Authorised By:
Authorised Date:
Authors:
Date Time Printed:
Document Status:
Version:
Pathology User Guide
Nicola Bullough
PATH.QM.002
Debbie Gulla, Nicola Bullough, and Tony Tetlow
3.5
22-May-2019
22-May-2019 10:14
Pathology - Quality Management
Authorised
Pathology User Guide - Version: 3.5. Index: PATH.QM.002. Printed: 22-May-2019 10:14
Authorised on: 22-May-2019. Authorised by: Nicola Bullough. Document Unique Reference: 1312-89467136. Due for review on: 22-May-2021
Author(s): Debbie Gulla, Nicola Bullough, Tony Tetlow
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INTRODUCTION
The information contained within this guide is intended for users of the services provided by the Pathology
Directorate at Tameside and Glossop Integrated Care NHS Foundation Trust. Please contact the Pathology
Quality Manager if you have any comments or suggestions concerning this guide.
AUTHORITY FOR ISSUE
This document has been authorised by the Pathology Management Team – See front page or iPassport for full
details.
DOCUMENT INFORMATION
See footer and front page for basic information; see iPassport QMS for full details.
REFERENCES
A list of references is not given in this document. Please contact the Pathology Quality Manager for more
information if required.
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Table of Contents
Introduction ............................................................................................................................................................ 1
Authority for Issue .............................................................................................................................................. 1
Document Information ....................................................................................................................................... 1
References .......................................................................................................................................................... 1
Contact Details ........................................................................................................................................................ 7
Pathology Management Team ............................................................................................................................ 7
Pathology IT Systems .......................................................................................................................................... 7
Pathology General ............................................................................................................................................... 7
Blood Sciences (Haematology, Biochemistry and Blood Transfusion) ................................................................ 7
Microbiology ....................................................................................................................................................... 7
Mortuary ............................................................................................................................................................. 7
General Information ............................................................................................................................................... 8
Service Provision ................................................................................................................................................. 9
Location ............................................................................................................................................................... 9
Address ............................................................................................................................................................. 10
Internet ............................................................................................................................................................. 10
Advice ................................................................................................................................................................ 10
Test Selection ................................................................................................................................................ 10
Individual cases ............................................................................................................................................. 10
Advice on the interpretation of results ......................................................................................................... 10
Complaints ........................................................................................................................................................ 10
Quality ............................................................................................................................................................... 11
Quality of results (The Uncertainty of Measurement) ...................................................................................... 11
Reference Ranges .............................................................................................................................................. 11
Consent ............................................................................................................................................................. 11
Confidentiality ................................................................................................................................................... 11
Tests not present in User Guide ........................................................................................................................ 11
Laboratory opening times ................................................................................................................................. 13
Blood Sciences & Transfusion ....................................................................................................................... 13
Microbiology ................................................................................................................................................. 13
Requesting and Reporting ..................................................................................................................................... 14
Requests for Blood Products: ........................................................................................................................ 15
Ward Order Communications ....................................................................................................................... 15
GP Electronic Reporting ................................................................................................................................ 15
Requests for further tests on samples already held by laboratory ............................................................... 15
Distribution of printed reports ...................................................................................................................... 15
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Telephoned results........................................................................................................................................ 16
Specimen Collection and Transport ...................................................................................................................... 18
Introduction ...................................................................................................................................................... 19
Basic Rules for Taking Specimens...................................................................................................................... 19
Problem Samples .......................................................................................................................................... 19
Caution – EDTA Contamination ..................................................................................................................... 20
Container Guide ................................................................................................................................................ 21
Biochemistry ................................................................................................................................................. 21
Haematology ................................................................................................................................................. 22
Transfusion .................................................................................................................................................... 22
Microbiology ................................................................................................................................................. 23
Labelling ............................................................................................................................................................ 28
Labelling for Transfusion ............................................................................................................................... 28
Mislabelled Samples.......................................................................................................................................... 28
Why it matters .............................................................................................................................................. 28
Good Labelling .............................................................................................................................................. 28
Bad Labelling ................................................................................................................................................. 29
Repeatable Samples ...................................................................................................................................... 29
Non-Repeatable Samples .............................................................................................................................. 29
Consent ............................................................................................................................................................. 29
Sending Samples ............................................................................................................................................... 30
Blood Sciences............................................................................................................................................... 30
Microbiology ................................................................................................................................................. 30
Urgent samples ............................................................................................................................................. 30
High Risk Specimens .......................................................................................................................................... 30
Phlebotomy ....................................................................................................................................................... 31
In-patients ..................................................................................................................................................... 31
Out-patients .................................................................................................................................................. 31
GP Patients .................................................................................................................................................... 31
Transport of samples to laboratory .................................................................................................................. 32
Pneumatic Tube Delivery System (pod) ........................................................................................................ 32
From Wards and Out-patient Departments .................................................................................................. 32
GP's ............................................................................................................................................................... 32
Specimen Spillage ......................................................................................................................................... 33
Referred investigations ................................................................................................................................. 33
Biochemistry Department ..................................................................................................................................... 34
Contact Details .................................................................................................................................................. 35
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Biochemical Profiles .......................................................................................................................................... 35
Common Tests Information – Sample requirements and reference ranges (adult) ......................................... 37
Paediatric Reference Ranges ............................................................................................................................. 49
Paracetamol Interpretation .............................................................................................................................. 51
Therapeutic Drug Monitoring ........................................................................................................................... 52
Acute Kidney Injury (AKI) Alerts ........................................................................................................................ 53
Interpretation of Vitamin D results ................................................................................................................... 53
Faecal Occult Blood ........................................................................................................................................... 54
Dynamic Function Tests and Special Tests ........................................................................................................ 55
Oral Glucose Tolerance test .......................................................................................................................... 55
Short Synacthen Test .................................................................................................................................... 58
Dexamethasone suppression test (low dose) ............................................................................................... 58
Renin and Aldosterone .................................................................................................................................. 59
Water Deprivation Test ................................................................................................................................. 60
Tumour Markers ............................................................................................................................................... 62
NICE guidance on tumour markers ............................................................................................................... 62
Drugs of abuse .................................................................................................................................................. 64
Virology ............................................................................................................................................................. 64
Porphyrin Screen ............................................................................................................................................... 65
Cryoglobulins..................................................................................................................................................... 65
Haematology Department .................................................................................................................................... 66
Contacts ............................................................................................................................................................ 67
Turnaround Times ............................................................................................................................................. 67
Note .............................................................................................................................................................. 67
Blood Count Requests ....................................................................................................................................... 68
ESR..................................................................................................................................................................... 69
Reticulocytes ..................................................................................................................................................... 69
Anticoagulants .................................................................................................................................................. 70
NOAC Patients on Rivaroxaban, Apixaban or Dabigatran (Non vitamin K Anticoagulants) .......................... 70
Therapeutic Range for patients on Warfarin ................................................................................................ 70
Coagulation Tests .............................................................................................................................................. 71
Indication ...................................................................................................................................................... 71
Coagulation test – sample requirements ...................................................................................................... 71
Haemoglobinopathies ....................................................................................................................................... 73
Haemoglobinopathy tests available: ............................................................................................................. 73
Antenatal screening .......................................................................................................................................... 73
Haemolytic disorders ........................................................................................................................................ 73
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Haematinic assays ............................................................................................................................................. 73
Bone marrow aspirate and trephine bone biopsy ............................................................................................ 73
Haematology adult reference ranges................................................................................................................ 73
Other Haematological Investigations ................................................................................................................ 74
Sample storage times ........................................................................................................................................ 74
Referred Investigations ..................................................................................................................................... 75
Blood Transfusion ................................................................................................................................................. 77
Contacts ............................................................................................................................................................ 78
Caution .............................................................................................................................................................. 78
Request Forms .................................................................................................................................................. 78
Specimen Requirements ................................................................................................................................... 79
Dextran .............................................................................................................................................................. 79
Routine Requests .............................................................................................................................................. 79
Reservation of cross-matched blood ............................................................................................................ 79
Group and Save Plasma................................................................................................................................. 80
Issue of Blood .................................................................................................................................................... 80
Emergency Group O Negative Blood ................................................................................................................. 80
POCT (Point of Care Testing) ................................................................................................................................. 81
POCT Policy ................................................................................................................................................... 82
POCT Committee ........................................................................................................................................... 82
Training ......................................................................................................................................................... 82
Sample integrity and results ......................................................................................................................... 82
Pathology support ......................................................................................................................................... 82
Instrument failure ......................................................................................................................................... 83
Immunology .......................................................................................................................................................... 84
Contacts ............................................................................................................................................................ 85
Microbiology and Virology .................................................................................................................................... 86
Contacts ............................................................................................................................................................ 87
Microbiology Department ................................................................................................................................. 87
Virology Department ......................................................................................................................................... 88
Cellular Pathology & Neuropathology .................................................................................................................. 89
Cellular Pathology ............................................................................................................................................. 90
Service and Contact Information ...................................................................................................................... 90
Contact Details .................................................................................................................................................. 90
Consultant Contact Details ............................................................................................................................ 90
Neuropathology Samples .................................................................................................................................. 91
Neuropathology – muscle and nerve biopsy samples ...................................................................................... 91
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Transport ....................................................................................................................................................... 91
Mortuary and Bereavement ................................................................................................................................. 92
Mortuary Opening Hours .................................................................................................................................. 93
Contacts ............................................................................................................................................................ 93
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CONTACT DETAILS
Directorate internal hospital numbers (prefix with 0161 922 if dialling from outside). If in doubt concerning who
part of the directorate to contact then please use General Enquiries on 6497 who will then be able to advise
and re-direct your call. Full list of phone numbers can be found on hospital intranet.
PATHOLOGY MANAGEMENT TEAM
Clinical Director Dr Vicki Howarth 4003
Diagnostics Manager Dawn Clarke 6110
PA to Ms Clarke 4412
Quality Management System Manager Nicola Bullough 6419
Administration and Clerical Manager Alison Reece 6609
PATHOLOGY IT SYSTEMS
Clinical IT Team 4619
PATHOLOGY GENERAL
General Enquiries (non-results) 6393
General Enquiries (results) 6497
Laboratory Fax 6496
Blood Transfusion Fax 6504
BLOOD SCIENCES (HAEMATOLOGY, BIOCHEMISTRY AND BLOOD TRANSFUSION)
Blood Sciences Manager Gillian Lewis 6318
POCT Manager Alison Shanahan 4620
General Enquiries – Haematology & Biochemistry 6497
General Enquiries – Blood Transfusion 6391
Consultant Clinical Scientist (Biochemistry) Tony Tetlow 6495
Consultant Haematologists secretary 6596 & 4196
Specialist Practitioner of Transfusion Caroline Holt 5484
MICROBIOLOGY
Consultant Microbiologist Dr P Unsworth 6500
Consultant Microbiologist / Infection control Dr H. Sacho 4086
Please note that laboratory services have now transferred to Manchester University NHS Foundation Trust
(central site). Please see relevant part of user guide.
MORTUARY
Mortuary Manager Sharon McMinn 6520
Mortuary Office 6059
On-call mortuary technician Via hospital switchboard
Histopathology
Please note that laboratory services have now transferred to Manchester University NHS Foundation Trust
(UHSM site). Please see relevant part of user guide.
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GENERAL INFORMATION
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SERVICE PROVISION
The Pathology Department at Tameside General Hospital is committed to providing a full comprehensive
Pathology Service for Haematology/Blood Transfusion, Biochemistry and Mortuary to all its users.
The mortuary provides post mortem and body storage facilities serving the Trust and the Coroner, acting as a
public mortuary.
The Cellular Pathology service is provided by Manchester University NHS Foundation Trust (Wythenshawe site)
with a Service Level Agreement under a Cooperation Agreement.
The Microbiology and Immunology services are provided by Manchester University NHS Foundation Trust
(Central site) under Service Level Agreements.
Information Technology (IT) Services are provided under Service Level Agreements by the Tameside and
Glossop Integrated Care NHS Trust IT department and the Systems Development department.
LOCATION
The Directorate of Laboratory Medicine (Pathology) is located on Fountain Street opposite the Hartshead
Building. The post code suitable for a Sat. Nav. is OL6 9RW
The entrance to the department is denoted by the ‘red arrow’. The entrance on Fountain Street is for goods
and laboratory staff only.
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ADDRESS
All Directorates in pathology can be contacted by post at the following address
Directorate of Laboratory Medicine
New Fountain House
Tameside and Glossop Integrated care NHS Foundation Trust
Fountain Street
Ashton-under-Lyne
OL6 9RW
INTERNET
http://www.tamesidehospital.nhs.uk/
ADVICE
TEST SELECTION
Please use this guide in the first instance; for more complex matters please contact the laboratory or the
relevant consultant.
INDIVIDUAL CASES
For advice on individual cases, please contact either the relevant consultant or the laboratory who will be able
to advise you further.
ADVICE ON THE INTERPRETATION OF RESULTS
Please be aware that not all staff can give advice on the interpretation of results. Clinical advice can only be
given by consultant staff, not by Medical Laboratory Assistants or Biomedical Scientists
COMPLAINTS
Complaints may be sent to departments by phone, email or mail. All complaints are dealt with using the Trust’s
complaints procedure which can be found on the intranet or internet site. Initial contact may be by phone,
email or in writing and attempts are made to deal with any complaint immediately and at the point of contact.
If the complainant is not satisfied with the response them they should ask to speak to a more senior member of
staff (see relevant section of User Guide). If the complainant is still not satisfied then they may be referred to
the Trust’s complaints procedure. The Complaints and Patients Advice and Liaison Service (Complaints and
PALS) should be contacted for advice. The contact details are:
Telephone: 0161 922 4466
Emails: [email protected]
Further details are available in the Patient Handbook which available on the Trust’s public site
(https://www.tamesidehospital.nhs.uk/).
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QUALITY AND ACCREDITATION
Tameside and Glossop Integrated Care NHS Foundation Trust Department of Blood Sciences a UKAS accredited
medical laboratory No. 8912. This accreditation is to ISO 15189:2012 Medical laboratories – Requirements for
quality and competence. It is strongly recommended that users check the UKAS website
(https://search.ukas.com/#/tabbed/search?q=8912&ati=1) for the current accreditation status of the service as
the scope of accreditation can change over time. Any questions about accreditation should be addressed to a
senior member of the management team.
The mortuary is licensed by the Human Tissue Authority for: Making of a Post Mortem Examination, Removal
of Relevant Material, Storage of a Body or Relevant Material (Licence number: 12067)
Where appropriate, departments also take part in External Quality Assurance schemes to ensure that we
provide a high quality service to our users.
The department has a formal Quality Management System that meets the requirements of ISO 15189:2012.
The Quality Policy and Quality Manual are available to service users on request. Please contact the Quality
Manager for further information
QUALITY OF RESULTS (THE UNCERTAINTY OF MEASUREMENT)
All analytical results are assessed via internal quality controls and external quality assurance. The interpretation
of all results is subject to an uncertainty due to inter and intra individual variability plus the analytical variability
which all assays are subject to. Data relating to this is available for all reported tests done in-house or can be
obtained for referred investigation. If you have any queries regarding the interpretation of results (biological,
analytical variation or reference ranges) then please contact a senior member of staff (contact details provided
in this guide).
REFERENCE RANGES
All quoted reference ranges have been either:
• Adapted from the Pathology Harmonisation program and checked against our current methodologies
using the distribution of results within the Tameside and Glossop area (a posteriori reference range
surveillance).
