Chapter 11: Special
Collections and Point-of-
Care Testing
Special Collections: Blood Bank Specimens #1
• Identification & labeling requirements
• Patient’s full name, hospital ID # or SS #, DOB, date & time
of collection, phlebotomist’s initials
• Special identification systems
• ID bracelet w. self-carbon adhesive label for specimen
• Blood ID band w. linear barcoded BBID #s.
• Specimen requirements
• Lavender- or pink-top EDTA tubes
• Nonadditive glass red-top may be used
• Type, Screen, and Cross-Match
• Blood type (ABO) & Rh factor (+ or -) & screen
• Cross-match to determine compatibility
Special Procedures: Blood Bank Specimens #2
A phlebotomist compares a labeled blood bank tube with a
blood bank ID bracelet
To improve the accuracy of
patient identification by using
at least two patient identifiers
(neither to be the patient’s
room number) whenever
administering medications or
blood products; taking blood
samples and other specimens
for clinical testing, or
Copyright © 2020 Wolters Kluwer • All Rights Reserved providing any other treatments
or procedures.
Special Procedures: Blood Donor Collection #1
• General
• Collected for transfusions, not
diagnostic testing
• Collected in “units” from volunteers
• Requires special training & skills
• Donor eligibility
• Between ages 17 & 66 years
• Weight at least 110 lb
• Physical examination & medical
history required
• Written permission from donor
required
Special Procedures: Blood Donor Collection #2
• Lookback Program
• All blood components must be traceable to donor
• Requires notification to all blood recipients when donor tests
positive for transmissible disease
• Autologous Donation
• Person donates blood for own use (e.g., elective surgery)
• Cell Salvaging
• Patient’s blood can be salvaged, washed, & reinfused
• Salvaged blood must be tested for residual free hemoglobin
Special Procedures: Blood Cultures #1
• General
• Determine presence & extent of infection
• Identify type of organism responsible & best
antibiotic to use
• Ordered because:
1. Patient has a condition in which bloodstream
invasion is possible
2. Or presence of fever of unknown origin (FUO)
Special Procedures: Blood Cultures #2
• Sepsis
- Inflammatory responses throughout the body due to blood
infection
- Leading cause of death from infection (SCCM)
• Indications of Septicemia
- Fever
- Chills
- Malaise
- Low BP
- Changes in mental status
Special Procedures: Blood Cultures #3
• Specimen Requirements
• Two to four blood culture sets
• Drawn 30 to 60 minutes apart (unless patient in
critical condition)
• Collected in special bottles, one aerobic & one
anaerobic
One blood culture consists of blood from a single venipuncture inoculated into two
separate bottles to accommodate the optimal blood ‐to-broth ratio.
Special Procedures: Blood Cultures #4
• Timing Considerations
• Collection as close as possible to the time ordered
• Obtain second set from separately prepared site on opposite
arm if possible
• “Second-site” cultures may be more useful when drawn 30 to
60 minutes apart
• Recommended Volume
• Identification of pathogens increases in direct proportion to
the volume of blood cultured
• ASM’s weight-based recommendations
Special Procedures: Blood Cultures #5
• Specimen Collection
• Skin antisepsis
• Purpose
1. Destroy skin
microorganisms According to the
2. Prevent misinterpretation of CLSI, chlorhexidine
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microorganism as gluconate is the
pathogenic
recommended blood
• Acceptable antiseptics culture site
1. Chlorhexidine gluconate disinfectant for
2. Tincture of iodine or infants 2 months and
povidone older and patients
• Requires 30- to 60-second with iodine
friction scrub
sensitivity.
Special Procedures: Blood Cultures #6
• Initial Specimen
Diversion
• Technique to
reduce blood
culture
contamination
rates
Courtesy Magnolia Medical Technologies, Seattle, WA.
Special Procedures: Blood Cultures #7
• Media inoculation methods
• Direct inoculation
1. Collect specimen directly into blood culture
medium
2. Use butterfly & specially designed holder
• Syringe inoculation
1. Transfer blood to bottles after draw is completed
2. Safety transfer device is required
Special Procedures: Blood Cultures #8
• Collection procedure
1. ID patient, explain procedure, obtain consent
2. Sanitize hands, don gloves
3. Apply tourniquet, identify venipuncture site, release tourniquet
4. Aseptically select & assemble equipment
5. Perform friction scrub
6. Allow site to dry
7. Remove flip-off cap & inspect bottle for visible defects
8. Cleanse culture bottle stoppers while site is drying
9. Mark min. & max. fill on culture bottles
10. Reapply tourniquet & perform venipuncture w/o. touching or
repalpating site
Special Procedures: Blood
Cultures #9
• Performing friction scrub, removing flip-off cap, & cleansing
culture bottle stopper
Special Procedures: Blood Cultures #10
11.Direct draw: fill bottles, invert several times
12.Withdraw needle, place gauze, activate needle safety
feature, apply pressure
13.Direct draw: Discard blood collection unit
Syringe draw: Remove & discard needle, attach transfer
device, fill & mix bottles
14.Clean patient’s skin if applicable
15.Label specimen containers w. required ID info.
