Derriford Combined Laboratory (DCL)
The Combined Laboratory is located on levels 6 and 7 in Derriford Hospital, Plymouth. We are a large Department employing over 150 members of staff comprising medical, scientific, ancillary and clerical grades. The Combined Laboratory provides a full range of Clinical Chemistry, Haematology and Coagulation, Immunology, Molecular Biology, Stem Cell bank and Blood Transfusion. Detailed information relating to blood transfusion is covered in the Hospital Transfusion Manual, which is available on all wards and departments. The Department also offers a comprehensive range of tests through a Point of Care Testing service.
DATA PROTECTION POLICY
The Combined Laboratory regards the lawful and correct treatment of patients’ personal information as vital to successful operations and to maintaining the confidence of users of the service. Our policy is that we will treat personal information lawfully and correctly and therefore we fully endorse and adhere to the principles of data protection described in the Data Protection Act 1998.
As part of University Hospitals Plymouth NHS Trust we also work to its governance and data protection policies which incorporate the Data Protection Act.
Trust policy documentation is available upon request, please see section 5 of our Publication Scheme for details
FEEDBACK and COMPLAINTS
As a department we aim to provide you with the best possible service at all times. If you have cause to send feedback regarding the service you have received, whether complaint or compliment, please contact one of the managers below. We will do all we can to help.
DCL Quality Manager – Marion Tozer External 01752 431098, Internal 31098; email@example.com
DCL Operational Managers – Paul Cooper or Tony Cambridge External 01752 430050/431337, Internal 30050/31337
In the event of the service not meeting a user’s expectation, complaints can be made by letter, email and telephone to the contact details given at the beginning of this manual. All complaints are taken seriously and a full investigation is ensured. An acknowledgement of any complaint will be provided within 2 working days and an initial response will be provided within a 25 day period, in normal circumstances as per Trust policy. Consultant staff undertaking private service within the Trust is acting as self-employed practitioners and as such are wholly responsible for the medical care given to private patients. The Trust does not have a responsibility for investigating the medical element of a complaint received about private care.
|Useful Telephone Numbers|
|Point of care team||792299||52299|
|Derriford Combined Laboratory|
|Core hours are Monday-Friday 09:00 – 17:30.
The service operates 24/7 for Haematology and Biochemistry.
Paul Cooper, Lead Biomedical Scientist – Haematology & Coagulation
Tony Cambridge, Lead Biomedical Scientist – Chemistry, Automation & Reception
Sean Carey, Senior Principal Clinical Scientist – Immunology & H&I
Requesting and Reporting
In order for the correct tests to be applied to the blood samples, the clinical details section of the request form should be completed with as much detail as possible to help with results interpretation or indicate further appropriate testing. Simply stating “unwell” does not provide sufficient information.
All request forms must be completed fully with a minimum of 3 points of identification however; Blood Bank samples MUST have 4 points of identification to be accepted.
The date and time the sample was taken and the signature of the individual drawing the blood sample must be included.
Please use iSoft Clinical Manager (iCM) for all electronic ordering of pathology blood tests that originate within the Derriford site.
INPATIENT/SECONDARY CARE BLOOD TEST REQUESTS
Each request accepted by the laboratory for examination(s) shall be considered an agreement.
For all UHPNT inpatient tests, electronic requests should be made through iCM. For locations with no access to electronic ordering of tests, requests can be made electronically or via paper requests.
For inpatients, upon completion of a request barcode labels will be produced on local printers, no paper request forms are used; the samples must be labelled with printed barcode labels, placed in a bag and sent to the lab.
Paper request forms are available from Pathology Issue Stores.
PRIMARY CARE/EXTERNAL REQUESTS
Primary care test requests are generated using the ICE Sunquest electronic ordering system. Barcoded labels are printed and affixed to the correct blood tubes for the tests requested. The samples are then placed into specimen bags and collected by the transport team for delivery to the appropriate Pathology lab.
BLOOD TRANSFUSION REQUESTS
Important: Samples destined for Blood Bank can have either handwritten or iCM/ ICE labels attached but the label must always be signed by the person bleeding the patient. The request form must also be signed by the individual carrying out the second check. The sample must be accurately labelled with:
Date of Birth
HOSPITAL NUMBER or NHS Number
These must match on both the sample and the request form. Failure to do so will result in rejection of the blood sample and a delay in providing blood components.
It is the responsibility of the clinical requester to ensure that the patient has been adequately supported to make an informed decision to consent to testing. Provision of a request form and an associated sample to the pathology service is taken as consent to testing. The laboratory will conduct testing according to the information given on the request form. Any additional testing, including reflex testing, will only be undertaken either by direct request via the add-on process (see below) or as authorised by the pathology clinical staff on behalf of the Trust and CCG to support clinical care.
