Emergency Department and Laboratory Services

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ACCIDENT AND EMERGENCY DEPARTMENT

IMPORTANCE

The importance of a scientifically designed emergency department is as follows:

Public perception and opinion of a hospital is often based on their visit to the accident anemergency department.

This facility, usually accounts for a significant number of all hospital admissions. Effective functional operations in the department are important variables for staff, patien

and visitor satisfaction.

FUNCTIONS

The various functions of an emergency department include:

Provision of immediate and correct life-saving treatment at all times and for all situations. Capacity and capability to provide effective management during disaster situations. Liaison with courts and police in medico-legal cases. Provision of ambulance services. Act as information and communication center especially during disasters. To provide education, training and research.

KEY PLANNING AND DESING PARAMETERS

The various considerations which should be followed are:

The design and planning should be done so as not to impede the movement of patients anstaff and equipment. The equipment should be located in designated spaces to be readil

accessible when needed.

It should provide privacy during management of patients. There should be minimum criss-crossing of patient traffic. A separate entrance and exit ma

be planned to facilitate unidirectional patient flow.

It should provide easy access for ambulances, patients and general public. There should bdistinct, ideally separate, access for ambulances and ambulant cases.

The entrance should be easily identifiable, protected from inclement weather and accessiblto disable patients.

Depending on type and location of hospital a helipad may be planned. Ground level location is best since it avoids need for patient access by stairs or elevators, an

provides easy access for patients and ambulances.

It should ideally be situated near ICU and operating rooms(s). Patient waiting area should be welcoming, visually appealing and comfortable.


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There should be a readily identifiable triage area with expansion facilities for utilizationduring management of disasters.

It should have multiple walled in rooms or multi-bed bays. It should have acute care rooms arranged around the main nursing work area. It should have trauma rooms in proximity to the entrance. There should be effective day and night sign posting. The non-patient care areas should be located peripherally in the floor plan. Door should be wide enough to accommodate stretcher, trolleys and portable X-ray machine

A door of width 1.6 m allows attendants to walk on either side of a stretcher or trolley.

Clinical care areas should have exposure to maximum feasible day light. The department will receive a number of patients and visitors many of whom may b

intoxicated, mentally disturbed or distressed. Hence, for safety and security of staff, patient

and visitors, it is essential to plan and design security features. An office for security

personnel near the entrance should be considered. Duress alarms should also be positioned a

suitable places.

All patient spaces and clinical areas should have access to emergency call facility to enablstaff to summon urgent assistance.

Departments using telemedicine facilities should have a dedicated room with appropriatpower and communication cabling.

Emergency department must have provision for emergency X-ray and ultrasounexamination. It should also have provision for round-the clock emergency imagin

investigations.

A laboratory room may be provided in emergency department or laboratory medicindepartment should provide round-the-clock services.

Blood bank facilities should be available. The floor finishes in patient care areas and corridors should have non-slip surfac

impermeable to water and body fluids and should be easy to clean.

It will be ideal to provide a separate fracture treatment and plaster room. The emergency operation room should be self-contained. The following areas must be planned:

Public areas

Entrance for patients. Control station. Public waiting space with appropriate amenities.

Treatment facilities

Patientsobservation area examination and treatment cubicles. Critical care rooms.


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Supportive Services

Staff rooms along with amenities.COMPONENTS

The following should be included in an accident and emergency department:

May I help you desk. Reception and information area. Trolley bay. Resuscitation/major trauma room. Acute patient care room (with cardiac monitoring). Isolation room. Observation rooms. Registration/clerical area. Triage area/room. Nursing work area. Doctors work station. Toilets. Patient waiting room. Bereavement/counseling room. Medico-social worker room. Conference room. Lounge and/or locker room for staff.

Doctors duty room. Security office/station. Radio imaging room having facility of X-ray imaging and CAT scan. Laboratory services. Dirty utility room. Clean utility room. Equipment storage area. Administrative offices. Pharmacy. Orthopedic and plaster cast room. Room for brought-in-dead. Obstetric room. Operation room. In addition to standard treatment areas, some emergency departments may hav

specially designed areas for management of pediatric patients, psychiatric patients an

of patients following sexual assault.


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ENTRANCE

The emergency department must have its own entrance and it is desirable to have it located adjacen

to the outpatient department. The department should be accessible by two separate entrances one fo

the ambulant patients and the other for patients coming by ambulance.

The entrance should be well-marked and illuminate. It should open into a spacious lobby. There should be a porch outside the lobby to protect the unloading of the patients from rai

and sunlight and the approach to the lobby should be in the form of ramp and steps.

