B. Clinical Biochemistry ................................................................................................................................ 4
I. Standardization in Test Reporting .......................................................................................................... 4
Anion Gap .............................................................................................................................................. 5
NT PROBNP ........................................................................................................................................... 8
Osmolal Gap .......................................................................................................................................... 9
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Troponin ................................................................................................................................................ 9 II. New Test Codes ..................................................................................................................................... 9
III. Gender U and X .................................................................................................................................. 10
IV. Reference Interval and Critical Value Standardization ...................................................................... 11
a) Blood Gas Tests ............................................................................................................................... 13
b) Urinalysis ......................................................................................................................................... 14
c) General Chemistry Tests ................................................................................................................. 14
C. Therapeutic Drug Monitoring and Toxicology Tests ............................................................................... 16
D. Genetics and Genomics .......................................................................................................................... 20
E. Hematology , Coagulation and Flow Cytometry ................................................................................... 20
Hematology and Coagulation Reference Ranges .................................................................................... 20
Bone Marrows ......................................................................................................................................... 22
PTT .......................................................................................................................................................... 22
F. Point of Care Testing ............................................................................................................................... 23
G. Transfusion Medicine ............................................................................................................................. 24
H. Anatomic Pathology & Cytology ...........................................................................................................24
A. Clinical Microbiology
Result Delivery for ER4 clients • For clients using the ER4 system for electronic delivery of microbiology results, some results will
no longer be resulted this way. Results include cultures and Chlamydia/Gonorrhea NAAT done in Edmonton Zone (UAH Microbiology/ProvLab North or DynaLIFE). Results will be sent by fax, mail or eDelivery to your EMR depending on your provider preferences. All results will be available in Netcare and EPIC. Separate arrangements have been made for Medical Officers of Health, STI Services, and Environmental Public Health.
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PreTransplant testing • All testing related to pre-transplant screening for infectious disease markers for recipients and
donors of organ, tissues, and hematopoietic stem cells will continue to use the existing paper requisitions for these programs. Orders for these tests are not to be entered into Connect Care until further notice. Specimen types and volumes are unchanged. Requisitions continue to be found at the below links:
- Deceased organ donor requisition: https://www.albertahealthservices.ca/frm-20116.pdf
- Living donor infectious disease screening requisition: https://insite.albertahealthservices.ca/main/assets/frm/frm-20829.pdf
- Tissue and bone marrow transplant donor testing requisition: https://www.albertahealthservices.ca/frm-21278.pdf
- Solid organ transplant (adult) recipient screening
- Solid organ transplant (pediatric) recipient screening requisition: https://www.albertahealthservices.ca/frm-20971.pdf
Pediatric Blood Culture • Changes to the collection guidelines for pediatric blood cultures have been made and will be
reflected in EPIC. These changes were made to optimize the sensitivity of blood cultures and help identify line infections or contaminants. Changes to the blood collection guidelines for DynaLIFE labs and UAH microbiology/ProvLab North will be available in the test directories of each lab. The following table will also display in EPIC to guide blood culture collections.
Body Weight (kg) Site 1 Site 2 Max Blood Volume Range*
<2 kg Peds Vial 2-4 mL
2.1-12.7 kg Peds Vial Peds Vial (if two sites selected)
4-10 mL
12.8 kg-30 kg Aerobic + Anaerobic Aerobic (if two sites selected)
20-30 mL
>30 kg Aerobic + Anaerobic Aerobic + Anaerobic 40 mL
*See laboratory blood collection guidelines in the test directory for more specific weight-based maximum blood volume drawn in 24 hours. Blood cultures should ALWAYS be collected from two (2) sites in patients >30kg and is suggested for all patients except neonates. Collection from two sites identifies blood culture contaminants and/or line infections.
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B. Clinical Biochemistry
I. Standardization in Test Reporting
24 hour Urine Changes • Standardized acceptable time for 24 hour urine collection: 22 to 26 hours • Standardized reporting units: unit/day (e.g. 24 hour urine urate to be reported as mmol/day)
Allergy testing
• The following semi-quantitative interpretations will no longer append to allergy test results: Result (kU/L) Interpretation <0.35 Negative (0) 0.35 – 0.69 Equivocal (1+) 0.70 – 3.49 Positive (2+) 3.50 – 17.49 Positive (3+) 17.50 – 49.99 Strongly Positive (4+) 50.00 – 99.99 Strongly Positive (5+) >=100.00 Strongly Positive (6+)
• The above reporting will be replaced with a standard allergy testing narrative:
Specific IgE allergy tests should be interpreted in the context of the patient's allergy history. ≥0.35 ku/L: Positive - Positive IgE Antibody allergy tests are common in clinically asymptomatic and symptomatic patients. There is a greater likelihood of clinical allergy with high levels of specific IgE Antibody. Specific IgE Antibody values are not reliable tools to rule in or rule out allergies. <0.35 ku/L: Negative - A negative specific IgE Antibody allergy test should not be used on its own to reject a diagnosis of allergy. It is possible for a patient to have significant allergy yet have a negative test.
