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Online compliance and continuing education courses for clinical laboratories

Hospital Information and Courses from MediaLab, Inc.

These are the MediaLab courses that cover Hospital and links to relevant pages within the course.

Learn more about laboratory continuing education for medical technologists to earn CE credit for AMT, ASCP, NCA, and state license renewal and recertification. Or get information about laboratory safety and compliance courses that deliver cost-effective OSHA safety training and continuing education to your laboratory's employees.

Laboratories Individuals

Cerebrospinal Fluid
Specimen Labeling and Transport

The cerebrospinal fluid sample should be properly labeled with the tube number, patient's name and hospital number. The samples should be transported to the laboratory immediately.

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CLIA General Laboratory Review
Standard precautions means that:View Page

CLIA Microbiology / Serology Review
Which of the following statements about Rickettsia is false:View Page
A 20 year-old female was admitted into the hospital complaining of 10 to 15 bloody mucous stools per day, fever, gastrointestinal disturbances, abdominal pain, and nausea. The preliminary O & P report went out as "Probable Entamoeba histolytica trophozoites and cysts, confirmation pending." This patient is most likely suffering from:View Page

Current Topics in Clinical Microbiology
The patient was admitted to the hospital. The sputum specimen was inoculated to sheep blood agar. Based on the colony morphology seen in the accompanying photograph, the most likely identification is:View Page
Clinical History

A 67 year-old man entered the hospital with cough, right lower chest pain accentuated by deep breathing, and fever. He had a history of chronic obstructive pulmonary disease secondary to a long history of smoking. The temperature on admission was 39.2C, and auscultation of the chest revealed rales in the right lower lung field. The admission white blood count was 13,500/ml with 80% segmented neutrophils and a shift to the left. A blood culture was obtained.

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Review 1

Podschun R. Ullmann U.: Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenicity factors Clinical Microbiology Reviews. 11(4):589-603, 1998Bacteria belonging to the genus Klebsiella frequently cause human nosocomial infections. In particular, the medically most important Klebsiella species, Klebsiella pneumoniae, accounts for a significant proportion of hospital-acquired urinary tract infections, pneumonia, septicemias, and soft tissue infections.The principal pathogenic reservoirs for transmission of Klebsiella are the gastrointestinal tract and the hands of hospital personnel. Because of their ability to spread rapidly in the hospital environment, these bacteria tend to cause nosocomial outbreaks. Hospital outbreaks of multidrug-resistant Klebsiella spp., especially those in neonatal wards, are often caused by new types of strains, the so-called extended-spectrum-beta-lactamase (ESBL) producersThe incidence of ESBL-producing strains among clinical Klebsiella isolates has been steadily increasing over the past years. The resulting limitations on the therapeutic options demand new measures for the management of Klebsiella hospital infections.While the different typing methods are useful epidemiological tools for infection control, recent findings about Klebsiella virulence factors have provided new insights into the pathogenic strategies of these bacteria. Klebsiella pathogenicity factors such as capsules or lipopolysaccharides are presently considered to be promising candidates for vaccination efforts that may serve as immunological infection control measures.

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The hands of hospital personnel represents one of the major reservoirs for the persistence and potential spread of ESBL producing strains of Klebsiella pneumoniae in the hospital environment.View Page
Review 1

Garbutt JM. Littenberg B. Evanoff BA. Sahm D. Mundy LM. Enteric carriage of vancomycin-resistant Enterococcus faecium in patients tested for Clostridium difficile. Infection Control & Hospital Epidemiology. 20(10):664-70, 1999OBJECTIVE: To identify independent risk factors for enteric carriage of vancomycin-resistant Enterococcus faecium (VREF) in hospitalized patients tested for Clostridium difficile toxin.PATIENTS: Convenience sample of 215 adult inpatients who had stool tested for C. difficile between January 29 and February 25, 1996.RESULTS: 41 (19%) of 215 patients had enteric carriage of VREF. Five independent risk factors for enteric VREF were identified: (1) history of prior C. difficile infection, (2) parenteral treatment with vancomycin for > or = 5 days, (3) treatment with antimicrobials effective against gram-negative organisms, (4) admission from another institution, and (5) age > 60 years. These risk factors for enteric VREF were independent of the patient's current C. difficile status.CONCLUSIONS: Antimicrobial exposures are the most important modifiable independent risk factors for enteric carriage of VREF in hospitalized patients tested for C. difficile.

