Lesson 1, Topic 1
In Progress

Closing Comments

April 11, 2024

Patient Coaching
As with all other procedures, the laboratory test is only as valid as the specimen and the procedure performed on that specimen. You, as the provider’s agent, are responsible for that validity when you instruct the patient and when you perform the test. Be clear in your instructions. Give written materials to reinforce your instructions. Ask if the patient has any questions and take the time and effort to answer the questions in a way that is clear and understandable to the patient. If the patient has additional questions that you cannot answer, have the provider talk to the patient directly.


Legal and Ethical Issues
A medical assistant who is responsible for POL testing must clearly understand the basic concepts of laboratory medicine. Therefore, you must stay current with the rapid technological advances in laboratory medicine and help establish a protocol for testing that best suits your provider-employer.
You are responsible for properly collecting specimens and testing them accurately. Patient confidentiality is paramount when testing is performed, as is strictly conforming to all established quality control procedures.


Patient-Centered Care
The CMA plays an important role in the laboratory and patient care. Often many different tests are needed to assess a patient’s health. Many patients appreciate that they can have CLIA-waived tests done during a routine visit to their provider. With a simple fingerstick, a patient can have tests such as hemoglobin and hematocrit, protime, A1c, blood glucose, cholesterol, and ALT/AST completed in the POL. Saving patients’ time and the inconvenience of going to a different location are just a few benefits of having a CLIA-waived POL. Also, having test results available quickly and while patients are still in the clinic gives them the opportunity to ask questions and have them answered on the spot.


Professional Behaviors
An ever-increasing number of CLIA-waived hematology and chemistry blood tests are relatively simple to perform and require minimal training. This allows the provider to share the results with the patient quickly, which may lead to greater patient compliance with the prescribed treatment plan. Proper patient care demands attention to detail in all three areas of the testing process:
            • Preanalytic: Proper care of the testing supplies and equipment, and proper patient identification and specimen collection
            • Analytic: Running the tests according to the specific manufacturer’s instructions; recording and analyzing the controls and the patient results
            • Postanalytic: Proper disposal of biohazard supplies; routing of test results to the provider and patient
      Medical assistants are involved in all three areas of testing. They are responsible for the organization and documentation of each performed test on the appropriate lab flow sheet and in the patient’s health record.

FIGURE 34.13  Panel request form

Summary of Scenario

It has been another busy day for Anita at WMFM Clinic. She had a chance to see a variety of patients with a variety of concerns. It was a normal day at work! Anita enjoys the variety. She also enjoys the work she does in the laboratory. Anita prepares specimens for transport to the reference lab. She checks on results once they are posted in patients’ electronic medical records. She knows that Dr. Perez and all the providers at WMFM Clinic rely on lab results as part of patient diagnosis and treatment monitoring.
It has been another good day at work. Now Anita is going to go home and try to get a little gardening done!


Summary of Learning Objectives

1. Analyze the role of blood and the components found in the blood.

The circulating blood supplies the body’s cells with nutrients and oxygen. The blood also maintains homeostasis. Whole blood is composed of visible-formed elements suspended in plasma and cellular elements, including red blood cells (RBCs), white blood cells (WBCs), and platelets. Plasma transports the formed elements plus other substances, such as nutrients and plasma proteins, throughout the body to every cell.

2. Examine the hematology tests, including the erythrocyte sedimentation rate and coagulation testing, done in the physician’s office laboratory.

The erythrocyte sedimentation rate (ESR) test is a laboratory test that measures the rate at which red blood cells gradually separate from plasma and settle to the bottom of a specially calibrated tube in 1 hour. An ESR test is performed to assess inflammation and often is used to monitor rheumatoid arthritis. Refer to Procedure 34.1 for the steps in determining the ESR using a modified Westergren method.

Coagulation testing includes protime (PT) testing, which is a method of measuring how long it takes blood to clot. PT is used in combination with partial thromboplastin time (PTT) to screen for hemophilia and other hereditary clotting disorders. It is important to educate patients who take warfarin about the need for follow-up laboratory monitoring of their protime/international normalized ratio (INR). Helping patients identify foods high in vitamin K is crucial to maintaining a balance between the warfarin dosage and the lab values. Refer to Procedure 34.2 for information on how you can reassure a patient of the accuracy of PT/INR test results.

