Pathology Requesting and Reporting Updates

• ICE order comms at HH: HH pathology users will be able to request investigations via ICE order comms rather than handwriting manual request forms. Please complete the ICE elearning training if you do not already have access.
• Decommissioning of Review: At go-live, results will be reported back to ICE rather than EMIS Review and therefore results will no longer be viewable in Review.
• Combined blood sciences form: Biochemistry and Haematology requests will be generated on a single, combined request form

• Test repertoire: The test repertoire has been harmonised across the PCH and HH sites into a single orderable catalogue on ICE. If there is a test you require which is not listed on the pages, please select the ‘Unlisted Biochemistry’ tests
• Bone profile: Calcium, albumin, alkaline phosphatase and phosphate levels will no longer be available on ICE to request as individual tests, they are orderable as a collective Bone profile.
• Random urine tests: All random urine investigations will be requested and reported as a urine creatinine ratio
• 24hr urine tests: The 24hr urine repertoire has been reviewed and updated in accordance to clinical needs e.g., 24hr urine sodium and 24hr urine potassium orderables will replace the current 24hr urine electrolytes orderable
• Glucose test bottles: All glucose test requests must have a yellow fluoride-oxalate blood bottle sent with the request. Brown gel bottles will no longer be accepted at HH.
• Requesting questions: when requesting particular biochemistry tests, you may be asked a question relating to clinical details e.g., is the patient pregnant? Or is the patient on thyroxine treatment? Etc. Please ensure these are answered as accurately as possible as these help facilitate the safest and most efficient laboratory practice.

 

• Test repertoire: The orderables list on ICE has been reviewed and updated with the following changes;
  • Total IgE Reference Range is now 0-100.
  • PLA2R Reference Range is now 0-13.

If there is a test you require which is not listed on the pages, please select the ‘Unlisted Immunology’ tests

• Nut allergy requesting: The nut allergy tests will now be available as both individual orderables and as part of a new nut allergy panel
• Requesting questions: When requesting the mast cell tryptase test, you will be asked to note how long after the onset of symptoms the sample was taken

• Heparin & Warfarin test requesting: Heparin and Warfarin monitoring tests will be listed on ICE as two separate orderables rather than the current combined profile.
• INR requesting by the anti-coag team at HH: HH inpatients will no longer have their next INR test date ordered and request form printed by the laboratory team as this function is not available in the new LIM system. These will need to be requested by the clinical teams on ICE which is a significantly safer process for the patients.
• Requesting questions: Additional questions will be asked when requesting an INR test
• Glandular Fever Screen: there will be separate requests for the glandular fever screens for each site available on ICE
• Partner Testing: the partner testing for the Haemoglobinopathy screening will have a name change on ICE to Father Haemoglobinopathy, but can still be found under the Antenatal FOQ only heading
• Sickle Screening: There is an additional Sickle screen option for HH only to be able to select an urgent sickle test if required before the sample is sent to PCH for HPLC processing (at PCH the sickle screen will still form part of the full haemoglobinopathy screening test)

• Test repertoire: The cold agglutinins test has been removed from the internal laboratory repertoire; however it can be requested as a referral test by the laboratory if required
• Group & Screen requesting: A single Group and Screen orderable will replace the current ‘Routine Group and Save’ and ‘Antenatal Group and Save’. Information gathered as you make the request will determine which test is required
• Group & Screen blood bottles: The adult G&S blood bottle type will be changing from a red top EDTA bottle to a blue top EDTA bottle.
• Kleihauer test requesting: A single Kleihauer orderable will replace the current ‘Delivery Kleihauer’ and ‘Ad Hoc Kleihauer’.  Information gathered as you make the request will determine which test is required. For delivery Kleihauers a separate neonatal (baby) group request will be required for each baby.
• Anti-D Requesting: All requests for prophylactic anti-D must be made via ICE request.  The lab will telephone if additional doses are likely to be required following a bleed >4ml.
• Direct Coombs Test: Now named Direct Antiglobulin test (DAT)
• Haemorrhage packs: Massive haemorrhage packs can no longer be requested on ICE. The major haemorrhage protocol should be activated by phone/bleep to the laboratory directly, as per current policy
• Ordering blood products: Blood product requesting has been split into a list of available products to make identification easier. Information gathered as you make the request will be different according to the product required.
• Transfusion reaction investigations: Transfusion reaction investigations can now be ordered on ICE so that they can be recorded. This will automate the requesting of the following investigations; UE, LFT, Coag screen and FBC, as per Trust protocol.
• Requesting questions: When requesting blood components, you will be asked clinical questions to determine whether the patient has any special requirements e.g., CMV negative blood if the patient is pregnant
• Sample validity: Transfusion samples will be valid for up to 7 days whereas previously they were valid for up to 28 days.
• Does my patient have a current valid sample?  The new LIMS will contain historical information for patients with an existing transfusion history so a second sample may not always be required. However, samples received prior to 30/10/2023 cannot be used for crossmatching in the new LIMS. The Laboratory team will advise you if further samples are required prior to crossmatch.

