CHESHIRE PATHOLOGY SERVICES LABORATORY DEPARTMENT

Transcription

CHESHIRE PATHOLOGY SERVICES
LABORATORY
DEPARTMENT
HANDBOOK
April 2014
Clinical Lead/Laboratory Director
Dr R Rajendran
Tel No: 01625 66(1832)
Pathology Service Manager
Tony Currell
Tel No: 01270 27(3453)
Pathology Department
Macclesfield District General Hospital
Victoria Road
Macclesfield
SK10 3BL
ECT Pathology Handbook GP023
Author: Pathology Management Committee
Approved: Pathology Clinical Lead
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Issued April 2014
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PATHOLOGY IS LOCATED AT GRID REFERENCE E1
1
2
LOCATION OF PATHOLOGY DEPARTMENT
MACCLESFIELD DISTRICT GENERAL HOSPITAL
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Laboratory Handbook
Version 7 April 2014
CONTENTS
Section
Macclesfield Pathology Service
Introduction & General Information
Telephone Numbers
Urgent Requests
Out of Hours Service
Phlebotomy Service
Working Hours
Laboratory Supplies
Specimen Acceptance Policy
Specimen Transport
General Office
Complaint Procedure
Protection of Personal Information
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
0.10
0.11
0.12
Biochemistry
1.0
Haematology
2.0
Blood Transfusion
3.0
Microbiology
4.0
Cellular Pathology
5.0
Cytology
6.0
Mortuary
7.0
Immunology
8.0
Manual Index
9.0
Addresses of Referral Laboratories
10.0
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0.0 MACCLESFIELD PATHOLOGY SERVICE
Based at Macclesfield District General Hospital, Cheshire Pathology Services (CPS) offers a comprehensive range of
pathology investigations plus a full clinical service in all pathology disciplines. Most investigations are carried out on
site, although some are sent out to specialist centres.
The aim of CPS is to meet the need of users in all aspects of the service. It is our intention to adopt a flexible
approach and to satisfy users' requirements as often as possible.
Each CPS department participates in a wide range of internal and external Quality Assurance programmes, including
national schemes. The laboratories continually work to maintain Clinical Pathology Accreditation and are currently in
the process of implementing the requirements for quality and competence for medical laboratories as specified in the
International Standard ISO 15189:2012. Compliance with these standards will result in UKAS accreditation.
Address:
Pathology Department,
Macclesfield District General Hospital,
Victoria Road,
Macclesfield SK10 3BL
Telephone Enquiries:
01625 661802
Fax:
01625 661804
0.1 INTRODUCTION & GENERAL INFORMATION
Sample collections
There is a district wide transport service which will collect samples and deliver reports and consumables as required.
Results reporting
Printed reports are despatched daily via the transport system, Monday to Friday. Urgent results may be telephoned by
prior arrangement. Any grossly abnormal result which indicates that the patient may require urgent clinical intervention
will be telephoned immediately to the requesting clinician (or if contact cannot be made, to a suitable deputy with
instructions that the requesting medical officer should be informed urgently of the results) irrespective of whether the
sample has been marked as urgent. All GP practices now receive reports electronically. For further information about
this facility, contact Mr John Jones via 01625 661825.
Clinical advice
Advice on all matters relating to the provision and interpretation of results is available from the Consultant staff in the
relevant department. Outside routine laboratory opening hours, clinical advice can be obtained by contacting the
hospital switchboard, who hold the details of the covering arrangements for each pathology discipline.
Workload information
Detailed information about requesting patterns and other aspects of the service are available on request.
Enquiries
For further general information about any aspect of the service, please contact the Pathology Services Manager on
01625 661802. For clinical and technical advice please refer to individual specialities.
0.2 TELEPHONE NUMBERS (STD CODE 01625)
General, Management and Office
Notification of urgent requests
661809
General enquiries
661802
General enquiries FAX
661804
Specimen reception (supplies)
661046
Phlebotomy Department
661493
Clinical Lead for Pathology (Dr R Rajendran)
661832
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Pathology Services Manager (Mr T Currell)
661802
Pathology Governance Lead (Miss V Sandland)
661802
Support Functions Manager (Mrs G Walton)
661802
Microbiology Department
Reports and general enquiries
661811
Clinical Enquiries
663644
Consultant Microbiologist & Infection Control Doctor (Dr R Rajendran)
661810
Dr Rajendran’s secretary (Miss C Norbury)
661832
Chief BMS Microbiology (Mr K Wright)
661812
Lead Nurse in Infection Control (Mrs A Swaine)
661769 (Bleep 3034)
Haematology & Blood Transfusion Department
Reports and general Haematology enquiries
661807
Blood Transfusion
661808
Consultant Haematologist (Dr J Hudson)
661806
Dr Hudson's secretary
661801
Chief BMS Haematology (Mr J Flevill)
661017
Senior BMS Haematology
661807
Senior BMS Blood Transfusion
661808
Anticoagulant Clinic
661836
Anticoagulant Service Manager (Mr S Massey)
661198
Phlebotomy Department
661493
Biochemistry Department
Reports and general enquiries
661828
Consultant Chemical Pathologist (Dr D Oleesky)
661826
Principal Clinical Scientist (Mrs J Scott)
663941
Dr Oleesky's secretary (Miss D Whyte)
661629
Chief BMS Biochemistry (Miss J Clarke)
661833
Cellular Pathology Department
Histology & Non-Gynae Cytology enquiries (Histology Department, Leighton Hospital)
01270 273286
Gynae Cytology enquiries (Cytology Department, UHNS)
01782 674951
Mortuary
661847
Post mortem enquiries
01270 273286
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0.3 URGENT REQUESTS
Requests for truly urgent investigations to be carried out by the Haematology, Biochemistry and Microbiology
Departments during working hours should be pre-notified to the laboratory on extension 1809. The results of these
estimations will be made available to ward enquiry on an urgent basis. In order to reduce the risks due to incorrect
data transmission results will be transmitted by telephone to the requesting clinician only to those locations without
ward enquiry facilities. Requests for urgent blood transfusion should always be communicated directly to the Blood
Transfusion laboratory on extension 1808.
Microbiology urgent specimens coming from the Leighton site should be phoned to the Microbiology Department first.
The specimen should be identified as urgent and dispatched to pathology where a decision will be made, dependant
on the time until the next scheduled transport, whether to wait for this transport or arrange a taxi through switchboard.
0.4 OUT OF HOURS SERVICE
Blood Sciences Requests Outside Routine Hours
The blood sciences departments of Biochemistry and Haematology provide 24/7 cover, during weekends and out of
normal hours all samples sent to the laboratory will be processed as appropriate. If the tests are of extreme urgency or
the request is for blood or blood components, then the department concerned should be contacted with the details of
the request. The short code mobile phone number is 4437. Please note this is a mobile phone number and not a
pager, please allow time for the Biomedical Scientist on duty to answer your call.
Phone calls must be made for the following requests at all times:
i.
ii.
iii.
iv.
ALL requests for blood and blood components.
ALL blood gas requests.
True emergency requests requiring immediate results.
Requests from locations not on the air tube system.
Microbiology On Call Requests
All urgent requests outside of normal opening hours must be phoned to the on-call Microbiology Biomedical Scientist
via switchboard.
Please note that the out of hours Microbiology Service is an emergency on call service and staff are not on site
outside routine working hours.
0.5 PHLEBOTOMY SERVICE
Service to GPs
This excludes patients from Macclesfield Surgeries for whom phlebotomy clinics are available at Waters
Green Medical Centre.
A blood collection service is available in:
MACCLESFIELD
In the Blood Test Department on the ground floor of Macclesfield Hospital between 08:45h and 11:45h and 12:30h to
16:45h Monday to Friday,  01625 661493.
CONGLETON
At Congleton War Memorial Hospital every morning Monday to Friday:

08:30h to 11:15h – All patients

11:15h to 12 noon – Congleton Ward and OPD patients
KNUTSFORD
At Knutsford District Community Hospital every morning Monday to Friday 08:30h to 11:20h
Hospital users
A blood collecting service is available to Wards in the DGH each morning Monday to Sunday. Out Patient clinics are
covered from the Blood Test Department until 16:45h Monday to Friday.
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0.6 WORKING HOURS
All departments are open from 09:00h to 17:30h Monday to Friday. There is an out of normal hours service available
at all other times. A full result enquiry service is available from 09:00h to 17:30h Monday to Friday.
Microbiology is open from 09:00h to 20:00h Monday to Friday and 09:00 to 17:30 on weekends and Bank Holidays.
0.7 LABORATORY SUPPLIES
Request forms and laboratory specimen tubes and pots are available using answer phone number 661046 requisition forms are also available.
Standing order arrangements for consumables are possible and are advised for continuity of supply.
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0.8 SPECIMEN ACCEPTANCE POLICY
The Pathology Department implements a Specimen Acceptance Policy to ensure the safety of the patient.
The policy describes the procedures required to ensure that all specimens are correctly identified and that
appropriate reports can be sent to the correct destination.
The key points are summarised in the table below:
Requirement
Action by Laboratory if requirement not met
Samples MUST be labelled with 3 unique No analysis will be performed.
identifiers from
Where the sample is easily repeatable the
 Surname
laboratory will recommend the sample is
 Forename
discarded.
 Date of birth
 NHS / Hosp Number
Where the risk to the patient of rejection outweighs
The request form data MUST match the the risk of acceptance, the sender will be contacted
above information on the sample or be by a senior pathology staff member.
labelled with another suitable unique
identifier.
Pathology will accept no responsibility for samples
Multiple samples taken at different times tested which initially failed to meet the acceptance
on a patient MUST be labelled on the criteria and will issue a disclaimer on such reports.
sample container with the time (24 hr clock)
when the specimen is taken. The request
form should be labelled accordingly.
Request forms SHALL also contain:
 A unique patient identifier (i.e. hospital
number / new NHS number)
 Sending location
 Name of Consultant or GP
 Tests required
 Date and time of sample
 Time of last dose and dosage
information for drug assays
 Anatomical site and type of specimen
(where relevant)
 Sex
 Relevant clinical information
Lack of information may result in laboratory not
conducting the analysis.
It may not be possible to issue a report or to
interpret results.
Appropriate comments will be made on the report
where this can be issued.
For Blood Transfusion sample labelling please refer to the Hospital Blood Transfusion Policy on the
Trust Intranet
Please address all queries/enquiries about this policy to Vikki Sandland, Pathology Governance Lead.
0.9 SPECIMEN TRANSPORT
The van collection and delivery service covers the district twice daily and all GPs know their own collection times.
Alterations to the time table may be possible, but only by application to the Pathology Services Manager in writing.
Specimens from hospital wards may be sent via the airtube delivery system. For further, more detailed information,
please refer to the appropriate departmental section of this manual.
0.10 PATHOLOGY GENERAL OFFICE
The Pathology General office is staffed from 08:30h to 17:30h, Monday to Friday. Staff in the office provide secretarial
and clerical support for the consultants and other staff within the laboratory. They are responsible for sending out
reports.
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0.11 COMPLAINT PROCEDURE
We realise that there may be times when we do not always get things right. On these occasions we welcome your
feedback as this helps us to improve the services we provide. If you have any problems with any aspect of the
Pathology Services, please tell us by contacting a member of Pathology staff (refer to contacts list on page 4).
If you wish to make a complaint, the Customer Care Team will advise you on what you need to do and who to
contact.
If you feel that you have made every effort to try and resolve your concerns directly with the staff or through the
Customer Care Team, but this has not been successful you may decide to make a formal complaint. If this is what you
decide to do then it is important to do this as soon as possible; this should be normally within twelve months of the
event.
You can make a formal complaint by letter, telephone or by email:
Write to:
The Customer Care Manager
Victoria Road
Macclesfield
SK10 3BL
Telephone: 01625 661449 or 01625 661111
Freephone: 0800 161 3997
Email: ecn-tr.CustomerCareService@nhs.net
Visit the ECT website for further information on the customer care team and complaints procedure
http://echn2026.sitekit.net/Patients-Visitors/Complaints-and-concerns.htm
0.12 PROTECTION OF PERSONAL INFORMATION
The department takes the security of personal information very seriously. Everyone working for the NHS has a legal
duty to keep information about patients confidential.
Patients’ health information is protected through a number of measures, all Trust staff are required to:
a. Record patient information accurately and consistently
b. Keep patient information private
c. Keep patient information physically secure
d. Disclose and use information with appropriate care
Any breaches of security or incidents relating to Information Governance are investigated, actioned and reported via
the Trust’s Governance Structure.
In order to support our staff in ensuring personal information is kept securely the Trust have a number of policies
which set out the requirements staff must fulfil when accessing or sharing personal information. Furthermore, all staff
receive Information Governance Training which includes topics such as information security, confidentiality and data
protection.
Further information is available on the ECT website at the following address:
http://echn2026.sitekit.net/Patients-Visitors/Patient%20confidentiality.html
You can also contact the Information Governance Department:
Information Governance Manager
Victoria Road
Macclesfield
SK10 3BL
Email: ecn-tr.infogov@nhs.net
Telephone: 01625 661625 or 01625 663813
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1.0 BIOCHEMISTRY DEPARTMENT: THE SERVICE
The Biochemistry Department provides a comprehensive service covering a wide range of biochemical estimations
including diabetic monitoring, endocrine testing, lipid profiling, therapeutic drug monitoring and screening for drugs of
abuse. Arrangements are also in place to refer tests which cannot be performed on site to regional laboratories.
The department is led by a consultant chemical pathologist, supported by a principal clinical scientist; they are
available to discuss clinical aspects of cases and to suggest further tests that may be of value. The department is
staffed by a highly qualified and experienced team of biomedical scientists.
1.1 OPENING HOURS
The department is open from 9:00 am to 5:30 pm from Monday to Friday. For all out of hours arrangements see
General section 0.4
1.2 URGENT REQUESTS
For full information on the procedure for requesting urgent estimations see General section 0.3. Please note that ALL
requests for blood gas analysis should be pre-notified to the laboratory.
1.3 REPORTING TIMES
We aim to achieve the following turnaround times, from receipt in the laboratory to authorisation of results, on at least
95% of occasions:
Urgent requests:
Blood gases
General biochemistry (U&E/glucose/LFT etc.)
Drug assays (including antibiotics)
hCG (serum) assays
Troponin I assays
15 minutes
60 minutes
90 minutes
90 minutes
90 minutes
Routine Inpatient requests:
General biochemistry, hCG, Troponin I
Drug assays (excluding anticonvulsants)
3 hours
by end of same working day
Routine Outpatient and GP requests:
General biochemistry, hCG, Troponin I
Drug assays (excluding anticonvulsants)
1 working day
1 working day
Non-urgent routine assays:
Haematinics, PSA, Thyroid Function Tests
Other Endocrine assays & Tumour Markers
Lipids, HbA1c, Albumin/creatinine ratio (urine)
Anticonvulsants (unless urgent)
Serum & Urine Protein Electrophoresis
BNP
2 working days
1 week
2 working days
1 week
1 week
2 weeks
Results are available for remote enquiry via LabCentre Browser in hospital locations immediately after they have been
technically authorised. Hard copy reports for hospital requests are printed every weekday at 1400 and dispatched the
same day to wards and consultants’ secretaries. Reports for general practitioner requests are currently transmitted
electronically thrice daily (at 1200, 1930 and 2345).
1.4 THE REQUEST FORM
All Biochemistry requests can be made on the standard combined Haematology/Biochemistry request form. It is
essential that all details are clear and legible. Please remember to add the clinic/ward location, consultant and name
of the requesting medical officer and date and time of collection even if an addressograph label is affixed. A label
must be attached to all copies of the form. General practitioners should usually make requests via the Anglia ICE
electronic requesting system. Handwritten amendments to electronic requests will not be processed.
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Requesting Additional Tests on Existing Samples
Additional requests can only be made by sending a completed update form. Verbal requests will not be accepted
unless this form is sent subsequently.
1.5 HIGH RISK CASES
Specimens and request forms from patients suspected to be suffering from blood borne diseases must be sent to the
laboratory suitably identified with “Danger of Infection” stickers with a single sample per transport bag.
1.6 SAMPLE CONTAINERS
Yellow top plain containers containing gel (SST) are used for most routine serum Biochemistry requests. One sample
will suffice for tests analysed at Macclesfield (see section 1.8), but please send a separate sample for tests analysed
at other laboratories including Leighton Hospital (see alphabetical test list in section 1.24).
Requests for HbA1c, glucose, lactate and ethanol assays must be sent in a fluoride oxalate (grey top) container.
Fluoride oxalate and EDTA tubes should be filled last to avoid contamination of other tubes. Gently mix blood
samples by 2-3 inversions to ensure contact with the anticoagulant or clot activators.
Requests for certain less frequent or specialised investigations and tests not done on blood require special tubes or
handling arrangements. Please consult the alphabetical test list (section 1.24) for specific details of sample
requirements. Contact the Department (ext. 1828) if in any doubt.
Specimen handling and storage prior to receipt in the laboratory
Wherever possible, all samples should be sent to the laboratory on the same day as collection to ensure sample
integrity is maintained. If a delay in receipt of the sample is anticipated, please contact the laboratory to discuss
storage requirements. Refrigeration may not be appropriate, in particular for some general biochemistry tests such as
potassium and phosphate. See section 1.27 for details of other factors that may affect test results.
1.7 REFERENCE RANGES
Reference ranges are included with reports (paper and electronic) and displayed with results on the Clinisys
LabCentre Browser. Adult reference ranges for most tests analysed at Macclesfield are shown in the alphabetical test
list (section 1.24). Unexpected critically abnormal results will be telephoned to the requesting clinician/location as
appropriate (see section 1.26).
1.8 GENERAL TEST INFORMATION
One clotted blood sample (SST) will suffice for any combination of the following tests or test groups:
Profiles
U&E:
sodium, potassium, urea, creatinine; estimated GFR in adults over 18y (unless pregnant)
Bone:
calcium, phosphate, alkaline phosphatase, albumin;
adjusted calcium also reported if albumin below 40 g/L
LFTs:
albumin, bilirubin (total), alkaline phosphatase, ALT (alanine transaminase)
Proteins:
total protein, albumin, calculated globulin
Lipids:
total cholesterol, HDL cholesterol, triglycerides (fasting sample preferred);
calculated LDL cholesterol reported if sample fasting and triglycerides <= 4.0 mmol/L
Iron studies:
iron, transferrin, calculated transferrin saturation
Thyroid:
free T4 and TSH; free T3 measured at laboratory’s discretion
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Individual Tests
General:
amylase, aspartate transaminase (AST), bicarbonate, bile acids, chloride, creatine kinase (CK),
direct bilirubin, -glutamyl transferase (GGT), lactate dehydrogenase (LDH), magnesium,
osmolarity (calculated), troponin I, urate
Drugs:
carbamazepine, digoxin, gentamicin, lamotrigine, lithium, paracetamol, phenobarbital, phenytoin,
salicylate, theophylline, tobramycin, valproate, vancomycin
Endocrine:
cortisol, FSH, hCG, LH, oestradiol, prolactin
Haematinics:
ferritin, folate, vitamin B12
Proteins:
CRP (C-reactive protein), immunoglobulins, protein electrophoresis
Tumour Markers: CA-125, CEA, PSA (total)
Glucose and HbA1c
A separate fluoride oxalate tube (grey top) is required, but please use the same request form as for the above tests.
1.9 DRUG ASSAYS
Therapeutic Drug Monitoring (TDM)
Please give details of dosage, time of last dose and time of sample collection with ALL requests for therapeutic drug
monitoring. Generally samples taken pre-dose or at least 6h post dose give optimal information – see test list in
section 1.24. Therapeutic (target) ranges given are for guidance only.
Gentamicin, teicoplanin, tobramycin and vancomycin results should be discussed with the Microbiologist. Teicoplanin
requests are now handled by the Microbiology Department. See also the East Cheshire NHS Trust Antibiotic Policy.
Sample Requirements:

Drugs listed in section 1.8 (and teicoplanin)

