Urinalysis and Body Fluids

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3920_FM_i-xv 23/01/14 11:22 AM Page iii

To Harry—you will always be my Editor-in-Chief

—SKS

To my husband, Scott; my daughter, Lauren;

my sons, Michael and Christopher;
my daughters-in-law, Kathleen and Ashley;
and my grandsons, Cameron and Joseph.
—MSD
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Preface

As will be apparent to readers, the sixth edition of Urinalysis Each chapter opens with objectives and key terms and
and Body Fluids has been substantially revised and enhanced. concludes with multiple choice questions for student review.
However, the objective of the text—to provide concise, com- In response to readers’ suggestions, the number of color images
prehensive, and carefully structured instruction in the analysis and figures has been significantly increased. The text has been
of nonblood body fluids—remains the same. extensively supplemented with tables, summaries, and proce-
This sixth edition has been redesigned to meet the changes dure boxes. Case studies in the traditional format and clinical
occurring in both laboratory medicine and instructional situations relating to technical considerations included at the
methodology. end of the chapters offer students an opportunity to think crit-
To meet the expanding technical information required by ically about the material. A new feature, Historical Notes, pro-
students in laboratory medicine, all of the chapters have been vides a reference for topics or tests that are no longer routinely
updated. Chapter 1 covers overall laboratory safety, precautions performed. Another new feature, Technical Tips, emphasizes
relating to urine and body fluid analysis, and the importance of information important to performing procedures. An answer
quality assessment and management in the urinalysis laboratory. key for the study questions, case studies, and clinical situations
Preexamination, examination, and postexamination variables, is included at the end of the book. Key terms appear in bold-
procedure manuals, and current regulatory issues are stressed. face blue color within the chapters. General medical terms
Chapter 6 includes numerous additional images showing appear in boldface in the text and are also included in the
the various urine microscopic components. In Chapters 7 and Glossary. The abbreviations noted in boldface red color have
8 the most frequently encountered diseases of glomerular, been collected in a convenient Abbreviations list at the back
tubular, interstitial, vascular, and hereditary origin are related of the book. An electronic test bank, chapter-by-chapter Power-
to their associated laboratory tests. To accommodate advances Points, a searchable digital version of the textbook, resources
in laboratory testing of cerebrospinal, seminal, synovial, serous, for instructors, and interactive exercises and animations for
and amniotic fluids, all of the individual chapters have been students are provided on the DavisPlus Web site.
enhanced, and additional anatomy and physiology sections We thank our readers for their valuable suggestions, which
have been added for each of these fluids. An entirely new chapter have guided us in creating this exciting new edition and the
(Chapter 15) dedicated to vaginal secretions and covering electronic ancillary supports.
proper specimen collection and handling, diseases, and related Susan King Strasinger
diagnosis laboratory tests has been added.
Marjorie Schaub Di Lorenzo
Appendix A provides coverage of the ever-increasing
variety of automated instrumentation available to the urinalysis
laboratory. Appendix B discusses the analysis of bronchoalveolar
lavage specimens, an area of the clinical laboratory that has
been expanding in recent years.

v
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Reviewers

Lorraine Doucette, MS, MLS(ASCP)CM

Associate Professor and Medical Laboratory Technician Program Coordinator
Anne Arundel Community College
Arnold, Maryland

Pamela B. Lonergan, MS, MT(ASCP)SC

Medical Technology Program Director
Department of Nursing and Allied Health
Norfolk State University
Norfolk, Virginia

Jessica Loontjer, MLS(ASCP)CM, LS(ASCP)CM

Clinical Instructor, Special Chemistry and Urinalysis/Body Fluids
Nebraska Methodist Hospital Laboratory
Omaha, Nebraska

Michelle Moy, MAd Ed, MT(ASCP)SC

Program Director
Clinical Laboratory Science Program
Loyola University
Chicago, Illinois

C. Thomas Somma, PhD

Associate Professor
School of Medical Diagnostics and Translational Sciences
College of Health Sciences
Old Dominion University
Norfolk, Virginia