• Penicillin G and Amoxicillin are no longer a battery
o Ordered individually • The following comment for paper wasp IgE will be removed, as it is no longer applicable:
The current paper wasp allergen specific IgE test slightly underestimates the IgE level for patients with equivocal (0.35-0.69 kU/L) or weak positive (0.70-3.49 kU/L) levels of IgE.
Ammonia
• Reference intervals and critical thresholds for ammonia will change in Beaker as follows: Critical Values: 0-16 years: >110 umol/L >16 years: >200 umol/L
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Anion Gap • Standardization of reference intervals by instrument (Wave 1 sites included below):
Testing Site Instrument Reference Interval (mmol/L) EEHC, La Crete Abbott iSTAT 13 – 21 Fort Vermillion, Fort McMurray, High Level Siemens EXL 4 – 16 UAH Beckman DxC 5 – 10 EEHC and CCI Ortho Vitros 8 – 15 UAH (POCT) DynaLIFE Baselab
Radiometer Siemens Atellica
4 – 16
Anti-Glomerular Basement Membrane (GBM)
• Update to the reference interval: <25.0 U/mL (all ages) • There is no longer an equivocal range
Anti-Mitochondrial
• Update to the reference interval: <25.0 U/L (all ages) • There is no longer a weak positive range
Anti-Neutrophil Cytoplasmic Antibody Testing
• If only the MPO or PR3 antibody status is required (not the full slide testing), choose appropriate orderable:
o Anti-Proteinase 3 and Anti-Myeloperoxidase are available as stand-alone tests Bilirubin
• Standardization in available tests to order: o Bilirubin, Total o Bilirubin, Total and Conjugated
• Specific testing will follow when above tests are ordered based on patient age and instrument availability
• Both tests (Bilirubin, Total; Bilirubin, Total and Conjugated) will reflex to the Biliary Atresia protocol in the appropriate age group (7 days to 5 months)
o Note: If age 0-6 days or age >5 months, conjugated bilirubin will be performed only if “Bilirubin, Total and Conjugated” is ordered
Cortisol and Testosterone
• Standardization in collection times o AM Cortisol and AM Testosterone: 0700 - 1000 o PM Cortisol and PM Testosterone: 1500 – 1800
• Collection time needs to be provided at time of collection; if outside acceptable times above, consider ordering random Cortisol or random Testosterone
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Electrolyte Panel There are two separate panels for electrolytes:
• Electrolyte panel for inpatients (including day surgery and ED): Sodium, Potassium, Chloride, CO2, Anion Gap
• Electrolyte panel for outpatients (community patients): Sodium, Potassium o If a full electrolyte panel is required in community setting, complete order question:
• If Yes is answered, full electrolyte panel will be performed • If No is answered, only Na and K will be performed
Free Androgen Index
• This test is now available to order, and includes the following: o Sex Hormone Binding Globulin (SHBG), Testosterone, and Free Androgen Index o SHBG and Testosterone will cancel as duplicate orders if Free Androgen Index is ordered
Free PSA
• This test will change from reporting as a ratio (free PSA/total PSA) to a percentage (free PSA/total PSA *100)
• This test result will now be called “Prostate Specific Antigen % Free” • New units are % • Interpretive comments:
Prostate Specific Antigen % free results less than 10% are more likely to be prostatic carcinoma. As the ratio decreases, the likelihood of carcinoma increases. There is some overlap of clinical findings throughout the range of Prostate Specific Antigen % free. No result will conclusively rule out or rule in prostatic carcinoma.
Prostate Specific Antigen % free results between 10% and 20% show substantial overlap of clinical findings with both malignant and benign diagnoses. There is some overlap of clinical findings throughout the range of Prostate Specific Antigen % free. No result will conclusively rule out or rule in prostatic carcinoma.
Prostate Specific Antigen % free results greater than 20% are more likely to be benign. As the percentage increases, the likelihood of BPH increases. There is some overlap of clinical findings throughout the range of Prostate Specific Antigen % free. No result will conclusively rule out or rule in prostatic carcinoma.