Patient consent is required for the use of tissues removed at surgical procedures for research (with certain exceptions), transplantation or obtaining medical information relevant to another person e.g. genetic information.
Consent is not required for the use of tissue from living patients for the following purposes; clinical audit, quality control, public health monitoring, education or training in relation to human health, although it is good practice to inform patients that their tissues may be used for these purposes via patient information literature, and should any patient specify that they do not want their samples to be kept or used for such purposes, these should be respected. These latter uses of tissue are essential to ensure the high quality of service, which all patients have the right to expect. Wherever possible, samples of tissue used in this way should be anonymised or pseudonymised.
Some locations are treated as priority for sample processing including the emergency department, critical care and the medical assessment unit. Barcoded specimens have the location stated on the barcode and are sorted so that the processing takes place at a dedicated urgent workstation. Other locations and service users may request blood tests to be prioritized by phoning the laboratory reception who may refer the request to scientific or clinical staff before processing if necessary.
Results are not routinely phoned to the requestor. If results are abnormal but do not suggest a significant change in the state of the patient the result will not be phoned but will be made available at the earliest opportunity through iCM for review. If previous results indicate that this is a new presentation or represents a significant change then the result would be communicated to the requestor at the earliest opportunity.
ADD-ONs and REPEAT TESTS
Additional requests can be requested on samples already submitted dependent upon age and nature of sample available as detailed in the Test List and that the sample meets the physical requirement criteria for Acceptance (see below).
Haematology- via telephone or by bleep out of core hours
To complement our own test repertoire over 200 additional assays are available through the laboratory referral service. In these cases we aim to assure the quality of test results through the selection of suitably accredited laboratories that are able to provide efficient turnaround times for our patients’ results. The referred assays are integrated into the in-house test list, with guidance on sample requirements, expected TAT and site they are sent to. When the final report is issued, the reference laboratory will be identified, together with any applicable comments they, or our clinical staff, have made.
ICE/iCM DOWNTIME PROCEDURE
Completing a paper request
Paper requests should be used when the iCM/ICE system is down, or if a requested test is not available on the electronic ordering system. Stock of request forms is held in the Pathology Issue Store and the Laboratory Reception, whilst locations are encouraged to hold a small stock of request forms in case of unplanned downtime. Planned downtime is managed through communications from Pathology to the end user.
Please complete all sections of the correct form (see table below) using a ball point pen (addressograph labels can be used on forms only).
It is essential that you include a summary of the relevant clinical details and therapy, as the laboratory may initiate further appropriate tests on the basis of the results obtained and clinical information provided.
There should be at least three matching pieces of information between the form and the sample and they should be as listed below:
Surname and Forename and any other from list (a)below
Registration number and surname and any other from list (a) below
NHS number and surname and any other from list (a) below
Date of birth
Failure to complete forms correctly results in delay and inefficiency. If a report is required, you must include the correct hospital, ward and consultant codes or GP codes. A properly addressed report cannot be issued without this information.
All request forms must be signed by the requesting clinician before the specimen is taken.
Urgent requests must still be phoned to the laboratory by following the usual procedure on the urgent requests.
CLINICAL ENQUIRIES/DUTY BIOCHEMIST
Full contact details of medical staff providing clinical advice, diagnostic and/or interpretive services are listed at the beginning of each of the sections:
REJECTION AND ACCEPTANCE CRITERIA
Completed request form with relevant demographics and clinical details: Under the International Standard ISO 15189:2012 Requirements for quality and competence for medical laboratories fulfillment requires that the laboratory meets both the technical competence and management system standards that are necessary for it to consistently deliver technically valid results. All specimens must be clearly and unequivocally identified with a minimum of three of the key identifiers. Key identifiers must be correct and match the information given on the request form. ISO 15189:2012 also states that the request form must include the name or other unique identifier of clinician, healthcare provider, or other person legally authorised to request examinations or use medical information, together with the destination for the report. Any non-conformity in respect to this will lead to delay in the specimen pathway.
Physical requirements for individual tests are stated in the test list (notes column). Assays unable to be performed due to meeting one or more rejection criteria are reported as ‘Test Not Done’ stating the reason for this. The types of factors affecting blood samples include insufficient quantity to perform the test/s, haemolysis, jaundice, lipaemia, clot formation (affects coagulation testing), potassium contamination, high ferritin or cryoglobulin levels amongst others.
Patient collected samples
Self-collected samples are currently required for 24 hour urine testing. Full instructions are issued to patients with the sample packs.
No self-sent samples or samples from family members will be accepted for testing. It is unacceptable for clinicians, nursing staff or Laboratory staff to request tests for themselves. All such requests will be referred to the Laboratory Consultants who may agree to be, or identify, a requesting doctor.
Reviewed December 2019
This page will be updated March 2020