vii
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Acknowledgments

Many people deserve credit for the help and encouragement over the years: Donna L. Canterbury, BA, MT(ASCP)SH;
they have provided us in the preparation of this sixth edition. Joanne M. Davis, BS, MT(ASCP)SH; M. Paula Neumann,
Our continued appreciation is also extended to all of the MD; Gregory J. Swedo, MD; and Scott Di Lorenzo, DDS.
people who were instrumental in the preparation of previous We also thank Sherman Bonomelli, MS, for contributing
editions. original visual concepts that became the foundation for many
The valuable suggestions from previous readers and the of the line illustrations, and the students from the University
support from our colleagues at the University of West Florida, of West Florida, specifically Jennifer Cardenas, Shannel
Northern Virginia Community College, University of Nebraska Hill, Jelma Moore, and William Laguer, who worked under
Medical Center, and Methodist Hospital have been a great asset the guidance of Sherman Bonomelli to produce many of
to us in the production of this new edition. We thank each and the new images. Images for Chapter 14 were provided by
every one of you. Brenda Franks has provided us with many Carol Brennan, MT(ASCP), Diane Siedlik, MT(ASCP), Chris-
valuable documents for reference in this text. The authors thank tian Herdt, MT(ASCP), and Teresa Karre, MD, from Methodist
and acknowledge Pamela S. Hilke, MS, CT(ASCP), Education Hospital.
Coordinator and Instructor, and Sophie K. Thompson, MHS, We would like to express our gratitude for the help, patience,
CT, (ASCP) (IAC), Program Director and Associate Professor of guidance, and understanding of our editors at F. A. Davis: Christa
the Cytotechnology Program at the School of Medical Diagnos- Fratantoro, Senior Acquisitions Editor; George Lang, Manager of
tic and Translational Sciences, College of Health Sciences, Old Content Development, Health Professions/Medicine; and Molly
Dominion University, Norfolk, Virginia, for their contributions M. Ward, Development Editor. We thank all the members of the
of spectacular cytology images. F. A. Davis team who were instrumental in bringing this edition
We extend special thanks to the people who have pro- to fruition: Elizabeth Stepchin, Alisa Hathaway, Carolyn O’Brien,
vided us with so many beautiful photographs for the text and Sharon Lee.

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Contents

PART ONE: Background Suprapubic Aspiration 34

Prostatitis Specimen 34
CHAPTER 1 Pediatric Specimens 34
Safety and Quality Assessment 3 Drug Specimen Collection 35
SAFETY 4 CHAPTER 3
Biologic Hazards 4 Renal Function 39
Personal Protective Equipment 7 Renal Physiology 40
Hand Hygiene 7 Renal Blood Flow 40
Biologic Waste Disposal 9 Glomerular Filtration 41
Sharp Hazards 9 Tubular Reabsorption 43
Tubular Secretion 45
Chemical Hazards 10
Chemical Spills and Exposure 10 Renal Function Tests 46
Chemical Handling 10 Glomerular Filtration Tests 47
Chemical Hygiene Plan 10 Cystatin C 49
Chemical Labeling 10 Tubular Reabsorption Tests 50
Material Safety Data Sheets 10 Tubular Secretion and Renal Blood Flow Tests 52
Radioactive Hazards 11
Electrical Hazards 11 PART TWO: Urinalysis
Fire/Explosive Hazards 12 CHAPTER 4
Physical Hazards 13 Physical Examination of Urine 59
QUALITY ASSESSMENT 13 Color 60
Urinalysis Procedure Manual 14 Normal Urine Color 60
Abnormal Urine Color 61
Preexamination Variables 14
Examination Variables 16 Clarity 62
Postexamination Variables 20 Normal Clarity 62
CHAPTER 2 Nonpathologic Turbidity 63
Pathologic Turbidity 63
Introduction to Urinalysis 27
Specific Gravity 63
History and Importance 28
Refractometer 64
Urine Formation 29 Osmolality 65
Urine Composition 29 Reagent Strip Specific Gravity 66
Urine Volume 29 Odor 66
Specimen Collection 30 CHAPTER 5
Containers 30 Chemical Examination of Urine 71
Labels 30 Reagent Strips 72
Requisitions 31
Reagent Strip Technique 72
Specimen Rejection 31 Handling and Storing Reagent Strips 73
Specimen Handling 31 Quality Control of Reagent Strips 73
Specimen Integrity 31 Confirmatory Testing 73
Specimen Preservation 31 pH 73
Types of Specimens 32 Clinical Significance 73
Random Specimen 32 Reagent Strip Reactions 75
First Morning Specimen 33 Protein 75
24-Hour (or Timed) Specimen 33 Clinical Significance 75
Catheterized Specimen 34 Prerenal Proteinuria 75
Midstream Clean-Catch Specimen 34