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Case History

A 63 year old man was seen in the emergency room with the complaints of sudden onset of fever, chills, and abdominal pain, accompanied by mild diarrhea. The blood pressure was 140/84, the pulse rate 82/minute, and the body temperature 39.8C. A blood sample was drawn for a complete blood count, and a blood culture.A second blood culture was drawn from the opposite arm, with 10 ml of blood being placed into each an aerobic and an anaerobic bottle, following customary practice.The complete blood count revealed a hemoglobin of 15.8 mg/dl, a hematocrit of 45%, and a white blood count of 4.2/L. The neutrophils were 39%, lymphocytes 45%, monocytes 10%, eosinophils 4% and basophils 2%. The platelet count was 255/L. The patient was admitted to the hospital for further work-up and empiric antibiotic therapy.Within 24 hours after admission, the body temperature had decreased to 38.2C, although the mild diarrhea persisted.A stool toxin test for Clostridium difficile was negative and neither enteric pathogens nor Campylobacter species were recovered in stool culture after 24 hours incubation. Fecal neutrophils were not seen on direct examination. The anaerobic blood culture became positive 36 hours after inoculation.

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Review 1

Francois P. Vaudaux P. Foster TJ. Lew DP.: Host-bacteria interactions in foreign body infections. Infection Control & Hospital Epidemiology. 17:514-20, 1996Persistent staphylococcal infections are a major medical problem, especially when they occur on implanted materials or intravascular catheters.This review describes some of the recently discovered molecular mechanisms of Staphylococcus aureus attachment to host proteins coating biomedical implants.These interactions involve specific surface proteins, called bacterial adhesins, that recognize specific domains of host proteins deposited on indwelling devices, such as fibronectin, fibrinogen, or fibrin.Elucidation of molecular mechanisms of S. aureus adhesion to the different host proteins may lead to the development of specific inhibitors blocking attachment of S. aureus, which may decrease the risk of bacterial colonization of indwelling devices.

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Review 2

Hershow RC. Khayr WF. Smith NL.: A comparison of clinical virulence of nosocomially acquired methicillin-resistant and methicillin-sensitive Staphylococcus aureus infections in a university hospital (University of Illinois at Chicago). Infection Control & Hospital Epidemiology. 13(10):587-93, 1992OBJECTIVES: To compare the clinical virulence of nosocomially acquired methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) infections in 1989.DESIGN: A retrospective comparison of host factors, in-hospital exposures, sites of infections, and outcomes of patients with nosocomial MRSA and MSSA infections. PARTICIPANTS: Forty-four adult patients with nosocomial S.aureus infections.RESULTS: The 22 MRSA-infected and 22 MSSA-infected persons were similar regarding mean age, gender, underlying diseases, and exposure to surgery. Before developing infection, MRSA-infected persons were more likely to have received antibiotics and to have stayed in the hospital > 2 weeks. Bacteremia was the most common presentation in the MRSA and MSSA groups (55% and 59%, respectively). Infectious complications and death were infrequent in both groups.CONCLUSIONS: MRSA and MSSA strains infect patients with similar demographic features and underlying diseases, but MRSA infections are significantly more common among patients with previous antibiotic therapy and a prolonged preinfection hospital stay. Clinical presentations and outcomes did not differ significantly between the 2 groups. Thus, similar to studies in the early 1980s, our findings do not suggest greater intrinsic virulence of MRSA.

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Factors predisposing to infections with methicillin resistant Staphylococcus aureus (MRSA) include:View Page

Department of Transportation (DOT) Regulated Urine Specimen Collection Training
Non-federally regulated custody and control form

The Non-Federally Regulated Custody and Control Form is most often used in clinics and hospital emergency rooms when drug abuse is suspected, or by companies participating in their state's drug-free workplace program. Be aware that some states mandate the use of a special CCF for their drug-free workplace program. There are significant differences between the Federally Regulated CCF and the Non-Regulated CCF. You are strongly encouraged to review the difference between the two. Unless there are extenuating (which we will discuss next), remember that the two forms are not interchangeable. The Federally Regulated CCF can be used only for urine collections required by the Department of Transportation drug testing program.

