Measles Laboratory Request Form - Appendix 3D REQUEST FORMS
161
38. Permohonan Ujian TB - TBIS 20C
HTAA, KUANTAN
162
INTEGRATED LABORATORY INTEGRATED
163
INTEGRATED LABORATORY
HTAA, KUANTAN 1.0 Introduction
Integrated Laboratory is the main laboratory in the pathology department where the
main receiving counter is located. It provides routine biochemical and hematological
testing and operates 24 hours.
2.0 Services
2.1 Routine Test
The biochemistry and hematology routine tests are received and processed in this
laboratory.
Please refer to Table 1 : List of Tests Available At Pathology Department for further
information of each test.
Routine test can be divided into office hours test and 24 hours test.
2.1.1 Office hour test
Office hour tests are routine test conducted from 08:00 am to 05:00 pm.
Examples are ESR, Lipid profile, Iron/TIBC, CRP, C3 and C4.
2.1.2 24 hours test
These are all test that are offered 24 hours in Integrated Laboratory :
a. Amylase
b. Ammonia
c. APTT
d. Bilirubin Total / Direct
e. Blood Urea Serum Electrolyte (Na+, K+, Urea, Chloride)
f. Blood Gas Analysis
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g. Calcium
h. Creatinine
i. Creatine kinase
j. CSF Biochemistry : Glucose, Protein, Globulin
k. Cardiac Enzyme (AST, CK, LDH)
l. D-Dimer
m. Full Blood Count INTEGRATED
n. Fibrinogen
o. Glucose
p. Lactate
q. Lactate dehydrogenase
r. Liver Function Test
s. PT / INR
t. Renal Profile (BUSE + Creatinine)
u. Urine Paraquat
v. Urine Pregnancy Test
w. Urine Dipstick
2.2 STAT/ Urgent Test
These are short turnaround time tests for immediate patient management. STAT/
Urgent test should ONLY be requested when it is clinically indicated. The misuse of
STAT/ Urgent request will lead to a delay in the true urgent cases.
The laboratory will prioritize specimens from the critical care unit (ICU, CCU, PICU,
NICU, CICU) and emergency department. Specimen from other unit may be considered
as STAT/ Urgent if the clinical indication provided is justified.
2.3 24 Hours Microbiology Tests Received After Office Hour
After office hour, the tests listed below which are done in the Microbiology Laboratory
during office hour are performed in the Integrated Laboratory :
a. BFMP
b. CSF Microscopy
c. CSF Culture
d. CSF Gram Stain, Indian Ink and Latex.
2.4 Specialised Tests
The specialised tests will be received at the counter but they will be checked and
processed in the respective laboratory.
165
• Please refer to Table 1 : List of Tests Available at Pathology Department for
further information of each test.
HTAA, KUANTAN Please refer Pre Analytical Requirement on page 5-9 for specimen preparation.
3.0 SPECIMEN COLLECTION, STORAGE & TRANSPORTATION
4.0 SPECIAL COLLECTION
4.1 Blood Gas and Lactate Specimen
A) Specimen Collection
1. Rinse a 1 ml disposable syringe with heparin (5,000 units per ml). Expel the
excess heparin; leaving only the dead space of the syringe filled by the heparin.
2. Draw 1 ml of blood.
3. Remove the needle from the syringe using Standard Precaution and dispose the
needle in designated sharps container.
4. Invert the syringe upward and expel air bubbles. A significant dead space in the
syringe may invalidate PO2 results.
5. Cap the syringe tightly using blood gas syringe cap.
6. Mix well to prevent the sample from clotting by rolling between the palms and
inverting it vertically. Clotted blood gas specimen received in the laboratory will
be rejected.
7. Label the specimen with patient’s name, RN/IC, test requested (Blood gas /
Blood gas and lactate), time of sampling and type of specimen (arterial / venous).
8. Complete the request form including the test requested (Blood gas / Blood gas
and lactate), time of sampling and type of specimen (arterial / venous).
