North Carolina lab-oratory

              http://slph.state.nc.us/
I N S I D E
t h i s i s s u e
PAGES 2-4
Newborn Screening
A list of disorders
PAGES 5-6
LaCrosse Encephalitis in Western NC
PAGE 7
Blood glucose
PAGE 8
Microscope Tips
How to properly clean your
microscope
PAGE 9
QA
Clinical Sample Submissions
PAGE 10 / EDITORIAL
Needle Points
Patient Misidentification
From the Director’s Chair
We hope that you enjoyed the revival of the quarterly
newsletter LabOratory. I wanted to take the opportunity
to highlight some of the recent and ongoing activities
in which the North Carolina State Laboratory of Public
Health has been involved.
Celebrating National Laboratory Week: We always look
forward to this week in April! For the last two years, we
have had outstanding committees plan activities, door
prizes, and other morale-boosting events to celebrate the
important work all our staff do every day.
New Laboratory Information Management System:
We are excited to begin the lengthy process of adopt-ing
and confi guring a new commercial LIMS product.
Th e new LIMS system will not only enhance work fl ow, quality control and quality
assessment activities within the laboratory, but will also improve customer service.
Social Security Number Issues: We continue to work with local health departments on
a case-by-case basis as issues arise. Th e primary challenge is temporary numbers, and we
are working to ensure consistency in accepting and utilizing these numbers.
Lab-Oratory, June 2006 Number 84
Cont. on page 2
Leslie A. Wolf, PhD, HCLD (ABB)
Acting Laboratory Director
Th e State Laboratory of Public Health provides certain medical and environmental
laboratory services (testing, consultation and training) to public and private health
provider organizations responsible for the promotion, protection and assurance
of the health of North Carolina citizens.
M I S S I O N
statement
Lab-Oratory / June 2006
2
Local Health Department Accreditation:
Our Regional Laboratory Improvement
Consultants and other staff have been at-tending
meetings and providing the ten
local health departments with information
and any documentation required during
this important process.
Phlebotomy Initiative: Trainings continue to
be held throughout the state, and the response
has been overwhelmingly positive. We are
pleased to help address such a dire need in the
laboratory community.
Incident Command Training (ICS): As part
of the State of North Carolina’s commitment
to preparedness for public health emergencies,
all our staff has been completing ICS 100,
200 and 700 courses. Several members of
the laboratory management team have taken
ICS 300 and 400 courses, as well, to ensure coverage at the Public Health
Command Center in Raleigh.
Regional Response Laboratories (Buncombe, Mecklenburg, Pitt counties): Th e
Bioterrorism and Emerging Pathogens (BTEP) Unit has been working tirelessly
for three years to bring the regional laboratories on-line. Th e primary mission of the
Regional Response Laboratories is to perform analyses on suspicious samples
using the national Laboratory Response Network (LRN) protocols.
Secondarily, they will be performing testing to assist in specifi c outbreak
situations as time allows.
We look forward to the return of Dr. Lou Turner on July 1, 2006, when she
resumes her role as Laboratory Director. Enjoy the rest of the spring season and
have a safe summer!
Leslie A. Wolf, PhD, HCLD (ABB)
Acting Laboratory Director
Director’s Chair cont. from page 1
Newborn Screening: Making a Difference
When visiting a hospital, most people
enjoy peering through the window of the
newborn nursery and watching the activi-ties
of the tiny occupants. Most of these
babies are healthy and will go home to
thrive and grow normally. However, there
are some health problems that are not easily
discovered by the routine examination that
the newborn receives in the hospital. Th ese
conditions are detected by the newborn screen-ing
that is done when the baby’s heel is pricked
48-72 hours after birth, and the sample is sent
to the North Carolina State Laboratory of
Public Health.
Th e dried blood spots that are submitted
allow the laboratory to test for more than
30 abnormal conditions, many of which are
life-threatening and can cause serious long
term health eff ects if not treated early.
Although most of these disorders are inher-ited,
the family may not be aware that the po-tential
for the condition exists if the parents are only carriers for the disease.
Individuals in carrier states are usually healthy, but can have an aff ected child when
the defective gene is acquired from both parents. Early detection and
treatment with a special diet or other medical intervention can prevent mental
retardation, physical disabilities or even death.
Th e following is a list of the newborn disorders screened for by the N.C. State
Laboratory of Public Health:
Disorders detected by tandem
mass spectrometry
(MS/MS)
Amino Acid disorders – Th ese disorders result from a lack of enzymes needed
to break down amino acids, which are the building blocks of protein. Other
enzyme defi ciencies create an inability of the body to rid itself of the nitrogen
incorporated in amino acid molecules. Toxic levels of amino acids or ammonia
build up in the body, causing varying degrees of symptoms and even death
when untreated. Treatment involves dietary restrictions and supplements.
NCSLPH tests for the following disorders in this category:
Argininosuccinic aciduria (ASA)
Citrullinemia (CIT I)
Homocystinuria (cystathionine beta synthase) (HCY)
Cont. on page 3
Lab-Oratory / June 2006
3
Cont. on page 4
Maple syrup urine disease/Branched-chain ketoacid dehydrogenase
(MSUD)
Phenylketonuria /Hyperphenylalaninemia (PKU)
Tyrosinemia type II (TYR-II)
Tyrosinemia type III (TYR-III)
Organic Acid Disorders – Th ese diseases are also a result of loss of enzyme activity
involved in the breakdown of amino acids as well as other substances such as
lipids, sugars and steroids. Toxic acids build up in the body and may result
in coma and death. Treatment involves dietary protein restriction and dietary
supplements. Th e following conditions are currently detectable in this
category:
Glutaric acidemia type I (GA-I)
Multiple carboxylase defi ciency (MCD)
3-Hydroxy-3-methylglutaryl-CoA lyase defi ciency (HMG)
Isobutyryl-CoA dehydrogenase defi ciency (IBD)
Isovaleric acidemia/Isovaleryl-CoA dehydrogenase defi ciency (IVA)
Beta-ketothiolase (BKT)/Short-chain keto acylthiolase defi ciency (SKAT)
Methylmalonic aciduria (MMA)
2-Methylbutyryl-CoA dehydrogenase defi ciency (2-MBD)
3-Methylcrotonyl-CoA carboxylase defi ciency (3-MCC)
Propionic acidemia (PPA, PROP)
Fatty Acid Disorders – Th ese conditions result from defects in enzymes needed
to convert fat into energy. When the body’s supply of glucose is depleted, it
breaks down fat to aid in the production of alternate fuels. When this pathway is
blocked due to the defective enzymes, cells suff er an energy crisis when they run
out of glucose. Individuals with these types of disorders must ensure that they
consume meals on a regular basis and engage in a low-fat diet. NCSLPH screens
for the fatty acid disorders listed below:
Carnitine/acylcarnitine translocase defi ciency (CAT)
Carnitine palmitoyltransferase II defi ciency (CPT II)
Medium-chain acyl-CoA dehydrogenase defi ciency (MCAD)
Multiple acyl-CoA dehydrogenase defi ciency (GA-II)
Long-chain 3-hydroxyacyl-CoA dehydrogenase defi ciency (LCHAD)
Short-chain acyl-CoA dehydrogenase defi ciency (SCAD)
Tri functional protein defi ciency (TFP)
Very long-chain acyl-CoA dehydrogenase defi ciency (VLCAD)
Disorders detected by biochemical
and other technologies
Biotinidase Defi ciency (BIO) – Lack of this enzyme aff ects the body’s ability
to process biotin, a common vitamin found in many foods. Th is disorder may
result in skin rash, hair loss, hearing loss, seizures, mental retardation, and even
death. Biotinidase defi ciency is treated with free biotin that is not bound to
protein or other molecules.