• Or a position of “best practice” is adopted in line with current guidelines.
• Reference ranges for referred investigation are taken from the referral laboratory.
CONSENT
When a sample is taken then consent is implied. The responsibility for consent lies with the requesting
clinician. Investigations will only be undertaken for the diagnosis and/or monitoring of a particular condition at
the request of and with the authority of the requesting clinician or their nominated individual.
CONFIDENTIALITY
The department (and the Trust) follows the NHS code of conduct and is bound by the General Data Protection
Regulations. The Trust’s policies regarding this can be obtained via the internet and intranet sites or contact
any senior member of the directorate for a copy.
TESTS NOT PRESENT IN USER GUIDE
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Please note that the User Guide does not mention all possible investigations for reasons of brevity, only the
most commonly requested tests are included. If an assay is required but is not in this document then please
contact the relevant department.
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LABORATORY OPENING TIMES
BLOOD SCIENCES & TRANSFUSION
The Haematology/Blood Transfusion and Biochemistry Departments (Blood Sciences) operate a 24 hours
service; one qualified staff member is on duty in each of the 2 disciplines outside routine working hours. These
departments also operate a senior staff “on-call” rota in collaboration with neighbouring hospitals (contactable
via the Biomedical Scientist on duty for Biochemistry and via switchboard for Haematology).
MICROBIOLOGY
The laboratory based service has now transferred to Manchester University NHS Foundation Trust (central
site). The consultant microbiologist service remains at Tameside with two consultants (contactable via the
switchboard). Please see Microbiology Department on page 87 for further details.
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REQUESTING AND REPORTING
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REQUESTS FOR BLOOD PRODUCTS (TRANSFUSION):
All request forms must be signed by the requesting clinician. Additionally the sample tube must be hand
written, signed and dated.
WARD ORDER COMMUNICATIONS
The hospital has an electronic link between the Patient Administration System (Lorenzo) and the Pathology
Computer System. The system is available for Haematology, Transfusion, Microbiology and
Biochemistry requests from all wards and clinics; all requests for these departments must be made
electronically.
A signed request is an absolute requirement for Group & Save and Crossmatch. Please note that the label
produced by Lorenzo for blood transfusion MUST NOT be attached to the sample, Samples must be hand
written as per previous section.
Medical staff training on this system is undertaken by the IT Department. All Haematology, Transfusion,
Biochemistry and Microbiology results are available on Lorenzo once they are released. Please look for the
results on Lorenzo before telephoning.
GP ELECTRONIC REQUESTING AND REPORTING
GP practices are provided with tQuest; an electronic order communications product that interfaces to the lab
system and the Practice Management System allowing electronic requesting of pathology tests.
The Pathology Directorate transfers results electronically to GP Practices. Results are sent continuously in order
that patients' results are available for viewing next morning on the GP's' own computer systems.
GPs can access results for investigations done within the hospital via Review which works with tQuest.
For any query about pathology IT issues please contact the Clinical IT Team
REQUESTS FOR FURTHER TESTS ON SAMPLES ALREADY HELD BY LABORATORY
It is occasionally possible for further testing to be done on samples held by the laboratory. Samples are held for
a minimum of 5 calendar days by Biochemistry and a minimum of 2 calendar days (minimum 2 day) by
Haematology (for Microbiology and Histology please contact relevant department). Requests for further tests
are possible after considerations of:
• If there is sufficient sample remaining.
• If the requested analyte is stable under the storage conditions.
• The sample is the correct type.
DISTRIBUTION OF PRINTED REPORTS
In-patients: There are 2 report distributions per day, 12:30 and 17:30
GP patients: Reports are sent by transport (daily).
Please note the directorate operates a no-faxing policy unless the fax machine has been
established as a “safe haven”. Please see Trust’s data protection policy for further details or
contact laboratory for advice.
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TELEPHONED RESULTS
It would be appreciated if telephone enquiries to the laboratory asking for results, could be kept to a minimum.
All results from pathology are electronically sent to the Lorenzo EPR, if the request is made electronically or the
RMP number is used on the request. So please check the Lorenzo system before telephoning for results.
If contacting the department by phone then please ensure you have full patient details, date of collection and
tests required.
Note: in line with the Royal College of Pathology’s guideline (2010):
“Out-of-hours reporting of markedly abnormal laboratory test results to primary care: Advice to pathologists”
and in consultation with service users the following limits for telephoning seriously abnormal results have been
agreed:
BIOCHEMISTRY
Analyte Units Action limits
Below Above
Pro
file
Co
mp
on
en
ts
Sodium mmol/L 120 160
Potassium mmol/L 2.5 6.0*
Urea mmol/L - 30
Creatinine µmol/L 250
Glucose mmol/L 2.5 20**
Calcium (corrected) mmol/L 1.80 3.00
Magnesium mmol/L 0.4 -
Phosphate mmol/L 0.3 -
NTproBNP Pg/ml - >400
AKI - AKI stage 2 and 3
En
zym
es AST U/L - 750
ALT U/L - 750
CK U/L - 5000
Amylase U/L - 500
Th
era
pe
uti
c D
rug
s Carbamazepine µmol/L - 60
Digoxin nmol/L - 3.5
Theophylline µmol/L - 150
Phenytoin µmol/L - 150
Lithium mmol/L - 1.5
Valproate mmol/L - 1500
Gentamicin mmol/L 12
Oth
er
Troponin I – male ng/L 42.9
Troponin I – female ng/L 18.3
Paracetamol mg/L 10
Salicylate mg/L 10
*Check sample is not haemolysed (sample quality check), EDTA contaminated (check magnesium, calcium and
alkaline phosphatase) or if there has been a delay in separation (check phosphate)
** >30 mmol/L if known diabetic
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HAEMATOLOGY
Analyte Units Action limits
below Above
Pro
file
co
mp
on
en
ts
Haemoglobin g/L 80
Total White Cell Count 109/L 2
Absolute Neutrophil Count 109/L 1
Platelet Count 109/L 30
INR 5.0
APTTR 3.0
Fibrinogen g/L 1.0
Newly presenting leukaemia
Newly presented malaria
Positive Sickle Cell Haemoglobin in patients about to undergo anaesthesia
ADDITIONALLY
CSF (total protein and glucose) If not requested by ward order coms (WOC).
Blood gases If not requested by WOC.
The directorate will make every endeavour to communicate any results requiring immediate attention to the
initiator of the request. If there are insufficient details on the request form this may be impossible outside of
core laboratory hours and may cause delays in these results being transmitted.
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SPECIMEN COLLECTION AND TRANSPORT
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INTRODUCTION
In order for the laboratory to provide the service that you require, the laboratory needs samples to be taken
and labelled correctly. Additional information can be found in PATH.PROC.013 – Specimen Packaging and
Transport.
BASIC RULES FOR TAKING SPECIMENS
1. Ensure you only deal with one patient at a time
2. Check the expiry date of the tube
3. Do not label bottles before you take the sample
4. Bottles MUST be labelled next to the patient
5. Ask patient to confirm their name where possible
6. Take patient details from the wrist band (when present)
7. Sample MUST have 3 positive patient identifiers on the container
8. All details on the sample and the request form must match
9. Take EDTA tubes last (to prevent sample contamination (leads to high K+))
PROBLEM SAMPLES
Please note the following pre-laboratory errors frequently occur but may be avoided by
• Correct sample for relevant test.
• Correct mixing of blood sample with contents of blood collection tube (minimum of 12 full inversions).
• Prompt delivery to the department.
The most common reasons for pre-analytical factors affecting results are:-
Problem Common causes Consequences
Delay in separation Overnight storage. Delay in transit Increased K+, PO4, ALT, LDH.
Decreased HCO3-, (Na+
occasionally)
Storage Storing at 4°C Increased K+ Decreased HCO3-
Haemolysis Expelling blood through needle into tube
Over vigorous mixing of specimen
Storing specimen in freezer (-20°C)
Excessive delay in transit
Leaving specimen in hot environment.
Difficulties encountered when accessing
suitable vein.
Increased K+, PO4, ALT, LDH
Inappropriate sampling
site
Specimen taken from drip arm Increased drip analyte e.g. glucose,
K+, Mg2+ (dilution effect)
Incorrect container or
anticoagulant
No enzyme inhibitor, EDTA tube or
transferring blood from one tube to another
Low glucose, Increased K+, Na+,
Decreased Ca2+, ALP, Mg2+
Lipaemia Specimen taken after a fatty meal. Decreased Na+
Clotting of sample Inadequate mixing of samples with
anticoagulant causing blood to clot
Affects FBC, ESR, Coagulation &
other samples
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CAUTION – EDTA CONTAMINATION
Plasma or serum samples (white, brown or orange tubes) must be taken before EDTA sample
(red, blue or pink tubes).
Contamination of blood specimens with potassium EDTA is a major problem for the Biochemistry department
and the following will explain why.
Q. What are the effects of EDTA contamination?
• Increased potassium - leading to an incorrect interpretation of potassium levels.
• Decreased calcium, magnesium and alkaline phosphatase.
Q. Why use EDTA if it is such a problem?
Potassium EDTA is the anticoagulant primarily used by the Haematology department because the cellular
components and morphology of the blood cells are preserved and it is the recommended anticoagulant for
haematology.
Q. How does it work?
EDTA inhibits clotting by chelating calcium and magnesium which inhibits several calcium and magnesium
dependent enzymes critical to the clotting cascade.
Q. Can it be spotted by the lab?
Gross contamination can be spotted by the lab due to unbelievable levels of calcium (and/or magnesium),
potassium and alkaline phosphatase. It only takes a trace of EDTA to alter the results and this may not be
obvious. THE LABORATORY CAN NOT RELIABLY IDENTIFY EDTA CONTAMINATION. The safe practice is to avoid
contamination in the first place and that is the responsibility of the person taking the blood sample.
Q. How can contamination be avoided?
When taking a series of blood specimens, it is essential that specimens for biochemistry (e.g. urea and
electrolytes) are taken first and EDTA samples are taken last.
If you have any doubts about the accuracy of a potassium e.g. if it does not agree with the
patient’s condition or with previous results then obtain a fresh sample (of which you are sure of
the integrity) and have it analysed as an emergency.
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CONTAINER GUIDE
BIOCHEMISTRY
Routine – Adult
Routine – Paediatric
Glucose/Alcohol – Adult
Glucose/Alcohol – Paediatric
Lithium Heparin – Adult
Lithium Heparin - Paediatric
EDTA Red Top – Ammonia
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HAEMATOLOGY
EDTA – Adult
EDTA – Paediatric
Coagulation – Adult
Coagulation – Paediatric
ESR
Do not place labels over the clear part
of the tube (this is where the ESR is
read). Please place it over the existing
label. When filled, blood should reach
the arrow.
TRANSFUSION
Transfusion – Adult
Transfusion – Paediatric
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MICROBIOLOGY
MICROBIOLOGY LABELLING AND PACKAGING
Because microbiology is booked in here and processed at MRI the
requirements for labelling are slightly different to those for Blood Sciences:
Label the sample as normal. Only one sample per bag is allowed; request forms must not go in the bag with the
sample; attach the form to the bag/tag; if the sample leaks we or MFT will only have to discard one sample but
we will have the demographics available to issue a report informing you that the sample leaked.
URGENT SAMPLES FOR MICROBIOLOGY
Please inform the laboratory at Tameside that an urgent sample is being sent so that they know to look out for
it so that it can be sent to MFT as soon as possible and is highlighted to them. Please also let the laboratory at
MFT know so that they are aware.
BACTERIOLOGY
SINGLE ESWAB (PINK TOP)
Wound swabs & Genital Swabs: Infection Screen
WOUND SWABS
For wound swabs or MRSA screening sites excluding nose and groin/perineum. Please provide a site and clinical
information
GENITAL SWABS: INFECTION SCREEN
This screen will cover all potential pathogens, depending upon clinical information provided, with the exception of
Trichomonas vaginalis*
*Vaginal swabs for trans patients can be requested as “Genital – Other” or as a Wound Swab
STERILE CONTAINER – URINE
Urine Samples: Clean Catch Urine, Mid-Stream Urine & Catheter Urines
Please provide clinical information
*For Mycobacteria culture collect 3 consecutive early morning urine samples in
200mL containers
*For Schistosoma collect terminal urine portions over a 24hrs in standard urine
containers
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DOUBLE HEAD SWAB (RED CAP)
CPE Screens – rectal swabs only
The double head red swab should only be
used for CPE screening
FAECES POTS
Enteric Samples: C. difficile and Routine Screen
Please provide clinical information including recent travel
history
CHARCOAL AMIES SWAB
Trichomonas vaginalis (TV) Screen
For patients with symptoms of TV, such as frothy discharge. A TV screen may be considered for:
• abnormal vaginal discharge that may be thick, thin or frothy and yellow-green in colour
• producing more discharge than normal, which may also have an unpleasant fishy smell
The use of this swab is an interim measure only; in the future TV requests will be processed by molecular methods
alongside Chlamydia and Gonorrhoea.
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BLOOD CULTURE PACK – NEONATAL
BLOOD CULTURE – PAEDIATRIC
BLOOD CULTURE – ADULT
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QUANTIFERON PLUS TB
Please read the package insert when using these as there are very specific requirements for how they are taken,
stored and transported.
VIROLOGY
COBAS PCR MEDIA – SWAB
Viral infection Screen; Chlamydia trachomatis & Neisseria gonorrhoea (NAAT)
Please ensure the correct swab is used
for the test requested or the sample
cannot be processed. Please note only
ONE swab should be returned in the
specimen tube.
COBAS PCR MEDIA – URINE
Viral infection Screen; Chlamydia
trachomatis & Neisseria gonorrhoea
(NAAT)
Urine specimens must be collected in a
sterile container and transferred to the
Cobas media tube within 24 hours. Fill
level must be between the black lines.
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VIRAL TRANSPORT MEDIA (RED CAP)
All other virology
CLOTTED BLOOD
For all serology
EDTA ANTICOAGULANT
PCR and Viral load
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LABELLING
The Specimen Acceptance Policy for both T&GICFT and MFT Trusts is:
On the Tube On the Form
Patients full name (surname & forename) Patients full name (surname & forename)
Date of Birth Date of Birth / Gender
RMP Number or NHS Number NHS or RMP Number
Date of Collection Location of report
Consultant or GP
Clinical information
The only time this does not apply is for GUM Clinic patients or when the identity of the patient is unknown.
Also refer to the ‘Specimen Acceptance Policy’ on the Trust intranet.
Where Lorenzo (Hospital) or tQuest (GP) is used to generate the form much of this information is automatically
transmitted form the requesting system to the laboratory system.
LABELLING FOR TRANSFUSION
Transfusion has particular requirements over and above other disciplines:
On the Tube On the Form
Patients full name (surname & forename) Patients full name (surname & forename)
Date of Birth Date of Birth / Gender
NHS or RMP Number NHS or RMP Number
Date & time sample was taken Location of report
Signature of member of staff Consultant or GP
Location Clinical information
Lorenzo Barcodes must NOT be placed on Transfusion samples
Also see the ‘Blood Transfusion Policy’ on the Trust intranet.
All transfusion samples are regarded as repeatable without exception (see Caution page 78).
MISLABELLED SAMPLES
WHY IT MATTERS
On an average day the laboratory deals with approximately:
• Samples 2550
• Requests 5400 (a sample can have multiple requests on it)
• Tests 16590 (e.g. a U&E is made up of 6 individual tests)
If even a small proportion of samples are poorly labelled it can have a significant impact on the department
taking staff time when they could be doing more useful things.