B) Specimen Transportation
1. Put the syringe into a biohazard plastic bag and transport in ice slurry immediately
to the laboratory to ensure that analysis can be done within 30 minutes after
drawing of blood.
2. In circumstances whereby the result is needed urgently, the staff sending the
sample must wait for the result which will be ready within 15 to 20 minutes.
166
4.2 Fetal Cord Blood Gas Specimen
A) Specimen Collection
1. Rinse two (2) 1 ml disposable syringes with heparin (5,000 units per ml). Expel
the excess heparin; leaving only the dead space of the syringes filled by the
heparin. INTEGRATED
2. Double clamp the umbilical cord to isolate 10 cm of cord segment immediately
after birth.
3. Wipe the segment of cord to be sampled with alcohol swab.
4. Identify vessels in cord: 2 arteries (small vessels) and 1 vein (large vessel).
5. Insert the needle into an artery between the clamps, and withdraw 1 mL (at
least 0.5 ml) of blood (Always sample the artery first as the vessel is smaller and
the distended vein will stabilize the artery). Follow Procedure A3-A8 as in 4.1
Blood Gas and Lactate Specimen.
6. Repeat Procedure 5 with the vein.
B) Specimen Transportation
1. Follow Procedure B1-B2 as in 4.1 Blood Gas and Lactate Specimen.
Notes:
In the event when only one vessel can be sampled, the umbilical artery should be
sampled.
4.2 Ammonia
Specimen for ammonia analysis requires special procedure to prevent changes in
ammonia concentration while and after the specimen is drawn.
A) Preparation before Specimen Collection
1. The specimen should be collected in a fasted state (or at least 4 - 6 hours after
a meal), not following physical exercise, and smoking should be avoided for at
least 9 hours before specimen collection, unless in an emergency.
2. Contact Integrated Laboratory before the specimen is taken to ensure that
specimen analysis can be performed without delay.
B) Procedure of Collection
1. A venous specimen is best drawn without a tourniquet or immediately after the
tourniquet has been applied briefly.
167
2. If the tourniquet has been applied for long, it should be removed and blood
allowed to circulate for at least 2 minutes before the blood is withdrawn.
3. Collect 2 ml of blood in a container with EDTA as anticoagulant.
HTAA, KUANTAN C) Specimen Transportation
1. Chilled the specimen in ice slurry and send immediately to the laboratory.
Specimen received not in chilled condition will be rejected.
Notes:
Specimen for ammonia measurement must be centrifugated within 15 minutes of
collection to obtain the plasma. Delay in separation will cause elevation of ammonia
due to the generation and release of ammonia from the red blood cells. Once
separated, plasma is stable for 2 hours at 2 - 8 C and 3 weeks at -20 C.
o
o
4.3 Oral Glucose Tolerance Test (OGTT)
A) Preparation before Specimen Collection
1. The patient should be on unrestricted diet (containing at least 150 g of
carbohydrate per day for three days ) and activity.
2. Patient should fast overnight (at least 8 hours but not longer than 16 hours).
Plain water is allowed but no other beverage is permitted.
B) Procedure of Collection
1. In the morning following the overnight fast, take basal blood specimen for
glucose determination. Labelled the specimen as Glucose (FBS). Complete the
request form including the test requested (OGTT: FBS) and time of sampling.
2. Give 75 g glucose in 250-350 ml water (For children, the glucose dose is 1.75
g/kg body weight up to a maximum of 75 gm). Patient should finish the drink
within 5 minutes.
3. Take further blood specimen at 2nd hour after glucose load. Labelled the
specimen as Glucose (2HPP). Complete the request form including the test
requested (OGTT: Glucose (2HPP)) and time of sampling.
Notes:
Patient should rest throughout the test; smoking not permitted; drinks of plain water
are allowed.
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5.0 REFERENCE RANGE
Please refer reference range provided in the test results/reports.
6.0 REPORTING RESULTS INTEGRATED
After validation, the result will be despatched to the designated pigeon hole as soon as
the result is ready. If the result is a critical value, it will be informed to the requesting
doctor / ward staff via the telephone.