Approach and access should be appropriate to usage by the disabled.RECEPTION AND INFORMATION AREA

The following parameters are recommended:

It should be adjacent to triage area.

It should be close to the waiting area. It should have communication links such as telephones, pagers. It may also be utilized for storage of records.

WAITING AREA

The following are recommended:

The waiting area should provide sufficient and comfortable space for waiting patients anrelatives/escorts.

The area should be easily observed from reception and triage areas. It should be appropriately furnished with visual displays on health education and hospita

related information.

It should have public telephone booth, coffee/tea vending machine, as well as toilet facilitieseparately for men and women.

NURSING WORK STATION


It should be centrally located to enable staff to monitor patient care areas. It should preferably include central cardiac monitor station. It should have communication links to triage and resuscitation areas. It should have desks that will enable staff to work from either side.


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DOCTORS WORK AREA


It should be centrally located for facilitating response to an emergency. It should provide privacy. The location should be such that doctors and nurses are able to view central cardia

monitoring station.

ACUTE TREATMENT AREAS


The acute treatment areas are utilized for the management of patients with acute illnesses. The areas should be able to fit a standard mobile bed with ample storage and usage space fo

essential equipment. The area should include a service panel, examination light, wa

mounted sphygmomanometer, patient and emergency call facilities. There should be at least 2.4 m of clear floor space between beds. Each treatment area requires space of 15 m2.

RESUSCITATION ROOM

The patient is to be stabilized in the resuscitation room. Immediate attention is also given to patient

who require restoration of blood volume of the body and clearance of as passages. The following ar

recommended:

The resuscitation room/bay should have space to accommodate specialized resuscitation bedallow 360 degrees access to all parts of the patient for facilitating procedure monitoring anfor resuscitation equipment.

Imaging facilities should include overhead X-ray, lead lining of walls and partitions betweebeds, radiolucent resuscitation trolley with cassette trays, X-ray viewing/digital electroni

imaging system.

Ceiling-mounted power columns simplify access can monitoring lines and devices. An OT light should be made available (details are enumerated in chapter 7). All electric power should be on emergency stand-by circuits. Ceiling arrangement needs to be carefully planned so that surgical lights, X-ray track

curtains and IV racks do not interfere with each other.

If the room is not directly visible for the work area, it should have alarm line to the nursinwork area.

Storage cabinets should have glass panels to facilitate view of the stored items and theiretrieval as and when required.

It should have oxygen and suction outlets. Patient privacy should be ensured. An area of about 30 cm2is suggested.


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OBSERVATION WARD

This is utilized for patients who have been evaluated and need extended treatment, observation, re

evaluation or time consuming procedures. A 6-8 bedded ward is recommended.

SPECIAL TREATMENT ROOMS

Special treatment rooms, which may be planned depending on the type of hospital, are as follows:

Obstetric rooms: This should be equipped for pelvic examination, evaluation of patients inlabor and emergency delivery.

Ophthalmology and ENT rooms: These should be equipped with a slit lamp and othenecessary equipment.

Dental room: This should have a dental chair. Decontamination room: This should have a flexible hose shower.

DOCTORS DUTY ROOM

The doctors on duty must be available for all the 24 hours. For their convenience a retiring room

with amenities along with bath and toilet should be provided.

TYPES OF DESIGN

Designs which may be planned in an emergency department are as follows:

Core Design

In this type treatment spaces are situated around a central point in which emergency departmen

personnel work. Ideally, there should be a corridor outside the treatment area through which thpatients enter the cubicles. The support rooms (plaster cast room, obstetrics and gynecology room

and supply room) are along the periphery of the corridor. This plan design offers greatest freedom o

movement for emergency department personnel.

Arena Design

This is essentially a core plan design without the periphery corridor and is best suited for emergenc

departments that are smaller in size. The design provides a good view of all the cubicles from th

nursing and physician work areas.

Corridor Plan

Many variants are possible, depending on the size of the department. It is a desirable plan for larg

emergency departments. Separate space is provided for each specialty.


