Texas Health Steps: Specimen Collection and Handling


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    Texas Health Steps: Specimen Collection and Handling


    Contents

    Getting Started 
    • Contact Information
    •  Acceptable Identifiers
    Illustrations of Purple Top Tubes 
    THSteps Unsatisfactory Specimens and How to Avoid Them 
    Unsatisfactory Codes Related to Collection Tube or Specimen 


    Getting Started

    Obtain supplies to collect and ship or mail specimens to the DSHS Laboratory from the Container Preparation Department. DSHS offers THSteps supplies, including postage paid mailing labels and cold shipping boxes with air bills, at no cost to the medical provider. Enrolled THSteps providers may request supplies by telephone at 1 (888) 963-7111 ext. 7661 or (512) 776-7661, or by fax at (512) 776-7672.
    Review the specimen requirements for the desired test.
    Collect the appropriate blood specimens in the correct blood collection tubes. For specimens other than blood (e.g., GC/CT), collect the sample with the appropriate specimen collection device.
    All information recorded on the submission form and specimen collection tubes or other specimen collection devices must be clear and legible.  If a label is used, ensure that it is firmly attached to the specimen to ensure accurate identification.
    All specimens must be labeled with at least two patient identifiers that MUST match the identification on the submission form, see the list of acceptable identifiers below.  
    Complete the required fields of the appropriate submission forms accurately, completely, and legibly. Ensure that the patient name matches exactly on the specimen and the submission form.
    Clearly mark the type of specimen being submitted, the test(s) desired, and the payor source on the appropriate submission form. Submit a separate submission form for each specimen type.
    If necessary, complete any required information on the submission form that indicates how the specimen was stored before shipping (e.g., date/time specimen removed from freezer/refrigerator for glucose, cholesterol, or creatinine).
    For whole blood specimens shipped at ambient temperature through the U.S. Postal Service, mail specimens the day of collection or the following day to ensure that specimens are received in the laboratory within the required time-frame for each test. Specimens may be refrigerated overnight before being mailed the following day. NEVER freeze whole blood specimens.


    Acceptable specimen identifiers include but are not limited to: 

    • Patient Name
    • CDC Number
    • Unique Random Number
    • Medical Record Number
    • Medicaid Number
    • Newborn Screening Kit Number
    • Date of Birth

    Note: Location based identifiers are NOT acceptable (e.g., hospital room number or street address).


    Illustrations of Purple Top Tubes


    Venous blood collections

    Becton Dickinson (BD) 2 mL Vacutainer® K2 EDTA 3.6 mg tube
     

    This is the DSHS Laboratory-specified blood collection tube for hemoglobin and lead testing when collecting by venipuncture. It is provided by the DSHS Laboratory to enroll Texas health Steps providers. The Laboratory will also accept 3 mL and 4 mL tubes from the same manufacturer. The fill volume for each tube is stated at the bottom of the label. 

    Note the indicator mark on the edge of the label.  Some tubes may have different color labels and markings. The mark on the edge of the label indicates the approximate volume that the tube is designed to collect. Tubes that are designed to draw 3 mLs or 4 mLs will have this mark closer to the top of the tube.

    The 2 mL blood collection tubes have a low vacuum as they are designed to draw only 2 mL of blood. This means that blood will flow more slowly into the tube and the draw may take longer to obtain the desired volume of blood.

     

    There are three options for obtaining sufficient volume for the vacuum blood collection tubes.

    1.    Typical venipuncture technique using a Vacutainer® tube and a multidraw needle. The tube is designed to draw ~2 mL of blood. Do not remove the needle from the vein too soon or the vacuum of the tube will not have sufficient time to draw the correct volume. Once the draw is complete, mix by inversion at least 10 times to ensure adequate mixing of blood and anticoaqulant to avoid clotting..