Please refer to the laboratory turnaround time (LTAT) as guidance while tracing the
results.
Notes:
After result reporting, the laboratory keeps the routine tests samples for an average
of 2 days before they are discarded.
169
HTAA, KUANTAN CHEMICAL PATHOLOGY
170
CHEMICAL PATHOLOGY
1.0 INTRODUCTION
The Chemical Pathology Laboratory provides biochemical investigations for the CHEMICAL PATHOLOGY
purpose of diagnosis, monitoring disease progression and screening in Hospital Tengku
Ampuan Afzan. It also serves as a referral centre for the State of Pahang.
2.0 SERVICES
The Chemical Pathology Laboratory provides the following services:
1. Specialised Chemical Pathology - The tests offered include Hormonal Assays,
Tumour Markers, HbA1c and Urine/ Dialysate Chemistry. The specialised tests
are analyze in batches according to the workload and needs.
2. Drug of Abuse - The service provided are Morphine (screening and confirmation),
Cannabinoids (screening and confirmation) and Amphetamine-Type Stimulant
(screening).
3. Outsource - Specialised investigations not offered in are referred to outside
reference laboratories. Specimens received will be prepared and stored
according to the requirement before being transported to the referral laboratory.
All tests are offered during office hours; with the exception of TFT for congenital
hypothyrodism screening programme/ urgent and ThCG urgent.
Testing of samples for congenital hypothyroidism screening programme is available on
weekends and public holiday. Analysis of these samples will be done in batches.
Urgent testing may be required in the following conditions:
1. TFT in suspected thyroid storm
2. ThCG in suspected ectopic pregnancy
To arrange for urgent testing, please request via the pathology medical officer on-call/
chemical pathologist. Result of indicated urgent request will be relayed back to the
requesting clinicians within 24 hours.
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3.0 SPECIMEN COLLECTION, STORAGE & TRANSPORTATION
Please refer to Table 1: List of Tests Available at Pathology Department and Table 2: List
HTAA, KUANTAN 4.0 SPECIAL COLLECTION
of Tests to Referral Laboratories for further information of respective tests.
4.1 24 Hours Urine Collection
A 24 hours urine collection is important in determining the concentration of certain
analytes because it allows for circadian rhythmic changes in excretion at certain time
of day.
The 24 hours urine container for this collection is available at the Integrated Laboratory
Counter and will be provided upon request; with accompanying request form or
specimen containers request form.
For some investigations, an acid preservative is added to the collection bottle. These
bottles come with the following label :
WARNING!!!!!!!!
This bottle contains 6M HCl acid
preservative
On skin contact wash off immediately
Notes:
Do not empty the container, as it contains strong acid preservative which may cause
severe burns.
172
Procedure of Collection
1. Write the patient’s name, RN/IC and test requested on the label of the container
(If collection is done by the patient, the laboratory staff will write down the
patient’s detail as written on the request form). Once collection is started, all
urine excreted within the time should be collected in the container.
2. On the first day of collection, the first urine voided must be discarded. Time of CHEMICAL PATHOLOGY
first urine voided is the start of the timing for the 24 hours collection. Write the
date and time on the label.
3. Thereafter, all urine should be collected until the end of the 24 hours period.
4. Urine should be passed into a separate small container at each voiding and then
emptied into the 24 hours urine container. Do not urinate directly into the 24
hours urine container to avoid any injury cause by the content preservative (e.g.
acid).
5. If the patient has a bowel movement during the collection period, precautions
should be taken to prevent faecal contamination.
6. At the end of the collection, the last urine voided is collected. The collection is
now complete.
7. For in-patient, the ward staff must follow these insructions:
• Measure and record the 24 hours urine volume on the test request form and
patient’s record.
• Mix the contents of the 24 hours urine container gently but thoroughly.
• Examine to ensure that the contents appear homogeneous.
• Transfer at least 10mL of urine from the 24 hours urine container into a
universal container.
• Label the universal container with patient’s name, RN/IC and test requested.