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xii Contents

Renal Proteinuria 76 Sediment Examination Techniques 102

Postrenal Proteinuria 76 Sediment Stains 103
Reagent Strip Reactions 77 Cytodiagnostic Urine Testing 105
Reaction Interference 77 Microscopy 105
Glucose 79 Types of Microscopy 107
Clinical Significance 79 Urine Sediment Constituents 110
Reagent Strip (Glucose Oxidase) Reaction 81 Red Blood Cells 110
Reaction Interference 81 White Blood Cells 112
Copper Reduction Test (Clinitest) 81 Epithelial Cells 113
Clinical Significance of Clinitest 82 Bacteria 118
Ketones 82 Yeast 119
Clinical Significance 82 Parasites 119
Reagent Strip Reactions 83 Spermatozoa 120
Reaction Interference 83 Mucus 120
Casts 121
Blood 83 Urinary Crystals 128
Clinical Significance 84 Urinary Sediment Artifacts 138
Hematuria 84 CHAPTER 7
Hemoglobinuria 84
Myoglobinuria 84 Renal Disease 147
Reagent Strip Reactions 84 Glomerular Disorders 148
Reaction Interference 85 Glomerulonephritis 148
Bilirubin 85 Nephrotic Syndrome 149
Bilirubin Production 85 Tubular Disorders 150
Clinical Significance 86 Acute Tubular Necrosis 150
Reagent Strip (Diazo) Reactions 87 Hereditary and Metabolic Tubular Disorders 153
Reaction Interference 87
Interstitial Disorders 154
Urobilinogen 87
Acute Pyelonephritis 155
Clinical Significance 88 Chronic Pyelonephritis 155
Reagent Strip Reactions and Interference 88 Acute Interstitial Nephritis 155
Reaction Interference 88
Renal Failure 155
Nitrite 88
Renal Lithiasis 157
Clinical Significance 88
Reagent Strip Reactions 89 CHAPTER 8
Reaction Interference 89 Urine Screening for Metabolic Disorders 163
Leukocyte Esterase 90 Overflow Versus Renal Disorders 164
Clinical Significance 90 Newborn Screening Tests 164
Reagent Strip Reaction 90
Reaction Interference 91 Amino Acid Disorders 165
Phenylalanine-Tyrosine Disorders 165
Specific Gravity 91
Branched-Chain Amino Acid Disorders 167
Reagent Strip Reaction 91 Tryptophan Disorders 168
Reaction Interference 92 Cystine Disorders 169
CHAPTER 6 Porphyrin Disorders 170
Microscopic Examination of Urine 99 Mucopolysaccharide Disorders 172
Macroscopic Screening 100 Purine Disorders 174
Specimen Preparation 100 Carbohydrate Disorders 174
Specimen Volume 100
Centrifugation 100
Sediment Preparation 101 PART THREE: Other Body Fluids
Volume of Sediment Examined 101
CHAPTER 9
Commercial Systems 101
Examining the Sediment 101 Cerebrospinal Fluid 181
Reporting the Microscopic Examination 101 Formation and Physiology 182
Correlating Results 102
Specimen Collection and Handling 182
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Contents xiii

Appearance 183 Cell Counts 220

Traumatic Collection (Tap) 184 Differential Count 220
Uneven Blood Distribution 184 Crystal Identification 221
Clot Formation 184 Types of Crystals 221
Xanthochromic Supernatant 185 Slide Preparation 222
Cell Count 185 Crystal Polarization 222
Methodology 185 Chemistry Tests 224
Total Cell Count 186 Microbiologic Tests 224
WBC Count 186
Quality Control of CSF and Other Body Fluid Cell Serologic Tests 224
Counts 186 CHAPTER 12
Differential Count on a CSF Specimen 186 Serous Fluid 229
Cytocentrifugation 186 Formation 230
CSF Cellular Constituents 187
Specimen Collection and Handling 230
Chemistry Tests 193
Transudates and Exudates 231
Cerebrospinal Protein 193
CSF Glucose 196 General Laboratory Procedures 231
CSF Lactate 195 Pleural Fluid 232
CSF Glutamine 195 Appearance 232
Microbiology Tests 195 Hematology Tests 232
Gram Stain 196 Chemistry Tests 235
Microbiologic and Serologic Tests 236
Serologic Testing 197
Pericardial Fluid 236
CHAPTER 10
Appearance 237
Semen 203 Laboratory Tests 237
Physiology 204 Peritoneal Fluid 237
Specimen Collection 205 Transudates Versus Exudates 237
Specimen Handling 205 Appearance 238
Laboratory Tests 238
Semen Analysis 205
Appearance 205 CHAPTER 13
Liquefaction 206 Amniotic Fluid 243
Volume 206 Physiology 244
Viscosity 206
pH 207 Function 244
Sperm Concentration and Sperm Count 207 Volume 244
Sperm Motility 208 Chemical Composition 244
Sperm Morphology 209 Differentiating Maternal Urine From Amniotic
Fluid 245
Additional Testing 210
Specimen Collection 245
Sperm Vitality 211
Seminal Fluid Fructose 211 Indications for Amniocentesis 245
Antisperm Antibodies 212 Collection 246
Microbial and Chemical Testing 212 Specimen Handling and Processing 246
Postvasectomy Semen Analysis 213 Color and Appearance 246
Sperm Function Tests 213
Semen Analysis Quality Control 213 Tests for Fetal Distress 246
CHAPTER 11 Hemolytic Disease of the Newborn 246
Neural Tube Defects 247
Synovial Fluid 217
Tests for Fetal Maturity 248
Physiology 218
Fetal Lung Maturity 248
Specimen Collection and Handling 218 Lecithin-Sphingomyelin Ratio 248
Color and Clarity 219 Phosphatidyl Glycerol 249
Foam Stability Index 249
Viscosity 219 Lamellar Bodies 249
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xiv Contents