Congenital Adrenal Hyperplasia (CAH)
– Th is is a group of disorders characterized
by abnormal production of the hormones
produced by the adrenal glands. Th ese
hormones play an important role in sexual
development, sometimes resulting in
ambiguous genitalia when there is a defect in
production. A salt-wasting form of CAH in
newborns can produce symptoms of weakness,
vomiting, dehydration and shock. Treatment
with hormone replacements allows infants to
have normal growth and development.
Galactosemia (GAL) – Th is condition
prevents the body from using a sugar called
galactose that is found in milk. Early
symptoms include vomiting, liver damage and
even death. Th e infant is treated by switching
from breast milk or formula to a galactose-free
(soy-based) formula.
Congenital Hypothyroidism (primary)
(CH) – Th is disorder occurs when infants are
unable to produce suffi cient amounts of
thyroid hormone, which is necessary for
normal metabolism, growth and brain
development. Treatment with thyroid hor-mone
medication prevents these symptoms.
Hemoglobinopathies – Common hemo-globin
abnormalities include Sickle Cell
Disease, Hemoglobin C Disease, Hemoglo-bin
E Disease, Sickle/Hemoglobin C Disease
and Sickle/Hemoglobin E Disease. Th ese
disorders are caused by genetic variations that
result in structural defects of the hemoglobin
molecule. Sickle Cell Disease is the most
common hemoglobin disorder and is
characterized by hemolytic anemia, pain
episodes, serious infections and damage
to vital organs. Early detection and treat-ment
of infants with prophylactic penicillin
signifi cantly reduces morbidity and mortal-ity
from pneumococcal infections. Blood
transfusions and administration of hydroxy-urea
can be eff ective treatments to prevent the
Newborn cont. from page 2
Lab-Oratory / June 2006
4
Newborn cont. from page 3
sickling of red blood cells that causes a pain
crisis.
Although a Newborn Screening form requires
only a very small amount of sample to be
submitted, a wealth of information can be
obtained from the laboratory testing that is
performed. With early detection, treatment
and proper follow-up care, infants with these
disorders may avoid serious health problems
and even death. Th at is why it is import-ant
that samples be properly collected and
submitted promptly, with forms that are accurately fi lled out. For more
information on the collection of Newborn Screening fi lter form
specimens, check out the new educational Power Point presentation at the
State Laboratory of Public Health website (http://slph.state.nc.us/) and
locate “Form Training” under Newborn Screening. Any additional
questions may be directed to the Newborn Screening/Clinical Chemistry Unit at
(919) 733-3937.
Article Submitted by:
Patty Atwood, BSMT (ASCP)
Supervisor, Hemoglobinopathy Laboratory
Lab-Oratory / June 2006
5
LaCrosse Encephalitis in Western
North Carolina, 2005
Originally published in Epi Notes
LAC is a disease that resides in eastern
chipmunks, gray squirrels, and possibly
red foxes. Th ese animals produce high
amounts of virus within their bodies. A
mosquito bites (feeds on) an infected
chipmunk or squirrel. During this time,
the mosquito is extracting blood from the
animal, which could contain LAC virus
or other arboviruses. When the mosquito
bites a human, virus particles are allowed
to enter the human body and infect cells.
Th e virus takes over the infected cells,
and causes the cells to start making more
virus particles that infect additional cells
throughout the body. Th is causes an
infection that can result in disease.
Th e virus is not usually transferred
human to human. Th e mosquitoes that
transmit LAC are formally named
Aedes triseriatus, but often are called the
“treehole” mosquito. Th ey earned the
nickname because they require standing
water in man-made containers or natu-ral
treeholes to reproduce and mature.
By eliminating these water sources, the
number of mosquitoes available to
transmit infection will decrease.
LAC infection can present itself with
various symptoms. According to the
Centers for Disease Control and
North Carolina has a wide variety of
terrains. From the Atlantic Ocean on the
east to the Appalachian Mountains and
Tennessee border in the west, the state
has a varied geography and ecology. Th is
diverse ecology supports many arthropod
vectors, birds and mammals. In 2005,
our state witnessed a dramatic increase in
human LaCrosse Encephalitis (LAC)
infections. LAC is an arbovirus that is
transmitted by arthropod vectors such
as mosquitoes. Th ere are hundreds
of arboviruses found throughout the world,
and many arboviruses can infect
humans and cause mild to severe
disease. Th e most familiar arboviruses
found in North Carolina are West Nile
Virus (WNV), LaCrosse Encephalitis
(LAC), and Eastern Equine Encephalitis
(EEE). Th ese diseases are usually ter-ritorial,
meaning that they are usually
localized to certain parts of the state. WNV
and EEE tend to be found in the eastern
part of the North Carolina, and LAC is
usually confi ned to the western part of the
state. Travel within the state is common;
thus these viruses have been detected in
humans in areas outside of the normal
regions. Th e map below illustrates the
county of residence of humans infected
by LAC in 2005 (32 cases illustrated).