8. If collection is done by the patient, send the entire 24 hours urine sample with
request form to the laboratory.
Notes:
Ensure the container cap is firmly screwed before transportation to prevent leakage.
Refrigerate the sample for the best result.
4.2 Creatinine Clearance Test
1. Follow Procedure 4.1 for 24 hours urine collection.
2. During the 24 hours urine collection time (but not within 1-3 hours after a large
meal), send a blood sample for serum creatinine analysis.
Notes:
Serum creatinine level during the 24 hours urine collection is required to enable the
calculation of creatinine clearance.
173
4.3 Cord TSH for Congenital Hypothyroidism Screening Programme
1. Immediately after delivery, clean the maternal side of the cord with sterile gauze
HTAA, KUANTAN 2. Allow free flow of blood from the cord directly to the tube. If there is a need to
and collect the blood sample.
‘milk’ the cord, do it gently to prevent hemolysis.
3. The tube should be filled with a minimum of 3 ml of blood. Allow space for the
cap to be pushed in.
4. Label the tube immediately.
5. Complete the investigation form (HTAA-OBG-B-015)
6. Send the sample and request form to the laboratory at the normal routine
intervals.
Notes:
If for some reason the blood sample has not been taken from the cord, then it should
be taken from the baby as soon as possible after the third day of life. This is to avoid
the TSH surge that occurs from 1/2 hour after birth to about 72 hours of age and to
ensure early treatment before 2 weeks of life for better prognosis. Blood samples
collected after the 3rd day of life should be a venous samples of at least 2 mls.
4.4 Drug of Abuse Testing
1. Specimen collected must be properly supervised. Collection site must have
suitable toilet facilities and are free from soap, dispenser or cleaning agent.
2. Urine specimen should be collected in duplicate using 30 ml clean leak-proof
container and should be filled up at 2/3 full each. This is to ensure that further
analysis can be carried out to confirm the presence of drugs in the urine.
3. The urine containers should be securely capped and sealed.
4. Containers are labeled in front of suspect/ donor with the following particulars:
• Name
• I.C Number
• Date of Collection
• Time of Collection
• Signature of person:
a) Supervising the collection process
b) Suspect/ donor
5. The authorized personnel to request drug analysis should be a qualified Medical
Officer/ Sergeant and above.
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Flow Chart for Urine Drug Confirmation
CHEMICAL PATHOLOGY
Screening Test for
Morphine/Cannabinoids/
Amphetamine-Type Stimulants
(ATS)
Negative Positive ATS
Screening
Result
Positive
Morphine/Cannabinoids
Confirmation
Report Report Screening
report
175
4.5 Procedure for Collection of Dried Blood Spot on Whatmann Filter Paper
A) Filter Paper
HTAA, KUANTAN Whatmann 903 filter paper is required which has special thickness and is manufactured
solely for blood collection.
B) Time of Collection
Timing of collection is critical. It is recommended that the DBS sample for Newborn
Screening of IEM be collected from already fed baby at the age between 48-72 hours.
If a baby is to be discharged before 48 hours of age, blood can still be collected but
a repeat sample at >48-72 hours may be required. This allows for early metabolic
changes and the commencement of milk and protein feeds.
Samples collected too early may give false negative results. Samples collected too late
may place children with health problems at risk of irrevirsible damage.
C) Procedures
i) Making DBS from Heel-prick or Finger-prick
For normal newborn baby without any symptoms, it is advisable to collect blood from
heel-prick.
1. Label each card with baby’s identifications and date of collection and any other
pertinent information.
2. Wear gloves and warm the foot with warm cloth/ towel.
3. Clean the side area with either alcohol swab then dry with a clean gauze or
cotton wool swab.
4. Puncture heel with sterile lancet (point <2.4 um) on medial or lateral plantar
surface.
5. Allow puncture to ooze and wipe away first drop of blood with cotton swab.
6. Gently massage above the puncture to encourage blood flow and drop a big
spot of blood onto each of the 3 circles on the filter paper.