    2.    Venipuncture using a “butterfly”collection device with a vacuum blood collection tube. Once the “butterfly” device is attached to the tube, the “dead space” in the “butterfly” tubing will evacuate enough of the vacuum in the tube that it can no longer pull the desired volume. Avoid this problem by using a “waste” or “discard” tube – attach the “butterfly” to the tube and perform the venipuncture; once a small amount of blood is drawn into the vacuum tube, remove this “waste” or “discard” tube and replace it with a second vacuum tube that has not had its vacuum compromised. At this point, the second vacuum tube should pull the correct volume. Again, do not remove the needle from the vein too soon or the vacuum of the tube will not have sufficient time to draw the correct volume.  
    Another way to perform this action without use of a “waste” or “discard” tube is to attach the blood collection tube to the “butterfly” collection device once blood is flowing into the tubing.

    3.    Venipuncture using a syringe and “butterfly” collection device. This option allows the phlebotomist to use the “butterfly” device but uses a syringe of appropriate size to draw sufficient blood in order to meet the fill volume requirement for the blood collection tube to be used.  


    Fingerstick or heelstick blood collections

    Becton Dickinson (BD) Microtainer® MAP 250 µL – 500 µL tube
    • This is the DSHS Laboratory-specified blood collection tube for hemoglobin and lead testing when collecting by finger stick. It is provided by the DSHS Laboratory to enroll Texas Health Steps providers.
    • The minimum and maximum acceptable volumes are indicated on the tube by the 250 and 500 µL lines. The blood level must be anywhere between these two lines to be acceptable for fill volume. The target volume is indicated by the 375µL line.


    Unsatisfactory Specimens and How to Avoid Them

    The following table is specifically for Clinical Chemistry THSteps tests. Information regarding HIV, RPR, or Gonorrhea/Chlamydia unsatisfactory specimens may be references in the Laboratory Testing Services Manual (LTSM)

    Required information on G-THSTEPS/ G-1B form

    Rejection Statement 

     Explanation or Tip

     Test Affected

     No date of collection on request form. Please resubmit.Provide an accurate and legible Date of Collection in the space provided in Section 2 on the G-THSTEPS/G-1B form.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
     Invalid or incomplete date of collection on request form. Please resubmit.Provide an accurate and legible Date of Collection in the space provided in Section 2 on the G-THSTEPS/G-1B form. Submit a separate submission form for each specimen type.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
     
     Provider did not order test. Please resubmit.Clearly mark the test(s) required in the appropriate section of the G-THSTEPS/G-1B form. 
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
     Provider did not circle from which appliance specimens were removed. Please resubmit.Circle the appropriate appliance (freezer or refrigerator) from which specimens were removed in the bottom right-hand corner of the G-THSTEPS/G-1B form. 
    • Cholesterol/Lipid Profile
    • Glucose
     Provider did not give date and time specimen was removed from the freezer/refrigerator. Please resubmit   providing this information. Please remember to circle from which appliance the specimens were removed.Record the date and time the specimen was removed from the freezer/refrigerator in the bottom right-hand corner of the G-THSTEPS/G-1B form.
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
     
     Incomplete Form: Required information is missing from submission form.A submission form was received without information in required fields.  Provider did not provide missing information in time for specimen to be processed/tested.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine


    Miscellaneous situations related to G-THSTEPS/G-1B form

    Rejection Statement 

     Explanation or Tip

     Tests Affected

     Cannot identify: Two forms submitted with the same identification. Please resubmit. Double-check that each specimen has an appropriately completed G-THSTEPS/G-1B form.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
     Name on specimen does not match name on request form. Please resubmit. Label the specimen with the exact spelling of the name, as recorded on the G-THSTEPS/G-1B form.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine


    Unsatisfactory code related to collection tube or specimen

Unsatisfactory codes that will affect an entire mailing container
Rejection Statement 