Gestational Diabetes Screen (GDS)
• New reference interval: <7.8 mmol/L
Glucose meter check • This new test will have three required order questions:
o Fasting time o Glucose meter type o Glucose meter result
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HbA1c • New reference interval: 4.3 – 5.9% • New repeat testing rule:
o HbA1c testing permitted once every 60 days for males of all ages and females/gender X <10 years and >55 years
o HbA1c testing permitted once every 21 days for females/gender X 10-55 years
Human Chorionic Gonadotropin, Luteinizing Hormone, Follicle Stimulating Hormone • Units are standardized to IU/L (previous was U/L)
HIV Serology by Rapid Assay (Rapid HIV)
• This test is orderable in Epic as “HIV Serology by Rapid Assay” (previous name is Rapid HIV Antibody Screen)
• Process instruction on order screen: o Rapid HIV is intended for URGENT DIAGNOSIS of HIV for the indications listed in
“reasons for testing”. Order HIV 1 and 2 Serology (Antigen and Antibody) for routine diagnosis. For Blood and Body Fluid Exposures order “BBFE Panel”.
• All rapid HIV results (non-reactive, indeterminate, reactive, Invalid) will reflex to a HIV serology test (confirmation test performed at ProvLab)
• There are now only four clinical indications for testing. They are listed as order questions: o Female in labor and delivery with no prenatal care or recent HIV testing o Acutely ill patient with HIV in the differential diagnosis o Person with HIV high risk behaviors, unlikely to return for results o Other (specify)
Ionized Calcium
• Standardization of reference intervals by instrument has occurred for “Calcium, Ionized” and “Calcium Ionized, pH normalized” (Wave 1 sites included below):
o EEHC, Abbott iSTAT: 1.15 – 1.35 mmol/L o UAH, Radiometer: 1.10 – 1.48 mmol/L (<15 days), 1.09 – 1.25 mmol/L (15 days to 150
years) • Standardized critical values: <0.80 mmol/L and >1.50 mmol/L
Lactose Tolerance, 2 hours
• A cutoff of 1.1 mmol/L will be used to determine whether the test is normal or abnormal (the current inconclusive range of 1.1-1.7 mmol/L will be eliminated).
o If a difference of 1.1 mmol/L glucose or greater from baseline to either the 30 min, 60 min, or 120 min time point is observed, the test result is NORMAL
o If a difference of less than 1.1 mmol/L from baseline to ALL of the 30 min, 60 min, and 120 min time points is observed, then the result is ABNORMAL
• Standardization and recording of time to consume drink and drink dose: • If more than 5 minutes taken to drink the dose, the following comment will append to
the report: Drink consumed over X minutes, not the recommended 5 minutes. Interpret results with caution.
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NTproBNP
Old:
Before Connect Care launch
New: After Connect Care launch
Test code PBNP N-TERMINAL PROHORMONE B
TYPE NATRIURETIC PEPTIDE (NT PROBNP) SEND OUT
Ordering and restriction criteria
Restricted to pediatric cardiology, amyloidosis patients (preapproved CCI oncologists*), and
*Preapproved Cross Cancer Institute (CCI) physicians include, Drs. Christopher Venner, Irwindeep
Sandhu, Michael Chu, and Joanne Hewitt.
Why this is important: • When ordering NT PROBNP be sure to use the appropriate test code and ensure clinical indications are met.
For indications that do not meet criteria above BNP should be ordered by selecting “B-Natriuretic Peptide (BNP or NT-ProBNP)” in Epic.
• Conversion to ng/L will significantly alter values and corresponding reference intervals. Due to differences in units, results prior to November 3, 2019 are not directly comparable for monitoring purposes.
Action Required:
• Be aware of changes to test codes, reporting units, and reference intervals.
Background: • These changes were implemented as part of the standardization of laboratory practices across provincial APL
sectors and DynaLIFE Labs with the launch of Connect Care wave 1. • Changes to NT PROBNP units also align with the 2017 Canadian Cardiology Society guidelines for
Management of Heart Failure (Canadian Journal of Cardiology, Nov 2017, volume 33, issue 11).