GOOD LABELLING
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The barcode runs along the length of the tube and the print is clear and dark allowing our analysers to read the
barcode, this speeds up our process and minimises the risk of error
BAD LABELLING
Labels that are not running along length of tube or are scratched or have pale print or are not properly adhered
to the tube are not acceptable as they will not scan on our analysers (or may even jam). These have to be
manually relabelled which takes significant time and introduces a risk of error when transferring demographics
etc.
Please only put one label on a tube, multiple labels can make it impossible to read them or fit them in the
analyser racks.
REPEATABLE SAMPLES
The Department of Laboratory Medicine reserves the right not to analyse any repeatable specimen that it
receives that has not been adequately labelled. All inadequately labelled repeatable specimens will be disposed
of in accordance with the Trusts Waste Disposal Policy. A clinical incident form will submitted
NON-REPEATABLE SAMPLES
When a non-repeatable specimen is received and has been found to be inadequately labelled the laboratory
will contact the ward/department to inform them of this. It is the responsibility of the Health Care Worker
responsible for the specimen to come to Department of Laboratory Medicine and complete an Amendment to
Specimen Labelling Form.
CONSENT
It is the responsibility of the requesting clinician to obtain consent for the collection of specimens from the
patient. For certain tests (e.g. HIV tests or genetic tests) fully informed consent may be needed; for some tests
a consent form may be required in addition to the request forms/informed consent
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SENDING SAMPLES
BLOOD SCIENCES
Label the sample(s) as required, put the sample(s) in the bag, one patient per bag, seal the bag and attach the
request form/sticker to the bag/tag (if there are multiple Lorenzo forms these can be placed in the bag).
MICROBIOLOGY
Because microbiology is booked in here and processed at MRI the requirements for labelling are slightly
different:
Label the sample as normal. Only one sample per bag is allowed; request forms must not go in the bag with the
sample; attach the form to the bag/tag; if the sample leaks only one sample will have to be discarded but we
will have the demographics available to issue a report informing you that the sample leaked.
URGENT SAMPLES
If the sample is urgent you must telephone the lab and inform them that the sample is urgent please give
Patient Name, Date of Birth and NHS number or District Number
HIGH RISK SPECIMENS
Specimens from a patient deemed to be high risk must be labelled and transported to the laboratory following
the Trust’s Policy for high risk specimens/patients. This is to comply with our responsibilities under the Control
of Substances Hazardous to Health regulations (COSHH) and ‘The Carriage of Dangerous Goods and
Transportable Pressure Equipment Regulations 2009’
Specimens that are very high risk and requiring special precautionary measures (e.g. MERS and Ebola): It is the
responsibility of the clinician to inform the laboratory of suspected highly contagious sample required extra
PPE for handling. All such cases should be discussed with a Consultant Microbiologist prior to submission of
sample to lab. The laboratory requires knowledge of such samples for analysis and transport to referral
laboratory and has policies and procedures for doing so.
Where departments have been found to not comply with these requirements, a clinical incident will be raised
and there are likely to be prosecutions under the above Regulations.
Fuller details of the safe packaging and transport of high risk specimens can be found in PATH.PROC.013 –
Specimen Collection and Transport.
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PHLEBOTOMY
Phlebotomy within the trust is managed by the nursing directorate.
The service can be accessed by the following:
IN-PATIENTS
Blood samples are normally taken by a phlebotomist, but if one is not available, the doctor or a trained support
worker may take the blood. Requests for phlebotomy may be made via Lorenzo and blood collected when the
phlebotomist visits the ward. A limited phlebotomy service is available on Saturdays, Sundays and Bank
Holidays.
The department has standardised on the "Monovette" blood collection system which acts as a combined
syringe/blood container, rather than the conventional syringe and needle.
OUT-PATIENTS
Blood can be collected from out-patients by referring them to the phlebotomists at the Blue Suite Clinic
(internal 6637) between 9:00am and 4:30pm Mon-Fri.
GP PATIENTS
Patients can be referred to the hospital for the collection of blood. The phlebotomists are present between
9.00 am and 4.30 pm at the Blue Clinic (as above).
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TRANSPORT OF SAMPLES TO LABORATORY
PNEUMATIC TUBE DELIVERY SYSTEM (POD)
Air tube stations are situated around the site. Full operating details are available at each station, and further
details can be obtained via Pathology or the Estates Department. Breakdowns and faults should be reported to
Estates Tel: 6999. Please note that the air tube system is NOT the responsibility of Laboratory Medicine.
Do not send the following sample types in the pod:
• Histology samples in formalin
• Semen samples
• Blood Gases
• Blood Products
• Specimens known to be High Risk
Specimens for tests that are unstable (please refer to relevant section in user guide), blood
gas/CSF specimens and for requests which are very urgent then the pod system should NOT
be used. These specimens should be transported directly to the laboratory without delay.
FROM WARDS AND OUT-PATIENT DEPARTMENTS
Apart from the air tube system samples are also picked up from the following collection points.
Time Location
10:30am Ante Natal Clinic
Yellow Suite
Blue Suite
11:45am Ante natal Clinic
Yellow Suite
Blue Suite
2:00pm Occupational health
Ante Natal Clinic
Yellow Suite
Blue Suite
For urgent samples both during and after the working day, it is the responsibility of the originator of the
request to make arrangements for the transport of the sample to the laboratory by e.g. air-tube or portering
services. During the working day, samples should be brought direct to the laboratory or sent via the air-tube.
Outside working hours specimens should be sent via the air-tube or taken to the directorate (access is gained
via a buzzer/intercom system).
GP'S
The laboratory provides a transport service which collects samples from GP surgeries in the Tameside and
Glossop district in the morning and afternoon, every day from Monday to Friday. Please contact laboratory for
collection times for each practice.
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SPECIMEN SPILLAGE
When spillages occur during transport of specimens then:
Ward and clinic areas – inform nursing staff and follow local policy.
Pneumatic tube system – inform maintenance (ext. 6999).
Laboratory areas – inform senior staff, policy for cleaning/decontamination to be found in Risk Management
Policy and Blood Sciences Health and Safety Policy. Consult iPassport for relevant policy (Health and Safety
Procedures).
All other areas – contact laboratory for advice.
REFERRED INVESTIGATIONS
Not all investigations requests are performed in the Pathology Directorate at Tameside General. Specialist
investigations and the less requested investigation may be referred to other more specialist laboratories in the
region or throughout the country. These investigations may take longer to be reported. The directorate does
audit these tests and in the event of an excessive delay, please contact the laboratory for help and/or advice.
An indication of turnaround time is made for many tests in this handbook but this can only act as a guide.
If you wish to contact the referral laboratory then the directorate maintains a list of contact numbers. We
would strongly recommend that you request the laboratory here to follow up non-returned results (which is
audited by each department) to enable us to establish why the delay has occur.
If you require a list of referral laboratories the laboratory can supply this. The accreditation status of referral
laboratories is monitored on an annual basis.
A list of laboratories used for referred tests is available later in the user guide. Should you need
to contact an external laboratory we strongly recommend you discuss this with the TGH
laboratory first. This will save time and confusion.
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BIOCHEMISTRY DEPARTMENT
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CONTACT DETAILS
General Enquiries – Haematology & Biochemistry Results 6497
Blood Sciences Manager Gillian Lewis 6318
Point of Care Manager Alison Shanahan 4620
Consultant Clinical Scientist (Biochemistry) Tony Tetlow 6495
When phoning from outside the hospital use 0161-922 then the extension number.
BIOCHEMICAL PROFILES
These are tests grouped together to simplify requesting. All profiles require 5ml sample (minimum); the only
exception is when the sample is from a paediatric patient when a full microtainer is required.
Most profiles will be analysed the same day and if indicated as urgent, within 1 hour.
The common profiles are:-
Profile Tests Reference Range
Routine profile
(GP only)
Sodium
Potassium
Chloride
Urea
Creatinine
Calcium (adjusted calcium)
Albumin
133 – 146 mmol/L
3.5 – 5.3 mmol/L
95 – 108 mmol/L
2.5 – 7.8 mmol/L
41 – 110 µmol/L
2.12 – 2.63 mmol/L
31 – 45 g/L
U&E
Sodium
Potassium
Urea
Creatinine
133 – 146 mmol/L
3.5 – 5.3 mmol/L
2.5 – 7.8 mmol/L
41 – 110 µmol/L
Liver profile Total Protein
Albumin
Globulin
Bilirubin
Alkaline Phosphatase (ALP)
Alanine Transaminase
γGlutamyl Transpeptidase (GGT)
62 – 80 g/L
31 – 45 g/L
24 – 43 g/L
3 – 21 µmol/L
20 – 125 IU/L
<60 IU/L
<50 IU/L
Bone Profile Calcium (adjusted calcium)
Albumin
Phosphate
Alkaline Phosphatase (ALP)
Total Protein
2.12 – 2.63 mmol/L
31 – 45 g/L
0.8 – 1.5 mmol/L
25 – 125 IU/L
62 – 80 g/L
Nutritional Marker Magnesium
Prealbumin
C-Reactive Protein (CRP)
0.7 – 1.0 mmol/L
150 – 350 mg/L
<8.0 mg/L
Thyroid profile Thyroid Stimulating Hormone
Free Thyroxine
0.4 – 4.5 mU/L
7 – 17 pmol/L
Drug Profile (urine) – 14
day TRT
Opiates
Benzodiazepines
Amphetamines
Cocaine metabolite
Methadone metabolite
Creatinine
Not detected
Not detected
Not detected
Not detected
Not detected
>1.8 mmol/L
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Profile Tests Reference Range
Lipid Profile Cholesterol (total)
HDL Cholesterol
LDL Cholesterol
Triglycerides (fasting)
<5.0 mmol/L
>1.2 mmol/L
<3.0 mmol/L
<1.8 mmol/L
Androgen Profile (Male)
– 6 day TRT
Testosterone 10 – 28 nmol/L
Androgen Profile
(female) – 14 day TRT
Testosterone
Sex Hormone Binding Globulin
Androstenedione
Free Androgen Index (calculated)
Androstenedione
<1.6 nmol/L
18 – 114 nmol/L
<6.0 nmol/L
< 4.5
<6 nmol/L
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COMMON TESTS INFORMATION – SAMPLE REQUIREMENTS AND REFERENCE RANGES (ADULT)
Due to the large number of possible requests not all assays are listed. If you require a non-listed test, please
contact the laboratory for an estimated turnaround time. We will contact the referral laboratory on your
behalf.
The turn-around times are when we expect at least 90% of assays to be completed. If result has not been
returned within the quoted time then please contact the laboratory who will then investigate.
Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Adrenocorticotrophin (ACTH).
Second line test for adrenal
dysfunction.
plasma (send
to lab on ice)
10ml Referred
test – 12
days
0 – 46 ng/L
Alanine Aminotransferase
(ALT).
Increased levels indicate liver cell
damage of any cause.
serum 5ml <24hr <60 IU/L
Albumin
Low levels due to renal/GI loss, low
synthesis, dietary, over hydration of
redistribution.
serum 5ml <24hr 31 – 45 g/L
Alcohol (blood) blood
(fluoride)
5ml <24hr Not Detected
Alcohol (urine) random
urine
5ml <24hr Not Detected
Aldosterone
Measured with renin for diagnosis
of Conn’s Syndrome. See page 59
Renin and Aldosterone
plasma 10ml Referred
test – 21
days
See report
Aldosterone: renin ratio
random sampling of these
hormones gives a ratio used as an
initial screen for primary
hyperaldosteronism.
The sample must be immediately
taken to the laboratory would must
be notified if impending arrival. See
renin. See page 59 Renin and
Aldosterone
plasma (send
to lab on ice)
10ml Referred
test – 21
days
<630 pmol/L
Alkaline Phosphatase
Elevated in bone and liver disease
(naturally elevated in children and
pregnancy).
serum 5ml <24hr 25 – 125 IU/L
Alpha-1-antitrypsin
Evaluation of COAD, emphysema
and liver disease. Acute phase
reactant.
serum 5ml referred
test – 14
days
1.1 – 2.1 g/L
Alpha-1-antitrypsin
(phenotyping)
Evaluation of low alpha-1-
antitrypsin levels
serum 5ml referred
test – 14
days
see report
Alpha-fetoprotein
Tumour marker for hepatocellular
carcinoma
serum 5ml <24hr <5 KU/L
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
17-alpha-Hydroxyprogesterone
Diagnosis of CAH due to 21-
hydroxylase deficiency. 3rd line
investigation of hirsutism (late onset
CAH). Monitoring of CAH patients
serum 5ml referred
test - 14
days
<10 nmol/L
Amino acids (urine).
Disorders of amino acid metabolism
urine 10ml referred
test – 28
days
Normal pattern
Ammonia
Paediatric disorders e.g. urea cycle
disorders. Contact lab before
sending. Sample must be received in
ice immediately. Please contact
laboratory before sending.
Plasma –
EDTA - RED
microtainer
1ml <1hr Sick/prem = <150 µmol/L
neonate = <100 µmol/L
<16 yr. = <50 µmol/L
Amylase
Raises in acute pancreatitis
serum 5ml <24hr 20 – 110 IU/L
Amylase (urine)
Investigation of macroamylasaemia.
Comparison with serum, paired
sample should be taken at same
time
urine 10ml <24hr <35 IU/mmol creatinine.
Amylase:creatinine
clearance ratio: 0.02 – 0.05
Amino Acids
Investigation of inherited defects of
amino acid metabolism
urine 10ml referred
test – 28
days
see report
Androstenedione
Investigation of hirsutism
serum 5ml referred
test - 14
days
<6.0 nmol/L
Angiotensin converting enzyme
(ACE)
Monitoring sarcoidosis
serum 5ml referred
test – 12
days
15 – 55 IU/L
Antiepileptic drugs
Monitoring therapy and toxicity. See
page 52 Therapeutic Drug
Monitoring.
serum 5ml <24hr see individual drugs. See
also page 52 Therapeutic
Drug Monitoring.
Anti-Mullerian Hormone
Assessment of ovarian reserve.
Note: consultant request only.
serum 5ml referred
test - 14
days
<6.0 pmol/L low
6-24.pmol/L reduced
24 – 70 pmol/L optimum
>70 pmol/L PCOS
Aspartate aminotransferase
Raised in liver and muscle damage
serum 5ml <24hr 11 – 37 IU/L
Bence-Jones Protein
Monoclonal immunoglobulin free
light chains in urine
urine 20ml 14 days not detectable
Beta-2-microglobulin
prognostic indicator in
myelomatosis
serum 5ml 14 days 0.9 – 2.5 mg/L
Bicarbonate
acid-base status
serum 5ml <24hr 20 – 26 mmol/L
Bile acid
cholestasis of pregnancy
serum 5ml <24hr <14 µmol/L
Bilirubin
Raised in haemolysis, hepatocellular
damage or biliary obstruction
serum 5ml <24hr 3 – 21 µmol/L (adult)
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Bilirubin (neonate)
Spectrophotometric analysis only
suitable if <3 months old.
serum 0.5ml <24hr see paediatric ranges
Blood gases
Acid – base status – must be
received by lab within 30min of
sampling. Blood gas analysers
available in locations throughout the
hospital. Please note that the
sample must NOT contain any air
gaps and must have been
thoroughly mixed.