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SCHEDULE OF ACCOMMODATION

Room/Space Area in m2

Reception 10

Triage 12-30

Waiting 12-20

Consultation room* 12

Bay for mobile equipment* 4

Bay for hand washing 1

Toilet for Public* 4

Toilet for disabled 5

Treatment Areas

Treatment room* 15

Plaster room* 14

Clean utility* 8-12

Dirty utility 10

Bays for mobile equipment 4

Bay for linen 2

Bay for blood gas* 4

Bay for hand washing* 1

Patient bay (Treatment/observation)* 9

Patient bay (Resuscitation)* 20-30

Stores for equipment* 6-15

for general stores 9

Toilet for patients 4

Shower for patients 4

Meeting room 12


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Pharmacy/medication area 10-16

Staff station 14-20

X-ray general viewing 20

reporting 12

Isolation 15

Circulation 40%

Staff Support Area

Office single person* 9-12

shared* 12-15

Staff room 15

Store 8

Shared Areas

Change room 8

Meeting room 12-20

Shower for staff 4

Toilet for staff* 2

* (many may be required)

STAFFS OF THE EMERGENCY DEPARTMENT

The DoctorThe Doctor-in-Charge of the casualty is available round the clock or, in turn with others in th

panel and should be available without delay. Any delay in attending to casualty patients wi

create a good deal of animus. The prime concern should be to establish an initial diagnosis

necessary investigations, programming the emergency care and treatment modality. Thi

necessitates competent professional overview and definitive relief measures to alleviate agony. A

good amount of anxiety on the part of the patient would be visible and would require to b

controlled with solace and drugs. A proper assessment and admission into the particular specialt

department, if necessary, should be made.


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The NurseNursing care in the casualty wing is yet another aspect requiring greater vigilance and co

operation. The patient should be comforted and put in bed to rest. A personal approach to th

patient and the relatives would win their confidence and bring out any important aspect in th

history for diagnosis and would need to be told to the doctor when he arrives.

The AttendantThe attendants role is equally definite and would start from the time the patient arrives at th

gate and lasts till the patient is properly disposed either back home or into the wards of th

hospital.

The complete list of emergencies coming into the casualty cannot be listed and would b

superfluous. They would range from minor cuts and abrasions to very serious injuries, and man

other medical and surgical emergencies.

As an organization a hospital entails extensive division of labor encompassing differen

departments, staff, offices and position and calls for a high degree of interdependence of service

Doctors, nurses and other staff of the hospital cannot function separately or independently of on

another. This applies to the emergency service as well. The working is mutually supplementary

interlocking and interdependent. This calls for a high degree of co-ordination and needs t

develop a rather intricate and elaborate system. The emergency services must have adjustment

and co-ordination with the various departments of the hospital. Thus, there is a need fo

substantial professionalization and specialization characteristics of the hospital personnel. Thi

along with the gradual independence of the hospitals from religious and military institutions

and an impact of increasingly secular culture greatly reduces the authoritarian character o

hospitals, as Lentz has noted these changes during the last 50 years.

Code blue procedure:

It is an area where emergency staff is active in handling cardio-pulmonary resuscitation (CPR

Code blue is a term used in hospitals to announce an emergency of serious nature such a

cardiac arrest. There is a pre-established procedure and a pre- appointed team which promptl

responds to such emergencies. A cardiac arrest or similar emergencies may take place any wher

in the hospital. When the emergency staff is busy coping with a disaster, personnel outside th

emergency department may be instructed to respond to code blue call so that timely patient car

is provided in such situations.


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LABORATORY SERVICES

FUNCTIONS

The functions of laboratories are manifold. Amongst the important ones are:

Provision of comprehensive and accurate analytical test results. Assistance in confirming/rejecting a diagnosis, prognosis and follow-up therapy. Detection of diseases. Training and research.

OBJECTIVES

The following should be the main objectives of planning and designing the laboratory services:

The structural design should be consistent with the existing level of specializationautomation and scope for future expansion.

Plan for a safe, comfortable and controlled environment that assures consistent reliablresults.

Feature flexibility and adaptability to respond to unforeseen changes in the processes antechnologies. Modular building layouts enable future flexibility. Modules must be organize

in manner that allows space to be easily reconfigured. This may be achieved by the use o

demountable partitions or light weight non-load bearing walls. Dividers between laboratorie

should be erected on non-load bearing partitions which may be removed, if required, t

change the size of the rooms.

Provision should be made for pneumatic tube systems, either for the present or for futurinstallations.

Special plumbing, electrical, ventilation and anti-vibration design measures should bincorporated.

Daylight to be utilized maximally. There should be easy and distinct routes for disposal of laboratory waste from the principa

work area.

It is important to plan for intra and interdepartmental relationships. Air lock should be provided at the entrance to the laboratory. Chemical resistant and stain resistant materials should be used for laboratory worktops an

work station finishes.

