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PATHOLOGY

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					                           Dartford and Gravesham NHS Trust
                                        Darent Valley Hospital




  HAEMATOLOGY

                        USERS

           HANDBOOK

                        Darent Valley Hospital
                         Darenth Wood Road
                              Dartford
                              DA2 8DA

              Direct Line : Haematology 01322 428506
                            Transfusion 01322 428502




2nd Edition July 2007

                                                             1
                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital

Medical and Scientific staff within Haematology have compiled this handbook. It
has been designed to help our users gain knowledge of our services and ensure a
full understanding of that service to enable you to use them to their full potential.


The information is accurate at time of issue, but is reviewed and updated regularly
to incorporate new developments.

Please feel free to make any comments or suggestion about this Handbook so that
we can match your requirements in future editions.



Haematology Management Group
1st Edition January 2006
2nd Edition July 2007




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       Dartford and Gravesham NHS Trust
                    Darent Valley Hospital




Timely, Accurate Results,
Providing Effective Care




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                           Dartford and Gravesham NHS Trust
                                        Darent Valley Hospital



                                     Pathology Services – General Information


                                CONTENTS

1. GENERAL INFORMATION                                                 PAGE
1.1 Pathology Department Key Personnel                                 5
1.2 Opening Hours                                                      6
1.3 Pathology Sample Delivery Service                                  7
1.4 Air Tube Sample Delivery Service                                   7
1.5 Report Availability                                                8
1.6 Out-of-Hours Service                                               9

2.    SPECIMEN COLLECTION (GENERAL)
2.1   Potentially Infectious Specimens and High Risk Specimens         9
2.2   Requesting Tests                                                 10
2.3   Specimen Labelling                                               10
2.4   Unlabelled Specimens                                             11

3.    BLOOD SPECIMENS
3.1   Venous Blood Collection                                          12
3.2   Lymph Nodes                                                      12

4.    TRANSFUSION TRAINING FOR STAFF                                   13
5.    TRANSFUSION NEWSLETTER                                           13
6.    VISITORS TO THE LABORATORY                                       13
7.    SECURITY                                                         13
8.    RULES OF GOOD LABORATORY PRACTICE                                14
9.    BLOOD TUBE COLOUR CODE HAEMATOLOGY
                 & TRANSFUSION                                         15

HAEMATOLOGY/BLOOD TRANSFUSION                                          16-30




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                         Dartford and Gravesham NHS Trust
                                      Darent Valley Hospital



1.    GENERAL INFORMATION


1.1   Pathology Department Key Personnel


Department                 Telephone Extension   E-Mail Address
General Manager                       8499       sophie.glew@
Sophie Glew                                      dvh.nhs.uk
Clinical Director                     8478       colin.farquhar@
Colin Farquhar                                   dvh.nhs.uk
Haematology/ Transfusion
Dr. Ralph Ezekwesili                  8505       raphael.ezekwesili@
Lead Consultant Haematologist                    dvh.nhs.uk
Dr. Tariq Shafi                       8504       tariq.shafi@
Consultant Haematologist                         dvh.nhs.uk
Shirley Hannam                     8503/4884     shirley.hannam@
Senior Chief Biomedical                          dvh.nhs.uk
Scientist
Keith Holmes                       8503/4884     keith.holmes@
Senior Chief Biomedical                          dvh.nhs.uk
Scientist
Leslie Delieu                         4666       leslie.delieu@
Transfusion Practitioner                         dvh.nhs.uk




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                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital




1.2   Opening Hours


Pathology Help Desk                            Telephone 01322 428491


The Help Desk will be pleased to answer all your enquiries about Pathology
results, services and the department; they can also deal with routine day-to-day
administrative issues. For technical and clinical advice, they will ensure that your
enquiry is directed to a suitably qualified person in the relevant department.

Routine Opening Hours:

Pathology Reception
Monday – Friday
08.30 –17.00hrs

Haematology Laboratory
Monday – Friday
09.00 – 17.00hrs

Phlebotomy Out Patients Darent Valley
Monday – Friday
08.30 – 16.55hrs

There is an on-call rota for all other times out of routine hours for each laboratory.
There is no on-call service for Phlebotomy

On-Call
Monday – Friday
17.00 – 09.00hrs
Weekends and Bank Holidays 24hrs on-call cover.
Contact on-call BMS and Medical Staff through switchboard




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                             Dartford and Gravesham NHS Trust
                                          Darent Valley Hospital




1.3   Pathology Sample Delivery Service

Appropriate Pathology samples (see below) may be sent to the department by the
pneumatic air tube delivery system from a variety of locations in the hospital at
Darent Valley –
                     Phlebotomy Outpatients
                    Accident and Emergency (A/E)
                    Intensive Care Unit(ICU)
                    Tambootie Ward (SCBU)
                    Rosewood Ward
                    Woodlands Treatment Centre
                    Redwood Ward
                    Cherry Ward
In all other areas of the hospital, samples are sent to Pathology via the portering
services. If the pneumatic air tube system is not working samples should be sent
via the porting services, contact the Help Desk on 8888
Sample can also be transported via our Courier Service from GP surgeries covered
by that service.

Urgent Specimens
It is the responsibility of the person taking the sample to contact the portering
services to arrange speedy delivery to the laboratory or send via the pneumatic air
tube system. It is suggested that the laboratory concerned is contacted to expect
delivery of the urgent specimen.