 Explanation or Tip

 Tests Affected

 Specimen broken in transit. Please resubmit.The specimen was broken during the mailing process. All specimens are possibly contaminated. Add packing material to secure specimens in mailing container. 
  • Total Hemoglobin
  • Hemoglobin Type
  • Lead
  • Cholesterol/Lipid Profile
  • Glucose
  • Creatinine
 Specimen leaked in transit. Please resubmit.The specimen leaked during the mailing process. All specimens are possibly contaminated. Ensure that all specimens are securely capped before mailing. For Microtrainer® MAP tubes, ensure the cap is securely on the tube by snapping it into place and twisting.
  • Total Hemoglobin
  • Hemoglobin Type
  • Lead
  • Cholesterol/Lipid Profile
  • Glucose
  • Creatinine
 
 Laboratory specified tube not used. Please resubmit. For further   information, refer to the above Tube Illustrations or call 1 (888) 963-7111   ext. 7661The DSHS Laboratory only accepts specified blood collection tubes. Obtain appropriate blood collection tubes and recollect/resubmit specimen. 
  • Total Hemoglobin
  • Lead
 Cannot identify specimen. Label not attached. Please resubmit. Identifying label is not attached to specimen or detached from specimen. Ensure label is securely fixed to blood collection tube prior to mailing. 
  • Total Hemoglobin
  • Hemoglobin Type
  • Lead
  • Cholesterol/Lipid Profile
  • Glucose
  • Creatinine


Identification issues for blood collection tube/specimen

Rejection Statement 

 Explanation or Tip Tests Affected
No identification on specimen. Please resubmit.

Each specimen must be labeled with at least two patient identifiers that match the submission form to ensure correct identification of specimen. See list of acceptable identifiers above under the Getting Started section. If a label is used, ensure that it is firmly attached to the blood collection tube prior to mailing.

Labeling Guidelines for Hemoglobin and Lead Specimens

 
  • Total Hemoglobin
  • Hemoglobin Type
  • Lead
  • Cholesterol/Lipid Profile
  • Glucose
  • Creatinine
Cannot identify: Two specimens with the same identification. Please resubmit.Each specimen must be labeled with at least two patient identifiers that match the submission form to ensure correct identification of specimen. See list of acceptable identifiers above under the Getting Started section.  Ensure each specimen type has an accompanying G-THSTEPS/G-1B form. 
  • Total Hemoglobin
  • Hemoglobin Type
  • Lead
  • Cholesterol/Lipid Profile
  • Glucose
  • Creatinine
Specimen identification illegible. Please resubmit.  Label specimen legibly by writing clearly on the specimen or by applying a label that contains at least two patient identifiers that match the submission form. See list of acceptable identifiers above under the Getting Started section. All information on the submission form and specimen collection tubes or other specimen collection devices must be clear and legible. 
  • Total Hemoglobin
  • Hemoglobin Type
  • Lead
  • Cholesterol/Lipid Profile
  • Glucose
  • Creatinine


  • Identification issues for blood collection tube/specimen

     Rejection Statement Explanation or Tip Tests Affected
    No identification on specimen. Please resubmit.

    Each specimen must be labeled to ensure correct identification of specimen. Ensure label is securely fixed to blood collection tube prior to mailing.

    Labeling Guidelines for Hemoglobin and Lead Specimens

    		 
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
    Cannot identify; Two specimens submitted with the same identification. Please resubmit.Label each specimen appropriately with patient name. Ensure each specimen has an accompanying G-THSTEPS/G-1B form. 
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
    Specimen identification illegible. Please resubmit. Label specimen legibly by writing clearly on the specimen or by applying a label with patient name written or printed clearly. 
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine


  • Incorrect tube type or specimen submitted
    Rejection Statement  Explanation or Tip Tests Affected
    Must submit anti-coagulated (K2EDTA) specimen. Please resubmit.Test requested requires a purple-top specimen. Recollect specimen in DSHS-specified K2 EDTA Vacutainer® or Microtainer® MAP. 
    • Total Hemoglobin
    • Lead
    No filter paper specimen submitted. Must submit Texas DSHS Snap-apart filter paper card for Hemoglobin Electrophoresis testing.Test requested requires a filter paper specimen. NOTE: Contact Container Preparation at (888) 983-7111 ext. 7661 to order filter paper cards. Recollect specimen on DSHS Snap-apart filter paper card, allow to dry, and mail as soon as possible.  Hemoglobin Type
    Filter paper specimen submitted on improper collection card. Please resubmit.Specimen submitted on filter paper that is not Whatman 903® filter paper. See NOTE above. Hemoglobin Type
    Filter paper specimen submitted on expired collection card. Please resubmit.Specimen must be collected on filter paper card prior to expiration date. Check expiration date of filter paper cards. See NOTE above. Hemoglobin Type