Heparinised
arterial blood or
capillary sample
2 ml <0.5hr see report
NOTE the blood gas analyser
recently changed from a
GEM 4000 to an ABL90 Flew
Plus. This test is out of the
scope of our ISO 15189:2012
accreditation. It is intended
to gain ISO 22870
accreditation in the future.
BNP (NTproBNP)
Use to identify patients with left
sided heart failure who may require
echo ECG and in diagnosis of acute
heart failure.
Whole blood
(EDTA)
5ml <4hr reported as NTproBNP,
normal <400 ng/L.
Ca125 – see special tests section Please see section on Tumour Markers page 62.
Ca19-9 – see special tests section
Ca15-3 – see special tests section
Caeruloplasmin
Copper binding serum protein,
decreased in Wilson’s Disease
serum 5ml referred
test – 18
days
0.20 – 0.45 g/L
Calcitonin
Useful in diagnosis and monitoring
of medullary carcinoma of the
thyroid. May require a pentagastrin
stimulation test for diagnosis.
serum 5ml referred
test – 14
days
<18.9ng/L
Calcium
Report value corrected for albumin
serum 5ml <24hr 2.12 – 2.63 mmol/L
Calcium (urine) urine collected
in acid
<24hr Female = <6.5 mmol/24hr
Male = <7.5 mmol/24hr
Calculi
Identify component of renal, biliary
or bronchial stones
- Complete
sample
sent
referred
test – 14
days
see report
Calprotectin
Differentiation of IBD and IBS
faeces 1g Referred
test – 14
days
<60µg/g
Carbamazepine
Anticonvulsant drug monitoring.
See page 52 Therapeutic Drug
Monitoring.
serum
(pre-dose)
5ml <24hr therapeutic range:
20-40 µmol/L
Carboxyhaemoglobin
Measure % of carbon monoxide
bound to haemoglobin
heparinised
sample
(orange top)
5ml <24hr up to 10% in smokers,
normally <2%
Carcinoembryonic antigen (CEA)
Monitoring of colonorectal cancer,
of no use for diagnosis.
serum 5ml <24hr <3 U/L (up to 10 in smokers)
C1-esterase inhibitor
hereditary angioneurotic oedema
(type 1). C4 should be requested at
the same time, C1-esterase will not
be measured if C4 normal.
serum 5ml referred
test – 14
days
0.21- 0.50 g/L
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Catecholamines
Investigation of hypertension,
suspected phaechromocytoma.
urine
(collected
into acid)
24hr
collection
referred
test – 22
days
see report
CCP (anti-)
raised in rheumatic disease, more
sensitive than rheumatoid factor
serum 5ml referred
tests –
21 days
<10 U/ml
Chloride serum 5ml <24hr 95 – 108 mmol/L
Cholesterol
Coronary artery disease
serum 5ml <24hr <5 mmol/L or <4 mmol/L if
in high risk group
Cholesterol - HDL
Inverse association between HDL
cholesterol levels and coronary
artery disease.
serum 5ml <24hr Female = >1.1 mmol/L
male = >0.9 mmol/L
Cholesterol - LDL
Calculated parameter from
cholesterol and HDL cholesterol.
Cannot be calculated if triglyceride
greater than 2.4mmol/L
- - <24hr <3.0 mmol/L or <2.0 mmol/L
if high risk
Cholinesterase
Anaesthetic sensitivity and
organophosphate poisoning. If
deficiency detected then whole
required for genotyping.
serum (plus
whole blood
(EDTA))
5ml referred
test – 27
days
see report
Chromium
Required to assess MoM joint wear
according to MHRA alert.
whole blood 5ml referred
test – 21
days
see report
Clozapine
Anti-psychotic drug requiring
monitoring. See page 52
Therapeutic Drug Monitoring.
whole blood 5ml referred
test – 21
days
see report
Cobalt
Required to assess MoM joint wear
according to MHRA alert. Measured
with chromium (see above)
whole blood 5ml referred
test – 21
days
see report
Complement
C3 and C4 assay for monitoring
inflammatory and autoimmune
conditions. Single point
determinations of limited value
serum 5ml referred
test – 17
days
see report
Copper
Reduced in Wilson’s Disease.
Increased in many inflammatory
disorders, pregnancy and OCP. Also
request Caeruloplasmin.
serum 5ml referred
test – 14
days
13 – 26 µmol/L
Copper (urine)
Increased in Wilson’s Disease.
24hr urine
collection
(acid washed
container)
- referred
test – 14
days
<1.0 µmol/24hr
Cortisol
Investigation of adrenal function.
Important to note time of specimen
as reference ranges relate to 09:00.
Hydrocortisone, prednisone and
prednisolone will interfere with this
test but not dexamethasone.
serum 5ml <48hr 09:00h ref. range: 140 - 500
nmol/L
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Cortisol (urinary free)
First line investigation for Cushing’s
Syndrome
24hr urine
collection
(plain
container)
- referred
test – 14
days
<180 nmol/L
Creatinine
Assessment of renal function.
Affected by muscle breakdown and
diet as well as renal function
serum 5ml <24hr 40 – 110 µmol/L (age and
muscle mass dependent)
Creatinine (urine)
See above. Used for calculation of
creatinine clearance.
24hr urine
collection
- <24hr see report
C-reactive protein
Acute phase reactant.
serum 5ml <24hr <8 mg/L
Creatine Kinase (CK)
Muscle enzyme, cardiac and skeletal
serum 5ml <24hr F = <145 IU/L
M = <170 IU/L
Cryoglobulin
Essential to keep sample at body
temperature on way to lab. Please
contact lab before taking sample,
see Cryoglobulins section of user
guide.
serum 5ml 10 days See report
CSF (Xanthochromia)
Estimation of haemoglobin and
bilirubin in (xanthochromia) CSF for
investigation of SAH. Sample must
be taken >12hr post event and may
remain abnormal for up to 10 days.
Do not send sample by “air tube” as
this may affect result.
CSF 1ml (min)
– sample
less than
1ml cannot
be
processed
<2 hr see report
Cyclosporine
Monitoring immunosuppressant
therapy. Trough level taken
although 2hr level often used as
better indication of therapy. See
page 52 Therapeutic Drug
Monitoring.
Whole blood
(EDTA)
5ml referred
test – 10
days
see report
Digoxin
To assess compliance and toxicity.
Levels cannot be interpreted if
sample taken less than 6 hr post
dose – pre-dose levels
recommended. See page 52
Therapeutic Drug Monitoring.
serum 5ml <24hr 1.0 – 2.6 nmol/L
Down’s Screening
Pre-natal detection of Down’s
Syndrome.
serum 5ml Reported directly from screening service
at Royal Bolton Hospital to ANC.
Drug Screen
Screening for detection and
monitoring of drug abuse – opiates,
benzodiazepines, cocaine,
amphetamines, methadone
metabolite. Cannabis,
buprenorphine and ethanol can be
added on request. Please see Drugs
of abuse page 64.
urine 15ml Referred
test – 14
days
not detected
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Dehydroepiandrosterone
(DHAS)
Investigation of hirsutism.
serum 5ml referred
test – 14
days
<12 µmol/L (female)
Electrophoresis
Detection of paraproteins, immune
deficiency and non-specific acute
and chronic phase deficiency.
serum 5ml <14 days see report
Erythropoietin
Investigations of rbc production
serum 5ml 28 days 3 – 18 mIU/ml
Ethanol
To identify intoxication
Plasma
(fluoride
oxalate,
yellow tube)
5ml <24hr not detected
Ethylene Glycol (and methanol)
For identification of ethylene
glycol poisoning. All requests
must be discussed with
Consultant Clinical Scientist first
as this requires urgent referral.
Plama
(lithium
heparin,
serum gell
samples are
not suitable)
5ml <4hr not detected
Faecal Elastase
Measure of exocrine pancreatic
function.
faecal
sample
1g referred
test – 14
days
see report
Faecal Occult Blood
Identification of blood in faeces.
Please see page Error! Bookmark
not defined.
Faecal Occult Blood
Faecal
sample
1g <24hr negative
Faecal Reducing Substances
Malabsorption/digestion of
carbohydrates (of paediatric
interest).
Please note that samples more than
1hr old will not be processed,
faecal
sample
(must be
delivered to
lab
immediately
1g referred
test – 14
days
not detected
Ferritin
Assessment of iron stores
serum 5ml <24hr M = 24 – 337 µg/L
F = 11 – 307 µg/L
Folate (serum)
Investigation of anaemia and
neuropathy.
serum 5ml <24hr 3.0 – 19.9 ng/L
Free Androgen Index
Ratio of testosterone to SHBG
expressed as a percentage.
Investigation of Hirsutism.
serum 5ml referred
test – 14
days
F = <4.5
FSH
Assessment of ovarian failure,
infertility, pituitary dysfunction.
serum 5ml <24hr F = cyclical (see report)
M = 1 -7 IU/L
Gamma Glutamyl
Transpeptidase (GGT)
Sensitive indicator of liver disease.
Increased after exposure to enzyme
inducing drugs (including ethanol)
serum 5ml <24hr M = <50 IU/L
F = <32 IU/L
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Gastrin
Diagnosis of gastrinomas. Patient
must be fasted and have not
received omeprazole for at least 2
weeks or H2 blockers for 3 days.
plasma
(must be
delivered to
lab on ice).
5ml referred
test – 28
days
<40 pmol/L
Gentamicin
Therapeutic drug monitoring is
essential to prevent complications
of therapy. See page 52 Therapeutic
Drug Monitoring.
Serum 5ml <24hr See Trust guidelines for
antibiotic prescribing and
sampling
Globulins
Elevated in myeloma, infections and
autoimmune disorders
calculated
result
5ml <24hr 24 – 43 g/L
Glucose
Primarily measured in DM.
Plasma
(fluoride
oxalate,
yellow tube)
1ml <24hr 3.0 – 6.0 mmol/L (fasting)
Glucose Tolerance Test
Diagnosis of DM. See page 55 Oral
Glucose Tolerance test
This test is no longer performed within the Pathology Directorate.
Phone Phlebotomists (6637) for appointment. For interpretation see
relevant section in user guide.
Growth Hormone
Measured in acromegaly, pituitary
gigantism and dwarfism. Random
levels are of little value and
secretion is best assessed by
stimulatory or suppressive testing
serum 5ml referred
test – 21
days
see report
Gut Hormone Profile
(gastrin, VIP, PP, glucagon,
neurotensin, somatostatin,
chromogranin A&B)
Diagnosis of neuroendocrine
tumours of the alimentary tract.
Contact lab before taking sample –
sample must be received within
10minutes of being taken
Plasma 10ml referred
test – 25
days
see report
Haptoglobin
Intravascular haemolysis,
haemolytic anaemia
Serum 5 ml <24hr 100 – 300 g/dl
HbA1c
Diagnosis and monitoring of
diabetes
EDTA. Whole
blood
1ml <24hr DCCT 4.5 – 5.9 %
IFCC 26 – 41 mmol/mol
Human Chorionic
Gonadotrophin (HCG)
Increased in pregnancy, ectopic
pregnancy, hydatidiform mole,
seminoma, testicular and ovarian
teratomas
serum 5ml <24hr <5 IU/L
HCG (urine)
Pregnancy test, only performed if
POCT devices are not available
urine
(random)
5ml <24hr see report
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
5-Hydroxyindole-acetic acid
(HIAA)
Detection and monitoring of
carcinoid tumours. Some foods
(bananas, pineapples) can cause
increased levels.
24hr urine
collection
into acid
- referred
test – 27
days
<50 µmol/24hr
Immunoglobulins
Autoimmune disorders, liver
disease, infection and genetic
deficiencies.
serum 5ml <48hr IgG = 6.0 – 16.0 g/L
IgA = 0.8 – 4.0 g/L
IgM = 0.5 – 2.0 g/L
Immunoglobulin subclasses
Investigation of recurrent infection
in children
serum 5ml referred
test – 23
days
IgG1 = 2.4 – 12.6 g/L
IgG2 = 0.6 – 2.3 g/L
IgG3 = 0.2 – 1.4 g/L
IgG4 = 0.02 – 1.8 g/L
Immunoglobulin E
Allergic and atopic disease.
serum 5ml referred
test – 14
days
Age related – see report
Iron Studies
Investigation of deficiency and
overload.
serum 5ml <24hr
Iron 13 – 32 umol/L
Iron binding capacity 45 – 70 umol/L
% saturation 20 – 55 %
Transferrin 1.8 – 3.5 g/L (male)
2.0 – 3.6 g/L (female)
Insulin
Detection of insulinoma, Sample
must be taken during a
hypoglycaemic attack. Glucose must
be assayed at same time.
serum
(sample
must be sent
to lab on ice)
5ml referred
test – 13
days
see report
Insulin Growth Factor–1 (IGF-1)
Investigation of acromegaly and
growth disorders.
serum 5ml referred
test – 22
days
see report
Lactate
Send to lab immediately on ice
Serum
CSF
5ml 0.5 – 2.5 mmol/L
1.1 – 2.4 mmol/L
Lactate Dehydrogenase (LDH)
Measured in megablastic and
pernicious anaemias, leukaemias,
lymphomas and liver disease.
serum 5ml <24hr 350 – 600 IU/L
Lamotrigine
Anticonvulsant drug, TDM not
recommended. See page 52
Therapeutic Drug Monitoring.
serum 5ml referred
test – 21
days
3 – 15 mg/L
Lead
Monitoring environmental
exposure.
whole blood
EDTA
2ml referred
test – 14
days
see report
LH
Assessment of ovarian failure,
infertility, pituitary dysfunction.
serum 5ml <24hr F = cyclical (see report)
M = 3 – 12 IU/L
Lithium
Monitoring of lithium therapy.
Sample should be taken 12hr post
dose. See page 52 Therapeutic Drug
Monitoring.
serum 5ml <24hr 0.4 – 1.0 mmol/L
(0.4 – 0.8 mmol/L if >65yr)
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Magnesium
Measured in case of hypocalcaemia
and hypoparathyroidism. Low levels
commonly seen due to intestinal
losses and diuretic therapy.
serum 5ml <24hr 0.7 – 1.0 mmol/L
Mast Cell Tryptase
Suspected acute allergic reaction.
Sample should be taken at up to 3hr
post even and after 6 and 24hr.
serum 5ml referred
test – 14
days
<12.9 µg/L
Microalbumin (urine albumin)
Measured in diabetes as an
indicator of the development of
renal disease. Ratio to creatinine
urine
(random)
5ml <24hr <3.5 mg/mmol (male)
<2.5 mg/mmol (female)
Oestradiol
Investigation of female infertility
and monitoring of oestrogen
implants.
serum 5ml <48hr cyclical, see report
Organic Acids
Investigation of inherited defects in
organic acid metabolism.
urine 10ml referred
test – 47
days
see report
Osmolality
Estimation of “osmolar gap”.
Investigation of hyponatraemia.
serum 5ml <24hr 285 – 295 mOsm/kg
Osmolality (urine)
Investigation of SIADH (with serum
osmolality)
urine 5ml <24hr 250 – 750 mOsm/kg
Needs to be interpreted
with serum osmolality
Oxalate (oxalic acid)
Investigation of renal stones
serum 5ml referred
test – 24
days
see report
Oxalate (urine)
Investigation of renal stones
urine
(acidified)
5ml referred
test – 24
days
see report
P3NP (Procollagen Peptide)
Monitoring fibrogenic activity in the
liver of patients receiving long term
methotrexate
serum 5ml referred
test – 45
days
see report
Paracetamol
Paracetamol overdose, to assess
need for antidote. Sample must not
be taken less than 4hr since the
overdose. See Paracetamol
Interpretation page 51
serum 5ml <24hr Normal <10mg/L. For
overdose please see chart.