Requesting questions: At present, the laboratory team has to interpret which test is required via the clinical details which may or may not be present on the request form. To improve patient safety and laboratory efficiency, users will be asked a series of questions during ICE requesting to ensure the correct information is available. 

 

The following should be taken into consideration when ordering Microbiology tests in the new ICE environment:

General Serology

· IgG: Immunity (Past Infection)

· IgM: Acute (Current Infection)

General Molecular

· Qualitative: DETECTED/NOT Detected

· Quantitative: How much, Viral Load (e.g. 100 IU/ml)

 

The following phrases can be searched to give a broad range of available orders for Microbiology:

· General Bacteriology: MC&S

· MRSA Screening: MRSA

· General Serology: IgG, IgM, Antibody, Antigen

· General Molecular: PCR

 

MRSA Screening: At present, MRSA Screening is ordered on ICE as Elective MRSA screening, Emergency MRSA screening or Follow-up MRSA Screening. To improve laboratory efficiency MRSA Screening will now be available by ordering:

· MRSA (Nose & Axilla)

· MRSA (Nose & Groin)

· MRSA (Nose & Throat)

· MRSA (Nose, Throat, Axilla & Groin)

· MRSA (Urine)

· MRSA (Miscellaneous) – This order is to be used for any screening site that is not covered by any of the orders above (e.g. CVC Line Site, Leg)

 

Routine SARS-CoV-2 (COVID-19) PCR testing can be ordered using SARS-CoV-2 (COVID-19) PCR. Rapid testing is available, where appropriate, using the Rapid Respiratory PCR order.

 

To improve patient safety and laboratory efficiency, serology for Parasites (excluding Malaria testing) can be requested by ordering Parasitic serology. Specific parasite testing MUST be included in the clinical details along with reason(s) for testing. Failure to comply may result in a request being rejected.

 

To improve patient safety and laboratory efficiency, serology for Imported Pathogens (including Brucella, Leptospirosis, Rickettsia, West Nile Virus, Zika Virus, etc.) can be requested by ordering Imported Pathogen Screen. Specific virus testing MUST be included in the clinical details along with reason(s) for testing. Failure to comply may result in a request being rejected.

 

To improve patient safety, Pleural Fluid MC&S will now reflex an order for Mycobacteria Culture (e.g. Tuberculosis).

• Requesting questions: Users will be asked a series of questions when completing a Cellular Pathology ICE request form to improve patient safety and laboratory efficiencies by providing the correct specimen type information

• There will be no changes to the process for transferring deceased patient’s down to the Mortuary at this time. Manual completion of notification of death forms is still required.

• Combined blood sciences report: Biochemistry and Haematology results will be viewed in a single report on ICE
• When you request a test or investigation it is your responsibility, or that of your delegated team, to review and file the results. As requests are ordered on ICE, the expectation is that results review and filing will also be done on ICE. Several Sis have occurred when results have not been reviewed either at all or in a timely manner. Each area will need to have a robust process for ensuring compliance with this standard.

