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Compliance & Safety

Compliance & Safety, General Information

Pathology Narratives Release Hold Removed for Weekends and Holidays

Effective July 1, 2021, Pathology and Radiology Result Narratives will no longer be held on weekends and holidays. All finalized result narratives will be released at 6 a.m. and 12 p.m. daily. This adjustment aligns with the 21st Century Cures Act and corresponding CMS mandate to allow data to flow freely and securely between providers, payers, and patients.

Of note, patients may be able to see results in MyChart prior to a provider seeing the results. Ordering providers should consider discussing potential outcomes with patients to prepare patients for results. Results should only be held if releasing the result puts the patient at risk of physical harm, or the patient requests the information not be shared.

More information related to the 21st Century Cures Act and established interoperability requirements can be found on the Information Governance Insite page (Internal). Contact Information Governance at InformationGovernance@spectrumhealth.org with any questions or use the Contact Us link above.

Blood Bank, Compliance & Safety, General Information, Hemostasis/Coagulation, Referral/Sendouts, Test Utilization

Coagulation Blue Top Tube Shortage

There is currently a national shortage of sodium citrate (“blue top”) blood collection tubes used for coagulation testing as a result of unprecedented demand, in part due to COVID-19 surges, vaccine and treatment development. This is anticipated to last through August 2021. Please take this into consideration when ordering coagulation testing (i.e. Protime, aPTT, Fibrinogen, D-dimer, Lupus Screens, Factor Assays, Mixing Studies, von Willebrand testing, etc.).

Here are additional steps you can take to help:

• Eliminate collection of extra blue top tubes

• Discontinue standing orders for coagulation tests, when possible

• Avoid the use of coagulation tubes as discard tubes

• Please refrain from ordering Lupus Screens ( LAB478) when patients are actively taking non vitamin K antagonists, including apixaban, dabigatran, and rivaroxaban. They have a significant impact on clot-based coagulation testing.  It is best to carry these tests out prior to drug administration or during a trough setting.

• Reduce cancelled specimens by making sure to collect specimens correctly by using the lab catalog for specimen collection instructions.

Thank you for your help during this exceptional time.

If you have any questions or concerns, please use the “Contact Us” link above.

Chemistry, Compliance & Safety, General Information, Hematology, Hemostasis/Coagulation, Microbiology, Referral/Sendouts

CSF Priorities on QNS Specimens

When a Cerebrospinal fluid (CSF) specimen arrives into the laboratory and is deemed Quantity Not Sufficient (QNS) for ordered testing, the ordering provider is contacted to identify testing priorities. Occasionally, the laboratory is unable to secure these priorities.

If the lab is unable to secure priorities from the ordering provider within an hour of collection, the following will occur:

1. We will move forward with the Cell count with differential, Culture, and Protein/Glucose

2. The rest of the ordered testing will hold until we can clarify the priorities

Laboratory is partnering with Epic Beaker to discover if a prioritization of orders, upon CSF order entry, is possible.

If you have questions or concerns, please use the “Contact Us” link above.

Compliance & Safety, General Information

Inform: Interoperability and Information Blocking

The 21st Century Cures Act and Office of the National Coordinator for Health Information Technology (ONC) Final Rule states that Spectrum Health cannot engage in practices that interfere with access, exchange, or use of electronic health information (EHI), otherwise known as Information Blocking, unless a specific Information Blocking exception applies. Continue Reading

Compliance & Safety, Education & Training, General Information

Appropriate Specimen Labeling

Spectrum Health Regional Laboratory is committed to the safety of our patients, and the accuracy and quality of the testing we provide.  In order to do that, we need your help to ensure that patient specimens adhere to our internal policies and quality checks.