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Potassium • Hemolysis correction that was previously done at UAH will no longer be performed to align with
practice across the province
Osmolal Gap • There are three new orderable tests:
o Osmolal Gap o Osmolal Gap, Unaccounted o Osmolality, Calculated
• Standardization for reporting of “Osmolal Gap, Unaccounted” by applying factor of 1.25 on the ethanol result
o If ethanol <2, then zero will be used for ethanol to calculate “Osmolal Gap, Unaccounted”
Sweat Chloride • Standardization of classification of “Normal” results for all ages: <30 mmol/L • Standardization of classification of “Borderline” results for all ages: 30-59 mmol/L
Troponin
• Outpatients/Community patients with elevated troponin I (TnI) results (>0.15 ug/L) will have their results phoned to the ordering physician
II. New Test Codes
Current Test Name New Test Code Not previously available Angiotensin converting enzyme, CSF Not previously available Bile acid, body fluid Not previously available Citrate, Urine, Random Chylomicron (Serum or Fluid) Chylomicron
Chylomicron, Body fluid Not previously available Dexamethasone suppression test, 1 mg Not previously available Fecal Weight Not previously available Fecal Osmolal Gap Not previously available Fecal Magnesium (Random and Timed) Not previously available Free Androgen Index Not previously available Glucose meter check Not previously available High sensitivity CRP Rapid HIV Antibody Screen HIV Serology by Rapid Assay Free Kappa/Lambda Light Chains Immunoglobulin Free Light Chains Iron Iron Overdose Lactose Tolerance Test, Serum Lactose tolerance, 2 hours Not previously available Magnesium, solution PBNP N-terminal Prohormone B-Type Natriuretic Peptide (NT proBNP) SEND OUT Not previously available Osmolal Gap Not previously available Osmolal Gap, Unaccounted Not previously available Osmolality, Calculated
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III. Gender U and X • Changes have been made to improve reporting of Gender U and X results
o Tests that have different male and female reference intervals will have specific reference intervals designated for U and X and will include a reporting comment with the test result
• Examples are provided below: o CA125
Female: <35 kU/L Male: No reference intervals available
Patient identifies as gender X, or gender is unknown. Interpret result based on an appropriate reference interval listed above.
o Creatinine
≥ 15 years: 40-120 umol/L Patient identifies as gender X, or gender is unknown. The reference interval provided encompasses male and female ranges. Result should be interpreted in the context of the clinical history.
In above two age partitions, the following comment will append: Patient identifies as gender X, or gender is unknown. The reference interval provided encompasses male and female ranges. Result should be interpreted in the context of the clinical history.
o LH
For patients ≥10 years the following comment will append: Reference Interval: Follicular < 15.0 IU/L Luteal < 15.0 IU/L Midcycle 30.0 – 100.0 IU/L Post Menopausal: 18.0 – 65.0 IU/L Male < 12.0 IU/L
Patient identifies as gender X, or gender is unknown. Interpret result based on an appropriate reference interval listed above.
o Iron and TIBC
18 – 150 years: 6 – 30 umol/L Patient identifies as gender X, or gender is unknown. The reference interval provided encompasses male and female ranges. Result should be interpreted in the context of the clinical history.
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Patient identifies as gender X, or gender is unknown. Interpret result based on an appropriate reference interval listed above.
IV. Reference Interval and Critical Value Standardization a) Blood Gas Tests
The following reference intervals and critical values were standardized for the province in preparation for Connect Care Implementation through Clinical Knowledge and Content Management (CKCM). The Working Group assigned to this was created in consultation with the Critical Care Strategic Clinical Network, the Provincial Respiratory Professional Practice Council, and Laboratory Point of Care Testing Network, with additional experts consulted as required.
There has been provincial standardization of reference intervals, critical values and/or units. See below table for new reporting information.
Analyte Age Gender* (M, F, U, X)
Reference Interval Units Critical Value Comment
Albumin 0 d – 364 d
M, F, U, X 22 – 45
g/L None
365 d – 150 yr 30 – 45
Alkaline Phosphatase (ALP)
0 d – 14 d M, F, U, X 70 - 320 15 d – 364 d M, F, U, X 130 - 500
U/L
None
1 yr – 12 yr M, F, U, X 130 - 430 13 yr – 14 yr M 130 -500 15 yr – 17 yr M 60 - 250 13 yr – 14 yr F 60 - 225 15 yr – 17 yr F 50 - 140 13 yr – 14 yr U, X 60 - 500 15 yr – 17 yr U, X 50 - 250 18 yr – 150 yr M, F, U, X 40 - 120
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Alanine Aminotransferase (ALT)
0 d – < 18 yr M, F, U, X < 35
U/L
None
≥ 18 yr M < 60 ≥ 18 yr F < 40 ≥ 18 yr U, X < 60
Anti- Saccharomyces cerevisiae
0 d – 150 yr
M, F, U, X
<25.0
U/L
None
There is no equivocal range
Anti-Actin 0 d – 150 yr M, F, U, X <30 U/L None There is no weak positive range
Anti- Thyroglobulin 0 d – 150 yr M, F, U, X <=35 IU/mL None
B12 (UAH)
0 d – < 10 yr
M, F, U, X
>= 200
pmol/L
None
The following will append to results within RI: “A normal test result indicates adequate stores and should not be repeated. However, if specific clinical situations require re-testing, the interval should not be sooner than 1 year.”
