actrec supplement sample collection issue no.03

Tata Memorial Centre –ACTREC Diagnostics Services Status : Controlled

Doc.No. : ACTREC-01 Supplement Sample collection manual for ACTREC

Issue No : 03 Issue Date : 20/12/2018 Prepared & Issued By : MS, ACTREC Copy No.

Amend. No : 00 Amend Date : 00 Maintained by: Quality Manager, ACTREC

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AMENDMENT SHEET

Sr. Page Section/ Date of Amendment Reasons Signature

No. No. Clause Amendment made of Quality

Manager

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.





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AMENDMENT SHEET

Sr. Page Section/ Date of Amendment Reasons Signature

No. No. Clause Amendment made of

Quality

Manager

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.





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PREFACE

Supplement Sample Collection Manual for ACTREC, ACTREC 01, Issue Number. 03 has been brought to incorporate the Sample Collection information for Diagnostic services of Advanced Centre for Treatment, Research and Education in Cancer (ACTREC). The document is revised to comply with revised ISO Standards ISO 15189:2012 and NABL 112 Standards. The manual has been brought out for easy reference by the concerned staff at ACTREC. A copy of this document is made available at all Sample collection locations at ACTREC and TMH.





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CONTENTS

Section Subsection Contents Page no.

Title Page i

Quality System Manual Release Authorization ii

Amendment Sheet 1

Preface 3

Contents 4

Abbreviations 8

Distribution List 9

Normative references

10

5.0 Introduction 11

6.0 Registration 11

6.1 Types of patients 11

6.2 Requisition process 12

7.0 Sample collection and acceptance centres

7.1 In patients 12

7.2 Out patients 13

7.3 Staff patients 13

7.4 Referral patients

13

7.5 Instructions for ACTREC Liaison counter 14





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CONTENTS


8.0

Instructions for handling surgical pathology specimens for OT Nurses

14

Instructions for handling cytopathology specimens

16

Policy for dispatch and receipt of surgical pathology and cytopathology slides/blocks between TMH and ACTREC

20

Schedule of sample transport between TMH and ACTREC 21

9.0 Sample Collection – Blood

9.1 Instructions to patients 21

9.2 Instructions to phlebotomy (Blood culture) 22

9.3 Instructions to sample collection staffs (OPD & IPD) 23

9.4 Emergency services 25

9.5 Special instructions 25

9.6 Materials used for phlebotomy 25

9.7 Primary sample identification chart 25

9.8 Labelling of vacutainer tubes 25

9.9 Procedure for phlebotomy 26

9.10 Storage conditions 26

9.11 Criteria for rejection 26

10.0 Microbiology & Serology





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CONTENTS


10.1 Sample collection for microbiological investigations

28

10.2 Requirements for serological investigations 34

10.3 Sample collection and rejection chart for mycology 35

11.0 Transfusion medicine

11.1 List of tests 36

12.0 Hematopathology laboratory – Morphology, Flow cytometry and Molecular Division

12.1 Types of materials to be accepted for processing 36

12.2 Handling of samples 37

12.3 Procedure for sample collection (Peripheral blood/Bone marrow/body fluids/FNA/Fresh tissue)

37

12.4 Procedure for sample transportation 38

12.5 Sample receiving 39

12.6 Receipt of transported samples at Hematopath lab. 40

12.7 Sample rejection criteria 40

12.8 Critical alert for APML sample 40

12.9 Primary sample receiving record 40

12.10 Storage of examined samples 41

12.11 Sample disposal 41

12.12 Repeat examination due to analytical failure or further examination of same primary sample

41





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CONTENTS


12.13 Report collection 41

13.0 Cancer Cytogenetics Department

13.1 Types of materials to be accepted for processing 42

13.2 General instructions for sample collection & storage 42

13.3 Instruction to clinicians 43

13.4 Sample collection areas , requisitions , billing , transportation , receiving & outside referrals

43

13.5 Sample storage

45

13.6 Sample disposal 45

13.7 Transport of samples 45

13.8 Sample acceptance criteria 46

13.9 Sample rejection criteria 46

13.10 Primary sample receiving record 47

13.11 Repeat examination due to analytical failure or further examination of same sample

47

13.12 Report collection 47





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2.0 ABBREVIATIONS

ACTREC- Advanced Centre for Treatment, Research and Education in Cancer

Amend- Amendment

AMS- Assistant Medical Superintendent

Doc.-Document

DQM- Deputy Quality Manager

HOD-Head Of Department

ISO- International Organization for Standardization

NABL- National Accreditation Board for Testing and Calibration Laboratories

No. - Number

OIC- Officer In Charge

QA- Quality Assurance

QM- Quality Manager

QSM- Quality System Manual

SOP- Standard Operating Procedures

TMC- Tata Memorial Centre

TMH- Tata Memorial Hospital





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3.0 DISTRIBUTION LIST

NOTE: Soft copy of Supplement Sample Collection Manual is available on ACTREC Intranet , ACTREC APP Portal and ACTREC website.

Controlled Copy No. Designation of the Holder 01 Director, ACTREC

02 Deputy Director, CRC, ACTREC

03 Laboratory Director, TMC

04 MS, ACTREC

05 Quality Manager, ACTREC

06 Quality Manager, TMH

07 DNS, ACTREC

08 Officer Incharge, Transfusion Medicine, ACTREC

09 Officer Incharge, Composite laboratory, ACTREC

10 Officer Incharge Microbiology, ACTREC

11 Officer Incharge Surgical Pathology, ACTREC

12 Officer Incharge,Heamatopathology, ACTREC

13 Officer Incharge ,Cancer Cytogenetics ,ACTREC

14 Officer Incharge ,Hematopathology, TMH

15 Medical Oncologist, ACTREC

16 Physician , General Medicine, ACTREC

17 Surgical Oncologist, ACTREC

18 Radiation Oncologist, ACTREC

19 Staff Physician , ACTREC

20 Nursing Admin Office , ACTREC

21 Sister Incharge, Day Care (PS), ACTREC

22 Sister Incharge,IR,MRI Recovery (PS) ACTREC

24 Sister Incharge, Ground floor ward (JS), ACTREC

25 Sister Incharge, Second floor ward (JS), ACTREC

26 Sister Incharge, BMT (JS),ACTREC

27 Sister Incharge, ICU (JS), ACTREC

28 Sister Incharge, OT (JS), ACTREC

29 Sister Incharge, Hematolymphoid Ward, (PS), ACTREC

30 Sister Incharge, CRC ward (PS), ACTREC

31 Phlebotomist, Sample collection area- PS/126, ACTREC (Hard Copy)





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4.0 Normative References

The following references are the source material used in writing this document;

ISO 15189:2012 - Medical laboratories - Requirements for quality and competence.

Inputs from the Diagnostic Services at ACTREC, TMC





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5.0 Introduction: ACTREC, Advanced Centre for Treatment, Research and Education is the Research arm of Tata Memorial Centre and Consists of CRC and CRI. Clinical Research Centre (CRC) started in 2005 is involved in developing and testing more effective, refined and affordable method of Cancer treatment. The Cancer Research Institute carries out Basic Research in Oncology. 6.0 Registration:

ACTREC:

Patients on IRB approved protocol are referred to ACTREC by the Principal Investigator and are treated at ACTREC both as IPD or OPD as required.

Patient enrolled in IRB approved protocol referred from TMH to ACTREC are to be registered at ACTREC. It is mandatory to have following documents in Patient Case file for the Registration process at ACTREC. This includes duly filled Informed Consent form for the Protocol, Document copy of Approval Scientific and Ethics Committee and the Reference letter. The patient can fill the consent form in any of the three languages i.e. Hindi, Marathi or English. The documents are sent for the appropriateness at the ACTREC Liaison counter located at TMH on the ground floor of the Main Building.