CHAPTER 14 Diagnostic Tests 271

Fecal Analysis 255 pH 271
Physiology 256 Microscopic Procedures 272
Diarrhea and Steatorrhea 257 Vaginal Disorders 277
Diarrhea 257 Bacterial Vaginosis 277
Steatorrhea 258 Trichomoniasis 278
Candidiasis 278
Specimen Collection 258 Desquamative Inflammatory Vaginitis 279
Macroscopic Screening 258 Atrophic Vaginitis 279
Color 258 Additional Vaginal Secretion Procedures 279
Appearance 259 Fetal Fibronectin Test 279
Microscopic Examination of Feces 259 AmniSure Test 279
Fecal Leukocytes 259 APPENDIX A Urine and Body Fluid Analysis
Muscle Fibers 259 Automation 283
Qualitative Fecal Fats 260
APPENDIX B Bronchoalveolar Lavage 293
Chemical Testing of Feces 261
Answers to Study Questions and Case Studies and
Occult Blood 261 Clinical Situations 297
Quantitative Fecal Fat Testing 262
APT Test (Fetal Hemoglobin) 263 Abbreviations 305
Fecal Enzymes 264 Glossary 307
Carbohydrates 264 Index 315
CHAPTER 15
Vaginal Secretions 269
Specimen Collection and Handling 270
Color and Appearance 271
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PART ONE

Background
Chapter 1: Safety and Quality Assessment
Chapter 2: Introduction to Urinalysis
Chapter 3: Renal Function
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CHAPTER 1
Safety and Quality
Assessment
LEARNING OBJECTIVES
Upon completing this chapter, the reader will be able to:
1-1 List the six components of the chain of infection and 1-7 Discuss the components and purpose of chemical
the laboratory safety precautions that break the chain. hygiene plans and Material Safety Data Sheets.
1-2 State the purpose of the Standard Precautions policy 1-8 State and interpret the components of the National
and describe its guidelines. Fire Protection Association hazardous material
labeling system.
1-3 State the requirements mandated by the Occupational
Exposure to Blood-Borne Pathogens Compliance 1-9 Describe precautions that laboratory personnel should
Directive. take with regard to radioactive, electrical, and fire hazards.
1-4 Describe the types of personal protective equipment 1-10 Explain the RACE and PASS actions to be taken when
that laboratory personnel wear, including when, how, a fire is discovered.
and why each article is used.
1-11 Recognize standard hazard warning symbols.
1-5 Correctly perform hand hygiene procedures following
1-12 Define the preexamination, examination, and postex-
Centers for Disease Control and Prevention (CDC)
amination components of quality assessment.
guidelines.
1-13 Distinguish between the components of internal
1-6 Describe the acceptable methods for handling and
quality control, external quality control, electronic
disposing of biologic waste and sharp objects in the
quality control, and proficiency testing.
urinalysis laboratory.

KEY TERMS
Accreditation External quality assessment (EQA) Postexposure prophylaxis (PEP)
Accuracy External quality control Precision
Biohazardous Fomite Preexamination variable
Chain of infection Infection control Preventive maintenance (PM)
Chemical hygiene plan Internal quality control Proficiency testing
Clinical Laboratory Improvement Material Safety Data Sheet (MSDS) Quality assessment (QA)
Amendments (CLIA) Occupational Safety and Health Quality control (QC)
Clinical and Laboratory Standards Administration (OSHA) Radioisotope
Institute (CLSI) Personal protective equipment Reliability
Electronic quality control (PPE)
Standard Precautions
Examination variable Postexamination variable
Turnaround time (TAT)
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4 Part One | Background

