PRE-ANALYTIC UNIT

PRE-ANALYTIC PRETEST DISCUSSION

The pictures and images below are the most common

equipment and apparatus that are found in the VMMC DOP Pre-
Analytic Unit.

5. Non-Contact Thermal Scanner

For temperature checking of anyone who enters the laboratory

premises, especially in this time of COVID-19 Pandemic.

1. Barcode Printer

Since almost all specimen are assigned their own unique

barcodes which contain patient information and test requests,
the barcode printer is one of the most essential pieces of
equipment in the Pre-Analytic unit.

6. Phlebotomy Chair

A chair specially designed for out-patient phlebotomy purposes

is placed inside the specimen collection room.

2. Barcode Scanner

Though not fully utilized yet, the Pre-Analytic unit has a barcode
scanner to be used for phlebotomy purposes. It works side-by-
side with the Barcode Printer of the unit.

7. Portable HEPA Filter

Since the Pre-Analytic unit serves as the laboratory reception,

the medical technologists assigned in the unit are exposed to
3. Centrifuge both patients and fellow healthcare workers (including
asymptomatic Covid patients). The HEPA filter serves as a
Not really unique to Pre-Ana, but one of the most important means of protection from airborne particles within the reception
equipment utilized to prepare specimens for the analytical area.
phase.
8. Specimen Collection Room

Contains a specimen collection bed (for skin scraping, scotch

tape swab collections, etc.), a phlebotomy chair, and the
phlebotomy kit.

4. Electronic Time Stamp

Used to imprint the date and time when a certain laboratory

request is received by the Pre-analytic unit (for requests with or
without specimen). This electronic time stamp avoid s the
possibility of altering the date and time when receiving the 9. Phlebotomy Kit/Warding Box
laboratory request and specimen.
Contains all equipment needed for phlebotomies such as blood
collection tubes, syringes, ETS needles and hubs, cotton,
alcohol, and iodine. We also have spare needles with various
gauges, depending on the need (i.e. Gauge 25 for hard to
extract patients)

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2. Request Checking and Specimen Container

PRE-ANALYTIC UNIT DISCUSSION
Preparation
a. ALWAYS check your laboratory request prior to
performing phlebotomy
● Pre-analytic Unit b. Prepare needed tubes according to the requested
- The primary processing unit in the laboratory. It is tests (Purple Top for CBC, Gold Top for
made up of correct patient identification and collection Chemistry) (FOR COMPLETE LIST OF TESTS
of samples, like blood samples. AND APPROPRIATE TUBES, PLEASE GO TO
- this is where the screening and validation of biological PAGE 477 APPENDIX A: LABORATORY TESTS
samples that are forwarded to the laboratory take OF PHLEBOTOMY ESSENTIALS 5TH ED BY
place. MCCALL AND TANKERSLEY)
c. If ETS Method isn’t used, make sure that the
syringe used will have enough volume for the
● Laboratory Specimen Preparation blood needed in the lab requests
- Before submitting a patient specimen to the pre- d. Note if there are any patient preparations needed
analytic unit, the following steps must be followed. to be done prior to specimen collection
1. The patient must fast for 8-12 hours before e. Note if there are special instructions/special
examination of FBS and Lipid Profile (DLD, HDL, requirements after collecting the specimen (e.g.
Triglycerides, Cholesterol). Drinking of water is transporting the specimen on ice for ammonia
allowed. analysis)
2. Exercise can affect the result of chemistry
analytes, and is discouraged for a patient who
needs to undergo blood testing. 3. Tourniquet Application and Venipuncture Site
3. Specimen for a routine urinalysis must be a Disinfection
midstream catch and is put in a sterile container. a. Ask the patient to make a fist
4. Urine and stool samples must be submitted to the b. Apply the tourniquet at least 3-4 inches above the
laboratory within 1 hour. Delaying may give puncture site.
erroneous results. c. The venipuncture site must be cleaned with a
5. Only a pea-sized stool is need ed for routine disinfectant (preferably 70% isopropyl/ethyl
fecalysis, and it must be placed in a sterile alcohol) applied to a cotton ball or gauze using firm
container. but gentle pressure, starting from the center of the
6. If the specimen is to undergo a Fecal Occult Blood venipuncture site and moving downward and
Test (FOBT), advise the patient not to consume outwards, covering an area of 2 cm or more.
red meat 3 days prior to stool collection. Place the d. Keep the tourniquet applied while performing
specimen in a sterile container. venipuncture.
7. For semen analysis, advise the patient to abstain e. Have a steady hand to support the syringe's body
from having sex for 2-5 days prior to collection of while pulling the syringe's plunger.
semen. Collection of the specimen should be done f. Remove the tourniquet prior removing the needle
near the laboratory so it could be submitted ASAP. from the patient's arm
8. In microbial analysis, proper ways of collecting the g. Apply a cotton ball with medical tape over the
specimen must also be observed. For Sputum venipuncture site after the needle is removed. Ask
samples, it is best to collect in the morning. Advice the patient to press on it for a few minutes.
the patient to gargle with clean water before
obtaining the specimen. The patient must
4. Proper Blood Transfer and Sharps Disposal
expectorate in a sterile container.
1. All sharps must be properly disposed of in a leak -
resistant, puncture-proof, heavy duty container (usually
● Pre-analytic unit tasks in VMMC DOP
made of plastic)
- Phlebotomy (in/outpatient)
- Specimen Receiving
In VMMC DOP, they utilize needle cutters for their
- Specimen transporting (floating)
sharps disposal. Bigger sharps containers are
- Emergency ward (specimen Pick-up only; VMMC has available for the disposal of used lancets, skin
emergency WARD instead of emergency ROOM) scrapers, broken glass slides, etc.