10 yr – 150 yr >= 110
B12 (excludes UAH)
0 d - < 10 yr >= 250
10 yr – 150 yr
>= 160
Calcium (Wave 1 sites: UAH, CCI,
EEHC, DynaLIFE Baselab)
0 d – 10 d M, F, U, X
1.80 - 2.90 mmol/L
<1.65 & >3.25
11 d – 365 d 2.20 - 2.80 > 1 yr 2.10 - 2.60
Calcium (Wave 1 sites: Fort Vermillion, Fort McMurray, High Level)
0 d – 10 d M, F, U, X
1.80 - 2.70 mmol/L <1.65 &
>3.25
11d – 365 d 2.20 - 2.70 > 1 yr 2.05 - 2.45
Chloride 0 d – 150 yr M, F, U, X 98 – 112 mmol/L None
Ferritin
0 d – < 6 mo M, F, U, X 50 - 500
ug/L
None
6 mo – 15 yr M, F, U, X 15 - 100 > 15 yr F 20 - 300 > 15 yr M 30 - 500 > 15 yr U,X* 20 - 500
GGT
0 – < 15 d M, F, U, X 20 - 200
U/L
None
15 d – < 1 yr M, F, U, X < 100 1 yr – < 18 yr M, F, U, X < 27 18 – 150 yr F < 50 18 – 150 yr M < 80 18 – 150 yr U,X* <80
Magnesium 0 – 150 yr M, F, U, X 0.70 - 1.00 mmol/L <0.4 & >1.9
Phosphate
0 - 14 days
M, F, U, X
1.40 - 2.70
mmol/L
<0.40
15 d – 30 d 1.60 - 2.70 31 d – 4 yr 1.20 - 2.20 5 yr – 12 yr 1.10 - 1.90 13 yr – 17 yr 0.90 - 1.70 18 yr – 150 yr 0.70 - 1.50
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Comment for Guide to Lab Services: Potassium concentration is 0.2 to 0.5 higher in serum (gold top)
1 yr -150 yr DynaLIFE M, F, U, X 3.6 - 5.2
DynaLIFE
Protein/Creatinine 2 - 12 yr M, F, U, X 2 - 20
mg/mmol None
>12 yr M, F, U, X < 13 Sodium 0 d – 150 yr M, F, U, X 135 – 145 mmol/L <120 & >155
Sweat Chloride
0 d – 150 yr
M, F, U, X
<30
mmol/L
None
Results of 30-59 mmol/L are considered “Borderline” for all ages
Total Bilirubin
0 d - 8 d M, F, U, X N/A µmol/L
<30 d: >300
9 d - 28 d M, F, U, X N/A 29 d - 150 yr M, F, U, X <20
Total CO2 0 d - 150 yr M, F, U, X 20 – 32 mmol/L None
Total Protein 0 - 364 d M, F, U, X 40 - 70
g/L None
365 d - 150 yr M, F, U, X 62 - 82
Urea
0 d - 2 yr M, F, U, X 1.0 - 7.5
mmol/L
None
2 yr - 17 yr M, F, U, X 2.0 - 7.0 18 yr - 55 yr F 2.0 - 7.0 18 yr - 55 yr M 3.0 - 8.0 18 yr – 55 yr U,X* 2.0 – 8.0 > 55 yr F 3.0 - 8.0 > 55 yr M 3.0 - 9.0 >55 yr U,X* 3.0 – 9.0
25- Hydroxy Vitamin D 0 d – 150 yr M, F, U, X 80-200 nmol/L None
*If Gender U, X (occurs when M and F have different reference interval with given age partition), result will include following comment until we are able to complete larger studies: “Patient identifies as gender X, or gender is unknown. The reference interval provided encompasses male and female ranges. Result should be interpreted in the context of the clinical history”
C. Therapeutic Drug Monitoring and Toxicology Tests
• Acetaminophen and Salicylate lower reporting limits have been standardized:
o Salicylate: 0.3 mmol/L o Acetaminophen: Testing Site Instrument Lower Reporting Limit (mmol/L) Fort Vermillion, Fort McMurray, High Level Siemens EXL 33 UAH Beckman DxC 66
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• There has been provincial standardization of reference intervals, critical values and/or units. See below table for new reporting information.
Analyte Therapeutic Range Units Critical Value Comment Acetaminophen “Consult Poison and Drug
Information Service (PADIS) at 1- 800-332-1414 if appropriate.”
Amikacin Pre-Dose: 4.0-8.0 Post: 15.0 – 30.0
mg/L Pre > 10.0 Post > 40.0 Other > 40.0
Pre-Dose: “Note: If patient is receiving extended interval dosing the target trough is less than 1.0 mg/L. Dosing is 4 to 10 mg/kg and interval is 24h or more.”
