Processing specimens: Overview

Preparing laboratory specimens for storage or testing

After ensuring the patient’s safety and completing the venipuncture procedure accurately, the next step is to process the specimen and properly transport it to the laboratory. Laboratories face challenges with time management, test accuracy, specimen rejection, and specimen transportation processes. Abide by any specific handling requirements for the requested test in a timely manner to ensure accurate results. The time it takes for the entire process—including ordering, specimen collection, transportation, processing, analysis, and reporting—is the turnaround time.

In a hospital or a large laboratory facility, you will handle specimens and perform testing on-site. Whether you are performing tests on-site, working in a reference laboratory, or performing POC testing, it is imperative to follow specimen-handling processes with accuracy. Prior to processing, important steps in handling and transporting include mixing the sample, creating aliquots, adding diluents, centrifuging, packaging the labeled specimen in a biohazard bag, and following thermal and light-sensitivity procedures.

When tubes contain an additive, invert them gently to mix the additive with the blood and to distribute the additive evenly throughout the sample. Mix it as soon as possible after the collection. Shaking the tube can result in a hemolyzed specimen. Not mixing it enough can result in the formation of clots, which can alter the test results. It is not necessary to mix blood samples in tubes that do not contain additives.

Special handling

Special handling is a requirement for transporting some specimens.

Tests that require special handling of specimens include ammonia and lactic acid, for which the blood tube must sit in an ice slurry (a thick mixture of water and ice) immediately after collection. For cold agglutinins, the sample must remain at body temperature—37° C (98.6° F). Protect blood samples for bilirubin and folate levels by wrapping the blood tube in foil. Blood gas tests can be stored at room temperature for 15 to 30 minutes or in an ice slurry for up to 1 hour. Delivery speed is crucial to prevent the loss of gases from the blood prior to analysis. For coagulation tests, analysis should take place within 1 hour of collection. Prothrombin time (PT) is an exception. A delay up to 24 hours at room temperature will not affect the results. Room temperature for laboratory purposes is 22° C (71.6° F).

Centrifuging

Some specimens require centrifuging or other additional processing prior to transporting them to the reference laboratory. Specimens that require separating the serum or plasma from the cells require centrifuging. To use the correct centrifuge, be aware of the tube type, rotor, spin time, capacity, noise level, and proximity to other equipment. Some centrifuges accommodate only a few tube sizes, while others have adapters for various sizes. The type of rotor can produce either a flat gel barrier (which is best for immunoassay and chemistry tests) or an angled gel barrier (which can be problematic for some chemistry tests).

Steps of centrifuging

Some specimens have time limits and temperature requirements after centrifuging—room temperature, refrigeration, storage in the dark, or freezing—depending on the testing requirements.

Aliquoting

Aliquot specimens right after completing the centrifugation process. To aliquot a sample, hold the empty tube adjacent to the specimen tube, use a disposable pipette to transfer the serum (without cells) from the specimen tube to the aliquot tube, and label the specimen accordingly.

Packaging

When transporting specimens via postal service mail or express delivery services, be sure to comply fully with local, state, and federal laws that govern their special packaging and biohazard identification. Complete shipping paperwork, including the patient’s identification, specimen identification, and test information.

To prepare samples for transportation to a reference laboratory, package the specimens using the following supplies.

Placing in biohazard bags

Prior to placing specimens in biohazard bags, be sure to label the specimen with the patient’s full name, the date and time of the specimen collection, and the source and type of specimen. To prepare these samples correctly, place the labeled specimen into a biohazard bag and then into a primary container with absorbent material surrounding it and usually above any necessary coolants. Place all of these materials within the secondary container and place the specimen documentation above the secondary container. The documentation may have a separate bag. Make sure to use this bag and seal if required. Then place the secondary container and the documentation inside the shipping container.

Specimen handling

In many settings, the phlebotomy team accepts and accessions (checks in) all specimens that come into the laboratory for testing. Therefore, it is important to know how to handle and process these specimens correctly. Handling requirements also include pre-collection specifics (time, temperature, light). When tests require specific timing, heat, cold, or protection from light, your role in transporting specimens to the laboratory after collection is as important as the venipuncture for securing a high-quality test result.

For timed tests when patients are taking a specific medication or drinking a liquid preparation (such as for a glucose tolerance test) make sure they have satisfied the testing requirements. Examples include a 2-hour postprandial blood glucose level, which requires a fasting blood glucose level plus a blood glucose test at exactly 2 hours after patients started eating their meal or consumed the liquid preparation. Other timed tests include peak and trough values for antibiotics like gentamicin or vancomycin, for which the phlebotomist collects blood samples at a specific time after the administration of the antibiotics. Coordinate these procedures with the clinical staff—including nurses and medical assistants—to ensure accurate results.