Prevention (CDC), 80%-90% of
children with LAC infection develop a
mild febrile illness that includes fever,
headache and vomiting. Symptomatic
children have seizures in about 50% of
cases and develop encephalitis and men-ingitis
similar to enteroviral infection.
LAC infection can produce lethargy
and behavioral changes within three
to four days post-infection, with sei-zures
progressing to coma in 8-24 hours
post-infection. Seizures can occur for
up to eight years post-infection in a few
cases.
N.C. Public Health epidemiologists re-quested
assistance from the CDC in
September 2005 to help investigate
the LAC outbreak in western North
Carolina. From this work, the state
was able to gain important informa-tion
and begin to understand the causes
of the increased number of infections
over the previous years. Of note, North
Cont. on page 6
Lab-Oratory / June 2006
6
Carolina had 32 of the 70 cases (46%)
detected in the entire United States in 2005.
In 2005, eight adult infections and 24 child
LAC infections were detected. Th e symptoms
ranged from headache, fever and other fl u-like
symptoms to central nervous system defi -
ciencies such as encephalitis and meningitis.
Th is disease caused more severe symptoms in
children than in adults. In 2005, 22 of 32
LAC infections occurred in humans under 15
years old, and seven of 32 were older than 60
years old. Th e remaining three human LAC
infections were in humans 20-42 years old.
Since 2000, North Carolina has seen a
steady increase in human cases (Table
1). Overall, North Carolina has had a
457% increase in the number of cases
in the past fi ve years. Th is fi nding has resulted
in heightened surveillance and has increased
public health concern. While the cause of
the increase is not completely understood,
raising awareness of public understanding
regarding how and why the disease is trans-mitted
may help decrease the number of
infections. Since the discovery of WNV in
the United States, arbovirus surveillance has
increased in most states, and due to media
attention, reporting of other arboviral
infections such as LAC has increased.
In 2005, the enhanced surveillance activities incorporated N.C. entomolo-gists
who performed mosquito habitat evaluations, mosquito trapping, and
small mammal evaluations at residences of LAC-infected individuals. Th is was
an attempt to determine where the virus was most prevalent and what had
contributed to the infections in the area. Decreasing the mosquito vectors is
one way to decrease future infections and gather important data.
Th e information gathered in 2005 and the enhanced surveillance suggests
that LAC infections in North Carolina continue to be a serious problem
that aff ects many people, especially children, in the western part of our state.
Considerable time and resources on the local, state, and federal levels have been
devoted to raising awareness of the potential for arboviral infections and to
determining the cause and prevention of infection and the proper diagnosis of the
disease. Th e key public health message is to help prevent infection in and around
residential areas by eliminating mosquito habitat, wearing insect repellants, and
avoiding outdoor areas at dusk and dawn if at all possible. In 2006, public
health surveillance will continue and arboviral testing will be conducted at the
N.C. State Laboratory of Public Health. For more information on protection
from mosquito bites and decreasing mosquito habitat, visit the Public Health
Pest Management Website at:
http://www.deh.enr.state.nc.us/phpm/html/mosquitoes.html.
Submitted by: Joey Johnson, Medical Laboratory Supervisor II, Special Serology
March 16, 2006
Photographs appear courtesty of a CDC training presentation.
Calendar
Year
Number of
Cases
2000 7
2001 14
2002 20
2003 24
2004 14
2005 32
Table 1. Increase in LAC cases
in North Carolina.
LaCrosse cont. from page 5
Lab-Oratory / June 2006
7
In addition, there are non-pathological
reasons for increased blood glucose. Th ese
could include stress, IV fl uids, pregnancy,
and medications such as antidepressants,
beta-adrenergic blocking agents, corti-costeroids,
dextrothyroxine, diazoxide,
diuretics, epinephrine, estrogens, gluca-gons,
isoniazid, lithium, phenothiazines,
phenytoin, salicylates and triamterene.
Certain drugs, such as acetaminophen,
alcohol, anabolic steroids, clofi brate,
disopyramide, gemfi brozil, insulin mono-amine
oxidase inhibitors, pentamidine,
propranolol, tolazamide and tolbutamide,
may cause a decrease in glucose level.
References
Kaplan LA, Pesce AJ. Clinical Chemistry: Th eory,
Analysis, and Correlation. 3rd ed. St. Louis: Mosby,
Inc; 1996.
Pagana KD, Pagana TJ. Diagnostic and Laboratory
Test Reference. 4th ed. St. Louis: Mosby, Inc; 1999.
Submitted by:
Jennifer Anderson, BS, MT (ASCP)CM
Consultant, Laboratory Improvement
Lab Test of the Quarter
Blood Glucose (Also known as Blood Sugar)
Blood glucose is a very common laboratory
test that measures the amount of glucose
in the blood. Glucose (C6H12O6), a six-carbon
polyhydroxyl aldehyde, is
metabolized in cells to form ad-enosine
triphosphate (ATP) which
is the energy source for all biological
functions. When we consume carbo-hydrates,
they are broken down into
smaller sugars, one of which is glucose.
Part of the glucose is directly absorbed
into the blood stream for immediate
energy production. Th e hormone insu-lin
causes the body to store any excess
glucose in the form of glycogen, fats and
proteins for times of glucose shortage
(hypoglycemia.) If the glucose levels in
the body become too low, these storage
molecules are hydrolyzed (broken down)
into glucose and released into the blood
stream. Th is is an essential process, be-cause
glucose is necessary for our survival.
Th e human brain could not survive with-out
a constant supply of glucose, its pri-mary
source of energy. Likewise, it’s dan-gerous
to have too much glucose in the
blood stream (hyperglycemia) because it
can be both a symptom and a cause of-diabetes.
Specimen Type:
Blood (venous or capillary)
Normal Ranges:
Premature Infant: 20-60 mg/dl
Neonate: 30-60 mg/dl
Infant: 40-90 mg/dl
Child <2 years: 60-100 mg/dl
Child >2 years-adult: 70-105 mg/dl
Elderly: increase in normal range
after age 50 years
Critical Values
(may vary slightly by facility)
Newborn: <30 and >300 mg/dl
Infant: <40 mg/dl
Adult Female: <40 and >400 mg/dl
Adult Male: <50 and >400 mg/dl
When evaluating a patient’s blood glu-cose
level it is important to be aware
of the fasting status of the patient. For
instance, a glucose level of 150 mg/dl is
an expected value in a person who ate just
one hour ago, but would be considered
abnormal if a person had been fasting for
eight hours. Th ere are several diff erent
diseases state that cause abnormal blood
glucose results (see Table 1).
