SPECIFIC DEPARTMENT INSTRUCTIONS:

Transcription

1 Subject LIS Downtime Instructions - Regional Clinic / Affiliate Hospital Laboratories Index Number Lab-1520 Section Laboratory Subsection Regional Clinic / Affiliate Hospital Laboratories Category Departmental Contact Blum, Rachel L Last Revised 10/4/2017 References Required document for Laboratory Accreditation by the College of American Pathologists (CAP), Centers for Medicare and Medicaid (CMS) and/or COLA. Applicable To Employees of the Gundersen Health System clinical laboratories, Gundersen St. Joseph s Medical Center laboratories, Gundersen Tri-County Hospital laboratories, Gundersen Boscobel Area Hospital Laboratory and Gundersen Palmer Lutheran Hospital and Clinic Laboratories. Detail This document will serve as the departmental procedure for the handling of patient orders when the Epic is not operational. Handling of orders will be divided into: Status 1 = expected down time <2 hours. Status 2 = expected down time >2 hours. Status 1 or 2, run all Stat tests. Run routine tests as time permits. General Rule: Document all results that have been called, to who, what time, etc. After the Epic is functional again, this information, along with the sample results, will need to be recorded or specimen linked into the appropriate record. Implementation For general downtime instructions, see Lab-0633 LIS Beaker Downtime Plan. SPECIFIC DEPARTMENT INSTRUCTIONS: Reception 1. Patient presents at the front desk and is registered. A route sheet or downtime form is labeled with the patient name, clinic number, date of birth and provider name. Orders are located in the BCA or are written on the paper downtime order form. Patient is sent to lab. Phlebotomy 1. Phlebotomist calls patient in and identifies patient according to Lab-1330 Patient Identification. Downtime labels are created. 2. Phlebotomist initials order sheet and writes on time drawn, hours fasting and any other pertinent information and draws the samples. Phlebotomist labels tubes to include patient name, medical records number, provider name, date and time of collection, collector ID, test(s) and test comments. Lab-1520 LIS Downtime Instructions - Regional Clinic / Affiliate Hospital Laboratories Page 1 of 6

2 Specimen Processing 1. Technical staff will centrifuge samples for testing and/or shipment. Specimens tested on site are delivered to each department rack or counter. Specimens for La Crosse are placed in the refrigerator or freezer per requirements. All samples for La Crosse are held until Epic is operational. NOTE: Special consideration must be given to referral tests, culture specimens, coagulation tests and body fluids. 2. Pap, Cytology and Histology tests may be sent as usual with the courier. 3. If downtime is extended or if there are specimens that must be processed by Referral, the specimens will be sent to La Crosse by courier or cab with a copy of the order. 4. When Epic is operational, staff will order tests and will match barcode labels with tubes for La Crosse and send on the next courier run. Urinalysis and All Manual Testing Clinitek Status 1. Specimen processing places samples on the counter or in the rack. 2. Tech will review samples for STATS and manual tests and will place urine samples in the refrigerator if extended downtime is suspected. IN the event of an extended downtime of greater than 2 hours, there will be ongoing evaluation of specimen stability by managers and supervisors with notifications of downtime status to staff by management. 3. STAT urine samples will be run on the Clinitek Status analyzer, using MRN and alpha character, with the tech reflexing the microscopic as per protocol. 4. Results will be written on the printout or the multi-copy regional urinalysis form and STATS will be called or hand delivered to the department. Time called, etc. will be documented. 5. All manual tests (wet preps, pregnancy tests) will be run as usual with result being written on the LIS patient downtime tracking log attached to Lab When Epic is operational, the tech will take out any samples stored in the refrigerator to warm up, help type in orders and will match urinalysis samples and results with barcodes. 7. When Epic is operational, Clinitek Status results will automatically download from the DI system into Epic. All manual test results must be hand entered into Epic. Clinitek Advantus -Onalaska 1. Specimen processing places samples on the counter or in the rack. 2. Tech will review samples for STATS and manual tests and will place urine samples in the refrigerator if extended downtime is suspected. In the event of an extended downtime of greater than 2 hours, there will be ongoing evaluation of specimen stability by managers and supervisors with notification of downtime status to staff by management. 3. STAT urine samples will be run on the Clinitek Advantus using the medical record number for ID. The tech will reflex the microscopic as per protocol. 4. Results will be written on the printout or multi-copy regional urinalysis form and STATS will be called or hand delivered to the department. Time called, etc. will be documented on the report form. 5. All manual tests (wet preps, pregnancy test, pinworm preps, post vas, and mono tests) will be run as usual with result being written on the LIS patient downtime tracking log attached to Lab Lab-1520 LIS Downtime Instructions - Regional Clinic / Affiliate Hospital Laboratories Page 2 of 6