2. Remember to transfer the collected blood from the

● Phlebotomy syringe to the tube ALONG THE INSIDE WALL OF
1. Proper Patient Identification THE BLOOD COLLECTION TUBE. Do not push the
a. See the patient’s laboratory request. Let th e syringe down abruptly.
patient state their COMPLETE NAME (F,M,L)
along with their COMPLETE DATE OF BIRTH
b. Middle names and complete birth dates are ● Specimen Receiving
important since they can help distinguish patients - All collected specimen are brought to the Pre-Analytic
with the same names from one another. Unit's receiving area
c. Always ask for the patient’s ID. If the p atient is - ALL SPECIMEN SHOULD COME WITH A
unconscious, unable to speak, or not of sound CORRESPONDING LABORATORY REQUEST—
mind, check the patient’s nametag, ask the completely filled out by the requesting physician.
patient’s relative, or check in with the nurse-on- [Patient's complete name, birthday, age, laboratory
duty for patient identification. tests to be done]
d. Remember to be courteous and friendly at all
1. Laboratory Requests and Specimen Labels
times.
● Side by side checking of specimen labels and
e. DONT’S: Don’t state the patient’s complete
requests is done.
details for them. Patients have the tendency to
● All specimens should be labeled with the
say yes even if the information is incorrect. Don’t
patient's complete name and birthday
pre-label the collection tubes.
● Always label at bedside (for inpatients) or in
the presence of your patients (for
outpatients).

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● FOR HEMATOLOGY SAMPLES, checking 4. Laboratory Request and Specimen Receiving;

for clots in the collection tube and proper Time Stamp Imprint
blood/anticoagulant ratio - The name of the Medical Technologist who
● FOR CHEMISTRY/IMMUNOLO G Y received and checked the specimen for
SAMPLES, at least 3mL of clotted blood is irregularities from the label to specimen
required quality and quantity, are stamped beside the
time imprint on the request.
- Proper documentation of specimen receipt is
A MISSPELLED NAME OR ANY
done using hand written records of the
DISCREPANCY WITH THE PATIENT'S
patient's laboratory request in a logbook.
BIRTHDAY IS A CRITERIA FOR
[laboratory sections have individual receiving
REJECTION
logbooks of their own]
a. URINE
i. Date and time of when the specimen is
- Label should contain the
received
patient's complete name,
date of birth and time of ii. The patient's ward
collection
- Specimen container should iii. Initials of the lab test request (C for
chemistry, E for EDTA only, C for Citrated
be sterile
tube, I for immunology)
- Specimen viability: 2 hours
upon collection iv. Patient's complete name
- Urine collected should be
at least 10mL v. Ime the specimen is received by the
b. STOOL respective analytic unit (Chem, Hema, CM,
- Label should contain the etc.)
patient's complete name,
date of birth and time of
collection ● Specimen Transport (Pre-analytic unit to Analytic)
- Stool sample should be - After all necessary specimen preparation and
collected in a wide-moth, documentation (e.g. centrifugation, getting aliquot of
leak-proof container samples) and documentation are done, they are then
- Specimen viability: 1 hour forwarded to their respective analytic units for
upon collection processing.
- Stool sample collected - "Floating" is the term used in reference to specimen
should be at least pea- transport.
sized or thumb-sized