Ciclosporin A, sirolimus and tacrolimus

Other drugs analysed at external laboratories
SST (gel) tube
EDTA blood taken immediately pre-dose
Plain red top tube (without gel)
Paracetamol
Samples should be collected at least 4 hours after ingestion, as results obtained before 4 hours may be misleading.
Repeated measurements are unnecessary. Results above the following levels are potentially toxic and merit
treatment: 100 mg/L at 4 hours, 50 mg/L at 8 hours, 25 mg/L at 12 hours. See graph in section 1.25 for assessing the
severity of paracetamol overdose.
Salicylate
Serum therapeutic range (adults):
Concern level associated with toxicity:
Severe poisoning occurs at:
150 - 300 mg/L
350 mg/L (280 mg/L if <5y)
over 700 mg/L
1.10 LIPIDS
A fasting sample (taken after a fast of at least 12 hours) is preferred, where practicable. LDL cholesterol will not be
reported on random samples and cannot be calculated if triglycerides exceed 4.0 mmol/L.
The triglyceride reference range of 0.4-1.7 mmol/L strictly applies to fasting samples only. If the random triglyceride
level exceeds 1.7 mmol/L, a repeat fasting sample is recommended.
HDL cholesterol reference ranges are as follows: Female 1.2-2.1 mmol/L, Male 1.0-1.9 mmol/L.
Low levels are associated with increased cardiovascular risk.
Targets
For secondary prevention (patients with pre-existing cardiovascular disease or diabetes mellitus), the aim of
cholesterol lowering should be to decrease LDL cholesterol to less than 2 mmol/L or by more than 30% from baseline,
whichever gives the lower value. The equivalent figures for total cholesterol are a decrease to less than 4 mmol/L or
by more than 25% from baseline, whichever gives the lower value. Intervention with lipid-lowering drug therapy may
be needed to achieve such cholesterol concentrations, where not attained with dietary measures.
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For primary prevention, refer to the Joint British Societies’ Coronary Risk Prediction Chart in the BNF (issues 49 or
later for current version). The total/HDL cholesterol ratio will be reported to facilitate risk estimation, unless the patient
is known to have pre-existing cardiovascular disease or diabetes mellitus or is coded as already being on statin
therapy. A reference range of 2.0-6.0 is quoted for the total/HDL cholesterol ratio; values over 6.0 indicate increased
cardiovascular risk per se.
Guidance ranges are quoted on reports for total and LDL cholesterol for adults of 2.5-5.0 mmol/L and 1.0-3.0 mmol/L
respectively. These are not reference ranges as such, but provided solely to enable high and low cholesterol results
to be flagged on reports. Decisions regarding treatment of dyslipidaemia should be based on a full risk assessment of
the patient, not just the cholesterol level.
1.11 BLOOD GASES
Please phone the laboratory on extension 1828 before collection to ensure that sample receipt does not coincide with
machine maintenance. Blood gas syringes must be sent to the laboratory packed in ice, with the needle removed
from the syringe and replaced with a blind hub before despatch.
The standard profile comprises pH, pCO2, pO2, bicarbonate and base excess.
carboxyhaemoglobin and methaemoglobin can be measured on the same sample if requested.
Oxygen saturation,
Test
pH
pCO2
pO2
Bicarbonate (standard)
Base Excess
Ref. Range
92.0 - 99.0
0.0 - 1.5
0.0 - 1.5
Reference Range
7.36 – 7.44
4.5 – 6.1
12.0 – 15.0
22.0 – 26.0
-2.5 to +2.5
Units
kPa
kPa
mmol/L
mmol/L
Test
Oxygen Saturation
Carboxyhaemoglobin
Methaemoglobin
Units
%
%
%
1.12 URINES
Random urine samples
For quantitative assays, including albumin/creatinine ratio, protein/creatinine ratio and U&E, a 10 mL Sarstedt
Monovette tube, with an incorporated syringe to aspirate urine into the tube, is strongly preferred.
For qualitative assays (e.g. pregnancy tests and protein electrophoresis), please send a plain white top Universal
container. Red top bottles containing boric acid are unsuitable for biochemistry tests.
24 hour urine samples
Use plain 3 Litre bottles, except for some tests which require a bottle containing an acid preservative. Please contact
the laboratory (extension 1809) to obtain bottles and patient instructions for collecting the 24 hour urine sample.
Test
U&E, Creatinine, Cortisol, Protein, Urate, Trace Elements (e.g. copper)
5-HIAA, Calcium, Citrate, Oxalate, Metadrenalines
Preservative in Bottle
NONE (plain container)
20 mL 50% HCl
1.13 FAECES
For all faecal tests, please use a sterile collection pot or Universal container. Occult blood testing is no longer done.
1.14 CEREBROSPINAL & OTHER FLUIDS
CSF

Samples should be collected in a plain white top Universal container (don’t need fluoride oxalate tube for glucose).

Please remember to contact Microbiology “on call” staff out of hours for CSF microbiology testing.

Samples should be sent to the laboratory via a porter. The air tube system must not be used.

Xanthochromia determination by spectrophotometry requires an additional sample of at least 1 mL CSF (protected
from light), which should be the last sample collected. This test is only available Monday to Friday 09:00 - 17:00h.
Samples should be collected at least 12 hours after the suspected subarachnoid haemorrhage and sent to the
laboratory (protected from light) within 30 minutes of collection.
OTHER FLUIDS
Samples for Biochemistry (except pH) should be sent in Vacutainers, which should be filled as far as the top of the
label on the tube by attaching a green (21 gauge) needle to the syringe used for fluid aspiration and inserting the
needle through the rubber cap so that the tubes will fill using the vacuum.
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
For most biochemistry tests (e.g. protein, LDH), send a yellow top SST.

For glucose, send a separate grey top Vacutainer (fluoride oxalate preservative).

For pH, please send a separate sample in blood gas syringe (ensuring that it contains no air) and process as for
blood gases (section 1.11).
Pleural fluid samples for general biochemistry tests (except pH) must be sent in Vacutainers otherwise they
will not be analysed. It may not be possible to analyse fluids that are especially turbid or viscous.
1.15 DIABETES – DIAGNOSIS AND MONITORING
Diagnosis
The preferred screening test is fasting venous plasma glucose – the patient should fast for at least 12 hours.
Fasting Glucose
<= 6.0 mmol/L
6.1-6.9 mmol/L
>= 7.0 mmol/L
Action
Normal. Repeat test may be appropriate if result borderline (5.8-6.0) & there are symptoms
or other features (e.g. high triglycerides) suggesting diabetes.
Repeat. If repeat also raised (>6.0 mmol/L), do an oral glucose tolerance test.
Suggests diabetes. If patient asymptomatic, need repeat test for confirmation.
Random Glucose
<= 6.0 mmol/L
6.1-7.7 mmol/L
7.8-11.0 mmol/L
>= 11.1 mmol/L
Action
Normal. No further action.
Probably normal, but consider checking fasting plasma glucose.
Check fasting plasma glucose. If this is raised (>6.0 mmol/L), do an OGTT.
Suggests diabetes. If patient asymptomatic, check fasting glucose to confirm.
Oral Glucose Tolerance Test (OGTT)
Procedure:
 The test should be done in the morning following an overnight fast (at least 12 hours).

Obtain a fasting blood sample in a grey top Fluoride Oxalate Vacutainer tube and include the time of the specimen
on the label and request form.

Give the patient a drink containing 75g of glucose (e.g. 410 mL Lucozade) - chilled to reduce nausea. The drink
should be consumed within 10 minutes and the time noted.

During the test the patient should rest and should not eat or drink, other than glasses of water.

Take the second venous blood sample in a grey top Vacutainer tube exactly 2 hours after the patient finished the
glucose drink. Label the bottle and request form with the time of the sample.

The test is now complete and the patient may eat as normal.
Interpretation of plasma glucose concentrations (mmol/L):
Fasting
2h Post Load
Normal
<6.1
and
<7.8
Diabetes
>=7.0
and/or
>=11.1
Impaired Glucose Tolerance
<7.0
and
7.8 - 11.0
Impaired Fasting Glycaemia
6.1-6.9
and
<7.8
HbA1c (Glycated Haemoglobin)
The primary use of HbA1c is for assessing glycaemic control, but it can also be used for diagnosis. Measurements
more frequently than every 2 months are of minimal value due to the red cell lifetime of approximately 120 days.
While fasting glucose is still recommended as the initial screening test for suspected diabetes, WHO (2011) has now
recommended that HbA1c can be used as a diagnostic test for diabetes in most situations. The main exceptions are
rapid onset diabetes (as HbA1c reflects glycaemia over the preceding 2–3 months) and some genetic, haematological
and other disorders; in particular haemoglobinopathies, anaemia and other diseases associated with changes in red
cell turnover (e.g. malaria, drug-induced haemolysis) or glycation rates (e.g. chronic renal disease). In these
situations, HbA1c is not recommended as the sole test to diagnose diabetes.
An HbA1c of ≥48 mmol/mol is recommended as the cut point for diagnosing diabetes, and can therefore be
used to confirm a diagnosis of diabetes in an asymptomatic individual with a fasting glucose ≥7.0 mmol/L or random
glucose ≥11.1 mmol/L, precluding the need for a repeat glucose measurement or glucose tolerance test. However, an
HbA1c value <48 mmol/mol does not exclude diabetes diagnosed using glucose tests.
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Criteria for Glycaemic Control using HbA1c in Patients with Type 1 and Type 2 Diabetes
Type 1
Good
< 48 mmol/mol
Borderline
48-58 mmol/mol
Sub-optimal
> 58 mmol/mol
Type 2
Low risk
< 48 mmol/mol
Arterial risk
>= 48 mmol/mol
Microvascular risk
> 58 mmol/mol
1.16 THYROID FUNCTION TESTS (TFTs)
Please give full details of drug treatment and also gestation if applicable. Free T4 and TSH are the front line thyroid
function tests. Free T3 is assayed at the laboratory’s discretion (it is only useful in borderline hyperthyroidism or if the
patient is on liothyronine therapy). Thyroid peroxidase antibody will be assayed if the TSH is persistently borderline
raised. Thyroid hormone levels change slowly and there is little point in repeating TFTs within 1 month.
Test
Free T4 (thyroxine)
TSH (thyroid stimulating hormone)
Free T3 (tri-iodothyronine)
TPO (thyroid peroxidase) antibody
Reference Range
7.0 - 17.0
0.2 – 4.5
3.5 - 6.5
0-35
Units
pmol/L
mu/L
pmol/L
kiu/L
(6.0 –15.0 in 2nd & 3rd trimesters)
(0.35 - 5.50 in children <5y)
(values 36-150 indicate a low titre)
1.17 ADRENAL FUNCTION
Adrenal Cortex
Random or midnight serum cortisol levels are generally of minimal value, and measurement of 9 am cortisol has poor
sensitivity for adrenal dysfunction. If there is significant clinical suspicion of adrenal disease, it is preferable to do one
of the following dynamic function tests.
Short Synacthen (Tetracosactide) Test for suspected Hypoadrenalism
 Take 3.5 mL clotted blood (SST) for serum cortisol between 09:00h and 10:00h.
 Give 250 ug tetracosactide (Synacthen) by intramuscular injection.
 Take a further SST sample for cortisol at 30 minutes post tetracosactide injection.
 A 60 minute sample is not required.
Overnight Dexamethasone Suppression Test for suspected Cushing’s Syndrome
 1 mg dexamethasone should be taken orally at 11 pm (± 1 hour).
 Take 3.5 mL clotted blood (SST) for serum cortisol at 9 am (± 1 hour) the following morning.
This test is preferred to measurement of 24 hour urine free cortisol.
Adrenal Medulla
Measurement of 24 hour urine metadrenalines is the preferred test for investigating suspected phaeochromocytoma.
The sample must be collected into a bottle containing hydrochloric acid preservative, which is available from the
laboratory on request.
1.18 SPECIALISED ENDOCRINE TESTS
Please phone extension 1826/3941 to discuss requests for the following specialised/dynamic function tests and obtain
protocols before collecting samples. Interpretation will be provided with the report.










Dexamethasone Suppression Tests (low and high dose)
Glucose Tolerance Test with Growth Hormone measurements
Growth Hormone stimulation tests (arginine, glucagon)
Gut Hormone profile (gastrin, glucagon, PP, somatostatin, VIP)
Insulin and C-Peptide measurements
Metoclopramide test
Pituitary Stimulation tests: Gn-RH (gonadorelin), TRH (pro-tirelin) and Insulin
PTH-related Peptide measurement
Renin and Aldosterone measurements
Water Deprivation test
This list is not comprehensive and other tests may be available on request.
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1.19 SEX HORMONE INVESTIGATIONS
Adult Reference Ranges
FSH*
LH*
Progesterone
Prolactin**
hCG
Testosterone***
SHBG***
Free Androgen Index (FAI)***
Oestradiol
Females
2.5-10.0 (25-185 post-menopause)
1.5-13.0 (20-60 post-menopause)
>=30 indicates ovulation
40-530 (40-425 if >=50y)
0-5 (non-pregnant)
0.0-2.1 (0.0-1.7 if >=50y)
20-126
0.0-5.6 (0.0-4.5 if >=50y)
follicular 100-600, luteal 100-900
mid-cycle 500-1500
post-menopausal <100
Males
2.5-10.0
1.5-10.0
not applicable
40-360
0-5 (as tumour marker)
8.3–28.7 (lower if >=40y)
14-79
22-70 (11-52 if >=45y)
0-150
Units
iu/L
iu/L
nmol/L
mu/L
iu/L
nmol/L
nmol/L
pmol/L
* In menstruating women, ranges apply to follicular & luteal phases; levels are higher mid-cycle.
** Samples with a significantly raised prolactin (>600) will be tested for presence of macroprolactin.
*** In men, testosterone ranges apply to blood taken between 0800h & 1000h; SHBG & FAI not usually measured;
ranges (nmol/L) for men ≥40 years are 7.3-26.0 (40-49y), 6.3-25.0 (50-59y), 5.7-24.5 (60-69y), 4.6-23.3 (≥70y).
PREGNANCY TESTING
Urine hCG is the first-line test for confirming pregnancy; the test is sensitive to 25 iu/L. Serum hCG measurement is
useful for investigating/monitoring a suspected non-viable pregnancy (e.g. ectopic). Please include the date of the last
menstrual period (LMP) with all requests.
INFERTILITY INVESTIGATIONS
Mid-luteal phase serum progesterone is useful to define ovulation. In women with a regular 28 day cycle, a day 21
serum progesterone of at least 30 nmol/L indicates an ovulatory cycle (for ovulation, median 60 nmol/L, range 30 - 95
nmol/L). In some cases, several samples for serum progesterone during luteal phase may be helpful, particularly in
those with irregular cycles. Progesterone measurement is only indicated for investigating infertility and is
inappropriate in the follicular phase or if there is amenorrhoea.
In women without clear evidence of ovulation, measurement of FSH at day 2-5 of the cycle is the most helpful
investigation available locally for assessing ovarian reserve.
For interpretation of serum FSH, LH, progesterone and oestradiol results in menstruating women, please supply the
date of the last menstrual period (LMP), due to the cyclicity of these hormones.
INVESTIGATION FOR MENOPAUSE
Diagnosis of the menopause is primarily clinical, but if laboratory confirmation is required, the preferred biochemical
test is serum FSH measurement, at cycle day 2-5 if the woman is menstruating. Please supply the date of the LMP or
other relevant menstrual details.
The post-menopausal state is usually clearly indicated by high FSH and LH levels. Less pronounced increases,
particularly of follicular phase FSH, are characteristic of the peri-menopause. Oestradiol measurement rarely provides
extra information, but may be added occasionally at the discretion of laboratory staff.
MONITORING HORMONE REPLACEMENT THERAPY (HRT)
Before initiating treatment, measure FSH and oestradiol to increase the diagnostic certainty of menopausal transition if
the woman is not clearly menopausal.
Serum oestradiol measurement is useful to assess the adequacy of oestradiol HRT implants, but with patch or oral
therapy it is only useful for testing for non-absorption and non-compliance respectively. Measurement is not
appropriate if taking HRT other than oestradiol, as the assay is specific for this steroid and will not measure
ethinyloestradiol, oestriol, oestrone or tibolone. Oral conjugated equine oestrogens undergo first pass metabolism in
the liver to oestrone as the major circulating oestrogen.
HRT reduces FSH & LH levels (by 10-25 %), but they are not restored to basal pre-menopausal levels and their
measurement is not useful for monitoring HRT.
Please supply the HRT preparation used and the route of administration with the request.
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1.20 PSA (PROSTATE SPECIFIC ANTIGEN)
The following age-related reference ranges are in use for total PSA (ug/L):
up to 49y
50 to 59y
60 to 69y
over 70y
0 - 2.0
0 - 2.75
0 - 3.5
0 - 5.0
Total PSA levels greater than 15 ug/L indicate a high probability of prostatic cancer.
Total PSA levels greater than 75 ug/L strongly suggest metastatic disease.
In addition to prostatic cancer, elevated serum total PSA levels may be found in patients:

With benign prostatic hypertrophy (BPH), prostatitis or prostatic infarction.

Undergoing prostate manipulation (prostate massage/rectal examination/prostatectomy/biopsy).

With acute retention or constipation.

Undergoing catheterisation.
1.21 RENAL DISEASE
eGFR: Estimated GFR calculated in adults over 18 y (unless pregnant); a value below 60 mL/min/1.73m2 indicates
chronic kidney disease (CKD) stage 3 or worse, providing this persists for at least 3 months.
Stage/Category of CKD
1
Normal*
2
Mild impairment*
3
Moderate impairment
eGFR (mL/min/1.73m2)
>90
60–89
45–59 [CKD stage 3A]
30–44 [CKD stage 3B]
15–29
<15
Recommended Frequency of Testing
annually*
annually*
6-monthly
6-monthly
3-monthly
3-monthly
4
5
Severe impairment
Established renal failure
*
Stages 1 & 2 are only considered as CKD, needing yearly creatinine with eGFR, if there is other laboratory or
clinical evidence of kidney disease
Urine Albumin/Creatinine Ratio (“Microalbumin”)
This test is recommended as part of the diabetic annual review, along with serum creatinine/eGFR. Non-diabetic
subjects who are dipstick negative for protein but found to have CKD stage 3 or worse should also be tested once,
with the test repeated again only if there is a significant deterioration in renal function (e.g. progression from CKD
stage 3 to 4). In subjects who are dipstick positive for protein, the protein/creatinine ratio is the preferred test.
For both albumin/creatinine and protein/creatinine ratios, send 5-10 mL of first morning urine in a container without
preservative, preferably a plain 10 mL Sarstedt Monovette tube. Red top bottles containing boric acid are unsuitable.
Guidelines for interpretation of Urine Albumin/Creatinine ratio (mg/mmol):

Up to 2.5 (male) or 3.5 (female): Normal - rescreen annually.

Raised but less than 30.0 indicates “microalbuminuria”.
If this finding is new, suggest repeat within 3 months to confirm.
To establish “microalbuminuria”, at least 2 out of 3 samples over 3-6 months should test positive.

30.0 or above indicates “macroalbuminuria”.
Urine Protein/Creatinine Ratio
This will be determined if the urine microalbumin concentration exceeds 1000 mg/L. It is also preferred to a 24 hour
urine collection for protein as the initial test for suspected proteinuria. Values over 100 mg/mmol (equivalent to 1.0
g/24h) indicate significant proteinuria and a nephrology referral may be appropriate.
1.22 SWEAT TESTS
To aid in the diagnosis of Cystic Fibrosis. Please phone the laboratory (ext 1823) to arrange this test. Interpretation
will be provided with the report.
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1.23 TROPONIN I
This is now the first-line test for investigating possible acute coronary syndrome or myocardial infarction. Please state
the time of the suspected event on the request form.

For “rule-out” purposes, samples should be collected at least 12 hours after the event, as the Troponin I level may
not increase until then.

A raised level over 34 ng/L indicates myocardial injury and supports the diagnosis of acute myocardial infarction,
providing there are consistent symptoms or ECG changes.