16.Dispose of used & contaminated materials
17.Thank patient, remove gloves, sanitize hands
18.Transport specimens to lab as quickly as possible
Special Procedures: Blood
Cultures #11
• Performing venipuncture & inoculating medium
Special Procedures: Blood Cultures #12
• Intermediate collection tube
• Sometimes used in place of blood culture bottle
• Yellow-top SPS tube is acceptable
• Use is discouraged, however, because:
1. Final concentration of SPS is increased
2. Presents another opportunity for contamination
3. Increased exposure risk to lab staff
Special Procedures: Blood Cultures #13
• Antimicrobial Neutralization
Products
• Removes or neutralizes
antimicrobials/antibiotics
from blood
• Prevents antimicrobials from
inhibiting growth of
microorganisms
• Fastidious antimicrobial
neutralization (FAN) resin or
antimicrobial removal device Copyright © 2020 Wolters Kluwer • All Rights Reserved
(ARD)-activated charcoal
Special Procedures: Blood Cultures #14
• Pediatric Blood Culture
Considerations
• Critical nature of
pediatric specimens
• In place of iodine,
cleanse twice with
separate alcohol
pads
Copyright © 2020 Wolters Kluwer • All Rights Reserved
Special Procedures: Blood Cultures #15
• Catheter Considerations
• Blood cultures should not be drawn
through indwelling IV or arterial catheter,
unless no other option available
• Catheter-related infections are common
but difficult to diagnose
Special Procedures #1
• Coagulation Specimens
• A “clear” or discard tube is required for all
coagulation tests except for PT or PTT
• Sodium citrate tubes must be filled until vacuum is
exhausted
• Never pour two partially filled tubes together
• Cooling on ice during transport may be required
• When drawing from an indwelling catheter: draw &
discard 5 mL of blood or six times the dead-space
vol. of catheter
Special Procedures #2
• Two-Hour Postprandial Glucose
• Glucose in diabetics is significantly increased 2 hours
after meal
• Excellent screening test for diabetes
• Glucose Tolerance Test (GTT)
• Used to diagnose problems of carbohydrate metabolism
• Monitors patient’s tolerance to high levels of glucose
• Hyperglycemia: increased blood glucose level
• Hypoglycemia: decreased blood glucose level
Special Procedures #3
• Glucose Tolerance Test (GTT) (cont.)
• GTT preparation
• Patient must:
1. Eat balanced meals w. 150 g of carb for 3 days before
test
2. Fast at least 8 hours but not more than 16 hours before
test
3. Drink water during fast & test
4. Avoid excessive exercise for 12 hours before test
5. Avoid smoking or chewing gum for 8 hours before test
6. Receive both verbal and written instructions
Special Procedures #4
• Glucose Tolerance Test (GTT) (cont.)
• GTT procedure
1. Follow normal ID protocol & explain collection
procedure; advise of fasting requirements
2. Draw fasting specimen & check for glucose
3. Ask patient to collet fasting urine specimen (if needed)
4. Give patient determined dose of glucose beverage
5. Remind patient to finish beverage within 5 minutes
6. Note time patient finishes, start timing, calculate
collection times
Special Procedures #5
• Glucose Tolerance Test (GTT) (cont.)
• GTT procedure (cont.)