Increased Levels Decreased Levels
(Hyperglycemia) -Diuretic therapy (Hypoglycemia)
-Diabetes mellitus -Corticosteroid therapy -Insulinoma
-Acute stress response -Acromegaly -Hypothyroidism
-Cushing’s syndrome -Hypopituitarism
-Pheochromocytoma -Addison’s disease
-Chronic renal failure -Extensive liver disease
-Glucagonoma -Insulin overdose
-Acute pancreatitis -Starvation
Table 1
Lab-Oratory / June 2006
8
Microscope Tips
Cleaning the Brightfield Microscope
detergent, rinse thoroughly and dry before reusing.
4. Moisten lens paper or cotton swab with lens cleaner and gently wipe
all outer optical surfaces. Start from the center and work
toward the edge with a rolling and lifting motion.
Repeat the process, using a clean area of the paper
or a clean swab until all dirt and smudges are
removed.
5. Remove each objective from the
nosepiece, one at a time, to clean as
instructed in step 4. Return the clean
objective to its original location
before continuing to the next.
CAUTION: Do NOT
clean the interior of the
eyepieces or objectives
or the bottom of the
condenser.
Never take the eyepieces or
objectives apart.
6. Clean the mechanical stage and
other body parts (non-glass) with Kimwipes or a
cloth dampened with detergent or lens cleaner. Remove the
stage clips to clean the underside, and dry before returning the clips to
the stage.
CAUTION: If a corrosive liquid,
such as urine or KOH, spills on the
stage, immediately disassemble the
stage clips and clean the surface.
7. Cover the clean microscope with a non-linty material to prevent dust
from settling on clean surfaces. Plastic bags are acceptable replacements
for damaged or lost microscope covers.
Periodically inspect the power cords and plugs for safety; frayed cords are a
potential shock hazard. Always keep a replacement bulb available. Never
interchange bulbs between microscopes that are diff erent makes and models.
Treat your microscope with the care that a precision instrument deserves. Keep
a daily log to record the microscope maintenance as you would for any other
laboratory instrument. Watch for Koehler Illumination instructions in the
next publication.
Submitted by:
Colleen Miller, BS MT(ASCP)
Laboratory Improvement Consultant
Is the microscope in your laboratory dirty
and dusty? Has it been neglected and often
abused? Th e condition of a microscope’s
body is often an indication of its optical
and mechanical performance. Unfortu-nately,
too often, the microscope gets
overlooked for routine care and maintenance.
Microscopes are expected to provide many
years of reliable service despite continuous
neglect. Good preventive maintenance will
improve the performance of a microscope
and extend its years of service. Preventive
maintenance includes regular cleaning, setting
for Koehler Illumination, and annual service
by a professional.
Clean the microscope daily to remove dust,
grease and grime which can damage the optics,
erode the surfaces, and interfere with correct
use. Take particular care when cleaning
the optics as they are easily scratched.
Th e instructions that follow will
guide you as you perform an important
laboratory task.
1. Assemble the following supplies:
• Squirrel or camel hair brush
(such as an artist brush)
• Lens cleaner (formulated for
microscope or camera optics)
• Lens paper
• Cotton swabs
• Air bulb
• Detergent (mild) and Kimwipes
for cleaning stage and stand
2. Unplug the microscope and wash your
hands before starting.
3. Remove dust from the microscope,
starting at the top and working down.
Use the air bulb and brush to remove
dust from the optical glass surfaces, i.e.,
eyepieces, objectives, condenser lens and
fi lters.
CAUTION: Never use a dirty
brush. Clean a soiled brush with
Lab-Oratory / June 2006
9
Quality Assessment Updates
Clinical sample submissions
Accompanying each sample is a
requisition that contains the necessary
information for performing a test. It
is essential that all the information be
completed accurately and as neatly as
possible. Some facilities use labels,
which are easier to read than handwritten
information. Patient and facility informa-tion
that is unreadable or smudged on the
requisition or samples can cause a delayed
turnaround time for that sample.
Th e Clinical Laboratory Improve-ment
Amendments (CLIA ’88 and
’03), 42CFR493, Subpart K, lists the
minimum requirements for the clinical
sample requisition:
• Name and address of submitted,
including EIN number
• Patient’s name or unique identifi er
• Sex and date of birth or age
• Tests to be performed
• Source of specimen, if appropriate
• Date of collection and time, if
appropriate
• For Pap smears, the patient’s last
menstrual period, an indication
of whether the patient had a
previous abnormal report, treatment
or biopsy.
• Any additional information relevant
to testing
• Other additional information
required on State Laboratory
requisitions:
o Social Security Number (Patient
number)
o Medicaid Number, if applicable
o Race/Ethnicity
o County of residency
Th e sample itself needs two identifi ers
(State Laboratory requirement):
• Patient name or unique identifi er
and
• Either date of birth or Social
Security number (SSN)
• Source of specimen, if appropriate
Th e use of the patient’s Social Secu-rity
number on sample requisitions has
recently raised questions. After legal
review, it was determined that “collection
of SSNs from patients will be impera-tive
to the performance of several legally
prescribed duties, including:…..sub-mission
of specimens to the state public
health laboratory…” (Hoke & Moore
memo, November 30, 2005, p.2). It is
necessary that the patient’s SSN be
submitted. Occasionally, a patient may
present to the facility without a SSN. A
temporary SSN may be constructed and
used until a permanent SSN is obtained.
Directions for creating a temporary
SSN have been provided to all the local
health departments. It is imperative that
the local facilities are consistent in the
creation of this temporary SSN;
hyphenated names present a chal-lenge
for a temporary SSN. Some
facilities have developed policies to
address Hispanic names. Th is is an
excellent step because it provides a
standard that can be applied across the
facility. Being consistent in creating a
temporary number at the local level will
always provide the same temporary num-ber
on specimens submitted to the State
Laboratory.
Questions about sample submission may
be addressed to the Quality Assessment
Unit, 919-807-8750.