3. Examine the complete blood count, including the collection technique, components of the complete blood count, and the results.

The most frequently ordered reference laboratory procedure for hematology is the complete blood count (CBC). This test requires a lavender-topped EDTA blood specimen. A CBC can be done in the physician’s office laboratory (POL) or the reference lab. The normal values for the CBC are found in TABLE 34.1. A CBC includes the following tests:

• Red blood cell tests: Includes an RBC count, hematocrit, hemoglobin, and RBC indices. A reticulocyte count can be done at a reference laboratory as part of a CBC.

White blood cell tests: Includes a WBC count and a WBC differential.

• Platelet tests: Includes a platelet count. Platelet indices, including mean platelet volume, plateletcrit, and platelet distribution width, can be done at a reference laboratory as part of a CBC.

4. Examine the hematology tests done in a reference laboratory.

Many hematology tests are done in the reference laboratory. When abnormal hematology results are obtained in the POL, further testing may be done in the reference laboratory. The partial thromboplastin time test is a coagulation test done in the reference laboratory. The medical assistant may help with creating and staining a blood smear. Blood smears are used to microscopically examine the cells. They can be used for a manual WBC differential, RBC morphology, and platelet analysis.

With automated hematology analyzers, platelet indices may be reported as part of the CBC and used to diagnose thromboembolic disease. There are several platelet indices, including platelet volume (MPV), plateletcrit (Pct), and platelet distribution width (PDW).

5. Examine immunohematology.

Both the ABO blood type and the Rh type result from antigens on the surfaces of RBCs, and both groups are crucial when it comes to transfusion. There are four different ABO types (A, AB, B, and O). The body produces natural antibodies against the AB antigens that are not present in the blood cells. For example, if a person has type A antigens in the cells, there will be anti-B antibodies in the plasma. Type O blood has both anti-A antibodies and anti-B antibodies because they are both foreign to someone with type O blood. There are only two Rh types (positive and negative). Unlike the ABO group, an Rh-negative blood type does not have natural antibodies against Rh-positive cells. The Rh-negative individual must first be exposed to Rh-positive cells via transfusion or childbirth, which initiates the formation of anti-Rh antibodies that attack and destroy Rh-positive cells.

6. Examine blood chemistry in the physician’s office laboratory.

The blood glucose level is monitored routinely in patients with diabetes type 1 or type 2 and in women who have gestational diabetes during pregnancy (see Procedure 34.6). Hemoglobin A1c levels are measured to determine the average blood glucose level during the 2 to 3 months before the test; this test assists in the management of diabetes. Cholesterol testing generally refers to assessing levels of total cholesterol, HDL, and LDL (see Procedure 34.7). Cholesterol testing is done to help determine a patient’s susceptibility to coronary artery disease. Liver enzyme testing (ALT and AST) is performed in the POL primarily to monitor the side effects of certain therapeutic drugs, such as those used to treat elevated cholesterol and diabetes. Thyroid testing is performed in the POL to detect elevated thyroid-stimulating hormone (TSH) levels and to assist in the diagnosis of hypothyroidism.

Procedure 34.1  Perform CLIA-Waived Hematology Testing: Determine the Erythrocyte Sedimentation Rate Using a Modified Westergren Method
TASKS:
Fill a Westergren tube properly and observe an erythrocyte sedimentation rate (ESR) obtained by using a modified Westergren method. Document the result on the lab flow sheet and in the patient’s health record.
Equipment and Supplies
             • Patient’s health record
             • Provider’s order or lab requisition
             • Erythrocyte sedimentation rate (ESR) laboratory log
             • Ethylenediaminetetraacetic acid (EDTA)–anticoagulated blood specimen
             • Safety tube decapper (if tubes do not have Hemogard plastic tops)
             • Disposable transfer pipet
             • Sediplast ESR system (prefilled Sediplast vial)
             • Sediplast rack
             • Timer
             • Fluid-impermeable lab coat, eye protection, and gloves
             • Biohazard waste container
             • Biohazard sharps container
Procedural Steps
1. Wash hands or use hand sanitizer. Put on a fluid-impermeable lab coat, eye protection, and gloves. Comply with safety practices.

PURPOSE: To ensure infection control.

2. Assemble the materials needed.

3. Check the leveling bubble of the Sediplast rack.

PURPOSE: The rack must be horizontal on the table or bench to ensure that the tube is vertical.