Parathyroid Hormone (PTH)
Investigation of hypo- and
hypercalcaemia. Sample must be
analysed within 4hr of being taken
serum 5ml <48hr 19 – 67 pg/ml
Phenobarbitone
Check for toxicity and compliance.
See page 52 Therapeutic Drug
Monitoring.
serum 5ml referred
test – 21
days
15 – 50 mg/L
Phenytoin
Check for toxicity and compliance.
See page 52 Therapeutic Drug
Monitoring.
serum 5ml <24hr 30 – 70 µmol/L
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Phosphate
Investigation of calcium
abnormalities.
serum 5ml <24hr 0.8 – 1.5 mmol/L
Porphyrin Screen
Detection of porphyrias.
Investigation of such symptoms as
abdominal pain and skin
photosensitivity. All samples must
be kept in the dark. See Porphyrin
Screen page 65.
plasma
red cells
urine
faeces
5ml
2ml
20ml
10-15g
referred
test – 35
days
see report
Potassium
Seasonal and diurnal variation
observed. Old or haemolysed
samples are not suitable for
analysis. Please note that the
reference range applies to serum
samples only.
serum 5ml <24hr 3.5 – 5.3 mmol/L
Potassium (urine)
Investigation of hypokalaemia
urine
(random)
5ml <24hr see report
Progesterone
Detection of ovulation and
evaluation of corpus luteum
function
serum 5ml <48hr Luteal Peak:
18 – 72 nmol/L
Prolactin
May cause infertility, amenorrhaoea
and galactorrhoea when increased.
serum 5ml <48hr F = 102-426 mU/L
M = 86 - 324 mU/L
Prostate Specific Antigen (PSA)
Detection and treatment of
prostatic cancer,
serum 5ml <48hr <2.5 ng/ml (18 -50 yr)
<3.5 ng/ml (50 – 60 yr)
<4.5 ng/ml (60 – 70 yr)
<6.5 ng/ml (over 70 yr)
Protein (Total)
Relates to liver function, state of
hydration and is part of myeloma
screening
serum 5ml <24hr 62 – 80 g/L
Protein (urine)
Renal protein loss.
urine
(24hr or
random)
5ml <24hr 50 – 80 mg/24hr
<20 mg/mmol (random)
Protein (CSF)
Increased in meningitis or tumours
of the CNS
CSF 1ml <24hr <0.45g/L
RAST
Allergen specific IgE. Must include
clinical details to ensure correct
allergen screened for.
serum 5ml referred
test – 17
days
see report
Urine reducing substances
Screening for presence of sugars in
urine
Urine
(random)
5ml <48hr see report
Renin
Diagnosis of primary
hyperaldosteronism (Conn’s).
Sample must be taken to laboratory
immediately on ice. Inform
laboratory before sample is taken.
See page 59 Renin and Aldosterone
plasma
(on ice)
5ml referred
test – 21
days
0.3 – 2.2 nmol/L/hr
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Rheumatoid Factor
Diagnosis of rheumatoid arthritis
and Sjogren’s Syndrome
serum 5ml <24hr <20 IU/L
Salicylate
Investigation of salicylate poisoning.
serum 5ml <24hr not detected
Selenium
Nutritional monitoring..
serum 5ml referred
test – 14
days
0.9 – 1.7 mol/L
Sex Hormone Binding Globulin
(SHBG)
Part of androgen profile. HRT and
OCP raise SHBG and obesity lower it.
Not indicated in males.
serum 5ml referred
test – 14
days
F: 18 – 114 nmol/L
Sodium
Main use is state of hydration.
serum 5ml <24hr 133-146 mmol/L
Sodium (urine)
Measure of sodium excretion in
investigation of hyponatraemia.
urine
(random or
24hr)
5ml <24hr 40 – 220 mmol/24hr
Tacrolimus
Immunosuppressant therapy.
Trough level or 2hr post dose. See
page 52 Therapeutic Drug
Monitoring.
whole blood
(EDTA)
5ml referred
test – <7
days
see report
T3 (free)
May be added to thyroid profile.
Used to monitor treatment of
thyrotoxicosis in first few months
post diagnosis. Occasionally for
detection of T3 toxicosis (free T4
and TSH suppressed)
serum 5ml <24hr 3.9 – 6.9 pmol/L
T4 (free)
Part of thyroid profile for the
investigation of thyroid disorders
serum 5ml <24hr 7 – 17 pmol/L
Testosterone
Investigation of androgen disorders
in male and female
serum 5ml referred
test – 21
days
F: <1.5 nmol/L
M: 10 – 28 nmol/L
Theophylline
Assayed to check compliance and
therapeutic levels. See page 52
Therapeutic Drug Monitoring.
serum 5ml <48hr 55 – 110 µmol/L
Thiopurine Methyl Transferase
(TPMT)
Deficiency is a cause of intolerance
to azathioprine or 6-mercaptopurine
Whole blood
(EDTA)
5ml referred
test – 24
days
see report
Thyroid Peroxidase Antibodies
(TPO)
Diagnosis of pre-clinical
hypothyroidism
serum 5ml <48hr 0 – 9 IU/L
Thyroglobulin
This is used as a tumour marker,
post thyroidectomy only.
serum 5ml Referred
test – 21
days
See report
Thyroid Stimulation Hormone
(TSH)
Raised in hypothyroidism.
serum 5ml <48hr 0.4 – 4.5 IU/L
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Test Specimen
Type
Volume
Required
Turn
Around
Reference Range
Transthyretin (pre-albumin)
Nutritional assessment, always
measured with CRP to aid
interpretation.
serum 5ml <48hr 150 – 350 mg/L
Triglycerides
Measured as part of lipid
investigation
plasma 5ml <24hr <1.8 mmol/L
Troponin I
Currently best marker for cardiac
damage. Sample needs to be taken
>12 hours post suspected cardiac
event. Remains elevated for up to
10 days.
serum 5ml <24hr <40 ng/L
Urate
Raised in gout, renal failure,
malignancy and several other
conditions.
serum 5ml <48hr 200 – 430 µmol/L (male)
140 – 360 µmol/L (female)
Urea
Indication of renal function and
hydration. Low levels seen in
starvation and advanced liver
disease.
serum 5ml <24hr 2.5 – 7.8 mmol/L
Valproate
Useful to check compliance or
overdose, little use for therapeutic
drug monitoring. See page 52
Therapeutic Drug Monitoring.
serum 5ml <24hr 400 – 700 µmol/L
Vancomycin
Therapeutic drug monitoring is
essential to prevent complications
of therapy. See page 52 Therapeutic
Drug Monitoring.
serum 5ml <24hr See Trust guidelines for
antibiotic prescribing and
sampling or contact
Microbiology Department
VitaminB12
Investigation of anaemia
serum 5ml <24hr 145 – 910 ng/L
Vitamin D
Investigation of hypocalcaemia and
nutritional assessment. See page53
Interpretation of Vitamin D results
serum 5ml <24hr see report and section in
user guide
White cell enzymes
Investigation of suspected inborn
errors.
whole blood
(EDTA)
5ml referred
test – 36
days
see report
Xanthochromia (CSF) See CSF scan
Zinc
Nutritional assessment
serum 5ml referred
test – 15
days
12 – 22 mmol/L
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PAEDIATRIC REFERENCE RANGES
The following reference ranges are adapted from those in use at Royal Manchester Children’s’ Hospital (with
permission). They have been checked for consistency with the methods used within this trust but have not
been rigorously evaluated. This is not a complete list, please contact laboratory if further information required.
Please interpret results with this in mind. All reports for the following have age adjusted ranges.
Analyte Sample type Age Reference Range
Alanine Aminotransferase plasma up to 1 month
> 1month
<90 IU/L
<45 IU/L
Albumin plasma up to 1 month
1 to 6 months
Child
25 – 35 g/L
28 – 44 g/L
30 – 45 g/L
Alkaline Phosphatase (ALP) plasma 1 - 30 days
1 – 12 months
1 - 2 years
2 – 8 years
Pubertal
Adult
60 – 240 IU/L
52 – 444 IU/L
60 – 370 IU/L
60 – 320 IU/L
60 – 400 IU/L
20 – 125 IU/L
Ammonia
(Please ensure laboratory is
aware the sample is being
taken and transport to
laboratory immediately).
plasma Sick/prem = <150 µmol/L
neonate = <100 µmol/L
<16 yr. = <50 µmol/L
Bicarbonate plasma 20 – 26 mmol/L
Bilirubin, total plasma Full term infant
Child
Levels will rise from birth to
approximately 150 µmol/L at
5-6 days and then fall to
normal childhood levels by
day 10.
<17mmol/L
Bilirubin, conjugated plasma neonate up to 30µmol/L
Calcium plasma premature
up to 2 weeks
child
1.50 – 2.5 mmol/L
1.90 – 2.80 mmol/L
2.12 – 2.63 mmol/L
Chloride plasma 98 – 110 mmol/L
Cholesterol, total plasma up to 1 month
1m to 2 years
2 – 16 years
1.1 - 2.6 mmol/L
1.2 – 4.7 mmol/L
<5.0 mmol/L
Creatinine Kinase plasma up to 2 weeks
up to 1 month
up to 1 year
adult male
adult female
<600 IU/L
<400 IU/L
<300 IU/L
<170 IU/L
<145 IU/L
Creatinine plasma <1 week
1 – 2 weeks
2 – 4 weeks
1 month – 1 year
1 - 3 years
4 – 6 years
7 - 9 years
10 - 12 years
13 - 15 years
16 years - adult
<100 µmol/L
<80 µmol/L
<55 µmol/L
<40 µmol/L
<40 µmol/L
<46 µmol/L
10 - 56 µmol/L
30 - 60 µmol/L
40 - 96 µmol/L
Males 40 - 96 µmol/L
Females 26 - 86 mol/L
C-Reactive Protein plasma <8 mg/L
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Analyte Sample type Age Reference Range
Gamma Glutamyl
Transpeptidase
plasma 0 – 1 month
1 – 3 months
3 – 6 months
Adult
10 – 270 IU/L
10 – 155 IU/L
10 – 93 IU/L
10 – 50 IU/L
Glucose (fasting) plasma
(fluoride)
up to 1 month
child
2.5 – 6.5 mmol/L
3.0 – 6.5 mmol/L
Urea plasma 1 month
1 year
child
teens
2.0 – 5.0 mmol/L
2.5 – 6.0 mmol/L
2.5 - 6.5 mmol/L
3.0 – 7.5 mmol/L
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PARACETAMOL INTERPRETATION
Please note that levels can’t be interpreted without knowing the time since the paracetamol was taken. Levels
cannot be interpreted until 4hr post dose until the drug is in the elimination phase.
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THERAPEUTIC DRUG MONITORING
* The conversion factors are included since it is a national requirement to move to using mass units in the
immediate future.
** There is little evidence to support the therapeutic monitoring of valproate or lamotrigine.
*** Therapeutic range relates to peak levels. Samples should be take 2hr post dose for fast release and 4hr for
slow release preparation
Samples for non-standard anti-epileptic drugs (e.g. gabapentin) will NOT be processed as monitoring is not
necessary.
Drug Therapeutic
Range
Units Conversion
factor*
Half life Sampling
time
Time to
steady
state
Carbamazepine 20 – 40 µmol/L x 0.236
(µmol→mg/L)
10 – 20 hr pre-dose 2 - 6 days
Cyclosporine A variable – see
report
µg/L - 2 – 6 hr pre-dose 2 – 3 days
Digoxin 1.0 – 2.6 nmol/L x 0.781
(nmol→µg/L)
36 – 48 hr minimum of
6hr post dose
5 – 7 days
Lamotrigine** 3.0 – 15.0 mg/L - 20 – 35 hr pre-dose 4 – 15 days
Lithium 0.4 – 1.0 mmol/L - 10 – 35 hr 12hr post
dose
3 – 7 days
Phenobarbitone 10 - 30 mg/L - 80 – 120 hr pre-dose 10 – 25 days
Phenytoin 30 - 70 µmol/L x 0.253
(µmol→mg/L)
7 – 42hr pre-dose 7 – 35 days
Tacrolimus
(FK506)
4 - 12 µg/L - 4 – 33 hr pre-dose 2 days
Theophylline 55 - 110 µmol/L x 0.180
(µmol→mg/L)
3 – 13 hr *** 2 – 3 days
Valproic Acid** 400 - 700 µmol/L x 0.144
(µmol→mg/L)
8 – 20 hr pre-dose 2 – 4 days
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ACUTE KIDNEY INJURY (AKI) ALERTS
In line with national guidance the Biochemistry department reports all creatinine results with AKI staging. The
interpretation is as follows:
AKI Alert Stage Comment
NA Insufficient data to calculate AKI stage alert
0 AKI alert not activated by previous creatinine results
1 Increase of creatinine by >26.0 µmol/L or 1.6 to 1.9 times the baseline creatinine.
2 Increase of creatinine by 2.0 to 2.9 times the baseline creatinine.
3 Increase of creatinine by >3.0 times the baseline creatinine or a creatinine >354
mmol/L.
The above is part of the Trust’s response to NICE guidelines CG169. The algorithm used to calculate these alerts
can be found at http://www.england.nhs.uk/wp-content/uploads/2014/06/psa-aki-alg.pdf
Stage 2 and 3 alerts will be phoned to the wards and reported via Lorenzo/TQuest.
INTERPRETATION OF VITAMIN D RESULTS
Comments are appended to all vitamin D results. The Biochemistry Department reports total 25-OH vitamin D
(25-OH vitamin D2 and D3) and interprets according to the National Osteoporosis Society guidelines:
Total 25-OH vitamin D (nmol/L) Comment
<30 Consistent with vitamin D deficiency. Treatment with cholecalciferol
recommended.
30-50 May be inadequate in some patients. Treatment advised in high risk
groups
50-250 Adequate vitamin D status
>250 Associated with toxicity
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FAECAL OCCULT BLOOD
We use the hema-screen™ kit for faecal occult blood testing – the following text is taken from the package
insert.
SPECIMEN COLLECTION AND PREPARATION
The hema-screen™ test requires only a small faecal specimen. The specimen is applied to the guaiac paper of
the hema-screen™ slide as a thin smear using the applicator stick provided. The tests may be prepared and
developed immediately, or prepared and stored at room temperature, protected from heat and light for up to
twenty one (21) days before developing. Keep testing area, hands, etc. clean and free of blood to avoid false
positive results.
It is recommended for screening of asymptomatic persons that stool smears for testing be collected from at
least three consecutive bowel movements (i.e. hema-screen™ Patient Packs) since bleeding from
gastrointestinal lesions may be intermittent. Greegor recommends two samples per stool, with each test site (I,
II) prepared from a different part of each day's stool to increase the probability of detecting occult blood in each
stool.
INTERFERING SUBSTANCES
There are some oral medications such as aspirin, corticosteroids, reserpine phenylbutazone, indomethacin, etc.
that can cause gastrointestinal irritation and occult bleeding in some patients. Ascorbic acid (Vitamin C) taken
in units greater than 250 mg per day may cause false negative results. Iron or preparations containing Iron may
cause false positive results. Two days prior to and during the test period such medications should be avoided.
