Laboratory: Document Type: Original Date Adopted: Previous Document: Central Processing Area Procedure 05/10/2002 CPA 24, Revision 3

Transcription

1 Laboratory: Document Type: Original Date Adopted: Previous Document: Central Processing Area Procedure 05/10/2002 CPA 24, Revision 3 Document Author: Document Owner: Acknowledgement / Required Copy Holders*: Carsey Suedkamp Lab Manager All central processing area laboratory personnel Approval*: Central Processing Area Division Director University Hospital Laboratory Medical Director (Martha Morehouse Pavilion Laboratory) *Approval and Acknowledgements* Refer to QPulse system and Document Details report for laboratory directors(s) electronic signature approval, employee acknowledgment and effective date. Page 1 of 8

2 1. POLICY 1.1. Central Processing Area (CPA) personnel will continue to process specimens when the computer system is not working properly or during an outage. 2. PURPOSE OF DOCUMENT 2.1. Allows CID barcode labels to be used for the processing of specimens during periods of LIS Computer System downtimes. 3. SCOPE OF DOCUMENT 3.1. The Central Processing Area (CPA) and other personnel are responsible for following this procedure. 4. RESPONSIBILITY 4.1. The medical director of this laboratory is responsible for establishing this policy. The employees of CPA and other areas of the laboratory are responsible for maintaining this document and ensuring at least biennial review by the medical director. 5. PROCESS 5.1. IHIS (SMS order entry) If the order entry system is down, orders that had already downloaded to LIS will print labels on the nursing units at the scheduled times. New orders will be sent to the lab with a requisition and bedside labels on the tubes and manually entered by CPA staff INTERFACE (between IHIS and LIS) Orders will be in IHIS, but new orders will not download to LIS. Labels will not print on the nursing unit. The nursing unit will do a screen print from IHIS or fill out a lab requisition to send with the specimens. CPA will manually enter the requested tests in LIS LIS When LIS is down, labels will not print on the nursing unit for timed draws. Stat and collect now labels will not print on the nursing units. Specimens will be sent with a screen print from IHIS or a manual lab requisition. CPA will process specimens according to the LIS downtime procedure using downtime labels The LIS department provides downtime CID barcode labels. They are kept in a box labeled DOWNTIME LABELS in the CPA area. If this supply is low call the LIS department or page the LIS representative on call prior to the downtime. The large CID label is to be placed on the specimen A second label with a small CID barcode is put on the requisition. This label provides a place to record the test(s) associated with that particular CID and container type When the computer system is down, begin by writing downtime labels for all STAT tests. If there is EXTENDED downtime (greater than 30 minutes) use this procedure for all tests. Always process stats and lifethreats first Use the large CID label for each sample tube type. a. On the large CID label write: Patient name, MRN, Test(s) ordered, Nursing Unit or Location. (If tests are to be run STAT, STAT needs to be noted on the label). b. Put the large CID barcode label on the tube. c. Centrifuge all tubes that need to be spun. d. Repeat the process for each tube type on a single requisition. e. Deliver all tubes to appropriate testing areas Place the small CID corresponding to a particular tube type on the requisition. a. Write the tests associated with the CID and tube type on this label. b. Repeat this process for each tube type on a single requisition Keep the requisition. a. To be used for entering the tests into the computer when downtime is over. Page 2 of 8

3 Results for extended down time periods a. Central Processing will set up stacking files, which correspond to each nursing unit location a.1. Ross Heart Hospital a.2. James Cancer Hospital a.3. Rhodes Hall a.4. Doan Hall a.5. Neuro Psych a.6. Dodd Hall a.7. Stat results b. Hard copy results will be provided to Central Processing by CCL with the patient name and location provided on the results. c. Central processing will copy results for distribution c.1. Two copies of the results will be made for the phone room. These results will be hand delivered to the phone room for filing c.2. The phone room staff will be responsible for alphabetizing the results by patient name c.3. The phone room will be responsible for faxing any results needing faxed c.4. The phone room will use the alphabetized results to answer calls c.5. One copy of the results will be filed in the appropriate stacking file for distribution to the nursing units. d. Central Processing will return the original hard copy of the patient results to the Critical Care Laboratory. e. Central Processing will hand deliver results to the nursing units with the exception of those being faxed (i.e. ED, Ross, Neuro Psych, and Dodd Hall) e e.2. All STAT results will be delivered immediately in real time. All routine results will be delivered expeditiously every 30 minutes to one hour after testing. f. When computer comes back up f.1. Enter results in LIS > Order Entry f.1.1. Enter collect time and tests f f.2. DO NOT AUTO assign the accession number. This screen has a small box in the lower left side, labeled Manually Assign CID s. Click on this box. Assign the accession number in the usual manner and save. To resume regular order entry, click on box labeled Manually Assign CID NOTE: If LIS is not down, and there is a problem with label printing, order the tests as usual but record the Accession number on the tube. Technical staff can manually order tests in the instruments and use OEM to file results. 6. FIGURES 6.1. Downtime Labels Screen print of Order Entry with manually assigned CIDs Screen print assigning manual CID to chemistry test Screen print assigning manual CID to hematology test Screen print assigning manual CID to coagulation test. 7. RELATED DOCUMENTS 7.1. Refer to QPulse System or Document Detail Report for related Laboratory Policies, Procedures, and Master Forms Page 3 of 8

4 Page 4 of 8

5 Figure 6.2 Screen Print of Order Entry with manually assign CIDs Page 5 of 8

6 Figure 6.3 Screen Print assigning manual CID to chemistry test. Page 6 of 8

7 Figure 6.3 Screen print assigning manual CID to hematology test. Page 7 of 8

8 Figure Screen print assigning manual CID to coagulation test Page 8 of 8