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Descriptive Statistics
Identify the underlined phrase:The research team at the hospital selected 16 employees at random, and tested their BUN levels, and found an average of 16 mg/dL with a standard deviation of 6.5 mg/dL. They used this data to construct a range of normal values for the whole healthy population.View Page
Use the following data for the next 8 questions: Table VIIICreatinine levels in mg/dL for 21 healthy hospital employees .87 .98 .93 1.04 .86 .90 1.05 1.08 .84 .97 1.12 .95 .96 1.02 1.01 .93 .91 .98 .99 .94 1.04 What are the best classes to use when making a frequency distribution for this data?View Page
Table VIIICreatinine levels in mg/dL for 21 healthy hospital employees .87 .98 .93 1.04 .86 .90 1.05 1.08 .84 .97 1.12 .95 .96 1.02 1.01 .93 .91 .98 .99 .94 1.04 Using the classes .80-.85, .85-.90, .90-.95, .95-1.00, 1.00-1.05, 1.05-1.10, 1.10-1.15, what is the absolute frequency of the .90-.95 class?View Page
Table VIII Creatinine levels in mg/dL for 21 healthy hospital employees .87.98.931.04.86.901.05 1.08.84.971.12.95.961.02 1.01.93.91.98.99.941.04 Using the classes .80-.85, .85-.90, .90-.95, .95-1.00, 1.00-1.05, 1.05-1.10, 1.10-1.15, what is the relative frequency of the class 1.05-1.10?View Page
Table VIIICreatinine levels in mg/dL for 21 healthy hospital employees .87 .98 .93 1.04 .86 .90 1.05 1.08 .84 .97 1.12 .95 .96 1.02 1.01 .93 .91 .98 .99 .94 1.04 What is the mean of the data?View Page
Table VIIICreatinine levels in mg/dL for 21 healthy hospital employees .87 .98 .93 1.04 .86 .90 1.05 1.08 .84 .97 1.12 .95 .96 1.02 1.01 .93 .91 .98 .99 .94 1.04 What is the median of these data?View Page
Table Specifications

Here are the criteria for the preparation of tables, as specified by the Journal of Clinical Laboratory Science: Write table titles at the top of the table. Number tables sequentially with Roman numerals. Include the following information in a title, whenever possible: who, what, where, why and when. Put the independent variable in the left column, and the dependent variable in the right, if you are listing data with independent and dependent variables. Label each column with the appropriate units. Adequately space tables that appear on the same page. Example:Table I Patient specimens analyzed for blood urea nitrogen on the Dimension RxL and the Vitros 250 at City Hospital Sample # RxL (mg/dL urea) Vitros 250 (mg/dl) urea 1 8.8 8.8 2 11.2 10.0 3 12.4 13.6 4 16.2 13.2 5 20.0 21.2 6 25.0 20.0 7 28.8 26.2 In this case, the Dimension RxL is the "reference method" and is considered the independent variable, while the Vitros 250 is the "test method" and is considered the dependent variable.

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A Frequency Distribution Example

Table III shows the unsorted raw data that will be used to make a frequency table. Note that the low and high results are highlighted. These data are continuous; however, the testing equipment rounds the data off to the nearest whole number of milligrams.Table IIIConcentration of Serum Glucose (mg/dL) in 130 Hospital Employees 100 83 80 114 100 80 85 81 101 80 95 108 79 81 97 77 84 88 78 86 81 77 98 85 92 105 85 108 90 89 84 94 84 81 82 78 84 82 98 86 87 74 79 104 89 91 85 72 92 90 93 87 90 99 96 110 107 97 84 76 83 80 101 75 84 76 73 86 71 84 70 79 91 86 86 91 87 96 96 97 106 104 65 81 103 83 90 70 80 80 75 82 83 76 81 87 84 86 93 86 103 76 112 102 93 89 67 78 84 82 91 86 82 82 87 89 95 90 73 103 75 113 93 86 77 95 94 99 87 92

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Step 5: Determine Relative Frequencies

Relative frequency is the proportion of a sample that belongs to a particular class. We calculate the relative frequency by dividing the class frequency by the total number of data points, n. The sum of the relative frequencies should be one, but due to rounding errors, sometimes it is not exactly one.Table IV Actual and Relative Frequency of Serum Glucose Levels in 130 Hospital Employees Intervals (mg/dL) Tally Frequency Relative Frequency 65 - 70 \\ 2 0.015 70 - 75 \\\\ \\ 7 0.054 75 - 80 \\\\ \\\\ \ 16 0.123 80 - 85 \\\\ \\\\ \\\\ \\\\ \\\\ \\\\ \ 31 0.238 85 - 90 \\\\ \\\\ \\\\ \\\\ \\\\ 24 0.185 90 - 95 \\\\ \\\\ \\\\ \\\ 18 0.138 95 - 100 \\\\ \\\\ \\\ 13 0.100 100 - 105 \\\\ \\\\ 10 0.077 105 - 110 \\\\ 5 0.038 110 - 115 \\\\ 4 0.031 Total n = 130 0.999

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Bar Chart

Bar charts are preferred for discrete data.  The height of the bar between the "65" and "70" tick marks corresponds to the number of elements in the 65 - 70 class,  etc.Figure 3Frequency of Serum Glucose Levels in 130 Hospital Employees

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Histogram

Histograms are used for continuous or discrete data. When continuous data are charted, you can connect the midpoints of the tops of the bars with a dashed line.Figure 4Frequency of Serum Glucose Levels in 130 Hospital Employees