Blood specimens must not be kept on the ward overnight

1.4    Pneumatic Air Tube Sample Delivery System

The pneumatic air tube system has been provided primarily for the transport of
pathology specimens. (See separate Trust Policy for the use of the pneumatic air
tube system)

The pneumatic air tube system must not be used for:

Blood Products including used blood/FFP/platelets bags
Histology Specimens
Blood Culture bottles



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                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital
Known High Risk samples (e.g. viral haemorrhagic fever cases) or suspected
emerging diseases
Blood gases


Transporting Samples

All sample containers must be properly closed and packed in a dedicated leak-
proof Pathology specimen bag, with the request form in the attached unsealed
pouch. The sample(s) should be secured in the air tube carrier pod using
appropriate packaging (e.g. paper towels) to prevent excessive movement of the
sample during transportation and help prevent breakages and leaks.

It is the responsibility of the sender to ensure that:
a. The sample is labelled, packed appropriately and is accompanied by the relevant
paperwork.
b. The air tube sample carrier is secured properly before transport.
c. The air tube sample carrier is sent to the correct ‘system’ address.

Instructions for use of the system are at each pneumatic tube station

Spillages and Leaks

Specimen bags containing leaking containers will be discarded and the sender
notified. Where the leak has not contaminated the air tube carrier, no further action
will be necessary.

If the leak has contaminated the inside of the air tube carrier, the carrier will be
taken out of service and decontaminated appropriately.

If the air tube system has been contaminated by the leak, the system will be closed
down and the decontamination process commenced.
All areas with an air tube station will be notified to ensure other arrangements for
sample transportation can be put in place.
Once the decontamination process is complete and the air tube system is working,
the users will be notified.

1.5 Report Availability

Monday – Friday
All specimens for routine tests in Haematology received in the laboratory by
17.00hrs will usually be reported the same day.



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                             Dartford and Gravesham NHS Trust
                                          Darent Valley Hospital
All authorised results are available on the Laboratory computer system
(Telepath)



1.6 Out of Hours Service

Outside routine working hours (Monday – Friday) an On-call service is provided
for urgent specimens and clinical advice. Contact the Haematology BMS on-call
and the Consultant Haematologist on-call via the switchboard. See On-Call
Protocol for details of contact.




2. SPECIMEN COLLECTION (GENERAL)

2.1 Potentially Infective Specimens and High Risk Specimens

All specimens, but particularly those from patients suspected of having certain
blood borne and other infectious diseases, constitute a hazard to portering and
laboratory staff handling the specimen.
All specimens are therefore managed according to standard principles applied
universally.
Staff are reminded to wear gloves when handling blood, body fluids and tissue
samples.
If a patient is in a particularly high risk group e.g. viral haemorrhagic fever, SARS,
anthrax please contact the laboratory for further advice on sample testing.

Sending Specimens off Site

Specimens to be sent for testing at another hospital must always be sent via the
Pathology Laboratory. This will ensure correct packaging and provide an audit trail
for each sample.




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                             Dartford and Gravesham NHS Trust
                                          Darent Valley Hospital




2.2 Requesting Tests

All general Haematology requests must be on a Pathology Request Form , as well
as requests to Transfusion for Direct Anti-globulin test ( D.A.T.), Cold Agglutinin
screening , Cord blood ABO & D.A.T. or Kleihauer . Other Transfusion requests
for Blood grouping, Crossmatching etc must use the dedicated Transfusion request
form.
The information on the request form and the specimen bottle must correspond and
minimum details acceptable are set out in 2.3 Specimen labelling, sections a) – f )
The clinical summary section on the form must be completed, including relevant
information on patients’ medication e.g. warfarin therapy.
Incomplete forms may cause delays in availability of results.
Incorrectly labelled samples may be discarded.
If further Haematology tests are required on a sample already received by the
laboratory the requestor must contact the laboratory and the test be requested
verbally. If further specimens are required, the requestor will be informed at the
time of request. Additional tests can only be accepted on the same day as the
sample was taken.

2.3 Specimen Labelling

All specimens must have the following Patient Information:
    a) Patient surname
    b) Patient first name
    c) Patient Date of Birth ( if known * )
    d) Patient NHS number or Hospital ( PAS ) registration number for all
       Transfusion requests
    e) Location ( Ward, GP with address )
    f) Date and time of sampling
    g) Signature of person taking the sample
* If patient Date of birth is not known, the Hospital ( PAS ) or NHS number must
be used so that identity is established sufficiently.
 Hospital ( PAS ) or NHS numbers should always be used on Haematology
requests when known, as this aids successful allocation and maintenance of a
single patient file on the Laboratory computer , which in turn aids effective and
speedy result retrieval for users.




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                             Dartford and Gravesham NHS Trust
                                          Darent Valley Hospital
   Positive patient identification is essential and in-patients should have their
   wristbands checked before blood is drawn.
   Sample bottles must not be pre labelled before blood is drawn.

   Specimens received without full patient I.D. may be discarded and the
   appropriate doctor/ward informed. All unlabelled specimens will be
   discarded and the ordering doctor/department informed.