KEY PLANNING AND DESIGN PARAMETERS OF LABORATORY

Areas

The various areas which need to be planned for facilitating the laboratory services are as follows:


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Waiting area, examination cubicles and toilets for patients. Specimen and blood collection area having a work bench space for patient seating; han

washing facilities and a urine and feces collection room equipped with a toilet and han

basin.

Chemistry including urine analysis and toxicology. Photometry. Hematology. Microbiology. Immunology. Virology. Gross tissue. Histology and cytology. Autopsy (in specific hospitals). Specimen disposal, sluice room.

Staff lockers/toilets. Storage facilities for reagents, supplies, stained specimen microscope slides. Office. Report center. Other areas which must also be considered while planning include the culture medi

preparation room. Sterilizing area, storage areas for surgical specimens, chemicals an

flammable liquids, reagents, supplies and stained specimen microscopic slides.

Number of laboratory Units

The nature and type of healthcare facility determines whether a central laboratory is sufficient o

sub-units are required in the acute and ambulatory patient care units.

Location

The following factors need to be considered while planning the location of laboratory:

It should preferably be situated on the ground floor/first floor in close proximity to thambulatory and acute patient care areas as well as in-patient areas.

The processing areas of the laboratory do not necessarily have to be accessible to patients buthe collection point for specimens must be conveniently located, especially for ambulator

patients. The collection point must provide space for patient reception, registration, waitin

area and toilet facility.

Due to the higher volume of tests in biochemistry and hematology, these may be locatedcloser to the specimen reception area to facilitate the transport of specimens from th

reception to the respective sections of the laboratory. The microbiology section may be locate

farthest from the reception are due to the lesser volume of tests as compared to biochemistr

and hematology and also to isolate the bio-hazardous activities from other procedures.


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Space Requirements

The main determinants of space in a laboratory are the extent of automation and type of technology

used in it. A standing human body requires 4 square feet space, whereas a sitting posture requires

square feet. The working space should be adequate with equipment and materials within easy reac

of the worker.

Specimen Collection Area

There should be adequate specimen collection are for blood, urine and faeces. In the blood collectio

area, there should be work counter providing space for patients seating and for urine and faece

collection. There should be separate toilets for men and women with washbasins and counter tops t

place the specimens. Hatch windows may be provided through which the specimens may be passe

through.

Storage

Storage facilities include those for refrigeration, reagents and supplies, maintenance of patien

records and water purification. Appropriate and separate storage for flammable liquids should b

provided. Separate facilities should also be provided for incompatible materials, such as acids an

bases. Vented storage for volatile solvents should be provided.

Safety

There should be provision for safety, including eye flushing devises, emergency shower and fir

extinguishers.

Work Station

Work counters with space for equipment, microscopes, incubators, centrifuge, under the counter an

overhead cabinets should be provided. They should be equipped with vacuum gas, electrica

services, sinks and water supply. The drainage system of work areas where highly corrosive liquid

are used should consist of glass lined iron traps and pipes. Counter sinks for hand washing shoul

be provided. Chemical and stain resistant materials should be used for laboratory work and cas

work finishes.

Lighting

Natural light should be advantageously utilized for providing the requisite illumination. Receptio

areas and stores require 200 lux, offices require 300 lux, while at working places, the requirement i

of 500 lux. Essential equipment should be on emergency power backup systems and uninterrupte

power supply (UPS). Dedicated earthing should be provided for laboratory equipment.


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Fume Hoods

These are particularly required in laboratories where radioactive substances are used. Force

ventilation should be accompanied by an extraction system. The fume hoods should be located awa

from the traffic areas and doorways. Depending on the anticipated usage, central/individual still

should be provided for the supply of distilled and de-ionized water supplies.

Floors

These should be made of materials that can be cleaned and disinfected easily. They should be acid

alkaline and salt-resistant. The use of seamless or self-leveling epoxy flooring is desirable option

The vibrating equipment exerts a load of two or three times its static weight, hence floor requires

high load bearing capacity. It may be desirable to have some sections of floor isolated from the

surroundings in order to prevent vibration from one equipment affecting other equipment. The loa

bearing capacity of the floor should not be less than 500 kg/m2. The requirement may be as high a

2000 kg/m2in laboratories having heavy equipment.

Doors

Laboratory doors should not be less than 1m wide. Some double doors of total width of 1.50 m

should be constructed. (One of the doors in these may be of 1.0 m width and the other of 0.50 m)

Corridors

Width of corridors is recommended to be of 2 to 2.5 m to facilitate movement of patients includin

those on wheelchairs.