Carbamazepine 17-50 umol/L >65
Digoxin Heart Failure: 0.6 - 1.2 Atrial Fibrillation: Not defined
nmol/L >2.6 “Caution: Results > 1.5 nmol/L are associated with a higher risk of toxicity in heart failure patients”
Lamotrigine 10 – 60 umol/L >79
Gentamicin (Pre-Dose)
“Note: If patient is receiving extended interval dosing the target trough is less than 0.5 mg/L. Dosing is 4 to 10 mg/kg and interval is 24h or more.”
Gentamicin, 8h Interval
“CAUTION: Specimen should be collected 7-9 hours after the START of infusion for proper interpretation. Refer to Hartford Nomogram (Applies only to 7 mg/kg dose. If other dose used, obtain pharmacokinetic consult). Please refer to Aminoglycoside Dosing/Monitoring Guidelines, AHS Bugs and Drugs Online Document May 2019 Revision.”
Methotrexate Removed umol/L >99.99 “Level interpretation dependent on institution protocols, type of therapy (intermediate versus high dose) and individual patient factors.”
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Tobramycin (Pre-Dose)
“Note: If patient is receiving extended interval dosing the target trough is less than 0.5 mg/L. Dosing is 4 to 10 mg/kg and interval is 24h or more.”
Tobramycin, 8h Interval
“CAUTION: Specimen should be collected 7-9 hours after the START of infusion for proper interpretation. Refer to Hartford Nomogram (Applies only to 7 mg/kg dose. If other dose used, obtain pharmacokinetic consult). Please refer to Aminoglycoside Dosing/Monitoring Guidelines, AHS Bugs and Drugs Online Document May 2019 Revision.”
Valproate umol/L >1040
Vancomycin mg/L Other: > 60.0 “Routine monitoring of vancomycin levels is not generally recommended. Please refer to Vancomycin Dosing/Monitoring Guidelines, AHS Bugs and Drugs Online Document May 2019 Revision.
Stimulation Tests • Requests for dynamic testing associated with Endocrine disorders will be reviewed by Endocrinology
prior to collection with the exception of the Standard ACTH Stimulation Test and 1mg Dexamethasone Suppression Test.
Methanol/Ethylene Glycol • An unaccounted gap will not be automatically performed when either methanol or ethylene
glycol requested • Progressive testing algorithm will be discontinued. Requests for methanol and ethylene glycol
will proceed and will not be dependent on the unaccounted osmol gap
Barbiturate Screen, Serum • Testing discontinued
Benzodiazepine Screen, Serum
• Testing discontinued
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Tricyclic Antidepressant Screen, Serum and Urine • Test results will be reported as either:
o Negative Immunoassay tests may not detect all relevant drugs in this drug class. If further testing by definitive techniques is required, contact the laboratory. Results should not be used for guiding clinical management.
o Indeterminate No further testing is being performed. If further testing is by definitive techniques is required, contact the laboratory. Immunoassay tests are prone to a variety of interferences. Further testing is required to determine if substances of concern are present. Results should not be used for guiding clinical management.
Minor change to comment associated with drug test results.
• “This result must not be used for non-medical purposes” will be changed to “This result must not be used or disclosed for potentially medicolegal or other non-medical purposes.”
Vitamin A
• Fasting requirement added
N-Telopeptides • Gender X reference range added
For all Therapeutic Drug Monitoring (TDM)
• Order/collection questions: TDM dosing information (regimen/route/time of last and next dose/regimen duration).
• This request mirrors information collected on paper requisitions. • Dosing information will appear on the final report
Urine Drug Testing
• Order/collection question: Reason for Request. This request mirrors information collected on paper requisition.
• Order/Collection questions related to urine temperature. This is not a hard stop question but allows sites that are currently performing urine temperature to identify whether the temperature was acceptable.
• Order/Collection questions related to whether the patient presented with appropriate identification.
• There are 2 orderable drug testing panels: o Urine Opioid Dependency Panel – meant to be ordered for patients who are in Opioid
Dependency Programs (also referred to as Opioid Agonist Therapy) o Urine General Toxicology Panel – ordered on patients other than those in Opioid
Dependency Programs. o These panels are not new as they have been in place for approximately one year.
However, the change may not have been readily apparent to sites utilizing an old version of the paper requisition.
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D. Genetics and Genomics -Biochemical Genetics, Cytogenetics and Molecular Genetics
I. General Instructions:
The North Sector Genetics and Genomics laboratories, biochemical genetics, cytogenetics and molecular genetics will be going live with Wave 1.