The patient then gets registered with ACTREC with unique TMC Identity number and the patient data from TMH is transferred in the HIS at ACTREC for future reference. For all transaction purpose the patients unique Case file no. will be used which is common across both TMH and ACTREC.

Further Non protocol patients are also registered in case of Hemtolymphoid malignancies, patients residing in Navi Mumbai and Raigad district and patients for Intervention Radiology procedures.

6.1 Types of Patients:

Patients seeking investigations in TMC are categorized as follows:

ACTREC:

In patients : Patients who are admitted and treated at ACTREC

Out patients : Patients treated at ACTREC but not admitted

Referral Patients: These are patients referred to ACTREC for investigations only

Protocol Patients: Patients who enroll for project and research protocol

Staff Patients: Patients who are employees of TMC





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6.2 Requisition Process:

The treating clinicians will order investigations based on the clinical condition of the patient. These investigations are entered on the HIS system by the doctors, Nurses and authorized trained and competent clerical staff as per convenience. For Inpatients the Requisitions and memos are generated at the Nursing stations and for Outpatients at the Front office.

The requisition has the details of the patients and the investigations to be performed in the following format:

a) Name of the organization b) Name of the laboratory for which the test requisition is raised c) Unique Case file number (patient identity) d) Name of the patient e) Age and Sex f) Status of the patient whether inpatient / outpatient g) Unique requisition number h) Referral DMG (Disease Management Group) i) Nature of sample j) Investigations requested k) Clinical history/ Provisional diagnosis l) Date and time of raising the requisition m) Category (General/private/semiprivate) n) Service/Department o) Modality (section) p) Date, Time and Memo number q) Signature and name of the personnel raising the requisition

7.0 Sample Collection and Acceptance Centres:

The personnel at the sample collection centre collect or accept samples from the patients and forward the same to the appropriate laboratory in the hospital. The following are the different locations where samples are collected / accepted.

7.1 In-Patients:

Protocol patients registered for the various research programs approved by the organization and their samples are collected by the personnel chosen by the Project In-charge or Principal Investigator and sent to the respective laboratories.





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The Sample Collection for all the In patients is collected in the respective Wards, OT, ICU and BMT. Also, the sample collection for patients undergoing Chemotherapy admitted in the Daycare ward located on the first floor of Paymaster Shodhika is performed in the Daycare.

Sample collection in the wards is performed by qualified and trained nurses and doctors.

Samples requested for Vitamin D and Methotrexate has to be collected in Plain tube and it has to be covered with silver foil or paper to avoid exposure to light.

The frozen section samples are collected during the Surgical procedure in the respective Operation Theatres in the ICU OT complex located on the first floor of Jussawala Shodhika and taken to the Frozen section laboratory located in the ICU - OT Complex itself, in order to facilitate intraoperative diagnosis and staging. The surgical biopsy samples are collected in a suitable container and sent appropriately in the Surgical Pathology laboratory situated on the Ground floor of Khanolkar Shodhika for Primary diagnosis.

7.2 Out-patients:

Sample collection for all the Out patients is done by trained technicians/

phlebotomists, in room no. PS 126 (Sample Collection Area), 1st Floor, Paymaster Shodhika. The building has provision of elevator for the same in order to help the patients to reach the Sample Collection Area.

Hours of working: Collection timings at Sample Collection Area Room no. PS 126 are 8.30 to 4.30 pm (Monday to Friday).

Lunch time 1.30pm to 2.00 p.m.

Saturday working time: 9.30 am to 1.00pm

7.3 Staff patients:

The employees of TMC are referred to as Staff Patients. The samples of the staff patients can be collected at any of the above mentioned sample collection areas.

7.4 Referral patients:

The patients referred from outside for surgical pathology opinion, bring slides/blocks or specimen and get registered at front office counter and are sent to surgical pathology lab.





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7.5 Instruction to the staff at the ACTREC Liaison Counter – 1st Floor HBB at TMH:

The Patient referred to ACTREC from TMH is guided by the ACTREC Liaison counter staff for receiving the relevant documents needed to register at ACTREC.

The documents brought by the patients are checked thoroughly to avoid any incomplete documentation. These documents are Patient consent forms, Reference letter, approval from Ethics Committee and Scientific Committee with the signatures of the Principal Investigator.

The ACTREC Liaison Counter is responsible for proper delivery of samples dispatched from ACTREC through our in-house transportation vehicle to the respective laboratory at TMH.

ACTREC liaison counter is also responsible for dispatch of sample collected at TMH with appropriate documents to the in-house transportation vehicle running between TMH and ACTREC.

The counter maintains record for the sample acceptance time and report dispatch time along with the name of the personnel attending to the sample or report.

Reference: QSP for transportation of samples – QSP - 19

8.0 Surgical Pathology and Cytopathology

8.1 Instructions for handling Surgical Pathology Specimens for Operation Theatre Nurses

Specimen receiving time in Pathology Lab:

Specimens will be accepted in the pathology department if sent before 5pm on all working weekdays (Monday to Friday).

On Saturday, the specimens will be accepted up to 1:30pm only.

Frozen section timing:

All working weekdays (Monday to Friday): 9:30am to 5:00pm

Saturday: 9:30am to 1:30pm.

1. Specimens will be accepted for frozen section, only if they reach frozen section

laboratory BEFORE above mentioned time.

2. All the specimens should be labelled properly with case no., name and site of

operation and also numbered when more than one sample is received from one

patient, against the requisition forms as soon as the surgery is over.





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3. The requisition form should clearly mention the total number of specimens sent

along with the forms.

4. If any one of the specimen is sent for frozen section that should be clearly indicated.

5. Type of surgery should be clearly mentioned in full form.

6. Before taking to the department of pathology all the forms and specimens should be

checked for the case number and details. Entry should be made in the OT register

with signature of the staff checking.

7. Pathology department will provide with 2 different sizes of containers: small and medium size.

8. OT staff is expected to inform the pathology department about the approximate

number of containers expected to be used on that day for surgical specimens – an hour prior to collection of these containers since these containers will be issued with formalin contained within.

9. The frozen section sample should be sent along with the main specimen and should

attach the pathology requisition form.

10. No specimen should be sent to pathology laboratory without raising requisition and

payment should be done against it.

11. Specimens will be accepted the pathology department only if they reach the

department BEFORE the time mentioned above.

12. In the event that the specimen is anticipated to reach the pathology department after

the above mentioned working hours, the specimens stored in the refrigerator, should

remain there overnight, and removed only when they are scheduled to be transported.

13. The samples (small biopsy) should be transported from various collection areas in

containers with formalin which are provided by the pathology lab. Bone marrow biopsy

should be transported in containers with AZF fixative which are provided by the

pathology lab, with proper label.





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8.2 Instructions for handling Cytopathology Specimens:

Instructions to Clinicians:

Separate requisition forms should be filled for Gynecological, Non-

gynecological and FNA samples. All requisitions for cytological examination

should have following information.

1. Case no., name, age, sex

2. Type of specimen:

Vulval scrapings, Vagina, Exocervix, Endocervix, Endometrial aspiration

Pleural fluid, Pleural washing, Pericardial fluid, Ascitic fluid, Intra-

operative peritoneal washing

Sputum (Pre and Post-bronchoscopic), Bronchial lavage, BAL,

Bronchial brushing

Oesophageal lavage/brushing, Gastric lavage/brushing, Colorectal

brushing

Bile, CBD brushing

Oral smears

Urine, Bladder washing

Nipple discharge

Penile scrapings, Skin scrapings etc.