Benches

Countertop heights (750-900 mm) vary depending on whether work is to be conducted sitting o

standing. For sitting it should be 750 mm and for standing 900 mm. Depth of wall tables should b

700 mm. The height of conveniently reached overhead table cupboards should be 1500 mm from floo

level. Length of bench needed for each technician ranges from 1.6 m to 1.8 m. Each laboratory bench

should have a sink with swan neck fittings with facility of cold and hot water supply. In plannin

the under bench units, adequate knee space should be left at intervals for the convenience o

workers. The bench tops are to be seamless and acid/alkali resistant.

Ventilation

Mechanical ventilation system is required with 10-15 air changes per hour in areas where fumes ar

expected, and 8-10 air changes in other areas.

Pathology, Autopsy and Body Holding

It is important that systems serving pathology areas be independent of other systems. Exhaust from

these areas must be designed not to create any harmful effect to occupants or contamination to an

adjacent areas. Facilities that conduct autopsies must include the following:


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Air-conditioning that utilizes 100% exhaust of all air. Exhaust intakes arranged to provide maximum fume and odor removal with protection o

personnel.

Room operation at negative pressure relative to adjacent areas.SCHEDULE OF ACCOMMODATION

Room/Area Recommended Area m m2

Reception 15

Specimen collection* 10

Specimen reception/sorting 12

Stores* 10

Laboratory 25

Clean up/Sterilization 12

Staff change room 06

Toilet patient 04

staff (common) 14

Waiting (based on patient load) 15

Office*

10

Circulation 30%

Division of pathology, Histology and Cytology

Office 10 Histopathology lab 10-15 Cytology lab 10-15 Specimen stores 10-15 Microphotography room 10 FNAC room (Fine needle aspiration cytology room) 10-15

Division of Microbiology

Office 12 Bacteriology laboratory 12-20 Mycology laboratory 12-20 Tuberculosis laboratory may include specimen


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Collecting room, specimen processing room, ABST 60-70

Room (Antibiotic sensitivity testing), incubator room,

Wash room

Incubator room 03 Cold storage 03 Media rooms to include media kitchen,

Media storage and sterilizing room 12

Division of Clinical Biochemistry

Office 12 Bio-chemistry laboratory 15 Photometry, chromatography and electrophoresis 15

Division of Hematology

Office 12 Hematology laboratory 10-20 Stool, virus examination with specimen cubicle 10-15

Division of Virology

Office 12 Serology laboratory to include egg and animal

Inoculation cubicle 15

Tissue culture room 10

Animal room 10* (many may be required)

STAFFING

The hospital laboratory service should be under the control and direction of a doctor with

qualifications in pathology or a PG degree in the new discipline of Laboratory Medicine. Hbecomes the overall in charge of the laboratory with responsibilities of quality contro

standardization and administration. He should be a part of the regular medical staff of th

hospital, and this would actually be the case in respect of large hospitals. The amount of work in

smaller hospitals may not justify full-time services of a pathologist. The other personnel that ar

needed are technicians, phlebotomists and attendants.

The number of medical laboratory technicians (MLTs) will depend upon:


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(i) the number of samples per day,

(ii) the range of tests to be performed under various sections, viz. clinical chemistry, hematology

microbiology and histopathology (or other specialist laboratories),

(iii) emergency service, and

(iv) leave reserve.

MLTs perform all technical procedures in various sections, prepare reports of complete

investigations, check and maintain equipment, and requisition necessary supplies and materials.

MLTs are responsible for most of the routine technical work of the laboratory. The selection

training and experience of MLTs should instill confidence in the medical staff as regards th

standard of their output. A committed person with basic qualification and experience can

successfully handle various technical functions under the supervision of the pathologist eve

under adverse working conditions. MLTs in a section work under a technical supervisor who ha

special expertise and experience in that section. For large laboratories

supervisory/administrative person is needed who can take care of indents, records, stocks

technicians, rotation, etc.

Number of Personnel

Staffing requirement of laboratory technicians can be worked out empirically on the basis o

generally accepted norm, which were about 30 tests per day technician. With the advent o

automatic and semi-automatic specimen processing machines, it can be worked out on the basi

of observed time.

For the purpose of development of guide material, historical data from 360 hospitals collecte

by American College of Pathologists in the 60sis presented in Table 1.