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Frequency Polygon

The frequency polygon resembles a continuous curve, and is therefore appropriate for illustrating continuous data. Instead of bars, the class midpoints are plotted at heights corresponding to the class frequency. The midpoints are then joined by a line.Figure 5Frequency of Serum Glucose Levels in 130 Hospital Employees

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Absolute vs. Relative Frequency

You also have the choice of plotting the relative or the absolute frequency along the y-axis. The relative frequency is better for large samples. The shape of the graphs, however, is the same for both methods. Figure 6 Absolute Frequency of Serum Glucose Levels in 130 Hospital Employees Figure 7 Relative Frequency of Serum Glucose Levels in 130 Hospital Employees

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Use the following data for the next four questions:Table V Serum BUN values (mg/dL) from hospital employees at Kettering Medical Center 15.922.59.116.8 6.428.615.223.7 10.317.013.820.5 7.425.04.118.4 12.713.630.921.3 What are best classes to use for this data?View Page
Table V Serum BUN values (mg/dL) from hospital employees at Kettering Medical Center 15.922.59.116.8 6.428.615.223.7 10.317.013.820.5 7.425.04.118.4 12.713.630.921.3 Use the following classes: 0-5, 5-10, 10-15, 15-20, 20-25, 25-30, 30-35. What is the absolute frequency of the class 15-20?View Page
Table V Serum BUN values (mg/dL) from hospital employees at Kettering Medical Center 15.922.59.116.8 6.428.615.223.7 10.317.013.820.5 7.425.04.118.4 12.713.630.921.3 Use the following classes: 0-5, 5-10, 10-15, 15-20, 20-25, 25-30, 30-35. What is the relative frequency of the class 10-15?View Page
Table V Serum BUN values (mg/dL) from hospital employees at Kettering Medical Center 15.922.59.116.8 6.428.615.223.7 10.317.013.820.5 7.425.04.118.4 12.713.630.921.3 What types of charts are appropriate for illustrating this data?View Page

HIPAA Privacy and Security Regulations
Case Study: Administrative Safeguards You are the technologist in charge of the hematology section in a hospital laboratory, and you are reviewing blood count results for 100 patients as part of an internal quality assurance project. You review the clinical findings in the electronic medical record to correlate with the laboratory results. The following week get a call from your hospital security officer. She says that a routine computer system audit has revealed that you accessed the records of 100 patients and she would like to know why.You tell her:View Page
Case Study: Business Associate Your hospital hired a consulting firm to help review and update its HIPAA privacy program. The firm has submitted a proposal that will require limited access to records containing PHI. The hospital must have a business associate agreement in place before the consultants begin working.View Page
Which of the following entities are covered by HIPAA?View Page
Who does HIPAA apply to?

HIPAA applies to: Health Plans (such as health insurance companies) Healthcare Clearinghouses (such as billing companies), and Healthcare Providers (including doctors, hospitals, laboratories, and pharmacies). HIPAA refers to these 3 groups as covered entities.

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Introduction to Bioterrorism
Members of the chemical component of the LRN define their network participation with a designation of level 1, 2, or 3. The level primarily responsible for working with hospitals and private laboratories is:View Page
Advantages of using Biological Agents as WMDs

They are easily available.Biological pathogens can be obtained from nature, hospital  laboratories, university research facilities, etc.They can be hard to detect.Small quantities can have potentially deadly or incapacitating effects on a susceptible population.They can be used covertly.They can be spread throughout large areas by natural convection, air or water currents. They can be easily spread.Ventilation systems in buildings is one way biological agents may be spread. In addition, transportation facilities could become part of the dissemination system by carrying biological agents far from their initial source.

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The LRN Pyramid

The LRN is a multilevel system designed to link frontline clinical microbiology laboratories and hospitals and other institutions to state and local public health laboratories in supporting advanced capacity public health, military, veterinary, agricultural, water and food testing laboratories at the federal level. Laboratories within the LRN are divided into 3 levels: Sentinel Labs, Reference Labs, and National Labs.

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Laboratory Response - Chemical, Level 3

Level 3 laboratories are responsible for: Working with hospitals and private laboratories in their jurisdiction Knowing how to properly collect and ship clinical specimens Ensuring that specimens, which can be used as evidence in a criminal investigation, are properly handled and that chain-of-custody procedures are followed Being familiar with chemical  agents and how they can affect health and well-being Training on anticipated clinical sample flow and shipping regulations Working to develop a coordinated response plan for their respective state and jurisdiction

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The Fear Factor in Bioterrorism

 As the term suggests, Terrorists excel at creating panic. What is so insidious about chemical and biological terrorism is that it involves agents that we can’t see. People don’t know how to react when they can’t see what is hurting them. There are several examples, from a commercial bus crash to someone who reported smelling gas in a school, where rumors that the incidents were caused by either biological or chemical terrorism triggered an “epidemic hysteria”. In both areas the local hospital’s emergency room was overwhelmed. In each of the incidents mentioned, State and Federal officials spent countless hours investigating and found no possible biohazard, but the panic was real. From these experiences we see more than ever that healthcare workers are not just the first line of defense in the event of an actual attack, they are who the public looks to for rationality and reliable information in an bioterrorism emergency.