4. Bring the blood sample to room temperature if it has been refrigerated, and mix the sample well by gently inverting the tube 6 to 8 times, making sure the tube has no bubbles.

PURPOSE: Cells settle when a specimen stands, and blood must always be well mixed before sampling. Test results will be altered if refrigerated blood is not brought to room temperature.

5. Remove the plastic Hemogard stopper on the blood sample by twisting and slowly pushing up on the stopper with your thumbs (or by using a tube decapper on rubber-stoppered blood tubes). Label with the patient’s name and then remove the stopper on the prefilled Sediplast vial.

PURPOSE: Using the Hemogard cover or removing the rubber cap with a protective device blocks blood splashes and helps prevent aerosolization of the specimen.

6. Fill the Sediplast vial with blood to the indicated line using a disposable transfer pipet (see Figure 1). Replace the stopper on the prefilled vial and invert it several times to mix. Recap the blood collection tube with its stopper.

PURPOSE: This dilutes the blood in accordance with the Westergren procedure.

7. Insert a Sediplast pipet through the pierceable stopper on the prefilled vial and push down until the pipet touches the bottom of the vial. The pipet automatically draws the blood up and over the zero mark (see Figure 2).

 

8. Insert the filled Sediplast pipet and its vial into the Sediplast rack, making sure the vial is vertical.

PURPOSE: A pipet that is not vertical produces incorrect results.

9. Note the start time on the ESR log sheet and allow the vial to stand undisturbed for 60 minutes.

PURPOSE: Jarring or moving the vial increases the sedimentation rate.

10. After 60 minutes, measure the distance the erythrocytes have fallen at the top of the tube. The scale reads in millimeters—each line is 1 mm.

PURPOSE: Precise timing is important with this test method.

11. Properly dispose of all biohazard materials. Dispose of the plastic Sediplast pipet and its vial into a biohazard sharps container. Disinfect the work area. Remove your gloves, protective eyewear, and lab coat. Wash hands or use hand sanitizer.

PURPOSE: To ensure infection control.

12. Record the findings in the lab’s ESR log and the patient’s health record. Remember that the Westergren ESR is reported in millimeters per hour (mm/hr). Using the normal range, determine if the test result is normal or abnormal.

PURPOSE: A procedure is not considered complete until it has been recorded.

Procedure 34.2  Perform a CLIA-Waived Protime/INR Test
TASKS:
Perform a capillary puncture and perform a coagulation test to determine PT/INR using the CoaguChek XS instrument with built-in quality control. Document the result on the lab flow sheet and in the patient’s health record.
Equipment and Supplies
            • Patient’s health record or flow chart (see FIGURE 34.3)
            • Provider’s order or lab requisition
            • PT/INR lab log
            • Gauze, alcohol wipes, bandage
            • CoaguChek XS PT test monitor (see FIGURE 34.2)
            • CoaguChek lancet
            • CoaguChek test strip container and code chip
            • Package insert or flow chart with directions
            • Fluid-impermeable lab coat, protective eyewear, and gloves
            • Biohazard waste container
            • Biohazard sharps containers


Procedural Steps
1. Wash hands or use hand sanitizer. Put on a fluid-impermeable lab coat, protective eyewear, and gloves. Comply with safety practices.

PURPOSE: To ensure infection control.

2. Check the provider’s order and collect the necessary equipment and supplies.

3. If you are using test strips from a new, unopened container, you must change the test strip code chip. The three-number code on the test strip container must match the three-number code on the code strip. To install the code strip, follow the instructions in the Code Chip section of the user’s manual.

PURPOSE: To ensure that the instrument is calibrated correctly, to produce accurate, precise, and reliable results.

4. Place the meter on a flat surface so that it will not vibrate or move during testing.

PURPOSE: The test results are based on the back-and-forth movement of the blood sample that stops when the clot has formed. Vibrations or other movements will result in an error message, and the test will have to be repeated.

5. Greet the patient. Identify yourself. Verify the patient’s identity with the patient’s full name; ask patients to spell their first and last names and to state their date of birth.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient.

6. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have about the procedure. Obtain permission for the capillary puncture.

PURPOSE: Explaining the procedure can make the patient feel more comfortable and reduces anxiety.