Table 1: Tests performed annually per medical technologist

Laboratory unit Tests

Hematology 13,400

Urinalysis 30,120

Serology 11.520

Biochemistry 9,600

Bacteriology 7,680Histology 3,840

Parasitology 9,600

A large hospital study showed that in laboratory with 8 technicians, 2804 tests were average

per technician per month, whereas the actual requirement of technicians based on time study an

standard time was 14 technicians. A very high utilization ratio may have negative bearing on

quality control.


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Nonproductive Activities

Studies have shown that a considerable amount of technicians time is spent on a variety o

nontechnical activities like documentation, and other administrative work, giving a ratio o

technical to other work at 63:37. This adds to underutilization of an already short technica

manpower. The Endeavour should be to ensure optimum utilization of technicians time on thworkbench in a efficiently functioning laboratory, with general duty personnel employed o

nontechnical and administrative work.

Scheduling and Turnover

For the day-to-day working, staff scheduling should ensure that all technical staff are turned ove

between different sections from time-to-time. This ensures that all staff sharpen their skills o

different analytical procedures, besides overcoming the monotony of carrying out similar tests a

throughout. Adequate provision must be made for leave entitlements.

Avoiding Monotony

Laboratory technicians job is a long cycle, repeat task type of job, leading to early fatigue

psychological strain, poor time keeping, low productivity, and what is most important poo

quality. Efforts should be made to develop a balance between workload, working conditions an

technical manpower. Regular in-service continuing education to keep abreast of th

developments in techniques, instrumentation and quality control adds to the efficiency an

commitment of the staff.

EQUIPMENT

The tendency towards more and more automation is leading hospitals to acquire sophisticatedautomated electronic, laboratory instruments with a high level of investment. However, goo

equipment pays for itself over a reasonable period of time if the volume of work is appropriate t

the capacity of the equipment.

Instruments

Some of the core instruments that are needed are listed below.

Colorimeters/Spectrophotometers: These were used a lot in the old days. They were particularl

useful for end-point biochemistry tests. In kinetic tests that are faster they were not of much use

These have been replaced by the new autoanalysers these days. However, smaller laboratorie

still use them.

Colorimeters are based on filters. There are different colour filters that allow only light o

certain wavelength to pass through. The wavelengths that are commonly used are 340, 505, 546

578 and 620nm. Spectrophotometers on the other hand are based on the principle of prism tha


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defracts light into various wavelengths. In this a specific wavelength from 340 to 640 can b

obtained. The light of a specified wavelength passes through a burette that holds the solution

The absorbance is then detected by a photodiode.

Autoanalysers: This is the core of any laboratory. This is the instrument that is used maximum fo

all the biochemistry work. Biochemistry is the major chunk of pathology work. There arautoanalysers of many makes. They include semiautoanalysers and batch autoanalysers

Semiautoanalysers require some manual pipetting before the reagents are fed to the machine

These instruments are based on colorimetric or spectrophotometer principle. The advantage the

have over colorimeter or spectrophotometer is that they can take the light absorbance readin

over a continuous period of time. This is essential in kinetic based biochemistry.

There are some analysers that use dry biochemistry for analysers that do not use liquids a

reagents. They are based on strips impregnated with reagents.

A major advantage of autoanalysers is the speed with which they can handle large workload

The chances of manual error are also reduced.

Cell-counter: Labs now prefer cell counter to manual blood cell analysis procedures. This gives

more complete blood picture. The principle of the instrument is that the cells are made to pas

through a thin capillary. A laser beam passes through the capillary and scatters the light. Th

scatter is based on the type of blood cell that passes. The light scatter is than detected. The RCB

WBC and platelet counts are more accurately measured in a cell counter. The RBC indices (MCV

MCH and MCHC) are also better calculated. The limitations are in case of leukaemia where th

morphology on peripheral smear needs evaluation by an expert eye.

The following is a list of the important items of equipments and instruments in a genera

hospital laboratory.

1. Centrifuge2. Microhaematocrit centrifuge3. Refrigerators4. Water still5. Pressure sterilizers6. Pipette washer7. Flame photometer8. Spectrophotometer9. Colorimeter10.Analytical balance11.Incubator12.Semiautoanalyser13.Random access autoanalyser14.Haematology cell counter15.Sodium, potassium, calcium analyser


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16.ELISA reader17.Blood gas analyser18.PCR equipment19.Flow cytometer.

The above equipments are common to most hospital laboratories. As the level of technologicasophistication increases, new equipments get introduced. The advantage with the moder

technologically sophisticated equipment is that they are fully automated and programmed for al

stages of test procedures, so much so that except for placing the sample on the machine no human

element is involved, thus eliminating all human errors.