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In Case of a Dirty Bomb Attack

Stay inside or get inside quickly. Find a “Shelter-in-place”. To “shelter in” is a way to make the building you are in safe as possible to protect yourself until help arrives. You should not try to “shelter in” in a vehicle unless you have no other choice. The best room to use is one with as few windows and doors as possible. Be sure to close all windows and doors, and turn off the furnace, air conditioners, and exhaust systems. As best as possible, seal all openings in windows and doors. Monitor your radio for instructions from authorities. If you believe you’ve been exposed and you can’t get to a hospital, shed all your clothes as quickly as possible. Don’t take the clothes inside because you may spread contamination. Go straight to the shower and thoroughly wash all body parts with a coarse soap. It is important not to ingest radiation by eating contaminated food or even chewing on contaminated fingernails. Also, certain types of radioactivity can be flushed from the body by drinking large amounts of water. After an attack don’t travel through heavily contaminated areas. If you can get out of the general area through an uncontaminated route, do so—otherwise, stay indoors until assistance arrives.               

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Laws and Rules of the Florida Board of Clinical Laboratory Personnel
Kickback and Inducement Violations

Offering or taking a bribe, kickback, bonus, commission, or inducement is against the rules of the Board and against the law. Many companies give away small promotional items, such as pens or note pads, to promote their products. This is legal, but be cautious about accepting more valuable items. This could be seen as a bribe. All of the following are serious violations of Board, state, and federal rules:Participating in any commissions, bonuses, kickbacks, inducements, or split-fee arrangements from physicians, health care providers, suppliers, hospitals, nursing homes, other clinical laboratories, pharmacies, and other facilities.Exploiting or influencing a patient for financial gain, including promoting, selling, or withholding services, drugs, or referrals.

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Medical Error Prevention
Which statement(s) are true?View Page
JCAHO Sentinel Event ALERTS Since 1998, JCAHO has issued 25 Sentinel Event ALERTS to the healthcare community. These publications include more than 50 evidence or expert-based recommendations for preventing adverse events. Sentinel Event Alerts address various error reduction topics: Transfusion reactionsInpatient suicideInfant abductionsWrong site surgery or other proceduresPatient falls Laboratory professionals can be involved in all of these types of Sentinel Events. JCAHO's first Sentinel Event ALERT addressed the common practice of storing concentrated potassium chloride solutions in hospital nursing units. View Page
Direct Error Detection Even perfect systems designs cannot avert human limitations. Medical errors occur and they have to be detected before they can be resolved. Sometimes people directly observe and immediately report these mistakes.View Page
Speak Up Campaign JCAHO also encourages people to do things themselves to prevent errors. It joined other groups in 2002 to launch the consumer Speak Up campaign. It encourages the public to become active participants in their healthcare and "speak up" when they have questions and concerns. As a healthcare professional, you should be aware that JCAHO has started a program to encourage patients and their families to become more involved in their medical care.View Page
Where Errors Occur

Insurance industry analysis of data from 1985 through 2003 shows that about two thirds of medical errors occur in hospitals and about one third occur in physician offices. About half of hospital errors occur in operating rooms and one sixth occur in patient rooms. Wherever medical errors occur, laboratory professionals can be involved.

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Preanalytic Medical Errors

Medical errors are possible at any phase of patient care. Preanalytic medical errors begin with the patient and the places he or she receives medical care--the bedside, chair-side, hospital, clinic-- wherever the patient is located. The possibility for these errors continues through the ordering processes for medical tests or procedures. Preanalytic medical errors also happen with the systems, processes, and procedures involved in the collection of test samples from patients. These medical errors occur during the time before the laboratory is directly involved in assaying and analyzing test samples. Examples of preanalytic medical errors: Wrong patient Wrong test Wrong timing Wrong collection procedure Wrong tube, container, additive

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Postanalytic Medical Errors

Errors also occur after analyses are completed and reported. Postanalytic errors begin with the medical professionals who receive test results, and they include interpretation of the results. These errors can occur at--the bedside, chair-side, hospital, clinic-- wherever the patient and the medical professional are located. The possibility for postanalytic medical error continues through diagnosis and treatment procedures and processes. These medical errors occur during the time after the laboratory reports test results. Examples: Wrong test value associated with patient Wrong test interpretation Wrong diagnosis Wrong treatment Laboratory professional might believe they are not associated with postanalytic medical errors, but they can. One deadly example is fatal hemolytic transfusion reactions involving laboratory errors.