General Considerations

Printed labels may be used on Haematology samples and request forms, providing
they contain the appropriate information and are in the correct format. Check with
the Laboratory before introducing printed labels to ascertain their suitability.
The Blood Transfusion Department will not accept printed labels and will discard
samples and request forms labelled this way.

All sample containers must be properly closed and packed in a dedicated specimen
bag, with the request form in the attached unsealed pouch.

2.4 Unlabelled Specimens

As a general matter of quality assurance and good risk management any sample
arriving in the laboratory unlabelled will be discarded. The requesting doctor will
be informed and a repeat sample requested.




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                            Dartford and Gravesham NHS Trust
                                         Darent Valley Hospital



3. BLOOD SPECIMENS

3.1 Venous Blood Collection

ONLY AUTHORISED PERSONS SHOULD TAKE VENOUS BLOOD

An evacuated blood collection system is used for venous blood collection within
the Trust. A needle and syringe system is available for paediatric patients.

IMPORTANT NOTE: If taking blood using a syringe and needle do not
transfer the blood into a vacutainer by using the vacuum to draw the blood into
the bottle. This haemolyses the sample. If you are not sure about blood collection
techniques please contact the laboratory on extension 8506.

The laboratory is only responsible for the Phlebotomy Outpatient Department at
Darent Valley. This is situated on Level 2 in the Outpatient Department. Hospital
ward phlebotomy is the responsibility of the specialty on that ward i.e. medical,
surgical etc and is managed by the directorate concerned.

3.2 Lymph Nodes

The laboratory MUST always be contacted prior to the lymph node being removed.
Please refer to the policy on Dealing with Lymph Nodes.

.




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                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital


4. TRANSFUSION TRAINING FOR STAFF

ALL staff handling blood or blood products MUST undertake mandatory training.
This training ensures the safest practice in clinical care. Update courses should be
completed annually. For further details contact the Transfusion Practitioner on
ex4666 or the Philip Farrant Education Centre on ex8551.

5. TRANSFUSION NEWSLETTER

The Transfusion Newsletter is still under development. It will be published
quarterly and aim to discuss issues pertinent to transfusion. It will contain updates
on guidelines for transfusion and published SHOT data with respect to Darent
Valley Hospital. Please contact the Transfusion Practitioner or Senior Chief BMS
in Transfusion for further details.

6. VISITORS TO THE LABORATORY

All visitors to Pathology should report to Pathology Reception. Pathology
Reception staff are responsible for meeting and greeting all visitors and will inform
laboratory personnel of the arrival of the visitors. All visitors must sign in the
visitors’ book on arrival and will be issued with a visitor’s badge. On departure
visitors must sign out the visitors’ book and return the badge to the reception staff.
Laboratory personnel will escort visitors at all times.

7. SECURITY

All doors to the Pathology Department are locked at all times. Entry is for
authorised staff only. All other personnel must report to Pathology Reception.




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                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital



8. RULES OF GOOD LABORATORY USAGE

8.1 The Haematology Laboratory operates a normal working day of 09.00hrs to
17.00hrs. Monday to Friday. All other times are covered by the out of hours
service. Where possible please organise routine samples to arrive by 16.30hrs. All
non-urgent work arriving after 17.00hrs will be refrigerated and tested the
following day. Samples not suitable for refrigeration e.g. clotting screens will be
discarded.

8.2 Complete the request form with care. Please ensure ALL information is given
including clinical details. These are essential if the correct tests are to be carried
out, to aid interpretation and help with appropriate advice where relevant.

8.3 On-call tests should only be those required for the immediate care of the
patient.

8.4 If the request is clinically urgent please contact the laboratory and give the
appropriate information to ensure appropriate priority is afforded.

8.5 A successful Pathology service depends on the quality of the relationship
between requestors and providers. Please feel free to visit the department and meet
the staff.




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                                 Dartford and Gravesham NHS Trust
                                              Darent Valley Hospital


9. BLOOD TUBE COLOUR CODE FOR HAEMATOLOGY
           & TRANSFUSION
Haematology
- Phone 8506 if test not listed or there is uncertainty
ONE sample only sufficient - unless specified
      TEST                                             COLOUR TUBE

Anti – Cardiolipin Antibodies                       Gold
Anti-thrombin 111                                   Blue – One sample
Anti Xa level                                       Blue – One sample
APTT                                                Blue
B2 Microglobulin                                    Gold
B12 & Folate                                        Gold
BCL-abl                                             Mauve x 2
Blood film                                          Mauve
CD4 / CD8 Count                                     Mauve
Cell Markers ( bottles in Haem Lab )                Mauve
Coagulation Screen                                  Blue
Cyclosporin                                         Mauve
Cytogenetics / Chromosome studies                   Dark Green
D Dimers                                            Blue
Erythropoetin level                                 Gold
ESR                                                 Mauve
Factor V111                                         Blue – One sample
Factor V Leiden                                     Mauve
Ferritin                                            Gold
FK 506                                              Mauve
Fragile X                                           Mauve
Full Blood Count                                    Mauve
Haemoglobinopathy Screen                            Mauve
HLA B27                                             Mauve
Karyotyping                                         Dark Green
Malarial Parasites / Screen                         Mauve
N.A.P. Score                                        Mauve
Paul Bunnell / Monospot – must have FBC             Gold if possible
Protein C                                           Blue – One sample
Protein S                                           Blue – One sample
Prothrombin Gene Mutation                           Mauve
Prothrombin Time / INR                              Blue
Red Cell Folate                                     Mauve
Sickle Test                                         Mauve
Viscosity                                           Mauve

Transfusion
Blood Group & antibody screen                        Pink
- for enquiries about other Transfusion requests please phone ex 8502.