7. Continue step (5) and (6) until all the circles are filled. One full drop of blood
equivalent to 50ul is required to fill each circle. Blood must soak through the
card to the other side. Do not drop more than one drop of blood on one circle.
8. Completely dry the card at room temperature (25 C to 30 C) on a clean, flat,
o
o
non-absorbent surface or a drying rack designed for the purpose, for more than
4 hours or overnight. Minimum time needed for drying is 4 hours.
9. To avoid contamination of the sample, do not touch the blood spot circle with
bare hand.
176
10. Place dried filter paper in an individual plastic bag for transport. It is
recommended that the filter paper (dried blood spot) is store away from any
source of heat, liquid and organic fumes.
ii) Making DBS from Blood Collected from Venepuncture
1. Label each card with patient reference, sample collection date and any other CHEMICAL PATHOLOGY
pertient information.
2. Collect blood in heparinised tube (green top). If blood is drawn in a syringe,
transfer it into a green tube.
3. Set a hand-held pipettor to 50uL volume and fill the pipette tip with blood. (If
the tube has been sitting still for more than 2 minutes, it must be mixed by
inverting it up and down few times before pipetting).
4. Follow Procedure (8)-(10) as in C.i) Making DBS from Heel-prick or Finger-prick.
Notes:
The filter paper card(s) must be completely dry before dispatch. Protect them from
moisture or condensation at all times.
Store at 4 C if the card is transported the next day after it is dried. Freeze at -20 C for
o
o
long-term storage.
The DBS must be prepared at least 4 hours ahead of transportation to allow complete
drying.
D) Quality of DBS
i) Acceptable Blood Sample Cards
Each blood spot is checked for acceptability. Blood spot should be dry, the pre-printed
circles filled and appear as an even dark colour on both sides of the card without lighter
discolouration.
ii) Rejection Criterias
Unsuitable DBS will be rejected such as follows:
1. Lack of blood coverage (Quantity insufficient for testing - Blood spot’s diameter
is too small)
2. Layering of blood
3. Incomplete blood saturation
4. Separation of red blood cells and serum
5. Blood spot contaminated with fungus
6. Blood spot is diluted/ contaminated with water
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4.6 Requirements for Requesting Molecular Diagnostics Services
1. All cases requiring molecular diagnostics testing must be referred to any Clinical
HTAA, KUANTAN 2. Please ensure that the patient or their parent/ guardian both understand the
Geneticist/ Neurologist/ Physician/ Paediatrician and they must endorsed the
test before any sample submission be made. Sample received without referral
from Clinical Geneticist/ Neurologist/ Physician/ Paediatrician will be rejected.
implications of genetic testing and provide their consent to undertake the test.
3. Please ensure samples are sent rogether with both request from and informed
consent form.
5.0 REFERENCE RANGE
Please refer to reference range provided in the test results.
6.0 REPORTING RESULTS
After validation, the result will be despatched to the designated pigeon hole/post
according to the location stated on the form.
Please refer to the laboratory turnaround time (LTAT) as guidance while tracing the
results.
Note:
After result reporting, the laboratory keeps the tests samples (excluding drug of
abuse testing) for an average of 2 days before they are discarded.
178
HAEMATOLOGY HAEMATOLOGY
179
HAEMATOLOGY
HTAA, KUANTAN 1.0 INTRODUCTION
Haematology Laboratory serves as referral centre for haematology service in Pahang.
This laboratory offers specialized haematology testing including some coagulation
tests.
2.0 SERVICES
Test offered in hematology laboratory are listed below. Specialised tests are performed
in batches according to the workload and needs.
Routine Hematology :
1. Full Blood Count (FBC)
2. Erythrocyte Sedimentation Rate (ESR)
3. D-dimer
4. Prothrombin time (PT)
5. Activated partial thromboplastin time (aPTT)
6. Fibrinogen
These routine hematology test are performed at Integrated laboratory and offered 24
hours except ESR which is only offered during office hour.