S A F E T Y received in the clinical laboratory. Understanding how microor-

ganisms are transmitted (chain of infection) is essential to
preventing infection. All health-care facilities have developed
The clinical laboratory contains a variety of safety hazards, procedures to control and monitor infections occurring within
many of which are capable of producing serious injury or life- their facilities. This is referred to as infection control. The
threatening disease. To work safely in this environment, labo- chain of infection requires a continuous link between an in-
ratory personnel must learn what hazards exist, the basic safety fectious agent, a reservoir, a portal of exit, a means of trans-
precautions associated with them, and how to apply the basic mission, a portal of entry, and a susceptible host.4 Infectious
rules of common sense required for everyday safety for agents consist of bacteria, fungi, parasites, and viruses. The
patients, co-workers, and themselves. reservoir is the location of potentially harmful microorganisms,
As can be seen in Table 1–1, some hazards are unique to such as a contaminated clinical specimen or an infected
the health-care environment, and others are encountered rou- patient. It is the place where the infectious agent can live and
tinely throughout life. Safety procedure manuals must be read- possible multiply. Humans and animals make excellent reser-
ily available in the laboratory that describe the safety policies voirs. Equipment and other soiled inanimate objects, called
mandated by the Centers for Disease Control and Prevention fomites, will serve as reservoirs, particularly if they contain
(CDC) and the Occupational Safety and Health Adminis- blood, urine, or other body fluids. Some microorganisms form
tration (OSHA), and strict adherence to these guidelines by spores or become inactive when conditions are not ideal and
laboratory personnel is essential. The manual must be updated wait until a suitable reservoir is available. The infectious agent
and reviewed annually by the laboratory director. The Clinical must have a way to exit the reservoir to continue the chain
and Laboratory Standards Institute (CLSI) provides the of infection. This can be through the mucous membranes of
guidelines for writing these procedures and policies.1-3 the nose, mouth, and eyes, and in blood or other body fluids.
Once the infectious agent has left the reservoir, it must have
a way to reach a susceptible host. Means of transmission include:
Biologic Hazards
1. Direct contact: the unprotected host touches the patient,
The health-care setting provides abundant sources specimen, or a contaminated object (reservoir)
of potentially harmful microorganisms. These mi- 2. Airborne: inhalation of dried aerosol particles circulating
croorganisms are frequently present in the specimens on air currents or attached to dust particles
3. Droplet: the host inhales material from the reservoir (e.g.,
aerosol droplets from a patient or an uncapped centrifuge
Table 1–1 Types of Safety Hazards tube, or when specimens are aliquoted or spilled)
Type Source Possible Injury 4. Vehicle: ingestion of a contaminated substance (e.g., food,
water, specimen)
Biologic Infectious Bacterial, fungal,
5. Vector: from an animal or insect bite
agents viral, or parasitic
infections After the infectious agent has been transmitted to a new
Sharps Needles, lancets, Cuts, punctures, or reservoir, it must have a means to enter the reservoir. The por-
broken glass blood-borne tal of entry can be the same as the portal of exit, which includes
pathogen exposure the mucous membranes of the nose, mouth, and eyes, breaks
in the skin, and open wounds. The susceptible host can be an-
Chemical Preservatives and Exposure to toxic, other patient during invasive procedures, visitors, and health-
reagents carcinogenic, or care personnel when exposed to infectious specimens or
caustic agents needlestick injuries. Immunocompromised patients, newborns
Radioactive Equipment and Radiation exposure and infants, and the elderly are often more susceptible hosts.
radioisotopes Stress, fatigue, and lack of proper nutrition depress the im-
Electrical Ungrounded or Burns or shock mune system and contribute to the susceptibility of patients
wet equipment; and health-care providers. Once the chain of infection is com-
frayed cords plete, the infected host then becomes another source able to
Fire/ Open flames, Burns or transmit the microorganisms to others.1
explosive organic dismemberment In the clinical laboratory, the most direct contact with a
chemicals source of infection is through contact with patient specimens, al-
though contact with patients and infected objects also occurs.
Physical Wet floors, heavy Falls, sprains, or Preventing completion of the chain of infection is a primary ob-
boxes, patients strains jective of biologic safety. Figure 1–1 illustrates the universal sym-
From Strasinger, SK, and DiLorenzo, MA: The Phlebotomy Textbook, third
bol for biohazardous material and demonstrates how following
edition, FA Davis, Philadelphia, 2011, p 52, with permission. prescribed safety practices can break the chain of infection.
Figure 1–1 places particular emphasis on laboratory practices.
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Chapter 1 | Safety and Quality Assessment 5

Break the link Break the link

• Immunizations • Disinfection
• Patient isolation Infectious agent • Hand hygiene
• Nursery • Bacteria
precautions • Fungi
• Healthy lifestyle • Parasites
Susceptible • Viruses
host Reservoir
• Patients • Humans
• Elderly • Animals
• Newborns • Insects
• Immuno- • Fomites
compromised • Blood/body
• Health-care fluids
workers

Portal of exit
Portal of
entry • Nose
• Mouth
• Nose
• Mucous
• Mouth
membranes
• Mucous
• Specimen
membranes
collection
• Skin
• Unsterile
equipment

Means of transmission
• Droplet
• Airborne
Break the link • Contact Break the link
• Hand hygiene • Vector • Sealed biohazardous
• Standard precautions • Vehicle waste containers
• PPE • Sealed specimen
• Sterile equipment containers
• Hand hygiene
• Standard precautions
Break the link
• Hand hygiene
• Standard precautions
• PPE
• Patient isolation

Figure 1–1 Chain of infection and safety practices related to the biohazard symbol. (From Strasinger, SK, and DiLorenzo, MA: The Phlebotomy
Textbook, FA Davis, Philadelphia, 2011, with permission.)

Proper hand hygiene, correct disposal of contaminated of all needles and sharp objects in puncture-resistant contain-
materials, and wearing personal protective equipment (PPE) ers. The CDC excluded urine and body fluids not visibly
are of major importance in the laboratory. Concern over expo- contaminated by blood from UP, although many specimens can
sure to blood-borne pathogens, such as hepatitis B virus contain a considerable amount of blood before it becomes vis-
(HBV), hepatitis C virus (HCV), and human immunodefi- ible. The modification of UP for body substance isolation
ciency virus (HIV), resulted in the drafting of guidelines and (BSI) helped to alleviate this concern. BSI guidelines are not
regulations by the CDC and OSHA to prevent exposure. In limited to blood-borne pathogens; they consider all body
1987 the CDC instituted Universal Precautions (UP). Under fluids and moist body substances to be potentially infectious.
UP all patients are considered to be possible carriers of blood- According to BSI guidelines, personnel should wear gloves at
borne pathogens. The guideline recommends wearing gloves all times when encountering moist body substances. A major
when collecting or handling blood and body fluids contami- disadvantage of BSI guidelines is that they do not recommend
nated with blood and wearing face shields when there is danger handwashing after removing gloves unless visual contamina-
of blood splashing on mucous membranes and when disposing tion is present.
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6 Part One | Background