Article submitted by:
Vickie Whitaker, BA, MT (ASCP)
Quality Assurance Manager
Lab-Oratory / June 2006
10
the wrong patient. Tragically, patient identfi ca-tion
errors often mark the beginnings of a
journey leading to patient mismanagement,
misdiagnosis, and even death. Th at is why
the Clinical and Laboratory Standards
Institute (CLSI) recommends the following
steps for outpatient identifi cation:
• Ask outpatients to give their full name, address,
identifi cation number, and/or birth date.
• Compare the information with the information on
the test request form.
• Report any discrepancy, however minor, to a
responsible party and have the patient identifi ed by
name and identifi cation number before collecting
any specimen. Document according to facility
policy.
For outpatients who are too young, mentally incompetent, or do not
speak the language, the collector should:
• Ask the nurse, a relative, or a friend to identify the patient by name,
address, and identifi cation number and/or birth date. If unable to
identify the patient, then contact the nurse or physician.
Interpreter services should be accessible for non-English speaking patients who
present to the laboratory without a relative or friend who can interpret for
them.
So, what assumptions lead to patient misidentifi cation?
• Assuming errors in patient orders never occur, so that you never verify the
information presented.
• Assuming that any minor discrepancy noted in the identifi cation process
is not worth pursuing.
• Assuming the correct patient is in your phlebotomy chair simply because
he/she responded when you called their name, without regard for patients
who may have misunderstood you because they are hard of hearing or do
not fl uently speak English.
• Assuming that under certain circumstances, it’s okay to deviate from your
agency’s patient identifi cation policy (i.e., during staffi ng shortages, when
dealing with a backlog of patients, etc.).
I eventually made it home that fi rst day of second grade, thanks to a
compassionate bus driver. But make assumptions about the identity of your
patients and the results that follow may not be nearly as forgiving.
Patient misidentifi cation: It’s an unintended journey you don’t have to take.
Patient Misidentification:
An Unintended Journey
Some of my most vivid childhood memories
are of the fi rst day of school. Th e fi rst day
meant my mom would drive me to school
rather than having to ride the bus, and
together we would carefully check the class
rosters for my name. I distinctly recall the
fi rst day of second grade. Until that day, I
hadn’t known who my teacher would be or the
classmates who shared a similar fate.
However, I was sure about one thing; I
knew which school bus would take me
home. After all, I had ridden Bus 78 all
of fi rst grade.
When class dismissed for the day, I headed
across the parking lot toward the bus that
had taken me home every school day the
year before. As I climbed aboard, the
children were abuzz with conversa-tions
I quickly joined. It was not
until minutes later that I realized
Bus 78 was heading down a diff erent road
in the opposite direction of my house.
My realization soon turned to panic and
ultimately into sobs as the landscape outside
the bus window became more foreign. So
on that fi rst day of second grade, I learned an
important lesson about making assumptions.
Just like reassigned school buses, assumptions
can take you on an unintended journey. With
regard to patient identifi cation, making an
assumption about one’s identity rather than
consistently adhering to patient identifi cation
protocols can set into motion unintended con-sequences
for the patient, the employee, and
the employer.
Patient identifi cation is the fi rst and most
critical step in blood specimen collection.
No amount of technological advancement or
sophisticated equipment can produce an
accurate result from a specimen drawn on
Needle Points
By Lisa O. Ballance, BSMT (ASCP)
EDITORIAL
Lab-Oratory / June 2006
11
The Safety Corner
Exposure Control Plan Series-Exposure Determination
According to OSHA’s Bloodborne
Pathogen Regulation, each employer
who has an employee(s) with occupa-tional
exposure shall prepare an expo-sure
determination. An occupational
exposure is any reasonably anticipated
skin, eye, mucous membrane, or parenter-al
contact with blood or other potentially
infectious materials that may result
from the performance of an employee’s
duties. An exposure determination is a
listing of all job classifi cations in which
employees will be exposed—such as
laboratorians—or may occasionally be
exposed—such as custodians—to po-tentially
infectious materials on the job.
Each supervisor should identify, evalu-ate
and classify each task performed
within the facility. Th is should be done
without regard to the use of personal pro-tective
equipment. In order to classify, a
supervisor and employee must:
• Identify the body fl uids that are
likely to be contaminated with HIV,
HBV and other viruses.
• Determine the amount of body
fl uids that the employee is likely to
encounter as a result of performing
the procedure.
• Determine the probability of the
employee being exposed to
contaminated body fl uids as a result
of performing the procedure.
• Identify the ways HIV, HBV or
HCV could enter the employee’s
body as a result of performing the
procedure.
• Identify the engineering controls
that should be used while
performing the procedure.
• Identify the work practice controls
that are necessary to perform the
procedure.
Once the exposure determination has
been completed and all engineering and
work practice controls are in place, proper
personal protective equipment may be
added to ensure a safe work environment.
Look for the next installment of the
Exposure Control Plan series in the Fall
Lab-Oratory, when employee education
and training will be discussed!
Article submitted by
Kristy O’Briant, BS, Laboratory
Improvement Consultant, NCSLPH
Upcoming Event:
North Carolina Clinical Laboratory Day
Americans, causing debilitating complica-tions
such as coronary artery disease, renal
failure, adult-onset blindness, stroke and
neuropathy.
Th e conference is designed for health-care
professionals, including physicians,
medical technologists/technicians, nurses,
educators and others involved in the
diagnosis, care and management of
patients with diabetes. Exciting lec-tures
are scheduled throughout the day.
Exhibitors will provide free samples and
information on tests for diagnosis and
management of diabetes. For more infor-mation,
call the Laboratory Improvement
Mark your calendar for an exciting edu-cational
event on Friday, August 4, 2006
at Wake Technical Community Col-lege.
Th e focus of the 2nd annual North
Carolina Clinical Laboratory Day is
“Th e Diabetes Challenge: Diagnosis,
Education, and Management.” Th e Texas
Health Foundation, the North Carolina
State Laboratory of Public Health, and
the North Carolina Diabetes Prevention
and Control Branch will cohost the con-ference.
Participants will fi nd the forum
an opportunity to learn about the disease
that is the sixth-leading cause of death in
the United States. Diabetes has become a
major public health threat to millions of
offi ce at 919/733-7186, or visit
http://slph.state.nc.us/LabImprovement
(after June 12th).