Other than urgent testing, expect that some testing started before the Go Live date will continue to be reported through legacy systems (eg. Cerner and Co-Path) into Netcare. This may continue for several months.
Ordering of genetic tests is available within the Epic system. Multiple aliases of test names have been included as a convenience for ordering providers.
Important: Pedigree/ family history, pregnancy information and clinical information are still required for genetics and genomic testing. Ordering providers are encouraged to order genetic tests within Epic. Necessary information, such as pedigrees and reports from external laboratories, should be scanned into the patient’s EHR. If this is not possible the information can be faxed/sent to the laboratory.
Samples which are being sent to an out of province laboratory may require lab specific paper requisitions and consent forms, these should accompany specimens to the laboratory.
Health care providers who do not have access to ordering within EPIC should continue to use existing paper requisitions. All original paperwork presented at the time of specimen collection must accompany that specimen to the genetics laboratories. Missing information may result in delay of testing.
Please refer to the Genetics and Genomics website for information on the ordering of genetic tests, requisitions, information sheets and the Genetic Resource Centre (https://www.albertahealthservices.ca/lab/Page8667.aspx).
For questions and further information health care providers can contact the Genetics and Genomics Genetic Counsellors at 780-407-1015.
II. Specific Instructions:
Reference Ranges for Amino Acid Quantification Amino Acid Quantification (plasma, csf and urine) reference ranges have changed and are now standardized with the Biochemical Genetics Laboratory at the Alberta Children’s Hospital. These new reference ranges are available within Epic/Beaker.
First and Second Trimester Prenatal Screens First and Second Trimester Prenatal Screens will be ordered in Epic (requisitions are still required to be submitted with the sample, there is an order comment stating this in Epic) but no change to how results are reported. All result reports will continue to be mailed. Positive screens will continue to be faxed and mailed.
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Newborn Metabolic Screening: As an exception Newborn Metabolic Screening is not going live with Wave 1, however results will be reported in Epic. Procedures for collection, receipt and reporting of critical results for newborn metabolic screening will not be changed for Newborn Metabolic Screening with Wave 1.
E. Hematology , Coagulation and Flow Cytometry
I. Hematology and Coagulation Reference Range changes
Hematology and Coagulation Reference
II. Blood Smears • Blood “Smears” will be resulted in Epic/ConnectCare as each lab goes Live in each wave. These
results will also be available in NetCare, but not other legacy systems. There are two types of reports:
o Smear for Consult – these are Clinician requested consults for Pathologist review. Note that a technologist will review all of these requests for appropriateness. If the morphology is perfectly normal, there are no (or minimal) numeric
abnormalities and there are no abnormal analyzer flags the smear will be cancelled with a comment: “Slide reviewed by technologist. No blasts, schistocytes, spherocytes or other abnormal morphology seen. Smear not reviewed by pathologist per established laboratory procedure.
If there is any other concern, please contact the lab within 7 days to provide a clinical reason that smear requires review by pathologist.” Clinicians will have an opportunity to re-activate the smear if they can provide a reason why pathologist review is necessary.
o Smear to Pathologist – these are CBC/D orders which are flagged by the lab as having an abnormality that requires a Pathologist to review a slide. Whenever such a review is triggered in Epic/ConnectCare a “Smear to Pathologist” is accessioned. If the pathologist sees something that may be of additional clinical significance (beyond what is reported on the CBCD) they will dictate a comment; otherwise it will just be resulted with the name of the reviewing pathologist.
• Peripheral Blood Films resulted at labs not yet live in Epic/ConnectCare will continue to report in
legacy systems. Results will also continue to be available in NetCare.
• Caution: patients are not necessarily collected at the same site at which the clinician placed the order. For example a patient seen at the University of Alberta Hospital (wave 1 site) may elect to have their blood collected at the Grey Nuns Hospital (subsequent wave site), and therefore have results reported in the legacy system only. Check NetCare if an expected report is not available in either system.
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III. Bone Marrows - For clinicians performing a bone marrow aspiration and/or trephine biposy:
• Recommend ordering a “Bone Marrow Performable” in Epic. This automatically orders a Panel of tests which includes a:
o CBC and Differential o Reticulocyte Count o Bone Marrow Cell Differential o Bone Marrow Exam (LAB6; needed for AP to build the case) o Leukemia/Lymphoma Immunophenotyping o Cytogenetic Analysis o HOLD DNA FOR MOLECULAR PATHOLOGY o HOND RNA FOR MOLECULAR PATHOLOGY
• NOTE: If any of the above are not required, then simply do not collect the tube associated with the test. Ideally, the ordering clinician would also note which testing is not needed in the comment field provided within Epic but this is not essential.