In 1996 the CDC and the Healthcare Infection Control and reprocessed appropriately. Ensure that single-use
Practices Advisory Committee (HICPAC) combined the major items are discarded properly.
features of UP and BSI guidelines and called the new guidelines 6. Environmental control: Ensure that the hospital has
Standard Precautions. Although Standard Precautions, as adequate procedures for the routine care, cleaning, and
described below, stress patient contact, the principles can also disinfection of environmental surfaces, beds, bedrails,
be applied to handling patient specimens in the laboratory.5 bedside equipment, and other frequently touched sur-
Standard Precautions are as follows: faces. Ensure that these procedures are being followed.
1. Hand hygiene: Hand hygiene includes both hand 7. Linen: Handle, transport, and process linen soiled with
washing and the use of alcohol-based antiseptic blood, body fluids, secretions, and excretions in a man-
cleansers. Sanitize hands after touching blood, body ner that prevents skin and mucous membrane exposures
fluids, secretions, excretions, and contaminated items, and clothing contamination and that avoids the transfer
whether or not gloves are worn. Sanitize hands immedi- of microorganisms to other patients and environments.
ately after gloves are removed, between patient contacts, 8. Occupational health and blood-borne pathogens:
and when otherwise indicated to avoid transferring Take care to prevent injuries when using needles,
microorganisms to other patients or environments. scalpels, and other sharp instruments or devices; when
Sanitizing hands may be necessary between tasks handling sharp instruments after procedures; when
and procedures on the same patient to prevent cross- cleaning used instruments; and when disposing of used
contamination of different body sites. needles. Never recap used needles or otherwise manip-
2. Gloves: Wear gloves (clean, nonsterile gloves are ade- ulate them using both hands or use any other technique
quate) when touching blood, body fluids, secretions, that involves directing the point of a needle toward any
excretions, and contaminated items. Put on gloves just part of the body; rather, use self-sheathing needles or a
before touching mucous membranes and nonintact mechanical device to conceal the needle. Do not remove
skin. Change gloves between tasks and procedures on used unsheathed needles from disposable syringes by
the same patient after contact with material that may hand, and do not bend, break, or otherwise manipulate
contain a high concentration of microorganisms. Re- used needles by hand. Place used disposable syringes
move gloves promptly after use, before touching non- and needles, scalpel blades, and other sharp items in
contaminated items and environmental surfaces, and appropriate puncture-resistant containers, which are lo-
between patients. Always sanitize your hands immedi- cated as close as practical to the area in which the items
ately after glove removal to avoid transferring microor- were used, and place reusable syringes and needles in a
ganisms to other patients or environments. puncture-resistant container for transport to the repro-
3. Mouth, nose, and eye protection: Wear a mask and cessing area. Use mouthpieces, resuscitation bags, or
eye protection or a face shield to protect mucous mem- other ventilation devices as an alternative to mouth-
branes of the eyes, nose, and mouth during procedures to-mouth resuscitation methods in areas where the need
and patient care activities that are likely to generate for resuscitation is predictable.
splashes or sprays of blood, body fluids, secretions, or 9. Patient placement: Place a patient in a private room
excretions. A specially fitted respirator (N95) must be who contaminates the environment or who does not (or
used during patient care activities related to suspected cannot be expected to) assist in maintaining appropriate
mycobacterium exposure. hygiene or environment control. If a private room is not
4. Gown: Wear a gown (a clean, nonsterile gown is ade- available, consult with infection control professionals
quate) to protect skin and to prevent soiling of clothing regarding patient placement or other alternatives.
during procedures and patient care activities that are 10. Respiratory hygiene/cough etiquette: Educate
likely to generate splashes or sprays of blood, body health-care personnel, patients, and visitors to contain
fluids, secretions, or excretions. Select a gown that is respiratory secretions to prevent droplet and fomite
appropriate for the activity and the amount of fluid transmission of respiratory pathogens. Offer masks to
likely to be encountered (e.g., fluid-resistant in the coughing patients, distance symptomatic patients from
laboratory). Remove a soiled gown as promptly as others, and practice good hand hygiene to prevent the
possible, and sanitize hands to avoid transferring transmission of respiratory pathogens.
microorganisms to other patients or environments. The Occupational Exposure to Blood-Borne Pathogens
5. Patient care equipment: Handle used patient care Standard is a law monitored and enforced by OSHA.6,7 These
equipment soiled with blood, body fluids, secretions, controls are required by OSHA to be provided by or mandated
and excretions in a manner that prevents skin and mu- by the employer for all employees. Specific requirements of
cous membrane exposure, clothing contamination, and this OSHA standard include the following:
transfer of microorganisms to other patients or environ- Engineering Controls
ments. Ensure that reusable equipment is not used for 1. Providing sharps disposal containers and needles with
the care of another patient until it has been cleaned safety devices.
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Chapter 1 | Safety and Quality Assessment 7