Submitted by:
Colleen Miller, BS MT(ASCP)
Laboratory Improvement Consultant
Lab-Oratory / June 2006
12
“Dear Lab-bey”
While this clinician’s concern for patient discomfort is admirable, it is not
advisable to use anything other than sterile non-bacteriostatic saline to reduce
discomfort when collecting a male urethral smear. According to Cami Hartley, State
Lab Microbiology Supervisor, Neisseria gonorrhoeae is very sensitive and can be killed
very easily. Xylocaine would defi nitely kill the organism and any oil-based substance will
inhibit or prevent growth.
Th e Sexually Transmitted Disease Assessment, Prevention, and Treatment Protocols, published by the N.C. HIV/
STD Prevention and Care Branch, lists the following steps for collecting the male urethral specimen for gram stain
and gonorrhea culture:
“Use a Calgiswab to collect a sample of the discharge. If discharge is not apparent, penis should be milked
from base to tip to express discharge for collection. Insert the tip of the swab one to two centimeters into
the meatal opening and gently rotate for three to fi ve seconds. Th e swab may be moistened with sterile
non-bacteriostatic saline to reduce discomfort.
- For gram stain, roll the swab along the glass slide.
- For gonorrhea culture, roll the same swab in Z pattern on the gonorrhea culture plate and cross streak.”
Every health department should have a copy of this valuable reference. If you do not, please contact the HIV/STD
Prevention and Care Branch at (919)733-2030.
One of our clinicians would like to use xylocaine or KY jelly
on the urethral swab for GC culture to reduce discomfort.
Will this interfere with the growth of the GC?
“Dear Lab-bey…”
If you have a technical laboratory question
that you would like to have answered
please submit it to:
Jennifer.A.Anderson@ncmail.net.
The answer to your question may be
featured in the next edition of Lab-Oratory.
Lab-Oratory / June 2006
13
North Carolina Public Health
Phlebotomy Initiative
A new and innovative phlebotomy competency assessment program,
especially designed for North Carolina local health department laboratories
and other interested public health agencies, was introduced in March by the
Laboratory Improvement Unit. From March through May, eight half-day North
Carolina Public Health Phlebotomy Initiative training sessions were held
at various locations spanning the state. A total of 125 N.C. Public Health
employees attended.
Th e goal of Session 1: Assessing Competency was to deliver current continuing
education to participants, along with guidance for establishing standardized
and comprehensive phlebotomy assessment programs in their own facilities.
Th is was accomplished using a combination of educational videos, question
and answer sessions, and formal lecture. Also provided to attendees were
competency assessment tools and a model blood collection procedure, all based
on the current standard of care for phlebotomy.
As a prerequisite, participants—including supervisors, laboratory profession-als,
phlebotomists, nurses, and other healthcare staff —were required to possess
at least one year of phlebotomy experience. Attendees who scored 80% or
higher on the fi nal examination were awarded a certifi cate of completion for
the course.
Th e benefi ts of implementing a phlebotomy competency assessment
program include reducing to the lowest possible degree the risk of patient and/or
employee injuries associated with blood specimen collection and thus
reducing the employer’s potential for legal liability. In addition, regular
evaluation of blood collection policies and procedures, as well as of the staff
who perform these duties, is key to ensuring that consistently high-quality
specimens are obtained and submitted for patient testing.
Laboratory Improvement strives to provide comprehensive and relevant
training designed to meet the ongoing needs of the laboratory community it
serves. Th e North Carolina Public Health Phlebotomy Initiative is just one
example of the Unit’s creative approach to meeting an identifi ed need with a
new course topic, unique format, and local delivery. Due to the overwhelming
positive response to this initial course off ering, we look forward to developing
additional sessions for this series.
Article submitted by:
Lisa O. Ballance, BSMT(ASCP)
Regional Laboratory Improvement Consultant, Course Director
Fayetteville Regional Offi ce, NCSLPH
Lab-Oratory / June 2006
14
Who’s New in Public Health?
We have a few more newcomers to North Carolina’s Public Health arena. We would like to extend a
warm welcome to you all. As always, we hope you will continue to stay with us and will fi nd your job
both enjoyable and fulfi lling as you serve the citizens of North Carolina.
Johnston County welcomes Ree Wiley. She will begin at
Johnston County on June 12, 2006.
---------------------------------------------------------------------------
Moore County welcomes Nicole Cooley, MLT (ASCP.)
Nicole started at Moore County in January 2006.
---------------------------------------------------------------------------
Onslow County welcomes Loretta Lloyd.
---------------------------------------------------------------------------
Pitt County would like to welcome Fashikie Smith and
Latrica Hodges as new employees.
---------------------------------------------------------------------------
Person County would like to welcome Jessica Walker.
Jessica is an MLT I and joined Person County
on March 13, 2006.
---------------------------------------------------------------------------
Richmond County welcomes Jo Ann Meany.
---------------------------------------------------------------------------
Here at the State Lab in Raleigh, we would like to recognize the
following individuals:
Virology welcomes Jamie Batchelor and Delshawn McLean.
Special Serology welcomes Kalpana Patel, Medical Laboratory
Technologist I.
Microbiology welcomes Lara Godwin, Debra Springer,
and Kemmy Ajisebutu.
Cyto Prep welcomes Rebecca Sheppard, a Peace College
student.
Laboratory Improvement welcomes Janice West, Medical
Laboratory Technologist I.
Lab-Oratory / June 2006
15
Kudos!
In the spring of 2005, the NCSLPH began naming a State Lab
Employee of the Month. Employees are encouraged to nominate
co-workers who demonstrate great work ethics and always lend a
helping hand. In March, Cora Gibson in Lab Improvement was
honored, and Juanita Harris of Virology/Serology was the April
recipient of the award. Th e May recipient was Laurent Th ibault
from our Laboratory Preparedness branch. Congratulations to all of
our winners and thank you for your contributions to the NCSLPH!
Congratulation also goes out to Claudette Bass from the Pitt County
Health Department on her retirement! Good luck, Claudette, and
enjoy!
Xinhua Song and Natalie Sonin from Cancer Cytology have
taken and passed the Specialist in Cytology exam given by the
American Society for Clinical Pathology. Th is is the highest
designation of Cytotechnologist recognized by the ASCP.