Label every type of collection container immediately after collection with the patient’s name, the date and time of collection, and the specimen type. Position it correctly on the tube or container. If the facility requires it, sign or initial the specimen. Then compare the information on the label with the patient’s wristband, or verbally verify it with the patient. If the container has a lid, make sure that the label is on the container, not on the lid.

Wear gloves when handling patient-collected, nonblood specimens. Change gloves between each specimen. Correct handling is essential, because incorrect handling can affect the quality of the specimen. For example, components of urine change if the specimen stands at room temperature for an extended period of time. If the specimen will not be tested immediately, refrigerate urine specimens and process them within 1 hour of collection. Some urine tests are best performed at room temperature. Be aware of what the specimen is being tested for to ensure proper handling. Use evacuated transport tubes containing preservatives for transporting urine specimens to reference laboratories. To transfer urine from a collection container to the transport container, use a disposable pipette, or pour the urine into the tube after removing the stopper. Preservatives in these tubes prevent bacterial overgrowth and prevent changes in the urine that can affect test results.

When handling preserved urine specimens, keep the tubes at room temperature no longer than 72 hours before performing a urinalysis with chemical reagent strip testing. Keep tubes for culture and sensitivity (C&S) tests at room temperature for up to 72 hours. Otherwise, if not preserved, refrigerate them if there is any delay in transferring the urine to the culture medium. Complete the laboratory requisition forms for all specimens for transportation to other sites for analysis. This form should include the patient’s name, date, type of test, ordering provider’s name, ICD-10-CM code for diagnosis (if the form requires it), and a line where the provider can sign after reviewing the results. When sending specimens to the laboratory, use plastic biohazard bags with zipper seals. These bags feature an outside pocket in which to place the laboratory request. They also protect those who transport the specimen from any pathogens in the specimen. Ideally, blood tubes should remain upright during transportation to prevent unnecessary agitation (which could cause hemolysis) and to promote effective clotting in specimens that do not have anticoagulant additives.

Delivery of specimens from clinics or blood-collection stations to reference laboratories should be as prompt as possible. With delays between collection and processing, glucose in blood cells can break down and interfere with results of various tests (phosphorus, glucose, aldosterone, calcitonin, enzymes). It is also essential to transport microbiology specimens quickly so that the laboratory technicians can transfer the specimens to the culture media or incubator. These samples include blood, urine, sputum, wound exudate, stool, and other body substances. The sooner they get to the environment where micro-organisms can grow, the sooner the technicians can identify them and generate the results so that the patients can receive proper treatment.

The delivery process must include adequate specimen handling, packaging, and communication with the courier or other delivery services. Coordinate the schedule of pickups, including the process for delivering stat specimens, where to place the specimens for pickup, and how to document the delivery process accurately and completely.

Specimen delivery methods include the following.

Chain of custody

The process that maintains control of and accountability for each specimen from the time of collection to the time of disposal is the chain of custody. All individuals who have handled a specimen must document their identity on the chain-of-custody form each time the specimen transfers. The form also requires the following components.

When transferring specimens during chain-of-custody processes, label the specimen correctly and place it in a biohazard bag with a permanent seal that verifies that no one has opened it until it is ready for analysis. These specimens are legal evidence; there must be no tampering with them until they reach their final destination. An intact seal provides evidence that there has been no tampering during the specimen’s transfer to the laboratory.

Several situations require initiating and following a chain-of-custody process, including forensic analysis, workplace drug testing, drug testing of professional athletes, neonatal drug testing, and blood alcohol content (BAC) testing. Occasionally DNA analysis, rape test kits, and parentage testing require following chain-of-custody guidelines for legal purposes.

Forensic specimens

Forensic laboratory analysis involves various types of specimens, for example, from vaginal swabs after rape, blood and body fluids from crime scenes, and postmortem specimens from autopsies. Special handling of specimens is crucial, because the specimens might be decomposing, available in only trace amounts, or require analysis by a forensic scientist in extreme environments. Forensic specimens also involve toxicology testing of substances after poisoning or substance abuse. Collecting these specimens can require special training or experience and supervision. Unlike specimens collected in a clinical setting, forensic specimens can be in any condition, clotted, or in containers that would otherwise be unacceptable.