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                            Dartford and Gravesham NHS Trust
                                         Darent Valley Hospital


   DEPARTMENT OF HAEMATOLOGY AND BLOOD TRANSFUSION

1. GENERAL INFORMATION                                               PAGE
1.1 Key Personnel                                                      17
1.2 Anticoagulant Clinics                                             18
1.3 Haematology Clinics                                               18
1.4 Thrombophilia Clinic                                              18

2. HAEMATOLOGY AND BLOOD TRANSFUSION TESTS
2.1 Routine Tests (and urgent/abnormal results)                       19
2.2 Coagulation Studies                                               20
2.3 Reference ranges for Routine Haematology tests                    21
2.4 Thrombophilia Studies                                             22/3
2.5 Special Tests                                                     24
2.6 Details of Referral Laboratories used                             25/6
2.7 Blood Transfusion Tests                                           27
2.8 Blood Products                                                     28

3. TRANSFUSION REACTION
3.1 Action                                                            29
3.2 Samples Required                                                  29

4. BLOOD PRODUCTS
4.1 Red Blood Cells                                                  30
4.2 ‘Flying Squad’ Blood                                             30
4.3 Platelet Concentrates                                            31
4.4 Fresh Frozen Plasma                                              31
4.5 Anti-D Immunoglobulin                                            32

5. URGENT CROSSMATCH REQUESTS
5.1 Urgency and Options                                              33
5.2 Contacting the Transfusion Laboratory for Urgent requests        33
5.3 Identification of Urgent samples and request forms               33




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                            Dartford and Gravesham NHS Trust
                                         Darent Valley Hospital



1. GENERAL INFORMATION

1.1 Key Personnel

Lead Consultant Haematologist       Dr Raphael Ezekwesili 01322 428505

Consultant Haematologist            Dr Tariq Shafi          01322 428504

Specialist Registrar                On rotation             Bleep 546

Haematology SHO                     On rotation

Senior Chief Biomedical Scientist Mr. Keith Holmes          01322 428503
Haematology
Senior Chief Biomedical Scientist Mrs. Shirley Hannam       01322 428503
Blood Transfusion
Emergency Out of Hours Service Haematology                  Contact via
                                  Blood Transfusion         Switchboard


Please also use the following numbers when appropriate: -

Results Inquiry                      01322 428491 Pathology Help Desk
                                     01322 428506 Haematology
                                     01322 428502 Blood Transfusion
Haematology Secretary                01322 428507
for clinical enquiries
Fax                                  01322 428134




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                            Dartford and Gravesham NHS Trust
                                         Darent Valley Hospital
1.2 Anticoagulant clinics

Darent Valley Hospital
Wednesday 9.00 – 11.00

Darent Valley Hospital
Thursday 14.00 – 16.00


1.3 Haematology clinics

Darent Valley Hospital
Wednesday 9.00 – 12.00
Wednesday 14.00 – 16.00
Friday     9.00 – 12.00

1.4 Thrombophilia clinic

Darent Valley Hospital
Thursday 10.00 – 12.00 on alternate weeks




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                                   Dartford and Gravesham NHS Trust
                                                Darent Valley Hospital
2. HAEMATOLOGY AND BLOOD TRANSFUSION TESTS
2.1 Routine Tests
Because of limited staffing resources at weekends, routine working days are
Monday to Friday
SPECIMEN         TEST GROUP COMMENTS                       LABORATORY
REQUIRED                                                   TURNAROUND
4ml blood in       FBC, platelets                                  1 working day
MAUVE top          and differential ,
bottle (EDTA)      unless blood film
                   required

                   ESR                                             1 working day

                   Blood Film                                      3 working days
                   Reticulocytes                                   2 working days
       
                   Malarial parasites   All positive results
                                        telephoned same day.
                                        Please give countries      2 working days
                                       visited, recent
                                        malaria prophylactic
                                        drugs and contact
                                        number with request
6mL. blood in      Paul Bunnell         FBC sample should          2 working days
GOLD top bottle                         also be sent

4ml blood in       Sickle Cell screen   For investigation of
MAUVE top          and Haemoglobin      abnormal haemoglobin.      3 working days
bottle (EDTA)      studies (HPLC)       Telephone laboratory
                                        with urgent requests.
                                        Sickle Cell status
                                        available in 20 minutes.
                                        (Please telephone
                                        Laboratory)
                                        Give ethnic origin
6mL. blood in      Vitamin B12 and                                 3 working days
GOLD top bottle    Serum Folate
                   Ferritin                                        3 working days
       
4mL. blood in      Red Cell Folate      Please contact           3 working days
MAUVE top                               Consultant Haematologist
bottle                                  for advice
4mL. blood in      HLA B27                                       5 working days
MAUVE top
bottle

Urgent or seriously abnormal results will be phoned to the ward or Doctor




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                               Dartford and Gravesham NHS Trust
                                            Darent Valley Hospital
2.2 Coagulation Studies


SPECIMEN            TEST GROUP            COMMENTS               LABORATORY
REQUIRED                                                         TURNAROUND
1.8 mL. blood in    Clotting Screen       Includes PT, APTT,
LIGHT BLUE top                            INR, APTR.
citrate bottle                            Laboratory will do 1 working day
                                          additional tests if
                                          indicated
                    Prothrombin time                          1 working day
      

                    APTT for heparin      Please state if patient 1 working day
                   control               is on anticoagulants

                    INR for oral          Please give clinical
                   anticoagulant control details and details    1 working day
                                          of anticoagulation
                   Fibrinogen                                   1 working day

                   D-Dimer               Please give clinical   1 working day
                                          details

Samples that are significantly under filled will not be tested as results will be
meaningless.
Smaller volume blood tubes are available for difficult to bleed patients.