Susie Lavender, Supervisor-Cancer Cytology and Chris O’Connell,
Head Cytotechnologist are also recognized as Specialists. Great job!
Please contact Kristy O’Briant at (919) 733-7186 or
kristy.obriant@ncmail.net if you would like to recognize a co-worker
at your facility.
Each year, our Bath Building employees are
honored with service awards. In September, we
will honor many employees who have served the
people of North Carolina from 5 to as long as
35 years! Please join us in thanking all of these
employees for their hard work and dedication to
the state of North Carolina!
5 years
Alisa Alston (Feb)
Joy Chiavacci (Jun)
Graciela Reynoso(Jun)
Deborah Campbell (Jul)
Julie Kase (Jul)
Holly Lee (Jul)
Kate Sperry (Jul)
Wayne Maynard(Aug)
Crystal Poppler (Aug)
Larry Th omas (Oct)
Yolande Williams (Dec)
10 years
Earl Hazelton (Mar)
Peggy Brantley (Apr)
Gloria Silber (May)
Shirley Jordan (Jun)
Roger Brown (Aug)
Colleen Miller (Dec)
20 years
Denise Givens (Jan)
Mark Minzer (Mar)
Mary Noel Dodd (Aug)
Cynthia Currie (Nov)
25 years
William Glenn (Jan)
Samuel Merritt (Apr)
Nancy Jones (Jun)
Joy Hayes (Sept)
Terry Hogg (Sept)
Robert King (Sept)
Vickie Whitaker (Nov)
30 years
Georgena Millar (Jan)
Sallie Szymcyk (Jan)
James Harris (Aug)
35 years
Linda Wall (Sept)
Lab-Oratory / June 2006
16
Newborn Screening
E R V Y P U V K R F A E M T J M R E H G S H U R M
S I S B H T D E T E C T I O N G D D O T E Y N P S
A E E R E D R O S I D D I C A O N I M A A O W Y I
E J L V N U T E X V Q R X R I L Z X L O I E D I L
S M U W Y Z E T A X C B O B C A P T R T E S D N O
I K Z H L K L A N T S R N S H S H E A S Y Q I R B
D D B S K Z K N W O M S D Y I Y C D A L Q B G A A
L R A J E S H D O Z I E M H Y D R T L X O A Y S T
L F U S T C Z E B K V T N S L A D D L L N P Q X E
E U C A O H I M Y L R W N T T Q O I G I Y G F C M
C K T X N F I M T E X E R E D Y N O C N F D R H X
E P T R U C Y A V D O Z R O V M M A G A C I Y P I
L N D L R I T S X F D L H S V E C I R U Y P Z C H
K E S H I K U S Z J A E F W H I R A C Y O T M D B
C W U G A B S S Q T M J C V D F T P R T E X T O X
I B U O Q W Q P N Z G F C D N M L X H Q O I G A D
S O U N G P M E R I R F I O Q G L Y M N F D Z M F
Y R W X M Z M C C M A S P R W B R C L T U C P L R
Y N Q W C U Z T B L O O D S P O T S P E C I M E N
G T N V S R D O A R E I H A I M E S O T C A L A G
L Q B D L Q O M D J P W B D Q U F D C N Z J E G F
V S H M Z G U E Y Y P A I I T U X M A A S E V X C
Z Z J L I F R T B F F S Y W Z T F W D D C K X Y I
E I R F K E X R O N M O M V W H K D Z E M F M V C
C I T E N E G Y R D Q O W B V J I E D W E C F B F
AMINO ACID DISORDER
BLOOD SPOT SPECIMEN
DEATH
DETECTION
FATTY ACID DISORDER
GALACTOSEMIA
GENETIC
HEALTHY
HEMOGLOBIN
HYPOTHYROIDISM
MENTAL RETARDATION
METABOLISM
NEWBORN
ORGANIC ACID DISORDER
PHENYLKETONURIA
PKU
PREVENTION
SICKLE CELL DISEASE
TANDEM MASS SPECTOMETRY
TREATMENT
Created by Puzzlemaker at DiscoverySchool.com
Lab-Oratory / June 2006
17
Brain Exercise
Test your laboratory knowledge. Select
the best answer(s).
1. What arbovirus causes the highest incidence of
disease in the western part of the state and has
the greatest eff ect on children? (West Nile, Eastern
Equine Encephalitis, Rocky Mountain Spotted Fever or
LaCrosse Encephalitis)
2. Generally speaking, what is/are the preferred sample(s) to
diagnose a current or recent infection in Serology? (CSF only,
Acute serum only, or Acute and Convalescent serum, or
Convalescent Serum only)
3. For serology testing at the CDC, where should the submitting
lab send the sample? (CDC directly, Private lab for referral or
State Lab/with request for testing at CDC)
4. What form(s) is/are required for samples that need to be sent
to the CDC for serology testing? (NC Serology form DHHS #3445,
CDC DASH 50.34 form, both, or neither)
5. What serological method is used for Brucella testing at the N.C. State
Lab? (Tube Agglutination, Immunofl uorescent Assay, Enzyme
Immunoassay, or Latex Agglutination)
6. In what year was West Nile Virus fi rst detected in N.C.? (2000, 2001,
2002, or 2003)
7. What does the RPR test detect? (only syphilis antibodies, only
anti-treponemal antibodies, or only reagin antibodies)
8. Why is it important to check the needle drop volume when
performing RPR testing? (assure no restrictions in needle bore, assure
proper antigen/antibody ratio, or assure proper antibody volume)
9. Who is responsible for assuring that all reagents and supplies have
proper dating? (supervisor, health director or testing personnel)
10. What type of specimen is needed for follow-up testing of abnormal
hemoglobins at the N.C. State Lab? (dried blood spots, serum, or
EDTA blood)
11. At the N.C. State Lab (Blood Group/Antibody Screen Lab), what
test(s) otherthan blood grouping and typing, is/are performed on
prenatal patients? (antibody screening, antibody identifi cation, and/or
weak D (Du) typing)
12. What type of specimen is acceptable for blood lead testing at the N.C.
State Lab? (serum or EDTA blood)
Questions submitted by:
Pat Th ompson, BS MT(ASCP)
Lab Manager
Wilson County Health Department
Joey Johnson, Supervisor
Special Serology
NC State Lab of Public Health
Lab-Oratory / June 2006
18
Th e Th ird Annual Epi Teams Conference
was held on May 17, 2006 at the Sheraton
Imperial Hotel in the Research Triangle Park
in Durham. North Carolina Public Health
Preparedness and Response sponsored the
event, partnering with the Division of Pub-lic
Health, the Division of Environmental
Health, the State Laboratory of Public Health,
General Communicable Disease Control, and
the Institute for Public Health.