If the Troponin I level has been significantly raised (at least 120 ng/L) in the last week, repeat testing is of minimal
value due to its long half-life and is only warranted if myocardial re-infarction is suspected.
1.24 ALPHABETICAL LIST OF BIOCHEMISTRY TESTS
The list is not exhaustive; other tests are available on request. Please contact the laboratory about tests that are not
listed (extension 1809 for information about tubes, 1826 for more detailed advice).
Certain tests are referred to external laboratories, mainly in Birmingham, Crewe, Liverpool, Manchester, Salford and
Sheffield, for analysis. However, requests should be referred via the Macclesfield DGH laboratory and not sent
directly to the external laboratory. The external laboratories used may change as a consequence of harmonisation of
practice with Leighton Hospital, Crewe. Reference ranges will be issued with reports of these tests where appropriate.
Analyses are done on blood samples collected in yellow top (SST) containers except where indicated.
TEST
ACE (Angiotensin
Converting Enzyme)
Acetylcholine Receptor Ab
ACTH
(Adrenocorticotrophin)
AFP (Alpha-Fetoprotein)
Albumin
Albumin/Creatinine: urine
Alcohol [Ethanol]
Aldosterone
Alkaline Phosphatase
Alk. Phos. Isoenzymes
Alpha-1-Antitrypsin &
Phenotype
ALT (Alanine Trans.)
Amiodarone
Amino Acids: urine
Ammonia
Amphetamines: urine
Amylase: serum
Amylase/Creatinine: urine
Androstenedione
Apolipoprotein E
AST (Aspartate Trans.)
Barbiturates: urine
Bence Jones Protein:
random urine
Benzodiazepines: urine
Beta-2 Microglobulin
Bicarbonate: serum
Bile Acids
SAMPLE
ADULT REF.RANGE / COMMENT / EXTERNAL LAB
Separate SST
Referred to Wythenshawe Hospital, Manchester
Separate SST
Referred to Manchester Royal Infirmary
Phone lab 1809 before collection & send immediately to lab
after taken. Referred to Royal Liverpool Hospital
0-10 ku/L (non-pregnant). Analysed at Leighton Hospital, Crewe
35-50 g/L
Female ≤3.5; Male ≤2.5 mg/mmol. See section 1.21
Analysed at Leighton Hospital, Crewe
Done with renin. Referred to Royal Liverpool Hospital
30-130 iu/L; levels higher in children and in pregnancy
Only done if total high. Referred to King’s College Hosp, London
Please specify if phenotyping also required.
Referred to Sheffield Immunology Laboratory
Female 10-50 iu/L; Male 10-60 iu/L
Referred to Llandough Hospital, Penarth, South Wales
Referred to Willink Laboratory, Manchester
0-40 umol/L; higher in children <2y. Phone lab 1823 before
collection; send immediately to lab after taken
Part of drugs of abuse screen
0-110 iu/L
0-9 iu/mmol; values up to 12 are borderline
Referred to Salford Royal Hospital
Genotype. Referred to Christie Hospital, Manchester
Full container required. Referred to Salford Royal Hospital
Qualitative screen by electrophoresis;
positive samples confirmed by immunofixation
0.6-2.4 mg/L. Analysed at Leighton Hospital, Crewe
22-29 mmol/L
0-14 umol/L. Only for use in pregnancy
EDTA, on ice
Separate SST
SST
Plain Monovette
Fl. Ox. [grey]
Li Hep [green]
SST
Separate SST
Separate SST
SST
Plain red top
Plain Universal
Li Hep [green],
on ice
Plain Universal
SST
Plain Monovette
Separate SST
2x EDTA
SST
Plain Universal
Plain Universal
[full container]
Plain Universal
Separate SST
SST
SST
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TEST
Bilirubin: Total
Bilirubin: Direct
Blood Gases profile
SAMPLE
SST
SST
See para 1.11
BNP
Separate EDTA
Bone profile
Buprenorphine: urine
C1 Esterase Inhibitor
C3 & C4 Complement
CA-125
CA-15-3
CA-19-9
Caeruloplasmin
SST
Plain Universal
Separate SST
Separate SST
SST
Separate SST
Separate SST
Separate SST
Plain red top,
on ice
SST
Bottle with acid
Plain Monovette
Plain Universal
Plain Universal
SST
Li Hep (green)
Li Hep (green)
24h urine in acid
bottle
Calcitonin (fasting)
Calcium: serum
Calcium: 24h urine
Calcium/Creatinine: urine
Calculi (renal stones)
Cannabinoids: urine
Carbamazepine
Carboxyhaemoglobin
Carnitine profile
Catecholamines: urine
(metadrenalines done)
CCP Antibody (Cyclic
Citrullinated Peptide)
CEA
Chloride
Cholesterol: total, HDL
Cholinesterase
Chromogranin A
Ciclosporin A
Separate SST
SST
SST
SST
Separate SST
SST
EDTA
Citrate: 24h urine
Bottle with acid
Cocaine: urine
Complement C3 & C4
Copper: serum
Copper: 24h urine
Plain Universal
Separate SST
Separate SST
Plain bottle
Cortisol: serum
SST
Cortisol: 24h urine
C-Reactive Protein
Creatine Kinase (CK)
Creatinine: serum
Creatinine Clearance:
serum AND 24h urine
Plain bottle
SST
SST
SST
24h urine (plain
bottle) and SST
Cryoglobulins
2x Plain red top
Cystine: urine
DHEA Sulphate
Digoxin
Plain Universal
Separate SST
SST
0-21 umol/L. Much higher in neonates
0-10 umol/L
pH, pCO2, bicarbonate, base excess & pO2
0-99 ng/L. To lab within 4h. Available for primary care only.
Must answer associated clinical questions on electronic requesting.
Calcium, phosphate, alkaline phosphatase, albumin
Immunology test. Referred to Manchester Royal Infirmary
0-34 ku/L. Females only
0-33 ku/L. Analysed at Leighton Hospital, Crewe
after taken. Referred to Christie Hospital, Manchester
2.20-2.60 mmol/L. Adjusted value reported if Alb <40 g/L
2.5-7.5 mmol/24h. Phone lab 1809 to obtain container
0.10-0.75 mmol/mmol. Higher in children <18 months
Referred to Birmingham City Hospital
Qualitative screen
4.0-12.0 mg/L. Collect sample >6h post dose
0.0-1.5 %. Can use heparinised blood gas sample
Phone lab 1809 to obtain bottle with acid preservative
For rheumatology use only.
Referred to Salford Royal Hospital Immunology Laboratory
0-7 ug/L
95-108 mmol/L
See section 1.10
Referred to Manchester Royal Infirmary
Collect pre-dose. Referred to Manchester Royal Infirmary
Referred to Wythenshawe Hospital
Referred to Royal Liverpool Hospital
215-560 nmol/L at 9am. Random samples are of limited value.
Dynamic tests are preferred: see section 1.17
0-7 mg/L
Female 50-100 umol/L; Male 60-120 umol/L; lower if <18y
Female 60-120 mL/min, Male 60-140 mL/min. Generally replaced
by estimated GFR derived from serum creatinine
Phone lab 1823 before collection, keep warm at 37C & send
immediately to lab after taken, NOT via air tube
Qualitative screen. Analysed at Leighton Hospital, Crewe
0.5-1.0 ug/L. Collect sample >6h post dose
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TEST
Drugs of abuse: urine
Elastase: faeces
Erythropoietin
Ferritin
Folate
Free Androgen Index
(FAI)
Free Fatty Acids
Free Thyroxine (fT4)
Free Tri-iodothyronine
FSH
Gal-1-Phos. Uridyl Tr:
galactosaemia screen
Gamma GT (GGT)
SAMPLE
Plain Universal
Plain pot
Separate SST
SST
SST
Separate SST
Fl. Ox. [grey]
SST
SST
SST
Li Hep (green)
Gentamicin
GFR - Estimated
Globulin (calculated)
Glucose: plasma
SST
2x 6 mL EDTA
tubes, on ice
SST
SST
SST
Fl. Ox. [grey]
Glucose: CSF
Plain Universal
Glucose: other fluid
Glucose tolerance test
Glycosaminoglycans
Gonadotrophins
Growth Hormone
Gut Hormone profile
(fasting):gastrin, glucagon,
somatostatin, PP, VIP
Haptoglobin
HbA1c [glycated Hb]
HCG: serum
HCG: urine
HDL Cholesterol
Fl. Ox. [grey]
2x Fl.Ox. [grey]
Plain Universal
SST
Separate SST
4x 6 mL pink
EDTA tubes,
on ice
Separate SST
Fl. Ox. [grey]
SST
Plain Universal
SST
Fl. Ox. [grey],
on ice
Fl. Ox. [grey]
24h urine in acid
bottle
Separate SST
Separate SST
Separate SST
Gastrin (fasting)
Homocysteine (fasting)
3-Hydroxybutyrate
5-Hydroxyindole Acetic
Acid (5-HIAA): urine
17-Hydroxy-progesterone
IgE & specific IgE
IGF-1
IgA
Immunoglobulins: IgG
IgM
Insulin & C-peptide
(preferably fasting);
also request glucose
Intrinsic Factor Antibody
Iron
Iron Studies
SST
Plain red top,
on ice AND
Fl. Ox. [grey]
Separate SST
SST
SST
Qualitative screen
Referred to King’s College Hospital, London
Female <50y 5-85, >50y 10-150 ug/L; Male: 15-200 ug/L
3.0-20.0 ug/L. Measured with vitamin B12
Female 0.0-5.6 (0.0-4.5 if >= 50y), Male 22-70 (11-52 if >= 45y)
Calculated from testosterone and SHBG results
To lab within 1h. Referred to Sheffield Children’s Hospital
7.0-17.0 pmol/L. Part of Thyroid Function Test Profile
3.5-6.5 pmol/L. Only measured at laboratory’s discretion
See 1.19. State LMP if cycle; day 2-5 sample preferred
Don’t take on Fridays. Invalid if recent blood transfusion.
after taken. Referred to Charing Cross Hospital, London
Range depends on dosing regime; state time of last dose
>=60 mL/min; not reported if age <18y. See section 1.21
18-36 g/L. Calculated from total protein and albumin
Fasting 3.5-6.0 mmol/L; Random 3.5-7.7 mmol/L.
2.5-4.5 mmol/L. Don’t need Fl.Ox. tube if tested within 2h
Interpret result against contemporaneous plasma glucose
Interpret result against contemporaneous plasma glucose
Collect at 0 & 2 hours. Separate form. See section 1.15
Urine sample. Referred to Willink Laboratory, Manchester
FSH & LH. State LMP if cycle; day 2-5 sample preferred
Only as part of DFT. Referred to Royal Liverpool Hospital
Phone lab 1826 to discuss request before collection.
Send immediately to laboratory after collected.
Referred to Charing Cross Hospital, London
See section 1.15
0-5 iu/L (non-pregnant). State LMP if applicable
Qualitative pregnancy test, sensitive to 25 iu/L. State LMP
Female 1.2-2.1 mmol/L, Male 1.0-1.9 mmol/L. See 1.10
To lab within 1h. Referred to Sheffield Children’s Hospital
Referred to Royal Liverpool Hospital (to RMCH for infants <1 year)
0.8-4.0 g/L; 0.8-2.8 g/L if 12-45y, lower in children <12y
6.0-16.0 g/L; lower in children <15y
0.5-2.0 g/L; 0.5-1.9 g/L if 12-45y, lower in children <12y
Phone lab 1809 before collection
Send immediately to laboratory after taken.
Female 9-30 umol/L; Male 11-30 umol/L
Iron, transferrin, calculated transferrin saturation
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TEST
Lactate: plasma, CSF
Lamotrigine
LDH: serum
LDH: fluid
LDL Cholesterol
Lead
LH
Lipid profile
(preferably fasting)
Lithium
Liver Function (LFT)
Lysosomal Enzymes
Magnesium: serum
Magnesium: 24h urine
Manganese
Mercury: blood
Mercury: urine
Metadrenalines: urine
(Catecholamines)
Methadone: urine
Methaemoglobin
“Microalbumin”: urine
Mucopolysaccharides
Myoglobin: urine
Occult Blood: faeces
Oestradiol
Oligoclonal bands & CSF
Immunoglobulins
Oligosaccharides
Opiates: urine
Organic Acids: urine
Osmolarity: serum
Osmolarity: urine
SAMPLE
Fl. Ox. [grey],
on ice
SST
SST
SST
SST
EDTA
SST
SST
SST
SST
2x EDTA
SST
Bottle with acid
EDTA
EDTA
Plain Universal
24h urine in acid
bottle
Plain Universal
Li Hep (green)
Plain Monovette
Plain Universal
No longer done
Not applicable
SST
CSF AND
blood [SST]
Plain Universal
Plain Universal
Plain Universal
SST + Fl. Ox.
Plain Monovette
Oxalate: 24h urine
Bottle with acid
Oxygen Saturation
P3NP
See para 1.11
Plain red top
Paracetamol
SST
Paraprotein testing
Paraquat: urine
pH: fluid
Phenobarbital
Phenylalanine
Phenytoin
Phosphate
Phytanic Acid
Porphobilinogen (PBG) &
Porphyrins:
blood, urine & faeces
SST AND urine
Plain Universal
Bl. Gas syringe
SST
separate SST
SST
SST
2x EDTA
Blood: EDTA
Urine & Faeces
each Plain pot
Plasma 0.6-2.5 mmol/L, CSF 1.1-2.8 mmol/L. Phone lab 1823 in
advance & send immediately to lab after taken
310-620 iu/L
Normally less than 2/3rd of contemporaneous serum level
See section 1.10. Only reported if sample fasting
See 1.19. State LMP if cycle; day 2-5 sample preferred
total & HDL cholesterol, triglycerides, LDL chol if fasting &
total/HDL ratio if primary prevention. See Section 1.10
0.4-1.0 mmol/L. Collect sample at 12h post dose.
Albumin, bilirubin (total), alkaline phosphatase, ALT
Not Fridays. Referred to Willink Laboratory, Manchester
0.70-1.00 mmol/L
2.4-6.5 mmol/24h. Phone lab 1809 to obtain container
Organic exposure. Referred to Birmingham City Hospital
Inorganic exposure. Referred to Birmingham City Hospital
0.0-1.5 %. Can use heparinised blood gas sample
Female ≤3.5; Male ≤2.5 mg/mmol creatinine. See section 1.21
Please measure serum creatine kinase (CK) instead
Test no longer available
See Section 1.19
Need serum as well as CSF.
If screen positive, referred to Salford Royal Hospital to confirm
State drugs. Referred to Willink Laboratory, Manchester
275-295 mmol/L. Calculated from Na/K/urea/glucose
Calculated from sodium, potassium, urea & creatinine
92.0 – 99.0 %. COHb & MetHb also reported
Not SST. Referred to Sheffield Immunology Laboratory
See sections 1.9 and 1.25. State time after alleged ingestion.
Do not collect sample before 4h after suspected overdose
See protein electrophoresis (serum and urine)
Qualitative screen
See sections 1.11/1.14 for sample collection procedure
Referred to Alder Hey Hospital, Liverpool
0.80-1.50 mmol/L. Higher in children less than 16y
Not Fridays. Referred to Willink Laboratory, Manchester
Send blood, urine & faeces for full screen
Protect from light in transit to laboratory.
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TEST
Potassium: serum
Pregnancy test: urine
Progesterone
SAMPLE
SST
Plain Universal
Plain red top
[not SST]
Prolactin
SST
Protein: 24h urine
Protein/Creatinine: urine
Protein electrophoresis
(serum)
(urine – Bence Jones)
Protein (Total): serum
Protein (Total): CSF
Protein (Total): fluid
Protein profile: serum
PSA (Total)
PTH: Parathyroid hormone
PTH-related Peptide
(PTHrP)
Plain bottle
Plain Monovette
Reducing Substances:
urine, faeces
Plain container
(e.g. Universal)
Renin
Rheumatoid Factor
Salicylate
Selenium
SHBG (Sex Hormone
Binding Globulin)
Sirolimus
Sodium: serum
Sweat Test (Chloride)
Tacrolimus
Teicoplanin
Testosterone
Theophylline
Thyroglobulin
Thyroid Function (TFT)
Thyroid Peroxidase
(TPO) Antibody
Tobramycin
TPMT
Transferrin
Transferrin Saturation
Triglyceride
SST
Plain Universal
[full container]
SST
Plain Universal
SST
SST
SST
Separate SST
Special tube,
on ice
EDTA
NOT on ice
Separate SST
SST
Separate SST
Separate SST
EDTA
SST
Special
EDTA
Separate SST
Separate SST
SST
Separate SST
SST
Separate SST
SST
EDTA
SST
SST
SST
Troponin I
SST
Tryptase (mast cell)
TSH
TSH Receptor Antibody
Separate SST
SST
Separate SST
3.5-5.3 mmol/L
Qualitative hCG assay, sensitive to 25 iu/L. State LMP.
Females only. Collect in luteal phase only & state LMP.
Result >=30 nmol/L indicates ovulation
Female 40-530 mu/L if 11-50y, 40-425 mu/L if >=50y
Male 40-360 mu/L.
Up to 0.15 g/24h. Acidified samples cannot be analysed.
Up to 10 mg/mmol
Samples with paraproteins quantitated, and also confirmed by
immunofixation if paraprotein if not previously known
Qualitative screen by electrophoresis; positive samples confirmed
by immunofixation if not previously known
60-80 g/L
0.15-0.45 g/L
Transudate <25 g/L; Exudate >30 g/L; 25-30 g/L borderline
Total protein, albumin, calculated globulin
Males only. Age-related ranges quoted: see section 1.20
1.3-6.8 pmol/L. Analysed at Leighton Hospital, Crewe
Not routinely available; phone lab 1826 to discuss request and
obtain special tube; send immediately to lab after collection
Sample must reach laboratory on day collected. Qualitative
report. Faecal analysis not routinely available; please phone 1826.
Urine samples referred to Leighton Hospital, Crewe for analysis.
0-12 kiu/L; values between 13-24 borderline. Analysed at Crewe
Concern level >350 mg/L (>280 mg/L if <5y). Section 1.9
Female 20-126 nmol/L; Male 14-79 nmol/L. Used to derive FAI.
Collect pre-dose. Referred to Wythenshawe Hospital
133-146 mmol/L
For suspected cystic fibrosis. Phone lab 1823 to arrange
Collect pre-dose. Referred to Wythenshawe Hospital
Collect pre-dose. Microbiology test. Sent to Southmead Hospital.
See section 1.17. Analysed at Leighton Hospital, Crewe
10-20 mg/L. Collect sample 4-6h post dose (slow release tablets)
free T4 & TSH; free T3 analysed at laboratory’s discretion
0-35 kiu/L. Results in range 36-150 indicate a low titre.
Trough < 2 Peak 8-12 mg/L. State time of last dose.
2.0-3.6 g/L
15-45 %. Calculated from iron & transferrin levels
0.4-1.7 mmol/L (applies if fasting). See section 1.10
0-34 ng/L; only valid for excluding myocardial infarction if collected
>12h post event
0.20-4.50 mu/L. Part of Thyroid Function Test profile
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TEST
TTG Antibody (IgA)
Urate: serum
Urate: 24h urine
Urea: serum
U&E: random urine
U&E: 24h urine
SAMPLE
Separate SST
SST
Plain bottle
SST
Plain Monovette
Plain bottle
Valproate
SST
Vancomycin
Very Long Chain Fatty
Acids (VLCFA)
Vitamins A & E
Vitamin B12
Vitamin D (25OH-D3)
Xanthochromia: CSF
SST
Zinc
2x EDTA
separate SST
SST
separate SST
Plain Universal
Special blue top
Vacutainer
Fem. 140-360 umol/L; Male 200-430 umol/L; lower if <12y
1.5-4.5 mmol/24h. Acidified samples cannot be analysed.
2.5-7.8 mmol/L
sodium, potassium, urea, creatinine, calculated osmolarity
sodium, potassium, urea, creatinine
50-100 mg/L (poorly defined). Measurement only useful to assess
compliance. Collect sample 2–4h post dose.
10-15 mg/L (trough). Collect sample pre-dose
Do not collect on Fridays.
Protect from light. Referred to Wythenshawe Hospital
145-910 ng/L; values between 145-179 borderline
Need 1 mL. Protect from light. Do not send by air tube
Phone lab 1809 before collection to obtain tube
1.25 GRAPH TO ASSESS SEVERITY OF PARACETAMOL OVERDOSE
Patients whose serum paracetamol concentration related to time from ingestion is above the line require specific
treatment. This line was revised by the Commission on Human Medicines (MHRA) on 3rd September 2012.
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1.26 CRITICAL ABNORMAL RESULTS
Biochemistry results outside the following limits will be telephoned immediately to the requesting
clinician/location as soon as the results are confirmed to be analytically correct.
Test (serum/blood if not otherwise stated)
Ammonia
Lower Limit
Upper Limit
100 µmol/L
Alcohol
300 mg/dL
ALT
AST
900 iu/L
600 iu/L
Amylase
250 iu/L
Anticonvulsants: Carbamazepine
Lamotrigine
Phenobarbital
Phenytoin
25.0 mg/L
30.0 mg/L
75.0 mg/L
25.0 mg/L
Bilirubin (neonates)
280 µmol/L (35 cord blood)
Bile Acids (in pregnancy only)
14 µmol/L
Bicarbonate
10 mmol/L
50 mmol/L
Calcium (adjusted if albumin <40 g/L)
1.80 mmol/L
3.00 mmol/L
} (GP/OP only,
} if new/increasing)
Carboxyhaemoglobin
20 %
C-Reactive Protein
250 mg/L (GP/OP only)
Creatine Kinase (CK)
2000 IU/L
Creatinine
350 µmol/L (only if a new finding)
Digoxin
2.0 µg/L
Gases: pH
7.10
7.80
Glucose: plasma (fasting or random)
2.5 mmol/L
20.0 mmol/L
Glucose: CSF
1.7 mmol/L
15.0 mmol/L
Lithium
1.2 mmol/L
Lactate
5.0 mmol/L
Magnesium
0.40 mmol/L
Paracetamol
40 mg/L
Phosphate
0.35 mmol/L
Potassium
2.5 mmol/L
6.5 mmol/L
Protein: 24 hour urine
2 g/24h (pregnancy)
Protein/Creatinine ratio: random urine
200 mg/mmol (pregnancy)
Salicylate
350 mg/L
Sodium
120 mmol/L
155 mmol/L
Theophylline
20.0 mg/L (neonates 15.0)
Troponin I
34 ng/L (GP/OP Only)
Urea
30.0 mmol/L (only if a new finding)
Xanthochromia: CSF
Any Positive Result
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1.27 SAMPLE COLLECTION NOTES
Certain substances, drugs and procedures can affect the results of some laboratory tests:
1.
Haemolysis
Can increase serum levels of potassium, magnesium, phosphate, PTH, zinc, folate
and many enzymes, and cause analytical interference with other assays (including
lithium and troponin I).
2.
Delayed separation
As with haemolysis, this may increase serum levels of potassium, magnesium,
phosphate, PTH, zinc, folate and many enzymes.
3.
EDTA contamination
Occurs if samples are tipped from an EDTA tube into another tube - will increase
potassium and decrease calcium, magnesium and alkaline phosphatase levels.
4.
Intravenous infusions Samples collected from a “drip arm” into which an intravenous infusion is running will
give artefactually high results for analytes in the infusion and artefactually low results
for any other analytes.
5.
Lipaemia
Can interfere with many assays - results should be interpreted with caution.
6.
Proteins/Calcium
Posture and/or prolonged venous stasis can increase concentrations.
7.
Uric acid
Thiazide diuretics and paracetamol can affect levels.
8.
Glucose/Triglycerides Time of food intake should be taken into account.
9.
CK (creatine kinase)
Injections, trauma, surgery and hypothermia can increase levels.
10.
Cortisol
Stress, time of day and steroids (e.g. prednisolone) affect levels.
11.
Jaundice
High levels of bilirubin interfere with creatinine and urate assays at Macclesfield.
12.
Ketones
High levels interfere with creatinine assays at Macclesfield.
In all cases, a repeat sample should be collected if doubt exists regarding the validity of the results.
1.28 IRON STUDIES AND FERRITIN
Acute or chronic disease can affect measurements used to assess iron status. In particular, a low serum iron level,
which is especially common in hospital inpatients, does not necessarily indicate iron deficiency. A low serum iron with
a low transferrin saturation (below 15%) is suggestive of iron deficiency if the transferrin is raised or high normal (≥ 3.0
g/L). However, a low serum iron with a low or low normal transferrin (typically < 2.5 g/L) usually suggests disease due
to a cause other than iron deficiency, such as a chronic inflammatory disorder.
Therefore, the preferred biochemical test for suspected iron deficiency is serum ferritin. A ferritin value below
the lower limit of the reference range supports the diagnosis of iron deficiency. However, as serum ferritin is
increased by the acute phase response, an apparently “normal” value in the lower part of the reference range
(< 75 µg/L) does not exclude iron deficiency. If a patient is unwell, it is therefore desirable to request a marker of the
acute phase response (such as CRP) at the same time as requesting serum ferritin. In addition, a high ferritin value
above the reference range does not necessarily indicate iron overload, due to the effect of the acute phase response.
Serum ferritin may also exceed the reference range in liver disease not due to haemochromatosis.
Therefore, the preferred test for screening for haemochromatosis is serum iron studies. The serum iron and
transferrin results are used to calculate the transferrin saturation - a value above 45% is suggestive of this diagnosis,
provided that the patient is not on iron therapy, but clinical haemochromatosis is unlikely if the transferrin saturation
does not exceed 40%. Please do not directly request haemochromatosis (HFE) genotyping without seeking specialist
haematology advice unless the transferrin saturation is above 45% (preferably on at least 2 occasions).
Please note that age- and sex-related reference ranges are used for both iron and ferritin results. Where appropriate,
senior biochemistry laboratory staff may add additional tests (including CRP) in order to assist with the interpretation
of equivocal serum ferritin and iron/transferrin results.
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1.29 CLINICALLY SIGNIFICANT CHANGES IN RESULTS
Many of the laboratory tests requested each year are used to monitor patients rather than for diagnosis. Sequential
changes in cumulative results, when placed in a clinical context, can be as important as the absolute value of the
result. The laboratory undertakes regular quality assurance activities to ensure the reliability of the results, but it must
be noted that there will always be some degree of uncertainty associated with all results.
When a single specimen from a patient is assayed several times identical results are not found every time. This is
due to analytical imprecision. IQC programmes allow the laboratory to calculate and to know the analytical
imprecision for each analyte measured. In addition, the concentration of an analyte from any individual subject varies
from day to day. This may be termed biological, intra-individual or within subject variation. Biological variation may
itself be inherent in nature or dependent on variables such as timing (e.g. cyclical rhythms, which may be daily,
monthly or seasonal), diet, stress, and posture.
Changes in results may therefore be caused by a combination of: analytical imprecision plus biological variation in
addition to deterioration or amelioration of the patient's condition under assessment. The "critical difference" between
results, i.e. the change that must occur before significance can be claimed, can be calculated. The critical differences
for specific tests are available from the laboratory on request.
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2.0 HAEMATOLOGY DEPARTMENT: THE SERVICE
Our highly trained, professional staff combine the use of both manual techniques and automated equipment to provide
a comprehensive haematology service. Participation in National Quality Control Programmes ensures compatibility of
results with other centres, whilst internal Q.C. provides a continual monitoring of precision. The Consultant
Haematologist and the Chief BMS are available to provide clinical and technical advice respectively.
2.1 OPENING HOURS
The department is open from 9:00 am to 17:30 pm from Monday to Friday.
For all out of hours arrangements see section 0.4.
2.2 URGENT REQUESTS
The department must be contacted prior to sending the specimen. Please mark the request card as urgent and state
details of to whom results should be rung. Inpatient results will be made available on the laboratory computer system
as soon as practicable for ward enquiry.
2.3 REPORTING TIMES
Normally routine reports to the wards will be available to ward enquiry within 4 hours of receipt in the laboratory. We
endeavour to provide urgent test results for ward enquiry within one hour of receipt of the specimen in the laboratory.
Electronic reports to the GP practices are sent out in the early evening for the following working day. Any FBC
requiring film examination should be reported by 16:30h the next working day. Any gross or unexpectedly abnormal
results will be telephoned to the requesting ward, department or GP practice as soon as possible.
2.4 REQUEST FORM
HAEMATOLOGY: Combined Haematology/Biochemistry (White/Red/Green) is used for all Haematology tests and
incorporates a bag for the safe transport of specimens. Please tick appropriate box or state test requested in box
provided. Where patient is anticoagulated please state drug and dosage.
NOTES ON USE OF FORMS
A) When using addressograph labels please use a label on each layer of NCR forms and add all other relevant
information to the form (e.g. ward is not supplied on the addressograph label alone). DO NOT use addressograph
labels on specimens.
B) Use ball point pen to ensure transcription through all layers of NCR (multipart) form.
C) Forms should be filled in completely and correctly.
D) Please ensure there is a ``source'' stated on form otherwise we cannot return the report to you.
E) Relevant clinical information is very important in Haematology requests, please state pregnancy gestation period
where relevant.
F) The Lab will NOT ACCEPT unlabelled samples.
G) LABELLING - Please fill in all details on both sample and request form. The hospital number in particular
is extremely useful as this is the only search parameter available to Haematology. Where hospital
numbers are given, the ``booking in'' process is speeded up making for quicker turnaround times.
2.5 SPECIMEN CONTAINERS
Within the main hospital these are available from the Phlebotomy area (Blood Tests) situated near the Cash Office.
For other users these are obtained from Pathology Specimen Reception (1809).
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2.6 HIGH RISK CASES
Specimens and request forms from patients suspected or suffering from blood borne diseases must be sent to the
laboratory suitably identified with ``Danger of Infection'' stickers with a single sample per transport bag.
2.7 COLLECTION OF SPECIMENS
All samples must be mixed after collection according to the information provided by BD which is 8 – 10 inversions.
Coagulation samples must be filled to the frosted fill line on the bottle as under or over filled samples will give
erroneous results.
Requests for additional tests should be received on the same day as the original request as sample degradation will
occur and render the sample unsuitable for testing.
D-dimer requested as an additional test must be received within 4 hours of the sample collection.
Minimum sample requirement for an FBC is 0.5ml.
2.8 SPECIMEN REQUIREMENTS
TEST
SAMPLE BOTTLE
Comments
Lavender Top 4ml
FBC/ESR/IM Screen/Reticulocytes/Malaria
Can be stored overnight in refrigerator. Some
EDTA or 1.3ml EDTA
screens/Blood Film
additional tests can be added up to 24 hours.
paediatric sample
Coagulation Tests: PT (INR)/ APTT/ DDimer
Test should be performed immediately, delays
Blue Top 2.7ml citrate can seriously affect results. Additional requests
– fill exactly to line
for D-Dimers can be made up to 4 hours after the
time of collection.
Haemoglobinopathy studies: Sickle Screen, Lavender Top 4ml
Hb electrophoresis, HbA2 & HbF estimation EDTA or 1.3ml EDTA
paediatric sample
G-6PD screen
Thrombophilia screen: antithrombin,
Proteins S&C, APCR Lupus anticoagulant
4 x Blue Top 2.7ml
citrate – fill exactly to
line
Factor V Leiden, Prothrombin Gene Variant 2 x 4ml EDTA
Haemochromatosis Gene Variant
(lavender)
Not urgent tests, can be sent Monday to Friday
09:00 to 16:00
Sent to referral centre
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2.9 ADULT NORMAL RANGES
TEST / PARAMETER
GENERIC
MALE
FEMALE
130 – 180 g/L
115 – 165g/L
RBC
12
4.5 – 6.5 x 10 /L
3.8 – 5.8 x 1012/L
HCT
0.4 – 0.52 L/L
0.36 – 0.47 L/L
Hb
WBC
9
4 – 11 x 10 /L
PLTS
9
150 – 450 x 10 /L
MCV
80 – 100 fL
MCH
27 – 32 pg
9
27 – 93 x10 /L
22 – 76 x109/L
0-14mm/Hr
0-20mm/Hr
Protein S (functional)
75-130 iu/dL
60-130 iu/dL
Protein S (antigen)
75-130%
60-130%
RETICS
9
Neutrophils
1.7 – 7.5 x 10 /L
Lymphocytes
9
1.0 – 4.0 x 10 /L
Monocytes
0.2 – 0.8 x 10
Eosinophils
9
0.04 – 0.4 x 10 /L
Basophils
9
0.00 – 0.1 x 10 /L
9/L
ESR
HbA2
1.7-3.3%
HbF
0.2-1.0%
PT
9-12 s
INR
0.9-1.2
APTT
21-29 s
APTT Ratio
0.8-1.2
FIBRINOGEN
1.5-4.0 g/L
d-Dimers
<200 g/ml
Antithrombin
80-150 iu/dL
Protein C
70-150 iu/dL
Factor VIII
50-171 iu/dL
Factor IX
50-150 iu/dL
APCr
Ratio >0.8 normal
Cold Agglutinins
< 1 in 64
G6PD
Normal Activity
Tests that do not have a numerical value will be reported with interpretative comments dependant on the result. Other
tests may also have comments to qualify the result or provide further information relating to that test.
Age and sex-related reference range are printed on the final report.
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2.10 TURNAROUND TIMES AND FACTORS AFFECTING TESTING
TEST
ROUTINE
URGENT
FACTORS
AFFECTING TEST*
H, L, C
FBC
4 hours from receipt
1 hour from receipt
C, U
ESR
1 hour from receipt
Reticulocyte
1 hour from receipt
IM screen
Same working day
Malaria parasites
Same working day
PT/INR
1 hour from receipt
APTT
1 hour from receipt
Coagulation screen
1 hour from receipt
R
R – Immunological
test only
H, U, L, O
H, U, L, O
H, U, L, O
Thrombophilia screening
Up to 6 weeks
depending on results
and send away aspects
of screen.
Not applicable
Pt on
anticoagulants.
H, U, O
A
Haemoglobinopathy
screening
Up to 4 weeks
depending on results
and confirmation at
referral laboratory.
Sickle screen 1 hour
from receipt
G6PD
Within 3 working day
Same working day
D-DIMER
1 hour from receipt
Raised reticulocyte
levels
H, U, L, O
*
H = Haemolysis
L = Lipaemia
C = Cold Agglutinins
U = Underfilled Sample
O = Overfilled Sample
R = Increased level of Rheumatoid factor
A = Aged Sample (> 3 days old)
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2.11 TELEPHONE RESULTS
The following is a guide to what may be telephoned but can vary depending on the clinical information provided.
To GPs
Hb. < 80 g/L and > 185 g/L.
WCC. < 2.0 x10 9/L and > 25.0 x 109 /L.
PLTS. < 50 x 10 9 /L. and >1000 x 109 / L
Absolute neutrophil count < 1.0 x 109 /L.
INR. > 6.0 (patients on Warfarin).
To Wards and Departments
Hb. < 70 g/L and > 190 g/L.
WCC. < 1.5 x 109 /L and > 30.0 x 109 /L. (depends on the ward).
Absolute neutrophil count < 1.0 x 109 /L.
PLTS. < 30 x 109 /L.
INR. > 6.0
APTT clotting times greater than 250 seconds
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2.12 REFERRED TESTS
Test
Anti Factor Xa
BCR/ABL Fusion Gene
Product.
JAK2 Gene Marker
Cell Markers
Sample
Requirements
1 x 3mL
citrated blood
(blue top). Pre
and 2 hrs post
dose
2-3 x fresh
EDTA samples
if possible.
2-3 x fresh
EDTA samples
if possible.
or Bone
marrow
Cell Markers
CD4, CD8
1x3ml EDTA
Cell Markers
CD55, CD59
CD52
3 x EDTA
samples
<24hrs old plus
4-6 labelled but
unfixed films
Fresh bone
marrow or
blood in
specific
transport
medium
Cytogenetic Testing
Testing Laboratory
Autolab / Coagulation Dept
Manchester Royal Infirmary
Oxford Road
Manchester M13 9WL
Tel. No. (0161 276 4082) ask
for Coagulation Department.
Dr. Abida Awan
Molecular Diagnostics Centre
Top Floor, Multipurpose
building
York Place (Gate 3)
Oxford Road
Manchester M13 9WL
Dr Awan 0161 276 4137
0161 276 8039 or 4809
Stem Cell Flow Cytometry
Lab,
Christie Hospital, Wilmslow
Road,
Manchester M20 4BX
(Tel 0161 918 7337/3286)
Immunology Department
Oxford Road
Manchester M13 9WL
Tel. No. (0161 276 8766/6440)
HMDS Department
Level 3 Bexley Wing
St James University Hospital
Leeds LS9 7TF
Tel 0113 206 7851
Oncology Cytogenetics
Christie Hospital
Manchester M20 4BX
Tel. No. 0161 446 3165. Nick
Telford Ext.3163
Turnaround
Times
14 days
Request
Form
Copy of
request form
35 days
Copy of
request form
Storage
Frozen
Additional Comments
Used to monitor LMW heparin dose in
selected patients.
o
2 – 8 C.
Preferably sent
fresh.
Sample must be less than 48 hours old when
received by Manchester.
Samples accepted Monday – Thursday
o
2–8 C
12 days
Urgent
requests
shorter.
As above.
3 days
Copy of
request form
Room
Temperature
21 days
Leeds
request form
(Available
from Dr
Hudson)
2-8 C
Preferably fresh
Urgent: up
to 5 days
28 days
Must be less than 24 hours old when received
at Christie.
Samples accepted Monday – Friday (14:30 at
latest
Specific
request forms,
which are held
by Clinical
Haematology
team
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o
Reports returned directly to requester
Must be less than 24 hours old when received
at MRI.
Send by First Class post.
Specific cell marker form to be completed for
each request.
2 – 8oC.
Preferably sent
fresh.
Sent via Macclesfield Hospital internal
transport who go to Manchester each morning
@ 09:15
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Test
DNA analysis for Thal /
Hp opathy
Factor V Leiden
Prothrombin Gene
Variant.
Haemochromatosis
Gene (HFE Gene)
Confirmation &
speciation of Malaria
Plasma Viscosity
Sample
Requirements
10mL EDTA
blood (<5 days
old). Testing is
possible on
2mL
1 x 3mL
citrated or
EDTA sample.
1 x 3mL
citrated or
EDTA sample.
The original
EDTA sample,
2 unstained
thick films, 2
unstained,
unfixed thin
films and the
original Giemsa
films
EDTA sample
(If both ESR
and PV
requested 2 x
EDTA required)
Testing Laboratory
Dr Steve Keeney
Molecular Diagnostics Centre,
Top Floor
Multipurpose Building
Manchester Royal infirmary
Oxford Road
Manchester M13 9WL
Tel. No. 0161 276 4809/4880
Steve Keeney
Top Floor
Oxford Road
Manchester M13 9WL
Tel. No. 0161 276 4809/4880
Steve Keeney
Top Floor
Oxford Road
Manchester M13 9WL
Tel. No. 0161 276 4809/4880
Turnaround
Times
8 weeks
longer for
complex
cases
Request
Form
As above.
Storage
o
2–8 C
Additional Comments
Samples should be less than 48 hours old.
Consent form must be sent with sample –
includes ethnic origin.
Sample forwarded to Oxford for testing.
Contact MRI before sending samples.
21 days
Copy of
request form
Room
Temperature
Whole blood samples are required.
Less than 48 hours old when received at
Manchester.
Samples accepted at Macclesfield
Monday - Thursday.
14 days
Copy of
request form
o
2–8 C
APCR result should be available before
sending
Sent via Macclesfield Hospital internal
transport who go to Manchester each morning
@ 09:15
Less than 48 hours old when received at
Manchester.
Samples accepted at Macclesfield
Monday - Thursday.
Diagnostics Laboratory
Liverpool School Of Tropical
Medicine.
Pembroke Place
Liverpool L3 5QA
Tel.No. 0151 705 3220
Out of hours: 07909 910 899
1 day
Department of Haematology
University Hospital of North
Staffordshire NHS Trust
City General Hospital
Newcastle Road
Stoke-on-Trent ST4 6QG
12 days
Copy of
request form
o
2-8 C
Preferably fresh.
Malaria is a notifiable disease and the LSOTM
will notify the correct body.
Clinical and travel information required for
HPA request form.
Middle copy
of request
form or
photocopy.
(Delete any
other tests
appearing on
request)
Page 33 of 77
Separate
plasma and
store at room
temperature.
Sent by First Class Post
Version 7.0
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Test
Pyruvate Kinase
Deficiency
Sample
Requirements
4ml EDTA
can be stored
at 4 oC for a
week
Thrombophilia
Screening, Protein S,
Protein C ATIII, APCR,
LUPUS
5 x 3 ml
Citrated
samples
VWF, RICOF,
Any other coagulation
assays & inhibitor
screens
2 x 3 ml
citrated blood
Testing Laboratory
Red Cell Laboratory
Haematology Dept
Kings College Hospital
Denmark Hill
London
SE5 9RS
TEL 02032999000
Haematology Department
Leighton Hospital,
Middlewich Road
Crewe CW1 4 QJ
01270 255 141 ext.2646
Autolab / Coagulation
Department
Oxford Road
Manchester M13 9WL
Tel. No (0161 276 4082) ask
for Coagulation. Department.
Turnaround
Times
2 weeks
Request
Form
As above
Storage
2 – 8oC
Additional Comments
Avoid posting over weekends.
Samples should be received in the lab by
16:30 Monday - Friday
6 weeks
Copy of
request form
Frozen
35 days
Copy of
request form
Frozen
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2.13 THROMBOPHILIA (PROTHROMBOTIC) SCREENING
Involves a set of assays to measure the level of coagulation inhibitors present in the body. The risk of VTE increases if
patent presents with the following thrombophilia results:
1. The presence of Lupus Anticoagulant.
2. Deficiency of coagulation inhibitors: Antithrombin III, Protein C and Protein S.
3. The presence of genetic mutation of Factor V Leiden as measured by the Activated Protein C Resistance screen
or the Prothrombin G20210A mutation.
4. A raised factor VIII level (>150 iu/dl).
Patients must not be on anticoagulation therapy when thrombophilia screening is requested.
In addition, sampling should be avoided during acute episodes, intercurrent illness, pregnancy and use of COCP,
HRT.
2.14 ANTICOAGULATION
MONITORING OF HEPARIN
This is necessary when using standard unfractionated Heparin, for therapeutic purposes the APTT Ratio should be
between 1.5 – 2.0.
MONITORING OF LOW MOLECULAR WEIGHT HEPARIN, utilising the anti-factor Xa assay, is necessary for the
following groups of patients:
1.
2.
3.
4.
5.
Patients with morbid obesity.
Patients with renal failure.
Pregnant women.
Children (who might require up to twice the usual dose as calculated from body weight).
Patients with malignant disease.
The Xa assay is expensive and prior discussion with the lab is essential.
MONITORING OF WARFARIN
The INR, derived from the Prothrombin Time, is used to monitor oral anticoagulants such as warfarin. The target
range will depend on the clinical reason for warfarinisation.
There is now a centrally run outreach anticoagulant service. Clinics operate at all the towns within the Central and
Eastern Cheshire PCT area. For referral of patients to these clinics please telephone 01625 661836.
NEW ORAL ANTICOAGULANTS
New oral anticoagulants (NOACs) are now also available.
These include: Dabigatran
Rivaroxaban
Apixaban
Information about the use of these anticoagulants can be found in the policies section of the Trust website.
There are currently no antidotes for NOACs.
In cases of severe blood loss, refer to the Massive Haemorrhage Protocol, appendix 7 of the Blood Transfusion
Policy.
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3.0 BLOOD TRANSFUSION
Please contact Consultant Haematologist on ext. 1806 for clinical advice regarding blood transfusion.
Please contact Transfusion Practitioner on ext. 1236 or bleep 5164 regarding the process of transfusing a
patient.
3.1 SPECIMEN COLLECTION FOR TRANSFUSION
Two request forms are used in transfusion:
a)
Pink Group and Screen, Crossmatch or Blood product requests, DAT (coomb's test), Kleihauers, cord sample
requests.
b) Yellow Antenatal form for booking blood requests (FBC, Antenatal virology testing and Blood Group and antibody
screening) and subsequent requests.
WITH THE PINK REQUEST FORM
The pink transfusion request forms are printed with an attached number, THE TRANSFUSION NUMBER. This serves
as an extra, unique identifier but does not supersede the other patient identifiers.
1.
2.
3.
4.
Remove bar coded Transfusion number (T number) and place on appropriate space as indicated on Request
Card.
Place bar code number along length of sample, avoiding patient details on the label.
Complete the large sticker and place in case notes.
If patient is unconscious or unidentified place 4th T number on patient's wrist band
For further information on sample collection refer to the reverse of the request card or the Trust Transfusion Policy
Specimens for transfusion request should be taken by the requesting medical officer or appropriately trained,
designated representative.
The specimen container must be labelled with the patient's full name, DOB, hospital number and/or address / NHS
number, and the ward handwritten on the label at the time of collection. The sample must be signed and dated.
ADDRESSOGRAPH LABELS ARE NOT ACCEPTABLE ON SAMPLES. DO NOT PRELABEL SPECIMEN
CONTAINERS.
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3.2 TRANSFUSION DEPARTMENT INVESTIGATIONS
TEST REQUEST
SPECIMEN
Group and Antibody
6ml EDTA (Pink top)*
Screen
Crossmatch
REPORT
TIME
NOTES
2 working
days
Plasma samples normally saved for 7 days but if patient transfused
or pregnant in previous 3 months sample for crossmatching must
be less than 72 hours
24 hours notice required for provision of blood for elective surgery.
Current guidelines require second sample prior to the issue of
blood where the patient is not known to the laboratory. Exceptions
can be made where blood is required urgently.
6ml EDTA (Pink top)*
Alkali Precipitation
Various
Test
1 day
Please contact the laboratory staff where the need to establish
whether blood contamination of items is of foetal or maternal origin.
Atypical Antibody
investigation
2 x 6ml EDTA (Pink top)*
1-2 weeks
Referred to Liverpool NHSBT
Direct Antiglobulin
Test (DAT)
EDTA (Pink or purple top)* Same day
1
2 x 6 ml EDTA (Pink
Investigation of
top)and used/part used
Transfusion reaction
blood units*
Next
working
day
Refer to the Trust Transfusion policy and procedure and complete
A4 transfusion reaction form
HLA Typing (HLA
B27)
2 x EDTA (purple top)
1-2
weeks
Referred to Sheffield NHSBT 2
HLA Antibodies
6ml clotted (red top)
1-2
weeks
Referred to Sheffield NHSBT 2
Platelet Antibodies
6ml clotted (red top)
1-2
weeks
Referred to NHSBT Bristol 3
Cold Agglutinins
6ml clotted (red top) and
an EDTA sample. Kept at 1 week
37oC. Ring Dept. for advice
6ml EDTA (Pink top)
Antenatal Screening 6ml clotted (Red top)
EDTA (Purple top)
Post Natal screen
for RhD Negative
Mothers
Maternal - 6ml in pink
EDTA
1 hr post delivery
Cord 6ml in pink EDTA
2 working
days
For Group and Antibody Screen
Serological investigations
FBC
1 working
day
Mother with Red Cell Maternal - 6ml pink EDTA
Antibodies
Cord - 6ml purple EDTA
1 working
day
Kleihauer
2 working
days
EDTA pink or purple
By prior arrangement with laboratory
>20 weeks gestation
1. NHS Blood & Transplant Liverpool, 14 Estuary Banks, Speke, Liverpool, L24 8RB.
2. NHS Blood & Transplant Sheffield, FAO Histocompatibility & Immunogenetics, Longley Lane, Sheffield, S5 7JN
3. NHS Blood & Transplant Bristol, 500 North Bristol Park, Northway, Filton, Bristol, BS34 7QH
* For paediatrics/ neonates please use appropriate specimen either 3ml/1.3ml EDTA sample
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3.3 ROUTINE REQUESTS
When non-urgent transfusions are planned, requests for cross matching should be made at least 24 hours in advance.
This allows time for extra investigations to be made if unknown antibodies are found. Any such finding will be notified
to the requesting doctor.
3.4 URGENT REQUESTS
Please phone the blood transfusion laboratory (ext 1808) to advise of an urgent request.
3.5 GROUP AND SCREEN REQUESTS
We encourage the use of group and screen requests. For many operations it is not necessary to have cross matched
blood available. For group and screen requests a screening test is performed to detect irregular antibodies. The
finding of any clinically significant antibodies will be notified to the requesting officer/ward. If they are not found there
should be no difficulty in providing cross matched blood in an emergency. Updated guidelines insist that where a
patient is unknown to the Transfusion laboratory a second sample should be obtained to confirm the blood group prior
to the issue of blood components.
The plasma will be held for 7 days but if blood is requested for patients who have been transfused or pregnant within
the previous 3 months a sample less than 72 hours old is required for crossmatching.
3.6 RECLAIMING CROSSMATCHED BLOOD
Unused crossmatched blood will routinely be taken back into stock 24 hours after the time the blood was stated to be
required. If blood is likely to be needed longer than this period, the medical officer must inform the Transfusion
Department.
3.7 ISSUE OF BLOOD
When blood is required for transfusion, it is collected by Nursing staff from the Blood Fridge located at:
1) For Orthopaedic Theatre, wards 5, 6: Outside staff locker rooms within Orthopaedic Theatre Suite.
2) For all other wards and departments at entrance to main theatre suite, First Floor, General Hospital.
FOR FURTHER INFORMATION REFER TO THE TRUST’S BLOOD TRANSFUSION POLICY AND
PROCEDURES
3.8 WARMING OF BLOOD
Blood must only be warmed in special blood warmers specifically designed for the purpose. If there is a need to warm
blood it will be indicated on the compatibility statement.
3.9 REACTIONS
In all cases of reaction to transfusion, please notify the blood transfusion laboratory immediately.
3.10 IRRADIATED BLOOD/PLATELETS FOR TRANSFUSION
It is not always possible for transfusion staff to identify patients who require irradiated blood products from the clinical
information provided.
It is the responsibility of the requesting Medical Officer to identify any patient who requires irradiated blood products.
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3.11 BLOOD ORDER SCHEDULE
PLEASE REFER TO THE TRUST’S BLOOD TRANSFUSION POLICY AND PROCEDURES
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4.0 MEDICAL MICROBIOLOGY
The Microbiology Department provides a diagnostic microbiology service to both Macclesfield and Crewe and the
surrounding areas.
Clinical advice is offered on 9-5pm Monday to Friday, by a Consultant Medical Microbiologist on a dedicated advice
line:
 From Macclesfield, use extension 3644 (outside line 01625 663644).
 From Leighton, use extension 3370 (outside line 01270 273370)
Both numbers link to the Consultant Microbiologist on duty for clinical calls for both sites, on that day.
Outside routine laboratory opening hours, clinical advice can be obtained from a Consultant via the hospital
switchboard.
Scientific and technical enquiries should be directed towards the Biomedical Scientists of the Department. The
Department aims to provide a high quality, comprehensive service to hospital and community users. Full quality
control is carried out and the Department strives to achieve and maintain UKAS accreditation status. Tests not
available on site are referred to specialist laboratories.
In collaboration with the local Infection Control Team and Public Health England, the Department contributes to the
surveillance, control and prevention of nosocomial infection and cross infection in the Trust hospitals, the local
community and nationally.
4.1 OPENING HOURS
The Department is open from 09:00h - 20.00h from Monday to Friday. A service for urgent requests and enquiries is
offered on Saturday, Sunday and Bank Holiday mornings from 09:00h to 17:30h.
4.2 URGENT REQUESTS
The requesting medical officer must contact the laboratory reception (ext 1809) before sending the specimen and
must add a contact number, either bleep or telephone, to the request form.
Urgent investigations available on-call:




CSF
Ascitic Fluids (only for diagnosis of SBP)
Joint Aspirates
Pus from deep head and neck collections (e.g.orbital abscess, retropharyngeal collections)
NB: Blood cultures do not require the attendance of the BMS. Out of hours transport the samples to Pathology as
quickly as possible, where the on-site Pathology staff will transfer them to an incubator. Other non-urgent specimens
can be left overnight in a fridge until the next day e.g. urine, sputum, but if in doubt please contact the on-call
Biomedical Scientist.
4.3 REPORTING TIMES AND SPECIMEN CONTAINERS
The reporting times given in the following tables are those for average routine specimens. Occasionally an unusual
organism is isolated which may be antibiotic resistant, or difficult to identify, so the report may be delayed in leaving
the department.
A single yellow top tube will suffice for one of more of the following tests that are referred to serology at Leighton
Hospital laboratory: Rubella, Varicella, Syphilis, HIV, Hepatitis A IgM, Hepatitis B surface antigen, Hepatitis B core
antigen, Hepatitis B surface antibody, Hepatitis C antibody.
For all other serum tests stated to require a yellow top bottle in the table below, please send a separate tube for each
test.
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SPECIMEN
TYPE
CONTAINER
STORAGE
REPORT TIME
Arterial Line Tips Sterile Universal Container Fridge*
3 days
Aspergillus pptns Yellow top bottle
Referred up to 7
days
Fridge
REFERRAL
LABORATORY
Immunology Dept.
Manchester Royal
Infirmary
3 days Anaerobes
Aspirates, Pus,
Sterile Universal Container Room Temp. may take up to 10
Pleural Fluid etc.
days
Avian pptns
Yellow top bottle
Fridge
Referred up to 7
days
Immunology Dept.
Manchester Royal
Infirmary
Blood for ASO
Yellow top bottle
Fridge*
Up to one week
Microbiology,
Leighton Hospital
Blood Culture
Special bottle
At 37oC
Min of 5 days (for
negative)
Chlamydia
Special bottles
Fridge*
Referred up to 7
days
C.S.F.
Sterile Universal Container
Send to Lab.
2 days
immediately
Faeces
60ml Plain Container
Fridge*
3 days
See separate section
Functional
antibodies
(pneumococcal,
Hib etc..)
Yellow top bottle
Fridge
Referred up to 10
days
Gamma
Interferon
Blood bottles available as
part of collection pack
(contact Department)
Must be at
referral lab
within 16
hours
Referred up to 7
days
Gentamicin
Yellow top bottle
Fridge*
Same day
Use biochemistry
request form
Hydatid Serology Yellow top bottle
Fridge
Referred up to 7
days
Liverpool School of
Tropical Medicine.
Leptospira (Weils) Yellow top bottle
Fridge
Referred up to 7
days
County Hospital,
Hereford
Lyme Disease
Yellow top bottle
Fridge
Referred up to 14
days
Microbiology, Porton
Down
Measles
Yellow top bottle
Fridge
Referred up to 7
days
Manchester Royal
Infirmary
Meningococcal
PCR
EDTA bottle
Fridge
Referred up to 7
days
Manchester Royal
Infirmary
MRSA swabs
Charcoal swab
Room Temp. 2 days
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Manchester Royal
Infirmary
Immunology Dept.
Manchester Royal
Infirmary
Version 7.0
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SPECIMEN
TYPE
CONTAINER
STORAGE
Referred up to 7
days
REFERRAL
LABORATORY
Manchester Royal
Infirmary
Mumps
Yellow top bottle
Mycology (Fungi)
Microscopy 7
Sterile Universal or Special
Room Temp. days/Culture 4
Envelope
weeks
Seminal Fluid
(post vasectomy
only)
Must be fresh 1 day
and warm
60 ml plain container
Fridge*
1 week
Hepatitis A,B,C
Yellow top bottle
Fridge
Referred, 2 days
Serology, Leighton
Hospital
Hepatitis B or C
type/viral load
EDTA bottle
Fridge
Referred up to 7
days
Manchester Royal
Infirmary
Rubella
Yellow top bottle
Fridge
Referred, 2 days
Serology, Leighton
Hospital
Sputum
Room Temp.
Sputum for
A.A.F.B.
Fridge*
Swabs
Transwab
Room Temp. 3 days
Syphilis
Yellow top bottle
Fridge
Referred, 2 days
Tissue
Fridge*
3 days
Urine
Boric Acid Container
Room Temp. 2 days
Urine for A.A.F.B.
3 x 30ml white topped
container
Fridge*
Referred - 6 weeks
(for negative)
University Hospital of
North Staffs
Varicella zoster
Yellow top bottle
Fridge
Referred, 2 days
Serology, Leighton
Hospital
Viral Culture
If swabs; must be in
transport medium
Fridge
Referred up to 8
weeks
Manchester Royal
Infirmary
Viral Titres†
Yellow top bottle
Fridge
Referred up to 7
days
Manchester Royal
Infirmary
Helicobacter
(faecal sample)
Fridge
REPORT TIME
3 days
Referred - 6 weeks
(for negative)
University Hospital of
North Staffs
Serology, Leighton
Hospital
* If a fridge for patient specimens is not available a cool dark place is preferred
† For viral titres please ensure clinical details or specific investigation required indicates type of virus suspected.
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Timeframe for requesting additional investigations
For in-house tests, specimens are retained for one week (urines are retained for three days) and cultures are
stored for at least two days after the report has been issued. We will attempt to comply with reasonable requests
for additional investigations within these limitations.
Key factors known to affect performance of Microbiology tests:










Specimen inappropriate to the clinical condition
Delay in transport to laboratory
Environmental conditions during transport
Contamination during transport
Unsuitable container for specimen
 Desiccation in large container
 No, or inappropriate, transport medium
 Presence of formalin or cytology fixative in container
Contamination with antibacterial substances (detergents, antiseptics, antibiotics, preservatives)
Incorrect labelling of specimen
 Wrong patient
 Wrong site
Incomplete or inaccurate clinical details (leading to inappropriate processing of specimen)
Insufficient material
Container not sterile
4.4 REQUEST FORMS AND SPECIMEN LABELLING
If available, use ICE electronic requesting, otherwise use a blue Microbiology request form for all Microbiology
investigations. Requests for blood tests including serology and virology tests can be indicated on a blood sciences
form.
Full patient details (a minimum of surname, forename and DOB as per specimen acceptance policy) must be written
on both the request form and the specimen plus the TIME AND DATE OF COLLECTION on the specimen. The
laboratory will not examine unlabelled/incompletely labelled specimens.
Write clearly and in capital letters.
Please help the laboratory by giving the details of onset of the infection, details of foreign travel (if appropriate) and
details of any antimicrobial therapy with commencement date. The organisms and antibiotic susceptibilities which are
reported depend upon the information given on the request form.
Appropriate information is also needed for staff safety. Please refer to the following link from HSE regarding provision
of key clinical information on laboratory request form http://www.hse.gov.uk/safetybulletins/clinicalinformation.htm
As outlined in the Health and Safety Executive Safety Notice HID 5-2011 all staff requesting diagnostic testing
must ensure that clinical details supplied on Pathology request forms contain clear information regarding the
nature of test being requested and sufficient detail to inform laboratory staff upon the safety precautions they
need to take in order to process the specimen without risk of infection.
All samples should be sent to the laboratory without delay. If delay is inevitable then see the enclosed list for suitable
temperatures at which to store. The laboratory will not accept specimens more than 48 hours old.
4.5 HIGH RISK CASES
Specimens which are classified as `high risk' must be labelled as such. The more frequent agents included in the `high
risk' group are Salmonella typhi, HIV, Hepatitis B and Mycobacterium tuberculosis. Please ensure all relevant clinical
information (including foreign travel) is included on the request so potential high risk samples can be identified and
effective Health and Safety procedures initiated.
Please refer to HSE Safety Notice HID5-2011 http://www.hse.gov.uk/safetybulletins/clinicalinformation.htm
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4.6 GENERAL ADVICE ON SPECIMEN COLLECTION AND SUITABILITY
All disposable equipment used in the collection of Microbiological samples must be disposed of as clinical waste in
accordance with current regulations. Particular care must be taken when disposing of sharps to ensure such articles
are handled and disposed of in the correct designated containers in such a manner as to prevent injury to any
individual.
Re-usable equipment must be appropriately disinfected or sterilised after use in accordance with local policies.
4.6.1 ANTIBIOTIC LEVELS
ANTIBIOTIC MANAGEMENT GUIDELINES ARE AVAILABLE ON THE TRUST INTRANET
Sample collection: Please state the date and time of sample collection, and the date and time of the last dose, on the
request form. A minimum of 1ml-clotted blood in a gold top bottle is usually required, but smaller sample volumes
may be acceptable for neonates and infants. Please do not use intravenous lines to take the blood sample.
Indications: A few antibiotics, e.g. aminoglycosides, chloramphenicol and vancomycin, exhibit a narrow range between
the therapeutic and toxic concentrations. Assays of blood antibiotic levels may be required to:

confirm that adequate concentrations of antibiotic are being achieved, e.g. in patients with known defective
intestinal absorption or in the treatment of meningitis; OR

in order to avoid excessive blood concentrations when the drug is known to be toxic, especially if the patient
has impaired renal of hepatic function, or in neonates whose renal and hepatic handling of drugs is imperfectly
developed.
Gentamicin assays are undertaken in the Biochemistry departments at Leighton and Macclesfield Hospitals and are
available at all times, including “out of hours”. Please notify the Biochemistry department if the request is urgent.
Vancomycin and Tobramycin assays are analysed in the Biochemistry department at Macclesfield Hospital. There is
no need to take a peak sample, post vancomycin dose.
Teicoplanin assays are referred to a specialist centre for testing. Trough sample only required. Blood should be
collected immediately before a dose. This should not be collected until the patient has received treatment for 5-7 days.
Treatment with teicoplanin should be continued whilst awaiting the results of the pre-dose level.
Please use a microbiology request form for teicoplanin requests.
Serum level assays for itraconazole, 5-flucytosine, voriconazole are performed at reference laboratories and should
be booked with Microbiology staff in advance. Samples must reach the laboratory by 9am to allow transport to the
appropriate laboratory.
Please use a biochemistry request form for these “sendaway” tests.
Therapeutic drug level monitoring – reference ranges
Pre dose
Post dose
Trough
Peak
Tobramycin (multiple
daily dosing for cystic
fibrosis patients only)
< 2 mg/L
8 -12 mg/L
Tobramycin (multiple
daily dosing for NON
cystic fibrosis patients)
< 2 mg/L
6 - 10 mg/L
Vancomycin
Gentamicin
Teicoplanin
On the advice of
consultant
microbiologist only
10 -15 mg/L
See guideline on hospital intranet
20 - 60 mg/L
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For severe infections
only (e.g. MRSA,
osteomyelitis, septic
arthritis)
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4.6.2 BLOOD CULTURES
In bacteraemic patient the number of viable bacteria in the blood varies from hour to hour and may frequently be as
few as one or two organisms per ml., therefore, a relatively large volume of blood (5-10ml) must be used as the
inoculum.
A specific single bottle (yellow top) is provided for paediatric specimens, this is inoculated with up to 4ml of blood.
Blood cultures are required:1) To isolate and identify an organism present in blood and
2) To determine the antibiotic sensitivity of the pathogens isolated so that treatment with the optimal antibiotic or
combination of drugs at correct dosage can be used.
METHOD OF COLLECTION
Disinfection of the skin and good technique are vital in the collection of blood cultures. Ideally, blood for culture should
be collected by one venepuncture, while blood for other investigations is collected from another venepuncture site.
If this is impractical, inoculate the culture bottles before distributing blood to other containers. Blood culture bottles are
available from the main or sub laboratory. If bacterial endocarditis is suspected, it may be advisable to take several
sets of cultures at different times and from different sites. 10 ml of blood should be inoculated into each bottle.
It is very important that the exact collection time and date is written on the specimen bottles. This is in addition to fully
completing the request form with the patient details, full clinical details and any antibiotic therapy given.
Blood culture specimens MUST be returned to the laboratory as soon as possible after collection. There is no
requirement to inform the laboratory or the on call Biomedical Scientist.
4.6.3 CEREBRO-SPINAL FLUID
Please label all samples clearly with the patient’s name, DOB or Hospital number, date and time collected.
NB: IT IS VERY IMPORTANT TO SPEAK WITH THE CONSULTANT MICROBIOLOGIST BEFORE ANY
SPECIMENS ARE TAKEN FROM PATIENTS SUSPECTED OF TSE/CJD.
Please send as large a volume as possible. CSF is normally collected sequentially into three or more separate
containers, which should be numbered consecutively. Ideally a minimum volume of 1 ml should be sent if culture for
Mycobacterium species is required.
Collection of a separate fluoride oxalate sample for glucose estimation is not required.
Equipment:
As provided by C.S.S.D.
Skin preparation:
70% alcohol + povidone-iodine
Method:
As demonstrated by senior colleague
Collect the CSF in sterile screw topped containers, without preservative, label the containers 1-3 in the order in which
they are collected. Send specimens 2 and 3 to Microbiology and specimen 1 to Biochemistry. If examination for
Xanthochromia is required please collect an extra sample and send this last sample taken (number 4) to Biochemistry.
If only one specimen is available, please send to Microbiology where it will be forwarded as required.
Meningococcal disease
Where Meningococcal meningitis or septicaemia is suspected, blood specimens can be referred for PCR (molecular
techniques). Please send 2.7 ml EDTA blood sample.
Please discuss any problems with diagnosis, or treatment of meningitis with the Consultant Microbiologist.
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4.6.4 CHLAMYDIA PCR
This test is referred.
Testing for East and Mid Cheshire PCT is covered by Team Chlamydia who supply all forms and specimen
containers. The telephone contact number is 01260 277477. Referred to Aintree Hospital, Liverpool.
Other testing, including hospital patients, is referred by pathology at Macclesfield DGH to Manchester Royal Infirmary.
Use a blue Microbiology form. Specimen containers are available from pathology at Macclesfield. There are 3 types:

Yellow Aptima tube for urine.