CSF

FNAC (Specific site to be mentioned. If USG or CT guided FNAC is

done, the name of aspirator has to be mentioned)

Drainage fluid, Pus etc.

3. Clinical impression

4. Following information as pertinent to type of specimen

LMP, PS/PV findings

Visual inspection findings (VIA/VIAM/VILI)

Presence of IUCD

Clinical complaints/symptoms

Occupational history and habits

Imaging findings

Endoscopy findings

Previous diagnosis and corresponding histopathology

Previous treatment (Surgery/RT/CT/BCG/Tamoxifen/HRT/AKT)





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A. Female Genital tract

Cervical or endometrial aspirations should not be attempted if patient

is pregnant

Smears should not be collected during menstrual period

Smears should not be collected immediately after

o D & C biopsy

o Vaginal Douche

o Pessaries

o PS/PV examination

o Colposcopy

Smears should be fixed immediately

In radiated patients, smears should be collected 3 months after the

completion of radiation treatment

Cervico-vaginal cytology is not indicated if there is an obvious growth

in cervix

Endometrial aspiration should be collected only in case of post-

menopausal bleeding or suspected uterine carcinoma.

B. Oral cytopathology

Patients should not use mouthwash or gargle, nor chew betel leaves

or tobacco before smear collection

Gentian violet or any other medicine should not be applied to oral

cavity prior to smear collection

Smears should not be collected at least 15 days after biopsy or

immediately after spectroscopy (preferably next days)

Glass slides should be labelled correctly if multiple lesions are to be

scraped

The lesion should be scraped sufficiently hard with commercially

available tooth brush to get adequate material from deeper layer and

spread immediately on to albuminized glass slide in a rotatory motion

and fix immediately

The dry and crusty lesions should be flushed with normal saline before

scraping

Necrotic slough, pus or blood overlying the lesion should be cleaned

with a cotton swab before smear collection





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C. Alimentary

Smear collection should be done by Endoscopist

Smears should be collected prior to biopsy

Smears should be spread on previously albuminized slides and fixed

immediately in 100% methanol

D. Serous fluids

A minimum of 20-30 ml fluid should be sent to laboratory (after shaking

entire tapped fluid so as to homogenize the suspended cells)

The sample should be sent in a clean and dry disposable screw

capped container which need not be sterile

Fluid specimen should be sent immediately to laboratory for processing

It should be refrigerated at 40C, if there is any delay and should not be

kept in freezer.

No preservative should be added to the specimen

E. Urine and bladder washings

Random urine sample is collected

Voided urine sample should not be collected immediately after

cystoscopy. If cystoscopy is done, collect urine sample on next day.

If collected in wards, urine specimen should be sent immediately to the

laboratory for processing. The sample should be sent in a clean and

dry disposable screw capped container which need not be sterile

Delay in dispatch should be avoided as it leads to degeneration and

bacterial growth

If delay is unavoidable for hours, sample may be refrigerated at 40C.

F. Nipple discharge

It is collected at Dept. of Cytopathology at TMH and clinicians from Breast DMG

at ACTREC.

History of pregnancy and lactation should be mentioned. Presence of

mass/lump should be mentioned.

Duration and gross appearance of discharge and whether unilateral or

bilateral should be mentioned.

Express discharge on to previously albuminized and appropriately

labeled slides and spread with the help of a cotton swab stick and fixed

immediately in 100% methanol.





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G. Respiratory tract (Sputum and bronchial specimens)

Three sputum samples collected on three consecutive days are

considered optimal.

The patient should not eat or chew betel nut or tobacco or smoke at

least one hour before collecting sample.

Patient should be instructed to rinse his mouth with water prior to

sputum collection.

Patient should be instructed to give a deeply coughed productive

sputum sample and not saliva. Bronchoscopic samples (collected by

surgeon in OT) for cytopathology should be sent immediately to the

laboratory for processing to avoid degeneration. If delay is

unavoidable, sample may be refrigerated at 40C.

H. Bile & CBD brushings

Collected by surgeons or radiologists

Bile specimen for cytology should be sent immediately to the laboratory

for processing to avoid degeneration. If delay is unavoidable, sample

may be refrigerated at 40C.

CBD brushing smears should be spread on previously albuminized

slides and fixed immediately in fixative (100% methanol) to avoid air-

drying artifacts

I. Penile & skin scrapings

Smears should not be collected at least 15 days after biopsy

Glass slide should be labelled correctly if multiple lesions are to be

scraped

The lesion should be scraped sufficiently hard with a spatula to get

adequate material and spread immediately onto albuminized glass

slides in a rotatory motion and fix immediately (100% methanol)

The dry and crusty lesions should be flushed with normal saline before

scraping

Necrotic slough, pus or blood overlying the lesion should be cleaned

with a cotton swab before smear collection





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J. CSF

Collect CSF in cryovials or plain tube without clot activator for cytology test.

For more details refer section 9:b:i.

Cryovials can be procured from KS 31 Surgical Pathology (Monday to Friday

between 10.00am to 3.00pm).

K. FNAC

Onsite examination for adequacy of aspirate should be performed if

cytotechnologist or pathology resident is available.

Cystic fluid should be sent immediately to laboratory for processing. If

delay is unavoidable, sample may be refrigerated at 40C.

The gauge of the needle and the nature of aspirate should be

mentioned in the form.

The FNAC form, duly filled with clinical/radiological details by the

performing resident with her/his name on the form, should be sent to

laboratory.

Non-guided FNAC samples are collected by resident in the OPD or

ward

USG or CT guided FNAC samples are collected by radiologist in

radiology department.

8.3 Policy for dispatch and receiving histopathology slides/blocks for

reporting as well as cytopathology samples/slides for processing and

reporting, between TMH and ACTREC

Histopathology slides and blocks are transported between TMH and

ACTREC for reporting as reporting is done as per specialty (DMG) and

only one consultant is posted in ACTREC on rotation, who is

responsible for signing out in 2 or 3 DMGs at a time.

There is a computer program to enter dispatch and receiving of

slides/blocks. It is used by histopathology staff at TMH and ACTREC

and it helps in keeping accountability.

Residents / tehcnicians make an entry in computer program of slides /

blocks to be sent to TMH.

The material is packed properly in plastic bag and it is labelled. This

packed bag is submitted at Liasion counter in Paymaster Shodhika,

ground floor, as per schedule given below.





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Delivery boys are recruited by management and they are trained for

this job by individual department. In addition, tehcninicans / residents /

housekeepihg staff also carry parcel to Liasion counter, if needed.

Slides are sent only when they are packed properly. Histopathology

technicians ensure that the parcel is packed properly.

For the slides / blocks received from TMH, entry of receiving is made

in the computer by technician / resident and the slides are submitted

to consultant or sent for filing.

Cytopathology samples:

o Cytopathology samples are processed in Histopathology lab, smears

are prepared and fixed.

o Fixed cytopathology smears are properly labelled and transported in

Coplin jar, sealed with parafilm along with the requisition in a plastic

bag.

o All the samples / fixed smears are transported in a box, which is

sent to Liasion counter at Paymaster Shodhika, ground floor and

transported to Cytopathology lab, 5th floor Annexe building in TMH.

Schedule of sample transportation between TMH and ACTREC

8.4 Schedule of sample transportation between TMH and ACTREC:

Sl. No. Time from TMH-ACTREC Time from ACTREC-TMH

1 0800 hrs. 1000 hrs.

2 1200 hrs. 1400 hrs.

3 1600 hrs. 1800 hrs.