    Age of Specimen
    Rejection Statement  Explanation or Tip Tests Affected
    Specimen too old for testing, greater than 14 days old. Please resubmit.Purple-top specimen submitted for Total Hemoglobin/Lead testing was received greater than 14 days after collection. Day of collection equals Day 1. Recollect specimen and ship the day of collection or the next day. 
    • Total Hemoglobin
    • Lead
    Specimen too old for testing, greater than 13 days old. Please resubmit.DSHS Snap-apart filter paper card submitted for Hemoglobin Electrophoresis testing was received greater than 13 days after collection. Day of collection equals Day 1. Recollect specimen and ship as soon as specimen is dry.  Hemoglobin Type
    Specimen decomposed. Please resubmit.Specimen decomposed, unacceptable for testing. Decomposition usually occurs when a specimen is exposed to excessively high temperatures. Avoid dropping specimens in a receptacle that is exposed to direct sunlight or high temperatures. If possible, make a trip to the Post Office and deliver specimens inside the building or ship via courier. 
    • Total Hemoglobin
    • Lead
    Specimen clotted. Please resubmit. 

    Purple-top specimen was clotted. Clotting occurs at the time of collection; a specimen does not clot as it ages.

    To avoid clotting of a venous specimen, mix immediately after collection. Ensure that blood comes in contact with the entire inner surface of the tube. Mix thoroughly for at least 2 minutes.

    To avoid clotting on a fingerstick specimen, ensure hands are warm to encourage blood flow to the fingers. Wipe away the first drop of blood and avoid scraping the site which stimulates clotting. If necessary, mix during collection by tapping on the counter or shaking slightly. After collection, mix the tube thoroughly, ensuring that blood comes in contact with the entire inner surface of the tube. Mix thoroughly for at least 2 minutes.    		 
    • Total Hemoglobin
    • Lead
    Specimen unsuitable for testing. Please resubmit.Specimen was compromised in some way and is unacceptable for testing. Call the Laboratory at (888) 963-7111 ext. 6236 to learn the reason for unacceptability. 
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
    Filter paper specimen appeared contaminated or discolored. Please resubmit. Filter paper specimen appeared compromised in some way. NOTE: After collection, allow filter paper to dry completely before mailing. Fold specimen at score line and tuck into flap to protect filter paper, before mailing. Place filter paper specimen with submission forms between inner plastic liner and outer cardboard mailing container. Hemoglobin Type
    Incomplete elution of blood from filter paper. Please resubmit.Blood was not able to be eluted from filter paper to perform testing; specimen possibly compromised in some way. See NOTE above.  Hemoglobin Type
    Filter paper specimen damaged during transport to Laboratory. Please resubmit. Filter paper specimen appeared damaged in some way, preventing specimen from being tested. Recollect specimen and place with submission forms between inner plastic liner and outer cardboard mailing container. Hemoglobin Type
    No blood on filter paper card. Please resubmit. Drop blood on 2-3 circles on filter paper card. Label with patient name and date of collection. Allow filter paper to dry completely before mailing. Hemoglobin Type


  • Specimen volume requirements
    Rejection Statement  Explanation or Tip Tests Affected
     

    Specimen quantity not sufficient. Please resubmit.

    		Specimen volume in purple top (K2 EDTA) tube, OR volume of serum was insufficient to perform testing.   