7. Examine the patient’s fingers and choose the site to obtain the blood sample.

PURPOSE: Proper site choice will help ensure a good sample.

8. Prepare the site:

            a. Warm the hand by placing it under the arm, using a hand warmer, or washing the hand in warm water.

            b. Have the patient hold his or her arm down to the side so that the hand is below the waist.

            c. Massage the palm toward the base of the finger and toward the tip until the fingertip has increased color.

            d. If necessary, immediately after lancing, gently squeeze the finger from its base to encourage blood flow.

PURPOSE: The hanging drop blood sample must be sufficient to travel down the three channels on the test strip. It must be free of contaminants, tissue fluids, and alcohol.

9. When you are ready to test, remove a test strip from the container and immediately close the container. Make sure it seals tightly. Do not open the container or touch the test strips with wet hands or wet gloves.

PURPOSE: Exposure to moisture damages the test strips.

10. Insert the test strip as far as you can into the meter. This powers the meter ON (see Figure 1).

 

11. Disinfect the finger with an alcohol wipe and allow the finger to air-dry. Perform the fingerstick. If necessary, immediately after lancing, gently squeeze the finger to encourage blood flow. Do not wipe away the first drop of blood.

PURPOSE: To ensure infection control

12. Hold the finger with a blood drop very close to the target (the clear area of the test strip). Apply one drop of blood to the top or side of the target area and wait until you hear the beep. You must apply a hanging drop of blood to the test strip within 15 seconds of the fingerstick. Do not add more blood. Do not touch or remove the test strip while the test is in progress. The flashing blood drop symbol changes to an hourglass symbol when the meter detects a sufficient sample (see FIGURE 34.2).

13. Read the results.

Note: The result appears in approximately 1 minute. It may be displayed in three ways: as the INR, as the protime (PT) in seconds, or as %Quick (a unit used mainly in Europe). Laboratory reports and manufacturers must supply their own reference ranges for PT results, along with each patient’s results. This is because different methodologies may create different reference ranges and different units of measurement.

14. Dispose of the sharps into the biohazard sharps container. Dispose of regulated medical waste into the biohazard waste container. Disinfect the test area and remove your PPE.

15. Wash hands or use hand sanitizer.

16. Record the result in the lab’s PT/INR log and the patient’s warfarin therapy flow sheet or the patient’s health record. Using the normal range, determine if the test result is normal or abnormal. For the paper log and paper patient health record, circle any results that do not fall into the desirable ranges. Identify critical values and take appropriate steps to notify the provider. Document the steps taken.

PURPOSE: The provider needs to know the result while the patient is still in the office for proper follow-up with the patient.

Procedure 34.3  Perform Preventive Maintenance for the Microhematocrit Centrifuge
TASKS:
Perform daily, monthly, semiannual, and annual maintenance on a micro hematocrit centrifuge. Document the preventive maintenance in the laboratory logbook.
Equipment and Supplies
            • Microhematocrit centrifuge
            • Maintenance logbook
            • Utility gloves
            • Fluid-impermeable lab coat, eye protection, and gloves
            • Disinfectant
            • Biohazard waste container
Procedural Steps
1. Wash hands or use hand sanitizer. Put on a fluid-impermeable lab coat, eye protection, and gloves. In all maintenance procedures, gloves are worn under the utility gloves.

Note: These are general recommendations. Always check the manufacturer’s guidelines for specific instructions. Always unplug the power cord before cleaning or servicing the centrifuge.

Daily Maintenance
2. Clean the inside of the centrifuge and the gasket with a disinfectant recommended by the manufacturer. Plastic and nonmetal parts may be cleaned with a fresh solution of 5% sodium hypochlorite (bleach) mixed to a 1:10 dilution with water (1 part bleach plus 9 parts water).

PURPOSE: To remove any dried blood or shattered glass. Do not use bleach on the gasket because it may harden the rubber.

Monthly Maintenance
3. Check the reading device. Misuse and zeroing of reading devices can result in considerable error. Always use a second, simple reading device as a cross-check. Use a ruler or a flat plastic card specially made for this purpose. To use these cards, lay the spun hematocrit tube on the card and align the red blood cell with a line on the card to obtain the reading.

PURPOSE: To ensure the accuracy of quality control and patient results.