9.0 Sample Collection – Blood:

9.1 Instructions to patients

Patient preparation Instructions are given by the treating doctors for biochemical and other tests and include the following:

Patients are encouraged to seek information from treating clinicians / sample collection centres pertaining to the investigations.

Sl. No. Time from ACTREC-TMH Time from TMH-ACTREC

1 0730 hrs. 0900hrs.

2 1230hrs. 1500 hrs.

3 1630 hrs. 1800 hrs.

4 0815 hrs. (on Saturday) 1430 hrs. (on Saturday)





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The patient is directed to come fasting the next morning for blood collection for following investigations-

o Lipid profile

o Determination of Fasting Blood sugar Which may be relaxed in case of pediatrics patients, however the requisition must clearly state that patient is not fasting. Staff samples are accepted with a proper requisition and authorization from the staff physician and the reports are available on their respective C.C.No. on Employee Portal.

The patient is also instructed not to wait in the queue once the two hours are completed and directly approach the phlebotomist for collection. For infectious Diseases Serology which is done in the Microbiology laboratory a minimum period of three hours fasting is recommended. Random samples may be accepted, however if found lipemic will be rejected.

Note- The counselling and consenting for HIV testing is done by clinician/ staff physician. Records are maintained with clinicians as well as Microbiology laboratory.

9.2 Instructions for Phlebotomy (Blood Culture)

i. Blood can be collected by venepuncture of peripheral veins or arteries, from intravascular catheter lumens.

First, disinfect the culture bottle stoppers -Apply 70% alcohol & wait for a

minute.

Palpate the vein first

Step 1: Vigorously cleanse site with 70% alcohol (for 30 sec)

Step 2: For Adult: Swab concentrically starting at center and cover a 5 x5 cm area

with either tincture of iodine (2%) or chlorhexidine (2%). Povidone Iodine (PI)

10% may also be used.

For children: Omit the iodine/chlorhexidine step and clean two additional

times with separate preparation pads saturated with 70% alcohol.

Allow the disinfectant to dry (at least 30 sec each for tinc. iodine and

chlorhexidine and 2 min for PI)





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Do not palpate vein at this point

Collect required amount of blood

After venipuncture, dispose off needle in sharp container and clean area

with alcohol.

After collection do not store the blood in refrigerator, send immediately to the

microbiology lab. Dispose of the collection material in accordance with

hospital waste policy.

Method of Blood collection for BacTalert Blood Culture

o Remove the flip-off cap from the BacTAlert vial top o Swab the septum on the cap with 70% alcohol before inoculation

o Skin disinfection procedure: please see above – instructions for

phlebotomy blood collection for blood culture. o Draw required amount of blood ( For Padeiatric patients- BacTAlert

PF plus 4 ml, while for Adult patients- BacTAlert FA 5 ml through a syringe and needle and deliver it aseptically into a sterile blood culture bottle, which should be brought to room temperature. The cap of the blood culture bottle should be disinfected if stained with blood, prior to dispatch. Blood culture bottles are vacuum calculated so one can use vacutainer for blood collection.

o Send the vial to microbiology laboratory as quickly as possible o Mention the name of the patient registration no, time and site of collection on the vial.

Note: Do not stick labels on the barcode labels of the BacTalert culture bottle.

9.3 Instructions to Sample collection staff/s (OPD / IPD):

Phlebotomists are responsible for collecting blood samples in appropriate quantity and container and transport them to the laboratory.

The following are the guidelines for the Phlebotomists

1. To keep the sample collection area clean and spacious. 2. To be extremely polite and decent with the patients and

their relatives. 3. To identify the patient prior to collecting a sample 4. Capillary collection as finger prick shall be discouraged and

this Method will be used only in the following circumstances;





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a. Infants: heel prick

b. Patients where peripheral venous access is very difficult as in thrombosis veins, collapsed veins.

5. To avoid hemolysis.

6. To arrange and draw the samples as per the following Order of Draw.

6.1 Blood culture vials

6.2 Citrate [Blue Top]

6.3 Non-additive tubes [Red Top] Additive tubes in this order:

6.4 Heparin [Green Top]

6.5 K2 EDTA [Lavender Top]

6.6 Oxalate and fluoride [Grey Top]

7. To fill the additive tubes up to the stated volume.

8. To gently invert 10 times end to end all tubes containing an additive.

9. Not to decant specimens from one type of container into another.

10. To mention the time of collection and the identification of the personnel collecting the sample.

11. To deliver specimens to the laboratory promptly and maintain the record of the same.

12. The samples are delivered to the laboratories in safe containers to avoid spillage and leakage.

13. Samples for levels of Vitamin D and Methotrexate have to be collected and sent

in container covered with silver foil, protected from light.

14. Write hour of collection on the sample container for methotrexate to avoid

confusion, especially when two tubes of different collections are sent

simultaneously.





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9.4 Emergency Service: The emergency service section is located in the PS Building on the first floor and provides 24 x 7 coverage for emergency investigations including, routine biochemistry, hematological investigations and microbiology (Gram stain of positive Blood culture and CSF, Blood C/S, CSF C/S, Procalcitonin level, Clostridium difficile toxin detection, Viral antigen detection in stool, Dengue test and Rapid malarial antigen and any other sample in consultation with microbiologist).

9.5 Special Precautions

Not to collect a sample from a patient who does not have a proper requisition.

From an inpatient who is not properly identified Above an IV site. Also the laboratory should be informed about the type

of the infusion carried out along with the time of infusion. From the arm with a heparin lock from a triple lumen cannula, fistula

and vascular graft.

From an arm which is on the same side as a mastectomy.

From bruised areas or site of hematoma unless distal to this area.

9.6 Materials used for phlebotomy:

Reference: Primary Sample Collection manual – TMC-02

9.7 Primary sample identification chart:


9.8 Labelling of vacutainer tubes

The vacutainer tubes and other containers are labelled with barcode or manually by the personnel performing the blood collection or the personnel assisting after going through all the requisition forms and thoroughly scrutinizing them. The required number of anticoagulant tubes and plain tubes are determined and labelled and arranged accordingly. The labels are either pre-printed or provided in the patient’s case charts or machine readable bar codes are affixed on the sample containers by the personnel performing the blood collection.





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9.9 Procedure for phlebotomy:


9.10 Storage conditions:

The samples drawn or received during non-working hours of the laboratory or

during any sort of delay in transportation are refrigerated at 40C and delivered as soon as practicable except for CSF and blood culture (These sample should be kept at Room temperature).

9.11 Criteria for rejection:

Mismatched labels or unlabelled samples: Any incorrect information found in the test request form which is not

matching with that of the information given on the sample tube like name, case number; the sample should be rejected by the laboratories.

Unlabelled or incorrectly labelled samples must not be analysed and the doctor requesting the test must be informed without delay. If the doctor is confident that the sample can be correctly identified, it may be analysed after the tube has been correctly labelled by the doctor or his authorized representative. If there is any doubt about the correct identity of the sample, it must be discarded.

If found correct then the specimen should be mixed and checked for clots and also for quantity. Samples of insufficient quantity are rejected.

Clotted or haemolysed samples:

The sample should be rejected if it shows any clots / haemolysis for specific tests.

Leaking samples:

Where a small volume of blood has leaked from the specimen tube, if the request form is contaminated, a new form must be completed and the original form discarded as biohazard waste.

If a larger volume of blood has leaked from the tube, the sample should be discarded, as the results may be misleading. The doctor requesting the test should be informed immediately and a fresh specimen requested.





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Rejection criteria for Microbiology investigations

Containers: Broken containers and containers with contaminated / soiled cotton plugs are rejected.