● Additional Pre-Analytic Tasks in VMMC DOP

2. Laboratory Request Checking Through the 1. Emergency Ward Specimen Pick-Up
Hospital Information System - Pre-analytic unit staff are tasked to pick-up
- All laboratory requests are required to be collected specimens at the hospital's
encoded when received in the lab Emergency Ward after every 30 minutes
- Orders from the patient's physician should during their shift.
reflect through a computer program called - Non-laboratory E-ward personnel
HOSPITAL INFORMATION SYSTEM (physicians, nurses) primarily perform
wherein all test requests are uploaded and phlebotomy and other specimen collections.
results are released. (Phlebotomy seminars are actually conducted
- Laboratory requests on paper should match for them by the laboratory to avoid any
the lab requests on the computer specimen collection errors)
- Marking of the encoded test requests through
- All collected specimens should have
HIS are done corresponding requests and are to be double-
- Writing of patient demographics on the test checked by the Pre-analytic unit staff—from
requests are also done, it includes: labelling, time of collection, and the quality
a. Patient's last, first and middle name and quantity of the specimen collected.
b. Patient's category (Paying or Non- - The Emergency Ward Nurse-On-Duty (NOD)
paying) is assigned to have the laboratory request of
c. Patient's birthday
patients uploaded in the Hospital Information
- Laboratory test requests are imprinted with
System.
the date and time of when the specimen is
received.
- Pre-Analytic Turn-Around Time or TAT should REMEMBER: Lab requests on paper
be within 30 mins from the time the specimen should match the lab request on the
is received up to the time the Analytic Unit computer.
receives the sample for processing
- Encoded or uploaded laboratory test requests
by the E-ward NOD are then checked by the
3. Assigning Unique Barcodes Pre-analytic unit staff for correctness and
- All blood collection tubes are assigned unique completeness.
barcodes. These barcodes contain all - Patient information is also written by the staff
information uploaded through the Hospital on the lab request.
Information System, including the patient's - Laboratory specimens and requests are
complete details, as well as the physician's documented through handwriting in a
laboratory requests designated Emergency Ward Specimen
- The barcodes are then scanned by machines Logbook. These are then forwarded to the
used in the analytic unit. Pre-analytic unit and routine specimen
receiving is done.

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- Proper documentation of specimens receiving 2. Causes of Hemolysis

is vital for the traceability of errors of pre- ● Using a needle that is too small
analytical variables that may have occurred ● Pulling a syringe plunger back too fast
prior to the lab testing process. (e.g. missing ● Expelling the blood strongly into a tube
specimens, mislabeled specimens, ● Forcing the blood from syringe into an
incomplete specimen tubes, etc.) evacuated tube
● Shaking or mixing the tubes vigorously
● Performing blood collection before the alcohol
● Specimen Contain ers/Collection Tubes/Vials
has dried at the collection site
1. STERILE TUBES
- For microbiology use 3. Sites to be Avoided in Venipuncture
- Inversion: 8-10 times
● Intravenous lines in both arms
- Each bottle must contain 5-10 mL of blood
● Burned or scarred areas
collected from 2 different sites
● Areas with hematoma
● Thrombosed veins
VMMC DOP Microbiology currently uses ● Edematous arms
BACTEC brand bottles for adult (blue) and ● Partial/radical mastectomy on one or both
pediatric (pink) patients arms
● Arms with arteriovenous (AV) shunt or fistula
2. CITRATE TUBE (Blue Top) ● Cast(s) on arm(s)
- Used for coagulation studies
● Prothrombin Time 4. Common Preanalytical Variations
● Activated Partial Thromboplastin - These are events that occur from the
Time physician's test ordering until right before
- Used for D-dimer test sample analysis and may affect the
- Inversion: 3-4 times specimens prior to testing
- Blood:Anticoagulant Ratio: 9:1 ● Misidentification of patient
● Mislabeling of specimen
3. PLAIN TUBE ● Short draws/wrong
- Used for routine chemistry anticoagulant/blood ratio
- Used for routine immunology ● Mixing problems/clots
- Used for blood typing ● Wrong tubes/wrong anticoagulant
- Used for cross-matching ● Hemolysis/lipemia
- Inversion: 5-8 times ● Hemoconcentration from prolonged
tourniquet time
4. GEL SEPARATOR (Gold Top) ● Exposure to light/extreme
- Used for routine chemistry temperatures
- Inversion: 5-8 times ● Improperly timed
specimens/delayed delivery to
laboratory
5. ETYHLENE DIAMINE TETRAACETIC ACID ● Processing errors: Incomplete
(EDTA/Purple Top) centrifugation,
- Used for routine hematology tests (BC, PLT ● Incorrect log-in, improper storage
count) - There have been instances wherein non -laboratory
- Used for glycosylated hemoglobin (HbA1C) personnel who collected blood samples from a patient
- Inversion: 8-10 times interchange blood collection tube tops.
THESE SPECIMENS ARE AUTOMATICALLY
REJECTED BY THE PRE-ANALYTIC UNIT
6. HEPARIN (Green Top)
- Used for special chemistry - Erasures on blood collection tubes (or even urine/stool
- Used for special hematology collection containers) are mostly due to pre-labelling
- Inversion: 5-10 times - Any alterations, superimpositions, erasures in the
- Not routinely used in VMMC DOP. sample collection vials are UNACCEPTABLE.
Again, THESE SPECIMENS ARE AUTOMATICALLY
REJECTED BY THE PRE-ANALYTIC UNIT
7. SODIUM FLUORIDE (Gray Top)
- Used for glucose determination
- Weak anticoagulant
● Patient Preparation
- Potassium Oxalate as anticoagulant
1. Fasting for Blood Chemistry
- Not routinely used in VMMC DOP
- Glucose (FBS): 8-10 hrs
- Lipid Profile Only: 12-14 hrs
● Specimen Rejection - Glucose and Lipid profile: 10-12 hrs
1. Common Causes of Specimen Rejection 2. Preparation for Fecal Occult Blood
● Unlabeled specimen - Abstain from any kind of red meat and dark
● Hemolysis/lipemia colored food for at least 3 days prior collection
● Clots in an anticoagulated tube and submission of specimen
● Non-fasting specimen (if required) 3. Tourniquet Application
● Wrong blood collection tube - Not more than 1 minute (60 secs)
● Short drawn/Improper blood/Anticoagulant - 3-4 inches above site of puncture
ratio - Lactate and ammonia requests: tourniquet
● Improper transport (temperature) application should be minimal to none
● Discrepancies between requisition and 4. Physiological Variation
specimen label - Refers to changes that occur within the body
● Contaminated specimen/leaking container such as cyclic change
● Mislabeled specimen (esp those with - Affected by age
erasures, overwriting)