Orange Aptima tube for swabs

Purple Aptima tube for urethral and endocervical swabs
Eye swabs can be sent using either the orange or purple kits.
Please state which tube type is needed when re-ordering
4.6.5 FAECES
Specimens should be collected into a sterile 60ml container. Never completely fill the container. Clinical details must
include details of foreign travel, contact with known infected patients and consumption of suspect food, if known.
Microscopy
All suitable specimens are examined for red and white cells together with obvious infestations with Giardia lamblia. All
specimens are routinely examined for Oocysts of Cryptosporidia.
Culture
Specimens are routinely cultured for:

Salmonella

Shigella

Campylobacter
Where indicated by the clinical details, history of foreign travel and with diarrhoeal samples we can also test for:

Vibrio cholerae

E. coli O157

Yersinia enterocolitica

Aeromonas and Plesiomonas
Toxin testing for Clostridium difficile is performed on unformed stools from hospital patients who fit Department of
Health criteria and patients over the age of 65 and liquid stools from GP patients. The test is not suitable for formed
samples.
Virology
Specimens from all children under the age of 5 years are examined for Rotavirus.
Samples from adults will be referred for virology only as part of outbreaks or if specifically agreed with the Consultant
Microbiologist
Parasitology
Routine samples are examined for parasites associated with acute diarrhoea. If there is clinical evidence of chronic
intestinal parasitic infection, send stool samples from 3 consecutive days with a single request for OCP and clinical
details including foreign travel.
For threadworm investigations please send anal washing. Instructions and saline bottle are available from the
laboratory.
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a) Inpatients: Adults: The stool is passed into the bedpan without urinating. Using a spatula select (when possible) a
suitable portion containing blood and mucus and place in container.
Wash your hands!
Infants: - Where possible a spatula should be used to collect material from soiled napkins and the specimen
transferred to the container as above
b) Outpatients: Adults: The patient is issued with a screw capped container and advised to proceed as follows:i. Place in the W.C. pan a few loosely packed toilet papers
ii. Defaecate onto the paper in the W.C. pan.
iii. Collect a faecal sample from the paper using a spatula and transfer to the screw capped container avoiding
contaminating the outside of the container. Screw down the lid tightly, discard the spatula wrapped in
paper/polythene bag into the household dustbin.
iv. Wash hands with soap and water.
Infants: Instruct mothers to collect a specimen from the napkin as above.
Where AMOEBIC infection is suspected, please inform the laboratory and send a specimen without delay.
METHOD FOR COLLECTING SPECIMENS FOR INVESTIGATION FOR OVA OF ENTEROBIUS VERMICULARIS
(THREADWORM EGGS)
1. You will require a cotton tipped swab and a bijou bottle of sterile saline
2. Moisten the swab in the saline and wipe moistened swab around perianal area first thing in the morning (i.e.
before defaecation or washing).
3. Break off swab into saline bottle.
4. Label bottle and send to laboratory as soon as possible.
4.6.6 FUNGAL INFECTIONS
For superficial infections associated with:
1. Hair please send whole hair complete with roots. Cut hairs are unsuitable.
2. Skin send loose skin scraped from the edge of the lesion.
3. Nail scrapings from discoloured or dystrophic areas.
Large specimens collect into a dry sterile plastic container. Smaller specimens use the special Dermopak transport
system. Send to the laboratory immediately.
Wash hands and put on gloves
HAIR: Remove distorted or fractured hairs with forceps. Pluck hair from scalp.
DO NOT USE CUT HAIR
SKIN: Cleanse with alcohol wipe, before a specimen is collected, to reduce the level of contaminating skin flora.
Take shavings of epidermal scales at the active border of the lesion onto a collection envelope using a
scalpel.
NAIL: Cleanse nail with alcohol wipe
The outermost layer of the nail is then removed by scraping with a scalpel onto a paper towel.
Deeper scrapings, debris from under the edge of the infected nail, and nail clippings from the
infected areas, are also suitable for culture.
Put specimens either into “Dermapack” or a screw-capped container and label clearly.
4.6.7 H. PYLORI (Faeces test)
The faeces test for Helicobacter pylori antigen detects active infection. It can be used as a test of cure provided proton
pump inhibitors are stopped for 2 weeks and antibiotics are stopped for 4 weeks prior to testing.
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4.6.8 LEGIONELLA ANTIGEN TEST
A test on urine samples is available for community acquired pneumonias which fulfil the criteria defined by the British
Thoracic Society Guidelines.
4.6.9 MYCOBACTERIUM (T.B.)
All are referred to the laboratory at Stoke. Urgent Zeihl-Neelson’s for A.A.F.B can be carried out on site but the
method is much less sensitive than that used at Stoke and all requests would have to be authorised by the Consultant
Microbiologist.
Ziehl-Neelsen's for A.A.F.B. are performed on all specimens except urines.
Sputum
Please collect the first early morning specimen into a sterile 60 ml. Container. Please send specimens on each of
three consecutive days.
Urine
Please collect early morning MSU specimens over 3 consecutive days into 30ml polypropylene urine containers (white
tops).
Pus
It is always preferable to send aspirated pus in a sterile plastic container.
Pleural Fluid
Use a sterile plastic container.
Gastric Washings
Use a sterile 60 ml. container.
The acid content may kill the bacteria present, so please send these specimens to the laboratory without delay.
Tissue
Send in a sterile plastic container. If only a very small amount of tissue is available, please cover the tissue with sterile
saline to prevent drying.
DO NOT ADD FORMALIN FIXATIVE, THIS WILL DESTROY ANY BACTERIA PRESENT
4.6.10 PUS
FOR HEALTH & SAFETY REASONS DO NOT SEND PUS IN SYRINGES WITH NEEDLE ATTACHED.
Wherever possible, pus should be aspirated from the lesion and collected into a dry, sterile plastic container. This
enables a full microbiological examination to be done including TB culture if necessary. Pus swabs are NOT suitable
for TB culture. Please give full clinical details especially antimicrobial therapy, as this may influence the interpretation
of the results.
Aspirated material may be placed directly into the screw capped container, alternatively pus may be transferred
directly to the container from a sterile receiver. Do not place the container in contact with the lesion, to avoid
contaminating the outside of the container.
Aspirates (e.g. pleural, joint, peritoneal, pelvic, spinal fluids, etc) as well as surgical and biopsy specimens requiring
microbiological examination are to be placed in sterile screw capped containers with NO ADDED FIXATIVES OR
PRESERVATIVES.
If the patient is suspected of having T.B. please request this investigation on the accompanying form.
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4.6.11 SEMEN ANALYSIS
Semen analysis is only carried out, “in-house” for post vasectomy patients. For fertility testing the patient should be
referred to the Patrick Murphy Unit at Leighton (please do not refer patients to the Pathology Department at Leighton).

Specimens should be collected into the 60ml plastic containers and should arrive in the laboratory as soon as
possible after collection between the hours of 9.00 and 11.00 am, Monday to Friday. These specimens are not
accepted on weekends or Bank Holidays.

The specimen should be kept as near to body temperature as possible until arrival in the laboratory. It is
essential that collection time is written down on the sample and the request form.
The essentials are that a fresh specimen is collected without contact with any chemical, to
arrive for analysis very quickly at the right temperature.
1. There must be 3 days abstinence before collection of the specimen.
2. The specimen must be collected by masturbation into the small sterilised container provided but the container
must be at body temperature.
3. No rubber contraceptives must be used in the collection.
4. The container is kept at body temperature e.g. in trouser pocket or under the clothing and brought to the
laboratory immediately.
5. Note the time of collection and please make sure that a request form accompanies the specimen.
6. Please label all specimens with full name and address, date and time of collection and the name of the doctor
or surgeon.
For checking after vasectomy, the first specimen must be collected three months after the operation and the
second specimen one month later still or as directed by the surgeon.
4.6.12 SPUTUM AND BRONCHIAL WASHINGS
The laboratory prefers to receive early morning specimens taken by deep productive cough after the patient has
rinsed the mouth to remove overnight debris. Specimens taken from the bedside sputum pot MUST NOT be sent.
Salivary specimens are NOT suitable.
All sputum specimens should arrive in the laboratory on the day of collection. Full clinical details are very important for
the investigation of Legionella, fungal infections, lung abscesses, cystic fibrosis and mycobacteria. Specimens for
mycobacteria are referred to the University Hospital of North Staffordshire.
BAL and associated specimens should be collected according to local protocol. Please send as large a volume as
possible.
Please note that BAL are examined for AAFB (TB and other Mycobacterium species) only on request.
The best time to obtain a sputum specimen is in the morning when the patient awakes.
Specimens should be taken before antimicrobial therapy is commenced where possible.
Care should be taken to ensure the specimens sent for examination is sputum – NOT SALIVA.
Instruct the patient to cough sputum directly into the container avoiding contamination with saliva and contamination of
the outside of the container.
Encourage the patient to cough deeply. If problems obtaining an expectorated specimen are encountered ask
Physiotherapist for assistance.
If the patient is suspected of having T.B., wear gloves when handling the container and any waste tissues. Replace
the lid of the container immediately.
4.6.13 ASPIRATES (PLEURAL, JOINT, PERITONEAL, PELVIC)
Please label all samples clearly with the patient’s name, DOB, NHS or Hospital number, date and time
collected and the specimen site.
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Specimens should be collected according to specialist local protocols into a sterile container. Aspirates requiring
microbiological examination are to be placed in sterile screw capped containers WITHOUT ADDED FIXATIVES OR
PRESERVATIVES.
Please note that pleural fluids are examined for AAFB (TB and other Mycobacterium species) only on request.
Notes on transport: Specimens should be transported and processed as soon as possible. The volume of
specimen influences the transport time that is acceptable. Large volumes of purulent material maintain the viability of
anaerobes for longer; however the recovery of anaerobes is compromised if the transport time exceeds 3 hours.
If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 48 hours will not
produce optimum results and are strongly discouraged.
4.6.13 SWABS
Sites or lesions should be swabbed accurately avoiding the surrounding areas. It is essential that the site or nature of
the wound being swabbed is noted on the request form together with any antimicrobial therapy. If it is a post operative
wound the operation and surgeon should be stated.
The site of female genital swabs should be identified, e.g. `High Vaginal' or Endocervical', together with the age of the
patient, pregnancy and any recent operative procedures. All these factors influence the culture techniques we use on
the specimen (see also Chlamydia).

Nasal Swab: Moisten the swab with the N/Saline and gentle rotate around the anterior nares. Replace the swab
stick into the transport medium.

Throat swab: position patient comfortably and arrange for the throat to be properly illuminated. Depress the
patients tongue with the spatula.
Use the swab to obtain material from both fauces.
Transfer the swab into the required transport medium.

Pernasal swab: to isolate Bordetella pertussis (Whooping cough). Use special swab available from the
microbiology laboratory. Position the patient comfortably. Introduce the pernasal swab below the interior turbinate
and into the post nasal space and gently rotate the swab to collect the sample. Transfer the swab into the
transport medium.

Wound swabs: Place the sterile swabs deep into the wound and collect specimen. Transfer the swab into the
transport medium.

High vaginal and cervical swabs: Put on gloves
Place patient in dorsal position (lying on the back, knees flexed and widely separated).
With gloved hand part labia and introduce the speculum into the vagina and under good vision collect material
from:a) posterior fornix
b) cervical os
Carefully withdraw the swab, avoid contamination with lower vaginal and perineal flora. Transfer the swab into the
transport medium.

Eye Swabs: swabs should always be taken before local anaesthetics are applied to the eye.
Hold the swab parallel to the eye with your free hand, part the patient; eyelids and gently rub the conjunctiva of
the lower eyelid with the swab, transfer this swab into the transport medium.
Repeat with viral or Chlamydia transport media as required.
Keratitis/corneal ulcer: kit available from the Microbiology Department. If acanthamoeba is suspected, please
contact department so that arrangements can be made for referral to the reference laboratory.
Endopthalmitis: Conjunctival cultures are generally regarded as being inadequate. All cases of traumatic and post
surgical endopthalmitis should have aqueous and vitreous aspiration for cultures and smears. The material
obtained from these taps should be inoculated into a sterile container which should be transported to the
laboratory immediately. Two sets of blood cultures must be taken when endopthalmitis is suspected.
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
MRSA swabs: The request form has a section for MRSA screening. Tick the boxes as appropriate for the site of
the swab and the reason – emergency admission, elective admission, or contact of MRSA.
4.6.14 URINE
Please use boric acid containers for all urines for culture.
Fill to line marked on container. Do not overfill or underfill (if sufficient urine cannot be obtained then use a plain
sterile container and refrigerate if necessary).
A mid stream urine is required for accurate results. The patient should be instructed to pass an initial sample into the
toilet. Then, without stopping, the bottle should be filled to the line marked on the side. Remaining urine should be
passed into the toilet.
Catheter specimens should be collected from the drainage sampling port, and not the bag itself.
The specimen should arrive in the laboratory on the day of collection. If this is impossible, the specimen should be
stored at room temperature overnight.
Wash hands and put on gloves.
In males: retract the foreskin and clean the glans penis and urethral meatus with soap and water.
In females: clean the urethral meatus and vulva with soap and water; swab with cotton wool balls from front to back
Ask the patient to micturate into bedpan/toilet/urinal and then collect the mid stream of the urine (20-30mls) into the
specimen container (men) receiver (women)
Infants
Boys – After preliminary cleansing, a sterile tube is strapped to the penis to serve as collecting vessel.
Girls – A polythene bag with adhesive fitting is placed over the previously cleansed perineum. (Alternatively a sterile
latex glove may be used as a collecting vessel).
CATHETER SPECIMEN OF URINE

Clamp the drainage bag tubing below the rubber self-sealing sampling port.

Wash your hands

Cleanse the sleeve/port with alcohol swab.

Insert the assembled needle and syringe at a 45º angle into the rubber sleeve and 90º angle into the protected
sampling port. (All sampling sleeves are designed to occlude puncture holes when needle is withdrawn).

Aspirate catheter urine into the syringe.

Withdraw the needle and syringe from the catheter.

Re-swab the sampling sleeve/port with alcohol swab.

Transfer urine sample into container.

REMOVE CLAMP from the drainage bag tubing.
4.6.15 VIROLOGY/SEROLOGY
The following virology/serology tests are referred to Serology at Leighton: Rubella, Varicella, Syphilis, HIV, Hepatitis A
IgM, Hepatitis B surface antigen, Hepatitis B core antigen, Hepatitis B surface antibody, Hepatitis C antibody and ASO
tests.
All other tests are referred to accredited specialist centres e.g. Manchester HPA.
All requests must be accompanied by a blood sciences request form and include as much clinical detail as possible
together with date of onset.
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For virus serology and all other serology send a separate yellow topped bottle with 5 -10ml. of clotted blood. For virus
culture there are special transport bottles available from pathology reception.
The results are usually available within 10 days but culture may take longer.
Any urgent requests eg. hepatitis B or HIV from needle stick injuries must be directed through the Consultant
Microbiologist.
4.6.16 MYCOBACTERIUM (T.B.)
All are referred to the laboratory at Stoke. Urgent Zeihl-Neelson’s for A.A.F.B can be carried out on site but the
method is much less sensitive than that used at Stoke and all requests would have to be authorised by the Consultant
Microbiologist.
Ziehl-Neelsen's for A.A.F.B. are performed on all specimens except urines.
Sputum
Please collect the first early morning specimen into a sterile 60 ml. Container. Please send specimens on each of
three consecutive days.
Urine
Please collect early morning MSU specimens over 3 consecutive days into 30ml polypropylene urine containers (white
tops).
Pus
It is always preferable to send aspirated pus in a sterile plastic container.
Pleural Fluid
Use a sterile plastic container.
Gastric Washings
Use a sterile 60 ml. container.
The acid content may kill the bacteria present, so please send these specimens to the laboratory without delay.
Tissue
Send in a sterile plastic container. If only a very small amount of tissue is available, please cover the tissue with sterile
saline to prevent drying.
DO NOT ADD FORMALIN FIXATIVE, THIS WILL DESTROY ANY BACTERIA PRESENT
4.7 INFECTION CONTROL
The infection control team is managed by Mrs Anita Swaine, Lead Nurse in Infection Control
Infection control link nurses support this team.
The team offers a high quality advisory service on many topics including:







Hand washing
Patient and staff protection
Disposal of clinical waste
Handling of linen
Disinfection and sterilisation procedures
Specific infection control precautions/isolation nursing
MRSA
Advice and training sessions are also available on:





Food hygiene
Tissue damage minimisation and wound management
Management of patients with indwelling urinary catheters
Monitoring of infection control practices.
Aseptic procedures
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5.0 CELLULAR PATHOLOGY DEPARTMENT: THE SERVICE
The Cellular Pathology Department for East Cheshire NHS Hospital Trust (Macclesfield District General Hospital)
provides a Consultant-led diagnostic service for inpatients, outpatients and patients under the care of General
Practitioners in the region.
As part of a collaborative arrangement with Mid Cheshire Hospitals NHS Foundation Trust (Cheshire Pathology
Services), the laboratory receives a variety of specimens which include surgical and post mortem Histology, nongynaecological Cytology, Post Vasectomy Semen Analysis specimens and Autoimmune Serology samples. The
Cellular Pathology laboratory is located at Leighton hospital. The Mortuary facility remains located within the main
hospital at Macclesfield.
The Department comprises a team of Consultant Pathologists who will readily give clinical advice if required. The
laboratory is staffed by Biomedical Scientists who are available to provide technical information and advice regarding
sample collection and processing where necessary.
5.1 OPENING HOURS
The Department is open from 09:00 to 17:00 Monday to Friday.
No service is available outside routine working hours or at the weekend.
5.2 THE REQUEST FORM
All specimens must be received with a request form.
The request form should bear the following clearly legible information:
●
Patient details i.e. full name, date of birth, address and hospital number
●
Ward / location, Consultant / GP so that the report can be returned to the appropriate individual when available.
This is essential as copy reports will not be issued.
Where an extra copy of a report is required please ensure that this is noted in the same field on the request form
●
Signature and printed name of the person making the request
●
Specimen type
●
Appropriate clinical information – e.g. any known previous malignancies, any relevant clinical data regarding the
patient’s physical state.
Please ensure that any relevant clinical information is also available to the Radiologists so that the card can be
completed fully.
●
Date of specimen collection
●
Patient type i.e. NHS, Private Patient
It is essential that request forms from General Practitioners have the practitioner's surname and initials on the form.
The GP code is not acceptable.
5.3 URGENT REQUESTS
Urgent specimens must be clearly marked as such so that they can be given priority. The laboratory should be
informed where possible by telephone (01270 273286) that a specimen is urgent so that it can be identified at the
earliest opportunity on receipt in the laboratory.
5.4 HISTOLOGY HIGH RISK CASES
If the patient is suspected of having a Category 3 infection then the request form must be labelled High Risk - Danger
of Infection and details provided as part of the clinical information. The specimen and form must be sent to the
laboratory in the approved plastic specimen bag.
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5.5 PRODUCTS OF CONCEPTION (POC)
Products of conception (POC) specimens require a completed consent form for examination of foetal material
following a miscarriage. The Department will not accept a POC specimen without this consent form being fully
completed and will return it to source. A routine Histology request form should also accompany the specimen.
Specimens requiring histological examination must be less than 12 completed weeks gestation. Specimens greater
than 12 weeks gestation should be sent directly to the Mortuary.
5.6 SPECIMEN CONTAINERS
All specimen containers must bear the following clearly legible information:
●
Surname in full
●
Forename, first name in full and initials of any other
●
Date of birth
●
Hospital number and date of collection
●
Precise nature of the specimen
On removal, the tissue should be placed immediately into a suitably sized container which itself should contain 10%
buffered formalin. It is important to select a container of adequate size – tissue must never be ‘forced’ into a container
which is too small. Ideally, the volume of fixative should be at least 10 times the volume of the specimen and the
specimen should be completely immersed. Failure to place the tissue in a suitable container with an adequate volume
of formalin may affect the diagnostic process.
Ensure that the lids are secure and the specimen container is not leaking. Hazardous specimens must be clearly
labelled
Urgent specimens should be labelled appropriately and transported to the laboratory immediately.
Once tissue has been placed in formalin it is unsuitable for bacteriological investigation. Tissues requiring
this type of analysis should be placed in a dry, sterile container and sent to the Microbiology Department.
Formalin is a hazardous chemical and should be handled appropriately. Safety data sheets are available from
the laboratory on request.
Supplies of specimen containers and formalin are available from the Pathology Department at Macclesfield.
Formalin Spillages
For a small spillage of formalin i.e. no more than 0.5 litres the following action is recommended:
(1) Evacuate the room and prevent others from entering.
(2) Wear Personal Protective Equipment, gloves and goggles.
(3) Ensure adequate ventilation when mopping up the spillage.
(4) Use a dishcloth or mop and bucket, which must be washed out well in running water afterwards.
(5) Wash formaldehyde down the sink with copious amounts of water.
For a larger spillage of Formalin evacuate the room and prevent others entering. Spill kits are available in the
main theatre areas.
5.7 TRANSPORT OF HISTOLOGY SPECIMENS
Ensure that lids are the correct size and securely placed on the container, the container is not leaking and that the
specimen is double-bagged where necessary to contain any possible leakage.
Hazardous specimens must be clearly labelled.
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Operating theatres should deliver specimens to the laboratory immediately after each theatre session. This enables
the laboratory to part-dissect large specimens to ensure adequate fixation.
Specimens for frozen section or immunofluorescence should be notified to the laboratory, packaged and labelled, then
brought to the laboratory immediately. See below for further information.
Urgent specimens should be labelled and sent directly to the laboratory to avoid any delay. If an urgent result
is required telephone 01270 273286 and ask to speak to a Consultant Pathologist.
5.8 REPORTING TIMES
The average reporting times for histology specimens is as follows:
Specimen Turnaround Time
Specimen Type
Urgent Biopsies
Within 48 hours
Small biopsies
Within 5 Working Days
Large Lesions and Resections
Within 10 Working Days
Bone Specimens
2 – 6 Weeks
The above reporting turnaround times are for guidance only and may be subject to variation in certain circumstances
such as if the case is particularly difficult, further diagnostic tests are required or referral to another Hospital Trust is
necessary.
Below is a list of the referral laboratories used to provide second opinions or specialist investigations:
BONE and JOINT
Dr D C Mangham
Department of Musculoskeletal Pathology
Royal Orthopaedic Hospital
111 Dale Road
Sellyoak
Birmingham
West Midlands
B29 6AY
Prof A J Malcolm
Department of Histopathology
Royal Shrewsbury Hospital
Mytton Oak Road
Shrewsbury
SY3 8XQ
BREAST
Dr I Ellis
Department of Pathology
City Hospital
Hucknall Road
Nottingham
NG5 1PB
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BRAIN
Dr Duplessis
Consultant Neuropathologist
Hope Hospital
Stott Lane
Salford
Manchester
M6 8HD
CARDIOVASCULAR
Dr J R Gosney
University Department of Pathology
Duncan Building
Royal Liverpool University Hospital
Daulby Street
Liverpool
Merseyside
L69 3GA
CARDIOVASCULAR
Dr M Burke
Harefield Hospital
Hill End Road
Harefield
Uxbridge
Middlesex
UB9 6JH
Dr M Shepherd
National Heart & Lung Institute
Royal Brompton Hospital
Sydney Street
London
SW3 6NP
CYTOLOGY
Dr M Desai
Department of Histopathology & Cytopathology
Clinical Sciences Building
Oxford Road
Manchester
M13 9WL
Dr L Turnbull
Duncan Building
Daulby Street
Liverpool
Merseyside
L69 3GA
DENTAL / ORAL
Prof P Sloan
Unit of Experimental Pathology
Turner Dental School
Higher Cambridge Street
Manchester
M15 6FH
ENDOCRINE
Dr S S Banerjee / Dr J H Shanks / Dr Menasce
Christie Hospital
Wilmslow Road
Manchester
M20 9BX
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ENDOCRINE
Dr T Stephenson
E Floor
Royal Hallamshire Hospital
Glossop Road
Sheffield
S10 2JF
EAR, NOSE AND THROAT
Dr S S Banerjee / Dr J H Shanks
Christie Hospital
Wilmslow Road
Manchester
M20 9BX
Dr T Helliwell
University of Liverpool
Duncan Building
Daulby Street
Liverpool
Merseyside
L69 3GA
EYE
Dr R E Bonshek
Central Manchester Health Care NHS Trust
Oxford Road
Manchester
M13 9WH
Dr M A Parsons
Ophthalmic Sciences Unit
Glossop Road
Sheffield
South Yorkshire
S10 2JF
GASTROINTESTINAL TRACT Dr F Campbell
Duncan Building
Daulby Street
Liverpool
Merseyside
L69 3GA
Prof N A Shepherd
Gloucestershire Royal Hospital
Great Western Road
Gloucester
GL1 3NN
GYNAECOLOGICAL
Dr T P Rollason
Birmingham Women’s Hospital
Edgbaston
Birmingham
West Midlands
B15 2TJ
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Dr S Ismail
University Hospital of South Manchester
Wythenshawe Hospital
Southmoor Road
Wythenshawe
Manchester
M23 9LT
Dr G E Wilson
Department of Histopathology & Cytopathology
Oxford Road
Manchester
M13 9WL
KIDNEY / URETER /
BLADDER / PROSTATE /
PENIS
Dr F Knox
University Hospital of South Manchester
Southmoor Road
Wythenshawe
Manchester
M23 9LT
Prof C S Foster
Duncan Building
Daulby Street
Liverpool
Merseyside
L69 3GA
LIVER
Dr F Campbell
Duncan Building
Daulby Street
Liverpool
Merseyside
L69 3GA
Dr S G Hubscher
Medical School
University of Birmingham
Birmingham
West Midlands
B15 2TJ
Dr A D Burt
Royal Victoria Infirmary
Queen Victoria Road
Newcastle Upon Tyne
Tyne and Wear
NE1 4LP
LYMPH NODE / SPLEEN
Dr Banerjee / Dr J H Shanks
Christie Hospital
Wilmslow Road
Manchester
M20 9BX
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PAEDIATRIC / FOETAL
Dr G Kokai
Liverpool Children’s Hospital
Alder Hey
Eaton Road
West Derby
Liverpool
L12 2AP
RESPIRATORY
Dr P S Hasleton
Southmoor Road
Manchester
M23 9LT
Dr B J Addis
Level E South Block
Southampton General Hospital
Tremona Road
Southampton
Hampshire
SO16 6YD
SKIN
Dr D N Slater
Floor E
Glossop Road
Sheffield
South Yorkshire
S10 2JF
Dr K Blessing
Western Infirmary
Dumbarton Road
Glasgow
G11 6NT
Dr N Leonard
Duncan Building
Daulby Street
Liverpool
Merseyside
L69 3GA
Dr Eduardo Calonje
Director of Diagnostic Dermatopathology
Department of Dermato-Histopathology
St John’s Institute of Dermatology
St Thomas’s Hospital
London
SOFT TISSUE
Dr D C Mangham
Department of Musculoskeletal Pathology
Royal Orthopaedic Hospital
111 Dale Road
Sellyoak
Birmingham
West Midlands
B29 6AY
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Prof C D M Fletcher
Brigham and Women’s Hospital
75 Francis Street
Boston
MA 02115
U.S.A
EYE SPECIMENS
Ophthalmic Specimens
Specimen Reception
th
5 Floor Duncan Building
Daulby Street
Liverpool
L7 8XP
FRESH MUSCLE
Dr Daniel Crooks
Department of Neuropathology
The Walton Centre for Neurosurgery
Lower Lane
Fazakerly
Liverpool
L9 7LJ
FIXED MUSCLE
Dr Daniel Crooks
Department of Neuropathology
The Walton Centre for Neurosurgery
Lower Lane
Fazakerly
Liverpool
L9 7lJ
5.9 FROZEN SECTIONS
Frozen sections are available by arrangement. At least 24 hours notice should be given when booking this
service. To arrange, please contact the Cellular Pathology Department (01270 273286) detailing the date, time,
requesting Consultant, specimen type and any relevant clinical information.
Specimens for frozen sections must not be sent in fixative but sent fresh and dry to the laboratory with a completed
request form.
Frozen sections cannot be cut on material from patients who are infected or potentially infected with any category 3
pathogen i.e. who are regarded as High Risk.
Where a frozen section is required in an emergency contact the Histology laboratory directly by telephoning
01270 255141 ext 2629 and they in turn will liaise with a Consultant Pathologist.
The Consultant Pathologist will telephone the requesting Clinician in theatre when the result is ready. To avoid
unnecessary delay it is vital that the relevant telephone extension number is written clearly on the request form that
accompanies the frozen section.
5.10 ACCESSING REPORTS
Histopathology reports are available electronically within the hospital via the Labcentre computer system in all areas
where terminals are situated. Paper copies of the reports are sent out daily to requesting clinicians and General
Practitioners. It is the Departmental policy not to issue extra paper copies of reports except in exceptional
circumstances.
Giving verbal reports over the telephone for histological specimens is discouraged because of the risk of
misinterpretation. Any request for a verbal report will be passed on to a Consultant Pathologist. Laboratory and
Clerical staff are not permitted to give out verbal results.
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5.11 SPECIMENS TAKEN AT WEEKENDS
These specimens should be immersed in a sufficient volume of formalin to facilitate adequate fixation. The specimen
containers must be kept at room temperature and must not be refrigerated.
5.12 IMMUNOFLUORESCENCE SERVICE
Where possible 24 hours notice should be given when requiring this service.
The Histology laboratory must be notified by telephone on 01270 255141 ext 2629 prior to each specimen being
taken. At this point the patients name, hospital number and estimated time of specimen arrival into the laboratory will
be required.
Two skin biopsies must be taken from the bulla and / or the skin adjacent to the bulla depending on the nature of the
disease suspected. Take two 5mm punch biopsies from these areas:
●
Biopsy 1
Place the biopsy into a pot of 10% buffered formalin. Label the specimen container.
●
Biopsy 2
Place the biopsy into Michel's medium and label the container. Vials of Michel's medium are available from
Pathology at East Cheshire, ext 1809.
Complete a specimen request form with the specimen type as follows:
Biopsy 1 - Punch biopsy from (area) for histological examination
Biopsy 2 - Punch biopsy from (area) for Immunofluorescence
Both specimens and the specimen request card should be transported immediately to the Cellular Pathology
Department via Pathology at East Cheshire.
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6.0 CYTOLOGY
The Cytology Department is now based at Mid Cheshire NHS Hospitals Trust at Leighton hospital. It sits within the
Cellular Pathology laboratory and provides a routine diagnostic service to inpatients, outpatients and those under the
care of their General Practitioner (GP). Post vasectomy semen analysis is also performed in the department.
6.1 URGENT REQUESTS and HIGH RISK SAMPLES
URGENT REQUESTS
Samples requiring urgent examination must be clearly marked and the laboratory telephoned on 01270 255141 ext
2629. These samples will then be given priority.
HIGH RISK SAMPLES
Please state clearly on the request form the nature of the risk and attach HIGH RISK stickers to both the specimen
request form and the sample.
6.2 NON GYNAECOLOGICAL CYTOLOGY SPECIMENS
Non-gynaecological cytology specimens should be submitted to the Department in a tightly closed container within a
sealed plastic bag accompanied by a fully completed specimen request form. The type of container used is
dependent upon the nature of the specimen (see below). Please state the specimen type clearly on the request form.
Clinical data should always be provided as it will help with the interpretation of the sample. In accordance with the
Laboratory Acceptance Policy it is essential that patient details, including full surname and forename(s), date of
birth and test date are included on both the request form and specimen container and that they match in every
detail. The laboratory advises that the details on the sample container be hand written as the use of preprinted labels bearing patient details has been found to be unsafe.
If both Histology and Cytology specimens are sent to the laboratory (e.g. bronchial biopsy and bronchial washings)
then each specimen must be placed in a separate plastic bag but the bags should be attached to one another. Don’t
forget to complete a separate Histology request form for the Histology specimen.
Separate specimens and request cards are also required when bacteriological or chemical investigations are needed
in addition to cytological examination.
Ideally specimens should reach the laboratory on the day they are collected otherwise please refrigerate and
send the following morning.
High risk specimens must be clearly labelled (both specimen request form and sample container).
Specimen request forms, sample containers and transport media are supplied by the Pathology specimen reception
at East Cheshire – contact extension 1046.
On receipt by specimen reception at East Cheshire Pathology samples are transported to Mid Cheshire Hospitals
NHS Foundation Trust (Leighton Hospital, Crewe – part of Cheshire Pathology Services collaborative) for processing,
followed by reporting by a Consultant Pathologist.
TURNAROUND TIMES
Results should be available on the laboratory browser for non-gynaecological cytology specimens within 3 working
days.
6.3 SPUTUM
Sputum cytology has been shown to give very poor diagnostic results. Sputum samples should not be sent for
cytology unless the patient is unsuitable for bronchoscopy. If samples are sent they should be early morning ‘deep
cough’ specimens collected before the patient eats, drinks or cleans their teeth. Please use a plain 60ml. collecting pot
and sent to the laboratory as soon as possible.
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6.4 URINE
Urine for cytology should preferably be an early morning, mid stream sample collected into a 30 ml plain (white top)
universal container. Please do not use a boric acid bottle as this renders the specimen unsuitable for cytology.
Samples should be sent to the laboratory without delay (preferably within 2 hours of voiding). Urine may be
refrigerated for up to 48 hours if necessary but this is not ideal.
6.5 SEROUS EFFUSIONS / CEREBROSPINAL FLUID (CSF)
Please collect all pleural, ascitic and cerebrospinal fluids in a 30 ml plain (white top) universal container and send to
the laboratory as soon as possible. Samples taken overnight should be refrigerated and sent to the laboratory first
thing the following morning.
6.6 FINE NEEDLE ASPIRATES (FNA)
A transport medium is available for fine needle aspirate (FNA) specimens, these containers are clearly labelled with
an expiry date. Please contact the laboratory for supplies and advice. For reasons of health and safety, the Cytology
Department advises that following fine needle aspiration the syringe needle is not sent to the laboratory. However, to
maximise cellular yield, please ensure that before disposal the needle is thoroughly flushed out into the specimen
container.
Nipple Discharges - If the clinician prepares smears on slides they must be air dried as soon as possible and
appropriately labelled.
6.7 JOINT FLUIDS
Sample should be collected into a lithium / heparin specimen container (available from the specimen reception at East
Cheshire Pathology).
Joint fluid samples submitted to the Cytology Department are sent to the University of Manchester via Pathology
specimen reception at East Cheshire at the following address to be reported:
Osteoarticular Pathology,
Division of Regenerative Medicine,
School of Medicine,
The University of Manchester,
The Stopford Building,
Oxford Road,
Manchester
M13 9PT
The samples are sent using the laboratory courier service leaving the Pathology Department at Macclesfield District
General Hospital at 9.30am each day.
6.8 GASTROINTESTINAL TRACT (GI) BRUSHINGS
Please place brush tip in a 30 ml (white top) universal specimen container containing buffered electrolyte solution
(available from the Cytology Department).
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6.9 BRONCHIAL WASHINGS / BRONCHIAL BRUSHINGS
BRONCHIAL WASHINGS
A minimum of 5 ml of specimen in a clean dry container is required. Please send separate specimens and request
cards where bacteriological investigation is required in addition to cytological examination. Samples should be sent to
the laboratory as soon as possible.
BRONCHIAL BRUSHINGS
A transport medium is available for bronchial brush specimens. Please contact the laboratory for supplies and advice.
Please detach the brush and remove the plastic outer sleeve before placing the brush in transport medium for sending
to the laboratory.
6.10 SEMEN ANALYSIS
Semen analysis is only carried out, “in-house” for post vasectomy patients. For fertility testing the patient should be
referred to the Patrick Murphy Unit at Leighton (please do not refer patients to the Pathology Department at Leighton).

Specimens should be collected into the 60ml plastic containers and should arrive in the laboratory as soon as
possible after collection between the hours of 9.00 and 11.00 am, Monday to Friday.