Patients with bleeding from other conditions such as haemorrhoids, dental work, constipation or menstrual
bleeding should not be tested while such conditions are present. Do not collect a specimen if patient is using
rectal preparations. The patient's physician should be consulted when discontinuing prescription medications.
PATIENT PREPARATION
For three days (3) before and during the stool collection period, avoid red meats (Beef, Lamb and Liver). Eat a
well-balanced diet including fibre such as bran cereals, fruits and vegetables. Raw fruits and vegetables which
contain peroxidase-like substances (turnips, broccoli, horseradish, cauliflower, cantaloupe, parsnips, red radish
etc.) should be avoided during the test period. A diet such as this helps reduce the number of false positive test
results and at the same time provides roughage to help uncover silent lesions which may bleed only
intermittently. If any of the above foods are known to cause patient discomfort, patient should be instructed not
to eat them or to make appropriate substitutions. In an initial three-test series, the patient may disregard the
recommended diet. If patient has one or more positive tests, then he or she should be placed on the above
suggested diet and retested for another three-test series. However it should be remembered that bleeding may
be intermittent and no positive test result should be disregarded.
For further advice or information, please contact the laboratory.
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DYNAMIC FUNCTION TESTS AND SPECIAL TESTS
ORAL GLUCOSE TOLERANCE TEST
PATIENT PREPARATION:
• This test is only necessary if fasting and/or random glucose measurements are equivocal i.e. 6.0 to 7.0
mmol/L.
• This test should NOT be performed in patients who fulfil the criteria for diabetes mellitus. These are:
o A fasting plasma glucose >7.0 mmol/L on two or more occasions and
o Clinical symptoms of diabetes e.g. polydipsia, polyuria, ketonuria and rapid weight loss with a
random plasma glucose of >11.1 mmol/L).
• This test should not be performed in patients who are under physical stress e.g. post-surgery, trauma,
infection or extreme psychological stress as these may give misleading results.
The patient should have a normal unrestricted diet with a minimum of 150g carbohydrate for at least 3 days
prior to test. Smoking prohibited on day of test. All drugs should be clearly indicated on the request form.
Patient should fast overnight (14 hrs) taking water only, and should sit quietly during the test.
INSTRUCTIONS:
• Collect fasting blood sample for glucose. Ensure tube is appropriately labelled fasting. The glucose is
analysed immediately (glucose meter). If the glucose is >8.0 mmol/L the sample should be sent
immediately to the laboratory for confirmatory analysis. If confirmed as >8.0 mmol/L; then the test
should be discontinued.
• Give patient 75g (anhydrous) oral glucose dissolved in 300 ml water.
o As an alternative the patient may be given 394ml of “Lucozade Energy” (73kcal/100 ml
formulation), which provides the equivalent of 75g anhydrous glucose. The glucose solution
should be drunk over a period no longer than 5 minutes. Please note that the some
formulations for “Lucozade Energy” are 70kcal/100 which will require 410ml to be given –
please check labelling on bottle.
• Two hours after giving the glucose load, take a further blood sample for glucose. Ensure tube is
appropriately labelled “2 hr sample”.
Both samples must be collected into fluoride oxalate tube and both should be sent immediately to the
laboratory on completion of the test
INTERPRETATION:
Normal OGTT Fasting glucose ≤6.0 mmol/L and 2hr blood glucose
<7.8 mmol/L.
Impaired fasting Glycaemia Fasting Glucose 6.1 – 6.9 and 2hr glucose <7.8
mmol/L.
Impaired Glucose Tolerance Fasting glucose ≤7.0 mmol/L and 2hr glucose
between 7.8 and 11.0 mmol/L
Diabetes Fasting glucose ≥7.0 mmol/L and 2hr fasting
glucose ≥11.1 mmol/L.
(from: Methods and Criteria for Diagnosing Diabetes Mellitus – WHO criteria, June 1st 2000).
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EXTENDED GTT
The GTT above can be extended for the investigation of reactive hypoglycaemia. Addition blood samples are
taken at 2.5hr, 3hr, 3.5hr and 4hr for glucose.
ADDITIONAL CRITERIA FOR DIABETES DIAGNOSIS
Recent guidelines from WHO for diabetes diagnoses (January 2011) have recommended the use of HbA1c for
diagnosis. The use of the following algorithm is now recommended.
HBA1C FOR MONITORING OF DM
The following has been recommended under advisement of the Diabetes Service and local practice the
following comments are added to reports:
“Patients with diabetes agree with their healthcare professional a documented personalised HbA1c target,
usually between 48 and 58 mmol/mol (6.5% and 7.5%), and receive ongoing review of treatment to minimise
hypoglycaemia. HbA1c levels <48 mmol/ml (6.5%) represent tight control but with increased risk of significant
hypoglycaemic attacks.”
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SHORT SYNACTHEN TEST
This test evaluates the ability of the adrenal gland to produce cortisol after stimulation by synthetic ACTH
(Synacthen) and forms part of the differential diagnosis of Addison’s Disease.
PATIENT PREPARATION:
The patient need not be fasted for this test but the test must be performed in the morning. The difference
between morning and late afternoon cortisol may be as great as 100 nmol/L for the 30min post Synacthen
sample.
INSTRUCTIONS:
• Blood is taken for basal cortisol assay. Clearly marked sample as “baseline”.
• 250µg of Synacthen (from Pharmacy) is injected (IV or IM)
• 30 minutes post injection blood is taken for cortisol assay. Clearly mark sample as “30 min”.
INTERPRETATION
In normal individuals the serum cortisol should increase by minimum of 200 nmol/L to a level of at least 550
nmol/L at 30 minutes.
DEXAMETHASONE SUPPRESSION TEST (LOW DOSE)
This is a simple screening procedure for Cushing’s syndrome and may be performed on an outpatient basis.
PATIENT PREPARATION:
The patient should not be on rifampicin, anticonvulsants or any other enzyme inducing drugs. This will cause
rapid metabolism of dexamethasone leading to an unreliable result. The patient should not be on any steroid
therapy (please note hydrocortisone is another name for cortisol) as this leads to adrenal suppression and an
unreliable result.
INSTRUCTIONS:
• Patient takes 1mg dexamethasone tablet at 23:00hr.
• At 09:00 (next day) a blood sample is taken for cortisol. The sample should labelled “post
dexamethasone”.
INTERPRETATION:
A normal response is shown by a suppression of 09:00hr cortisol to <50nmol/L.
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RENIN AND ALDOSTERONE
INDICATIONS
Investigation of hyperaldosteronism.
PATIENT PREPARATION:
• Avoid salt losing diuretics, purgatives and correct gastrointestinal losses.
• Diet should contain 100-300 mmol/L Na+ per day and 50-100 mmol/L K+ per day for 10 days before
test.
• Correct hypokalaemia with oral potassium supplements before testing.
• A number of anti-hypertensive drugs may influence the interpretation of results.
EFFECT OF DRUGS ON RENIN AND ALDOSTERONE:
• Diuretics and vasodilators elevate renin and aldosterone.
• β-blockers in large doses lowers renin and aldosterone.
• Calcium channel blockers elevate renin and lower aldosterone.
• ACE inhibitors elevate renin and lower aldosterone.
• Indomethacin and other prostaglandin synthetase inhibitors lower renin and aldosterone.
• Aldosterone antagonists (spironolactone) produce variable effects on aldosterone.
RECOMMENDED LENGTH OF TIME FOR WHICH DRUGS SHOULD BE DISCONTINUED:
Spironolactone 6 weeks
Diuretics 2 weeks
Prostaglandin synthetase inhibitors 2 weeks
Cyproheptadine 2 weeks
ACE inhibitors 2 weeks
Vasodilators 1 week
Calcium channel blockers 1 week
Sympathomimetics 1 week
For patients in whom therapy cannot be withdrawn Prazosin, Doxazosin or Guanethidine would be the drug of
choice. NSAIDs should also be discontinued for two weeks prior to testing
PROCEDURE
• The patient should be seated for 10 min.
• Collect blood for renin and aldosterone (10 ml heparin tube, should be taken to laboratory urgently,
but not on ice and separated as soon as possible).
INTERPRETATION:
• Aldosterone secreting tumours or bilateral adrenal hyperplasia result in hyperaldosteronism and
suppression of renin levels.
• The upright posture normally stimulates renin and aldosterone release unless renin production is
suppressed by tumour induced hyperaldosteronism.
Adult Reference Range (Results are method dependent)
Aldosterone (pmol/L) Renin (pmol/ml/hr)
Random 100 – 800 0.5 – 3.1
Recumbent (overnight) 100 – 450 1.1 – 2.7
Ambulant (30 min) not applicable 2.8 – 4.5
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ALDOSTERONE / RENIN RATIO
The aldosterone / renin ratio provides additional useful information.
• Aldosterone/renin ratio less than 800, Conn’s syndrome unlikely.
• Aldosterone/renin ratio greater than 2000, Conn’s syndrome probable.
Diagnosis of the cause of primary hyperaldosteronism requires further investigation after the demonstration of
primary hyperaldosteronism and specialist endocrinological advice is recommended.
WATER DEPRIVATION TEST
Performed for the investigation of suspected cranial or nephrogenic diabetes insipidus and primary polydipsia.
SCREEN
24hr urine volume. Three 24hr urine collections are performed; if volumes are less than 3 litres then DI is
unlikely.
WATER DEPRIVATION TEST.
ADH secretion is stimulated by hypovolaemia and hypertonicity. Failure to maintain normal urine and plasma
osmolarity when dehydrated suggests DI. Failure to correct the osmolality with exogenous DDAVP suggests a
nephrogenic problem, whereas correction following exogenous DDAVP suggests ADH deficiency (cranial DI).
The Laboratory must be informed that this test is planned to ensure all analyses are performed promptly.
Samples must NOT be batched but sent to the laboratory immediately.
Patient preparation – do NOT restrict food or fluid until the start of the test. Exclude adrenocortical or thyroid
deficiency. No tobacco or alcohol for at least 24hr.
Note – this test is potentially dangerous and must be undertaken with care and under clinical supervision.
Patients unable to conserve water may become critically dehydrated within a few hours of water restriction.
STOP TEST IF:
• Weight loss >3% of baseline value (check plasma osmolality). Note test requires accurate weighing of
the patient.
• Urine osmolality ever greater than 800 (i.e. normal response to fluid restriction).
• Plasma osmolality >350 (give DDAVP 2mcg iv and fluids).
• Urine output exceeds 5 litres in absence of weight loss (suggests surreptitious drinking).
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PROTOCOL
0800hr – insert cannula, weight patient, patient empties bladder. Measure urine volume and send for
osmolality. Measure blood pressure, weight, urine osmolality, plasma osmolality and urine volume hourly for 8
hours according to the schedule:-
INTERPRETATION:
Post-dehydration osmolality
(mmol/kg)
Post-DDAVP osmolality
(mmol/kg)
Diagnosis
Plasma Urine Urine
283-293 >750 >750 Normal
>293 <300 >300 Nephrogenic diabetes insipidus
>293 <300 >750 Cranial diabetes insipidus
<293 300-750 <750 Chronic polydipsia
<293 300-750 >750 Partial nephrogenic DI or primary
polydipsia
Weight BP U&E Plasma
Osmolality
Urine
Osmolality
Urine
Volume
08:00
08:30
09:30
10:30
11:30
12:30
13:30
14:30
15:30
16:30
If urine osmolality remains <750, give DDAVP (desmopressin) 2mcg im.
Give free fluids from now on.
17:30
18:30
19:30
20:30
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TUMOUR MARKERS
Due to the over requesting of tumour markers, in particular “tumour marker screens” it was felt that some
guidance should be offered. No serum marker in current use is specific for malignancy.
• Many patients with early localized disease will have normal levels of serum tumour markers.
• No cancer marker has absolute organ specificity. PSA however, appears to be relatively specific for
prostate tissue.
• Requesting of multiple markers in an attempt to identify an unknown primary cancer is rarely of use
(see previous).
• Reference ranges for tumour marker are not well defined and are used for only guidance. A level
below the reference range does not exclude malignancy whilst levels above do not necessarily mean
the presence of cancer. Changes in levels over time are of more use that absolute levels at a single
point in time.
With the exception of PSA, tumour markers are only of use in monitoring response to treatment if the tumour
has been demonstrated to be excreting that marker. They are of little use in diagnosis.
Recently NICE has issued the following guidance (CG104) for the use of tumour markers in the investigation of
CUP (carcinoma of unknown primary):-
NICE GUIDANCE ON TUMOUR MARKERS
Identification of elevated serum tumour markers can sometimes facilitate diagnosis of certain treatable cancers
and their timely measurement in some circumstances can be associated with significant clinical gain.
In general however, tumour marker measurements are not recommended for diagnosis due to their low
sensitivity and specificity. Nevertheless, their use for this purpose had increased in recent years, due to their
routine availability on automated analysers in almost all clinical biochemistry laboratories. However,
inappropriately requested tumour marker results can lead to unnecessary and costly further investigations and
incorrect management as well as causing needless distress and worry to patients.
Clarifying which tumour markers should be measured and awareness of their significant limitations are critical
to their use in the diagnosis and management of patients with CUP.
Recommendation
• Do not measure tumour markers during diagnosis except for:
o AFP and hCG in patients with presentations compatible with germ-cell tumours (particularly
those with mediastinal and/or retroperitoneal masses and in young men).
o AFP in patients with presentations compatible with hepatocellular cancer.
o PSA in men with presentations compatible with prostate cancer.
o CA125 in women with presentations compatible with ovarian cancer (including those with
inguinal node, chest, pleural, peritoneal or retroperitoneal presentations). Carefully interpret
the results because of limited test specificity
Qualifying statement
Evidence to support recommendations on measurement of serum tumour markers for patients with MUO is
sparse and of low quality. These recommendations therefore rely on additional evidence of the diagnostic
utility of these markers in patients who do not have MUO. The GDG reached a strong consensus that tumour
markers should be limited.
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Further information can be found in following article:
C M Sturgeon, L C Lai and M J Duffy: “Serum tumour markers: how to order and interpret them”. BMJ 2009;
339: 852-858. https://www.bmj.com/content/339/bmj.b3527.full
And from the Association for Clinical Biochemistry and Laboratory Medicine - Recommendations as a Result of
the ACB National Audit on Tumour Marker Service Provision http://www.acb.org.uk/docs/default-
source/guidelines/tumour-marker-guidelines.pdf?sfvrsn=4
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DRUGS OF ABUSE
The approximate detection times for some of the commonly abused drugs are:
Drug Duration of detection in urine
Alcohol 4 - 12hrs
Amphetamines (including MDMA, MDA) 1 - 3 days
Benzodiazepines 1 – 3 days (can be significantly longer with chronic
use)
Cannabis 1 – 14 days (can be significantly longer with chronic
use)
Cocaine 1 – 3 days
Opiates 1 – 2 days
6-Monacetyl Morphine (6-MAM) up to 1 day (can be useful for confirming opiate
positive as heroin use)
Methadone 1 – 3 days (very dependent on dose)
Please note that detection times very approximate and are dependent on dose, its frequency, route of
administration, urine pH and urine dilution.
All samples have a creatinine measured. If level found to <1.8mmol/L then the sample is suspect. European
guidelines indicate that any sample with a creatinine less than 1.8 mmol/L should be considered too dilute and
not analysed.
Please contact laboratory for further information.
VIROLOGY
The biochemistry department does offer initial screening for the following:
• Hepatitis A, B and C
• Rubella
• HIV
Negative screen results are reported immediately (<24hr, Monday to Friday only) but positive results are
referred to a specialist laboratory for confirmation. The reports for positive results will be delayed for this
reason.