Unacceptable specimen sources

Saliva will not be accepted in place of sputum samples

Foleys catheter tips are unacceptable for culture

24 hours urine/sputum specimens are unacceptable for culture

A single swab submitted for multiple requests (for eg: aerobes, fungus etc) will be processed only for aerobic bacteriology

Any specimen received in formalin/other fixatives

Samples that are obviously contaminated as evidenced by presence of foreign materials such as barium color dyes etc.

Hemolysed /Lipemic/Icteric blood sample for Dengue test.

Duplicate specimen:

Most duplicate specimen received on the same date will not be processed, exception include blood cultures, CSF, Tissue, sterile body fluids excluding urine.

Rejection criteria for Surgical Pathology samples (biopsy and large specimen)

1. The name of the patient, case no and site/source of specimen on label of the sample do not match with that in the requisition form or sample register.

2. Samples are sent in multiple containers and one container is missing as per requisition form

3. Referral note addressed to the pathology department is not received 4. Pertinent clinical history is not provided in the note (Sample is accepted and

clinician is contacted immediately for further information). 5. In case the container of the biopsy does not show any tissue.

Rejection criteria for referral cases ( glass slides and paraffin blocks)

1. The referral slides are broken beyond repair. 2. Paraffin blocks are not in solid state and are stuck to each other 3. Tissue is completely depleted in the blocks.





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Rejection criteria for cytopathology specimen

1. Name of patient and case number on the label of sample do not match with that in requisition form.

2. Referral note addressed to department is not there. 3. Referral slides are broken beyond repair 4. There is discrepancy between type of sample and the requisition 5. Payment is not done 6. Sample collection time and date is not entered or written on

requisition form in case of serous fluid samples, bronchial lavage/brushings, CSF, Bile, CBD brushings, oesophageal brushings, GEJ brushings, gastric brushings, colon brushings and rectal brushings.

10.0 Microbiology and Serology

10.1 Sample Collection for Microbiological Investigations:

Test requisition form of bacteriological culture and sensitivity samples of sputum, BAL, NDBAL, urine / PCN and body fluids may mention absolute neutrophil count (ANC) and total leukocyte count (TLC).

a. Urine (Culture & routine microscopy)

Instructions for urine sample collection:

a) Never collect urine from the bedpan or urinal.

b) Use sterile container to collect urine samples for culture.

c) It is recommended that urine be collected after a thorough bath which should include a proper cleaning of the genitalia.

d) Send the first morning voided urine. Three consecutive first morning

urine specimens are recommended for Mycobacterial culture (AFB).

e) It is recommended that first morning voided urine be collected for routine urine examination and pregnancy test for Beta HCG.





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Clean Catch urine specimen (Female):

For clean catch specimen patients are given the instructions by staff along with the labelled container.

a. Wash hands with soap and water, rinse and dry. b. Cleanse the external genitalia (urethral openings and vaginal vestibule area) with soap and water or clean gauze pads soaked in liquid soap. c. Rinse the area well with water or wet gauze wipes. d. Hold labia apart while voiding. e. Allow a few millilitres to pass and then catch mid-stream specimen in a sterile

urine container.

Clean Catch urine specimen (Male):

f. Wash hands with soap and water, rinse and dry. g. Cleanse the penis, retract the foreskin and wash with soapy water. h. Keeping foreskin retracted; allow a few millilitres of urine to pass.

i. Collect the mid-stream portion of the urine in a sterile container.

If the above is not possible practically, the patient is asked to collect the sample after bath.

All the urine samples should be transported to the laboratory immediately. In case of delay refrigerate all the urine samples for culture prior to transport.

For collecting Urine from Indwelling Catheter (for microbiological investigations) following instructions should be followed:-

Clean the catheter collection port with 70% isopropyl alcohol/an effective alternative.

Using sterile techniques, puncture the collection port with a needle attached to a syringe

Do not collect urine from collection bag

Aspirate the urine and place it in a sterile container.





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b) Body Fluids Instructions to patients for CSF and Other Body fluid samples:

These are given by the staff in their respective wards for inpatients and for outpatients (general) in the bone-marrow theatre room. The samples are collected in the appropriate vacutainer or containers and sent to the concerned department immediately along with the specific requisitions.

i) CSF:

The body fluids and CSF should be collected in the sterile containers which are properly labelled with the patients name and case no., date and fluid type of the specimen. For CSF specimen the tube number is also indicated.

Tube 1: In this tube the first fluid from the tap is placed for the Biochemical tests. (Biochemistry Laboratory)

Tube 2: The second portion of the fluid is placed in this tube which is sent for culture requests (Always send the most turbid tube for microbiological examination). (Microbiology laboratory)

Tube 3 and Tube 4: The final portion of the fluid is placed in these tubes and sent for cell counts & morphology to Hemato-pathology and Cytology laboratories.

Note- if the sample received is in one tube only then it is first process for microbiology.

ii) Other Body fluids:

Body fluid for microbiological investigations, are collected in sterile container and are sent to Microbiology laboratory, PS/115.

Note- For other investigations the fluids are collected in red top vacutainer and sent to Hematopathology for morphology and Biochemistry Laboratory for other biochemical investigations.

For surface marker studies on body fluids, the sample should be collected in EDTA i.e. lavender top vacutainer.To maintain the viability of the cells for flow cytometry testing, sample will be enriched with equal volume of tissue culture media (RPMI 1640 with 10% fetal calf serum).





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c) Respiratory tract specimens (for microbiological/investigations):

i) Expectorated Sputum:

If possible, have the patient rinse his mouth and gargle with water prior to sputum collection.

Instruct the patient not to expectorate saliva or post-nasal discharge into the container.

Collect the specimen resulting from deep cough in sterile screw capped cup or container.

ii) Induced Sputum:

Using a wet toothbrush, brush the Buccal mucosa, tongue and the gums prior to the procedure

Rinse the patients mouth thoroughly with water

Using an ultrasonic Nebulizer, have the patient inhale approximately 20-30 ml of 0.85% NaCl

Collect the sputum in a sterile container.

iii) Broncho-Alveolar Lavage:

Obtain the sample through the biopsy channel of the bronchoscope and transport it in a sterile container with a small amount of non-bacteriostatic sterile 0.85% NaCl.

Transport the sample immediately to the laboratory. If there is any delay, refrigerate the sample.

iv) NDBAL

A sterile catheter (22 gauges) is introduced through an endotracheal or tracheotomy tube. Approximately 20ml of sterile saline is flushed through the catheter and aspirated.





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v) Throat swabs:

Do not obtain the samples if the epiglottis is inflamed.

Depress tongue gently with the tongue depressor.

Extend sterile swab between the tonsillar pillars and behind the uvula.

Avoid touching cheeks, tongue, uvula or lips.

Sweep the swab back and forth across the posterior larynx, tonsillar areas and any inflamed or ulcerated areas to obtain the sample.

Transport the sample as soon as possible to the lab.

vi) Nasal Swabs:

Insert a sterile swab into the nose until resistance is met at the level of the turbinate (approximately 1” into the nose) .

Rotate the swab against the nasal mucosa.

Repeat the process on the other side.

Send the sample immediately to the lab.

d) Subcutaneous tissue and skin specimens (for microbiological investigations):

i) Superficial Wound (bacterial):

Syringe aspiration is preferable to swab collection.

Disinfect the surface of wound with 70% iso-propyl alcohol/an effective alternative and then with an iodine solution. Allow the disinfectant to dry prior to collecting the specimen.

Using a 2 / 5 ml syringe with a 22 / 23 gauge needle, a physician will aspirate the deepest portion of the lesion. If vesicle is present, collect both the fluid and the cells from the base of the lesion.