Automation ensures speed, accuracy, and less use of consumables and lesser manpowe

Autoanalysers can take on a large number and vast array of tests at a very rapid rate. If the number o

tests to be carried out is much smaller than this capacity, procurement of such equipment should b

reconsidered. The cost-per-test on automated versus manual or sophisticated mechanical method i

generally the criterion which clinches the decision apart from other advantages of sophisticate

equipment or instruments.

A judicious use of semiautomated equipment may well serve the purpose of a small hospital wit

limited workload whereas in case of large hospital, fully automated equipments and the possibilit

of interfacing with laboratory computer should be considered3.

Calibration and testing of automated equipment is a matter of high technology. Instructions of th

manufacturers should be meticulously followed in the daily upkeep and maintenance of suc

equipment. For prompt attention to breakdowns or malfunctioning, there is no other way but to ente

into annual maintenance contract with the manufacturers. For other simple mechanical equipment o

instruments, periodic preventive maintenance should be carried out by the hospitals own trainedtechnicians.

POLICIES AND PROCEDURES

Laboratory Samples

Sample to be examined by the laboratory fall into two groups, viz. (i) samples collected by nursing

staff in nursing units or OPD and sent to the laboratory, and (ii) samples obtained by laborator

personnel from patients sent to the laboratory. All requests for laboratory examinations must be i

writing.

Sample Receiving

In the reception area, all samples of blood, feces, urine, pus, body fluids, swabs, etc., should b

received at the reception window counter. Sufficient racks/shelves and a hand washing facility mus

be available in this area. Under no circumstances, samples should be collected from any patient in

any room used as laboratory work area.


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Specimen collection for fine-needle aspiration cytology (FNAC) requires a separate cubicle in th

patient reception area or in the pathologists laboratory.

Request Forms

All request forms should be uniform in size and contain only pertinent information. A laborator

request form has two basic components, viz. (i) the patients particulars including brief clinica

details, and (ii) the laboratory test results. Unplanned laboratory forms have resulted in a waster o

paper and effort. Very few hospitals have standardized forms. Use of structured request forms, with

appropriate color coding, standard size and appropriate design leads to time saving all around and

definite aid in quality control.

Time for Accepting Specimens

Establishment of a time schedule for accepting certain types of specimen will facilitate the operation

of the laboratory although emergency requests are accepted at all times and have priority over a

other requests. Medical staff and nursing personnel at times develop a tendency to assign suchpriority when in reality they should have requested the examination much before. Laborator

personnel tend to lose respect for such emergency classifications.

Containers

All specimens sent to the laboratory should be in proper containers. Instructions on the time o

taking specimens, minimum volume necessary, type of container, preservatives, etc., should b

posted at the nurses station in wards, together with the list of commonly requested examination

and the time schedule for sending specimens to the laboratory.

Identification of Specimens

The laboratory personnel are responsible for the proper disposition of all specimens and request

within the laboratory. No specimen or request should be permitted to be left in the laboratory unles

a laboratory representative is present. In order to properly identify specimens received, a numberin

system should be devised whereby the specimen and the request form is given the same number

and this number is also entered in the request register. This number becomes the sole means o

identification of the patients name with the specimen. Therefore, the patients particulars should b

double checked with the specimen label and request form.

Bar coding system for samplesthis modern system of identification of samples has bee

discussed earlier.

Reports

Laboratory personnel should give reports only to authorized ward/OPD personnel and never directl

to patients.


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Records

A daily record register should be kept of all examinations performed in the laboratory in order t

maintain a monthly and yearly account of the work done. Sufficient space is allowed against th

name of the patient for noting the results.

The system of preparing two copies of request form and entering examination results on both

copies can be obviated if the register is meticulously maintained. This becomes the permanen

master record for reference at any time in future. The task of this register is now being taken over b

computer.

Outpatient Samples

Provision of sample collection centre in the outpatient department will be a necessity in large

hospitals where the volume of workload from outpatient department is considerable. A technicia

receives urine and clinical chemistry. The samples are then sent to the main laboratory fo

processing.

HIV

Necessary safety precaution should be understood clearly by all concerned while drawing bloo

samples from suspected HIV and hepatitis patients, with disposable syringes and needles.

Liaison with Clinicians

Differences between laboratory reports as compared to the patients clinical status may arise from

time-to-time. These should be discussed in the medical audit committee. Additionally, meetings ca

be held by the officer in charge of the laboratory with the clinicians to pinpoint short-comings if any

Such meetings should be utilized for assisting the clinicians to understand the scope of availabl

laboratory facilities and newer methodologies.