THE DETAILS

To that end, we are asking for your help in the process of labeling specimens before they are sent to our laboratory.  It is our policy at Spectrum Health Regional Laboratory that the routine labeling of laboratory specimens MUST INCLUDE FULL LEGAL NAME and DATE OF BIRTH, and if possible, additional identifiers such as medical record number, specimen number, etc. If this information is missing, incomplete or incorrect, the specimen is considered a mislabeled specimen, and will be canceled upon receipt.  (The only exception to this is “precious specimens,” ex. cerebrospinal fluid or surgical specimens, which can sometimes be given an opportunity for relabeling after correct identification).

If a patient specimen is labeled with a NICKNAME instead of the FULL LEGAL NAME, this specimen would be considered a mislabeled specimen and have to follow the above process, which will delay patient care and/or employee eligibility to work.

EXAMPLES

“Alli” Smith Unacceptable  Allison Lynn Smith Acceptable
“Johnny” D Parker Unacceptable John David Parker Acceptable
“Dan” Stevens Unacceptable Daniel Stevens III Acceptable

WHAT WE NEED YOU TO DO

Please review this notice with your collecting/labeling staff as soon as possible to ensure proper labeling practices.  Though not new, this policy has been reviewed by our team members in central specimen processing, and will be strictly adhered to going forward.  Please feel free to forward this notice to anyone involved in the collecting or labeling of laboratory specimens that are sent to Spectrum Health.

Thank you for continuing to trust Spectrum Health Regional Laboratory for your testing needs, and thank you for partnership in attention and commitment to quality and safety!

For questions or concerns regarding this policy, please use the “Contact Us” link above.

RESOURCES

Spectrum Health Labeling Guide

The Joint Commission 2021 Patient Safety Goals

Clinical Laboratory Standards Institute

Spectrum Health Laboratory Policy #9955

Compliance & Safety, Education & Training, General Information

Self-Swab for STI Testing

Self-collected vaginal swabs may be used for STI testing as opposed to provider-collected swabs. Self-collected swabs are supported by current clinical guidelines as recent studies have shown their equivalence, if not superiority, in quality and their association with increased patient satisfaction.

NOTE: Self-collection must still take place in a healthcare setting and is not approved for at-home collection.

Continue Reading

Compliance & Safety, General Information

Reminder: Winter Lock Box

march-winter-lockboxTo maintain optimal specimen integrity, Spectrum Health Laboratory requests that you load your outdoor lock box properly for winter weather temperatures. Please follow the diagram on the right to prevent freezing of specimens.

Frozen specimen should never be left in the lock box for after-hours pickup. These tests may be better preserved in the office freezer until the next day’s courier pickup.

Request for specimen pickup should be made to the Laboratory Call Center at 616.774.7721.

Compliance & Safety, General Information, Immunochemistry, Main lab

Serum Kappa/Lambda Free Light Chain Assay Update

Effective September 28th, 2020, a new generation of the serum kappa/lambda free light chain assay has been implemented.

With the implementation of the new generation of the assay there is an approximately 20% negative bias for kappa free light chains in serum containing >20 mg/dL kappa free light chain.  This may affect the trending for patient who are serially monitored by this assay. Continue Reading

Compliance & Safety, Education & Training, General Information

Leaky Specimen Containers

Leaky specimen containers may cause compromised test results and it is also a hazard to lab couriers and registration personnel. Leaky specimen containers are not acceptable and may be rejected.

In order to prevent leaky containers, please be sure to:

  • Pay close attention to the lid, making sure the screw-cap lids are fastened evenly and securely, with the threads aligned. If a patient has challenges with tightening the lid, please have them notify lab staff when they return to drop off their container.
  • Containers should be upright at all times, with lid on the top during transport. If container is placed in a biohazard bag, please maintain in the upright position by gripping the cup or the handle and not by the top of the bag.

The Laboratory provides a brochure “Laboratory Specimen Home Collection” for patient collection instructions. Internal offices (i.e. SHMG) may order these from Document Services using the order number X17776 (X19611 for the Spanish version). External offices may order these from Laboratory Courier Services using the Supply Order Form.