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                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital
2.3 Reference ranges for Routine Haematology tests

     White Blood cell Count                           4.0 - 11.0 x 10*9 / l
     Haemoglobin         Men                          13.0 – 17.0 g/dl
                         Women                        12.0 – 16.0 g/dl
                         Children                     11.0 – 15.0 g/dl
     Red Cell Count      Men                          4.4 – 5.8 x 10*12/l
                         Women                        3.8 – 5.0 x 10*12/l
     Haematocrit ( PCV )Men                           0.40 - 0.52 l/l
                        Women                         0.36 - 0.48 l/l
                        Children                      0.33 - 0.45 l/l
     M.C.V.              Adults                       80 - 98 fl
                         Children                     76 - 96 fl
     M.C.H.              Adults                       27.0 - 33.0 pg
                         Children                     26.0 - 33.0 pg
     R.D.W.                                           11.0 – 16.0
`    Platelets                                        140 - 400 x 10*9 / l

     Reticulocytes      Adults & children             20 – 100 x 10*9/l

     Differential W.B.C. Adults       - Neutrophils 2.0 - 7.5 x 10*9 / l
                                      - Lymphocyte 1.5 - 4.0 x 10*9 / l
                                      - Monocytes 0.1 - 0.8 x 10*9 / l
                                      - Eosinophils   0 - 0.4 x 10*9 / l
                                      - Basophils     0 - 0.1 x 10*9 / l
                         Children 6 y - Neutrophils 2.0 - 6.0 x 10*9 / l
                                      - Lymphocytes 5.5 - 8.5 x 10*9 / l
                                      - Monocytes 0.4 - 1.4 x 10*9 / l
                                      - Eosinophils   0 - 0.8 x 10*9 / l
                                      - Basophils     0 - 0.1 x 10*9 / l

     E.S.R.                                           up to 15mm/hr
     Prothrombin Time                                 11.5 – 14.5 secs
     I.N.R.                                           0.9 – 1.1
     A.P.T. Ratio                                     0.9 – 1.1
     Fibrinogen                                       1.5 - 4.5 g/l
     D Dimer                                          up to 240 ng/ml
     Serum B12                                       160 - 970 ng/l
     Serum Folate                                    2.8 - 14.9 ug/l
     Red Cell Folate                                 Greater than 160 ng/l
     Serum Ferritin      Male - 13 yrs upwards       10 - 300 ug/l
                         Female 13 - 45 yrs          10 - 83 ug/l
                         Female 45 upwards           10 – 300 ug/l
                         Children up to 13 yrs        8 - 60 ug/l


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                                Dartford and Gravesham NHS Trust
                                             Darent Valley Hospital
2.4 Thrombophilia Studies
Requests for these tests should be discussed with a Consultant Haematologist, prior
to submission of specimens, so that appropriate testing is instigated, as well as
clinical follow up where necessary. Where Consultant advice has not been sought
prior to submission of specimens for Thrombophilia testing, the Laboratory may
reject the request.
Antiphospholipid screening, such as in cases of repeated miscarriage, will be
accepted if requested directly by a Consultant.

SPECIMEN              TEST GROUP                COMMENTS LABORATORY
REQUIRED                                                 TURNAROUND
3x 1.8 mL. blood in Thrombophilia Screen        Test not done
LIGHT BLUE top                                  in-house,
citrate bottle      Includes the following      turnaround time   8 weeks
                                                is an
                    Free Protein S              approximation
                    Protein C
                    Antithrombin
                    APC Resistance
2x 1.8 mL. blood in Antiphospholipid            Test not done
LIGHT BLUE top      Screen                      in-house,
citrate bottle                                  turnaround time   8 weeks
                    Includes the following:     is an
                                                approximation
1 x 6.0 ml blood in   -Anti Cardiolipin
Gold top SST          antibodies (IgG +IgM)
                      -Lupus anticoagulant by   DRVVT cannot
                      Dilute Russell Viper      be performed if
                      Venom Time                patient is
                      ( DRVVT)                  anticoagulated
4ml blood in          Factor V Leiden           Test not done
MAUVE top             includes Prothrombin      in-house,         8 weeks
bottle (EDTA)         G20210A mutation          turnaround time
                                                is an
                                                approximation

A Standard Repertoire of Tests for Thrombophilia investigation
Full blood count
Clotting screen
Antithrombin, Protein C, Protein S levels
Factor V Leiden and Prothrombin gene mutation
Anti Cardiolipin antibodies and lupus anticoagulant (DRVVT)
Anti-nuclear Factor (ANF)




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                             Dartford and Gravesham NHS Trust
                                          Darent Valley Hospital
Timing of Testing

Prothrombotic testing is best performed when the coagulation system is in a
steady-state, and is best avoided:

(i) in an acute thrombotic state
(ii) during anticoagulant treatment
(iii) during pregnancy or the puerperium
(iv) when taking oestrogen containing contraceptive pills or hormone replacement
therapy

There will be occasional situations where testing during the above is beneficial, but
these should be discussed with Haematology medical staff to ensure that the
interpretation made and advice given is valid.