2. Requiring discarding of needles with the safety device dermatitis, which produces patches of dry, itchy irritation on
activated and the holder attached. the hands; delayed hypersensitivity reactions resembling poison
3. Labeling all biohazardous materials and containers. ivy that appear 24 to 48 hours after exposure; and true, imme-
diate hypersensitivity reactions often characterized by facial
Work Practice Controls
flushing and breathing difficulties. Hand sanitizing immediately
4. Requiring all employees to practice Standard Precau- after removing gloves and avoiding powdered gloves may aid
tions and documenting training on an annual basis. in preventing the development of latex allergies. Replacing latex
5. Prohibiting eating, drinking, smoking, and applying gloves with nitrile or vinyl gloves provides an alternative. Any
cosmetics in the work area. symptoms of latex allergy should be reported to a supervisor
6. Establishing a daily work surface disinfection protocol. because true latex allergy can be life-threatening.10
Fluid-resistant laboratory coats with wrist cuffs are worn
Personal Protective Equipment
to protect clothing and skin from exposure to patients’ body
7. Providing laboratory coats, gowns, face shields, and substances. These coats should always be completely buttoned,
gloves to employees and laundry facilities for nondis- and gloves should be pulled over the cuffs. They are worn at
posable protective clothing. all times when working with patient specimens and are re-
Medical moved prior to leaving the work area. They are changed when
8. Providing immunization for the hepatitis B virus free of they become visibly soiled. Disposable coats are placed in con-
charge. tainers for biohazardous waste, and nondisposable coats are
placed in designated laundry receptacles. Shoes must be
9. Providing medical follow-up to employees who have
closed-toed and cover the entire foot.
been accidentally exposed to blood-borne pathogens.
The mucous membranes of the eyes, nose, and mouth
Documentation must be protected from specimen splashes and aerosols. A va-
10. Documenting annual training of employees in safety riety of protective equipment is available, including masks and
standards. goggles, full-face plastic shields that cover the front and sides
11. Documenting evaluations and implementation of safer of the face, mask with attached shield, and Plexiglas countertop
needle devices. shields. Particular care should be taken to avoid splashes and
aerosols when removing container tops, pouring specimens,
12. Involving employees in the selection and evaluation of
and centrifuging specimens. Specimens must never be cen-
new devices and maintaining a list of those employees
trifuged in uncapped tubes or in uncovered centrifuges. When
and the evaluations.
specimens are received in containers with contaminated exte-
13. Maintaining a sharps injury log including the type and riors, the exterior of the container must be disinfected or, if
brand of safety device, location and description of the necessary, a new specimen may be requested.
incident, and confidential employee follow-up.
Any accidental exposure to a possible blood-borne Hand Hygiene
pathogen must be immediately reported to a supervisor. Evalu-
ation of the incident must begin right away to ensure appropriate Hand hygiene is emphasized in Figure 1–1 and in the Standard
postexposure prophylaxis (PEP). The CDC provides periodi- Precautions guidelines. Hand contact is the primary method
cally updated guidelines for the management of exposures and of infection transmission. Laboratory personnel must always
recommended PEP.8,9 sanitize hands before patient contact, after gloves are removed,
before leaving the work area, at any time when hands have
been knowingly contaminated, before going to designated
Personal Protective Equipment break areas, and before and after using bathroom facilities.
PPE used in the laboratory includes gloves, fluid-resistant Hand hygiene includes both hand washing and using alcohol-
gowns, eye and face shields, and Plexiglas countertop shields. based antiseptic cleansers. Alcohol-based cleansers can be used
Gloves should be worn when in contact with patients, speci- when hands are not visibly contaminated. They are not recom-
mens, and laboratory equipment or fixtures. When specimens mended after contact with spore-forming bacteria, including
are collected, gloves must be changed between every patient. Clostridium difficile and Bacillus sp.
In the laboratory, they are changed whenever they become no- When using alcohol-based cleansers, apply the cleanser to
ticeably contaminated or damaged and are always removed the palm of one hand. Rub your hands together and over the
when leaving the work area. Wearing gloves is not a substitute entire cleansing area, including between the fingers and
for hand hygiene, and hands must be sanitized after gloves are thumbs. Continue rubbing until the alcohol dries.
removed. The CDC has developed hand washing guidelines to
A variety of gloves types are available, including sterile and be followed for correct hand washing.1,11 Procedure 1-1
nonsterile, powdered and unpowdered, and latex and nonlatex. demonstrates CDC routine hand washing guidelines.4 More
Allergy to latex is increasing among health-care workers, and stringent procedures are used in surgery and in areas with
laboratory personnel should be alert for symptoms of reactions highly susceptible patients, such as immunocompromised and
associated with latex. Reactions to latex include irritant contact burn patients.
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8 Part One | Background

PROCEDURE 1-1
Hand Washing Procedure 3. Rub to form a lather, create friction, and loosen debris.
Equipment Thoroughly clean between the fingers and under the
fingernails for at least 20 seconds; include thumbs and
Antimicrobial soap wrists in the cleaning.
Paper towels
Running water
Waste container
Procedure
1. Wet hands with warm water. Do not allow parts of
body to touch the sink.