• It does not include the following which must be ordered individually if/when needed
(indicate Specimen Src: Bone Marrow Aspirate when ordering): o Bone Marrow Culture o Mycobacteria Culture o Fungal Culture o Viruses – must order each specific type of test needed individually
- Bone Marrow results in Netcare:
• All bone marrows in the Edmonton Zone will be reported in Epic with the Wave 1 launch. • All new bone marrow reports will now appear in the Pathology folder in Netcare. Previously
most of these reports appeared in the Hematology folder.
IV. PTT and Heparin Nomogram With the standardization requirement in both pharmacy and lab, it was a challenge to create a single heparin nomogram that would work with the different reference ranges generated by the various reagent / analyzer combination. The document in the link below describes how this has been accomplished.
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V. Flow cytometry o The B, T, and NK Enumeration test is no longer available.
Instead T-cell Subsets, or B Cell Enumeration can be ordered separately. NK cell enumeration is not routinely available but can be obtained as part of an
Immunodeficiency Screening Panel.
o Leukemia and Lymphoma Flow Cytometry FACS (Acute Leukemia Flow Cytometry) and XFACS (Lymphoma Flow Cytometry) will
roll together into one “Leukemia/Lymphoma Immunophenotyping” However, clinicians will be given a hard stop question requiring a clinical indication to
be selected that will allow the lab to run the correct panel. • The hard stop answers are: Lymphoma-Lymphoproliferative Disorder, Acute
Leukemia, Plasma Cell Neoplasia, Minimal Residual Disease, and Pancytopenia (Bone Marrow ONLY). Of these selections, only the Lymphoma- Lymphoproliferative Disorder answer is routinely indicated on peripheral blood. The other indications usually require bone marrow testing; “Pancytopenia (Bone Marrow ONLY)” can only be performed on bone marrow and will be auto-cancelled if requested on peripheral blood.
o Hereditary Spherocytosis
“Hereditary Spherocytosis by Flow Cytometry” is adequate for diagnosis of Hereditary Spherocytosis in the vast majority of individuals and can be ordered directly in Epic.
“Hereditary Spherocytosis by Flow Cytometry and Osmotic Fragility” may be needed in some select cases and requires booking for collection through Client Response (780- 407-7484).
F. Point of Care Testing (POCT) Results from POCT devices will now either directly flow from the device through the new POCT middleware into the electronic medical record (e.g. glucose meter, blood gas), or be manually entered into EPIC using Enter/Edit functionality (e.g. qualitative urine pregnancy) and resulted in the electronic medical record. When performing POCT, ensure:
• Valid operator ID (employee e-People number) is entered by device users to access the device and result reporting
• Valid patient ID (Client Serial Number [CSN]) is entered for positive patient identification • Glucose and i-STAT1 meters are frequently docked to facilitate data transfer
POCT programs that will have patient results directly connected into EPIC and the patient electronic medical record at Wave 1 Go-Live are:
• Abbott i-STAT1 Chemistry and Blood Gas Testing • Radiometer ABL Blood Gas Testing • Roche Accu-Chek Inform II Glucose Meter Testing
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POCT programs that will require patient results to be manually charted by the end user into the electronic medical record via the EPIC Enter/Edit function at Wave 1 Go-Live are:
• DCA Vantage HBA1C Testing • Innovatek Urine pregnancy testing • pocHi Hematology testing • Roche Coaguchek Meter Testing
G. Transfusion Medicine There are several resources available pertaining to transfusion medicine on the Connect Care Knowledge Library (https://insite.albertahealthservices.ca/main/assets/Pages/ListView.aspx?listName=Connect%20Care&v iewName=tms-cis-doc-name ) and the Transfusion Medicine insite page (https://insite.albertahealthservices.ca/lab/Page7421.aspx)
Transfusion Prenatal testing should continue to be ordered on the Canadian Blood Services requisition.
Since transfusion of Red cells, platelets, plasma and cryoprecipitate requires administration within an AHS facility, pretransfusion testing and component requests will be restricted to physicians who have privileges within those environments.
H. Anatomic Pathology
Preliminary results In EPIC and in some of the downstream electronic applications, preliminary reports will be overwritten by final reports on the patient chart once the final report is verified.
Biomarker results Biomarker results will now be reported as addendum reports to the corresponding surgical specimen. These are available in NetCare by hovering the cursor over the surgical case specimen and a “corrected” text box will signal that the biomarker report is available.
Cytology Cytology specimens will have a new maximum of 5 parts per case. Cases are produced by encounter, and cases with more than 5 parts will be issued additional report(s).