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                                Dartford and Gravesham NHS Trust
                                             Darent Valley Hospital
2.5 Special Tests

SPECIMEN          TEST GROUP             COMMENTS              LABORATORY
REQUIRED                                                       TURNAROUND
4ml blood in      HLA typing             Monday to Friday      1 week
MAUVE top                                only
bottle (EDTA)
6mL. blood in     Beta 2 Microglobulin                         2 weeks
GOLD top bottle

      *           Platelet antibodies    By arrangement with   4 weeks
                                         Haematologist
6mL. blood in     Erythropoietin         By arrangement with   2 weeks
GOLD top bottle                          Haematologist
                 Bone marrow             By arrangement with   2 weeks
       *         investigation           Haematologist
Early morning    Haemosiderin            Discuss with          1 week
urine                                    Haematologist
4.0 ml blood in  Cell Markers            Discuss with          1-2 weeks
MAUVE top bottle                         Haematologist

* tubes available from the Haematology Laboratory extension 8506

N.B. The above is not a complete list of all tests performed and other less common
tests can also be provided by consultation with the Haematologist. We are always
available to help and advise. The ‘Laboratory Turnaround time’ indicates the time
by which results will be available within the laboratory.




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                            Dartford and Gravesham NHS Trust
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2.6 Referral Laboratories used by Haematology and Transfusion

A number of specialist tests are referred to other Laboratories for testing.
These laboratories are subject to change and it would be advisable to
approach Haematology at Darent Valley first to find out the situation at that
time. However, whilst this list cannot be definitive, it currently includes –



         Tests referred                 Referral Laboratory
Protein C , Protein S ,            Coagulation Laboratory
Antithrombin , Anticardiolipin     University College London
antibodies , DRVVT , Anti – Xa ,            Hospitals NHS Trust
                                    nd
APCR                               2 Floor
Plasma Viscosity                   60, Whitfield Street
Methyl                             London W1T 4EU
Tetrahydrafolate Reductase
Factor V Leiden , Prothrombin      Haemophilia Laboratory
Gene mutation                      East Kent Hospitals NHS Trust
                                   Kent and Canterbury Hospital
                                   Canterbury
                                   CT1 3NG
Coagulation Factor assays          Haemostasis Laboratory
( V11 ,V111 , 1X , X, X1 , X11 )   4th Floor , North Wing
vWF Antigen , vWF Activity         St Thomas’s Hospital
HIT screen , PFA 100 ,             Lambeth Palace Road
Inhibitor screen inc Bethesda      London SE1 7EH
Confirmation of Malaria type       Dept. of Clinical Parasitology
                                   3rd Floor
                                   Hospital for Tropical Diseases
                                   Mortimer Market Capper St.
                                   London WC1E 6AU
Specialist Haemoglobinopathy       Haematology Department
investigation , G6PD / PK or       Kings College Hospital
other Red Cell enzyme assay        Denmark Hill
                                   London SE5 8RX
Serum Erythropoetin , serum        Biochemistry Department
Haptoglobin                        Kings College Hospital
                                   Denmark Hill
                                   London SE5 8RX
Cyclosporin level , Tacrolimus     Immunosuppressive Drug
level                                     Monitoring section
                                   Kings College Hospital

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                          Dartford and Gravesham NHS Trust
                                       Darent Valley Hospital
                                         ( As above )
           Tests referred                   Referral Laboratory
Beta 2 Microglobulin                Biochemistry Department
                                    Queen Elizabeth Hospital
                                    Stadium Road
                                    Woolwich
                                    London SE18 4QH
Cell Markers ( immunophenotyping) Special Haematology Laboratory
, ZAP 70 , JAK 2 mutation , P50     4th Floor
                                    St Thomas’s Hospital
                                    Lambeth Palace Road
                                    London SE1 7EH
Bone Marrow & Lymph node            Cytogenetics Department
Cytogenetics                        Rayne Institute
                                    123, Coldharbour Lane
                                    London SE5 9NU
Chromosome analysis , Fragile X     Genetics Centre
                                    5th Floor , Guy’s Tower
                                    Guy’s Hospital
                                    St Thomas Street
                                    London SE1 9RT
Complex Red Cell Antibody           National Blood Service
Investigations , HLA investigations 37, Cranmer Terrace
( not HLA B27 ) , Platelet          Tooting
Immunology                          London SW17
Granulocyte Immunology              National Granulocyte Immunology
                                                 Laboratory
                                    National Blood service
                                    Southmead Road
                                    Bristol BS10 SND




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                                   Dartford and Gravesham NHS Trust
                                                Darent Valley Hospital