7. Give a copy of collection times to patient
8. Collect blood & urine specimens at
computed times
9. Label all specimens w. collection times,
intervals, patient ID
10.Deliver or send specimens to lab ASAP
Special Procedures #7
• Oral Glucose Challenge Test (OGCT)
(one-hour Glucose Screening Test)
1. Patient is given drink cont. 50 g of glucose
2. Patient blood specimen collected after 1
hour
3. If glucose result is >140 mg/dL, then
suggested that patient complete follow-up
OGTT within 1 week
Special Procedures #8
• Molecular Genetic Testing
• Determining whether an individual has or is at
increased risk for a certain genetic disease
• Classifying an individual’s genetic makeup to
determine drug/dosage suitability
• Examining the whole genome to discover genetic
alteration that may cause disease
Special Procedures #9
• Paternity/Parentage Testing
• Excludes possibility of paternity rather than proves
it
• Requires a chain-of-custody protocol & specific ID
procedures
• Mother, child, & alleged father are all tested
• Blood samples preferred, but cheek swabs
increasingly used
• Blood sample testing includes ABO & Rh typing
Special Procedures #10
• Therapeutic Drug Monitoring
• Establishes & maintains drug dosage at therapeutic level
• Avoids drug toxicity
• Typically used for drugs w. narrow therapeutic ranges
• Therapeutic Phlebotomy
• Withdrawal of large volume of blood to treat:
• Polycythemia
• Hemochromatosis
Special Procedures #12
• Toxicology Specimens
• General
• Toxicology: scientific study of toxins (poisons)
• Concerned with detection of toxins & treatment of
effects
• Forensic blood alcohol (ethanol) specimens
• Often requested by law enforcement officials
• Used to determine levels in breath, urine, or blood
• Specimen collection must follow chain of custody
Glass tubes are preferred for blood alcohol specimens because of the
porous nature of plastic tubes.
Special Procedures #13
• Toxicology Specimens (cont.)
• Blood alcohol (ethanol) specimens
• Normally ordered by physician for treatment purposes
• Chain of custody not required, but follow standard
protocol
• Required in connection to on-the-job injury, employee
insurance programs, & employee drug screening
• Skin preparation: don’t use alcohol-based disinfectant
• Specimen requirements: gray-top sodium fluoride tube;
fill tube until vacuum is exhausted & don’t remove
stopper
Special Procedures #14
• Toxicology Specimens (cont.)
• Drug screening
• Required by many healthcare organizations,
sports associations, & major companies
• May be random
• May detect a specific drug or screen for up to 30
drugs
• Typically performed on urine rather than blood
• Chain of custody is required
Special Procedures #15
• Trace Elements
• Tests for aluminum, arsenic, copper, lead,
iron, & zinc
• Measured in small amounts
• Traces of them in glass, plastic, or stopper
material can leach into specimen
• Special trace element–free tubes must be used
(royal blue & contain EDTA, heparin, or no
additive)
Special Procedures #16
• Tuberculosis Blood
Tests
• Skin testing requires
two visits; blood
testing requires only
one, increasing
compliance
• Interferon-gamma
release assays Courtesy of © QuantiFERON, all rights reserved.
• TB-Gold test
Point-of-Care Testing #1
• General
• Brings lab testing to location of patient
• Made possible by development of small, portable
testing devices
• Offers convenience to patient & short turnaround
time
• Requires carrying out quality control & maintenance
procedures necessary to ensure that results are
accurate
Point-of-Care Testing #2
• POCT Quality Control
• Waived versus nonwaived quality control checks
• Electronic quality control (EQC) built into POC instruments
• Specimen collection & handling not checked by EQC
• Daily external liquid QC for noninstrumented POCT
• POCT Infection Control
• POC instruments become possible fomites for disease
• Disinfect with 10% bleach
• Reduce cross-contamination between patients
Point-of-Care Testing #3
• Coagulation Monitoring by POCT
• Coagulation tests that are monitored:
• Prothrombin time (PT) & international
normalized ratio (INR)
• Activated partial thromboplastin time (APTT or
PTT)
• Activated clotting time (ACT)
• Platelet function
Point-of-Care Testing #4
• Coagulation Monitoring by POCT
• POCT instruments
• CoaguChek XS Plus—PT/INR
• Hemochron Signature Elite—ACT
• i-STAT—ACT, PT/INR
• VerifyNow—Platelet function
Point-of-Care Testing #5
• Arterial Blood Gases and Electrolytes
• Arterial blood gases measured
• pH
• pCO2
• pO2
• sO2
Point-of-Care Testing #6
• Arterial Blood Gases and Chemistry Panels
• Electrolytes measured
• Sodium
• Potassium
• Chloride
• Bicarbonate ion
• Ionized calcium
Point-of-Care Testing #7
• Multiple-Test-Panel Monitoring by POCT
• Commonly ordered stat tests such as blood gases,
electrolytes, & hemoglobin
• Instruments with a menu of several different tests:
• GEM Premier
• i-STAT
• NOVA Stat Profile Analyzer
• ABL80 Flex
Point-of-Care Testing #8
• Other Tests Performed by
POCT
• B-type natriuretic peptide • Hematocrit
• Bilirubin
• Hemoglobin
• Cardiac troponin T & I
• Lactate
• Complete blood count
• Lipid/Cholesterol
• C-reactive protein
• Glucose • Rapid syphilis
• Glycosylated hemoglobin