4. Check the rotor for cracks or corrosion and check the interior for signs of white powder.

PURPOSE: Cracks, corrosion, or powder may indicate impending rotor failure; these findings require the immediate attention of a service technician.

Semiannual Maintenance
5. Check the gasket for cuts and breaks.

PURPOSE: Cut gaskets allow tubes to leak and must be replaced.

6. Check the timer with a stopwatch to verify timer accuracy.

PURPOSE: To ensure timer accuracy.

7. Perform a maximum cell pack to verify the time required for complete packing by reading a sample after centrifugation and then recentrifuging for 1 minute. The results should be the same. If they are not, perform preventive maintenance or call the service technician.

PURPOSE: If the cells compact further during recentrifugation, the centrifuge is not rotating at the proper speed, and hematocrit results will be falsely elevated.

Annual Maintenance (or Maintenance Performed as Needed)
8. The centrifuge functions and maintenance verification should be performed by qualified personnel. This includes checking the centrifuge mechanism, rotors, timer, speed, and electrical leads.

PURPOSE: To ensure proper centrifuge function.

9. Record all professional service calls in the laboratory logbook.

PURPOSE: Proper documentation is essential for all laboratory maintenance.

Procedure 34.4  Perform CLIA-Waived Hematology Testing: Perform a Microhematocrit Test
TASKS:
Perform a microhematocrit test accurately. Document the result on the lab flow sheet and in the patient’s health record.
Equipment and Supplies
                • Patient’s health record
                • Provider’s order or lab requisition
                • Microhematocrit lab log
                • Fresh sample of blood collected in a tube containing ethylenediaminetetraacetic acid (EDTA) anticoagulant (or equipment for fingerstick specimen: lancet, alcohol wipe, gauze, bandage)
                • Plastic-coated self-sealing capillary tubes or plain capillary tubes (blue-tipped)
                • Sealing clay (if capillary tubes are not self-sealing)
                • Gauze
                • Microhematocrit centrifuge
                • Fluid-impermeable lab coat, protective eyewear, and gloves
                • Biohazard waste container
                • Biohazard sharps containers


Procedural Steps
1. Wash hands or use hand sanitizer. Put on a fluid-impermeable lab coat, protective eyewear, and gloves. Comply with safety practices.

PURPOSE: To ensure infection control.

2. Assemble the materials needed.

a. If the capillary tubes are self-sealing: Fill two tubes by inserting the end opposite the sealed end into the well-mixed EDTA blood sample. Note: If the capillary tube and the EDTA tube are held almost parallel to the table, the capillary tubes fill easily by capillary action. When the self-sealing capillary tubes are two-thirds to three-fourths filled, tilt them upright, causing the blood sample to flow down the tube and meet the sealant. Continue to hold the tube vertically when the blood contacts the sealant for an additional 15 seconds.

PURPOSE: Duplicates should always be done as a means of quality control.

b. Alternative: Fill two plain (blue-tipped) capillary tubes two-thirds to three-fourths full of a well-mixed EDTA blood sample. Tip the blood tube slightly, touching the capillary tube into the blood using the side that is opposite the blue band. When enough blood has filled the capillary tube, tip the blue end of the tube down, causing the blood to flow toward the blue tip. Then readjust the tube horizontally while inserting the blue tip of the capillary tube into the clay sealant. Insert the tube as many times as needed to achieve a plug-up to the blue band (Figure 1).

PURPOSE: Duplicates should always be done as a means of quality control. Tubes are not filled completely to provide space for the sealing clay.

 

3. Wipe the outside of the tubes with clean gauze without touching the wet open end of the tube.

PURPOSE: Wiping the outside of the capillary tube removes any blood. Touching the blood inside the capillary tube with absorbent material removes more plasma than blood cells and can alter the hematocrit.

4. Place the tubes opposite each other in the centrifuge with the sealed ends securely against the gasket (see FIGURE 34.4).

PURPOSE: The centrifuge must always be balanced to prevent damage. If the clay ends of the capillary tubes are not outermost against the gasket, the sample will spin out of the tubes, contaminating the centrifuge.

5. Note the numbers on the centrifuge slots and record the numbers on the log sheet, along with the patient’s name

PURPOSE: The sample must be identified throughout the entire procedure.