2.7 Blood Transfusion Tests

SPECIMEN              TEST GROUP           COMMENTS             LABORATORY
REQUIRED                                                        TURNAROUND
6ml blood in PINK     Full blood group    *Sample MUST
top round bottom      and antibody screen have patient’s full
bottle (EDTA)                             name, hospital
                                          number, date of birth, 2 working days
                                          date sample taken,
                                          and be signed by the
                                          person taking the
                                          sample. DO NOT
                                          USE pre- printed
                                          labels*
                      Emergency blood
       “              group                       “              15 minutes

                      Routine crossmatch                        1 working day
       “                                         “

                      Emergency                                 40 minutes
       “              crossmatch                 “

6ml blood in RED      Cold agglutinins    As above *-* PLUS
top bottle                                very important that   5 working days
(no anticoagulant)                        the sample is taken
This bottle is only                       into a warm bottle
available directly                         kept at 37oC
from Transfusion                          and taken directly
                                          to the laboratory
4ml blood in          Direct antiglobulin As above *-*          1 working day
MAUVE top             test (DAT)
bottle (EDTA)
4ml blood in          Kleihauer            As above *-*         2 working days
MAUVE top
bottle (EDTA)
6ml blood in PINK     Rh Genotype          As above *-*         2 working days
top round bottom
bottle (EDTA)
6ml cord blood in     Cord blood ABO       As above *-*
 PINK top round       and DAT              Cord blood sample
bottom bottle                              MUST have baby’s     2 working days
(EDTA) and                                 details on
6ml maternal blood
in PINK top round
bottom bottle
(EDTA)



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                                Dartford and Gravesham NHS Trust
                                             Darent Valley Hospital

2.8 Blood Products

SPECIMEN            TEST GROUP           COMMENTS            LABORATORY
REQUIRED                                                     TURNAROUND
6ml blood in PINK   Issue of Anti-D      *Sample MUST
top round bottom    immunoglobulin       have patient’s full
bottle (EDTA)                            name, hospital         1 hour
                                         number, date of birth,
                                         date sample taken,
                                         and be signed by the
                                         person taking the
                                         sample. DO NOT
                                         USE pre- printed
                                         labels*
6ml blood in PINK   Issue of Platelets   As above *-*
top round bottom                         Sample not required Up to 8 hours
bottle (EDTA)                            if blood group is
                                         known. Guidelines
                                         for use of platelets
                                         MUST be followed
6ml blood in PINK   Issue of Fresh       As above *-*
top round bottom    Frozen Plasma        Sample not required
bottle (EDTA)       (FFP)                if blood group is      1 hour
                                         known. Guidelines
                                         for use of FFP
                                         MUST be followed
6ml blood in PINK   Issue of             As above *-*
top round bottom    Cryoprecipitate      Sample not required
bottle (EDTA)       (CRYO)               if blood group is      1 hour
                                         known. Guidelines
                                         for use of CRYO
                                         MUST be followed.

Integrated Care Pathway (ICP) for Adult Transfusion is now in use and this
evidence based ICP must be used by all healthcare staff for each episode of
transfusion of up to six units of blood and blood products, a continuation sheet is
available for transfusion of more than six units in one episode. For further
information please contact the Transfusion Practitioner ex 4666




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                                           Darent Valley Hospital


3. TRANSFUSION REACTION

3.1 Action

If within the first fifteen minutes* the patient develops sudden raised temperature
(above 38oC), chill, rigor or flushing, chest pain or loin pain, rash, tachycardia,
hypotension, nausea, tachypnoea, shock, haematuria, oliguria/anuria

The following action should be taken immediately:-

a) Stop the transfusion and inform the clinical team immediately

b) Renew the infusion line and keep vein open with a suitable solution (0.9%
sodium chloride)

c) Re-check the patient’s identity and the product label to ensure that the patient is
receiving the correct product

d) Inform the Transfusion Laboratory (ext 8502 or bleep on call BMS, via
switchboard, out of hours). Send the remainder of the blood bag and infusion line
to the laboratory together with a completed transfusion reaction form.

3.2 Samples Required

Take 30mls of blood from the patient (adults only) for the following investigation:

    4mls MAUVE top bottle (EDTA) for FBC and platelet count
    7mls PINK top, round bottom bottle (EDTA) for transfusion reaction
     investigation, repeat compatibility testing and direct antiglobulin test
    4mls BLUE top bottle (citrate) for coagulation screen
    7mls GOLD top bottle for urea and electrolytes (U&E)
    A set of blood cultures for Microbiology

Also check urinalysis for haematuria and monitor urine output
Perform an ECG if clinically indicated or in the presence of hyperkalaemia

ENSURE THAT ALL ACTIONS ARE CLEARLY DOCUMENTED IN THE
PATIENTS CASE NOTES AND ON THE ICP

For management of anaphylactic reaction please refer to the Trust Management of
Anaphylactic Reaction protocol

                                                                           29
                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital


4. BLOOD PRODUCTS

4.1 Red Blood Cells

Requests for Red blood cells must be made by a clinician. Send a 6ml EDTA
sample with a request form to the laboratory.