Specialised Hematology :
1. Full Blood Picture (FBP)
2. Hb Analysis
3. Bone Marrow Aspiration (morphology and cytochemistry)
4. CD4 and CD8 count
5. G6PD screening
6. NAP score
7. Kleihauer test
8. Osmotic Fragility test
9. Urine Hemosiderin
180
Coagulation test :
1. Lupus Anticoagulant study
2. Mixing aPTT test
3. Factor VIII assay
4. Factor IX assay HAEMATOLOGY
5. Factor VIII inhibitor assay
6. Factor IX inhibitor assay
Other test : Seminal Fluid Analysis.
Please refer to each test below for further information.
3.0 SPECIMEN COLLECTION, STORAGE AND TRANSPORTATION
1. Please refer to Table 1 : List Of Tests Available At Pathology Department for type
of specimen, container and sample volume required for each test. To ensure
consistent and accurate result, follow strictly to the volume of blood required or
fill the blood sample to the mark on the container.
2. The optimum anticoagulant use for blood cell analysis in Haematology is K
2
EDTA.
3. The optimum anticoagulant for coagulation test is 3.2 % sodium citrate.
4. Clotted sample is NOT suitable for blood cell analysis.
Avoid clot formation by:
- Ensuring a smooth venepuncture and steady flow of blood into the syringe.
- Introducing the blood in the anticoagulant bottle as soon as the blood has
been drawn.
- Immediate mixing of the blood by inverting the tube at least 6-10 times
gently.
- Putting correct volume of blood into the tubes.
5. To prevent hemolysis:
- Avoid vigorous mixing.
- Send the specimen to the laboratory as soon as possible.
- Use large bore needle.
181
4.0 SPECIAL COLLECTION
HTAA, KUANTAN a. Please call haematology laboratory at ext. 2077 to arrange for an appointment
4.1 Bone Marrow Aspiration
AT LEAST 2 days prior to the procedure except for the new case of suspected
acute leukemia.
b. On the appointment date, laboratory technologist will be at the procedure
room to prepare smears from the bone marrow aspirated by the doctor. The
ward is requested to ensure that all necessary preparations are ready to avoid
unnecessary waiting of the laboratory technologist prior to commencement of
procedure.
c. The procedure should be conducted as scheduled below:
Time Name/Patient IC
9:00am - 10.00 am First patient
10:00 am -11:00 am Second patient
11:00 am - 12:00 pm Third patient
12:00 pm - 1:00 pm Fourth patient
d. All bone marrow sample must be accompanied by FBP sample.
e. All sample tubes must be labeled by requesting doctor.
f. Request forms must be completely filled by the requesting doctor including
clinical history, relevant physical findings, previous drug/treatment history,
indications or reason for performing the test etc.
g. Special test eg: Immunophenotyping, Molecular Study and cytogenetic test
will be sent to other hospital as stated in the Table 2: List of Tests to Referral
Laboratories.
4.2 Haemoglobin Analysis
a. For request from district hospitals or health clinics, it must be accompanied by
validated FBC result, blood smear and EDTA blood sample.
b. During transportation from outside hospital, samples should be kept at room
temperature. Avoid direct contact with ice to prevent haemolysis.
c. For cascade thalassaemia/family screening, please include stamp which contain
details of index patient:
182
Cascade Thalassaemia Screening
Case Index Name: HAEMATOLOGY
Case Index Identification Number:
Case Index Registered Laboratory:
Diagnosis:
Case Index Relationship with Client:
Client example: Ali bin Ahmad
Cascade Thalassaemia Screening
Case Index Name: Ali bin Ahmad
Case Index Identification Number: 070707-07-5777
Case Index Registered Laboratory: Hospital Sungai Buloh
Diagnosis: Hb Constant Spring
Case Index Relationship with Client: Son
DONT’S in the haemoglobin analysis request:
- Do not send post transfusion sample
- Do not send haemoglobin analysis for newborn/baby less than 1 year.