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Medicare Compliance for Clinical Laboratories
Utilization and other regulations

Laboratories must not induce physicians to order unnecessary tests through their marketing or education activities: They must monitor the use of laboratory services by their clients. They must correct any situation where something they did caused an unnecessary increase in test utilization. Cost Reports Hospitals laboratories must ensure that information used in hospital Medicare cost reports is accurate and includes only those costs which are appropriate. Laboratories must follow all CLIA and OSHA regulations: failure to do so may result in a False Claims Act violation.

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Equipment and space

Laboratories may only lease space from physicians who refer Medicare patients to them under certain circumstances: There must be a written lease for at least one year. Lease price must be at "fair market value." All leases must be reviewed by legal counsel to ensure compliance with antikickback and Stark laws.When leasing or renting equipment to a physician or from a physician the same basic rules apply as for space.If the laboratory is located in a hospital, the relationship between the hospital and a physician who refers to the lab may have antikickback or Stark implications.

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Case Study 9

The setting is automated chemistry department, night shift, busy core laboratory for a hospital based outreach laboratory. A medical technologist who operates the automated chemistry analyzer on third shift encounters short samples a couple of times a night. When this happens, he runs as many of the ordered tests as he can and fills in the blank results with a comment indicating that a short sample occurred. As far as he knows there isn't a policy that addresses this problem directly.The test reports out with the results and the comments. The technologist does not have to change the physician order in any way and is providing the maximum results that can be reported for the specimen in a timely fashion. This is done as a matter of patient care and quality service. There has not ever been a complaint about this practice as far as he knows. Are there any additional steps this technologist should be taking?Correct Answer: The technologist should follow the procedures that the laboratory has in place for testing and billing samples for which there is no order or for ambiguous orders. If the policies do not seem to address his particular situation, he thinks there should be a separate policy to cover this situation or has a question about it, he should talk to his supervisor or to the laboratory compliance officerDiscussion: This choice addresses the problem in the most complete manner, in that the employee fulfills his responsibility to take action when he thinks there is a problem.

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Case Study 7

The setting is the cafeteria in a hospital or the lounge in an independent laboratory. Two employees from different departments are old friends are having lunch together. A billing clerk and a medical technologist are friends and are having lunch together. The billing clerk mentions that she saw a bill go through the system for one of her coworkers for a biopsy. She asks the medical technologist if she has the necessary security level access to see pathology test results because she is concerned about the welfare of the coworker. The medical technologist does have the necessary security clearance to see the results. She should:Correct Answer: Refuse to look up the results for the clerk and remind the clerk that it is a violation of compliance policies to do so, or to ask another to do so. Remind her of the requirement for each employee to report any violations of policy. Discussion: The Medical technologist has a responsibility to report violations of compliance policies and the friend has put her in a difficult position. For that reason, it is not enough to just refuse the clerk's request. If the medical technologist does not take the responsibility to inform the employee of the policy then there is a possibility that the employee would ask some other employee to do it for her.

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Case Study 4

Busy hospital laboratory in a 350 bed urban hospital that provides laboratory testing for the hospital and for the hospital's outreach testing laboratory. A medical technologist in the microbiology department receives a call from a friend who works in a laboratory in a physician office. The physician is not a regular client of the laboratory currently but uses another laboratory for most of their work. The microbiologist knows that the sales department would like to get this account. The friend explains to her that she is doing a quality control check on her in-office microbiology testing and her regular laboratory will do it but is going to charge her for it. She asks the microbiologist if she will do it for free since it is quality control, not Medicare and is not going to be billed to anyone.She tells the microbiologist that she would like to use the hospital lab for everything but her doctor insists on using the competitor. She indicates that the favor might help get the doctor to try the hospital laboratory for other tests. The microbiologist should:Correct Answer: Explain to her friend that if the hospital does the tests for no charge on the promise of other referrals, both the physician office and the hospital could be liable for violations of the antikickback statute.Discussion: The antikickback statute is implicated in this scenario because the free testing is solicited on the condition that other referrals may occur as a result of providing the favor. In fact, the solicitation itself is a violation of the law. The fact that Medicare patients are not specifically mentioned in the scenario is not sufficient to remove the risk. The technologist should also report the incident to the Compliance Officer and seek advise about what documentation, if any, should be kept concerning the incident.