6. Secure the locking top, fasten the lid down, and lock it.

PURPOSE: If the locking top is not firmly in place during the spinning cycle, the tubes will come out of their slots and break. The lid is always locked during centrifugation for safety purposes to prevent the ejection of aerosols or broken glass.

7. Set the timer to 3 to 5 minutes and adjust the speed to 11,000 to 12,000 rpm, or as indicated by the manufacturer’s instructions.

Note: Check the manufacturer’s instructions for time and speed, as models vary.

8. Allow the centrifuge to come to a complete stop. Unlock the outer locking top and then remove the inner lid.

PURPOSE: Opening the centrifuge before it has stopped could result in harm to the user.

9. Remove the tubes immediately and read the results. If this is not possible, store the tubes in an upright position.

PURPOSE: Tubes left in the centrifuge will show altered results because the RBC layer will spread out horizontally

10. Determine the microhematocrit values using one of the following methods:

      a. Centrifuge with built-in reader using calibrated capillary tubes.

      (1) Position the tubes as directed by the manufacturer’s instructions.

      (2) Read both tubes.

      (3) The average of the two results is reported.

      (4) The two values should not vary by more than 2%.

      b. Centrifuge without a built-in reader.

      (1) Carefully remove the tubes from the centrifuge.

      (2) Place a tube on the microhematocrit reader.

      (3) Align the clay-RBC junction with the zero line on the reader. Align the plasma meniscus with the 100% line. The value is read at the junction of the red blood cell layer and the buffy coat. The buffy coat is not included in the reading (see Figure 2).

      (4) Read both tubes.

      (5) The average of the two results is reported.

      (6) The two values should not vary by more than 2%.

11. Dispose of the capillary tubes in a biohazard sharps container.

12. Disinfect the work area and properly dispose of all biohazard materials. Remove your gloves, eyewear, and lab coat.

13. Wash hands or use hand sanitizer.

PURPOSE: To ensure infection control.

14. Record the results in the Hematocrit Patient Log and document the results in the patient’s medical record. Using the normal range, identify if test results are normal or abnormal.

PURPOSE: A procedure is not considered done until it is charted.

Procedure 34.5  Perform CLIA-Waived Hematology Testing: Perform a Hemoglobin Test
TASKS:
Accurately determine the level of hemoglobin present in a blood sample using the HemoCue B-Hemoglobin System. Document the result on the lab flow sheet and in the patient’s health record.
Equipment and Supplies
            • Patient’s health record
            • Provider’s order or lab requisition
            • Hemoglobin laboratory log
            • HemoCue monitor
            • HemoCue microcuvette
            • Safety blood lancet
            • Alcohol wipes
            • Gauze
            • Fluid-impermeable lab coat, protective eyewear, and gloves
            • Biohazard waste container
            • Biohazard sharps containers


Procedural Steps
1. Perform an instrument quality control check by inserting the control cuvette into the instrument. Make sure the reading is within acceptable limits before proceeding.

PURPOSE: Only instruments that record values within acceptable control limits can be used for patient testing. If the value is outside the control limits, refer to the troubleshooting guide for the instrument or contact the manufacturer.

2. Wash your hands or use hand sanitizer. Put on a fluid-impermeable lab coat, protective eyewear, and gloves. Comply with safety practices.

PURPOSE: To ensure infection control.

3. Check the provider’s order and collect the necessary equipment and supplies.

4. Greet the patient. Identify yourself. Verify the patient’s identity with the patient’s full name; ask patients to spell their first and last names and to state their date of birth.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient.

5. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have on the procedure. Obtain permission for the capillary puncture.

PURPOSE: Explaining the procedure can make the patient feel more comfortable and reduces anxiety.

6. Examine the patient’s fingers and choose the site to be used to obtain the blood sample.

PURPOSE: The site must be free of trauma, calluses, and scarring.

7. Clean the site with an alcohol wipe or another recommended antiseptic preparation.

PURPOSE: To ensure a properly cleaned puncture site; and infection control.

8. Perform a capillary puncture and wipe away the first drop of blood.

PURPOSE: This drop may contain tissue fluid or antiseptic that may hemolyze the blood.

9. Obtain a large drop of blood on the surface of the finger.

PURPOSE: To ensure enough blood for an adequate sample.

10. Touch the microcuvette to the drop of blood. Do not touch the finger. The correct volume is drawn into the cuvette by capillary action. Wipe off any excess blood from the sides of the cuvette (Figures 1 and 2).