 

• Communication of critical values: Table One (below) details all changes in the laboratory phoning results policy, these results will be communicated to users if the patient has no previous relevant history. All other analyte results will continue to be communicated as they are now:

Table One: Changes in Critical Value Reporting

Test/Analyte	New Communication Policy
Prolactin	>1000 mU/L (paediatrics) >5000 mU/L (adults)
Total Bile Acid	>39 umol/L
Serum Creatinine	>199 umol/L (<15 years) >353 umol/L (≥16 years)
Creatine Kinase	>5000 U/L
Total Bilirubin	>250 umol/L
Direct Bilirubin	>25 umol/L (<27 days old)
Iron (overdose)	>55 umol/L
Alanine Transaminase	>500 U/L (<17 years) >615 U/L (Adult male) >495 U/L (Adult female)
Triglyceride	>20 mmol/L
Gentamicin	>0.9 mg/L
Vancomycin	<11 mg/L and >19mg/L
Tobramicin	>0.9 mg/L

 

• AKI alerts: During the implementation period, serum creatinine results processed in the weeks leading up to 30^th October will not be available in the new LIMS system for use in the calculation of AKI alerts, meaning that AKI alerts may not be issued as expected. During this period users are advised to monitor serum creatinine results for changes which may indicate acute kidney injury. The completed set of creatinine data is expected to be migrated to the new system within 4 weeks of go-live, at which point AKI alerts will be issued as expected. 
• Delta checks:  With the exception of serum creatinine, historical patient results will not be available in the new LIMS system for use in the calculation of delta checks, meaning that delta check alerts may not be issued as expected.
• Reference ranges: Please see Table Two below for all reference ranges that have been updated as part of the harmonisation work across the Trust and aligning to national guidance. Please note, all reference ranges will continue to be present on reports
• Referral laboratory: The referral laboratories for tests not performed at NWAFT have been reviewed and harmonised so that pathology service users get consistent reports for patients across both sites. All referral reports include a comment stating where the sample has been processed.
• Units of measurement:
  • The units for urine creatinine and urine urate results have been changed from umol/L to mmol/L
• Sample age and analyte stability: A review of analyte stability has allowed analyte-specific sample age limits to be applied. If the specimen age exceeds these limits, tests will be reported as 'Not Available'
• Iron studies: HH will no longer report a transferrin result as part of the iron studies profile, this will be replaced with UIBC testing
• B12 result reporting: Reference ranges and reports comments for B12 and Folate reporting have been aligned to the local CCG guidelines
• Prolactin result reporting: Prolactin results >700mU/L will have a macroprolactin test performed, to replace the current limit >1000mU/L.
• HbA1c testing: Due to a difference in methodology for HbA1c testing across the PCH and HH laboratories, only paediatric samples will be processed at HH. All other HbA1c samples will be sent to PCH for HPLC analysis.

 

Table Two: Updated Reference Ranges

 

 

 

Updated Clinical Biochemistry Reference Ranges, from 30/10/2023
Analyte	Sex	Age	Reference Range		Analyte	Sex	Age	Reference Range
Potassium (mmol/L)		<27D <11M <16Y >16Y	3.4-6.0 3.5-5.7 3.5-5.0 3.5-5.3		Ammonia (umol/L)		<27D >27D	<100 <50
Creatinine (umol/L)	M F	<27D <11M <2Y <4Y <6Y <8Y <10Y <13Y <14Y >15Y >15Y	27-77 14-34 15-31 23-37 25-42 30-47 29-56 39-60 40-68 59-104 45-84		Amylase (U/L)			<100
Albumin (g/L)		<11M <16Y >16Y	30-45 30-50 35-50		Magnesium (mmol/L)		<27D >27D	0.60-1.00 0.70-1.00
Total Bilirubin (umol/L)		>13D	0-21		24hr Urine Sodium (mmol/24hr)			40-220
ALT (U/L)	M F M F	<16Y <16Y >16Y >16Y	<41 <33 <41 <33		24hr Urine Potassium (mmol/24hr)			25-125
Total Protein (g/L)			60-80		24hr Urine Urea (mmol/24hr)			428-714
Conjugated Bilirubin (umol/L)			<7		24hr Urine Protein (g/24hr)			<0.14
AST (IU/L)	M F		10-50 10-35		Urine Amylase (U/L)	M F		<491 <447
GGT (U/L)	M F		<60 <40		B12 (pg/ml)		<30D <11M <11Y <18Y >18Y	187-1866 168-1675 354-1599 270-1132 200-771
Adjusted Calcium (mmol/L)			2.20-2.60		Ferritin (ug/L)	M F		30-400 13-150
Phosphate (mmol/L)		<27D <11M <16Y >16Y	1.30-2.60 1.30-2.40 0.90-1.80 0.80-1.50		TSH (uIU/ml)		<27D <11M <14Y <18Y >18Y	1.23-27.2 1.03-6.80 1.12-5.01 0.68-4.09 0.30-4.20
Glucose (mmol/L)		Pregnant	3.9-5.4 2.0-10.0		FT4 (pmol/L)		<27D <11M <18Y >18Y	16.0-50.0 14.0-22.0 13.0-21.0 11.9-21.6
Digoxin (ug/L)			0.5-1.0		FT3 (pmol/L)		<27D <11M <13Y <18Y >18Y	4.2-13.0 5.2-8.6 4.6-7.8 5.0-8.2 3.1-6.8
Uric Acid (umol/L)	M F		200-430 140-360		Testosterone (nmol/L)	M M F F	19Y-49Y >49Y 19Y-49Y >49Y	8.6-29.0 6.7-25.7 0.3-1.7 0.1-1.4