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Mycology: Hyaline and Dematiaceous Fungi
Match each of the names of the hyaline molds listed with the environmental conditions or natural objects with which it is most likely associated.View Page

Mycology: Yeasts and Dimorphic Pathogens
Match the names of each of the diseases listed with its appropriate situation:View Page
The colonies illustrated in this photograph were recovered from a blood culture after 48 hour incubation at 30°C. The most likely source for the septicemia is:View Page

OSHA Bloodborne Pathogens
Importance of Handwashing

Handwashing is the single most important method of infection control and prevention available.It prevents many other community and hospital acquired infections.It is essential in the prevention of bloodborne pathogen transmission.

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OSHA Electrical Safety (updated 2007)
Space heaters

Electrical space heaters are prohibited unless they are approved for use and inspected by your facilities management department. Space heaters are not permitted in hospital sleeping areas or in laboratories containing flammable liquids or gases. The heating elements in the space heater cannot exceed 212 degrees Fahrenheit, and cannot be exposed elements. Heaters with hot elements, even with guards, are not allowed. The approved heater must be connected directly to an outlet without the use of an extension cord. Reference: NFPA 101 Life Safety Code. National Fire Protection Agency. Paragraph 18/19.7.8. Quincy, MA: 2006.

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Phlebotomy
Case

Julie Smith was a newly certified phlebotomist and had been working at Northwood Hospital for several months. As she approached room 825, she looked on her collection list to verify this was the correct room for her first collection. Indeed it was, even though there was no patient name on the door. Her collection list told her the patient in room 825 was a 55 year old male named John Ready. After knocking several times, Julie entered the room to find a middle aged man who appeared to be sleeping. Julie approached the patient and said, “Good day Mr. Ready. My name is Julie and I am from the lab. I need to draw blood for some tests ordered by your doctor.” The man awoke and seemed irritated as Julie repeated herself. The patient responded and told Julie to do whatever she needed to do so he could go back to sleep Julie then proceeded to do the venipuncture.

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Case

Bobby Jones, a phlebotomist at Georgetown Hospital, entered the room of Mrs. Mary Grayson with a physician's order to draw some blood work. After properly greeting Mrs. Grayson, identifying himself and checking her armband, Bobby prepared for the venipuncture. He suddenly notice a sign posted above the bed that read: “Restricted left arm usage. Previous mastectomy - Do no use left arm for venipuncture.” Bobby set up his equipment to use her right arm and noticed an IV line in Mrs. Grayson’s right arm positioned in a vein slightly above her wrist on the dorsum (top) of her forearm.

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Case

Marcie Moore was a phlebotomist at a community hospital in Atlanta. It was her week to collect the pediatric unit and she was on her way to the room of a newborn for which she had just received orders to draw a STAT BMP (chem-7) and bilirubin. After informing the mother of the baby about the test she needed to perform, Marcie set up to perform a heel stick on the baby. Marcie chose a site on the outer edge of the heel on the bottom of the baby’s foot ( the correct area for a heel stick) and made a small incision with a Tenderfoot lancet after cleaning the site well with alcohol.She immediately began collecting the blood in the correct tube for the BMP and bilirubin. Blood flow was not strong so Marcie squeezed the baby’s foot a little to help the blood come out faster – the newborn was screaming and Marcie could tell it was making the mother uncomfortable. She wanted to hurry and get done so the mother could hold the baby.After the chemistry tech ran the blood tests on the tube, she informed Marcie that the newborn had a panic potassium level which did not coincide with the previous blood work on the newborn. Also the chemistry instrument could not perform the bilirubin due to hemolysis. Marcie was asked to recollect the specimen.

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Case

James Brown, a phlebotomist from the laboratory went to the second floor of Memorial Hospital to draw a STAT BMP (chem-8), CBC, and PT on a patient. The patient was in critical condition so the lab results were crucial for treatment. James quickened his pace in order to speed up the result time. He collected the specimens and took them back to the lab. However, the technologist in hematology and coagulation notified him that he would need to recollect the specimen because the CBC and PT were clotted.

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Case

John Wagner, a phlebotomist at General Hospital, went up to the 7th floor to draw routine blood work on a patient. As he approached the door of the patient’s room he noticed a red stop sign on the door with the words “Respiratory Isolation” written on it.

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Discussion

At John’s particular hospital, a stop sign on the door means not only means respiratory isolation, but also that special precautions for tuberculosis are in effect. At this point, John should obtain a a special particulate respirator mask which will be available outside the patient's room. He should put on the mask before entering the room, wash his hands before and after contact with the patient, and wear gloves and appropriate protective clothing during all contact with the patient. TB and most respiratory infections are transmitted via droplets in the air from respiratory secretions – thus the need for the masks.