PURPOSE: Blood on the cuvette may alter the readings or contaminate the instrument.

 

11. Place the cuvette in the cuvette holder of the HemoCue sample door and close the door of the instrument (Figure 3).

PURPOSE: To begin the testing process.

12. Read the result.

13. Dispose of biohazard waste in the biohazard waste container and the sharps in the biohazard sharps container. Turn off the instrument. Properly disinfect the work area.

14. Remove your gloves and dispose of them in the biohazard waste container. Remove the lab coat and protective eyewear.

15. Wash hands or use hand sanitizer.

PURPOSE: To ensure infection control.

16. Record the result in the lab’s hemoglobin log and the patient’s health record. Using the normal range, determine if the test result is normal or abnormal.

PURPOSE: A procedure is not completed until the result has been recorded.

Procedure 34.6 Perform a Blood Glucose Test
TASKS:
Perform a blood test for blood glucose accurately. Document the result in the patient’s health record.
Equipment and Supplies
            • Patient’s health record
            • Provider’s order or lab requisition
            • Glucometer glucose monitoring device
            • Blood glucose test strip
            • Lancet and autoloading finger-puncturing device
            • Alcohol wipes
            • Gauze
            • Fluid-impermeable lab coat, protective eyewear, and gloves
            • Biohazard waste container
            • Biohazard sharps container
Procedural Steps
1. Check the provider’s order and collect the necessary equipment and supplies. Perform quality control measures according to the manufacturer’s guidelines and office policy.

Note: A variety of blood glucose monitors are available for testing blood glucose. Follow the specific instructions given by each individual manufacturer in the monitor/kit package insert.

2. Wash hands or use hand sanitizer. Put on a fluid-impermeable lab coat, protective eyewear, and gloves. Comply with safety practices.

PURPOSE: To ensure infection control.

3. Greet the patient. Identify yourself. Verify the patient’s identity with the patient’s full name; ask patients to spell their first and last names and to state their date of birth.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient.

4. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have on the procedure. Obtain permission for the capillary puncture.

PURPOSE: Explaining the procedure can make the patient feel more comfortable and reduces anxiety.

5. Ask the patient to wash his or her hands in warm, soapy water, then rinse them in warm water, and finally dry them completely.

PURPOSE: To clean the area that will be punctured; also, warming the fingers may increase peripheral blood flow.

6. Check the patient’s middle and ring fingers and select the site for a puncture (both forearm and fingertip testing can be done).

PURPOSE: To make sure the site of puncture is free of trauma.

7. Turn on the glucometer by pressing the ON button (Figure 1). Coding may or may not be necessary, depending on the monitor; follow the package insert directions for the specific glucose monitor you are using.

8. Check the expiration date on the test strip container. Take out a test strip and insert it into the glucometer.

PURPOSE: Test strips should not be used if they have expired.

9. Cleanse the selected site on the patient’s fingertip with an alcohol wipe and allow the finger to air-dry.

PURPOSE: To ensure infection control.

10. Perform the capillary puncture and wipe away the first drop of blood.

PURPOSE: Tissue fluid may be present in the first drop of blood.

11. Apply a small blood sample to the end of the test strip (Figure 2).

12. Give the patient gauze to hold securely over the puncture site; apply a hypoallergenic bandage or wrap if needed.

PURPOSE: To aid in the stoppage of blood flow.

13. Read the test results before the glucometer turns off.

Note: The glucometer automatically begins the measurement process, and results are obtained as soon as 4 seconds. The test result is shown in the display window in milligrams per deciliter (mg/dL) for most glucometers. Read the manufacturer’s instructions to find out how the result is displayed. The glucometer will likely turn off automatically.

14. Discard all biohazard waste in biohazard waste containers and the sharps in the biohazard sharps container.

PURPOSE: To ensure infection control.

15. Clean the glucometer according to the manufacturer’s guidelines. Disinfect the work area.

16. Remove your gloves and dispose of them properly. Remove protective eyewear.

17. Wash hands or use hand sanitizer.

PURPOSE: To ensure infection control.

18. Record the test results in the patient’s health record.

PURPOSE: A procedure is not complete until the patient’s results have been recorded.