If the initial aspiration fails to obtain material, inject sterile, non-bacteriostatic 0.85% NaCl subcutaneously.

Repeat the aspirate attempt.

If no material is obtained, rinse the needle and the syringe with broth by drawing the culture medium through the needle into the syringe.





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ii) Superficial lesions (fungal):

Clean the surfaces with sterile water

Using a scalpel blade, scrape the periphery of the lesion border. Samples from scalp lesion should include hair that is selectively collected for examination. If there is nail involvement, obtain scrapings of debris or examination. If there is nail involvement, obtain scrapings of debris or material beneath the nail plate. Transport in sterile petriplate or container.

iii) Ulcers and nodules (for microbiological investigations):

Clean the area with 70%iso-propyl alcohol/an effective alternative and then with an iodine solution. Tincture of iodine must be removed with alcohol after the procedure to prevent burns.

Remove overlying debris.

Curette the base of the ulcer or nodule.

If exudate is present in nodule or ulcer, collect it with a syringe or sterile swab.

e) Fecal Specimens for culture /ova, cyst, parasite examination & Clostridium difficle:

Keep specimens cool; do not incubate them.

Stool sample should be transported to the laboratory within one hour of collection.

Do not use toilet paper to collect stool.

Have patient obtain stool sample by the following method-

Pass stool into a clean, dry bedpan and transfer a spoonful of stool into a clean leak proof container with a tight-fitting lid.

f) Wound swabs and Pus swabs (for microbiological investigations):

Aspirate pus from the wound or obtain it at the time of incision and drainage or debridement of infected wound. If the wound is dried or there is no discharge, moist the swab with non-bacteriostatic saline.





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Deep wounds or abscesses:

o Disinfect the surface with 70% iso-propyl alcohol/an effective alternative and then with an iodine solution. Tincture of iodine should be removed with 70% iso-propyl alcohol/an effective alternative to prevent burns.

o Aspirate the deepest portion of the lesion, avoiding contamination by the wound surface. If collection is done at the time of surgery, a portion of the abscess wall should be sent for culture.

o If the sample is for Mycobacterial culture (AFB) culture, frank pus or pus aspirate should be sent and not pus swabs / wound swabs.

g) Gastric biopsies and washing (for microbiological investigations):

All specimens should be collected in sterile containers with non-bacteriostatic saline (0.85% NaCl) and sent to lab immediately. If there is any delay, refrigerate the sample and send to the lab as soon as possible.

10.1 Requirement for serology investigation

Sr.No Test Sample required (3 to 5 ml blood)

1. Rapid malaria antigen EDTA blood

2. Dengue NS1 antigen/ IgG Antibodies/ Antibodies IgM Serum/plasma

3. Anti HIV antibodies to Human immunodeficiency virus

Serum/plasma

4. HBsAg-Hepatitis B surface Antigen Serum/plasma

5. Anti HCV-Antibodies to hepatitis C Virus Serum/plasma 6. Anti HBc IgM antibodies Serum 7. Anti HBc total antibodies Serum

8. Procalcitonin level Serum/plasma 9. Antibodies to salmonella ( WIDAL Test) Serum

10. Viral antigen detection Stool





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10.2 Sample collection & rejection criteria chart for mycology

Sample Type of container Transport time and temperature

Unacceptable specimen

Eye- Corneal scrapings/conjunctiva

Media plates & inoculated slides.

I ≤ 15 min Room temp.If longer, Room temp.

Swab or dried specimen, expired media

Ear -external

Swabs in transport media

I ≤ 15 min Room temp.If longer, Room temp

Dried specimen

Abscesses (drainage, pus &wound material )

Sterile container I ≤ 2 hrs Room temp

Swabs

Catheter tip Sterile container with at least 1ml sterile preservative-free saline

I ≤ 15 min Room temp.If longer 4⁰C.

Foleys tip or other urinary catheter tip

Vagina/cervix Swabs in transport medium

I ≤ 2 hrs Room temp.If longer, room temp.

Dried swabs

Medical devices/Prosthesis, implants etc

Sterile container with 1-5 ml sterile preservative free saline to keep moist

I ≤ 15 min Room temp.If longer, 4⁰C

Swabs

Tissue Sterile container ( keep moist with few saline drops)

I ≤ 15 min Room temp.If longer, Room temp.

Swabs & formalized tissue

*Stool Specimen should be discouraged.

Culturing of stool for fungal culture may be considered on a case-to-case basis in consultation with clinician

NOTE: For any special investigations required, contact the Microbiology Laboratory for details of collection on below mentioned extensions. Contact number- Extension 5313/5093

Microbiology laboratory (ACTREC) - 1st floor. Paymaster Shodhika - Room, No. 115)





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11.0 Transfusion Medicine:

Transfusion Medicine receives mostly venous blood samples from wards, OPDs, Operation theatres, ICU and collection centres. It is emphasized that samples received without properly filled requisition forms, clear and legible labels or signature of the phlebotomist are likely to be rejected. This can cause undue delay in the issue of blood and blood products. The following table gives the list of tests done by the department and the samples required for the tests.

11.1 List of tests:

Reference: Primary Sample Collection manual, TMC -02

12.0 Hematopathology Laboratory – Morphology, Flowcytometry and Molecular Division:

12.1 Type of Materials to be accepted for processing.

Morphology: Air dried unstained or stained smears.

Flowcytometry (Immunophenotyping testing):

Fresh blood in K2EDTA vials (10 ml or 3 EDTA vials for minimal residual disease monitoring, for all other tests one EDTA tube/3ml).

Bone marrow aspirates preferably in EDTA or but sample in heparin can also be acceptable.

CSF and body fluids sample one EDTA vial.

(To maintain the Viability of the cells for flow cytometry during transportation, the body fluids samples are collected in with equal volume of tissue culture media (RPMI 1640 with 10% fetal calf serum).

Fresh tissue & FNA are collected in normal saline or RPMI media.

Molecular testing:

DNA based testing: 10ml of fresh peripheral blood /Bone marrow aspirates in K2 EDTA vials.

Air dried unstained smears are also accepted (in case fresh sample is not available).

RNA based testing: 10ml of fresh peripheral blood /Bone marrow blood in K2 EDTA vials.

CSF and body fluids sample in EDTA vials





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12.2 Handling of Sample

• Instruction for handling Bone marrow slides from BMOT to Hematopathology Laboratory.

Prior to transport:

Labelled all the frosted slides with case number.

Mention total numbers of slides sent to the laboratory for each case in sample transport book.

Transport the slides in a safe container so as to prevent the mix up and breakage of the slides.

Always wear powder-free gloves during transport and storage of samples.

12.3 Procedure for Sample Collection (Peripheral blood/ Bone Marrow/ Body Fluids/FNA/ fresh tissue)

• Blood / Bone Marrow: - Sample collection done as per the guidelines of primary sample collection manual.

12.4 Procedure for transport of sample:

The following procedure has to be followed by all responsible staff for transportation of samples within and outside the organization.

a. General requirements for transportation of samples:

i. All laboratory specimens are potentially hazardous. It is important that care is taken when collecting and handling clinical samples to ensure that the risk of infection to staff is kept to an absolute minimum. Biosafety and personnel protection rules must be observed at all times and never allowed to lapse at busy periods or because of a failure to maintain adequate supplies of bags or containers.

ii. All specimens, in appropriate containers, inside the designated sealed specimen bags must be transported to the laboratory in either a sealed Transport Box.

The box must be clearly labelled with the International BIOHAZARD label.

Specimen should be transported to the respective laboratory as rapidly as possible after collection to ensure that no significant deterioration occurs before processing.