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Case

Julie Smith, a newly certified phlebotomist at Northlake Hospital, entered a patient’s room on the third floor for a routine blood draw. The patient was an elderly woman who had very small fragile veins. Julie therefore decided to use a safety butterfly needle attached to a Vacutainer tube in order to draw the blood. When Julie was finished with the venipuncture, she detached the butterfly needle from the Vacutainer, and approached the Biohazard needle disposal box. She noticed that the disposal box was full , but decided to try to fit the butterfly into the box anyway. Holding the butterfly by the tubing, she tried to push the butterfly into the box. The needle suddenly recoiled and stuck Julie’s finger. Julie left the patient’s room in a panic and headed back to the lab to report the needle stick injury.

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Case

Bobby Jones, a phlebotomist at Georgetown Hospital, was called to the pre-op area to perform a bleeding time. Bleeding times may be requested on selected preoperative patients to help assure that they will not bleed excessively during surgery. Bobby gathered the appropriate equipment, then placed the blood pressure cuff of the patient’s upper arm, and pumped it to 40 mm Hg. After finding the appropriate site (a few inches below the elbow on the inside of the forearm), Bobby cleaned the site with an alcohol pad and immediately made the incision with a Surgicutt parallel to the bend of the elbow. Bobby then wiped away the first drop of blood with an alcohol pad, and blotted the incision every 30 seconds thereafter. Fifteen minutes later the patient was still bleeding.

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Case

A phlebotomist at Memorial Hills Hospital entered the room of a 6 year old patient. The only test ordered was a CBC, so the phlebotomist decided to do a finger stick. After gathering proper supplies for the finger stick, the phlebotomist began the procedure by putting on gloves and wiping the tip and side of the patient’s ring finger with alcohol. He positioned the safety lancet between the ball and the side of the finger and made a small incision. The child cried as the blood was collected.

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Case

A phlebotomist from the laboratory at Midtown Memorial Hospital was working evening shift. Her shift ended at 11 PM and it was 10:30 PM. She suddenly got orders for a STAT blood culture on the second floor. The order specified blood culture times two, 30 minutes apart. The phlebotomist went to the patient’s room and decided to collect both blood cultures at the same time form the same site so she would be able to leave on time without having to come back in thirty minutes to collect the second set. She also wanted to “save” the patient from an extra stick. While the phlebotomist was preparing for the collection, she realized she didn’t have any Betadine on her tray, and decided she would just clean the site twice with alcohol. She finished the blood culture collections and was able to leave by 11 PM.

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Discussion

This phlebotomist violated hospital procedures in several ways that could adversely impact patient care: Cleaning the site only with alcohol, not iodine, could result in a false-positive contaminated blood culture. This might result in the patient receiving unnecessary intravenous antibiotics, and could prolong the patients hospital stay unnecessarily. Drawing both cultures at the same time lessens the chance of recovering a bloodstream organism.Drawing both cultures from the same site might result in both of them being contaminated, making it very difficult for the physician to distinguish contamination from a “real” bloodstream infection.Relevant topics:Blood cultures: introduction, Avoid skin contamination, Blood culture site preparation 1, Blood culture site preparation 2

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Allergies

Posted signs should alert you to patient allergies. Some patients may be allergic to latex gloves or tourniquets, or to iodine.Avoid using latex in case of allergy. Latex allergies are fairly common, and can be severe. May health-care institutions have reduced the use of latex because of allergies, but complete elimination of latex in the hospital environment is difficult, since it is a component of many medical products.

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Signs

Be alert to signs posted on the hospital room door or above the hospital bed.Such signs may warn you to use appropriate personal protective equipment according to your institution’s isolation policies and procedures. Other signs may specify that the left of right arm should be avoided. Patients may also alert you to avoid the use of an arm.

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What is a phlebotomist’s role in health care facility? [continued]

Phlebotomists work in a variety of settings including: Hospitals Physician Offices Nursing Homes Home Health Care Clinics, and Military facilities. A well trained phlebotomist will therefore have a variety of job opportunities available.Other medical professionals, including nurses, respiratory therapists, and medical assistants may also be trained to collect blood specimens.

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White Cell and Platelet Disorders: Peripheral Blood Clues to Nonneoplastic Conditions
Case History

A 17-year-old young woman was admitted to the hospital with abdominal pain and a tentative diagnosis of appendicitis.The total white blood count was 14,500 cells/cumm with a left shift and neutrophils with changes tagged by the arrow in the photographs (see blue arrow).The bluish-staining, blurred accumulations in the cytoplasm (Doehle bodies), are located at the cell periphery in neutrophils with toxic changes.Doehle bodies are remnants of endocytoplasmic reticulum and are products of cytokine activity in the induction and shortened activity of neutrophil activation.They are often present in conditions with increased neutrophil lysosomal activity, manifest as toxic granulation.In this case, the presence of Doehle bodies serves as markers for infection-induced leukocytosis and supports the diagnosis of acute appendicitis.

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