If adding on a crossmatch from a group and save sample already in the laboratory,
please telephone the laboratory (or contact the on-call Biomedical Scientist (BMS)
via switchboard) with full patient details including reason for transfusion

Cross matched blood will be available from the Transfusion laboratory blood bank
in routine working hours and 09.00 – 17.00 and weekends 09.00 –17.00. All other
times it is located in the issue fridge in the blood bank room accessible from the
main street, next to Pathology Reception

Collect blood following the collection procedure as determined in ‘The Protocol
for Blood Collection’


4.2 ‘Flying Squad’ blood

‘Flying Squad’ blood should only be requested when blood is required
immediately

Telephone the Transfusion Department on ex. 8502 or contact the on-call BMS via
switchboard when the ‘Flying Squad’ blood is required, stating full patient details
and reason for requirement.

Only TWO units of group O Rh CDE negative, Kell (K) negative and Haemolysin
free ‘Flying Squad’ blood are kept in stock.

A fully labelled specimen must be sent to the Transfusion Department immediately
in order that group compatible blood can be provided.

Specimens without a hospital number will not be accepted and will be discarded.

The Transfusion Department MUST be informed of the fate of ‘Flying Squad’
blood, i.e. name of patient transfused, transferred with patient to another hospital
etc



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                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital


Return unused units and/or empty bags to Transfusion Department. Blood kept out
of the blood fridge, not in a white transfer box, for more than 30 minutes will be
discarded.


4.3 Platelet Concentrates

Request for Platelet Concentrates should be discussed with the Consultant
Haematologist. The BCSH guidelines for platelet transfusion should be adhered to.
Please telephone the Transfusion Department (or contact on-call BMS via
switchboard) to request platelets giving patient’s full details and reason for
transfusion

Platelet Concentrates are stored at room temperature (20oC – 24oC) DO NOT
refrigerate as this will impair platelet function.

Use platelet giving set to infuse platelets. These are issued with the platelets.

Platelet Concentrates stocks are not available from the Transfusion Department.
Each order is requested from National Blood Service (NBS) at Tooting. It can take
up to 4 hours to receive platelets from NBS.

Platelets are collected from the Transfusion Department.


4.4 Fresh Frozen Plasma (FFP)

All requests for FFP must be made by a clinician. Telephone the Transfusion
Department (or contact the on-call BMS via switchboard) with the patient’s full
details and reason for transfusion. The BCSH guidelines for FFP transfusion
should be adhered to.

If a group and save sample has already been sent, no further samples are required.

FFP should be infused as soon as possible but always within two hours of thawing,
or 24hours if refrigerated.


FFP must be completely thawed before infusion. This takes approximately 40
minutes. Therefore at least 1 hour should be allowed before FFP will be available.



                                                                            31
                             Dartford and Gravesham NHS Trust
                                          Darent Valley Hospital
FFP is collected from the Transfusion Department.

4.5 Anti-D Immunoglobulin (Ig)

Anti-D Ig is given on a named patient basis. Anti-D Ig issued for a named patient
MUST NOT be given to another patient.

Anti-D Ig is available in 250i.u. and 500i.u. doses.

Anti-D Ig is given to Rh D negative women during and after pregnancy for the
following reasons:

250i.u. dose Anti-D is required for Per Vaginal (PV) bleeding up to 20 weeks
gestation, threatened abortion/miscarriage after 12 weeks and up to 20 weeks
gestation and invasive procedures ( chroionic villi sampling, amnioic fluid testing)
up to 20 weeks. Also Evacuation and Removal of Products of Conception (ERPC)
from 12 weeks gestation.

500i.u. dose Anti-D is required for any PV bleeding after 20 weeks gestation, any
invasive procedure after 20weeks gestation, seat-belt injury with or without PV
bleeding and trauma to the abdomen with or without PV bleeding after 20 weeks
gestation. Also post delivery for the birth of an Rh D positive baby.

There is an ante-natal prophylatic Anti-D program. All Rh D negative women are
offered two 500i.u. doses of Anti-D Ig, the first dose at 28weeks gestation and the
second dose at 34 weeks gestation.

FOLLOW COLLECTION PROCEDURE FOR ALL BLOOD PRODUCTS




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                              Dartford and Gravesham NHS Trust
                                           Darent Valley Hospital


5. URGENT CROSSMATCH REQUESTS

5.1 Urgency and Options
1) IMMEDIATE
FLYING SQUAD
2 units Group O Rh (CDE) negative, Kell negative
No printed labels issued blank labels on blood bags to be filled in with patient
details.

2) TEN MINUTES
(from receiving the sample)
UNCROSSMATCHED
GROUP COMPATIBLE ONLY
Bag labels and report forms issued
Blood crossmatched retrospectively

3) FORTY MINUTES
(from receiving the sample)
FULLY CROSSMATCHED

5.2 Contacting the Transfusion Laboratory for Urgent requests

The Transfusion department should be phoned at the earliest opportunity to
inform them of urgent cross-match requests on Ext 8502 (or contact the On
call BMS via Switchboard). The following information should be stated
            Patient Full Name (if known)
            Patient date of birth (if known)
            Hospital Unit number
            Location
            Nature of clinical problem
            Urgency of request
            Number of units of blood required
            Identity of clinician making the request

5.3 Identification of Urgent request forms and samples
Correct patient sample and request form identification is mandatory. Valuable time
will be lost if requests are rejected by Transfusion staff due to inadequacy or
inconsistency of information supplied. The following details must be provided
             Patient full name (if A & E Unknown patient – state Sex)
             Patient date of birth (if known)
             Hospital Unit number


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           Dartford and Gravesham NHS Trust
                        Darent Valley Hospital
Location




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