It is not acceptable to carry specimen by hand or in your pocket at any time.

iii. Patient confidentiality must be observed at all times.

iv. Samples should not be transported with / have contact with other items.





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v. Never leave samples unattended in a public area.

12.4 Procedure for Sample Transportation

A. For samples collected at TMH:

Peripheral blood samples: Samples collected from patients in Wards or from Sample collection center in OPDs are sent along with test requisition forms to Hematopathology laboratory, 7th Floor Room No 727, Annexe Building, TMH.(024177000. EXT – 4367 / 4371).

Bone Marrow and Body fluid samples: Bone marrow samples for molecular testing, flow cytometery testing and air dried smears for morphology is collected in the Bone marrow Operation theatre (OT) in 3rd floor Golden Jubilee Building. In rare circumstances and in emergency the Bone marrow sample may be collected in ICU or in Wards. The smears are labelled and allowed to dry and arranged in slide boxes labelled with the case number of the patient.

In both circumstances the samples and smears are sent to Hematopathology laboratory, 7th Floor Room No 727, Annexe Building, TMH.

The body fluid samples for flow cytometry are collected in with equal volume of tissue culture media (RPMI 1640 with 10% foetal calf serum).

The body fluid samples for morphology are initially processed for cytospin preparation and cell counting at Hematopathology laboratory, 7th Floor Room No 727, Annexe Building, TMH. The labelled slides after cytospin are transported to ACTREC in slide boxes for staining and cytomorphology reporting.

B. For samples collected at or sent to Referral Counter at ACTREC:

All samples collected at and sent to Referral Counter at ACTREC are directly sent to Hematopathology Laboratory, Ground floor, CCE building at ACTREC.(EXT:- 5452 /5495/5424)

C. For sample collected outside TMH and ACTREC:

Bone marrow aspiration smears, Bone marrow aspiration samples, peripheral blood samples and body fluid samples collected outside TMH and ACTREC are accepted at Referral Counter (RF Counter) at 1st floor Homi Bhaba Block at TMH. The samples after acceptance are sent to Hematopathology laboratory, 7th Floor Room No 727, Annexe Building, TMH.





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12.5 Sample Receiving:

All the samples collected at Bone marrow OT, wards, and referral counters are received at Hematopathology laboratory, 7th Floor Room No 727, Annexe Building, TMH.

Sample Transportation:

The samples are segregated into various containers based on the test requested. There are separate containers for Air dried smears, Samples for Flow cytometry testing and samples for Molecular testing.

The container for air dried smears and Flow cytometry samples are transported at room temperature (20°C to 24°C).

The containers for Molecular testing samples are packed with ice packs so that the temperature during transportation is maintained between 2°C to 8°C.

The samples are transported from TMH to ACTREC 3 times a day for Monday to Friday and 1-2 times a day for Saturday based on requirement of transportation of samples.

The sample containers are accompanied by trained personnel to ensure appropriate sample transport to ACTREC and to prevent spillage, loss or damage to the samples during transportation. A list of sample numbers and number of samples and slides transported is maintained. The list is checked and verified at the time of receiving samples at ACTREC.

The transport timings are:

Monday to Friday: at 12:00 PM, 3:00 PM and 6:00 PM

Saturday: at 10:00AM (if required) and 2:30PM

In case of any unavoidable disruption in transportation the samples are stored at Hematopathology Laboratory, 7th Floor Room No 727, Annexe Building, TMH and sent to ACTREC in the subsequent trip or the following day.

In case of samples are received after 5:00PM Monday to Friday at Hematopathology laboratory, 7th Floor Room No 727, Annexe Building, TMH, the samples are sent latest by next day 12:00 PM TMH to ACTREC organization transport.





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12.6 Receipt of transported samples at Hematopathology Laboratory, Ground floor, CCE building at ACTREC

The transported samples are delivered at Hematopathology Laboratory, Ground floor, CCE building at ACTREC. (EXT: - 5452 /5495/5424)

The number of samples received is physically verified with the list of samples transported. Discrepancy if any is notified to Hematopathology laboratory, 7th Floor Room No 727, Annexe Building, TMH. (024177000. EXT – 4367 / 4371).

12.7 Sample Rejection Criteria

• Unlabelled sample.

• Incorrectly labelled.

• Tube containing sample is broken or cracked or leaking.

• Inappropriate anticoagulant containers (Note that samples in heparin are accepted but reports are issued with a disclaimer that negative results may be interpreted with caution) any of the above samples unaccompanied by duly filled requisition form.

• Clotted samples: Clotted samples are processed however the referring physician is informed that the sample is clotted and a repeat sample is warranted.

Bone marrow slides for morphology slides: if the referral slides are broken beyond repair.

* Invasive sample like BM, CSF etc. which are clotted, semi-clotted or haemolysed, may be processed even if of insufficient quantity with the report stating limitations regarding the same.

12.8 Critical Alert for APML Sample

All the new cases of suspected APML are treated as critical samples and reported within three days. If, in any case the requisition of the samples has not received then we are unable it to report on DIS then immediately informed it to particular clinician and record maintained in the lab.

12.9 Primary sample receiving record

All the samples received in the laboratory are recorded in an accession log (both for ACTREC and TMH separately) and stored it in soft copy as well as hard copy.





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12.10 Storage of examined samples:-

cDNA- except RQPCR BCR ABL all the cDNA stored at -20⁰C for 10 years.

RNA Later/RLT back up: 6 months for real time PCR based CML MRD testing at -80⁰C, all else 10 years.

Extracted DNA: - 10 years at RT.

Molecular gel pictures/ Results of Sanger Sequencing data/ Results of Capillary Electrophoresis- 10 years

12.11 Sample disposal:-

• After 1 week, the samples are safely disposed in the yellow bags as per the instruction of Waste Disposal Manual, TMC.

12.12 Repeat examination due to analytical failure or further examination of same primary sample:-

Molecular testing two Backup samples are used for the repeat examination due to analytical failure.

If the results are non-satisfactory then only ask for repeat collection of sample (patient do not pay again).

Further examination of same primary sample processed only on the request of clinician.

12.13 Report Collection:-

• Outside referral patients are given the tentative date and time for report collection. Hard copy of the report is collected by the patient from the Hematopathology Laboratory either from TMH or ACTREC.

• The turn‐ around –time (TAT) is mentioned in the department Quality Control Manual and must be referred for the same.

• Verbal communication on reports is made by Clinicians, fellow or senior staff members to only to the referring doctor/ clinician.

• The reports for in- house patients can be directly viewed on the DIS system by the clinicians/ referring doctor.





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13.0 Cancer Cytogenetics Department

13.1 Type of Materials to Be Accepted For Processing:-

1-4 ml Bone marrow aspirates (BMA) is the vastly preferred primary tissue sample in sterile sodium heparin vacutainer in aseptic condition.

4 -5 ml Peripheral blood in sterile sodium heparin vacutainer is accepted only if blast percentage in peripheral blood is more than 30%.

4-5 ml peripheral blood sample to be collected in sterile sodium heparin vacutainer for Fanconi anemia (FA)/ Aplastic anemia (AA) along with 4- 5 ml

peripheral blood sample in sterile sodium heparin vacutainer from healthy age-matched normal individual with no blood relation to the patient to be arranged by clinician.

5-6ml of bone marrow aspirate for Multiple Myeloma (MM) is collected in sterile sodium heparin vacutainer in aseptic condition.

Stained /Unstained bone marrow morphology smear slides will be accepted in case no bone marrow aspirate is available and only FISH testing will be done.

FFPE (Formalin fixed paraffin embedded) tissue / Paraffin block/ 3µ paraffin sections on poly L-lysine coated slides (minimum 2 slides) for FISH testing along with marked H&E slide.