3 6. When Epic is operational, the tech will take out any samples stored in the refrigerator to warm up and help type in orders using the correct date and time of collection. Barcode labels will be printed and matched to the samples and results. 7. STAT and manual test results will be manually entered into Epic. QC will be entered manually as needed. CoaguChek, I-STAT (Chemistry), I-STAT (Blood gas), Accucheck and HemoCue - (Devices connected to RALS) 1. Tech will run all capillary and stat specimens on the analyzer, using MRN and alpha character. Select the "DO NOT CHART" comment. Write the result(s), tech, date and time tested on the LIS patient downtime tracking log attached to Lab STATS will be called or hand delivered to the department. Time called or delivered will be written on the form and initialed by the tech. 2. When EPIC is operational, the results will download into RALS, but the POC staff will NOT upload the results into EPIC. 3. Regional lab staff will check to see that each patient has an arrived encounter. In this situation, the tech will take the order into collection, allowing them to enter the collection information from the downtime forms. Once collected, the order falls into each lab's Outstanding List. The tech will use the result entry function to manually record the result, remembering to verify and final verify. As the order is completed, the order falls off the outstanding list. 4. Fax a copy of your downtime logs/forms to the LaCrosse POC office at ext The POC staff will cross-reference the results received in RALS interface from the MRN + alpha patient ID used to the patient's correct encounter (CSN). Hematology Sysmex KX21 1. Specimen processing will place the tubes in the rack on the counter. All specimens will be held unless STAT. Make slides on all CBC s and stain. 2. Tech will run all STATs in the Sysmex KX21 using the clinic number and print a copy for the department or call results to the department. Time called, etc. will be written on a printout and initialed by the tech. Also document on LIS patient downtime tracking log attached to Lab During extended periods of downtime, the tech will run samples in the Sysmex KX21 using the clinic number and print results. In the event of an extended downtime of greater than 2 hours, there will be ongoing evaluation of specimen stability by managers and supervisors with notification of downtime status to staff by management. 4. When Epic is operational, the tech will assist with matching barcode labels with hematology specimens and run per procedure. Sysmex XS 1000i with DI 1. All specimens will be held unless STAT. 2. All stat samples will be run on the Sysmex analyzer using the downtime barcode number as the specimen ID. (If a regular barcode is available, use that barcode number.) Print a copy for the ordering department and/or call results to the department. 3. Results for samples run using the downtime barcodes as the sample ID will be in the Specimen Worklist in DI. 4. Make slides and stain slides as necessary. Document manual differential and morphology results on the instrument printout and LIS patient downtime tracking log attached to Lab Lab-1520 LIS Downtime Instructions - Regional Clinic / Affiliate Hospital Laboratories Page 3 of 6

4 5. Write any additional information on the analyzer printout (i.e., morph, manual diff, called time, called to whom, tech initials, etc.) 6. When LIS is operational, the tech may assist with ordering tests in LIS using the correct date and time of sample collection. 7. NOTE: Samples drawn with barcode labels before the downtime may now be run as per procedure. 8. Barcode labels will be printed and matched to the hematology specimens and analyzer printouts. Aliquot labels should be placed on slides. 9. Using the instrument printouts, edit the sample ID on the Sysmex analyzer to the barcode ID (MPI#) on the newly ordered barcode. From the main menu on the Sysmex XS1000i: a. Click on [Explorer] (making sure that [last 20] is deselected). b. Click on the first sample at the top of the list to highlight. c. From Toolbar, click [Edit] and [Find]. The "Find" dialog box is displayed. d. Enter sample ID number used when LIS was down (downtime barcode number or other identifier used.) e. Click [Next] to locate the sample number entered in the list. The sample will appear highlighted in the list. Click [Close]. f. Click [Validate] or [F11] to un-validate the sample. ("V" will be removed from far left column). g. Click [Edit] then [Modify]. The "Modify" dialog box displays with the selected sample ID. h. Overwrite current information with the correct sample number from the barcode label (can use the handheld barcode scanner). Make sure that everything matches the printout. i. Click [OK] and the edited sample information will be stored. Screen will display Explorer list with newly edited sample highlighted. j. Click "Validate" to transmit the sample to DI. (By clicking validate, results are transmitted to the host and positive results are reprinted). k. Specimen results can now be validated by rack or sample number in DI. l. Repeat steps b-j until all samples have been edited. Reminder: Samples run as "unregistered" in DI will run test parameters according to the default setting on the Sysmex analyzer. Most often, the default setting includes all tests. You may have more results than you need in DI. Select the associated test or run groups that you wish to report out and release the results to the LIS. Ensure that appropriate results crossed to EPIC. Reject unnecessary results that are still pending on the DI worklist. Chemistry Roche Integra 400+, C311 and E Tech will run all STAT specimens on the Integra 400, Cobas C311 and the Cobas E411. The medical record number will be used as the "Order ID" for unbarcoded specimens. Write the patient name on the instrument printout. STATS will be called or a copy of the printout hand delivered to the department. Time called or delivered will be noted on the printout. 2. When Epic is operational, the tech will help order tests using the correct date and time of collection. All chemistry specimens and results will be matched with the barcode labels. Lab-1520 LIS Downtime Instructions - Regional Clinic / Affiliate Hospital Laboratories Page 4 of 6