Please contact the laboratory for further information.
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PORPHYRIN SCREEN
The porphyrias are a group of eight inherited disorders classically presenting with either photosensitization or
neurological complaints such as abdominal pain. The sample requires are:
Sample type Volume/amount Test request
Urine 20ml Urinary porphyrins
Whole blood (EDTA), red top. 2.5ml RBC protoporphyrins and plasma
protoporphyrin screen.
Faeces A pea sized sample Faecal porphyrins
All samples must be protected from the light and delivered to the laboratory immediately after collection.
Porphyrins are photo-labile.
Please note that the pattern of porphyrin excretion is important in diagnosing the different types of porphyria.
In order to offer a full interpretation of the screen it is essential that full clinical details are written on the
request form.
Please note that some of the acute porphyria can show a normal excretion of porphyrins and their precursors.
It is important that any urine sample is obtained, if possible, during or as close as possible to any attack.
CRYOGLOBULINS
The laboratory must be contacted before the samples are taken. A Biomedical Scientist (BMS) will attend with a
Dewar flask containing sand at 37oC. The sample must not be taken until the BMS is in attendance, the sample
should then be taken and placed in the flask immediately. The BMS will return to the laboratory with the
sample. After separation at 37oC the sample is then referred to a specialist lab for analysis.
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HAEMATOLOGY DEPARTMENT
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CONTACTS
Haematology Department General Enquiries 6491
Consultant Haematologist 6501
Consultant Haematologist 4634
Blood Science Manager Gillian Lewis
6318
Secretaries to Haematologists 6596 & 4196
TURNAROUND TIMES
Routine working hours are 09:00 to 17:30 Monday to Friday.
• All routine investigations which are required urgently - reports available within one hour.
• Routine investigations (inpatients) are reported within four hours (i.e.: FBC, INR, coagulation screen,
D-Dimers, malaria screen).
• GP samples processed within 24 hours
• Blood film reports within 48 routine working hours
• Haemoglobin Variant Screening for Antenatal Clinics within 72 routine working hours. Haemoglobin
Electrophoresis within 14 working days
Referred tests – please see Referred Investigations page 75.
NOTE
The haematinic and haemoglobinopathy tests are performed during normal working hours therefore out of
hours requests will be stored until the next batch is processed. Sickle screening however is available during all
working hours for urgent requests.
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BLOOD COUNT REQUESTS
This includes WBC, RBC, HB, HCT, MCV, MCH, MCHC, platelet count, and five part differential (neutrophil,
lymphocyte, monocyte, eosinophil and basophil populations).
Specimens that contain small clots and/or are leaking, will be assessed for suitability for testing and repeat
requested if necessary.
The sample requirement for a full blood count is 2.7ml blood in a red (EDTA) tube.
Blood films and WBC manual differential, will be performed when the clinical information indicates a particular
leucocyte problem, or the blood count indicates abnormal findings. If you, or your senior medical staff wish to
have it performed for any specific reason, or would like the opinion of the consultant haematologist, please
state that clearly on the request.
Reference ranges:
Test Range Units
White Blood Cell count (WBC) 4.0 – 11.0 10*9/L
Red Blood cell Count (RBC) Male: 4.6 – 6.0
Female: 3.9 – 5.7
10*12/L
Haemoglobin (Hb) Male: 130 - 180
Female: 115 – 165
g/L
Haemocrit (HCT) Male: 0.40 – 0.54
Female: 0.36 – 0.48
-
Mean Cell Volume (MCV) Male: 80.0 – 96.0
Female: 79.0 – 95.0
fL
Mean Cell Haemoglobin (MCH) 27.0 – 32.0 pg
Mean Cell Haemoglobin
Concentration (MCHC)
315 - 355 g/L
Platelets (PLT) 130 – 400 10*9/L
Mean Platelet Volume (MPV) 6.0 – 12.0 fL
Red Cell Distribution (RDW) 12.0 – 15.0 -
Neutrophil Count 1.8 – 7.5 10*9/L
Lymphocyte Count 1.5 – 4.0 10*9/L
Monocyte Count 0.2 – 1.0 10*9/L
Eosinophil Count <0.4 10*9/L
Basophil Count <0.1 10*9/L
Nucleated Red Cells Differential - 10*9/L
Please note the turnaround time for an emergency sample is <1hr and for all other samples this is <2hr (from
receipt at laboratory).
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ESR
The sample requirement for an ESR is 3.5 ml of blood in a citrate (purple) tube. Because of the amount of liquid
anticoagulant in an ESR tube, it is most important that the right amount of blood is used in the tube. A separate
specimen must be sent for an ESR request. Only proven or suspected cases of temporal arteritis indicate the
need for an urgent ESR request.
Reference range:
Sex Age (years) esr
Males 17- 50 0 - 10mm in first hour
51-60 0 - 12mm in first hour
61-70 0 - 14mm in first hour
>70 0 - 30mm in first hour
Female 17- 50 0 - 12mm in first hour
51-60 0 - 19mm in first hour
61-70 0 - 20mm in first hour
>70 0 - 35mm in first hour
RETICULOCYTES
Reticulocyte count is a useful but under-utilised test. It reflects the ability of marrow to respond to stress
(bleeding, haemolysis, etc.) or its response to haematinic therapy. It will be performed if blood film indicates
the need for it (reflex testing) or on request.
Reference range:
0.5 – 2.5% (20 – 100 x 109/L)
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ANTICOAGULANTS
It is beyond the scope of this publication to give a fully comprehensive account of anticoagulation. You are
advised to refer to B.N.F. or discuss problems and queries with your seniors or the Haematologist. It is worth
noting that recommendations and practices can change rapidly in this field.
Parenteral and oral anticoagulants are used with increasing frequency. Oral anticoagulants may be used alone
or in combination with Heparin.
NOAC PATIENTS ON RIVAROXABAN, APIXABAN OR DABIGATRAN (NON VITAMIN K ANTICOAGULANTS)
To assess the anticoagulant status of patients taking NOACs – samples are sent for referral to MFT. Please
contact the laboratory to make arrangements for these tests.
Sample required: 1 x Sodium Citrate (green, 5ml)
Expected TRT (days) Stated as 7 days. If required urgently then please contact
laboratory.
Stability: Must be received by laboratory, aliquoted and frozen within
2hr. Transported frozen.
THERAPEUTIC RANGE FOR PATIENTS ON WARFARIN
The following are the ranges recommended by the British Society of Haematology.
INR Clinical State
2.0 – 3.0 Treatment of deep vein thrombosis.
Pulmonary embolism.
Transient ischemic attacks.
3.0-4.0 Recurrent deep vein thrombosis and pulmonary embolism.
Arterial disease including myocardial infarction.
Arterial grafts.
Cardiac prosthetic valves and arterial grafts.
For details refer to the British Society of Haematology guidelines.
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COAGULATION TESTS
INDICATION
SUSPECTED BLEEDING DIATHESIS
It is important to take a full history of present and past bleeding incidents and to enquire about family history
and drug ingestion. For screening purposes, the following tests are normally sufficient:-
P.T. and INR, APTT, Fibrinogen, Platelet count.
Requests for bleeding time and platelet function studies should be discussed with the Consultant
Haematologist.
SUSPECTED DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
PT, APTT, Fibrinogen and FDP (D-dimer), platelet count and blood film should be requested.
SCREENING FOR LIVER BIOPSY
PT, APTT and platelet count should be requested.
COAGULATION TEST – SAMPLE REQUIREMENTS
Analyte (Coagulation) Sample type Volume Turn
Around
Reference
Range
PT and INR Green Citrate
plasma (green)
2.7 ml <2hr INR: 0.8 – 1.2
PT: 8.5 - 12.5s
APTT Green Citrate
plasma (green)
2.7 ml <2hr 17 – 32 s
Fibrinogen Green Citrate
plasma (green)
2.7 ml <2hr 1.5 – 4.0 g/L
FDP (d-dimer).
Note, the sample must be analysed within
4hr of collection.
Green Citrate
plasma (green)
2.7 ml <2hr <500 ug/L
Factor assays Green Citrate
plasma (green)
2.7 ml x 2 Referred
investigation,
expected TRT
of 28 days.
See report
Thrombophilia screen Green Citrate
plasma
2.7ml x 5 Please note that some parts
of the screen have to be
referred to other
laboratories. The expected
turnaround time for this is
quoted as 4 weeks.
Serum (brown) 5 ml
EDTA 2.7ml x 2
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Analyte (Coagulation) –
Referred investigations
Sample type Volume(ml) Turn Around Reference
Range
Anti-Factor Xa Green citrate 1 x 2.7ml 11 days See report
Antithrombin III Green citrate 2 x 2.7ml 28 days See report
Protein C & Protein S Green citrate 2 x 2.7ml 28 days C: 77 – 148 IU/dl
S: 56 – 150 IU/dl
Anticardiolipin Antibodies Serum 5ml 13 days <16 units
Prothrombin Gene Variant EDTA 2.7ml 28 days See report
Factor V Leiden EDTA (2.7ml) 2.7 See report
Von Willebrands Factor Green citrate 2 x 2.7ml 28 days See report
Lupus anticoagulant Green citrate 4 x 2.7ml 28 days See report
Factors affecting coagulation tests
It is critical to fill the green citrate bottles to the line as they contain liquid anticoagulant – this must be in the
correct proportion to the blood to obtain the correct results, otherwise incorrect diagnosis and/or treatment
may occur. Under filled or overfilled samples will be rejected as will samples that are haemolysed or those
found to have a clot, as the results are unreliable. Samples should be sent directly to the laboratory without
delay. Results may also be unreliable in patients with very low or high haematocrits please contact the
laboratory if you wish to discuss.
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HAEMOGLOBINOPATHIES
For haemoglobinopathy screen please send an EDTA specimen in addition to one for FBC.
HAEMOGLOBINOPATHY TESTS AVAILABLE:
• Haemoglobin electrophoresis
• Haemoglobin A2 level
• Haemoglobin F level
• Sickle cell
Also a serum ferritin may be performed to assess iron status.
ANTENATAL SCREENING
Antenatal patients are tested following the NHS Sickle Cell and Thalassaemia Screening Programme.
HAEMOLYTIC DISORDERS
For screening purposes, a blood count, reticulocyte count, direct antiglobulin (Coombs) test and haptoglobins
should be requested together with bilirubin from the Biochemistry department. Having established the
presence of haemolysis, further tests should be carried out to detect the underlying cause. Please discuss this
with the Consultant Haematologist.
HAEMATINIC ASSAYS
Tests for investigations of B12, folate and/or ferritin deficiency – now performed by Biochemistry, see relevant
section.
Additional EDTA specimen required if RCF & FBC requested.
BONE MARROW ASPIRATE AND TREPHINE BONE BIOPSY
By arrangement after consultation with the Consultant Haematologist.
HAEMATOLOGY ADULT REFERENCE RANGES
Please see report form
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OTHER HAEMATOLOGICAL INVESTIGATIONS
Test Specimen Type Volume
required
Turn Around Ref Range
IM screen Serum (brown) 5ml <5 days See report
RA screen Serum (brown) 5ml <1 day <20 IU/ml
Haptoglobins Serum (brown) 5ml <1 day See report
IF antibodies Serum (brown) 5 ml <2 days See report
Malarial parasites Whole blood (red, EDTA) 2.7 ml <1 day See report
G-6-PD screen EDTA (2.7ml) 2.7ml <1 day See report
SAMPLE STORAGE TIMES
FBC, ESR, Retics, malaria samples - 24 hours
PT, APTT, Fibrinogen samples - 24 hours.
Haematinics, RA LE and IM screens - 7 days.
Any further tests required must be requested within these storage times.
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REFERRED INVESTIGATIONS
Analyte Specimen
Type
Volume
Required
Turn Around Ref range
Bone Marrow for MDT Stained Slides 14 days See report
Erythropoetin Serum 5 ml 15 days See report
HBE - Abnormal Hb. Variant
Confirmation
EDTA 4 x 2.7ml 25 days See report
Plasma Viscosity EDTA 1 x 2.7ml 14 days 1.45 – 1.80 cp
WT1 Marker Blood EDTA 4 x 2.7ml 14 days See report
WT1 Marker Marrow EDTA 1 x 2.7ml 14 days See report
BCR/ABL EDTA 2 x 2.7ml 28 days See report
HFE Hereditary Haemochromatosis
Gene Typing
EDTA 2 x 2.7ml 18 days See report
CALR mutation EDTA 4 x 2.7ml 21 days See report
Janus Kinase 2 EDTA 3 x 2.7ml 28 days See report
Immunophenotyping - Blood Must
be received in laboratory before 12
noon on day of collection (Monday
to Thursday)
EDTA 2.7 ml x 2 14 days See report
Immunophenotyping – Marrow
Must be received in laboratory
before 12 noon on day of collection
(Monday to Thursday)
Special bottle 2ml 14 days See report
Spherocytosis must be fresh - by
arrangement with laboratory only
EDTA 1 x 2.7ml Contact
referral
laboratory
See report
Chromosome analysis - blood. Must
be received in laboratory before 12
noon on day of collection (Monday
to Thursday)
EDTA 2 x 2.7ml 28 days See report
Chromosome analysis - marrow Special bottle 2ml 28 days See report
Pyruvate Kinase EDTA 2 x 2.7ml Contact
referral
laboratory
See report
HAMS / Paroxysmal Nocturnal
Haemoglobinuria
EDTA 2 bottles 14 days See report
Details of referral laboratories can be provided by the laboratory on request – see also page Error! Bookmark
not defined.. Please note that for brevity this is not a complete list of available tests, if in doubt please contact
laboratory.
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BLOOD TRANSFUSION
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CONTACTS
General Enquiries 6391
Consultant Haematologist 6501
Consultant Haematologist 4634
Secretaries to Haematologists 6596
Hospital Blood Transfusion Manager Gillian Lewis 6318
Advanced Biomedical Scientist Andrew Blackburn 6391
Specialist Practitioner of Transfusion Caroline Holt 5484
Trust Intranet page: http://tis/Pages/bloodtransfusion.asp
CAUTION
Fatal transfusion accidents still occur. Nationally reported errors show that a high
percentage is due to failure of the bedside check or specimen labelling errors. They are due
to carelessness and are avoidable. At every stage of the procedure from taking blood for the
cross-match specimen to the actual transfusion of the blood, meticulous attention to detail is
essential.
REQUEST FORMS
The Request form must be filled in completely and correctly – see Specimen Acceptance Policy available on
Trust Intranet
Phlebotomists have been instructed not to take blood if the name, district number and date of birth are not on
the request form and patient's wristband.
Please note that in line with national guidelines pre-printed labels (from any source) on samples
are not acceptable.
Please note (as previously stated):
All request forms must be signed by the requesting clinician.
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SPECIMEN REQUIREMENTS
Test Specimen requirement
Group and save plasma/Cross match EDTA (blue,4.5ml)
DAT EDTA (blue, 4.5ml)
ANC investigations
Kleihauer
Cord and Maternal bloods EDTA (blue, 4.5ml) from mother and baby
HLA typing (use NBA form) –
PLEASE CONTACT LABORATORY (ESSENTIAL)
EDTA (2 x 2.7ml)
HLA antibodies (use NBA form) 10ml clotted (white top)
Platelet antibodies (use NBA form) Contact laboratory
Requests for:
Platelets/Cryoprecipitate/fresh frozen plasma
Contact laboratory AND Consultant Haematologist
Requests for:
Human albumin
Send signed request form
Request for:
Novoseven/Prothrombin complex
Strictly by discussion with the Consultant
Haematologist
NB. When FFP or platelets are required a FBC and coagulation screen must be requested to assess the need
and/or dosage of the FFP, Cryoprecipitate or platelets. In case of major life threatening haemorrhage contact
the laboratory immediately. Full patient, clinical and requestor details must be provided.