183
4.3 Guidelines for Full Blood Picture request:
Full blood picture are indicated in cases as below:
HTAA, KUANTAN a. History and clinical findings of:
• thrombocytopenia (petechial rash, easy bruising)
• neutropenia
• symptomatic anaemia
b. Suspicion of haematological malignancy e.g. acute/ chronic leukemias, MPN,
MDS, LPD based on:-
• Symptoms e.g . weight loss, fever/ PUO, itching, easy bruising,
hyperviscosity syndrome
• Clinical findings: lymphadenopathy, splenomegaly, hepatomegaly, plethora,
petechia.
c. Suspicion of disseminated non-haematological malignancy
d. Clinical suspicion of:
• Haemolysis
• MAHA/ fragmentation syndrome supported by relevant biochemical,
coagulation and hematological investigation results (e.g. serum bilirubin,
reticulo cyte count, LDH, DCT, PT, APTT etc.)
e. Infection/ inflammatory condition that may require FBP to confirm or support
diagnosis e.g. infectious monucleosis, parasitic disease (malaria).
f. Clinical suspicion of thalassemia/ hemoglobinopathy or membrane disorder
g. When performing bone marrow aspirates procedure.
h. Abnormal blood cell indices :
WBC > 30 x 109/L , WBC < 3 x 109/L .
Abnormality of the differential WBC:
Neutrophils: < 1.0 x 109/L, > 20 x 109/L
Lymphocytes: > 5 x 109/L
Monocytes: > 1.5 x 109/L
Eosinophils > 1.5 x 109/L
Platelets count < 100 x 109/L or Platelet > 1000 x 109/L.
Hb < 8 g/dL (ISLH: 7), Hb: > 18g/dl (male), 16.5g/dl (female).
MCV < 75fl, MCV > 100 fl
184
i. FBP is NOT indicated in the following:
• Healthy patient with normal blood cell indices including medical check-up
except personnel exposed to radiation.
• Post transfusion sample except as part of investigation of transfusion reaction.
• Investigation of anaemia with clinical evidence of recent bleed.
j. It is compulsory to write relevant clinical information ( clinical summary and
indication for FBP request) in the request form. HAEMATOLOGY
k. FBP urgent : If FBP is really needed urgently, please state reasons and you should
contact/see medical officer or pathologist in charge.
4.4 Osmotic Fragility Test, CD4/CD8 Count, Sickling test, Kleihauer test and Neutrophil
Alkaline Phosphatase score
All these test require appointment. On the appointment date, collect the blood
specimen in the EDTA tube and send to the laboratory immediately.
4.5 Coagulation and Hemostasis test (PT, aPTT, fibrinogen, D-dimer, mixing test,
factor assays, lupus anticoagulant, inhibitor study).
a. For haemostasis test venous blood sample should be obtained by clean
venepuncture at a site away from an intravenous line. This is important as
heparin/ other contamination will cause spurious abnormal result.
b. During blood collection, use light pressure using a tourniquet and avoid
prolonged application (if possible < 1 minute). Avoid slow flowing draws and/or
traumatic venepunctures.
c. Use sodium Citrate tube container and it must be adequately filled (follow the
ring mark on the tube).
d. Sample should be mixed thoroughly with the anticoagulant by gentle inversion
of the blood tube.
e. The sample must be transported to the laboratory as soon as possible and
processed (centrifuged)/tested within 3 hours after sampling.
f. Request for D-dimer, mixing test, factor assays and inhibitor are on appointment
basis. Please call medical officer on call for approval.
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4.6 Thrombophilia investigations
a. This test is referred to Pusat Darah Negara, Kuala Lumpur.
HTAA, KUANTAN c. Collect 6 tubes of 2.7 ml blood in Trisodium Citrate container.
b. Test included are : Protein C, Protein S, Anti thrombin, activated protein C
resistance and molecular study ( Factor V laiden, PT 20210A mutation ) if
indicated.
d. Mix well by inverting gently the container a few times to avoid clot formation.
e. The specimen should be accompanied by ‘ADEQUATE’ clinical history of the
patient using special dedicated form (Refer to Page 157-159 form Pusat Darah
Negara). Other particulars and doctor’s name together with any contact
address/telephone number should be legibly written (for confirmation of
patient’s clinical condition and laboratory result).