Fixed cell suspensions for FISH testing

Pleural fluid in rare cases is accepted.

*Bone marrow samples received in EDTA are accepted as they are clinically critical, however the clinician is informed and it is mentioned in the report

13.2 General instructions for Sample Collection and Storage:-

Label the container/ tube/bulb with patients name, case number, age/ sex, requisition number

After collection of BMA and PB, shake the container / tube to avoid clotting. Do not freeze the specimen and send in ambient temperature.

If the sample has been collected late in the evening or at night, it is stored in refrigerator at 4°C as per instruction and is sent to the department immediately the next day.





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Sample collection (Peripheral Blood / Bone Marrow) done as per the guidelines of primary sample collection manual.

Always wear gloves during direct contact with samples.

13.3 Instructions to the Clinicians:-

Manual requisition form (Medical oncology) should be filled for each Cytogenetic test. It should have the following information regarding the patient-

Case no, name of patient

Type of sample

Study required. i.e. Cytogenetic studies

Provisional diagnosis

13.4 Sample collection areas, requisitions, billing, transportation, receiving and outside referrals:-

Sample collection areas and general instructions:

Bone marrow Minor OT(TMH)

BMT OPD/ Wards in ACTREC

General wards (blood collection room of Golden Jubilee Bldg, TMH)

Private wards (blood collection room of 101 ,Homi Bhabha Bldg, TMH)

Green top sodium heparinized vacutainer tube is labelled by sister. Label contains the patients name, case number, age/ sex, requisition number.

Requisition and Billing:

Before sending the samples to the Department of Cancer Cytogenetics all the requisition forms and specimens should be checked if in proper condition. No specimen should be sent to Cancer Cytogenetics Department without raising requisition.

The clerk of the respective place i.e. general ward, private ward and outside referral (RF counter / Front Office) raise the requisition with the help of the test code/ test name mentioned by the doctor in the requisition form/ referral letter, the entry of name, age, sex, case file no. is done in DIS program, a memo is generated with chargeable amount and is given to the patient and the requisition forms is sent to the department along with the sample.





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Transportation:

Samples from O.T are transported to the department along with a list of sample transport record with every shift.

Peripheral blood (PB) for general category patients is collected in blood collection room of Golden Jubilee Bldg and for private category patients in 101, Homi Bhabha Bldg. and transported with requisition forms to the 7th floor (727) Annex bldg by a ward boy or ayabai which is then collected by the sample collection boy and sent to Cancer Cytogenetic Department with the sample transport record.

The RF counter clerk will send the sample and the sample transport record along with requisition forms with every shift.

The samples are transported from TMH, by transport facilities at three fixed shifts/ timing i.e. 12.00pm, 3.00pm, and 6.00pm. directly to Cancer Cytogenetics Department, ACTREC at ambient temperature.

Samples generated from BMT OPD/ Wards in ACTREC are directly sent to Cancer Cytogenetic Department by ward boy or ayabai and this record in maintained.

Sample Receiving:

The specimens from the 12.00pm and 3.00 pm shift are received by authorized staff

from the Cancer Cytogenetics Department. Details of each specimen are recorded in

the daily sample receiving log. The samples from the last shift i.e. 6.00 pm are

received by the staff from the adjoining Hematology department, is stored at 4ºC and

received in Cancer Cytogenetics Department the next day.

After the specimen has reached the department, the entry is made in the main register

(soft copy) by the authorized staff who files the requisition forms, and receiving of the

sample is done in the DIS program. The collection time is the same as the requisition

time.

All sample transport records are signed by the Cytogenetics staff after receiving of the

samples in the department and is sent back to the respective collection areas ( a copy

of which is retained with department).





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Outside Referrals:

Outside referrals samples are received at RF Counter (TMH ) and at Front Office (ACTREC)

For outside referrals BMA / PB specimens should reach the department within 24 - 48hrs at ambient temperature after collection. The clinical details including history, provisional diagnosis or immunophenotype details like name, age, sex, date, time of collection in the referring letter of the doctor should be present. The clinicians name with telephone no. should be recorded for necessary communication.

Kindly note, sample collection details for Cancer Cytogenetic department is mentioned in the primary sample collection manual of TMH and ACTREC

13.5 Sample Storage:-

If the sample has been collected late in the evening or night, the sample is to be stored at 4ºC in the refrigerator and to be sent to the dept. immediately the next day at room temperature.

13.6 Sample disposal:-

After 1 week, the samples are safely disposed in the yellow bags and autoclaved at source as per the instruction of Waste Disposal Manual, TMC.

13.7 Transport of the samples:-

Samples are transported from TMH to ACTREC in three shifts 12.00pm, 3.00pm and 6.00pm.

The samples are delivered to the department in Sample transport container to avoid spillage, leakage and maintain the ambient temperature.

Container should be kept in upright position and should not tilt during transportation.

Sample transport container should have a biohazard label with department name and address.

Samples are received in the department upto 5 pm however in certain cases if any delay in transport or any other reason, samples are accepted upto 5.30pm.





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Specimens are accepted before 5.00 p. m. on Monday-Friday and before 12.00 p.m. on Saturday. For any clarification contact Cancer Cytogenetic Department between 9.15 a. m. to 5. 30 p. m. on Monday - Friday and between 9.15 a. m. to 1. 00 p. m. on Saturday (Contact Tel.No. 022 27405000 ext. 5759).

13.8 Sample Acceptance Criteria:-

The peripheral blood sample quantity should be atleast 4-5 ml.

Bone marrow samples should be at least 1-4 ml*.

For Multiple myeloma (MM) Bone marrow samples should be at least 6 ml

Fanconi Anemia/ Aplastic Anemia, peripheral blood samples will be accepted on alldays except on Thursday and Saturday. On other days sample should reach by 2 pm.

Samples should be sent in ambient temperature.

Date of sample collection should be mentioned.

Details such as name of patient, case no, type of sample and provisional diagnosis for every sample should be mentioned along with requisition

*Since bone marrow samples are critical, we accept even low volume (0.5 ml) and semi-clotted samples and the clinician is informed

Inappropriate anticoagulant containers (Note that BM samples in EDTA are accepted but reports are issued with a disclaimer and the results may be interpreted with caution

Semi Clotted samples: are processed however the referring physician is informed that the sample is clotted and a repeat sample is warranted

13.9 Sample Rejection Criteria:-

Unlabelled sample

Incorrectly labelled

Haemolysed

Blood Collection Tube expired

Fully Clotted

Tube containing sample is broken or cracked or leaking.

Samples reaching department after 48 hrs.

Any of the above samples unaccompanied by duly filled requisition form.





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13.10 Primary sample receiving record:-

All the samples received in the department are recorded in the daily sample receiving log (both for ACTREC and TMH) and also in the main register soft copy.

13.11 Repeat examination due to analytical failure or further examination of same primary sample:-

Fixed cell pellets are used for the repeat examination due to analytical failure. If the results are non- satisfactory only then repeat collection of sample (patient do not pay again) is asked.

• Additional examination of same primary sample is processed only on the verbal request

of clinician followed by requisition

13.12 Report Collection:-

Outside referral patients are given the tentative date and time for report collection. Hard copy of the report is collected by the patient from the RF counter or the Cancer Cytogenetic Department.

The turn‐ around –time (TAT) is mentioned in the department Quality Control Manual and must be referred for the same.

Verbal communication on reports is made by senior staff members to only to the referring doctor/ clinician and the record is maintained for the same.

The reports for in- house patients can be directly viewed on the DIS system by the clinicians/ referring doctor.

actrec supplement sample collection issue no.03

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