The specimen should be kept as near to body temperature as possible until arrival in the laboratory. It is
essential that collection time is written down on the sample and the request form.
The essentials are that a fresh specimen is collected without contact with any chemical, to arrive for analysis very
quickly at the right temperature.
1. There must be 3 days abstinence before collection of the specimen.
2. The specimen must be collected by masturbation into the small sterilised container provided but the container
must be at body temperature.
3. No rubber contraceptives must be used in the collection.
4. The container is kept at body temperature e.g. in trouser pocket or under the clothing and brought to the
laboratory immediately.
5. Note the time of collection and please make sure that a request form accompanies the specimen.
6. Please label all specimens with full name and address, date and time of collection and the name of the doctor
or surgeon.
For checking after vasectomy, the first specimen must be collected three months after the operation and the second
specimen one month later still or as directed by the surgeon.
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7.0 MORTUARY
OPENING HOURS
The Mortuary is open between 08.00 and 12.00 and between 14.00 and 16.30 Monday to Friday.
Mortuary staff provide out of hours cover for advice, urgent requests and special arrangements.
Post-mortem examinations are usually carried out between 09.00 and 12.00 during the week when, unless previously
agreed with the Mortuary technicians, the removal of bodies and viewing of bodies is not available.
Viewing of the deceased should be arranged with the Mortuary staff prior to arrival by telephoning extension 1847.
TRANSFER OF DECEASED PERSONS TO THE MORTUARY
Deceased persons should be transferred to the mortuary as soon as possible after death.
●
Contact the Porters desk (extension 1659) - they will transfer the body appropriately.
●
Part 1 of the Hospital Identification of Personal Details of the Deceased Form HI.F079 should be completed by the
Nursing staff and given to the Porters. The patient details on the form must match those on the body / shroud.
Particular attention should be paid to the accurate recording of the presence of valuables on the body. Unless this
form is fully completed, Porters cannot accept the body for removal.
●
Part 2 of the form is to be completed by the Porters when transfer to the Mortuary has been carried out.
VIEWING OF DECEASED PERSONS
Requests to view a deceased person must be made by appointment with the Mortuary Technicians on extension
1847.
Apart from exceptional circumstances, viewing should take place between 13.00 and 16.30 Monday to Friday. Please
contact the Mortuary Technician on-call for advice if a viewing is requested outside of these hours.
To arrange viewing outside of these hours contact the Ward or Bed Manager and they in turn will make arrangements
with the Portering staff. During an out-of-hours viewing the Bed Manager must accompany the relatives at all times. A
Viewing of Deceased Relatives Form must be completed.
7.1 THE POST-MORTEM
Post-mortem examinations usually take place from 09.00 to 12.00 Monday to Friday. Clinicians directly involved in the
care of the deceased can arrange to be present during an examination. Mortuary Technicians will contact Clinicians
and / or their secretaries prior to the examination beginning.
The Mortuary at East Cheshire NHS Hospital Trust (Macclesfield District General Hospital) does not have a viewing
gallery therefore staff entering the post mortem examination room will be expected to wear personal protective
clothing and overshoes at all times.
7.2 HOSPITAL POST MORTEMS EXAMINATIONS
The following are some practical points in connection with requests for hospital post mortem examinations:
1. The senior Clinician concerned should see the relatives and obtain written consent using the appropriate form as
soon as possible. It is not desirable for this to be delegated. It is important to point out to relatives the clause in the
Post Mortem Consent Form regarding removal and / or retention of organs. A Clinical Summary sheet for Hospital
Post Mortems and case notes should be brought personally by the House Officer to the Consultant Pathologist as
soon as possible. It is not advisable to put case notes and requests for hospital post-mortems in the internal mail
as the Funeral Director may have collected the body before the post mortem request has been received by the
Mortuary.
Neither the Pathologist nor the Hospital has any power to retain a body once a death certificate has been
signed.
2. Signing or issuing of a death certificate must not be held up pending the result of a post-mortem. To do
so, is in fact illegal. If the Clinician involved is not prepared to offer a Death Certificate without the results of a post
mortem examination, then the case must be referred to the Coroner.
Contact the Consultant Histopathologist for advice on Death Certification should a problem arise.
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7.3 PAEDIATRIC POST MORTEM EXAMINATIONS
All foetuses and stillbirths are examined at Manchester Children’s Hospital. Full and informed consent is necessary for
the examination and a copy of the completed consent form must accompany the body to the mortuary along with a
Return to Mortuary form and a Coroners Hospital ID and Conformation form.
If cytogenetic investigations are required it is the responsibility of the Clinician or midwife to take relevant tissue
samples and arrange transfer.
It is hospital policy to provide a Christian burial for all foetuses under 28 weeks gestation if the parents do not wish to
arrange their own.
All stillbirths should be either buried or cremated. This is the responsibility of the next of kin.
7.4 CORONERS POST MORTEM EXAMINATIONS
Any death which may possibly come into the list below must be reported to the Coroner through the Coroner’s Office
which can be contacted during normal working hours via General Office (extension 1105 or 1107) or by telephoning
(01925) 442483.
If in doubt speak to a Coroner’s Officer for advice or contact the Cellular Pathology Department and speak to a
Consultant Pathologist (extension 1820).
REPORTABLE DEATHS IN CHESHIRE
Deaths must be reported in the following circumstances:(i)
The cause of death is unknown. Remember, you must know the cause of the death, rather than the mode of
dying (heart failure for instance, is not considered a cause of death but a mode of dying).
(ii)
You did not attend (in the sense of treating or at the least monitoring treatment) the deceased in his or her last
illness and to your knowledge, no other doctor so attended or if they did attend, they are not currently available.
(iii)
The Registration Regulations cannot be satisfied for some other reason (e.g. the name of the deceased is not
known).
(iv)
The deceased has not been seen by you for treatment within the 14 days before death.
(v)
The death was violent, unnatural, suspicious or unexpected.
(vi)
The death may be linked to poison or drugs.
(vii)
The death may be due in whole or in part to an accident, no matter when the accident occurred.
(viii) The death may be due to self-neglect or neglect by others, including poor care in a residential or nursing home.
(ix)
The death may be due to an industrial disease or related to the deceased’s employment or the deceased was in
receipt of industrial injury or disablement pension or war pension, even if the death does not appear to be
related to the condition for which the pension has been awarded.
(x)
The death may be due to an abortion.
(xi)
The death occurred during an operation or before recovering from the effects of an anaesthetic.
(xii)
The death occurred within 24 hours of admission to hospital.
(xiii) The death may be linked to an operation or any other medical procedure or drug (medicinal or otherwise and
whether or not prescribed).
(xiv) The death may be due to lack of medical care or allegations of medical mismanagement have been made.
(xv)
The death may be due to the actions of the deceased, including suspected suicide or solvent abuse, etc.
(xvi) The death (whether natural or not) occurred during or shortly after detention in police or prison custody.
Remember that although a prisoner may die in hospital he is still in custody for these purposes.
(xvii) The deceased suffered a recent fracture, fall or other significant injury whether or not you believe that the cause
of death was natural or the injury had any bearing on the death.
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(xviii) Deaths involving children under the age of 18 from whatever cause must be reported.
(xix) The death was that of a mother and occurred following childbirth.
If the case needs reporting to the Coroner then enter the fact in the patient's notes after the entry confirming the
death. You do need to ring the Coroner or the Coroner's Officer yourself to report the case. All medical notes are sent
to the General Office as soon after death as possible so that relatives can collect Medical Certificates and personal
property to be able to register the death and make funeral arrangements. They are asked to attend from 11.00
onwards on the day after death (except Saturdays and Sundays) and it is therefore very important that all
paperwork is complete when they arrive.
Deaths should be reported to the Coroner's Officer via the General Office before 10.00.
In some cases reportable to the Coroner the cause of death will be known (e.g. death in Coronary Care within a few
hours of admission where cause is clear) so a Medical Certificate should be completed as normal then await further
instructions from the Corner’s Office.
Coroners post mortem examinations may be carried out by a Consultant Pathologist from the Cellular Pathology
Department at East Cheshire NHS Hospital Trust or may be carried out by a Consultant Pathologist based in another
hospital Trust appointed by the Coroner.
Under normal circumstances a post mortem examination will be carried out within 48 hours of death. Examinations
may be delayed by an additional day where there is an intervening weekend.
COMMON MISCONCEPTIONS AND ISSUES

The year and a day rule no longer applies. If a death is related to an unlawful, accidental or intentional injury or
non-natural cause, it is reportable, no matter how long ago the original event occurred.

Industrial diseases and employment deaths often have their counterpart in natural disease processes. Always
consider very carefully the possibility of an employment connection, particularly with a respiratory illness or
cancer. Refer to the death certificate book for a list of many of the industrial diseases. Do not deprive a family of a
legitimate claim for compensation by failure to report.

It is inappropriate to rely on viewing the body after death to overcome the fact that the deceased was not seen
within 14 days of death. At best this may help to rule out a violent death but will not assist in establishing the
cause of death.

Death due to alcoholism or smoking or sexually transmitted AIDS is not considered unnatural but please note that
death due to the acute effects of alcohol is reportable.

It is not a legal requirement for the certifying doctor to view the body before issuing a Death Certificate, but good
practice nevertheless.

Old age as the cause of death should be avoided unless entirely appropriate in all circumstances and then unless
the person is over 80 the death should be reported.

Some doctors confuse unnatural with unlawful; a death following a fall, choking on food or through the transfusion
of infected blood is as unnatural as a death due to hanging, stabbing or gun shot wounds.

Do not guess, you have a duty to report on the cause of death to the best of your knowledge, information and
belief. Do not use the formula of myocardial infarction or bronchopneumonia or stroke based on statistical
likelihood rather than diagnosis.

Families will be much assisted in avoiding unnecessary post mortems and delays if Doctors could plan
strategically for their holidays and prolonged absences. If you have a patient who is expected to die while you are
away, please ensure that a colleague attends the patient before your departure so that the doctor can issue a
death certificate if your patient dies in your absence.

If you patient has suffered a recent facture or other significant injury then the death should be reported whether or
not you believe that the cause of death was natural.

If before completion of the medical certificate as to cause of death you have cause to wonder whether the
death should be reported, the answer is likely to be yes because otherwise you would not have had the
thought process!
IMPORTANT
If the doctor is in any doubt whether the death of a patient under his care should be notified to the Coroner or not,
please contact the Coroner’s Office or Consultant Histopathologist for advice. This in the long term is very much in
the interest of the doctor concerned. The Coroner regards wilful failure to notify appropriate deaths as a serious
matter.
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7.5 CONTACT NUMBERS
Mortuary
Extension 1847
General Office
Extension 1105 / 1107
Coroner’s Office
(01925) 442483 / 442478
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8.0 IMMUNOLOGY
Pathology Specimen Reception at East Cheshire NHS Hospital Trust administers the referral of Immunology tests to
Manchester Royal Infirmary (MRI) for analysis. Samples are transported daily to MRI and the return of the results is
monitored.
Clinical advice is available on these referred samples should this be required.
Contact details for MRI are given below:
Oxford Road
Manchester
M13 9WL
General Result Enquiries:
Telephone (0161) 276 8766
Clinical Interpretation:
Dr. Matthew Helbert (0161) 276 6468
Managerial Interpretation:
Mr. Colin Dennett (0161) 276 6440
Once the reports for Immunology samples are available they will be sent directly to the requesting Clinician.
Sample Requirements
Send 1 yellow top SST tube for immunology tests listed on the immunology request form with the following exception:
 A separate SST is required for intrinsic factor antibody and any immunology tests not specified on the form.
Please send separate yellow top SST samples with a biochemistry form, for each of the following:

Immunoglobulins/protein electrophoresis

Rheumatoid factor

CCP antibody

GAD antibody

Thyroid peroxidise antibody

TSH receptor antibody
Please send separate yellow top SST samples with a microbiology form, for:

ASO titre

Aspergillus/avian/farmer’s lung precipitins
For assays on neonates or on very young children send 1mL clotted samples instead of the above.
Request Form
A specific Immunology Request form must be used for all Immunology requests. Full patient and clinical details must
be given. It is essential that request forms from General Practitioners have the doctor's surname and initials on the
form. The GP's code is not acceptable.
Supplies of sample request forms can be ordered / obtained from the Pathology Department Specimen Reception –
telephone (01625) 661046.
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9.0 MANUAL INDEX
Item
Manual Section
Alpha 1 antitrypsin
ACTH
AAFB
Albumin
Alcohol (blood)
Aldosterone
Alanine aminotransferase (ALT)
Alkaline phosphatase
Alphafeto protein (tumour marker)
Amino acids (urine)
Amiodarone
Ammonia
Amphetamines (urine screen)
Amylase
Androstenedione
Angiotensin converting enzyme
Antibiotic levels
Antibody to mitochondria
Antibody to parietal cells
Antibody to smooth muscle
Anti-D immunoglobulin
Antinuclear antibody
Apoproteins (A1,B,E)
APTT
Ascitic fluid (Cytology)
Aspartate aminotransferase (AST)
1.24
1.20
4.18
1.24
1.24
1.18, 1.24
1.24
1.24
1.24
1.24
1.24
1.24
1.24
1.24
1.24
1.24
1.9, 1.24, 4.21
5.12
5.12
5.12
3.16
5.12
1.24
2.9
6.6
1.24
B2 microglobulin
1.24
Barbiturates (urine screen)
1.24
BenceJones protein
1.24
Benzodiazepines (urine screen)
1.24
Bilirubin (total/direct)
1.24
Bleeding time
2.9
Blood/blood products
3.11
Blood cultures
4.6
Blood gases
1.11, 1.24
Blood grouping
3.5
Bone marrow examination
2.10
Breast biopsies
5.11
Breast fine needle aspiration
6.7
Bronchial brushings/washings (Cytology) 6.10
Bronchial washings (Microbiology)
4.14
CA-125
C-peptide
C-reactive protein (CRP)
1.24
1.18, 1.24
1.24
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C-1 esterase inhibitor
C3/C4
Caeruloplasmin
Calcium
Calculi (stone analysis)
Cannabinoids (urine screen)
Carbamazepine
Carboxyhaemoglobin
Cardiac enzymes
Catecholamines – see Metadrenalines
Cell marker studies
Cervical smears
Chlamydia
Chloride
Cholesterol total
Cholesterol HDL
Cholinesterase (pseudo)
Coagulation factors
Cocaine metabolites (urine screen)
Cold agglutinins
Copper (serum/urine)
Cord blood testing
Cortisol (serum/urine free)
Creatine kinase (CK)
Creatinine
Creatinine clearance test
Cross infection
Cross matching
Cryoglobulins
CSF (Biochemistry)
CSF (Microbiology)
Cyclosporin
Cystine (urine)
1.24, 5.12
1.24, 5.12
1.24
1.24
1.24
1.24
1.24
1.11, 1.24
1.24
1.17, 1.24
2.9
6.2
4.8
1.24
1.10, 1.24
1.10, 1.24
1.24
2.8
1.24
3.2
1.24
3.2
1.17, 1.24
1.24
1.24
1.24
4.20
3.2
1.24
1.14, 1.24
4.7
1.24
1.24
D-Dimer
2.9
Dexamethasone suppression test
1.17, 1.18
DHEA-sulphate
1.24
Digoxin
1.24
Direct antiglobulin test
3.2
Drugs of abuse in urine screening (DAU) 1.24
EB virus (see IM screening test)
Erythropoeitin
ESR
2.9
1.24
2.8, 2.9
Faeces (Microbiology)
Fetal remains
Ferritin
FFP
Fibrinogen
Fibrinolysis
4.9
7.3
1.24, 1.28
3.15
2.9
2.9
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Folate
Free androgen index
Free thyroxine (free T4)
FSH
Full blood count
Fungi
1.24
1.19, 1.24
1.16, 1.24
1.19, 1.24
2.8, 2.9
4.10
G6PD screening
Gastric washings (Microbiology)
Gastrin
Gentamicin
GFR
Glandular fever (see IM screening test)
Glucose
Glucose tolerance test
Glycated haemoglobin (HBA1c)
Gamma glutamyl transpeptidase (GGT)
Group and save serum
Growth hormone/GTT
Gut hormones
2.9
4.18
1.20
1.9
1.21, 1.24
2.9
1.15, 1.24
1.15, 1.24
1.15, 1.24
1.24
3.5
1.18
1.18, 1.24
Haematinics
1.18, 1.24
Haemoglobin
2.9
Haemoglobin A1c (Glycated haemoglobin) 1.15, 1.24
BHCG
1.19, 1.24
HDL-cholesterol
1.10, 1.24
Helicobacter
4.11
High risk specimens - Biochemistry
1.5
High risk specimens - Blood Transfusion 2.6
High risk specimens - Haematology
2.6
High risk specimens - Histology
5.7
High risk specimens - Microbiology
4.5
Histology specimens
5.6
HRT monitoring
1.19
IgA
IgE
IgG
IgM
Immunology
Infection control
Infertility investigations - Microbiology
Infertility investigations - Biochemistry
Insulin
Insulin stress test
Iron
Iron studies
1.24
1.24, 5.12
1.24
1.24
8.0
4.19
4.13
1.19
1.18, 1.24
1.18
1.24, 1.28
1.24, 1.28
Joint fluids for crystals and cytology
6.8
Lactate
1.24
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Lactate dehydrogenase (LDH)
LDL cholesterol
Lead
LH
LH-RH (Gonadorelin) test
Lipid profile
Lithium
Liver function tests
1.24
1.10, 1.24
1.24
1.19, 1.24
1.18
1.10, 1.24
1.24
1.8, 1.24
Magnesium
Menopause monitoring
Mercury
Metadrenalines (urine)
Methadone (screening test in urine)
Microalbumin (urine)
Mucopolysaccharides
Mycology
1.24
1.9
1.24
1.17, 1.24
1.24
1.21, 1.24
1.24
4.10
Occult blood (faeces)
Oestradiol
Opiates (screening test in urine)
Organic acids (urine)
Oxalate (urine)
Not available
1.19, 1.24
1.24
1.24
1.24
Paracetamol
Paraquat screen
Parasitology
Parathyroid hormone (PTH)
Parathyroid hormone related protein (PTHrP)
Phenobarbitone
Phenytoin
Phosphate
Pleural fluid (Cytology)
Pleural fluid (Microbiology)
Porphobilinogen (urine)
Porphyrin screen (urine)
Post mortems
Potassium
Pregnancy test
Progesterone
Prolactin
Prostate specific antigen (PSA)
Protein total
Prothrombin time
Pus
1.9, 1.24, 1.25
1.24
4.9
1.24
1.18, 1.24
1.24
1.24
1.24
6.6
4.18
1.24
1.24
7.1
1.24
1.19, 1.24
1.19, 1.24
1.19, 1.24
1.20, 1.24
1.24
1.24
2.9
4.12
RAST (specific IgE)
Red cell count
Reducing substances (urine/faeces)
Renin
1.24, 5.12
2.9
1.24
1.18, 1.24
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Reticulocytes
Rhesus typing
2.9
3.5
Salicylate
Semen analysis
Sickle screen - HbS screen
Sodium
Sputum (Cytology)
Sputum (Microbiology)
Swabs
Sweat Test
Synacthen test
1.9, 1.24
4.13
2.9
1.24
6.4
4.14
4.15
1.22, 1.24
1.17
T3 (Triiodothyronine)
1.16, 1.24
T4 (Thyroxine)
1.16, 1.24
TB (see AFB)
4.18
Testosterone
1.19, 1.24
Theophylline
1.24
Therapeutic drug monitoring
1.9
Thrombin time
2.9
Thrombophilia screen (protein S+C AT III) 2.9
Thyroglobulin
1.24
Thyroid antibodies
1.16, 1.24
Thyroid function tests
1.16, 1.24
Thyroxine
1.16, 1.24
Tissue (Microbiology)
4.18
Transferrin & saturation
1.24, 1.28
Transfusion reaction
3.10
Triglycerides
1.10, 1.24
TRH (protirelin) test
1.18
Troponin I
1.23, 1.24
TSH
1.16, 1.24
Urate
Urea
Urea/electrolytes (U+E)
Urine chemistries
Urine (Cytology)
Urine (Microbiology)
1.24
1.24
1.8, 1.24
1.12, 1.21, 1.24
6.5
4.16
Valproate
Vitamin A
Vitamin B12
Vitamin D metabolites
Virology/Serology
1.24
1.24
1.24
1.24
4.17
Water Deprivation Test
White cell count
White cell differential
1.18
2.9
2.9
Zinc
1.24
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10.0 ADDRESSES OF REFERRAL LABORATORIES
City Hospital NHS Teaching Trust
Dudley Road
BIRMINGHAM, B18 7QH.
HIstocompatibility and Immunogenetics
NHS Blood and Transplant Service
500 North Bristol Park
Northway
Filton
BRISTOL, BS34 7QH.
Antimicrobial Reference Laboratory
Microbiology Department, Lime Walk Building
Southmead Hospital
Westbury on Trym
BRISTOL, BS10 5NB.
The Director
Carlisle Health Protection Agency
CARLISLE, CA2 7HY.
Leighton Hospital
Middlewich Road
CREWE, CW1 4QJ.
Reference Laboratory
County Hospital
Union Walk
HEREFORD, HR1 2ER
Alder Hey Children’s Hospital
Eaton Road
LIVERPOOL, L12 2AP.
Diagnostic Laboratory
School of Tropical Medicine
Pembroke Place
LIVERPOOL, L31 5QA
Royal Liverpool Hospital
Prescott Street
LIVERPOOL, L7 8XP.
Page 75 of 77
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Charing Cross Hospital
Fulham Palace Road
LONDON, W6 8RF.
Kings College Hospital
Denmark Hill
LONDON, SE5 9RS.
Christie Hospital
Wilmslow Road
MANCHESTER, M20 4BX.
Oxford Road
MANCHESTER, M13 9WL.
Willink Unit, Genetic Medicine
6th Floor, Pod 1
St. Mary's Hospital
Oxford Road
MANCHESTER
M13 9WL
Immunology
St Mary’s Hospital
MANCHESTER, M13 0JH.
Southmoor Road
MANCHESTER, M23 9LT.
Toxicology Laboratory
The Academic Centre
Llandough Hospital
PENARTH, CF64 2XX.
Salford Royal Hospital
Eccles Old Road
SALFORD, M6 8HD
PO Box 894
SHEFFIELD, S5 7YT.
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Histocompatibility and Immunogenetics
National Blood Service
Sheffield Centre
Longley Lane
SHEFFIELD, S5 7JN.
Sheffield Children’s Hospital
Western Bank
SHEFFIELD, S10 2TH.
Health Protection Agency
Southampton Laboratory
South Laboratory Block
Southampton General Hospital
SOUTHAMPTON, SO16 6YD
University Hospital North Staffordshire NHS Trust
City General Hospital
Newcastle Road
STOKE-ON-TRENT, ST4 6QG
Page 77 of 77
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CHESHIRE PATHOLOGY SERVICES LABORATORY DEPARTMENT

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