DEXTRAN
Dextran and other plasma expanders may seriously interfere with cross-matching. Avoid giving them before
taking the cross-match specimen. If this is unavoidable the fact that they have been given should be indicated
on the request card.
ROUTINE REQUESTS
When non-urgent transfusions are planned, requests should be made at least 24 hours before the transfusion.
This allows time for extra investigations to be made if the cross-match is not straightforward.
RESERVATION OF CROSS-MATCHED BLOOD
Blood ordered for theatre and not used is taken back into stock for other patients at 9.00 am on the day
following operation. If blood is required after this, then please inform the laboratory before 9.00 am, or leave a
signed and dated note on the appropriate fridge.
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GROUP AND SAVE PLASMA
The use of group and save plasma is encouraged. For many operations it is not necessary to have cross-
matched blood available. Certain patients for elective surgery must have a group and save at pre-op
assessment – please refer to the Maximum Surgical Blood Order Schedule for in the Blood Transfusion Policy
for details.
For expected blood usage please refer to Maximum Surgical Blood Order Schedule:
http://tis/documents/BloodTransfusionPolicy.pdf
With group and save requests plasma is tested for irregular antibodies. If these are detected the M O. will be
informed. Patients for surgery with irregular antibodies should be discussed with the Blood Transfusion
Department a minimum of 24hr before surgery.
If blood is required, a signed request form should be sent to the laboratory stating the number of units
required. In the majority of cases (but not all cases) a sample is valid for issue of blood for 72hr – please contact
laboratory for information.
ISSUE OF BLOOD
N.B. blood left out of a specified blood fridge for more than 30 minutes must not be used -
please label any such unit indelibly on the front - not suitable for use, and inform the blood
transfusion department, tel. 6391
Blood must not be stored in any ward or drug fridge but only in designated controlled and
alarmed blood fridges.
EMERGENCY GROUP O NEGATIVE BLOOD
Contact Blood Transfusion (ext. 6391) before use. Note that the blood transfusion sample must be
taken before use.
2 units of uncross-matched blood Group O Negative, are kept in the A&E fridge for Accident and Emergency,
and 2 units in the Maternity fridge for use in life threatening emergency. These may not be suitable for patients
exhibiting adverse antibodies.
It is stressed that this blood is uncross-matched and its use should be governed by the patient's clinical
condition.
If any O Negative blood is used in an emergency, then the appropriate red form MUST be filled in and sent to
the laboratory immediately. The Blood Transfusion staff MUST also be informed by telephone in order that
replacement O Negative can be issued immediately on receipt of the completed red form.
Please see and read the hospital transfusion policy for comprehensive guidance
This guidance is also available on the Pathology website and also on the Trust Documents section on the
intranet.
Any problems or queries please contact the Blood Transfusion Laboratory, the Consultant Haematologist or the
Specialist Practitioner of Transfusion as appropriate.
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Tameside and Glossop Integrated Care NHS Foundation Trust Pathology User Guide
POCT (POINT OF CARE TESTING)
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Point of Care Testing (POCT) is defined as any analytical test performed by a Healthcare Professional outside
the conventional laboratory setting.
The POCT Service is required to comply with:
1. Guidelines from the MHRA; Management and use of IVD POCT devices
2. ISO 22870:2016 POCT Requirements for Quality and Competence
3. ISO 15189:2012 Medical Laboratories Quality and Competence
As the Pathology Directorate manages and leads on all POCT issues, direct liaison from the users of the POCT
service with the Pathology Directorate and primarily the POCT Co-ordinator is essential to ensure compliance is
achieved.
POCT POLICY
The POCT Policy is available on the Trust intranet and outlines the roles and responsibilities of all individuals
associated with POCT.
POCT COMMITTEE
The POCT Committee monitors and audits current POCT devices for compliance of policies and procedures and
report any issues and breaches of policy to Clinical Risk Management.
No POCT device is to be introduced and implemented within the Trust without approval from the POCT
Committee.
If considering the implementation of a POCT device, the POCT Co-ordinator must be contacted, not company
representatives regarding procurement. The POCT Co-ordinator will then assist with business case and
planning, including cost-benefit analysis, clinical need, and equipment evaluation and selection.
TRAINING
Only personnel who have completed training and demonstrated competence shall be issued passwords to carry
out POCT. Passwords MUST NOT be shared; sharing of passwords is a disciplinary offence.
To arrange training contact POCT Co-ordinator on Ext 4620
SAMPLE INTEGRITY AND RESULTS
Instructions for sample collection and preparation given during training are crucial to obtain accurate results.
PATHOLOGY SUPPORT
The Pathology Directorate provides advice on and facilitates the mechanism and methodology of the tests,
limitations of the method, troubleshooting, training, support, quality control and quality assurance, risk
management, health and safety and infection control issues.
Maintenance and daily monitoring of blood gas analysers is performed by Pathology staff.
Provision of the following consumables is also available via Pathology:
Blood Gas: Reagents, Printer Paper, Capillary Tubes
Glucose: Glucometer, Batteries, Quality Control, QC Record Book
Urinalysis: Urinalysis Results Stickers
All other consumables are ordered locally or via Pharmacy.
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INSTRUMENT FAILURE
In the event of equipment failures refer to local instructions; the laboratory needs to be informed immediately
and is available as backup and will assist where possible.
To report any issues ring Ext 4620 failing that 6498.
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Tameside and Glossop Integrated Care NHS Foundation Trust Pathology User Guide
IMMUNOLOGY
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The referral laboratory for immunological investigations is the Immunology Department at Manchester
University Hospital NHS Foundation Trust (previously CMFT)
Note: this service is not covered by the UKAS ISO 15189:2012 accreditation No. 8912; it operates under UKAS
accreditation number 8195.
CONTACTS
For test results call the results hotline on 0161 276 8766.
For other enquiries:
Information concerning laboratory services can be found at:
http://www.cmft.nhs.uk/info-for-health-professionals/laboratory-medicine/immunology
(If this link does not function then please copy/paste into your web browser)
Name Title Tel Email
Dr Tomaz Garcez Head of Service and Consultant
Immunologist
0161 276 6468 [email protected]
Dr Sara
Drinkwater
Consultant Immunologist 0161 276 6468 [email protected]
Dr Hana Alachkar Consultant Immunologist 0161 206 5572 [email protected]
Dr Archana
Herwadkar
Consultant Immunologist 0161 206 5572 [email protected]
Philippa Coles Laboratory Manager 0161 276 6442 [email protected]
John Hewitt Chief Biomedical Scientist
(Infomatics Lead)
0161 276 7162 [email protected]
Andrew Moran Chief Biomedical Scientist
(Training Lead)
0161 276 1209 [email protected]
Angela Bedford Administration Manager 0161 276 6468 [email protected]
Jill Edmonds Immunology Specialist Nurse 0161 276 6186 [email protected]
Colette McAlister Client Services Manager 0161 276 6042 [email protected]
- Clinic secretaries 0161 276
6686/5653
-
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MICROBIOLOGY AND VIROLOGY
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Please note that the service has now moved to Manchester University Hospital
NHS Foundation Trust (previously CMFT)
Note: this service is not covered by the UKAS ISO 15189:2012 accreditation No. 8912; it operates under UKAS
accreditation numbers 8393 and 10175.
CONTACTS
For test results call the results hotline on 0161 276 8766.
MICROBIOLOGY DEPARTMENT
Information concerning laboratory services can be found at:
http://www.cmft.nhs.uk/info-for-health-professionals/laboratory-medicine/manchester-medical-microbiology-
partnership/opening-hours-clinical-advice-and-results-line/microbiology-department-cmft
(If this link does not function then please copy/paste into your web browser)
Name External number
Dr Andrew Dodgson
Clinical Lead, Consultant Microbiologist, Infection Control Doctor (0161) 276 6010
Dr Ed Kaczmarski
Lead Consultant Microbiologist for Christie Hospital (0161) 276 5746
Dr Debasis Sanyal
Consultant Microbiologist (paediatrics) (0161) 276 5089
Dr Ahmed Qamruddin
Consultant Microbiologist (0161) 276 4282
Dr Kirsty Dodgson
Consultant Clinical Scientist & Deputy Infection Control Doctor (0161) 276 5746
Dr Barzo Faris
Consultant Microbiologist (0161) 746 2470
Mrs Geraldine Featherstone
Microbiology Secretary (0161) 276 5686
Specialist Registrars Office (0161) 276 6333
Mr Bernard Wood
PHE Regional Head of Laboratory Operations/Head BMS MMMP (0161) 276 4420
Mrs Rachel Jones
Laboratory Manager (0161) 276 5747
Mr Malcolm Armstrong
Deputy Laboratory Manager (0161) 276 8822
Mrs Katherine Mather
Deputy Laboratory Manager (0161) 276 4909
Fax (0161) 276 5744
Hospital Switchboard (0161) 276 1234
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VIROLOGY DEPARTMENT
Information concerning laboratory services can be found at:
http://www.cmft.nhs.uk/info-for-health-professionals/laboratory-medicine/manchester-medical-microbiology-
partnership/opening-hours-clinical-advice-and-results-line/virology
(If this link does not function then please copy/paste into your web browser)
Name External number
Dr Andrew Turner
Clinical Lead
Consultant Medical Virologist
(0161) 276 8853
Dr Nick Machin
Consultant Virologist (0161) 276 8838
Dr Louise Hesketh
Consultant Clinical Scientist (0161) 901 0188
Dr Malcolm Guiver
Consultant Clinical Scientist,
Head of Molecular Diagnostics
(0161) 276 8853
Miss Christel Matthews
Secretary (0161) 276 8787
Mr Peter Tilston
Clinical Scientist - Resistance testing (0161) 276 8849
Dr Alex Sargent
Clinical Scientist (HPV lead) (0161) 276 8680
Mr Benjamin Brown
Clinical Scientist (0161) 276 8680
Mr John Marsh
Laboratory Manager (0161) 276 8838
Mr Alan Lord
Deputy Laboratory Manager (0161) 276 8843
Fax (0161) 276 8787/5744
Hospital Switchboard (0161) 276 1234
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CELLULAR PATHOLOGY & NEUROPATHOLOGY
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CELLULAR PATHOLOGY
Please note that the service has now moved to Manchester University Hospital
NHS Foundation Trust (previously UHSM)
Note: this service is not covered by the UKAS ISO 15189:2012 accreditation No. 8912; it operates under UKAS
accreditation number 9083.
Please use the link below for all detail regarding the service provided by the Cellular Pathology service at
Wythenshawe Hospital
SERVICE AND CONTACT INFORMATION
https://mft.nhs.uk/wythenshawe/services/pathology/
The user handbook is a link available off this page (if this link does not function then please copy/paste into
your web browser)
CONTACT DETAILS
All telephone extensions should be prefixed with 0161 291 when calling from outside the hospital unless
otherwise stated
Generic contact details Location Extension Information
Report enquiries Office 4813 At times, this number may have an answering
machine: please leave a clear request and a number
for us to call you back
Report Fax Number Office 4809
Laboratory Tel No. (Fax No.)
Head Biomedical Scientist 4804
Specimen reception 4800
Histology laboratory 4800
Histology laboratory fax 4801
Cytology laboratory 2156
CONSULTANT CONTACT DETAILS
Please use the Wythenshawe website for this information to ensure the most up-to-date information is
accessed
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NEUROPATHOLOGY SAMPLES
Note: this service is not covered by the UKAS ISO 15189:2012 accreditation No. 8912; at the time of writing, the
service was not accredited to ISO15189:2012 by UKAS.
Neuropathology samples should not be sent to pathology as these need to go direct to the histology
department at Salford Royal Foundation Trust.
NEUROPATHOLOGY – MUSCLE AND NERVE BIOPSY SAMPLES
Diagnosis of neuromuscular disorders relies on ultrastructural and/or enzyme histochemical studies. Careful
and optimal handling is essential to preserve these features and avoid traumatic damage. Prompt submission
of freshly excised tissue is vital.
The department must be notified in advance that a sample for neuropathology is being sent –
0161 206 5015.
Biopsies sent from remote centres (where some time delay is inevitable) should be wrapped in gauze
dampened (not wetted) with isotonic saline to maintain humidity. DO NOT Place in formalin or other fixative
The biopsy must be taken and despatched in time so that it can arrive at the laboratory between the hours of
08:30 and 16:00, Monday to Friday (excluding bank holidays). Biopsies should preferably arrive by lunchtime as
they can then be dealt with the same day (optimal), but in any case before 16:00.
TRANSPORT
DO NOT send neuropathology samples to Pathology at Tameside General.
It is the responsibility of the referring department to arrange transport (by taxi) of neuropathology samples.
Please ensure that the request form is clearly marked that the sample is for Neuropathology and include full
clinical details to assist in making a diagnosis. The specimen acceptance criteria at SRFT are the same as at TGH;
please ensure that the request form and sample are correctly labelled
Ensure the sample is packed in a leakproof bag (e.g. a pathology sample bag).
Ensure the driver/courier is instructed to bring the specimen promptly to cellular pathology reception
Specimens should be handed directly to a member of the cellular pathology team and not left at specimen
reception.
ADDRESS
Cellular Pathology
Pathology at Wigan and Salford
Level 2, Turnberg Building
Salford Royal Hospital
Stott Lane
M6 8HD
Phone 0161 206 5015
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MORTUARY AND BEREAVEMENT
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The service is based at Tameside General Hospital.
The services that we provide to the Trust and the Community includes storing of the deceased, post mortem
examinations, tissue donations, identifications and viewings for the bereaved relatives.
Note: this service is not covered by the UKAS ISO 15189:2012 accreditation No. 8912
We follow strict guidelines under the HTA (Human Tissue Authority) license ensuring safety and security at all
times, also demonstrating respect and sensitivity for bereaved families.
Our dedicated and caring team deals with approximately >2,000 deaths a year from the hospital and the local
community, around >600 post mortem examinations are performed most of which from the direction of Her
Majesty’s Coroner for South Manchester.
The mortuary team consists of one Mortuary Manager and three Anatomical Pathology Technologists all who
show a caring dedicated approach in their roles.
The mortuary works very closely with the following services:
• HM Coroner’s office
• Greater Manchester police
• Doctors and Nursing staff
• Transplant teams
• Patient Advice and Liaison service (PALS)
• Chaplaincy
• Funeral Directors
MORTUARY OPENING HOURS
The mortuary is open Monday to Friday 8am-4.00pm.
Viewings and identifications can be made by appointment during these hours via the mortuary office.
An out of hours service is provided seven days a week until 8:00pm.
This is by appointment and arrangements can be made by contacting the on call technician via the hospital
switchboard.
CONTACTS
Telephone number (prefix 0161 922 from outside
hospital)
Sharon McMinn (Mortuary Manager ) 0161 922 6520
Mortuary Office 0161 922 6059
On call technician (via the hospital switchboard) 0161 922 6000
Bereavement service 0161 922 5192
The Mortuary department also includes Bereavement services and is located behind the Pathology Building
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