Drug testing

The Department of Health and Human Services initiated federal drug testing, which is mandatory for some government employees and many private-sector employees. Workplace drug testing often follows the U.S. Department of Transportation’s mandated testing regulations, which have become an industry standard. Many employers require urine drug testing and use the Federal Drug Testing Custody and Control Form (CCF) for the process. This form must document the handling and storage information for specimens from the time they are obtained to their final disposal. Phlebotomists must undergo training and evaluation in the correct use of the CCF per federal guidelines. The process for collection has extremely specific guidelines to ensure that employees providing the specimen cannot tamper with it, such as adding water to dilute it or replacing it with urine they previously collected from someone else and concealed in clothing or a handbag.

Urine drug tests can usually detect marijuana use within the past week and the use of cocaine, heroin, and other illegal drugs within the past 2 days. However, they do not measure the degree of impairment or the frequency of use.

Law enforcement officers who detain individuals they suspect of driving under the influence might conduct various sobriety tests. Then, depending on state laws, they might request or require a urine, blood, or breath test. The most accurate of these methods for identifying alcohol levels is blood specimen analysis from a routine venipuncture or capillary stick procedure. In the U.S., the legal limit for BAC is 0.08%, or 80 mg/100 mL. Drivers younger than age 21 must have no detectable alcohol in their blood.

When collecting specimens for BAC testing, follow the chain-of-custody guidelines and special collection techniques. Clean the venipuncture site with an antiseptic that does not contain alcohol, such as chlorhexidine. Using alcohol for this purpose could lead to a false positive result. Do not use iodine swabs, because they contain alcohol.

Coordinating communication with non-laboratory personnel

As a phlebotomist, you will interact with many medical professionals, including physicians, nurses, laboratory technicians, respiratory therapists, and radiologic technologists. It is important to coordinate communication with non-laboratory personnel about processing and collection, and to monitor and adjust communication according to best practices and patients’ needs.

Computer programs now manage workflows and communication specific to each provider of services. In addition, effective communication involves using standard terminology and abbreviations, and accurate documentation. Documentation includes recording contact notes on laboratory reports or laboratory logs. All computer interactions provide documentation that managers can monitor and review for HIPAA compliance and the quality of patient care.

Computers and networks play key roles in the scheduling, managing, and processing of patients, specimens, and clinical workflow. You must become familiar with the software, communication methods, and processes within your organization. Software that supports the ordering, processing, and routing of specimens helps streamline workflows that once were paper-intensive. Software that links test results to provider alerts depending on preset values contributes to an effective and efficient communication process. Each organization establishes policies and procedures for communication about specimen processing and collection.

The use of laboratory information systems requires knowledge of software and hardware components to communicate effectively with non-laboratory personnel. You will use these and other essential instruments for the following tasks.

Always follow HIPAA guidelines and policies. By enhancing security measures—such as creating passwords, firewalls, and back-up programs—health care facilities comply with HIPAA requirements for protecting the confidentiality of patients’ records. HIPAA regulations also apply to the electronic communication of laboratory information, including scanning, faxing, and e-mail.

Laboratory informatics

In the clinical laboratory, personnel use technology every day to input and retrieve specimen data. For phlebotomists, computerization has become critical in the processing, handling, and communication of laboratory processes. These include common procedures for POC testing, Clinical Laboratory Improvement Amendments (CLIA)-waived test machinery, and the electronic transmission of results. Depending on the location of testing (hospital, provider’s office, mobile health unit, ambulance), phlebotomists encounter highly integrated computer systems. These complex systems include the following.

It is important to be able to adapt and keep an open mind about informatics. New technologies provide health care facilities with opportunities to move from manual to semi-automated or automated systems, allowing for fewer clinical or documentation errors, timely and accurate reports, and an overall higher quality of patient care. Computer systems can perform quality checks and controls on the input of data, as long as all information is entered correctly.

For semi-automated and automated methods of laboratory processing, be sure to input the following.

Bar codes, quick response (QR) codes, and radio frequency identification (RFID) are examples of informatics increasingly used in practice. Each of these developments reduces errors in transmission and speeds up the processing of specimens. Each health care facility must consider the costs of these systems and ensure that phlebotomists receive training on standardization and privacy protection.

As a phlebotomist, you’ll work with laboratory information systems, electronic medical records, and scheduling systems as part of your daily job tasks. Each organization’s system and processes are unique, so it is important to learn your facility’s system, and use it according to the policies and procedures it mandates.

Reporting and distributing laboratory results

Point-of-care (POC) tests are laboratory tests performed close to the site of patient care (such as the patient’s bedside or the examination room of a provider’s office). When performing POC testing, be aware of values that indicate a potentially life-threatening or health-endangering situation. A critical value is a test result that is significantly above or below the expected reference range. It could indicate a potentially life-threatening situation for the patient and requires an immediate response.