Cross-training of Technicians

Laboratory policy must lay down that all technical staff is cross-trained to work in all the differen

sections of the laboratory. Training programmes should be organized if necessary so that the staf

can handle any situation in case of exigencies of the situation.

Laboratory Waste Disposal

Histopathology and microbiology laboratory waste should be considered as hazardous waste an

should be disposed accordingly. In fact, all waste material from all the sections of the laboratory ca

be treated as hazardous waste and should be disposed of by burning in the hospital incinerator.


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BLOOD BLANK

It is said that there is no greater therapeutic tool than the administration of whole blood when it i

needed, and perhaps no more lethal weapon at out disposal than administering contaminated bloo

or improperly given blood.

Every hospital should have a committee, of which the pathologist is a member, to establish writte

procedures for the proper use of blood and blood derivatives, including identification and

compatibility testing of blood, criteria for use, and review of all transfusion reactions occurring in

the hospital. Storage facilities under adequate control and supervision are necessary. An alarm

system should be instituted to notify personnel of the loss of electric power and faulty temperature.

With a view to modernizing the blood banking system in the country, the Government of Indi

recently introduced amendments to the Drugs and Cosmetics Rules, 1972. Under these amendments

existing blood banks and those which intend to apply for a license to operate a blood bank ar

required to fulfill the conditions set out in the amendments. The salient features of the condition

are:

Seven rooms within a space of 100 sq. meters; Two laboratories, one for blood group serology and another for screening the blood for Hb

Ag, HIV antibodies and Syphilis. The two laboratories and the blood collection room are t

be air-conditioned;

Two refrigerators maintaining temperature between 4 to 6C with recording thermometer analarm device, one for the blood collection room and another for the laboratory;

Personnel a medical officer trained in blood banking for six months, a registered nurse antwo trained technicians (MLTs);

For AIDS test, the hospital can have its own testing facilities or can avail the facilities of thlaboratories of the Central Government.

The rules specify procedures and other requirements relating to;

licensing list of equipment and supplies needed for the blood bank refreshment services laboratory equipment reagents general supplies personnel testing the whole human blood expiry date records, labels and labeling.Hospitals are advised to write to the State Director of Drugs Control for more informatio

regarding this.


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QUALITY CONTROL

Quality control is the sheet anchor for accuracy of tests carried out in the hospital laboratory. Qualit

control in hospital laboratory starts from the person who sweeps and cleans the premises throug

laboratory technicians and terminates at the level of the pathologist.

As a part of quality control function, standard operating procedures (SOPs) should be laid down

by the incharge pathologist for each function and each functionary in the laboratory. Calibration

forms a part of quality control for each equipment. For automated equipment, equipment supplier

have arrangement for periodical checking and calibration of each equipment at specified interval

Calibrators are also supplied with some equipment like autoanalysers.

There is an internal and an external quality control that is recommended. The internal qualit

control is done in the lab itself. Standards are run at regular intervals. The national external qualit

control for biochemistry and hematology is run by CMC, Vellore. Some private companies also ruthe external quality control quality programme. If the lab is enrolled in this program, a sample is sen

to the lab and the various biochemistry/hematology parameters performed. Results are then maile

to the managing organizations where they are studied, evaluated and corrective action taken.

Medico legal Issues and Insurance

All medical reports are documentary evidence in the Court of Law. The treatment that was given

during the illness is based on the lab reports. Histopathology, Cytology reports that give a diagnosi

of malignancy carry great importance. There are documented litigations even for simple things lik

pregnancy test on urine. It is hence important that all records be properly maintained and report

issued after due verification. Pathologists sign all the reports and hence the authenticity of threports is his prime responsibility.

Some insurance companies also offer insurance for Pathology Labs which cover the liabilities upt

a certain limit. This is more popular in the West than in India. Pathologists working in a big hospita

set-up are covered by the hospital and may not be individually liable. Pathologists working in sma

labs may need to take a separate insurance on their own.

Accreditation

Getting accreditation with Pathology Boards is not a must in India. However, a National Board o

Laboratories (NABL) exists and getting an accreditation is useful. The process is stringent and irequires external and internal quality control records to be maintained. The Board has also to certif

the quality control records maintained. There are very few labs that are accredited at present.

ISO certification involves quality control checks and also staff behavior. Getting an ISO

certification is relatively easy as compared to National Laboratory Board accreditation.

Emergency Department and Laboratory Services

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