4. Rinse hands in a downward position to prevent

recontamination of hands and wrists.

2. Apply soap, preferably antimicrobial.

5. Obtain paper towel from the dispenser.

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Chapter 1 | Safety and Quality Assessment 9

PROCEDURE 1-1—cont’d
6. Dry hands with paper towel. 7. Turn off faucets with a clean paper towel to prevent
contamination.

Biologic Waste Disposal

All biologic waste, except urine, must be placed in appropriate
containers labeled with the biohazard symbol (Fig. 1–2). This
includes both specimens and the materials with which the
specimens come in contact. The waste is then decontaminated
following institutional policy: incineration, autoclaving, or
pickup by a certified hazardous waste company.
Urine may be discarded by pouring it into a laboratory
sink under a Plexiglas countertop shield. Care must be taken
to avoid splashing, and the sink should be flushed with water
after specimens are discarded. Disinfection of the sink using a
1:5 or 1:10 dilution of sodium hypochlorite should be per-
formed daily. Sodium hypochlorite dilutions stored in plastic
bottles are effective for 1 month if protected from light after
preparation.12 The same solution also can be used for routinely
disinfecting countertops and accidental spills. The solution
should be allowed to air-dry on the contaminated area. Ab-
sorbent materials used for cleaning countertops and removing
spills must be discarded in biohazard containers. Empty
urine containers can be discarded as nonbiologically hazardous
waste (Fig. 1–3).

Sharp Hazards
Sharp objects in the laboratory, including needles,
lancets, and broken glassware, present a serious bi-
ologic hazard, particularly for the transmission of
blood-borne pathogens. All sharp objects must be
disposed in puncture-resistant, leak-proof container with the
biohazard symbol. Puncture-resistant containers should be
conveniently located within the work area. The biohazard Figure 1–2 Biohazard symbol. (From Strasinger, SK, and DiLorenzo,
sharp containers should not be overfilled and must always be MA: The Phlebotomy Textbook, FA Davis, Philadelphia, 2011, with
replaced when the safe capacity mark is reached. permission.)
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10 Part One | Background

removed as soon as possible. No attempt should be made to

neutralize chemicals that come in contact with the skin. Chem-
ical spill kits containing protective apparel, nonreactive
absorbent material, and bags for disposing of contaminated
materials should be available for cleaning up spills.

Chemical Handling
Chemicals should never be mixed together unless specific in-
structions are followed, and they must be added in the order
specified. This is particularly important when combining acid
and water. Acid should always be added to water to avoid the
possibility of sudden splashing caused by the rapid generation
of heat in some chemical reactions. Wearing goggles and
preparing reagents under a fume hood are recommended safety
A precautions. Chemicals should be used from containers that
are of an easily manageable size. Pipetting by mouth is unac-
ceptable in the laboratory. State and federal regulations are in
place for the disposal of chemicals and should be consulted.

Chemical Hygiene Plan

OSHA also requires all facilities that use hazardous chemicals
to have a written chemical hygiene plan (CHP) available to
employees.13 The purpose of the plan is to detail the following:
1. Appropriate work practices
2. Standard operating procedures
3. PPE
4. Engineering controls, such as fume hoods and flamma-
bles safety cabinets
5. Employee training requirements
6. Medical consultation guidelines
Each facility must appoint a chemical hygiene officer, who
is responsible for implementing and documenting compliance
with the plan. Examples of required safety equipment and
information are shown in Figure 1–4.

Chemical Labeling
B
Hazardous chemicals should be labeled with a description of
Figure 1–3 Technologist disposing of urine (A) sample and (B)
their particular hazard, such as poisonous, corrosive, flamma-
container.
ble, explosive, teratogenic, or carcinogenic (Fig. 1–5). The
National Fire Protection Association (NFPA) has developed the
Chemical Hazards Standard System for the Identification of the Fire Hazards of
Materials, NFPA 704.14 This symbol system is used to inform
The same general rules for handling biohazardous firefighters of the hazards they may encounter with fires in
materials apply to chemically hazardous materials; a particular area. The diamond-shaped, color-coded symbol
that is, to avoid getting these materials in or on bod- contains information relating to health, flammability, reactivity,
ies, clothes, or work area. Every chemical in the workplace and personal protection/special precautions. Each category is
should be presumed hazardous. graded on a scale of 0 to 4, based on the extent of concern.
These symbols are placed on doors, cabinets, and containers.
Chemical Spills and Exposure An example of this system is shown in Figure 1–6.
When skin contact occurs, the best first aid is to flush the area
with large amounts of water for at least 15 minutes, then seek
Material Safety Data Sheets
medical attention. For this reason, all laboratory personnel The OSHA Federal Hazard Communication Standard requires
should know the location and proper use of emergency show- that all employees have a right to know about all chemical haz-
ers and eye wash stations. Contaminated clothing should be ards present in their workplace. The information is provided