When a critical value occurs, report this result promptly and directly to the ordering provider. Not all laboratory values have a critical level, but each laboratory or facility has a list of tests that require monitoring patients’ results for critical values. Learning the difference between an elevated or decreased value and a critical value is important. Depending on the nature of the test—from simple screening to complex profiles—a change in a patient’s homeostasis will result in an abnormal test value in either a quantitative numeric value or a simple positive or negative outcome.

The specific critical values can differ by facility and can change over time. Become familiar with the general tests that providers monitor for critical values, and learn the values for your organization. For example, if the laboratory’s expected reference range for a fasting blood glucose level is 70 to 100 mg/dL and a patient’s result is 464 mg/dL, that is a critical value that warrants immediate reporting to the provider.

With POC and CLIA-waived testing, collect and prepare specimens to insert immediately into automated clinical analyzers for fast and accurate results. These tests include the following.

Microbiology and toxicology testing, including the rapid antigen detection test (for identifying streptococcal pharyngitis), fecal occult blood studies, chemical reagent strip testing, and urine pregnancy testing provide positive or negative results or—with reagent strip testing—a variety of numeric values or ranges for interpretation.

A common POC test is a blood glucose level. Patients who have diabetes mellitus routinely have results greater than the high limit of the reference range. Sometimes these results are within normal limits for those specific clients. You need to know when a high result is normal or expected for patients due to their condition, and when to notify the provider. When using a coded glucometer, compare the code on the glucometer with the code on the strips prior to each patient’s testing. Complete quality controls with a control material when opening a new package of test strips, when several tests have been significantly out of range, or when changing the glucometer’s batteries.

You will collect and handle specimens, perform some POC and CLIA-waived tests, identify abnormal and critical values, and report results. However, a licensed health care professional must then review and evaluate those results.

Results to providers

In reference laboratory facilities, laboratory personnel (including phlebotomists) are responsible for ensuring correct and timely delivery of laboratory test results. For POC testing, provide the results to clinical staff directly or by logging the data in the electronic health record system. Confirm and date-stamp all laboratory results, and submit them via a secure method of distribution (verbal, telephone, written, computer reports), depending on the urgency the values warrant.

Report stat and critical results immediately with a telephone call or in person, requesting a verbal read-back of the results to reduce risk of communicating incorrect information. When sharing verbal results, document the following information.

Written and electronic reports are less prone to error than verbal or telephone reports of laboratory results. Regardless of the type of report, always maintain patients’ privacy and confidentiality in compliance with HIPAA guidelines. Most providers’ offices use electronic medical records that can link to laboratories to receive patients’ results automatically. With this technology, electronic reports are the most common and secure means for transmitting laboratory test results to providers. Phlebotomists can e-mail or upload test results for immediate access by the ordering provider. These systems help track results, trigger alerts for laboratory changes or urgent results, help with correct and efficient billing, and save time and costs.

Glucose monitoring test

Processing specimens: Summary

As a phlebotomist, you will complete procedures to obtain specimens from patients, handle and process specimens, communicate with non-laboratory personnel, use various methods of communication and documentation, and distribute results to providers. Patient safety is essential whether you are working in a hospital, large facility, or reference laboratory; or performing POC testing.

After collection of specimens, processing them includes centrifuging, aliquoting, diluting, labeling, and packaging them. When transporting specimens to other laboratories, be aware of time limitations and temperature, lighting, and packaging requirements. Methods of delivery include hand delivery, pneumatic tube systems, automated carriers, and postal service mail. Be sure to comply with local, state, and federal laws addressing special packaging and biohazard identification.

Several situations require initiating and following chain-of-custody processing, including forensic analysis, workplace drug testing, federal drug testing for athletes and neonates, blood-alcohol testing, DNA analysis, rape test kits, and parentage testing. Chain-of-custody guidelines are for legal purposes and require that every individual who has handled the specimen document their identity, date, and each time that the specimen was transferred on the chain-of-custody form.

When performing POC or CLIA-waved testing, identify critical values and the best means of communicating this information to the ordering provider. Critical value results fall significantly above or below the expected reference range and can reflect a life-threatening situation. Although it is important to understand expected and unexpected results and recognize critical values, a licensed health care professional must also review and interpret the results.

Phlebotomists interact with many other types of medical professionals. It is important to coordinate communication among these individuals to reduce misunderstandings and errors. Technology helps improve communication and the quality of patient care. Be sure to always protect patients’ privacy and confidentiality, regardless of the method of specimen collection, testing, and reporting of results.