5.0 REFERENCE RANGE
Please refer to reference range provided in the test results.
6.0 REPORTING OF RESULT
a. All bone marrow aspiration report must be collected from the Haematology
laboratory. Other reports will be despatched through designated pigeon hole.
b. Reports for cases from district Hospitals or Health clinic will be despatched by
post.
c. The reporting of bone marrow trephine biopsy is by haematopathologist and
report must be collected from Histopathology counter.
186
MICROBIOLOGY MICROBIOLOGY
187
1.0 INTRODUCTION
HTAA, KUANTAN Medical Microbiology is an essential component in the infectious disease field and
knowledge in this area is vital to the clinical management of infection. Microbiology
unit is particularly involved in isolation of the causative agents as well as monitoring
and screening of diseases.
Microbiology unit divided into five sub-units:
i. Bacteriology
ii. Mycology
iii. Serology
iv. Parasitology
v. Molecular
2.0 SERVICES
Microbiology unit provides the following services:
i. Diagnostic microbiological services which comprise of bacteriology, mycology,
serology, parasitology, TB diagnosis and molecular testing.
ii. Participation in hospital wide infection control activities related to
surveillance,control and anticipation of nosocomial infections.
iii. Provision of microbiologic studies of the hospital environment and sterility
testing.
188
3.0 SPECIMEN COLLECTION AND HANDLING
3.1 General guidelines
a. The quality of laboratory results depends greatly on the proper collection
and handling of the specimen as well as obtaining satisfactory material for MICROBIOLOGY
examination.
b. The clinical specimen must be material from the actual infection site and must
be collected with minimum contamination from adjacent tissues, organs or
secretions.
c. A sufficient quantity of specimen must be obtained in order to perform the
examination required.
d. Appropriate collection devices, specimen containers and culture media must be
used to ensure optimal recovery of microorganisms.
e. Ideally, the specimen must be collected before the commencement of antibiotic
therapy.
f. The specimen container must be properly labelled, placed in a biohazard plastic
bag and accompanied by a completed laboratory request form.
g. Specimens are best transported immediately to the laboratory.
4.0 REJECTION CRITERIA
Requests which do not fulfill the laboratory reuirement will be rejected. Apart from
general rejection criteria used (page 10), there are specific rejection criteria for
microbiology laboratory which are:
1. Incorrect ratio of urine and boric acid (urine volume too little, <20 ml).
2. Sample not suitable for testing - saliva send for sputum culture and formed stool
send for rotavirus and Clostridium difficile antigen and toxin detection.
3. Tissue for culture send in formalin.
4. Wrong container - adult blood culture in paediatric blood bottle and body fluid
other than urine send in boric acid container.
5. Two or three sputum AFB samples taken at the same time.
6. BFMP smear too thin or too thick.
7. BFMP smear dislodged during staining.
8. Swab send without VTM for influenza and MERS-CoV testing.
9. Sample for influenza and MERS-CoV test send without ice.
189
10. Stool for rotavirus andtigen detection received from patient of more than 2
years old.
HTAA, KUANTAN 12. HIV/Hepatitis request without risk factors or indication stated on the form.
11. Dengue NS1 test not requested through Clinical Microbiologist.
13. HIV/Hepatitis screening requested is less than 3 months from the previous
request for HDU patient.
14. HIV/Hepatitis screening requested is less than 6 months from the previous
request for patient with risk factors, regular transfusion patient, patient
undergoing surgery or procedures eg: COROS.
I. BACTERIOLOGY
1.0 REQUEST FORM
All requests shall be made by using Pathology Service Request Form
(PER-PAT 301) except for H1N1 by using Lab Request Form for Suspected Case of
Influenza A (H1N1) (Annex 11) in duplicate; MERS-CoV and TB culture.
2.0 SPECIAL COLLECTION
2.1 Blood cultures and bone marrow aspirate for culture
An automated blood culture system with different types of bottles according to age
and tests is available:
190
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