5 3. Results will auto-transmit to Epic when the computer system is operational again. When the computer system is operational again, the barcode labels for the specimens will be distributed to the appropriate departments. Match the MRN and patient name and attach barcodes to the instrument printouts. Roche C Tech will run all specimens on the Cobas C-111 and write results on the LIS patient downtime tracking log attached to Lab STATs will be called or hand delivered to the department. Time called or delivered will be noted on the form. 2. When Epic is operational, the tech will assist with making barcode labels, matching the labels with the proper patient specimens and running specimens per procedure. 3. All test results and QC will be entered manually into Epic. Coagulation (NOT CoaguChek) 1. Place samples in the rack on the counter to be spun. 2. Samples will be held in the rack for up to 2 hours or until Epic is operational or will be run if STAT. 3. STAT specimens and specimens collected during downtime will be run on the analyzer using the clinic number as the specimen ID. In the event of an extended downtime of greater than 2 hours, there will be ongoing evaluation of specimen stability by managers and supervisors with notification of downtime status to staff by management. All results will be printed from the analyzer. All STATS will be called or a copy of the print out delivered to the department. The tech will write time called, etc. on the analyzer printout and also on the LIS patient downtime tracking log attached to Lab When Epic is operational, the tech will help order tests using the correct date and time of collection and match coagulation samples and results to the barcodes. 5. All sample results and QC run during downtime will be manually entered into Epic or will be retransmitted to Epic through the interface. Microbiology Rapid Streps 1. The tech will automatically process strep tests (based on results, will label and plate accordingly with the name, clinic number and date) and streak it with the swab. The plate will be placed in the incubator. 2. The rapid tests will be run as per procedure and the results, time, and initials will be written on the microbiology form and attached to the regional lab order form. 3. The swab and extraction tube will be thrown away once the result is written on the microbiology form. 4. All positives will be called to the department and time called will be documented on the regional lab order form. 5. When Epic is operational, the tech will help type in orders, and will match all plates, regional lab order forms and results with the barcodes. 6. All QC and rapid results will be entered manually into Epic as needed. 7. All plates from negative rapids will be barcoded and sent as usual with the courier or placed in the incubator to be read on site per location procedure. Lab-1520 LIS Downtime Instructions - Regional Clinic / Affiliate Hospital Laboratories Page 5 of 6

6 General Cultures If culture is labeled with a bar-code, continue set-up process as usual. 1. If culture was not logged in Epic and does not have any bar-codes, proceed as follows: 2. Label a work aid with the patient s name, clinic number, source, date, time of collection, and time of set-up. 3. Set up the culture following protocol. 4. Label the media and slides using the patient name and birthdate, date and source. 5. Place the slides and media in the same locations as you would if Epic were operational. Blood Cultures 1. Blood culture bottles need to be labeled with the following information: a) Patient s first and last name b) Clinic number c) Source of blood draw d) Date and time of draw e) Phlebotomist s initials f) Where the patient was when the blood cultures were drawn (i.e. TEC) 2. Load blood culture bottles into the BacTec. NOTE: Issue handwritten reports if necessary. Photocopy all handwritten reports and place copy on the blood culture desk for documentation. When Epic is back up, transfer information to appropriate order number. Make sure to note manual log number in media window for completion. Place an Epic label on manual log sheet next to corresponding manual number. Blood Bank 1. Blood products cannot be issued unless confirmation of current testing is available and Blood Bank armband number is documented. 2. Proceed with testing, recording results, and interpretations on paper forms/logs. 3. Select products needed and record choices on paper form. 4. Call floor or surgery (OR) when products are available. 5. Issue products using paper form and handwritten unit tags for documentation. 6. When Epic is again operational, take handwritten paperwork and manually enter testing results and any manually issued blood products using the actual time issued and not the computer default time. REVIEW AND CHANGES: This document and all attached forms should be reviewed optimally on an annual basis, with 2 years as the maximum review date. Review will be done by the Technical Leader, Supervisor, Manager, Medical Director or designated person. Changes require retyping document or form and review by the Medical Director. Lab-1520 LIS Downtime Instructions - Regional Clinic / Affiliate Hospital Laboratories Page 6 of 6