 

 

• Factor 8: Factor 8 reference ranges have been aligned across both sites and you will see IU/dl for HH after go-live
• Referral laboratory: PCH and HH referral centres have been harmonised so that pathology service users get consistent reports for patients across both sites. Referral repertoire also consolidated.

 

• Report comments: Report comments have been harmonised across the PCH and HH laboratories and therefore you may notice a change in wording
• Antibody screen: Reports will state which specific antibody(s) a patient has rather than just stating ‘positive antibody screen’
• Kleihauer reports at delivery: the maternal report will also include the blood group of each baby delivered.
• Referral laboratory reports: reports that were previously only accessed through NHSBT SpICE can now also be visible in ICE.
• Direct Antiglobulin test: Reports for Direct Coombs test (Direct Antiglobulin tests) results will include an interpretative comment to prevent users from having to refer to the user handbook
• Blood product labels (traceability tags): The labels attached to blood products have been harmonised across both sites and resemble the ones currently in use at Hinchingbrooke with some additional barcodes for laboratory use. There is space on the label to record the date and time collected so that the ‘yellow paperwork’ at PCH is no longer required. You must still sign and date the return portion of the tag to the laboratory.
• Blood product issue paperwork: these reports accompany the issued blood components to be signed upon collection. Both sites will see one white copy only with the yellow copy removed at PCH. The new format includes a ‘Use by Date’ which may be before the final expiry date of the product. There is also space to sign a product back into the fridge after it has been collected (same return rules apply). The back of the report will have a new Blood Movement Record designed to record the transfer of blood between storage locations (not currently applicable at HH)

• Introduction of urine negative screen: If no markers of infection are seen during microscopy examination, no urine culture will be performed (exceptions being immunodeficient, diabetic, renal and <7 year old patients.

To improve patient safety, initial Blood Culture Gram Stain results will be reported when available prior to culture and antimicrobial susceptibility results being performed. Culture and antimicrobial results will, on average, be available 24 hours after a Gram Stain result is released.

Initial Blood Culture Positive -> Gram Stain Result -> Culture and Antimicrobial Susceptibility Report

There is no change to how Cellular Pathology reports will appear in ICE. Both Hinchingbrooke and Peterborough reports will appear as before.

Supplementary reports will appear below original reports as before and they are also prompted at the top of the report.

There is no reporting requirement for patients who pass away and are transferred to the Mortuary. There will be no change to the way Post Mortem reports are disseminated to relevant parties. Any request for Post Mortem results on Coroner’s cases will require a formal request to be submitted to H.M Coroner.

Point of care testing at NWAFT does not usually use ICE order comms to generate a request to perform a POCT test. The patient will be identified to the POCT device by their DIS number during the test procedure, then the test result will automatically appear in the ICE reporting area.

 

The one exception to this currently is POCT HbA1c measurement: ICE request forms are generated for these tests and returned to the POCT department together with the analyser printout, where they are manually entered into the IT system for reporting to ICE. When the new LIMS goes live, there will no longer be a requirement to generate the ICE request form for POCT HbA1c; as long as the patient is correctly identified to the analyser by their DIS number at the time of the test, the result will automatically appear in ICE. This change has been made to reduce the administrative workload of clinic staff and will also reduce the time it takes for POCT HbA1c results to appear in ICE. By removing the need to send paper request forms and printouts to the POCT department and the requirement to manually enter test results, the risk of losing results and transcription errors are also eradicated.