    Purple top, K2EDTA:

    • Total Hemoglobin
    • Lead


    Serum from Red Top:

    • Cholesterol/Lipid Profile
    • Glucose 
    • Creatinine
    Insufficient blood on filter paper card. Please resubmit.Insufficient blood dropped on DSHS Snap-Apart filter paper card to perform testing. Drop blood on 2-3 circles on filter paper card, ensuring complete saturation, and resubmit. Hemoglobin Type


    Shipping Errors
    Rejection Statement  Explanation or Tip Tests Affected
    Specimen was received at ambient temperature.  Please resubmit cold specimen.Specimen requirements mandate a cold serum specimen. Refer to the DSHS Laboratory website for further information:  www.dshs.state.tx.us/lab/serumSpecimenCriteria.shtm 
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
    Serum was received greater than 48 hours from time of collection and specimen was not frozen. Please resubmit. For shipping instructions, refer to http://www.dshs.state.tx.us/lab/MRS_shipping.shtmor call 1 (888) 963-7111 ext. 7430.Serum for Cholesterol/Lipid Profile/Glucose must be frozen and shipped cold. NOTE: Recollect red top tube, remove serum within 2 hours of collection, and freeze until shipped. 
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
    Specimen was received at ambient temperature due to inadequate cold packs. Please resubmit. For shipping instructions, refer to http://www.dshs.state.tx.us/lab/MRS_shipping.shtmor call 1 (888) 963-7111 ext. 7430.Specimen for Cholesterol/Lipid Profile/Glucose/Creatinine must be received cold. See NOTE above. 
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
    Whole blood was received greater than 2 hours from time of collection. Please resubmit. Serum must be frozen and received cold. For shipping instructions, refer to http://www.dshs.state.tx.us/lab/MRS_shipping.shtmor call 1 (888) 963-7111 ext. 7430.Serum for Cholesterol/Lipid Profile/Glucose/Creatinine must be frozen and shipped cold. See NOTE above. 
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
    Serum was received at ambient temperature greater than 8 hours from time of collection. Please resubmit. Serum must be frozen and received cold. For shipping instructions, refer to http://www.dshs.state.tx.us/lab/MRS_shipping.shtmor call 1 (888) 963-7111 ext. 7430.Serum for Cholesterol/Lipid Profile/Glucose/Creatinine must be frozen and shipped cold. See NOTE above. 
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine


  • Miscellaneous Rejections
    Rejection Statement  Explanation or Tip Tests Affected
     Specimen submitted in expired blood collection tube. Please resubmit.Specimen was collected and submitted in a blood collection tube that was past its expiration date. Recollect specimen, ensuring that blood collection tube is not expired.  
    • Total Hemoglobin
    • Lead
     Specimen not received. Please resubmit.Be sure to include specimen in mailing container with submission form. 
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine
     Submitter cancelled test request.Submitter contacted laboratory and cancelled test request. A report is sent to document disposition of specimen.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine 
     Laboratory accident. Please resubmit.Specimen compromised or destroyed in laboratory due to error. Recollect specimen and resubmit.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine 
     Specimen was received greater than 48 hours from time of collection due to courier failure. Please resubmit.Specimen rejected because it was too old for testing, due to courier failure. Recollect specimen.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine 
     Please resubmit to confirm abnormal value.Insufficient specimen to confirm abnormal hemoglobin or lead value. Recollect specimen, ensuring sufficient volume of specimen is submitted to complete testing.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    Creatinine 
     Inconsistent results. Please resubmit.Specimen giving inconsistent results. Unable to determine accurate laboratory result. Recollect specimen, ensuring appropriate collection and shipping methods to maintain integrity of specimen. 
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    Creatinine
    Specimen was delayed in transit. Please resubmit. Specimen was received after significant delay in transit, resulting in specimen being too old for testing. Recollect and resubmit specimen.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine 
    Specimen not tested due to courier failure. Please resubmit. Specimen was rejected because it did not meet pre-analytical requirement due to a courier failure. Recollect specimen.
    • Total Hemoglobin
    • Hemoglobin Type
    • Lead
    • Cholesterol/Lipid Profile
    • Glucose
    • Creatinine 








Last updated July 1, 2022