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● Increase levels of Albumin, ALP, e. Renzo Thomas D. Valmonte, RMT

Cholesterol, Phosphorus - FEU (MICO 2018)
f. Anna Dominique B. Dalag, RMT
- FEU (RICO 2019)
- Affected by gender
g. Ralph Timothy A. Maguyon, RMT
● Increase levels of :
- UST (2016)
a. Male - Albumin, ALP,
h. Michael Allan D. Canales, RMT
Creatinine, Uric acid,
- FEU
Cholesterol, BUN
i. Jacquiline C. Obiles, RMT
b. Females - HDL, Iron and - FEU (2017)
Cholesterol j. Ameerah S. Piad, RMT
- Affected by recent food intake
- Manila Central University (2018)
● Increase levels of glucose, TAG,
k. Carl David C. Pavo, RMT
gastrin, free Ca2+
- FEU (RICO 2019)
● Decrease levels of electrolytes (Cl,
l. Jayka Elline G. Inciong, RMT
K, P) and AMS
- CEU (2019)
5. Diurnal Variation
m. Mary Coleen F. Rubio, RMT
Laboratory tests affected by Diurnal Variation:
- Trinity University of Asia (2019)
a. CORTISOL n. Athea D. Galvan, RMT
- Peak: 4am - 6am - UST (1999)
- Lowest: 8pm - 12am o. Alma C. Martin
- 50 % lower at 8pm than 8am - Pre-analytic unit Secretary
- Increased with stress - FEU
b. ADRENOCORTICOTROPIC HORMONE p. Carizza Irra L. Ormillion, RMT
- Lower at night - St. Louis University (2014)
- Increase with stress q. Ghe Anne Masangkay, RMT
c. PLASMA RENIN ACTIVITY r. Patrick Sapnu, RMT
- Lower at night s. Jovy Fontanil
- Increase with stress - Pre-analytic secretary
d. ALDOSTERONE
- Lower at night
- Higher standing than supine
e. INSULIN
- Lower at night
f. GROWTH HORMONE
- Higher in the afternoon and evening
- Increase with exercise
g. ACID PHOSPHATASE
- Higher in the afternoon
- Increase with exercise
h. THYROXINE
- Higher in the afternoon
- Increase with exercise
i. PROLACTIN
- Higher with stress
- Higher levels at 4 am and 8 am and
at 8 pm and 10 pm
j. IRON
- Peaks early to late morning
- Decrease up to 30 % during the day
k. CALCIUM
- 4 % decrease supine

● House Rules Requirements and Quota

a. House Rules
- RESPECT ONE ANOTHER
b. Quota and Merits (Pre-covid internship)
- 30 successful extractions ( for 1 year interns)
- 15 successful extractions at emergency ward
( for 6 months interns)
- MERIT is awarded to any MedTech intern
able to successfully collect blood from Hard-
To-Extract (HTE) patients
● Staff
a. Gamaliel A. Fulgueras, RMT
- Supervisor
- UST
b. Ma. Lorraine N. Leal, RMT
- Assistant Supervisor
- UST
c. Marben Kate R. Kalaw, RMT
- CEU (2016)
d. Francis Joy Cabato, RMT
- Capitol Medical Center College (2017)

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