Documentation Example
08/16/20XX 1:00 p.m. Glucometer screening completed as ordered by Dr. Misha. NFBS 144. Pt took a routine dose of 10 units of Humalog insulin at noon. Pt had no questions. ————————————————————————————————————————————————————————————————————————- Anita James, CMA (AAMA)


Procedure 34.7 Perform a CLIA-Waived Chemistry Test: Determine the Cholesterol Level or Lipid Profile Using a Cholestech Analyzer
TASKS:
Perform a Cholestech test for total cholesterol level or a lipid panel and accurately report the results. Document the result on the lab flow sheet and in the patient’s health record.
Equipment and Supplies
            • Patient’s health record
            • Provider’s order or lab requisition
            • Cholestech analyzer
            • Package insert or flow chart with directions
            • Optics check cassette
            • Test cassettes (provided by Cholestech)
            • Levels 1 and 2 liquid controls
            • Capillary tubes and plungers for fingerstick sample (provided by Cholestech)
            • Mini-Pet pipet and pipet tips for venipuncture sample (provided by Cholestech)
            • Lancet, gauze, alcohol wipes, bandage for capillary blood, or lithium heparin (green-topped) tube for venous blood
            • Safety tube decapper (if tubes do not have a Hemogard plastic top)
            • Fluid-impermeable lab coat, protective eyewear, and gloves
            • Biohazard waste container
            • Biohazard sharps containers
Procedural Steps
1. Check the provider’s order and collect the necessary equipment and supplies. Allow refrigerated testing cassettes to come to room temperature (at least 10 minutes before opening).

PURPOSE: The test is temperature and time-sensitive when reading results.

2. Wash hands or use hand sanitizer. Put on a fluid-impermeable lab coat, protective eyewear, and gloves. Comply with safety practices. Assemble the materials needed.

PURPOSE: To ensure infection control.

3. Perform quantitative quality control by performing a calibration check with the optics check cassette (Figure 1). Then test level 1 and level 2 liquid controls if using a new set of cassettes.

PURPOSE: To ensure that the instrument is reading results accurately, precisely, and reliably.

4. Greet the patient. Identify yourself. Verify the patient’s identity with the patient’s full name, ask the patient to spell the first and last name, and state the date of birth.

5. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have on the procedure. Obtain permission for a capillary puncture.

6. Remove the cassette from its pouch and place it on a flat surface without touching the black bar or magnetic strip.

PURPOSE: The black bar is the testing area, and the magnetic strip must be read by the analyzer. Touching either may interfere with test results.

7. Press RUN on the analyzer, allowing it to do a self-test; this will be followed by OK on the screen, then the test drawer will open. The drawer will stay open for 4 minutes while the specimen is prepared.

PURPOSE: Ensures the instrument’s electronics are working properly before patient testing.

8. Perform a fingerstick and collect the capillary blood to the black line of the Cholestech capillary tube with its plunger inserted into the red end of the tube. Or collect the fresh venous whole blood with the Cholestech Mini-Pet pipet.

PURPOSE: Both collecting devices are provided by Cholestech to ensure that the exact volume of blood necessary is tested.

9. Place the whole blood sample into the well of the cassette.

Note: The capillary specimen must be in the cassette within 5 minutes of collection (Figure 2).

PURPOSE: Fingerstick blood will clot if not tested within 5 minutes.

 

10. Immediately put the cassette into the drawer of the analyzer and press RUN. (Note: If the drawer has closed, press RUN again to open the drawer; load the specimen into the drawer and then press to close the drawer.) When the test is complete, the analyzer beeps. The screen displays and then prints out the results (Figure 3).

PURPOSE: This is a test with a color reaction that continues to change over time.

 

11. Dispose of all sharps in the biohazard sharps container (i.e., lancet and capillary pipet with plunger). Place all regulated medical waste into the biohazard waste container (i.e., gauze, alcohol wipes, and cassettes).

12. Disinfect test area, remove PPE, and dispose of gloves in biohazard waste container.

13. Wash hands or use hand sanitizer.

PURPOSE: To ensure infection control.

14. Record the findings in the laboratory log and in the patient’s health record. Using the normal range, determine if the test result is normal or abnormal. If using paper health records, circle the results that do not fall within the Desirable Ranges column of the following table. Identify critical values and take appropriate steps to notify the provider. Document the steps taken.

PURPOSE: A procedure is not considered complete until it has been recorded.