Th is free event included the following topics:
• Teamwork for Successful Public Health
Investigations
• Legionellosis Outbreak Associated with
a Rental Cottage in the Outer Banks
in May 2005
• Cluster of LaCrosse Encephalitis Cases
in Western North Carolina in July
and August 2005
• ICS for Disease Outbreaks
• Planning and Executing a Drive-Th rough
Infl uenza Vaccination Clinic Using ICS
in Catawba County in December 2005
Third Annual Epidemiology Teams Conference:
LEADING THE INVESTIGATION
• Mercury Incident in a School in Granville County in 2005
• An explanation of the HIV/ STD Rapid Intervention Outbreak Team
• Epi Team Standard Operating Procedures Committee Report
• Summary of the Intra-uterine Fetal Demise Investigation done
in Alamance County in December 2005
• Investigation to determine Community Acquired Pneumonia or Bird Flu
• Hospital Surveillance for Community-Associated Methicillin-Resistant
Staphylococcus aureus
• Communicable Disease Surveillance Reports: A Tool for Local Health
Departments.
Th e topics were relevant and up-to-date, and the conference allowed
participants to hear the background stories behind the headlines from the
individuals who had experienced them fi rst-hand. It also provided the
opportunity to meet and network with other public health workers. Most
importantly, the conference provided participants from all over the state the
opportunity to learn from each other and gather information that may be
useful should a similar event occur in other regions.
Submitted by:
Crystal Poppler
Lab Manager, Laboratory Improvement
Learning On-Line
Due to rapid advances in medical technology, continuing
education is vital to laboratorians. It is important to review
information previously learned to maintain current skills,
and continuously learn new information in order to
provide the best possible care for patients. Often, employers
require a certain number of hours of continuing education each
year as well. With budgetary and staffi ng constraints, this is sometimes
diffi cult to achieve. Fortunately, there are many sources of laboratory
continuing education, many of them FREE or very inexpensive, on the
Internet. We will be sharing some of our favorites each quarter in the
Lab-Oratory. Two such sites are
www.merckservices.com/portal/site/merckservices/index.jspzQzmenuItemzEzMedi-calzUz20EducationzUz20Sites
www.ascp.org/education/default.aspx
We have provided the links to
these sites because they have
information that may be of
interest to our readers. Th e State
of North Carolina and the N.C.
State Laboratory of Public Health
do not necessarily endorse the views
expressed or the facts presented on
these sites. Further, the State of North
Carolina and the N.C. State Labora-tory
of Public Health do not endorse any
commercial products or information that may
be presented on or could be advertised on
these sites.
Submitted by
Jennifer Anderson, BS, MT(ASCP)CM
Consultant, Laboratory Improvement
Lab-Oratory / June 2006
19
UPCOMING EVENTS . . .
June 20-23, 2006 Bacteriologic Methods in the Analysis of Drinking Water*
July 13, 2006 Packaging and Shipping Workshop*
July 18, 2006 PHTIN: Group B Strep presented by Melissa Miller, PhD of UNC Hospitals,
and Sheila Cromer of Women’s and Children’s Health (More information to follow)
July 21, 2006 State Lab Orientation*
August 4, 2006 2nd Annual Clinical Lab Day
“Th e Diabetes Challenge: Diagnosis, Education, and Management”
August 8-9, 2006 Basic Microscopy: Viewing and Reviewing*
August 10, 2006 Wet Mount Workshop*
August 15-18, 2006 Process Control Chemistry Workshop*
August 24, 2006 Bioterrorism Workshop*
September 6-7, 2006 Advanced Urinalysis Workshop*
September 12, 2006 Packaging and Shipping Workshop*
September 13-14, 2006 Lab Methods in the Diagnosis of Gonorrhea*
September 27, 2006 Diabetes Training Workshop—CANCELLED (Please Refer to Clinical Lab Day)
September 29, 2006 State Lab Orientation*
October 11, 2006 Advanced Microscopy: Viewing and Reviewing *
October 12, 2006 Wet Mount Workshop*
October 25, 2006 Basic Microbiology and Gram Staining Workshop*
November 1-2, 2006 Lab Methods in the Diagnosis of Gonorrhea*
November 8, 2006 Policy and Procedure Writing*
November 14-17, 2006 Bacteriologic Methods in the Analysis of Drinking Water*
November 30, 2006 Bioterrorism Workshop*
*Additional information for laboratory improvement workshops and applications can be found
on the SLPH web site at http://slph.state.nc.us/LabImprovement/default.asp.
Lab-Oratory can also be found on the web at http://slph.state.nc.us/ under “Lab Improvement”.
Laboratory Improvement
P.O. Box 28047
Raleigh, NC 27611
State of North Carolina • Michael F. Easley, Governor
Department of Health and Human Services • Carmen Hooker Odom, Secretary
Division of Public Health • www.dhhs.state.nc.us
N.C. DHHS is an equal opportunity employer and provider.
600 copies of this public document were printed at a cost of $448.91 or $0.75 per copy. 06/06
Holly Lee, Virology/ Serology; Patty Atwood, NBS/CC; Susie Lavender, Cytology; Brenda Webber, Cytology
Jennifer Anderson, Lab Improvement; Kristy O’Briant, Lab Improvement; Colleen Miller, Lab Improvement
Crystal Poppler, Lab Improvement; Janice West, Lab Improvement; Tony Ivosic, QA; Debra Springer, Microbiology
E D I T O R I A L
b o a r d
Brain Exercise Answers:
1. LaCrosse Encephalitis; 2. Acute and Convalescent Serum; 3. State Lab/with request for testing at CDC; 4. both;
5.Tube Agglutination; 6. 2000; 7. only reagin antibodies; 8. assure proper antigen/antibody ratio; 9. testing personnel;
10. EDTA blood; 11. antibody screening and weak D (Du) typing; 12. EDTA blood